International Health - Articles in Press

Nerve damage in leprosy: a continuing challenge to scientists, clinicians and service providers - Corrected Proof

Diana N. Lockwood, Paul R. Saunderson — 2012-05-14

Abstract: This review focuses on nerve damage in leprosy. We present evidence to support the argument that leprosy is best seen as a chronic neurological condition rather than a simple skin disease. Nerve damage affects small dermal nerves and peripheral nerve trunks. Perineural inflammation is a characteristic and hallmark of early leprosy. T cell-mediated inflammation is the main pathological process in leprosy nerve damage. The level of nerve damage in leprosy is high with up to 60% of multibacillary patients having clinically apparent nerve damage at the time of diagnosis; 30% of patents may develop further nerve damage during treatment and 10% may develop new nerve damage after drug treatment. Since the nerve damage is immune mediated, the antibiotics used to treat Mycobacterium leprae infection have little effect on the accompanying nerve damage. This requires treatment with immunosuppressants to stop the inflammation. Treatment of nerve damage with steroids can be effective but about 50% of patients relapse and require a further course of steroids. Research is needed to refine steroid regimens to be used and define appropriate alternatives. Neuropathic pain is now being recognised as another late complication for leprosy patients. There are also service challenges relating to how best to identify patients who need steroid treatment and how to manage patients with established neuropathy who may require health services for many years.

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

Franco Pagnoni, John C. Reeder, Robert D. Newman — 2012-05-14

Aubouy's commentary, while praising the overall concept of home-based management of malaria (HMM), rightly raised two potential problems. However, it is worth noting that some recent developments in the HMM strategy have substantially addressed these issues.

Treatment of schistosomiasis in African infants and preschool-aged children: downward extension and biometric optimization of the current praziquantel dose pole - Corrected Proof

José C. Sousa-Figueiredo, Martha Betson, J. Russell Stothard — 2012-05-09

Summary: To facilitate administration of praziquantel (PZQ) to African infants and preschool-aged children using a dose pole, the performance of two downwardly extended versions (the first created in 2010 using biometric data from Uganda alone and the second version created here using data from 36 countries) was assessed against height/weight data from a total of 166210 preschool-aged children (≤6 year olds) from 36 African countries. New and optimized thresholds for PZQ tablet administration at one tablet (600mg), ¾ and ½ tablet divisions are suggested here. Both dose poles investigated estimated an acceptable PZQ dosage (30–60mg/Kg) for more than 95% of children. Extension and optimization of the current PZQ dose pole, followed by theoretical validation using biometric data from preschool-aged children (0–6 years of age, 60–110cm in height) from 36 African countries will help future mass drug administration campaigns incorporate younger children. This newly optimized dose pole with single 600mg (height: 99–110cm), ¾ (height: 83–99cm) and ½ (height: 66–83cm) tablet divisions, also reduces drug waste and facilitates inclusion of preschool-aged children. Our findings also have bearings on the use of other dose poles for treatment of young children.

Diagnosis and treatment of malaria by health care providers: findings from a post conflict district in Sri Lanka - Corrected Proof

J. Lima, R.R. Abeyasinghe, Ray Fitzpatrick, S.D. Fernando — 2012-05-07

Abstract: This study determines whether 72 health care providers in a previously conflict-affected district in Sri Lanka adhere to the recommendations of the Anti Malaria Campaign with regard to diagnosis, prescribing antimalarials and reporting of a positive case. All patients suspected of clinically having malaria are being referred for laboratory confirmation, indicating that presumptive treatment is not practiced. The knowledge amongst health care providers regarding accurate management and reporting of a malaria positive case needs to be improved.

Location and vocation: why some government doctors stay on in rural Chhattisgarh, India - Corrected Proof

2012-04-25

Abstract: We conducted a qualitative research study in Chhattisgarh State, India, to explore why some qualified medical practitioners decide to stay on in government rural service. The fieldwork consisted of in-depth interviews with 37 practitioners who had an established record of rural service, and data were analyzed using the ‘framework’ approach for applied policy research. Study participants cited complexes of reasons for staying on, including geographical and ethnic (tribal) affinities, rural upbringing, availability of schools, personal values of service, professional interests, co-location with spouses, and relations with co-workers. Extrinsic (environmental) and intrinsic (personal) factors both play a part in determining the decisions of doctors to stay on, and are interdependent. Some doctors were influenced to remain by the close relationships they had developed with local communities and their acclimatisation over time to rural life. The policy imperative of rural workforce adequacy may be served less by choosing one retention strategy over another than by developing multi-dimensional solutions focused simultaneously on identifying and incentivising rural practitioners with appropriate characteristics, and on creating external conditions for their improved performance and welfare. Further, in a low-income setting such as India, questions of rural workforce adequacy cannot be addressed in isolation, but need to be tackled as part of broad agenda of social development that include strengthening public service systems and empowering communities.

Full-term newborns with congenital microcephaly and macrocephaly in Southwest Nigeria - Corrected Proof

Bolajoko O. Olusanya — 2012-04-13

Summary: This retrospective cohort study set out to determine perinatal and maternal factors associated with full-term (≥37 weeks) newborns with abnormal head sizes at birth in Lagos, Nigeria. Age and gender specific head circumference was determined with the current Child Growth Standards of the World Health Organization while maternal and infant factors independently associated with microcephaly (z-score < −2) and macrocephaly (z-score >2) were explored using multinomial logistic regression. Of the 3196 infants enrolled, 340 (10.6%) were microcephalic underpinned by suspected cytomegalovirus (CMV) infection while 74 (2.3%) were macrocephalic. Compared with normocephalic newborns, microcephalic infants were more likely to be growth restricted in-utero (OR: 10.89; 95% CI: 7.86–15.08); underweight (OR: 18.61; 95% CI: 13.28–26.07); stunted (OR: 15.45; 95% CI: 11.70–20.40); and wasted (OR: 3.64; 95% CI: 2.52–5.27); as well as having an increased risk of unconjugated hyperbilirubinaemia but unlikely to be associated with prolonged/obstructed labour (OR: 0.49; 95% CI: 0.31–0.78). In contrast, macrocephalic infants were likely to be delivered by emergency caesarean section (OR: 2.32; 95% CI: 1.33–4.04) and at greater risk of neonatal sepsis (OR: 4.12; 95% CI: 1.68–10.40). Risk of sepsis in macrocephalic infants was more than two-fold compared with microcephalic infants but not statistically significant (p=0.066). In conclusion, improved fetal growth monitoring, early nutritional intervention and management of perinatal infections are likely to curtail the burden of congenital microcephaly and macrocephaly in resource-poor settings. The underpinnings of unconjugated hyperbilirubinaemia in microcephalic infants in this CMV hyper-endemic population merit further investigation.

Cytomegalovirus retinitis associated with HIV in resource-constrained settings: systematic screening and case detection - Corrected Proof

Sophia Pathai, Stephen D. Lawn, Clare Gilbert — 2012-03-26

Abstract: Although cytomegalovirus (CMV) can cause a wide spectrum of multi-system disorders in HIV-infected patients, retinal disease is by far the most common clinical manifestation and may lead to blindness if untreated. We discuss the rationale for systematic case detection for CMV retinitis (CMVR) within the HIV-affected population, focusing particularly on resource-limited settings. The gold standard for detection of CMVR is indirect ophthalmoscopy performed by a trained ophthalmologist. However this is generally not feasible in resource-constrained settings. Alternative methods include fundus photography or the use of laboratory techniques to detect CMV infection. Training and deployment of non-ophthalmic personnel to detect CMVR by ophthalmoscopy or with novel strategies may be a paradigm shift that needs to occur in order to provide effective systematic case detection for those at risk of CMVR in resource-constrained settings. Further research is needed to determine the diagnostic accuracy and operational feasibility of different strategies in resource-limited settings.

The Maoist insurgency (1996–2006) and child health indicators in Nepal - Corrected Proof

Uttara Partap, David R. Hill — 2012-02-20

Abstract: The association of conflict and child health indicators in Nepal was examined for the period of the Communist Party of Nepal–Maoist (CPN-Maoist) insurgency (1996–2006). National and subregional trends in neonatal protection against tetanus, measles and diphtheria–pertussis–tetanus (DPT) vaccine coverage, infant mortality, under-5 mortality, and proportion of underweight or stunted children were examined. During the period of the insurgency there were overall improvements in vaccination coverage; however, measles vaccine and DPT coverage remained static during several years of conflict. A decline in infant and under-5 mortality rates occurred: however, there were smaller improvements in stunting and underweight children. Improvements in health indicators from the Mid-western Hill subregion of the country, an area that was consistently conflict-affected, were less than those achieved nationally or by the less-affected Eastern Hill subregion. In comparison with Bangladesh and India, improvements in Nepal were the same or better, except for stunting and underweight children. Health interventions that are more easily delivered, such as vaccination, showed improvements, although the changes were less in a region of high conflict. Improvements in child nutrition indicators that necessitate multiple, coordinated interventions and access to at-risk populations over time as well as ongoing food security were not as successful. Continued commitment to development of systems for delivery of child health is important to gain improvements across all childhood health indicators.

Treatment costs of Mycobacterium ulcerans in the antibiotic era - Corrected Proof

Jason Pak, Daniel P. O’Brien, Tricia Quek, Eugene Athan — 2012-02-20

Abstract: Mycobacterium ulcerans infection results in significant disfiguring morbidity, and treatment is expensive. To estimate the cost of treatment in the antibiotic era, a retrospective study of 71 patients diagnosed and treated for M. ulcerans in the Bellarine Peninsula (Victoria, Australia) between 1998 and 2006 was performed. Patients were categorised into minor single episode infection, major single episode infection and recurrent disease. Data were collected on each treatment cost component. To determine the change from costs in the pre-antibiotic era, mean direct costs were compared with those from a study in a nearby region between 1991 and 1998. All costs were in Australian dollars in 2006–2007 prices. The mean overall cost was $6181 per episode, with the highest cost components being hospitalisation (mean $3977; 63%) and surgeon fees ($949; 12%). Treatment costs per episode increased significantly from minor infection ($2235) to major infection ($6338) to recurrent disease ($13 372). Compared with the pre-antibiotic era, costs have significantly decreased, with a 52% reduction in overall cost per episode, driven mainly by a reduction in hospitalisation costs. Therefore, earlier diagnosis and treatment of M. ulcerans, including the use of outpatient-based oral antibiotic regimens, has the potential to reduce the cost of treatment.

A qualitative study exploring delayed diagnosis and stigmatisation of tuberculosis amongst women in Uganda - Corrected Proof

Laura Macfarlane, James N. Newell — 2012-02-17

Abstract: A qualitative study was undertaken to attempt to understand reasons for the delayed diagnosis of tuberculosis (TB) amongst Ugandan women and to describe the nature of TB stigma and its effects in Uganda. Twelve women were interviewed. Participants were selected on the basis that they had smear-positive TB and had delayed consulting healthcare services for ≥30 days. Semi-structured interviews were conducted and analysed using thematic content analysis. The study showed that the main reason for delayed diagnosis amongst women interviewed was a lack of recognition of symptoms. This may be due to low levels of TB awareness in the community. The study also showed that TB is stigmatised in Uganda, mainly due to associations with HIV. Many participants believed that TB only exists with HIV and that TB causes HIV tests to appear negative even for HIV-infected people. Health education programmes would be helpful to improve the understanding of TB and to combat harmful beliefs about TB and HIV in the community.