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[The results of implementation of the International Bank for Reconstruction and Development Loan Project "Prevention, diagnosis, and treatment of tuberculosis and AIDS", a "tuberculosis" component]
Tuberkulez I Bolezni Legkikh. 2010; (3):10-7.Due to the implementation of the International Bank for Reconstruction and Development (IBRD) loan project "Prevention, diagnosis, treatment of tuberculosis and AIDS", a "Tuberculosis" component that is an addition to the national tuberculosis control program in 15 subjects of the Russian Federation, followed up by the Central Research Institute of Tuberculosis, Russian Academy of Medical Sciences, the 2005-2008 measures stipulated by the Project have caused substantial changes in the organization of tuberculosis control: implementation of Orders Nos. 109, 50, and 690 and supervision of their implementation; modernization of the laboratories of the general medical network and antituberbulosis service (404 kits have been delivered for clinical diagnostic laboratories and 12 for bacteriological laboratories, including BACTEC 960 that has been provided in 6 areas); 91 training seminars have been held at the federal and regional levels; 1492 medical workers have been trained in the detection, diagnosis, and treatment of patients with tuberculosis; 8 manuals and guidelines have been prepared and sent to all areas. In the period 2005-2008, the tuberculosis morbidity and mortality rates in the followed-up areas reduced by 1.2 and 18.6%, respectively. The analysis of patient cohorts in 2007 and 2005 revealed that the therapeutic efficiency evaluated from sputum smear microscopy increased by 16.3%; there were reductions in the proportion of patients having ineffective chemotherapy (from 16.1 to 11.1%), patients who died from tuberculosis (from 11.6 to 9.9%), and those who interrupted therapy ahead of time (from 11.8 to 7.8%). Implementation of the IBR project has contributed to the improvement of the national strategy and the enhancement of the efficiency of tuberculosis control.
Releve Epidemiologique Hebdomadaire. 2013 Jul 12; 88(28):285-96.This epidemiologic record discusses recent data about yellow fever outbreaks and cases in Africa and South America between 2011 and 2012. During this period, major outbreaks were reported in Sudan and Uganda while significant clusters of cases were reported in Cameroon, Chad and Cote d’Ivoire, necessitating an extended vaccination response. In addition, some isolated cases occurred in districts reporting high yellow fever vaccination coverage (Burkina Faso, Central African Republic, Togo), for which no vaccination response was undertaken. In South America, the World Health Organization American Region reported 32 cases (2011-2012), including 9 deaths, in Brazil, Ecuador, Plurinational State of Bolivia and Peru. As of 2012, most countries in the Caribbean and Latin America with enzootic areas had introduced the yellow fever vaccine into their national routine immunization schedules. The 2008 outbreaks in the Southern Cone expanded the area considered at risk to include northern Argentina and Paraguay. Building upon the yellow fever investment case strategy, which has reduced the frequency and size of disruptive outbreaks, the Yellow Fever Strategic Framework 2012-2020 prioritizes endemic countries according to their epidemic risk. This framework will enable WHO and partners to identify the populations’ high priority needs through a systematic approach so that limited resources can be allocated most effective to reduce the burden of yellow fever in Africa. Following a request from the countries, a form of yellow fever experts met in Panama to discuss how countries can make scientific evidence-based risk assessments and suggested that endemic countries should strive to enhance yellow fever surveillance systems.
Children with severe malnutrition: Can those at highest risk of death be identified with the WHO protocol?
PLoS Medicine. 2006 Dec; 3(12):e500.With strict adherence to international recommended treatment guidelines, the case fatality for severe malnutrition ought to be less than 5%. In African hospitals, fatality rates of 20% are common and are often attributed to poor training and faulty case management. Improving outcome will depend upon the identification of those at greatest risk and targeting limited health resources. We retrospectively examined the major risk factors associated with early (< 48 h) and late in-hospital death in children with severe malnutrition with the aim of identifying admission features that could distinguish a high-risk group in relation to the World Health Organization (WHO) guidelines. Of 920 children in the study, 176 (19%) died, with 59 (33%) deaths occurring within 48 h of admission. Bacteraemia complicated 27% of all deaths: 52% died before 48 h despite 85% in vitro antibiotic susceptibility of cultured organisms. The sensitivity, specificity, and likelihood ratio of the WHO-recommended ''danger signs'' (lethargy, hypothermia, or hypoglycaemia) to predict early mortality was 52%, 84%, and 3.4% (95% confidence interval [CI] = 2.2 to 5.1), respectively. In addition, four bedside features were associated with early case fatality: bradycardia, capillary refill time greater than 2 s, weak pulse volume, and impaired consciousness level; the presence of two or more features was associated with an odds ratio of 9.6 (95% CI = 4.8 to 19) for early fatality (p < 0.0001). Conversely, the group of children without any of these seven features, or signs of dehydration, severe acidosis, or electrolyte derangements, had a low fatality (7%). Formal assessment of these features as emergency signs to improve triage and to rationalize manpower resources toward the high-risk groups is required. In addition, basic clinical research is necessary to identify and test appropriate supportive treatments. (author's)
WHO guidelines for management of severe malnutrition in rural South African hospitals: effect on case fatality and the influence of operational factors.
Lancet. 2004 Apr 3; 363(9415):1110-1115.WHO case-management guidelines for severe malnutrition aim to improve the quality of hospital care and reduce mortality. We aimed to assess whether these guidelines are feasible and effective in under-resourced hospitals. All children admitted with a diagnosis of severe malnutrition to two rural hospitals in Eastern Cape Province from April, 2000 to April, 2001, were studied and their case fatality rates were compared with the rates in a period before guidelines were implemented (March, 1997 to February, 1998). Quality of care was assessed by observation of medical and nursing practices, review of medical records, and interviews with carers and staff. A mortality audit was used to identify cause of death and avoidable contributory factors. At Mary Theresa Hospital, case-fatality rates fell from 46% before implementation to 21% after implementation. At Sipetu Hospital, the rates fell from 25% preimplementation to 18% during 2000, but then rose to 38% during 2001, when inexperienced doctors who were not trained in the treatment of malnutrition were deployed. This rise coincided with less frequent prescribing of potassium (13% vs 77%, p<0·0001), antibiotics with gram-negative cover (15% vs 46%, p=0·0003), and vitamin A (76% vs 91%, p=0·018). Most deaths were attributed to sepsis. For the two hospitals combined, 50% of deaths in 2000–01 were due to doctor error and 28% to nurse error. Weaknesses within the health system—especially doctor training, and nurse supervision and support—compromised quality of care. Quality of care improved with implementation of the WHO guidelines and case-fatality rates fell. Although major changes in medical and nursing practice were achieved in these under-resourced hospitals, not all tasks were done with adequate care and errors led to unnecessary deaths. (author's)
Outcome for children under 5 years hospitalized with severe acute lower respiratory tract infections in Yemen: a 5 year experience.
JOURNAL OF TROPICAL PEDIATRICS. 1998 Dec; 44(6):343-6.In developing countries, more than 4 million children under 5 years old die annually of acute respiratory infections (ARI), especially pneumonia. ARI is a leading cause of morbidity and mortality among children under age 5 years in Yemen. During 1991-95, 2554 children under age 5 years hospitalized with severe acute lower respiratory tract infection in Al-Sabeen Hospital, Sana'a, Yemen, were studied to document their case fatality rates (CFRs) and the effects upon outcome of introducing the WHO-ARI standard case management protocol for inpatients with severe/very severe pneumonia. 47.7% (1218) of the children were under age 6 months, while 74.1% were under 1 year old. 64% were male. 221 of the 2554 cases died, for an overall CFR of 8.7%. 118 of the deaths (53.4%) were among children under age 6 months and 188 (85%) were under 1 year old. Although the WHO standard case management guidelines were implemented in 1995, there was no significant reduction in case fatality rates in 1995 relative to 1991, 1992, 1993, and 1994. Late hospital admission with cyanosis, malnutrition, and rickets increased resistance of the common causative organisms such as pneumococci and H. influenzae to WHO-recommended antibiotics. Measures to reduce lower respiratory tract infection-related mortality could include improving maternal nutrition, health education, promoting breast-feeding, preventing rickets and nutritional anemia among vulnerable age groups, and vaccination against pneumococci and H. influenzae type b.