Predictive value of conjunctival pallor in the diagnosis of anaemia.

Because of the need to develop a simple yet reliable method of diagnosing anaemia, a compelling health problem, several studies had examined the possibility of utilizing physical examination of mucous membranes as a test of anaemia, but have produced conflicting results. This study was undertaken to determine if physical examination of a patient's mucous membranes will give predictive values of his haemoglobin concentration. A representative sample was drawn from the population of the Local Government Area selected for the study. Data collected on each study subject included age, sex, body weight, diagnosis, if any and conjunctival tint. At the same time, a venous blood sample was also obtained and its haemoglobin concentration determined with the oxyhaemoglobin concentration method. This was matched with the survey data on each subject for analysis. Results showed that 2697 subjects were s surveyed and that the prevalence of anaemia in the study population, defined in this report as Hb < 100g/l, was 29.9%; 14.9% was found to have conjunctival pallor. Statistical analysis gave sensitivity and specificity scores of 25% and 89% respectively and positive and negative predictive values of 46.9% and 75.4% respectively. The study observed that these results indicate that while conjunctival pallor is not a reliable measure of the presence of anaemia, the probability that it correctly excludes those that are not anaemic is high. Conjunctival pallor is recommended as a screening rather than a diagnostic tool.

How disease prevention fails without good communication.

Even where resources are plentiful, efforts to achieve full immunization coverage fail if staff and users are misinformed and unmotivated. A highly practical study in Lagos pinpoints some of these failures and suggests ways of overcoming them.

PIP: After a preliminary assessment in 1991 showed that immunization services in Lagos were among the worst in Nigeria, Resources for Child Health (REACH) started a multi-component demonstration project in the city. The communications component consisted of focus groups with users and interviews with providers to determine beliefs and practices in order to assess the support for the immunization service and discover ways of strengthening it. Based on data from the 1991 survey, questions were designed to discover why opportunities for immunization were missed and why health workers were giving mothers misinformation. The 15 focus groups consisted of 15 people each (3 with fully immunized children) from each socioeconomic group. The interviews were conducted in the same 4 localities as the focus groups with 11 physicians, 25 nurses, and 12 community health workers. In the focus groups, users blamed incomplete immunization on attributes of the health services and on factors which they themselves controlled. The former included negative staff attitudes, long waiting times, missed opportunities (including refusal to immunize even mildly sick children), and reduced potential contact hours. The latter included fear of side effects, lack of motivation, misinformation, pressures of work, and the laziness or carelessness of the mother (in the view of fathers). The nurses and health workers blamed lack of coverage on the mothers working or traveling, ignorance or carelessness on the part of the mothers, illness in the children, side effects, a preference for native methods, and staff attitudes. It was found that 84% of the nurses and 81.8% of the health workers provided completely accurate counseling information. After analyzing the suggestions of the health workers for improving services and the perception of the physicians about areas in which staff training could improve, REACH recommended that possible contact hours between the mother and the health services be increased, that staff attitudes be improved, and that the knowledge of health workers be updated and improved. Each immunization district in Lagos State now has its own plan to implement these recommendations.

Epidemiologic survey of menstrual patterns amongst adolescents in Nigeria.

Nine hundred and fifty secondary school girls aged between 10 and 18 years were randomly selected and surveyed. Information on their age at menarche, regularity of menstruation at onset and the time of survey and length of period of irregularity were sought using a well structured questionnaire. Estimation of blood loss per period premenstrual symptoms and signs, prevalence and severity of dysmenorrhoea were also inquired about. This study demonstrated a secular trend in the age at menarche when compared with other similar studies conducted in the previous decade in Nigeria. A higher prevalence of 71.8% of any grade of dysmenorrhoea was found in this study when compared with figures from developed countries, this and the short mean duration of irregular menstruation (3.7 months after menarche) were taken to be evidence of early establishment of regular ovular menstruation.

Immunization by inhalation of aerosolized measles vaccine.

The importance of effectively protecting infants against measles is substantial because of the number of lives that can be saved and the morbidity that can be prevented. (i) Infants contract measles before the recommended age of immunization. (ii) Circulating maternal antibodies render measles vaccination ineffective in many infants. These problems have led to clinical trials of immunizing infants using routes other than the usual subcutaneous one. One promising approach is the inhalation of aerosolized vaccine. This study was undertaken to try to immunize very young infants using easily accessible vaccine and ordinary equipment. Infants aged 4-6 months were selected for measles immunization by inhalation. They were clinically well, with no history of tuberculosis or asthma. From each child, 0.2 ml of blood was obtained by finger-prick. The blood was kept on ice, then centrifuged and the serum stored in a freezer at -20 degrees C. Each child was weighed and clinically assessed and his rectal temperature recorded. Using a plastic nebulizer to hold reconstituted vaccine by SCLAVO of Italy and an ordinary foot pump, the vaccine was aerosolized. One thousand TCID50 of the vaccine was administered to each child with a vinyl face mask for a period of at least 30 s, to allow him to retain 250 TCID50. The child was then clinically followed up three times a week for 4 weeks with particular reference to (i) fever, (ii) conjunctivitis, (iii) cough, and (iv) skin rash. None of the infants developed any of the above signs during the interval.(ABSTRACT TRUNCATED AT 250 WORDS)

A village health worker programme in Nigeria.

A study was made of the training and performance of village health workers near Lagos, and of the management of the scheme to which they belonged. Among the deficiencies observed were inadequate drug control and poor record-keeping. Nevertheless, the scheme led to a significant extension of primary health care coverage.

PIP: In 1982, the Institute of Child Health and Primary Care (IHCPC) in Lagos, Nigeria, was asked to develop a primary health care (PHC) service for a rural population of about 35,000 people in 56 villages approximately 50 km. from Lagos. A core of volunteer village health workers (VVHW) would be established. A health care center was completed. The 1st step was to encourage village health committees to form. Then VVHS are nominated for training. Initial training lasts 3 weeks and takes place in the community. There have been 4 courses; 82 village health workers have been trained. The trainers are PHC workers connected to the ICHPC who have been trained. The courses cover promotional, curative, and preventive activities. Active learning is encouraged; song and dance are used. At graduation, a formal occasion, certificates and drug kits are given out. They contain essential drugs, which are donated. There are sufficient drugs for 3-6 months. The workers are advised to sell the drugs to the villagers at a small profit. They keep the profit, and get some pay. The rest of the selling price resupplies the drug fund. VVHWs are supervised by a midlevel PHC worker, the community health assistant. The ICHPC field research team interviewed 75 of the 82 VVHWs. The number of patients seen by VVHWs in a month ranged from none to 300; the average was 17.8. 91% of the villages have a VVHW service. The activities of 75 VVHWs during 1 month in relation to selected characteristics in rural Ogun State, 1987 are presented in tabular form. Of the 82 VVHWs who were trained, 10 became nonfunctioning over a period of 4 years. Service management should have attention paid to it. Drug stocks with VVHWs are shown in tabular form. Record keeping was not very good. Active village health committees were interfering with the VVHWs. The role of the village health committees in relation to the VVHWs has now changed, but it is difficult to provide supervision for the VVHWs.

Separating the factors in measles vaccine failure.

Three possible reasons for failure of measles vaccine were identified as follows: (a) circulating maternal antibodies, (b) administration of non-viable vaccine, and (c) misdiagnosis. A study designed to test the role played by each of these in the high measles vaccine failure rate was carried out at the Oguntolu Street Clinic, Lagos, from October 1982 to February 1983. Failure to seroconvert was the cause of 67.7% of measles vaccine failure, particularly at ages 6-7 months, though this was not associated with high prevaccination titres. In 32.3% incorrect diagnosis was responsible. Non-viable vaccine was found not to be a reason because all vials of measles vaccine were potent at the time of administration.

Informed consent in the developing world.

KIE: A hypothetical case is presented involving the problem of obtaining informed consent for participation in a study of the distribution of a tapeworm disease in a North African country. Ekunkwe, from the College of Medicine at the University of Lagos, describes how the experiment is likely to be misperceived by potential participants. Given that the proposed study is a relatively safe and routine one, however, he suggests that the investigator proceed as honestly as possible on the basis of "uninformed consent." Kessler, from the University of Maryland School of Medicine, addresses the question whether different standards of informed consent are appropriate in different cultural settings. He concludes that the elements of free and informed consent are the same regardless of setting and that the investigator must find ways to enter the belief system of his subjects to ensure valid consent.^ieng