bluuebunny/crossref_metadata_2025 huggingface dataset:
Comparison of serological and parasitological assessments of Onchocerca volvulus transmission after 7 years of mass ivermectin treatment in Mexico
Authors: Rodríguez‐Pérez Mario A. , Danis‐Lozano Rogelio , Rodríguez Mario H. , Bradley J. E.
Published: March 2003

Summary objective and method  To compare the utility of an ELISA using 3 recombinant antigens with that of the skin biopsy to estimate incidence of infections in a sentinel cohort of individuals living in an endemic community in southern Mexico during a set of 11 subsequent ivermectin treatments.

results  The apparent community prevalence of infection and microfilarial skin infection before and after 11 treatments with ivermectin plus nodulectomy were 78% and 13%, and 0.68 mf/mg and 0.04 mf/mg, respectively, as measured by skin biopsy. Of a group of 286 individuals participating in all surveys, a sentinel cohort of 42 mf and serologically negative individuals had beeen followed since 1994. The annual percentage of individuals becoming positive in this cohort was 24% (10/42), 28% (9/33), 0%, and 4.3% (1/23) in 1995, 1996, 1997 and 1998, respectively. Likewise, the incidence in children 5 years and under (n= 13) within this sentinel cohort was 15% (2/13), 18% (2/11), 0% and 11% (1/9), respectively. All individuals became positive to both tests simultaneously, indicating that seroconversion assessed infection incidence as accurately as skin biopsy in the sentinel group.

conclusion  Incidence monitoring of a sentinel cohort provides an estimation of the parasite transmission in the community; it is less costly than massive sampling, and a finger prick blood test might be more acceptable in some communities.
The contribution of α+–thalassaemia to anaemia in a Nigerian population exposed to intense malaria transmission
Authors: Mockenhaupt Frank P. , Falusi Adeyinka G. , May Juergen , Ademowo Olusegun G. , Olumese Peter E. , Meyer Christian G. , Bienzle Ulrich
Published: March 2003

Summary The proportion to which α‐thalassaemia contributes to anaemia in Africa is not well recognized. In an area of intense malaria transmission in South‐West Nigeria, haematological parameters of α‐thalassaemia were examined in 494 children and 119 adults. The –α3.7 type of α+‐thalassaemia was observed at a gene frequency of 0.27. Nine and 36.5% of individuals were homozygous and heterozygous, respectively. P.falciparum‐infection was present in 78% of children and in 39% of adults. The α‐globin genotypes did not correlate with the prevalence of P. falciparum‐infection. α+‐thalassaemic individuals had significantly lower mean values of haemoglobin, mean corpuscular volume, and mean corpuscular haemoglobin than non‐thalassaemic subjects. Anaemia was seen in 54.7% of children with a normal α‐globin genotype, in 69.9% of heterozygous (odds ratio: 1.99, 95% confidence interval: 1.32–3.00, P= 0.001), and in 88.4% of homozygous α+‐thalassaemic children (odds ratio: 7.72, 95% confidence interval: 2.85–20.90, P= 0.0001). The findings show that α+‐thalassaemia contributes essentially to mild anaemia, microcytosis, and hypochromia in Nigeria.
Changing home treatment of childhood fevers by training shop keepers in rural Kenya
Authors: Marsh V. M. , Mutemi W. M. , Muturi J. , Haaland A. , Watkins W. M. , Otieno G. , Marsh K.
Published: March 2003

Summary background Malaria control in Africa relies primarily on early effective treatment for clinical disease, but most early treatments for fever occur through self‐medication with shop‐bought drugs. Lack of information to community members on over‐the‐counter drug use has led to widespread ineffective treatment of fevers, increased risks of drug toxicity and accelerating drug resistance. We examined the feasibility and measured the likely impact of training shop keepers in rural Africa on community drug use.

methods In a rural area of coastal Kenya, we implemented a shop keeper training programme in 23 shops serving a population of approximately 3500, based on formative research within the community. We evaluated the training by measuring changes in the proportions of drug sales where an adequate amount of chloroquine was purchased and in the percentage of home‐treated childhood fevers given an adequate amount of chloroquine. The programme was assessed qualitatively in the community following the shop keeper training.

results The percentage of drug sales for children with fever which included an antimalarial drug rose from 34.3% (95% CI 28.9%–40.1%) before the training to a minimum of 79.3% (95% CI 71.8%–85.3%) after the training. The percentage of antimalarial drug sales where an adequate amount of drug was purchased rose from 31.8% (95% CI 26.6%–37.6%) to a minimum of 82.9% (95% CI 76.3%–87.3%). The percentage of childhood fevers where an adequate dose of chloroquine was given to the child rose from 3.7% (95% CI 1.2%–9.7%) before the training to a minimum of 65.2% (95% CI 57.7%–72.0%) afterwards, which represents an increase in the appropriate use of over‐the‐counter chloroquine by at least 62% (95% CI 53.7%–69.3%). Shop keepers and community members were strongly supportive of the aims and outcome of the programme.

conclusions The large shifts in behaviour observed indicate that the approach of training shop keepers as a channel for information to the community is both feasible and likely to have a significant impact. Whilst some of the impact seen may be attributable to research effects in a relatively small scale pilot study, the magnitude of the changes support further investigation into this approach as a potentially important new strategy in malaria control.
Proposed panel of diagnostic criteria, including the use of ultrasound, to refine the concept of ‘endemic normals’ in lymphatic filariasis
Authors: Dreyer G. , Santos A. , Noroes J. , Addiss D.
Published: March 2003

Summary Although living adult Wuchereria bancrofti worms can be detected by ultrasound examination of the scrotal area in approximately 80% of men infected with this filarial parasite, the location of the adult worms in the remaining 20% remains unclear. To determine this, 32 individuals who had W. bancrofti microfilaraemia but no adult worms detectable on ultrasound were treated with diethylcarbarmazine (DEC), either with a single 6 mg/kg dose (n = 13) or with a 12‐day course of 6 mg/kg per day (n = 19). They were then monitored with serial physical and ultrasound examinations. Thirteen (41%) subjects developed small, single scrotal nodules 12 h to 7 days after treatment; this rate was unaffected by the dose of DEC. No nodules were detected outside the scrotal area. All 5 men with lymphangiectasia suspected on ultrasound before treatment developed scrotal nodules, compared to 8 (29.6%) of 27 men without ultrasonographic evidence (P = 0.006). Thus, using both ultrasound and ‘provocative’ treatment with DEC, adult W. bancrofti can be detected in the scrotal area of an estimated 88% of infected men. Because no single diagnostic test for W. bancrofti infection is completely sensitive, a panel of tests, including ultrasound, is proposed to identify with greater accuracy ‘endemic normals’ for immunological and epidemiological studies.
Prevalence of antibodies against hepatitis A and E viruses among rural populations of the Chaco region, south‐eastern Bolivia
Authors: Bartoloni Alessandro , Bartalesi Filippo , Roselli Mimmo , Mantella Antonella , Caceres Arce Cleto , Paradisi Franco , Hall Andrew J.
Published: March 2003

Summary We conducted a cross‐sectional study to determine the seroprevalence of antibodies against hepatitis A and hepatitis E viruses (HAV and HEV) in the population of two rural areas, Camiri and Villa Montes, of the Chaco region, south‐eastern Bolivia. HAV antibodies were detected in 461 (94.1%) of 490 serum samples tested, not differing significantly between sexes and study areas. The HAV seropositivity rate (64.7%) was high even in the youngest age group (1–5 years). The prevalence of HEV was 7.3%, with no significant differences between sexes. The prevalence of HEV antibodies in the population of the Camiri area (10.4%) was significantly higher than in the Villa Montes area (4.4.%), possibly due to the better quality of drinking water in the Villa Montes area. In the population ≤ 30 years of age, the HEV seropositivity rate (4.4%) was significantly lower than in the ≥ 31 year‐old group. This is consistent with findings in other countries. This is the first report of the prevalence of HEV infection in Bolivia.
Spatial implications of the tuberculosis DOTS strategy in rural South Africa: a novel application of geographical information system and global positioning system technologies
Authors: Tanser Frank , Wilkinson David
Published: March 2003

Summary We used GIS/GPS technology to document and quantify improved access to tuberculosis treatment through a community‐based programme in Hlabisa, South Africa. We plotted tuberculosis supervision points used by the district health system in 1991 (programme's first year) and 1996 (programme fully established), and quantified access by using GIS to measure the mean distance from each homestead in the district to hospital, clinics, community health workers (CHW) and volunteer supervisors. While the tuberculosis caseload tripled, the number of community supervision points used increased from 37 in 1991 to 147 in 1996. Adding clinics and then CHWs to the hospital as treatment points reduced the mean distance from homestead to treatment point from 29.6 km to 4.2 km and to 1.9 km, respectively. Adding volunteers further decreased the distance to 800 m. GIS/GPS effectively documents and quantifies the impact of community‐based tuberculosis treatment on access to treatment.
Assessment of IgG antibodies against yellow fever virus after vaccination with 17D by different assays: neutralization test, haemagglutination inhibition test, immunofluorescence assay and ELISA
Authors: Niedrig M. , Lademann M. , Emmerich P. , Lafrenz M.
Published: March 2003

Summary We analysed serum samples of 209 subjects immunized with yellow fever vaccine 17D by different assays: neutralization test, immunofluorescence assay, haemagglutination inhibition test and ELISA, for presence of 17D‐specific antibodies. Serum samples were taken from a few weeks up to 35 years after vaccination. The neutralization test had the highest sensitivity. There was no correlation of results between the serological assays. Considering NT titres > 1:10 as indicating protection, we found that about 75% of subjects remained immune even 10 years after vaccination, with a median NT titre of 1:40 in reactive sera.
Reliability of malaria microscopy in epidemiological studies: results of quality control
Authors: Kilian A. H. D. , Metzger W. G. , Mutschelknauss E. J. , Kabagambe G. , Langi P. , Korte R. , von Sonnenburg F.
Published: March 2003

Summary To assess the interrater reproducibility of malaria microscopy in epidemiological studies, 711 thick blood films from population‐based surveys were randomly selected and reread by 4 experienced microscopists. Sample estimates of the prevalence of P. falciparum infection, geometric mean parasite density and the proportion of samples above various parasite density cut‐off levels were almost identical in the routine and quality control readings. Differences were, however, encountered in the sample estimates for gametocyte ratio, proportion of mixed infection and average density index. In all three cases the quality control result was significantly higher than the routine evaluation. On the level of the individual slide there was good interrater agreement for the presence of P. falciparum infections (Kappa index κ = 0.79) which was even better when parasite densities between 4 and 100/μl were excluded (κ = 0.94). With respect to the assessment of parasite density, a high level of disagreement was found. While the mean difference between the two readings was not different from 0, the second reading was between 0.12 and 10 times that of the first. However, the level of disagreement significantly fell with increasing parasite densities. Thus malaria microscopy is very reliable for the estimation of parasite ratios and geometric mean parasite densities within and between studies as long as the same methodology is used, but tends to underestimate the gametocyte ratio and proportion of mixed infections. Care must be taken, however, when individual parasite density is related to other explanatory variables, due to the high degree of variability in the parasite enumeration.
International multi‐centre evaluation of a dipstick assay for human leptospirosis
Authors: Smits Henk L. , Hartskeerl Rudy A. , Terpstra Wiepko J.
Published: March 2003

Summary A dipstick assay for the detection of Leptospira‐specific immunoglobulin M (IgM) antibodies in human sera was evaluated in 27 laboratories in 23 countries. 873 serum samples from 711 patients including 329 laboratory‐confirmed leptospirosis case patients, 239 noncase patients and 69 patients with viral infections causing heamorrhagic fever were tested. Relative to the results of the reference leptospirosis test, the sensitivity of the dipstick assay was 84.5% for serum samples collected during the first 10 days of the disease and 92.1% for serum samples collected 10–30 days after the onset of disease. The specificity was 87.5% and 94.4%, respectively. Similar to viral haemorrhagic fevers, leptospirosis may cause bleeding. A small number of serum samples from patients with haemorrhagic viral infections gave a weak (1 +) stain. All other samples were negative. In conclusion, the dipstick assay is sensitive and specific and reacts well with serum samples from patients infected with a range of leptospiral strains. It is also easy to use and does not require special equipment or refrigeration. Therefore the assay is ideal for use in developing countries and rural settings.
The global epidemiology of HIV/AIDS
Authors: De Cock Kevin M. , Weiss Helen A.
Published: March 2003

Summary The HIV pandemic continues to evolve, in both magnitude and diversity. In this paper, we briefly review the global epidemiology of HIV/AIDS, reflecting on the differences by region, and the challenges posed by the evolving epidemics in terms of prevention and surveillance. Despite the reduction in numbers of new AIDS cases in the US and Western Europe due to advances in treatment, a constant number of new HIV infections persists every year, with evidence that in some settings high‐risk behaviour has increased, indicating failure in primary prevention. However, the vast majority of new infections still occur in developing countries. The two giants, India and China, are set to determine Asia's ultimate contribution to the pandemic, but currently it is Africa that remains in the eye of the storm, with rapidly increasing epidemics in many countries in the south and east of the continent impacting on all levels of society.
Sociodemographic characteristics, care, feeding practices, and growth of cohorts of children born to HIV‐1 seropositive and seronegative mothers in Nairobi, Kenya
Authors: Sherry Bettylou , Embree Joanne E. , Mei Zuguo , Ndinya‐Achola Jackoniah O. , Njenga Simon , Muchunga Elisha R. , Bett Josephine , Plummer Francis A.
Published: March 2003

objectives To compare sociodemographic profiles, child care, child feeding practices and growth indices of children born to HIV‐1 seropositive and seronegative mothers.

methods A cohort study of 234 children (seropositive and seronegative) born to HIV‐1 seropositive mothers and 139 children born to seronegative mothers in Pumwani Maternity Hospital which serves a low‐income population in Nairobi, Kenya from December 1991 and January 1994.

results With few exceptions, at the time of their birth children in all three cohorts had parents with similar characteristics, lived in similar housing in similar geographical areas, had their mothers as their primary care givers, had similar feeding practices and similar growth status and patterns. However, the HIV‐1 seropositive mothers were slightly younger (23.8 years vs. 25.0 years, P < 0.01), if married they were less likely to be their husband's first wife (79% vs. 91%, P = 0.02) and more likely to have a one‐room house (75% vs. 63%, P = 0.04). All three cohorts had mean Z‐scores in length‐for‐age and in weight‐for‐height within the normal range (≥ 2.0 Z‐scores) from birth to 21 months with the exception of the length‐for‐age of the seropositive children at the 18‐month visit. In all cohorts length‐for‐age became more compromised than weight‐for‐length, dropping to about −1.45 Z‐score by 21 months; in contrast, weight‐for‐length dropped to about −0.5 Z‐score by this age. The only statistically significant differences in growth indices among the three cohorts were between the two cohorts of seronegative children: those with seronegative mothers were less compromised in length‐for‐age at 1.5 months (mean Z‐score =−0.19 vs.−0.48, P < 0.05) and more compromised in weight‐for‐length at 6 months (mean Z‐score = 0.10 vs. 0.45, P < 0.05) and at 18 months (mean Z‐score =−0.73 vs.−0.16, P < 0.05). 27–34% were exclusively breastfed at 1.5 months; 52–61% consumed solid foods in addition to breast milk by 2.5 months.

conclusions Low‐income HIV‐1 seropositive‐ and seronegative‐born children were from families with similar characteristics and similar housing environments. Similar growth patterns in the cohorts suggest that the challenging environment and the choice of weaning foods had an impact on all three cohorts. The aggressive care given the children with HIV‐1 seropositive mothers and their children may have reduced the progression and impact of HIV‐1 disease on the growth of the seropositive children. Further research is needed to corroborate our findings to be certain that our results are not affected by loss to follow‐up bias: we lost the same proportion in all three cohorts but cannot verify that the children we lost had the same growth patterns as those who remained in the study.
Evaluation of clinical pallor in the identification and treatment of children with moderate and severe anaemia
Authors: Muhe Lulu , Oljira Birhane , Degefu Hirut , Jaffar Shabbar , Weber Martin W.
Published: March 2003

Summary background  Anaemia from malaria is a common problem in developing countries. Blood transfusion in developing countries is available in few hospitals. Children who are severely anaemic and may require urgent blood transfusion usually present to peripheral first‐level health facilities from where they must be referred to hospitals. Since most peripheral facilities do not determine haemoglobin levels, the decision on referral has to be made on clinical grounds.

objectives  To evaluate the sensitivity and specificity of clinical pallor of the palms, nailbeds, conjunctivae, buccal mucosa or tongue against haemoglobin values and their reproducibility among health workers.

methods  A total of 2540 children 2 months to 5 years of age presenting to a rural health centre in Ethiopia were enrolled. Clinically detected pallor was compared with measured blood haemoglobin concentrations.

results  Any anaemia (haemoglobin < 11 g/dl) was found in 61% of the children. Severe anaemia (haemoglobin < 5 g/dl) was found in 4%. The presence of any pallor clinically correlated with moderate anaemia (haemoglobin level < 8 g/dl) could be detected with a sensitivity of 95% and a specificity of 64–68% when the palm and nailbeds were used and a sensitivity of 84% and a specificity of 81% when the conjunctivae were used. Severe anaemia was detected clinically as severe pallor in 50–56% of cases (with a specificity of 95–96%). Agreement between physicians was highest for conjunctivae and nailbed pallor (87%) and lowest for palm pallor (73%). Using multivariate analysis, identification of a systolic ejection murmur or altered sensorium, the presence of splenomegaly or malarial parasitaemia were independently predictive of severe and moderately severe anaemia.

conclusions  Moderate and severe anaemia can be identified clinically in most cases for treatment and referral purposes. A systolic ejection murmur, altered sensorium, the presence of splenomegaly or malarial parasitaemia may be used as additional tools in considering urgent referral for blood transfusion.
Tolerability and efficacy of single‐dose diethyl carbamazine (DEC) or ivermectin in the clearance of Wuchereria bancrofti microfilaraemia in Pondicherry, south India
Authors: Subramanyam Reddy G. , Vengatesvarlou N. , Das P. K. , Vanamail P. , Vijayan A. P. , Kala Sasi , Pani S. P.
Published: March 2003

Summary In a double blind design the tolerability and efficacy of single‐dose DEC (6 mg/kg/body weight) or ivermectin (400 μg/kg/body weight) was studied in 30 asymptomatic W. bancrofti parasite carriers each. Although both drugs were tolerated well, the adverse reaction score (DEC 0.5; ivermectin 1.5) and overall incidence (DEC 65.0%; ivermectin 93.3%) were significantly higher in the ivermectin group. Major adverse reactions were fever, headache and myalgia, all of which peaked on the second day post‐therapy. Efficacy was measured in terms of proportion of cases clearing parasitaemia and reduction in mean parasite density compared to pre‐therapy levels. Although at the end of one year the ivermectin group showed a significantly higher efficacy (34.8%, 97.0%) compared to DEC (8.3%, 83.8%), at the end of the second year there was no significant difference in efficacy between the drugs (73.7%, 99.5% for ivermectin; 47.8%, 98.9% for DEC). The tolerability and efficacy of the two drugs were not significantly different between gender, age and weight classes of patients.
Child malaria treatment practices among mothers in the district of Yanfolila, Sikasso region, Mali
Authors: Aly Théra Mahamadou , D'alessandro Umberto , Ouedraogo Adama , Packou Julienne , Ahmed Deida Souleymane Ould , Fané Moussa , Ade Gabriel , Alvez Fernanda , Doumbo Ogobara
Published: March 2003

Summary We studied child malaria treatment practices among mothers living in the District of Yanfolila in southern Mali. For sampling, we first chose five of 13 health areas with probability proportional to size. Then villages, compounds and mothers with at least one child aged 1–5 years were randomly chosen. We assessed the spleen size of one 1–5 year‐old child of each mother, collected a thick blood film and recorded the body temperature of every child whose mother thought he/she was sick. 399 mothers in 28 villages were interviewed with a structured questionnaire divided into two parts. If the child had had soumaya (a term previously associated with uncomplicated malaria) during the past rainy season, we asked about signs and symptoms, health‐seeking behaviour (who the mother consulted first) and treatment. If not, information about knowledge of the disease and treatment to be given was collected. 86% of the mothers interviewed stated that their child had been sick and almost half of them had had soumaya. All mothers named at least one sign by which they recognized the disease. Vomiting, fever and dark urine/yellow eyes/jaundice were the three most common signs mentioned. 75.8% managed their child's disease at home and used both traditional and modern treatment. The most common anti‐malarial drug was chloroquine, often given at inappropriate dosage. The sensitivity and specificity of the mothers' diagnosis was poor, although this might be explained by the large percentage of children who had already been treated at the time of the interview. The results of our survey call for prompt educational action for the correct treatment of uncomplicated malaria/soumaya, particularly for mothers and possibly for shopkeepers. The high spleen rate (58.1%) among randomly selected children confirms that malaria is a common disease in this area. Improved case‐management at home could only be beneficial.
Antibodies to tetanus toxoid in women of childbearing age in Dar es Salaam and Bagamoyo, Tanzania
Authors: Aboud S. , Matre R. , Lyamuya E. F. , Kristoffersen E. K.
Published: March 2003

Our aim was to determine tetanus immunity in women of childbearing age (15–44 years) with histories and/or documentation of having been vaccinated with Tetanus Toxoid (TT) under the Expanded Programme on Immunization in Dar es Salaam and Bagamoyo, Tanzania. Using an ELISA technique, serum levels of TT antibody, antibody avidity and distribution of TT IgG subclass antibodies were determined in 207 apparently healthy women. A TT antibody level of 0.1 IU/ml was considered protective. 99% and 100% of women in Dar es Salaam and Bagamoyo, respectively, had a TT antibody level ≥0.1 IU/ml. Anti‐toxin binding avidity was found to be high in most of the women. In addition to TT IgG3 subclass antibody, TT IgG1 subclass antibody was the most dominant subclass type. A substantial number of women also had TT IgG2 and TT IgG4 subclass antibody responses. A better recording system on TT immunization is recommended to avoid hyper‐immunization of women and to optimize the cost‐effectiveness of the immunization programme.
Clinical description of encephalopathic syndromes and risk factors for their occurrence and outcome during melarsoprol treatment of human African trypanosomiasis
Authors: Blum J. , Nkunku S. , Burri C.
Published: March 2003

Encephalopathies are the most feared complications of sleeping sickness treatment with melarsoprol. To investigate the existence of risk factors, the incidence of encephalopathic syndromes and the relationship between the development of different types of encephalopathies and the clinical outcome was studied in a clinical trial with 588 patients under treatment with melarsoprol. The 38 encephalopathy cases were classified into three types according to the leading clinical picture: coma type, convulsion type and psychotic reactions. Nine patients were attributed to the convulsion type, defined as a transient event of short duration with convulsions followed by a post‐ictal phase, without signs of a generalized disease. None of these patients died from the reaction. Febrile reactions in the 48 h preceding the reaction were generally not observed in this group. Twenty‐five patients were attributed to the coma type, which is a progredient coma lasting several days. Those patients often had signs of a generalized disease such as fever (84%), headache (72%) or bullous skin (8%) reactions. The risk of mortality was high in this group (52%). About 14/16 patients with encephalopathic syndrome of the coma type were infected with malaria. Patients with psychotic reactions or abnormal psychiatric behaviour (3/38) and one patient who died after alcohol intake were excluded from the analysis. The overall rate of encephalopathic syndromes in the cases analysed (n=34) was 5.8%, of which 38.2% died. We did not find any parameters of predictive value for the risk of developing an encephalopathic syndrome based on the symptoms and signs before treatment initiation. The appearance during treatment of febrile reactions (RR 11.5), headache (RR 2.5), bullous eruptions (RR 4.5) and systolic hypotension (RR 2.6) were associated with an increased risk for the occurrence of encephalopathic syndromes especially of the coma type.
Monitoring drug resistance in leishmaniasis
Authors: Croft Simon L.
Published: March 2003

There are many factors that can influence the efficacy of drugs in the treatment of leishmaniasis. These include both an intrinsic variation in the sensitivity of Leishmania species, described for pentavalent antimonials, paromomycin, azoles and other drugs that have reached clinical trials, as well as acquired drug resistance to antimonials. Acquired resistance has been studied in the laboratory for several decades but it is only recently that clinical resistance in L. donovani field isolates has been demonstrated. The monitoring of resistance is problematic due to a reliance on the amastigote‐macrophage culture assay to adequately correlate clinical and in vitro resistance and a lack of knowledge about the molecular and biochemical mechanisms of resistance to antileishmanial drugs.
Introducing insecticide‐treated nets in the Kilombero Valley, Tanzania: the relevance of local knowledge and practice for an Information, Education and Communication (IEC) campaign
Authors: Minja Happiness , Schellenberg Joanna A. , Mukasa Oscar , Nathan Rose , Abdulla Salim , Mponda Hadji , Tanner Marcel , Lengeler Christian , Obrist Brigit
Published: March 2003

Since 1997 the WHO has been recommending an integrative strategy to combat malaria including new medicines, vaccines, improvements of health care systems and insecticide‐treated nets (ITNs). After successful controlled trials with ITNs in the past decade, large‐scale interventions and research now focus on operational issues of distribution and financing. In developing a social marketing approach in the Kilombero Valley in south‐east Tanzania in 1996, a combination of qualitative and quantitative methods was employed to investigate local knowledge and practice relating to malaria. The findings show that the biomedical concept of malaria overlaps with several local illness concepts, one of which is called maleria and refers to mild malaria. Most respondents linked maleria to mosquitoes (76%) and already used mosquito nets (52%). But local understandings of severe malaria differed from the biomedical concept and were not linked to mosquitoes or malaria. A social marketing strategy to promote ITNs was developed on the basis of these findings, which reinforced public health messages and linked them with nets and insecticide. Although we did not directly evaluate the impact of promotional activities, the sharp rise in ownership and use of ITNs by the population (from 10 to > 50%) suggests that they contributed significantly to the success of the programme. Local knowledge and practice is highly relevant for social marketing strategies of ITNs.
Anthelmintic resistance in human helminths: a review
Authors: Geerts S. , Gryseels B.
Published: March 2003

We briefly review reports on drug resistance in human helminths and compare the factors which contribute to the development of anthelmintic resistance in livestock and man, i.e. high treatment frequency, single‐drug regimens, targeting and timing of mass treatments and underdosing. Conclusions are drawn from the mistakes in the treatment and control of livestock helminths. The advantages and inconveniences of current methods for the detection of drug resistance in helminths of livestock are discussed and some suggestions are put forward to standardize the tests for the detection of resistance in human helminths. Finally, based on veterinary experience, some recommendations are made to reduce the risks of development of drug resistance in human helminths. The dramatic and rapid spread of resistance to all major classes of veterinary anthelmintics should be a warning against too strong a reliance on drugs in helminth control programmes.
Drug resistance in Indian visceral leishmaniasis
Authors: Sundar Shyam
Published: March 2003

Throughout the world, pentavalent antimonial compounds (Sbv) have been the mainstay of antileishmanial therapy for more than 50 years. Sbv has been highly effective in the treatment of Indian visceral leishmaniasis (VL: kala‐azar) at a low dose (10 mg/kg) for short durations (6–10 days). But in the early 1980s reports of its ineffectiveness emerged, and the dose of Sbv was eventually raised to 20 mg/kg for 30–40 days. This regimen cures most patients with VL except in India, where the proportion of patients unresponsive to Sbv has steadily increased. In hyperendemic districts of north Bihar, 50–65% patients fail treatment with Sbv. Important reasons are rampant use of subtherapeutic doses, incomplete duration of treatment and substandard drugs. In vitro experiments have established emergence of Sbv resistant strains of Leishmania donovani, as isolates from unresponsive patients require 3–5 times more Sbv to reach similarly effectiveness against the parasite as in Sbv responders. Anthroponotic transmission in India has been an important factor in rapid increase in the Sbv refractoriness. Pentamidine was the first drug to be used and cured 99% of these refractory patients, but over time even with double the amount of initial doses, it cures only 69–78% patients now and its use has largely been abandoned in India. Despite several disadvantages, amphotericin B is the only drug available for use in these areas and should be used as first‐line drug instead of Sbv. The new oral antileishmanial drug miltefosine is likely to be the first‐line drug in future. Unfortunately, development of newer antileishmanial drugs is rare; two promising drugs, aminosidine and sitamaquine, may be developed for use in the treatment of VL. Lipid associated amphotericin B has an excellent safety and efficacy profile, but remains out of reach for most patients because of its high cost.
New approaches to spatially analyse primary health care usage patterns in rural South Africa
Authors: Tanser Frank , Hosegood Victoria , Benzler Justus , Solarsh Geoffrey
Published: March 2003

OBJECTIVE To develop indices to quantitatively assess and understand the spatial usage patterns of health facilities in the Hlabisa district of South Africa.

METHODOLOGY We mapped and interviewed more than 23 000 homesteads (approximately 200 000 people) in Hlabisa district, South Africa and spatially analysed their modal primary health usage patterns using a geographical information system. We generated contour maps of health service use and quantified the relationship between clinic catchments and distance‐defined catchments using inclusion and exclusion error. We propose the distance usage index (DUI) as an overall spatial measure of clinic usage. This index is the sum of the distances from clinic to all client homesteads divided by the sum of the distances from clinic to all homesteads within its distance‐defined catchment. The index encompasses inclusion, exclusion, and strength of patient attraction for each clinic.

RESULTS Eighty‐seven per cent of homesteads use the nearest clinic. Residents of homesteads travel an average Euclidean distance of 4.72 km to attend clinics. There is a significant logarithmic relationship between distance from clinic and their use by homesteads (r2=0.774, P < 0.0001). The DUI values range between 31 and 198% (mean=110%, SD=43.7) for 12 clinics and highlight clinic usage patterns across the district.

CONCLUSIONS The DUI is a powerful and informative composite measure of clinic usage. The results of the study have important implications for health care provision in developing countries.
Pricing of drugs and donations: options for sustainable equity pricing
Authors: Pérez‐Casas Carmen , Herranz Emilia , Ford Nathan
Published: March 2003

Effective medicines exist to treat or alleviate many diseases which predominate in the developing world and cause high mortality and morbidity rates. Price should not be an obstacle preventing access to these medicines. Increasingly, drug donations have been established by drug companies, but these are often limited in time, place or use. Measures exist which are more sustainable and will have a greater positive impact on people’s health. Principally, these are encouraging generic competition; adopting into national legislation and implementing TRIPS safeguards to gain access to cheaper sources of drugs; differential pricing; creating high volume or high demand through global and regional procurement; and supporting the production of quality generic drugs by developing countries through voluntary licenses if needed, and facilitating technology transfer.
Effectiveness of community and health services‐organized drug delivery strategies for elimination of lymphatic filariasis in rural areas of Tamil Nadu, India
Authors: Ramaiah K. D. , Vijay Kumar K. N. , Chandrakala A. V. , Augustin D. J. , Appavoo N. C. , Das P. K.
Published: March 2003

Lymphatic filariasis (LF) is targeted for global elimination. Repeated annual single‐dose mass treatment with antifilarials has been recommended as the principal strategy to achieve LF elimination. This requires an effective and sustainable strategy to deliver the drug, diethylcarbamazine (DEC), to communities. In this study, a new drug delivery strategy – community‐directed treatment (comDT) – was developed and implemented and its effectiveness compared with that of the traditional health services‐organized drug delivery, in rural areas of Tamil Nadu, India. Qualitative and quantitative data showed that the communities and health services were able to distribute the drug in almost all villages. The drug distribution rate and treatment compliance rate of comDT and health services treatment were statistically compared after adjusting them for clustering. Under the comDT 68% (n=20 villages; range: 0–97%) of the population received DEC, compared with 74% (n=20 villages; range: 48–95%) with the health services treatment strategy (P > 0.05). However, only about 53% (range: 0–91%) of comDT recipients and 59% (range: 32–79%) of those who received DEC from the health services consumed the drug (P > 0.05). Although statistically not significant, the distribution and compliance rates were lower under the comDT strategy. Also, the strategy’s operationalization appears to be difficult because of some social factors, and the tradition of communities’ dependence on health services for treatment, whereas health services‐organized distribution was much less cumbersome and found to be more acceptable to people. However, the distribution (74%) and compliance rates (59%) achieved by health services were also only moderate and may not be adequate to eliminate LF in a reasonable time frame. Health services manpower alone may not be sufficient to distribute the drug. We conclude that drug distribution by health services is the best option for India and participation of the community volunteers and village level government staffs in the programme is necessary to effectively distribute the drug and attain the desirable levels of treatment compliance to eliminate LF.
Drug‐based helminth control in Western Pacific countries: a general perspective
Authors: Urbani Carlo , Palmer Kevin
Published: March 2003

Helminthiases still have a relevant detrimental role in the health of large groups of human population. Where poor hygiene and lack of access to education, health services and essential care characterize living conditions, parasitic infections dramatically affect essential aspects of individual life, such as nutrition, cognitive performance, susceptibility to infections and micronutrient deficiency. Severe illness is associated with schistosomiasis, lymphatic filariasis and food‐borne trematode infections. Drugs are the cornerstone of control strategies for such infections, the World Health Organization (WHO) list of essential drugs contains several highly efficacious anthelmintics which are all safe, single‐dose and cheap. If given regularly to infected communities, these drugs effectively control the morbidity related to the major endemic helminth infections. New strategies for mass drug administration to human populations have been tested, and several endemic Western Pacific countries have achieved excellent results in reducing morbidity in spite of continuous transmission. In this region, experience over the last decades proves the feasibility of helminth control, but also shows the need for long‐term commitment and continuous support.
Weekly chloroquine prophylaxis and the effect on maternal haemoglobin status at delivery
Authors: Salihu H. M. , Naik E. G. , Tchuinguem G. , Bosny J. P. L. , Dagne G.
Published: March 2003

Our aim was to determine the effectiveness of chloroquine prophylaxis in reducing the frequency of malaria‐induced anaemia at delivery. We estimated the haemoglobin levels of 207 parturients; 82 (39.6%) had been on chloroquine prophylaxis [treatment group (TG)] while 125 (60.4%) did not take any malaria preventive medication antenatally [control group (CG)]. The proportion of women with malaria parasitaemia was significantly higher in CG than TG [risk ratio (RR=1.57, CI=1.05–2.34)]. The dose–response relationship between the severity of parasitaemia and the risk of being anaemic (P < 0.001) confirms a strong correlation between gestational malaria and maternal anaemia. There was a 35% reduction in risk for anaemia in the TG compared with the CG (RR=0.65, 0.40–1.06). The difference in risk was more pronounced after adjusting for disparity in place of residence, educational status and obstetric history (adjusted RR=0.54, CI=0.21–0.98). Primiparous mothers appeared to have benefited more from the antianaemic effects of malaria chemoprevention than mothers of higher parity (protective effectiveness 43% compared with 33%, respectively). In conclusion, despite reports of widespread Plasmodium falciparum resistance to chloroquine on the African continent, malaria chemosuppression with the drug was found beneficial in reducing the risk of anaemia at delivery among Cameroonian women.
Factors associated with coverage in community‐directed treatment with ivermectin for onchocerciasis control in Oyo State, Nigeria
Authors: Brieger William R. , Otusanya Sakiru A. , Oke Ganiyu A. , Oshiname Frederick O. , Adeniyi Joshua D.
Published: March 2003

Community‐directed distribution with ivermectin (CDTI) has been adopted by the African Programme for Onchocerciasis Control (APOC) as its main strategy for achieving sustained high coverage in endemic communities. This article describes the coverage results achieved when CDTI was introduced in four local government areas of Oyo State, Nigeria. Using a household survey after the second distribution, researchers documented that 68.6% of the community overall received the drug, and as did 85.0% of those who were eligible (not pregnant, not sick and at least 5 years of age). Six factors were associated with having received ivermectin. Four were personal characteristics: being male, being at least 35 years of age, belonging to the Fulani ethnic minority, having taken the drug at a previous distribution. Two village characteristics were smaller size, as measured by number of houses, and use of the central place mode of distribution as opposed to house‐to‐house. In‐depth interviews with village leaders and volunteer community‐directed distributors (CDDs) and focus group discussions among villagers provided qualitative data to help interpret the findings. Women in many villages felt excluded from decision making. The concerns of migrant farm workers living in Yoruba farm settlements were not well understood by health staff or the majority population. The main factor associated with receiving the ivermectin was having received it before, and qualitative comments about side‐effects and beliefs about orthodox drugs indicated that issues of personal preferences, not addressed in a household coverage survey, need to be explored further. The findings can provide guidance in re‐orienting health workers to the importance of fostering participation and cohesion among all segments of the community, especially the inclusion of women and minority groups.
Malaria control by residual insecticide spraying in Chingola and Chililabombwe, Copperbelt Province, Zambia
Authors: Sharp Brian , Van Wyk Pieter , Sikasote Janet B. , Banda Paul , Kleinschmidt Immo
Published: March 2003

Malaria is endemic in the whole of Zambia and is the leading cause of morbidity and mortality. Prior to 1980, effective malaria control was achieved in the northern mining towns of Chingola and Chililabombwe by means of annual residual spraying programmes. In the 1970s, incidence rates wereaslow as 20/1000 p.a., but by 2000 had increased to 68/1000 p.a. in Chingola and to 158/1000p.a.in Chililabombwe. Konkola Copper Mines (KCM) initiated a malaria control programme in which all dwellings in the two towns and within a 10‐km radius were sprayed with either dichlorodiphenyltrichloroethane or a synthetic pyrethroid (Icon by ZENECA or Deltamethrin by Aventis). Houses were sprayed in November and December 2000, at the start of the peak transmission period. There was a statistically significant reduction in malaria incidence recorded at KCM health facilities in the two towns, representing a protective incidence rate ratio of 0.65 (95% CI 0.44, 0.97) when comparing the post‐spraying period with the corresponding period of the previous 2 years. This reduction followed a single round of house spraying during a year with higher rainfall than the preceding two and in an area where chloroquine was first‐line treatment. This house‐spraying programme is an example of private/public sector collaboration in malaria control.
Private pharmacies in Hanoi, Vietnam: a randomized trial of a 2‐year multi‐component intervention on knowledge and stated practice regarding ARI, STD and antibiotic/steroid requests
Authors: Chalker J. , Chuc N. T. K. , Falkenberg T. , Tomson G.
Published: March 2003

Objectives  To assess the effectiveness of a multi‐component intervention on knowledge and reported practice amongst staff working in private pharmacies in Hanoi regarding four conditions: urethral discharge [sexually transmitted diseases (STD)], acute respiratory infection (ARI), and non‐prescription requests for antibiotics and steroids.

Method  Randomized controlled trial with staff working in 22 matched pair intervention and control private pharmacies who were administered a semistructured questionnaire on the four conditions before and 4 months after the interventions. The interventions focused on the four conditions and were in sequence (i) regulations enforcement; (ii) face‐to‐face education and (iii) peer influence. Outcome measures were knowledge and reported change in practice for correct management of tracer conditions.

Results  The intervention/control‐pairs (22 after drop‐outs) were analysed pre‐ and post‐intervention using the Wilcoxon signed rank test. STD: More drug sellers stated they would ask about the health of the partner (P = 0.03) and more said they would advise condom use (P = 0.01) and partner notification (P = 0.04). ARI: More drug sellers stated they would ask questions regarding fever (P = 0.01), fewer would give antibiotics (P = 0.02) and more would give traditional medicines (P = 0.03). Antibiotics request: Fewer said they would sell a few capsules of cefalexin without a prescription (P = 0.02). Steroid requests: No statistical difference was seen in the numbers who said they would sell steroids without a prescription as numbers declined in both intervention and control groups (P = 0.12).

Conclusion  The three interventions in series over 17 months were effective in changing the knowledge and reported practice of drug sellers in Hanoi.