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Improving control of African schistosomiasis: towards effective use of rapid diagnostic tests within an appropriate disease surveillance model.
Transactions of the Royal Society of Tropical Medicine and Hygiene. 2009 Apr; 103(4):325-32.Contemporary control of schistosomiasis is typically reliant upon large-scale administration of praziquantel (PZQ) to school age children. Whilst PZQ treatment of each child is inexpensive, the direct and indirect costs of preventive chemotherapy for the whole school population are more substantive and, at the national level where many schools are targeted, maximising cost effectiveness and the health impact are essential requirements for ensuring longer-term sustainability (i.e. >5 years). To this end, the WHO has issued a set of treatment guidelines, inclusive of re-treatment schedules, such that, where possible, treatment decisions by school are based upon local disease prevalence as determined by parasitological and/or questionnaire methods. As each diagnostic method has known shortcomings, presumptive treatment of at-risk schools may initially be preferred, especially if the existing infrastructure for disease surveillance is poor. It is against this background of school-based preventive chemotherapy that a rapid diagnostic test (RDT) for schistosomiasis is most urgently needed, not only to improve initial disease surveillance but also to focus drug delivery better through time. In this paper, the development, evaluation and application of selected diagnostic tests are reviewed to identify barriers that impede progress, foremost of which is that a new disease surveillance and evaluation model is required where the in-country price of each RDT ideally needs to be less than US$1 to be cost effective both in the short- and long-term perspective.
Geneva, Switzerland, WHO, 2004 Jan. 118 p. (Integrated Management of Adolescent and Adult Illness [IMAI] No. 1; WHO/CDS/IMAI/2004.1)The IMAI guidelines are aimed at first-level facility health workers and lay providers in low-resource settings. These health workers and lay providers may be working in a health centre or as part of a clinical team at the district clinic. The clinical guidelines have been simplified and systematized so that they can be used by nurses, clinical aids, and other multi-purpose health workers, working in good communication with a supervising MD/MO at the district clinic. Acute Care presents a syndromic approach to the most common adult illnesses including most opportunistic infections. Instructions are provided so the health worker knows which patients can be managed at the first-level facility and which require referral to the district hospital or further assessment by a more senior clinician. Preparing first-level facility health workers to treat the common, less severe opportunistic infections will allow them to stabilize many clinical stage 3 and 4 patients prior to ARV therapy without referral to the district. (excerpt)
In: Health and disease in developing countries, edited by Kari S. Lankinen, Staffan Bergstrom, P. Helena Makela, Miikka Peltomaa. London, England, Macmillan Press, 1994. 281-6.The World Health Organization (WHO) and UNICEF are collaborating in the development of an integrated approach to the management of the sick child. Acute respiratory infections, diarrhea, malaria, measles, and malnutrition cause 7 out of 10 deaths in children under 5 years of age in developing countries. Integrated management means effective, simple, and affordable treatments for all the leading killers of young children. Health workers using such guidelines can prevent serious disabilities resulting from measles and vitamin A deficiency. The integrated clinical guidelines rely on detection of cases based on simple clinical signs and empirical treatment without laboratory tests. They are based on a few essential drugs for outpatient use: oral rehydration salts, an antibiotic (co-trimoxazole), an oral antimalarial, vitamin A, iron tablets, and oral antipyretic (paracetamol), an antibiotic eye ointment, and gentian violet. Parenteral antibiotic and antimalarial drugs and intravenous fluids are needed for severely ill children before referral to hospital. The integrated clinical guidelines for sick children 2 months to 5 years old are summarized on 3 case management charts: 1) assess and classify the sick child 2 months to 5 years old; 2) treat the child; and 3) advise the mother. The implementation of case management will entail the use of several key preventive interventions: immunization, promotion of breast feeding, improved infant feeding, and vitamin A. All children with measles are given vitamin A. Those with severe pneumonia, stridor when calm, corneal clouding, or severe malnutrition are referred to hospital. Mothers are taught to manage mouth ulcers and conjunctivitis at home and to administer antibiotics for otitis media and pneumonia. Wherever Plasmodium falciparum is sensitive to sulfadoxine-pyrimethamine, fast breathing and fever can be treated with co-trimoxazole alone. The WHO prepared a report in 1993 demonstrating that management of the sick child in low-income countries averts 14% of the disease burden at only $ 1.60 per capita annually.
[The Collaborating Centers of the World Health Organization and AIDS: report of a meeting of the World Health Organization] Les Centres Collaborateurs de l'OMS et le SIDA: memorandum d'une reunion de l'OMS.
BULLETIN OF THE WORLD HEALTH ORGANIZATION. 1986; 64(1):63-8.The World Health Organization (WHO) meeting on acquired immune deficiency syndrome (AIDS) held in Geneva in September 1985 stressed the importance of the WHO collaborating centers in the worldwide struggle against AIDS. The network of collaborating centers was established after and April 1985 WHO meeting to facilitate international cooperation in training of laboratory personnel, supplying reference reactives, evaluating diagnostic tests, and organizing activities to establish the natural history of the disease in different parts of the world. The AIDS virus is transmitted during sexual intercourse, by parenteral exposure to blood or contaminated blood products, or from the mother to the infant during the perinatal period. In the US and Western Europe, over 90% of victims are still homosexual and bisexual men, intravenous drug users, and their sexual partners, but in many developing countries heterosexuals with active sex lives are the main victims. There are no indications that the virus is spread by casual contact or by insect vectors. Health authorities of all countries should establish surveillance programs to measure the extent of AIDS infection. A precise case definition including only the most serious manifestations of the disease should be used. The US Centers for Disease Control definition has been approved for countries with appropriate diagnostic capabilities. Only immunological diagnostic methods are practical for large scale routine testing. Radioimmunological and immunoenzymatic titers are the most frequently used routine testing procedures. They are very sensitive, but because of the possibility of false positive results, confirmation using another test is needed for individuals belonging to low risk populations. The Western blot or other immunoblotting tests are most often used for confirmation. Progress in laboratory diagnosis would be furthered if international reference standards, simpler diagnostic tests, and other measures were made avaliable. Until drugs capable of preventing and treating AIDS become available, prevention will depend mainly on reduction of risks based on information and education. Cases of AIDS spread by blood transfusion can be eliminated by excluding donors belonging to high-risk groups and by testing the blood for antibodies before transfusion. Reuse of nonsterile needles and syringes should be absolutely avoided. Despite efforts to identify an effective agent for treatment of AIDS, no substance has been found as yet that supplies more than a transitory arrest of viral replication. Interferon has been shown to be effective against Kaposi's sarcoma. New antiviral agents should be careful studied in conformity with accepted protocols for drug evaluation. Numerous attempts to develop an anti-AIDS vaccine are underway. The heterogeneity of the virus poses a significant problem. Several specific recommendations for its 1986-87 program were made to further the role of the WHO as a centraL clearinghouse for AIDS information.
[Record of the second meeting of the WHO Collaborating Centers on AIDS] Deuxieme reunion des centres collaborateurs de l'OMS pour le SIDA: memorandum d'une reunion de l'OMS.
BULLETIN OF THE WORLD HEALTH ORGANIZATION. 1986; 64(2):221-31.Participants at the 2nd meeting of World Health Organization (WHO) collaborating centers on AIDS (acquired immune deficiency syndrome) held in Geneva in December 1985 reported on progress since the 1st meeting in September 1985 and made a number of recommendations for future action in the areas of information, education, and prevention; reference reactants and tests of anti-HTLV-III antibodies; epidemiologic evaluation; and research on vaccines and antiviral agents. It was recommended that ministries of health, education, and social services provide the public with timely and accurate information on AIDS, that physicians, nurses, and similar personnel inform the ill and the public about AIDS and its prevention, and that school age children and young people be informed about AIDS and how to avoid infection. Systems of registration of AIDS cases should be implemented in order to provide the WHO and member states with data on the international level. Standardization and availability of serologic tests is also required. Instructions for avoiding infection should be provided for health personnel and others caring for AIDS patients, for individuals providing personal services to the public, and to ensure adequate methods of disinfection. Instructions for preventing AIDS should discuss sexual and parenteral transmission as well as perinatal transmission. Specific recommendations for education and family placement for children with AIDS have already been published. Instructions should be provided for prisons and similar estabilshments. Requiring international travellers to provide certificates attesting to their AIDS-free status is not justified as a preventive measure. The significant existing demand for reference reactants including human serums with anit-HTLV-III antibodies and controls is being addressed by several institutes in different countries, but it would be premature to furnish reference reactants other than serums. The WHO collaborating centers should furnish materials for purposes of training in diagnostic techniques. Existing tests for diagnosis and confirmation should be imporved and new tests should be developed, with particular attention to simple methods appropriate for use in developing countries. It will be necessary to establish international biological standards for the HTLV-III virus, but the required specifications are not yet known. Technical cooperation and epidemiological evaluation must be planned separately, based on the different prevalence of infections and technical expertise of different countries. A clinical definition of AIDS is needed for countries lacking resources needed to apply the Centers for Disease Control/WHO definition. Surveillance methods and laboratories can be installed with WHO assistance, to help evaluate the extent of AIDS infection in different countries. Later technical cooperation in the areas of continued surveillance and laboratory capacities will depend on results of the initial evaluation in each country. Research is currently underway in several countries of possible vaccines and drugs. Careful preclinical studies should be done to evaluate the toxicity of an agent before clinical studies are conducted. Convenient animal models should be sought for future research. 3 annexes to this report specify methods of disinfection; general principles of preventing transmission of the AIDS virus through parenteral exposure or following donation of organs, sperm, or other tissue; and a proposed definition of clinical cases of AIDS.
In: Wood C, Rue Y, ed. Health policies in developing countries. London, England, The Royal Society of Medicine, 1980. 167-72. (Royal Society of Medicine. International Congress and Symposium Series; No. 24)Research is the tool which can help accelerate control of filariasis including the most important, river blindness and elephantiasis. The principles for control include eliminating the vectors and changing the way of life of the people. However these methods do not take into account the different ecologies of the land, cultures of the people and technical and political differences of the endemic areas. The WHO Onchocerciasis Control Program in the Volta Basin has been highly successful, but reinvasion of vectors is possible and there is concern that unacceptable levels of pollution will occur. Several successful limited programs of control are cited, but the absence of suitable drugs to kill the parasites is evident. One of the areas of research is centering on the characterization of the parasites and their vectors. More studies of isoenzyme markers are needed to distinguish different species of filarial parasites. An important advance in the diagnosis of filariasis has been the application of membrane filtration techniques for detecting light infection. Some of the current vector research is noted. This is particularly important because the main vectors of filariasis in Africa are also the main vectors of malaria. WHO is encouraged to stimulate collaborative research in this area. Chemotherapy is currently the most encouraging aspect of research. WHO is supporting 4 major centers where old and new filaricides are being evaluated. Some experiments are indicating the possibility that resistance to the disease can be stimulated by using irradiated larvae as appear in a cat model. Testing is now underway in a bovine onchocerciasis model. The new laboratory developments must continue so they can be applied clinically.
World Health Organization Technical Report Series. 1982; (674):1-75.The World Health Organization (WHO) Scientific Group on Treponemal Infections met in Geneva during October 1980 with the objective of reviewing all aspects of the treponematoses and of providing updated standards and guidelines for their diagnosis, treatment, and control. WHO has always attached great importance to the sexually transmitted diseases and to the nonvenereal endemic treponematoses, because of the heavy burden they impose on both the individual and the society. This report of the WHO Scientific Group on Treponemal Infections covers the following: epidemiological aspects (syphilis and nonvenereal treponematoses); clinical aspects; laboratory aspects (diagnosis, microcsopic tests used to identify treponemes, serological tests for the detection of antibodies in individuals with treponemal infections, and diagnosis of neurosyphilis by cerebrosponal fluid (CSF) examination); management aspects; control aspects; and research aspects. The diagnosis of a primary or secondary treponemal infection should be established by identification of the causative organisms using darkfield microscopy. A reliable nontreponemal serological test has confirmatory value in such circumstances. A combination of nontreponemal and treponemal serological tests is essential for the diagnosis of all other stages of syphilis. In clinical outposts where nonmedical health workers deliver health care, simple clinical algorithm may help to ensure that genital ulcers and other clinical manifestations of treponemal infections are treated immediately with adequate doses of suitable penicillin preparations. After nearly 40 years, penicillin remains the drug of choice in the treatment of all forms of syphilis. The following were among the recommendations made by the Scientific Group on Treponemal Infection: the following categories should be used in reporting cases of syphilis, i.e., primary and secondary infections, early latent infections, late latent infections, symptomatic late infections, congenital infections in patients under 2 years of age, and congenital infections in patients 2 years of age and older; improved teaching should have the highest priority, particular attention being directed to congenital syphilis; darkfield microscopy should be the preferred diagnostic test for infectious treponemal disease; physicians should be cautioned never to use less than the recommended dosages of penicillin; practical guidelines should be established on the efficient epidemiological analysis of the extent of syphilis, the logistics of syphilis control programs, and the indications for, and application of, various control strategies; and the highest priority should be given to the prevention of congenital syphilis.