Threats posed by stockpiles of expired pharmaceuticals in low- and middle-income countries: a Ugandan perspective

In some low- and middle-income countries, the national stores and public-sector health facilities contain large stocks of pharmaceuticals that are past their expiry dates. In low-income countries like Uganda, many such stockpiles are the result of donations. If not adequately monitored or regulated, expired pharmaceuticals may be repackaged and sold as counterfeits or be dumped without any thought of the potential environmental damage. The rates of pharmaceutical expiry in the supply chain need to be reduced and the disposal of expired pharmaceuticals needs to be made both timely and safe. Many low- and middle-income countries need to: (i)strengthen public systems for medicines' management, to improve inventory control and the reliability of procurement forecasts; (ii) reduce stress on central medical stores, through liberalization and reimbursement schemes; (iii) strengthen the regulation of drug donations; (iv) explore the salvage of officially expired pharmaceuticals, through re-analysis and possible shelf-life extension; (v) strengthen the enforcement of regulations on safe drug disposal; (vi) invest in an infrastructure for such disposal, perhaps based on ultra-high-temperature incinerators; and (vii) include user accountability for expired pharmaceuticals within the routine accountability regimes followed by the public health sector

Enhancing Policy Maker Decisions: a Framework to Assess Determinants and Space-Time Risk of Infant; Child and Adult Mortality in Rural South Africa and Elsewhere

"Reliable mortality data are essential for planning health interventions; yet such data are often not available or reliable in developing countries; especially in sub-Saharan Africa. Health and socio-demographic surveillance sites; such as Agincourt in South Africa; are often the only way to assess and prospectively understand health trends at a population level; and thus have the potential to address this gap. This article summarises the main findings from my PhD in which advanced methods were applied to better understand the dynamics of age-specific mortality both in space and time; to identify age-specific mortality risk factors which have a high ""impact"" at a population level; and to relate inequalities in risk factor distributions to observed spatial mortality risk patterns."

Reproductibilite interobservateurs des scores de Knodell et Metavir en milieu Camerounais pour les hepatites virales chroniques

Introduction. Plusieurs scores ont ete proposes a l'histopathologie du materiel de biopsie hepatique dans le cadre de la prise en charge des hepatites virales chroniques parmi lesquels le score de Knodell et le score Metavir. L'objectif de notre travail etait de comparer la reproductibilite des scores Metavir et de Knodell pour determiner lequel serait le plus adequat dans les conditions d'exercice des pathologistes locaux. Materiel et methode. Trente blocs de biopsies hepatiques provenant de patients porteurs d'hepatite virale chronique B ou C ont ete retenus pour notre etude. Ceux-ci ont ete recoupes et colores a l'hemateine-eosine et au Trichrome de Masson. Les lames ainsi confectionnees ont ete interpretees independamment par deux pathologistes disposant d'au moins cinq annees d'experience avec etablissement des scores de Knodell et Metavir. Resultats. La concordance entre les deux pathologistes en ce qui concerne les composantes du score Metavir etait elevee pour la fibrose et moyenne pour l'activite. Pour ce qui est du score de Knodell la concordance pour la fibrose etait egalement elevee; elle etait moyenne pour les scores partiels de necrose intralobulaire et de necrose portale tandis que le pourcentage de scores globaux concordants etait faible. Conclusion. Nous avons observe une concordance acceptable pour les differentes composantes des deux scores cependant celle-ci etait meilleure pour le score Metavir. Le score Metavir pourrait donc etre utilise dans nos conditions d'exercice par des pathologistes non specialises en pathologie hepatique

Repeatability of Manual Coding Of Cancer Reports in the South African National Cancer Registry; 2010

"Data validity is a very important aspect of cancer registries in ensuring data quality for research and interventions. This study focused on evaluating the repeatability of manual coding of cancer reports in the South African National Cancer Registry (NCR). This cross-sectional study used the Delphi technique to classify 48 generic tumour sites into sites that would be most likely (""difficult"") and least likely (""not difficult"") to give rise to discordant results among coders. Reports received from the Charlotte Maxeke Academic Hospital were manually recoded by five coders (2 301 reports; e.g. approximately 400 reports each) for intracoder agreement; and by four coders (400 reports) for inter-coder agreement. Unweighted kappa statistics were calculated and interpreted using Byrts' criteria. After four rounds of the Delphi technique; consensus was reached on the classification of 91.7 (44/48) of the sites. The remaining four sites were classified according to modal expert opinion. The overall kappa was higher for intra-coder agreement (0.92) than for inter-coder agreement (0.89). ""Not difficult"" tumour sites reflected better agreement than ""difficult"" tumour sites. Ten sites (skin other; basal cell carcinoma of the skin; connective tissue; other specified; lung; colorectal; prostate; oesophagus; naso-oropharynx and primary site unknown) were among the top 80 misclassified sites. The repeatability of manual coding at the NCR was rated as ""good"" according to Byrts' criteria. Misclassified sites should be prioritised for coder training and the strengthening of the quality assurance system."

Test-Retest Reliability of a Questionnaire to Assess the Knowledge and Attitude of Dental Students toward Tobacco Counseling Services

Objective: To determine the test-retest reliability of a new questionnaire designed to assess the attitude of students in a Nigerian dental school to tobacco cessation services. Materials and Methods: A self-administered questionnaire was administered twice at 4 weeks interval to the same set of final year dental students (N = 36) in one of the Nigerian dental schools. Ten questions were randomly selected from the 35-item questionnaire. Intra-class correlation (ICC) coefficients at 95confidence interval were computed for each selected item and the Cronbach's alpha coefficients were calculated to assess the internal consistency of the questionnaire. Results: The results showed that the least Cronbach's alpha value was 0.49 and the highest was 0.98. Only two items had less than a substantial agreement level (0.60) and seven items had an almost perfect agreement level (0.80). The results also indicated that the ICC coefficient is very highly statistically significant (P 0.001). Conclusion: The questionnaire demonstrated adequate test-retest reliability to assess the attitude of dental students to tobacco cessation services

Using Different Approaches to Assess the Reproducibility of a Culturally Sensitive Quantified Food Frequency Questionnaire

Objective: To report on the use of different approaches to assess the reproducibility of a culturally sensitive quantified food frequency questionnaire (QFFQ) used for assessment of the habitual dietary intake of Setswana-speaking adults in the North West Province of South Africa.Method: A previously developed and validated QFFQ was completed by trained fieldworkers. Portion sizes were estimated using different methods. Food intake was coded and analysed for nutrient intake per day for each subject. The first interview (n = 1 888) took place during the baseline data collection period. For the second interview (n = 175); a convenient sample from the subjects who had completed the first interview was collected and the interview was conducted within four to six weeks of the first interview.Results: There were good correlations between the first and second QFFQ for all the nutrients (p 0.0001). The Wilcoxon signed-rank test showed that there were no significant differences in the median intake between the two administrations; except for energy and total fat. The Bland-Altman plots showed good agreement. Between 41 and 58 of the subjects were correctly classified into the same quartile; with less than 3 grossly misclassified. The weighted ? statistics showed moderate agreement between the two applications.Conclusion: Our results show that more than one statistical approach is needed to assess the reproducibility of a QFFQ. The reproducibility of this culturally sensitive QFFQ was good

Rapid Identification and Susceptibility Testing of Gram-Negative Bacilli from Blood Cultures Using the Vitek 2 System

Providing rapid results for blood culture isolates is a critical function of clinical microbiology laboratories. This study evaluated the accuracy and turnaround time for identification and susceptibility testing of Gram-negative bacilli inoculated directly from positive blood cultures into the Vitekr 2 system. Direct inoculation was compared to conventional methods; which included biochemical tests; commercial identification systems and disc diffusion susceptibility testing. Two hundred and ninety-one of 327 isolates (89) were correctly identified to at least genus level by the direct Vitekr method. Susceptibility test results were compared for 3;925 organism antibiotic combinations. The overall rate of categorical agreement of direct and conventional antimicrobial susceptibility testing was 92with less than 3very major and major errors combined. The mean turnaround time for identification and susceptibility testing was 7.5 hours (SD 3.0 hours) compared to a mean of 32.3 hours (SD 14.7 hours) for the conventional method. These results suggest that direct inoculation of the Vitekr 2 system from blood cultures provides accurate; reliable identification and antimicrobial susceptibility results for the majority of commonly occurring Gram-negative pathogens; while the significantly reduced turnaround time should benefit patients and permit earlier rationalisation of antibiotic therapy; with a reduction in the use of broad spectrum antibiotics. A suggested protocol for routine use is included

Adherence to Laboratory Findings in the Management of Malaria in the High and Low Transmission Areas of Nakasongola and Kabalore Districts of Uganda

Malaria is one of the leading causes of morbidity and mortality in Africa today. It is estimated that a single bout of malaria in Africa costs a sum equivalent to earning for over ten working days. In Uganda; more than 95of the malaria cases are due to Plasmodium falciparum ; the most virulent parasite species that causes severe forms of disease. It has acquired resistance to the commonly used and cheap antimalarial medicines like Chloroquine and Sulfadoxine/Pyrimethamine (CQ/SP) combination. The Uganda Government changed the malaria treatment policy in 2005 to include Artemisinin Combination Therapies (ACTs) as first line treatment for the uncomplicated malaria. Whereas prompt and accurate laboratory diagnosis of malaria is the key to the effective management malaria; clinical syndromic diagnosis has been the most widely used approach in Uganda. This was widely advocated for in sub-Saharan Africa as a means of increasing antimalarial coverage and reducing the risk of progression to severe disease and death. However; such practice was only tolerated in the era of inexpensive and safe antimalarial therapy of CQ/SP. An adult course of the new recommended first-line ACTs costs more than 10 times the cost of a course of CQ/SP. It is therefore difficult to afford this treatment at individual and national levels. Therefore; presumptive treatment becomes economically and clinically less acceptable and raises a need for a more accurate diagnosis. To make a definitive diagnosis of malaria; demonstration of the parasite in the blood is essential. However; it was not whether health workers have started adopting the reliance on laboratory results before making antimalarial prescriptions. The study was an attempt to understand the practices of health workers in the health facilities with laboratory services in one high and one low malaria transmission areas of Uganda. Nine health facilities in Nakasongola and Kabalore were selected on the basis of possession of functional laboratory services and 487 patients with fever/receiving antimalarial treatment were enrolled for the survey. It was found that access to laboratory services was limited to a small population. Although the majority of patients reporting to these health facilities (over 95for the two districts) were sent to the laboratory; only 52and 32of those that received their results for Nakasongola and Kabarole respectively tested positive for the presence of malaria parasites. However; all patients reporting to the health facilities with fever still received antimalarials despite health worker training and guidelines under the new first-line treatment policy. This meant that health workers have not changed their prescription practices and laboratory findings were not being used in the management of malaria

Development of a WHO child care facility schedule (CCFS) : a pilot collaborative study

This paper describes the research conducted by a WHO collaborative study group for the development of a questionnaire method for the assessment of quality in child-care settings. The results of an inter-rater reliability study undertaken in Greece and Nigeria suggest that the Child Care Facility Schedule (CCFS), composed of 80 items, offers a satisfactory system of rating, especially after modifications were made to refine certain items, alter the scoring system so as to grasp nuances, and clarify the instructions in the users' manual, including revisions in the interviewing technique. A validity study to confirm the usefulness of this method is being carried out in Athens

Nutrition survey in the Republic of the Congo: results from a national survey conducted in 1987

The objective was to evaluate the nutritional status of preschool children in the rural areas in order to establish a baseline for the measurement of the impact of a Government Nutrition Education Project (NUTED) in forthcoming years. The household cross-sectional survey was carried out on a representative sample of the rural population. The sample was stratified in order to portray the nutritional status of the children in the northern regions (more thinly populated) and in the southern regions: one stratum for small towns (between 2000 and 30,000 inhabitants) and 4 strata for rural localities. The sampling method used was by clusters of 30 children, distributed randomly in 20 zones per stratum. The nutritional indices of 2429 children were calculated and analysed according to WHO recommendations. The prevalence of the different types of malnutrition was 27.5% (95% confidence interval (CI), 24.2-30.8) for stunting (height-for-age retardation) and 5.5% (CI = 4.2-6.8) for wasting (weight-for-height retardation). Both types coexisted among 1.9% of the children; 23% of children were underweight for their age (CI = 21.6-26.2), and 15.8% (CI = 14.7-16.9) aged greater than 12 months had a mid-arm circumference below 135 mm. No sex difference was observed in the results. Stunting seems to appear in the second trimester of life (3-5 months), and wasting appeared between 9 and 23 months (highest rate between 12 and 17 months: 14.0% (CI = 9.3-18.8], which presents a real public health problem. The stratification did not show any significant differences in nutritional status among the children living in rural zones and those living in the small towns. However, the prevalence of malnutrition in the rural zones was 2 or 3 times higher than that observed in 1986 in Brazzaville. The division of the country into five main ecological zones allows some useful comparisons, e.g., the prevalence of stunting ranges from 15.5% (CI = 12.8-18.2) in the northern inundated forest zone to 38.8% (CI = 32.9-44.7) in the southern forests of Mayombe and Chaillu. The diet also varied, the frequency of animal protein consumption on the preceding day ranging from 76.3% to 59.1% in the different zones. The Republic of the Congo differs from other African countries in having relatively lower rates of stunting but an astonishingly high prevalence of wasting