Fatality trends in United Nations Peacekeeping Operations, 1948-1998.

CONTEXT: The rising number of deaths among United Nations (UN) peacekeeping forces after the Cold War has made some troop-contributing countries hesitant to participate in peacekeeping operations. While the number and scale of missions have increased, no data have demonstrated a parallel increase in risks to peacekeepers. OBJECTIVE: To determine the association of characteristics of UN peacekeeping operations with risks and mortality rates among UN peacekeeping forces in both the Cold War and post-Cold War periods. DESIGN, SETTING, AND PARTICIPANTS: Descriptive analysis of 1559 personnel deaths during 49 UN peacekeeping missions from 1948-1998 based on the casualty database maintained by Department of Peacekeeping Operations, UN Headquarters. MAIN OUTCOME MEASURES: Number and percentage of deaths by circumstance, total crude death rate, and crude death rate and relative risk of death by circumstance (hostile acts, unintentional violence, and illness or other causes) and time period (Cold War vs post-Cold War), geographic region, and nature of peacekeeping response; and regression analysis of mission variables (strength, duration, and humanitarian mandate) associated with total number of deaths. RESULTS: More deaths have occurred among UN peacekeeping forces in the past decade alone than in the previous 40 years of UN peacekeeping (807 vs 752), but crude death rates did not differ significantly by time period (Cold War vs post-Cold War, 21.8 vs 21. 2 deaths per 10,000 person-years; P =.58), level of peacekeeping response, or for geographic regions other than East Europe and Central America, where rates were lower (P<.001 for both regions). Unintentional violence accounted for 41.2% of deaths, followed by hostile acts (36.1%), and illness or other causes (22.7%). Deaths from hostile acts increased after the Cold War (relative risk [RR] 1. 51; 95% confidence interval [CI], 1.22-1.88), while rates for deaths caused by unintentional violence decreased (RR, 0.79; 95% CI, 0.67-0. 94) but remain high, particularly in the Middle East and Asia (RR, 1. 39; 95% CI, 1.15-1.69). Regression analysis showed a significant association between number of deaths and the strength (P<.001) and duration (P<.001) of a peacekeeping mission. CONCLUSION: The increase in number of deaths among UN peacekeeping personnel since 1990 can be attributed to the increased number and scale of missions after the Cold War rather than increased RR of death. Post-Cold War peacekeeping personnel have a higher risk of dying from hostile acts in missions where more force is required. In missions providing or facilitating humanitarian assistance, both the RR of deaths from all causes and deaths from hostile acts are increased. JAMA. 2000;284:598-603

Mortality in North Korean migrant households: a retrospective study.

BACKGROUND: A deteriorating economy, coupled with a series of natural disasters in 1995-97, led to a severe food crisis in North Korea. Although the country has received substantial international aid since 1996, demographic assessments of crisis impact have been limited. We assessed mortality trends in North Korea since 1995. METHODS: At 15 randomly selected sites in China, 440 North Korean adult migrants were interviewed during July-September, 1998. Respondents were asked about births, deaths, and migration patterns in their households between mid-1994 and mid-1998, and about household food sources. The respondents also provided basic demographic information about the households of their relatives. We compared mortality rates from migrant households with data from the 1993 census and with data about households of non-migrant relatives. FINDINGS: Households that included a recent migrant to China showed increasing mortality: crude death rates rose from 28.9 per 1000 in 1995, to 45.6 per 1000 in 1996, and to 56.0 per 1000 in 1997 (p=0.0001), with a 3-year average rate of 42.8 per 1000. The crude 3-year birth rate was 11.0 per 1000. Average household size declined from 4.0 at the beginning of 1995 to 3.4 at the end of 1997 (p=0.0002). Among 259 households of non-migrant relatives, the crude death rate was 43.2 per 1000 and the crude birth rate was 8.8 per 1000. In these households, the 3-year trend of increasing mortality was significant (p=0.001), as was the decline in average household size from 4.3 at the beginning of 1995 to 3.7 at the end of 1997 (p=0.0001). INTERPRETATION: Among North Korean households that include a recent migrant to China, mortality has increased and household size has declined since 1995. This trend raises concern about the state of the general population, at least in the province of North Hamkyong, from where most of the migrants originated.

The effects of ivermectin on onchocercal skin disease and severe itching: results of a multicentre trial.

OBJECTIVE: To determine the effects of ivermectin in annual, 3-monthly and 6-monthly doses on onchocercal skin p6isease (OSD) and severe itching. METHOD: A multicentre, double-blind placebo controlled trial was conducted among 4072 residents of rural communities in Ghana, Nigeria and Uganda. Baseline clinical examination categorized reactive skin lesions as acute papular onchodermatitis, chronic papular onchodermatitis and lichenified onchodermatitis. Presence and severity of itching was determined by open-ended and probing questions. Clinical examination and interview took place at baseline and each of 5 subsequent 3-monthly follow-up visits. RESULTS: While prevalence and severity of reactive lesions decreased for all 4 arms, those receiving ivermectin maintained a greater decrease in prevalence and severity over time. The difference between ivermectin and placebo groups was significant for prevalence at 9 months and for severity at 3 months. Differences between placebo and ivermectin groups were much more pronounced for itching. From 6 months onward, the prevalence of severe itching was reduced by 40-50% among those receiving ivermectin compared to the trend in the placebo group. CONCLUSION: This is an important effect on disease burden as severe itching is for the affected people the most troubling complication of onchocerciasis. The difference among regimens was not significant, and the recommended regimen of annual treatment for the control of ocular onchocerciasis appears also the most appropriate for onchocerciasis control in areas where the skin manifestations predominate. The final determination of the effect on skin lesions requires a longer period of study.

Adverse reactions to ivermectin treatment for onchocerciasis. Results of a placebo-controlled, double-blind trial in Malawi.

A three-year placebo-controlled, double-blind trial involving 7148 persons was conducted to determine adverse reactions to ivermectin given annually for treatment of onchocerciasis by mass distribution. Musculoskeletal pains, oedema of the face or extremities, itching and papular rash were statistically associated with ivermectin treatment in the first year. In the second year of treatment these reactions were less frequently reported, although still more prevalent in ivermectin recipients. During the third year of treatment all persons received ivermectin. Persons who had missed ivermectin treatment in the second year did not have significantly more adverse reactions after treatment in the third year. Those who had received placebo during the first 2 years reported some adverse reactions more frequently following ivermectin than did those who had received ivermectin from the beginning of the study. Oedema was the adverse reaction of greatest concern to patients and this involved the face most commonly. A single episode of bullous skin lesions developed in 5 persons who had received ivermectin. These lesions did not reoccur with subsequent treatment. No episode of hypotension after treatment was observed.

Onchocerciasis in Malawi. 2. Subjective complaints and decreased weight in persons infected with Onchocerca volvulus in the Thyolo highlands.

In the course of an onchocerciasis survey in southern Malawi, body weight was recorded for 10,335 persons aged 20 years and older, and the body mass index was calculated for 5572. A history of symptomatic complaints was elicited from 5653 persons 20 years of age and older. Persons with microfilariae in the skin snips weighed significantly less than persons with negative skin snips. Symptomatic complaints of musculoskeletal pains, itching, dizziness and poor vision were reported more commonly in the group with microfilariae. These findings suggest that onchocerciasis should no longer be considered a disease affecting the eye and skin only but an infection which produces systemic effects as well. Systemic effects of onchocerciasis may lessen productivity of an endemic region by a process distinct from the effects of visual impairment.

Onchocerciasis in Malawi. 1. Prevalence, intensity and geographical distribution of Onchocerca volvulus infection in the Thyolo highlands.

Skin snips from 23,373 persons living in the Thyolo (formerly Cholo) highlands focus of southern Malawi showed infection with Onchocerca volvulus to be unevenly distributed within the highland area. In the centre of the focus most adults were infected, though intensity of infection was light, not exceeding a geometric mean of 8 microfilariae per mg of skin. It was estimated that 327,000 persons live in areas where prevalence of infection exceeds 10% and, of these, 94,500 persons over the age of one year are infected with O. volvulus. There is a significant relationship between infection with O. volvulus and bilateral blindness in the Thyolo focus, although the number of persons blind from onchocerciasis is probably less than 300.

Onchocerciasis in Malawi. 2. Subjective complaints and decreased weight in persons infected with Onchocerca volvulus in the Thyolo highlands

In the course of an onchocerciasis survey in southern Malawi; body weight was recorded for 10;335 persons aged 20 years and older; and the body mass index was calculated for 5572. A history of symptomatic complaints was elicited from 5653 persons 20 years of age and older. Persons with microfilariae in the skin snips weighed significantly less than persons with negative skin snips. Symptomatic complaints of musculoskeletal pains; itching; dizziness and poor vision were reported more commonly in the group with microfilariae. These findings suggest that onchocerciasis should no longer be considered a disease affecting the eye and skin only but an infection which produces systemic effects as well. Systemic effects of onchocerciasis may lessen productivity of an endemic region by a process distinct from the effects of visual impairment

Onchocerciasis in Malawi. 1. Prevalence; intensity and geographical distribution of Onchocerca volvulus infection in the Thyolo highlands

Skin snips from 23;373 persons living in the Thyolo (formerly Cholo) highlands focus of southern Malawi showed infection with Onchocerca volvulus to be unevenly distributed within the highland area. In the centre of the focus most adults were infected; though intensity of infection was light; not exceeding a geometric mean of 8 microfilariae per mg of skin. It was estimated that 327;000 persons live in areas where prevalence of infection exceeds 10 percent and; of these; 94;500 persons over the age of one year are infected with O. volvulus. There is a significant relationship between infection with O. volvulus and bilateral blindness in the Thyolo focus; although the number of persons blind from onchocerciasis is probably less than 300

HIV seropositivity and tuberculosis in a rural Malawi hospital

This study was undertaken to determine the extent to which human immunodeficiency virus (HIV) infection has increased hospital admissions for tuberculosis (TB) in a rural population of southern Malawi. The notes and chest X-rays of TB patients admitted to Malamulo hospital in 1983 and 1984; before the recognition of acquired immune deficiency syndrome (AIDS) in Malawi; were compared with those of patients admitted in 1987 and 1988. We found a 160 percent increase in TB admissions between the 2 periods. Extrapulmonary TB; especially pleural TB; was much commoner in 1987-1988 and occurred in a younger age group. HIV seroreactivity was measured in a third group of 152 tuberculosis patients admitted during 1988-1989. HIV seropositivity was found in 52 percent of all tuberculosis admissions and in 75 percent of those with extrapulmonary disease. There was no difference in clinical response to TB therapy between the HIV seropositive patients and those who were seronegative. Extrapulmonary TB should be considered in all HIV seropositive patients; especially in areas where the prevalence of TB is high. Health personnel involved in TB programmes where HIV and TB infections are prevalent should plan for a large increase in the TB case load secondary to the HIV pandemic

Pernicious anaemia, neurological changes and gastric ulceration in a Malawian woman. A case report.

Gastric acid is held to be necessary for the development of gastric ulcers. The absence of gastric ulcers in patients with pernicious anaemia is cited as evidence for the pivotal role of acid. There have been a few reports of gastric ulcers occurring in elderly persons with pernicious anaemia. Presented here is a 35-year-old Malawian woman with pernicious anaemia who also had gastric ulcerations and neurological changes. This report of gastric ulceration in a patient with pernicious anaemia is thought to be the first from Africa and the patient is the youngest on record.

The immune system in malaria: part II; immunologic changes in malaria

When a host; infected with malaria; is challenged with several antigens; the immune system may be altered by different mechanisms for each antigen involved. The article looks at some of these responses

Progress toward onchocerciasis control in Malawi

"Discusses a project by the Liverpool School of Tropical Medicine and the Ministry of Health to study the breeding habits of the simulium fly; which is responsible for the spread of onchocerciasis or ""river blindness""; in order to formulate vector control strategies"

Malarial immunity: part III

A review of attempts to make a vaccine against malaria to counteract the growing resistance to chloroquine