Cost-effectiveness of improved treatment services for sexually transmitted diseases in preventing HIV-1 infection in Mwanza Region, Tanzania

Improved management of sexually transmitted diseases (STDs) is consistently advocated as an effective strategy for HIV prevention. The impact, cost, and cost-effectiveness of this approach were evaluated in a prospective, comparative study of six communities in Tanzania's Mwanza Region in which primary health care center workers were trained to provide improved STD treatment and six matched non-intervention communities. The baseline prevalence of HIV was 4% in both groups. During the 2-year study period, 11,632 cases of STDs were treated in the intervention health units. The HIV seroconversion rate was 1.16% in the intervention communities and 1.86% in the comparison communities--a difference in HIV incidence of 0.70 (95% confidence interval, 0.37-1.09) and a reduction of about 40%. The total annual cost of the intervention was US$59,060 ($0.39 per person served). The cost of STD treatment was $10.15 per case. An estimated 252 HIV-1 infections were averted each year. The incremental annual cost of the program was $54,839, equivalent to $217.62 per HIV infection averted and $10.33 per disability-adjusted-life-year (DALY) saved. The estimated cost-effectiveness compares favorably with that of childhood immunization programs ($12-17 per DALY saved) and could be further enhanced through implementation of the intervention on a wider scale. The intervention subsequently has been expanded to encompass 65 health units in Mwanza Region, with no increase in investment costs.     

Sexual and reproductive health among primary and secondary school pupils in Mwanza, Tanzania: need for intervention

A cross-sectional questionnaire survey was conducted among 892 randomly selected pupils, aged 12 and above, attending 18 primary schools (PS) and five secondary schools (SS) in four communities of Mwanza Region in Tanzania. The goals were to assess the level of knowledge adolescents have about sexual and reproductive health (SRH), to assess the magnitude of SRH problems and to help design appropriate interventions. Median age of respondents was 15 years (range 12-20 years) and 14 years (range 12-19 years) for PS boys and girls, respectively, and 19 years (range 16-24 years) and 17 years (range 14-19 years) for SS boys and girls. Eighty per cent of PS boys and 68% of PS girls were already sexually active; the corresponding figures were 89% for SS boys and 48% for SS girls. Vaginal sex was the most common first sexual act reported by SS pupils, but 40% of PS pupils reported orogenital sex and 9% of PS pupils reported anal sex as their first sexual act. Almost half of PS girls have had sex with adults, including teachers and relatives. 'Forced sex' was reported by nearly half of PS and SS girls. Fourteen per cent of PS girls had already been pregnant, and over half of these pregnancies ended in illegally induced abortions. Despite a rather high (30%) lifetime rate of condom use, 33% and 25% of PS boys and girls, respectively, reported past experience of sexually transmitted diseases (STDs). STD rates were lower among SS pupils who had a better knowledge of STDs/HIV and fertility issues and reported higher condom use. The survey demonstrated the great vulnerability of school-going adolescents of Mwanza Region to consequences of sexual intercourse. The response should urgently come in the from of comprehensive adolescent SRH programmes.     

Correct case management of childhood diarrhea: a survey of nine state capitals in northeast Brazil

The National Program for Maternal and Child Health (COSMI) of the Ministry of Health (MOH) of Brazil conducted a survey in nine state capitals from 29 March to 30 April 1993 to assess how well health facilities were managing diarrhea cases in patients under 5 years of age. One of seven PAHO/WHO health facility surveys performed in Latin America and the Caribbean in 1992-1993, the Brazilian survey took place in the Northeast Region where most diarrheal morbidity and mortality occur. Like the other six surveys, it used a new PAHO/WHO methodology designed to collect data on certain principal indicators through observation, interviews, and review of clinical records. Overall, 475 cases of patients with diarrhea were observed in 192 facilities, and 463 health workers and 474 caretakers were interviewed. The results indicated that few diarrhea patients received care that strictly followed the PAHO/WHO/Ministry of Health treatment guidelines. In terms of these guidelines, the correct procedure was used to assess the patient's hydration status only 8% of the time, and only 1% of the health workers provided correct advice to the caretaker on prevention and home care aspects of diarrheal diseases. The procedure used to rehydrate patients with oral rehydration salts (ORS) was correct in only 6% of the cases. Of those patients with bloody stools, 24% were treated appropriately with antibiotics. Besides collecting information on correct case management, the survey provided a basis for developing two-year operational plans of action in each of the nine participating states to strengthen efforts directed at controlling and preventing diarrheal diseases, including cholera.     

Ultrasonic examination in soft-tissue and long-bone injuries of the limbs

Compulsory sterilization, where jail sentences will be imposed on couples if both partners remain unsterilized after the birth of their 3rd child, will be introduced in India, and it is thought that such a program will fail. Indian officials justify compulsory sterilization on the grounds that the country's survival is at stake. This argument, however, is not self-evident. Coercion entails potential moral and political consequences. Preliminary evidence on the effects of a combination of income redistribution, lowered infant mortality, improved literacy, and readily available family planning services and information show that such "packages," however slow and costly, may make smaller families an attractive alternative to the poorest family. The Indian government seems to be looking for a "short-cut," which will require complicated record keeping and readily available health facilities. If India were ready for the successful introduction of compulsory sterilization, it would also be ready for "development" since much the same structure would be required.     

Disinfection and sterilization of reusable devices]

Official of quality assurance requirements for the disinfection and sterilization of reusable medical devices in health care facilities has been reminded recently. These requirements concern good manufacturing practices, essential to avoid adverse events. Identification of non critical and invasive devices, protocols for pre-disinfection, cleaning, high level disinfection and sterilization for thermosensitive materials must be evaluated. Monitoring and process control of these operations are defined by French regulations and European standards, and every health professional has to become aware of these limits.     

Potentially avoidable hospitalizations: inequalities in rates between US socioeconomic groups

OBJECTIVES: The National Hospital Discharge Survey (NHDS) was used to evaluate potentially avoidable hospital conditions as an indicator of equity and efficiency in the US health care system. METHODS: With the use of 1990 data from the NHDS, the National Health Interview Survey, and the census, national rates of hospitalization were calculated for avoidable conditions by age, race, median income of zip code, and insurance status. RESULTS: An estimated 3.1 million hospitalizations were for potentially avoidable conditions. This was 12% of all hospitalizations in 1990 (excluding psychiatric admissions, women with deliveries, and newborns). Rates of potentially avoidable hospitalizations were higher for persons living in middle- and low-income areas than for persons living in high-income areas, and were higher among Blacks than among Whites. These class and racial differences were also found among the privately insured. Differences among income and racial groups for persons aged 65 and over were not significant. CONCLUSIONS: Inequalities in potentially avoidable hospitalizations suggest inequity and inefficiency in the health care delivery system. Avoidable hospital conditions are a useful national indicator to monitor access to care.     

Basic and clinical control of nosocomial infections

Nosocomial infections, especially opportunistic infections and occupationally acquired infections, are causing major problems in perioperative period. Opportunistic infections are increased by opportunism secondary to antibiotic therapy and lower body defences. Organisms that cause opportunistic infections come from either exogenous or endogenous sources. Exogenous infections result from transmission of organisms from a source other than the patient. Control of person-to-person spread, such as handwashing and gown technique, disinfection and sterilization of equipment, and environmental cleaning are necessary to prevent exogenous infections. Endogenous infections are caused by the patient's own flora. Antibiotic policies are required to prevent endogenous infections. The main preventive measure of occupationally acquired infections, especially blood-borne infections, is practices of universal precautions. Universal precautions are intended to prevent parenteral, mucous membrane, and nonintact skin exposures to blood-borne pathogens in health care settings.     

The sign of stress incontinence--should we believe what we see?

Isolates of Plasmodium falciparum obtained from 12 children attending different health facilities in the Madang Province, Papua New Guinea were typed for allelic variants of merozoite surface protein-1 and merozoite surface protein-2. Blood was obtained just before treatment with either amodiaquine or chloroquine and at intervals following treatment. All patients examined were found to be infected with genetically different parasites. Nine of the children were found to have single infections while three had mixed infections. In all patients, parasites reappearing in the blood following treatment had the same genotype as parasites in the primary infection. These results indicate that parasites reappearing in the blood following treatment were the result of true recrudescence and not new infections.     

Cytotoxicity of lindane and paraquat to human hepatoma cell lines

A serosurvey was conducted in a random sample of 259 women and 231 men in 12 rural communities in Mwanza Region, Tanzania, using a type-specific ELISA for Herpes simplex virus type 2 (HSV-2) infection. Seroprevalence rose steeply with age to approximately 75% in women >=25 years old and 60% in men >=30. After adjusting for age and residence, HSV-2 prevalence was higher in women who were married, in a polygamous marriage, Treponema pallidum hemagglutination assay (TPHA)-positive, had more lifetime sex partners, or who had not traveled. Prevalence was higher in men who were married, had lived elsewhere, had more lifetime partners, had used condoms, or were TPHA-positive. HSV-2 infection was significantly associated with recent history of genital ulcer. The association between HSV-2 infection and lifetime sex partners was strongest in those <25 years old in both sexes. This association supports the use of HSV-2 serology as a marker of risk behavior in this population, particularly among young people.     

Avoidable mortality among psychiatric patients

Avoidable mortality is a selection of causes of death considered to be amenable to health care and thereby used as an indicator of the quality of health care. In this study avoidable mortality for more than 30,000 psychiatric patients discharged from any hospital of Stockholm County between 1981 and 1985 has been followed up in the Cause of Death Register for the period 1986-1990. Standardised rate ratios were calculated for different groups of psychiatric disorders compared to the general population of Stockholm County for indicators of avoidable mortality, suicide, other mortality ("unavoidable") and causes possibly related to treatment with psychotrophic drugs. As expected, the psychiatric patients had the most pronounced elevated risk for suicide. i.e. 6- to 24-fold compared to the general population, and noticeably more elevated for women. It is also noteworthy that the relative mortality risks for diagnoses amenable to medical interventions and potential side-effects of psychotrophic drugs are higher than for other causes of death ("unavoidable"). The relative risks for avoidable mortality were 4.7 for men and 3.8 for women and for diagnoses possibly related to side-effects of psychotrophic drugs, 7.2. The relative risks for "unavoidable" mortality were 3.4 for men and 3.2 for women. The excess avoidable mortality rates for psychiatric patients and the elevated suicide risk, especially for female patients, are warning signals of shortcomings in psychiatric care that warrants further investigation.     

Demographic predictors of asthma treatment site: outpatient, inpatient, or emergency department

We evaluated physical activity changes resulting from a six-month public health model intervention that encouraged seniors (N = 89) 62-91 years of age (mean = 76) living in two low-income congregate housing facilities to increase their physical activity by participating in existing community-based physical activity classes and programs of their choice. The program was offered to everyone regardless of their health problems. Enrollees were encouraged to adopt activities tailored to their preferences, physical abilities, health status, income, and transportation resources. Using a comparison-group design, the intervention group was more active for all comparison months of the intervention period (p values < .05). The intervention also was associated with improvements in self-esteem (p < .05), though not with an array of other measures of health-related quality-of-life. Those who adopted and maintained a new physical activity over the six-month intervention period experienced improvements in anxiety, depression, and overall psychological well-being relative to those who did not. The intervention was subsequently replicated through a senior center (N = 22). A much larger proportion of the senior center sample adopted and maintained a new activity for six months (68%) compared to the congregate facilities sample (35%), which may have been due to differences in recruitment methods and sample characteristics in the two settings. An intervention promoting increased physical activity through the use of existing community resources may help increase physical activity in older adults.     

Current human and canine seroprevalence of Chagasic infection in San Pedro de Atacama County, II Region of Antofagasta, Chile, 1995

In order to assess the impact of a control program against Triatoma infestans launched in 1988, based on insecticide spraying of dwellings, a serological survey for chagasic infection was carried out during 1995 in three localities from San Pedro de Atacama County (22 degrees 55' South lat., 68 degrees 12' West long.), II Region of Antofagasta in northern Chile. Blood samples from 531 children and adolescents and 65 dogs were subjected to ELISA test and indirect immunofluorescent test for Chagas' disease respectively. Tests resulted positive in 12 (2.3%) persons, all above 5 years old, in contrast with the 16.8% serological positivity observed in 1985. Three (4.6%) dogs (two 0-12 months old) resulted positive. These results indicate that dwelling sprayings with long-term activity insecticides against T. infestans is a good tool to prevent new human infections with T. cruzi. However, active vector transmission among domestic animals (canines) could be recently acquired.     

Effect of dietary fish oil supplementation on peroxidation of serum lipids in patients with non-insulin dependent diabetes mellitus

Target 17 of the Health Policy for Europe calls for the health-damaging consumption of dependence-producing substances such as alcohol, tobacco and psychoactive substances to be significantly reduced in all Member States between the year 1980 and the year 2000. With regard to alcohol, it is suggested that alcohol consumption be reduced by 25%, with particular attention to reducing harmful use. A question posed by a number of Member States is what is the level of per capita alcohol consumption of lowest risk to physical, psychological and social harm. A working group was convened to consider population levels of alcohol consumption with particular reference to the Member States of the European Region of WHO. A basis for understanding population problem experience can be established through the interaction between individual risk and distribution of consumption levels within the population. The working group concluded that public health policy within the European Region should continue to advise decreases of per capita consumption. Even when taking into account coronary heart disease, it can be concluded at the population level, across all ranges of alcohol consumption found in almost all countries of Europe, that a reduction in consumption is linked to better health. However, public health policy concerning alcohol should not be based solely on mortality. All outcomes of drinking, that is mortality, morbidity, social and criminal consequences, as well as quality of life, should be considered. The existing data relating alcohol consumption to health originates from countries primarily with a cultural experience of consuming alcohol. In those countries, where there is a cultural or religious tradition of not consuming alcohol, there can be no public health grounds for recommending alcohol consumption.     

Promoting breastfeeding: a view of the current position and a proposed agenda for action in Scotland

The prevalence of breastfeeding in Scotland is the second lowest in Europe. There is good evidence that breastfeeding results in decreased gastrointestinal, and to a lesser extent respiratory infections, in the first year of life, and reduced serious infections in low-birthweight babies. Published evidence for the effectiveness of interventions which seek to promote successful breastfeeding within populations is scanty and of poor quality, although numerous studies have highlighted hospital practices which discourage and undermine breastfeeding. Changing these poor practices has been shown to be achievable and can lead to improved breastfeeding rates. Experience in other industrialized countries such as Canada, Australia and Norway has shown that substantial increases in breastfeeding are achievable through combined government and health service action over a period of one or two decades. We recommend a combination of government and health service action to promote breastfeeding in Scotland including: implementation of the International Code on Marketing of Breastmilk Substitutes; reviews of health professional basic and in-service training in breastfeeding management, maternity leave and allowances, and workplace facilities for breastfeeding mothers; promotion of the Baby Friendly Initiative; development of community support for breastfeeding mothers; routine collection of breastfeeding data to support annual monitoring of breastfeeding rates; and support for research on the effectiveness of strategies which seek to promote breastfeeding.     

B cell mitogenic activity of house dust mite, Dermatophagoides farinae, antigens

Hong Kong, Taiwan, Singapore, and Malaysia are initiating health care reform to meet the changing demands of populations with improved socioeconomic status and access to modern technologies and who are living longer than in previous generations. Hong Kong, in particular, is facing a unique set of circumstances as its people prepare for the transition in 1997 from a British colony to a Special Administrative Region of China. While spending only 4% of its gross domestic product on health care, it has a large and regulated public hospital system for most inpatient medical care and a separate, loosely regulated private health care system for most outpatient medical care. In 1993 the Secretary for Health and Welfare of Hong Kong initiated a year-long process to debate the pros and cons of 5 fundamental programs for health care reform. After a year of open consultation, options were chosen. We describe the Hong Kong health care system, the fundamental changes that have been adopted, and lessons for reformers in the United States.     

The effect of distance from home on attendance at a small rural health centre in Papua New Guinea

BACKGROUND: The willingness of patients in the rural tropics to seek medical care at primary health care facilities is influenced by the distance they have to travel, but few studies have tried to estimate these distance effects. METHODS: Distance decay effects in attendance rates were estimated from a database of 4348 attendances at a rural health centre in Papua New Guinea, linked to demographic and house position data for the catchment population. Small-scale spatial patterns and differences between diagnoses, age groups and gender are described. RESULTS: Attendance decreased markedly with distance both overall (50% decrease at 3.5 km) and for patients with malaria or acute respiratory infections. This decrease was non-linear (on log scale) with distance. Although constant over time, there were big differences in this distance effect among age and gender groups: Female patients showed less distance decay in adolescents and adults, but higher in the infant group. Spatial patterns accounted for 32% of the variation in age- and gender-specific attendance rates. Of the spatial effects more than 50% were due to distance effects. CONCLUSIONS: Distance effects were similar in magnitude to those reported elsewhere, suggesting that distance effects may be generalizable to many parts of the rural tropics. The non-linearity of distance decay implies that a bell-shaped demand function should be used in health planning.     

Corticofugal regulation of auditory sensitivity in the bat inferior colliculus

Risk factors for severe acute asthma involve the patient, the environment and the society in general. In addition, there are strong interrelationships between these factors. Personal characteristics linked to acute severe asthma include age (teenagers), denial leading to poor compliance, depression with atypical symptoms in children, and some medical features of asthma associated with increased severity. Environmental factors include airborne allergens, infections, irritants such as air pollutants and passive smoking. Life events have not been extensively studied but are likely to play a predominant role. The social setting, particularly the health care system, acts as an interface between the patient and the environment. Most all asthma deaths are avoidable and related to dysfunctions in the health care system.     

Factors associated with the knowledge, treatment, and control of arterial hypertension in an adult population of the community of Valencia

OBJECTIVE: To identify the level of hypertension awareness, treatment and control in the adult population (14 years and older) at the Valencian Region. Type of treatment and associated factors to the hypertension awareness will be also explored. DESIGN: Cross-sectional study (population survey). SETTING: Valencian Region, Spain. PARTICIPANTS AND MEASUREMENTS: Data from this study are based on a representative sample of the adult population collected for the Nutrition and Health Examination Survey carried out in the Valencian Region in 1994. Blood pressure measurement was based in two readings on each person at a single sitting. RESULTS: Awareness of hypertension among subjects classified as hypertensive was 50%. The frequency of treated patients among all those subjects who knew as hypertensive, was 85%. The proportion of well controlled among treated hypertensive people was lightly higher than 50%. 14.6% of people aware of being hypertensive were not under treatment. CONCLUSIONS: The rule of halves still applies to the Valencian Region, though the proportion of diagnosed hypertensive under treatment is much better (> 85%).     

Evaluation of acceleration plethysmograms in dermatology--efficacy of lipo PGE1 preparations against herpes zoster and neuralgia following herpes

Utilisation of outpatient services in government owned district hospitals in Dar es Salaam, declined by more than 50% following the introduction of user charges in these health facilities in mid July 1993. Outpatient attendances in the private health facilities studied remained constant throughout the year although these charged higher fees. Education and employment status were found to be major factors influencing utilisation of public versus private health facilities. Public facility users (62.8%) had five to eight years of formal education. Private facility users with five to eight years of education were 45.5% and those with more than years of education were 47.1%. While 68.6% of public facility users paid for their own healthcare, more than a quarter (27.3%) had their costs met by relatives or friends. The employer paid for 72% of private facility users, 49.2% of whom stated that this was the reason why they used private facilities. Despite introduction of charges in public hospitals, availability of prescribed medication was poor. Drugs were reported to be always available by only 27.3% of public health facility users compared to 80% of private health facility users.