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Generic protocol to estimate the burden of Shigella diarrhoea and dysenteric mortality. Field test version, May 1999.
Geneva, Switzerland, World Health Organization [WHO], Department of Vaccines and Biologicals, 1999. 37 p. (WHO/V&B/99.26)The WHO Department of Vaccines and Biologicals (V&B) has an increasing interest in vaccines against Shigella, and several candidate vaccines are being tested in clinical trials. The promise of having a new generation of vaccines available in the relatively near future emphasizes the need to understand the disease burden and the epidemiology of Shigella infection in developing countries. The V&B Steering Committee on Epidemiology and Field Research and the V&B Steering Committee on Diarrhoeal Disease Vaccines jointly identified the need for a practical method for immunization programme managers and clinical epidemiologists to assess the local disease burden due to Shigella. At the request of these Steering Committees, this generic protocol was prepared by staff at the U.S National Institute of Child Health and Human Development, the University of Maryland, and the U.S. Centers for Disease Control and Prevention. This protocol provides a general outline for a study and describes the main procedures involved. However, it will need to be adapted to the local setting, and details of field work and operational procedures should be added by local investigators with experience in conducting field studies of diarrhoeal diseases. WHO provides this protocol free-of-charge. In return, WHO would appreciate being informed about studies conducted using this protocol. This WHO document should be referenced in any publication resulting from its use. Comments or suggestions for improving this generic protocol are welcome and should be sent to the Department of Vaccines and Biologicals, WHO, 1211 Geneva 27, Switzerland. (excerpt)
WORLD HEALTH FORUM. 1994; 15(4):393-7.The fact that food safety is given a low priority in the health care systems of many countries despite an increase in food-borne diseases may be due to a lack of reliable quantitative data on incidence of disease. The World Health Organization (WHO) has linked this increase to intensive methods of livestock production which foster the spread of salmonella and other pathogens. By relying on legislation, regulations, and standards to monitor food commerce, policy-makers have failed to emphasize health education for food handlers and consumers. WHO has proposed a collaborative, intersectoral approach between governments, food industries, and consumers which will emphasize consumer education. WHO has also prepared 10 rules for safe food preparation. Governments can insure the education of consumers and food handlers by using the primary health care (PHC) mechanism for health education. To date, the most intensive involvement of the PHC community has been in efforts to avoid diarrheal diseases through hand-washing, sanitation, and safe storage of water. Insufficient cooking, faulty food storage, and improper reuse of leftovers have all been neglected topics. Food safety efforts at the local level should 1) identify specific food-related practices and behavior relevant to risk factors, 2) change risky behavior and practices through health education, 3) involve the community in making improvements related to food safety, 4) mobilize and coordinate relevant activities of other sectors, 5) report incidences of food-borne illnesses, 6) generate a strong public demand for food safety, and 7) research diseases and cultural practices related to food handling and safety. To achieve these objectives, PHC workers should be trained in the epidemiology of food-borne diseases and the sociocultural characteristics of their area, in health education and community involvement, and in research methodology.
In: Disease and mortality in Sub-Saharan Africa, edited by Richard G. Feachem, Dean T. Jamison. Oxford, England, Oxford University Press, 1991. 173-89.In Sub-Saharan Africa (SSA), 1% of all children die of neonatal tetanus, 9% of measles, 3% of tuberculosis (TB), and 4% of pertussis. Further, .6% acquire paralytic polio. 20% of the .6% who acquire diphtheria die. Even though vaccination can control these diseases, only 20% of children in SSA receive the complete course of vaccination against the 6 diseases targeted by WHO's Expanded Programme on Immunization (EPI). But high vaccine coverage is not always a cure-all. For example, in the Gambia coverage is high but high mortality levels persist. Of the EPI diseases, measles is the greatest threat since it kills 2 million people annually in developing countries. Measles related mortality is highest in the 9 months following the disease. Even though tetanus is a major cause of death in neonates, tetanus also kills adults such as those that work with the land. Further the tetanus vaccination is effective in adults, but no adult program operates in SSA. Trained midwives reduce neonatal tetanus mortality by 76.6% and vaccination of pregnant mothers with 2 doses of tetanus toxoid reduces mortality 93.3%. Lameness surveys in SSA countries show that, contrary to earlier beliefs, paralytic polio is quite common (range 0.7-13.2). Administration of the oral polio vaccine and improved sanitation are responsible for a real fall in polio cases in the Gambia, the Ivory Coast, and Cameroon. TB was introduced into SSA in the 19th century. It mainly occurs in adults. The estimated life long risk of developing smear positive TB in SSA is 63. The case fatality rate of pertussis in the 1st year of life is high (3.2) and infants do no acquire maternal immunity against it, so the best control measures are early vaccination and identifying secondary cases among young siblings. Of the EPI diseases, scientists know the least about diphtheria in SSA. Its case fatality rate is high (11-38%) yet it is treatable. Primary problems of adequate vaccination coverage for the EPI diseases are managerial problems rather than technological.
Lancet. 1989 Feb 18; 1(8634):396.The World Health Organization (WHO) issued a consensus statement about AIDS and sexually transmitted diseases (STD) and partner notification for patients with HIV infection. Evidence that genital ulcer disease (GUD) is a risk factor and facilitator for HIV-1 infection in heterosexual people is strong, especially in developing countries. A few studies have shown an association of antibodies to herpes simplex virus type 2 (HSV-2) and Treponema pallidum (the chief cause of genital and anorectal ulcers in developing countries). A consistent relation between HIV-1 and HSV-2 and T. pallidum has been demonstrated in seroepidemiological studies. Data assessing the link between other STD pathogens and HIV-1 transmission are insufficient, but it is plausible that all STD pathogens that cause genital ulcers or inflammation are risk factors for increased susceptibility to HIV-1 infection. Investigating this possibility should be a research priority, as genital ulcer diseases intervention may help to prevent sexual transmission of HIV-1 infection. Partner notification programs, as part of a comprehensive AIDS prevention and control program, should be carefully designed. Because the notification procedure can cause individual and social harm and detract from other AIDS prevention and control activities, a careful assessment of medical, legal, logistic, social, and ethical issues needs to be made. Other variables, such as cost, local environment, and epidemiology need to be taken into account. Issues of patient referral, target populations, training of notification personnel, patient consent, diagnostic accuracy, and the logistics of notification need to be addressed. WHO suggests that the following criteria be monitored when assessing efficiency of partner notification activities: number of index persons; number of partners identified; number of partners notified and their seroprevalence; cost; satisfaction; compliance and acceptability; counseling and support; staff training; confidentiality; and adequacy of follow-up.
Geneva, Switzerland, WHO, 1986. 22 p.Maternal care is the most appropriate target for reducing the high perinatal and neonatal mortality typical of the least developed countries. The principles formulated by the 25th session of the WHO/UNICEF Joint Committee on Health Policy in 1985 are outlined here. Perinatal mortality is defined as infant death from 1000 g, even if intrauterine or stillborn, to 1 week of age. Neonatal mortality is that occurring in the 1st month of life. Half of infant mortality (up to 1 year of age) occurs in the 1st month, most of that during the 1st week, and these deaths are directly related to maternal care during pregnancy and delivery. They are caused by low birth weight, intrauterine or birth asphyxia, birth trauma, or infections, usually of the cord or amniotic fluid. Tetanus is the primary lethal infection. Tetanus can be prevented by immunizing women, or giving tetanus toxoid to pregnant women, but also very effectively by training birth assistants in hygiene. Traumatic deaths can best be prevented by training midwives and strengthening the support system for referral to clinics. The most cost-effective strategies for improving maternal health are nutritional intervention, malaria prevention, treatment of infections and of toxemia, reducing heavy workload of pregnant women, and family planning services. Points where community involvement is effective are discussed. WHO and UNICEF will increase support in health education, tetanus immunization, training of birth attendants, equipping birth facilities, appropriate technology, and operational research.
AMERICAN JOURNAL OF TROPICAL MEDICINE AND HYGIENE. 1986 Jan; 35(1):1-2.A paper by Hazlett et al. is of particular importance because it addresses the question of the role of acute respiratory infections (ARI) as a cause of morbidity and especially mortality in 3rd world children. Diarrheal disease and malnutrition are generally thought to be the major killers of these children, and until recently little attention was paid to ARI. Recent data suggest that ARI are more important than realized previously and almost certainly are the leading cause of death in children in developing countries. It is estimated that each year more than 15 million children less than 5 years old die, obviously most in socially and economically deprived countries. Since death usually is due to a combination of social, economic, and medical factors, it is impossible to obtain precise data on the causes of death. It has been estimated that 5 million of the deaths are due to diarrhea, over 3 million due to pneumonia, 2 million to measles, 1.5 million to pertussis, 1 million to tetanus, and the other 2.5 million or less to other causes. Since pertussis is an acute respiratory infection and measles deaths frequently are due to infections of the respiratory tract, it is becoming clear that ARI are associated with more deaths than any other single cause. The significance of this is emphasized when the mortality rates from ARI in developed and underdeveloped nations are compared. Depending on the countries compared, age group, and other factors, increases of 5-10-fold have been reported. These factors raise the question of why respiratory infections are so lethal for 3rd world children. The severity of pneumonia, which is the cause of most ARI deaths, seems to be the big difference. Data are accumulating which show that bacterial infections are associated with the majority of severe infections and "Streptococcus pneumoniae" and "Haemophilus influenzae," infrequent causes of pneumonia in developed world children, are the microorganisms incriminated in a large proportion of cases. The increase in severity of ARI in 3rd world children has been associated, at least in port, with malnutrition, diarrheal diseases, an increased parasite load, and more recently with air pollution. Crowding and other factors associated with poverty doubtless also play a role. How these various factors contribute to increased severity and lethality is not well understood. The increasing recognition of the important role played by ARI as causes of mortality in 3rd world children is encouraging. The UN International Children's Emergency Fund (UNICEF) has joined the World Health Organization in the battle against ARI in developing countries, and the 2 organizations recently issued a joint statement on the subject in which they pledged to collaborate to integrate an ARI component into the primary health care program.
[Experience with the expanded WHO program on immunization against tetanus] Opyt rasshirennoi programmy VOZ po immunizatsii protiv stolbniaka.
ZHURNAL MIKROBIOLOGII, EPIDEMIOLOGII I IMMUNOBIOLOGII. 1985 Nov; (11):97-103.According to (WHO) statistics, over 1 million infants in the developing countries die each year from tetanus. The estimated annual occurrence of tetanus in the 3rd World exceeds 2.5 million cases, including approximately 1.3 million newborn infants. In 1974, WHO began an expanded program for the systematic immunization of infants against tetanus and certain other diseases. The program uses 2 approaches for preventing tetanus: 1) immunization of infants under 1 year of age with the AKDS vaccine; and 2) immunization of pregnant women or, if possible, all women, with tetanus anatoxin. The 2nd approach is more effective, especially when 2 doses of tetanus anatoxin are administered within a minimum interval of 4 weeks. The anatoxin has no harmful effects on the fetus and can be used during any stage of pregnancy. The program strives to reduce infant mortality caused by tetanus to less than 1 case in 1000 by 1990, and to 0 by 2000. To attain these goals, systematic immunization should be combined with drastic improvements in delivery techniques and hygiene in developing countries. Specialized surveys indicate that initial steps toward implementation of the program resulted in a significant reduction of infant mortality caused by tetanus. Experience with the expanded WHO program shows that elimination of tetanus in infants is a realistic and attainable goal.
In: Medical education in the field of primary maternal child health care [edited by] M.M. Fayad, M.I. Abdalla, Ibrahim I. Ibrahim, Mohamed A. Bayad. [Cairo, Egypt, Cairo University, Faculty of Medicine, Dept. of Obstetrics and Gynecology, 1984]. 421-34.This paper begins by stating that the mortality from neonatal tetanus has been peculiarly underestimated until recently, and discusses why this has been the case. The availability of a methodology for retrospective surveys and undertaking of such surveys in recent years has thrown much light on the subject. The results of these surveys from 15 countries are presented in tabular form. It is apparent that at present between 500,000 and 1 million newborn infants a year succumb to tetanus. The prospects for control, using the combined approach of improved maternity care and maternal immunization, are discussed, and an appropriate schedule of immunization suggested. The prospects for control are good wherever there is realization of the magnitude of the problem plus reasonable access to even quite basic primary health care. Some activities of WHO in this field are briefly described. (author's)