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Program Implementation of Option B+ at a President's Emergency Plan for AIDS Relief-Supported HIV Clinic Improves Clinical Indicators But Not Retention in Care in Mbarara, Uganda.
AIDS Patient Care and STDs. 2017 Aug; 31(8):335-341.2013 WHO guidelines for prevention of mother to child transmission recommend combination antiretroviral therapy (ART) for all pregnant women, regardless of CD4 count (Option B/B+). We conducted a retrospective analysis of data from a government-operated HIV clinic in Mbarara, Uganda before and after implementation of Option B+ to assess the impact on retention in care. We limited our analysis to women not on ART at the time of their first reported pregnancy with CD4 count >350. We fit regression models to estimate relationships between calendar period (Option A vs. Option B+) and the primary outcome of interest, retention in care. One thousand and sixty-two women were included in the analysis. Women were more likely to start ART within 6 months of pregnancy in the Option B+ period (68% vs. 7%, p < 0.0001) and had significantly greater increases in CD4 count 1 year after pregnancy (+172 vs. -5 cells, p < 0.001). However, there was no difference in the proportion of women retained in care 1 year after pregnancy (73% vs. 70%, p = 0.34). In models adjusted for age, distance to clinic, marital status, and CD4 count, Option B+ was associated with a nonsignificant 30% increased odds of retention in care at 1 year [adjusted odds ratio (AOR) = 1.30, 95% CI 0.98-1.73, p = 0.06]. After transition to an Option B+ program, pregnant women with CD4 count >350 were more likely to initiate combination therapy; however, interventions to mitigate losses from HIV care during pregnancy are needed to improve the health of women, children, and families.
Implementation effectiveness of revised (post-2010) World Health Organization guidelines on prevention of mother-to-child transmission of HIV using routinely collected data in sub-Saharan Africa: A systematic literature review.
Medicine. 2017 Oct; 96(40):e8055.BACKGROUND: To synthesize and evaluate the impact of implementing post-2010 World Health Organization (WHO) prevention of mother-to-child transmission (PMTCT) guidelines on attainment of PMTCT targets. METHODS: Retrospective and prospective cohort study designs that utilized routinely collected data with a focus on provision and utilization of the cascade of PMTCT services were included. The outcomes included the proportion of pregnant women who were tested during their antenatal clinic (ANC) visits; mother-to-child transmission (MTCT) rate; adherence; retention rate; and loss to follow-up (LTFU). RESULTS: Of the 1210 references screened, 45 met the inclusion criteria. The studies originated from 14 countries in sub-Saharan Africa. The highest number of studies originated from Malawi (10) followed by Nigeria and South Africa with 7 studies each. More than half of the studies were on option A while the majority of option B+ studies were conducted in Malawi. These studies indicated a high uptake of human immunodeficiency virus (HIV) testing ranging from 75% in Nigeria to over 96% in Zimbabwe and South Africa. High proportions of CD4 count testing were reported in studies only from South Africa despite that in most of the countries CD4 testing was a prerequisite to access treatment. MTCT rate ranged from 1.1% to 15.1% and it was higher in studies where data were collected in the early days of the WHO 2010 PMTCT guidelines. During the postpartum period, adherence and retention rate decreased, and LTFU increased for both HIV-positive mothers and exposed infants. CONCLUSION: Irrespective of which option was followed, uptake of antenatal HIV testing was high but there was a large drop off along later points in the PMTCT cascade. More research is needed on how to improve later components of the PMTCT cascade, especially of option B+ which is now the norm throughout sub-Saharan Africa.
Swiss Medical Weekly. 2017 Jun 21; 147:w14432.PURPOSE: Sayana(R) was introduced as the first depot medroxyprogesterone acetate-containing contraceptive that is administered via subcutaneous injection. Within 10 months, the Regional Pharmacovigilance Centre (RPVC) Zurich received several anonymous reports of serious local reactions after Sayana(R) administration. In this retrospective study, individual case safety reports (ICSRs) on local adverse drug reactions (ADRs) related to Sayana(R) were analysed from the WHO pharmacovigilance database. METHODS: International, national and regional ICSRs during Sayana(R) administration up to 1 January 2016 were examined. Data on ADRs were retrieved from the WHO Global Database VigiBase. Demographic data, drug administration information, duration of Sayana(R) treatment, latency time of the ADR, and its course, severity and outcomes were analysed. RESULTS: Worldwide, 398 ICSRs after Sayana(R) use were registered in the database. We identified 20 reported terms that were potentially used to describe a persistent lipodystrophy. When only cases containing one or more of these 20 reported terms were selected, 323 (81.2%) international ICSRs remained for analysis. Of those, 91.6% (n = 296) were categorised as serious. The majority of the reactions (n = 193, 54.4%) did not recover. In the 67 Swiss ICSRs, 77 ADRs were reported using 10 different terms including severe or persistent local reactions like lipodystrophy, atrophy or fat necrosis. Thirty-two patients (47.7%) did not recover. All 11 regional cases reported to the RPVC Zurich were categorised as serious ADRs. For the majority of the patients (n = 7, 63.6%) the interval between the application of Sayana(R) and development of the lipodystrophy was between 2 and 4 months. Most of the reactions were irreversible (n = 9, 81.8%). One patient underwent plastic surgery for artificial infill of the dent. CONCLUSIONS: Persistent local injection site reactions such as lipodystrophy, fat tissue necrosis or atrophy occur frequently after subcutaneous Sayana(R) use. These adverse drug reactions were recently integrated in the Swiss product information. Physicians and patients should be informed and advised about these potentially irreversible effects.
Towards the WHO target of zero childhood tuberculosis deaths: an analysis of mortality in 13 locations in Africa and Asia.
International Journal of Tuberculosis and Lung Disease. 2013 Dec; 17(12):1518-23.SETTING: Achieving the World Health Organization (WHO) target of zero paediatric tuberculosis (TB) deaths will require an understanding of the underlying risk factors for mortality. OBJECTIVE: To identify risk factors for mortality and assess the impact of human immunodeficiency virus (HIV) testing during anti-tuberculosis treatment in children in 13 TB-HIV programmes run by Medecins Sans Frontieres. DESIGN: In a retrospective cohort study, we recorded mortality and analysed risk factors using descriptive statistics and logistic regression. Diagnosis was based on WHO algorithm and smear microscopy. RESULTS: A total of 2451 children (mean age 5.2 years, SD 3.9) were treated for TB. Half (51.0%) lived in Asia, the remainder in sub-Saharan Africa; 56.0% had pulmonary TB; 6.4% were diagnosed using smear microscopy; 211 (8.6%) died. Of 1513 children tested for HIV, 935 (61.8%) were positive; 120 (12.8%) died compared with 30/578 (5.2%) HIV-negative children. Risk factors included being HIV-positive (OR 2.6, 95%CI 1.6-4.2), age <5 years (1.7, 95%CI 1.2-2.5) and having tuberculous meningitis (2.6, 95%CI 1.0-6.8). Risk was higher in African children of unknown HIV status than in those who were confirmed HIV-negative (1.9, 95%CI 1.1-3.3). CONCLUSIONS: Strategies to eliminate childhood TB deaths should include addressing the high-risk groups identified in this study, enhanced TB prevention, universal HIV testing and the development of a rapid diagnostic test.
Completion of the modified World Health Organization (WHO) partograph during labour in public health institutions of Addis Ababa, Ethiopia.
Reproductive Health. 2013; 10:23.BACKGROUND: The World Health Organization (WHO) recommends using the partograph to follow labour and delivery, with the objective to improve health care and reduce maternal and foetal morbidity and death. The partograph consists of a graphic representation of labour and is an excellent visual resource to analyze cervix, uterine contraction and foetal presentation in relation to time. However, poor utilization of the partograph was found in the public health institutions which reflect poor monitoring of mothers in labour and/or poor pregnancy outcome. METHODS: A retrospective document review was undertaken to assess the completion of the modified WHO partograph during labour in public health institutions of Addis Ababa, Ethiopia. A total of 420 of the modified WHO partographs used to monitor mothers in labour from five public health institutions that provide maternity care were reviewed. A structured checklist was used to gather the required data. The collected data were analyzed using SPSS version 16.0. Frequency distributions, cross-tabulations and a graph were used to describe the results of the study. RESULTS: All facilities were using the modified WHO partograph. The correct completion of the partograph was very low. From 420 partographs reviewed across all the five health facilities, foetal heart rate was recorded into the recommended standard in 129(30.7%) of the partographs, while 138 (32.9%) of cervical dilatation and 87 (20.70%) of uterine contractions were recorded to the recommended standard. The study did not document descent of the presenting part in 353 (84%). Moulding in 364 (86.7%) of the partographs reviewed was not recorded. Documentation of state of the liquor was 113(26.9%), while the maternal blood pressure was recorded to standard only in 78(18.6%) of the partographs reviewed. CONCLUSIONS: This study showed a poor completion of the modified WHO partographs during labour in public health institutions of Addis Ababa, Ethiopia. The findings may reflect poor management of labour or simply inappropriate completion of the instrument and indicate the need for pre-service and periodic on-job training of health workers on the proper completion of the partograph. Regular supportive supervision, provision of guidelines and mandatory health facility policy are also needed in support of a collaborative effort to reduce maternal and perinatal deaths.
Tuberculosis retreatment category predicts resistance in hospitalized retreatment patients in a high HIV prevalence area.
International Journal of Tuberculosis and Lung Disease. 2009 Oct; 13(10):1274-80.SETTING: Rates of multidrug-resistant tuberculosis (MDR-TB) are currently as high as 7.7% in retreatment cases in KwaZulu-Natal, South Africa. MDR-TB prevalence is known to be high in patients categorized as treatment failures. Recent reports have questioned the effectiveness of the World Health Organization (WHO) Category II regimen in retreatment TB cases. OBJECTIVE: To determine whether treatment category predicts susceptibility patterns and outcomes in a hospitalized population of retreatment TB cases. DESIGN: Retrospective cohort of 197 pulmonary retreatment cases. RESULTS: Retreatment cases treated with the standard retreatment regimen had a high in-hospital mortality (19.8%), or poor outcome (26.4%) and a high rate of MDR-TB (16.2%). The 'treatment failure' category predicted resistance, with 57.1% of patients exhibiting any resistance compared to other treatment categories (P = 0.02); 53.8% of patients with any resistance experienced poor outcomes, compared to 16.6% of pan-susceptible cases (P = 0.02). There was a trend towards poor outcome in the treatment failure category (42.9%, P = 0.13). CONCLUSION: The retreatment category 'treatment failure' is associated with a high prevalence of resistance in an area of high human immunodeficiency virus (HIV) prevalence. The 'treatment failure' category should be used to identify patients who may benefit from alternative regimens using directed, intensified therapy or second-line agents instead of the current standard retreatment regimen.
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.
The evolving cost of HIV in South Africa: Changes in health care cost with duration on antiretroviral therapy for public sector patients.
Journal of Acquired Immune Deficiency Syndromes. 2007 Jul; 45(3):348-354.A retrospective costing study of 212 patients enrolled in a nongovernmental organization-supported public sector antiretroviral treatment (ART) program near Cape Town, South Africa was performed from a health care system perspective. t-Regression was used to analyze total costs in 3 periods: Pre-ART (median length = 30 days), first 48 weeks on ART (Year One), and 49 to 112 weeks on ART (Year Two). Average cost per patient Pre-ART was $404. Average cost per patient-year of observation was $2502 in Year One and $1372 in Year Two. The proportion of costs attributable to hospital care fell from 70% Pre-ART to 24% by Year Two; the proportion attributable to ART rose from 31% in Year One to 55% in Year Two. In multivariate analysis, Pre-ART and Year One costs were significantly lower for asymptomatic patients compared with those with AIDS. Costs were significantly higher for those who died Pre-ART or in Year One. In Year Two, only week 48 CD4 cell count and being male were significantly associated with lower costs. This analysis suggests that the total cost of treatment for patients on ART falls by almost half after 1 year, largely attributable to a reduction in hospital costs. (author's)
JPMA. Journal of the Medical Association of Thailand. 2006 Dec; 89(12):2091-2096.The objective was to evaluate WHO guideline for the treatment of severe malaria. A retrospective study in 41 pediatric patients who were admitted and diagnosed as severe malaria in Somdejtprachaotaksinmaharaj Hospital between July 2003 and June 2006 was performed. Most patients were older than 5 years (83%). The common clinical features and complications were cerebral malaria (12%), severe anemia (7.3%), metabolic acidosis (7.3%), acute renal failure (4.8%) and pulmonary edema (4.8%). These were not different from other reports. Hypoglycemia and hemoglobinuria were not found. 58.5% of the children were classified as having increased risk of dying. All of them received intravenous artesunate and oral mefloquine with improvement. None of them died. Paracitic clearance time was about 2.6 days, fever clearance time was about 3.4 days and resistant type was about 4%. Intravenous administration of antimalarial drug is essential for the group of children at increased risk of dying and artesunate plus mefloquine is effective. (author's)
The added value of a CD4 count to identify patients eligible for highly active antiretroviral therapy among HIV-positive adults in Cambodia.
Journal of Acquired Immune Deficiency Syndromes. 2006 Jul; 42(3):322-324.In a retrospective study of 648 persons with HIV infection in Cambodia, we determined the sensitivity, specificity, and accuracy of the 2003 World Health Organization (WHO) criteria to start antiretroviral treatment based on clinical criteria alone or based on a combination of clinical symptoms and the total lymphocyte count. As a reference test, we used the 2003 WHO criteria, including the CD4 count. The 2003 WHO clinical criteria had a sensitivity of 96%, a specificity of 57%, and an accuracy of 89% to identify patients who need highly active antiretroviral therapy (HAART). In our clinic, with a predominance of patients with advanced disease, the 2003 WHO clinical criteria alone was a good predictor of those needing HAART. A total lymphocyte count as an extra criterion did not improve the accuracy. Nine percent of patients were wrongly identified to be in need of HAART. Among them, almost 50% had a CD4 count of more than 500 cells/KL, and 73% had weight loss of more than 10% as a stage-defining condition. Our data suggest that, in settings with limited access to CD4 count testing, it might be useful to target this test to patients in WHO stage 3 whose staging is based on weight loss alone, to avoid unnecessary treatment. (author's)
An economic evaluation of the national schistosomiasis control programme in China from 1992 to 2000.
Acta Tropica. 2005; 96:255-265.The World Bank Loan Project, by far the largest effort in China for schistosomiasis control since control activities were initiated in the mid 1950s, was carried out for a 9-year period commencing in 1992 in the 8 provinces where Schistosoma japonicum remained endemic when the project started. To evaluate its impact, a retrospective economic evaluation was done in 2001. Six representative counties, i.e. Huarong in Hunan province, Qianjiang in Hubei province, Yugan in Jiangxi province, Tongling in Anhui province, Xichang in Sichuan province and Dali in Yunnan province, were selected for the study. The total financial input in these counties from 1992 to 2000 was RMB Yuan 90.334 million with the World Bank loan accounting for 40.9%. Control efforts resulted in reduction of human prevalence rates in the six counties from 0.7–9.0% in 1992 to 0.1–2.7% in 2000. With regard to S. japonicum infection in bovines, a high reduction was observed in Qianjiang, and smaller decreases were noted in four counties, while there was an increase in Dali. In general, the areas infested by the intermediate host snail fluctuated around the initial level. The net benefit-cost ratio was 6.20, which means that this project gained US$ 6.20 for every dollar spent. The correlation coefficients of the net benefit-cost ratio to the human and bovine infection rates at the beginning of the project were 0.55 and 0.66, respectively. It is conceivable that further progress in schistosomiasis control is an important feature for sustained growth of the local economy, particularly in areas where control of the disease has been most challenging. (author's)
Geneva, Switzerland, World Health Organization [WHO], 2001. , 35 p.This paper was commissioned by the Department of Reproductive Health and Research at the World Health Organization to examine lessons learned from more than two decades of experience in applying information, education and communication (IEC)a interventions in support of public health. It represents an attempt to gather and synthesize experiences in IEC for public health, and to succinctly analyse and share these experiences so that IEC can be effectively integrated into, and support, improved reproductive health programmes and service delivery. This effort is intended to serve as an orientation, or a ‘tour d’horizon’, to future IEC work as educators, practitioners, policy-makers and communication specialists in all aspects of public health strive to build upon past experience in enabling people to effect more healthful behaviours. The document is primarily intended for individuals working in public health generally, and in reproductive health specifically, who are conversant with – but not expert in – the principles and practices of IEC. It is a retrospective rather than a prospective work. The paper is qualitative in nature and attempts to articulate lessons learned throughout the years. It is not the purpose of this document to critique the projects from which it has drawn lessons or to report evaluation findings, although wherever available, documented evidence of effectiveness has been included (in many cases, impact is anecdotal). For a more refined view of projects cited, readers may find it necessary to consult original sources as listed in Appendix 3: Information sources. Further, it is not possible in a document such as this to offer definitive IEC choices, best practices, or recipes for programming in individual situations. Each strategy must be designed and implemented based upon its own IEC objectives, the intended audience, cultural, social and political characteristics, and any facilitators or barriers that may exist in a given situation. (author's)
Variation in incidence of serious adverse events after onchocerciasis treatment with ivermectin in areas of Cameroon co-endemic for loiasis.
Tropical Medicine and International Health. 2003 Sep; 8(9):820-831.Objective: To determine the incidence of serious adverse events (SAEs) after mass treatment with ivermectin in areas co-endemic for loiasis and onchocerciasis, and to identify potential risk factors associated with the development of these SAEs, in particular encephalopathic SAEs. Methods: We retrospectively analysed SAEs reported to have occurred between 1 December 1998 and 30 November 1999 in central-southern Cameroon by chart review, interview and examination of a subset of patients. Results: The overall incidence of SAEs for the three provinces studied was 6 per 100,000. However, for Central Province alone the incidence of SAEs was 2.7 per 10,000 overall, and 1.9 per 10,000 for encephalopathic SAEs associated with Loa loa microfilaremia (PLERM). The corresponding rates for the most severely affected district within Central Province (Okola) were 10.5 per 10,000 and 9.2 per 10,000 respectively. Symptoms began within the first 24–48 h of ivermectin administration but there was a delay of approximately 48–84 h in seeking help after the onset of symptoms. First-time exposure to ivermectin was associated with development of PLERM. Conclusion: In Cameroon, the incidence of SAEs following ivermectin administration in general, and PLERM cases in particular, varies substantially by district within the areas co-endemic for loiasis and onchocerciasis. More intense surveillance and monitoring in the first 2 days after mass distribution in ivermectin-naïve populations would assist in early recognition, referral and management of these cases. The increased reporting of SAEs from Okola is unexpected and warrants further investigation. Research is urgently needed to find a reliable screening tool to exclude individuals (rather than communities) at risk of PLERM from the mass treatment program. (author's)
Epidemiology of measles in the central region of Ghana: a five-year case review in three district hospitals.
East African Medical Journal. 2003 Jun; 80(6):312-317.Objective: As part of a national accelerated campaign to eliminate measles, we conducted a study, to define the epidemiology of measles in the Central Region. Design: A descriptive survey was carried out on retrospective cases of measles. Setting: Patients were drawn from the three district hospitals (Assin, Asikuma and Winneba Hospitals) with the highest number of reported cases in the region. Subjects: Records of outpatient and inpatient measles patients attending the selected health facilities between 1996 and 2000. Data on reported measles eases in all health facilities in the three study, districts were also analysed. Main outcome measures: The distribution of measles eases in person (age and sex), time (weekly, or monthly, trends) anti place (residence), the relative frequency, of eases, and the outcome of treatment. Results: There was an overall decline in reported eases of measles between 1996 and 2000 both in absolute terms and relative to other diseases. Females constituted 48%- 52% of the reported 1508 eases in the hospitals. The median age of patients was 36 months. Eleven percent of eases were aged under nine months; 66% under five years and 96% under 15 years. With some minor variations between districts, the highest and lowest transmission occurred in March and September respectively. Within hospitals, there were sporadic outbreaks with up to 34 weekly eases. Conclusion: In Ghana, children aged nine months to 14 years could be appropriately targeted for supplementary, measles immunization campaigns. The best period for the campaigns is during the low transmission months of August to October. Retrospective surveillance can expediently inform decisions about the timing and target age groups for such campaigns. (author's)
Management of severely ill children at first-level health facilities in sub-Saharan Africa when referral is difficult. [La prise en charge au niveau des installations sanitaires de premier niveau des enfants gravement malades, en Afrique sub-saharienne, en cas de difficulté d'orientation vers d'autres structures]
Bulletin of the World Health Organization. 2003 Jul; 81(7):522-531.Objectives: To quantify the main reasons for referral of infants and children from first-level health facilities to referral hospitals in sub- Saharan Africa and to determine what further supplies, equipment, and legal empowerment might be needed to manage such children when referral is difficult. Methods: In an observational study at first-level health facilities in Uganda, the United Republic of Tanzania, and Niger, over 3–5 months, we prospectively documented the diagnoses and severity of diseases in children using the standardized Integrated Management of Childhood Illness (IMCI) guidelines. We reviewed the facilities for supplies and equipment and examined the legal constraints of health personnel working at these facilities. Findings: We studied 7195 children aged 2–59 months, of whom 691 (9.6%) were classified under a severe IMCI classification that required urgent referral to a hospital. Overall, 226 children had general danger signs, 292 had severe pneumonia or very severe disease, 104 were severely dehydrated, 31 had severe persistent diarrhoea, 207 were severely malnourished, and 98 had severe anaemia. Considerably more ill were 415 young infants aged one week to two months: nearly three-quarters of these required referral. Legal constraints and a lack of simple equipment (suction pumps, nebulizers, and oxygen concentrators) and supplies (nasogastric tubes and 50% glucose) could prevent health workers from dealing more appropriately with sick children when referral was not possible. Conclusion: When referral is difficult or impossible, some additional supplies and equipment, as well as provision of simple guidelines, may improve management of seriously ill infants and children. (author's)
[Descriptive report of the support delivered by the Institute of Nutrition of Central America and Panama (INCAP) to the Ministry of Health, within the National Plan of Child Survival during the period 1985-1989] Informe descriptivo del apoyo proporcionado por el Instituto de Nutricion de Centro America y Panama (INCAP) al Ministerio de Salud, dentro del Plan Nacional de Supervivencia Infantil, durante el periodo 1985 - 1989.
San Salvador, El Salvador, Instituto de Nutricion de Centro America y Panama [INCAP], 1991 Aug. 15 p.The Nutrition Institute of Central America and Panama (INCAP) conducted a retrospective analysis of assistance rendered to different agencies of El Salvador s Ministry of Public Health and Social Assistance during 1985-89 to evaluate its support of the Child Survival Action Plan, identify shortcomings and successes that could guide future planning, and identify future areas of cooperation. Information was obtained from 11 representatives of the different departments. The report describes assistance in training, research, advisory services, and educational materials chronologically by single years during 1985-89 for the agencies of the Ministry: the Maternal-Child Health Department, Nutrition Department, School of Health Training, Epidemiology Unit, and Education Unit, and for 14 nongovernmental organizations (NGOs) belonging to the Intersectorial Committee for Child Survival. The principal achievements were considered to be providing baseline research for planning of educational activities, distribution of 360,000 doses of vitamin A to children aged 1-6 years, providing oral rehydration training centers in two hospitals, training 80% of health personnel in the Eastern region in oral rehydration, introducing the methodology of distance education to local personnel, operationalizing the Diarrhea Control and Oral Rehydration Project in 350 rural and semiurban communities attended by 14 NGOs, and integrating training in oral rehydration into the Social Pediatrics Area of the Bloom Hospital. Since 1987, an average of 280 students in the sixth year of medicine have received training. One of the major limitations was the lack of participation of program coordinators and INCAP consultants in planning. Lack of financing was a problem in some activities.
Dengue: an evaluation of dengue severity in French Polynesia based on an analysis of 403 laboratory-confirmed cases.
Tropical Medicine and International Health. 1999 Nov; 4(11):765-73.WHO has published a regularly updated guide to improve the diagnosis and management of severe dengue cases by determining the severity using the prognostic criteria, evaluating the impact and improving the control of the disease. This retrospective study aimed to assess the validity of the WHO classification through the analysis of 403 laboratory-confirmed cases in French Polynesia, Tahiti between August 1989 and March 1997. According to standard WHO criteria, 337 cases were considered dengue fever (DF) and 64 were dengue hemorrhagic fever (DHF). About 10 fatal cases were recorded, 6 of which were DF and 4 DHF. As an alternative, a correspondence analysis procedure was used to define dengue severity based on basic clinical and biological criteria for which a severity score was assigned, and then 50 most severe cases from the analysis were selected. Of the latter, 17 patients had been classified as DF and 33 as DHF by the WHO criteria. From this analysis, hemorrhages and decreased platelet counts associated with hepatic disorders were the main criteria associated with the severe dengue cases. This study confirmed that WHO classification does not accurately account for the severity of dengue. Hepatic failure causing plasma leakage, a pathophysiologic hallmark of DHF, should be considered because this is one of the pathogenic mechanisms to the severity of dengue.
The use of a large-scale surveillance system in Planned Parenthood Federation of America clinics to monitor cardiovascular events in users of combination oral contraceptives.
International Journal of Fertility and Women's Medicine. 1999 Jan-Feb; 44(1):19-30.In response to studies reporting an excess of thrombotic events in women who used oral contraceptives (OCs) containing third-generation progestins, the Planned Parenthood Federation of America (PPFA) launched a retrospective review of clients at all PPFA-affiliated centers during 1993-95. During the 3-year study period, 2,265,087 woman-years of OC use were recorded in clinic drug sale records. All OCs prescribed in this period contained 30 or 35 mcg of estrogen and either norgestimate (21.0%), desogestrel (8.9%), norethindrone (46.6%), or levonorgestrel (23.6%) as the progestin. 70 major thrombotic events among clients using OCs (3 vascular complications per 100,000 woman-years of OC use) were reported to PPFA's risk management division during 1993-95; these included 25 cases of deep vein thrombosis, 20 cases of pulmonary embolism, 22 cerebrovascular accidents, and 3 myocardial infarctions. There were 5 deaths (0.22/100,000 woman-years of use), all from pulmonary emboli. The thrombotic event rates were calculated as the relative risk of complication, comparing the risk of each event for one progestin relative to the other three classes of progestins. The overall risk varied from a low of 1.895 events/100,000 woman-years for norgestimate OC users to a high of 3.969 events/100,000 woman-years for desogestrel OC users, but these differences were not statistically significant. In the progestin comparison, desogestrel users showed elevated risks for pulmonary emboli and fatalities, norgestrel use was associated with an increased risk of deep vein thrombosis, and norgestimate an increased risk of deep vein thrombosis and pulmonary embolism. Generally, these four groups of low-dose OCs appear safer than any previously published study has indicated. In part, this may reflect PPFA's careful prescribing guidelines. In addition to following US Food and Drug Administration contraindications, PPFA affiliates do not provide OCs to women over 35 years of age who smoke more than 15 cigarettes a day.
INTERNATIONAL JOURNAL OF TUBERCULOSIS AND LUNG DISEASE. 1998 Mar; 2(3):225-30.In 1995, Pakistan adopted the guidelines published by the World Health Organization (WHO) for the treatment of tuberculosis in developing countries. The present study, conducted at a tertiary care teaching hospital (Aga Khan University Hospital) in Karachi, assessed physician compliance with the WHO guidelines through a retrospective review of the records of all 229 patients admitted with tuberculosis in 1995. 191 of these patients were classified into WHO Category 1 (new cases of pulmonary tuberculosis and severe cases of extrapulmonary tuberculosis), 9 were Category 2 (relapses and treatment failures), and 29 were Category 3 (children and non-severely ill cases). A total of 53 Category 1 patients (23%) had a diagnostic bacteriologic sputum smear examination, of which 38% were smear-positive and 47% were culture-positive. 12% of the 25 cerebrospinal fluid cultures performed were positive. No sputum smear tests were conducted. Of the 58 Category 1 patients who completed treatment, 43 (74%) received a 2-month intensive protocol consisting of isoniazid, rifampicin, pyrazinamide, and ethambutol, while 24 (41%) underwent a 6-month continuation phase with isoniazid and ethambutol. Most patients received these medications as part of a course that exceeded the 8-month regimen recommended by WHO. Over 70% of patients were lost to follow up, primarily during the intensive phase of treatment. Only 52% of patients who completed treatment showed complete recovery. Overall, these findings reveal poor awareness of and low physician compliance with the WHO guidelines. Recommended are physician education programs and development of a standard tool to monitor physician compliance with these guidelines.
Ann Arbor, Michigan, UMI Dissertation Services, 1995. , vi, 460 p. (UMI No. 9608121)This project examines the global politics of "technical assistance" as they shape and are reflected in struggles over solutions to the AIDS crisis in Kenya. Drawing on and refining feminist Nancy Fraser's analysis of the role of welfare experts in securing state control of women's bodies through the elaboration of "needs talk" and contextualizing the process in class-centered theories of African underdevelopment, the dissertation focuses on the implications of debates among international health experts at the World Health Organization (WHO) and struggles over donor money among Kenyan bureaucrats, researchers, and consultants for local efforts to help low-income Kenyan women avoid HIV infection. The author argues that in Kenya the relationship of scientific knowledge to the making of policies guiding how the national government defines its needy population, decides what is needed, and delivers public services is determined by the actions of groups of ideological and financial brokers within the network linking international, national, and local sites of interventions in crisis. The author examines the emergence in Kenya of a post-colonial discourse identifying low-income women as the culprits in the transmission of sexual disease prior to the appearance of AIDS. The depoliticization of AIDS from a problem of sexual inequality into a problem of inequality of technical know-how is their analyzed. At the local level, these historical processes have translated into hegemonic control of problem definition by Canadian, American, and European doctors enforcing a notion of masculine sexuality as promiscuous and fixed and feminine sexuality as subject to control and containment. The author concludes by arguing that such a deployment of a supposedly gender and nationality neutral science results in policies for the control of AIDS that are ineffective at best and potentially dangerous for women and men alike. (author's)
AIDS. 1992 Mar; 6(3):295-9.The 1st case definition for AIDS was developed by the Centers for Disease Control (CDC) in 1982. WHO adopted CDC definitions for use in some countries and also developed a clinical case definition where HIV serology tests were not feasible. A multivariate analysis of data of Brazilian AIDS patients with positive HIV serology provided the basis for the Caracas definition in 1989 and it subsequent revision. The accuracy of these 3 clinical definitions was evaluated to see their predictive value in an advanced stage of AIDS. The records of 224 HIV-positive adults were reviewed in 1990. Scores were assigned to various symptoms. 80% of men and 20% of women with a median age of 33 years; 1/4 were white and 2/3 were black. 1/3 were homosexuals and 1.2 were iv drug users. 139 were asymptomatic (CDC stage I-II) and 85 were symptomatic (CDC stage IV). 58 patients had total CD4 cell counts of over 500 x 1 million/1; 91 had 200-500 x 1 million/l; and 70 had < 200 x 1 million/1. 48 were taking zidovudine and Pneumocytis carinii drugs. The sensitivities of the WHO, original Caracas definition, and revised Caracas definition were 40%, 67%. and 60%, respectively, with 99-100% specificities and positive predictive values of 97-100%. The mean CD4 cell counts for the WHO, original and revised Caracas definitions were 184, 160, and 158 x 1 million/1, respectively, compared with 199 x 1 million/1 of patients with CDC stage IV disease. The predictive values of the 3 definitions for CD4 cell counts < 200 x 1 million/1 reached 62%, 73%, and 71% vs. only 59% for CDC stage IV patients. The combination of stage IV symptoms or a CD4 cell count < 200 x 1 million/1 produced sensitivities of 31%, 53%, and 47%, respectively, with 100% specificity and positive predictive values. The definitions were highly specific, but only moderately sensitive for advanced AIDS; the Caracas definitions were more sensitive than the WHO definition.
Maternal mortality associated with hypertensive disorders of pregnancy in Africa, Asia, Latin America and the Caribbean.
BRITISH JOURNAL OF OBSTETRICS AND GYNAECOLOGY. 1992 Jul; 99(7):547-53.An epidemiologist analyzed community and hospital-based data obtained from the WHO data base on maternal mortality and morbidity to examine maternal mortality associated with hypertensive disorders of pregnancy (HDP) in Africa, Asia, the Caribbean, and Latin America. Overall estimates of mortality associated with HDP among countries in Africa, Latin America, and the Caribbean did not differ, even though overall maternal mortality was much higher in Africa than in Latin America and the Caribbean. In Asia, however, estimates of both maternal mortality and mortality associated with HDP were quite varied (maternal mortality range = 15-905 and percentage of deaths due to HDP range = 4 = 55%). Qatar had the lowest maternal mortality (15) and the highest percentage of deaths due to HDP (55%). Even though maternal mortality was lowest in southern Africa (90-115 vs. 80-1140), percentage of deaths due to HDP was basically high (10-27%). In West Africa, the same HDP levels ranged from 7% to 18%. Maternal mortality was relatively low in the Caribbean (30-80), but it had a very high percentage of deaths due to HDP (30-73%). In Argentina and Chile, maternal mortality was higher than that of the Caribbean (180 and 110. respectively), yet had a low percentage of deaths due to HDP (10%). These data indicated that overall 10-15% of all maternal deaths were associated with HDP. In those countries with detailed data, 60-100% of these deaths were due to eclampsia. Thus eclampsia caused 10% of all maternal deaths. These results suggested that infection and hemorrhage were responsible for the excess maternal mortality. They also implied that deaths associated with HDP may be the most difficult to prevent in developed and developing countries. Health practitioners do not agree on the optimal management of preeclampsia and eclampsia. Several clinical trials worldwide are now evaluating the various management options.
PACIFIC BASIN MATERNAL AND CHILD HEALTH RESOURCE CENTER WHAT'S NEW IN.... 1991 Dec; 3(58):1-2.The WHO has published partial results of an epidemiological study of the safety with respect to breast cancer of the injectable contraceptive depomedroxyprogesterone acetate, known as DMPA or Depo-Provera. The WHO Special Program of Research, Development and Research Training in Human Reproduction has been conducting a collaborative retrospective study of cancer and DMPA in 3 developed and 8 developing countries. Results from Kenya, Mexico and Thailand are published in Lancet on October 5, 1991. Comparing 869 women with breast cancer <64 years old and 11,890 matched hospital-based controls, the relative risk was 1.21, not statistically significant. 12.5% of the cases and 12.2% of the controls had used DMPA. Fine analysis pointed to a possibility of increased risk over the 1st 4 years of use. The data were not compatible with the hypothesis that DMPA. Fine analysis pointed to a possibility of increased risk over the 1st 4 years of use. The data were not compatible with the hypothesis that DMPA causes cancer, but only that it may speed the growth of early pre-existing cancer. When contemplating the choice of DMPA, people should evaluate their risks relative to the excellence of DMPA as a highly effective, convenient, long-acting, but reversible method.
In: United Nations. Economic and Social Commission for Asia and the Pacific, World Fertility Survey, and International Institute for Population Studies. Regional Workshop on Techniques of Analysis of World Fertility Survey data: report and selected papers. New York, UN, 1979. 15-36. (Asian Population Studies Series No. 44)The World Fertility Survey provides data from national maternity history inquiries. Detecting trends and differentials is only as accurate as the data collected. Where evidence suggests error, the analysis may be restricted to obtaining only a measure of fertility level. The basic data is the date and order of birth of each live born child for a sample of women in the reproductive period, according to the current age of the women and their duration of marriage. The cohort marker is usually separated into 7 5-year classes determined by age at interview; sample of women is representative of the female population of childbearing age. Total births for each cohort are allocated to different periods preceding the survey date. Reading down the columns gives the births to different cohorts over different ranges in the same time interval preceding the survey. To detect omissions, check the overall sex ratio and the sex ratios by periods; examine the trends of infant mortality by cohorts and periods; an excess of male mortality over female indicates poor reporting of dead female children and/or of sex (a common omission). From data on age of mother and number of surviving children at the survey and estimates of mortality level, the numbers of births at preceding periods may be calculated.
A retrospective analysis of family planning Papanicolaou smear data: lessons for the future. 2. Planned Parenthood's national experience, 1975.
Advances in Planned Parenthood. 1978; 12(3):144-148.In 1975, 96,254 Papanicolaou smears were submitted by Planned Parenthood clinics in 9 of the 10 Health, Education, and Welfare regions to a single laboratory. Smears were interpreted and classified as I (negative), II (negative, benign reactive changes), II+ (minimal dysplasia), IIIA (mild dysplasia), III (moderate dysplasia), III+ (moderate to severe dysplasia), IV (severe dysplasia and/or carcinoma in situ), V (invasive carcinoma), or 0 (inadequate for evaluation). Of the 95,907 smears suitable for cytologic evaluation, 4572 (5.3%) showed evidence of dysplastic or neoplastic changes. Histopathologic specimens were obtained for 242 women with abnormal cervical cytology. Mild to moderate dysplasia was noted in 86 (35.5%), severe dysplasia in 34 (14%), carcinoma in situ in 54 (22.3%), and invasive cancer in 4 (1.7%). 64 (27.2%) tissue specimens proved to be normal. 75% of smears demonstrating at least moderate dysplasia were obtained from women under 25. Since the pap smear is only a screening procedure, abnormalities detected by this method require diagnostic confirmation and follow-up. The low response rate of local affiliates to laboratory requests for information on cytology/histology correlates of their patients makes it impossible to determine if this was provided. In addition, the "false negative" rate of the pap smear screening program could not be determined as biopsies were not obtained for women with Class I or II smears. While lessening clinic autonomy, the standardization of medically relevant protocols for follow-up and computerized methods of data collection would increase factual information and knowledge of the cost-effectiveness of services provided.