Objective:  To understand reasons for suboptimal and delayed uptake of antiretroviral therapy (ART) by describing the patterns of HIV testing and counselling (HTC) and outcomes of ART eligibility assessments in primary clinic attendees.

Methods:  All clinic attendances and episodes of HTC were recorded at two clinics in Blantyre. A cohort of newly diagnosed HIV-positive adults (>15 years) was recruited and exit interviews undertaken. Logistic regression models were constructed to investigate factors associated with referral to start ART. Qualitative interviews were conducted with providers and patients.

Results:  There were 2398 episodes of HTC during 18 021 clinic attendances (13.3%) between January and April 2011. The proportion of clinic attendees undergoing HTC was lowest in non-pregnant women (6.3%) and men (8.5%), compared with pregnant women (47.2%). Men had more advanced HIV infection than women (79.7% WHO stage 3 or 4 vs. 56.4%). Problems with WHO staging and access to CD4 counts affected ART eligibility assessments; only 48% completed ART eligibility assessment, and 54% of those reporting WHO stage 3/4 illnesses were not referred to start ART promptly. On multivariate analysis, HIV-positive pregnant women were significantly less likely to be referred directly for ART initiation (adjusted OR: 0.29, 95% CI: 0.13–0.63).

Conclusions:  These data show that provider-initiated testing and counselling (PITC) has not yet been fully implemented at primary care clinics. Suboptimal ART eligibility assessments and referral (reflecting the difficulties of WHO staging in primary care) mean that simplified eligibility assessment tools are required to reduce unnecessary delay and attrition in the pre-ART period. Simplified initiation criteria for pregnant women, as being introduced in Malawi, should improve linkage to ART.

Objective  To determine the expression of Pfg377 ortholog gene in Plasmodium vivax, and examine its correlation with mosquito infection.

Methods  Seventy clinical blood samples positive for P. vivax by microscopy, were used for the mosquito infectivity assay. Infectivity to female Anopheles dirus was determined from oocyst counts. The transcripts of Pfg377 ortholog gene of P. vivax from blood samples infective and non-infective to mosquitoes were examined using quantitative real-time reverse transcriptase-polymerase chain reaction (RT-PCR).

Results  Of 70 P. vivax positive blood samples, 50 (71.4%) samples were mosquito-infective and 20 (28.6%) were not. In infective samples, the expression level of Pfg377 ortholog gene was significantly higher than in the non-infective group (P < 0.05). In infective samples, the expression level of Pfg377 ortholog gene at ≥100 copies/ml of blood cut-off point correlated with ≥10 oocysts/mosquito cut-off point of average oocyst numbers and with ≥50% cut-off point of per cent infected mosquitoes (Pearson’s chi-square correlation, P = 0.014 and P = 0.026, respectively).

Conclusion  The cut-off point of the expression level of Pfg377 ortholog gene could be used to predict the infectiousness of P. vivax gametocytes leading to mosquito infection and parasite transmission in the field.

Objective  To analyse survival and retention rates of the Tanzanian care and treatment programme.

Methods  Routine patient-level data were available from 101 of 909 clinics. Kaplan–Meier probabilities of mortality and attrition after ART initiation were calculated. Mortality risks were corrected for biases from loss to follow-up using Egger’s nomogram. Smoothed hazard rates showed mortality and attrition peaks. Cox regression identified factors associated with death and attrition. Median CD4 counts were calculated at 6 month intervals.

Results  In 88,875 adults, 18% were lost to follow up 12 months after treatment initiation, and 36% after 36 months. Cumulative mortality reached 10% by 12 months (15% after correcting for loss to follow-up) and 14% by 36 months. Mortality and attrition rates both peaked within the first six months, and were higher among males, those under 45 kg and those with CD4 counts below 50 cells/μl at ART initiation. In the first year on ART, median CD4 count increased by 126 cells/μl, with similar changes in both sexes.

Conclusion  Earlier diagnoses through expanded HIV testing may reduce high mortality and attrition rates if combined with better patient tracing systems. Further research is needed to explore reasons for attrition.

Objective  To describe a participatory approach to implement and evaluate ways to integrate and train community care workers (CCWs) to enhance collaborative TB/HIV/PMTCT activities, and home-based HIV counseling and testing (HCT) at community level.

Methods  The intervention study was conducted in Sisonke, a rural district of KwaZulu Natal, South Africa. A baseline household (HH) survey was conducted in 11 villages. Six villages were randomly selected into intervention and control clusters. Training was provided first to CCWs from the intervention cluster (IC) followed by the control cluster (CC). Routine monthly data from CCWs were collected from March–December 2010. The data was subjected to bivariate tests.

Results  The baseline HH survey revealed that of 3012 HH members visited by CCWs in 2008, 21% were screened for TB symptoms, 7% were visited for TB adherence support and 2% for ART adherence, and 1.5% were counselled on infant feeding options. A total of 89 CCWs were trained. Data show that during the study period in IC, 684 adults were offered HCT by CCWs, 92% accepted HCT and tested and 7% tested HIV-positive and were referred to the clinic for further care. Of 3556 adults served in IC, 44% were screened for TB symptoms and 32% for symptoms of sexually transmitted infections (STIs) and 37% of children were traced as TB contact. Out of 6226 adults served in CC, 10% were screened for TB symptoms and 7% for STI symptoms. The differences in uptake of services between IC and CC were statistically significant (p < 0.05).

Conclusion  The findings of this study suggest higher uptake of TB and STI symptoms screening, TB contact tracing and home based HCT in the intervention clusters. This study suggests that up-skilling CCWs could be one avenue to enhance TB/HIV case finding, TB contact tracing and linkages to care.

Objectives  This study evaluates the diagnostic accuracy of Haemoglobin Colour Scale (HCS), compared with clinical diagnosis, to detect anaemia and severe anaemia in preschool-age children attending primary healthcare clinics in rural Zanzibar.

Methods  In all participants, haemoglobin (Hb) concentration was independently estimated by clinical examination for palmar pallor, HCS and HemoCue™. HemoCue was considered the reference method. Data collection was integrated into the usual health services and performed by local healthcare workers (HCWs). Sensitivity, specificity, positive and negative predictive values were calculated for HCS and clinical examination for palmar pallor. The limits of agreement between HCS and HemoCue, and inter-observer variability for HCS, were also defined.

Results  A total of 799 children age 2–59 months were recruited to the study. The prevalence of anaemia (Hb < 11 g/dl) and severe anaemia (<5 g/dl) were 71% and 0.8% respectively. The sensitivity of HCS to detect anaemia was 33% [95% confidence interval (CI) 29–36] and specificity was 87% (83–91). The sensitivity of HCS to detect severe anaemia was 14% (95% CI 0–58) and specificity was 100% (99–100). The sensitivity of palmar pallor to detect anaemia was low, but superior to HCS (58%vs. 33%, P < 0.001); specificity was inferior to HCS (55%vs. 87%, P < 0.001). There was no evidence of a difference in either sensitivity (P > 0.1) or specificity (P > 0.1) between HCS and palmar pallor to detect severe anaemia.

Conclusions  Haemoglobin Colour Scale does not improve the capacity of HCWs to diagnose anaemia in this population. Accuracy is limited by considerable variability in the performances of test operators. However, optimizing the training protocol for those using the test may improve performance.

During the 1990s, Cuba was able to overcome a severe crisis, almost without negative health impacts. This national retrospective study covering the years 1989–2000 analyses the country’s strategy through essential social, demographic, health process and health outcome indicators. Gross domestic product (GDP) diminished by 34.76% between 1989 and 1993. In 1994 slow recuperation started. During the crisis, public health expenses increased. The number of family doctors rose from 9.22 to 27.03 per 104 inhabitants between 1989 and 2000. Infant mortality rate and life expectancy exemplify a series of health indicators that continued to improve during the crisis years, whereas low birth weight and tuberculosis incidence are among the few indicators that suffered deterioration. GDP is inversely related to tuberculosis incidence, whereas the average salary is inversely related to low birth weight. Infant mortality rate has a strong negative correlation with the health expenses per inhabitant, the number of maternal homes, the number of family doctors and the proportion of pregnant women receiving care in maternal homes. Life expectancy has a strong positive correlation with health expenses, the number of nursing personnel and the number of medical contacts per inhabitant. The Cuban strategy effectively resolved health risks during the crisis. In times of serious socio-economic constraints, a well conceptualized public health policy can play an important role in maintaining the overall well-being of a population.

Objective  To evaluate the effect of integrating ITN distribution on measles vaccination campaign coverage in Madagascar.

Methods  Nationwide cross-sectional survey to estimate measles vaccination coverage, nationally, and in districts with and without ITN integration. To evaluate the effect of ITN integration, propensity score matching was used to create comparable samples in ITN and non-ITN districts. Relative risks (RR) and 95% confidence intervals (CI) were estimated via log-binomial models. Equity ratios, defined as the coverage ratio between the lowest and highest household wealth quintile (Q), were used to assess equity in measles vaccination coverage.

Results  National measles vaccination coverage during the campaign was 66.9% (95% CI 63.0–70.7). Among the propensity score subset, vaccination campaign coverage was higher in ITN districts (70.8%) than non-ITN districts (59.1%) (RR = 1.3, 95% CI 1.1–1.6). Among children in the poorest wealth quintile, vaccination coverage was higher in ITN than in non-ITN districts (Q1; RR = 2.4, 95% CI 1.2–4.8) and equity for measles vaccination was greater in ITN districts (equity ratio = 1.0, 95% CI 0.8–1.3) than in non-ITN districts (equity ratio = 0.4, 95% CI 0.2–0.8).

Conclusion  Integration of ITN distribution with a vaccination campaign might improve measles vaccination coverage among the poor, thus providing protection for the most vulnerable and difficult to reach children.

Objectives  To establish levels of handwashing after defecation among students at the University of Cape Coast in Ghana, and to test hypotheses that gender and washroom environment affect handwashing behaviour.

Methods  Data on students’ handwashing behaviour after defecation were collected by structured observations in washrooms. Eight hundred and six observations were made (360 female students and 446 males) in 56 washrooms over 496 observation periods. Observers recorded gender, duration of handwashing, use of soap, and physical characteristics of the washroom (cleanliness, availability of soap, tap flow and presence of handwashing posters).

Results  Fewer than half the students observed washed their hands or bathed after defecation. Of these, only two-thirds washed both hands and a minority (20%) used soap; only 16 students (all men) washed their hands for the recommended 15 s or longer. Female students were more likely to wash their hands at all, and were more likely to wash both hands, than males. Cleanliness of the washroom was strongly associated with improved handwashing behaviour for both women and men, as was tap flow quality for female students.

Conclusions  Handwashing behaviour is generally poor among UCC students, mirroring results from North American Universities. The findings underline the plasticity of handwashing behaviour among this population, and highlight the need for ensuring that the physical environment in washrooms on university campuses is conducive to handwashing.

Objective  The Brazilian National Hansen’s Disease Control Program recently identified clusters with high disease transmission. Herein, we present different spatial analytical approaches to define highly vulnerable areas in one of these clusters.

Method  The study area included 373 municipalities in the four Brazilian states Maranhão, Pará, Tocantins and Piauí. Spatial analysis was based on municipalities as the observation unit, considering the following disease indicators: (i) rate of new cases/100 000 population, (ii) rate of cases <15 years/100 000 population, (iii) new cases with grade-2 disability/100 000 population and (iv) proportion of new cases with grade-2 disabilities. We performed descriptive spatial analysis, local empirical Bayesian analysis and spatial scan statistic.

Results  A total of 254 (68.0%) municipalities were classified as hyperendemic (mean annual detection rates >40 cases/100 000 inhabitants). There was a concentration of municipalities with higher detection rates in Pará and in the center of Maranhão. Spatial scan statistic identified 23 likely clusters of new leprosy case detection rates, most of them localized in these two states. These clusters included only 32% of the total population, but 55.4% of new leprosy cases. We also identified 16 significant clusters for the detection rate <15 years and 11 likely clusters of new cases with grade-2. Several clusters of new cases with grade-2/population overlap with those of new cases detection and detection of children <15 years of age. The proportion of new cases with grade-2 did not reveal any significant clusters.

Conclusions  Several municipality clusters for high leprosy transmission and late diagnosis were identified in an endemic area using different statistical approaches. Spatial scan statistic is adequate to validate and confirm high-risk leprosy areas for transmission and late diagnosis, identified using descriptive spatial analysis and using local empirical Bayesian method. National and State leprosy control programs urgently need to intensify control actions in these highly vulnerable municipalities.

Objective  To assess the effect of intermittent preventive treatment with sulfadoxine–pyrimethamine (IPTp-SP) on birth weight in sites with varying degrees of drug resistance.

Methods  Birth weight data from three regions in Democratic Republic of Congo with varying degrees of sulfadoxine–pyrimethamine (SP) resistance (1.6% in Mikalayi, 21.7% in Kisangani and 60.6% in Rutshuru) were analysed retrospectively by means of a logistic model that included the number of SP doses taken by the mother and other potentials confounding factors.

Results  The IPTp-SP reduced the risk of low birth weight (LBW) in Kisangani (adjusted OR, 0.15; IC95%, 0.05–0.46) and in Mikalayi (adjusted OR, 0.12; IC95%, 0.01–0.89). In both sites, the average birth weight was higher for mothers having received two rather than one or no SP doses (P < 0.001). In Rutshuru, IPTp-SP had an effect in primigravidae but not in multigravidae. However, after adjustment for other LBW risk factors, there was no difference in the proportion of LBW (adjusted OR 0.92; IC95%, 0.37–2.25) between women having taken at least 2 SP doses and those with only one dose or none.

Conclusion  IPT-SP remains an effective strategy in Kisangani and Mikalayi where the therapeutic failure to SP in children with clinical malaria was 21.7% and 1.6%, respectively, while IPTp-SP effect seems lower in Rutshuru where the therapeutic failure to SP was 60.6%. The threshold value of SP resistance at which IPTp-SP fails to have a significant impact on birth weight and LBW is unknown. Considering that no alternative is currently available, additional studies on the efficacy of IPTp-SP in the areas of high SP resistance such as Rutshuru are needed so that the threshold at which this intervention fails to provide any benefit is determined with some precision.

The Health InterNetwork Access to Research Initiative (HINARI), which arose in response to medical literature needs in developing countries, gives online access to scientific information to a variety of institutions throughout the world. This is a great resource; however, little research has been performed on the effectiveness and usefulness of HINARI, specifically to medical schools. Our study sought to find out whether the textbooks (e-books) available on HINARI could form a virtual library that would cover the curriculum of a medical school. After categorising and reviewing the medically relevant e-books on HINARI, we found that they were insufficient in providing adequate subject material relevant to medical school curricula from Rwanda, the United Kingdom and the United States. This literature gap could be closed by additional medical textbooks being made available from contributing publishers. An increase of only 14% in HINARI e-book resources would provide material for the entire medical school curriculum.

Objective  To evaluate the serological and parasitological status of patients with chronic Chagas disease (CD) after chemotherapy with benzonidazole.

Methods  Retrospective study of patients treated with benzonidazole (5 mg/kg/day for 60 days) between 1980 and 2010. Twenty-nine patients who had CD confirmed by two reagent immunological tests and/or one positive xenodiagnosis before treatment were included. Conventional serology (ELISA and IIF) and parasitological tests (haemoculture and N-PCR) were performed.

Results  At the time of treatment, the mean age of patients was 36 ± 7.24 years (20–39 years) and the time post-treatment varied from 1 to 29 years. After chemotherapy, all individuals had reagent ELISA and 93.1% had positive results for the IIF test. T. cruzi DNA was detected by N-PCR in 48.3%. Negative results were observed in 41.4% and inconclusive ones in 10.3%. Haemoculture was negative for all individuals.

Conclusions  Our results suggest that N-PCR may be useful in the early identification of therapeutic failure of CD. Although it is difficult to determine parasitological cure in negative N-PCR cases, we can infer that this condition represents a declination of parasitaemia as a favourable consequence of aetiological treatment.

Objectives  Before antiretroviral therapy (ART) introduction, pregnancy was associated with a sustained drop in CD4 cell count in HIV-infected women. We examined the effects of pregnancy on immunological and virological ART outcomes.

Methods  Between January 2004 and March 2009, we studied HIV-infected women receiving ART in a prospective open cohort study in rural Uganda. We used random effects regression models to compare the CD4 counts of women who became pregnant and those who did not, and among the pregnant women before and after pregnancy. CD4 count and proportions with detectable viral load (≥400 copies/ml) were compared between the two groups using the Mann–Whitney rank sum test and logistic regression respectively.

Results  Of 88 women aged 20–40 years receiving ART, 23 became pregnant. At ART initiation, there were no significant differences between those who became pregnant and those who did not in clinical, immunological and virological parameters. Among women who became pregnant, CD4 cell count increased before pregnancy (average 75.9 cells/mm³ per year), declined during pregnancy (average 106.0) but rose again in the first year after delivery (average 88.6). Among women who did not become pregnant, the average CD4 cell count rise per year for the first 3 years was 88.5. There was no significant difference in the proportions of women with detectable viral load at last clinic visit among those who became pregnant (8.7%) and those who did not (16.1%), P = 0.499.

Conclusion  Pregnancy had no lasting effect on the immunological and virological outcomes of HIV-infected women on ART.

Objectives  There has been increased attention to access to water, sanitation and hygiene (WASH) at schools in developing countries, but a dearth of empirical studies on the impact. We conducted a cluster-randomized trial of school-based WASH on pupil absence in Nyanza Province, Kenya, from 2007 to 2008.

Methods  Public primary schools nested in three geographical strata were randomly assigned and allocated to one of three study arms [water treatment and hygiene promotion (WT & HP), additional sanitation improvement, or control] to assess the effects on pupil absence at 2-year follow-up.

Results  We found no overall effect of the intervention on absence. However, among schools in two of the geographical areas not affected by post-election violence, those that received WT and HP showed a 58% reduction in the odds of absence for girls (OR 0.42, CI 0.21–0.85). In the same strata, sanitation improvement in combination with WT and HP resulted in a comparable drop in absence, although results were marginally significant (OR 0.47, 0.21–1.05). Boys were not impacted by the intervention.

Conclusion  School WASH improvements can improve school attendance for girls, and mechanisms for gendered impacts should be explored. Incomplete intervention compliance highlights the challenges of achieving consistent results across all settings.

Objective  To calculate perinatal mortality (stillbirth and early neonatal death: END) rates in the Upper East region of Ghana and characterize community-based stillbirths and END in terms of timing, cause of death, and maternal and infant risk factors.

Methods  Birth outcomes were obtained from the Navrongo Health and Demographic Surveillance System over a 7-year period.

Results  Twenty thousand four hundred and ninty seven pregnant women were registered in the study. The perinatal mortality rate was 39 deaths/1000 deliveries, stillbirth rate 23/1000 deliveries and END rates 16/1000 live births. Most stillbirths were 31 weeks gestation or less. Prematurity, first-time delivery and multiple gestation all significantly increased the odds of perinatal death. Approximately 70% of END occurred during the first 3 postnatal days, and the most common causes of death were birth asphyxia and injury, infections and prematurity.

Conclusion  Stillbirths and END remain a significant problem in Navrongo. The main causes of END occur during the first 3 days and may be modifiable with simple targeted perinatal policies.

The choice of research method relevant to the evaluation of delivery of a health intervention is not always straightforward. We use the evaluation of HIV and tuberculosis community treatment supporters in promoting adherence to treatment in Africa as a case study to illustrate the pros and cons of operational research and randomised controlled trials. The choice of this intervention for the case study reflects the importance of maximising the benefits of unprecedented efforts to scale-up treatments of these two epidemics. International policy supporting the role of community treatment supporters in tuberculosis is largely based on the findings of operational research studies. This reflects the advantages that operational research is less costly than randomised controlled trials, provides more rapid answers to policy questions, enables standard evaluation of the intervention in ‘real life’ conditions in several diverse settings and has in-built potential to influence policy and practice, because the research is conducted within health programmes. Recent evidence on the role of community treatment supporters in HIV is largely based on randomised trials. This reflects the advantages that randomised trials compared to operational research are more rigorous and generate a more convincing result. Operational research and randomised trials may be viewed as providing complementary findings to inform new policies and practice aimed at improving programme performance and patient outcomes. However, in practice, insufficient funds are likely to be made available for randomised trials to answer all the current research questions on delivery of programme interventions. In deciding on the type of research to evaluate a particular health intervention, dialogue is necessary with policy-makers to weigh up explicitly the trade-offs between research rigour and other factors such as cost, speed of implementation of research and speed of policy uptake and of change in programme practice.

Objectives  We conducted a case study of an urban immunization outreach strategy to determine the feasibility of the intervention and to measure administrative immunization coverage outcomes.

Methods  A multipronged strategy for improving immunization coverage in Urban Patna, India, was implemented for 1 year (2009/2010). The strategy was designed to increase immunization sites, shift human resources, plan logistics, improve community mobilization, provide supervision, strengthen data flow and implement special vaccination drives.

Results  Over 1 year, the coverage of all primary vaccines of the Universal Immunization Program improved by over 100%.

Conclusion  Coverage can be rapidly improved through outreach immunization in low socioeconomic areas if existing opportunities are carefully utilized.

Objective  Pre-eclampsia contributes significantly to maternal, foetal and neonatal morbidity and mortality. The risk factors for pre-eclampsia have not been well documented in Uganda. In this paper, we describe the risk factors for pre-eclampsia in women attending antenatal clinics at Mulago Hospital, Kampala.

Methods  This casecontrol study was conducted from 1st May 2008 to 1st May 2009. 207 women with pre-eclampsia were the cases, and 352 women with normal pregnancy were the controls. The women were 15–39 years old, and their gestational ages were 20 weeks or more. They were interviewed about their socio-demographic characteristics, past medical history and, their past and present obstetric performances.

Results  The risk factors were low plasma vitamin C (OR 3.19, 95% CI: 1.54–6.61), low education level (OR 1.67, 95% CI: 1.12–2.48), chronic hypertension (OR 2.29, 95% CI 1.12–4.66), family history of hypertension (OR 2.25, 95% CI: 1.53–3.31) and primiparity (OR 2.76, 95% CI: 1.84–4.15) and para≥5 (3.71, 95% CI:1.84–7.45).

Conclusion  The risk factors identified are similar to what has been found elsewhere. Health workers need to identify women at risk of pre-eclampsia and manage them appropriately so as to prevent the maternal and neonatal morbidity and mortality associated with this condition.

Objective  To describe the distribution, size and characteristics of formal and non-formal meeting places for gay men in Mexico City, the general characteristics of this population, and the factors influencing HIV status and sexual behaviour among gay men.

Methods  Meeting sites for gay men in Mexico City were mapped, and the results were used as a sampling frame for an individual-level survey. For the survey, a random sample of sites was selected using a selection probability proportional to size, with the aim of interviewing approximately 3000 gay men. Multivariate logistic models were constructed to analyse the correlations between the population profile, and characteristics and behaviours related to HIV status.

Results  Mapping produced an estimated population attending these meeting places in Mexico City of about 6000–14 000 gay men, who were mostly young and economically active individuals with higher educational and socioeconomic levels than the average levels of the population as a whole. Approximately 67% of these men reported being tested for HIV at least once, and 30% of the men reported being HIV-positive.

Discussion  Participants’ profile depicted the gay population in Mexico City as a highly educated community with a relatively high socioeconomic level. Despite their exposure to prevention efforts, members of this community reported unsafe behaviours consistent with the high prevalence of self-reported HIV infection.

Objective  To assess health workers’ compliance with the procedures set in the focused antenatal care (ANC) guidelines in rural Uganda, Tanzania and Burkina Faso; to compare the compliance within and among the three study sites; and to appraise the logistic and supply of the respective health facilities (HF).

Methods  The cross-sectional study was conducted in the rural HF in three African countries. This descriptive observational study took place in HF in Nouna, Burkina Faso (5), Iganga, Uganda (6) and Rufiji, Tanzania (7). In total, 788 ANC sessions and service provisions were observed, the duration of each ANC service provision was calculated, and the infrastructures of the respective HF were assessed.

Results  Health workers in all HF performed most of the procedures but also omitted certain practices stipulated in the focused ANC guidelines. There was a substantial variation in provision of ANC services among HF within and among the country sites. The findings also revealed that the duration of first visits was <15 min and health workers spent even less time in subsequent visits in all three sites. Reagents for laboratory tests and drugs as outlined in the focus ANC guidelines were often out of stock in most facilities.

Conclusion  Health workers in all three country sites failed to perform all procedures stipulated in the focused ANC guideline; this could not be always explained by the lack of supplies. It is crucial to point out the necessity of the core procedures of ANC repeatedly.

To determine the effect of maternal anaemia on pregnancy outcome and describe its impact on infant haemoglobin level in the first 18 months of life, we conducted a prospective study of 617 pregnant women and their children in Benin. Prevalence of maternal anaemia at delivery was 39.5%, and 61.1% of newborns were anaemic at birth. Maternal anaemia was not associated with low birth weight [OR = 1.2 (0.6–2.2)] or preterm birth [OR = 1.3 (0.7–2.4)], whereas the newborn’s anaemia was related to maternal anaemia [OR = 1.8 (1.2–2.5)]. There was no association between an infant’s haemoglobin level until 18 months and maternal anaemia. However, malaria attacks during follow-up, male gender and sickle cell trait were all associated with a lower infant haemoglobin level until 18 months, whereas good infant feeding practices and a polygamous family were positively associated with a higher haemoglobin level during the first 18 months of life.

Objective  Kenya, like many resource-constrained countries, has a single mycobacterial laboratory, centrally located in Nairobi, with capacity for drug-susceptibility testing (DST) – the gold standard in diagnosing drug-resistant tuberculosis. We describe and evaluate a novel operational design that attempts to overcome diagnostic delivery barriers.

Methods  Review of the public DST programme identified several barriers limiting access: lack of programme awareness amongst physicians, limited supplies, unreliable transport and no specimen tracking methods. Staff visited 19 clinic sites in western Kenya and trained healthcare providers in regard to the novel diagnostics model. Provincial laboratory registries were reviewed to assess utilization of DST services prior to and after programme modification.

Results  Onsite training consisted of the inclusion criteria for re-treatment patients – the high-priority group for DST. Additionally, infrastructural support established a stable supply chain. An existing transport system was adapted to deliver sputum specimens. Task shifting created an accession and tracking system of specimens. During the 24 months post-implementation, the number of re-treatment specimens from the catchment area increased from 9.1 to 23.5 specimens per month. In comparing annual data pre- and post-implementation, the proportion of re-treatment cases receiving DST increased from 24.7% (n = 403) to 32.5% (n = 574) (P < 0.001), and the number of multidrug-resistant (MDR) TB cases increased from 5 to 10 cases.

Conclusion  The delivery model significantly increased the proportion of re-treatment cases receiving DST. Barriers to accessing the national MDR-TB surveillance programme can be overcome through an operational model based on pragmatic use of existing services from multiple partners.

Vitex madiensis Oliv. (Lamiaceae) is traditionally used to treat malaria symptoms in Haut-Ogooué, Gabon. Leaves and stem barks extracts were obtained using dichloromethane (CH₂Cl₂), ethyl acetate (EtOAc) and methanol (MeOH) as extraction solvents and fractionated on silica gel column. The in vitro antiplasmodial activity of CH₂Cl₂, EtOAc and MeOH extracts and fractions was evaluated against the chloroquine-resistant FCB strain and field isolates of Plasmodium falciparum using the DELI test. The cytotoxicity of the extracts was tested on MRC-5 and THP1 cells using the tetrazolium salt MTT colorimetric assay, and the selectivity index (SI) of each extract was calculated. CH₂Cl₂ extract, the EA1 fraction from EtOAc extract of stem barks and cyclohexane (L_cycl), dichloromethane (L_DM) and butanol (L_but) fractions from MeOH/H₂O extract of leaves exhibited the highest in vitro antiplasmodial activity on FCB strain and field isolates (IC₅₀ from 0.53 to 4.87 μg/ml) with high selectivity index (of 20.15–1800). These data support the use of V. madiensis in malaria treatment along with continued investigations within traditional medicines in the search of new antimalarial agents. The EA1, C₆H₁₂ and CH₂Cl₂ fractions could be selected for future investigation or/and for the treatment of malaria symptoms after standardization.

Objective  Intermittent preventive treatment in infants (IPTi) is a malaria control strategy currently recommended by WHO for implementation at scale in Africa, consisting of administration of sulphadoxine-pyrimethamine (SP) coupled with routine immunizations offered to children under 1 year. In this study, we analysed IPTi acceptability by communities and health staff.

Methods  Direct observation, in-depth interviews (IDIs) and focus group discussions (FGDs) were conducted in Benin, Madagascar and Senegal during IPTi pilot implementation. Villages were stratified by immunization coverage. Data were transcribed and analysed using NVivo7 software.

Results  Communities’ knowledge of malaria aetiology and diagnosis was good, although generally villagers did not seek treatment at health centres as their first choice. Perceptions and attitudes towards IPTi were very positive among communities and health workers. A misconception that SP was an antipyretic that prevents post-vaccinal fever contributed to IPTi’s acceptability. No refusals or negative rumours related to IPTi coupling with immunizations were identified, and IPTi did not negatively influence attitudes towards other malaria control strategies. Healthcare decisions about children, normatively made by the father, are starting to shift to educated and financially independent mothers.

Discussion  Intermittent preventive treatment in infants is well accepted by providers and communities, showing a synergic acceptability when coupled with routine immunizations. However, a misconception that SP alleviates fever should be addressed when scaling up implementation.

Objectives  During mass antibiotic distributions for trachoma, certain individuals are difficult to locate and go untreated. These untreated individuals may serve as a source of community reinfection. The importance of this difficult-to-locate, untreated population is unclear. We sought to determine whether individuals who are difficult to locate were more likely to be infected with ocular chlamydia than those who were easier to locate.

Methods  We monitored 12 Ethiopian communities 1 year after a third annual mass azithromycin treatment for trachoma. Conjunctival swabbing for chlamydial RNA was performed in a random sample of children from each community. If insufficient numbers of children were enrolled on the first monitoring day, we returned on subsequent days.

Results  Of the 12 communities, 10 required more than one monitoring day. On average, 16.1% (95% CI 7.9–30.0) of children were enrolled after the initial day. Evidence of chlamydia was found in 7.1% (95% CI 2.7–17.4) of 0- to 9-year-old children. No ocular swabs collected after the initial day were positive for chlamydial RNA. Children examined after the initial monitoring day were significantly less likely to have ocular chlamydial infection than children seen on the initial day; Mantel–Haenszel common OR = 0 (95% CI 0–0.77).

Conclusions  In a setting of repeated annual mass azithromycin treatments, after approximately 80% of individuals have been located in a community, extra efforts to find absent individuals may not yield significantly more cases of ocular chlamydia.

Objective  To investigate the quality of malaria case management in Cameroon 5 years after the adoption of artemisinin-based combination therapy (ACT). Treatment patterns were examined in different types of facility, and the factors associated with being prescribed or receiving an ACT were investigated.

Methods  A cross-sectional cluster survey was conducted among individuals of all ages who left public and private health facilities and medicine retailers in Cameroon and who reported seeking treatment for a fever. Prevalence of malaria was determined by rapid diagnostic tests (RDTs) in consenting patients attending the facilities and medicine retailers.

Results  Among the patients, 73% were prescribed or received an antimalarial, and 51% were prescribed or received an ACT. Treatment provided to patients significantly differed by type of facility: 65% of patients at public facilities, 55% of patients at private facilities and 45% of patients at medicine retailers were prescribed or received an ACT (P = 0.023). The odds of a febrile patient being prescribed or receiving an ACT were significantly higher for patients who asked for an ACT (OR = 24.1, P < 0.001), were examined by the health worker (OR = 1.88, P = 0.021), had not previously sought an antimalarial for the illness (OR = 2.29, P = 0.001) and sought treatment at a public (OR = 3.55) or private facility (OR = 1.99, P = 0.003). Malaria was confirmed in 29% of patients and 70% of patients with a negative result were prescribed or received an antimalarial.

Conclusions  Malaria case management could be improved. Symptomatic diagnosis is inefficient because two-thirds of febrile patients do not have malaria. Government plans to extend malaria testing should promote rational use of ACT; though, the introduction of rapid diagnostic testing needs to be accompanied by updated clinical guidelines that provide clear guidance for the treatment of patients with negative test results.

Objective  Clinical laboratories in low- and middle-income countries (LMIC) need fundamental improvement because quality laboratory services are essential for the decision-making capacity of clinicians, health workers and public health authorities. To this end, a tiered accreditation scheme Stepwise Laboratory Improvement Process Towards Accreditation (SLIPTA) was developed by WHO-AFRO, CDC and others for clinical laboratories in LMIC. One to five stars are accredited to laboratories based on the level of compliance with a checklist. Our aim was to evaluate the quality and applicability of this accreditation scheme compared with international quality standards.

Methods  We performed a critical review of this scheme to formulate recommendations for implementation, harmonization and improvement. Two analyses were performed: one assessing its coverage of the ISO 15189:2007 standard and one to identify and evaluate priorities of the accreditation checklist.

Results  Although the content of the checklist covers all aspects of total quality management, it strongly prioritizes resource management activities. We recommend identifying critical requirements for each tier of accreditation to assure a certain level of quality for each tier or instead using a pass/fail approach towards accreditation. In addition, the checklist should include more questions for assessing proper management, ethics and continuous improvement to meet ISO 15189.

Conclusion  Launching accreditation schemes for laboratories in LMIC should be encouraged. After further optimization of SLIPTA, clinical laboratories may certainly benefit, leading to more correctly diagnosed patients and less waste of resources.

Objective  In view of the substantial incidence of bloodborne diseases and risk to surgical healthcare workers in low- and middle-income countries (LMICs), we evaluated the availability of eye protection, aprons, sterile gloves, sterilizers and suction pumps.

Methods  Review of studies using the WHO Tool for the Situational Analysis of Access to Emergency and Essential Surgical Care.

Results  Eight papers documented data from 164 hospitals: Afghanistan (17), Gambia (18), Ghana (17), Liberia (16), Mongolia (44), Sierra Leone (12), Solomon Islands (9) and Sri Lanka (31). No country had a 100% supply of any item. Eye protection was available in only one hospital in Sri Lanka (4%) and most abundant in Liberia (56%). The availability of sterile gloves ranged from 24% in Afghanistan to 94% in Ghana.

Conclusion  Substantial deficiencies of basic protective supplies exist in low- and middle-income countries.

Objectives  Concerns about unsafe injection practices and possible infections with blood-borne pathogens in the Syrian Arab Republic motivated an assessment of the injection safety situation in the country in July 2001. In light of the recommendations from this assessment, the Ministry of Health of Syria, with the assistance of WHO, implemented a set of activities under the ‘Focus Project’, which aims to ensure immunization safety. The first phase of the project ran from May 2002 to February 2004, and consisted of the improved provision of injection safety equipment and supplies, the elaboration and wide distribution of national guidelines on injection safety and safe waste management, a behaviour change and communication campaign targeting the general public, and comprehensive training of healthcare workers. A follow-up survey was carried out in February 2004, 2 years after initiation of the project.

Methods  Two representative surveys were conducted using a standardized assessment tool. A cluster sampling strategy, with probability proportionate to the population size, led to the inclusion of 80 health facilities in eight districts in 2001 and of 120 health facilities in 12 districts in 2004.

Results  Injection practices had significantly improved 2 years after the start of the project. The 2001 study had pointed to a low, but non-negligible risk to patients (2% unsafe injections), coupled with a high risk to healthcare workers (61% reported needle-stick injuries in the last 12 months) and to the communities owing to unsafe waste disposal (sharps waste found outside 37% of health facilities, waste disposal considered unsafe in 48% of them). The 2004 survey showed that 90% of Syrian healthcare workers had received training in injection safety. All injections observed were given safely (difference to 2001 not significant), although some problems in preparation and reconstitution prevailed. The risk to healthcare workers was significantly reduced as only 14% of the staff reported needle-stick injuries (p < 0.001). The risk to the communities was notably decreased following improvements in sharps waste management (sharps were found in the surroundings of only 13% of health facilities, p < 0.001).

Conclusions  The example of Syria shows that rapid improvement in injection safety is possible and that the necessary tools and methods to monitor and evaluate progress are at our disposal. Challenges remain in transferring this successful programme from the well-structured immunization programme to the more diverse curative health services.

Objectives  This enquiry aimed to provide a snap-shot of availability, price and quality of malaria rapid diagnostic tests (RDTs) in private health facilities at selected sites in six malaria-endemic countries in Africa, South East Asia and South America.

Methods  In each study site, data collectors surveyed private healthcare facilities which were selected based on accessibility from their home institution. Using a questionnaire, information was recorded about the facility itself and the malaria RDT(s) available. Where possible, a small number of RDTs were procured and quality control tested using a standardized procedure.

Results  Of the 324 private healthcare facilities visited, 35 outlets (mainly private clinics and hospitals) were found to supply 10 different types of RDTs products. RDT prices across the six countries ranged from US$1.00 to $16.81. Five of the 14 malaria RDTs collected failed quality control testing.

Conclusions  In the private outlets sampled, the availability of RDTs was limited. Some of the RDTs whose quality we tested demonstrated inadequate sensitivity. This presents a number of risks. Given the more widespread distribution of antimalarials currently planned for private sector facilities, parasite-based diagnosis in this sector will be essential to adhere to the WHO guidelines for effective case management of malaria. Considerable regulation and quality control are also necessary to assure the availability of accurate and reliable RDTs, as well as adequate case management and provider adherence to RDT results. Public sector engagement is likely to be essential in this process.

Objective  To assess the genotype prevalence and the multiplicity of Plasmodium falciparum infections in the maritime region of Togo.

Methods  We enrolled 309 symptomatic individuals aged from 6 months to 15 years from Bè/Lomé and Tsévié, two malaria endemic zones. The number and the proportions of merozoite surface proteins 1, 2 and 3 genotypes in patients were determined using capillary electrophoresis genotyping. We further investigated the possible association between transaminases and homocysteine, and the severity of the disease.

Results  Of the 309 samples genotyped, 210 tested positive to msp-1, 227 to msp-2 and 193 to msp-3. The nested PCR revealed 22 different alleles for the allelic family msp-1, 33 for msp-2 and 13 for msp-3. At each locus, the family distribution was 54.58% of K1, 25% of MAD20 and 20.42% of RO33 for msp-1, and 51.71% and 48.29% of FC27 and 3D7, respectively, for msp-2. For all these allelic variants, the distribution was associated with neither the severity of malaria nor the zone of habitation. Pearson correlation coefficients between either the levels of homocysteine or the transaminase and the severity of the disease were very low.

Conclusion  The severity of malaria was not associated with higher multiplicity of infections and did not appear restricted to particular genotypes. More comprehensive explorations including immunity, genetic factors, nutritional and sociologic status of the population could clarify the situation.

Objectives  To assess the extent to which sexually transmitted infections (STIs) have contributed to the spread of HIV in South Africa and to estimate the extent to which improvements in STI treatment have reduced HIV incidence.

Methods  A mathematical model was used to simulate interactions between HIV and six other STIs (genital herpes, syphilis, chancroid, gonorrhoea, chlamydial infection and trichomoniasis) as well as bacterial vaginosis and vaginal candidiasis. The effects of STIs on HIV transmission probabilities were assumed to be consistent with meta-analytic reviews of observational studies, and the model was fitted to South African HIV prevalence data.

Results  The proportion of new HIV infections in adults that were attributable to curable STIs reduced from 39% (uncertainty range: 24–50%) in 1990 to 14% (8–18%) in 2010, while the proportion of new infections attributable to genital herpes increased. Syndromic management programmes are estimated to have reduced adult HIV incidence by 6.6% (3.3–10.3%) between 1994 and 2004, by which time syndromic management coverage was 52%. Had syndromic management been introduced in 1986, with immediate achievement of 100% coverage and a doubling of the rate of health seeking, HIV incidence would have reduced by 64% (36–82%) over the next decade, but had the same intervention been delayed until 2004, HIV incidence would have reduced by only 5.5% (2.8–9.0%).

Conclusions  Sexually transmitted infections have contributed significantly to the spread of HIV in South Africa, but STI control efforts have had limited impact on HIV incidence because of their late introduction and suboptimal coverage.

Objectives  Evaluating treatment failure is critical when deciding to modify antiretroviral therapy (ART). Virologic Assessment Forms (VAFs) were implemented in July 2008 as a prerequisite for ordering viral load. The form requires assessment of clinical and immunologic status.

Methods  Using the Electronic Medical Record (EMR), we retrospectively evaluated patients who met 2006 WHO guidelines for immunologic failure (≥15 years old; on ART ≥6 months; CD4 count <baseline OR CD4 count >50% drop from peak OR CD4 persistently <100 cells) at the Lighthouse Trust clinic from December 2007 to December 2009. We compared virologic screening, VAF implementation and ART modification during the same period using Fisher’s exact tests and unpaired t-tests as appropriate.

Results  Of 7000 enrolled ART patients ≥15 years old with at least two CD4 counts, 10% had immunologic failure with a median follow-up time on ART of 1.4 years (IQR: 0.8–2.3). Forty (6%) viral loads were ordered: 14 (35%) were detectable (>400 HIV RNA copies/mL) and one (7%) patient was switched to second-line therapy. Overall, 259 VAFs were completed: 67% for immunologic failure and 33% for WHO Stage 4 condition. Before VAF implementation, 1% of patients had viral loads drawn during routine care, whereas afterwards, 8% did (P < 0.0001; 95% CI: 0.03–0.08).

Conclusions  Clinicians did not identify a large proportion of immunologic failure patients for screening. Implementation of VAFs produced little improvement in virologic screening during routine care. Better training and monitoring systems are needed.

Objective  To systematically review articles describing complications of abortion in settings where abortions are thought to be unsafe and to determine the incidence of severe acute maternal morbidity (SAMM) attributed to abortion at the population level.

Methods  We searched relevant databases using search terms related to abortion and complications. We included population-representative studies that listed complications of abortion. We extracted data on the definitions and numbers of severe complications and SAMM, and we report abortion complication rates (per 100 000 women of reproductive age) and ratios (per 100 000 live births) for SAMM, severe complications and any complications.

Results  We included 15 studies representing eleven countries (six in Africa, four in Asia and one in Latin America). We found a median abortion ratio of SAMM of 237 (range 91–1892) per 100 000 live births and a median abortion ratio of severe complications of 596 (range 435–5298). There was a great degree of heterogeneity between definitions and study populations.

Conclusions  The burden of SAMM attributed to abortion is much greater than what is reported for deaths caused by abortion. However, the great heterogeneity in definitions makes it difficult to draw firm conclusions. We call for future work on the burden of unsafe abortion to use strict definitions of SAMM.

Objective  Vitamin C alone or in combination with vitamin E has been proposed to prevent pre-eclampsia. In this study, we assayed the plasma vitamin C in women of reproductive age in Kampala and assessed its association with pre-eclampsia.

Methods  Participants in this study were 215 women with pre-eclampsia, 400 women with normal pregnancy attending antenatal clinic and 200 non-pregnant women attending family planning clinic at Mulago Hospital’s Department of Obstetrics and Gynaecology from 1st May 2008 to 1st May 2009. Plasma vitamin C was assayed using the acid phosphotungstate method; differences in the means of plasma vitamin C were determined by anova.

Results  Mean plasma vitamin C levels were 1.72 (SD 0.68) × 10³ μg/l in women with pre-eclampsia, 1.89 (SD 0.73) × 10³ μg/l in women with normal pregnancy and 2.64 (SD 0.97) × 10³ μg/l in non-pregnant women. Plasma vitamin C was lower in women with pre-eclampsia than in women with normal pregnancy (P = 0.005) and non-pregnant women (P < 0.001).

Conclusion  Health workers need to advise women of reproductive age on foods that are rich in vitamin C, as this may improve the vitamin status and possibly reduce the occurrence of pre-eclampsia.

Objectives  Pneumonia is the most common reason for visiting an outpatient facility among children <5 years old in Fiji. The objective of this study is to describe for the first time the costs associated with an episode of outpatient pneumonia in Fiji, in terms of cost both to the government health sector and to the household.

Methods  Costs were estimated for 400 clinically diagnosed pneumonia cases from two outpatient facilities, one in the capital, Suva, and one in a peri-urban and rural area, Nausori. Household expenses relating to transport costs, treatment costs and indirect costs were determined primarily through structured interview with the caregiver. Unit costs were collected from a variety of sources. Patient-specific costs were summarised as average costs per facility.

Results  The overall average societal cost associated with an episode of outpatient pneumonia was $18.98, ranging from $14.33 in Nausori to $23.67 in Suva. Household expenses represent a significant proportion of the societal cost (29% in Nausori and 45% in Suva), with transport costs the most important household cost item. Health sector expenses were dominated by personnel costs at both sites. Both the average total household expenses and the average total health sector expenses were significantly greater in Suva than Nausori.

Conclusions  A single episode of outpatient pneumonia represents a significant cost both to the government health sector and to affected households. Given the high incidence of this disease in Fiji, this places a considerable burden on society.

Objectives  The Malawian Social Cash Transfer Scheme (SCT) is a social protection programme for ultra poor and labour-constrained households, including people living with HIV/AIDS (PLWHA). We aimed to gain insight into respondents’ circumstances prior to becoming transfer beneficiaries and to examine how PLWHA used transfers to support themselves and their families.

Methods  We conducted 24 semi-structured qualitative interviews with PLWHA who were also SCT beneficiaries and living in villages where the scheme was operational in 2008.

Results  Respondents were destitute and lacked food and basic necessities prior to the transfer. As cash recipients, the majority of respondents reported positive impacts on health, food security and economic well-being as well as an improved ability to care for their families.

Conclusion  Important unanswered programmatic questions persist, such as ‘What is the appropriate transfer level?’ And ‘Should recipients graduate from the scheme?’ Moreover, the scheme’s long-term sustainability is still unclear. Nevertheless, this analysis presents evidence describing how PLWHA used cash transfers to improve their situation and mitigate the impact of HIV/AIDS on families.

Objectives  To investigate antibiotic use in five national household surveys conducted with the WHO methodology to identify key determinants of antibiotic use in the community.

Methods  Data from The Gambia, Ghana, Kenya, Nigeria and Uganda surveys were combined. We used logistic regression models that accounted for the clustered survey design to identify the determinants of care seeking outside the home and antibiotic use for 2914 cases of recent acute illness.

Results  Overall, 95% of individuals with acute illness took medicines, 90% sought care outside their homes and 36% took antibiotics. In multivariate analyses, illness severity was a strong predictor of seeking care outside the home. Among those who sought outside care, the strongest predictor of antibiotic use was the presence of upper respiratory symptoms (OR: 3.02, CI: 2.36–3.86, P < 0.001), followed by gastrointestinal symptoms or difficulty breathing, and antibiotics use was less likely if they had fever. The odds of receiving antibiotics were higher when visiting a public hospital or more than one healthcare facility.

Conclusions  The nature and severity of symptoms and patterns of care seeking had the greatest influence on decisions to take antibiotics. Antibiotics were widely available and inappropriately used in all settings. Policies to regulate antibiotics distribution as well as interventions to educate prescribers, dispensers and consumers are needed to improve antibiotic use.

Objectives  Refugees and immigrants are likely to be vulnerable to mortality from infectious diseases as a result of high prevalences in their countries of origin and barriers in access to healthcare in the recipient countries. Consequently, we aimed to compare and investigate differences in mortality from infectious diseases among refugees and immigrants and native Danes.

Methods  A register-based, historical prospective cohort design. All refugees (n = 29 139) and family-reunited immigrants (n = 27 134) who, between 1 January1993 and 31 December1999, were granted the right to reside in Denmark were included and matched 1:4 on age and sex with native Danes. Civil registration numbers were cross-linked to the Register of Causes of Death, and fatalities owing to infectious diseases (based on ICD-10 diagnosis) were identified. Mortality ratios were estimated separately for men and women by migrant status and region of birth; adjusting for age and income; using a Cox regression model, after a mean follow-up of 10–12 years after arrival.

Results  Female [hazard ratio (HR) = 4.15; 95% CI: 2.38, 7.25] and male (HR = 2.05; 95% CI: 1.27, 3.33) refugees experienced significantly higher mortality risks from infectious diseases than did native Danes, as was the case for male immigrants (HR = 2.39; 95% CI: 1.20, 4.76) but less so for female immigrants (HR = 1.23; 95% CI: 0. 50-3.01). Mortality by region of origin was notably higher for individuals from North Africa and sub-Saharan Africa.

Conclusions  Higher mortality among refugees and immigrants than among the native population should lead to reflections on medical reception systems in recipient countries and subsequent possibilities of access to specialised diagnostic and curative healthcare.

Africa reports 90% of human plague cases yet no guidelines currently exist for the safe and accurate collection of sputum from patients with suspected pneumonic plague. Using existing tuberculosis guidelines as a model and in conjunction with epidemiological and clinical features of pneumonic plague, the authors describe the importance of formal guidelines to enhance sputum collection practices and improve safety in developing countries. A model for suggested guidelines is given.

L’Afrique rapporte 90% des cas de peste humaine. Cependant, il n’existe toujours pas de directives pour la collecte sûre et précise des crachats de patients suspects de peste pneumonique. En utilisant les directives existantes pour la tuberculose comme modèle et en conjonction avec les caractéristiques épidémiologiques et cliniques de la peste pneumonique, les auteurs décrivent l’importance des directives officielles pour améliorer les pratiques de collecte des crachats et améliorer la sécurité dans les pays en développement. Un modèle de directive est suggéré.

África reporta un 90% de los casos de plagas humanas y sin embargo aún no existen guías para la recolección de esputo de pacientes con sospecha de plaga neumónica. Utilizando las guías existentes para tuberculosis como modelo, en conjunción con características clínicas y epidemiológicas de plaga neumónica, los autores describen la importancia de guías formales para mejorar las prácticas de recolección de esputo y mejorar la seguridad en países en vías de desarrollo. Se presenta un modelo para guías sugeridas.

Objective  To develop a single-step multiplex PCR to differentiate the aquatic stages of Aedes aegypti, Aedes albopictus and Aedes vittatus collected from different breeding spots in arbovirus endemic/epidemic areas and to detect the most abundant species by the multiplex PCR.

Methods  Aquatic stages of different mosquito species were sampled by inspecting artificial and natural breeding sites in domestic and peridomestic areas. DNA was isolated from different stages of the three Aedes species. Using novel primers based on 18S rDNA sequence, a single-step multiplex PCR was developed to clearly distinguish the three Aedes species. It was then evaluated in the aquatic stages of Aedes species collected from different areas.

Results  A total of 1150 aquatic stages were collected from 294 breeding spots, of which 156 contained Aedes species. Discarded tires were the major breeding spots of Aedes species. The aquatic stages were clustered into 230 pools; Ae. albopictus was detected in the largest number of pools, followed by Ae. aegypti and Ae. vittatus.

Conclusions  The Multiplex PCR clearly differentiated the aquatic stages of the three Aedes species and detected that Ae. albopictus was most profuse in different breeding spots surveyed, hence indicating to be the main vector in this region. So control measures can be designed against Ae. albopictus at an early stage to prevent any arboviral outbreak. This method is a convenient tool for precise identification of Aedes vectors during entomological surveys in arbovirus endemic/epidemic areas where several species coexist.

Objective  To analyse the leprosy case detection rates in Amazonas State, Brazil, by age group from 1980 to 2009.

Method  The historical data series of leprosy cases by age group from 1980 to 2009 were fitted as a function of time using Poisson regression models. Relative annual reduction in the detection rate (RAR) by age group was estimated as one minus the exponential of the estimated regression coefficient for time. To compare the regression coefficients, we used their 95% confidence interval.

Results  The relative annual reduction varied from 9% in the age group of 0–4 years to 1% in the age group of 60–69 years. There was a declining trend of the RAR in the younger age groups that disappeared after 29 years of age. The detection rate in people >29 years old declined very little over time, with no statistically significant difference between age groups.

Conclusion  Our findings show a reduction in the infection risk in the last 30 years and a birth cohort effect: cohorts born in more recent years faced smaller risks of leprosy infection than older cohorts.

Background and objective  The high prevalence of numerous transfusion-transmitted infectious diseases such as HIV, HBV, HCV and syphilis in sub-Saharan Africa affects blood safety for transfusion recipients. The aim of this study was to evaluate the prevalence and incidence of transfusion-transmissible infectious diseases among blood donors in Burkina Faso.

Methods  A retrospective study of blood donors’ records from January to December 2009 was conducted. Prevalence and incidence of viral infections were calculated among repeat and first-time blood donors.

Results  Of the total of 31 405 first-time volunteer blood donors in 2009, 24.0% were infected with at least one pathogen and 1.8% had serological evidence of multiple infections. The seroprevalence of HIV, HBV, HCV and syphilis in first-time volunteer donors was 1.8%, 13.4%, 6.3% and 2.1%, respectively. In 3981 repeat donors, the incidence rate was 3270.2, 5874.1 and 6784.6 per 100 000 donations for anti-HIV-1, HBsAg and anti-HCV, respectively. These numbers varied significantly according to populations where blood is collected and blood centres in Burkina Faso.

Conclusion  The relatively high prevalence of viral markers in first-time volunteers and remarkably high incidence of infections in repeat donors raise concerns regarding the safety of these donors and suggest that implementation of NAT might significantly improve the situation.

Objectives  To assess the burden of rotavirus disease in Guatemala, in view of the recent introduction of a national rotavirus vaccination programme.

Methods  We examined data from an active, facility-based surveillance system in Santa Rosa, Guatemala, from October 2007 through September 2009 among children <5 years of age presenting to the hospital or ambulatory clinics with diarrhoea (≥3 loose stools in 24 h during the last 7 days). Demographic and epidemiological data were collected, and specimens were tested for rotavirus via enzyme immunoassay. Genotyping was performed via reverse transcriptase polymerase chain reaction.

Results  We enrolled 347 hospitalized patients <5 years of age with diarrhoea and 1215 from ambulatory clinics. Specimens from 275 (79%) hospitalized children and 662 (54%) from ambulatory visits were tested for rotavirus. Rotavirus accounted for 32% of hospitalizations and 9% of ambulatory visits for diarrhoea, resulting in adjusted annual rates of 36 hospitalizations and 372 ambulatory visits per 10 000 children. Ninety-one per cent of hospitalizations and 81% of ambulatory visits for rotavirus diarrhoea occurred in children <2 years. G1P8 represented 71% and 95% of rotavirus genotypes for 2007–2008 and 2008–2009 rotavirus seasons, respectively.

Conclusions  Rotavirus is a major cause of diarrhoea in children <5 years of age in Santa Rosa, Guatemala, highlighting the potential health benefits of vaccination and the need for continued surveillance to assess impact and effectiveness of the rotavirus vaccination programme in Guatemala.