Multidisciplinary studies of disease burden in the Diseases of the Most Impoverished Programme.

With limited healthcare resources, rational prioritization of healthcare interventions requires knowledge and analysis of disease burden. In the absence of actual disease-burden data from less-developed countries, various types of morbidity and mortality estimates have been made. Besides having questionable reliability, these estimates do not capture the full burden of a disease since they provide only the number of cases and deaths. The modelling methods that include disability are more comprehensive but are difficult to understand, and their reliability is affected by baseline approximations. To provide policy-makers with information needed for rational decision-making, the Diseases of the Most Impoverished (DOMI) Programme of the International Vaccine Institute has used a multidisciplinary approach to describe the burden of disease due to typhoid fever, shigellosis, and cholera. Recognizing the relative advantages and disadvantages of various methodologies, the programme employs passive clinic-based surveillance in defined communities to provide prospective data. The prospective data are complemented with retrospectively-collected information from existing sources, frequently less accurate and complete but readily available for the whole population over extended periods. To create a more complete picture, economic and qualitative studies specific to each disease are incorporated in these prospective studies. The goal is to achieve a more complete and realistic picture by combining the results of these various methodologies, acknowledging the strengths and limitations of each. These projects also build in-country capacity in terms of treatment, diagnosis, epidemiology, and data management.

Diarrhoea episodes and treatment-seeking behaviour in a slum area of North Jakarta, Indonesia.

Visits to household during a census in an impoverished area of north Jakarta were used for exploring the four-week prevalence of diarrhoea, factors associated with episodes of diarrhoea, and the patterns of healthcare use. For 160,261 urban slum-dwellers, information was collected on the socioeconomic status of the household and on diarrhoea episodes of individual household residents in the preceding four weeks. In households with a reported case of diarrhoea, the household head was asked which form of healthcare was used first. In total, 8,074 individuals (5%)--13% of children aged less than five years and 4% of adults--had a diarrhoea episode in the preceding four weeks. The two strongest factors associated with a history of diarrhoea were a diarrhoea episode in another household member in the four weeks preceding the interview (adjusted odds ratio [OR] 11.1; 95% confidence interval [CI] 10.4-11.8) and age less than five years (adjusted OR 3.4; 95% CI 3.2-3.5). Of the 8,074 diarrhoea cases, 1,969 (25%) treated themselves, 1,822 (23%) visited a public-health centre (PHC), 1,462 (18%) visited a private practitioner or a private clinic, 1,318 (16%) presented at a hospital, 753 (9%) bought drugs from a drug vendor, and 750 (9%) used other healthcare providers, such as belian (traditional healers). Children with diarrhoea were most often brought to a PHC, a private clinic, or a hospital for treatment. Compared to children, adults with diarrhoea were more likely to treat themselves. Individuals from households in the lowest-income group were significantly more likely to attend a PHC for treatment of diarrhoea compared to individuals from households in the middle- and higher-income groups.

Factors associated with reported diarrhoea episodes and treatment-seeking in an urban slum of Kolkata, India.

In an urban slum in eastern Kolkata, India, reported diarrhoea rates, healthcare-use patterns, and factors associated with reported diarrhoea episodes were studied as a part of a diarrhoea-surveillance project. Data were collected through a structured interview during a census and healthcare-use survey of an urban slum population in Kolkata. Several variables were analyzed, including (a) individual demographics, such as age and educational level, (b) household characteristics, such as number of household members, religious affiliation of the household head, building material, expenditure, water supply and sanitation, and (c) behaviour, such as hand-washing after defecation and healthcare use. Of 57,099 study subjects, 428 (0.7%) reported a diarrhoea episode sometime during the four weeks preceding the interview. The strongest independent factors for reporting a history of diarrhoea were having another household member with diarrhoea (adjusted odds ratio [OR]=3.8; 95% confidence interval [CI] 3.3-4.4) and age less than 60 months (adjusted OR=3.7; 95% CI 3.0-4.7). The first choice of treatment by the 428 subjects was as follows: 151 (35%) had self- or parent-treatment, 150 (35%) consulted a private allopathic practitioner, 70 (16%) went directly to a pharmacy, 29 (7%) visited a hospital, 14 (3%) a homoeopathic practitioner, 2 (0.5%) an ayurvedic practitioner, and 12 (3%) other traditional healers. The choices varied significantly with the age of patients and their religion. The findings increase the understanding of the factors and healthcare-use patterns associated with diarrhoea episodes and may assist in developing public-health messages and infrastructure in Kolkata.

Coverage and costs of mass immunization of an oral cholera vaccine in Vietnam.

The objective of this study was to describe a mass-immunization campaign of a locally-produced oral, killed whole-cell cholera vaccine in Hue city, Vietnam. Mass immunization with a 2-dose regimen of the vaccine was conducted in 13 communes in early 1998. The total, age- and sex-specific vaccine coverage was calculated using data from the vaccination records and the government census. The number of vaccine doses procured, administered, wasted, and left over, and the human and other resources required to prepare and conduct the vaccination campaign were systematically recorded. Government expenditure for planning, procurement, and delivery of the vaccine were documented. In total, 118,555 (79%) of the 49,557 targeted population were fully vaccinated during the mass-vaccination campaign. The total expenditure for the project was US dollar 105,447, resulting in a cost per fully-vaccinated person of US dollar 0.89. Mass immunization with this locally-produced oral, killed cholera vaccine was found to be feasible and affordable with attainment of high vaccination coverage.