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A Rapid Appraisal on Anemia Prevalence and Major Hematological Indices among School-aged Children in Rural Area, Northern China |
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Institution:
Swiss Tropical & Public Health Institute, Basel
Author:
Gao, Jianing
Graduate date:
2003-02-10 |
Last update:
2005-04-04 |
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Determination of Knowledge, Behaviour and Attitudes of University Students and Youth and the Evaluation of Two Peer Education Programmes in Turkey and in Armenia |
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Institution:
Institute of Tropical Medicine and International Health, Berlin
Author:
Kilic, Alper
Today, the number of people living with HIV/AIDS (Acquired Immunodeficiency Syndrome) exceeds 40 million and the number is still increasing. Worldwide, approximately half of the HIV infected people are in the age group 15-24. In Turkey and in Armenia the numbers of HIV infected people are increasing despite the low prevalence.
Currently a cure for HIV is not available and therefore changing behaviours of the young people still plays a key role in preventing new infections. One of the key health education methods on the prevention from HIV transmission, peer education method has been widely used in different parts of the world.
The increasing number of HIV/AIDS transmission both in Turkey and Armenia led the organisations working on HIV/AIDS and health education area to organise peer education sessions on HIV/AIDS. This cross sectional study aims to evaluate two peer education programmes among the youth and university students in Turkey and in Armenia. Face to face surveys conducted among 351 university students in Turkey, and youth in general population in Armenia (n= female; n= male mean age: 21.6) with conventional sampling methods. The university students and young people who took part in the survey contained of those who have participated in peer education and those who have not participated to the peer education programmes. The participants of the study were assessed in terms of their knowledge on prevention from HIV and its transmission methods, perception and attitude towards people with HIV/AIDS, and their risk behaviours related to the HIV/AIDS.
Survey results have shown that survey participants from both Armenia and Turkey, have similar knowledge, perception and risk behaviours regarding the HIV/AIDS. In both countries, the level of knowledge on the HIV, its ways of transmission, and prevention methods are rather low. Additionally, issues such as confidentiality of the HIV positive people and their involvement in the work force have to be addressed by the educators.
Almost half of the total number of participants has reported that they were sexually active. In Armenia, survey participants have reported higher number of sexual activity when compared with the survey participants in Turkey. The survey showed that there was a very low level of condom use in all groups.
In both countries, the peer education group demonstrated slightly more knowledge on the transmission of the HIV. Furthermore, it was observed that the students? attitude towards PLWHA had improved in the peer education group in comparison to those who had not taken part in peer education sessions. However, risk behaviours related with the HIV had not significantly changed among any of the groups participating. Peer education participants did not report higher ratios of condom usage.
This research suggests that the peer education programmes are being effective, and more has to be done in order to increase awareness and change behaviour of the young people. However, it also suggests that these two peer education programmes were inadequate with regard to prevention of risk behaviours.
Graduate date:
2007-03-29 |
Last update:
2007-07-18 |
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Development of a Curriculum for Participants of Voluntary Organizations – Analysis of Demand for the Calcutta Project Basel Foundation |
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Institution:
Swiss Tropical & Public Health Institute, Basel
Author:
Chattopadhyay, Chandon
Graduate date:
2002-06-03 |
Last update:
2005-03-31 |
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Epilepsy and Neurocysticercosis: an Incidence Study in a Peruvian Rural Population |
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Institution:
Institute of Tropical Medicine and International Health, Berlin
Author:
Villaran, Manuel
Background: Epilepsy is defined as two or more unprovoked epileptic seizures; seizures are uncontrolled, paroxysmal neuronal discharges in any part of the brain, causing physical or mental symptoms which may be convulsive or nonconvulsive.
Neurocysticercosis is the most common central nervous system helminthic infection. It is caused by the ingestion of Taenia solium eggs released in feces of the tapeworm carriers. Seizures are one of the most common acute neurologic manifestations of this infection, and epilepsy is rated among the most serious neurologic disorders. They are caused by the inflammatory process that takes place surrounding the parasite as it decays. Another severe, life threatening form of the disease is racemose cysticercosis, which can cause intracranial hypertension and/or hydocephalus.
Although there is a strong relationship between neurocysticercosis and epilepsy prevalence in endemic areas, incidence studies are scarce. Previously reported incidences range from 30 to 50/100,000 in industrialized countries and 30 ? 120/100,000 in developing countries.
Objectives: To determine the incidence of epilepsy in a neurocysticercosis endemic area.
Methods: A community-wide screening survey for possible seizure cases was performed between years 2000 and 2005 in seven villages of Tumbes (Northern Peru), a well known cysticercosis endemic area, using a validated questionnaire. Positive respondents were later examined in the field by neurologists. Seizure cases were categorized as single seizure, active epilepsy, or inactive epilepsy. Non-contrasted brain CT scans and contrasted MRI?s were performed in all individuals with seizures.
Results: Follow up was carried out in 817 individuals (most of them permanent residents), with a mean duration of 4.38 years (range: 0-5.49) for a total of 3575 person-years of observation. Eight individuals (0.98%) developed seizures during the study, resulting in a cumulative incidence of 2.16 / 1000 (95% C.I. 0.97 ? 4.40). Two of the eight individuals with seizures had a positive serologic test from the beginning and one turned positive by the time the first epileptic seizure episode took place, therefore 3/8 (37.5%) of these individuals were at some point seropositive. Four of the eight individuals presented neuroimages compatible with neurocysticercosis (50%), all of them calcification. However, one was left out the analysis because the calcification was very near the falx and it could have been the result of a physiological process.
Conclusion: The incidence of epilepsy in this endemic cysticercosis area is one of the highest among the reported rates in developing countries. Out of the eight individuals with epileptic seizures, four presented evidence of cysticercosis.
Graduate date:
2007-01-25 |
Last update:
2007-07-18 |
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Evaluation of the treatment outcome of patients with Buruli Ulcer after surgical treatment in Ghana |
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Institution:
Prince Leopold Institute for Tropical Medicine
Author:
Schunk, Mirjam
Problem statement
Buruli Ulcer disease (BUD) has been recognized to be an emerging public health problem in many topical countries, especially in the West African Region. In Ghana prevalence rates of up to 150 per 100.000 individuals were reported form most affected districts, making BUD the most prevalent mycobacterial disease in these areas. Although the disease related mortality is very low, disfiguring and disabling sequelae are common if the disease is left untreated or is treated in an advanced stage. Until recently surgical excision of the affected skin was the only treatment option. Because of encouraging results of drug trials antimycobacterial treatment was introduced in the standard treatment advised by WHO in 2004. In the context of improving the quality of clinical management, the need for follow-up studies to monitor the treatment outcome has been emphasised. However, there are only few studies of long-term outcome and relapse rates so far. In the published studies recurrence rates after hospital treatment vary from 2 to 35 %.
Objectives
A follow-up study of BUD patients who received surgical treatment was conducted with the aim of assessing the frequency of recurrences and the frequency of functional limitations as late sequelae of BUD in the follow-up sample as well as to analyse the occurrence of recurrences and /or functional limitations in association to clinical and treatment specific factors and to evaluate psychosocial aspects in the follow-up sample.
Methods
The follow-up was conducted in the catchment area of the Agogo Presbyterian Hospital, Asante Akim North District, Ashanti Region and the Dunkwa Government Hospital, Dunkwa-on-Offin, Upper Denkyira District, Central Region, Ghana. In both districts BUD is highly endemic. In total 129 laboratory confirmed BUD patients who received surgical treatment in either of the two treatment centres from September 2003 to September 2006 were included in the study. Baseline clinical data were extracted from Buruli Ulcer surveillance forms and hospital records, if available. Between February and March 2006, 16 field trips were conducted to visit included patients in their homes. The retrieved patients were interviewed using a semi-structured questionnaire for post-treatment history with a special focus on possible recurrences and sequelae as well as the psychosocial impact of the disease. In addition physical examinations were performed to clinically assess treatment outcome.
Results
Out of a total of 129 laboratory confirmed BU-patients, 79 (61%) were retrieved for follow-up. In the follow-up sample there were 7 (9%) recurrences, 6 cases of recurrences had occurred in the interim time between first treatment and follow-up, only one recurrent case was observed at follow-up. In the analysis of factors influencing the probability of recurrence no significant association was found between recurrence and size/ type of primary lesion, wound closure technique, use of antimycobacterial treatment, duration of disease before treatment and place of treatment.
27% (n=21) of the followed-up patients showed a functional limitation caused by a reduced range of motion of one or more joints as a sequel to the BU-infection. There was no significant correlation concerning type and size of primary lesion; however, no functional limitation was caused by a nodule as primary lesion. Regarding the wound closure technique a significant association was noted. In 90% (n=19) of the patients presenting with functional limitations at follow-up, skin grafts were applied for wound closure.
In patients over 15 years of age (n=55) the acceptance of the outcome after clinical interventions was with 73% (n=40) quite high. 29% (n=16) in this group reported that due to functional impairments or other sequelae they were not able to fulfil all tasks of daily life.
Conclusions
The results show a low recurrence rate in our study group. Since no single factor proved to have an essential influence on the occurrence of recurrent cases, the low incidence of recurrences is attributed to an effective clinical management of BUD in the study area, including early detection efforts, adherence to treatment guidelines, growing expertise of surgery and introduction of the use of antimycobacterial treatment in addition to surgical excision of the BUD lesions. However, functional limitations were relatively frequent. This emphasises the importance of the improvement of pre- and post-operative wound care to avoid functional sequelae and the urgent need for the provision of rehabilitation programmes.
With ongoing efforts to optimize clinical management for BUD, routine follow-up surveillance is essential to evaluate the impact of theses measures on treatment outcome.
Graduate date:
2007-07-19 |
Last update:
2007-07-18 |
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Exposure of Expatriates to HIV/AIDS ? The Influence of Contextual Factors and Knowledge about HIV/AIDS on Sexual Risk or Preventive Behaviour |
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Institution:
Swiss Tropical & Public Health Institute, Basel
Author:
Müller, Brigitte
Graduate date:
2001-01-18 |
Last update:
2007-10-31 |
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Feasibility of scaling up child health interventions: Exploring constraints that affect the implementation of breastfeeding and antibiotics for pneumonia child interventions in Uruguay health settings
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Institution:
Institute of Tropical Medicine and International Health, Berlin
Author:
Sarganas, Giselle
Objective: To explore constraints affecting the implementation of breastfeeding and antibiotics for pneumonia child interventions in Uruguay health settings by using the conceptual framework developed by Gericke et al. (2003, 2005) and to make suggestions on the feasibility of scaling up these interventions.
Design: This exploratory case study includes a conceptual and an empirical assessment of the degree of complexity of the selected child health interventions. For the conceptual assessment, international recommendations and global documented constraints and related recommendations were analysed. For the empirical assessment, field visits and semi-structured face-to-face interviews were conducted.
Results: The conceptual assessment of breastfeeding showed that this intervention requires knowledge, continuous education, advocacy and promotion. In the empirical assessment constraints were identified under the framework?s categories ?human resources?, ?pre existing demand? and ?regulation?. In the conceptual assessment, antibiotics for pneumonia proved to be a more complex intervention which requires a regular supply and consistent availability of the product, technically skilled health workers for its delivery, and a well informed community. The empirical assessment identified constraints in the categories ?supplies?, ?regulation?, ?human resources?, ?ease of usage? and ?pre existing demand?.
Suggestions: For scaling up the breastfeeding intervention in Uruguay health settings it is recommended to reinforce education of the general public and update health workers training; to start breastfeeding promotion earlier and include both partners; to elaborate supportive policies in the labour market; and the supervision and control of breast milk substitutes. For scaling up antibiotics for pneumonia child intervention in Uruguay health settings it is recommended to dispel the irrational demand and the irrational delivery of antibiotics by educating the community and health workers; to use a check list and an antibiotic sample for facilitating the explanation to caregivers regarding antibiotic usage; and to regulate the amount of antibiotics provided by public pharmacies in coherence with national guidelines.
Conclusion: The conceptual assessment facilitated the empirical assessment and structured identification of constraints. The framework proved to be a very useful systematic tool for the conceptual as well as for the empirical assessment of the selected child interventions. It is feasible to scale up breastfeeding and antibiotics for pneumonia child interventions in the selected health settings in Uruguay by narrowing the capacity gap through changes to the intervention design and upgrading capacity to overcome the constraints identified in this analysis.
Graduate date:
2007-02-01 |
Last update:
2007-07-18 |
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Gesundheitsversorgung unter den Bedingungen der italienischen "Centri di Permanenza temporanea ed Assistenza." Erfahrungen und Wahrnehmungen der "Gäste" und des medizinisch-psychologischen Fachpersonals |
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Institution:
Institute of Tropical Medicine and International Health, Berlin
Author:
Poluda, Julian
Am Ende des Jahres 1998 wurde unter der Mittelinksregierung Prodi die landesweite Konstruktion von ?Zentren des zeitweiligen Aufenthalts? (Centri die Permanenza temporanea - CPT) beschlossen. Diese fungieren als Aufnahme/-Abschiebelager für Migranten mit irregulärem Aufenthaltsstatus auf italienischem Territorium. Zurzeit gibt es in Italien 16 über das ganze Land verteilte CPTs, die landesweite Konstruktion weiterer CPTs ist in Planung. Während sich bereits die Erfahrungen im Herkunftsland wie auch während der Migration negativ auf psychische wie physische Gesundheit von Migranten auswirken können, sorgt das soziale Umfeld der von der Außenwelt weitestgehend isolierten Aufnahme/-Abschiebelager für weitere potentielle Belastungsfaktoren. Jedoch liegen bislang kaum Kenntnisse der Versorgungsbedürfnisse der in den Abschiebelagern internierten Migranten sowie der dort geleisteten Gesundheitsversorgung vor.
Die vorliegende Studie möchte daher, über die Exploration der Vorstellungen und
Meinungen des medizinisch-psychologischen Personals wie auch der internierten
Migranten selbst, eine Einschätzung der bestimmenden Gesundheitsprobleme im
CPT ermöglichen. Auf Grundlage dieser Erkenntnis erfolgt dann eine Untersuchung
der medizinisch-psychologischen Versorgung innerhalb der italienischen CPTs,
wobei dem Einfluss der sozialen Determinanten im CPT besondere Aufmerksamkeit gilt. Dabei bildet die Perspektive der Betroffenen den Schwerpunkt der Auseinandersetzung, so dass ein explorativer, qualitativer Studienansatz gewählt wurde. Semistrukturierte Tiefeninterviews mit den ?Gästen? wie auch mit dem medizinisch-psychologischen Personal konzentrieren sich auf Gesundheitssituation, medizinisch-psychologische Versorgung und die weiteren Versorgungsdienstleistungen im CPT. Ausgehend von einer bio-psycho-sozialen
Krankheitsauffassung wird dabei versucht, ein Verständnis der vielfältigen
Interaktionen von interpersonellen, soziokulturellen, aber auch soziopolitischen
Einflussfaktoren auf das Wohlbefinden wie auch auf die Versorgung der Betroffenen
zu entwickeln.
Die Untersuchung der Gesundheitssituation und -Versorgung in den CPTs ergab
deutliche Hinweise auf eine hohe Prävalenz psychosomatischer Erkrankungen.
Desweiteren weisen psychologischer Symptomkomplex, Vorgeschichte der ?Gäste? im CPT und Berichte über Akte der Selbstverletzung auf das hohe Vorkommen 7 psychotraumatischer Belastungsreaktionen hin. Wissensdefizite in der psychologischen Betreuung von Migranten, personelle Unterbelegung mit
psychologisch geschultem Fachpersonal, transkulturelle Missverständnisse zwischen Arzt und Patient, eine unzureichende Kooperation zwischen Ärzten und
psychologischem Personal und Probleme in der Arzt-Patientenbeziehung tragen zu
Defiziten in der medizinisch-psychologischen Versorgung bei.
Weitere medizinisch-psychologische Problemfelder betreffen die Diagnose und
Therapie bei Infektionskrankheiten, die gynäkologische Versorgung und die Therapie von Abhängigkeitserkrankungen.
Die sozialen Bedingungen der CPTs erschweren maßgeblich die medizinischpsychologische Versorgung und zeigen sich zugleich für die Entstehung neuer Krankheiten mitverantwortlich. Hervorzuheben sind dabei die psychologischen Auswirkungen von Kriminalisierung, rechtlicher Unsicherheit, dem Verlust individueller und kollektiver Bewältigungsressourcen und die fehlende Möglichkeit der Eigenbestimmung über das eigene Leben.
Die Ergebnisse der vorliegenden Studie lassen daher den Schluss zu, dass die zur
Zeit existierenden Aufnahme/-Abschiebelager für Migranten nach Gesundheitsaspekten nicht geeignet sind und dass konkreter Handlungsbedarf für
die Verbesserung der Gesundheitsversorgung und der Lebensbedingungen in den
italienischen CPTs besteht.
Graduate date:
2006-12-20 |
Last update:
2007-07-18 |
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HEALTH SYSTEM INTERVENTION ANALYSIS: The Recommending-Financing Gap of International Organizations for Health System Interventions. Meddling or Money?
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Institution:
Institute of Tropical Medicine and International Health, Berlin
Author:
Dini, Lorena
International Organizations have been launching many initiatives to support the efforts of developing countries and countries in transition to improve their development status and to achieve goals such as ?Health for all?, ?Millennium Development Goals? or the ?Poverty Reduction Strategy?. As these have been implemented, questions have arisen as to how to improve aid effectiveness, how to track aid flows at global and national levels, and how to harmonize donor practices. The development community?s work in developing countries depends on a complex mix of factors that go beyond the political, economic, environmental, social and humanitarian causes. Development professionals have recognized that even with the best intentions it is possible to have little or no impact or even to harm rather than help others. Nevertheless, flows of aid to developing countries through partnerships based regional programmes could be designed in such a way, at the global level, that the efforts are cost-effective, with minimal or no duplication or overlap, gaps or waste of resources. Priorities of international organizations could be aligned so as to ensure consistent elaboration and complementarity of goals focused towards the attainment of the overall vision. Such harmonization of the work of international organizations could increase aid effectiveness, and developing countries and countries in transition could make more progress.
Health Systems are recognized as multisectoral systems in the complex development world, affecting and affected by economic, social and political development. In recent years, strengthening health systems has been given a high priority in the development agenda.
This is a multiple case study, designed to develop and test tools to explore the relationship between recommended and financed health system interventions in the work of the major international organizations. This pilot study considers the work of three international organizations, the World Health Organization (WHO), the Organization for Economic Cooperation and Development (OECD) and the World Bank (WB), in two regions, the Latin America and Caribbean Region (LAC) and the Central and Eastern European countries and New Independent States of the Former Soviet Union (CEE-NIS), over a period of four years, from 2001 to 2004.
To document recommendations on health system interventions, the yearly reports issued by two organizations, the World Health Organization and the World Bank, were selected. Information on financing of health system interventions through projects was obtained from the projects database of the World Bank and from the OECD CRS database on disbursements on aid to health. To retrieve information on recommended health system interventions from the selected documents, two data collection methods were piloted in parallel, Content Analysis Coding (CAC), a coding-while-reading method, and the Frequency of Key Term Count (FKC), a computer based count of pre-selected key terms. Collection of data on financed health system interventions was done using the Content Analysis Coding method. Data on recommended and financed health system interventions identified in each document was classified according to the World Health Organizations framework of four health system functions, Stewardship, Financing, Resource generation, and Service provision. Health systems interventions identified in each document were ranked according to priorities the document?s authors gave them (as assessed using procedures developed and piloted in this study), using a four to-one hierarchical ranking system that permits comparison between recommended and financed priorities. Yearly and four year average priorities are presented in percentages and in priority rankings for each recommended and financed health system function analysed.
Based on this pilot study and the tools developed and tested in it, the author proposes two indicators, a Recommending-Financing Score for Health System Functions (R-F Score) and a Recommending-Financing Gap for Health System Interventions (R-F Gap for HSI).
The R-F Score is proposed as a measure of the consistency of the priorities rankings given to each health system function in recommendations, and the priority ranking given to the same health system function in terms of financing, for a given period.
The R-F Gap for HSI covers all health system functions and is proposed as a measure of the degree of harmonization in the work of international organizations regarding recommended and financed health system interventions during a period.
According to the initial estimates of this pilot study, the analysed ?pairs? of international organizations show variations in their degrees of consistency between the priorities rankings given to each health system function in recommendations and the priority ranking given to the same health system function in terms of financing, for the 2001 to 2004 period.
Most of the analysed ?pairs? show variation in the degree of harmonization of their work regarding recommended and financed health system interventions during the four years analysed for the LAC and for the CEE-NIS region.
Despite variations in the degree of harmonization, this pilot study?s initial estimates show improvement in the work of the selected international organizations regarding health system interventions, particularly after 2003. This improvement is in accordance with international initiatives, including the Monterrey Consensus (International Conference on Financing for Development (March 2002) and the Conference on Harmonization on Aid Effectiveness (June 2003), for the improvement of strategic aid delivery and harmonizing development assistance to developing countries and countries in transitions regarding strengthening of health systems.
By considering the Recommending-Financing Gap of International Organizations for health system interventions and the Recommending-Financing Score for each health system function, new avenues and opportunities for targeting and strengthening particular health system functions could be revealed. This could allow more strategic allocations of resources and more efficient delivery of aid.
Graduate date:
2007-05-21 |
Last update:
2007-07-18 |
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household coverage rate and utilisation of insecticidal mosquito nets one year after start of a community-participatory malaria prevention project in a rural village in northern Tanzania |
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Institution:
Institute of Tropical Medicine and International Health, Berlin
Author:
Ineichen, Johannes
Background: Malaria is a leading cause of morbidity and mortality in many tropical countries including Tanzania. Despite that Insecticidal mosquito nets (ITNs) are a major tool in malaria prevention both for individuals and for communities, ITN household coverage rate in Manyara region in northern Tanzania was 8.1% according to the last Demographic and Health Census of 2004-05. In the rural village of Massieda (Manyara Region) with 3647 inhabitants a community-participatory malaria prevention project has been started in April 2006. Socially marketed ITNs have been offered to community members, who furthermore have been sensitised about malaria disease and prevention opportunities including appropriate ITN use.
Study Objectives: to assess the ITN household coverage and ITN utilisation of community members one year after project start.
Methods: In this cross-sectional survey a systematic random sample of 110 households out of 550 has been selected. Needed information has been collected from household representatives by an interviewer-administered questionnaire. Additional data on malaria occurrence and outpatient numbers were collected from the local dispensary records.
Results: Data of 102 households and of 767 household residents and overnight guests have been included in the analysis after accounting for non-responders. The ITN household coverage rate was 59% (60/102). Forty-six percent (326/703) of persons staying in the surveyed households preceding night have used an ITN, and of children aged below five years 60% (76/126), and of pregnant women 56% (5/9). ITN household coverage of houses located within two hours walking time to the next water source was higher compared to more distant houses (74% vs. 51%; Chi2, p = 0.03). Houses built of tin roofs or stone walls rather possessed ITNs compared to traditional flat-ceiling houses (91% vs. 55%, Fisher?s exact, p = 0.025). No association has been observed between ITN household possession or ITN use of children aged below five years and occurrence of fever in the last two weeks. Dispensary records revealed that proportion of malaria patients out of all outpatients has decreased from 33% in 2005 to 28% in 2006 (Chi2, p = 0.016).
Conclusion: The project is one among several possible factors that might have contributed to the high ITN household possession rate, ITN utilisation rates and declining proportion of malaria patients. Mosquito nuisance near water sources might enhance residents? willingness to obtain ITNs. Low ceilings of traditional houses might be hindrance factors for inhabitants to install ITNs, as might be economic constraints. A health impact of ITN use on fever in children has not been observed, whereby fever is an inaccurate proxy indicator for malaria illness.
Graduate date:
2007-07-19 |
Last update:
2007-07-18 |
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Migration and health in China: the situation of female migrant workers and strategies to limit the spread of HIV. A literature review. |
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Institution:
Institute of Tropical Medicine and International Health, Berlin
Author:
Müller, Leonie Macbeth
Economic reforms since the late 1970s have resulted in much rural to urban migration in China. This paper is a literature review and looks at the connection between female rural to urban migration in China, limiting the spread of HIV and how the healthcare system is placed to deliver adequate HIV prevention and control in China in general and for the migrant population in particular. The issue of access to social services and medical care for migrants is framed in the context of the hukou system, a household registration system unique to China. An overview of the HIV epidemic is given including gender considerations and potential HIV-related economic implications for China?s development. Conceptual approaches to HIV responses are discussed prior to looking at China?s current prevention and control strategies. HIV demands on the healthcare system are also discussed. The final recommendations include a stronger need for inter-sector collaboration amongst the various actors already working in HIV and those who could potentially be recruited to work in the field. A strengthened healthcare system, with an emphasis on rural areas is called for to deliver timely and adequate HIV treatment and prevention.
Graduate date:
2006-08-10 |
Last update:
2007-07-18 |
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Occurrence, Clinical Characteristics and Management of Aids-related Kaposi?s Sarcoma in Central Malawi |
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Institution:
Institute of Tropical Medicine and International Health, Berlin
Author:
Breitenecker, Florian
Background: In sub-Saharan Africa (SSA) Aids-related Kaposi?s sarcoma (AKS) is a common malignancy which substantially contributes to HIV-associated morbidity and mortality. Single-agent chemotherapy with vincristine together with HAART is currently the recommended treatment for advanced AKS in Malawi. We conducted an AKS treatment observation in central Malawi, where Medecins sans Frontieres (MSF) had launched an HIV/HAART program in close collaboration with the Dowa District Hospital.
Methods: Assessment and follow-up of HIV-infected patients with clinically diagnosed AKS who received NNRT-based antiretroviral regimens and singe-agent chemotherapy with vincristine at a dose of 2mg/m² every week. Standard statistics including odds ratio and Kaplan Meier function were used to describe demographic and clinical characteristics as well as treatment outcomes.
Results: Thirty-four patients (4,5% of all registered HIV- infected individuals, 68% male) presented with AKS, the vast majority (88%) in advanced tumour stages (T1/I1, T1/I0) with lymphoedema (65%), pain (41%), ulcerations (32%) and possible visceral involvement (53%). Of 27 individuals starting vincristine chemotherapy one third (33%) died during the observation period (11 months). No patient achieved complete or partial responses according to definitions set up by the Aids Clinical Trial Group (ACTG) which is mainly focused on regression of skin lesions. However, many patients showed clinical improvement most markedly with regards to oedema and pain reduction and alleviation of visceral symptoms. This observation gave rise to the introduction of an additional response category termed ?any response? to which 71% of patients could be assigned to. Still, even this minor response subsided after about three months in spite of continued chemotherapy in addition to HAART. Peripheral neuropathy was a common complication of treatment (3 patients grade 3/4, all others grade 1/2) sometimes prohibiting continuation of chemotherapy.
Conclusions: This study revealed that in advanced stages of AKS, lesion progression and emergence of AKS-related complications can not be controlled by vincristine single-agent chemotherapy even when immune competence is being restored by concomitant HAART. Mortality is high and tumour progression inevitable (100% after 16 weeks). It became evident that vincristine monotherapy is not an adequate choice for treating HIV-infected individuals with advanced AKS in resource-limited settings. The Malawi Ministry of Health should revise their AKS treatment guidelines. More effort is needed to increase access to a wider range of cytotoxic drugs with higher efficacy. The implementation of comparative studies in SSA could provide urgently required data on the efficacy, tolerability, feasibility and accessibility of different treatment strategies. Furthermore, intensified research on transmission of human herpes virus 8 and the development of a vaccine must be encouraged.
Key Words: Aids, Kaposi?s sarcoma, sub-Saharan Africa, Malawi, vincristine, chemotherapy, Medecins sans Frontieres
Graduate date:
2009-09-28 |
Last update:
2010-11-04 |
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Populations perspective in the case of access to essential drugs in basic health services, focused on a participatory approach in rural Mexico |
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Institution:
Swiss Tropical & Public Health Institute, Basel
Author:
Hartmann, Annette
Graduate date:
2007-10-31 |
Last update:
2009-07-10 |
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Provision of Antiretroviral Treatment at Crossroads HIV Clinic in the Metropole
Region of Cape Town: Factors Influencing the Degree of Adherence.
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Institution:
Institute of Tropical Medicine and International Health, Berlin
Author:
Vezertzi, Marianthi
Background: South Africa is currently facing one of the most severe HIV epidemics worldwide.
According to UNAIDS, in the year 2005, there were five and a half million people
living with HIV in South Africa, while the prevalence of HIV among adults (15-49 years old)
was 18.8%. ART has been accredited with having a significant positive effect on the quality
of life of people living with HIV/AIDS. Adherence to antiretroviral medication is the
cornerstone of successful HIV/AIDS care, especially because of the potential emergence of
drug-resistant HIV. A 95% degree of adherence is highly associated with therapeutic success
of ART, namely viral suppression, increase of CD4 count and decrease in the incidence of
opportunistic infections, especially tuberculosis. Additionally, non-adherence or sub-optimal
adherence to ART could predict progression to AIDS. Patient advocacy goes hand-in-hand
with patient empowerment and patient education. It should be a fundamental component of
health care structures, as empowered and educated patients are more likely to take
responsibility for their therapy.
Objectives: The objective of this study was to review the ARK database at Crossroads HIV
clinic and to explore the impact of demographic and socio-economic characteristics, of patient
advocacy and disclosure on the degree of adherence, in order to make recommendations that
could lead to improved ART adherence.
Methods: An anonymous documentary review of the Crossroads patient database provided by
ARK, in order to extract as much information as possible, concerning the health of the
patients and the degree of adherence has been performed. The questionnaire ?Community
Adherence Home Social Assessment Form? used by ARK, concerning demographic and
socio-economic characteristics of the patients, has been reviewed. A focus groups discussion
with fourteen of the PAs, who are involved in the ARK programme, concerning the
challenges that patients face in regard to adherence, disclosure and the role of the PAs was
conducted. Detailed literature review has been conducted, in order to elicit information about
the trends on the issues of adherence to ART and patient advocacy.
Results: The number of women attending the HIV clinic at Crossroads is more than the
double of the number of men, while from January 2004 until December 2006, there was a
constant increase in enrolment at the HIV for both men and women. A cohort analysis
revealed that there is a first increase in deaths between the first and the second trimester and a
second one after one year of being on ART. There is also an increase in deaths between the
viii
trimesters October-December 2005 and January-March 2006, regardless of the cohort.
Interestingly, there is also an increase in the number of patients who were LTF between the
trimesters July-September 2005 and October-December 2005, regardless of the cohort.
According to the patient advocates, factors that promote adherence among patients who
receive ART the commitment to the well-being of their children and the family and the belief
that they have a life worth living and that they can set and achieve short and long term goals,
while reasons for sub-optimal adherence were lack of information about HIV and poor
understanding of HIV and ARV regimens, certain spiritual practices and religious beliefs,
non-acceptance of their HIV status, reliance on the disability grant, alcohol consumption, fear
of stigma and abandonment, fear of disclosing, non-supportive family. The problem of fear of
stigma and abandonment seems to be more extensive for women who generally are financially
dependent on their partners. The impact of the patients advocates is reflected in the low
numbers of patients who defaulted. Nevertheless, there was a difficulty to differentiate which
outcomes are attributable to the patients advocates and to the health system in general.
Conclusion: Knowledge of the factors that facilitate or hinder ART adherence, as well as of
the profile of the patients who are more likely not to be adherent, would facilitate the design
and implementation of interventions and support strategies which promote ART adherence.
These programmes would possibly lead to improved health outcomes by identifying and
assisting those patients who are more likely to be partially or non-adherent to ART and by
reinforcing the patients who are adherent. In this way they could easier achieve their
therapeutic goals and improve their quality of life.
Graduate date:
2006-08-31 |
Last update:
2007-07-19 |
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Qualitative Aspekte der Tuberkulosebehandlung in sechs Regionen Deutschlands. Datenauswertung der DZK Studie "Untersuchungen zur Tuberkulose in Deutschland: Molekulare Epidemiologie, Resistenzsituation und Behandlung" unter besonderer Berücksichtigung sozioökonomischer Faktoren |
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Institution:
Institute of Tropical Medicine and International Health, Berlin
Author:
Kimmich, Martin
Hintergrund:
Internationale Veröffentlichungen zeigen, dass Management und Effektivität der Tuberkulosebehandlung von sozioökonomischen Faktoren beeinflusst werden. Aktuelle Untersuchungen hierzu liegen aus Deutschland nicht vor. Die im Rahmen der Neufassung des Infektionsschutzgesetzes erweiterte Datenerfassung, vor allem aber die detaillierten Erhebungen im Rahmen der DZK-Fingerprinting-Studie (durchgeführt in den Regionen Hamburg, Berlin, Hannover, München, Unterfranken und Oberpfalz) machen nun Auswertungen zu diesem Themenkomplex anhand eines großen Datenpools möglich. Eine derartige Analyse erscheint notwendig, um Risikogruppen bzw. Schwächen im Behandlungsmanagement aufzudecken und gezielte Interventionen zu ermöglichen.
Methoden:
Alle Patienten, die im Rahmen der DZK-Fingerprinting-Studie zwischen 1.10.2001 und 30.09.2002 erfasst wurden, wurden mit einem Datenstand von Juli 2003 in die Auswertung einbezogen (n = 766). Als Endpunkte zur Beurteilung der Therapiequalität wurden die vier Kriterien ?Therapieergebnis?, ?Dauer des stationären Aufenthalts?, ?Wahl des ersten Therapieregimes? und ?Zeitverzögerung zwischen erstem Arztbesuch und Diagnosestellung? gewählt. Als unabhängige Variablen wurden primär erkrankungsbezogene (Erkrankungstyp, d.h. pulmonal, extrapulmonal, offen, nicht offen, Schweregrad der Erkrankung, Resistenzsituation und Begleiterkrankungsstatus) und primär patientenbezogene Variablen (Geschlecht, Alter, Geburtsland, Soziale Schicht, Wohnsituation, Anzahl der Kinder im Haushalt, Aufenthaltsstatus, Art der Fallfindung, Armutsrisiko und Region der Behandlung) untersucht.
Ergebnisse:
Die Verzögerung zwischen erstem Arztbesuch und Diagnosestellung (?health system delay?) betrug 22 Tage im Median. Aktives Screening verkürzte die Latenz (OR für frühere Diagnosestellung 2,11. CI 1,64 ? 2,70), ebenso wurden pulmonale Manifestationen früher als extrapulmonale diagnostiziert (OR 1,31. CI 1,04 ? 1,65). Deutsche Herkunft verlängerte die Zeit bis zur Diagnosestellung im Vergleich zu Patienten nicht-deutscher Abstammung (OR 0,76. CI 0,62 ? 0,94). Außerdem hatte die Behandlungsregion Einfluss auf die Diagnoselatenz (in den Regionen Unterfranken und Berlin wurde die Diagnose später gestellt). Die Kriterien Art der Fallfindung und Region der Behandlung blieben auch nach Korrektur des Signifikanzniveaus für multivariate Analysen hochsignifikant.
57 % der Patienten wurden initial mit einer Standard-Vierfachtherapie (Isoniazid, Rifampicin, Pyrazinamid, Ethambutol mit oder ohne Streptomycin, HRZE/S) behandelt. 63,8 % erhielten eine Ersttherapie entsprechend den Empfehlungen des Deutschen Zentralkomitees zur Bekämpfung der Tuberkulsoe (DZK). Kinder und Patienten über 65 Jahren wurden seltener mit Vierfachkombinationen behandelt, außerdem wurden Patienten ausländischer Herkunft seltener mit Vierfachtherapien behandelt als in den DZK Therapieleitlinien empfohlen. Es wurden auffällige regionale Unterschiede im Therapiemanagement festgestellt. In der multivariaten Analyse unter korrigiertem Signifikanzniveau erwies sich jedoch keine der Variablen als unabhängig.
Die stationäre Aufenthaltsdauer (rein ambulante Behandlung wurde als 0 Tage stationär mit einbezogen) betrug durchschnittlich 43 Tage. Folgende Faktoren verkürzten den stationären Aufenthalt: Alter unter 15, Zugehörigkeit zu oberer Mittelschicht bzw. Oberschicht, leichtgradige Erkrankung, weibliches Geschlecht. Mit längerer Aufenthaltsdauer waren verbunden das Vorliegen von Begleitkrankungen, Resistenz gegen (ein oder mehrere) antituberkulöse Standardmedikamente (HRZE/S), Unterbringung in Gemeinschaftsunterkunft bzw. Obdachlosigkeit, das Vorliegen einer offenen TBC und Behandlung in der Region München. Alle genannten Variablen mit Ausnahme des Geschlechts erwiesen sich als unabhängige Einflussfaktoren.
76,7% aller Patienten schlossen mit einem günstigen Therapieergebnis ab. Von höherer Mortalität betroffen waren Männer, Patienten älter als 65 Jahre, Kinderlose und Patienten mit Begleiterkrankungen bzw. mit Tuberkulostatika-resistenter Erkrankung, Patienten aus den Regionen Berlin und Hannover, sowie Patienten, die aufgrund der Datenlage keiner sozialen Schicht zugeordnet werden konnten. Die Merkmale Alter über 65, nicht berechenbare Schichtzugehörigkeit und Region Hannover erwiesen sich als unabhängig.
Die Endpunkte Therapieabbruch bzw. Therapie mit unbekanntem Ausgang traten bei folgenden Patientengruppen häufiger auf: Patienten mit leichtgradiger Lungen TBC (OR 2,83. CI 1,42 ? 5,62), aktiv gescreente Patienten (d.h. Angehörige von Risikogruppen, einschließlich Asylbewerber, OR 4,19. CI 1,94 ? 9,04), andere Patienten ohne deutsche Staatsbürgerschaft (OR 2,81. CI 1,41 ? 5,64), Behandlungsregion München (OR 2,92. CI 1,25 - 6,78. Region Hamburg als Referenzkategorie). Nach Korrektur des Signifikanzniveaus blieben die Merkmale leichte TBC, nicht-deutsche Staatsbürgerschaft und aktive Fallfindung signifikant als unabhängige Einflussfaktoren.
Schlussfolgerung:
Neben Schlüsselvariablen wie Alter, Geschlecht, Erkrankungsform und Begleiterkrankungsstatus beeinflussten sozioökonomische Faktoren (Aufenthaltsstatus, Zugehörigkeit zu Risikogruppen, Schichtzugehörigkeit) den Verlauf und das Ergebnis der Tuberkulosebehandlung im untersuchten Krankengut. Risikogruppen-spezifische Interventionen erscheinen notwendig, um die Behandlungsergebnisse zu verbessern. Darüber hinaus bestanden auffällige regionale Unterschiede im Behandlungsmanagement, die gezielte Problemanalysen in einzelnen Behandlungszentren erforderlich erscheinen lassen.
Graduate date:
2006-12-08 |
Last update:
2007-07-18 |
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Risks and benefits associated with wastewater irrigation in the
Mezquital Valley, Mexico: Exploring the farmers? perspective
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Institution:
Institute of Tropical Medicine and International Health, Berlin
Author:
Friedrich, Carla
The use of urban wastewater for agriculture is a widespread practice with positive and negative effects. In most developing countries, urbanization has been more rapid than the capacity to safely dispose of the wastewater from the cities. The management of Mexico City?s wastewater is a complex issue with environmental, economic, and public health implications. Wastewater is transferred into the nearby state of Hidalgo, where its use for irrigation enhances agriculture in the semi-arid Mezquital Valley. Therefore, it provides economic benefits to farmers in the valley and, at the same time, provides a low-cost solution to the city?s need to dispose of its wastewater. However, it poses a threat to the health of producers and consumers of crops irrigated with wastewater, as well as to the environment on which the livelihoods of the farmers ultimately depend.
There are numerous published studies regarding epidemiological and environmental effects of wastewater irrigation in the Mezquital Valley. However, little is known about farmers? perspectives on this issue. The general objective of this project was to analyze the risks and benefits of wastewater irrigation within the broader socio-economic context of the Mezquital Valley. More specifically, the goal was to explore farmers? perceptions of the effects of wastewater irrigation on their health, their economic situation, and their local environment.
Four focus groups discussions and five individual interviews were conducted with farmers who irrigate their crops with wastewater from Mexico City.The discussions and interviews showed that the high level of contamination of the wastewater used for irrigation is a topic of high priority for the farmers in the Mezquital Valley, who are concerned about the detrimental effects of wastewater to their health, crops, and soils.. The health problems most often mentioned were skin ailments of different degrees, for which risk aversion methods such as the use of boots, and hygiene practices such as hand washing/bathing after being in contact with the wastewater were advocated by many farmers. Other health concerns included the contamination of fish in the reservoirs and the propagation of mosquitoes in the irrigation channels. The farmers generally agreed that the introduction of this resource to the Mezquital Valley has brought economic benefits to the region. The availability of water to cultivate year-round has increased farmers? income, and thus improved food security. Therefore, they are likely to continue using it for irrigation as long as it is available.
Future policies addressing health and other concerns regarding wastewater irrigation need to be analyzed in the context of other issues that are important for farmers in the region. It seems that the treatment of wastewater from Mexico City before its use in agriculture is both feasible and of high priority. Complementary policies, based on farmers? own opinions, should include hygiene promotion, better market regulation, improved technical assistance to the farmers regarding irrigation and the use of pesticides, and the promotion of crops and other agricultural activities better suited for the region. The inclusion of the farmers in the decision-making process will better guarantee the success of these policies.
Graduate date:
2007-02-01 |
Last update:
2007-07-18 |
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Spectrum of Travel Associated Infectious Disease in Relation to Purpose of Travel in Switzerland. Analysis of the Zürich GeoSentinel Surveillance Data January 2004 - May 2005. |
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Institution:
Institute of Tropical Medicine and International Health, Berlin
Author:
Fenner, Lukas
Abstract
Problem statement/objectives:
Migration and increasing travel have a major impact on the importation of infectious diseases. We evaluated the epidemiology of imported infectious disease in Switzerland.
Methods:
Descriptive and analytical analysis of patients presenting to Zürich University hospital with travel associated illness during the period January 2004 to June 2005. We compared the frequency of occurrence of selected diagnoses in travellers based on ?purpose of travel?. The University Hospital of Zürich is a local site of the global GeoSentinel surveillance network contributing clinician-based surveillance data.
Findings:
When comparing travellers and tourists (n=217) with persons whose purpose of travel was visiting friends and relatives (VFR) (n=121), VFR presented with a distinct infectious disease and risk spectrum. VFR were more likely to be diagnosed with malaria (adjusted odds ratio [OR] = 2.9, 95% confidence interval [CI] 1.2-7.3), viral hepatitis (OR = 3.1, 95% CI 1.1-9) and HIV/AIDS or sexually transmitted infections (OR = 2.6, 95% CI 1.2 ? 5.6) compared to tourists, but less likely to have the diagnosis of acute diarrhoea (OR = 0.4, 95% CI 0.2 ? 0.8) and less likely to seek pre-travel advice (20% vs. 67%, p=0.0001). Proportionate morbidity of acute diarrhoea was lower in VFR (173 vs. 364 / 1000 returnees). Sub-Saharan region contributed most to malaria morbidity by VFR.
Discussion and Conclusion:
Reason for travel is associated with the probability of diagnosis of certain post travel diseases. It is particularly important to identify VFR travellers in both the pre-and post travel settings as they are least likely to seek medical advice before travel and most likely to present with more serious disease, including malaria, post travel. In countries with a high migrant proportion improved public health strategies are needed to approach this vulnerable group.
Graduate date:
2007-03-29 |
Last update:
2007-07-13 |
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The stability of microsatellite markers for analysis of Leishmania infantum strains |
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Institution:
Institute of Tropical Medicine and International Health, Berlin
Author:
Keyes, Heather
Accurately determining which Leishmania species is present is of very important in preventing the development of drug-resistant parasites and in the case of HIV-Leishmania coinfection, differentiation of parasite strains is necessary to determine whether patients are suffering from relapse or reinfection so that they can be treated appropriately. Accurate typing is also very important in understanding worldwide epidemiological changes in the leishmaniases so that better control programs can be designed and implemented.
Analysis of L. infantum strains using microsatellite markers is a highly discriminatory method that is easily reproducible between different laboratories and has high throughput potential. Microsatellite marker analysis is particularly important in an epidemiological situation like that of leishmaniasis in Europe, in which several different Leishmania strains are known to be present, the bulk of them have been identified as belonging to zymodeme MON-1, and there is a relatively high number of known cases of HIV-Leishmania coinfection.
The purpose of this study was to examine the stability of 11 independent microsatellite markers developed for the analysis of L. infantum zymodeme MON-1 during long-term in vitro cultivation and upon passage through animals. Nine of the 11 markers were found to be stable. Two markers exhibited instability upon long-term in vitro cultivation and one marker was unstable after animal passage. All markers described in this study should be used for the continued study of L. infantum, but they should be applied to isolates as soon as possible following isolation and number of in vitro cultivations should be limited to lessen the chance of instability.
Graduate date:
2006-12-08 |
Last update:
2007-07-18 |
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The Usefulness of the T.A.L.C growth chart and the single parturient symphysis-fundal height measurement in the prediction of low birth weight in Cameroon: The case of the Central Maternity of Yaounde |
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Institution:
Institute of Tropical Medicine and International Health, Berlin
Author:
Kom Mogto, Christelle
Background:
Low birth weight is one of the leading causes of perinatal mortality nearly everywhere. In some places, serial symphysis-fundal height measurements made throughout pregnancy are plotted on charts, in order to predict the birth weight. In Cameroon, symphysis-fundal height measurements are usually done in routine antenatal care but a chart is not in use to visualise the growth of the fetus.
Objectives:
We designed this study to assess the validity of:
? the T.A.L.C. growth chart which has been developed in the Democratic Republic of Congo for use in developing countries.
? the single parturient SFH measurement as a method of LBW prediction, for pregnant women who are seen only at the time of delivery.
Methods:
Type of study: A retrospective study design was adopted for the measurements of symphysis-fundal height.
A cross-sectional study was adopted for birth weights.
Population and sample size: The study was conducted at the Central Maternity of the Central Hospital of Yaounde. Our sample was made up of pregnant women who have attended an antenatal clinic from the 20th week of gestation or earlier, until delivery, who have given birth during our study period and who have at least three serial SFH measurements in their antenatal card.
Data collection: Data were collected from January 5th to February 15th , 2004.
Identity, previous obstetrical history and SFH measurements were recorded for each woman included.
Data analysis: All SFH measurements done throughout pregnancy and at delivery were plotted on the T.A.L.C. growth chart.
The validity of the two screening methods was evaluated in terms of sensitivity, specificity, positive and negative predictive values.
Results:
We found with the use of the T.AL.C. growth chart as a screening method a sensitivity of 70%, a specificity of 95.2%, a positive predictive value of 72.7% and a negative predictive value of 97.9%.
The single pre-delivery SFH measurement equal or less than 30 cm as a predictor of LBW gave us a sensitivity of 66%, a specificity of 97.9%, a positive predictive value of 50% and a negative predictive value of 97.3%.
Discussion:
The sensitivity and the specificity of the T.A.L.C. growth chart are similar to the results obtained with the Togolese chart in Togo.
A chart constructed in South Africa is less sensitive and specific than ours, whereas better results are obtained in other studies.
In our population and in other studies, the sensitivity and the specificity of a single parturient SFH measurement setting a cut-off of 30 cm are comparable.
Conclusion:
Given our results, we recommend the use of both the T.A.L.C. growth chart and the single parturient measurement for the prediction of LBW in Cameroon.
Graduate date:
2007-06-15 |
Last update:
2007-07-18 |
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Tuberculosis recurrence in children under five years of age: A subgroup analysis from the Cape Town Observational Study |
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Institution:
Institute of Tropical Medicine and International Health, Berlin
Author:
Mall, Sabine
Rationale:
In Cape Town, South Africa, the Cape Town Observational Study showed a very high incidence of tuberculosis (860/100.000 person-years) in children under two years of age. Among the 5332 children, 81 had repeat episodes of tuberculosis (TB).
Objective:
To describe baseline characteristics and clinical profile of both groups (single and recurrent episodes of TB) and describe factors that may be associated with the occurrence of second episodes of TB in children.
Methods:
A retrospective analysis of an observational study with a ?before and after? design was performed. The dataset of 81 children with repeat episodes was extracted from the Cape Town Observational study which was conducted from1999-2004 in the Cape Town Metropole area to observe a changeover in BCG (Bacille Calmette-Guerin) vaccination policy. The data was collected as part of the routine process in health facilities.
A group of 3900 children with a single episode of tuberculosis who presented between 29th of September 1999 and 10th of June 2002 was taken as a control group and the group of 81 children with two episodes who presented during the same time. Both groups were analysed descriptively and compared for possible differences in known risk factors. Where appropriate, also the first and second episodes of the 81 children were analysed separately and compared with each other and the control group.
Results:
37, 1% of children in the group with recurrent episodes were HIV positive versus 11, 9% in the single episode group, the risk ratio of having a second episode of TB when HIV infected was RR 3, 16. Malnutrition was more pronounced in the first episode of the group with recurrent TB. 99, 6% of children diagnosed with single or repeat episodes of TB were either black or coloured and came from poor areas with a high background incidence of TB. In the group with repeat episodes coloured children represented the majority of cases, whereas in the single episode group it was black children.
Children with repeat episodes of TB were hospitalized more often (37, 0% vs. 9, 4%) and the disease was more severe (46, 9% vs. 38, 1%).
Conclusions:
Children with repeat episodes of TB had a higher rate of HIV infection, were more malnourished when diagnosed with their first episode and presented with more severe disease. Whether the recurrent episodes of TB were due to re-infection or relapse could not be answered from this routine data. Studies including information about treatment outcome, bacteriological results and equal follow up time periods are needed to provide answers to this question.
Graduate date:
2006-08-31 |
Last update:
2007-07-19 |
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Tungiasis in a rural community in Alagoas State, Brazil: prevalence, morbidity, seasonal variation and risk factors |
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Institution:
Institute of Tropical Medicine and International Health, Berlin
Author:
Heukelbach, Jörg
Introduction
The tropical parasitic skin disease tungiasis is defined as an infestation with the sand flea Tunga penetrans (Linnaeus 1758). The female flea penetrates into the epidermis and undergoes a hypertrophy, reaching the size of up to one cm in diameter. Severe tungiasis is linked to poverty, and the disease can be seen as a paradigm for a Neglected Tropical Disease. Complications due to tungiasis include severe inflammation, bacterial superinfection, ulcers, fissures, deformation and loss of toenails, as well as deformation of digits. The sand flea occurs in most Latin
American countries, in the Caribbean, and throughout sub?Saharan Africa. Tungiasis is common in resource-poor populations throughout northeast Brazil. Alagoas State is the second smallest State of Brazil with an extension of about 28.000 km2 and a population of three million. It lies in the Northeast, the poorest region of the country. However, the epidemiological situation of the disease in Alagoas State is not fully understood, and systematic epidemiological studies have never been performed.
Methods
To describe the prevalence and severity of tungiasis, associated pathology, risk factors for infestation, and the seasonal variation of the prevalence in rural Alagoas, we performed a clinical-epidemiological study. The study was done in the municipality of Feliz Deserto, a community situated approximately 120 km south of the capital Maceió. Two cross-sectional surveys were done. All households in the study area were visited in June/July 2003 (rainy season) and in October/November 2003 (dry season). The household members were examined clinically for the presence of tungiasis. Numbers of lesions, as well as symptoms and signs associated with the infestation were documented. Additionally, household members were interviewed to assess factors associated with the infestation. In the rainy season, 88,6% (1.015/1.146), and in the dry season 91,1% (990/1.087) of the respective target populations were examined.
Results
The overall prevalence of tungiasis was 21,6% (95% CI: 19,0-24,1) in the rainy
season and 29,5% (95% CI: 26,6-32,3) in the dry season (p < 0,0001). In both
surveys, the prevalence of tungiasis was not significantly higher in males as compared to females (23,5% vs. 20,0%; p=0,2). The highest prevalence was found in boys (5 ? 9 years) in the dry season (48,5%; 95% CI: 8,2-58,8). Prevalence was high in the children and decreased abruptly in the age groups > 15 years. The median number of lesions was one in both surveys (mean = 2,99 in the rainy season and mean = 3,65 in the dry season). A maximum of 42 lesions per individual was counted in the rainy season, and of 45 lesions in the dry season. In the rainy season 190/219 (86,8%), and in the dry season 246/292 (87,7%) individuals with tungiasis had a mild infestation (1 ? 5 lesions). Only one (0,5%) individual in the rainy, and five (1,7%) in the dry season were heavily infested (> 20 lesions). The five heavily infested individuals represented less than 2% of the individuals with tungiasis, but harboured 17,3% of the total parasite load in the community. Most lesions occurred on the feet (rainy season: 96,3%; dry season: 97,5%). About 70% of infested individuals had periungual lesions, and 50% had lesions on the toes excluding the periungual areas. A considerable number of individuals presented with lesions on the hands (6,9% and 5,1%, respectively). The most common signs in individuals with tungiasis were desquamation of the skin (57,5% in the rainy season; 44,5% in the dry season), hyperkeratosis (51,6% and 34,6%) and nail deformation (32,0% and 23,3%). Signs of superinfection were present in 15,5% and 13,7% of cases, respectively. Severe pathology, such as fissures (10,5% and 9,3%), loss of toe nails (5,5% and 2,4%) and difficulty walking (1,4% and 0,7%) occurred less commonly; 67% of the individuals stated that they usually felt the flea penetrating into the skin. Several socio-economic, demographic and behavioural variables were significantly associated with tungiasis.
In the bivariate analysis, highest odds ratios were found for individuals living in
houses with sandy floors (OR=2,45; 95% CI: 1,66-3,59), aged < 15 years (OR=2,34; 95% CI: 1,75-3,13), living in big families (OR=2,34; 95% CI: 1,51-3,72), and those spending the evening in the endemic area (OR=2,26; 95% CI: 1,18-4,67). The odds ratio of living in palm houses was 2,83 (95% CI: 0,81-10,27). However, only two families did not live in brick or adobe houses, and this association was not statistically significant (p=0,07). All five members of the only family in the community that kept pigs were infested with T. penetrans. Independent risk factors for tungiasis, as 8 obtained from the logistic regression analysis, were: age < 15 years (adjusted OR=2,14; 95% CI: 1,60-2,88), living in a house with sandy or clay floor (adjusted OR=2,11; 95% CI: 1,43-3,09), dog ownership (adjusted OR=1,63; 95% CI: 1,22- 2,19), living in a family with four or more members (adjusted OR=1,57; 95% CI: 1,02-2,46), and never wearing shoes (adjusted OR=1,37: 95% CI: 1,02-1,84).
Conclusions
The results of this study show that tungiasis occurs to an important degree in Alagoas State and that prevalence varies according to the season. The distribution of sand flea lesions in the community was described in detail, as well as the pathology caused by the infestation. Similar to other studies, children were identified as a high risk group. Risk factors for infestation were identified as possible targets for intervention, such as cementing floors of houses. The data of this study will help to elucidate the epidemiology of tungiasis and to plan and implement effective control measures.
Graduate date:
2007-02-20 |
Last update:
2007-07-18 |
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Understanding the patterns of chronic obstetric morbiditiy and validation of self reports by women living in an urban slum distirct of Dhaka, Bangladesh |
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Institution:
Swiss Tropical & Public Health Institute, Basel
Author:
Sultana, Samina
Graduate date:
2007-10-31 |
Last update:
2009-08-03 |
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Usefulness and Cost of Implementing LightCycler PCR Diagnostic Service for Dengue Virus at the Institute Pasteur in New Caledonia |
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Institution:
Institute of Tropical Medicine and International Health, Berlin
Author:
Lichtfuss, Gregor
In 2003 New Caledonia, a French Département d?outre mer in the South Pacific, was struck by the worst dengue fever epidemic ever recorded, affecting a total of 7558 persons and resulting in 17 fatalities. Dengue infection in all its clinical manifestations (febrile disease, dengue fever, dengue haemorrhagic fever and dengue shock syndrome) is caused by four types of closely related Flaviviruses (DEN1, DEN2, DEN3 and DEN4), which are transmitted by mosquitoes. A fast diagnosis of dengue is not only important for differential diagnosis of other diseases with dengue-like symptoms but also for public health measures. The most common approach to contain an emerging outbreak is insecticide spraying of the neighbourhood after laboratory confirmation of a case, which has to be done in a timely manner to prevent a spreading of the disease by the vector. Standard diagnostic methods for people suspected of being infected with dengue range from the cultivation of virus isolates, over detection of dengue specific antibodies in the patient, the detection of viral proteins circulating in the body, to the direct detection of the virus?s nucleic acids. The current methods which the Institut Pasteur de Nouvelle Calédonie (IPNC) uses to diagnose dengue virus infection suffer from being relatively slow (turn-around times being at least 24 hrs) and having a relatively limited capacity for high test loads. As a result reports of positive tests often do not reach executive government levels for days or even weeks and individual diagnosis during an outbreak is limited to only the most severe cases. With most tests being demanding in both laboratory expertise and time, real-time PCR systems, like the LightCycler? instrument, look promising to lead the dengue diagnostic process to a new level.
Therefore this study was undertaken with the objectives to set-up a LightCycler? (LC) based diagnostic method at the IPNC in order to improve the local laboratory?s capacity to rapidly diagnose dengue, to asses whether the LC would be financially beneficial for the IPNC and to determine if the LC would speed up the notification process and timeliness of preventive measures in New Caledonia.
To reach these objectives, a published LC protocol was first set-up and then optimized , using dengue infected mouse tissues, and then validated testing 202 human sera (49 DEN1, 55 DEN2, 57 DEN3, 2 DEN4, 6 DEN1+3, 33 controls) against the standard semi-nested PCR (snPCR) . To asses and compare both methods, timing and material use was recorded during these experiments and the material costs of both methods were calculated. Additionally, the yearly costs for the IPNC of running both PCRs were calculated, including building, equipment and personnel costs. Further, the costs for standard sentinel work and for an outbreak situation were predicted. To asses the value of the LC for the IPNC and the local sentinel system, questionnaires and interviews were the basis to construct a timing model of the sentinel network (SN) and to predict the impact of the LC.
The LC showed a sensitivity of 92% to 96% and a specificity of 100% with the snPCR as the reference test. The LC has a 40% higher material cost (at 5 or more samples tested per run) with 11,80? per sample (5? snPCR). Running the programme for sentinel work costs 38.600,00? (snPCR) and 37.300,00? per year (LC = 97% of snPCR costs). The total cost per sample is 53? (snPCR) and 51? (LC). During a simulated outbreak the snPCR programme is predicted to cost 141.134,00? and the LC 140.775,00? (99,75%) for the outbreak year, but at the same time the LC can diagnose up to 62% more samples (average costs per sample: 52? snPCR, 32? LC (62%). In the laboratory, the LC diagnosis is 1.57 times faster than the snPCR (6.5 hrs vs. 10.25 hrs) but the impact of faster diagnosis on the SN is low. At best, a 2% speed increase in the notification process can be achieved by switching from the snPCR to the LC. The shortened delay at the laboratory however is close to insignificance compared to the time frame of the overall process from the onset of first symptoms to the end of vector control measures.
Based on these findings, the implemented LC protocol is seen as a good alternative to the snPCR as the standard diagnostic PCR test at the IPNC. Even with higher material costs running the LC within a diagnostic programme has the same overall costs as running a snPCR based programme, as shortened handling time reduces the involved personnel costs. At the same time the LC is up to two times faster and has twice the capacity than the snPCR. Thus a shift away from the snPCR to the LC will not result in direct financial savings but will be rewarded by higher throughput and higher productivity of the facility.
Graduate date:
2006-08-31 |
Last update:
2007-07-19 |
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