bluuebunny/crossref_metadata_2025 huggingface dataset:
Assessment of a national monitoring and evaluation system for rapid expansion of antiretroviral treatment in Malawi
Authors: Lowrance David , Filler Scott , Makombe Simon , Harries Anthony , Aberle‐Grasse John , Hochgesang Mindy , Libamba Edwin
Published: August 2010

Objectives  Monitoring and evaluation of national antiretroviral therapy (ART) programs is vital, but routine, standardized assessment of national ART patient monitoring systems has not been established. Malawi has undertaken an ambitious ART scale‐up effort, with over 57 000 patients initiated on ART by June 2006. We assessed the national ART monitoring and evaluation system in Malawi to ensure that the response to the epidemic was being monitored efficiently and effectively, and that data collected were useful.

Methods  The evaluation, performed in August 2005, generally followed the Updated Guidelines for Evaluating Public Health Surveillance Systems (CDC) and Interim Patient Monitoring Guidelines for HIV Care and ART (WHO). Assessment was conducted with qualitative methods, including twelve ART site visits, with standardized key informant interviews with ART clinic coordinators, clinical staff, and data managers, at each site. Meetings were also held with key governmental stakeholders, including Ministry of Health and National AIDS Commission.

Results  The national monitoring and evaluation system devised by the Ministry of Health HIV/AIDS Unit is successful in achieving its objectives, and facilitates important aspects of the national response to HIV. Several basic changes in the data collection tools and system would facilitate more effective long‐term assessment of the ART program and support improved patient care. As the number of ART sites and patients continues to expand, the current manual paper‐based system may be overwhelmed. Identification and implementation of a feasible electronic data system that would maintain and improve data quality and the efficiency of data recording and reporting and enhance patient care is a priority.

Conclusions  The assessment of ART monitoring and evaluation systems can optimize the effectiveness of national ART programs, and should be considered in other resource‐constrained countries rapidly scaling up ART.
Community‐randomized trial of lambdacyhalothrin‐treated hammock nets for malaria control in Yanomami communities in the Amazon region of Venezuela
Authors: Magris M. , Rubio‐Palis Y. , Alexander N. , Ruiz B. , Galván N. , Frias D. , Blanco M. , Lines J.
Published: August 2010

We conducted a community‐randomized controlled trial in an area of moderate malaria transmission in the Amazon region, southern Venezuela, home of the Yanomami indigenous ethnic group. The aim was to compare the malaria incidence rate in villages with lambdacyhalothrin‐treated hammock nets (ITHN) or with placebo‐treated hammock nets (PTHN). In both arms of the study, intensive surveillance for early case detection was maintained and prompt malaria treatment was administered. Baseline data were collected before the intervention and a population of around 924 Yanomami was followed for 2 years. Despite the recent introduction of nets in the Yanomami villages and the adverse natural conditions in the area, the nets were accepted enthusiastically by the study population, used conscientiously and looked after carefully. The malaria incidence rate per thousand person‐years at risk was 114.6 in the IHTN group and 186.8 in the PTHN group. The adjusted rate ratios indicated that ITHN prevent 56% [IRR: 0.44, 95% confidence interval (CI): 52–59%] of new malaria cases. ITHN reduced the prevalence of parasitaemia by 83% [relative risks (RR): 0.17, 95% CI: 47–100%], according to a cross‐sectional survey carried out during the high transmission season. The prevalence of splenomegaly and anaemia was too low to detect any possible reduction as a result of ITHN. The main conclusion of the present study is that ITHN can reduce malaria incidence in the area and it is the most feasible method for malaria control in a forested area where indigenous villages are scattered over a large territory. This is the first community‐level epidemiological trial to show that ITHN are highly effective against malaria transmitted by Anopheles darlingi.
Association between haemoglobin variants S and C and Mycobacterium ulcerans disease (Buruli ulcer): a case‐control study in Benin
Authors: Nackers Fabienne , Tonglet René , Slachmuylder Véronique , Johnson Roch C , Robert Annie , Zinsou Claude , Glynn Judith R , Portaels Françoise , Gala Jean‐Luc
Published: August 2010

Risk factors for Buruli ulcer (BU) are poorly understood. We conducted a case‐control study in southern Benin to investigate the association between haemoglobin variants S or C and BU, and particularly the association between haemoglobinopathies HbSS/SC and BU osteomyelitis. We compared the haemoglobin genotype of 179 patients with BU and 44 with BU osteomyelitis to that of 242 community controls. We found no evidence of an increased risk of BU according to the presence of haemoglobin variants S and/or C [odds ratio adjusted for sex, age, region of residence and ethnicity: 1.24 (95%CI: 0.80–1.93), P = 0.34]. Haemoglobin variants S and C are unlikely to play a role in the BU burden. However, haemoglobinopathies HbSS/SC were more frequent among BU osteomyelitis patients than among controls (6.8%vs. 1.0%, Fisher's exact P‐value = 0.045), which may suggest that those disorders facilitate growth of Mycobacterium ulcerans in the bone matrix.
Editorial: A view from beneath: Community Health Insurance in Africa
Authors: Ndiaye Pascal , Soors Werner , Criel Bart
Published: August 2010

This paper presents an overview of the development of Community Health Insurance (CHI) in sub‐Saharan Africa. In 2003, nearly 600 CHI initiatives were registered in a dozen countries of francophone West Africa alone. At regional level, coordination networks have been created in Africa with the aim to support and monitor the developments of this innovative model of health care financing. At national level, governments are preparing the necessary legal frameworks for CHI implementation. CHI is increasingly seen as a strategy to meet other development goals than only health. It constitutes an interesting model to finance health care, to pool financial resources in a fair way and to empower health care users. The CHI movement however still faces many challenges. The relevance of more professional inputs in the management of CHI and the need for careful subsidy of CHI schemes are increasingly recognized. There is also need to optimize the relationship of CHI with the other actors in the health system and to scale‐up CHI so as to gain in effectiveness and efficiency. The boom in the number of schemes in Africa during the last years is an indicator of the increasing attractiveness of the model. In practice however, enrolment rates per scheme remain low or are only slowly increasing. Context‐specific research is needed on the reasons that prevent people from enrolling in larger numbers. On that basis, relevant action to be taken locally can be identified.
Effect of costing methods on unit cost of hospital medical services
Authors: Riewpaiboon Arthorn , Malaroje Saranya , Kongsawatt Sukalaya
Published: August 2010

Objective  To explore the variance of unit costs of hospital medical services due to different costing methods employed in the analysis.

Methods  Retrospective and descriptive study at Kaengkhoi District Hospital, Saraburi Province, Thailand, in the fiscal year 2002. The process started with a calculation of unit costs of medical services as a base case. After that, the unit costs were re‐calculated based on various methods. Finally, the variations of the results obtained from various methods and the base case were computed and compared.

Results  The total annualized capital cost of buildings and capital items calculated by the accounting‐based approach (averaging the capital purchase prices throughout their useful life) was 13.02% lower than that calculated by the economic‐based approach (combination of depreciation cost and interest on undepreciated portion over the useful life). A change of discount rate from 3% to 6% results in a 4.76% increase of the hospital's total annualized capital cost. When the useful life of durable goods was changed from 5 to 10 years, the total annualized capital cost of the hospital decreased by 17.28% from that of the base case. Regarding alternative criteria of indirect cost allocation, unit cost of medical services changed by a range of −6.99% to +4.05%. We explored the effect on unit cost of medical services in one department. Various costing methods, including departmental allocation methods, ranged between −85% and +32% against those of the base case. Based on the variation analysis, the economic‐based approach was suitable for capital cost calculation. For the useful life of capital items, appropriate duration should be studied and standardized. Regarding allocation criteria, single‐output criteria might be more efficient than the combined‐output and complicated ones. For the departmental allocation methods, micro‐costing method was the most suitable method at the time of study.

Conclusions  These different costing methods should be standardized and developed as guidelines since they could affect implementation of the national health insurance scheme and health financing management.
Submicroscopic Plasmodium falciparum gametocyte carriage is common in an area of low and seasonal transmission in Tanzania
Authors: Shekalaghe Seif A. , Teun Bousema J. , Kunei Karaine K. , Lushino Paminus , Masokoto Alutu , Wolters Liselotte R. , Mwakalinga Steve , Mosha Frank W. , Sauerwein Robert W. , Drakeley Chris J.
Published: August 2010

Objective:  Recently developed molecular gametocyte detection techniques have shown that submicroscopic Plasmodium falciparum gametocytes are common in symptomatic patients and can infect mosquitoes. The relevance for the infectious reservoir of malaria in the general population remains unknown. In this study, we investigated submicroscopic asexual parasitaemia and gametocytaemia in inhabitants of an area of hypoendemic and seasonal malaria in Tanzania.

Methods:  Two cross‐sectional malariometric surveys were conducted in the dry and wet seasons of 2005 in villages in lower Moshi, Tanzania. Finger prick blood samples were taken to determine the prevalence of P. falciparum parasites by microscopy, rapid diagnostic test and real‐time nucleic acid sequence‐based amplification (QT‐NASBA).

Results:  2752 individuals participated in the surveys, of whom 1.9% (51/2721) had microscopically confirmed asexual parasites and 0.4% (10/2721) had gametocytes. In contrast, QT‐NASBA revealed that 32.5% (147/453) of the individuals harboured asexual parasites and 15.0% (68/453) had gametocytes. No age dependency or seasonality was observed in submicroscopic parasite carriage.

Discussion:  Molecular detection techniques reveal that carriage of submicroscopic asexual parasite and gametocyte densities is relatively common in this low transmission area. Submicroscopic gametocytaemia is likely to be responsible for maintaining malarial transmission in the study area.
Risk factors for treatment denial and loss to follow‐up in an antiretroviral treatment cohort in Kenya
Authors: Karcher Heiko , Omondi Austin , Odera John , Kunz Andrea , Harms Gundel
Published: August 2010

Objectives:  To evaluate risk factors for treatment denial and loss to follow‐up in an antiretroviral treatment (ART) cohort in a rural African setting in western Kenya.

Method:  Sociodemographic and clinical data of patients enrolled in an ART cohort were collected within 18 months of an observational longitudinal study and analysed by logistic and Cox regression models.

Results:  Of 159 patients with treatment indication 35 (22%) never started ART. Pregnancy [adjusted odds ratio (AOR) 3.60, 95% confidence interval (CI) 1.10–11.8; P = 0.035] and lower level of education (AOR 3.80, 95% CI 1.14–12.7; P = 0.03) were independently associated with treatment denial. The incidence of total loss of patients under therapy was 43.2 per 100 person years (pys) (mortality rate 19.2 per 100 pys plus drop out rate 24 per 100 pys). Older age [adjusted hazard ratio (AHR) 1.06, 95% CI 1.01–1.12; P = 0.04], AIDS before starting treatment (AHR 5.83, 95% CI 1.15–29.5; P = 0.03) and incomplete adherence to treatment (AHR 1.05, 95% CI 1.03–1.07; P < 0.001) were independent risk factors for death. Incomplete adherence also independently predicted drop out because of other reasons (AHR 1.06, 95% CI 1.04–1.09; P < 0.001).

Conclusion:  Pregnancy and lower level of education, higher age, advanced AIDS stage and impaired compliance to ART were identified as risk factors for treatment denial and death, respectively. Adequate counselling strategies for patients with these characteristics could help to improve adherence and outcome of treatment programmes in resource‐limited settings.
Community participation in Aedes aegypti control: a sociological perspective on five years of research in the health area ‘‘26 de Julio’’, Havana, Cuba
Authors: Pérez D. , Lefèvre P. , Sánchez L. , Sánchez L. M. , Boelaert M. , Kourí G. , Van der Stuyft P.
Published: August 2010

Objective:  Effective dengue prevention and Aedes aegypti control is a priority for the Cuban health authorities. To enhance effectiveness, strategies oriented towards a more active involvement of communities in control activities are being tested. This paper presents a sociological perspective on a pilot project conducted in the health area ‘‘26 de Julio’’ (La Havana) in 1999–2004.

Methods:  Instrumental case study based on an exhaustive content analysis of project documents and on observations of a sociologist.

Results:  The context and the pilot project are systematically described and an analysis of the evolution of the underlying concept of community participation is provided. The pilot experience was a dynamic process influenced by self‐reflection of the research team, feedback from research partners and changes in the epidemiological context (provoked by two dengue outbreaks during the study period). Community participation evolved from being just one component in Aedes aegypti control directed by the health staff into a learning and empowering process for the people. This change in the concept of participation was reflected in different aspects of the pilot project such as the learning and evaluation processes.

Conclusion:  Empirical evidence from 5 years of research in the particular context of Cuba showed that moves towards community‐based Aedes aegypti control are feasible. However, in order to be successful, community‐based dengue prevention should be a social learning process, implying a transfer of power and responsibilities to local people. Actions undertaken must be oriented towards creating local capabilities, strengthening existing structures and organizations and promoting group work for learning participation from participation itself.
Early growth of infants of HIV‐infected and uninfected Zambian women
Authors: Makasa M. , Kasonka L. , Chisenga M. , Sinkala M. , Chintu C. , Tomkins A. , Filteau S.
Published: August 2010

Objective  Parental HIV infection may affect even those exposed children who remain uninfected. We investigated early growth, an indicator of overall health, of infants born to Zambian mothers recruited for a study of breastfeeding and postpartum health.

Methods  HIV‐infected and uninfected women in Lusaka were followed regularly from late pregnancy to 16 weeks postpartum. Infant weight and length were measured at birth, 6 and 16 weeks. Infant HIV status could not be specifically determined in this cohort so comparisons were between all infants of HIV‐uninfected mothers (n = 184) and those infants of HIV‐infected mothers who were known to be alive and showed no clinical evidence of HIV infection at age 2–4 years (n = 85).

Results  Most infants were exclusively or predominantly breastfed until 16 weeks. At all time points infants of HIV‐infected mothers tended to have lower weight and length standard deviation (Z) scores (significant for weight at 6 weeks; P = 0.04), even after adjustment for their lower gestational age at birth, compared with infants of uninfected mothers. In multivariate analyses the major factors affecting weight or length at 6 or 16 weeks of age were birth weight or length, and maternal subclinical mastitis, primiparity and weight during pregnancy.

Conclusions  Early growth of infants of HIV‐infected mothers is less than that of uninfected mothers, in part associated with subclinical mastitis, and this effect cannot be overcome with intensive support of mothers to follow international recommendations regarding exclusive breastfeeding.
Active dispersal by wild Triatoma infestans in the Bolivian Andes
Authors: Richer Wilfrid , Kengne Pierre , Cortez Mirko Rojas , Perrineau Marie Mathilde , Cohuet Anna , Fontenille Didier , Noireau François
Published: August 2010

Triatoma infestans is the main vector of Chagas disease and target of control programmes in the Southern Cone countries. So far Bolivia is the only country where true T. infestans wild foci are documented. The dispersal ability for wild T. infestans was studied at microgeographical scale in Bolivian Andes, to assess the possibility for wild populations to actively recolonize insecticide‐treated villages. Nine microsatellite loci were used to detect the extent of gene flow between neighbouring collecting sites. The detection of restricted gene flow between close but distinct sylvatic sites supports the hypothesis that wild T. infestans does not disperse by flying at high altitude (2 750 m asl). It gradually disperses over small distances by walking within a ‘patch’ of continuous land cover. The genetic differentiation detected between sylvatic and domestic populations suggests a limited short‐term role of wild insects in the process of recolonization of insecticide‐treated houses in the Andes.
Characteristics of latrine promotion participants and non‐participants; inspection of latrines; and perceptions of household latrines in Northern Ghana
Authors: Rodgers Ann F. , Ajono Lydia A. , Gyapong John O. , Hagan Maria , Emerson Paul M.
Published: August 2010

Objectives To examine characteristics of household heads in two districts of Northern Ghana who had or had not participated in latrine promotion programmes; to inspect latrines; and to explore perceptions of latrine ownership.

Methods One hundred and twenty latrine owners and 120 non‐owners were randomly selected from all trachoma‐endemic villages and interviewed. Structured questionnaires assessed demographics, household data, wealth indicators, and perceptions of latrine ownership. Latrines were inspected.

Results Latrine owners and non‐owners were similar demographically, but owners were more likely to report any education or wealth indicators: any education OR = 2.0, (95% CI 1.2–3.4); large family size OR = 4.6 (2.6–8.2); children in school OR = 3.8 (1.3–10.5); and metal roof OR = 9.1 (2.0–40.0). All 120 latrine owners were participating in promotion programmes; no latrines had been self‐built without programme support. Inspection showed 73/120 (60.1%) latrines were completed and used. Of the uncompleted latrines 41/47 (87.2%) were more than a year old. Programme participants (regardless of whether they had a completed latrine) had contributed cash (mean $16.74 S.D.18.09) and 117/120 had provided labour and/or construction materials. The most frequently reported advantages of latrine ownership were convenience, cleanliness and health benefits; reported disadvantages were the need for maintenance and cleaning and bad odour.

Conclusions Current latrine promotion programmes do not reach all households equally. Joining a latrine programme was expensive and did not guarantee latrine ownership; this may cause people to lose trust in such programmes. Latrines were perceived to be useful, suggesting unmet demand. Reliable and inclusive programmes that provide low cost latrines may receive community support.
Factors affecting home delivery in rural Tanzania
Authors: Mrisho Mwifadhi , Schellenberg Joanna A. , Mushi Adiel K. , Obrist Brigit , Mshinda Hassan , Tanner Marcel , Schellenberg David
Published: August 2010

Background  Studies of factors affecting place of delivery have rarely considered the influence of gender roles and relations within the household. This study combines an understanding of gender issues relating to health and help‐seeking behaviour with epidemiological knowledge concerning place of delivery.

Methods  In‐depth interviews, focus group discussions and participant observation were used to explore determinants of home delivery in southern Tanzania. Quantitative data were collected in a cross‐sectional survey of 21 600 randomly chosen households.

Results  Issues of risk and vulnerability, such as lack of money, lack of transport, sudden onset of labour, short labour, staff attitudes, lack of privacy, tradition and cultures and the pattern of decision‐making power within the household were perceived as key determinants of the place of delivery. More than 9000 women were interviewed about their most recent delivery in the quantitative survey. There were substantial variations between ethnic groups with respect to place of delivery (P < 0.0001). Women who lived in male‐headed households were less likely to deliver in a health facility than women in female‐headed households (RR 0.86, 95% CI 0.80–0.91). Mothers with primary and higher education were more likely to deliver at a health facility (RR 1.30, 95% CI 1.23–1.38). Younger mothers and the least poor women were also more likely to deliver in a health facility compared with the older and the poorest women, respectively.

Conclusions  To address neonatal mortality, special attention should be paid to neonatal health in both maternal and child health programmes. The findings emphasize the need for a systematic approach to overcome health‐system constraints, community based programmes and scale‐up effective low‐cost interventions which are already available.
Combined use of an antigen and antibody detection enzyme‐linked immunosorbent assay for cysticercosis as tools in an epidemiological study of epilepsy in Burundi
Authors: Prado‐Jean A. , Kanobana K. , Druet‐Cabanac M. , Nsengyiumva G. , Dorny P. , Preux P. M. , Geerts S.
Published: August 2010

Objective To evaluate the benefits of the detection of both circulating antibodies (Ab) and antigens (Ag) for the diagnosis of cysticercosis in people with epilepsy. Neurocysticercosis is a cause of neurological diseases world‐wide, especially epilepsy. The clinical symptoms of neurocysticercosis are non‐specific and diagnosis is often difficult.

Methods Serum samples were collected from subjects in a matched case–control study for epilepsy in the Kiremba area, Burundi, between March and April 2001 (epileptic cases = 303; controls without epilepsy = 606). The enzyme‐linked immunosorbent assay (ELISA) was used for the detection of antibodies (Ab‐ELISA) and circulating Ag (Ag‐ELISA).

Results The Ab‐ELISA revealed 58.7% positivity in epilepsy cases and 31.4% in healthy controls; and Ag‐ELISA revealed 38.3% positivity in epilepsy cases and 20.0% in controls. The matched odds ratios were 3.6 (95%CI: 2.5–4.9) for Ab‐ELISA, and 2.9 (95%CI: 2.1–4.3) for Ag‐ELISA.

Conclusion Both Ag‐ and Ab‐ELISA detected a significantly higher number of seropositives among people with epilepsy than among controls. The risk of epilepsy was high in cases with a positive Ag‐ELISA, although less important than in cases with positivity for Ab‐ELISA. Dead or degenerating cysticerci appear to be more frequently associated with epilepsy than living cysts. The high number of people with circulating Ag ofTaenia soliumsuggests that the study area is a focus of active transmission of the parasite.
Insular pathways to health care in the city: a multilevel analysis of access to hospital care in urban Kerala, India
Authors: Levesque Jean‐Frédéric , Haddad Slim , Narayana Delampady , Fournier Pierre
Published: August 2010

Objectives  To identify individual and urban unit characteristics associated with access to inpatient care in public and private sectors in urban Kerala, and to discuss policy implications of inequalities in access.

Methods  We analysed the NSSO survey (1995–1996) for urban Kerala with regard to source and trajectories of hospitalization. Multinomial multilevel regression models were built for 695 cases nested in 24 urban units.

Results  Private sector accounts for 62% of hospitalizations. Only 31% of hospitalizations are in free wards and 20% of public hospitalizations involve payment. Hospitalization pathways suggest a segmentation of public and private health markets. Members of poor and casual worker households have lower propensity of hospitalization in paying public wards or private hospitals. There were important variations between cities, with higher odds of private hospitalization in towns with fewer hospital beds overall and in districts with high private–public bed ratios. Cities from districts with better economic indicators and dominance of private services have higher proportion of private hospitalizations.

Conclusions  The private sector is the predominant source of inpatient care in urban Kerala. The public sector has an important role in providing access to care for the poor. Investing in the quality of public services is essential to ensure equity in access.
Effect of a large dam on malaria risk: the Koka reservoir in Ethiopia
Authors: Lautze Jonathan , McCartney Matthew , Kirshen Paul , Olana Dereje , Jayasinghe Gayathree , Spielman Andrew
Published: August 2010

Objective  To determine whether the Koka water reservoir in the Rift Valley of Ethiopia contributes to the malaria burden in its vicinity.

Methods  Frequency of malaria diagnosis in fever clinics was correlated with distance of residence from the margin of the Koka reservoir. Annual as well as seasonal malaria case rates were determined in cohorts residing < 3, 3–6 and 6–9 km from the reservoir. Plasmodium falciparum risk was compared with that of Plasmodium vivax. A multiple variable regression model was used to explore associations between malaria case rates and proximity to the reservoir, controlling for other suspected influences on malaria transmission.

Results  Malaria case rates among people living within 3 km of the reservoir are about 1.5 times as great as for those living between 3 and 6 km from the reservoir and 2.3 times as great for those living 6–9 km from the reservoir. Proximity to the reservoir is associated with greater malaria case rates in periods of more intense transmission. Plasmodium falciparum is most prevalent in communities located close to the reservoir and P. vivax in more distant villages. The presence of the reservoir, coupled with inter‐annual climatic variations, explains more than half of the region's variability in malaria case rates.

Conclusion  Large water impoundments are likely to exacerbate malaria transmission in malaria‐endemic parts of sub‐Saharan Africa.
A serological study of Cryptosporidium transmission in a periurban area of a Brazilian Northeastern city
Authors: Teixeira M. C. A. , Barreto M. L. , Melo C. , Silva L. R. , Moraes L. R. S. , Alcântara‐Neves N. M.
Published: August 2010

Objectives  To study the prevalence of Cryptosporidium infection by measuring the levels of anti‐Cryptosporidium IgG antibodies among people inhabiting three neighbourhoods of a periurban area of Salvador, Northeast of Brazil; and to investigate the effects of environmental sanitation measures, hygienic habits and household water supply, storage and handling on the frequency of these antibodies in sera of the studied population.

Methods  Cryptosporidium inter‐household transmission was studied by comparing the frequency of anti‐Cryptosporidium IgG antibodies among people inhabiting areas with or without different environmental sanitation measures and intra‐household transmission by comparing the presence of these antibodies in families with or without cases of diarrhoea, associated with the presence of Cryptosporidium oocysts in their stools. Children or family members with diarrhoeal episodes were evaluated parasitologically for Cryptosporidium infection by testing stool specimens with the Ritchie‐modified formol‐ether concentration and the acid‐fast staining methods. All groups were serologically evaluated for parasite exposure by an indirect enzyme‐linked immunosorbent assay.

Results  A statistically significant difference was detected in the prevalence of Cryptosporidium infection between area 1 which had no environmental sanitation measures and area 3 which had improved environmental sanitation measures (P = 0.044). Most of the hygienic habits investigated did not correlate with the presence of anti‐Cryptosporidium antibody in sera of the population studied. However, positive associations were found between both poor household water supply (OD = 0.17; 90% CI = 0.09–0.32; P = 0.0001) and drinking unboiled/unfiltered water (OD = 0.40; 90% CI = 0.24–0.67; P = 0.0002) with high levels of anti‐Cryptosporidium antibodies in sera.

Conclusions  These data suggest that although uncorrected household water supply, storage and handling play an important role on Cryptosporidium transmission in periurban areas of developing country cities, like Salvador, Brazil, inadequate environmental conditions may also contribute to the spread of this parasite.
Immune responses after single‐dose sulphadoxine–pyrimethamine indicate underestimation of protective efficacy of intermittent preventive treatment in infants
Authors: Schreiber Nadine , Kobbe Robin , Adjei Samuel , Adjei Ohene , Klinkert Mo‐Quen , May Jürgen
Published: August 2010

Objective  To assess how intermittent preventive treatment in infants (IPTi) with sulphadoxine–pyrimethamine (SP) affects Immunoglobulin (IgG) immune responses against Plasmodium falciparum in infants from rural Ghana.

Methods  Randomized, placebo‐controlled and double‐blinded clinical trial with participants randomized in blocks of 10 to receive either 250 mg sulphadoxine/2.5 mg pyrimethamine or placebo at the age of 3 (IPTi‐1), 9 (IPTi‐2) and 15 (IPTi‐3) months and followed‐up for 21 months. (i) Anti‐P. falciparum IgG levels were measured in 180 children at the age of 9 months. (ii) Longitudinal study of the relationship between IgG levels and P. falciparum infections and/or clinical malaria in 17 naive children until they reached the age of 2 years.

Results  IgG antibody levels against crude P. falciparum lysate were dependent on the frequency of preceding infections and significantly lower in children treated with SP.

Conclusion  Placebo‐treated children had an indifferentially higher incidence of P. falciparum infections than clinically observed, which implicates an underestimation of the protective efficacy of IPTi. IgG profiles in 17 children followed up until the age of 2 years provided no evidence for impaired immune responses after a single dose of SP within the framework of IPTi.
Scaling up clinical audits of obstetric cases in Morocco
Authors: Muffler Nathalie , Trabelssi Mohammed El Hassane , De Brouwere Vincent
Published: August 2010

Objectives  To follow‐up on the process of implementing clinical audits of obstetric cases in Morocco as recommended by the Ministry of Health (2001) and to explore both the barriers to and factors facilitating sustainability of clinical audits.

Method  Questionnaires were sent to heads of all 61 Moroccan health provinces (response rate 69%) to ask if their maternity units had implemented clinical audits between 1998 and 2003. Twenty of the 42 public maternities which responded had performed so. Thirteen of these 20 hospitals were visited and 56 semi‐structured interviews held with administrators and health professionals. Locally available audit registers were consulted to triangulate data.

Results  Eleven of 13 maternities visited conducted an average of 6.8 case reviews per year with a total average of 16.7 cases per hospital (range 4–38). Although interviewees confirmed that audits resulted in better quality of care, five hospitals had ceased performing audits altogether and the remainder did them less frequently, because of audit teams encountering staff resistance, insufficient understanding of the audit concept, difficulties in organizing sessions, and lack of administrative support. Insufficient training and external assistance hindered the implementation of complete audit loops, resulting in a loss of staff motivation.

Conclusion  Implementing clinical audits as a means to improving quality of care requires a significant investment in training and various kinds of on‐going assistance – factors which decision‐makers should be aware of.
Detection of mutant P2 adenosine transporter (TbAT1) gene in Trypanosoma brucei gambiense isolates from northwest Uganda using allele‐specific polymerase chain reaction
Authors: Nerima Barbara , Matovu Enock , Lubega George W. , Enyaru John C. K.
Published: August 2010

Objective  To assess the application of allele‐specific PCR (AS‐PCR) as a fast, cheap and reliable method for detecting mutant TbAT1 associated with melarsoprol relapse in Trypanosoma brucei gambiense isolates from northwest Uganda.

Methods  A total of 105 trypanosome isolates were analysed using SfaN1 restriction fragment length polymorphism (RFLP) and AS‐PCR, the former used as the gold standard. Sensitivity, specificity, positive and negative predictive values of AS‐PCR as well as agreement between the tests were determined.

Results  Eleven trypanosome isolates had mutant TbAT1 while 94 exhibited the wild‐type TbAT1 genes. There was a highly significant agreement between SfaN1 RFLP and AS‐PCR with kappa and intra‐class correlation values of 1.0. The sensitivity and specificity of AS‐PCR were both 100%, while the positive and negative predictive values were found to be equal to 1.0. Cost and time analyses were performed and AS‐PCR was 4.3 times cheaper than SfaN1 RFLP, in addition to the less time required for its execution.

Conclusion  AS‐PCR should be the test of choice for screening for mutant TbAT1 in the ever‐increasing numbers of field trypanosome isolates.
Influence of larval density or food variation on the geometry of the wing of Aedes (Stegomyia) aegypti
Authors: Jirakanjanakit N. , Leemingsawat S. , Thongrungkiat S. , Apiwathnasorn C. , Singhaniyom S. , Bellec C. , Dujardin J. P.
Published: August 2010

Background and Method  Variation in wing length among natural populations of Aedes (Stegomyia) aegypti (L.) (Diptera: Culicidae) is associated with different vectorial capacities. Geometric morphometrics allowed us to use a more powerful estimator of wing size (‘centroid size’), as well as to visualize the variation of wing shape, to describe the effects of density or food variation at larval stage on 20 anatomical landmarks of the wing of A. aegypti.

Results  Almost perfect correlations between (centroid) size and larval density or size and larval food were observed in both sexes: a negative correlation with increasing density and a positive one with increasing amount of food. The allometric component of shape change was always highly significant, with stronger contribution of size to shape under food effects. Within each experiment, either food or density effects, and excluding extreme conditions, allometric trends were similar among replicates and sexes. However, they differed between the two experiments, suggesting different axes of wing growth.

Conclusion  Aedes aegypti size is highly sensible to food concentration or population density acting at larval stages. As larger individuals could be better vectors, and because of the stronger effect of food concentration on size, vector control activities should pay more attention in eliminating containers with rich organic matter. Furthermore, as a simple reduction in larval density could significantly increase the size of the survivors, turning them into potentially better vectors, the control activities should try to obtain a complete elimination of the domestic populations.
Healthcare‐seeking behaviour and use of traditional healers after snakebite in Hlabisa sub‐district, KwaZulu Natal
Authors: Sloan Derek J. , Dedicoat Martin J. , Lalloo David G.
Published: August 2010

Objetive  To quantify snakebite incidence in Hlabisa sub‐district and examine healthcare seeking behaviour, focussing on the use of traditional healers and medications.

Methods  Snakebite incidence was calculated by retrospective register review at Hlabisa Hospital for the period 2000–2005 and at associated primary health care clinics for 2005. Fifty consecutive in‐patient snakebite victims were interviewed. Treatment‐seeking pathways, bite‐to‐admission times and factors associated with delay or use of traditional therapy were analysed.

Results  The annual hospital snakebite incidence was 53 bites per 100 000 population. In 2005, combined hospital and community incidence was 58 per 100 000. Eighty per cent of admitted snakebite victims used traditional medicine and 62.5% of these consulted a traditional health practitioner (THP). The median time until admission was 7 h 15 min (interquartile range: 4–14.25 h). The median time until THP consultation was 15 min (interquartile range 5–50 min). THP consultation was associated with bite‐to‐hospital admission delays of more than 6 h [relative risk: 1.82, 95% confidence interval (CI): 1.09–3.03, P = 0.0016). Non‐statistically significant trends towards THP use were observed if hospital access was poor or if patients were younger than 9 years.
Duration and associated factors of patient delay during tuberculosis screening in rural Cameroon
Authors: Cambanis Alexis , Ramsay Andy , Yassin Mohammed A. , Cuevas Luis E.
Published: August 2010

Objectives  (i) To determine patient delay – the time from the onset of symptoms to presentation at a health facility – and its causes in patients undergoing sputum smear examination in Cameroon; and (ii) to compare the results with those of a previous study in Ethiopia.

Methods  A cross‐sectional study of 243 consecutive patients using a structured questionnaire.

Results  Median (interquartile range) patient delay in Cameroon was 2.0 (1–4) weeks, shorter than the 4.3 (2–13) week delay in Ethiopia. Significantly fewer patients delayed more than 1, 2 and 3 months in Cameroon than in Ethiopia (P < 0.001). Delays in Cameroon were significantly associated with being the main income earner, the belief that TB is stigmatizing, and the use of traditional medicine – the latter being the only factor significant in both studies.

Conclusion  Engaging traditional healers in TB control programs and reducing stigma through education could help to reduce patient delays, accelerate diagnosis, improve clinical outcomes and reduce disease transmission. These results, when placed in context of national human development indices, suggest that economic development, investment in health care and literacy may all be involved in improving access to TB services in sub‐Saharan Africa.
Do exemptions from user fees mean free access to health services? A case study from a rural Cambodian hospital
Authors: Jacobs Bart , Price Neil Lewis , Oeun Sam
Published: August 2010

Objectives  To assess the effects of a user fee scheme, and related fee exemption system, on the health care seeking behaviour, the out‐of‐pocket expenditure and the coping mechanisms of fee‐exempted patients (FEP) at Kirivong Referral Hospital in Cambodia.

Methods  A pre‐coded structured questionnaire administered to pre‐identified FEP and fee‐paying patients (PP) of the same age group and with the same medical condition, who were paired for comparison. Survey data were supplemented with unstructured in‐depth interviews.

Results  199 pairs of patients were compared. The timing of the start of health care seeking was equal for FEP and PP, although significantly more FEP consulted first‐line public health providers than PP. Only a third of interviewees who visited public health facilities prior to hospitalization were referred. The direct costs of health care seeking were US$4.3 for FEP and US$15.3 for PP. FEP borrowed at a ratio of 3.4:1 to direct costs incurred, vs. 0.74:1 for PP. Hospitalization rates were 32.5/1000 population and 18.4/1000 population for FEP and PP, respectively.

Conclusions  User fee exemption schemes can be pro‐poor provided that the fee exemption system is based on effective pre‐identification of intended beneficiaries, that these beneficiaries are informed of their right to free health care and that health care providers are reimbursed for the revenue foregone due to exemptions. To be effective in the Cambodian context, exemption schemes need to be underpinned by a range of additional interventions.
Short communication: Impact of climate variability on the incidence of dengue in Mexico
Authors: Hurtado‐Díaz M. , Riojas‐Rodríguez H. , Rothenberg S. J. , Gomez‐Dantés H. , Cifuentes E.
Published: August 2010

We evaluated the impact of weather variables and climatic indicators associated with the incidence of dengue in two municipalities of the state of Veracruz, Mexico, from 1995 to 2003. A retrospective ecological study was conducted, using time‐series analysis in which we compiled the weekly reported cases of dengue and the weather and climatic parameters: temperature, rainfall and sea‐surface temperature (SST), the latter as an El Niño Southern Oscillation indicator. We statistically evaluated the data with autogressive models. The models’ predictive abilities were evaluated using data collected from 1995 to 2002 and were validated with those observed for 2003. Each degree Centigrade increase in SST was followed by an increase in the number of dengue cases: 46% in San Andrés Tuxtla (P = 0.001) 16 weeks later and 42% in Veracruz 20 weeks later (P = 0.002). Increases in weekly minimum temperature and rainfall were also significant factors in the increase in the reported cases of dengue. We recommend future studies using the same method, involving larger populations with different geographic location, climate and weather. We also recommend strengthening environmental, health and entomological surveillance systems to improve preparedness and emergency responses.
Reducing microbial contamination on wastewater‐irrigated lettuce by cessation of irrigation before harvesting
Authors: Keraita Bernard , Konradsen Flemming , Drechsel Pay , Abaidoo Robert C.
Published: August 2010

Objective  To assess the effectiveness of cessation of irrigation before harvesting in reducing microbial contamination of lettuce irrigated with wastewater in urban vegetable farming in Ghana.

Methods  Assessment was done under actual field conditions with urban vegetable farmers in Ghana. Trials were arranged in completely randomized block design and done both in the dry and wet seasons. Seven hundred and twenty‐six lettuce samples and 36 water samples were analysed for thermotolerant coliforms and helminth eggs.

Results  On average, 0.65 log units for indicator thermotolerant coliforms and 0.4 helminth eggs per 100 g of lettuce were removed on each non‐irrigated day from lettuce in the dry season. This corresponded to a daily loss of 1.4 tonnes / ha of fresh weight of lettuce. As an input for exposure analysis to make risk estimates, the decay coefficient, k, for thermotolerant coliforms was 0.66 / day for the wet season and 1.49 / day for the dry season.

Conclusion  In combination with other measures for improving water quality, the measure can significantly reduce faecal contamination of lettuce during the dry season. However, it is not suitable for the wet season due to unfavourable conditions for pathogen die‐off and re‐contamination by splashes from contaminated soils. The results provide a good basis for risk assessments and for devising more appropriate measures for risk reduction, especially in sub‐Saharan Africa.
Dermatitis among farmers engaged in peri‐urban aquatic food production in Hanoi, Vietnam
Authors: Anh Vuong Tuan , Van Der Hoek Wim , Ersbøll Annette Kjær , Thuong Nguyen Van , Tuan Nguyen Dang , Cam Phung Dac , Dalsgaard Anders
Published: August 2010

Objective  To assess whether exposure to wastewater is a risk factor for dermatitis (eczema) among farmers engaged in peri‐urban aquatic food production in Hanoi, Vietnam.

Methods  A cross‐sectional study with two follow‐ups was conducted from April to December 2005 in two peri‐urban communes in Hanoi, one using wastewater and another using river, rain and well water for aquatic food production. In each commune, 100 households were randomly selected and adult household members engaged in farming field work were interviewed in three surveys. Farmers who reported skin problems at the time of interviews were examined and treated by a dermatologist. Data were analysed for one farmer per household.

Results  The overall prevalence of dermatitis from 592 interviews was 6.3%. The commune which used wastewater had a much higher overall prevalence of dermatitis (10.4%) than the commune that did not (2.1%; P‐value < 0.001). Multivariable logistic regression analyses showed that occupational wastewater contact was an important risk factor for dermatitis (odds ratio [OR] 3.0; 95% confidence interval [CI] 1.1–7.7). Duration of daily wastewater contact was not significantly associated with dermatitis. Aquaculture work in the wet season carried an increased risk of dermatitis in both communes (OR 2.8; 95% CI 1.02–7.6). The use of personal protective measures during field work and washing hands and feet after work did not reduce the risk for dermatitis. However, observations showed that these practices were applied in such a way that they were unlikely to provide effective protection against wastewater contact.

Conclusion  Contact with wastewater is an important risk factor for dermatitis among farmers engaged in wastewater‐fed peri‐urban aquatic food production. Additional studies should test preventive and mitigating measures such as improved personal protection and hygiene.