The ethics of psychiatric care and research in resource-poor settings: The case of a research trial in a prayer camp in Ghana

A communication in the January 2018 issue of the British Journal of Psychiatry detailed a clinical trial on persons with mental illness (PWMI), some of whom were in chains in a prayer camp setting in Ghana. The camp’s advertised mission statement was to “set free those held captive by Satan” through its “ministry of fasting and prayer”. This article considers the potential ethical problems raised by the clinical trial on chained PWMI against the background of Ghanaian ethnoanthropological beliefs.It highlights two significant categories of ethical issues: first, those associated with standard psychiatric practice in the treatment of persons with severe mental illness (specifically, the issue of informed consent and the use of physical restraint and seclusion in psychiatric practice); and second, issues pertaining to the study under discussion (specifically, issues of study methodology and the principle of equipoise; biological determinism as against the multifactorial paradigm of mental illness/practice, implied or assumed; misalignment between the research methodology, results, and the underlying aim of the study, bordering on epistemology and pragmatism/values; and finally, the association of the trial researchers with the practice of chaining). This article, in highlighting the ethical issues raised by the clinical trial in question, attempts to suggest what Ghanaian healthcare professionals, policymakers, and the national government can do (and how) to institute workable, enforceable measures towards ending the practice of chaining PWMI in Ghana.

Medical Ethics and Medical Professionalism in Low and Middle Income (LAMIC) Countries: Challenges and Implications.

ABSTRACT: This article examines the (bio) ethical and professionalism issues that may arise in the context of medical practice in low and middle income countries (LAMIC), and the challenges this poses for medical regulatory bodies in the regions, in upholding ethics in professional practice. A quadrangle of source of the problems given rise to the breach of ethics in medical practice is identified, and suggested steps, based on ethical principles and concept, is proposed towards the resolution of the problems presented. As LAMIC progress to improve the health of its population, this endeavour should occur hand in hand with contemporary medical ethics theories, taking in context the region’s ethnographic and cultural beliefs and practices.

In vitro susceptibility of Campylobacter jejuni from Kuwait to tigecycline & other antimicrobial agents.

Background & objectives: There is an increasing frequency of resistance of Campylobacter jejuni to antimicrobial agents making treatment difficult. In this study, the in vitro susceptibility of C. jejuni isolates collected over an eight year period was tested against tigecycline, a glycylcycline, the previously tested antimicrobial agents in Kuwait, ciprofloxacin, erythromycin and tetracycline, and other antimicrobial agents not previously tested in Kuwait, amoxicillin-clavulanic acid, gentamicin, imipenem and meropenem. Methods: A total of 97 C. jejuni isolates from diarrhoeal stools of Kuwaiti patients during 2002-2010 were studied for susceptibility to the above antimicrobial agents by E test. Results: Erythromycin resistance increased from 5.0 per cent in 2002-2003 to 13.8 per cent in 2007-2010. The figures for ciprofloxacin resistance for the same periods were 53 and 65.5 per cent, respectively. Tetracycline resistance increased from 40.0 per cent in 2003-2006 to 62.1 per cent in 2007-2010 (P=0.05). However, all isolates were uniformly susceptible to tigecycline and other antimicrobial agents. Interpretation & conclusions: There was a progressive increase in the prevalence of resistance to ciprofloxacin, erythromycin and tetracycline. As all isolates were uniformly susceptible to tigecycline, this antimicrobial agent can be considered as a potential candidate for treatment in clinical studies.

Cross-reactivity of outer membrane proteins of Campylobacter species with cholera toxin.

Campylobacter jejuni is a foodborne pathogen and a leading cause of diarrhoea worldwide. It is believed that a cholera toxin-like toxin (CTLT) produced by C. jejuni may mediate watery diarrhoea. However, the production of a CTLT by C. jejuni is controversial. A cholera toxin gene (ctx) homologue has not been identified in Campylobacter species. We investigated the identity of the CT cross-reactive antigen from Campylobacter species previously and the results are reviewed here. Filtrates of C. jejuni grown in four different liquid media, reported to promote CTLT production, were tested by Chinese hamster ovary (CHO) cell elongation assay for functional toxin and for reactivity with CT antibody using GM1 ganglioside ELISA (GM1 ELISA) and immunoblotting. Protein sequence of the CT antibody-reactive band was determined by matrix-assisted laser desorption ionization-time of flight (MALDI TOF-TOF). Non-jejuni species (C. coli, C. lari, C. foetus, C. hyointestinalis and C. upsaliensis) were investigated by CHO cell assay and immunoblotting. Filtrates from seven C. jejuni reference strains reported to produce CTLT and from 80 clinical strains were negative in the CHO cell assay. However, filtrates from three reference strains and 16 clinical strains were positive by GM1 ELISA. All strains irrespective of GM1 ELISA reactivity, possessed a 53-kDa protein which reacted with CT antibody by immunoblotting. This band was identified as the major outer membrane protein (PorA) of C. jejuni. CT antibody reacted with a C. jejuni recombinant PorA on immunoblotting. All non-C. jejuni strains were negative by CHO cell assay, but the common 53-kDa proteins reacted with CT antibody on immunoblots. The cross-reactivity of PorAs of Campylobacter species with CT may lead to the erroneous conclusion that Campylobacter species produce a functional CTLT.

Low-dose β-carotene Supplementation and Deworming Improve Serum Vitamin A and β-carotene Concentrations in Preschool Children of Bangladesh.

Despite the national vitamin A and antihelminthic prophylaxis programmes, both intestinal geohelminths and subclinical vitamin A deficiency continue to be prevalent among children in developing countries. Studies on potential synergistic effects of vitamin A supplementation and deworming on retinol status have inconsistent results. The purpose of the present study was to investigate the impacts of low-dose β-carotene supplementation and antihelminthic therapy on serum retinol and β-carotene concentrations in preschool children of Bangladesh. Two hundred and forty-four children, known to be infected with Ascaris lumbricoides, were randomized into four treatment groups: I-IV. Group I and II received two oral doses of 400 mg of albendazole each, the first dose at baseline and the second dose after four months; Group III and IV received placebo in place of albendazole. In addition, Group I and III received 1.2 mg of β-carotene powder in capsule daily for six months, and Group II and IV received placebo in place of β-carotene. Serum retinol and β-carotene levels were measured before and after six months of the interventions. Serum retinol and β-carotene increased significantly in Group I where both antihelminthic therapy and daily β-carotene supplementation were given (p<0.05 and p<0.001 respectively). Antihelminthic therapy alone only improved serum β-carotene concentration (p<0.0001). Low-dose β-carotene supplementation, along with an antihelminthic therapy, synergistically improved vitamin A status. This finding has public-health implications for improving vitamin A status of children in developing countries.

Inflammatory cytokines and childhood obstructive sleep apnoea

<p><b>OBJECTIVE</b>To evaluate serum cytokine concentrations in children with and without obstructive sleep apnoea (OSA) and to investigate the effects of OSA treatment on cytokines.</p><p><b>MATERIALS AND METHODS</b>Consecutive children with habitual snoring and symptoms suggestive of OSA were recruited. They completed a sleep apnoea symptom questionnaire, underwent physical examination and overnight polysomnography (PSG). OSA was diagnosed if obstructive apnoea index (OAI) >1. A blood sample was collected for analysis of IL-6, IL-8, and TNF-alpha after PSG.</p><p><b>RESULTS</b>One hundred forty-two children (97 males) with a median (IQR) age of 11.1 years (9.0-12.8) were recruited. The commonest presenting symptoms were nocturnal mouth breathing, prone sleeping position and poor attention at school. Forty-seven children were found to have OSA and they had higher serum IL-6 [0.1 (0.1-0.4) vs 0.1 (0.1-0.1) pg/mL, P = 0.001] and IL-8 [1.7 (1.0-2.3) vs 1.3 (0.9-1.7) pg/mL, P = 0.029] concentrations compared to their non-OSA counterparts. Multiple regression analysis indicated that OAI was significantly associated with both IL-6 (r = 0.351, P <0.001) and IL-8 (r = 0.266, P = 0.002). Sixteen children underwent treatment and there was significant reduction in mean (SD) serum IL-8 after intervention [pre vs post levels of 1.9 (1.0) vs 1.1 (0.6) pg/mL, P = 0.001] independent of weight loss.</p><p><b>CONCLUSION</b>Children with OSA had elevated levels of pro-inflammatory cytokines that normalised following treatment suggesting that the inflammatory response is potentially reversible. Early detection and intervention may be beneficial.</p>

Aetiology of diarrhoea in a birth cohort of children aged 0-2 year(s) in rural Mirzapur, Bangladesh.

The incidence of aetiology-specific diarrhoea and the pathogenicity of infectious agents in a birth cohort (n=252) in rural Bangladesh were determined. Stool specimens or rectal swabs were collected from diarrhoeal cases over two years and routinely on a monthly basis. Stool samples from children with diarrhoea were compared with stool samples from children without diarrhoea to calculate rates of isolation and pathogenicity of agents. In total, 1750 stool specimens from diarrhoea patients and 5679 stool specimens from children without diarrhoea were tested. An infectious agent was identified in 58% of the stool specimens from diarrhoea patients and 21.6% of the stool specimens from children without diarrhoea. The most commonly-isolated pathogens from all specimens were enterotoxigenic Escherichia coli (ETEC), enteroadherent E. coli, Shigella, Campylobacter jejuni, Giardia, and rotavirus. ETEC (ST and LT-ST toxin), enterotoxigenic Bacteroides fragilis, Shigella, and rotavirus were associated more with disease than with asymptomatic infections. Aetiology-specific infections were associated with acute episodes. The isolated enteropathogens were essentially the same as those found in other tropical rural settings. Enterotoxigenic B. fragilis was also identified as a pathogen. Ongoing vaccine efforts focusing on Shigella, rotavirus, and ETEC would be useful.

A survey of the supply and bacteriologic quality of drinking water and sanitation in Jakarta, Indonesia.

We assessed the water supply, water quality and human waste disposal and their association with diarrheal illness in Jatinegara, East-Jakarta, where part of the area has been involved in the Kampung Improvement Program (KIP). Three hundred seventy-eight households, randomly selected in the study area, were visited and questioned about water source, sanitation and diarrheal illness during the previous 3 months. Microbiological quality of drinking water was assessed. The water sources were boreholes (243; 64%), the water mains (77; 20%), bottled water (45; 12%), and vendors or dug wells (243; 4%). Fecal coliforms were isolated in 56% of the samples [median 23 (IQR 6-240) /100 ml in the contaminated samples]. Only 2 (3%) of the water mains' samples contained >100 fecal coliforms/100 ml, compared to 57 (24%) groundwater samples. Most residents used private toilets with drainage into on-site septic tanks, yet in over one quarter of households human excreta was disposed of into rivers or gutters. KIP areas lagged behind in environmental hygiene. Diarrheal episodes, reported in one third of the households, were significantly associated with water contaminated with >100 fecal coliforms/100 ml [OR 2.4 (95% CI: 1.4-4.2)], but no association with water source or environmental contamination was found. Significantly, all individuals reported boiling water before consumption.

The role of epidemiology in the introduction of vi polysaccharide typhoid fever vaccines in Asia.

Despite the availability of at least two licensed typhoid fever vaccines--injectable sub-unit Vi polysaccharide vaccine and live, oral Ty21a vaccine--for the last decade, these vaccines have not been widely introduced in public-health programmes in countries endemic for typhoid fever. The goal of the multidisciplinary DOMI (Diseases of the Most Impoverished) typhoid fever programme is to generate policy-relevant data to support public decision-making regarding the introduction of Vi polysaccharide typhoid fever immunization programmes in China, Viet Nam, Pakistan, India, Bangladesh, and Indonesia. Through epidemiological studies, the DOMI Programme is generating these data and is offering a model for the accelerated, rational introduction of new vaccines into health programmes in low-income countries. Practical and specific examples of the role of epidemiology are described in this paper. These examples cover: (a) selection of available typhoid fever vaccines to be introduced in the programme, (b) generation of policy-relevant data, (c) providing the 'backbone' for the implementation of other multidisciplinary projects, and (d) generation of unexpected but useful information relevant for the introduction of vaccines. Epidemiological studies contribute to all stages of development of vaccine evaluation and introduction.

Survival of Shigella dysenteriae type 1 on fomites.

Studies have shown that various objects, such as utensils, toys, and clothes, can serve as vehicles for transmission of Shigella spp. Shigellae can become viable but non-culturable (VBNC) when exposed to various environmental conditions as shown in earlier studies. The present study was carried out to detect VBNC Shigella dysenteriae type 1 on various fomites by direct viable counting, polymerase chain reaction (PCR), and fluorescent antibody methods. S. dysenteriae type 1 was inoculated onto cloth, wood, plastic, aluminum, and glass objects. Results showed that 1.5-4.0 hours after inoculation, S. dysenteriae type 1 became non-culturable, and after five days, non-culturable but viable S. dysenteriae type 1 could be detected by both PCR and fluorescent antibody techniques. Fomites can be considered an important potential route of transmission of VBNC S. dysenteriae type 1 and a significant factor in the epidemiology of shigellosis.

Epidemiology & molecular biology of Vibrio cholerae O139 Bengal.

The emergence of Vibrio cholerae O139 Bengal as the second aetiologic agent of epidemic cholera in October 1992 in the south Indian coastal city of Madras has shattered the long-held notion that only V. cholerae belonging to serogroup O1 are capable of causing epidemic (and pandemic) cholera. Within months of its appearance in Madras, V. cholerae O139 engulfed the entire Indian subcontinent in a series of outbreaks of cholera. It also spread to several neighbouring countries in Asia. Several western countries also reported imported cholera cases due to this organism. In the regions of the Indian subcontinent where cholera due to V. cholerae O1 is endemic, children are mostly susceptible because adults would have acquired at least some immunity due to earlier exposure. However, when V. cholerae O139 struck people in these areas, even though all age groups were affected, the disease was more prevalent in adults, which suggested that the disease is new in this population. As with O1 cholera, water and food seemed to be the vehicles of infection. Many family contracts of index cases of O139 cholera were found to be infected with V. cholerae O139, and in many of them, the infection was asymptomatic which is reminiscent of O1 EITor infection. Again as with O1 EITor infection, individuals of blood group O were more susceptible to O139 infection than those with other blood groups. In its molecular aspects, O139 vibrio resembles O1 EITor vibrio. The virulence genes encoding cholera toxin, zonula occludens toxin, accessory cholera enterotoxin and core-encoded pilin are present in a 4.5 kb 'virulence cassette' region of the chromosome as in EITor vibrios and the expression of these virulence factors, toxin coregulated pilus (TCP) and several outer membrane proteins are found to be under the control of the master regulator ToxR as in EITor vibrios. The iron-regulated genes involved in virulence are also found in the same locus as in EITor vibrios. However, the genes involved in the somatic antigen synthesis in O1 vibrios are found to be deleted in O139 vibrios and are replaced by a new region of chromosome which encodes the new surface antigen synthesis in O139 vibrios. When V. cholerae O139 emerged and caused outbreaks, the prevailing O1 EITor vibrios virtually disappeared from most of the areas. The disappearance of EITor vibrios, the rapid spread of O139 vibrios and the resemblance of O139 vibrios to EITor vibrios seemed to suggest that O139 vibrios might be the causative agent of the 'eighth' pandemic of cholera. However, after a year of its appearance, O139 vibrios are on the wane and O1 EITor vibrios have re-emerged as the predominant organism, in the Indian subcontinent. Thus, the immediate threat of a new cholera pandemic posed by V. cholerae O139 may not be as large as it first seemed. However, whether it will follow the pattern of EITor vibrio which took approximately 60 yr since its first isolation before emerging as the seventh pandemic strain of cholera, is not clear. The factor(s) contributing to the diminished isolation of O139 vibrios and the re-emergence of O1 EITor vibrios are not understood. The vibrios might have undergone changes that would have affected their ability to survive and compete in the environment.

La evolución de la mortalidad infantil en Bolivia / The infant mortality evolution in Bolivia

Para este estudio se ha re-tabulado las encuestas de 1975, 1980, 1983 y 1988. Por dificultades técnicas, no fue posible re-tabular el Censo de 1976. Más bien, las cifras correspondientes al Censo se toman de un exelente trabajo, "la mortalidad infantil en Bolivia", publicado en 1985, que es producto de un análisis coloborativo hecho por la UNICEF y CELADE