Temporal patterns and forecast of dengue infection in Northeastern Thailand.

This study aimed to determine temporal patterns and develop a forecasting model for dengue incidence in northeastern Thailand. Reported cases were obtained from the Thailand national surveillance system. The temporal patterns were displayed by plotting monthly rates, the seasonal-trend decomposition procedure based on loess (STL) was performed using R 2.2.1 software, and the trend was assessed using Poisson regression. The forecasting model for dengue incidence was performed in R 2.2.1 and Intercooled Stata 9.2 using the seasonal Autoregressive Integrated Moving Average (ARIMA) model. The model was evaluated by comparing predicted versus actual rates of dengue for 1996 to 2005 and used to forecast monthly rates during January to December 2006. The results reveal that epidemics occurred every two years, with approximately three years per epidemic, and that the next epidemic will take place in 2006 to 2008. It was found that if a month increased, the rate ratio for dengue infection decreased by a factor 0.9919 for overall region and 0.9776 to 0.9984 for individual provinces. The amplitude of the peak, which was evident in June or July, was 11.32 to 88.08 times greater than the rest of the year. The seasonal ARIMA (2, 1, 0) (0, 1, 1)12 model was model with the best fit for regionwide data of total dengue incidence whereas the models with the best fit varied by province. The forecasted regional monthly rates during January to December 2006 should range from 0.27 to 17.89 per 100,000 population. The peak for 2006 should be much higher than the peak for 2005. The highest peaks in 2006 should be in Loei, Buri Ram, Surin, Nakhon Phanom, and Ubon Ratchathani Provinces.

Monitoring and evaluation of a model demonstration project for the control of cervical cancer in Nakhon Phanom province, Thailand.

Cancer of the uterine cervix is the second most common cancer in females in the world with about half a million new patients per year. Since the introduction by Papanicolaou of cervical smear screening, the incidence of cervical cancer has declined in many developed countries. The decrease in the incidence of and mortality from cervical cancer is mainly due to the organized mass screening using Pap smear programmes. Uterine cervical cancer is the leading cancer among women in Thailand with age-standardized incidence rates of 24.7 per 100,000 in 1999. Most cases present at advanced stages with poor prognoses of survival and cure. In the present study, cervical cancer screening programme with cervical cytology was organized for Nakhon Phanom province, Thailand. The specific objectives were: 1) to evaluate the reduction in incidence and mortality from cervical cancer in the province by means of an organised low-intensity cervical cytology programme. 2) to demonstrate the different aspects of programme implementation as a potential model for nationwide implementation. The screening activities were integrated in the existing health care system. Organized screening for women in the target population (aged 35-54 years) at 5-year intervals was free of charge. Sample taking was done by trained nurses (midwives) and primary health care personnel in the local health care centers. Sample quality was under continuous controlled by the cytology laboratories and pathologists. Confirmation and treatment were integrated into the normal health care routines. The screening results of the programme, including histologically confirmed diagnosis, were registered at the National Cancer Institute using PapReg and CanReg 4 programmes. A population-based cancer registry in Nakhon Phanom province was also set up in 1997. In the period 1999-2002, 32,632 women aged 35-54 years were screened. Women with low-grade lesions returned for routine follow-up smears. High-grade preinvasive disease was further evaluated by repeating Pap smear, conization or biopsy and subsequent treatment through surgical removal or ablation. This organized low-intensity cervical cytology programme showed a considerable increase in early carcinoma in situ and CIN II -III cases and should reduce incidence of and mortality from cervical cancer in Nakhon Phanom province in the future. Screening with the Papanicolaou smear plus adequate follow-up diagnosis and therapy can achieve major reductions in both incidence and mortality rates.

Survival time of HIV-infected patients with cryptococcal meningitis.

OBJECTIVE: To study survival time and risk factors of mortality among HIV-infected patients who had cryptococcal meningitis. DESIGN: Retrospective cohort study. MATERIAL AND METHOD: Patients' medical records of those who had HIV-infection with newly diagnosed cryptoccocal meningitis between January 2002 and December 2004 were reviewed. Each patient was classified into one of two groups, according to their anti-retroviral status (ART). RESULTS: Five hundred and forty nine patients enrolled in the present study: 281 (51.2%) in the ART+ group and 268 (48.8%) in the ART-group. The mean age was 33.4 +/- 6.9 years old in the ART + group and 33.6 +/- 7.0 years old in the ART-group. There were more male in both groups: 207 males and 74 females in the ART+ group, and 195 males and 73 females in the ART-group. Baseline CD4 cell count of both groups was 20 (6-74) cells/mL and 24 (9-72) cells/ml. About 30% of both groups of patients experienced major opportunistic infection before cryptococcal meningitis. All patients were treated by standard amphotericin B for a 2-week duration followed by fluconazole for an additional 8 weeks. There were no differences of baseline characteristics between the two groups (p > 0.05). The survival rates at 12, 24, and 36 months were 92.8%, 87.4%, and 85.4% in the ART+ group and 55.3%, 42.2%, and 36.8% in the ART- group, respectively (p < 0.01). The median survival time in the ART- group was 15 months. From the Cox regression model, the hazard ratio for "not received ART" was 4.87 (95%CI = 2.48-9.44, p < 0.01). CONCLUSION: The present study demonstrated the substantial increasing of survival time of HIV-infected patients with cryptococcal meningitis by initiated ART even in a resource limited setting (no flucytosine, local combined antiretroviral drugs with NVP based regimens).

Potential association of dengue hemorrhagic fever incidence and remote senses land surface temperature, Thailand, 1998.

A pilot study was designed to analyze a potential association between dengue hemorrhagic fever (DHF) incidence and, temperature computed by satellite. DHF is a mosquito transmitted disease, and water vapor and humidity are known to have a positive effect on mosquito life by increasing survival time and shortening the development cycle. Among other available satellite data, Land Surface Temperature (LST) was chosen as an indicator that combined radiated earth temperature and atmospheric water vapor concentration. Monthly DHF incidence was recorded by province during the 1998 epidemic and obtained as a weekly combined report available from the National Ministry of Public Health. Conversely, LST was calculated using remotely sensed data obtained from thermal infrared sensors of NOAA satellites and computed on a provincial scale. Out of nine selected study provinces, five (58.3%) exhibited an LST with a significant positive correlation with rainfall (p < 0.05). In four out of nineteen surveyed provinces (21.3%), LST showed a significant positive correlation with DHF incidence (p < 0.05). Positive association between LST and DHF incidence was significantly correlated in 75% of the cases during non-epidemic months, while no correlation was found during epidemic months. Non-climatic factors are supposed to be at the origin of this discrepancy between seasonality in climate (LST) and DHF incidence during epidemics.

Sexual behaviors of alcohol drinkers and non-drinkers among adolescents and young adults in Nha Trang, Vietnam.

A cross-sectional quantitative survey was conducted during August to November 2005 with 880 youths (16-24 years-old), including 412 males and 468 females in Nha Trang city, Vietnam. It aimed to examine the association between alcohol use and sexual behaviors by gender difference. The data revealed that the majority of respondents (65.9%) had consumed alcohol, 25.8% had sexual touching with boy/girl friends, and 10.1% of respondents had engaged in sexual experiences including vaginal sex, anal sex, and/or oral sex. Young men were significantly more likely to drink than young women were (p < 0.001), and alcohol use was significantly associated with engagement in sexual experiences (p < 0.001). There was a strong significant different between sexual touching and alcohol drinking among males (p < 0.001) and females (p < 0.001). Forty percent of young men who did not use condom in last sex and 45% of young men who had multiple sex partners were drinkers compared to 4.8% and 1.6% of non-drinkers, respectively. These significant findings will be baseline data for integrating and adapting into intervention programs for alcohol and HIV among Vietnamese youth.

Early detection of malaria in an endemic area: model development.

A malaria epidemic warning system was established in Thailand in 1984 using graphs displaying the median or mean incidence of malaria over the previous five years compiled from malaria surveillance data throughout the country. This reporting mechanism is not timely enough to detect the occurrence of a malaria epidemic which usually occurs at the district level over a short period of time. An alternative method for early detection of a malaria epidemic employing the Poisson model has been proposed. The development of this early malaria epidemic detection model involved 3 steps: model specification, model validation and model testing. The model was based on data collected at the Vector Borne Disease Control Unit (VBDU) Level. The results of model testing reveal the model can detect increasing numbers of cases earlier, one to two weeks prior to reaching their highest peak of transmission. The system was tested using data from Kanchanaburi Province during 2000 to 2001. Results from model testing show the model may be used for monitoring the weekly malaria situation at the district level. The Poisson model was able to detect malaria early in a highly endemic province with a satisfactory level of prediction. As the application is essential for the malaria officers in monitoring of malaria epidemics, this early detection system was introduced into malaria epidemiological work. The model may be helpful in the decision making process, planning and budget allocation for the Malaria Control Program. The software for early malaria detection is currently implemented in several endemic areas throughout Thailand.

Missed appointments at a tuberculosis clinic increased the risk of clinical treatment failure.

We investigated the charts of 381 new smear-positive tuberculosis patients at Khon Kaen Medical School during 1997-2001 using World Health Organization definitions to evaluate associations among treatment success or failure (defaulted, failed, died, or not evaluated) and tuberculosis clinic contact, demographics and clinical characteristics of the patients. Multinomial logistic regression was used for three-category outcome analysis: treatment success, transferred-out and clinical treatment failure. The treatment success and clinical treatment failure rates were 34.1% and 34.4%, respectively. About 46.5% and 85.8% of patients missed appointments at the tuberculosis clinic in the treatment success and treatment failure groups, respectively. The results show that patients who were absent from the tuberculosis clinic were 5.95 times more likely to have clinical treatment failure than treatment success, having adjusted for the effect of transfering-out and the effect of the treatment regimen and the sputum conversion status (adjusted odds ratio = 5.95; 95% CI: 2.99 to 11.84). The review showed that absence from the tuberculosis clinic was an independent risk factor for clinical treatment failure. We recommended that all new smear-positive tuberculosis patients should be followed closely at a tuberculosis clinic.

Estimation of non-fatal road traffic injuries in Thai Nguyen, Vietnam using capture-recapture method.

Road traffic injuries (RTIs) are increasing in developing countries where accurate routine data are usually not available. Although a capture-recapture technique has increasingly been employed in studies of human populations to provide reliable estimates of the magnitude of problems, it has rarely been used in road traffic injury research. We applied two sample capture-recapture methods using hospital and traffic police records to estimate non-fatal road traffic injuries in Thai Nguyen City during the years 2000-2004. We generated a conservative adjusted estimate of non-fatal RTIs using data from the two sources matched by name, surname, sex of victims and at least one of the other matching variables, of age, address of victim and date of injuries. We then compared the estimated rates with those reported based on police and hospital data. The results show that during years 2000-2004, the police reported 1,373 non-fatal RTIs, while hospital records revealed 6,069 non-fatal RTIs. Most reported victims on both hospital and police reports were males (67.3 % and 74.4%, respectively). More than half the victims on both hospital and police reports were drivers (77.5% and 66.1%, respectively) or pedestrians (10.6% and 7.1%, respectively). Youth and young adults (ages 15-34) constituted the majority of the victims on the hospital and police reports (52.8% and 63.7%, respectively). The capture-recapture analysis estimated that 11,140 (95% CI: 10,626-11,654) subjects were involved in RTIs during the study period. In comparison to the estimated figure, official sources accounted for only 21.9 to 60.1% of total non-fatal RTIs. Estimated rates of non-fatal RTIs were 105.5 injuries/10,000 population per year and 393 injuries/10,000 vehicles. Given the fact that under reporting of RTIs has been a major limitation of routine official data sets in developing countries, we suggested the capture-recapture method be used as a tool to provide affordable and reliable estimates of RTIs in resource-poor countries.

In vitro susceptibility and genetic variations for chloroquine and mefloquine in Plasmodium falciparum isolates from Thai-Myanmar border.

In vitro drug susceptibility to chloroquine (CQ) and mefloquine (MF) were assessed in 39 P. falciparum isolates from the Thai-Myanmar border area. To further characterize CQ- and MF-resistance profiles in this area, we also analyzed pfcrt K76T mutation that is critical for CQ resistance, and pfmdr1 polymorphism that has an association with MF resistance. Eighteen isolates were successfully examined by in vitro tests for CQ, and 17 of them had resistance to the drug. Geometric mean concentration of CQ that inhibited the growth of parasites at 50% (IC50) was 371 +/- 227 nM (105-971 nM). Sixteen isolates were successfully examined by in vitro tests for MF, and 8 of them were resistant to the drug. Geometric mean of IC50 for MF was 41 +/- 31 nM (4-125 nM). Genotypes of drug resistance, such as pfcrt and pfmdr1 mutations, were also analyzed. All the 39 isolates had the same haplotype (CVIET) for PfCRT at its 72-76th amino acids. A pfmdr1 Y86 mutation was found in 95% of isolates. A pfmdr1 D1042 mutation was also present in 7 isolates, while no pfmdr1 Y1246 mutation was observed. These results indicated a correlation between CQ resistance and the pfcrt T76 and pfmdr1 Y86 mutations.

Chronicle of malaria epidemics in Thailand, 1980-2000.

The occurrence of malaria epidemics in Thailand was reviewed from the malaria surveillance report of the National Malaria Control Program. The literature review revealed that the four epidemic periods recorded during 1980-2000 almost always occurred in the provinces and districts located along international borders. Malaria epidemics are caused by various factors such as: extensive population movement, multi-drug resistance development, low immune status of the population, lack of knowledge and appropriate personal protection against mosquito biting, and the re-emergence of malaria transmission in low malarious areas. Such factors can lead to changes in the parasite ratio and appearance of malaria epidemics throughout the country. Evidence related to the burden of malaria epidemics was also reviewed to identify causal factors that will be helpful in future research.

Causal relationship between health promoting behavior and quality of life in cervical cancer patients undergoing radiotherapy.

The purpose of this cross-sectional study was to examine the causal relationships among age, education, family income, and stage of carcinoma, perceived benefits, perceived barriers, perceived self-efficacy, health promoting behavior and quality of life in patients with cervical cancer. Pender's Health Promotion Model (1996) provided a guide for the conceptual framework of this study. Purposive sampling was employed to recruit 488 cervical cancer patients who were undergoing radiotherapy at seven public hospitals in five areas of Thailand. The instruments used in this study included a Personal Data Form, Cognitive perception Form, Health promoting behavior scale, the social support questionnaire and The Functional Assessment of Cancer Therapy General (FACT-G) form. The proposed model was tested and modified by the LISREL Program. The modified model adequately fitted with the data. The results demonstrate that health promoting behavior had a significant direct positive effect on quality of life (beta = 0.71, p < 0.01). Cognitive perceptual factors had a significant direct effect on health promoting behaviors (P = 0.69, p < 0.01). Social support had a significant direct effect on the cognitive perceptual factors (P = 0.64, p < 0.01), health promoting behavior (beta = 0.70, p < 0.01), and the quality of life (beta = 0.48, p < 0.01). Age and education did not have a significant total effect on the quality of life. Family income had a significant direct effect on cognitive perceptual factors (beta = 0.10, p < 0.05). The stage of cancer had a significant direct negative effect on cognitive perceptual factors (beta = -0.11, p < 0.05) and the quality of life (beta = -0.12, p < 0.01). The direct effect of the predictors on the quality of life indicated that cervical cancer patients with higher practice of health promoting behavior tended to have a higher quality of life. The findings indicate that Pender's Health Promotion Model is a useful guide for explaining and predicting the health promoting behavior and the quality of life of Thai cervical cancer patients who were undergoing radiotherapy. The significance of cognitive perceptual factors and social support confirm health promoting behavior as a goal directed towards the level of well being. This has implications for health care systems in planning interventions to promote health promoting behavior in a health promotion setting in cervical cancer patients for a better quality of life and healthy. A longitudinal study and experimental study are recommended for further study.

The Asian center of international parasite control (ACIPAC): five years of achievement. I. Introduction.

ACIPAC has made an effort to promote the concept of the school-based approach to malaria and STH control, mainly through human resource development, which could be eventually extended to any other health promotion program. Implementation of SSPP resulted in the establishment of national policies on parasite control and/or school health in some partner countries. It also provides a good opportunity for the formulation of partnerships among health and education sectors and international partners, although it did cause some problems concerning the enrollment of persons of authority from partner countries, and the staff of JICA resident offices as well. As described in the Joint Evaluation Report, ACIPAC is expected to further contribute to human resource development and to strengthening human resource and information networking at regional and global levels.

Water quality and breeding habitats of anopheline mosquito in northwestern Thailand.

Malaria transmission is dependent upon many hydrology-driven ecological factors that directly affect the vectorial competence, including the presence of suitable habitats for the development of anopheline larvae. Larval habitats were identified and characterized at three malaria endemic villages (Ban Khun Huay, Ban Pa Dae, and Ban Tham Seau) in Mae Sot district, Tak Province, in northwestern Thailand between July 2002 and June 2003. The Global Positioning System (GPS) was used to provide precise locational data for the spatial distribution of anopheline mosquito larvae and their habitats. Ten habitat categories were identified. Eighteen adult Anopheles species were identified from larvae in all the surveyed habitats. An. minimus was the most common species throughout the year. The relationship between eight abiotic variables (temperature, hardness, carbon dioxide, dissolved oxygen, nitrate, phosphate, silica and pH) and the abundance of four major species of malaria vectors (An. (Cel.) dirus, An. (Cel.) minimus, An. (Cel.) maculatus, and An. (Cel.) sawadwongporni), and six species of non-vectors (An. (Cel.) kochi, An. (Cel.) jamesii, An. (Ano.) peditaeniatus, An. (Ano.) barbirostris, An. (Ano.) campestris, and An (Cel.) vagus) larvae was investigated. The results from the multiple regression models suggest that hardness, water temperature and carbon dioxide are the best predictor variables associated with the abundance of An. minimus larvae (p < 0.001); water pH for An. dirus larvae (p < 0.001); temperature and pH for An. kochi larvae (p < 0.01); temperature and silica concentration for An. jamesii larvae (p < 0.001); dissolved oxygen and silica concentration for An. campestris larvae (p < 0.001); and pH and silica concentration for An. vagus larvae (p < 0.001). We could not identify key environmental variables for An. maculatus, An. sawadwongporni, An. peditaeniatus, and An. barbirostris.

Ikonos-derived malaria transmission risk in northwestern Thailand.

We mapped overall malaria cases and located each field observed major malaria vector breeding habitat using Global Positioning System (GPS) instruments from September 2000 to October 2003 around the three malaria-endemic villages of Ban Khun Huay, Ban Pa Dae, and Ban Tham Seau, Mae Sod district, Tak Province, Thailand. The land-use/land-cover classifications of the three villages and surrounding areas were performed on IKONOS satellite images acquired on 12 November 2001 with a spatial resolution of 1 x 1 m. Stream network was delineated and displayed. Proximity analysis was performed on the locations of the houses with and without malaria cases within a 1.5 km buffer from An. minimus immature mosquito breeding habitats, mainly stream margins. The 1.5 km used in our proximity analysis was arbitrarily estimated based on the An. minimus flight range. A statistical t-test at 5% significance level was performed to evaluate whether houses with malaria cases have higher proximities to streams than houses without malaria cases. The result shows no significant difference between proximity to streams between houses with malaria cases and houses without malaria cases. We suspect that the actual flight range of An. minimus may be greater than 1.5 km. The An. minimus larval habitat deserves more detailed investigation. Further studies on human behavior contrary to that required for adequate malaria control among these three villages are also recommended.

Gender difference in socio-epidemiological factors for leprosy in the most hyper-endemic district of Nepal.

Leprosy which has caused stigma and social ostracism for millennium is nearing elimination worldwide as a public health problem, but the leprosy burden in Nepal is still 4.4 times greater than WHO's target level of less than one case per 10,000 population. Although leprosy affects both the sexes, in most parts of the world males are affected more than females at a ratio of 2:1. The general objective of the study was to investigate the gender difference in socio-epidemiological factors for leprosy. The analytic cross-sectional study was carried out in one of the most hyper endemic district- Dhanusa district of Nepal. Stratified random sampling method was applied for the selection of the patients. Chi-square/Fisher's exact test was applied to assess statistically significant differences in values between males and females. There were 580 leprosy patients (385 male and 195 female) aged above 15 years registered for multi drug therapy between April 1, 2001 to March 31,2002 in the 16 main health centers of the district. Out of 580 patients, 273 patients (183 males and 90 females) were included in the study in order to collect the data on socio-demographics, patient's knowledge on leprosy, treatment seeking behaviour, and social problems faced by the patients. Data were collected using a structured interview schedule. The mean age of the male patients was 45.1 years (range 15-77 years) and female patients were 40.3 years (range 15-75 years). Among male patients 93.4% were married while among female patients 70.0% were married. Among male patients 51.9% were illiterate whereas 71.1% were illiterate among female patients. Most of the patients (69.6%) lived in joint family and the rest in nuclear family. Among male patients, 86.9% had good knowledge about the disease compared to 73.3% among females. This study showed that among the female patients 12.2% were facing high level of social problems, while among male patients only 4.4% were facing the same. About 15% patients had poor treatment seeking behaviors (8.2% among males and 27.8% among females). A significant gender differences among leprosy patients have been found in age distribution, educational status, marital status, caste types, family members, and overall knowledge on the general aspect of leprosy, social problems faced by the patients and treatment seeking behaviour.

A survey of the Th2R and Th3R allelic variants in the circumsporozoite protein gene of P. falciparum parasites from western Thailand.

Allelic variation in the Plasmodium falciparum circumsporozoite protein (CS) gene has been determined by sequencing the immunodominant T-cell epitopes, Th2R and Th3R, from 95 isolates from two malaria-endemic areas in the west of Thailand. Comparison with a reference sequence revealed only non-synonymous point mutations in the two epitope regions. Point mutations were found outside these epitopes in a minority of samples, and all but four were also non-synonymous. A relatively high number of variants, 11 Th2R and 9 Th3R, were detected and comprised some that had not been previously observed. However, the Th2R*05 and the Th3R*01 allelic variants predominated, as they were found in more than 70% of the 101 sequences obtained.

Gender differences in epidemiological factors associated with treatment completion status of leprosy patients in the most hyperendemic district of Nepal.

The introduction of multidrug therapy (MDT), recommended by WHO, has been a major advance in the treatment of leprosy because of its relatively short treatment course and low rate of relapse. Although leprosy treatment is provided to both sexes equally, in most parts of the world significant differences have been found in treatment status. The main objective of the study was to investigate gender differences in epidemiological factors associated with treatment status of leprosy patients. An analytic cross-sectional study was carried out in the most hyperendemic Dhanusa District, Nepal. Stratified random sampling was applied for selection of the patients. Statistical analysis of the differences in treatment status, between males and females, and among other epidemiological factors of interest was carried out using multiple logistic regression. Chi-square/Fisher's exact test were also used to assess significant differences in values between males and females. There were 580 leprosy patients (385 male and 195 female) aged >15 years registered for MDT between April 1, 2001 to March 31, 2002 in the 16 main health centers of the district. Of the 580 patients, a total of 273 (183 male and 90 female) were included in the study, to collect data on clinical type of leprosy, patterns of physical deformity/disability, site of skin lesions, and socio-demographic information. There were 183 male (68.3% on MB-MDT) and 90 female (61.1% MB-MDT) leprosy patients. We found that 79.2% of male patients completed treatment, while 34.4% female patients did not complete within the given time frame. Significant gender differences among leprosy patients were found in the distribution of disability grades and treatment completion status. However, there was no significant gender difference in the distribution of leprosy types and skin lesion sites. The study also found significant associations between treatment completion status and gender (adjusted OR 2.05, 95% CI: 1.07-3.94), educational status (adjusted OR 2.37, 95% CI: 1.12-4.99), disability grade I (adjusted OR 3.14, 95% CI: 1.23-8.04), and disability grade 0 (adjusted OR 2.92, 95% CI: 1.14-7.47) after adjustment for all other leprosy/demographic factors.

Gender difference in treatment seeking behaviors of tuberculosis cases in rural communities of Bangladesh.

This descriptive cross-sectional study was conducted to investigate gender differences in the epidemiological factors associated with the treatment seeking behaviors of TB cases in the rural communities of Bangladesh. The study reveals that there is significant gender difference in treatment seeking behaviors of rural TB cases and the majority of them (52%) have taken prior treatment from various traditional healers, 70% of them are females who attended health centers (UZHCs) as the other choice (adjusted OR: 4.2, 95% CI: 2.0-8.4). It was found that the mean patient delay was 63 days (range 14-210 days) where half of the females delayed more than 60 days while they were spreading their disease. The study findings reveal gender differences in treatment seeking behaviors associated with socio-cultural barriers, particularly among females in their access to TB care. Fifty-five percent of cases wanted the diagnosis of TB remain confidential to avoid being labeled as TB patients, where 82.7% were female, 85.6% of female TB patients had problems in their relationships with their spouse (61%) and family members (58%) after being diagnosed with TB. The results of the TB service factors found that 39% of females were not satisfied with their provider's behaviors, which was significantly associated with treatment seeking behavior (adjusted OR: 2.6, 95% CI: 1.0-6.6). The study findings strongly suggest that there was a significant gender difference in treatment seeking behavior in rural Bangladesh. Based on the study findings, we recommend developing an appropriate gender strategy for developing a TB control program, comprised of operational, socio-cultural and community awareness interventions aimed at treating undiscovered reservoirs of female TB cases in rural Bangladesh.

Association of intestinal helminths with decreased liver size and sCD23 concentration during falciparum malaria.

To determine if intestinal helminths and the CD23/nitric oxide pathway had an influence on liver size, we conducted a cross-sectional study on 438 patients with confirmed P. falciparum malaria admitted at the Hospital for Tropical Diseases in Bangkok. For all patients the liver size was measured as number of centimeters below the rib cage, a stool examination was conducted, and CD23 and reactive nitrogen intermediates were measured. The median liver size was smaller in helminth-infected patients than in helminth-free patients (chi2 for trend = 9.1, p = 0.003). Liver size significantly increased with the concentration of sCD23 (p < 0.0001). The median sCD23 concentration (OD) was significantly lower in helminth-infected patients than in helminth-free patients, respectively 0.33 (quartiles 0.24-0.57) and 0.45 (quartiles 0.27-0.59), (p = 0.01). There was a negative correlation between sCD23 concentrations and RNI (Spearman's rho = -0.40, p < 0.0001). All the above results remained significant after controlling for potential confounders. These results are compatible with a CD23/NO-mediated decrease in liver size in helminth-infected patients.