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Bronchodilators and other medications for the treatment of wheeze-associated illnesses in young children.
[Unpublished] 1993. , [iv], 37 p. (WHO/ARI/93.29)The World Health Organization's (WHO) Programme for the Control of Acute Respiratory Infections (ARIs) reviewed the literature to provide this background paper on available drugs for the treatment of wheeze, the common causes of wheeze, and the pathogenesis and pathophysiology of asthma and bronchiolitis. It focuses on children in countries with a high infant mortality rate and where bacterial pneumonia is a major public health problem. When health providers manage wheeze in children, they must consider the fact that bacterial pneumonia is the leading cause of respiratory death in young children in developing countries. Even health providers in developed countries should consider bacterial pneumonia as the cause of wheeze. These providers tend to associate viral infections with wheeze. Many children with an ARI have combined viral and bacterial infections. About 50% of outpatient cases with confirmed Haemophilus influenzae and Streptococcus pneumoniae bacteremic pneumonia have wheeze. The first bronchodilator physicians should use to manage acute episodes of wheeze is a beta-2 adrenergic agent, e.g., salbutamol. Financial limitations will restrain the likelihood of long-term preventive therapy of acute episodes of wheeze caused by asthma. The best prophylactic options for asthma-related recurrent wheeze are sodium cromoglycate and inhaled corticosteroids. The leading therapeutic drugs for treating acute asthma include an inhaled beta-2 adrenergic agent with oral corticosteroids if needed. This treatment will achieve bronchodilatation and reversal of the airway narrowing caused by mucosal edema, by mucus hypersecretion, and by smooth muscle spasm. Long-term beta agonist therapy alone will not reduce airway inflammation. Allergen avoidance can also protect against recurrent wheeze in some cases. The annexes include tables on the presentation and dosage of bronchodilators and other drugs for the treatment of wheeze in children aged 0-5 and on bronchodilators and other drugs for the treatment of wheeze in the WHO list of essential drugs.
Geneva, Switzerland, WHO, Action Programme on Essential Drugs, 1993. ii, 87 p. (WHO/DAP/93.1; DAP Research Series No. 7)The WHO Action Program on Essential Drugs has developed and field tested a core set of drug use indicators capable of describing drug use patterns and prescribing behaviors in a country, region, or individual health facility. These indicators can be used to measure the impact of interventions designed to change prescribing practices, detect performance problems, and compare the performance of providers and institutions. Three categories have been developed: 1) prescribing indicators--average number of drugs per encounter, percentage of drugs prescribed by generic name, percentage of encounters with antibiotic prescribed, percentage of encounters with injection prescribed, and percentage of drugs prescribed from essential drugs list or formulary; 2) patient care indicators--average consultation time, average dispensing time, percentage of drugs actually dispensed, percentage of drugs adequately labelled, and patients' knowledge of correct dosage; and 3) facility indicators--availability of copy of essential drugs list or formulary and availability of key drugs. All data required to measure the core indicators can be derived from medical records or direct observation. Field testing in developing countries such as Nigeria and Tanzania found these measures both feasible to obtain and informative as first-level indicators. Also presented are descriptions of key issues related to study design and sampling, field methods, analysis, and follow up.
[Unpublished], 1993. Background paper for the WHO Advisory Group Meeting on STD Treatments, Geneva, Switzerland, February 18-19, 1993. 14 p.The introduction for this core list of essential drugs recommended for the treatment of sexually transmitted diseases (STDs) notes that STD drug selection for individual countries should be based on ongoing epidemiological studies of the population to be served and that STD treatment should afford a minimum 95% cure rate. Programs that use a cost justification to settle for a 85-95% cure rate may increase drug resistance and unrealistically depend upon the patient presenting for a second course of treatment. While the newer, effective drugs are expensive, they are less expensive than the alternative, which includes increased HIV transmission. The criteria used for the choice of drugs presented here were: high efficacy, lowest cost, availability, acceptable toxicity, and delayed or unlikely resistance development. Additional criteria seek, when possible, single dose, oral administration, and same treatment for pregnant women. The effect of concurrent HIV infection was not taken into consideration for the development of this list of drugs. Presumptive, syndrome-oriented treatment is recommended as more cost effective than even the most inexpensive diagnostic tests. The objectives of STD service provision can be met through appropriate case management, and STD services should be integrated in the primary health care system. Three tables in this report list 1) the selected drugs to be used in cases diagnosed etiologically, 2) those recommended in cases diagnosed syndromically, and 3) those recommended as alternative for some etiologies (with advantages and disadvantages noted). A table shows the ratios of the costs of World Health Organization (WHO) treatments as compared to treatments recommended in Gambia, Papua New Guinea, Honduras, Sri Lanka, Jamaica, and Zimbabwe. In all cases, the WHO recommended treatments are more expensive.
In: Annual technical report, 1992, [of the] World Health Organization [WHO]. Special Programme of Research, Development and Research Training in Human Reproduction. Geneva, Switzerland, WHO, 1993. 63-78. (WHO/HRP/ATR/92/93)This document contains the 1992 Annual Report of the Task Force on [the development of safe, effective, reversible, and acceptable] Methods for the Regulation of Male Fertility of the World Health Organization's Special Programme of Research, Development, and Research Training in Human Reproduction. In the area of hormonal methods, the Task Force is currently concentrating its research activities on 1) the evaluation of the functional capacity of sperm produced by men who have been suppressed to severe oligozoospermia, 2) the development of testosterone buciclate as an injectable method and as replacement therapy for hypogonadal men, and 3) the development of second generation progestogens and new gonadotrophin-releasing hormone antagonists as gonadotrophin suppressing agents. The safety and acceptability of hormonal methods for men remain a concern and topic of research activities. As an alternative to hormonal methods, the Task Force is continuing its search for a drug with a reversible, post-testicular action on the normal function of sperm stored in the epididymis. An ideal preparation would be quickly effective and quickly reversible. Collaborative studies in China also continue to investigate the antifertility action of pure compounds isolated from the plant species Tripterygium wilfordii. During 1992, the Task Force also continued its support of studies on three methods of vas occlusion: the no-scalpel method, a chemical sterilization method, and the polyurethane-plug. The efficacy and reversibility of silicone vas occlusion also remains under study. A training workshop on vas occlusion methods was attended by 32 participants in Indonesia in April 1992, and the safety of vasectomy continues to be monitored by the Task Force. This report notes the state of research on inhibin isolated from porcine follicular fluid and on the possibility of an immunization approach based on a vaccine against follicle-stimulating hormone. Two projects supported in 1992 sought to identify sperm surface proteins as putative immunogens. The report ends by recounting its investigator initiatives, its collaborative research programs, and its efforts in the area of information distribution. A summary describes 10 areas in which substantial progress was made during 1992.
AIDS LINK. 1993 Jun-Aug; (23):14.In Uganda, medical researchers at Makerere University in Kampala compared data on 280 HIV-seropositive people with HIV infection symptoms and CD4 lymphocyte counts less than 300, who took 150 IU/day oral interferon alpha, with 280 matched controls who took a placebo to learn whether low-dose oral interferon alpha benefits symptomatic HIV-infected patients. The study lasted 5 months. Mortality, progression of HIV infection, ability to care for oneself, symptoms, body weight, and CD4 lymphocyte counts were similar in both case and control groups. No one reverted to HIV seronegative. The findings of a smaller study in 1990 conducted by the Kenyan Medical Research Institute showed that low doses of oral interferon alpha began to alleviate AIDS symptoms within days after beginning treatment and completely alleviated symptoms in all patients within 8-10 weeks. The study reported that 18 patients reverted to HIV seronegativity. It did not have a control group. THe study lasted at least 10 weeks and consisted of 199 symptomatic and 5 asymptomatic patients. Based on the findings of the Uganda study, the World Health Organization has decided that low-dose oral interferon alpha does not help HIV-seropositive individuals and cannot rid the body of HIV.
HEALTH POLICY AND PLANNING. 1993 Dec; 8(4):349-59.In 1974, WHO established the Onchocerciasis Control Programme (OCP) in the Volta River Basin in West Africa which largely consisted of longterm aerial spraying of the blackfly (Simulum damnosum), thereby killing the larvae of Onchocerca volvulus, the causative agent of onchocerciasis. OCP has since added the microfilarial drug, ivermectin, to its control efforts. Prior to the establishment of the OCP, the participating countries understood that they would gradually assume operational responsibility for the OCP, the participating countries understood that they would gradually assume operational responsibility for OCP activities (devolution). Ivermectin's introduction changed the content of devolution to progressive national participation rather than operational responsibility. The national staff have access to manuals on skin-snip surveys, ivermectin distribution, and monitoring of adverse reactions to the drug which comprise the first step of devolution. The aim of devolution is weaning OCP activities from a single disease vertical operation to their integration into national primary health care (PHC) services. Yet PHC services essentially do not exist in many parts of the Volta River Basin. Plans for devolution of the OCP included appropriate training in PHC management, epidemiology, multidisease surveillance, community sensitization and participation, and research in integration of vertical programs into horizontal ones. Fiscal obstacles currently threaten the OCP. Other obstacles facing the OCP are reinvasion of the blackfly, symptoms recurring after temporary abatement, and deteriorating health, economic, and political conditions in the region. These constraints prevent the OCP from implementing its new managerial and diplomatic tasks successfully, unless the donor community can support it. The optimism present at the beginning of the OCP has waned mainly because it was based on a vertical program. The donor community and participating governments (not the OCP management) are needed to maintain the progress the OCP made against onchocerciasis and to keep it on the list of national health priorities.
SANTE-SALUD. 1993 Summer; (2):5-6.The World Health Organization (WHO) has coordinated and supported the eradication of malaria in various countries of the world since 1957. Unlike some countries in the temperate zone which have been successful in eradicating the disease, malaria remains endemic in tropical and subtropical countries. In 1969 WHO recommended that, although eradication should remain an ultimate goal, malaria control operations may form a transitional phase in countries where eradication does not appear feasible. Malaria control, however, remains an impossible goal in many countries where the disease is endemic. Plasmodium falciparum is the predominant malaria pathogen responsible for severe disease and death. It is estimated that 90% of all malaria cases worldwide occur in Africa, where the majority of people live in highly endemic or endemic prone areas. Only about 12% of the population lives in risk-free or low-risk areas. Between one-third and two-thirds of all cases of fever among children are associated with malaria, and in some parts of Africa the case-fatality rate is as high 31.9% for infants and 20.4% for children. The malaria situation in the African continent is rapidly changing due to variants of P. falciparum that are resistant to chloroquine; mosquitoes that are resistant to insecticides; movement of nonimmune individuals to endemic areas; increasing short-term travel patterns; and ecological reasons. Malaria is also appearing in previously free areas because of technological (agricultural) advances. Adult and pediatric dosages of antimalarial drugs are suggested for the treatment and prevention of P. falciparum malaria.
Recommendations for the management of sexually transmitted diseases. WHO Advisory Group Meeting on Sexually Transmitted Diseases Treatments, Geneva, 18-19 February 1993. Draft.
[Unpublished] 1993 May 11. 54 p. (WHO/GPA/STD/93.1)Sexually transmitted diseases (STD) are problems of global scale with significant and enormous health, economic, and social consequences. These consequences are extremely expensive in monetary terms and include but are not limited to infertility, fetal wastage, neonatal, and infant infections, ectopic pregnancy. anogenital cancer, and death. Being infected with an STD also increases one's risk of contracting and transmitting HIV through sexual intercourse. While measures are urgently needed to treat STDs, the antimicrobial resistance of several sexually transmitted pathogens has increased. New agents capable of treating infections with resistant strains, however, tend to be too expensive for use in some areas where they are really needed. the introduction to this text discusses the rationale of standardized treatment recommendations, principles of good case management, syndromic management, and treatment. High efficacy, low cost, acceptable toxicity and tolerance, the unlikely development or delay of organism resistance, single dose and oral administration, and the absence of contraindications for pregnant and lactating women are put forth as national program criteria for selecting drugs against STDs. Therapeutic recommendations for STD-associated syndromes and for specific infections are offered. Discussions underlying recommendations, practical considerations in case management, the management of sexual partners and partner notification, children and STDs, a list of recommended drugs, and a list of participants are included.
Geneva, Switzerland, WHO, 1993 Nov 16. 2 p. (Press Release WHO/90)In a World Health Organization (WHO) Global Program on AIDS (GPA) meeting held November 11-13, 1993, it was decided to launch a research effort to develop a safe antimicrobial agent capable of inactivating HIV in a woman's vagina. The ideal microbicide will be in the form of a foam or gel to be applied in the vagina; will prevent HIV from attaching itself to the lining of the vagina; will protect against other sexually transmitted diseases; and will not impair fertility. While many existing contraceptive spermicides have been shown to confer protection against HIV in the test tube, no evidence exists to show that they protect against HIV in actual sexual intercourse. Some studies have even suggested that their use may damage the vagina and increase the risk of HIV transmission, especially when used frequently and in high doses. Even though condom use and safer sex practices are widely promoted along with steps to control other sexually transmitted diseases, these measures are inadequate against the transmission of HIV. Where the male-female transmission of HIV is concerned, the Executive Director of the WHO/GPA argues that a safe, effective microbicide is needed for women to use especially when they may be at a loss to negotiate partners' condom use. Further information on coordination efforts may be obtained by contacting the WHO GPA Public Information Officer in Geneva.
WORLD HEALTH FORUM. 1993; 14(4):390-5.About 80% of the world's people depend largely on traditional plant-derived drugs for their primary health care (PHC). Medicinal plants serve as sources of direct therapeutic agents and raw materials for the manufacture of more complex compounds, as models for new synthetic products, and as taxonomic markers. Some essential plant-derived drugs are atropine, codeine, morphine, digitoxin/digoxin, and quinine/artemisinin. Use of indigenous medicinal plants reduces developing countries' reliance on drug imports. Costa Rica has set aside 25% of its land to preserve the forests, in part to provide plants and other materials for possible pharmaceutical and agricultural applications. The Napralert database at the University of Illinois establishes ethnomedical uses for about 9200 of 33,000 species of monocotyledons, dicotyledons, gymnosperms, lichens, pteridophytes, and bryophytes. Sales of crude plant drugs during 1985 in China equaled US$1400 million. Even though many people use medicinal plants, pharmaceutical firms in industrialized nations do not want to explore plants as sources of new drugs. Scientists in China, Germany, and Japan are doing so, however. Screening, chemical analysis, clinical trials, and regulatory measures are needed to ensure safety of herbal medicines. WHO has hosted interregional workshops to address methodologies for the selection and use of traditional medicines in national PHC programs. WHO, the International Union for the Conservation of Nature and Natural Resources, and the World Wide Fund for Nature developed guidelines for conservation of medicinal plants. Their 2-pronged strategy includes prevention of the disappearance of forests and associated species and the establishment of botanical gardens. WHO's Traditional Medicine Programme hopes that people will apply known and effective agroindustrial technologies to the cultivation and processing of medicinal plants and the production of herbal medicines and the creation of large-scale networks for the distribution of seeds and plants.
BMJ. British Medical Journal. 1993 Nov 27; 307(6916):1375-6.The World Health Organization (WHO), at a meeting in Geneva in November 1993, launched a campaign that will coordinate efforts of the pharmaceutical industry, academic research institutes, and drug regulatory bodies to find a vaginal antiviral agent that will either inactivate the human immunodeficiency virus (HIV) or prevent its attachment to vaginal cells, without harming the genital tract or killing sperm. Spermicides, such as nonoxynol 9, which kill HIV in test tubes may increase HIV transmission by harming the vaginal lining. However, this may be due to the carrier substance. Clinical research, using a protocol designed by the WHO and international regulatory authorities, will begin examining existing vaginal microbicides. Other candidates include sulphated polysaccharides and reverse transcriptase inhibitors. Included are comments by Dr. Michael Merson and Prof. Don Jefferies. The meeting was organized by the United Kingdom's Medical Research Council and Department of Health.
Approaching STDs and AIDS on a global scale. Interview with Peter Piot, Associate Director, Sexually Transmitted Diseases, Global Programme on AIDS (GPA), World Health Organisation (WHO).
AIDS BULLETIN. 1993 Jul; 2(2):4-5.Dr. Piot became involved with the World Health Organization (WHO) Global Program on AIDS (GPA) through his early involvement as Chairman of the WHO Steering Committee on the Epidemiology of AIDS. He responds to questions about the HIV pandemic. Although researchers realized early on that HIV could be transmitted sexually and suspected that condom use could confer protection against HIV infection as it does against other STDs such as gonorrhea and syphilis, only minimal light was shed to the public on the association of HIV with STDs. The delay in clearly pointing out the association stemmed from professionals' lack of desire to further stigmatize HIV/AIDS by designating it as a STD. Furthermore, many Western hematologists had little interest in STDs, and STD control in many countries tended to be coercive. Regarding the risk of HIV infection, Dr. Piot notes that the presence of a genital ulcer caused by syphilis, chancroid, or herpes increases one's risk 10-20-fold; risk increases 3- to 4-fold where gonorrhea or chlamydia are present. Acknowledging the association between STDs and the risk of contracting HIV and understanding the need to control STDs for the prevention of HIV/AIDS, the WHO's STD program was brought under the auspices of and integrated with the GPA. People, and especially women, who may present at STD clinics for treatment are prime candidates for much needed help in avoiding HIV infection; Dr. Piot notes that unlike men, many women do not realize they are infected with an STD until complications develop. Dr. Piot's recent appointment at GPA means the WHO will increase its focus upon the prevention and treatment of STDs. The WHO favors an integrated program approach. Additionally, the GPA plans to develop a short-list of recommended drugs for treating STDs and hopes to develop ways for developing countries to buy them affordably with help from UNICEF and the World Bank. Finally, Dr. Piot explains that, with some exceptions, the prevalence of STDs is lower in developed countries and, therefore, less of a prevention priority.
Tuberculosis control and research strategies for the 1990s: memorandum from a WHO meeting] Estrategias de control e investigacion de la tuberculosis en el decenio de 1990: memorandum de una reunion de la OMS.
BOLETIN DE LA OFICINA SANITARIA PANAMERICANA. 1993 May; 114(5):429-36.Mycobacterium tuberculosis, the pathogenic agent causing tuberculosis, is carried by one third of the world's population. Some 8 million new clinical cases of tuberculosis are diagnosed annually. Pulmonary tuberculosis is the most infectious clinical manifestation, tubercular meningitis is the principal form causing infant death, and tuberculosis may affect various other organs. Untreated tuberculosis has a fatality rate of over 50%. Chemotherapy greatly reduces the rate, but some 2.9 million persons die of tuberculosis each year because of the inadequacy of many national treatment programs. Tuberculosis is the most important cause of death from a single infectious agent in the world. An estimated one fourth of avoidable deaths to adults aged 15-59 in the developing world are attributed to tuberculosis. Tuberculosis is especially prevalent in Africa south of the Sahara and in Southern Asia. Two new obstacles threaten to aggravate the problem: the HIV epidemic and drug resistance. HIV infection is the most serious risk factor yet identified because it converts latent tuberculosis infection into active disease. In Africa almost half of all persons seropositive for HIV are also infected with tuberculosis. Ineffective treatment programs favor the formation of pharmacoresistent strains, and drug resistance has become a major problem in various parts of the world. Effective measures exist to control tuberculosis. Although it does little to protect adults against infectious forms of tuberculosis, the BCG vaccine prevents the most lethal forms. Coverage of infants the BCG is over 80% in the developing world as a whole, but under 60% in sub-Saharan Africa. Chemotherapy can cure almost all cases and convert cases with positive sputum into noninfectious cases, reducing transmission. Normal treatment must be administered over at least 12 months, straining the resources of health services in developing areas. The introduction of a shorter therapy has revolutionized treatment in some national programs, which have achieved cure rates of 80% in new patients. Evaluation of some national programs has demonstrated that well managed short duration chemotherapy is cost effective even under difficult conditions. Progress in controlling tuberculosis has been slower than expected in developing countries because of excessive optimism about the prospects for quick declines as occurred in the industrialized countries, and because of lack of resources. A well organized and vigorous international effort under World Health Organization leadership is required to bring the tuberculosis problem to the world's attention, mobilize assistance on a wide scale, and provide information and direct support to national programs. Research will be needed to adapt proven control techniques to local cultures, develop new drugs, shorten treatment regimens, and encourage greater patient compliance.
Lancet. 1993 Jan 30; 341(8840):304-5.WHO provides health workers with guidelines for case management strategies for children with acute respiratory infections (ARI) to reduce child mortality. Its clinical case definitions for ARI do not assume that a child has only 1 disease, however. The guidelines also help health workers diagnose and treat other conditions in those children with fever who live in malaria endemic areas such as Africa where Plasmodium falciparum is transmitted. They also guide health workers on how to refer children with danger signs of severe malaria, meningitis, or severe malnutrition to the hospital. Based on studies in Malawi and the Gambia, WHO 1st recommended using co-trimoxazole and chloroquine to treat children with malaria who have a cough and fever and who are breathing quickly. Experts at a WHO meeting in April 1991 now recommend 5 days of co-trimoxazole alone to treat such children in areas where malaria is moderately to highly endemic, the leading parasite is P. falciparum, and it is sensitive to sulfadoxine/pyrimethamine. WHO has incorporated this change into its clinical guidelines and training materials. The guidelines emphasize that local health workers must adapt the guidelines for children with concomitant malaria as necessary to guarantee appropriate identification and referral of children with severe anemia. WHO and UNICEF are developing a fully integrated training package to address case management of children with pneumonia, diarrhea, malaria, measles, and/or malnutrition. This package also instructs health workers on how to manage middle ear inflammation, anemia, meningitis, and acute ocular problems from measles and vitamin A deficiency. WHO and UNICEF hope to have this integrated training package available in late 1993.