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Comparison of previous and present World Health Organization clinical staging criteria in HIV-infected Malawian children.
AIDS. 2009 Sep 10; 23(14):1913-6.In many settings, HIV infected children are looked after with limited access to CD4 cell count or viral load. The decision to initiate antiretroviral therapy (ART) is made clinically, based on the WHO paediatric staging criteria, which were revised in 2006. Results of using new and old criteria were compared. Of 694 children, 626 (90.2%) fulfilled criteria to start ART when applying the new WHO staging guidelines, whereas 330 (47.6%) children were eligible for ART when using the old WHO criteria. This signifies a marked rise in the number of paediatric patients qualifying for ART on clinical grounds.
Validation of 2006 WHO prediction scores for true HIV infection in children less than 18 months with a positive serological HIV test.
PloS One. 2009; 4(4):e5312.INTRODUCTION: All infants born to HIV-positive mothers have maternal HIV antibodies, sometimes persistent for 18 months. When Polymerase Chain Reaction (PCR) is not available, August 2006 World Health Organization (WHO) recommendations suggest that clinical criteria may be used for starting antiretroviral treatment (ART) in HIV seropositive children <18 months. Predictors are at least two out of sepsis, severe pneumonia and thrush, or any stage 4 defining clinical finding according to the WHO staging system. METHODS AND RESULTS: From January 2005 to October 2006, we conducted a prospective study on 236 hospitalized children <18 months old with a positive HIV serological test at the national reference hospital in Kigali. The following data were collected: PCR, clinical signs and CD4 cell count. Current proposed clinical criteria were present in 148 of 236 children (62.7%) and in 95 of 124 infected children, resulting in 76.6% sensitivity and 52.7% specificity. For 87 children (59.0%), clinical diagnosis was made based on severe unexplained malnutrition (stage 4 clinical WHO classification), of whom only 44 (50.5%) were PCR positive. Low CD4 count had a sensitivity of 55.6% and a specificity of 78.5%. CONCLUSION: As PCR is not yet widely available, clinical diagnosis is often necessary, but these criteria have poor specificity and therefore have limited use for HIV diagnosis. Unexplained malnutrition is not clearly enough defined in WHO recommendations. Extra pulmonary tuberculosis (TB), almost impossible to prove in young children, may often be the cause of malnutrition, especially in HIV-affected families more often exposed to TB. Food supplementation and TB treatment should be initiated before starting ART in children who are staged based only on severe malnutrition.
Low levels of antiretroviral-resistant HIV infection in a routine clinic in Cameroon that uses the World Health Organization (WHO) public health approach to monitor antiretroviral treatment and adequacy with the WHO recommendation for second-line treatment.
Clinical Infectious Diseases. 2009 May 1; 48(9):1318-22.A cross-sectional study, performed at a routine human immunodeficiency virus (HIV)/AIDS clinic in Cameroon that uses the World Health Organization public health approach, showed low rates of virological failure and drug resistance at 12 and 24 months after initiation of antiretroviral therapy. Importantly, the cross-sectional study also showed that the World Health Organization recommendation for second-line treatment would be effective in almost all patients with HIV drug resistance mutations.
Human Reproduction Update. 2003 Jan-Feb; 9(1):49-59.Progestogen-only implantable contraceptives are used by increasing numbers of women worldwide. This review outlines the evidence accumulated on these methods to date. Reviews of toxicological evaluations, clinical trials, endocrinological, epidemiological and social science studies, as well as operations research and economic evaluation were undertaken in preparation for an Expert Consultation convened by the World Health Organization in 2001. At the meeting, these reviews were further evaluated and the research results summarized in this consensus paper. A large body of evidence demonstrates the high contraceptive effectiveness and safety of the 5-year levonorgestrel-releasing implants Norplant and Jadelle. Information on the 3-year etonogestrel-releasing implant Implanon is more limited, but suggests that this implant has a high contraceptive effectiveness and a satisfactory safety pro®le. Information available on levonorgestrel-releasing implants manufactured and approved in China suggests that their clinical performance is satisfactory, but was insufficient to allow their full safety assessment. For all implants, there is insufficient information on their use by women with medical conditions. Provision of contraceptive implants requires good quality family planning services and specific provider training.
Journal of Tropical Pediatrics. 2008 Dec; 54(6):364-9.AIM: To assess the clinical outcomes of a combined approach to the treatment of severe acute malnutrition in an area of high HIV prevalence using: (i) an initial inpatient phase, based on WHO guidelines and (ii) an outpatient recovery phase using ready-to-use therapeutic food. METHODS: An operational prospective cohort study implemented in a referral hospital in Southern Malawi between May 2003 and 2004. Patient outcomes were compared with international standards and with audits carried out during the year preceding the study. RESULTS: Inpatient mortality was 18% compared to 29% the previous year. Programme recovery rate was 58.1% compared to 45% the previous year. The overall programme mortality rate was 25.7%. Of the total known HIV seropositive children, 49.5% died. CONCLUSIONS: Inpatient mortality and cure rates improved compared to pre-study data but the overall mortality rate did not meet international standards. Additional interventions will be needed if these standards are to be achieved.
Comparison of the new World Health Organization growth standards and the National Center for Health Statistics growth reference regarding mortality of malnourished children treated in a 2006 nutrition program in Niger.
Archives of Pediatrics and Adolescent Medicine. 2009 Feb; 163(2):126-30.OBJECTIVE: To compare the National Centre for Health Statistics (NCHS) international growth reference with the new World Health Organization (WHO) growth standards for identification of the malnourished (wasted) children most at risk of death. DESIGN: Retrospective data analysis. SETTING: A Medecins Sans Frontieres (Doctors Without Borders) nutrition program in Maradi, Niger, in 2006 that treated moderately and severely malnourished children. PARTICIPANTS: A total of 53 661 wasted children aged 6 months to 5 years (272 of whom died) in the program were included. INTERVENTIONS: EpiNut (Epi Info 6.0; Centers for Disease Control and Prevention, Atlanta, Georgia) software was used to calculate the percentage of the median for the NCHS reference group, and the WHO (igrowup macro; Geneva, Switzerland) software was used to calculate z scores for the WHO standards group of the 53 661 wasted children. OUTCOME MEASURES: The main outcome measures are the difference in classification of children as either moderate or severely malnourished according to the NCHS growth reference and the new WHO growth standards, specifically focusing on children who died during the program. RESULTS: Of the children classified as moderately wasted using the NCHS reference, 37% would have been classified as severely wasted according to the new WHO growth standards. These children were almost 3 times more likely to die than those classified as moderately wasted by both references, and deaths in this group constituted 47% of all deaths in the program. CONCLUSIONS: The new WHO growth standards identifies more children as severely wasted compared with the NCHS growth reference, including children at high mortality risk who would potentially otherwise be excluded from some therapeutic feeding programs.
Bulletin of the World Health Organization. 2008 Sep; 86(9):658.The incidence and prevalence of tuberculosis (TB) in children are increasing and becoming a particular problem in countries that are also affected by the HIV epidemic.1 Tuberculosis in children has been seen as hard to diagnose but, at least in developed countries, relatively easy to treat. However, in children with HIV, severe disease is more frequent and this has led to a reexamination of treatment regimens. (excerpt)
Symptom-based screening of child tuberculosis contacts: improved feasibility in resource-limited settings.
Pediatrics. 2008 Jun; 121(6):e1646-52.OBJECTIVE: National tuberculosis programs in tuberculosis-endemic countries rarely implement active tracing and screening of child tuberculosis contacts, mainly because of resource constraints. We aimed to evaluate the safety and feasibility of applying a simple symptom-based approach to screen child tuberculosis contacts for active disease. METHODS: We conducted a prospective observational study from January through December 2004 at 3 clinics in Cape Town, South Africa. All of the children <5 years old in household contact with an adult tuberculosis source case were assessed by documenting current symptoms and tuberculin skin test and chest radiograph results. RESULTS: During the study period, 357 adult tuberculosis cases were identified; 195 cases (54.6%) had sputum smear and/or culture positive results and were in household contact with children aged <5 years. Complete information was available for 252 of 278 children; 176 (69.8%) were asymptomatic at the time of screening. Tuberculosis treatment was administered to 33 (13.1%) of 252; 27 were categorized as radiologically "certain tuberculosis," the majority (n = 22) of which had uncomplicated hilar adenopathy. The negative predictive value of symptom-based screening varied according to the case definition used, with 95.5% including all of the children treated for tuberculosis and 97.1% including only those with radiologically "certain tuberculosis." CONCLUSIONS: Our findings support current World Health Organization recommendations, demonstrating that symptom-based screening of child tuberculosis contacts should improve feasibility in resource-limited settings and seems to be safe.
Outcome of severely malnourished children treated according to UNICEF 2004 guidelines: a one-year experience in a zone hospital in rural Ethiopia.
Transactions of the Royal Society of Tropical Medicine and Hygiene. 2008 Sep; 102(9):939-44.Malnutrition still has a dramatic impact on childhood mortality in sub-Saharan African countries. Very few studies have tried to evaluate the outcome of severely malnourished children treated according to the UNICEF 2004 guidelines and reported fatality rates are still very high. During 2006, 1635 children were admitted to the paediatric ward of St. Luke Catholic Hospital in Wolisso, South West Shewa, Ethiopia. Four hundred and ninety-three (30.15%) were severely malnourished and were enrolled in the study. We reviewed the registration books and inpatient charts to analyze their outcome. A mortality rate of 7.1% was found, which is significantly lower than reported in the literature. 28.6% of deaths occurred within 48 h of admission; the recovery rate was 88.4%; the drop-out rate was 4.5%. Early deaths were due to the poor condition of the children on admission, leading to failure of treatment. Late mortality was considered to be related to electrolyte imbalances, which we were unable to measure. The clinical skills of nursing and medical staff were considered an important factor in improving the outcome of malnourished patients. We found that proper implementation of WHO guidelines for the hospital treatment of severely malnourished children can lead to a relatively low mortality rate, especially when good clinical monitoring is assured.
Zinc treatment to under-five children: applications to improve child survival and reduce burden of disease.
Journal of Health, Population, and Nutrition. 2008 Sep; 26(3):356-65.Zinc is an essential micronutrient associated with over 300 biological functions. Marginal zinc deficiency states are common among children living in poverty and exposed to diets either low in zinc or high in phytates that compromise zinc uptake. These children are at increased risk of morbidity due to infectious diseases, including diarrhoea and respiratory infection. Children aged less than five years (under-five children) and those exposed to zinc-deficient diets will benefit from either daily supplementation of zinc or a 10 to 14-day course of zinc treatment for an episode of acute diarrhoea. This includes less severe illness and a reduced likelihood of repeat episodes of diarrhoea. Given these findings, the World Health Organization/United Nations Children's Fund now recommend that all children with an acute diarrhoeal illness be treated with zinc, regardless of aetiology. ICDDR.B scientists have led the way in identifying the benefits of zinc. Now, in partnership with the Ministry of Health and Family Welfare, Government of Bangladesh and the private sector, the first national scaling up of zinc treatment has been carried out. Important challenges remain in terms of reaching the poorest families and those living in remote areas of Bangladesh.
Appropriate infant feeding practices result in better growth of infants and young children in rural Bangladesh.
American Journal of Clinical Nutrition. 2008 Jun; 87(6):1852-1859.The World Health Organization and the United Nations International Children's Emergency Fund recommend a global strategy for feeding infants and young children for proper nutrition and health. We evaluated the effects of following current infant feeding recommendations on the growth of infants and young children in rural Bangladesh. The prospective cohort study involved 1343 infants with monthly measurements on infant feeding practices (IFPs) and anthropometry at 17 occasions from birth to 24 mo of age to assess the main outcomes of weight, length, anthropometric indexes, and undernutrition. We created infant feeding scales relative to the infant feeding recommendations and modeled growth trajectories with the use of multilevel models for change. Mean (+or- SD) birth weight was 2697 +or- 401 g; 30%weighed less than 2500 g. Mean body weight at 12 and 24 mo was 7.9 +or- 1.1 kg and 9.7 +or- 1.3 kg, respectively. More appropriate IFPs were associated (P less than 0.001) with greater gain in weight andlength during infancy. Prior IFPs were also positively associated (P less than 0.005) with subsequent growth in weight during infancy. Children who were in the 75th percentile of the infant feeding scales had greater (P less than 0.05) attained weight and weight-for-age z scores and lower proportions of underweight compared with children who were in the 25th percentile of these scales. Our results provide strong evidence for the positive effects of following the current infant feeding recommendations on growth of infants and young children. Intervention programs should strive to improve conditions for enhancing current infant feeding recommendations, particularly in low-income countries. (author's)
International Journal of Tuberculosis and Lung Disease. 2008 Jan; 12(1):108-110.The information provided in the guidelines of the World Health Organization and the International Union Against Tuberculosis and Lung Disease for Ziehl-Neelsen staining is not practical on a number of points. The advice given here is meant to supplement the guidelines. It is based on experiments on and field experience of basic fuchsin stain and staining solutions.
Use of WHO clinical stage for assessing patient eligibility to antiretroviral therapy in a routine health service setting in Jinja, Uganda.
AIDS Research and Therapy. 2008 Feb 28; 5(4): p.In a routine service delivery setting in Uganda, we assessed the ability of the WHO clinical stage to accurately identify HIV-infected patients in whom antiretroviral therapy should be started. Among 4302 subjects screened for ART, the sensitivity and specificity (95% CI) of WHO stage III, IV against a CD4 count less than 200 x 10/6/l were 52% (50, 54%) and 68% (66, 70%) respectively. Plasma viral load was tested in a subset of 1453 subjects in whom ART was initiated. Among 938 subjects with plasma viral load of 100,000 copies or more, 391 (42%, 95% CI 39, 45%) were at WHO stage I or II. In this setting, a large number of individuals could have been denied access to antiretroviral therapy if eligibility to ART was assessed on the basis of WHO clinical stage. There is an urgent need for greater CD4 count testing and evaluation of the utility of plasma viral load prior to initiation of ART to accompany the roll-out of ART. (author's)
Acta Paediatrica. 2007 Aug; 96(8):1135-1138.The objectives were to evaluate the effectiveness of the World Health Organization (WHO) Essential Newborn Care (ENC) course in improving knowledge and skills of nurse midwives in low-risk delivery clinics in a developing country. The investigators identified the content specifications of the training material, developed both written and performance evaluations and administered the evaluations both before and after training clinical nurse midwives in Zambia. Based on these evaluations, both the knowledge and skills of the nurse midwives improved significantly following the course (from a mean of 65% correct pretraining to 84% correct post-training and from 65% to 77% correct on the performance and written evaluations, respectively). The ENC course written evaluation was validated and both tools allowed evaluation of the ENC course training. We found significant improvements in trainees' knowledge and skills in essential newborn care following the WHO ENC course; however, lack of basic resources may have limited the application of the ENC guidelines. Implementation of the ENC course should be undertaken in consideration with the local conditions available for newborn care. (author's)
Advocating the new WHO antenatal care model in a free maternity care setting in a developing country.
Tropical Doctor. 2008 Jan; 38(1):24-27.In a free maternity care setting the number of antenatal clients can be overwhelming for the obstetric staff. Using the World Health Organization (WHO) classifying form, most of the women can be triaged for the basic component of the new WHO antenatal care model. Our aim was to evaluate the risk status of pregnant women in a tertiary health institution providing free maternity care in Nigeria. We interviewed 1022 randomly selected clients using the WHO classifying form at our booking clinic over a 12-month period. The analysis was performed using the epi info statistical program. Seven hundred and sixty-five clients (74.9%) were found eligible for the basic component of the new antenatal care model. The associated risk in pregnancy increased with increasing parity. The basic component of the new WHO antenatal care model can safely be implemented in centres such as ours. (author's)
Inferiority of single-dose sulfadoxine-pyrimethamine intermittent preventive therapy for malaria during pregnancy among HIV-positive Zambian women.
Journal of Infectious Diseases. 2007 Dec 1; 196(11):1577-1584.The World Health Organization advocates 2-3 doses of sulfadoxine-pyrimethamine (SP) for intermittent preventive treatment of malaria (SP IPTp). The optimal number of doses and the consequences of singledose therapy remain unclear. Data were from a randomized, controlled study of human immunodeficiency virus-positive Zambian women comparing monthly versus 2-dose SP IPTp. We compared maternal and neonatal birth outcomes as a function of how many doses the mothers received (1 to >/= 4 doses). Of 387 deliveries, 34 received 1 dose of SP. Single-dose SP was significantly associated with higher proportions of maternal anemia, peripheral and cord blood parasitemia, infant prematurity, and low birth weight. SP conferred dose-dependent benefits, particularly in the transition from 1 to 2 doses of SP. Women randomized to the standard 2-dose regimen were much more likely to receive only 1 dose than were women randomized to monthly IPT (relative risk, 16.4 [95% confidence interval, 4.0-68.3]). Single-dose SP was a common result of trying to implement the standard 2-dose regimen and was inferior to all other dosing regimens. At a programmatic level, this implies that monthly SP IPTp may ultimately be more effective than the standard regimen by reducing the risk of inadvertently underdosing mothers. (author's)
Lancet. 2007 Sep 22; 370(9592):1030-1031.Young Kwang Chae and Jeong Hyun Yun query whether data from our randomised controlled trial of early, high-dose vitamin A supplementation (50 000 I given with the three diphtheria-tetanus-pertussis [DPT] vaccinations at 6, 10, and 14 weeks) in Gambian infants can contribute to the ongoing controversy about whether there might be harmful interactions between vitamin A supplementation and killed vaccines, particularly in girls. Several notes of caution are necessary. The observations by Benn and colleagues that have raised the concerns relate to excess mortality. Our trial is greatly underpowered for this endpoint. There were two postneonatal deaths in the high-dose group (n=99) and none in the standard WHO dose group (n=98). One male infant died of pneumonia and septicaemia at 7 months and one female of unknown causes at 3 months. This overall post-neonatal infant mortality rate equates to 10 in 1000, which is exceptionally low for this region and reflects the high level of monitoring and clinical care offered to the study participants. This point reduces the usefulness of our data in contributing to the debate. In response to Chae and Yun's query as to whether the vitamin A might have exacerbated DTP-related side-effects, we have reanalysed our data in an attempt to identify potentially life-threatening illnesses. In our original paper we restricted the analyses to clinic visits that elicited a treatment. Numerous non-critical conditions such as colds and skin rashes remained. We have now excluded these and repeated the analysis of potentially life-threatening events for the time window between the first DPT vaccination and vitamin A dose at 6 weeks and the first live vaccine (measles at 9 months). We analysed four diseases (malaria, diarrhoea, pneumonia, and septicaemia) separately and combined. There were 73 events in the high-dose group and 79 events in the WHO group. Owing to small numbers of events there were wide confidence intervals and no differences were significant. The closest to significance (pneumonia) was, if anything, lower in the high-dose group. In summary, our trial is under powered to contribute to this important debate, but we will be happy to contribute the data to future meta-analyses. (full text)
Lancet. 2007 Sep 22; 370(9592):1030.In their study of the effectiveness of early supplementation with high-dose vitamin A versus standard WHO protocol in Gambian mothers and infants, Momodou Darboe and colleagues report that the proportion of infants attending the clinic was greater in the high-dose vitamin A group than in the WHO protocol group in the first 6 months of life (p=0.018). However, they do not provide any detailed description of the chief complaints responsible for the differences in clinic attendance. It would be worthwhile to learn whether vitamin A supplementation exacerbated side-effects related to diphtheria-tetanuspertussis (DTP) vaccination, since both DTP vaccination and three out of five scheduled supplementations were done in the first 6 months of life. This finding is also interesting because it is consistent with the findings of previous studies that there is a null or detrimental effect of vitamin A supplementation on infant mortality when supplementation is given close to the DTP vaccination. These reportsare of note since the protective effect of vitamin A supplementation is well established when given with the BCG vaccine (at birth) and with the measles vaccine (after 6 months of life). As Darboe and colleagues mention, Benn and colleagues suggested that vitamin A supplementation could amplify the non-specific effects of vaccines, causing differing effects between killed (DTP) and live (BCG and measles) vaccines. We believe that the findings from this study that high-dose vitamin A supplementation around the time of DTP vaccines revealed no advantageous effect and even a negative effect on clinic visits only buttresses the immune modulatory role of vitamin A supplementation with routine vaccines. (full text)
Safety of switching to nevirapine-based highly active antiretroviral therapy at elevated CD4 cell counts in a resource-constrained setting [letter]
Journal of Acquired Immune Deficiency Syndromes. 2007 Aug 15; 45(5):598-600.The World Health Organization recommends the use of generic nevirapine (NVP)/efavirenz (EFV)-based highly active antiretroviral therapy (HAART) regimens as first-line therapy in the management of HIV in resource-limited settings. Initiating NVP-based HAART at elevated CD4 cell counts can lead to liver toxicity. Short-term risk of liver toxicity has been reported in men with CD4 counts greater than 400 cells/mL and in women with CD4 counts greater than 250 cells/mL. Hence, clinicians are advised to monitor the results of liver chemistry tests closely in the first 18 weeks of therapy because of the potential to develop life-threatening hepatic events. Mocroft et al showed that initiating NVP therapy at elevated CD4 levels may be safe for use in antiretroviral-experienced patients. Little is known about short-term adverse consequences and clinical outcome at elevated CD4 cell counts in a resource-limited setting. (author's)
Antiretroviral treatment and prevention of peripartum and postnatal HIV transmission in West Africa: Evaluation of a two-tiered approach.
PLoS Medicine. 2007 Aug; 4(8):e257.Highly active antiretroviral treatment (HAART) has only been recently recommended for HIV-infected pregnant women requiring treatment for their own health in resource-limited settings. However, there are few documented experiences from African countries. We evaluated the short-term (4 wk) and long-term (12 mo) effectiveness of a two-tiered strategy of prevention of mother-to-child transmission of HIV (PMTCT) in Africa: women meeting the eligibility criteria of the World Health Organization (WHO) received HAART, and women with less advanced HIV disease received short-course antiretroviral (scARV) PMTCT regimens. The MTCT-Plus Initiative is a multi-country, family-centred HIV care and treatment program for pregnant and postpartum women and their families. Pregnant women enrolled in Abidjan, Cote d'Ivoire received either HAART for their own health or short-course antiretroviral (scARV) PMTCT regimens according to their clinical and immunological status. Plasma HIV-RNA viral load (VL) was measured to diagnose peripartum infection when infants were 4 wk of age, and HIV final status was documented either by rapid antibody testing when infants were aged >/= 12 mo or by plasma VL earlier. The Kaplan-Meier method was used to estimate the rate of HIV transmission and HIV-free survival. Between August 2003 and June 2005, 107 women began HAART at a median of 30 wk of gestation, 102 of them with zidovudine (ZDV), lamivudine (3TC), and nevirapine (NVP) and they continued treatment postpartum; 143 other women received scARV for PMTCT, 103 of them with sc(ZDV+3TC) with single-dose NVP during labour. Most (75%) of the infants were breast-fed for a median of 5 mo. Overall, the rate of peripartum HIV transmission was 2.2% (95% confidence interval [CI] 0.3%-4.2%) and the cumulative rate at 12 mo was 5.7% (95% CI 2.5%-9.0%). The overall probability of infant death or infection with HIV was 4.3% (95% CI 1.7%-7.0%) at age week 4 wk and 11.7% (95% CI 7.5%-15.9%) at 12 mo. This two-tiered strategy appears to be safe and highly effective for short- and long-term PMTCT in resource-constrained settings. These results indicate a further benefit of access to HAART for pregnant women who need treatment for their own health. (author's)
[Implementation of World Health Organization guidelines for management of severe malnutrition in a hospital in Northeast Brazil] Implementacao do protocolo da Organizacao Mundial da Saude para manejo da desnutricao grave em hospital no Nordeste do Brasil.
Cadernos de Saude Publica. 2006 Mar; 22(3):561-570.To assess the implementation of WHO guidelines for managing severely malnourished hospitalized children, a case-series study was performed with 117 children from 1 to 60 months of age. A checklist was prepared according to steps in the guidelines and applied to each patient at discharge, thus assessing the procedures adopted during hospitalization. Daily spreadsheets on food and liquid intake, clinical data, prescribed treatment, and laboratory results were also used. 36 steps were evaluated, 24 of which were followed correctly in more than 80% of cases; the proportion was 50 to 80% for seven steps and less than 50% for five steps. Monitoring that required frequent physician and nursing staff bedside presence was associated with difficulties. With some minor adjustments, the guidelines can be followed without great difficulty and without compromising the more important objective of reducing case-fatality. (author's)
[Diagnosis and treatment of tuberculosis in children -- an updated review of an old problem] Diagnostico e terapeutica da tuberculose infantil -- uma visao atualizada de um antigo problema.
Jornal de Pediatria. 2002 Nov-Dec; 78 Suppl 2:S205-S214.Tuberculosis is still one of the most severe chronic diseases, especially in the world's poorest regions. Developing countries still have to face serious problems related to this endemic disease, in spite of the control programs they have implemented. The present study aims at updating the diagnosis and treatment of tuberculosis in three South American countries: Brazil, Chile and Argentina. Sources: Medline and Lilacs databases, official guidelines and consensuses of the three countries involved. Brazil, Chile and Argentina have guidelines based on the World Health Organization documents and on international consensuses. The standardization is similar between these countries, allowing the unification of language and favoring control measures. Within the Brazilian context, the new guidelines on the treatment of tuberculosis set out by the Ministry of Health are presented. Since each country had to make adaptations in an attempt to solve the epidemiological differences between them, the treatments against tuberculosis still present some discrepancies, such as the use of three or four drugs in some cases. (author's)
WHO HIV clinical staging or CD4 cell counts for antiretroviral therapy eligibility assessment? An evaluation in rural Rakai district, Uganda [letter]
AIDS. 2007 May 31; 21(9):1208-1210.The ability of WHO clinical staging to predict CD4 cell counts of 200 cells/µl or less was evaluated among 1221 patients screened for antiretroviral therapy (ART). Sensitivity was 51% and specificity was 88%. The positive predictive value was 64% and the negative predictive value was 81%. Clinical criteria missed half the patients with CD4 cell counts of 200 cells/µl or less, highlighting the importance of CD4 cell measurements for the scale-up of ART provision in resource-limited settings. (author's)
AIDS. 2007 May; 21(9):1205-1209.Thanks to the leadership of the World Health Organisation (WHO), and massive financial support from programmes such as the Global Fund and the US President's Emergency Plan for AIDS Relief (PEPFAR), the number of HIV-infected individuals accessing antiretroviral therapy (ART) in resource-limited settings has tripled from 2001 to 2005. An estimated 1.3 million HIV-infected individuals were on ART in 2005, representing 20% of those in need of treatment. Contrary to initial fears, numerous reports have now been published describing successful early outcomes in many ART patient populations. This is as a result of a number of factors including the fact that the majority of patients are treatment naive, that a low prevalence of primary drug resistance still prevails, and that adherence is better than expected, particularly in patients receiving treatment free of charge. (excerpt)
Geneva, Switzerland, World Health Organization [WHO], 2006. 37 p.Recommendations for birth spacing made by international organizations are based on information that was available several years ago. While publications by the World Health Organization (WHO) and other international organizations recommend waiting at least 2-3 years between pregnancies to reduce infant and child mortality, and also to benefit maternal health, recent studies supported by the United States Agency for International Development (USAID) have suggested that longer birth spacing, 3-5 years, might be more advantageous. Country and regional programmes have requested that WHO clarify the significance of the USAID-supported studies. With support from USAID, WHO undertook a review of the evidence. From 13 to 15 June 2005, 37 international experts, including the authors of the background papers and WHO and United Nations Children's Fund (UNICEF) staff , participated in a WHO technical consultation held at WHO Headquarters in Geneva. The objective of the meeting was to review evidence on the relationship between different birth-spacing intervals and maternal, infant and child health outcomes and to provide advice about a recommended interval. Six background papers were considered, along with one supplementary paper. Prior to the meeting, the six main papers were sent to experts for review. Thirty reviews were received: 10 from staff in international organizations and 20 from experts from 13 countries. The reviews were compiled and circulated to all meeting participants. At the meeting, the authors of the background papers presented their work, and selected discussants presented the consolidated set of comments, including their own observations. Together, the draft papers and the various commentaries formed the basis for the discussions of the evidence and for the recommendations made by the group at the meeting for spacing after a live birth and after an abortion. (excerpt)