A flowchart for managing sexually transmitted infections among Nigerian adolescent females.

OBJECTIVE: To devise a flowchart suitable for assessing risk of trichomoniasis, chlamydia and gonorrhoea in an adolescent population, not all of whom will be sexually experienced or currently in a relationship. METHODS: The data used to derive the flowchart were generated from cross-sectional microbiological surveys of girls aged 14-19 years in Port Harcourt, Nigeria. The flowchart screened on the basis of: (i) sexual experience; (ii) recent sexual activity; (iii) a positive urine leukocyte esterase (LE) test; and (iv) among LE negatives, a history of malodorous/pruritic discharge. FINDINGS: Using this flowchart, we found that 26.2% of all adolescents screened would receive treatment for cervicitis and vaginitis. Chlamydial, gonococcal, and trichomonal infections were correctly diagnosed in 37.5%, 66.7%, and 50% of the cases, respectively. CONCLUSION: Although the flowchart is more suitable for an adolescent population than the vaginal discharge algorithm used in syndromic management protocols, it still lacks precision and needs adapting to local settings.

Reproductive tract infections, gynaecological morbidity and HIV seroprevalence among women in Mumbai, India.

Reported are the prevalence of reproductive tract infections and their contribution to pelvic inflammatory disease (PID), as well as the seroprevalence of human immunodeficiency virus (HIV), among women living in three inner city wards of Mumbai, India. Women aged < or = 35 years were recruited and screened as cases if they had been admitted to hospital for gynaecological investigation for suspected PID (n = 151) or infertility (n = 295); controls were healthy fertile women attending for laparoscopic tubal ligation (n = 2433). The women were mainly of low socioeconomic status. A total of 59.4% were migrants and 14.9% of these came to Mumbai to seek treatment. Cases reported a history of adverse pregnancy outcomes significantly more often than controls, and 30.5% of suspected PID cases had previously undergone laparoscopic tubal ligation. At examination 24.2% of cases and 8.4% of controls had a vaginal discharge. Pelvic infection was confirmed in 42.0% of suspected PID cases and 14.6% of infertile cases for whom diagnostic laparoscopy was performed. The prevalence of sexually transmitted diseases was low: Chlamydia trachomatis was found in 0.2%; and Neisseria gonorrhoeae was cultured from the cervix in only four cases. Neither of these infections was detected in laparoscopic aspirates. The prevalence of HIV1/2 infections in unlinked samples was 1.9%. Sexually transmitted diseases were not major factors leading to gynaecological morbidity. Heterosexual spread of HIV infection to this population of married women is still relatively low but needs to be carefully monitored. The gynaecological morbidity detected may be a consequence of widespread use of invasive methods of fertility regulation.

PIP: A case-control study conducted in 1993-95 among women 35 years of age and younger living in three inner-city wards of Mumbai, India, investigated the prevalence of reproductive tract infections and their contribution to pelvic infection. Enrolled as cases were 151 women admitted to the hospital with suspected pelvic inflammatory disease (PID) and 295 infertile women; 2433 healthy fertile women undergoing laparoscopic tubal ligation served as controls. Adverse pregnancy outcomes were reported significantly more often by cases than controls. 31.8% of suspected PID cases, 9.1% of infertile women, and 53.1% of tubal ligation patients reported ever-use of a contraceptive method, primarily a copper IUD. At examination, 24.2% of cases and 8.4% of controls had a vaginal discharge. Pelvic infection was confirmed in 42.0% of suspected PID cases and in 14.6% of infertile women in whom diagnostic laparoscopy was performed. HIV prevalence was 1.9% in unlinked samples. The prevalence of other sexually transmitted diseases (STDs) was under 1%. The gynecologic morbidity recorded in this study is presumed to be a result of widespread use of invasive methods of fertility regulation, not STDs.

Measles incidence, case fatality, and delayed mortality in children with or without vitamin A supplementation in rural Ghana.

Data on measles incidence, acute case fatality, and delayed mortality were collected on 25,443 children aged 0-95 months during the course of a community-based, double-blind, placebo-controlled, randomized trial of vitamin A supplementation in rural, northern Ghana between 1989 and 1991. Measles vaccine coverage in these children was 48%. The overall estimated measles incidence rate was 24.3 per 1,000 child-years, and acute case fatality was 15.7%. There was not significantly increased mortality in survivors of the acute phase of measles compared with controls (rate ratio = 1.22, 95% confidence interval (CI) 0.65-2.30). Reported incidence rates and case fatality were higher in families with low paternal education, in the dry season, and in unvaccinated children, and case fatality was higher in malnourished children. There was no sex difference in incidence, but acute case fatality was somewhat higher in girls than boys (adjusted odds ratio = 1.3, 95% CI 0.9-2.1). Measles incidence was lower in vitamin A-supplemented groups (23.6 per 1,000 child-years) than in placebo groups (28.9 per 1,000 child-years), but this difference was not statistically significant (p = 0.33). Among 946 measles cases in clusters randomized to receive vitamin A or placebo, there was no marked difference in acute measles case fatality between vitamin A-supplemented and placebo groups (15.4% vs. 14.5%, respectively). The biologic effects of vitamin A supplemented on the subsequent clinical manifestations and severity of measles need further elucidation.

PIP: As part of a community-based, placebo-controlled trial of vitamin A supplementation in rural northern Ghana in 1989-91, data were collected on measles incidence and mortality among 25,433 children 0-95 months of age. Measles vaccination coverage was 48%. A total of 961 measles cases were identified, with a median age at onset of 41 months. The overall measles incidence rate was estimated at 24.3/1000 child-years and the acute case fatality rate was 15.7%. Both measles incidence and fatality were higher in families with low paternal education, in the dry season, and in unvaccinated children. Case fatality was also higher in malnourished children. There was a lower, although nonsignificant, measles incidence in vitamin-A supplemented groups (23.6/1000 child-years) than in placebo groups (28.9/1000 child-years). Among 946 measles cases in clusters randomized to receive vitamin A or placebo, there was no marked difference in acute measles case fatality (15.4% and 14.5%, respectively). These findings confirm the importance of sustained measles vaccination in Africa.

How do they grow? A study of south-eastern Nigerian adolescent girls.

This study assessed the nutritional status of Nigerian adolescent girls living in two areas of south-eastern Nigeria. A cross sectional survey was undertaken in a rural village in Ogoniland, and five secondary schools in Port Harcourt, south-eastern Nigeria. All (386) menarcheal girls aged 14-19 y living in the rural village, and a stratified cluster sample (845) of menarcheal girls aged 14-19 in the five urban schools were investigated. Mean heights and weights of rural girls were around -1 Z-score below the British reference median. 10.4% of rural and 4.7% of urban girls were stunted (< OR =2nd centile, British 1990 reference values). After calculating mean body mass index-for-age, various cut-off points for low body mass index were tested. At a cut-off of < OR =9th centile, 15.6% of rural and 8.0% of urban girls would be classified as thin. Girls with a haemoglobin <10.Og/dl were significantly more likely to have a low body mass index than those with haemoglobin values > OR =10.0 g/dl. More studies are needed to refine the definition and interpretation of low body mass index in adolescents.

Drinking water sources, mortality and diarrhoea morbidity among young children in northern Ghana.

In the Upper East Region of Ghana, considerable resources have been invested in the provision of boreholes. As part of the Ghana Vitamin A Supplementation Trials' Survival Study which was carried out in one of the districts of the Upper East Region between January 1989 and December 1991, data were collected over a period of one calendar year on the drinking water sources used by approximately 13,000 mothers/guardians of over 20,000 children and on the morbidity and mortality experiences of these children. These data were used to describe seasonal and geographical variations in drinking water sources; to look for other predictors of water source use; and to establish whether the drinking water source was associated with the risk of child death or the period prevalence of diarrhoea among young children. Boreholes were used as the main source of drinking water by about 60-70% of respondents. They were used slightly more frequently in the dry season. In the rainy season, the use increased of more traditional sources such as rainwater or holes dug in stream beds. The use of boreholes was greatest in the northern zone of the study area and was more common in those who had had some formal education and were of higher socioeconomic status. Some association was found between reported drinking water source and diarrhoeal morbidity, although this association appeared to be seasonal. No significant association was found between drinking water source and child mortality.

Effect of vitamin A supplementation on the growth of young children in northern Ghana.

The effect of prophylactic vitamin A supplementation on child growth was studies in two randomized, placebo-controlled trials carried out in adjacent areas of northern Ghana between 1989 and 1991. In the Health Study, the midupper arm circumference (MUAC) and weight of the approximately 1500 children (aged 6-59 mo) in the trial were measured every 4 wk for up to 52 wk. In addition, MUAC, weight, and height were measured at each of the four potential vitamin A or placebo dosing times, which were at 4-mo intervals. In the Survival Study, MUAC and weight were measured at 4-mo intervals at each of seven dosing rounds in the approximately 15 000 children currently in the trial. Overall, there were > 90 000 observations of weight and MUAC in > 25 000 children, and 3347 observations of length/height in 1546 children. Within each study, the mean monthly weight, MUAC, and gains in length/height in each treatment group were compared by using multilevel modeling. There were no significant differences in either MUAC or gains in length/height. The only significant difference in weight gain was in the Survival Study: children in the vitamin A-supplemented group who were > or = 36 mo of age had a mean weight gain that was 3 g lower per month (95% CI: 0.4, 5.0, P = 0.02) than that in the placebo group; a difference that was unlikely to be functionally important in this age group. Vitamin A supplementation did not lead to any increased growth in this population of young children, in whom supplementation reduced mortality and severe morbidity substantially.

Lay reporting of elephantiasis of the leg in northern Ghana.

Within a large scale community trial in northern Ghana lay interviewers were trained to inquire about and identify elephantiasis of the leg by the use of local terms and simple examination of respondents. This was repeated a year later after moving the interviewers to different geographical areas. The proportions of extended family compounds reported to have at least one member with elephantiasis of the leg were 12.2% and 12.1 % respectively in the first and second surveys (kappa = 0.60). 'Blind' re-examination of a sub-sample by a physician showed a high level of agreement with the lay interviewer's findings in the first and second surveys (kappa = 0.67 and 0.82 respectively). This study has shown that lay people, even with minimal training, can obtain repeatable and valid estimates of the prevalence of elephantiasis of the leg, at least within an area where local terms for the condition are available. This method could potentially be used for other diseases with visible manifestations.

Child morbidity and mortality following vitamin A supplementation in Ghana: time since dosing, number of doses, and time of year.

OBJECTIVES: The impact of large-dose vitamin A supplementation given at intervals of 4 months on child mortality and morbidity was examined according to the time interval since dosing, number of doses received previously, and time of year. METHODS: Two double-blind, randomized, placebo-controlled trials of large doses of vitamin A administered at intervals of 4 months were conducted in adjacent populations in northern Ghana. RESULTS: While vitamin A supplementation significantly reduced the overall incidence of severe illnesses (especially diarrhea with dehydration), clinic attendances, hospital admissions, and mortality, there was no evidence that the impact of each dose of vitamin A was related to the number of doses the child had received previously. There was no evidence that the effectiveness of the supplement waned over the 3 to 5 months between doses. The impact on mortality did not differ significantly by the month in which the supplement had been given. CONCLUSIONS: In the study population, there was no evidence that an interval between doses of less than 4 months would have had a greater impact on severe morbidity or mortality, and the effectiveness of supplementation did not vary by time of year.

Vitamin A supplementation and childhood malaria in northern Ghana.

Two companion, randomized, placebo-controlled trials of prophylactic vitamin A supplementation provided the opportunity to assess the impact of supplementation on malaria parasitemia, morbidity, and mortality in young children in northern Ghana. In the mortality study, 21,906 children were visited every 4 mo over 2 y, and in the morbidity study 1455 children were visited weekly for 1 y. There was no difference between children supplemented with vitamin A and those given placebo in malaria mortality rates (rate ratio = 1.03; 95% CI 0.74, 1.43) or fever incidence based on reported symptoms. Malaria parasitemia rates, parasite densities in children with a positive blood smear, and rates of probable malaria illness also did not differ between treatment groups. There was no correlation between serum retinol at the beginning of the trial and subsequent malaria parasitemia in children who received placebo (r = 0.01). It is concluded that vitamin A supplementation had no impact on malaria in this population.

Reproductive tract infections and abortion among adolescent girls in rural Nigeria.

Few studies from developing countries have investigated reproductive tract infections or other indicators of sexual health among unmarried adolescent girls in rural areas. We have obtained baseline demographic, clinical, and microbiological data on reproductive tract infections and induced abortion in girls in a rural area of southeast Nigeria, in order to assess the need for health care for adolescents. 868 females attended for interview and examination: 458 aged 20 and above and 410 aged 12-19, the latter representing 93.4%of the adolescent population. 43.6% of those < 17 and 80.1% aged 17-19 years were sexually active and at least 24.1% had undergone an induced abortion; only 5.3% had ever used a modern contraceptive. Vaginal discharge was reported by 82.4%, though few sought treatment. 94.1% of sexually active adolescents and 97.6% of sexually active women 20 years old or over were gynaecologically examined and screened for reproductive tract infections. Of those aged less than 17, 19.8% had symptomatic candida and 11.1% trichomonas infections. Among those aged 17-19 years, chlamydia was detected in 10.5%, and symptomatic candidosis in 25.6%; this was the group most likely to have any infection (43.8%). 42.1% of sexually active adolescents had experienced either an abortion or a sexually transmitted disease. Syphilis was the only infection for which the incidence clearly increased with age. Health-care services for adolescents in this community are needed and should include sex education, contraceptive provision (especially barrier methods), and access to treatment for reproductive tract infections. Investments in health for this age group will have an effect on subsequent reproductive health.

Measurement of the frequency and severity of childhood acute respiratory infections through household surveys in northern Ghana.

BACKGROUND: Methodological issues in the design and interpretation of cross-sectional interview surveys of the prevalence of acute respiratory infections (ARI) were assessed among young children. METHODS: A cross-sectional survey was conducted in approximately 20,000 children in the north of Ghana. Approximately half were administered a questionnaire in which the initial questions about recent illnesses were direct questions about the presence or absence of three specific ARI-related symptoms (cough, rapid breathing, difficulty breathing), while the other half were administered a questionnaire which started with an open-ended question on whether the child was ill, designed to elicit spontaneous responses. A 2-week recall period was used in addition to point prevalence questions for half of the children in each group, while 4 weeks was used for the other half. The results were compared with those from a longitudinal morbidity surveillance system in an adjacent population of children. The repeatability of the responses to each of the symptoms/conditions was assessed in a subsample of the children. RESULTS AND CONCLUSIONS: The point and period prevalence rates of ARI symptoms or conditions based on spontaneously elicited responses were more likely to be valid than those based on prompted responses. Furthermore, using a 2-week recall period appeared to give more valid period prevalence rates than a 4-week recall period. The repeatability of the various ARI questions was not high (kappas 0.14 to 0.49), irrespective of the questionnaire design. Whether these findings will also be true in other populations needs to be assessed.

Uptake of immunisation in district health authorities in England.

The uptakes of immunisation in the district health authorities in England were studied for the years 1983-5. Multiple regression analysis showed that the factors significantly associated with a low uptake of immunisation were mainly related to social conditions, particularly overcrowding of households and population density. Of the service factors, high proportions of elderly and singlehanded general practitioners and high average list sizes were also associated with a low uptake of immunisation in some of the analyses. The results suggest that the measures outlined in the government's white paper on improving primary health care services are likely to lead to improved uptakes of immunisation. If, however, the uptakes of immunisation are used as a measure of standards of the services provided they should first be adjusted to control for variations in social conditions, and the quality of vaccination data would have to be improved.

A community based study of risk factors in maternal mortality in the Kassena-Nankana district of Northern Ghana

Maternal mortality rates in Northern Ghana are extremely high and for an individual woman in the district; the risk of dying from maternal mortality is 1 in 18. Efforts to reduce the scale of suffering in the area are tampered by the lack of community based data. A community based study was designed in mid 1991 to determine the principal risk factors of maternal mortality in the Kassena-Nankana district and to suggest appropriate interventions to reduce maternal mortality in the region