International Health

Editorial Board

2009-12-01

Building research capacity through international partnerships

Andy Haines, Hazel Dockrell — 2009-12-01

Over recent decades there have been a number of calls for greater investment in health research in low-income countries. For example, the Commission on Health Research for Development suggested in 1990 that at least 2% of national health budgets and 5% of development aid should be invested in health research and building research capacity. Despite several subsequent calls these aspirations have not yet been met. The same constraints identified by the Commission are still present today – weak human resources, institutional infrastructure and financing. Despite Africa's high disease burden only 0.6% of scientific publications on health worldwide are authored by African investigators. An editorial in 2005 described African health research as ‘moribund’ and suggested that ‘research with, rather than in or about, Africa is the goal’.

The social history of older age

Eric Midwinter — 2009-12-01

Summary: In the making and execution of public policy of every kind, health and welfare services crucially among them, a long demographic perspective is a valuable instrument. It becomes clear that, amid the exponential growth of world population, with its attendant expansion of those in the older age-group, survival, rather than longevity, is the key. Adopting the UK as a working model, the use of a social and numerical analysis by function rather than chronological age is advocated as a help-meet, not least because this evades some of the negativity with which older age is regarded. A brief summation of age prejudice is added as a further caution about the watchfulness necessary when in pursuit of social goals, such as health and welfare.

The International Union Against Tuberculosis and Lung Disease: past, present and future

2009-12-01

Summary: The International Union Against Tuberculosis and Lung Disease (The Union) is the oldest international non-governmental organization involved in the fight against tuberculosis. This review documents the history and structure of The Union up to 2009, and describes the achievements that have taken place in the field of tuberculosis and lung health. The progress made in tackling the major killer (pneumonia) of children less than 5 years of age, the barrier to affordable essential asthma medicines, the complex issue of tobacco control, the move into the realm of HIV and AIDS, and new ideas and activities around the increasingly important domain of operational research are described and discussed. Finally, as with many institutions that have seen a rapid phase of growth, expansion and decentralisation to regional offices around the world, the review highlights the internal strategic initiative that aims to fine-tune the organisational structure, clarify lines of authority, create more efficient business, human resource and financial systems and revise, where necessary, The Union's guiding mission, vision and values for the future.

Staple diets and duodenal ulcer prevalence

Frank I. Tovey — 2009-12-01

Summary: The prevalence of duodenal ulceration in India, Africa, China and other developing countries is high in some regions and low in others, despite a high prevalence of Helicobacter pylori infection throughout the areas. This variation is related to the staple diet of the regions involved. In regions where, because of the climate, the staple food is milled white rice, wheat or maize, or cassava, yams,sweet potato and green bananas the prevalence of duodenal ulcer is higher than in regions where the staple diet is based on unrefined wheat or maize, soya, certain millets or pulses. These differences have been reproduced in animal peptic ulcer models. Using these models it has been shown that the protective factor against ulceration lies in the lipid fraction present in staple foods from the low prevalence areas. The lipid fraction not only gave protection in the experimental models against ulceration but also promoted healing. The pulse Dolichos biflorus (horse gram) gave the greatest yield of the lipid and this was used for further investigations. It was found that the ulceroprotective activity of the lipid lay in its phospholipid and sterols fractions.The presence or absence of protective lipid in the diet would account for the regional differences in duodenal ulcer prevalence.

Comparison and critical appraisal of dengue clinical guidelines and their use in Asia and Latin America

2009-12-01

Summary: The World Health Organization (WHO) dengue classification scheme for dengue fever (DF) and dengue haemorrhagic fever (DHF)/dengue shock syndrome (DSS) has been adopted as the standard for diagnosis, clinical management and reporting. In recent years, difficulties in applying the WHO case classification have been reported in several countries. A multicenter study was carried out in Asia and Latin America to analyze the variation and utility of dengue clinical guidelines (DCGs) taking as reference the WHO/PAHO guidelines (1994) and the WHO/SEARO guidelines (1998). A document analysis of 13 dengue guidelines was followed by a questionnaire and Focus Group discussions (FGDs) with 858 health care providers in seven countries. Differences in DCGs of the 13 countries were identified including the concept of warning signs, case classification, use of treatment algorithms and grading into levels of severity. The questionnaires and FGDs revealed (1) inaccessibility of DCGs, (2) lack of training, (3) insufficient number of staff to correctly apply the DCGs at the frontline and (4) the unavailability of diagnostic tests. The differences of the DCGs and the inconsistency in their application suggest a need to re-evaluate and standardise DCGs. This applies especially to case classification and case management.

Official development assistance for health–how neglected are neglected tropical diseases? An analysis of health financing

Bernhard H. Liese, Liane Schubert — 2009-12-01

Summary: The increasing amounts of official development assistance (ODA) for health have been aimed primarily at fighting HIV/AIDS, malaria and tuberculosis. Neglected tropical diseases (NTD), one of the most serious public health burdens among the most deprived communities, have only recently drawn the attention of major donors. While frequently stated, the low share of funding for NTD control projects has not been calculated empirically. Our analysis of ODA commitments for infectious disease control for the years 2003 to 2007 confirms that Development Assistance Committee (DAC)-countries and multilateral donors have largely ignored funding NTD control projects. On average, only 0.6% of total annual health ODA was dedicated to the fight against NTDs while the average share of control projects for HIV/AIDS was 36.3%, for malaria 3.6%, and for tuberculosis 2.2%. This allocation of health ODA does not reflect the diseases’ respective health burdens. Furthermore, the availability of cost-efficient treatments for NTDs supports the call for an increase in funds dedicated to the control of NTDs.

The shift from public to private health care providers and malaria deaths in Jalpaiguri district, West Bengal, India, 2006

Puran K. Sharma, T. Sen, R. Ramakrishnan, Y. Hutin, M. Murhekar — 2009-12-01

Abstract: We investigated an increase in malaria deaths in order to formulate control measures. A search of records in health care facilities for cases of death following fever, with a blood smear or rapid antigen test positive for Plasmodium falciparum, identified 77 fatalities. Of these, 72 (93%) occurred in hospitals (78% of which in the 24hours following admission). Of 60 family members of the patients who died interviewed, 70% reported that the patient had received care from unqualified rural private practitioners available round the clock. Among 100 of these rural practitioners assessed, 21% knew anti-malarial dosage and 7% knew malaria severity criteria. There were 65% and 42% vacancies among 240 community health worker and 12 microscopist positions, respectively, in the public sector in the area. As a result, the mean interval between active case search rounds in the community was 35 days (standard: 14) and the median time between blood slide collection and radical treatment was 12 days (standard<2 days). Deficiencies in the public health system may have led to a shift towards rural practitioners. Poor management of malaria may have contributed to deaths. We posted microscopists and community health workers in the area to restore appropriate malaria management in the public sector.

Evaluation of community intervention with pit latrines for trachoma control in Ghana, Mali, Niger and Nigeria

2009-12-01

Summary: Trachoma is the leading cause of preventable blindness worldwide and is controlled with an integrated strategy of treatment and prevention which includes latrine provision and promotion. We aimed to evaluate the latrine uptake, construction, and usage in villages participating in latrine promotion programmes supported by The Carter Center in Ghana, Mali, Niger and Nigeria where 113 457 new latrines have been reported from 2002 to 2008.In each country a two stage cluster random sampling design was used to select villages and households for evaluation. Household heads were interviewed using a standardised structured questionnaire and latrines were inspected.The sample included 1154 households (Ghana: 326; Mali: 293; Niger: 300; and Nigeria: 235). Overall, 813 (70.5%, 95% confidence interval [CI] 65.7-74.8) had pit latrines, ranging from 30.3% of households in Niger to over 92.0% of households in Ghana and Mali. Of those with latrines 762 (93.7%) were found to be usable and 659 (86.5%) were in use. Overall 659/1154 (57.1%) of households in the targeted communities were using latrines at least 12 months after latrine promotion was initiated.Latrine promotion had been successful increasing access to sanitation in different country contexts and demonstrates the target population are willing to construct, use and maintain household latrines.

Perceptions on onchocerciasis and ivermectin treatment in rural communities in Uganda: implications for long-term compliance

Richard Ndyomugyenyi, Andrew Byamungu, Rose Korugyendo — 2009-12-01

Summary: Registers of community-directed distributors of ivermectin for onchocerciasis from 2000 to 2005 were reviewed to identify people highly and poorly compliant to ivermectin treatment. Compliance was termed ‘high’ if a person took annual ivermectin ≥4 out of 6 times and ‘poor’ if it was taken <4 times. Individuals (409 and 362 highly and poorly compliant, respectively) were interviewed on knowledge of onchocerciasis, severity of the disease, benefits of ivermectin treatment and its adverse events. Those who believed onchocerciasis to be a serious disease and also believed ivermectin treatment alleviated symptoms (71.9%), were highly compliant compared with (37.7%) who believed that onchocerciasis was not a serious disease and ivermectin did not alleviate symptoms (P<0.001). Those who believed that ivermectin caused itchiness were 6.1% and 39.5% of highly and poorly compliant respectively (P<0.001). Given that people more highly compliant with ivermectin mass drug administration (MDA) appear to better recognize the severity of onchocerciasis and the salutary effects of ivermectin, their enthusiasm to take ivermectin should be maintained through regular health education on the benefits and importance of continued treatment, and proper management of adverse events. The conclusions drawn in this article may equally apply to other MDA programmes.

Attitude of men in Nigeria to vasectomy

Hyginus Uzo Ezegwui, Jamike Osondu Enwereji — 2009-12-01

Summary: The objective of this study was to assess the attitude of men in Nigeria towards vasectomy as a method of family planning. This was a cross-sectional study, using self-administered pre-tested questionnaires containing mainly close-ended questions. The questionnaires were given to 146 randomly selected men. The responses were analyzed with descriptive statistics. Ten (6.8%) may accept vasectomy with the knowledge they have while 130 (89.0%) will not. Eighty-eight (67.7%) believe sterilization procedures should be left for women only. Vasectomy was viewed as castration by 55 (40.7%). Forty-three (31.2%) may consider vasectomy if they understand that it is not associated with problems, 82 (59.4%) refused while 13 (9.4%) did not know if they would ever accept the procedure. There was a lack of knowledge of vasectomy and attitudes towards it were based on myths and misconceptions regarding the procedure; some may accept it if they understand the safety of it. Interestingly, level of education does not improve vasectomy uptake. A concerted effort to involve men in reproductive health is needed. Interpersonal communication and counseling will greatly improve vasectomy uptake in developing countries.

Relative efficacy of repellent-treated wristbands against three major mosquito (Diptera: Culicidae) vectors of disease, under laboratory conditions

Kaliyaperumal Karunamoorthi, Shanmugavelu Sabesan — 2009-12-01

Summary: A laboratory study was carried out to evaluate the relative efficacy of N-N-diethyl-m-toluamide (DEET)- and N,N-diethyl phenylacetamide (DEPA)-treated wristbands against three major vector mosquitoes viz., Anopheles stephensi Liston, Culex quinquefasciatus Say and Aedes aegypti (L.), at two different concentrations viz., 1.5 and 2.0mg/cm2. Overall, both DEET and DEPA have shown various degrees of repellency impact against all three vector mosquitoes. DEET offered the highest 317.0min mean complete protection against An. stephensi and DEPA provided 275.6min complete protection to Cx. quinquefasciatus at 2.0mg/cm2. However, DEPA-treated wristbands did not show any significant differences in terms of reduction of human landing rate and mean complete protection time against An. stephensi and Ae. aegypti between 1.5 and 2.0mg/cm2. DEET demonstrated relatively higher repellency impact to vector mosquitoes than DEPA. However, χ2 analysis revealed that there was no statistically significant difference found in repellent efficiency between DEET and DEPA (P=0.924). The present study result suggests that repellent-treated wristbands could serve as a means of potential personal protection expedient to avoid insect's annoyance and reduce vector-borne disease transmission. They are extremely valuable whenever and wherever other kinds of personal protection measures are unfeasible.

Hearing impairment in Tanzanians with albinism

2009-12-01

Summary: Community-based studies have suggested that those affected with albinism, an important condition in East Africa, may be at a greater risk of developing hearing problems. This study shows that the prevalence of hearing loss is increased in Tanzanians with albinism and that hearing loss is associated with fewer years in education. 64 participants with albinism and 90 controls without were recruited from clinics held in the Western Kilimanjaro area. Hearing was evaluated using pure-tone audiometry at frequencies between 250Hz to 8000Hz and patients completed a questionnaire to evaluate their educational history. Of the participants with albinism, 33 (51.6% [95% CI: 39.3–63.8%]) had hearing impairment. This was significantly greater than the control group, where 20 (22.2% [95% CI: 13.6–30.8%]) had a similar hearing impairment (P<0.001). Within the albinism group those with hearing impairment spent a mean of 6.9 years in education compared with those with normal hearing who spent a mean of 8.3 years in education (P=0.046). Further studies are now required to determine the cause of these differences. Healthcare providers should be aware of hearing impairments when managing those with albinism and make the appropriate specialist referrals if further evaluation and treatment is required.

Estimation of population coverage for antibiotic distribution for trachoma control: a comparison of methods

2009-12-01

Summary: Trachoma control includes mass drug administration (MDA) with antibiotics targeting coverage of at least 80%. Coverage is traditionally calculated by dividing doses distributed by population estimate, which is unreliable. We compared a verifiable coverage assessment method against self-reported participation and the traditional calculation, and examined factors associated with MDA participation in Akobo County, Southern Sudan. During MDA, recipients were marked with indelible ink and followed-up using a two-stage household survey: 25 clusters from three districts, and 10 households per cluster. All household members were enumerated; asked about self-reported participation and observed for indelible marks. Household heads were interviewed to assess factors associated with MDA. Overall 11 419 treatments were given and 1358 residents from 247 households surveyed. By traditional methods MDA coverage was 20.9% (95% CI: 20.6-21.3); 61.5% (95 % CI: 49.4-73.6) by self-reporting; and 37.5% (95% CI: 25.1%-49.9%) from observed ink marks. Controlling for other factors, presence of a health worker (OR 2.3, 95% CI: 1.5-3.6); head of household knowledge of azithromycin (OR 1.6, 95% CI: 1.5-3.1); and head of household advance notice of MDA (OR 34.9, 18.1-66.3) were independent predictors of participation. Cluster randomised surveys can estimate MDA coverage better than the traditional method and implementation of indelible marking merits investigation.

Caffeine for the management of apnea in preterm infants

Eunice Mueni, Newton Opiyo, Mike English — 2009-12-01

Summary: Considerable uncertainty persists regarding the efficacy and safety of methylxanthines (caffeine, theophylline – in intravenous form named aminophylline) for the prevention and treatment of infant apnea. To help inform national guideline development in Kenya we undertook structured literature searches to identify current evidence on caffeine therapy for infant apnea. Available evidence shows that caffeine is as effective as intravenous theophylline (aminophylline), but is safer and easier to give and has better therapeutic properties. It is therefore recommended for the treatment of apnea of prematurity. Caffeine is also the preferred drug if clinicians plan to provide apnea prophylaxis. As prematurity is likely to result in more than 1 million deaths a year, mostly in resource-poor settings, greater efforts need to be made to ensure interventions such as caffeine, currently unavailable in countries such as Kenya, are made more widely available.

News and Views

2009-12-01