ABSTRACT
OBJECTIVES: To measure the effects of diabetes clubs on peer support, disclosure of diabetes status, and the source of information regarding the management of diabetes among persons living with type-2 diabetes (T2D) in rural Vietnam. STUDY DESIGN: A pre- and post-pilot intervention study was carried out in Thai Binh Province, Vietnam (n = 222). RESULTS: Post-intervention, 57.7 % reported using experiences shared by other persons with T2D during the diabetes club sessions. Compared to pre-intervention, there was an increase in the proportion of persons with T2D who disclosed their diabetes status to friends and/or community members (an increase of 15.3 and 13.8 percentage points, respectively). The proportion of persons who reported gathering their own information regarding diabetes management without any support from others decreased from 15.7 % to 6.3 %. Those who reported a relative inside their home or a relative outside their household as their primary source of T2D-relevant information increased from 10.8 % to 18.6 % and from 2.7 % to 9.5 %, respectively. Persons who mentioned that they did not have a need for further support for their diabetes care increased from 18.5 % to 32.0 %. Specific support regarding diabetes-related knowledge received from family members, friends, and/or community members increased from 27.5 % to 62.2 % CONCLUSIONS: These findings suggest a promising potential for the implementation of diabetes clubs to enhance diabetes-relevant knowledge and the quality of self-management among persons living with T2D diabetes in rural areas of Vietnam.
Subject(s)
Diabetes Mellitus, Type 2 , Disclosure , Humans , Vietnam , Diabetes Mellitus, Type 2/therapy , Family , Information SourcesABSTRACT
BACKGROUND: There is paucity of data on risk factors for reduced fertility in low-income countries. OBJECTIVE: To investigate factors associated with fertility among women in rural north eastern Tanzania. SUBJECTS AND METHODS: A cohort of 1248 non-pregnant women was followed with urine pregnancy testing every third month or more regularly if they reported a missed menstrual period. Pregnancy was confirmed with trans-abdominal ultrasound. Information regarding general health, socioeconomic status and obstetric-gynaecological history was collected. Factors associated with conceiving within 180 days were identified using multivariate logistic regression analyses. RESULTS: Among the 1248 women, 736 were followed for 180 days and 209 of these had an ultrasound confirmed pregnancy. During the follow-up period, 169/736 women were diagnosed with urogenital infections, including suspected sexually transmitted or reproductive tract infections, urinary tract infection, and vaginal candidiasis. Urogenital infections were significantly associated with reduced odds of conceiving within 180 days (adjusted OR (AOR) 0.21, 95% CI 0.11-0.36). Being above 30 years of age was also negatively associated with odds of conceiving (AOR 0.45, 95% CI 0.26-0.77). In contrast, women who recently stopped using hormonal contraceptives (AOR 2.86, 95% CI 1.45-5.70) and women with low socioeconomic status (AOR 1.56, 95% CI 1.04-2.33) were significantly more likely to become pregnant within 180 days. CONCLUSION: Urogenital infection seems to be a major health factor associated with reduced chances of conceiving. Considering the availability of effective treatment options for these diseases, public health authorities should increase awareness of diagnostic tools in settings with limited resources in order to improve fertility.
Subject(s)
Female Urogenital Diseases/complications , Infertility, Female/epidemiology , Adult , Africa/epidemiology , Age Factors , Cohort Studies , Female , Female Urogenital Diseases/microbiology , Humans , Infertility, Female/complications , Multivariate Analysis , Pregnancy , Pregnancy RateABSTRACT
OBJECTIVE: To evaluate effect of locally tailored labour management guidelines (PartoMa guidelines) on intrahospital stillbirths and birth asphyxia. DESIGN: Quasi-experimental pre-post study investigating the causal pathway through changes in clinical practice. SETTING: Tanzanian low-resource referral hospital, Mnazi Mmoja Hospital. POPULATION: Facility deliveries during baseline (1 October 2014 until 31 January 2015) and the 9th to 12th intervention month (1 October 2015 until 31 January 2016) [corrected]. METHODS: Birth outcome was extracted from all cases of labouring women during baseline (n = 3690) and intervention months (n = 3087). Background characteristics and quality of care were assessed in quasi-randomly selected subgroups (n = 283 and n = 264, respectively). MAIN OUTCOME MEASURES: Stillbirths and neonates with 5-minute Apgar score ≤5. RESULTS: Stillbirth rate fell from 59 to 39 per 1000 total births (RR 0.66, 95% CI 0.53-0.82), and subanalyses suggest that this was primarily due to reduction in intrahospital stillbirths. Apgar scores between 1 and 5 fell from 52 to 28 per 1000 live births (RR 0.53, 95% CI 0.41-0.69). Median time from last fetal heart assessment till delivery (or fetal death diagnosis) fell from 120 minutes (IQR 60-240) to 74 minutes (IQR 30-130) (Mann-Whitney test for difference, P < 0.01). Oxytocin augmentation declined from 22% to 12% (RR 0.54, 95% CI 0.37-0.81) and timely use improved. CONCLUSION: Although low human resources and substandard care remain major challenges, PartoMa guidelines were associated with improvements in care, leading to reductions in stillbirths and birth asphyxia. Findings furthermore emphasise the central role of improved fetal surveillance and restricted intrapartum oxytocin use in safety at birth. TWEETABLE ABSTRACT: #PartoMa guidelines aided in reducing stillbirths and birth asphyxia at a Tanzanian low-resource hospital PLAIN LANGUAGE SUMMARY: PartoMa guidelines help birth attendants in Tanzania to save lives Every year, 3 million babies die on the day of birth. The vast majority of these deaths occur in the poorest countries. If their mothers had received better care during birth, most babies would have survived. At Mnazi Mmoja Hospital, an East African referral hospital, the PartoMa study shows that use of locally developed guidelines helps birth attendants to deliver better quality of care, which has led to improved survival at birth. At the hospital studied, resources are scarce. Each birth attendant assists four to six birthing women simultaneously, and many have less than 1 year of professional experience. International guidelines are available, but they are often unachievable and seldom applied. The PartoMa guidelines were developed in close collaboration with the birth attendants and approved by seven international experts. The result is an 8-page pocket booklet providing locally achievable and simple decision support for care during birth. Use of the PartoMa guidelines began in February 2015. As the staff group frequently changes, quarterly seminars are conducted where birth attendants are welcomed after working hours to learn about the guidelines. The guidelines have been positively received, and seminar attendance remains high. Use of the PartoMa guidelines is associated with: A decrease by one-third in stillbirths (59 to 39 per 1000 total births) A nearly halving in the number of babies born in immediate poor medical condition (52 to 28 per 1000 live births) The results presented here derive from a comparison of births before using the PartoMa guidelines and during the 9th-12th month of use. Such a 'before-after' study cannot exclude the possibility of other causes of better survival at birth. However, the improved survival is consistent with improved care during birth, which is in line with the PartoMa guidelines.
Subject(s)
Asphyxia Neonatorum/epidemiology , Labor, Obstetric , Outcome Assessment, Health Care , Practice Guidelines as Topic , Stillbirth/epidemiology , Adult , Apgar Score , Female , Hospitals , Humans , Infant, Newborn , Middle Aged , Pregnancy , Prenatal Care , Referral and Consultation , Tanzania/epidemiology , Young AdultABSTRACT
AIM: To compare HbA1c and fasting plasma glucose assessment, with the 2-h oral glucose tolerance test as reference, in screening for diabetes in people with turberculosis. METHODS: Individuals (N=268) with newly diagnosed smear-positive tuberculosis were screened for diabetes at a tertiary hospital in Lahore, Pakistan. Diabetes diagnosis was based on WHO criteria: thresholds were ≥48 mmol/mol (≥6.5%) for HbA1c and ≥7.0mmol/l for fasting plasma glucose. RESULTS: The proportion of participants diagnosed with diabetes was 4.9% (n =13) by oral glucose tolerance test, while 11.9% (n =32) and 14.6% (n =39) were diagnosed with diabetes using HbA1c and fasting plasma glucose criteria, respectively. The area under the receiver-operating characteristic curve was 0.79 (95% CI 0.64 to 0.94) for HbA1c and 0.61 (95% CI 0.50 to 0.73) for fasting plasma glucose, with a borderline significant difference between the two tests (P=0.07). CONCLUSIONS: HbA1c and fasting plasma glucose performed equally in terms of diagnosing new diabetes cases in individuals with tuberculosis, but the proportion of participants falsely classified as positive was higher for fasting plasma glucose. This may be explained by acute blood glucose fluctuations when using fasting plasma glucose. HbA1c may be a more reliable test in individuals with transient hyperglycaemia.
Subject(s)
Blood Glucose/analysis , Diabetes Mellitus, Type 2/blood , Diabetes Mellitus, Type 2/diagnosis , Fasting/blood , Glycated Hemoglobin/analysis , Mass Screening/methods , Tuberculosis/blood , Adult , Aged , Aged, 80 and over , Diabetes Mellitus, Type 2/complications , False Positive Reactions , Female , Glucose Tolerance Test , Humans , Male , Mass Screening/standards , Middle Aged , Pakistan , Tuberculosis/complicationsABSTRACT
BACKGROUND: Syphilis testing conventionally relies on a combination of non-treponemal and treponemal tests. The primary objective of this study was to describe the positive predictive value (PPV) of a screening algorithm in a combination of a treponemal rapid diagnostic test (RDT) and rapid plasma reagin (RPR) test at Komfo Anokye Teaching Hospital (KATH), Ghana. MATERIALS AND METHODS: From February 2014 to January 2015, 5 mL of venous blood samples were taken from 16 016 blood donors and tested with a treponemal RDT; 5 mL of venous blood was taken from 526 consenting initial syphilis sero-reactive blood donors. These RDT reactive samples were confirmed with an algorithm, applying the Vitros® /Abbott-Architect® algorithm as gold standard. RESULTS: A total of 478 of 526 RDT reactive donors were confirmed positive for syphilis, making a PPV of 90·9%. Of the 172 (32·7%) donors who were also RPR positive, 167 were confirmed, resulting in a PPV of 97·1%. The PPV of the combined RDT and RPR (suspected active syphilis) testing algorithm was highest among donors at an enhanced risk of syphilis, family/replacement donors (99·9%), and among voluntary donors above 25 years (98·6%). DISCUSSION: Screening of blood donors by combining syphilis RDT and RPR with relatively good PPV may provide a reasonable technology for LMIC that has a limited capacity for testing and can contribute to the improvement of blood safety with a minimal loss of donors.
Subject(s)
Algorithms , Antibodies, Bacterial/blood , Blood Donors , Donor Selection/methods , Syphilis Serodiagnosis/methods , Syphilis/blood , Adult , Cross-Sectional Studies , Developing Countries , Donor Selection/organization & administration , Donor Selection/standards , Female , Ghana , Humans , Male , Middle Aged , Syphilis Serodiagnosis/standardsABSTRACT
AIMS: To assess young healthy men from rural India, who had normal or low birth weights, using magnetic resonance spectroscopy to determine the potential differences in ectopic fat storage between birth weight groups, and to determine if ectopic fat storage was associated with insulin resistance in this population. METHODS: A total of 54 lean men with normal birth weight and 49 lean men with low birth weight (age range 18-22 years) from rural India were recruited. All the men underwent anthropometry, magnetic resonance spectroscopy, a hyperinsulinaemic-euglycaemic clamp and a dual-energy X-ray absorptiometry. RESULTS: The median (interquartile range) values for hepatic cellular lipids, intramyocellular lipids and extramyocellular lipids, measured using magnetic resonance spectroscopy were 0.76 (0.1-1.8)%, 1.27 (1.0-2.3)% and 1.89 (1.3-3.2)%, respectively, for the normal birth weight group and 0.4 (0.1-1.3)%, 1.38 (0.9-2.2)% and 2.07 (1.2-2.8)%, respectively, for the low birth weight group (P > 0.05). No difference in ectopic fat storage was observed between the low and normal birth weight groups, with or without adjustment for age and total fat percentage. Homeostatic model assessment of insulin resistance values were not associated with hepatic cellular, intramyocellular or extramyocellular lipid content in any of the groups. Total fat percentage was the only independent predictor of intramyocellular and extramyocellular lipid content. CONCLUSION: Young and lean men from rural India with low birth weight were not observed to have ectopic fat storage in the liver or muscle, and the amount of liver and muscle fat was unrelated to insulin resistance. Older age and/or an urban affluent lifestyle may be required to show a potential role of ectopic fat storage on insulin resistance in Indian people with low or normal birth weight.
Subject(s)
Adiposity , Infant, Low Birth Weight/physiology , Insulin Resistance/physiology , Liver/metabolism , Muscle, Skeletal/metabolism , Adolescent , Adult , Humans , India , Infant, Newborn , Lipid Metabolism , Lipids/analysis , Liver/chemistry , Magnetic Resonance Spectroscopy , Male , Muscle, Skeletal/chemistry , Rural Population , Young AdultABSTRACT
BACKGROUND: The association between diabetes mellitus (DM) and tuberculosis (TB) has been established on the basis of cross-sectional studies; however, only a few longitudinal studies have been conducted, with inconsistent results. OBJECTIVE: To study the effect of ethnicity and the presence and duration of DM on the risk of incident TB based on 15 years of follow-up of the entire Danish population. DESIGN AND METHODS: Using Poisson regression analysis, we estimated TB incidence in individuals with DM vs. those without DM by linking nationwide DM and TB registers to the National Civil Register at case level. RESULTS: The TB rate ratio was 1.9 in individuals with DM compared to non-DM individuals, regardless of country of birth, with the exception of African-born individuals (rate ratio 0.5). The risk decreased drastically within the first 2 years after the diagnosis of DM; no association was found with longer durations of DM. The risk also decreased the later the year of DM diagnosis. CONCLUSIONS: The study confirmed DM as a risk factor for TB, except in the case of African-born individuals. Other non-DM risk factors for TB could act as effect-modifiers on the DM-TB association. Implementing earlier DM diagnosis and improving metabolic control may reduce the risk of DM-related TB.
Subject(s)
Diabetes Complications/epidemiology , Diabetes Mellitus/epidemiology , Tuberculosis/epidemiology , Adult , Aged , Aged, 80 and over , Denmark/epidemiology , Diabetes Complications/ethnology , Female , Follow-Up Studies , Humans , Incidence , Longitudinal Studies , Male , Middle Aged , Poisson Distribution , Risk Factors , Time Factors , Tuberculosis/ethnology , Tuberculosis/etiology , Young AdultABSTRACT
Physical inactivity and low birth weight (LBW) may lead to an increased risk for developing type 2 diabetes. The extent to which LBW individuals may benefit from physical exercise training when compared with those with normal birth weight (NBW) controls is uncertain. We assessed the impact of an outdoor exercise intervention on body composition, insulin secretion and action in young men born with LBW and NBW in rural India. A total of 61 LBW and 56 NBW healthy young men were recruited into the study. The individuals were instructed to perform outdoor bicycle exercise training for 45 min every day. Fasting blood samples, intravenous glucose tolerance tests and bioimpedance body composition assessment were carried out. Physical activity was measured using combined accelerometry and heart rate monitoring during the first and the last week of the intervention. Following the exercise intervention, the LBW group displayed an increase in physical fitness [55.0 ml (O2)/kg min (52.0-58.0)-57.5 ml (O2)/kg min (54.4-60.5)] level and total fat-free mass [10.9% (8.0-13.4)-11.4% (8.0-14.6)], as well as a corresponding decline in the ratio of total fat mass/fat-free mass. In contrast, an increase in total fat percentage as well as total fat mass was observed in the NBW group. After intervention, fasting plasma insulin levels, homoeostasis model assessments (HOMA) of insulin resistance (HOMA-IR) and insulin secretion (HOMA-IS), improved to the same extent in both the groups. In summary, young men born with LBW in rural India benefit metabolically from exercise training to an extent comparable with NBW controls.
Subject(s)
Body Composition , Exercise , Infant, Low Birth Weight , Insulin Resistance , Accelerometry/methods , Adolescent , Bicycling , Diabetes Mellitus, Type 2/epidemiology , Heart Rate/physiology , Humans , India/epidemiology , Infant, Newborn , Male , Rural Population , Young AdultABSTRACT
On top of the unfinished agenda of infectious diseases in low- and middle-income countries, development, industrialization, urbanization, investment, and aging are drivers of an epidemic of noncommunicable diseases (NCDs). Malnutrition and infection in early life increase the risk of chronic NCDs in later life, and in adult life, combinations of major NCDs and infections, such as diabetes and tuberculosis, can interact adversely. Because intervention against either health problem will affect the other, intervening jointly against noncommunicable and infectious diseases, rather than competing for limited funds, is an important policy consideration requiring new thinking and approaches.
Subject(s)
Chronic Disease/epidemiology , Chronic Disease/prevention & control , Communicable Disease Control , Communicable Diseases/epidemiology , Cost of Illness , Developing Countries , Comorbidity , Health Policy , Humans , World Health OrganizationABSTRACT
Molecular genotyping of Mycobacterium tuberculosis has proved to be a powerful tool in tuberculosis surveillance, epidemiology, and control. Based on results obtained through 15 years of nationwide IS6110 restriction fragment length polymorphism (RFLP) genotyping of M. tuberculosis cases in Denmark, a country on the way toward tuberculosis elimination, we discuss M. tuberculosis transmission dynamics and point to areas for control interventions. Cases with 100% identical genotypes (RFLP patterns) were defined as clustered, and a cluster was defined as cases with an identical genotype. Of 4,601 included cases, corresponding to 76% of reported and 97% of culture-verified tuberculosis cases in the country, 56% were clustered, of which 69% were Danes. Generally, Danes were more often in large clusters (≥ 50 persons), older (mean age, 45 years), and male (male/female ratio, 2.5). Also, Danes had a higher cluster frequency within a 2-year observation window (60.8%), and higher clustering rate of new patterns over time, compared to immigrants. A dominant genotype, cluster 2, constituted 44% of all clustered and 35% of all genotyped cases. This cluster was primarily found among Danish males, 30 to 59 years of age, often socially marginalized, and with records of alcohol abuse. In Danes, cluster 2 alone was responsible for the high cluster frequency level. Immigrants had a higher incidence of clustered tuberculosis at a younger age (0 to 39 years). To achieve tuberculosis elimination in Denmark, high-risk transmission environments, like the cluster 2 environment in Danes, and specific transmission chains in immigrants in the capital area, e.g., homeless/socially marginalized Somalis/Greenlanders, often with alcohol abuse, must be targeted, including groups with a high risk of reactivation.
Subject(s)
Molecular Typing , Mycobacterium tuberculosis/classification , Mycobacterium tuberculosis/genetics , Tuberculosis/epidemiology , Tuberculosis/microbiology , Adolescent , Adult , Aged , Aged, 80 and over , Child , Child, Preschool , Cluster Analysis , DNA Transposable Elements , DNA, Bacterial/genetics , Denmark/epidemiology , Female , Genotype , Humans , Infant , Infant, Newborn , Male , Middle Aged , Molecular Epidemiology , Mycobacterium tuberculosis/isolation & purification , Polymorphism, Restriction Fragment Length , Retrospective Studies , Young AdultABSTRACT
OBJECTIVE: To audit the quality of obstetric management preceding emergency caesarean sections for prolonged labour. DESIGN: A quality assurance analysis of a retrospective criterion-based audit supplemented by in-depth interviews with hospital staff. SETTING: Two Tanzanian rural mission hospitals. POPULATION: Audit of 144 cases of women undergoing caesarean sections for prolonged labour; in addition, eight staff members were interviewed. METHODS: Criteria of realistic best practice were established, and the case files were audited and compared with these. Hospital staff were interviewed about what they felt might be the causes for the audit findings. MAIN OUTCOME MEASURES: Prevalence of suboptimal management and themes emerging from an analysis of the transcripts. RESULTS: Suboptimal management was identified in most cases. Non-invasive interventions to potentially avoid operative delivery were inadequately used. When deciding on caesarean section, in 26% of the cases labour was not prolonged, and in 16% the membranes were still intact. Of the women with genuine prolonged labour, caesarean sections were performed with a fully dilated cervix in 36% of the cases. Vacuum extraction was not considered. Amongst the hospital staff interviewed, the awareness of evidence-based guidelines was poor. Word of mouth, personal experience, and fear, especially of HIV transmission, influenced management decisions. CONCLUSION: The lack of use and awareness of evidence-based guidelines led to misinterpretation of clinical signs, fear of simple interventions, and an excessive rate of emergency caesarean sections.
Subject(s)
Cesarean Section/statistics & numerical data , Emergency Treatment/statistics & numerical data , Obstetric Labor Complications/surgery , Adolescent , Adult , Emergencies , Female , Hospitalization/statistics & numerical data , Hospitals, Rural/statistics & numerical data , Humans , Medical Audit , Midwifery , Pregnancy , Quality Assurance, Health Care , Tanzania , Workforce , Young AdultABSTRACT
The prevalence of diabetes mellitus is increasing at a dramatic rate, and countries in Asia, particularly India and China, will bear the brunt of this epidemic. Persons with diabetes have a significantly increased risk of active tuberculosis (TB), which is two to three times higher than in persons without diabetes. In this article, we argue that the epidemiological interactions and the effects on clinical presentation and treatment resulting from the interaction between diabetes and TB are similar to those observed for human immunodeficiency virus (HIV) and TB. The lessons learned from approaches to reduce the dual burden of HIV and TB, and especially the modes of screening for the two diseases, can be adapted and applied to the screening, diagnosis, treatment and prevention of diabetes and TB. The new World Health Organization (WHO) and The Union Collaborative Framework for care and control of TB and diabetes has many similarities to the WHO Policy on Collaborative Activities to reduce the dual burden of TB and HIV, and aims to guide policy makers and implementers on how to move forward and combat this looming dual epidemic. The response to the growing HIV-associated TB epidemic in the 1980s and 1990s was slow and uncoordinated, despite clearly articulated warnings about the scale of the forthcoming problem. We must not make the same mistake with diabetes and TB. The Framework provides a template for action, and it is now up to donors, policy makers and implementers to apply the recommendations in the field and to 'learn by doing'.
Subject(s)
AIDS-Related Opportunistic Infections/epidemiology , Coinfection/epidemiology , Diabetes Complications/epidemiology , Epidemics , Global Health , Tuberculosis/epidemiology , AIDS-Related Opportunistic Infections/diagnosis , AIDS-Related Opportunistic Infections/therapy , Antitubercular Agents/therapeutic use , Cooperative Behavior , Diabetes Complications/diagnosis , Diabetes Complications/therapy , Health Policy , Humans , International Cooperation , Mass Screening , Prevalence , Risk Factors , Time Factors , Tuberculosis/diagnosis , Tuberculosis/therapyABSTRACT
Antimicrobial drug use and overuse have been a topic of interest for many years, lately focusing on the growing resistance worldwide. This study was conducted in a small Indian hospital, where more than 80% of all admitted patients received antimicrobial drugs. Penicillin, gentamycin, co-trimoxazole, ciprofloxacin and metronidazole were most commonly used and all antimicrobial drugs were given empirically with no confirmation of the infective agent. Reports of increasing resistance to antimicrobial drugs in India, and elsewhere, necessitates a focus on how antimicrobials drugs are used in relation to investigations of resistance patterns among the local strains of pathogens. This study may be considered a base-line study, though of relevance for other hospitals, in particular in low-income areas, where development of resistance to standard antimicrobial drugs may have severe implications for both patients and health managers.
Subject(s)
Anti-Infective Agents/therapeutic use , Drug Prescriptions/statistics & numerical data , Drug Utilization/statistics & numerical data , Inpatients/statistics & numerical data , Adolescent , Adult , Female , Hospital Bed Capacity, under 100 , Hospitals, Religious , Humans , India , Length of Stay , Male , Middle Aged , Practice Patterns, Physicians'/statistics & numerical data , Prospective Studies , Rural Population , Young AdultABSTRACT
Although critical for good case management and the monitoring of health interventions, the health-laboratory services in sub-Saharan Africa are grossly compromised by poor infrastructures and a lack of trained personnel, essential reagents and other supplies. The availability and quality of diagnostic services in 37 health laboratories in three districts of the Tanga region of Tanzania have recently been assessed. The results of the survey, which involved interviews with health workers, observations and a documentary review, revealed that malaria accounted for >50% of admissions and out-patient visits. Most (92%) of the laboratories were carrying out malaria diagnosis and 89% were measuring haemoglobin concentrations but only one (3%) was conducting culture and sensitivity tests, and those only on urine and pus samples. Only 14 (17%) of the 84 people found working in the visited laboratories were laboratory technologists with a diploma certificate or higher qualification. Sixteen (43%) of the study laboratories each had five or fewer types of equipment and only seven (19%) had more than 11 types each. Although 11 (30%) of the laboratories reported that they conducted internal quality control, none had standard operating procedures (SOP) on display or evidence of such quality assurance. Although malaria was the main health problem, diagnostic services for malaria and other diseases were inadequate and of poor quality because of the limited human resources, poor equipment and shortage of supplies. If the health services in Tanga are not to be overwhelmed by the progressively increasing burden of HIV/AIDS, malaria, tuberculosis and other emerging and re-emerging diseases, more funding and appropriate policies to improve the availability and quality of the area's diagnostic services will clearly be required.
Subject(s)
Clinical Laboratory Techniques/standards , Communicable Disease Control/standards , Diagnostic Services/standards , Laboratories/standards , Malaria/diagnosis , Quality Assurance, Health Care/standards , Clinical Laboratory Techniques/instrumentation , Cross-Sectional Studies , Diagnostic Services/supply & distribution , Humans , Laboratories/supply & distribution , Malaria/prevention & control , Surveys and Questionnaires , TanzaniaABSTRACT
Amodiaquine (AQ), an effective antimalarial drug for uncomplicated malaria, has been greatly restricted after cases of life-threatening agranulocytosis and hepatic toxicity during prophylactic use. We conducted a hospital based open-label randomised clinical trial in 40 indigenous semi-immune healthy adult male volunteers with and without malaria parasites. The objective was to collect data on biological and haematological safety, tolerability, and parasitological efficacy to serve as baseline in the evaluation of the effectiveness of AQ preventive intermittent treatment against malaria morbidity in infants. Volunteers were stratified according to parasitaemia status and randomly assigned 20 participants each arm to three days treatment with either AQ or chloroquine (CQ). The level of difference of selected haematological and hepatological values pre-and post-trial were marginal and within the normal limits. Clinical adverse effects mostly mild and transient were noticed in 33.3% CQ treated-aparasitaemic, 23.8% of CQ treated-parasitaemic, 28.6% ofAQ-treated parasitaemic and 14.3% of aparasitaemic receiving AQ. Amodiaquine attained 100% parasitological clearance rate versus 70% in CQ-treated volunteers. The findings indicate that there was no agranulocytosis or hepatic toxicity suggesting that AQ may pose no public health risk in its wide therapeutic dosage uses. Larger studies are needed to exclude rare adverse effects.
Subject(s)
Amodiaquine/adverse effects , Antimalarials/adverse effects , Chloroquine/adverse effects , Malaria, Falciparum/drug therapy , Adolescent , Adult , Agranulocytosis/chemically induced , Amodiaquine/administration & dosage , Analysis of Variance , Animals , Antimalarials/therapeutic use , Chemical and Drug Induced Liver Injury , Chloroquine/administration & dosage , Humans , Liver/drug effects , Malaria, Falciparum/blood , Malaria, Falciparum/parasitology , Male , Middle Aged , Tanzania , Treatment Outcome , Young AdultABSTRACT
The main objective of this study was to assess whether traditional birth attendants, drug-shop vendors, community reproductive health workers and adolescent peer mobilisers could administer intermittent preventive treatment (IPTp) with sulfadoxine-pyrimethamine (SP) to pregnant women. The study was implemented in 21 community clusters (intervention) and four clusters where health centres provided routine IPTp (control). The primary outcome measures were the proportion of women who completed two doses of SP; the effect on anaemia, parasitaemia and low birth weight; and the incremental cost-effectiveness of the intervention. The study enrolled 2785 pregnant women. The majority, 1404/2081 (67.5%) receiving community-based care, received SP early and adhered to the two recommended doses compared with 281/704 (39.9%) at health centres (P<0.001). In addition, women receiving community-based care had fewer episodes of anaemia or severe anaemia and fewer low birth weight babies. The cost per woman receiving the full course of IPTp was, however, higher when delivered via community care at US$2.60 compared with US$2.30 at health centres, due to the additional training costs. The incremental cost-effectiveness ratio of the community delivery system was Uganda shillings 1869 (US$1.10) per lost disability-adjusted life-year (DALY) averted. In conclusion, community-based delivery increased access and adherence to IPTp and was cost-effective.
Subject(s)
Antimalarials/administration & dosage , Drug Delivery Systems/economics , Malaria/prevention & control , Pregnancy Complications, Parasitic/prevention & control , Pyrimethamine/administration & dosage , Sulfadoxine/administration & dosage , Adolescent , Anemia/drug therapy , Anemia/prevention & control , Animals , Antimalarials/economics , Community Health Services/economics , Community Health Services/standards , Cost-Benefit Analysis , Drug Combinations , Drug Delivery Systems/standards , Female , Health Services Accessibility/standards , Humans , Infant, Newborn , Malaria/drug therapy , Maternal-Child Health Centers/economics , Maternal-Child Health Centers/standards , Patient Acceptance of Health Care/psychology , Pregnancy , Pregnancy Complications, Parasitic/drug therapy , Pregnancy Outcome , Prenatal Care/standards , Pyrimethamine/economics , Risk Factors , Sulfadoxine/economics , UgandaABSTRACT
Estimation of the prevalence of the molecular markers of sulfadoxine/pyrimethamine (SP) and chloroquine (CQ) resistance and validation of the association of mutations with resistance in different settings is needed for local policy guidance and for contributing to a global map for anti-malarial drug resistance. In this study, malaria patients treated with SP alone (60) and SP with CQ (194) had a total treatment failure (TF) of 35.4%, with no difference between the two arms. The polymerase chain reaction-enzyme-linked immunosorbent assay (PCR-ELISA) method was used to identify polymorphisms in 15 loci in the dhfr, dhps and pfcrt genes in a subset of 168 infections. The results revealed a similar frequency of all single nucleotide polymorphisms (SNPs) in the two arms, except dhps 581G, which was over-represented in infections that failed to respond to SP alone (TF). In all infections, a high frequency of dhfr CICNI haplotype (51I and 108N) was found, but without discrimination between the adequate clinical and parasitological response (ACPR, 75.6%) and TF (82.9%). Similarly, the dhps SGEAA haplotype (437G and 540E) (ACPR, 60.5%; TF, 65.9%) and the combined CICNI/SGEAA haplotype (ACPR, 50%; TF 55%) were not associated with TF. In contrast to other studies in Africa, the triple 51I/59R/108N mutation was rare (0.6%). In addition, the pfcrt CVIET haplotype (93%) was found to be associated with the CICNI/SGEAA haplotype. Finally, these data represent a baseline for SP resistance molecular markers needed before the deployment of SP/artesunate combination therapy in the Sudan.
Subject(s)
Antimalarials/pharmacology , Plasmodium falciparum/drug effects , Animals , Chloroquine/pharmacology , Drug Combinations , Drug Resistance , Humans , Mutation , Plasmodium falciparum/classification , Plasmodium falciparum/genetics , Pyrimethamine/pharmacology , Sudan , Sulfadoxine/pharmacologyABSTRACT
BACKGROUND: The impact of intermittent preventive treatment (IPTp) on malaria in pregnancy is well known. However, in countries where this policy is implemented, poor access and low compliance have been widely reported. Novel approaches are needed to deliver this intervention. OBJECTIVE: To assess whether traditional birth attendants, drug-shop vendors, community reproductive health workers and adolescent peer mobilizers can administer IPTp with sulphadoxine-pyrimethamine (SP) to pregnant women, reach those at greatest risk of malaria, and increase access and compliance with IPTp. STUDY DESIGN: An intervention study compared the delivery of IPTp in the community with routine delivery of IPTp at health units. The primary outcome measures were the proportion of adolescents and primigravidae accessed, and the proportion of women who received two doses of SP. The study also assessed the effect of the intervention on access to malaria treatment, antenatal care, other services and related costs. RESULTS: More women (67.5%) received two doses of SP through the community approach compared with health units (39.9%; P<0.0001). Women who accessed IPTp in the community were at an earlier stage of pregnancy (21.0 weeks of gestation) than women who accessed IPTp at health units (23.1 weeks of gestation; P<0.0001). However, health units were visited by a higher proportion of primigravidae (23.6% vs 20.0%; P<0.04) and adolescents (28.4% vs 25.0%; P<0.03). Generally, women who accessed IPTp at health units made more visits for malaria treatment (2.6 (1.0-4.7) vs 1.8 (1.4-2.2); P<0.03). At recruitment, more women who accessed IPTp at health units sought malaria treatment compared with those who accessed IPTp in the community (56.9% vs 49.2%). However, at delivery, a high proportion of women who accessed IPTp in the community had sought malaria treatment (70.3%), suggesting the possibility that the novel approach had a positive impact on care seeking for malaria. Similarly, utilization of antenatal care, insecticide-treated nets and delivery care by women in the community was high. The total costs per woman receiving two doses of SP for IPTp were 4093 Uganda shillings (US$ 2.3) for women who accessed IPTp at health units, and 4491 Uganda shillings (US$ 2.6) for women who accessed IPTp in the community. CONCLUSION: The community approach was effective for the delivery of IPTp, although women still accessed and benefited from malaria treatment and other services at health units. However, the costs for accessing malaria treatment and other services are high and could be a limiting factor in mitigating the burden of malaria in Uganda.
Subject(s)
Antimalarials/therapeutic use , Community Health Services/organization & administration , Malaria/prevention & control , Patient Acceptance of Health Care , Pregnancy Complications, Infectious/prevention & control , Pyrimethamine/therapeutic use , Sulfadoxine/therapeutic use , Adolescent , Adult , Antimalarials/administration & dosage , Drug Administration Schedule , Drug Combinations , Female , Health Services Accessibility/organization & administration , Humans , Middle Aged , Pregnancy , Pyrimethamine/administration & dosage , Socioeconomic Factors , Sulfadoxine/administration & dosage , Uganda/epidemiologyABSTRACT
OBJECTIVE: To assess whether traditional birth attendants, drug-shop vendors, community reproductive-health workers, or adolescent peer mobilizers could administer intermittent preventive treatment (IPTp) for malaria with sulfadoxine-pyrimethamine to pregnant women. METHODS: A non-randomized community trial was implemented in 21 community clusters (intervention) and four clusters where health units provided routine IPTp (control). The primary outcome measures were access and adherence to IPTp, number of malaria episodes, prevalence of anaemia, and birth weight. Numbers of live births, abortions, still births, and maternal and child deaths were secondary endpoints. FINDINGS: 1404 (67.5%) of 2081 with the new delivery system received two doses of sulfadoxine-pyrimethamine versus 281 (39.9%) of 704 with health units (P < 0.0001). The prevalence of malaria episodes decreased from 906 (49.5%) of 1830 to 160 (17.6%) of 909 (P < 0.001) with the new delivery system and from 161 (39.1%) of 412 to 13 (13.1%) of 99 (P < 0.001) with health units. Anaemia was significantly less prevalent in both arms. There was a lower proportion of low birth weight 6.0% with the new delivery system versus 8.3% with health units (P < 0.03). Few abortions and stillbirths were recorded in either arm. Fewer children and women who accessed IPTp with health units died than in the intervention group. CONCLUSION: The new approaches were associated with early access and increased adherence to IPTp. Health units were, however, more effective in reducing parasitaemia and malaria episodes. We recommend further studies to assess programming modalities linking the new approaches and health units.
Subject(s)
Antimalarials/therapeutic use , Malaria/prevention & control , Maternal Welfare , Pregnancy Outcome , Pyrimethamine/therapeutic use , Sulfadoxine/therapeutic use , Adolescent , Adult , Child , Drug Combinations , Female , Humans , Infant, Low Birth Weight , Infant, Newborn , Malaria/drug therapy , Malaria/epidemiology , Middle Aged , Pregnancy , Prevalence , Program Development , Risk Factors , Time Factors , Uganda/epidemiologyABSTRACT
Available data in Uganda indicate a resurgence of malaria morbidity and mortality countrywide. This study assessed the burden of malaria, treatment and prevention practices in order initiate a policy debate on the scaling-up of current interventions. A triangulation of methods using a cross-sectional survey and key informant interviews was used to assess self-reported malaria at a household level in Mukono District, Uganda. A total of 5583 households were surveyed, and a high proportion (2897, 51.9%) reported a person with malaria two weeks prior to the survey. Only 546 households (9.8%) owned and used insecticide-treated nets (ITNs) for malaria prevention. Similarly, only a few households (86, 1.5%) used indoor residual spraying. Self-treatment with home-stocked drugs was high, yet there was low awareness of the effectiveness of expired drugs on malaria treatment. Self-reported malaria was associated with socioeconomic, behavioural and environmental factors, but more especially with household ownership of ITNs. These results will contribute to the current debate on identifying new approaches for scaling-up prevention interventions and effective case management, as well as selection of priority interventions for malaria control in Uganda.