Male reproductive health research needs and research agenda: Asian and Chinese perspective.
Research that addresses male reproductive health should assist in the development of reproductive health programmes and policy; identify and test new leads in male contraceptive technology; establish effective male involvement initiatives which are likely to have a positive impact on the reproductive health of men and women; guide the allocation of health care resources to ensure cost-effectiveness of interventions; generate new knowledge, develop diagnostic technology in reproductive health and offer optimal treatment/care regimens. In considering the needs and demands of male reproductive health research in Asia and the Pacific, the following six research topics are recommended as the priority research areas: male contraceptive technology; male reproductive health behaviour and male adolescent reproductive health; male reproductive aging including male menopause and other diseases; male RTIs, STDs, HIV/AIDS; prevalence, management and prevention of male infertility; environment and semen quality and other male reproductive problems. One of the major challenges now facing us is the elaboration of a comprehensive, yet realistic male reproductive health research agenda that reflect the needs and demands of Asian developing countries. To this end, to make use of an interdisciplinary approach is of strategic importance. The most creative insights and productive leads are likely to emerge from a research team that is interdisciplinary especially in the field of reproductive health. (author's)
The cystic fibrosis transmembrane conductance regulator (CFTR) or the small conductance cAMP-activated chloride channel encoded by the CFTR gene has been shown to play an important role in the formation of the epididymal fluid microenvironment. Recent work in our laboratory has shown that this protein is also expressed by developing germ cells indicating a role of this protein in spermatogenesis. In view of the fact that the CFTR gene has a far reaching and widespread effect on human reproduction, understanding the role of CFTR in the male reproductive tissues and its intervention by pharmacological agents can open a new avenue of research into the development of novel male contraceptives. (author's)
Drug treatment of male fertility disorders.
Drug treatment remains an active domain in the therapy of male fertility disorders. Although there are only a few conditions that allow causal treatment, rational approaches are possible in many cases. Best results are obtained in cases requiring an anti-inflammatory treatment and in patients with an impaired sperm transport. High-dosage administration of FSH is a promising new development, aimed particularly at improving the disturbed sperm structures. A careful diagnostic work-up with elucidation of the underlying disease is essential to achieve a successful therapy. (author's)
Determination of sperm acrosin activity for evaluation of male fertility.
The aim was to investigate a simple method for assaying acrosin activity for the evaluation of male fertility. The acrosin activity of 7.5×106 sperm without seminal plasma and acrosin activity inhibitors was assayed using N-a-benzoyl-DL-arginine-p-nitroanilide (BAPNA) and detergent (Triton X-100) as substrate. The acrosin activity of 60 normal fertile men (35 ± 10 µI/106 sperm ) was higher than that of 168 infertile men (16 ± 8 µI/106 sperm) (P < 0.01). It was indicated that there was a significant positive correlation between the acrosin activity and the sperm motility (r = 0.6534, P < 0.01)and a significant negative correlation between the sperm malformed rate and the WBC number (r = 0.5426, P < 0.01). The temperature and time of incubation and the sperm concentration could influence the assay results. Acrosin activity is an important index for the evaluation of male fertility. The approach developed by the authors is a simple method for the determination of acrosin activity. (author's)
The aim was to evaluate KAI1/CD82 expression in Chinese patients with benign prostatic hyperplasia (BPH) and late-stage carcinoma of prostate (CaP). Thirty Chinese patients with benign prostatic hyperplasia and 34 with CaP (adenocarcinoma clinical stage C and D) were analyzed by means of immunohistochemical methods. The KAI1/CD82 expression in BPH tissue was all positive, which was uniformly located on the glandular cell membrane at the cell-to-cell borders, but KAI1/CD82 expression in metastasis CaP tissues was either significantly lower than that of BPH or negative, and the immunostaining pattern was not continuous. In late-stage CaP KAI1/CD82 expression was correlated inversely to the pathological grade (P < 0.05), but not to clinical stage (P>0.05). The authors believe that decreased and negative KAI1/CD82 expression in late-stage CaP may be related to tumor progression and metastasis, and appears to be a prognostic marker. (author's)
Early and late long-term effects of vasectomy on Zn, Cd, and Cu levels in prostatic fluid and serum.
The aim was to evaluate the early and late long-term effects of vasectomy on the serum and prostatic fluid trace elements. In 37 vasectomized and 25 non-vasectomized (control) men, the Zn, Cd and Cu levels in the serum and prostatic fluid were measured by means of inductively coupled plasma-atomic emission spectroscopy (ICP-AES). No significant difference was found in the prostatic Zn, Cd and Cu levels between the vasectomized and control group. The Zn level in the serum were significantly lower in the vasectomized men than in the controls (11.04 and 13.54 umol/L, respectively; P<0.05), while the serum Cd and Cu levels were not significantly different between the two groups. Vasectomy may decrease the serum, but not the prostatic Zn levels. Its pathophysiological significance is worthy of further investigation. (author's)
Evaluation of transurethral application of alprostadil for erectile dysfunction in Indonesians.
The aim was to evaluate the efficacy and safety of transurethral application of alprostadil (MUSE®) for the treatment of erectile dysfunction in Indonesians. Twenty erectile dysfunction patients aged between 32-74 years old were recruited in this study. The inclusion criteria were as follows: 1) adult males 18 years or older with a subjective complaint or erectile dysfunction, 2) to provide written informed consent, 3) to agree not to use other forms of treatment for erectile dysfunction, 4) fulfill the screening laboratory values. Part 1, eligible patients were titrated in the clinic starting with a dose of 250 µg and proceed in a stepwise manner to 500 µg and 1000 µg on separate clinic visits until they identified a dose that produced a satisfactory response. The interval between each in-clinic titration was 2-3 days. Each in-clinic titration dose was evaluate dat 15 min intervals over a one hour period for erection assessment, blood pressure and pulse. Part 2, patients used MUSE at home for three months at the dose identified during the in-clinic titration. Monthly interim visits were required for patient follow-up and drug distribution. At the end of the study, patients had another laboratory (except testosterone, only assayed in screening procedure) and physical examination. The etiology of erectile dysfunction was psychological in 5 patients and organic in 15 patients. The 65% of the patients achieved the erection scale of 4 or 5 either in the clinic or at home, 10% achieved the scale of 4 at home, but not in the clinic, and 25% only achieved the scale of 2 or 3 with the highest dose of 1000 µg either in the clinic or at home. No significant differences were found in biochemical examination before and after the study. The 60% of the patients who achieved erection scale 4 or 5 continued to use MUSE until the end of the study, while 40% of them complained of pain at the time of MUSE application, during erection and/or during intercourse. They withdrew from the study. Transurethral application of alprostadil (MUSE) is effective and safe to produce erection sufficient for intercourse in erectile dysfunction of various etiologies. Pain during application, erection and intercourse is a common side effect and a cause of withdrawal. (author's)
Constraints in the development of contraceptives for men.
Considerable efforts have been made to develop a male contraceptive and the studies have provided very useful information in this field. At least five different strategies to develop a male contraceptive have been pursued, namely: inhibition of sperm production, interference with sperm function, interruption of sperm transport, prevention of sperm deposition, and prevention of sperm-egg interaction. Of all these approaches, inhibition of sperm production by using androgens either alone or in combination with progestins have given the most encouraging results. A number of clinical trials substantiate that it is indeed possible to have a reversible, effective and safe hormonal method of contraception. A postmeiotic and epididymal approach to interfere with sperm function or the secretory and metabolic processes of the epididymis is another attractive option of male contraceptive development. A number of chemical compounds have been identified which interfere with sperm function in the epididymis without affecting sperm production, however, the compounds evaluated so far were found to be toxic. Interruption of sperm transport through the vas either by vasectomy or percutaneous intravasal injection of liquids which form cure-in-place plugs is also an attractive option. However, reversibility of the methods is of concern in their wide scale use. The major constraint in developing a long-acting male contraceptive seems to be the need for greater investment for product development. The clinical trials for evaluating the efficacy and safety of the new products and formulations stretch over several years and require enormous financial commitment. Nevertheless, the long-term gain of having a long-acting reversible contraceptive for men is far greater than the financial commitments over few years. Male attitude towards using methods of family planning is much more favourable than originally believed. The pharmaceutical industry as well as the health care providers therefore have a greater responsibility. For early development of a contraceptive for men, it is essential to increase investment and simplify the drug regulatory procedures. The advent of newer technologies coupled with the convergent efforts of scientists will certainly make it possible to have an effective, safe and reversible male contraceptive in the near future. (author's)
Hyperlipidemia and erectile dysfunction.
We have done consecutive studies to investigate the effects of impaired lipid metabolism on the contractile and relaxation response of cavernous smooth muscles and to elucidate its pathogenesis: 1) incidence of hyperlipidemia in impotent patients; 2) erection response to intracavernous injection of papaverine in impotent patients with hyperlipidemia; 3) relaxation responses of isolated cavernosal smooth muscles to endothelium-independent and endothelium-dependent vasodilators in impotent patients with hypercholesterolemia or hypertriglyceridemia; 4) involvement of superoxide radical in the impaired endothelium-dependent relaxation of cavernous smooth muscle in hypercholesterolemic rabbits; 5) effects of isolated lipoproteins and triglyceride, combined oxidized LDL plus triglyceride, and combined oxidized LDL plus HDL on contractile and relaxation response of rabbit cavernous smooth muscles; 6) involvement of e-NOS in the impaired endothelium-dependent relaxation of cavernous smooth muscle in hypercholesterolemic rabbit. Hypercholesterolemia may cause impairment of endothelium-dependent relaxation. Oxidized LDL is the major causative cholesterol of the impaired relaxation response. Achain reaction, the production of superoxide radicals and functional impairment of eNOS may be a major cause of the functional impairment in the early stages of hypercholesterolemia. (author's)
The aim was to explore the possible mechanisms of male infertility caused by antisperm antibody (AsAb). The soluble interleukin-2 receptor (sIL-2R) level in serum was analyzed by ELISA and Na+-K+-exchanging ATPase activity in semen by phosphorus (Pi) assay. The sIL-2R level in serum was significantly higher and the Na+-K+- exchanging ATPase activity in semen significantly lower in AsAb positive infertile men when compared with the controls. The AsAb titer varies with the sIL-2R level in serum. A decrease in Na+-K+- exchanging ATPase activity in semen may play a role in male infertility caused by AsAb. (author's)
Effect of smoking on semen quality of infertile men in Shandong, China.
The aim was to study the effect of smoking on the semen quality in infertile men in Shandong Province, China. Adult non-drinker males attending the infertility clinic, including 110 non-smokers and 191 smokers, were recruited for the study. Sixty-one fertile, non-smoker and non-drinker males, who had one or more children, served as the controls. The smokers were divided into subgroups according to the amount and duration of smoking. Semen parameters (semen volume and sperm density, viability, motility, and morphology) were examined and seminal plasma contents of Zn , Cu and superoxide dismutase (SOD) determined. The semen volume and acidity, and the sperm density, viability and forward progression, as well as the seminal plasma contents of Zn, Cu and SOD were much lower in the medium, heavy and long-term smokers than in the non-smokers (P < 0.01). The sperm density, viability and forward progression, and the seminal plasma Zn, Cu and SOD levels were negatively correlated with the amount and duration of cigarette smoking (P<0.01). Medium, heavy and long-term smoking adversely affected the semen quality in a population of men visiting the infertility clinic in Shandong, China. (author's)
Low dose gossypol for male contraception.
The aim was to ascertain whether the side effects of gossypol, hypokalemia and irreversibility, could be avoided on dose reduction. Seventy-seven male volunteers were divided into 3 groups: control (22 cases), 10 mg gossypol (29 cases) and 12.5 mg (26 cases). Serum levels of testosterone, FSH and LH were measured by RIA and potassium by flame photometry. Sperm counts and motility were examined before and regularly after treatment for the evaluation of contraceptive efficacy. The average sperm density and motility started to decrease significantly by the end of month 2 of medication and gradually reached the infertility levels (<4 million /mL) in both treated groups. After that the 10 mg group was asked to take the same dose every other day for up to a total observation period of 16-18 months for the maintenance of infertility. Subjects in the 12.5 mg group did not take gossypol any more so as to observe the length of the loading dose required, but in a few, a maintenance dose of 12.5 mg every other day was instituted for a few more months. In both treated groups, none of the spouses was pregnant during the maintenance dose period. Serum levels of potassium, FSH, LH and testosterone were not significantly changed and not a single volunteer complained of myoasthenia. After cessation of drug administratioin, the semen data returned to pretreatment levels. A regimen with 10 or 12.5 mg of gossypol as the daily loading dose and 35 or 43.75 mg as the weekly maintenance dose could induce infertility in male volunteers without developing hypokalemia or irreversibility. (author's)
Sperm function tests after vasovasostomy.
The aim was to evaluate the sperm function after vasovasostomy. Semen samples from 42 subjects after vasovasostomy (Group A: 1-6 months, Group B: 6-12 months; Group C: 12-18 months after vasectomy reversal) were investigated. Semen from 34 normal fertile men was used as controls. Sperm function tests, including hypoosmotic swelling test (HOST), acridine orange (AO) fluorescence, acrosome reaction (triple-stain), cervical mucus penetration test (CMPT), etc were done. After vasectomy reversal, the percentage of HOST was significantly lower than that of the normal fertile men. In regard to AO, there were no significant differences between the three vasovasostomy groups and between these 3 groups and the controls. With triple-stain, the percentage of normal acrosome reaction was significantly lower in Group A as compared with the controls, but not in Groups B and C. There were no significant differences in the results of CMPT between the vasovasostomy groups and the controls. However, the number of "poor" type was significantly higher in Groups A and C than in the controls; the percentage of "negative" type were higher in Groups A and B than in the controls. After vasovasostomy a lower level of HOST remained for one year and gradually recovered after one year. Six months after vasectomy reversal, the percentage of acrosome reaction could be changed from lower level to normal range. The data of AO indicated that the genetic material (double-stranded DNA) in spermatozoa was not affected by vasovasostomy. To evaluate the result of CMPT after vasectomy reversal, not only the normal results but also the abnormal results ("poor" and "negative" types) should also be considered. (author's)
New oral agents for erectile dysfunction: what is changing in our practice?
Erectile dysfunction (ED) is a highly prevalent disorder affecting an estimated 152 million men worldwide and is associated with a variety of behavioral risk factors, such as cigarette smoking and excessive alcohol consumption, as well as numerous age-related medical conditions, notably type-2 diabetes mellitus and cardiovascular disease. A rational step-wise approach which includes comprehensive medical and sexual history, a focused physical examination and essential laboratory tests such as fasting glucose, lipid profile and testosterone assay is to be preferred. Current diagnostic work-up does not recommend any of the specialized tests which were previously considered mandatory-i.e. penile pharmacotesting, Duplex ultrasound and nocturnal penile tumescence. Hormonal replacement therapy is appropriate only in the hypogonadal male with ED. Prior to direct intervention, the physician should consider altering modifiable risk factors or causes, although frequently insufficient to reverse ED completely. When indicated, oral therapy with new molecules (phosphodiesterase inhibitors or apomorphine) is the first-line treatment for the majority of patients because of potential benefits and lack of invasiveness. (author's)
The aim was to determine the immunoreactive pattern of human papillomavirus (HPV) antigen and p53 protein in condylomata acuminatum (CA) and squamous cell carcinoma (SCC) of penis. Immunohistochemistry for HPV and p53 were performed in 40 specimens of formalin fixed, paraffin embedded tissues using a polyclonal (rabbit) antibody against HPV and a monoclonal (mouse) antibody against human p53 protein. Twenty one cases of CA and nineteen cases of SCC were examined. HPV antigen was detected in all 21 CA and 2 penile SCC. p53 protein over-expression was observed in 12 of 19 (63%) SCC in which 6 cases were strong positive. Five of 21 CA (24%) showed low-grade p53 protein over-expression. CA is related to HPV infection and some cases show p53 protein low-grade over-expression. In contrast, p53 protein over-expression is common in penile SCC, which is seldom related to HPV infection. (author's)
Studies on self-esteem of penile size in young Korean military men.
The aim was to investigate the flaccid and stretched penile sizes of young Korean males and their complexes or pride about their penile size. After an explanation and agreement to the purpose and methods of this study, 123 Korean men in their early 20's visiting the Jinhae Military General Hospital were included in the study. The flaccid penile length, flaccid mid-shaft circumference, stretched length and pre-pubic bone fat pad depth were measured in a warm comfortable environment. The accuracy the subjects assessed their penile size was investigated by asking them to rate their penile size, as 'very small', 'small', 'normal', 'large' or 'very large'. All subjects were asked to complete the Minnesota multiphasic personality inventory (MMPI) test. The mean flaccid length, flaccid circumference, stretched length and fat pad depth of the 123 subjects were (6.9 ± 0.8) cm, (8.5 ± 1.1) cm, (9.6 ± 0.8) cm and (1.1 ± 0.4) cm, respectively. The answer distribution on penile size was 1 (0.8 %) 'very small', 29 (23.6 %) 'small', 86 (69.9 %) 'normal', 6 (4.9 %) 'large' and 1 (0.8 %) 'very large'. Subjects who underestimated their penile size showed significantly higher scores on the hypochondriasis (Hs), depression (D) and psychasthenia (Pt) subscales of the MMPI than those in the Unbiased Group (P < 0.05). In consultation, with a patient requesting penile augmentation, the urologist should consider the psychologic attitude of the patient to his penile size. (author's)
Fertility and sexual life of men after their forties and in older age.
Owing to the demographic development, the aging male will require more consideration in future. In contrast to a rapid decline of estradiol during menopause in women, the process of aging in the male is retarded and subject to high individual variations. Impairment of spermatogenesis is observed as a continuous process occurring over decades. However, only about 50% of men in their eighties show complete loss of fertility. In principle, spermatogenesis may be retained well into senescence. Of importance for the individual health condition is the fact that the number of Leydig cells declines with advancing age. Thus, altered sex hormone concentrations in aging men result from both functional disturbances and a gradual reduction in Leydig cells. Furthermore, an impaired feed-back mechanism of the pituitary-gonadal axis occurs, with disappearance of the circadian testosterone (T) rhythm. LH and FSH levels are increased, and a reduced bioavailability of sex hormones is observed. Lower total testosterone concentrations in men over 60 years are accompanied by clinical signs of reduced virility, such as decreased muscle mass and strength as well as reduced sexual hair growth and libido. An age-related decline in androgen secretion and plasma testosterone levels therefore suggests the use of androgen supplementation. However, there is a lack of risk-benefit long-term studies. Increased research in the male is mandatory to meet the requirements of the aging population. This should include the availability of precise epidemiological data about the frequency of partial androgen deficiency in aging males (PADAM). (author's)
The data on semen analysis of subjects attending the Fertility Clinic at NIHFW (National Institute of Health and Family Welfare) Munirka, New Delhi for the last 11 years were analyzed to verify the claims and speculations on declining sperm counts in men. Approximately 10 % of the records every year starting from 1990 to 2000 (numbering 1176 in total) were randomly selected for analysis. Subjects with azoospermia or severe oligozoospermia were excluded from analysis. The average age of the men attending the infertility clinic was 31.2 years. The average semen volume and sperm count were found to be (2.6±0.1) mL and (60.6±0.9) ×106/mL, respectively. No significant decline in sperm counts was observed in any year during the entire study period. Only 1.8 % of the total number of sperm counts in the random sampling were less then 20×106/mL. On the basis of WHO criteria on motility, the total percentage of non-progressive and non-motile sperm in the ejaculate was higher (63 %) as compared to the combined categories of slow and rapid linear progressive. The present study has confirmed similar findings from other different countries that declining sperm counts in humans is not a global phenomenon. (author's)
Penile venous anatomy: application to surgery for erectile disturbance.
The structure of the human penile venous system has been well studied, but disappointing outcomes of penile venous surgery in certain patients have called into question on the anatomy. We planned to extend the anatomic knowledge with the ultimate goal of improving operative success. Thirty-five patients, who had undergone penile venous surgery, complained of poor erection developed gradually 6 months to 7 years postoperatively. Cavernosography was performed again during their return visit. Seven new patients underwent spongiosography followed by immediate cavernosography. Eleven male cadavers were carefully dissected. The anatomical findings were applied to venous surgery in 155 patients, who were then followed with the International Index of Erectile Function Questionnaire-5 (IIEF-5). Imaging observation demonstrated that the deep dorsal vein served as a common vessel of the corpora cavernosa and corpus spongiosum. A prominent cavernosal vein was found coursing along each corpus cavernosum distally to the glans, in contrast to its reported description as a short segment at the penile hilum. All cadavers had two sets of para-arterial veins sandwiching the dorsal artery. In 148 men available for follow-up, their mean IIEF-5 score was 9.3 preoperative and increased to 22.7 after the operation. The 88.5% (131/148) of the patients believed that venous stripping was a worthy treatment modality. Five cases required sildenafil to maintain their potentia, which was not working preoperatively. The failure of penile venous surgery has traditionally been ascribed to penile vein regeneration. However, our finding of a long and independent cavernosal vein and an independent set of para-arterial veins may be the principal cause in patients experiencing poor postoperative results. (author's)
Normal and varicocele testis in adolescents.
The authors reviewed the results of their research on the structure and composition of normal and varicocele seminiferous tubules in adolescents. They give new evidences of normal structure of adolescent testis and demonstrate, for the first time, the ultrastructural and immunohistochemical modifications of the lamina propria and basal lamina in the adolescent varicocele patients, which are similar to those observed in adults, but less severe, and of the adherence junctions in seminiferous tubules. They also report the presence of oxidative stress in adolescents limited to testis and not generalised as in the adults. These data are well correlated to different clinical studies that support the hypothesis of a progressive course of varicocele and the need for surgical treatment in adolescent varicocele patients. (author's)
PCR analysis of Yq microdeletions in infertile males, a study from South India.
The aim was to estimate the frequency of microdeletions in the long arm of Y-chromosome of 20 infertile males from South India. Polymerase chain reaction (PCR) amplification using Y-specific STS of azoospermia factor (AZF) regions i.e., SY 84 for AZFa, SY 127 for AZFb and SY 254 for AZFc. Of the 20 infertile subjects 3 (15 %), one azoospermic and two oligozoospermic, showed microdeletions in the AZF region of Y-chromosome. The frequency of deletions involving AZF region of the Y-chromosome is 15 % in azoospermic and severely oligozoospermic infertile men. PCR amplification of AZF locus is useful for the diagnosis of microdeletions in the Y-chromosome. (author's)
The prolongation of life expectancy and the drastic reduction of fertility rate are the primary cause of an aging world. It is projected that the elderly (above 65) will increase within the next 25 years by 82%, whereas the new born only by 3%. Despite the enormous medical progress during the past few decades, the last years of life are still accompanied by increasing ill health and disability. The ability to maintain active and independent living for as long as possible is a crucial factor for aging in health and dignity. Therefore, the promotion of healthy aging and the prevention of disability in men must assume a central role in medical research and medical practice as well as in the formulation of national health and social policies. Effective programs promoting health and aging will ensure a more efficient use of health and social services and improve the quality of life in older persons by enabling them to remain independent and productive. The most important and drastic gender differences in aging are related to organs and or systems dependent or influenced by reproductive hormones. In distinction to the course of reproductive aging in women, with the rapid decline in sex hormones and expressed by the cessation of menses, aging men experience a slow and continuous decline of hormones. This decline in endocrine function involves: A decrease of testosterone, dehydroepiandrosterone (DHEA), oestrogens, thyroid stimulating hormone (TSH), growth hormone (GH), insulin-like growth factor-1 (IGF-1), and melatonin. This decrease is concomitant with an increase of LH and FSH. In addition sex hormone binding globulin's (SHBG) increase with age resulting in further lowering the concentrations of free biologically active androgens. Interventions such as hormone replacement therapy may prevent, delay or alleviate the debilitating conditions which may result from secondary partial endocrine deficiency. Primary and secondary preventive strategies such as the promotion of a safe environment, healthy lifestyle including proper nutrition, appropriate exercise, avoidance of smoking, avoidance of drug and alcohol abuses, if done effectively, should result in a significant reduction of the health and social costs, reduce pain and suffering, increase the quality of life of the elderly and enable them to remain productive and contribute to the well-being of society. In light of this, public awareness of medical knowledge needs to be increased and basic, clinical, socio-economic and epidemiological research intensified. (author's)
Male fertility following childhood cancer: current concepts and future therapies.
Prepubertal boys treated for cancer may exhibit impaired fertility in later life. A number of chemotherapeutic agents have been identified as being gonadotoxic, and certain treatment regimens, such as that used for Hodgkin's disease, are particularly associated with subsequent infertility. Radiotherapy may also cause gonadal damage, most notably following direct testicular irradiation or total body irradiation. Because of the varied nature of the cytotoxic insult, it can be difficult to predict the likelihood of infertility in later life. Currently it is not possible to detect gonadal damage early due to the lack of a sensitive marker of gonadal function in the prepubertal age group. Semen cryopreservation is currently the only method of preserving fertility in patients receiving gonadotoxic therapy. This is only applicable to postpubertal patients and can be problematic in the adolescent age group. At present there is no provision for the prepubertal boy, although there are a number of experimental methods currently being investigated. By harvesting testicular tissue prior to gonadotoxic therapy, restoration of fertility could be achieved following treatment, either by germ cell transplantation or by in vitro maturation of the germ cells harvested. Alternatively, rendering the testes quiescent during cytotoxic treatment may protect the germ cells from subsequent damage. In addition to the many scientific and technical issues to be overcome prior to clinical application of these techniques, a number of ethical and legal issues must also be addressed to ensure a safe and realistic prospect for future fertility in these patients. (author's)
Male infertility: risk factors in Mongolian men.
The aim was to determine the most common risk factors of male infertility in Mongolian men attending an infertility clinic. A prospective, case-control study was conducted in which 430 men were enrolled. All the men had sought their first infertility evaluation between 1998-2002 in the State Research Center on Maternal Child Health, Ulaanbaatar, Mongolia. They were divided into two groups depending on the results of their semen analysis: 191 with abnormal semen and 239 with normal semen profile. Univariate and multivariate analyses were performed to determine any association between risk factors and semen abnormality. Logistic regression analysis demonstrated that the testicular volume, a history of sexually transmitted infections (STI), epididymitis and testicular damage all have statistically significant associations with semen abnormality, when controlled for multiple risk factors. Adjusted odds ratios of 3.4 for mumps orchitis, 2.3 for other orchitis and 3.9 for testicular injury were found. Gonorrhoea, the most commonly reported STIs in this study, gave an adjusted odds ratio of 1.0 for having one or more sperm abnormality. An adjusted odds ratio for subjects with a history of other STIs was 2.7. However, as a predictor of azoospermia, STIs had very high odds ratio, being 5.6 in patients with gonorrhoea and 7.6 in patients with other STIs. A history of pathology involving testicular damage appeared to have the strongest impact on male infertility in Mongolia. STIs have less impact on semen quality except when complicated by orchitis, epididymitis and vasal obstruction. (author's)
Clinical trial of Butea superba, an alternative herbal treatment for erectile dysfunction.
The aim was to study the effect of Butea superba on erectile dysfunction (ED) in Thai males. A 3-month randomized double-blind clinical trial was carried out in volunteers with ED, aged 30 years ~ 70 years, to evaluate the therapeutic effect of the crude preparation of Butea superba tubers on ED. There was a significant upgrading in 4 of the 5 descriptive evaluations of the IIEF-5 questionnaire. Estimation of the sexual record indicated that 82.4 % of the patients exhibited noticeable improvement. Haematology and blood chemistry analysis revealed no apparent change. The plant preparation appears to improve the erectile function in ED patients without apparent toxicity. (author's)
The aim was to determine the age-adjusted prevalence of erectile dysfunction (ED) in 3 big cities of China and to explore its potential sociodemographic, medical and lifestyle correlates. A cross-sectional, population-based survey was conducted in three cities of China. Structured questionnaires were administered to 2 226 men, aged 20 - 86 years, by trained interviewers. The age-adjusted prevalence of ED was 28.34 % (mild 15.99 %, moderate 7.14 %, severe 5.21 %). In the men above 40, the prevalence was 40.2 %. Age was positively correlated with ED (P < 0.01). Education was negatively correlated with ED (P < 0.01). Spouse companionship, living condition were positively correlated with ED (P<0.01). Histories of cardiovascular disease, diabetes, and hyperlipidemia were positively correlated with ED (P<0.01). Cigarette smoking was not correlated with ED (P>0.05), while the cigarette consumption and duration were positively correlated with ED (P < 0.01). Alcohol drinking is negatively correlated with ED (P < 0.01). The duration of drinking was positively correlated with ED (P < 0.01). Weekly alcohol consumption was not correlated with ED (P > 0.05). The prevalence of ED increased with age. Cardiovascular disease, diabetes and hyperlipidemia were positively correlated with the increased prevalence. Sociodemographic and lifestyle factors, such as education, spouse companionship, living condition, cigarette and alcohol consumption or duration also have association with the prevalence of ED. (author's)
Management of erectile dysfunction: barriers faced by general practitioners.
The aim was to explore the barriers faced by general practitioners (GPs) in the management of patients with erectile dysfunction (ED). This was a qualitative analysis of focus group discussions and in-depth interviews involving 28 Malaysian GPs. GPs' perception of ED being not a serious condition was a major determinant of their prescribing practice. Doctor's age (younger), gender (female), short consultation time and lack of experience were cited as barriers. The GPs' prescribing habits were heavily influenced by the feedback from the first few patients under treatment, the uncertainty of etiology of ED without proper assessment and the profit margin with bulk purchase. Other barriers include Patients' coexisting medical conditions, older age, lower socio-economic status, unrealistic expectations and inappropriate use of the anti-impotent drugs. Cardiovascular side effects and cost were two most important drug barriers. The factors influencing the management of ED among the general practitioners were multiple and complex. An adequate understanding of how these factors (doctors, patients and drugs) interact can assist in the formulation and implementation of strategies that encourage GPs to identify and manage ED patients. (author's)
Interviews were conducted with 40 young African American men at risk of HIV/STIs and unintended pregnancy to explore cultural beliefs regarding 1) what makes men feel powerful in their relationships and 2) men's influencing strategies for condom use. Cultural consensus analyses were performed. Results indicated that the participants comprise a cultural group with shared beliefs about men's feelings of power and influencing strategies for condom use. Participants identified several factors that make men feel powerful (e.g., when they are able to provide for their families, are in control and make final decisions in their relationships). Regarding what men do to get their partners to use condoms, participants believed that men 1) use interactive strategies such as offering reasons for condom use; 2) use a variety of strategies involving condoms themselves; and 3) just ask their partners to use condoms. These cultural beliefs have important implications for HIV/STI and pregnancy prevention. (author's)
A study in human Onchocerciasis was undertaken in four endemic communities in Ondo State, Nigeria. In-depth interviews were conducted on peoples' knowledge, attitudes, and practices regarding Onchocerciasis aetiology, treatment, prevention, and symptoms. These were complemented by key informant interviews and focus group discussions. Based on this information, an educational program was set up which included the training of selected villagers (motivators) and community intervention organized by these motivators. Evaluation used a control group where intervention was focused on other health problems in the area. Onchocerciasis education took place only with the intervention group. At the start of the project, peoples' knowledge about Onchocerciasis, its cause, treatment, prevention, and symptoms were varied and only a small proportion could link the bite of the black-fly to Onchocerciasis. The educational intervention achieved a high level of participant satisfaction which was expressed in continuous attendance at workshops and keeping appointments with motivators. The intervention helped to bring a significant improvement in the knowledge, attitudes, and practices (KAP) of the respondents. The knowledge of Onchocerciasis aetiology increased to 79.8 percent, 71.5 percent, and 74 percent from 48.5 percent, 48.7 percent, 34 percent, and 45 percent pre-intervention in the four study areas used. The project demonstrated that a community-based health education can be effective in Onchocerciasis control. (author's)
A literature review synthesizing 19 recent journal articles related to sexual and reproductive health education in U.S. Latino and Latin American populations. Emphasis is on the role of culture and qualitative research methodologies and listening to the voice of communities. Part 1 deals with the cultural landscape: social influence on behavior by male partners, family, and community. Part 2 describes the roles played by lay health providers and promoters (parteras, promotoras, poetas) as cultural brokers influencing sexual and reproductive health behavior. (author's)
Developing photo-posters for health education on perceived teething problems in Nigeria.
The development of photo-posters to educate the Nigerian community on the perceived problems of teething was prompted by research findings which revealed that misconceptions about teething were widespread within the populace and in particular among some health professionals. Studies have shown that 58% of ethnic Yoruba rural dwellers in Nigeria attributed ailments to the teething process, while 70% of market women in Enugu State perceived diarrhea in their children was due to teething. In a recent survey, 61.4% of nurses believed diarrhea should accompany the teething process. Furthermore 82.1%, 35.8%, and 27.9% of them implicated fever, weight loss, and boils respectively as signs of teething. Photo-posters adopt the use of visual representation of a problem and the goal of using photo-posters is to begin to create an understanding in the minds of people that babies can be healthy in spite of their erupting teeth. It is believed that using pictures of real babies who are seen to be healthy when their teeth first emerge should go a long way to reducing some of the misconceived ideas. In its development, the participatory approach was adopted involving selected members of the target population, thus making it a culturally appropriate tool. This article describes the rationale behind the choice of the photo-posters and the process of developing them. (author's)
The clinical management of recurrent genital herpes: current issues and future prospects.
This article reports the proceedings of an expert panel discussion on current clinical management practices for the treatment of recurrent genital herpes. The panel reviewed the effectiveness of primary and specialist care settings in the UK and USA and identified the principal clinical needs of patients with recurrent genital herpes. The ideal alternative to daily suppressive nucleoside analogue therapy is a treatment with long-term impact on the natural history and prognosis of recurrent genital herpes. The potential of resiquimod, an immune response modifier, to resolve this unmet need was examined. Resiquimod is reported to delay the onset of recurrent genital herpes symptoms in patients in a Phase II clinical trial. While awaiting clinical confirmation of this new development in immunotherapy, the panel concluded with two recommendations: a reassessment of recurrent genital herpes management in terms of physician education of patients, and the promotion of a positive patient-physician relationship in the approach to treatment. (author's)
Microbicides for preventing transmission of genital herpes.
Available technologies for preventing sexual transmission of genital herpes infection are limited. This article focuses on the ongoing development of a new technology, topical microbicides, for preventing sexually transmitted infection. Recent data evaluating detergent-based spermicides as potential microbicides are reviewed. The first generation of broad-spectrum, non-detergent microbicides that are currently in clinical development, including the sulphated polymer-based inhibitors and acid buffers, are discussed. Finally, the potential of monoclonal antibodies as an example of a specific microbicide in late pre-clinical development is considered. (author's)
Condom use and the prevention of genital herpes acquisition.
Genital herpes establishes a lifelong infection associated with significant morbidity and mortality. In contrast to other sexually transmitted infections (STIs), herpes simplex virus type 2 (HSV-2) may be transmitted to sexual partners many years after initial infection and at times when the source partner may be asymptomatic. Consequently, HSV-2 has become one of the most common STIs worldwide. Current therapies suppress but do not eradicate infection. While many studies have examined the degree of protection offered through the use of condoms against HSV-2 acquisition, findings have been either difficult to interpret or inconsistent. However, the body of evidence supports the efficacy of condoms in preventing HSV-2 infection among women. More data are required for HSV-2 prevention in men. The infrequent use of condoms during pregnancy, coupled with the high incidence of complications associated with HSV-2 acquisition at this time, warrants efforts to improve condom use among male partners of pregnant women at risk of HSV-2 infection. (author's)
Indian women's groups protest at new contraceptive trial.
India's leading women's groups held a noisy demonstration outside the health ministry on World Population day last week against the introduction of contraceptives that they considered hazardous. They also demanded the withdrawal of "coercive" population policies in several states. It followed the announcement last month by the health minister, C P Thakur, that the long acting injectable contraceptive norethisterone would be introduced on a trial basis in 12 medical college hospitals across India. But Brinda Karat, general secretary of All India Democratic Women's Organisation, is concerned at the proposals. "The Indian Council of Medical Research had done some trials [of norethisterone] in the early 1980s which were withdrawn precisely because it was found that it was not suitable for Indian conditions," she said Women's groups say that the long acting hormonal contraceptive has many side effects, such as disturbances in the menstrual cycle, abnormal blood clotting, depression, severe headaches, and abdominal cramps. Use of the contraceptive requires ruling out contraindications such as heart disease, liver dysfunction, diabetes, and genital cancers, making their introduction highly problematic in Indian conditions. (excerpt)
It is now known that the physical presentation of genital herpes simplex (HSV) infection can be misleading in making the diagnosis of genital herpes. An incorrect diagnosis can be particularly damaging in pregnancy where it may result in extended exposure of the fetus to antiviral agents, an inappropriate route and timing of delivery and a significant increase in fetal exposure to HSV during labour and delivery. Case 1 describes a 32-year-old woman at 30 weeks in her first pregnancy who had the appearance and clinical course typically ascribed to primary genital HSV infection. In contrast, Case 2, a 24-year-old woman at 34 weeks' gestation, had the physical appearance of a recurrent episode. Type-specific serological testing revealed that what Case 1 was actually experiencing was the first symptomatic reactivation of genital herpes, whereas Case 2 had a true primary genital HSV-2 infection that was accompanied by minimal symptoms. Had serology testing not been available, Case 1 would probably have delivered unnecessarily by Caesarean section, and Case 2 would have been managed as a recurrent infection and allowed to deliver vaginally with potentially disastrous results. These cases illustrate the usefulness of a type-specific serology in diagnosing genital herpes in pregnant women. (author's)
Infantile tremor syndrome in Iraqi Kurdistan.
The objective of the study was to describe a rare condition that occurred for the first time in Iraqi Kurdistan during the UN Sanctions on Iraq in the nineties. Literature review was made to find possible causes. Patients were collected from various sources including private clinics, hospital outpatient clinics at the Center for Handicapped Children in the city of Arbil. Clinical features and proper history were the main diagnostic tools. Different treatment regimes were used on those patients. 24 patients were collected; the majority was between 6-18 months. Males were more affected than females. Half of the patients were exclusively breast-fed and three quarter have received blood anemia. Infantile tremor syndrome is a rare condition which was described both in India and outside India as well. It was observed among children in Iraqi Kurdistan during the difficult economic situation under the UN sanctions. The condition has the same features inside and outside India. The etiology is not very clear yet. (author's)
Neonatal screening for glucose-6-phosphate dehydrogenase deficiency.
This study was carried out to detect the incidence of erythrocytic Glucose-6 –Phosphate dehydrongenase (G-6-PD) efficiency, to compare the incidence of hyperbilirubinemia in G-6-PD deficient neonates as compared to G-6-PD normal neonates and to asses the usefulness of neonatal screening for G-6-PD deficiency. In a retrospective hospital based study, 2,479 male and female neonates consecutively born at Indraphrastha Apollo hospital between July 1998 to June 2003 who were screened for G-6-PD levels were evaluated for the incidence of G-6-PD deficiency. Incidence of G-6-PD deficiency was found in 2%. Incidence in males was 283% and female was 1.05%. The incidence of hyperbilirubinemia was found to be 32% in G-6-PD deficient neonates which was significantly higher than the incidence of hyperbilirubinemia in neonates with normal G-6-PD, which was 12.3% (p < 0.001). Our data suggests that neonatal screening for G-6-PD deficiency is a useful test for preventing and early treatment of complications associated with it. (author's)
Developmental and behavioral pediatrics -- the present and the future [editorial]
Developmental Pediatrics is emerging as an important specialty in pediatrics. With the better survival of high risk infants, because of advances in obstetric and neonatal care, the prevalence of developmental problems is increasing. It is also seen that there is a rise in conditions like childhood autism due to various environmental and genetic factors. In the bigger cities an metropolis, children with learning difficulties and ADHD are being addressed by various professionals including pediatricians. (excerpt)
Millions saved: proven successes in global health.
In the past 50 years, the developing world has benefited from tremendous improvements in health. Life expectancy has risen from 40 to 65 years. The chances that a child will survive to the age of five have doubled. In addition to directly improving people’s lives, this progress contributes to economic growth. While some of the improvement in health is the result of overall social and economic gains, about half of it is due to specific efforts to address major causes of disease and disability, such as providing better and more accessible health services, introducing new medicines and other health technologies, and fostering healthier behaviors. For Millions Saved: Proven Successes in Global Health the Center for Global Development convened a working group of experts to document 17 cases in which large-scale efforts to improve health in developing countries have succeeded — saving millions of lives and preserving the livelihoods and social fabric of entire communities. Taken together, this work provides clear evidence that large-scale success in health is possible — countering a common view that the health problems of the developing world are intractable, and that development assistance to health yields few benefits. (excerpt)
This report covers Year Two (FY04) key results under the “Healthy Families, Healthy Forests: Combining Reproductive Health with Biodiversity Protection for Effective Programming” grant. CI is implementing Population and Environment (PE) projects in three countries, the Philippines, Madagascar, and Cambodia. CI attempted to implement a PE project in Guatemala, but was unsuccessful in forging effective partnerships with local institutions and therefore discontinued activities there in December 2003. The goal of this project is to engage communities living in and around biodiversity hotspots in activities that integrate biodiversity conservation with improved access to reproductive health (RH) and family planning (FP). The projects seek to help local communities and policy-makers understand the relationship between having smaller and healthier families with an improved stewardship of natural resources. (excerpt)
This report covers the first half of Year Three (FY05) key results under the “Healthy Families, Healthy Forests: Combining Reproductive Health with Biodiversity Protection for Effective Programming” grant. CI is in the final year of its grant to implement Population and Environment (PE) projects in three countries - the Philippines, Madagascar, and Cambodia. The goal of this project is to engage communities living in and around biodiversity hotspots in activities that integrate biodiversity conservation with improved access to reproductive health (RH) and family planning (FP). The projects seek to help local communities and policy-makers understand the relationship between having smaller and healthier families with an improved stewardship of natural resources. (excerpt)
Senegal Maternal Health / Family Planning Project: final report.
This fourth year marks the end of the Maternal Health and Family Planning Project. In December of 2004, The MH/FP project was replaced with a new project called PREMOMA (Reduction of Maternal Morbidity and Mortality). This explains why the MH/FP activities should target those priority areas to strengthen what has been accomplished by the project. This shift in priorities led to a more rational plan of action in early 2004, with the adoption of the Performance Improvement approach (PI). The project close-out has been a major undertaking for both the staff and the partners. For the majority of people involved, this process has been a great learning experience. For instance, it has not had any negative impact on the project’s implementation, as shown by the high activities execution rate in 2004. The execution rate was 77%, a slight increase from the 2003 execution rate (76.14%)—the reference year. S03 recommended the same execution rate as 2003. This annual report is divided into 3 sections: i) review of major activities between May 1 and September 30 (project close-out), a detailed account of accomplishments during this period, Project close-out and transition; ii) accomplishments and outcomes; iii) challenges Delays in the new project start up allowed a transition period during which major activities were conducted to ensure continued support to the implementation of the DRH: Prevention of Mother-to-Child HIV Transmission (PMTCT), formative training and management of RH commodities. (excerpt)
Assessment of nutritional status for adults, using weight and height.
Good nutrition improves the quality of life and health of PLWHA. This is why it is important to monitor nutritional status. Measure weight: Make sure the scale pointer is at zero before taking a measurement; The person is required to dress in light clothes and take off shoes. Women should remove scarf; He/she must stand straight and unassisted on the centre of the balance platform; The weight should be recorded to the nearest 0.1kg. Measure height: The person is required to remove his/her shoes, stand erect, looking straight in a horizontal plane with feet together and knees straight; The heels, buttocks, shoulder blades and the back of the head should touch against the wall; Height should be recorded to the nearest 0.5cm. (excerpt)
Changing malaria treatment policy to artemisinin-based combinations: an implementation guide.
The purpose of this document is to provide guidance to countries on the actions that need to be taken when considering changing its national policy for the first-line treatment for malaria to an ACT consistent with WHO recommendations as well as implementing the change. It addresses operational and technical considerations for both the public and private sectors, and it may be used as a planning tool to identify technical assistance and resource needs. This document focuses on the implementation process after a decision is made to change the treatment policies. Some documents providing guidance on achieving the policy change are listed in Annex 4. (excerpt)
The Food and Nutrition Technical Assistance (FANTA) Project and the Regional Centre for Quality of Health Care (RCQHC) convened an HIV/AIDS and Food Aid: Assessment for Regional Programs and Resource Integration workshop in Entebbe, Uganda November 2-5, 2004. The workshop was funded by USAID’s Regional Economic Development Services Office for East and Southern Africa’s (REDSO). The objectives of the workshop were to improve understanding of food aid programming in the context of HIV/AIDS, strengthen capacity to assess the need for food aid interventions in HIV/AIDS-affected communities, and plan assessment activities that might identify opportunities for integrating food aid interventions into REDSO’s Transport Corridor Initiative (TCI). In addition, the workshop sought to assess partner needs for regional technical or other assistance to strengthen food aid programming addressing HIV/AIDS, including identifying and sharing lessons and promising practices. There were 51 participants at the workshop. Participants included PVOs implementing food aid programs in east or central Africa; REDSO HIV/AIDS implementing partners that seek to integrate or coordinate with food-based interventions in the transport corridor; World Food Program (WFP) regional and country office representatives; USAID Washington, regional and country Mission representatives from Offices of HIV/AIDS, Food for Peace and Poverty Analysis and Social Safety Net; Famine Early Warning System Network (FEWS NET); FANTA and RCQHC. (excerpt)
Nutrition for PLWHA -- counselling cards. Revised.
This is a flip chart containing counselling cards. These cards are designed for counselors and health workers to enhance nutrition counselling for PLWHA. Use these cards when counselling PLWHA or their caregivers to help them: Make informed choices for improving their nutrition; Identify and use locally available foods to meet their nutritional needs; Understand and adopt practices that promote a healthier nutritional status; Understand how to use diet to manage common HIV/AIDS related conditions. (excerpt)
Nutritional care for people living with HIV / AIDS. Answers to frequently asked questions.
People living with HIV/AIDS (PLWHA) need correct information about food and nutrition. Providing PLWHA with this information will help them make the best food and nutrition choices for proper HIV/ AIDS management and improved quality of life. This booklet has answers to commonly asked questions by PLWHA and caregivers. The questions are grouped into five sections: Section 1: The link between nutrition and HIV/AIDS Section 2: Dietary intake and food access by PLWHA Section 3: ARVs and nutrition Section 4: Traditional herb therapy Section 5: Maintaining body composition (excerpt)
This job aid provides step-by-step information to help counselors and service providers to effectively counsel on nutrition and HIV for PLWHA on ARVs. Using this job aid will enable counselors to help PLWHA on ARVs: a) Understand the food and nutrition implications of drug regimens. b) Identify appropriate and possible nutrition actions to: Promote effective treatment, Ensure adherence to drug regimens, Manage side effects, and Minimize negative effects on nutritional status. c) Implement the best nutrition actions and make necessary adjustments to dietary practices. (excerpt)
Laboratory reference manual for surveillance and control of vaccine-preventable diseases in Georgia.
A well-functioning laboratory service is an important component of the vaccine-preventable disease (VPD) surveillance system in Georgia. The second edition of the laboratory reference manual for VPD surveillance has been developed by a group of the Georgian specialists under the guidance of a PHRplus consultant from the World Health Organization’s Laboratory Surveillance Strengthening Unit in Lyon on a basis of needs identified during the laboratory system assessment carried out by partners in 2002, and feedback received during the piloting of the VPD surveillance reforms in the Imereti region of Georgia in 2003. The manual incorporates the standards for sample collection, storage and transportation, laboratory protocols and procedures for VPDs, and guidelines on biosafety and quality control. It is recommended for use by health workers nationwide. (author's)
The HIV/AID Orientation for Parliament was held with the objective of briefing the Members of Parliament (MPs) on the progress of activities on HIV/AIDS in Uganda and globally and to introduce the Parliamentary HIV/AIDS Communication Tool Kit. The Orientation started with the registration of participants, followed by introductory remarks by the Chairperson of the HIV/AIDS Committee, Hon. Dr. Elioda Tumwesigye, and then it was officially opened by the Rt. Hon. Speaker of Parliament who was represented by Hon. Beatrice Wabudeya, Minister in Charge of the Presidency. (excerpt)
2002 Child Survival and Health Grants Program review.
This report presents the state of projects funded by the U.S. Agency for International Development (USAID) Child Survival and Health Grants Program (CSHGP) as based on an analysis of grantee reports and documents submitted between January 1 and September 30, 2002. It draws largely from detailed implementation plans submitted in the spring of 2002, but also from midterm and annual reports from projects at different stages of their grants. These projects are implemented by nearly 30 different private and voluntary organizations (PVOs) in some of the most difficult areas of the world. It presents a thorough review of the accomplishments, challenges, and progress made by these innovative organizations in advancing USAID's goal of reduced child mortality and improved child health in the countries most in need. The report also discusses progress on various studies and initiatives that have taken place through the early part of 2003. (excerpt)
After security conditions in Iraq began to deteriorate in June 2003, the U.S.-led Coalition Provisional Authority (CPA) included restoring essential services in Iraq, such as water and sanitation, as part of its strategy for establishing a secure, peaceful, and democratic Iraq. From 1991 to 2003, a decreasing number of Iraqis had access to safe drinking water and sanitation services, and water-borne disease rates rose. The United States has made available $2.6 billion for rebuilding the water and sanitation sector. As part of GAO’s review of Iraq reconstruction under the Comptroller General’s authority, we assessed U.S. activities in the water and sanitation sector, including (1) the funding and status of U.S. activities, (2) U.S. efforts to measure progress, (3) the factors affecting the implementation of reconstruction activities, and (4) the sustainability of U.S.-funded projects. (author's)
This project planned to construct/rehabilitate 20 hand-dug wells and where this was not possible, to drill boreholes. Each of these 20 water points was to be maintained and managed by a water committee elected by the community. The project also aimed to construct 400 dry-pit latrines, conduct ongoing environmental education campaigns for the communities and organize 20 well-digging brigades. This project aimed to benefit 10,000 returnees. The construction of 20 water points (i.e., 19 hand-dug wells and 1 borehole) was completed successfully by of the end of the project period. All the water points are fully operational and are now serving the needs of 16,536 beneficiaries instead of the original target of 10,000 – an increase of about 65% over the targeted number of beneficiaries. In parallel, the project was able to facilitate the creation of 20 water committees, one for each water point constructed (100% of the target). The management and maintenance of the 20 water points was passed on to the water committees, which were elected by their respective communities. To further assure the sustainability of the water points, the elected water committees were trained by the project staff in the management and maintenance of the water points and in other related topics such as conflict resolution and basic accounting/bookkeeping. All the water committees are active and functional. (excerpt)
Jayapura City Young Adult Reproductive Health Survey, 2002-2003.
Jayapura City is the capital of Papua Province (previously known as Irian Jaya), the eastern-most province in Indonesia. The province constitutes the western half of the New Guinea island (the eastern half is Papua New Guinea), the second largest island in the world. The province of Papua is very sparsely populated. With 1.7 million population in 2000 and an area of close to 422,000 square kilometers, there are only 4 persons per square kilometer. Jayapura is located in the northern coast of the province, close to the border with Papua New Guinea. The city covers a large area, and is the largest municipality in Indonesia. With a population of 165,000, it is the most populated area in the province, with a density of 245 persons per square kilometer. Interest in adolescents in general stemmed partly from the fact that young women and men comprise a sizable proportion of the population. In Jayapura, one in four people belongs to the 15-24 age group. In 2000, they comprise more than 36 thousand. The population of Jayapura is characterized by a large proportion of migrants; three in ten inhabitants of the city were born outside the province. The largest ethnic group other than Papuans is Javanese, which constitutes 20 percent of the city’s population. (excerpt)
HIV infection in infants and children: July 2004.
A summary of challenges and progress concerning prevention and treatment of HIV infection in infants and children. The report concludes that the unique nature of the challenges for HIV-infected youth requires additional research (biomedical and social scientific) and integrated case management for those orphaned due to the disease and children who are HIV-infected. (author's)
Predictors of sexual behavior patterns over one year among persons at high risk for HIV.
This study examined the sexual risk act patterns of individuals who participated in the NIMH National Multisite HIV Prevention Trial. Patterns of sexual risk were examined over 1 year among 3,104 participants from 37 clinics in 7 regional sites, within both intervention and control conditions. Four patterns were assessed: 100% protected sex or abstinence at follow-up points; improved condom use or abstinence, but not completely protected behavior; relapse to unsafe sex; and unchanged protection. Participants in the intervention condition who responded to the intervention with consistently protected behavior were significantly more likely to be older or young adults, recent immigrants to the United States, and to not barter sex or have alcohol-related problems. The consistently protected participants in the control condition were also significantly more likely to be older. The intervention is likely to be particularly effective with clients in STD clinics with large immigrant populations. Specialized HIV prevention interventions may be needed for commercial sex workers, young persons, and those with alcohol-related problems. (author's)
Maximizing quality of care in health sector reform: the role of quality assurance strategies.
This paper explores the important role of quality assurance as an integral part of health sector reform. Chapter One presents a model for health sector reform, introduces the basic principles of quality assurance, and briefly reviews the LAC experience with both types of health system intervention. Chapter Two clarifies the ways that quality assurance and health sector reforms, with their respective foci of technical effectiveness and allocative efficiency, can reinforce each other. In addition to providing a conceptual framework, this paper presents a scheme for analyzing health sector reforms from the point of view of quality. Chapter Three presents a matrix that permits a comprehensive analysis of how a specific reform or set of reforms might affect key determinants of quality of care. Further, the analysis allows identification of quality assurance strategies that could enhance and reinforce the impact of health sector reform on quality. In conclusion, Chapter Four underscores the importance of including QA strategies when health sector reforms are initiated and outlines future directions for methodology development and research. (excerpt)
Accuracy of demographic indicators measured by geographical reconnaissance.
Each year fieldworkers from the Ministry of Health and Family Welfare attempt to visit all households in Bangladesh to collect extensive data in an activity termed geographical reconnaissance. We compared national estimates of crude birth rate; infant mortality rate and crude death rate calculated using data collected through geographical reconnaissance with results obtained from a sample vital registration system of the Bangladesh Bureau of Statistics and with the Bangladesh Demographic and Health Survey. While the estimates of crude birth rate were broadly similar, estimates of infant mortality rate were 75% lower and estimates of crude death rate were 40% lower from geographical reconnaissance than from the other systems. Given the substantial commitment of resources devoted to generating these data, and their inaccuracy, steps to streamline the process should be considered. (excerpt)
Total lymphocyte count has been proposed as an alternative to the percentage of CD4+ T-cells to indicate when antiretroviral therapy should be started in children with HIV in resource-poor settings. We aimed to assess thresholds of total lymphocyte count at which antiretroviral therapy should be considered, and compared monitoring of total lymphocyte count with monitoring of CD4-cell percentage. Longitudinal data on 3917 children with HIV infection were pooled from observational and randomised studies in Europe and the USA. The 12-month risks of death and AIDS by most recent total lymphocyte count and age were estimated by parametric survival models, based on measurements before antiretroviral therapy or during zidovudine monotherapy. Risks were derived and compared at thresholds of total lymphocyte count and CD4-cell percentage for starting antiretroviral therapy recommended in WHO 2003 guidelines. Total lymphocyte count was a powerful predictor of the risk of disease progression despite a weak correlation with CD4-cell percentage (r = 0.08-0.19 dependent on age). For children older than 2 years, the 12-month risk of death and AIDS increased sharply at values less than 1500-2000 cells per µL, with little trend at higher values. Younger children had higher risks and total lymphocyte count was less prognostic. Mortality risk was substantially higher at thresholds of total lymphocyte count recommended by WHO than at corresponding thresholds of CD4-cell percentage. When the markers were compared at the threshold values at which mortality risks were about equal, total lymphocyte count was as effective as CD4-cell percentage for identifying children before death, but resulted in an earlier start of antiretroviral therapy. In this population, total lymphocyte count was a strong predictor of short-term disease progression, being only marginally less predictive than CD4-cell percentage. Confirmatory studies in resource-poor settings are needed to identify the most cost-effective markers to guide initiation of antiretroviral therapy. (author's)
HIV counseling and testing for youth: a manual for providers.
At 1.7 billion strong, today’s generation of youth is the largest in history. Among the many challenges young people face is the risk of HIV/AIDS. Youth account for an estimated half of the five million new HIV infections each year — approximately 6,000 young people become infected every day. Although these statistics are sobering, with early detection of HIV through counseling and testing, more people can receive care and support and adopt healthy behaviors to improve their quality of life and avoid infecting others. In addition, HIV counseling and testing offers youth who test negative with an opportunity to change behaviors that may put them at risk of infection in the future. HIV counseling and testing provides an important opportunity for young people to think about issues related to sexual behaviors, including the prevention of other sexually transmitted infections (STIs) and unintended pregnancy. The counseling and testing process can be a powerful tool for helping young people deal with peer pressure and begin to adopt and sustain healthy behaviors that will benefit them the rest of their lives. (excerpt)
HIV/AIDS is one of the greatest challenges facing the world today. We, young people, remain at the centre of the epidemic in terms of transmission, vulnerability, impact, and potential for change. Our generation has not known a world without AIDS. The Declaration of Commitment (DoC) on HIV/AIDS, adopted by the Member States at the United Nations General Assembly Special Session on HIV/AIDS in June 2001, reflects global recognition of the pandemic as the single greatest threat to the well-being of future generations. It establishes, for the first time ever, time-bound targets to which governments and the United Nations may be held accountable. Most importantly, the Declaration recognizes young people’s particular to HIV infection and gives direction to governments on how to effectively address the HIV/AIDS pandemic among us. In publishing this report, UNFPA gives voice to young people from 12 countries around the world. Four years into the implementation of the DoC, we are reporting on our government’s achievements in addressing the AIDS pandemic among young people. Based on our own experiences, we have also highlighted shortfalls and challenges in the process, and have made specific recommendations to ensure that the targets set out in the DoC on HIV/AIDS are achieved. (excerpt)
This guide was developed to assist in the prevention of sexual and mother-to-child transmission (PMTCT) of HIV and to reduce the number of unwanted pregnancies in HIV-positive women. Further objectives are to improve the medical family planning counseling system for HIV-positive patients, identify the optimal contraceptive method in each individual case, and improve the quality of life for HIV-positive women in Odessa and the Odessa Oblast. Adoption of this guide by outpatient clinics and obstetric and gynecological service providers will enable the inclusion of important HIV-prevention measures in their practices. This guide is intended to provide healthcare workers with family planning guidelines, which are a component of HIV-transmission prevention. It is intended for use by obstetricians and gynecologists, midwives, nurses, family practitioners, and physicians specializing in infectious diseases. This guide is recommended for use at women’s outpatient clinics, polyclinics, and maternity hospitals in Odessa and the Odessa Oblast. (excerpt)
Integrated reproductive health and peer counseling in Kenyan universities.
Over the past 15 years, Pathfinder International has supported an integrated reproductive health and peer counseling program at two Kenyan universities: Kenyatta University in Nairobi and Egerton University in Njoro. The program aims to decrease unplanned pregnancies among students and to reduce the prevalence of sexually transmitted infections (STIs) and HIV. This two- pronged intervention offers students reproductive health related guidance and counseling through peer organized information, education and communication activities. It expands and strengthens existing student-friendly reproductive health services and provides a source of low-cost, gender-sensitive, family planning and reproductive health supplies and services to students on campus. The program’s off-campus activities also target in and out of school youth. (excerpt)
IWHC factsheet: Child marriage.
The legal minimum age for marriage is 18 under a number of ratified international agreements and the laws of many countries. In spite of these legal provisions, child marriage is still widely practiced in some areas of the world. The vast majority of those married as children are girls, and if current patterns continue, more than 100 million girls in the developing world will be married during the next 10 years. Child marriage is a violation of human rights. It forces children to assume responsibilities and handle situations for which they are often physically and psychologically unprepared. In places where child marriage is practiced, girls rarely have any say in when and whom they marry. Once married, these young girls have little power and limited autonomy. Girls are frequently much younger than their spouses, and the younger a girl’s age at marriage, the greater the age difference between her and her husband. Most girls enter marriage with little or no information about their reproductive health, including contraception, safe motherhood, and sexually transmitted diseases, including HIV/AIDS. They often face a greater risk of gender-based violence. (excerpt)
Sexual health -- CA version. An adolescent provider toolkit.
We are pleased to present to you the third module of the Adolescent Provider Toolkit: A Guide for Treating Teen Patients, entitled Sexual Health. This project has been made possible through the generous support of the California Endowment, the California Family Health Council, and the Open Society Institute. Designed for busy providers, the Toolkit includes materials that you are free to copy and distribute to your adolescent patients and their families or to hang in waiting and exam rooms. This module takes a closer look at the specifics of raising sexually healthy teenagers, and includes: Screening tools; Brief office interventions and counseling guidelines; STD protection advice for youth; A review of current practice guidelines; Community resources and referrals; Information and tip sheets; Health education materials for teens and their adult caregivers; Internet resources. (excerpt)
Preventing HIV / AIDS through family planning.
Family planning programs now reach millions of people in developing nations, though scores of millions still lack access to services. By definition, family planning programs serve those who are sexually active. A significant, though unknown, proportion of individuals seeking family planning services will be exposed to the risk for HIV infection or are already infected. While HIV/AIDS and family planning programs share the common goal of healthy sexuality, family planning services have been neglected, by and large, as a vehicle for preventing HIV infection or for identifying those who are infected. Redressing this lost opportunity would create an important new channel for expanding the battle against HIV/AIDS. There is a high degree of overlap between the population at risk for unintended, unsafe pregnancies and those at risk for HIV/AIDS. As the AIDS pandemic has spread, it has assumed a “woman’s face,” with almost six out of 10 new HIV infections occurring in women. Globally, nearly half of those currently affected by HIV/AIDS are women. Women and girls at high risk for unintended pregnancy and maternal death are often the same women and girls who are at high risk for HIV infection. Many women make contact with the health care system to seek care for their children, during the course of a pregnancy, and to secure family planning. These visits present valuable opportunities to reach women with information and services that can empower them to reduce their own risk for infection and the risks to their partners and children. (excerpt)
Preventing unintended pregnancy among HIV-positive women is an effective approach to reducing pediatric HIV infection and vital to meeting HIV-positive women’s sexual and reproductive health needs (WHO 2002, 2004; UNFPA 2004). Although contraceptive services for HIV-positive women is one of the four cornerstones of a comprehensive program for prevention of mother-to-child transmission of HIV (PMTCT), a review of PMTCT programs found that implementers have not prioritized family planning. While there is increasing awareness about the importance of family planning and HIV integration, data about family planning from PMTCT clients are lacking. The Horizons Program, in collaboration with International Medical Corps (IMC) and Steadman Research Services International (SRSI), is conducting an operations research study testing several community-based strategies to reduce mother-to-child transmission of HIV in a densely settled urban slum area in Nairobi, Kenya. The strategies being piloted by IMC include moving PMTCT services closer to the population via a mobile clinic, and increasing psychosocial support for HIV-positive women through the use of traditional birth attendants and peer counselors. Peer counselors are HIV-positive women who have already received PMTCT services. The effectiveness of each of these strategies on women’s utilization of key PMTCT services, including family planning, will be measured by comparing baseline to follow-up data. This research update presents key findings about family planning at PMTCT sites, including the interaction between providers and clients as well as HIV-positive women’s fertility desires and demand for contraceptives, from the baseline cross-sectional survey and qualitative interviews with postpartum women. (excerpt)
Voluntary counselling and testing (VCT) for HIV prevention.
Voluntary counseling and testing (VCT) for HIV allows individuals to know their HIV status and serves as the gateway for both HIV prevention and for early access to treatment, care and support. Knowing ones status provides for the choice to - for those who are negative, remain negative; and for those who are positive, seek access to treatment, care and support, and to reduce the risk of HIV transmission to future children and partners. UNFPA’s mandate as it relates to HIV/AIDS, is Prevention. Many approaches to HIV prevention require people to know their HIV status. In this way, VCT becomes a key component of UNFPA’s HIV preventive mandate. To promote VCT as an entry point for HIV prevention, UNFPA needs to continue to advocate for and to support the provision of high quality counseling and testing for HIV in the context of HIV/STI prevention programmes for young people, pregnant women and their partners, and for individuals most vulnerable to the infection. (excerpt)
Microbicides: new potential for protection.
Microbicides are substances that are designed, when applied vaginally, to reduce transmission of HIV or other sexually transmitted infections (STIs). This report concerns the protective potential of microbicides, some of which are under development to also function as spermicides to provide contraceptive protection.
The mother-to-child transmission (MTCT) model contains seven possible treatment choices: long course ZDV; short course ZDV following the Thailand, PETRA Arm A, and PETRA Arm B regmines; intrapartum and neonatal ZDV only; the HIVNET 012 regimen of single dose Nevirapine to the mother and child; and universal Nevirpine (Nevirpine provided to all women and children at the time of delivery without checking for HIV status). In addition to these seven treatment options, the model also allows the user to choose the proportion of women undergoing a Cesarean section, as well as the proportion of women that breastfeed their infants exclusively and with mixed breastfeeding and food supplements. Each of the treatment choices requires the user to supply various data, including the costs of these interventions, and possible user fees to offset these costs. The vertical transmission rate of the HIV virus varies by treatment option, and can be manipulated by the user. Finally, the user may specify a separate scenario, and compare the scenario results with the results from the original base case. (excerpt)
Preventing mother-to-child transmission of HIV: a strategic framework.
Mother-to-child transmission (MTCT) of HIV accounts for over 90 percent of HIV infections among young children. In the absence of interventions to prevent MTCT, 30 percent of infants born to HIV-infected women will become infected during pregnancy, labor and delivery, or through breastfeeding. In 2003 alone, there were an estimated 700,000 new infections and 500,000 HIV-related deaths among children under 15 years of age. Reported rates of mother-to-child HIV transmission in the absence of any intervention are higher in developing countries (25-45 percent) than in industrialized countries (15-25 percent). Offering HIV testing as part of routine antenatal care, combination antiretroviral drug regimens, and elective cesarean section and advising complete avoidance of breastfeeding has cut MTCT transmission of HIV to below 2 percent among the limited number of HIV-infected women in developed countries. However, in the developing nations where the vast majority of HIV-infected women of childbearing age reside, MTCT rates remain high due to lack of access to feasible, affordable prevention interventions and are compounded by the nearly universal practice of breastfeeding for prolonged periods of time. (excerpt)
New hope with New Start. The program which paved the way for VCT in 20 countries.
The success of a PSI pilot project in Zimbabwe, which used social marketing to stimulate demand for voluntary HIV counseling and testing (VCT), spurred the expansion of VCT and the creation of the New Start network of 20 VCT centers nationwide. Such an impression has New Start made upon Zimbabwean society that the government has immortalized the VCT network with its own postage stamp, believed to be a first in the short history of VCT. The achievements of the New Start network have prompted PSI to develop VCT programs in 19 other countries in Africa, Asia and the Caribbean. In 2004, VCT centers in these 20 countries are expected to counsel and test more than 300,000 clients. The success of New Start and the steady rise in client numbers at its 20 centers show that an increasing number of Zimbabweans want to know their HIV status. But learning one’s status can be a daunting proposition in a country where one in four people between the ages of 15 and 49 are already HIV positive and more than 3,000 people die every week from AIDS-related causes. (excerpt)
This report is a synopsis of the proceedings of the workshop and a record of the deliberations on the development of guidelines in specific program areas pertaining to orphans and other children made vulnerable by HIV/AIDS. The Orphans and Other Children Made Vulnerable by HIV/AIDS Workshop was held between 16-19 December 2001 at the Ndallas Hotel in Matuu, Machakos, Kenya. The workshop was organized the National AIDS Control Council Taskforce on Orphans and other Children made vulnerable by HIV and AIDS. The goal of the guidelines is to assist stakeholders in developing and implementing effective and sustainable programme responses to address the needs and rights of orphans and other children made vulnerable by HIV/AIDS, in Kenya. The specific purpose of the workshop was to “advance the development of national program guidelines on the care and support of orphans and other children made vulnerable by HIV/AIDS in Kenya.” (excerpt)
[Contraceptive measures and HIV transmission protection among women with HIV / AIDS]
Sexual intercourse is currently the route of transmission among women that has most contributed to the feminization of the HIV/AIDS epidemic. As an ongoing effort to establish more appropriate standards for health counseling, the study’s purpose was to investigate the use of contraceptive methods that would also prevent HIV/AIDS women against disease transmission. An exploratory study was developed in an outpatient clinic of a public university hospital, a reference center of HIV/AIDS patients in the mid-south region of the state of São Paulo, Brazil, during a 5-month-period (2000 and 2001). The study was carried out in 73 HIV/AIDS women. Data were collected using a semi-structured questionnaire exploring subjects’ sociodemographics, contraception method used and HIV status of their sex partners. A descriptive data analysis was performed and the contents of open answers were grouped into themes. Fischer’s exact test was applied for analyzing some variables at a 5% significance level. Content analysis was carried out according to Bardin’s proposal. Most women at reproductive age were married and had been infected almost exclusively through heterosexual contact. Of them, 35.4% reported having an HIV discordant partner and 13.7% used inadequate contraceptive methods that failed to protect them against HIV transmission. The study results call for the need of continuous education on safer sex among HIV/ AIDS women to empower them to discuss with their partners alternative options of exercising their sexuality and to raise awareness on their contraceptive choices in a way to protect their own health, their partner’s and even their unborn offspring’s health. (author's)
Creating options in family planning for the private sector in Latin America.
The countries of Latin America and the Caribbean are facing the gradual phaseout of international-donor support of contraceptive commodities and technical and management assistance, as well as an increased reliance on limited public sector resources and a limited private sector role in providing contraceptives to the public. Therefore, those nations must develop multisectoral strategies to achieve contraceptive security. The countries need to consider information about the market for family planning commodities and services in order to define and promote complementary roles for the public sector, the commercial sector, and the nongovernmental-organization sector, as well as to better identify which segments of the population each of those sectors should serve. While it is unable to mandate private sector participation, the public sector can create conditions that support and promote a greater role for the private sector in meeting the growing needs of family planning users. Taking steps to actively involve and expand the private sector's market share is a critical strategy for achieving a more equitable distribution of available resources, addressing unmet need, and creating a more sustainable future for family planning commodities and services. This paper also discusses in detail the experiences of two countries, Paraguay and Peru. Paraguay's family planning market illustrates a vibrant private sector, but with limited access to family planning commodities and services for those who cannot afford private sector prices. In Peru a 1995 policy change that sought to increase family planning coverage had the effect of restricting access for the poor and leaving the Ministry of Health unable to pay for the growing need for family planning commodities and services. (author's)
It is estimated that approximately 4 million deaths occur annually in developing countries in the neonatal period, attributable mostly to infection, birth asphyxia, and consequences of premature birth and low birth weight. Most sick newborns present with signs and symptoms related to more than one condition. A large number (up to 20% of all live births) develop an infection (sepsis, pneumonia, meningitis etc.) during the neonatal period. The identification and treatment of newborns with infection is unsatisfactory in such settings. Some estimates put half of newborn deaths in the community as being due to bacterial infections. The Department of Child and Adolescent Health and Development (CAH) recently commissioned a review of published and unpublished data on the management of neonatal sepsis in developing countries. The objective of the review was to scientifically and systematically evaluate existing therapeutic strategies for the management of serious bacterial infections (pneumonia, sepsis, and meningitis) among newborn infants in developing countries. The outcomes evaluated were success rates of therapy, ease of use of regimen, cost-effectiveness and methodological or other potential problems. Researchers at Aga Khan University, Karachi conducted the review with assistance from the Johns Hopkins University, Baltimore. At the same time researchers at Johns Hopkins University also completed a meta-analysis of available data on effectiveness of oral and parenteral therapy for treatment of neonatal pneumonia in the community in developing countries. (excerpt)
The Millennium Development Goals have established clear targets for improving the health of children and adolescents: reduce child mortality by two-thirds; halt and then reverse the spread of HIV/AIDS, and reduce maternal mortality ratios by three-quarters. Reaching these ambitious targets will not be easy. Concerted efforts are vital as a matter of human rights, development and security. In this spirit, WHO and UNICEF convened the Global Consultation on Child and Adolescent Health and Development in March 2002, with support from the Government of Sweden. Participants highlighted the plight of millions of children and adolescents, and the global challenge to scale up interventions to reach every child, every adolescent, rich or poor, with particular emphasis on those living in developing countries. As daunting as that challenge may appear, it is attainable. Cost-effective interventions to reach every child are readily available. Unfortunately, today they are reaching too few. (excerpt)
Every child - rich or poor - has the right to health and health care. Yet as we stand at the beginning of a new millennium, too many infants and children are dying prematurely and too many do not have a fair chance to develop to their full potential. We know what these children are dying of, and what prevents them from developing, and there are effective and affordable interventions that address the problem. So why does the problem persist? It persists because current health service delivery strategies do not reach children most in need, especially the poor; because their families lack the knowledge or financial resources to provide good nutrition; because families do not have access to the solutions that can save lives; because governments and the international community have not made a sufficient and sustained commitment to the rights, health and survival of children. Dealing with the toll of premature and unnecessary mortality and underdevelopment among poor children is a public health imperative that WHO and the World Bank are committed to address. Working together, and in close collaboration with governments and technical partners, we will lead a focused effort to tackle child health and poverty. This Special Report reflects that commitment, and extends an invitation to all interested stakeholders to join in renewed efforts to provide a fair chance of survival and healthy growth and development to all children. (author's)
Drug Supply Management training introduces the standard procedures of drug supply management for first-level health facilities. The training is divided into three segments: TRAINING OF TRAINERS WORKSHOP; DRUG SUPPLY MANAGEMENT WORKSHOP; FIELD TRAINING AT EACH PARTICIPANT'S HEALTH FACILITY. The Training of Trainers Workshop (TOT) trains district-level staff in good drug supply management procedures and effective training techniques. The Drug Supply Management Workshop (workshop) teaches first-level health workers the seven components of drug supply management and the standard procedures of each component. The Field Training at each Participant's Health Facility (Field Training) is a one day visit by a trainer to the participant's health facility. (excerpt)
Drug supply management training. Trainer's guide for the Drug Supply Workshop and field training.
Drug Supply Management training is a course that teaches the standard procedures of drug supply management at the first-level health facility. The training contains three segments: 6-day training of trainers workshop (TOT), 4-day Drug Supply Management workshop for first-level health workers (workshop), and a 1-day follow-up at each participant's health facility (Field Training). The TOT trains four district-level health workers to become trainers. Ideally, the district-level trainers have some responsibility for supervising or offering in-service training at first-level facilities. The district health workers should also have past experience in drug supply management. The workshop is for first-level health workers who are responsible for the drug supply at their health facilities. The workshop is designed for approximately 16 health workers. Each trainer facilitates a group of four participants throughout the workshop. (excerpt)
Drug supply management training. Participant's manual for the Drug Supply Workshop.
World drug experts identified the basic tasks to correctly manage each drug supply component. The tasks are called the standard procedures of drug supply management. Following the procedures will simplify the management of the drug supply. The Participant's Manual describes each component and explains its standard procedures. In each chapter, you will read an explanation of the component. You will do one or more activities to practice the procedures. Answer sheets for activities can be found in Annex A of this manual. As you complete the manual, you will make a plan to improve your drug supply. You will use your plan and the checklists and forms in Annex B of this manual to improve or begin (implement) the standard procedures at your facility. (excerpt)
World drug experts identified the basic tasks to correctly manage each drug supply component. The tasks are called the standard procedures of drug supply management. The procedures simplify the management of the drug supply. The Handbook for Drug Supply Management at the First-level Health Facility describes each component and explains its standard procedures. Each chapter explains how the component fits into the drug supply. There is an annex at the back of the handbook. It contains drug supply checklists and forms to use at your facility. (excerpt)
This report summarizes the results of the Informal Consultation on Epidemiologic Estimates for Child Health held on June 11 and 12, 2001, in Geneva, Switzerland. The consultation was sponsored by the Department of Child and Adolescent Health and Development (CAH) of the World Health Organization (WHO). The four objectives of the meeting were: a) Report back on work undertaken since February 2001 to improve estimates of mortality under five due to diarrhoea and acute lower respiratory infections. b) Review and comment on current WHO Evidence and Information for Health Policy (EIP) cause-specific mortality estimates for children under five for the world and the WHO regions, and trends since 1990, drawing on disease-specific estimates. c) Recommend region-specific estimates to be used at the global level in the immediate future. d) Report on progress in addressing issues of co-morbidity, and agree on next steps. (excerpt)
For more than 25 years WHO and UNICEF have recommended a single formulation of glucose-based Oral Rehydration Salts (ORS) to treat or prevent dehydration from diarrhoea of any aetiology, including cholera, and in individuals of any age. This product, which makes a solution that contains 90 mEq/l of sodium with a total osmolarity of 311 mOsm/l, has been used worldwide and has contributed substantially to the dramatic global reduction in mortality from diarrhoeal disease during this period. It has been well established, however, that ORS solution does not reduce stool output or duration of diarrhoea. There has been concern that this may limit its acceptance by mothers and health workers, who want a treatment that causes diarrhoea to stop. There has also been concern that the solution, which is slightly hyperosmolar when compared with plasma, may risk hypernatraemia or an osmotically driven increase in stool output, especially in infants and young children. For this reason paediatricians in some developed countries recommend that ORS contain about 60 mEq/l sodium and have a total osmolarity of 250 mOsm/l. (excerpt)
Urinary tract infections in infants and children in developing countries in the context of IMCI.
Urinary tract infections (UTI) are a common cause of febrile illness in young children. Due to lack of overt clinical features in children less than two years, appropriate collection of urine samples and basic diagnostic tests at first-level health facilities in developing countries, UTI are not generally reported as a cause of childhood morbidity. UTI are not included in the current Integrated Management of Childhood Illness (IMCI) algorithm as the main focus has been preventing mortality and severe morbidity by identifying children at risk of serious diseases including malaria, measles, meningitis, pneumonia, diarrhoeal diseases and malnutrition. Some countries have included assessment and management of dengue or streptococcal sore throat in the IMCI algothrim. However, in many countries without malaria and with a high measles vaccine coverage, the fever box of the IMCI algorithm provides limited guidance for health workers in first-level health facilities. (excerpt)
Although malaria is a leading cause of morbidity and mortality among children in sub- Saharan Africa, valid quantitative estimates of malaria mortality cannot be obtained from vital registration systems in most countries in the region. To fill this gap, a variety of estimates have been proposed using epidemiologic models, each of which has limitations. Our objective was to estimate the number of direct malaria deaths (i.e., malaria initiated the train of morbid events leading directly to death) for children under 5 years old in sub-Saharan Africa for the year 2000 by refining recent epidemiologic models and using all available contemporary mortality data. First, we conducted a literature review to identify community-based, longitudinal studies of malaria mortality among children 0-59 months old; these studies used verbal autopsies to determine causes of deaths. Second, for each country, we estimated sub-populations of children that had different risks for dying from malaria (in middle Africa: populations exposed to high-and low-intensity malaria transmission in rural areas, and high- and low-intensity transmission in urban areas; in southern Africa: populations exposed to high- and low-intensity transmission). Third, we estimated a malaria mortality rate for each malaria risk sub-population using mortality studies identified in the literature review. To estimate the malaria mortality rates, we developed a prediction model. Fourth, for each malaria risk sub-population in each country, we estimated the number of malaria deaths by multiplying the sub-population by its corresponding malaria mortality rate. Fifth, to estimate a total number of malaria deaths for Africa, we summed malaria death counts for all malaria risk sub-populations from all countries. Finally, a series of sensitivity analyses was performed to assess the impact of varying key assumption (author's)
Estimates of the burden of malaria morbidity in Africa in children under the age of five years.
We were commissioned by the Child Health Epidemiology Reference Group (CHERG) to develop epidemiological estimates of burden of malarial disease among children less than 5 years old in Sub-Saharan Africa for the year 2000, in order to ascertain the proportional distribution of childhood disease and death by cause. It is a challenge to measure the burden of malaria because of the non-specific symptoms of malaria (fever with or without various other signs), the large burden of asymptomatic infections in most malaria-endemic settings, and the incomplete coverage of health information systems in much of sub-Saharan Africa where the greatest burden of malaria lies. We used the stringent inclusion criteria, data abstraction and methodology of the CHERG to develop estimates of malaria morbidity that were comparable with those for the other major childhood diseases. We attempted to provide a transparent methodology and to use a more complex statistical modelling approach than has previously been presented. (author's)
Methods and assumptions for diarrhoea mortality estimates.
The objective of this paper is to carefully document all the assumptions and decisions made during the estimation of global and regional diarrhoea mortality among under-fives in the developing world. This should guarantee a transparent process and allow the reproducibility of methods and results. (excerpt)
Improving diarrhoea estimates.
Diarrhoeal diseases remain a leading cause of morbidity and mortality in the world, particularly in developing countries. WHO, UNICEF and other partners are interested in updating the previous reviews on total and cause-specific diarrhoea morbidity and mortality in the world, to best estimate the burden of diarrhoeal diseases for the world in the year 2000. In this study, we wanted to produce the following outcomes: 1. To produce a data base for each of the WHO regions and 14 sub-regions, in the period 1990-2000, for children under 5 years of age, on the proportion of diarrhoeal illness caused by each type of diarrhoeal pathogen, at the community and health facility level; 2. To apply these estimates to the current estimates of diarrhoea burden produced by the U. of Virginia team; 3. To compare the current burden with the last global burden of diseases exercise and discuss potential reasons for current trends; 4. To describe the methodology used, data availability and assumptions used in reaching these new estimates; 5. To provide recommendations on how these estimates could be improved, interpreted and used. It is expected that this exercise will contribute to the discussion and assessment of the diarrhoea-attributable burden of disease and injury for the year 2000 done by WHO. We present in this report our final results, to help in its discussion and interpretation. (excerpt)
This report summarizes the results of the first formal meeting of the CHERG, held on 6-7 February 2002, in Gex, France. The four objectives of the meeting were: a) To agree on the aims, functions and composition of the CHERG, and to review the proposed CHERG strategy and work plan; b) To review progress to date in the development of country, regional and global estimates for under-five morbidity and mortality due to pneumonia, diarrhoea, malaria, measles and HIV, deaths in the neonatal period, and the contribution of nutrition as an indirect cause of death; c) To review and refine standard protocols for the assessment of the quality of data underlying estimates, for moving from data points to more general estimates, and for estimating uncertainty; d) To agree on short- and longer-term work plans to improve epidemiologic estimates of the health status of children under five. (excerpt)
Oral rehydration salts (ORS): a joint UNICEF / WHO update.
This document was prepared to inform national authorities on the position of the United Nations Children's Fund (UNICEF) and of the World Health Organization (WHO) with respect to issues such as flavouring, colouring, and rice-based ORS. It is based on a document first published in July 1996 that was revised to take into account results of studies on ORS formulation and zinc supplementation. (excerpt)
Using radio spots to support national CDD programmes.
This guide is organized according to six steps in the development and use of effective communication materials, adapted to apply to radio spots: STEP 1 - INVESTIGATE: Gather information about the status of your CDD programme, and about radio listenership patterns in your country. Using that information, decide whether or not to use radio, whether to use free radio time or purchased (commercial) time, and whether to develop your own spots or to adapt the sample spots included in the Annex to this guide. Gather information about what people currently know, believe, and do about their child's diarrhoea, why they do it, what words and phrases they use to talk about it. Use that information to plan (Step 2). STEP 2 - PLAN: Decide what CDD problem you will focus on in your radio spots, who is your target audience, what they should do to solve the problem and why, and how many spots you will produce. STEP 3 - DEVELOP MATERIALS: Write (or adapt) and produce draft radio spots. STEP 4 - PRETEST AND REVISE: Pretest your radio spots to ensure that they are understandable, acceptable, relevant, attractive, and persuasive. Revise your spots based on the comments and suggestions made during the pretest. STEP 5 - IMPLEMENT: Broadcast your radio spots several times each day on the radio station(s) and at the times when people are listening. STEP 6 - MONITOR, EVALUATE, AND REVISE: Listen to the radio to ensure that your materials are being broadcast as scheduled. Evaluate to understand what people are learning and doing, and revise your spots and broadcast schedule based on their reactions. This guide should be used with a small team of people. The team members will be one or two staff of the national CDD programme, and the people who will actually write and produce your radio spots. In some countries, these may be staff from the health education unit, at the Ministry of Health. In others, these may be producers from national or local radio station(s). Other local experts - personnel at nongovernmental organizations (NGOs) working in radio promotion, for example - may be invited as appropriate. (excerpt)
The need for guidance on how to implement the new WHO/ UNICEF recommendations for the use of ORS and zinc supplementation in the clinical management of diarrhoea was articulated at a meeting at Johns Hopkins University in June, 2004. On behalf of USAID, MOST initiated the effort to prepare the needed guidance in anticipation of the introduction of zinc supplementation into the protocol for treating diarrhoea in several countries. These guidelines are designed to prepare clinic-based health workers to implement the new recommendations. The information is meant to complement, not replace, more comprehensive policy guidance available from WHO on the management of diarrhoea. The guidelines presented in this document are generic, that is, they will be most effective when modified to support the particular strategy being used to introduce the new recommendations in each country. (author's)
The treatment of diarrhoea: a manual for physicians and other senior health workers. 4th rev.
This manual describes the principles and practices of treating infectious diarrhoea, especially in young children. It is intended for physicians and other senior level health workers. Other publications are available to assist in the training of other health staff, including community health workers. This fourth revision of the manual reflects recent clinical experience and research findings in diarrhoea case management. Compared to earlier versions, it includes revised guidelines on the management of children with acute diarrhoea using the new reduced (low) osmolarity ORS formulation and using zinc supplements, which have been shown to reduce duration and severity of diarrhoeal episodes, and revised guidelines for the management of bloody diarrhoea. Guidelines in the manual are based on the revised WHO chart that are included at the end of this document. (excerpt)
Rice-based oral rehydration salts. Update.
Oral rehydration therapy (ORT) using the WHO/UNICEF glucose-based Oral Rehydration Salts (ORS) solution is the preferred method for treating most children with dehydration due to diarrhoea (except those with severe dehydration); it has been used successfully in millions of cases worldwide. In many countries glucose-ORS solution is also recommended for home treatment of children with diarrhoea after they have been seen at a health facility, even when there are no signs of dehydration. Glucose-ORS solution works because glucose is rapidly absorbed by most patients with diarrhoea, and this causes salt and water also to be absorbed, thus replacing the faecal losses. Although glucose-ORS solution efficiently replaces faecal losses of water and salts, it has one important shortcoming: it does not reduce stool volume during diarrhoea or shorten the duration of the illness, which are the results that mothers and many health workers seek. If an ORS formulation could be developed that had the positive features of the standard glucose-ORS, including low cost safety, and stability during prolonged storage, but also appreciably reduced the rate of stool loss during illness and/or the duration of diarrhoea, it could have considerable advantages over glucose-ORS. Most importantly, it could be promoted as having a true antidiarrhoeal effect, which should lead to increased acceptance and use of ORS by both health workers and mothers, and perhaps also to a reduction in the use of ineffective "antidiarrhoeal" drugs and inappropriate antibiotics. This would represent a major advance in efforts to control diarrhoeal morbidity and mortality through appropriate case management. (excerpt)
Third generation oral contraceptives and risk of venous thrombosis: meta-analysis.
The objective was to evaluate quantitatively articles that compared effects of second and third generation oral contraceptives on risk of venous thrombosis. Design: Metaanalysis. Studies: Cohort and casecontrol studies assessing risk of venous thromboembolism among women using oral contraceptives before October 1995. Main outcome measures: Pooled adjusted odds ratios calculated by a general variance based random effects method. When possible, two by two tables were extracted and combined by the MantelHaenszel method. The overall adjusted odds ratio for third versus second generation oral contraceptives was 1.7 (95% confidence interval 1.4 to 2.0; seven studies). Similar risks were found when oral contraceptives containing desogestrel or gestodene were compared with those containing levonorgestrel. Among first time users, the odds ratio for third versus second generation preparations was 3.1 (2.0 to 4.6; four studies). The odds ratio was 2.5 (1.6 to 4.1; five studies) for short term users compared with 2.0 (1.4 to 2.7; five studies) for longer term users. The odds ratio was 1.3 (1.0 to 1.7) in studies funded by the pharmaceutical industry and 2.3 (1.7 to 3.2) in other studies. Differences in age and certainty of diagnosis of venous thrombosis did not affect the results. This metaanalysis supports the view that third generation oral contraceptives are associated with an increased risk of venous thrombosis compared with second generation oral contraceptives. The increase cannot be explained by several potential biases. (author's)
Clinical gallery. Manifestations of neonatal herpes and herpetic cervicitis.
Image 1 depicts typical herpes simplex virus (HSV) skin lesions in the neonate. If vesicles are observed, think herpes first. In Image 2, healing skin lesions can be observed on the buttocks in this infant who was a breech delivery; if scalp electrodes have been used, look carefully for lesions in the scalp area. Also note that healing lesions are easily overlooked and a history of their earlier appearance needs to be obtained. (excerpt)
Is viral shedding a surrogate marker for transmission of genital herpes? A discussion document.
While the concept linking herpes simplex virus (HSV) shedding to transmission is plausible, few data support shedding as a surrogate marker. If shedding is to be used as a surrogate marker in future clinical studies, it must be clear how far shedding must be reduced, and what the shape of the transmission:viral load curve ) or transmission:detection frequency curve) is before transmission is reduced. It remains unclear whether peak virus load, frequency of detection of virus, or the area under curve of the time:virus load plot is critical parameter in the transmission of HSV. This paper reports on an international meeting of exerts and a debate at the International Herpes Management Forum (IHMF) Annual Meeting, convened to examine whether a surrogate marker for HSV transmission is necessary, and whether there is any evidence, either in studies involving HSV or other viral infections, to suggest that viral shedding could be used such a surrogate. (author's)
Should every STD clinic patient be considered for type-specific serological screening for HSV?
While initially attractive, the idea that all individuals attending sexually transmitted disease or genitourinary medicine clinics should be offered type-specific screening for herpes simplex virus may be impractical, and even undesirable, for a number of reasons. These include the lack of a cost-effective and sufficiently specific and sensitive screening test, the absence of an intervention that benefits the health of the individual or reduces the risk of onward transmission and, not least, the psychological, social and sexual sequelae of an unexpectedly positive result. (author's)
Treatment of herpes simplex labialis.
Recurrent herpes simplex labialis is associated with mild morbidity, but remains a significant problem for people with frequent and/or severe recurrences. Both topical and peroral episodic antiviral treatments of recurrences are modestly effective at reducing the duration of signs and symptoms. Recent studies with high-dose, short-course valaciclovir suggest that maximum benefit from antiviral therapy may be achieved with as little as 1 day of treatment. Topical steroids may be useful in combination with an antiviral agent, but more needs to be learnt about the appropriate strength and duration of steroid therapy before a general recommendation can be made. Selected subgroups of patients are candidates for prophylactic treatment with perorally administered nucleoside antiviral agents. Prophylaxis with topical agents is not effective. (author's)
The arguments against screening for all individuals attending sexually transmitted disease and genitourinary medicine clinics for herpes simplex virus may seem compelling, but an examination of the facts indicate that the case in favour is strong. While no screening test is perfect, testing can confirm the diagnosis, improve management, help to reduce the risk of transmission - including to the newborn - and assist in the development of public health strategies. Not least, patients want to know whether or not they are infected. In this article we look at the arguments in favour of screening. (author's)
The pharmacokinetics of antiviral therapy in paediatric patients.
Effective treatment requires administration of optimal drug dose. In paediatric patients this may be difficult to achieve due to lack of pharmacokinetic studies, administration of small doses, changes in body composition, continuous growth, and development and maturation of organs and systems. This article reviews the factors and misconceptions associated with determining optimal drug dose and route of administration in different paediatric populations. The pharmacokinetics, appropriate doses and preferred routes of administration for aciclovir, ganciclovir, famciclovir, foscarnet and cidofovir, for treating herpesvirus infections in the paediatric population, are discussed. (author's)
Herpes simplex virus infections: behavioural and biomedical aspects [editorial]
HERPES SIMPLEX VIRUS types 1 and 2 (HSV-1 and HSV-2) have the potential to cause a variety of illnesses depending on the site of infection, whether the infection is a primary or recurrent outbreak, and whether the host is immunocompetent or immunocompromised. Transmission of HSV infection generally requires intimate person-to-person contact and sexual transmission, in particular, may have psychosocial consequences not seen with other modes of transmission. Fortunately, most HSV infections can be managed with antiviral therapy, although drug therapy alone does not often adequately address the psychosocial impact of infection. In this issue of Herpes, five informative articles explore important behavioural and biomedical aspects of HSV infections. The possibility of HSV involvement should be considered when evaluating most sick neonates as neonatal herpes is a rare, but potentially devastating, illness that requires prompt and aggressive treatment. Decision-making regarding empirical antiviral treatment of the neonate may be guided by information on the sexually transmitted disease status of the parents; however, obtaining this information can cause feelings of anxiety and distress for both parents and physicians. Dr Sian Cotton and colleagues report the experiences of physicians who approached parents about the possible diagnosis of neonatal herpes. The article also provides some strategies for healthcare providers that might be useful for managing potential discomfort when discussing neonatal herpes with families. (excerpt)
Antivirals in the prevention of genital herpes.
Genital herpes remains one of the most common sexually transmitted infections. Despite best efforts to prevent sexually transmitted diseases in the era of AIDS, the incidence of genital herpes continues to rise, and evidence that herpes simplex virus type 2 is a significant cofactor in the transmission of HIV infection is mounting. Because of the common psychosocial consequences of genital herpes transmission, prevention modalities against transmission of genital herpes are urgently required from both personal and public health perspectives. Most discordant couples are either unaware of genital herpes in one partner or unaware of clinical activity of the virus during sexual exposure that results in transmission. Yet, the body of evidence available suggests that the antiviral drugs currently used in the treatment of genital herpes are effective in suppressing asymptomatic virus shedding and, thus, could play a future role in reducing transmission. The first study to examine that possibility has recently been made public. (author's)
Screening for neonatal herpes: physicians' descriptions of discussions with parents.
Screening for possible herpes simplex virus infection in neonates may raise feelings of anxiety and distress among parents and physicians. To elicit physicians' experiences of communicating with families when screening for neonatal herpes, we conducted a series of semi-structured interviews with 15 physicians from one paediatric institution, and coded the resulting audiotapes for common themes. These included how physicians prepared families for screening and treatment, how physicians managed stigma, and perceived parental reactions. Techniques for fostering good communication included being direct and honest and ensuring the time and place for discussion were appropriate; strategies for managing stigma included placing the diagnosis in epidemiological context, and discussing the potential severity of the disease. Physicians described many parental emotional reactions, some of which were herpes-specific, and suggested strategies to manage potential discomfort when discussing neonatal herpes with families. Future research can determine which strategies are most effective, which are associated with negative psychological outcomes, and how medical students and residents can be better trained to screen for this diagnosis. (author's)
Education and counselling for genital herpes: perspectives from patients.
The incidence and prevalence of genital herpes continue to increase in the USA, and the availability of new, accurate serological tests for herpes simplex virus (HSV) may identify millions of previously unrecognized cases. Newly diagnosed genital HSV infections place a serious burden on healthcare providers in terms of education and counselling. The study was initiated to assess the need for and potential use of an improved system for education and counselling of patients newly diagnosed with genital herpes. Patients' perspectives on current and ideal care, as well as barriers to education and counselling and recommendations are discussed. In addition, implications for practice and recommendations for future research are suggested. (author's)
Antiviral therapy in children with varicella zoster virus and herpes simplex virus infections.
A small number of antiviral drugs are available for the treatment of varicella zoster virus (VZV) and herpes simplex virus (HSV) infections in children. This review presents pharmacokinetic data on the following selected antiviral agents: aciclovir, valaciclovir, famciclovir, cidofovir and foscarnet. Support and current recommendations for the treatment of selected VZV and HSV infections in children will also be reviewed. (author's)
The first goal in minimizing herpes simplex virus (HSV) mortality and morbidity in infants is to reduce the risk of acquisition of new infections during pregnancy, especially in late gestation. Antenatal testing does not necessarily predict the risk of transmission to the newborn infant, since this risk is variable. In order to identify newly acquired infection in women who are HSV-seronegative, repeat testing in late pregnancy would need to be offered. In those who are HSV-seropositive, concern for transmission to the infant is likely to result in administration of antiviral drugs to the mother or in Caesarean delivery. The potential consequence is medical intervention for many pregnancies that would not have been complicated by perinatal HSV transmission. Risk- and cost-benefit analyses are needed to assess HSV type-specific serological screening of pregnant women. Practical benefit can be achieved by counselling all pregnant women against oral or unprotected sexual contact during pregnancy. (author's)
Increasing prevalence of HSV-2 points to need for more effective prevention strategies [editorial]
THESE PAST FEW YEARS have brought increased recognition of the prevalence of herpesvirus type 2 (HSV-2) infections worldwide. Once thought of as the 'American Disease', this virus is no longer a predominantly USA problem; indeed, it is now more prevalent in the southern than northern hemisphere. Seroprevalence studies in Africa, the Caribbean and South America have revealed startlingly high rates of infection, even among persons with few sexual partners. The high prevalence rates found among blood donors, patients at family clinics, and obstetrical populations now document in these regions of the world what the seroprevalence studies had shown in the USA - that HSV-2 infection is not just confined to traditional groups at high risk of sexually transmitted diseases, but has become prevalent in the general population. (excerpt)
Herpes simplex virus: who should be tested? [editorial]
THE DEBATE ARTICLES in this issue of Herpes on the use of type-specific serological testing for herpes simplex virus types 1 and 2 (HSV-1 and HSV-2) raise some controversial questions. Type-specific serological testing, now widely available, has the potential both to increase the degree of diagnostic certainty in genital herpes and to reduce the number of misdiagnosed and undiagnosed cases. However, universal serological screening would be inappropriate because of the risk of false-positive diagnosis - even with a test that has very high sensitivity and specificity. In addition, such a strategy is unlikely to gain acceptance in terms of public health, not only because it would be costly, but also because there are currently very few efficient interventions to reduce the risk of HSV transmission. Condom use has only been shown to be partially protective in preventing male-to-female HSV transmission;1 and, although antiviral drugs can reduce HSV shedding, there are no data available yet on the effect of suppressive therapy on HSV transmission. If it is premature to introduce widespread screening in the general population, however, type-specific serological tests could have greater clinical usefulness in certain populations. (excerpt)
Herpesviruses: agents of acute and chronic disease [editorial]
HERPES VIRUSES ARE REMARKABLE in their capacity to cause disease. Viruses of this family can produce infections that cause no apparent illness in some individuals while in others they cause acute life-threatening disease. These agents are stealthy, establishing a persistent infection in all but not all appear to suffer as a consequence of their persistence. Even the consequence of persistence varies with host and virus, ranging from self-limiting recurrent infections to more devastating chronic conditions. In this issue of Herpes, five instructive articles illustrate the nefarious nature of herpes viruses. (excerpt)
Molecular basis of the interactions between herpes simplex viruses and HIV-1.
Herpes simplex virus types 1 and 2 (HSV-1 and -2) are two of the major opportunistic agents involved in the pathogenesis of AIDS, which is caused by human immunodeficiency virus types 1 and 2 (HIV-1 and HIV-2). A body of evidence suggests that they can also act as co-factors by interacting with HIV-1, thereby influencing disease progression. Indeed, the HIV-1 life cycle can be affected by HSV at different levels of interaction, both in vitro and in vivo: (i) transactivation of the HIV-1 long terminal repeat can be mediated, probably through different pathways, by HSV-1-infected cell protein (ICP)0, ICP4, ICP27 and US11 gene products; the HSV-1 transactivator viral protein 16 is not able to transactivate the long terminal repeat; (ii) cytokine release and antigen presentation from HSV-infected cells are both able to stimulate HIV-1 expression; (iii) Pseudotyping of the HIV-1 core particle with HSV-1 envelope glycoproteins can expand HIV-1 tropism to new cell types. Moreover, in vivo studies report that aciclovir treatment can produce a survival benefit in HIV-1-infected patients and that recurrent genital herpes appears to be linked to HIV-1 transmission by both boosting plasma retroviral load and providing a portal of entry and exit for HIV-1. (author's)
The role of HSV in the transmission and progression of HIV.
Herpes simplex virus (HSV) is a common co-infection in persons infected with human immunodeficiency virus type 1 (HIV-1). Chronic perianal ulceration from herpes simplex virus type 2 (HSV-2) was one of the first opportunisitc infections identified among patients with AIDS. Subsequent research has established that the natural history of HSV-2 is altered in co-infected persons as they experience more frequent clinical and subclinical reactivation of HSV than persons infected only with HSV-2. In addition, there are accumulating data to suggest a significant biological interaction between these two viruses that result in more efficient sexual transmission of HIV-1 and an increased rate of HIV replication during both clinical and subclinical HSV reactivation. (author's)
The challenge for the prevention of acquisition of neonatal herpes is to identify those mothers at risk of acquiring herpes simplex virus (HSV) infection in pregnancy, and then to apply interventions to reduce this risk. Existing strategies to prevent neonatal herpes are based on recognition of clinical lesions in mothers at term, but these approaches may be of limited effectiveness, given that most cases of neonatal herpes result from unrecognized maternal acquisition of HSV in late pregnancy. The availability of type-specific serological tests for HSV-2 and HSV-1 now allows identification of at-risk pregnancies, and can enhance strategies to prevent both maternal and neonatal herpes infection. This may help to reduce the need for a Caesarean section, while promoting individual and public health gains. (author's)
The changing epidemiology of HSV-1 and HSV-2 and implications for serological testing.
An increased prevalence of genital herpes simplex virus (HSV) infection has been documented worldwide. In the USA, the National Health and Nutrition Examination Survey (NHANES), conducted from 1988 to 1994, revealed the seroprevalence of HSV-2 in persons 12 years of age or older to be 21.9%, an increase of 30% in age-adjusted seroprevalence of HSV-2 since the previous survey that was conducted from 1976 to 1980. Several European studies have documented a high prevalence of HSV-2 in antenatal populations. The advent of highly sensitive virological tests has confirmed that HSV-2 is the most common cause of genital ulceration in the developing world. People with a high standard of living may escape oral HSV-1 infection in childhood. Since asymptomatic oral shedding of HSV-1 is common, adults without immunity to HSV-1 who practise oral sex are especially at risk for genital HSV-1 infection. In some European cohorts, HSV-1 has been a more common aetiological agent of primary genital herpes than HSV-2. These patient groups may benefit from the use of HSV-1 in addition to HSV-2 type-specific serology. (author's)
Serological testing for human herpesvirus 8.
Human herpes virus 8 (HHV-8) has been identified in skin lesions of patients with Kaposi's sarcoma and is now considered a co-factor for the development of the neoplasm associated with this disease. Several laboratory tests are currently available for use in the detection of HHV-8 antibodies - immunofluorescence and enzyme-linked immunosorbant assays being the most frequently used tests. Epidemiological studies have demonstrated the existence of hyperendemic regions where HHV-8 infection is ubiquitous and often acquired early in childhood. The role of HHV-8 in the development of Kaposi's sarcoma has yet to be clarified completely and data collected from the epidemiological studies of HHV-8 prevalence may be useful in gaining a better understanding of the different factors involved in tumour development. (author's)
Population Reports quick guide to vasectomy counseling -- Vasectomy is quick and easy!
Having a vasectomy is quick and easy. The steps are as follows: Registering at the clinic; Meeting with a counselor to learn more about vasectomy and other family planning methods and to make sure vasectomy is the right choice; An injection of medicine that prevents pain but does not cause sleep; A small opening is made in the scrotum, and the tubes inside are blocked; Leaving the clinic, usually in less than an hour. The tubes inside the scrotum are cut and blocked in a vasectomy. Sperm cannot travel from the testicles, where they are made into the ejaculate, which is made in the seminal vesicle and the prostate. (excerpt)
Gender inequalities in health among older Brazilian adults.
The objective was to investigate gender differences among older Brazilians in their health status and their use of health services. Participants were individuals aged 60 years and older included in a national household survey conducted in Brazil in 1998. Data were analyzed by multiple logistic regression, taking into account the design effect due to multistage sampling. There were differences in the health and living conditions of older men and older women that were not explained by age or place of residence. Older women had worse indicators of schooling and personal income but better indicators of housing standards and per capita household income. The older women also reported more chronic diseases, had poorer indicators of independence and physical mobility, sought health services more often, and reported more medical visits in the previous year. Despite their apparent worse health conditions, elderly women in urban areas had lower hospitalization rates in the previous year (odds ratio = 0.89; 95% confidence interval, 0.82–0.96) than did elderly men in urban areas. Our results indicate that among older Brazilians there are gender inequalities in health that cannot be explained by age and place of residence. The findings raise questions on how health, socioeconomic, and cultural factors influence gender patterns of seeking and using health care in later life in the country. As pressures on health care and health funding increase in Brazil as a result of the aging of the population, there is a need to take a gender perspective into account. (author's)
The use of the female condom by women in Brazil participating in HIV prevention education sessions.
The objectives were to study HIV-positive women and women at risk of becoming infected with HIV who attended HIV prevention education group sessions at a university hospital in Brazil and to compare the use of the female condom and the male condom by these two groups of women. The study subjects were 165 women participating in HIV prevention education group sessions at the Medical School Hospital of Ribeirão Preto of the University of São Paulo, in the city of Ribeirão Preto, São Paulo, Brazil. Women could be enrolled in the study from August 2000 to June 2001, and the follow-up observation time period was from August 2000 to July 2001. Male condoms and female condoms were freely distributed to all the participants at the end of each educational session and also at the end of each follow-up visit that the participants made. Each woman took part in an initial interview and was asked to return monthly. At each follow-up visit an additional short interview was carried out in order to investigate use of the male condom and of the female condom. Variables that were examined for the study included age, education, ethnic group, marital or relationship status, number of children, the women’s use of male condoms and female condoms, commercial sex (whether the women had ever had sex in exchange for money, gifts, or favors), and previous knowledge of the female condom. The 165 women studied fell into the following three categories: 132 of them (80.0%) were HIV-positive, 26 of them (15.8%) had a sexually transmitted disease (STD) other than HIV and did not have an HIV-positive partner, and 7 of them (4.2%) had an HIV-positive partner but did not have HIV or any other STD. The women ranged in age from 15 to 64 years, with a mean of 30.3 years. Of the women in the study, 69.7% of them were married or were cohabitating, and 90.9% of them had a sexual partner. Just over two-thirds of the women had seven years of formal schooling or less. Out of 163 women, a total of 31 of them (19.0%) had never used the male condom with a partner, and 49 of the 163 (30.1%) had not used a male condom at the time of the last sexual intercourse. Out of the 165 women, 74 of them (44.8%) returned for at least one follow-up visit. Of these 74 women, 58 of them (78.3%) reported using the female condom between the initial interview and the first follow-up visit. The majority of the 74 women who returned for a visit liked using the female condom, and the women reported that their partners also generally accepted the female condom. In comparison to women at risk of HIV, HIV-positive women were more likely to have used the male condom with a partner before the initial interview. Women who continued returning over a longer follow-up period were more likely to have used the female condom at the time of the last sexual intercourse. No association was found between female condom use at the time of last sexual intercourse and the woman’s HIV infection status. In comparison to the women at risk of HIV, the HIV-positive women in our study were more likely to use male condoms with their partners, to return for follow-up visits, and to have a longer follow-up period. The acceptance of the female condom among the HIV positive women in this study, as reported at their first follow-up visit, appears to be similar to the acceptance of the female condom among women in general in Brazil. (author's)
The objective was to use a case-control study to analyze risk factors associated with teenage childbearing among adolescents who were in a birth cohort study that began in 1982 in the city of Pelotas, Rio Grande do Sul, Brazil. Adolescent mothers in Pelotas who gave birth between January 1995 and March 2001 and who had been born in 1982 were identified through the local birth information system. These subjects from the 1982 birth cohort were compared to adolescents from the same cohort who had not given birth before March 2001. Standardized interviews were used in 2001 to obtain information about socioeconomic, maternal reproductive, demographic, and lifestyle characteristics. This information was combined with data obtained in earlier phases of this 1982 birth cohort study. Unconditional logistic regression was used to analyze the risk factors associated with childbearing during adolescence. A total of 420 parous adolescents from the 1982 birth cohort were identified and then compared with 408 cohort adolescents who had not given birth by March 2001. Higher family income in 1982 and more parental schooling in 1982 were inversely related to childbearing among the birth cohort adolescents. Cohort girls whose mothers were under age 20 when they gave birth in 1982 had a higher risk of becoming pregnant while still an adolescent. Cohort girls who, during childhood, lived with siblings from different fathers were twice as likely to become an adolescent mother. Compared to cohort adolescents who had not failed during the first four years of school, those girls who had done so had twice the risk of giving birth during adolescence. Among the cohort girls a positive association was found between younger age at first intercourse and childbearing in adolescence. The results indicate that the educational level of the adolescent mothers must be considered in planning policies that attempt to disrupt successive cycles of socioeconomic deprivation. Early interventions to improve sex education and to increase the motivation of young girls to achieve higher levels of education are needed. The interventions should aim for a reduction in the risk of long-term poverty and poorer educational achievements of teenage mothers and their children. (author's)
Tuberculosis along the United States-Mexico border, 1993-2001.
Tuberculosis (TB) is a leading public health problem and a recognized priority for the federal Governments of both Mexico and the United States of America. The objectives of this research, primarily for the four states in the United States that are along the border with Mexico, were to: (1) describe the epidemiological situation of TB, (2) identify TB risk factors, and (3) discuss tuberculosis program strategies. We analyzed tuberculosis case reports collected from 1993 through 2001 by the tuberculosis surveillance system of the United States. We used those data to compare TB cases mainly among three groups: (1) Mexican-born persons in the four United States border states (Arizona, California, New Mexico, and Texas), (2) persons in those four border states who had been born in the United States, and (3) Mexican-born persons in the 46 other states of the United States, which do not border Mexico. For the period from 1993 through 2001, of the 16 223 TB cases reported for Mexican-born persons in the United States, 12 450 of them (76.7%) were reported by Arizona, California, New Mexico, and Texas. In those four border states overall in 2001, tuberculosis case rates for Mexican-born persons were 5.0 times as high as the rates for persons born in the United States; those four states have 23 counties that directly border on Mexico, and the ratio in those counties was 5.8. HIV seropositivity, drug and alcohol use, unemployment, and incarceration were significantly less likely to be reported in Mexican-born TB patients from the four border-states and the non-border-states than in patients born in the United States from the four border states (P < 0.001). Multivariate analysis revealed that among pulmonary tuberculosis patients who were 18–64 years of age and residing in the four border states, the Mexican-born patients were 3.6 times as likely as the United States-born patients were to have resistance to at least isoniazid and rifampin (i.e., to have multidrug-resistant TB) and twice as likely to have isoniazid resistance. Mexican-born TB patients from the four border states and the nonborder states were significantly more likely to have moved or to be lost to follow-up than were the TB patients born in the United States from the four border states (P < 0.001). Increased collaborative tuberculosis control efforts by the federal Governments of both Mexico and the United States along the border that they share are needed if tuberculosis is to be eliminated in the United States. (author's)
The objective was to investigate trends in AIDS mortality and incidence in Brazil over the period of 1984 to 2000 and to assess the impact of the introduction of universal access to highly active antiretroviral therapy (HAART) in the country in 1996. Data from the Brazilian disease notification system and the national mortality information system were used to calculate annual region-specific and sex-specific AIDS incidence and mortality rates. We also calculated sex- and region-specific ratios of the number of AIDS deaths in one year to the number of AIDS cases notified two years earlier. AIDS mortality rates for both men and women and in all five of the geographic regions of Brazil declined following introduction of HAART, despite continued growth in AIDS incidence. The ratio of the number of AIDS deaths in one year to the number of AIDS cases notified two years earlier for men equalized rapidly with the ratio for women following introduction of HAART. More recently, AIDS incidence declined for both sexes and in most of the regions of Brazil. Despite Brazil’s resource limitations and disparities in wealth between men and women and among the country’s regions, the introduction of universal access to HAART in Brazil has helped achieve impressive declines in AIDS mortality, and it may also be contributing to declines in AIDS incidence. (author's)
Epidemiologic trends of HIV / AIDS in Jamaica.
The Caribbean now ranks second to sub-Saharan Africa in terms of the number of cases of HIV/AIDS per capita. About 2.4% of the Caribbean’s adult population is living with HIV/AIDS. HIV/AIDS has become the leading cause of death for persons 15 to 44 years old in several English-speaking and several non-English-speaking nations of the Caribbean, and it is also responsible for leaving an estimated 80 000 Caribbean children orphaned. Jamaica is one of the Caribbean countries where the epidemic has spread from high-risk groups to the general population. The other Caribbean countries where this has happened are the Bahamas, Barbados, the Dominican Republic, Guyana, and Haiti. (excerpt)
In Paraguay, both IUDs and contraceptive pills come with "strings attached".
Despite government-sponsored efforts to develop, disseminate, and institutionalize national family planning guidelines, many providers in Latin America do not always comply with guideline recommendations, which are generally intended for public sector providers. The reasons for this noncompliance range from lack of knowledge of the guidelines to providers’ deeply held personal or cultural beliefs that run counter to the guideline recommendations. Providers have also been known to exhibit deliberate resistance to training. For example, one provider who attended a family planning training session in El Salvador reported that, even after four days of training, other providers in the session still believed the myth that the intrauterine device (IUD) is an abortifacient. Responding to community expectations on gender roles in order to avoid later problems with the husband of a female client has also been documented. Providers sometimes pick and choose which recommendations to follow. In Peru, for instance, there has been selective noncompliance with standards on voluntary surgical contraception. (excerpt)
Seroprevalence of Kaposi's sarcoma-associated herpesvirus in various populations in Cuba.
Little is known about the prevalence and distribution of Kaposi’s sarcoma-associated herpes virus (KSHV) infection in the Caribbean. The aim of this study was to determine rates of KSHV seropositivity in various populations in Cuba. During the years 1998 to 2002 we screened serum samples from 410 subjects in Cuba. Serologic screening for KSHV antibodies was a two-step process using (1) indirect immunofluorescence assay (IFA) specifically reactive to the KSHV latency-associated nuclear antigen (LANA) encoded by open reading frame 73 (ORF73), and (2) confirmatory immunoblot using recombinant KSHV ORF65.2, a lytically expressed, 20-kilodalton protein as the target antigen. Five different populations were studied: (1) 45 AIDS patients with Kaposi’s sarcoma (AIDS-KS), (2) 154 HIV-1-infected patients without clinical evidence of KS, (3) 171 HIV-negative blood donors, (4) 27 consecutive kidney transplant recipients, who were HIV negative, and (5) 13 contacts (sexual contacts or relatives) of the AIDS-KS-affected patients. Among the 45 AIDS-KS subjects, 35 of them (77.8%) were KSHV-seropositive. Thirty-two of the 154 HIV-positive patients without KS (20.8% of them) were KSHV-seropositive, and 6 of the 13 contacts of KS-affected patients (46.2% of them) were infected with KSHV. In contrast to other researchers, we did not find in the populations that we studied in Cuba that KSHV seropositivity was associated with male homosexual or bisexual activity. We found high KSHV seropositivity rates among women reporting sexual contact with bisexual men and among men who had acquired an HIV infection in Africa. There were low rates of KSHV infection among the blood donors (1.2%) and the renal transplant recipients (0.0%). The low rates of KSHV infection that we found among the non-HIV-infected populations in Cuba are similar to patterns found in populations in Europe and in the United States. Together with similar results from Brazil, Jamaica, and the United States of America, our results suggest that KSHV infection is uncommon in some populations in the Western Hemisphere and that KSHV is largely confined to patients with AIDS-associated KS. (excerpt)
Chagas cardiomyopathy and serologic testing in a small rural hospital in Chiapas, Mexico.
The objectives were to conduct a study in a small rural hospital located in the state of Chiapas, Mexico, to: (1) examine the prevalence of chagasic cardiomyopathy among patients with the diagnosis of congestive heart failure and (2) assess the prevalence of positive serologic results in blood donors in the hospital, in an attempt to ascertain whether Chagas’ disease remains an important cause of heart failure at least in some areas of Mexico. The study of patients with cardiomyopathy was conducted by retrospective chart review of patients with the diagnosis of congestive heart failure treated at the hospital during the years 2000–2002. With the blood donors, the results of their serologic screening were reviewed for a six-month period beginning in April 2002. Serologic testing was done in both groups with either indirect hemagglutination (IHA) or enzyme-linked immunosorbent assay (ELISA), or with both. Of 67 patients with heart failure and no risk factors for other causes of heart failure, 40 of them had serologic tests performed. Thirty-three of these 40 (82.5%) were positive by ELISA, IHA, or both. With 97 blood donors, one or both serologic tests were positive in 17 of them (17.5%). This research adds to the evidence that Chagas’ disease continues to be a major cause of heart failure in some areas of Mexico and that there continues to be a risk of transmission by blood transfusion if donated blood is not consistently screened. (author's)
Use of an artificial neural network for detecting excess deaths due to cholera in Ceará, Brazil.
The objective was to evaluate recurrent neural networks as a predictive technique for time-series in the health field. The study was carried out during a cholera epidemic which took place in 1993 and 1994 in the state of Ceará, northeastern Brazil, and was based on excess deaths having ‘poorly defined intestinal infections’ as the underlying cause (ICD-9). The monthly number of deaths with due to this cause between 1979 and 1995 in the state of Ceará was obtained from the Ministry of Health’s Mortality Information System (SIM). A network comprising two neurons in the input layer, twelve in the hidden layer, one in the output layer, and one in the memory layer was trained by back-propagation using the fist 150 observations, with 0.01 learning rate and 0.9 momentum. Training was ended after 22,000 epochs. We compare the results with those of a negative binomial regression. ANN forecasting was adequate. Excessive mortality (number of deaths above the upper limit of the confidence interval) was detected in December 1993 and October/ November 1994. However, negative binomial regression detected excess mortality from March 1992 onwards. The artificial neural network showed good predictive ability, especially in the initial period, and was able to detect alterations concomitant and a subsequent to the cholera epidemic. However, it was less precise that the binomial regression model, which was more sensitive to abnormal data concomitant with cholera circulation. (author's)
Tuberculosis contact tracing among children and adolescents, Brazil.
The objective was to detect tuberculosis (TB) disease or infection among contacts of pulmonary TB patients. Cross-sectional study in a Primary Healthcare unit in Rio de Janeiro (Brazil) with 184 child and adolescent contacts of pulmonary TB patients between March 1995 and March 1997. Subjects underwent clinical evaluation, chest radiographs, and tuberculin skin tests (TST); sputum smears were performed whenever possible. TB cases found were submitted to treatment and infected patients to chemoprophylaxis. Tuberculin converters, who tested positive for TST eight weeks after an initial negative result, received chemoprophylaxis. The sample included 98 boys and 86 girls; age ranged from 0 to 15 years; 26.9% were malnourished according to the Gomez criteria. Concerning the source of infection, 170 cases (92.4%) had household contacts, of which 66.5% were the child’s parents. BCG vaccination was verified in 98.4% of children, and 14.7% of children had been revaccinated. Strong TST reactions were observed in 110/181 children. Seventy-six children (41.3%) were considered as infected by M. tuberculosis and 25 cases (13.6%) of TB were detected, of which seven (28%) were asymptomatic. There was greater occurrence of disease when the contact lived with more than one source of infection (p = 0.02). The detection of TB disease and infection was high in the studied population. Contact control must be emphasized, for it allows for the diagnosis of TB in children who are still asymptomatic, in addition to identifying infected subjects who may profit from chemoprophylaxis. (author's)
Entomological aspects of Chagas' disease transmission in the domestic habitat, Argentina.
The objective was to study the risk of Trypanosoma cruzi domestic transmission using an entomological index and to explore its relationship with household’s characteristics and cultural aspects. There were studied 158 households in an endemic area in Argentina. Each household was classified according to an entomological risk indicator (number of risky bites/ human). A questionnaire was administered to evaluate risk factors among householders. Infested households showed a wide range of risk values (0 to 5 risky bites/human) with skewed distribution, a high frequency of lower values and few very high risk households. Of all collected Triatoma infestans, 44% had had human blood meals whereas 27% had had dogs or chickens blood meals. Having dogs and birds sharing room with humans increased the risk values. Tidy clean households had contributed significantly to lower risk values as a result of low vector density. The infested households showed a 24.3% correlation between time after insecticide application and the number of vectors. But there was no correlation between the time after insecticide application and T. infestans’ infectivity. The statistical analysis showed a high correlation between current values of the entomological risk indicator and Trypanosoma cruzi seroprevalence in children. The risk of T. cruzi domestic transmission assessed using an entomological index show a correlation with children seroprevalence for Chagas’ disease and householders’ habits. (author's)
Excess mortality by diarrhea simultaneous to a cholera epidemic in northeastern Brazil.
The objective was to evaluate excess mortality due to infectious diarrhea without etiological diagnosis, occurring simultaneously to Vibrio cholerae circulation. Statistical modeling was applied to a time series of deaths ascribed to “poorly defined intestinal infections” (International Classification of Diseases – ICD-9) and “presumably infectious diarrhea and gastroenteritis” (ICD-10), between 1980 and 1998 in the Northeast Region of Brazil. The prediction of expected values was obtained after a discontinuity point. Excess mortality was calculated as the difference between observed figures and those estimated by the model. Between 1992 and 1994, only 19.3% of deaths by cholera were actually notified. In 1993, the year in which the epidemic reached its peak in the area, our modeling estimated under-registration at 82.2%. Results indicate substantial under-registration of cholera mortality during the epidemic in Northeastern Brazil. (author's)
Trends in the modes of delivery and their impact on perinatal mortality rates.
The objective was to determine changes in the incidence of vaginal deliveries, cesarean sections, and forceps deliveries and their potential association with fetal, early neonatal, and perinatal mortality rates over time. A retrospective study was carried out and the occurrence of deliveries supervised by university services between January 1991 and December 2000 was determined. Data regarding fetal, early neonatal, and perinatal deaths were assessed using obstetric and pediatric records and autopsy reports. Of a total of 33,360 deliveries, the incidence of vaginal deliveries, cesarean sections, and forceps deliveries was relatively steady (around 60, 30, and 10%, respectively) while, at the same time, there was a marked reduction in fetal mortality (from 33.3 to 13.0‰), early neonatal mortality (from 30.6 to 9.0‰), and perinatal mortality (from 56.4 to 19.3‰). The marked reduction in perinatal mortality rates seen during the study period without an increase in cesarean sections indicates that the decrease in perinatal mortality was not impacted by cesarean section rates. The plausible hypothesis seems to be that the reduction in perinatal mortality of deliveries performed under the supervision of university services was more likely to be associated with better neonatal care rather than the mode of delivery. (author's)
The Baby-Friendly Hospital Initiative and breastfeeding in a neonatal unit.
The objective was to evaluate the impact of the Baby-Friendly Hospital Initiative on breastfeeding practices among newborns admitted to a neonatal unit, during hospitalization and during the first six months of life. The medical records of all newborns admitted to the neonatal unit of a teaching hospital in 1994 (N = 285) and 1998 (N = 368) were reviewed, and information on the infants’ feeding practices during hospitalization and during the first six months of life was analyzed. The duration of breastfeeding and exclusive breastfeeding and the differences between the two years were assessed using the Kaplan-Meier technique and the Log-Rank test. Logistic regression and Cox analysis were performed for confounder control. There was an important increase in the percentage of infants given breast milk exclusively (1.9% in 1994 to 41.7% in 1998) during hospitalization, and feeding with formula alone, observed in 17.7% of infants in 1994, was no longer noted in 1998. With respect to breastfeeding practices during the first six months of life, the median duration of exclusive breastfeeding increased from 12 days in 1994 to 45 days in 1998. As to breastfeeding, which includes the ingestion of other types of food, no significant difference was observed. The implementation of the initiative in the studied hospital contributed towards an increase in the exclusive breastfeeding of newborn babies during neonatal unit admission and during the first six months of life. (author's)
Social representations of the relationships between plant vases and the dengue vector.
The objective was to investigate how houseplant ‘caretakers’ represent the relationship between plant vases and breeding sites for the dengue vector, in order to reformulate educational policies. The present study was carried out among caretakers from three São Paulo State municipalities in which dengue is known to exist and in which extensive educational activities had been previously conducted. Twenty households from each of the municipalities studied were selected based on larval density evaluation bulletins elaborated by SUCEN (Endemic Disease Control Coordination) and classified as positive or negative for the presence of Aedes aegypti larvae in plant vases. The 60 participants were aged 20-65 years and were directly involved in plant care. Interviews were carried out using a semi-structured questionnaire, and recorded in cassette tapes. Data were tabulated using the collective subject discourse technique. Negative representations found included: erroneous information in the population’s imaginary universe; disbelief that a ‘tiny little mosquito’ could cause such extensive problems; belief in the disease only after its concrete manifestation; and mistrust in educational activities in general. Positive representations included: understanding of the basic mechanism of dengue transmission; appreciation of the role and constant presence of sanitary authorities; understanding of their own share of responsibility in fighting the disease. With respect to vector control activities, the exceedingly synthetic messages emitted by the sanitary authorities prevent the information from being assimilated by the population to the desirable extent. Educational activities must be understood by the population to which they are destined if any behavioral changes are to take place. (author's)
Cryptosporidiosis occurrence in HIV+ patients attended in a hospital, Brazil.
Cryptosporidiosis occurrence was determined in HIV+ patient assisted in the Clinic of Infect-parasitic Diseases in a hospital of Nova Iguaçu, Rio de Janeiro, Brazil, in the period from Juy/1998 to March/1999. In order to research, seventy-five patient, carriers of diarrhea or not, were appraised. The samples of feces were collected and placed in saline solution with formaldehyde (5%). The Modified Ritchie technique was used for the oocysts research, and the smears were stained with Safranine O methylene blue. The results verified 9.33% of positive samples, with higher frequency of cases in patients of the masculine sex from 20 to 50 years old, however without significant difference. (author's)
Distribution of acute respiratory diseases in Brazil from 1996 to 2001, Brazil.
Acute respiratory diseases - ARD, mainly pneumonias, are the most important cause of death among children under five years of age and are responsible for severe diseases among people over sixty years of age. This study aims to describe the main epidemiological characteristics of ARD cases notified by healthcare centers. ARD patients’ records from medical consultations at 100 public health care centers and hospitals were reviewed every week in the period from 1996 to 2001 and data was filled out on a specific form. Data was classified as pneumonia and not pneumonia according to age groups. During this period, 2,050,845 ARD cases were informed. May and June were the months with the largest number of cases. ARDs were more frequent among children aged one to four years old. The latter concentrated about twice the number of cases of other age groups. Pneumonias represented approximately 7.7% of the ARD cases. The magnitude of ARD numbers may be observed and it should stimulate appropriate diagnosis, early treatment, and prevention, both in regard to the event itself and complications ensuing from it. (author’s)
Hemoglobin concentration, breastfeeding and complementary feeding in the first year of life.
The objective was to assess the relationship between hemoglobin concentration and breastfeeding and complementary feeding during the first years of life. Cross-sectional study with 553 children under age 12 months, who attended public healthcare facilities. Hemoglobin concentration was measured by the cyanmethaemoglobin method, using the HemoCue system. Associations of interest were analyzed through multiple linear regression. Hemoglobin concentrations compatible with anemia were identified in 62.8% of the children studied, with greater occurrence among the 6-12 months age group (72.6%). Exclusive breastfeeding during the first six months of life was associated with the highest levels of hemoglobin. The remaining feeding regimes were associated with different levels of reduction in hemoglobin levels, which became compatible with anemia in children fed with formula (p = 0.009). Tea and/or water consumption was associated with a reduction in hemoglobin concentration of 0.76 g/dl (p < 0,001) among children under age 6 months. For children aged 6-12 months, hemoglobin concentrations increased significantly with the consumption of sugar (p = 0.017) and beans (p = 0.018), and decreased significantly with the consumption of fruit (p < 0.001). Exclusive breastfeeding until age 6 months and continuation of breastfeeding after this age, combined with qualitatively and quantitatively appropriate feeding may contribute towards an increase in hemoglobin concentration in the first year of life. (author's)
[HIV infection during pregnancy: the Sentinel Surveillance Project, Brazil, 2002]
The objective was to evaluate the actual coverage of HIV infection detection during pregnancy at national level. The actual coverage of HIV testing during pregnancy was defined as the proportion of women who attended prenatal care visits (at least one visit), ordering HIV testing and knowledge of test result before delivery. The coverage was estimated by sampling procedures based on the 2002 Sentinel Surveillance Study data. Actual coverage Inequalities were assessed by: country regions; population size of the municipality where delivery took place; and mother’s schooling. The actual coverage of HIV testing during pregnancy was 52%. Huge sociogeographic inequalities are seen between the Northeastern (24%) and Southern regions (72%); illiterate mothers (19%) and those with complete basic education (64%); mothers who delivered in small municipalities (36%) and those who delivered in municipalities with more than 500,000 inhabitants (66%). Ministry of Health recommendations were fully followed by only 27% pregnant women. The study results show a need for actions aiming at increasing HIV detection coverage during pregnancy, and indicate that HIV/STD programs should be intensified with joint strategies between the National AIDS Program and infant-maternal programs. (author's)
Susceptibility of Aedes aegypti to temephos and cypermethrin insecticides, Brazil.
The strategies for controlling the principal vector of dengue, Aedes aegypti, are based on the utilization of chemical and biological products, integrated with environmental management programs. In Brazil, the programs that aim to control Aedes aegypti mainly utilize chemical insecticides, among which organophosphates (OP) and pyrethroids (P) are prominent. These programs require constant monitoring. The numbers of dengue cases are rising every year, and different factors influence this increase. Resistance to chemical products may favor an increase in the mosquito populations, thereby resulting in increases in the numbers of dengue cases. For this reason, it is important to perform periodic monitoring of the susceptibility to insecticides of the populations implicated in the transmission of this disease. (excerpt)
Cow's milk consumption and childhood anemia in the city of São Paulo, southern Brazil.
The objective was to evaluate the influence of the consumption of cow’s milk on the risk of anemia during childhood in the city of São Paulo. We have studied a probabilistic sample (n = 584) of under-five children living in the city of São Paulo, southeastern Brazil, between 1995 and 1996. Anemia (hemoglobin < 11g/dl) was diagnosed using capillary blood obtained by fingertip puncture. The cow’s milk content and the density of heme and nonheme iron in the child’s diet were obtained using 24-hour recall questionnaires. Multiple linear and logistic regression models were used to study the association between cow’s milk content in the diet and hemoglobin concentration or risk of anemia, and included statistical control for potential confounders (age, sex, birth-weight, presence of intestinal parasites, family income, and mother’s schooling). The prevalence of anemia was 45.2% and the mean contribution of milk to the total caloric content of the children’s diets was 22.0%. The association between milk consumption and risk of anemia remained significant, even after considering the dilutive effect of milk consumption on the density of iron in the diet, thus indicating a possible inhibitor effect of milk on the absorption of the iron present in the other foods ingested by the child. The relative participation of cow’s milk in the child’s diet showed a significant positive association with risk of anemia in children between ages six and 60 months, regardless of the density of iron in the diet. (author's)
Infant mortality: comparison between two birth cohorts from Southeast and Northeast, Brazil.
The objective was to obtain population estimates and profile risk factors for infant mortality in two birth cohorts and compare them among cities of different regions in Brazil. In Ribeirão Preto, southeast Brazil, infant mortality was determined in a third of hospital live births (2,846 singleton deliveries) in 1994. In São Luís, northeast Brazil, data were obtained using systematic sampling of births stratified by maternity unit (2,443 singleton deliveries) in 1997-1998. Mothers answered standardized questionnaires shortly after delivery and information on infant deaths was retrieved from hospitals, registries and the States Health Secretarys’ Office. The relative risk (RR) was estimated by Poisson regression. In São Luís, the infant mortality rate was 26.6/1,000 live births, the neonatal mortality rate was 18.4/1,000 and the post-neonatal mortality rate was 8.2/1,000, all higher than those observed in Ribeirão Preto (16.9, 10.9 and 6.0 per 1,000, respectively). Adjusted analysis revealed that previous stillbirths (RR = 3.67 vs 4.13) and maternal age < 18 years (RR = 2.62 vs 2.59) were risk factors for infant mortality in the two cities. Inadequate prenatal care (RR = 2.00) and male sex (RR = 1.79) were risk factors in São Luís only, and a dwelling with 5 or more residents was a protective factor (RR = 0.53). In Ribeirão Preto, maternal smoking was associated with infant mortality (RR = 2.64). In addition to socioeconomic inequalities, differences in access to and quality of medical care between cities had an impact on infant mortality rates. (author's)
Immunogenicity of WHO-17D and Brazilian 17DD yellow fever vaccines: a randomized trial.
The objective was to compare the immunogenicity of three yellow fever vaccines from WHO-17D and Brazilian 17DD substrains (different seed-lots). An equivalence trial was carried out involving 1,087 adults in Rio de Janeiro. Vaccines produced by Bio-Manguinhos, Fiocruz (Rio de Janeiro, Brazil) were administered following standardized procedures adapted to allow blocked randomized allocation of participants to coded vaccine types (double-blind). Neutralizing yellow fever antibody titters were compared in pre- and post-immunization serum samples. Equivalence was defined as a difference of no more than five percentage points in seroconversion rates, and ratio between Geometric Mean Titters (GMT) higher than 0.67. Seroconversion rates were 98% or higher among subjects previously seronegative, and 90% or more of the total cohort of vaccinees, including those previously seropositive. Differences in seroconversion ranged from -0.05% to -3.02%. The intensity of the immune response was also very similar across vaccines: 14.5 to 18.6 I/mL. GMT ratios ranged from 0.78 to 0.93. Taking the placebo group into account, the vaccines explained 93% of seroconversion. Viremia was detected in 2.7% of vaccinated subjects from Day 3 to Day 7. The equivalent immunogenicity of yellow fever vaccines from the 17D and 17DD substrains was demonstrated for the first time in placebo-controlled double-blind randomized trial. The study completed the clinical validation process of a new vaccine seed-lot, provided evidence for use of alternative attenuated virus substrains in vaccine production for a major manufacturer, and for the utilization of the 17DD vaccine in other countries. (author's)
Air pollution and respiratory diseases among children in Brazil.
The objective was to assess the effects of air pollution levels on respiratory morbidity among children from 1999 to 2000. Daily records of health center attendance due to respiratory diseases among children were obtained from the public health system in Curitiba, State of Paraná, Brazil. Daily levels of particulate matter (PM/10), smoke, NO/2 and O/3 were obtained from both Paraná State Environmental Institute and the Development Technology Institute, a non-governmental agency. Daily measurements of temperature and relative humidity were obtained from the National Institute of Meteorology. Generalized additive Poisson regression models were used to assess the relationship between respiratory diseases and air pollution, controlling for long-term seasonality using loess (a non-parametric smoothing function), weather and weekdays. A significance level of 5% was adopted in all the analyses. All pollutants presented an effect on respiratory diseases among children. An increase of 40.4 µg/m3 in the 3-day moving average of smoke was associated with an increase of 4.5% (95% CI: 1.5-7.6) in the attendance of children with respiratory diseases. The results suggest that air pollution promotes adverse effects on children’s respiratory health even when pollutant levels are lower than the air quality standards. (author's)
Susceptibility of Aedes aegypti larvae to the insecticide temephos in the Federal District, Brazil.
The objective was to study the susceptibility status of Aedes aegypti to the organophosphate insecticide temephos. Samples of Ae. aegypti larvae were obtained, using ovitraps, from eight cities of the Federal District, central Brazil, in 2000 and 2001. Larvae were submitted to the diagnostic dose of 0.012 mg/l temephos, as recommended by standard World Health Organization methodology. Field populations were tested in parallel with reference strains Rockefeller and DIVAL, from the Environmental Surveillance Directory (DIVAL) insectary. The concentration and purity of temephos solutions were verified by gas chromatography. Correlation calculations were performed using StatView – SAS Institute Inc., version 5. Student’s t test was used for detecting differences in susceptibility, with significance levels of a = 0.05. In 2000, Ae. aegypti larvae populations from Taguatinga, Guará, and Núcleo Bandeirante showed resistance to temephos, with mortality ranging from 54.1 to 63.4%. The populations from Gama, Planaltina, and Sobradinho showed altered levels of susceptibility (mortality ranging from 83.6 to 92.8%). The population from Ceilândia was the only susceptible one, with 98% mortality. In 2001, all populations tested were resistant (44.4 to 66.4% mortality). No significant correlation was found between the susceptibility of populations and the distance between the cities of origin, or the amount of insecticide applied in the years preceding the study. Ae. aegypti susceptibility to temephos is changing in the Federal District. It is essential to continue monitoring the resistance of this vector to insecticides in order to ensure the efficiency of programs aimed at vector control and at the protection of human health. (author's)
Validation of methods for estimating HIV / AIDS patients' body fat.
The objective was to validate different methods for estimating HIV/Aids patients’ body fat: total body skinfold thickness, central (trunk) skinfold thickness, peripheral (limb) skinfold thickness, waist circumference (WC) and waist-to-hip ratio (WHR). Dual-energy X-ray absorptiometry (DEXA) and computed tomography of the abdomen (CTA) were used as the gold standard. An analysis was done on 15 adult HIV/AIDS patients (10 men and 5 women) who were being treated at the AIDS Clinic at a public university hospital, São Paulo, Brazil. Their total subcutaneous fat (TSF) was estimated from the sum of the thicknesses of the biceps, triceps, subscapular, midaxillary, suprailiac, abdominal and medial calf skinfolds. The central subcutaneous fat (CSF) was estimated by summing the subscapular, axillary, suprailiac and abdominal skinfold measurements. The peripheral subcutaneous fat (PSF) was estimated by summing the biceps, triceps and medial calf skinfold measurements. These were compared with DEXA. The WC, WHR and CSF were compared with CTA. In the statistical analysis, the Pearson correlation coefficient (r) and Mann-Whitney test were utilized. There was a correlation between fat mass measured by DEXA and by TSF, CSF and PSF, even after adjusting for age (r = 0.80 for all). WC, WHR and CSF presented correlation with total abdominal fat measured by CTA, even after adjusting for age (r = 0.80 for all). The methods for estimating body fat should be chosen according to the type of fat to be evaluated and can be used in research and healthcare services instead of DEXA and CTA for HIV/AIDS patients. (author's)
Control of Aedes aegypti with temephos in a Buenos Aires cemetery, Argentina.
The efficacy of a larvicide, temephos, for controlling Ae. aegypti was evaluated in a cemetery in Buenos Aires, Argentina. Breeding sites decreased from 18.4% in the first study period (Nov 1998 to May 1999, without temephos) to 2.2% in the second period (Nov 1999 to May 2000, two applications), and to 0.05% in the third one (Nov 2000 to May 2001, five applications). Ovitraps with eggs decreased from 17% in the first period to 5.8% in the second period, and to 2.9% in the third one. Results suggest that, in Buenos Aires, Ae. aegypti populations are highly susceptible to temephos. It is recommended to limit the use of temephos to prevent potential epidemics rather than for routine control. (author's)
Identification of malignant breast lesions in Mexico.
The objective was to evaluate the modes of detection of breast malignancies in Mexico City and to estimate the number of patients diagnosed in advanced stages. This cross-sectional study was conducted between 1994 and 1996, among 256 women with a histological diagnosis of breast cancer, at three tertiary level public hospitals in Mexico City. Personal interviews were conducted to collect data on reproductive characteristics, clinical history, and breast cancer modes of detection. Data analysis consisted of percentages, odds ratios, and 95% confidence intervals. Ninety percent of women sought medical care after identifying a breast lump by themselves. Only 10% of patients had a stage-I tumor; all 27 cases first identified by a physician were in stage II-B and higher. An increasing trend of breast cancer mortality in Mexico City will persist, unless a greater proportion of tumors in situ is detected; this would require enhancing breast cancer screening programs and conducting an intense educational intervention among women at risk. (author's)
[Quality of life and depression in women abused by their partners]
The objective was to evaluate quality of life and depression among women who suffer domestic violence and to describe the socioeconomic profile of women who were abused by their partners and aspects of these abuses. The study sample comprised 100 women who were abused by their partners and filed a complaint at the Police Office for Women of the state of Ceará, Brazil. Three questionnaires were applied: one for collecting demographic and violence data; the second one (GHQ-28) one to evaluate general quality of life; and the third one (Beck) to quantify depression. Abused women are young, married, Catholic, have children, low schooling and low family income. Alcohol use and jealousy were the main reported factors leading to partner’s abuse. Of all, 84% of women suffered physical attacks. It was observed that 72% had depression symptoms; 78% had anxiety symptoms and insomnia; 39% had already thought of killing themselves, and 24% started taking anxiety medications after been abused. Data analysis suggests that domestic violence is associated with a negative perception by women of their mental heath. (author's)
Bacterial meningitis constitutes a significant global public health problem. In particular, Neisseria meningitidis continues to be a public health problem among human populations in both developed and developing countries. Meningococcal infection is present as an endemic and an epidemic disease. Meningococcal disease is manifested not only as meningitis, but also as meningococcemia. The latter is usually fulminant. The global persistence of N. meningitidis is due to the significant number of carriers and the dynamics of transmission and disease. Approximately 500 million people worldwide are carriers of the bacterium in their nasopharynx. Multiple factors have been identified that predispose to the transmissibility of N. meningitidis, including active or passive inhalation tobacco smoking, upper viral respiratory tract infections, drought seasons, and overcrowding. These factors explain the frequent occurrence of outbreaks in military barracks, schools, prisons, and dormitories. Some of the determinants of invasiveness of the bacteria include nasopharyngeal mucosal damage in colonized individuals, virulence of the strains, absence of bactericidal antibodies, and deficiencies of the complement system. During both endemic and epidemic scenarios of meningococcal disease, control measures should include treating the cases with appropriate antimicrobial therapy (penicillin, ceftriaxone, or chloramphenicol); providing chemoprophylactic drugs to contacts (rifampin or ciprofloxacin), and close observation of contacts. Nevertheless, the key to effective control and prevention of meningococcal disease is immunoprophylaxis. Available vaccines include the polysaccharide monovalent, bivalent (serogroups A, C), or tetravalent (A, C, Y, W-135 serogroups) vaccines; conjugate vaccine (serogroup C); and the combined vaccine with outer membrane proteins and polysaccharide (serogroups B, C). Due to a recent increase in case reporting of serogroup C N. meningitidis in Mexico, we have developed a national response strategy that includes availability of vaccines and medications for chemoprophylaxis. This review aims at providing health care workers with updated information regarding the epidemiological, clinical, and preventive aspects of meningococcal disease. (author's)
[Evaluation of a screening method for Chagas disease in San Luis, Argentina]
Chagas disease is an endemic public health problem in the Province of San Luis, Argentina. The objective of this work was to evaluate the application of a screening method, focusing on the biochemical processing of capillary samples and diagnostic testing. In the year 2002, samples of capillary blood were collected from 250 children in their homes; the samples were placed in glycerin buffer and processed by quantitative PHA and ELISA. The results were compared with venous blood samples from the same children, that were analyzed using the same assays, as well as by IFA, the standard method. The sensitivity, specificity, and positive and negative predictive values were 98.03, 92.96, 78.12, and 99.46%, respectively. The serological assays PHA and ELISA conducted simultaneously were sufficiently sensitive and specific, thus validating the screening method. The method was easy to implement, had a low cost, and was well accepted by the selected population. (author's)
[Aedes aegypti infestation and occurence of dengue in the city of Belo Horizonte, Brazil]
The objective was to assess the association between the proportion of buildings positive for Aedes aegypti larvae measured by means of building infestation rate and dengue incidence rate. Autochthonous dengue cases were selected and building infestation rates assessed in the coverage areas of health districts in the city of Belo Horizonte, Brazil, from October 1997 to May 2001. After grouping building infestation rates according to their distribution in quartiles, mean dengue incidence rates (for the month following the building infestation assessment) were compared using ANOVA. A weak though statistically significant correlation was observed between monthly dengue incidence and building infestation rates for the health districts (r = 0.21; p = 0.02) and coverage areas (r = 0.14; p = 0.00) in the study period. After grouping building infestation rates in quartiles, coverage areas of building infestation between 0.46% and 1.32% (second quartile) showed a mean monthly dengue incidence rate twice as high as areas of building infestation lower or equal to 0.45% (first quartile). Areas of building infestation between 1.33% and 2.76% (third quartile) and equal to or higher than 2.77% had a mean monthly dengue incidence rate five and seven times, respectively, higher than those areas showing 0.45% or less. Despite the well-known limitations of building infestation rates for estimating vector infestation and prediction of dengue epidemics, the study results indicate that higher building infestation rates were associated to a higher risk of disease transmission in the health districts and coverage areas of Belo Horizonte. (author's)
Sexual violence and related problems in women attending a health care center.
The objective was to estimate the frequency of different forms of sexual violence and its association with mental health problems, such as depressive symptoms, suicidal ideation and attempt, and alcohol and drug use. From February to March 1998, a cross-sectional study was conducted among 345 women attending a healthcare center in Mexico City. All women were living with a partner/spouse at the time of the study. The proportions of three different types of sexual violence were obtained and compared with the chi-squared test. Nineteen per cent of women reported that they had been sexually fondled against their will at least once in their lifetime, 11% had been raped, and 5% had been forced to touch the sex organs of another person against their will. One in every five women reported that they had experienced sexual violence in the context of an intimate relationship. An association was found between some forms of sexual violence and depression, suicidal ideation, suicide attempts, and use of psychoactive drugs. Sexual violence is a severe public health problem that requires implementing specific programs to sensitize and train healthcare providers to prevent it. (author's)
The effect of weekly administration of folic acid on blood levels.
The objective was to evaluate the effect of weekly administration of 5 mg. folic acid (FA) intake on folic acid blood levels. This concurrent comparative study was conducted in 1998, in urban and rural areas of Nuevo Leon State, Mexico. The study population consisted of 74 women who delivered a child during 1997, 39 of whom had a child with a neural tube defect. Women were given 5 mg. of folic acid, weekly for 3 months. Blood levels of folic acid were determined by radioimmunoassay (RIA) at baseline, and a week after taking the last folic acid dose. Data are presented as means and standard deviations. Ninety per cent of the women had significantly increased folic acid intraerythrocytary blood levels. Red cell folate increased from 150.49 ± 31.17 ng/ ml to 184.21 ± 35.53 ng/ml (p < 0.005). Plasma folate increased from 5.93 ± 1.98 ng/ml a 7.03 ± 2.5 ng/ml (p < 0.05). Eighty-two per cent of women reached intracellular levels above 160 ng/ml. The weekly administration of folic acid is a simple and efficient method that could be used to supplement this vitamin to low-income populations. (author's)
Proposal for a death certificate to improve recording and reporting of perinatal mortality.
The objective was to analyze perinatal births and deaths recording at the Mexican Institute of Social Security (Instituto Mexicano del Seguro Social, IMSS), and to evaluate the correct classification of perinatal deaths. From January to March 2000, data were collected from the 37 MISS districts on the total number of births and deaths occurring during 1999, deaths occurring before the seventh day of life, and gestational age and weight at birth. Early neonatal and infant mortality rates were analyzed including or separating newborns with < 1000 g and < 28 weeks of gestational age. During 1999 there were 634 892 live births –whose gestational age and birth weight are unknown–and 3 984 stillbirths = 28 gestation weeks. There were 4556 newborns who died before the seventh day of extrauterine life; 1 385 of them (30.4%) weighed less than 1000 g and had a gestational age < 28 weeks. The analysis of mortality with and without these newborns shows a decrease of two points in early neonatal and infant mortality rates. This study shows that classification and reporting of perinatal mortality are inappropriate. A proposal is made to develop information systems that include weight and gestational age of all births. A new perinatal death certificate replacing current fetal and general death certificates would allow proper mortality classification and comparisons between countries. (author's)
Nosocomial bacteremia and pneumonia among children in a general hospital.
The objective was to determine the incidence of catheter-related bacteremia and ventilator-associated pneumonia in children admitted to a secondary care hospital. A prospective active surveillance system was conducted from January 1999 to June 2000, at the Hospital General of Instituto Mexicano del Seguro Social in Durango, Mexico. Daily visits to the pediatric ward were conducted to detect episodes of bacteremia and pneumonia, according to the Official Mexican Norm. Hospitalized patients under mechanical ventilation and/or with a central venous catheter, were followed from the first day of exposure, until a nosocomial infection was detected, or until the invasive device was removed. Blood and tracheal aspirate cultures were obtained from all exposed patients. Incidence rates with 95% confidence intervals were calculated for ventilator-associated pneumonia and bacteremia/ sepsis per 1000 exposure days. Also, the monthly infection rate is presented for days of exposure, using statistical control graphs. A total of 47 episodes of bacteremia/sepsis and 44 of ventilator associated pneumonia were recorded. The incidence rate of pneumonia and bacteremia/sepsis was 28 and 26 cases respectively, per 1000 days of exposure to and invasive device. The gram-positive rods (61.11%) were more common than the gram negative rods (38.88%). The most striking finding of this study was the higher incidence of these two nosocomial infections in children, as compared to that reported elsewhere. These findings call for preventive strategies and guidelines for handling intravenous catheters and mechanical ventilation in Mexico. (author's)
The objective was to assess the frequency and risk factors of malnutrition among children with congenital heart disease (CHD). Between August 1997 and May 1998, a cross-sectional survey was conducted among 244 children, at the congenital heart disease ward of the Cardiology Hospital, National Medical Center “Siglo XXI”, Mexican Institute of Social Security, in Mexico City. Study subjects were male and female children younger than 17 years, diagnosed with CHD and without any other congenital malformation. Weight/Age (W/ A), Height/Age (H/A) and Weight/Height (W/H) were used to measure nutritional status; Z scores greater than -2 was the case definition of malnutrition. Risk factors investigated were age, sex, perinatal history, dietary factors and nutritional supplementation, socioeconomic status, and family composition and functionality. Four CHD groups were studied: acyanotic with and without pulmonary hypertension (APH, AWPH) and, cyanotic with and without pulmonary hypertension (CPH, CWPH). Statistical analysis consisted of the chi-squared, Mann Whitney’s U, and Kruskal-Wallis tests. Confounding variables were controlled for with a logistic regression model; odds ratios (OR) and 95% confidence intervals (95%CI) were calculated. APH was the most frequent CHD (62.7%), followed by CWPH (15.6%), AWPH (11.5%), and CPH (10.2%). Malnutrition was identified in 40.9% children with the W/A index, in 24.6% with the H/A index; and in 31.1% with the W/H index. Infants and the CPH group had the worst nutritional status. Risk factors associated with malnutrition were: having a cyanotic CHD (OR 2.54; 95% CI, 0.98- 6.58), lack of nutritional supplementation (OR 2.38; 95% CI, 1.06-5.34), and a greater number of family members (OR, 1.42; 95%CI, 0.99-2.05). Older children were more likely to be well-nourished (OR 0.92; 95% CI, 0.89-0.96). Malnutrition is frequent among children with CHD; it is more common in younger children and in those with cyanotic CHD. Educational programs directed to the families of these children are needed to prevent and decrease the frequency of malnutrition. (author's)
Prevalence of asthma and other allergies in school children in Ciudad Juarez, Chihuahua, Mexico.
The objective was to assess the prevalence and severity of asthma and allergic diseases in schoolchildren residing in Ciudad Juarez, Chihuahua. A cross-sectional study was conducted from April 1998 to May 1999, among 6 174 children from 53 schools in Ciudad Juarez, Chihuahua. The method used was the one recommended by the International Study of Asthma and Allergies in Childhood (ISAAC) to determine the prevalence and severity of asthma, rhinitis, and eczema. Parents were asked to answer a standardized questionnaire on current and cumulative prevalence of asthma, rhinitis, and eczema. A sample stratified by level of pollution was selected. The cumulative prevalence of medically diagnosed asthma and wheezing was 6.8% (95% CI 6.2, 7.4) and 20% (95% CI 19.7, 21.8), respectively. The prevalence of wheezing in the last 12 months was higher in the group aged 6-8 years than in those aged 11-14 years (9.7% vs. 5.8 %, p<0.01). The prevalence of medically diagnosed rhinitis was 5.0 % (95% CI 4.5, 5.6). The prevalence of medically diagnosed eczema was 4.9% (4.3, 5.4). The prevalence of eczema symptoms in the last 12 months was 12.7% in the 6-8 years group and 13.3% in the 11-14 year group, respectively. Severe symptoms of asthma were significantly higher in the 6-8 years group and during the autumn months. The prevalence of medically diagnosed and symptomatic asthma was relatively low in comparison with findings from others studies that use similar methods, but the prevalence rates of rhinitis and eczema were higher. (author's)
The objective was to compare the costs and quality of cervical cancer screening between a non-governmental organization (NGO) and a Ministry of Health clinic. A quantitative and qualitative cross-sectional study was conducted between April and July 1999, in two healthcare clinics in Cuernavaca, Morelos, Mexico. Cervical cancer screening production processes were compared along four components: a) Pap smear collection; b) its transportation to the cytology center; c) analysis and interpretation; and d) notification of results. The framework developed by Bruce was used for assessing the quality of care. The framework includes users’ perceptions on information received and waiting times, as well as providers’ perceptions of space and equipment availability. The unitary cost of the production process in the public clinic ($144 pesos or US$15.5) was 26% higher than in the NGO ($ 114 pesos or US$ 12.3). Women attending NGO services reported a higher satisfaction with the quality of care than those who attended the public clinic. The waiting time prior to screening and the time each woman has to wait to receive test results were the main sources of insatisfaction. Analysis of costs and quality of care results suggest that NGOs should be considered as an alternative in the provision of cervical cancer screening. (author's)
The objective was to evaluate the safety and effectiveness of two oral rehydration techniques. A randomized clinical trial was conducted at the oral rehydration unit of Hospital Infantil de Mexico “Federico Gomez”, between September 1998 and June 1999. Forty patients five-year old and younger children, dehydrated due to acute diarrhea, were given oral rehydration solution (ORS) ad libitum (AL group); another forty patients received ORS in fractionated doses (FD group). Clinical characteristics were similar in both groups. Results are presented as means, standard deviations and medians, according the distribution of simple and relative frequencies. The mean stool output in the AL group was 11.0 ± 7.5 g/kg/h; as compared to 7.1 ± 7.4 in the FD group (p=0.03). ORS intake, rehydration time, and mean diuresis values were similar in both groups (p > 0.05). Six patients in the AL group and five in the FD group had high stool output (> 10 g/kg/h), that improved after administration of rice starch solution. One patient in the AL group and two in the FD group had persistent vomiting that improved with gastroclisis. No patient required intravenous rehydration. These results suggest that ORS administration ad libitum under supervision, is a technique as safe and effective as the fractionated doses technique, for the treatment of dehydrated children due to acute diarrhea. (author's)
Family strategies of life associated with malnutrition in children less than 2 years of age.
The objective was to identify the role of family life strategies on malnutrition in children aged 6-23 months of age. This case-control study was conducted in 1998 in the municipality of Teolocholco, State of Tlaxcala, Mexico, among families with children aged 6-23 months of age. The sample was conformed by 105 cases and 210 controls. Family life strategies were grouped into five types: family composition, means and distribution of family income, family and social networks, and life preservation strategies. Malnutrition was classified according to height for age. Data were analyzed using logistic regression to obtain odds ratios and 95% confidence intervals. Data were collected from 605 families, for a total of 445 controls and 160 cases. The predictive model included mother’s schooling, overcrowding, time elapsed between childbirths, per capita monthly income, and time devoted to child-rearing activities. Family life strategies determine children’s nutritional status; understanding the influence of the family on the children’s health status is necessary to develop effective programs aimed at improving the nutritional status of children. (author's)
The centennial of the Yellow Fever Commission and the use of informed consent in medical research.
The year 2000 marked the centennial of the discovery of the mode of transmission of yellow fever. Informed consent was systematically used for the first time in research. This process was the result of a complex social phenomenon involving the American Public Health Association, the US and Spanish Governments, American and Cuban scientists, the media, and civilian and military volunteers. The public health and medical communities face the AIDS pandemic at the beginning of the 21st Century, as they faced the yellow fever epidemic at the beginning of the 20th Century. Current medical research dilemmas have fueled the debate about the ethical conduct of research in human subjects. The AIDS pandemic is imposing enormous new ethical challenges on the conduct of medical research, especially in the developing world. Reflecting on the yellow fever experiments of 1900, lessons can be learned and applied to the current ethical challenges faced by the international public health research community. (author's)
With whom do Mexican teenagers talk about AIDS?
The objective was to establish whether certain characteristics of the young influence their choice of people with whom to discuss AIDS. A national survey was conducted in 1997 by the Consejo Nacional para la Prevención y Control del SIDA (CONASIDA, Mexican Council for AIDS Prevention and Control). Study subjects were 4 886 male and female 15-19 year-old teenagers. Multinomial logistic regression was used to analyze data. A model including the variables sex, sexual activity, work conditions, and father’s schooling level, turned out to be significant and highly predictive of people with whom teenagers discuss AIDS, as compared to teenagers speaking with no one. Male teenagers discuss AIDS with their fathers more than female teenagers, and female teenagers discuss AIDS more with their mothers. Sexually active teenagers discuss AIDS more with their friends and less with their teachers than sexually inactive teenagers. The greater schooling level the father has, the more people teenagers have with whom to discuss AIDS and the more they discuss AIDS at home, compared to teenagers with fathers without schooling. Differentiated sexual education training strategies should be designed in accordance with subpopulations’ characteristics. (author's)
Hemorrhagic disease of the newborn, a resurgent disease. Implications for prevention.
The objective was to describe the occurrence of hemorrhagic disease of the newborn (HDN) at a tertiary care pediatric hospital of Morelos state. A retrospective case series study was conducted between 1997- 2000 at Hospital del Niño Morelense (Morelos State Children’s Hospital), in 46 newborns aged under 12 weeks. Study subjects were referred from peripheral units with a diagnosis of HDN. The severe late-onset form of HDN was present in 91% of the cases. Fifty-two percent of childbirths were assisted by a physician and 48% by an empiric midwife. Application of vitamin K was unknown in 61% of cases, in 39% it was not applied and in 4% it was applied. The majority of infants presented severe symptoms due to intra-cranial bleeding, 11% died, and 41% had severe disease sequelae. Given the high prevalence of HDN in the State of Morelos, reproductive health programs should be reviewed and training programs intensified to promote the utilization of vitamin K by physicians and nurses for preventing this disease. (author's)
AIDS mortality trends in Mexico, 1988-1997.
The objective was to assess the geographic distribution and trends of AIDS deaths for the 1988-1997 period in Mexico. Crude and adjusted mortality rates were estimated for the 1988-1997 period. A trend test was performed using the simple linear regression method. Standardized mortality ratios (SMR) and years of potential life lost (YPLL) were calculated for each Mexican state. During the study period (1988-1997), there were 26,999 AIDS deaths in Mexico; 86.5% (23,354) of them were among men. The mean age at the time of death was 38.4 years for men and 37.7 years for women (p > 0.05). The crude AIDS mortality rate for the period of study was 3.02 cases (95% CI: 2.94, 3.06) per 100,000 inhabitants. The adjusted rate was 3.13 (95% CI: 3.09, 3.17), with 5.22 (95% CI: 5.16 - 5.29) for men and 0.82 (95% CI: 0.79-0.84) for women. The states with the highest SMR were: Baja California (SMR: 248.69; 95% CI: 234.02-263.36), Mexico City (SMR: 220.74; 95% CI: 215.57-225.91), and Jalisco (SMR: 169.16; 95% CI: 162.88-175.44). Similarly, a Potential Lost Life Years Index (PLLYI) analysis by state showed a greater risk of premature AIDS mortality in the same states [Baja California (PLLYI index: 236.33; 95% CI: 233.97-238.68), Mexico City (PLLYI: 194.68; 95% CI: 193.88 - 195.48), and Jalisco (PLLYI: 170.69; 95% CI: 169.60-171.79)]. Mortality trends indicate that AIDS mortality in Mexico increased by an annual rate of 23% between 1988 and 1997. The adjusted AIDS mortality rate increased from 0.75 per 100 000 in 1988, to 4.20 per 100 000 in 1997, with the largest burden of mortality in men (male to female ratio of 6:1). We therefore expect that a decreasing effect on AIDS mortality trends will be observed in the next years. (author's)
Exposure to Group B streptococci (Streptococcus agalactiae) among women of reproductive age.
The objective was to assess the prevalence of IgG antibodies against Group B streptococci (GBS) among women of reproductive age in Mexico. Serum specimens were drawn from 15 to 40 year-old women, representative of all regions and socioeconomic levels of the country. The sample was randomly selected from Banco Nacional de Sueros (National Sera Bank); serum samples were collected during a national seroepidemiologic survey conducted in 1987-1988. The assays for standardization and for evaluation of seroprevalence were carried out at the Hospital de Pediatría del Centro Médico Nacional Siglo XXI (Children’s Hospital) Instituto Mexicano del Seguro Social (IMSS) (Mexican Institute of Social Security) from January to November 1995. IgG antibodies against group B antigen were studied with an enzyme-linked immunosorbent assay (ELISA) developed in our lab. Group B antigen was produced and purified from the reference strain GBS 110. A total of 2669 serum samples were studied; 2405 were positive to anti-group B antigen IgG antibodies, for a seroprevalence of 90.2%. No differences in prevalence were found among the different age groups or among the different states of the country. The high seroprevalence of antibodies against GBS suggests that young women in Mexico are commonly exposed to GBS infection. (author's)
Interpretation of anthropometric indices in children of Arandas, Jalisco, Mexico.
The objective was to assess the nutritional status of children attending the Instituto Alteño para el Desarrollo de Jalisco (Highlands Institute for Development of Jalisco State, Inadej) in Arandas, Jalisco and to discuss the classification criteria of infant malnutrition in Mexico. A cross-sectional study was conducted in 775 children aged between twelve and one hundred and twenty months, who attended Inadej, including 432 children recently registered in INADEJ. Measurements included weight/age, height/age, and weight/height indices. The prevalence of malnutrition was compared using the WHO’s criteria and the Mexican Official Norm Classification (NOM-SSA) criteria. The weight/age, height/age and weight/height indices were compared using the chi-squared test. Parents’ schooling level was low (mean = 3.6 years); the mean family income was U.S. $198.00 dollars per month, with each family member receiving 0.56 dollars per day for three daily meals. The prevalence of malnutrition was significantly higher with any of the three indices when using the NOM-SSA criteria, as compared to the WHO criteria (weight/age 91.7 vs. 30.9%; height/age 66.9 vs 17.3%; and weight/height 62.5 vs. 9.5%, respectively). The weight/age index and the NOM-SSA criteria overestimate the prevalence of malnutrition and are not able to tell apart children with familial small size, nor those with acute and/or chronic or past malnutrition. The WHO criteria were found to be more useful; the weight/height (recent malnutrition) and height/age (chronic malnutrition) indices should be used for international comparisons. (author's)
The coadministration of a progestogen with testosterone increases the degree of suppression of spermatogenesis and is one approach to the development of hormonal male contraception. Depot formulations may allow a reduction in dosage, minimizing adverse effects. We have investigated the effects of a sc implant containing the progestogen etonogestrel (Implanon) with depot testosterone on spermatogenesis in normal men. Twenty-eight men were randomized to receive either one or two etonogestrel implants, removed after 24 wk. All men additionally received 400 mg testosterone pellets on d 1 and at 12 wk. Four men withdrew during the study, three because of side effects. Testosterone concentrations remained within the physiological range during treatment, although they were overall slightly reduced, compared with pretreatment. Both groups showed marked suppression of spermatogenesis, nine men in each group achieving azoospermia (64% and 75% in the one- and two-implant groups, respectively). Sperm concentrations in 13/14 men in the two-implant group fell to 0.1 x 10/6/ml or less. Spermatogenic suppression was more variable in the one-implant group, with partial recovery in three men. Incomplete suppression of spermatogenesis in the one-implant group was associated with less complete suppression of gonadotropins. There were no significant changes in body weight, hemoglobin, hematocrit, or high-density lipoprotein cholesterol concentrations during treatment. These data demonstrate that etonogestrel implants with depot testosterone provide effective suppression of spermatogenesis with reduced metabolic effects and are, therefore, a promising approach to the development of long-acting yet reversible male contraception. (author's)
The objective was to evaluate cytology laboratories and the performance of cytotechnologists for establishing efficient external quality control for Mexico’s National Program for the Prevention and Control of Cervical Cancer. During January and February 1998, an onsite evaluation of all cytology laboratories of the Ministry of Health found that only 70% of the microscopes were in adequate working conditions, reagents were out of date, and working conditions were sub-optimal. A program for external quality control based on proficiency testing was established for cytotechnologists. Fifty slide sets with 20 Papanicolaou slides and 10 photographic slides were prepared. The sets were given to the cytotechnologists for evaluation and again one year later by courier. Twenty-one percent of microscopes were repaired and 9% replaced; reagents were distributed and laboratory facilities improved. Only 16% of cytotechnologists passed the initial proficiency test. Cytotechnologists received a refresher training course: one year later 67% of them passed the proficiency test. To ascertain that each slide was correctly diagnosed, 41 sets were rescreened by expert cytopathologists or cytologists and their diagnoses compared to the original ones. Thirty-seven sets had 86% to 96% concordance. This new system for external quality control of cervical cytology allowed the opportune and reliable evaluation of the performance of cytotechnologists. (author's)
The relationship between family structure and exclusive breastfeeding prevalence in Nicaragua.
The objective was to examine the relationship between family structure and the prevalence of exclusive breastfeeding (EBF) in Nicaragua. A subset of the Nicaraguan Demographic and Health Survey conducted in 1998 was obtained by selecting all last-born infants less than 4 months old at the time of the survey. Weighted chi-squared and multivariate logistic regression analyses were used to examine the association. Interviewee women heads of household and interviewee women whose husbands were the heads of the household had a significantly lower prevalence of EBF. Exposure to the health care system was not related to EBF. New approaches are needed to promote that men support women’s decisions to breastfeed. Health institutions should effectively communicate the benefits of breastfeeding on both the mother and the child. (author's)
Gender-related family head schooling and Aedes aegypti larval breeding risk in southern Mexico.
The objective was to investigate if family head genre-associated education is related to the risk of domiciliary Aedes aegypti larval breeding in a dengue-endemic village of Southern Mexico. A family head was considered to have a low education level if he/she had not completed elementary school. To estimate larval breeding risk within each household, a three-category Maya index was constructed using a weighted estimation of controllable and disposable domestic water containers. A socio-economic index was constructed based on household construction characteristics. Low-level education of either family head was associated to higher larval breeding risk. Households with low-educated mothers had more larval breeding containers. These associations persisted after adjusting for household socio-economic level. These results indicate that households with female family heads with low education levels accumulate more containers that favor Ae. aegypti breeding, and that education campaigns for dengue control should be addressed to this part of the population. (author's)
The objectives were to estimate the prevalence of behavioral and emotional symptoms in children and adolescents; to identify parents’ perception of their children’s healthcare needs; and to estimate the frequency of seeking mental healthcare services. A household survey was carried out between July and November 1995 in Mexico City. The survey was representative of persons aged 18 to 65 years. Study subjects were 1685 children 4 to 16 years of age and living in the same household as their parents. Informant parents provided data on their children regarding the presence of 27 symptoms, their perceptions of healthcare needs of symptomatic children, and mental healthcare-seeking behaviors. Logistic regression was used for statistical analysis. Symptoms were reported for half of the population. Twenty-five percent of children was perceived by their parents as in need for healthcare, and only 13% sought healthcare. Internalization symptoms were more frequently perceived by parents and led to seeking healthcare. Study findings suggest a delay in seeking mental healthcare in children and should be of value for clinicians, and to establish primary level mental healthcare policies and programs. (author's)
Phylogenetic analysis of the envelope protein (domain III) of dengue 4 viruses.
The objective was to evaluate the genetic variability of domain III of envelope (E) protein and to estimate phylogenetic relationships of dengue 4 (Den-4) viruses isolated in Mexico and from other endemic areas of the world. A phylogenetic study of domain III of envelope (E) protein of Den-4 viruses was conducted in 1998 using virus strains from Mexico and other parts of the world, isolated in different years. Specific primers were used to amplify by RT-PCR the domain III and to obtain nucleotide sequence. Based on nucleotide and deduced aminoacid sequence, genetic variability was estimated and a phylogenetic tree was generated. To make an easy genetic analysis of domain III region, a Restriction Fragment Length Polymorphism (RFLP) assay was performed, using six restriction enzymes. Study results demonstrate that nucleotide and aminoacid sequence analysis of domain III are similar to those reported from the complete E protein gene. Based on the RFLP analysis of domain III using the restriction enzymes Nla III, Dde I and Cfo I, Den-4 viruses included in this study were clustered into genotypes 1 and 2 previously reported. Study results suggest that domain III may be used as a genetic marker for phylogenetic and molecular epidemiology studies of dengue viruses. (author's)
The objective was to describe the tuberculosis morbidity and mortality trends in Mexico, by comparing the data reported by the Ministry of Health (MH) and the World Health Organization (WHO) between 1981 and 1998. The number of cases notified in the past few years, their rates, and the trends of the disease in Mexico were analyzed. The incidence of smear-positive pulmonary tuberculosis was estimated for 1997 and 1998 with the annual tuberculosis infection risk (ATIR), to estimate the percentage of bacilliferous cases in 1997-1998. WHO reported more tuberculosis cases for Mexico than the MH. However, this difference has decreased throughout the years. The notification of smear-positive cases remained stable during 1993-1998. The estimated percentages of detection were 66% for 1997 and 26% for 1998 (based on ATIR of 0.5%). Tuberculosis mortality decreased gradually (6.7% per year) between 1990 and 1998, whereas the number of new cases increased, suggesting the persistence of disease transmission in the population. Inconsistencies between case notifications from national data and WHO were considerable, but decreased progressively during the study period. According to ATIR estimations, a considerable number of infectious tuberculosis cases are not detected. (author's)
Hookworm infection and anemia in adult women in rural Chiapas, Mexico.
The objective was to describe associations between anemia and hookworm (Necator americanus) infection in hospitalized women in rural Chiapas, Mexico. We retrospectively reviewed the hospital records of 68 anemic women (defined as having a hemoglobin level < 10mg/dl) or with intestinal parasitism, identified through hospital discharge and transfusion records for the calendar year 1999. The medical charts of 86 cases were located, 18 of which were not confirmed as anemia cases. The hospital is located in Altamirano, Chiapas. Characteristics of subjects were compared using Student’s t-test (for continuous variables) and the x/2 test (for categorical variables). A p-value = 0.01 was used for statistical significance. Chart review and data analysis took place during the year 2000. Fifty percent of women who had stool examinations were infected with N. americanus. Necator often coexisted with other potential causes of anemia, such as pregnancy and hemorrhage. Hemoglobin levels in hookworm-infected women (mean 4.1 g/dl) were significantly lower than in uninfected women (mean 7.0 gm/ dl), and Necator prevalence was significantly higher in the anemic women (50%) than in the overall hospital population (1.9%). Anemic women should be offered stool testing where Necator is present, and should be considered for antihelminthic treatment even if pregnant. Further inves tigation is recommended among women in Chiapas, and probably elsewhere in Mexico. (author's)
Prevalence and risk factors of urinary lithiasis in Yucatan, Mexico.
The objective was to measure the prevalence of urolithiasis in Yucatan, and to establish a possible association of the disease with family history and water hardness. During 1996, a survey was conducted on the population over one year of age in the State of Yucatan. Subjects were classified as having definite lithiasis (DL), probable lithiasis (PL), or no lithiasis (NL). Total hardness, calcium hardness, and magnesium hardness, were determined in drinking water samples. From a total of 5 832 questionnaires, 323 subjects (5.5%) were found to have DL, and 282 (4.8%) PL. The prevalence of lithiasis increased sharply with age, ranging from 1% in the population 18 years or younger, to 11.3% in those over 50 years. A family history of urolithiasis was positive in 44% of subjects with DL and in 34 % of those with PL, compared to 28% of those with NL (OR = 2.8, 95% CI = 2.2-3.4, p < 0.0001, and OR=1.8, 95% CI = 1.4-2.4, p < 0.0001, respectively). Water hardness above 400 ppm was associated with a higher prevalence of urolithiasis (OR = 1.9, 95% CI = 1.21-2.94, p = 0.003). The prevalence of urolithiasis in Yucatan is higher than that reported elsewhere in the scientific literature. A family history of the disease and high water hardness are risk factors that need to be investigated in future studies. (author's)
The presence of standards in AIDS / HIV human rights in Mexico and Central America. 1993-2000.
The objective was to analyze the inclusion of human rights in HIV/AIDS norms in Mexico and Central America for the 1993-2000 period. Norms and regulations for HIV/AIDS prevention and control in this region were analyzed. A constructivist perspective of judiciary subsystems and human rights was used as a reference framework, to establish categories of analysis with significance codes based on the Universal Declaration of Human Rights. During the study period, human rights were included within a vigorous legislative activity for HIV/AIDS transmission prevention. In some cases (as in the Panama Law and the Honduras Proposal) there were passages of law violating the right to non-discrimination and privacy. These laws lead to either of two conflicting paths: one ensuring human rights, and another increasing the vulnerability of some groups. The authors emphasize the importance of gaining a new understanding of social subjects and epidemiological surveillance, based on norms that incorporate human rights issues. (author's)
The vulnerability and invisibility of women before HIV / AIDS: constants and changes.
This paper presents some thoughts on the problems endured by women facing HIV/AIDS. World and nationwide statistics show an upward trend of the epidemic among women, calling for the need to address this problem. A case is made for the way in which gender structure and relations facilitate the vulnerability of women to this disease, increasing their risk of infection related with specific factors like migration, employment unsafe conditions, and domestic violence, among others. Emphasis is made on the main obstacles faced by women to flag their concerns and needs in society, as well as on their lack of empowerment to cope effectively with their problems. Some initiatives advanced by the organized civil society and governmental strategies are presented, including accomplishments, deficiencies, needs, and challenges. Finally, conclusions and recommendations are given, highlighting the need to establish and evaluate preventative programs and policies from a gender and human rights perspective, to promote a greater awareness and improved responses to the problems imposed on women by the HIV/AIDS epidemic. (author's)
Mortality by neural tube defects in Mexico, 1980-1997.
The objective was to describe the mortality due to neural tube defects (NTD) in Mexico for the 1980-1997 period. The annual NTD mortality rates per 10000 live-born infants were calculated by state and for the country. The time trend was evaluated with the annual percent change (APC) obtained using a Poisson regression model. The NTD mortality ratio was calculated using the average national rate as reference. NTD mortality rates and ratios were graphically displayed on maps. During the 1980-1997 period the gross NTD mortality rate was 5.8 per 10000 live-born infants. Anencephaly (International Classification of Diseases ICD-9 740.0) was the most frequent type of NTD (37.7%), followed by spina bifida without hydrocephaly (CIE9 741.9) (31.6%). The national trend of NTD mortality increased between 1980 and 1990 (APC 7.5 95% CI 6.5, 8.6) and decreased between 1990 and 1997 (APC -2.3 95% CI -3.6, -0.9). The high NTD mortality rates were related to the high frequency of anencephaly. Also, the increase observed is not only attributable to diagnostic factors or to improved reporting. In Mexico, the influence of some NTD-associated factors such as specific genetic polymorphisms, folic acid deficit, maternal obesity, occupational exposure to pesticides, and poverty, should be assessed in specific studies. (author's)
Hyperthyrotropinemia in Mexican newborns.
The objective was to assess the differences in the blood concentration levels of the thyroid stimulating hormone and their possible use as an indicator of iodine sufficiency, in a sample of Mexican newborns. A cross-sectional study was conducted from September 1999 to August 2000, among 25,427 Mexican newborns in the Ministry of Health clinics from 5 states. A total of 8 095 heel-prick and 17 332 umbilical cord blood samples were analyzed. Blood samples were collected in filter paper and processed by enzyme-linked immunosorbent assay. The Mann-Whitney U test and the Kruskal-Wallis test were used for statistical analyses. Hyperthyrotropinemia was found in 9.95% of heel samples and in 24.27% of umbilical cord samples (TSH > 5 µUI/ ml). The percentage of hyperthyrotropinemia observed in this study was higher than that expected in a population with sufficient iodine intake; these findings could be due to poor maternal iodine intake. (author's)
The objective was to asses the affective, cognitive, and behavioral attitudes of healthcare providers at the Mexican Institute of Social Security (MISS) in Morelos, Mexico; to identify the institutional and medical practice barriers that hinder screening and reference of battered women. A cross-sectional study was conducted between September and December 1999. A self-administered questionnaire was applied to 269 general practitioners, specialists, and pre- and postdoctoral students working in 30 primary and secondary level of healthcare units in Morelos State. The data collection instrument was designed to assess healthcare providers’ knowledge of and attitudes towards domestic violence during medical office visits. A knowledge index was constructed and analyzed using multivariate regression methods. Ninety percent of healthcare providers had never received training on violence against women. Healthcare providers’ affective and cognitive attitudes after receiving training on the subject matter were more favorable compared to those with no training. Favorable attitudes were directly related to the number of training sessions. Most participants (63%) showed a moderate degree of knowledge on the subject, whereas 21% were slightly knowledgeable and 16% were highly knowledgeable. Medical personnel with a moderate or high level of knowledge were 2.1 and 6 times more likely, respectively, to have favorable attitudes than those with a low degree of knowledge. Female physicians showed more favorable attitudes towards identifying and referring battered women. Medical personnel interested in further training on the subject of violence against women were 7.6 times more likely to show favorable attitudes than personnel not interested on the subject. Healthcare providers were not sufficiently able to assess and manage battered women. General and family practitioners were more interested in being trained, as compared with specialist physicians. Training on violence against women should be included in graduate medical, nursing, social service, psychology, and other public health areas. (author's)
Transvaginal bleeding during pregnancy associated with Rhesus-D isoimmunization.
The aim of the present study was to evaluate transvaginal bleeding (TVB) as a risk factor for Rhesus isoimmunization during pregnancy, in order to optimize the application of Anti-D gammaglobulin in nonimmunized pregnant women, as an alternative to the routine application of Anti-D at 28 weeks of gestation. This case-control study was conducted from 1995 to 2001 at Mexico’s National Perinatology Institute. Cases (n = 24) were non-immunized pregnant women who showed positive anti-D antibody seroconversion during pregnancy or during the early puerperium. Controls (n = 24) were non-immunized pregnant women who enrolled after each case, with similar clinical characteristics but who had no anti-D antibody seroconversion during pregnancy. In all cases the newborns were Rh-positive. None of the patients received immunoprofilaxis at 28 weeks of gestation. The presence of TVB was recorded at any stage of pregnancy and before labor. Odds ratios with 95% confidence intervals were used to assess associations. TVB was observed in 18/24 (75%) cases and in 5/24 (20%) controls. Preterm uterine contractions and threatened miscarriage were the most frequent causes of TVB. The presence of one TVB event during pregnancy increased 11.4 times (95% CI 2.9-44.0) the likelihood of Rhesus isoimmunization. TVB after 20 weeks of gestation increased the likelihood 5.0 times (95%CI 1.3-19.1). TVB before 20 weeks of gestation was not significantly associated with Rh isoimmunization (OR = 7.6, 95%CI 0.8-69.5). Prophylaxis with anti-D gammaglobulin should be given to all non-immunized Rhesus-negative pregnant woman with TVB at any stage of pregnancy. (author's)
Seroprevalence of hepatitis B in pregnant women in Mexico.
The objective was to determine the seroprevalence of hepatitis B in pregnant women from several regions of Mexico, as well as the risk factors associated with its occurrence. A cross-sectional study was conducted between May and August 2000. It included 9 992 pregnant women attending the health services of the Mexican Institute of Social Security (Instituto Mexicano del Seguro Social-IMSS) in five cities: Tijuana, Ciudad Juarez, Acapulco, Cancun, and Mexico City (Northeast and Southeast regions). The overall prevalence for confirmed cases was 1.65% (165/ 9 992). The prevalences for individual cities were as follows: Tijuana, 1.27%; Ciudad Juarez, 1.46%; Acapulco, 2.47%; Cancun, 0.93%; Northeastern Mexico City, 1.20%, and Southeastern Mexico City, 2.52%. The risk factors found to be associated with HbsAg were: age, age at first sexual intercourse, city (Acapulco and Southeastern Mexico City), and marital status (single or divorced). The prevalence of HBsAg in pregnant women (1.65%) was greater than that reported in previous studies and showed geographical differences. This high prevalence suggests that a considerable amount of cases of hepatitis B occurs perinatally and through contact with carriers in the general population. Vaccination of newborns of high-risk pregnant women should be considered. (author's)
Information from teachers on viral hepatitis transmission and prevention in Brazil.
The objective was to assess school teachers’ level of knowledge on prevention of viral hepatitis (VH). A cross-sectional study was conducted in three cities of Brazil, from August to November of 1999. The sample was composed of 360 subjects: 334 women and 26 men, 81 (22.5%) from Belém, 123 (34.2%) from Natal and 156 (43.3%) from Rio de Janeiro. Cultural differences in knowledge were identified using a questionnaire to classify, according to semantic content, categories of transmission and preventive practices. Responses were scored as right or wrong. Data were tabulated and analyzed using EPIINFO 6.04 and open answers were classified according to semantic content. Comparison of the answer frequencies between cities was done through the chi-square test. Transmission category (TC) (n=837 answers) and prevention category (PC) (n=771 answers) “food-and waterborne” transmission items were the most frequently mentioned (40%). For TC, “food-and waterborne” answers were followed by “bloodborne” (16%), “inadequate knowledge” (9%), “possible causes of hepatic disease” (9%), and “sexual transmission” (7%) answers. For PC items, “food-and waterborne” answers were followed by “general aspects of prevention” (13%), “immunization” (9%), “quality of health services” (8%) and “sexual prevention” (5%) items. “Right” scores for transmission mechanisms and prevention practices varied from zero to 80%. Study findings suggest that investments should be made to disseminate appropriate knowledge on VH prevention, mainly addressing sexual transmission and intravenous drug use. (author's)
The objective was to assess antibiotic use for upper respiratory infections (URI) treatment on patients under 16 years-old who are beneficiaries of a pre-paid health care scheme. A database containing the record of all the medical prescriptions for URI treatment, from May 1997 to April 1998 was analyzed. Patients were under 16 years old and had been diagnosed with common colds, pharyngitis, bronchitis, sinusitis, otitis, and other unspecified upper respiratory tract infections. Three hundred and fifty-one physicians of seven different specialties who attended 25 300 beneficiaries wrote such prescriptions. A total of 30 889 assorted medications were prescribed to 5 533 patients with the above diagnoses. Antibiotics were prescribed for 77.5% of all diagnoses, ranging from 58% for pharyngitis to 91% for laryngitis. The most frequently used antibiotics were: penicillin, cephalosporins, and macrolides. This study presents the information of antibiotics prescription practices for URI in a pre-paid health plan in Mexico. These findings may be used to support specific campaigns for rational use of antibiotics among children attended at private ambulatory health care practices. (author's)
Association between anti-Ras and anti-HPV16 E4/E7 with intraepithelial cervical lesions.
The objective was to evaluate whether serum antibodies anti-E4, E7 and Ras could be used as markers for early cervical lesions associated with HPV (human papillomavirus). A seroepidemiological case-control study was conducted between March 1999 and April 2000 at the dysplasia clinic of Hospital General Doctor Gea Gonzalez, in Mexico City, to evaluate the presence of antibodies anti-E4, E7, and Ras through a sandwich ELISA. Analysis was done using odds ratios and 95% confidence intervals. Anti-E7 antibodies were associated to women with CIN III lesions, while anti-E4 and Ras antibodies were strongly associated with CIN I-II lesions. The antibody profile of women with different cervical lesion showed that: a) the presence of antibodies against two proteins predicts the presence of CIN I-II lesions, and b) the presence of three antibodies predicts a CIN III lesion. The presence of serum antibodies against E4, E7 and Ras, together with other diagnostic techniques, could be useful for the timely detection of early uterine cervical lesions associated to HPV in women at risk of developing cancer. (author's)
Microbiological indicators of water quality in the Xochimilco canals, Mexico City.
The objective was to quantify microbiology indicators of fecal contamination in the effluents of two waste water treatment plants and in samples collected in several canals in Xochimilco. A cross sectional study was performed. Ten sites, 5 from plant effluents and 5 from canals, were selected for sampling during November and December 2001. Fecal coliforms and enterococci were quantified by membrane filtration, male specific (F+) and somatic coliphages by double agar layer technique, and Cryptosporidium oocysts and Giardia cysts by concentration with Envirocheck filter followed by immunofluorescence microscopy quantification. The average of organisms counts from effluents and canal water were compared with t Student test. Treated water discharge in canals showed a low count of Fecal Coliforms (average 40.4/100 ml), enterococci (average 58.8/100 ml) and Cryptosporidium oocysts (average 13.2/100 l), while coliphages and Giardia cyst rendered higher counts (average 1467.5/100 ml and 1199.8/100 l, respectively) suggesting the water treatment methods could fail to remove these agents. A significant lower count of Giardia cysts (average 45/100 l) and no Cryptosporidium oocysts were found in irrigation canals, which suggests a natural clearance of these pathogens. Strains of Escherichia coli isolated in one of the canals contaminated with sewage had antimicrobial multi-resistance that was transferred by conjugation suggesting that resistance is encoded in a plasmid potentially transferable to other pathogenic bacteria. Cost effective and culturally acceptable waste treatment methods will require careful planning and consultation if they are to be adopted and mantained by local populations. (author's)
Medical attention of intentional injuries due to domestic violence.
The objective was to describe and analyze the causes of emergency care services for intentional injuries, especially those caused by domestic violence, at four public hospitals in Mexico City. A cross-sectional study was conducted between January and April 1998, which included variables related with the victim, the aggressor, and the medical care provided to the victim. A questionnaire was applied to individuals who had been injured intentionally. Statistical analysis of data consisted of simple frequencies, the c2 test, and odds ratios (OR) with 95% confidence intervals (CI). A logistic regression model was also used to adjust for variables associated with the injury requiring emergency medical care. A total of 598 cases of intentional injuries were analyzed, 16% of which were due to domestic violence. Females were the most frequent victims (76%), followed by young people between 15 and 29 years old (46%). Variables associated with medical care due to injuries by domestic violence were: age 30 or older (OR 2.36, 95% CI 1.13-4.90), female gender (OR 8.60 95% CI 4.25-17.40), history of injuries (OR 4.93 95% CI 2.03-11.95), home as place of occurrence (OR 36.25 95% CI 16.59-79.18), and low education level (OR 2.33 95% CI 1.03-5.26). Study findings are consistent with those from other studies and call for enforcement of the Mexican Official Norm for Medical Care of Domestic Violence (Norma Oficial Mexicana para la Atención Médica de la Violencia Familiar) established in March 2000. (author's)
Epidemiology of human papillomavirus infections: new options for cervical cancer prevention.
In the last two decades, the cervical cancer puzzle has become a coherent description that includes the identification of human papillomavirus (HPV) as the sexually transmitted etiologic agent and the characterization of the major determinants of HPV acquisition. Triage studies have consistently shown that HPV testing is more sensitive that repeated cytology in identifying underlying high-grade lesions in women with atypical scamous cells of undetermined significance (ASCUS). Studies that reflect primary screening conditions have shown that the sensitivity of HPV tests is higher than standard cytology in detecting high-grade lesions whereas the specificity is similar only in women aged 30-35 and above. HPV vaccines have an intrinsic attraction as a preventive strategy in populations with limited resources. However, vaccines designed to widespread use are still in development and testing phases. Time is ripe for exploring in depth the clinical implications of current achievements and to devise novel strategies for the prevention of cervical cancer. (author's)
Serology for human papillomavirus.
Difficulties with serology for papillomavirus are associated with the large number of human papillomavirus, crossreactions between papillomavirus, and to the diversity of lesions and target sites for infection. In addition, the expression of the papillomavirus in the superficial layers of the epithelium gives rise to the weak presentation to immunocompetent cells of viral antigens, which in turn gives rise to a weak serological response. Distinct efforts have been made in previous decades to develop more specific and sensitive serological assays. These former studies use fusion proteins and synthetic peptides, although they remain on the whole uninteresting, due to their lack of sensitivity and specificity. Only in the last few years, and principally due to the advent of various virus-like particles (VLP), have more sensitive and specific assays become available. (author's)
Screening for cervical cancer: new alternatives and research.
Evidence for the clinical utility of human papillomavirus (HPV) DNA testing has increased over the years and has now become very convincing. Some specific uses of HPV detection are a) triage of women with cytological determinations of atypical squamous cells of undetermined significance (ASC-US) and related management strategies, b) as a marker for test of cure post-treatment, and c) most importantly, as an adjunct to cytology in routine cervical disease screening programs. There are many studies that support each of these applications and include 8 studies on ASC-US triage, 10 on test of cure and 13 on adjunctive or stand-alone HPV screening. The most notable investigation of ASC-US triage was ALTS, a randomized controlled trial of 3 488 women. With respect to routine HPV screening the combined studies included 77 000 women, providing as a histological endpoint more than 1 000 cases of high-grade cervical intraepithelial neoplasia (CIN) or cancer. Testing methods were either the Hybrid Capture 2 (HC2) test or the polymerase chain reaction (PCR) test. HPV testing of women with ASC-US cytology had on average a higher sensitivity (90%) and specificity (70%) than repeating the cytological test (sensitivity 75%, specificity 60%) and was also more sensitive than colposcopy for follow-up. As an adjunct to the Papanicolaou (Pap) cytology test in routine screening, HPV DNA testing was a more sensitive indicator for prevalent highgrade CIN than either conventional or liquid cytology. A combination of HPV DNA and Papanicolaou testing had almost 100% sensitivity and negative predictive value. The specificity of the combined tests was slightly lower than the specificity of the Papanicolaou test. One “double-negative” HPV DNA and Papanicolaou test indicated a higher prognostic assurance against risk of future CIN 3 than three subsequent negative conventional Papanicolaou tests and may safely allow three-year or longer screening intervals for such low- risk women. It appears that HPV DNA testing is on the way to becoming a common testing strategy in cervical cancer prevention programs. Research continues into approaches for improving the performance and cost-effectiveness of HPV detection methods. Hybrid Capture 3 will offer improved HPV typing capabilities and the Rapid Capture machine allows for robot-assisted HPV DNA testing, permitting greater test throughput. PCR test improvements are expected to contribute to the growth of flexible accurate and cost-effective HPV DNA tests. It is likely that improved diagnostic technology along with HPV genotyping and quantitation may provide more value in future. A particularly promising approach is to combine HPV DNA testing with expression levels of other markers such as proliferative or cell cycle regulatory proteins to subdivide HPV positive women into those who are at greater risk of cancer and those who can be safely followed by screening at longer intervals. (author's)
The male role in cervical cancer.
Experimental, clinical, and epidemiological evidence strongly suggests that genital Human Papillomaviruses (HPVs) are predominantly sexually transmitted. Epidemiological studies in virginal and HPV-negative women clearly indicate that sexual intercourse is virtually a necessary step for acquiring HPV. As with any other sexually transmitted disease (STD) men are implicated in the epidemiological chain of the infection. Penile HPVs are predominantly acquired through sexual contacts. Sexual contacts with women who are prostitutes play an important role in HPV transmission and in some populations sex workers may become an important reservoir of high-risk HPVs. Acting both as “carriers” and “vectors” of oncogenic HPVs male partners may markedly contribute to the risk of developing cervical cancer in their female partners. Thus, in the absence of screening programs, a woman’s risk of cervical cancer may depend less on her own sexual behavior than on that of her husband or other male partners. Although more rarely than women, men may also become the “victims” of their own HPV infections as a fraction of infected men are at an increased risk of developing penile and anal cancers. Male circumcision status has been shown to reduce the risk not only of acquiring and transmitting genital HPVs but also of cervical cancer in their female partners. More research needed to better understand the natural history and epidemiology of HPV infections in men. (author's)
Prospects for controlling cervical cancer at the turn of the century.
Cervical cancer morbidity and mortality have decreased substantially during the last 50 years mostly due to successful organized or opportunistic screening with Pap cytology in high and middle income countries. In many low income countries Pap cytology screening is yet to be effectively implemented or has failed to reduce cervical cancer rates to an appreciable extent. The fact that infection with certain human papillomavirus (HPV) types is now recognized as a necessary cause of this disease has led to new research fronts on prevention of cervical cancer. Testing for HPV DNA has shown great promise as a screening tool with better sensitivity but somewhat lower specificity than Pap cytology. In combination with the latter, HPV testing has the potential to improve the negative predictive value of cytology, thus allowing for increased testing intervals, which would lower program costs with acceptable safety. Advances in cytology processing and automation have also led to new screening approaches that are increasingly gaining acceptance in high and middle income countries. For low income countries, visual inspection with acetic acid has proven to be an effective alternative to conventional Pap cytology, especially in settings where no screening programs have been implemented. Concerning primary prevention of cervical cancer, recent research on the safety and efficacy of candidate prophylactic vaccines against HPV have shown very promising results with nearly 100% efficacy in preventing persistent infections and development of cervical cancer precursors. However, policy makers are strongly cautioned to avoid deferring decisions concerning the implementation of cervical cancer screening under the expectation that a successful vaccine could obviate the need for secondary prevention strategies. (author's)
Cervical carcinogenesis: the role of co-factors and generation of reactive oxygen species.
Several HPV co-factors have been proposed, some more or less consistently associated with cervical dysplasia and cancer risk. More research, using prospective cohort designs, is needed to further describe where in carcinogenesis these factors are working and to assess the biological mechanism of these factors. In addition, further research is needed to define the role of various hormonal contraceptive formulations in promoting cervical carcinogenesis. While many interesting scientific questions remain to be answered, results from the numerous epidemiological studies conducted to date indicate that cervical dysplasia and cancer may be reduced if the oxidant antioxidant ratio is shifted to more of and antioxidant profile. In addition to cervical cancer screening, a reduction in cervical cancer incidence may be accomplished by reducing tobacco use, increasing nutritional status, and utilizing barrier contraception to prevent infection with other sexually acquired infections. (author's)
Improving cervical cancer screening in Mexico: results from the Morelos HPV Study.
The purpose of this paper is to describe some of the results of the Morelos HPV Study. The main objective of the Morelos HPV Study is to evaluate the use of human papillomavirus (HPV) DNA testing, as compared to the Papanicolaou (Pap) test, for cervical cancer (CC) screening. The Morelos HPV Study is currently being conducted in Mexico, to examine the possibility of using HPV testing for CC screening. The HPV testing of self-collected vaginal and clinician-collected cervical specimens was evaluated as part of this study. The acceptability of the HPV testing of self-collected specimens was compared to that of the Pap test. A cost-effectiveness analysis (CEA) and cost-benefit analysis (CBA) was also performed. The Morelos HPV Study results indicate that HPV testing has a greater sensitivity to detect cervical intraepithelial neoplasia (CIN) 2/3 and CC than the Pap test. Our results also indicate an over-all lower acceptability of the Pap test as compared to the self-collected procedure. The results of the CEA and CBA indicate that screening women between the ages of 20-80 for CC using some type of HPV testing is always more cost-effective than screening for CC using the Pap test. Our results suggest that self- and clinician-collected HPV testing could be used in CC prevention programs, as an effective complement or substitute for the Pap test. (author's)
The Bethesda system is a system of terminology for reporting the results of cervical cytology. It was developed in 1988, and is now widely used in the United States. This system was updated in April 2001. The most important modifications are the following: a) elimination of the category “satisfactory but limited by”, b) the reintegration of benign modifications in the normal category, c) “atypical squamous cells of undetermined significance” is now named “atypical squamous cells” and subdivided into “atypical squamous cells of undetermined significance” and “cannot exclude high grade squamous intraepithelial lesion”; and d) endocervical adenocarcinoma in situ which is now a separate entity. Low grade squamous intraepithelial lesions and high grade squamous intraepithelial cells remain unchanged. Recommendations have been proposed concerning automated review and ancillary testing. (author's)
Prospects for primary prevention of cervical cancer in developing countries.
The HPV types that cause cervical cancer are sexually transmitted, but there is little evidence that infection can be avoided by behavioural changes, such as condom use. In contrast, prophylactic vaccines against HPV infection are likely to have high efficacy. In principle, the effectiveness of HPV vaccination as a strategy for cervical cancer control can be measured either by monitoring secular trends in cervical cancer incidence or by conducting randomized trials. The former approach is unlikely to provide convincing evidence of effectiveness, since cervical cancer rates are subject to strong secular trends that are independent of intervention measures. A few phase III trials of HPV prophylactic vaccines are now being started. Such trials are very expensive studies involving frequent and complicated investigations. It is important, however, to start as soon as possible simpler trials designed to demonstrate the effectiveness of HPV vaccine in field conditions, i.e. in developing or intermediate countries which suffer the major burden of mortality from cervical cancer. Such trials may capture a difference in the most severe, and rarest, preinvasive cervical lesions (i.e., the real target of any HPV vaccine) over a prolonged follow-up (20 years at least). The design of such studies is briefly considered for two areas: Southern India and South Korea. (author's)
The objective was to describe the epidemiology of iron, zinc and iodide deficiencies in a probabilistic sample of Mexican women and children and explore its association with some dietary and socio-demographic variables. We carried out in 1999 an epidemiological description of iron (percent transferrin saturation, PTS, < 16%), serum zinc (< 65ug/dl) and iodide (< 50 ug/l urine) deficiencies in a probabilistic sample of 1,363 Mexican children under 12 years and of 731 women of child-bearing age. Serum iron, Total Iron Binding Capacity (TIBC) and zinc were measured by atomic absorption spectrometry, and urinary iodide by a colorimetric method. Logistic regression models explored determinants for such micromineral deficiencies. Iron deficiency was higher (67%) in infants < 2 years of age. Prevalence declined (34-39%) at school age. The prevalence for iron deficiency in women was 40%. Zinc deficiency was higher in infants < 2 years of age (34%) than in school-age children (19-24%). Prevalence in women was 30%, with no rural/urban difference. In women the likelihood of iron deficiency decreased as SEL improved (p = 0.04) and increased with the intake of cereals (p = 0.01). The likelihood of low serum zinc levels was greater in women and children of low socioeconomic level (SEL) (p < 0.02 and p = 0.001) iodide deficiency was negligible in both children and women. The data shows high prevalence of iron deficiency specially in infants 12 to 24 months of age. It is suggested that in older children and women 12 to 49 years of age that iron bioavailability is low. The prevalence of zinc deficiency was also very high. (author's)
Today, “persistent” infections by certain types of human papillomavirus (HPV) are considered necessary for developing cervical cancer. Producing efficient vaccines against these viruses may eventually lead to a great reduction in incidence and mortality rates of this cancer. In the case of HPV, the production of traditional vaccines usually based in dead or attenuated viruses is not possible due in part to the lack of systems where large quantities of viral particles could be obtained. Fortunately, the expression of the late L1 protein alone, or in combination with L2, leads to the generation of structures resembling true virions that have been called virus-like particles (VLPs) and constitute excellent candidates as prophylactic vaccines. VLPs have shown to be very immunogenic, and have prevented development of natural or challenged infections in both animal systems and humans. Recently, HPV16 VLPs were shown to be very efficient to prevent the development of “persistent” infections, as determined by PCR assays, in a large group of vaccinated women. Therapeutic vaccines, on the other hand, are expected to have an impact on advanced lesions and residual illness, by taking advantaje of the fact that early E6 and E7 genes are thought to be constitutively expressed in cervical tumors and precursor lesions. Finally, DNA-based vaccines could represent a useful alternative for preventing infections by genital HPV. (author's)
The cervical cancer screening programs (CCSP) have not been very efficient in the developing countries. This explains the need to foster changes on policies, standards, quality control mechanisms, evaluation and integration of new screening alternatives considered as low and high cost, as well as to regulate colposcopy practices and the foundation of HPV laboratories. Cervical cancer (CC) is a disease most frequently found in poverty-stricken communities and reflecting a problem of equity at both levels gender and regional, and this, is not only due to social and economic development inequalities, but to the infrastructure and human resources necessary for primary care. For this reason, the CCSP program must be restructured, a) to primarily address unprivileged rural and urban areas; b) to foster actions aimed at ensuring extensive coverage as well as a similar quality of that coverage in every region; c) to use screening strategies in keeping with the availability of health care services. In countries with a great regional heterogeneity, a variety of screening procedures must be regulated and standardized, including a combination of assisted visual inspection, cervical cytology and HPV detection; d) regional community intervention must be set up to assess the effectiveness of using HPV detection as an strategy in addition to cervical cytology (pap smear); e) the practice of colposcopy must be regulated to prevent the use of it in healthy women at a population level, thus preventing unnecessary diagnosis and treatment which not only are expensive but also causes unnecessary anxiety to women at risk; f) the operation of those clinical laboratories using HPV as a detection strategy must likewise be accredited and regulated and g) the CCSP program for assuring health care quality should meet the expectations of its beneficiaries, and increase the knowledge in cervical cancer related matters. Finally, though a variety of clinical tests on prophylactic and therapeutic vaccines against HPV are recently being developed worldwide; it will take at least from 5 to 10-years time to have them available in the market. For this reason, it will be necessary to intensify the CCSP programs. All these reasons lay emphasis on the need to reinforce actions for CCSP programs. (author's)
The objective was to describe the reported energy and nutrient intake and adequacies in Mexican women. A 24-hour dietary recall was used to obtain nutrient intake in a representative sub-sample of 2 630 women from 12 to 49 years of age from the National Nutrition Survey 1999. Nutrient adequacies were estimated using the Dietary Reference Intakes and stratified according to region, area (urban or rural), socioeconomic status and obesity status (non-obese: BMI < 30 kg/m2, obese: = 30 kg/m2). Differences were analyzed using linear regression for complex surveys of log-transformed intake and adequacy, adjusting for multiple comparisons with the Bonferroni test. The median national energy intake was 1 471 kcal. The Risk of Inadequacy (RI) (prevalence of adequacy <50%) was: vitamin A:38.3%, vitamin C: 45.5%, and folate: 34.3%. Carbohydrates, folate, iron and calcium intake was significantly higher in rural than in urban areas. The RI was higher in women of the lowest socioeconomic status tertile for all nutrients with the exception of carbohydrates and calcium. Macro-nutrient adequacies were significantly higher in nonobese women. Differences within the country among regions, rural and urban areas, and socioeconomic status tertile reflect an increasing availability of inexpensive calorie-dense foods in marginal groups. However, total energy, cholesterol, saturated and total fat were consumed in greater quantities by women from the higher socioeconomic status tertile and from urban areas. These patterns could be a contributing factor to the rise of obesity and other noncommunicable nutrition-related chronic diseases in Mexico. (author's)
The objective was to describe the epidemiology of Vitamin A and C and folic acid deficiencies and their association with sociodemographic and dietary factors in a national probabilistic sample of Mexican women and children. This is a probabilistic sample from the National Nutrition Survey 1999 (ENN-99) including 1 966 children and 920 women. Vitamins A and C were measured in serum by high-performance liquid chromatography, and folic acid in total blood by a microbiological method. Determinants for such deficiencies were explored by multiple regression models. Vitamin A deficiency (retinol < 10 mg/dl) was rare in both children and women. But subclinical deficiency (retinol > 10 and < 20 mg/dl) was present in 25% of children. The likelihood of subclinical deficiency of vitamin A was less in older children (OR = 0.98, p = 0.01) and in women with higher body mass index (OR = 0.93, p = 0.01). About 30% of children < 2 years of age and 40% of women were vitamin C deficient. The likelihood of vitamin C deficiency was less in children and women as socioeconomic level increased (OR = 0.69, p = 0.03, and OR = 0.80, p = 0.04), and higher in older women (OR = 1.02, p = 0.05). The prevalence of folate deficiency varied in children (2.3 to 11.2), in women it was 5%. Folate deficiency was less in children of higher socioeconomic level (OR = 0.62, p = 0.01), and in those eating more vegetables (OR = 0.22, p = 0.01). The high prevalence of subclinical deficiency of vitamin A in children is indicative of risk of further deterioration under adverse circumstances. Vitamin C deficiency in both children and women implies in addition diminished ability for iron absorption. (author's)