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Bethesda, Maryland, University Research Company, Quality Assurance Project, 2004 Dec. 47 p. (QAP / WHO Field Report)The traditional approach to malaria diagnosis has been examination by microscope of a thick blood smear from the individual suspected of being infected. In an attempt to provide a more rapid alternative, companies worldwide have developed malaria rapid diagnostic tests (RDTs). Although RDTs can be effectively used in clinical settings by trained personnel, their greatest potential use is in rural areas with limited access to health and laboratory facilities. Using RDTs for diagnosis at the community level will shorten the delay between the onset of symptoms and the beginning of appropriate treatment. It will also slow development of resistance and lead to significant cost savings by avoiding unnecessary use of antimalarials. However, achieving a high level of sensitivity and specificity with RDTs in this context will require a product designed, labelled, and explained so that community health workers (CHWs) can use it accurately with minimal formal training and supervision. In partnership with theWHO Regional Office for the Western Pacific, the Quality Assurance Project (QAP) carried out quality-design research in the Philippines and the Lao People's Democratic Republic to develop and test a generic RDT job aid, mainly pictorial, that could be adapted with little modification for use with different RDT products and in different cultural settings by health workers with low literacy skills and with little or no prior training in product use. (author's)
[Unpublished] . 27 p. (USAID Contract No. DPE-5927-C-00-5068-00)Health personnel in Niger report that malaria is the leading diagnosis in health facilities (1980-1984), about 380,000 cases/year), but just 19% of the population live within a 5 km radius of a health facility. A 1985 household survey reveals that 31.4% of children had a febrile illness (presumptive malaria) within the last 2 weeks and 22.1% of all child deaths were presumptive malaria related. The Government of Niger began developing a national malaria program in 1985 to reduce malaria-related deaths rather than morbidity reduction, because available data indicated that morbidity reduction was not feasible. There is no standard treatment regimen for presumptive malaria, however. Some studies indicate that an effective dose regimen is 10 mg chloroquine/kg body weight in a single dose. Some health workers use other antimalarial arbitrarily. Lack of uniformity can increase the risk of chloroquine and Fansidar resistant falciparum. Government officials are thinking about having only chloroquine available at first level facilities. It plans to set up national surveillance for chloroquine resistance. Niger has just 1 trained malariologist, indicating a need for training of more staff. To keep government costs to a minimum, it wants to set chloroquine at all points in the distribution network. The program's plan of action also includes chemoprophylaxis for pregnant women, limited vector control in Niamey, and health education stressing reducing breeding sites. A REACH consultant believes that it is possible for the program to reach its coverage targets within 5 years. Obstacles include limited access to health care, unavailable chloroquine in warehouses, and lack of untrained personnel (the main obstacle). The consultant suggests various interventions to help Niger meet its targets, e.g., periodic coverage surveys. The World Bank, WHO, the Belgian Cooperation, and USAID are either providing or planning to provide support to the malaria control programs.
STUDIES IN FAMILY PLANNING. 1991 Jan-Feb; 22(1):1-18.A study investigative the pros and cons of financial payments for sterilizations to clients, medical personnel, and agents who motivate and refer clients was conducted by the government of Bangladesh in conjunction with the World Bank. Results indicate that Bangladeshi men and women opt to be sterilized both voluntarily and after consideration of the nature and implications of the procedure. Clients were also said to be knowledgeable of alternate methods of controlling fertility. A high degree of client satisfaction was noted overall with, however, 25% regret among those clients with less than 3 children. Money is a contributing factor in a large majority of cases, though dominating as motivation for a small minority. Financial payments to referrers have sparked a proliferation of many unofficial, self-employed agents, especially men recruiting male sterilization. Targeting especially poor potential clients, these agents focus upon sterilization at the expense of other fertility regulating methods, and tend to minimize the cons of the process. Examples of client cases and agents are included in the text along with discussion of implications from study findings.
[Unpublished] 1987 Apr 30. , 53 p.Neonatal tetanus, caused by the toxin of Clostridium tetani, is transmitted via unclean instruments used to cut the umbilical cord or contaminated dressings applied to the stump. The symptoms are inability to suck, trismus, convulsions, and (in 80-90% of cases) death on the 7th or 8th day. In the US between 1982 and 1984 only 2 cases of neonatal tetanus were reported; in the developing world an estimated 800,000 infants die of neonatal tetanus every year. The survey methodology used to determine the neonatal tetanus death rate was a 2-stage sampling method, known as the Expanded Program on Immunization 30 cluster sampling method, followed by questionnaires. Such surveys contain a certain amount of built-in bias due both to fact that the final selection of households is never completely random and that retrospectively gathered information is subject to recall bias. The surveys indicated that neonatal tetanus incidence was highest in rural areas, especially where animals were present; in the slums of cities; among families with many children; where mothers received no prenatal care; and where birth attendants were untrained. The best preventive strategy against neonatal tetanus is provided through immunization of the mother with tetanus toxoid, since the antibodies cross the placenta and protect the infant through the neonatal period. Unfortunately, the tetanus vaccination program lags at least 30% behind other World Health Organization Expanded Program on Immunization coverage. The World Health Organization recommends an initial immunization with .01 antitoxin International Units per milliliter of serum, a 2nd dose 4 weeks later (at least 2 weeks before delivery) and booster doses on each successive pregnancy up to 5; the 5th booster provides lifetime protection. Immunization should also be carried out among nonpregnant women of childbearing age and children. The World Health Organization has proposed that neonatal tetanus be made a reportable disease, which should be combatted by prenatal immunization of mothers and training of traditional birth attendants. Between 60% and 80% of all births in developing countries are attended by traditional birth attendants, but, except in China, the training of traditional birth attendants has not contributed as much to reduction of neonatal tetanus as has immunization. Alternative strategies for carrying out tetanus immunization programs include integrating them into prenatal clinics, schools, family planning programs, maternal food distribution programs, well-baby care centers, mass campaigns (especially in urban areas), and mobile team outreach strategies in rural areas. Tetanus immunization could also be linked to other Expanded Program on Immunization programs even though these are mainly targeted at children rather than mothers and other women of childbearing age. Indonesia initiated a tetanus immunization program in 1977 and a traditional birth attendant training program with assistance from the UN Childrens Fund in 1978. However, 3 neonatal tetanus surveys, conducted in 19 provinces, the city of Jakarta, and Java, estimated the total number of deaths/year from neonatal tetanus as 71,150--a neonatal tetanus mortality rate of 11/1000. 3 provincial level studies, also using the Expanded Program on Immunization 30 cluster sampling method, in Nusa Tenggara Barat, West Sumatra Province, and Daerah Istemewah Aceh revealed neonatal tetanus mortality rates of 8.3/1000, 18.5/1000, and 8.4/1000 respectively. In the Health portion of Indonesia's 4th 5-year plan (Pelita IV), the 1st priority is given to reducing the neonatal death rate of 93/1000 live births; the 7th priority is reduction of mortality due to neonatal tetanus by ensuring adequate immunization as part of routine health services and by requiring 2 tetanus immunizations of all women applying for a marriage certificate.
Brazilian popular healers as effective promoters of oral rehydration therapy (ORT) and related child survival strategies.
BULLETIN OF THE PAN AMERICAN HEALTH ORGANIZATION. 1988; 22(4):335-54.In Ceara State in northeastern Brazil in 1986 infant mortality reached 110-139 per 1000 live births, and 50% of those deaths were due to diarrhea and dehydration. Diarrheal deaths can be prevented by oral rehydration therapy (ORT), which replaces lost fluids and electrolytes with oral rehydration salts (ORS) and water. ORT was known in the 1830s, but only in the 1960s was the importance of sugar, which increases the body's ability to absorb fluid some 25 times, realized. In northeastern Brazil access to ORT has been severely limited by poverty, official incompetence, and bureaucratic restrictions. In 1984 a 2-year research project was initiated in the village of Pacatuba to test the theory that mobilizing and training popular healers in ORT would 1) increase awareness and use of ORS, 2) promote continued feeding during diarrhea, 3) increase breast feeding, and 4) reduce the use of costly and nonindicated drugs. 46 popular healers, including rezadeiras and oradores (prayers), Umbandistas (priests), espiritas (mediums), an herbalist, and a lay doctor, were recruited and trained. Most of these people practiced a mixture of folk medicine and religion and were highly respected in the community. For purposes of survey, Pacatuba was divided into 3 groups, each containing houses at 4 different income levels. The mothers in 204 Group 1 homes were interviewed concerning ORT and diarrhea-related knowledge before intervention, and 226 households in Group 2 were interviewed after intervention. The healers were taught the basic biomedical concept of rehydration and how to mix the ORS -- 7 bottle cap-fulls of sugar and 1 of salt in a liter of unsweetened traditional tea. The healers were also taught how to use the World Health Organization's (WHO) ORS packets (2% glucose, 90 mmol/1 of sodium chloride, 1.5 gm potassium chloride, and 2.9 gm sodium bicarbonate) for cases of moderate to severe dehydration. In addition, the healers were taught the 5 basic health messages: give ORS-tea for diarrhea and dehydration (or any similar folk illness, such as evil eye, fallen fontanelle), continue feeding, encourage breast feeding, eliminate drugs, and ask people to seek the healer quickly at the onset of diarrhea. The healers continued to perform all the popular rites and prayers traditionally associated with curing diarrhea. The healers distributed approximately 7400 liters of ORS-tea in 12 months at a unit cost of 48 cents (US). A post-intervention survey of diarrhea-related knowledge was then carried out among the 226 Group 2 households. Before the intervention 2.9% of the mothers knew about ORS; 71.2% did afterward. All of the healers demonstrated that they knew exactly how to mix the ORS-tea. Knowledge of the WHO packets also increased. The number of mothers who continued feeding their children during diarrhea increased to 92%. Following the introduction of the ORS-tea, purchases of the more costly WHO packets and other commercial medications and antibiotics fell off significantly. The people's belief in folk etiologies remained unchanged, showing that traditional healers can be successfully integrated into an effective health care program. The success rate of the ORT program in Pacatuba, carried out entirely by word of mouth, compares favorably with expensive mass media campaigns other places.