bluuebunny/crossref_metadata_2025 huggingface dataset:
Injury control in Africa: getting governments to do more
Authors: Forjuoh Samuel N. , Zwi Anthony B. , Mock Charles N.
Published: March 2003

Despite increasing recognition of injury as a major public health problem worldwide, it has received limited attention and resources. This lack of attention is most notable in low‐income countries. As part of efforts to develop coordinated injury control activities in Africa, a round table session was held at the Third International Conference on Injury Prevention and Control in Melbourne, Australia. The aims of the forum were to provide injury control researchers from Africa the opportunity to come together and reflect on issues of injury control in Africa, to deliberate on strategies of getting African governments to show more interest in injury control, and to solicit more assistance from the international donor community. Participants from Ghana, Kenya, South Africa and Zimbabwe presented the magnitude of the injury burden in their respective countries, reflected on current research efforts and highlighted the preventive efforts being undertaken. The forum made many recommendations including several regarding specific actions required of African governments, individual researchers and donor agencies.
Efficacy and safety of CGP 56697 (artemether and benflumetol) compared with chloroquine to treat acute falciparum malaria in Tanzanian children aged 1–5 years
Authors: Hatz Christoph , Abdulla Salim , Mull Robert , Schellenberg David , Schellenberg David , Gathmann Insa , Kibatala Pascience , Beck Hans‐Peter , Tanner Marcel , Royce Catherine
Published: March 2003

A randomized, open trial involving 260 Tanzanian children, aged 1–5 years, with acute Plasmodium falciparum malaria was conducted to evaluate the efficacy of the combination antimalarial CGP 56697 (artemether and benflumetol), and to compare it with chloroquine, the standard drug used for malaria treatment in the Kilombero area. Children who had received rescue medication within the first 48 h or had a negative slide at the same time were excluded. Seven‐day parasitological cure rates were 94% (95% CI 88–97.5) for CGP 56697 and 35.4% (95% CI 25.9–45.8) for chloroquine. Using the same definition, the 14‐day parasitological cure rates were 86.4% (95% CI 78.5–92.2) for CGP 56697 and 10.3% (95% CI 5.1–18.1) for chloroquine. Gametocytes were more effectively suppressed by CGP 56697 than by chloroquine. There were no major adverse events with either drug. CGP 56697 is highly efficacious against P. falciparum in this area of Tanzania. The study contributes to the discussion on treatment strategies, particularly whether chloroquine may still fulfil its role as first‐line drug in an area of high malaria transmission and very high levels of chloroquine resistance.
The impact of vitamin A supplementation given during a pneumonia episode on the subsequent morbidity of children
Authors: Nacul Luis C. , Arthur Paul , Kirkwood Betty R. , Morris Saul S. , Cameiro Araci C. , Benjamin Adriana F.
Published: March 2003

objective To evaluate the impact of large‐dose vitamin A supplementation given to infants > 6 months old (200 000 IU) and to preschool children aged 1–4 years (400 000 IU) during a pneumonia episode, on their subsequent morbidity and severe morbidity.

method In a randomized, double‐blind, placebo controlled trial, the children were followed‐up with 2‐weekly visits at home for 16 weeks, with the first visit 2 weeks after treatment for pneumonia was initiated. The field workers asked about the presence of morbidity on the day of the visit and in the previous two weeks and about the occurrence and number of clinic attendances and hospital admissions since the last visit. They also measured the patients' respiratory rate and temperature and assessed the children for the presence of cyanosis, chest indrawing and wheezing.

results Except for the prevalence of diet refusal which was higher in the vitamin A group, no differences between the study groups were observed, either in the prevalence of morbidity or in the incidence of clinic attendances and hospital admissions.

conclusion No evidence was found for a beneficial effect of vitamin A given during acute pneumonia on the subsequent morbidity and severe morbidity of children in a population with marginal vitamin A deficiency.
Potential implications of the integrated management of childhood illness (IMCI) for hospital referral and pharmaceutical usage in western Uganda
Authors: Kolstad P. Randall , Burnham Gilbert , Kalter Henry D. , Kenya‐Mugisha Nathan , Black Robert E.
Published: March 2003

Summary The integrated management of childhood illness approach (IMCI) is currently being implemented by a number of countries worldwide. This is the second report from a study in western Uganda comparing the assessment and classification of disease by medical assistants using the IMCI algorithm with that of hospital‐based general medical officers, who used their clinical judgement to assess and provide treatment. Treatment prescribed by the hospital medical officers was compared to that indicated by IMCI disease classifications. The study population comprised 1226 children aged 2–59 months. Medical assistants had some difficulty in completing the IMCI assessment, leading to incorrect classification of findings in 138 of 1086 completed forms (13%). If their classifications had been used to decide on hospital referral, 37 children who met IMCI criteria for referral would have been sent home. Consultations took on average 7.2 min, longer than usual for several African countries. Use of the IMCI guidelines would have referred 16.2% of children to hospital, compared with 22% referred by the medical officers. Use of IMCI could have reduced the cost of medication to US$0.17 per child compared to the treatment cost of US$0.82 as prescribed by medical officers. Medical officers prescribed both a greater number and a greater variety of drugs than indicated by the IMCI algorithm. Compared to the present management of sick children by medical officers at Kabarole district hospital, using the IMCI algorithm would bring major changes in pharmaceutical use and referral practices. However, there is concern about the difficulty medical assistants had in using it, and the potential for longer consultation times.
Measles vaccination before nine months
Authors: George Kuryan , Joseph Abraham , Muliyil Jayaprakash , Abraham Sulochana , Bhattacharji Sara , John
Published: March 2003

Summary objective  To measure the protective effect of measles vaccine administered before 9 months of age and compare overall mortality of children vaccinated at 6–8 months and at 9–11 months.nsp;Non‐concurrent cohort study involving all 13 134 children born between 16 January 1986 and 31st December 1991 in Kaniyambadi block near Vellore who had not left the area by six months of age. Main outcome measures were risk of disease and death among the under‐five‐year‐olds according to age at measles immunization.ensp;Unimmunized children had a higher risk of developing measles compared to the immunized(P < 0.05). There was no significant difference in risk of measles among those vaccinated prior to and after nine months of age. Unvaccinated children were at significantly higher risk of death than vaccinated children (P < 0.001). There was no difference in risk of death between infants vaccinated between 6 and 8 months and those vaccinated between 9 and 11 months. There was no difference in the risk of death between boys and girls vaccinated between 6 and 8 months with standard‐titre Edmonston‐Zagreb vaccine.p; Administration of standard‐titre Edmonston‐Zagreb measles vaccine at 6–8 months is an effective and safe preventive measure for measles, especially where the age‐specific attack rate for childrenis high.
Financially independent primary health care drug supply system in Cameroun
Authors: Von Massow Friedrich , Korte Rolf , Cheka Cosmas , Kuper Meinolf , Tata Helen , Schmidt‐Ehry Bergis
Published: March 2003

The drug supply system in the North‐west Province of Cameroun differs from ‘simple’ health financing projects in three important respects. Firstly, the system does not promote drug sales for cofinancing purposes but aims at supporting the prescribers to provide better medical care, and patients’ access to the most essential drugs at fair prices. Secondly, the project guarantees equal prices and services throughout the Province regardless of distance from the central warehouse and sales at a given location. Thirdly, along with the revolving fund‐financed drug supply system, a community‐based legal framework has been established. Built‐in management alert mechanisms helped the project resist common causes of collapse such as uneconomic behaviour and political interference. The drug supply system has gained full independence from subsidies and external authorities. Its strong community participation promotes good governance.
The effects of ivermectin on onchocercal skin disease and severe itching: results of a multicentre trial
Authors: Brieger  , Awedoba  , Eneanya  , Hagan  , Ogbuagu  , Okello  , Ososanya  , Ovuga  , Noma  , Kale  , Burnham  , Remme
Published: March 2003

objective To determine the effects of ivermectin in annual, 3‐monthly and 6‐monthly doses on onchocercal skin disease (OSD) and severe itching.

method A multicentre, double‐blind placebo controlled trial was conducted among 4072 residents of rural communities in Ghana, Nigeria and Uganda. Baseline clinical examination categorized reactive skin lesions as acute papular onchodermatitis, chronic papular onchodermatitis and lichenified onchodermatitis. Presence and severity of itching was determined by open‐ended and probing questions. Clinical examination and interview took place at baseline and each of 5 subsequent 3‐monthly follow‐up visits.

results While prevalence and severity of reactive lesions decreased for all 4 arms, those receiving ivermectin maintained a greater decrease in prevalence and severity over time. The difference between ivermectin and placebo groups was significant for prevalence at 9 months and for severity at 3 months. Differences between placebo and ivermectin groups were much more pronounced for itching. From 6 months onward, the prevalence of severe itching was reduced by 40–50% among those receiving ivermectin compared to the trend in the placebo group.

conclusion This is an important effect on disease burden as severe itching is for the affected people the most troubling complication of onchocerciasis. The difference among regimens was not significant, and the recommended regimen of annual treatment for the control of ocular onchocerciasis appears also the most appropriate for onchocerciasis control in areas where the skin manifestations predominate. The final determination of the effect on skin lesions requires a longer period of study.
Treatment costs and loss of work time to individuals with chronic lymphatic filariasis in rural communities in south India
Authors: Ramaiah K. D. , Guyatt Helen , Ramu K. , Vanamail P. , Pani S. P. , Das P. K.
Published: March 2003

Summary This year‐round case‐control study investigated treatment costs and work time loss to people affected by chronic lymphatic filariasis in two rural communities in south India. About three‐quarters of the patients sought treatment for filariasis at least once and 52% of them paid for treatment, incurring a mean annual expenditure of Rs. 72 (US $ 2.1; range Rs. 0–1360 (US $ 39.0)). Doctor's fees and medicines constituted 57% and 23% of treatment costs. The proportion of people seeking treatment was smaller and treatment costs constituted a higher proportion of household income in lower income groups. Most patients did not leave work, but spent only 4.36 ± 3.41 h per day on economic activity compared to 5.25 ± 3.52 h worked by controls; the mean difference of 0.89 ± 4.20 h per day was highly significant (P < 0.01). This loss of work time is perpetual, as chronic disease manifestations are mostly irreversible. An estimated 8% of potential male labour input is lost due to the disease. Regression analyses revealed that lymphatic filariasis has a significant effect on work time allotted to economic activity (P < 0.05) but not on absenteeism from work (P > 0.05). Female patients spent 0.31 ± 1.42 h less on domestic activity compared to their matched controls (P < 0.05). The results clearly show that the chronic form of lymphatic filariasis inflicts a considerable economic burden on affected individuals.
Control of malaria vectors: cost analysis in a province of northern Vietnam
Authors: Verlé P. , Lieu T. T. T. , Kongs A. , Van der Stuyft P. , Coosemans M.
Published: March 2003

Summary The cost of permethrin‐treated bednets (50% EC; 0.2 g/m2, 2 rounds per year) was compared to the cost of residual spraying with lambdacyhalothrin 10% WP (0.03 g/m2, once yearly) in Hoa Binh, a mountainous province in northern Vietnam. Calculations of the amounts of insecticides needed were based on national guidelines, on data from a cross‐sectional survey and on district activity reports. The actual cost of insecticide required per person per year was lower for impregnation (US$ 0.26) than for spraying (US$ 0.36), but the difference was smaller than expected. The total cost for impregnated bednets per person per year amounted to US$ 0.90 compared to US$ 0.47 for spraying. The determining factor was the cost of the net, amounting to US$ 0.58 per person per year, assuming a 5‐year life of the net. Other material (excluding nets), labour and transport combined, accounted for only 17% of the impregnation cost and 23% of spraying expenses. However, for the National Malaria Control Programme of Vietnam, the cost per person per year for impregnated bednets amounted to US$ 0.32 only, because the vast majority of nets are bought by the population. For spraying, the programme had to bear the entire cost.
Epidemic of self‐poisoning with seeds of the yellow oleander tree (Thevetia peruviana) in northern Sri Lanka
Authors: Eddleston M. , Ariaratnam C. A. , Meyer W. P. , Perera G. , Kularatne A. M. , Attapattu S. , Sheriff M. H. R. , Warrell D. A.
Published: March 2003

Summary Deliberate self‐harm is an important problem in the developing world. Ingestion of yellow oleander seeds (Thevetia peruviana) has recently become a popular method of self‐harm in northern Sri Lanka – there are now thousands of cases each year. These seeds contain cardiac glycosides that cause vomiting, dizziness, and cardiac dysrhythmias such as conduction block affecting the sinus and AV nodes. This paper reports a study of the condition's mortality and morbidity conducted in 1995 in Anuradhapura General Hospital, a secondary referral centre serving 750 000 people in Sri Lanka's north central province. 415 cases were admitted to the hospital during 11 months; 61% were women and 46% were less than 21 years old. A prospective study of 79 patients showed that 6% died soon after admission. 43% presented with marked cardiac dysrhythmias which necessitated their transfer to the coronary care unit in Colombo for prophylactic temporary cardiac pacing. The reasons for the acts of self‐harm were often relatively trivial, particularly in children; most denied that they wished to die. Unfortunately, the case fatality rate for oleander poisoning in Sri Lanka is at least 10%. This epidemic is not only causing many unnecessary deaths, it is also putting immense stress on the already stretched Sri Lankan health services. There is an urgent need for an intervention which could be used in rural hospitals, thus preventing the hazardous and expensive emergency transfer of patients to the capital.
Developing strategies to control schistosomiasis morbidity in nonenrolled school‐age children: experience from Egypt
Authors: Talaat Maha , Omar Mahmoud , Evans David
Published: March 2003

Summary Schistosomiasis is a major health problem in school‐age children in much of the tropical world. They harbour the most intense infections for both Schistosoma mansoni and S. haematobium. In Egypt, the Ministry of Health and Population (MOHP) has implemented a successful school‐based treatment programme in which children are screened and those found to be infected treated with praziquantel. High nonenrolment rates in some rural areas have a negative impact on the coverage of this programme and on its ability to reduce transmission in the community. The main aim of our study was to introduce and test a simple intervention to extend treatment to nonenrolled children using the routine MOHP schistosomiasis treatment programme. Twenty villages or ezbas in Tamia district, Fayoum governorate, with 8 schools and 1901 nonenrolled children were targeted. 88.5% of nonenrolled children attended schools to avail themselves of treatment. Coverage rates were significantly higher for girls (P < 0.001). These results are important for countries where schistosomiasis is endemic. They suggest that offering interventions in schools may not only improve the health of school attendees but also be an affordable way of extending services to out‐of‐school children.
Molecular epidemiology of Theileria parva in the field
Authors: Geysen D. , Bishop R. , Skilton R. , Dolan T. T. , Morzaria S.
Published: March 2003

Summary Molecular tools based on seminested RFLP‐PCR techniques to characterize field parasites in bloodspots dried on filter paper permitted investigation of the extent and the dynamics of diversity of Theileria parva populations in the field. Parallel molecular studies explored the long‐term genome stability of various isolates by probing Southern blots of EcoRI digested total genomic DNA with four different reference nucleic acid probes. Three polymorphic single copy loci encoding for antigen genes were developed for seminested PCR detection in order to apply them for a multilocus approach in population genetic studies. Seven alleles were identified for the polymorphic immunodominant molecule (PIM) locus by using restriction enzymes, and 4 alleles each for the p150 and p104 loci. A simple DNA extraction method gave good results in amplifying these loci from carrier animals using samples of blood dried on filter papers. Results from probing Southern blots of cultures taken at sequential timepoints indicate relative genome stability in T. parva in comparison to other parasitic protozoa such as Plasmodium. Comparatively homogeneous profiles in sympatric isolates from Zambia were identified using all four probes and PCR amplified products which contrasted with the variety found amongst Kenyan stocks. Preliminary characterization of T. parva field samples from the Southern Province of Zambia strongly suggest clonal expansion of one of the components of a non‐Zambian trivalent vaccine used on a limited scale in the Province from 1985 until 1992.
Insecticide‐treated curtains reduce the prevalence and intensity of malaria infection in Burkina Faso
Authors: Habluetzel A. , Cuzin N. , Diallo D. A. , Nebié I. , Belem S. , Cousens S. N. , Esposito F.
Published: March 2003

Summary A large, randomized controlled trial to investigate the impact of insecticide‐treated curtains (ITC) on child mortality was conducted in an area of seasonal, holoendemic malaria in Burkina Faso. 158 communities totalling some 90000 people were censused and grouped into 16 geographical clusters, 8 of which were randomly selected to receive ITC in June – July 1994, just prior to the rainy season. In September – October 1995, at the peak period of malaria transmission, a cross‐sectional survey was conducted in 84 of the villages. A random sample of 905 children aged 6–59 months was identified and visited. 763 children (84%) were present at the time of the visit and recruited into the study. Mothers were asked about fever in the past 24 h, the child's temperature was taken, and a sample of blood collected to identify and quantify malaria infections and to measure haemoglobin (Hb) levels. Children protected by ITC were less likely to be infected with Plasmodium falciparum (risk ratio = 0.92; 95% CI 0.86,0.98) or P. malariae (risk ratio = 0.42, 95% CI 0.19,0.95). The mean intensity of P. falciparum infections was lower among children protected by ITC (899 vs. 1583 trophozoites/μl; P < 0.001), while the mean Hb level was 0.4 g/dl higher (P < 0.001). While we found no evidence that ITC had an impact on the prevalence of malaria‐associated fever episodes, the confidence intervals around our estimates of the impact of ITC on malaria morbidity were wide. We conclude that widespread implementation of ITC in this area of high malaria transmission led to a modest reduction in the prevalence of malaria infection and to a more substantial reduction in the intensity of these infections which caused increased Hb levels. We were unable to demonstrate any impact of ITC on malaria morbidity, but the wide confidence intervals around our point estimates do not preclude the possibility of a substantial impact.
A new strategy for treating nets. Part 2: Users' perceptions of efficacy and washing practices and their implications for insecticide dosage
Authors: Miller J. E. , Jones C. O. H. , Ndunguru S. , Curtis V. , Lines J.
Published: March 2003

The conventional way to treat a mosquito net with pyrethroid insecticide is to apply a standard dosage every 6–12 months, and to avoid washing the net until just before retreatment. In some places, nets are normally washed much more often than this, and it may then be more appropriate to apply smaller amounts of insecticide after each wash. The choice of strategy must take into account not only biological effectiveness, but also users' perceptions of this effectiveness and their net‐washing habits. We used focus groups to compare users' responses to nets treated with different dosages and chemicals. One hundred current net users in urban Dar‐es‐Salaam were each given a net that had been pretreated either with permethrin (200 or 500 mg/m2), or with lambdacyhalothrin (3 or 15 mg/m2), or with water. Neither participants nor investigators knew which group had received which treatment. Focus group discussions were held after 2, 8 and 12 weeks. Participants greatly preferred treated nets. Low doses were perceived to be less effective, especially after 8 and 12 weeks. After 12 weeks most participants had washed their nets, despite requests to the contrary. Dirty nets were regarded as unhealthy and socially unacceptable. Few participants experienced side‐effects or expressed fears about the safety of treatment. We conclude that asking people to refrain from washing their nets is unrealistic. A ‘low‐dose frequent‐treatment’ strategy of insecticide application may be more appropriate in the long run. At first, however, low doses give perceptibly inferior protection. An initial high (loading) dose, followed by frequent lower (maintenance) dosages, might solve this problem.
Submicroscopic Plasmodium falciparum infections in pregnancy in Ghana
Authors: Mockenhaupt Frank P. , Rong Birgit , Till Holger , Eggelte Teunis A. , Beck Stefanie , Gyasi‐Sarpong Christian , Thompson William N. A. , Bienzle Ulrich
Published: March 2003

Summary Malarial parasitaemia below the threshold of microscopy but detectable by polymerase chain reaction (PCR) assays is common in endemic regions. This study was conducted to examine prevalence, predictors, and effects of submicroscopic Plasmodium falciparum infections in pregnancy. In a cross‐sectional study among 530 pregnant women in Ghana, plasmodial infections were assessed by microscopy and PCR assays. Concentrations of haemoglobin and C‐reactive protein (CRP) were measured and antimalarial drugs (chloroquine, pyrimethamine) in urine were demonstrated by ELISA dipsticks. By microscopy, 32% of the women were found to harbour malaria parasites. This rate increased to 63% adding the results of the parasite‐specific PCR. P. falciparum was present in all but one infection. With increasing gravidity, infection rates and parasite densities decreased and the proportions of submicroscopic parasitaemia among infected women grew. Correspondingly, anaemia, fever and evidence of inflammation (CRP > 0.6 mg/dl) were more frequent in primigravidae than in multigravidae. Antimalarial drugs were detected in 65% of the women and were associated with a reduced prevalence of P. falciparum infections and a raised proportion of submicroscopic parasitaemia. Both gravidity and antimalarial drug use were independent predictors of submicroscopic P. falciparum infections. These infections caused a slight reduction of Hb levels and considerably increased serum concentrations of CRP. Conventional microscopy underestimates the actual extent of malarial infections in pregnancy in endemic regions. Submicroscopic P. falciparum infections are frequent and may contribute to mild anaemia and inflammation in seemingly aparasitaemic pregnant women.
Congenital transmission of Trypanosoma cruzi: an operational outline for detecting and treating infected infants in north‐western Argentina
Authors: Blanco Sonia B. , Segura Elsa L. , Cura Estela N. , Chuit Roberto , Tulián Liliana , Flores Isolina , Garbarino Gabriela , Villalonga Juan F. , Gürtler Ricardo E.
Published: March 2003

Summary We designed a set of procedures for first‐line local health services to detect and treat the congenital transmission of Trypanosoma cruzi at a province‐wide scale, and field‐tested the programme in the province of Tucumán, northwestern Argentina, from 1992 to 1994. The programme consists of routine screening of pregnant women for seroreactivity to T. cruzi, serological and parasitological follow‐up of the newborn at least twice during the first year of age, treatment of the infected infants, and evaluation of the outcome. 927 (5.5%) of 16 842 pregnant women were seroreactive to T. cruzi by indirect haemagglutination assay and ELISA. Twenty‐one (6.7%) of 315 newborns to seroreactive mothers were diagnosed as infected with T. cruzi parasites microhaematocrit concentration before 30 days of age. Five newborns who initially tested negative had a T. cruzi infection detected by microhaematocrit and/or serological techniques at 3 or 6 months of age. Thus, congenital infection was diagnosed in 26 (7.1%) infants born to seroreactive women and residing in houses free of triatomine bugs. Four of 6 infants born to seroreactive mothers died during the first year of age and had some evidence of T. cruzi infection; one of the deaths was attributed to T. cruzi based on clinical evidence. After specific treatment with nifurtimox or benznidazole, 30 of 32 infants remained parasitologically and serologically negative. This study shows the feasibility of controlling the incidence of congenitally acquired T. cruzi infections at a province‐wide scale by means of a specific screening programme at first‐line health services level.
Interactions between HIV infection and other sexually transmitted diseases
Authors: Mabey David
Published: March 2003

Mechanisms and implications of the interaction between HIV and other STDs such as syphilis, Herpes simplex, Chlamydia and Neisseria gonorrhoeae infection are presented and relevant case reports and trials described.
Maternity care in rural Nepal: a health service analysis
Authors: Jahn Albrecht , Dar Iang Maureen , Shah Usha , Diesfeld H. J.
Published: March 2003

Summary This study assesses the performance of maternity care and its specific service components (preventive interventions in antenatal care, antenatal screening, referral, obstetric care) in Banke District, Nepal, using a set of structure, process, and output/outcome indicators. Data sources included health service documents in 14 first level health units and two hospitals, covering 1378 pregnancies and 1323 deliveries, structured observations, antenatal exit interviews (n = 136) and interviews with maternity users (n = 146). Coverage of antenatal care (28%) and skilled delivery care (16%) was low. In antenatal care, preventive interventions were only partially implemented (effective iron supplementation in 17% of users). On average one minute was spent on individual counselling per consultation. 41% of pregnancies were identified as high risk and 15% received referral advice, which was followed in only 32%. Hospital deliveries accounted for 9.8% of all deliveries. Hospital‐based maternal mortality was 6.8/1000 births and the stillbirth rate 70/1000. High rates of stillbirth were observed in breech delivery (258/1000 births), caesarean section (143/1000) and twin delivery (133/1000). The risk of stillbirth was higher for rural women (RR 2.3; 95% CI 1.51–3.50) and appeared to be related to low socio‐economic status. Emergency admissions were rare and accounted for 3.4% of hospital deliveries or only 0.4% of all expected deliveries. There was hardly any accumulation of high‐risk pregnancies at hospital. The population‐based rate of caesarean section was 1.1% (urban 2.3%, rural 0.2%). The estimated unmet obstetric need was high (82 cases or 61% of expected live‐threatening maternal conditions did not receive appropriate intervention). The limited effectiveness of maternity care is the result of deficiencies of all service components. We propose a two‐pronged approach by starting quality improvement of maternity care from both ends of maternity services: preventive interventions for all women and hospital‐based obstetric care. Antenatal screening needs to be rationalized by reducing inflated risk catalogues that result in stereotypical and often rejected referral advice.
The unreliability of the Kato‐Katz technique limits its usefulness for evaluating S. mansoni infections
Authors: Kongs A. , Marks G. , Verlé P. , Van der Stuyft P.
Published: March 2003

The Kato‐Katz technique, a (semi) quantitative stool examination technique, is generally recommended for diagnosis and evaluation of Schistosoma mansoni infection by schistosome experts. However, egg counts are subject to important variability. In order to quantify the reproducibility of egg counts using the Kato‐Katz technique, field data of 1255 observations on 299 subjects infected with Schistosoma mansoni were analysed. Agreement between repeated observations was assessed both categorically (kappa statistic) and continuously (analysis of variance). The day‐to‐day variation of egg counts was much greater than the variation due to different observers or different slides. The quantitative reproducibility was low: the weighted kappa statistic was 0.39 between specimens of different days, 0.62 between slides of the same specimen and 0.81 between observers of the same slide. Therefore the classification of individual patients into groups based on egg counts, used as a measure of morbidity, must be interpreted with great care, especially in longitudinal studies. Usefulness of the Kato‐Katz technique appears limited. Its reproducibility is low. It cannot be recommended as a routine test in a primary health care setting or in a hospital laboratory because safety and detection of other parasites are better assured by other techniques. It can be used in epidemiological studies and evaluation of schistosomiasis control programmes, but here too, other techniques might be preferred.
Intestinal helminth infections, anaemia and labour productivity of female tea pluckers in Bangladesh
Authors: Gilgen D. D. , Mascie‐Taylor C. G. N. C. G. N. , Rosetta L. L.
Published: March 2003

We conducted a randomized clinical intervention trial over 24 weeks on a tea estate in north‐east Bangladesh to investigate the effect of iron supplementation and anthelmintic treatment on the labour productivity of adult female tea pluckers. A total of 553 full‐time tea pluckers, not pregnant and not breastfeeding, were randomly assigned to one of the four intervention groups: group 1 received iron supplementation on a weekly basis, group 2 received anthelmintic treatment at the beginning and half‐way through the trial (week 12), group 3 received both iron supplementation as group 1 and anthelmintic treatment as group 2, and group 4 was a control group and received placebos. No significant difference in labour productivity was found between the four intervention groups over the trial period. However, there was a negative association for all three worms (Ascaris lumbricoides, Trichuris trichiura and hookworms) between the intensity of helminth infections (eggs/g faeces) and all measures of labour productivity. Lower haemoglobin values and anaemia (< 120 g/l Hb) were both associated with lower labour productivity and more days sick and absent. Taller women with greater arm circumference were able to pluck more green leaves, earn higher wages and were absent less often.
Hypothetical and actual willingness to pay for insecticide‐treated nets in five Nigerian communities
Authors: Onwujekwe Obinna , Chima Reginald , Shu Elvis , Nwagbo Douglas , Okonkwo Paul
Published: March 2003

OBJECTIVES To determine the hypothetical and actual willingness of households to pay (WTP) for insecticide‐treated nets (ITNs), and compare these in areas with and without previous exposure to free ITNs.

METHODOLOGY The contingent valuation method was used to determine the willingness of the heads of 1908 randomly selected households from five communities in south‐east Nigeria to pay for two sizes of ITNs. Two communities previously had free access to ITNs. Validity was assessed using multiple regression analyses, and by offering ITNs for sale to 200 randomly selected people drawn from the original sample. The data was collected between March and September 1998.

FINDINGS Most respondents were willing to pay for ITNs: Mbano (93.26%), Ugwogo (97.69%), Orba (83.24%), Alor‐uno (95.37%), and Ibagwa‐ani (87.34%). In multivariate analyses, WTP was significantly associated with the number of people living in a household, sex of the respondent, average yearly expenditure on gifts and the type of savings scheme (P < 0.05). Some of the residences were also statistically significant in the two models used, and those with prior exposure to free ITNs were negatively related to WTP. Seventy‐six percent of those who were hypothetically willing to pay actually purchased them, and the WTP technique correctly predicted the choices of 80% of the respondents.

CONCLUSION There was good evidence that stated WTP could be translated into actual WTP. However, peoples’ perception of affordability of the nets and its link to their WTP needs further exploration. The WTP technique is a potentially valid tool for market research in healthcare, as it was able to predict the direction of actual WTP for the ITNs. The hypothetical WTP amounts could be used as guide to know either the optimal price to charge for the ITNs or the level of subsidy to introduce.
Risk factors associated with an outbreak of dengue fever in a favela in Fortaleza, north‐east Brazil
Authors: Heukelbach Jörg , De Oliveira Fabíola Araújo Sales , Kerr‐Pontes Lígia Regina Sansigolo , Feldmeier Hermann
Published: March 2003

To increase the effectiveness of ongoing anti‐dengue control measures, we conducted a case–control study in a favela in Fortaleza (north‐east Brazil) during an outbreak of dengue fever. Cases were defined according to the national guidelines for dengue control as well as based on the detection of IgM‐dengue antibodies, and 34 cases and 34 controls were investigated. Significant risk factors were: living in a street perpendicular to the beach on which the favela is situated (P < 0.0001), an interval > 30 days since the last visit of the vector control agent (P=0.001), receptacles in the garden or courtyard (P=0.001), plants with temporary water pools on the property, gutter to collect rainwater, uncovered water storage container (all P=0.02), and no waste collection (P=0.03). Socio‐economic variables were not associated with dengue fever. The probable starting point of the epidemic was an uncovered water tank on the roof of the house adjacent to the index case. From there, the outbreak spread uphill parallel to the prevailing direction of the wind. Thus, the chronological and spatial evolution of the epidemic could have been forecast after the first cases had occurred. This example of investigative epidemiology in an operational setting shows that targeted intervention leading to increased effectiveness of control measures is possible.
Risk factors for hepatitis C virus infection in male adults in Rawalpindi–Islamabad, Pakistan
Authors: Bari Abdul , Akhtar Saeed , Rahbar Mohammad H. , Luby Stephen P.
Published: March 2003

OBJECTIVE To identify risk factors associated with HCV infection in Islamabad–Rawalpindi.

METHODS Fifty‐seven cases and 180 controls were enrolled from various departments of the nine major hospitals of the Rawalpindi–Islamabad during July–September 1998. Cases were enzyme‐linked immunosorbent assay (ELISA) positive for antibodies to HCV (anti‐HCV), aged 20–70 years, and residents of Islamabad or Rawalpindi division. Controls were anti‐HCV ELISA negatives of the same age range and from the same area. A structured questionnaire was used to collect data on demographic variables and potential risk factors, which was analysed by logistic regression to calculate crude and adjusted odds ratios (OR) and corresponding 95% confidence intervals (CI) for risk factors.

RESULTS The final multivariate logistic regression model revealed that after adjusting for age, cases were more likely to have received therapeutic injections in the past 10 years (1–10 vs. 0 therapeutic injections; adjusted OR=2.8, 95% CI: 1.1–7.1; > 10 vs. 0 therapeutic injections; adjusted OR=3.1, 95% CI: 1.2–7.9) and were significantly more likely to have daily face (adjusted OR=5.1, 95% CI: 1.5–17.0) and armpit shaves (adjusted OR=2.9, 95% CI: 1.3–6.5) by a barber.

CONCLUSION HCV control and prevention programs in this region should include safe injection practices and educate men about the risk of HCV infection from contaminated instruments used by barbers.
Extent and speed of spread of HIV infection in India through the commercial sex networks: a perspective
Authors: Venkataramana C. B. S. , Sarada P. V.
Published: March 2003

India has the world’s highest number of HIV/AIDS infections for any country outside Africa. Eighty‐five per cent of HIV transmission in India occurs through heterosexual contact. One billion population, a large number of female sex workers, high prevalence of sexually transmitted infection (STIs) and low condom use make a potent combination for explosive growth of the epidemic. Taking available estimates of the number of female sex workers (FSWs), their work patterns, prevalence of HIV and STIs and condom use among them in 1999 as the base, and adopting reasonable infectivity rates, this paper attempts to present a model to estimate the spread of HIV infection in commercial sex networks until 2005. HIV infections in commercial sex networks are estimated to increase from the 1999 level of approximately 2.49 million to about 3.93 million by 2005 in a favourable scenario, and to 6.87 million in a worse scenario. Spread of HIV is influenced in the short term by condom use and prevalence of STIs, and these are the only factors that can be manipulated to limit the spread of the infection.
Perception of chloroquine efficacy and alternative treatments for uncomplicated malaria in children in a holoendemic area of Tanzania: implications for the change of treatment policy
Authors: Tarimo D. S. , Minjas J. N. , Bygbjerg I. C.
Published: March 2003

Prior to policy change from chloroquine (CQ) to sulphadoxine/pyrimethamine (S/P; Fansidar) we assessed the perception of CQ efficacy and the alternative treatment options for malaria in children among parents/guardians (N=527) of under‐fives attending first level health facilities on account of fever. It was hypothesized that the long experience with CQ and its antipyretic effect (lacking in S/P) might impede acceptance of S/P for wider use as first‐line drug. Malarial fevers in children were most commonly treated with CQ (92.8%), followed by quinine (60.7%) and S/P (28.7%). A 63.2% knew the reasons for non‐response to antimalarial treatment, and only 50% were aware that CQ could fail to treat malaria, and 57.1% knew alternative treatment options, namely quinine (52.2%) and S/P (20.5%). Generally, decreased efficacy of CQ had been noticed, and quinine was prescribed for both suspected and proven CQ failures in first level health facilities and the district hospital. S/P was judged to be more effective than quinine, but too strong for children, and was the least known drug in the study area. All formulations of S/P cost more per dose for a child and an adult than CQ. The implications of these findings on the change of malaria treatment policy are discussed.
Reasons for poor cataract surgery uptake – a qualitative study in rural South Africa
Authors: Rotchford A. P. , Rotchford K. M. , Mthethwa L. P. , Johnson G. J.
Published: March 2003

OBJECTIVES To understand the reasons for poor cataract surgery uptake in people with blindness or severe visual impairment in rural South Africa.

METHODS A qualitative analysis of detailed, domiciliary interviews with a community‐based random sample of elderly Zulus who were blind or severely visually impaired as a result of operable cataract, who had previously been invited for surgery but had failed to attend.

RESULTS Fear of surgery and a fatalistic attitude to the inevitability and irreversibility of blindness in old age were the main reasons for failure to attend for surgery. There was a lower level of disability and perceived need than had been assumed for people with such poor visual acuity. Non‐surgical western style health care for systemic illness was common but few patients had sought any form of assistance for their poor vision. Issues of cost and accessibility were relatively unimportant.

CONCLUSION Provision of affordable and accessible cataract surgery for the blind and severely visually impaired members of a community does not guarantee that it will be taken up. Other barriers to surgery may be revealed when practical issues such as cost and accessibility are addressed. Perceptions of visual disability among subjects with cataract may differ from simple objective clinical standards.
Seroprevalence of varicella zoster and rubella antibodies among rural populations of the Chaco region, south‐eastern Bolivia
Authors: Bartoloni Alessandro , Bartalesi Filippo , Roselli Mimmo , Mantella Antonia , Dini Francesca , Carballo Esteban Salazar , Barron Virgilio Prieto , Paradisi Franco
Published: March 2003

OBJECTIVE  To determine the seroprevalence of antibodies against varicella zoster virus (VZV) and rubella virus among the population of two rural areas, Camiri and Villa Montes, Chaco region, south‐eastern Bolivia.

METHODS  In a cross‐sectional study, serum samples from randomly selected subjects were screened for VZV‐ and rubella antibodies using enzyme‐linked immunosorbent assay (ELISA).

RESULTS  The prevalence of VZV antibodies was 80% (391 of 489). No significant differences were observed between genders and study areas. The prevalence increased with age with a seropositivity rate of 21.2% in the 1–4‐year‐old children, 56.9% in the 5–9 age group and 83.7% in the 10–14 age group, and reached 98.2% in over 45‐year olds. The prevalence of rubella virus antibodies was 76.9% (377 of 490), without significant differences between genders and study areas. Similar to the trend observed for VZV antibodies, the seroprevalence increased with age with a seropositivity rate of 18.1% in the 1–4‐year‐old children, 53.9% in the 5–9 age group and 78.4% in the 10–14 age group, and reached 94.7% in over 45‐year‐old subjects. Among the 95 women of childbearing age (15–44 years) the susceptibility rate was 11.6%.

CONCLUSIONS  A common seroimmunological profile was evidenced for the two infections. The age‐specific profile of VZV seropositivity differs from that reported for other tropical countries where higher median age of seroconversion and lower seroprevalence among adults are observed. Data concerning the prevalence of immunity to rubella may be useful to evaluate the impact of the recently introduced rubella immunization programme.
Appropriate treatment of malaria? Use of antimalarial drugs for children's fevers in district medical units, drug shops and homes in eastern Uganda
Authors: Nshakira N. , Kristensen M. , Ssali F. , Reynolds Whyte S.
Published: March 2003

OBJECTIVE To evaluate the quality of pharmaceutical care of malaria for children in eastern Uganda prescribed at government health units and drug shops, and administered by caretakers at home; and to assess its appropriateness in relation to national treatment guidelines, which recommend chloroquine over 3 days.

METHODS We followed 463 children under 5 years whose caretakers attended two drug shops and two government health units to seek treatment for fever. The children were examined and the caretakers interviewed on the day of enrolment in the study (day 0), and in their homes on days 3 and 7. Data was collected on drug use prior to attending the shop or health unit, the treatment provided at these study sites, and the administration of drugs at home over the following 3 days.

RESULTS Before attending the study sites, 72% of children had already been given some biomedical drugs, and 40% had received the recommended drug, chloroquine. Health workers prescribed chloroquine for 94% of the children, but only 34% of the recommended doses followed guidelines. Two‐thirds of the children were prescribed an injection of chloroquine. By day 3, according to caretaker reports, about 38% of the children had received chloroquine in compliance with the instructions given by the health workers and drug shop attendants. Only 28% of the children had received chloroquine at the optimal dose of 20–30 mg/kg recommended by national policy.

CONCLUSION The methods were useful for examining adherence of both caretakers and health care providers to national guidelines and the extent to which caretakers were compliant with providers' prescriptions. Chloroquine and antipyretics were the drugs of choice for fever in these areas of rural eastern Uganda. But children did not receive the recommended dosage of chloroquine because of lack of compliance on the parts of providers as well as users of health care.
Comparison of three antigen detection methods for diagnosis and therapeutic monitoring of malaria: a field study from southern Vietnam
Authors: Huong Nguyen Mai , Davis Timothy M. E. , Hewitt Sean , Van Huong Nguyen , Uyen Tran Thi , Nhan Doan Hanh , Cong Le Dinh
Published: March 2003

OBJECTIVES To compare the sensitivity, specificity and post‐treatment persistence of three commonly used rapid antigen detection methods.

METHOD We studied 252 Vietnamese patients aged from 4 to 60 years, 157 with falciparum and 95 with vivax malaria and 160 healthy volunteers. An initial blood sample was taken for microscopy, and OptiMAL®, immunochromatographic test (ICT) malaria P.f./P.v.® and Paracheck‐Pf® tests. Patients with falciparum malaria were treated with an artesunate‐based combination regimen and those with vivax malaria received chloroquine. Eighty‐seven patients with falciparum malaria who were initially positive for one of the antigen tests and who remained blood smear‐negative underwent follow‐up testing over 28 days.

RESULTS Paracheck‐Pf® was the most sensitive test for Plasmodium falciparum (95.8% vs. 82.6% for ICT malaria P.f./P.v.® and 49.7% for OptiMAL®). Specificities were all 100%. For vivax malaria, OptiMAL® performed better than ICT malaria P.f./P.v.® (sensitivities 73.7% and 20.0%, respectively), with 100% specificity in both cases. All tests had low sensitivities (≤ 75.0%) at parasitaemias < 1000/μl regardless of malaria species. During follow‐up, Paracheck‐Pf® remained positive in the greatest proportion of patients, especially at higher parasitaemias (> 10 000/μl). Residual OptiMAL® positivity occurred only in a relatively small proportion of patients (< 10%) with parasitaemias > 10 000/μl during the first 2 weeks after treatment.

CONCLUSIONS Although microscopy remains the gold standard for malaria diagnosis, Paracheck‐Pf® may prove a useful adjunctive test in uncomplicated falciparum malaria in southern Vietnam. OptiMAL® had the lowest sensitivity for P. falciparum but it might have a use in the diagnosis of vivax malaria and perhaps to monitor efficacy of treatment for falciparum malaria where microscopy is unavailable.