International Health

Editorial Board

2011-12-01

Promotion of malaria home-based treatment in Africa: the dangers of creating a second health system

Agnès Aubouy — 2011-12-01

Abstract: Many African countries have begun to scale-up home-based management of malaria (HMM) with artemisinin-based combination therapy. Evidence shows that this strategy gives efficient results in reducing the malaria burden. This initiative should be promoted to reduce malaria-related mortality and morbidity. HMM could, however, lead to critical public health problems, including the misdiagnosis of serious infections distinct from malaria as well as desertion of the public health system. I wish to emphasise the importance of improving the existing health system in African malaria-endemic areas for long-term improvement of population health in this context of HMM implementation.

Ensuring tuberculosis infection control to support greater involvement of people living with HIV in health care

Masaya Kato, Katsunori Osuga, Masami Fujita, Masamine Jimba — 2011-11-11

Abstract: Health care workers (HCWs) in high TB burden countries bear significant risks of being infected with Mycobacterium tuberculosis and developing TB disease through their work. In recent years, an increasing number of people living with HIV (PLHIV) are taking part in delivering HIV and other health services in resource-limited settings with high TB burden. The greater involvement of PLHIV in health service delivery has many beneficial consequences on individuals and health systems, however, the involvement creates considerable opportunities for them to be exposed to patients with infectious TB disease. Due to their immunodeficiency, PLHIV are far more likely to develop active TB following the infection. Available evidence and recently revised WHO policy guidance on TB infection control suggest simple, predominantly administrative control measures are feasible and effective in reducing the infection. Nevertheless, many countries are still at the early stage of developing infection control policies. We call for evidence-based infection control measures in order to ensure a safe working environment for PLHIV in support of their greater involvement in health care. More research is needed to strengthen knowledge on TB infection risks amongst PLHIV through involvement in service delivery, and optimal interventions to reduce it.

Outbreak response immunisation: the experience of Chad during recurrent measles epidemics in 2005 and 2010

G. Guerrier, J. Guerra, F. Fermon, W.B. Talkibing, J. Sekkenes, R.F. Grais — 2011-11-11

Abstract: Despite impressive gains in measles control globally, measles epidemics continue to occur in countries with insufficient vaccination coverage. WHO guidelines now recommend outbreak response immunisation (ORI) for controlling measles outbreaks in certain contexts. The objective of this study was to describe late and early response vaccination activities during two consecutive measles outbreaks that occurred in 2005 and 2010 in N’Djamena, Chad. Using Lot Quality Assurance Sampling, vaccination coverage was estimated to be low before the interventions. Following mass vaccination campaigns, measles cases declined. The timeliness and quality of ORI activities are crucial determinants of success. However, effective outbreak response should be accompanied by strong routine vaccination programmes to ensure sustainable high vaccination coverage.

Rabies control initiative in Tamil Nadu, India: a test case for the ‘One Health’ approach

2011-11-11

Abstract: Although India accounts for nearly 50% of the global rabies mortality, there is no organised national rabies control programme. Rabies control is generally confined to small urban pockets, with minimal intersectoral co-ordination. Tamil Nadu is the first state in India to implement a state-wide, multisectoral rabies control initiative. The CDC Program Evaluation Framework guided the current assessment of this rabies prevention and control initiative in Tamil Nadu. Principle stakeholders were engaged through a series of interviews in order to document policy initiatives, to describe the programme and to understand their various roles. Surveillance data on dog bites were triangulated with vaccine consumption and dog population data to identify trends at the district level in the state. Findings and recommendations were shared at different levels. Rabies control activities in Tamil Nadu were conducted by separate departments linked by similar objectives. In addition to public health surveillance, animal census and implementation of dog licensing rules, other targeted interventions included waste management, animal birth control and anti-rabies vaccination, awareness campaigns, and widespread availability of anti-rabies vaccine at all public health facilities. In conclusion, this assessment suggests that it is possible to implement a successful ‘One Health’ programme in an environment of strong political will, evidence-based policy innovations, clearly defined roles and responsibilities of agencies, co-ordination mechanisms at all levels, and a culture of open information exchange.

Integration of deworming into an existing immunisation and vitamin A supplementation campaign is a highly effective approach to maximise health benefits with minimal cost in Lao PDR

2011-11-11

Abstract: Infection with soil-transmitted helminths (STH) is a major public health problem in many developing countries, with pregnant women and children particularly at risk. Preventive chemotherapy, which is the intervention currently recommended by the WHO against the main helminth infections including those caused by STHs, aims at reducing morbidity through periodical administration of anthelminthic drugs either alone or in combination. The Expanded Programme on Immunization is one of the most widely implemented health programmes in the world and has well established access to children and women. The present study investigated the cost of the provision of anthelminthic drugs during existing immunisation campaigns. In Lao PDR, use of this integrated approach compared with implementation of the vertical deworming campaign alone allowed a reduction of the individual cost of deworming by 10 times (from US$0.23 in the vertical deworming campaign to US$0.03 in the integrated campaign). When drug cost was excluded, the cost of deworming an individual was US$0.007, implying that deworming 100 children would cost less than US$1 if drug donation was in place. The burden posed on health workers by the integration process was perceived as minimal and manageable. Moreover, delivery of anthelminthic drugs during immunisation campaigns enabled campaign teams to observe drug intake directly, which assured safety. These findings prove that integration is an opportunity to maximise health benefits through the delivery of multiple health products and the attainment of high coverage.

Why we need to rethink the strategy and time frame for achieving health-related Millennium Development Goals

Emre Özaltin, S.V. Subramanian — 2011-11-11

Abstract: Targets and interventions for the Millennium Development Goals (MDG) related to reducing hunger (MDG 1) and child mortality (MDG 4) have ignored the role of intergenerational influences on health. In this study, the comparative importance of intergenerational and contemporaneous factors for achieving MDGs 1 and 4 targets was evaluated. A database of 735970 children from 109 Demographic and Health Surveys conducted between 1991 and 2008 in 54 countries was compiled. Modified Poisson regression models were used to estimate the association between child mortality/undernutrition and maternal education, wealth and height. Stochastic simulations of regression results were then used to evaluate changes in maternal height, education and wealth required to halve stunting and underweight and to reduce mortality by two-thirds. At mean height, 25 years of education were needed to achieve a two-thirds reduction in mortality, and halving the prevalence of stunting and underweight required 23 years and 17 years of education, respectively, for the poorest wealth quintile. When height was increased from the mean by 25cm, the prevalence of both growth outcomes was halved, even for those with no education and in the poorest wealth quintile. These results indicate that contemporaneous interventions will achieve MDG targets more readily in populations with greater accumulated health stock.

Evaluation of household latrine coverage in Kewot woreda, Ethiopia, 3 years after implementing interventions to control blinding trachoma

2011-12-01

Abstract: The SAFE strategy for trachoma control includes Surgery, Antibiotic distribution, Facial cleanliness and Environmental improvements, including promotion of latrine construction. In this study, household latrine coverage was estimated in order to evaluate SAFE implementation in a district of Ethiopia where reported coverage in rural areas was 97%. Characteristics of latrine adopters and non-adopters were explored. Interviews were conducted in 442 households selected at random in a multistage cluster sample. Overall, estimated household latrine coverage was 56.2% (95% CI 37.5–74.8%) and in rural areas coverage was 67.7% (95% CI 59.6–75.7%). Previously owning a latrine was reported by 12.7% (95% CI 8.9–16.5%) of respondents, of which 32.0% (95% CI 15.9–48.2%) had built a replacement. Latrine adopters were more likely to be male (P<0.0001), to report their primary occupation as agriculture (P<0.0001), have more than five residents in their household (P=0.004) and live in a rural area (P<0.0001). Respondents who were advised by a health extension worker (P<0.0001) or development agent (P<0.0001) were more likely to have built a latrine. Household latrine coverage has increased from the 2007 zonal estimate (8.9%), but was lower than that reported. Latrine promotion should include emphasis on rebuilding latrines. More support may be needed by small households as well as those with a female head if universal latrine access is to be achieved in Kewot.

Cost effectiveness of child pneumococcal conjugate vaccination in GAVI-eligible countries

2011-11-11

Abstract: Policy-makers increasingly rely on cost-effectiveness analysis, in addition to clinical effectiveness, when considering the introduction of new childhood vaccines. A previous analysis determined vaccination of infants with 7-valent pneumococcal conjugate vaccine (PCV) to be highly cost effective in preventing child mortality in countries eligible for financial support from the Global Alliance for Vaccines and Immunization (GAVI). We aimed to update this analysis by incorporating recent data on global disease burden, indirect effects and higher valency vaccines. Decision analytic models were built using an incidence-based approach in order to evaluate a three-dose vaccination schedule of infants in 72 GAVI-eligible countries over a 10-year programme. Seven-, 10- and 13-valent vaccine formulations were each compared with no vaccination. Depending on the formulation used, PCV could avert 294 000–603 000 deaths and 9.3–17.6 million disability-adjusted life-years (DALY) annually. The majority (91%) of the DALYs averted would be through the vaccine's direct effects in children under-5. Using WHO thresholds and a negotiated average dose cost, PCV would be highly cost effective in 69 of 72 GAVI-eligible countries. This finding was robust when assumptions regarding disease epidemiology and vaccine-related effects were varied in sensitivity analyses. The current analysis supports PCV introduction in GAVI-eligible countries owing to its potential to avert substantial numbers of deaths at relatively low incremental costs.

Cost effectiveness of child pneumococcal conjugate vaccination in middle-income countries

2011-11-11

Abstract: Policy-makers require information on the potential benefits of and economic case for pneumococcal conjugate vaccination in middle-income countries. We built decision analysis models to evaluate a three-dose infant series of the 7-, 10- or 13-valent pneumococcal conjugate vaccines in 77 middle-income countries compared with no vaccination, accounting for direct protection of vaccinated children as well as herd protection and serotype replacement in unvaccinated children and adults. Over 10 years, pneumococcal vaccination would prevent at least 11.0 million cases and 314000 deaths in children under-5, one-third of the pneumonia and invasive disease cases and deaths that would occur in this age group without vaccination. Herd protection would prevent 3.1 million cases and 163000 deaths in older children and adults. A total of 11.1 million discounted disability-adjusted life-years (DALY) would be averted. At a dose cost of $10 for lower- middle-income and $20 for upper-middle-income countries, the net pooled (for all countries together) discounted vaccination cost would be $18.1 billion ($1600 per DALY averted). Vaccination would be cost effective for 72 countries with the 7-valent vaccine and for all countries with the 10- or 13-valent vaccines. The economic case for vaccination is compelling for middle-income countries.

Association of community antibiotic consumption with clinically active trachoma in rural Ethiopia

2011-11-11

Abstract: Community antibiotic utilization and its relationship with trachoma has been poorly characterized in areas with endemic trachoma. A survey of all drug-dispensing facilities in an area of rural Ethiopia was conducted. Antibiotic use was calculated using both retrospective and prospective methodology, and expressed as defined daily doses (DDDs). Overall antibiotic consumption estimates ranged from 2.91 to 3.07 DDDs per 1000 person days. Macrolide antibiotics accounted for 0.01 to 0.02 DDDs per 1000 person days. Each additional DDD of antibiotic use per 1000 person days was associated with a 15.0% (95% CI -19.7 to -10.3) decrease in the prevalence of clinically active trachoma among children under 10 years of age after adjusting for age, gender, altitude and the distance to nearest town. Increased background community antibiotic use may therefore be an aspect of socioeconomic development that can partially explain why trachoma prevalence has decreased in some areas in the absence of a trachoma program. The low volume of macrolide consumption in this area suggests that selection for nasopharyngeal pneumococcal macrolide resistance after mass azithromycin treatments likely has little clinical significance.

Bolivian migrants with Chagas disease in Barcelona, Spain: a qualitative study of dietary changes and digestive problems

2011-11-11

Summary: Due to international migration, Chagas disease, endemic in Latin America, has become more common in non-endemic areas. Chronic Chagas disease can cause damage to the digestive system leading to constipation. However, a range of factors influences constipation and a better understanding of the role of non-Chagas related factors is required to improve management of Chagas-related digestive problems. This study explores perceptions of constipation and changes in food and exercise habits amongst Bolivians in Barcelona, Spain. Bolivian migrants attending the Tropical Medicine Unit (Hospital Clínic, Barcelona) were interviewed about their food habits in Spain and Bolivia, migratory experience, work and leisure activities. Chagas seropositive participants also received radiological examinations. Bolivian migrants experienced dietary changes, influenced by work-related factors, which included reductions in quantities of food and liquid consumed. Almost half the participants reported changes in digestive rhythm since arriving in Spain. Constipation, which was common, in some cases was only recounted during interviews. Bolivian migrants’ constipation may be associated with chronic Chagas disease or migration-related dietary changes. Careful questioning using the Rome III criteria is however required to ensure its diagnosis. Radiological studies are also required to confirm the role of Chagas disease and identify potentially serious intestinal damage.