Mobilizing demand for contraception in rural Gambia.

A community trial was conducted in rural Gambia in order to determine whether a community-based intervention designed to mobilize latent demand for contraception would increase use of modern contraceptives, even in the absence of improved availability of family planning services. Analysis of trial data indicates that the demand-mobilization intervention had a statistically significant positive effect on nonusers' adoption of modern contraception and that coterminous implementation of an intervention designed to improve access to services offered no additional benefit. The program component found to have the greatest impact was the "kabilo approach," in which village women provide basic health and family planning counseling to other women in their extended families. These results suggest that the principal barriers to increased contraceptive use in rural Gambia are psychosocial and that these barriers can be overcome through village-based interventions designed to provide socially appropriate counseling to potential contraceptive users.

National pathfinder survey of dental caries prevalence and treatment needs in The Gambia.

OBJECTIVE: The aim of this study was to assess dental caries status and treatment needs in The Gambia for the purpose of national planning. MATERIALS AND METHODS: 1,235 subjects were obtained with a multi-stage stratified random sampling technique. Clinical examinations were carried out using the criteria suggested in WHO Basic Methods (WHO 1987). The WHO J2 software programme was used for data analysis. RESULTS: More than half of the subjects had caries. Mean DMFT increased from 1.7 in the 7-year-old group to 8.8 in 65-99-year-olds. Mean DT peaked at 5.1 in the 30-34-year-old group before declining to 3.2 among the 65-99-year-olds. Mean filled teeth (FT) was zero in all ages. Missing teeth (MT) increased from 0.1 in 13-year-olds to 5.6 among the 65-99-year group. Mean DMFT was 2.3, 2.8, and 6.6 in 12-year-olds, 15-year-olds and 35-44-year-olds respectively. Unmet treatment need (DT/DMFT) was 90-100% in subjects below 25 years. Need for dental extraction increased from 15% to 63% in 65-99-year-olds. Between 0.3 and 2.8 teeth required extraction, and 46-79% of subjects needed conservative treatment. Dental auxiliaries should be trained to carry out extractions and fillings using the atraumatic restorative treatment (ART).

National pathfinder survey of periodontal status and treatment needs in The Gambia.

OBJECTIVE: The aim of the pathfinder survey was to assess the periodontal status and treatment needs in The Gambia. METHODS: A multistage stratified random sampling technique was used to obtain a sample of 1,235 (or 0.1% of the national population). The study was conducted according to the World Health Organisation's criteria (WHO, 1987). The WHO J2 software programme was used to analyse the data. RESULTS: Not more than 12% of subjects in any age group had healthy periodontal tissues. Two to three sextants were healthy among those under the age of 35 years. Shallow (4-5 mm) pockets were present in all ages. However, less than one sextant was involved among subjects younger than 25 years. Despite the high prevalence of pockets, few sextants were edentulous. The majority of subjects needed oral hygiene instructions and oral prophylaxis. Of the subjects between the ages of 8 and 29 years, 5-28% needed complex treatment in only half of a sextant. Similarly, 38% and 80% of older subjects needed complex treatment in 0.8-1.9 sextants. CONCLUSION: A national oral health plan in The Gambia should focus on health education and provision of oral prophylaxis by trained auxiliary health care workers. In conclusion, there is a need to develop a functional district oral health services system in The Gambia.

Efficacy trial of malaria vaccine SPf66 in Gambian infants.

SPf66 malaria vaccine is a synthetic protein with aminoacid sequences derived from pre-erythrocytic and asexual blood-stage proteins of Plasmodium falciparum. SPf66 was found to have a 31% protective efficacy in an area of intensive malaria transmission in Tanzanian children, 1-5 years old. We report a randomised, double-blind, placebo-controlled trial of SPf66 against clinical P falciparum malaria in Gambian infants. 630 children, aged 6-11 months at time of the first dose, received three doses of SPf66 or injected polio vaccine (IPV). Morbidity was monitored during the following rainy season by means of active and passive case detection. Cross-sectional surveys were carried out at the beginning and at the end of the rainy season. An episode of clinical malaria was defined as fever (> or = 37.5 degrees C) and a parasite density of 6000/microL or more. Analysis of efficacy was done on 547 children (316 SPf66/231 IPV). No differences in mortality or in health centre admissions were found between the two groups of children. 347 clinical episodes of malaria were detected during the three and a half months of surveillance. SPf66 vaccine was associated with a protective efficacy against the first or only clinical episode of 8% (95% CI -18 to 29, p = 0.50) and against the overall incidence of clinical episodes of malaria of 3% (95% CI -24 to 24, p = 0.81). No significant differences in parasite rates or in any other index of malaria were found between the two groups of children. The findings of this study differ from previous reports on SPf66 efficacy from South America and from Tanzania. In The Gambia, protection against clinical attacks of malaria during the rainy season after immunisation in children 6-11 months old at time of the first dose was not achieved.

PIP: During December 1993 to November 1994, in the Upper River Division of The Gambia, 630 infants aged 6-11 months at time of first dose received three doses of malaria vaccine SPf66 or injected polio vaccine (IPV) and were followed up at home during the rainy season using active and passive case detection methods to determine the protective efficacy of SPf66 against clinical episodes of malaria due to Plasmodium falciparum. The researchers were able to use data on only 547 children (316 SPf66/231 IPV) to determine efficacy. The definition of clinical malaria was fever (37.5 degrees Celsius or higher) and a parasite density of at least 6000/mcl. The two groups were essentially the same in terms of mortality, health center admissions, parasite rates, or any other index of malaria. Health workers identified 347 clinical episodes of malaria during the three months of surveillance. SPf66 vaccine had a protective efficacy against first or only clinical episode of malaria of 8% (p = 0.5). Its protective efficacy was 3% against all clinical episodes of malaria. The results of this trial were different than those from earlier reports on SPf66 efficacy from South America and Tanzania. Possible reasons accounting for the different findings were a mistake in coding syringes for the third dose, substantially less intensity of malaria infection in The Gambia than South America, younger children in The Gambia than in Tanzania, genetic differences in the populations, and difference in length of follow-up. In conclusion, protection against malaria during the rainy season after immunization with SPf66 vaccine in infants aged 6-11 months did not occur.

Anaesthesia in The Gambia.

We review the development of anaesthesia in The Gambia from 1977 to 1992 and the role of nurse anaesthetists. The anaesthetists service provided over a one year period at the Royal Victoria Hospital, Banjul shows that 58.3% are for Obstetrics and Gynaecology (O & G) procedures, 38.06% for Surgical and Dental while 3.164% was Ophthalmology. Nurse anaesthetists administered anaesthesia for 94.4% of the O & G Procedures with minimal complication. However anaesthesia for 65.6% of the general surgical and dental procedures required the expertise of a physician anaesthetist. The major problems associated with anaesthetic service delivery in The Gambia are highlighted and suggestions made on the future development of the specialty of anaesthesia.

Efficacy of hepatitis B vaccine in the Gambian expanded programme on immunisation.

Because of the high prevalence of hepatitis B virus (HBV) infection in The Gambia, HBV vaccination has been incorporated into the national expanded programme on immunisation. We have assessed the efficacy of the vaccine against HBV infection and chronic carriage by examining 720 3-4-year-old children who had received the vaccine in infancy and 816 who had not received it. The vaccine was 84% (95% CI 78-89%) effective against infection and 94% (84-98%) effective against chronic carriage. Vaccinated infants of mothers positive for hepatitis B surface and e antigens were at greater risk of breakthrough infection and chronic carriage than infants of uninfected mothers. The high vaccine efficacy against the HBV carrier state, the main risk factor for the development of chronic liver disease and liver cancer, offers hope that the prevalence of these diseases may be reduced in the future.

PIP: As part of the Gambia Hepatitis Intervention Study, hepatitis B antigens and antibodies were assayed in 720 3-4 year old children who had received 4 doses of 10 mcg plasma-derived hepatitis B vaccine in infancy, the findings were compared with 816 controls. The cross sectional study took place from September, 1990, to July, 1991. Study subjects were tested for hepatitis B core antigen (HBcAg), as well as antigens and antibodies to hepatitis surface, e, and core protein, and those testing positive were tested a year later for HBsAg to determine chronic carrier status. Children negative for core antibody and surface antigen were considered uninfected; those positive for core antibody were considered infected; those positive for surface antigen 2 times 6 months apart were considered carriers. 4.6% of the vaccinated children were infected, and 0.6% were chronic carriers. 3 of these carriers had infected or carrier mothers, and 1 had only received 1 dose of vaccine. In the controls, there were 29% judged infected by anti-HBc, including 13% who were also positive for HBsAg. 86% of these were considered chronic carriers when tested a year later. Thus the vaccine was estimated to be 84% effective against infection and 94% effective against chronic carriage. The current Gambian vaccine consists of 2.5 mcg recombinant hepatitis B vaccine.

The Gambia Hepatitis Intervention Study: follow-up of a cohort of children vaccinated against hepatitis B.

Hepatitis B vaccine has been introduced into The Gambia's national Expanded Programme on Immunization, with the aim of evaluating the impact on chronic liver diseases and in particular on hepatocellular carcinoma. As part of the project, a cohort of 1000 children was recruited to assess the long-term protection induced by the vaccine. The first 3 years of follow-up are described. By the age of 3 years, 95% of the children had protective antibody levels; 4 (0.6%) are known to be carriers in contrast to the 90-140 that would be expected in the absence of vaccination. The protective effectiveness of vaccine in preventing chronic carriage in the first 3 years of life is thus estimated as 95%. Since the risk of becoming a carrier is highest in those infected early in life, these results are encouraging.