[Suicide and attempted suicide in the armed forces in 1998]. / Données épidémiologiques sur les suicides et tentatives de suicide dans les armées en 1998.

UNLABELLED: Little data exists concerning suicides and attempted suicides on professional duty. Now that the French Army is becoming professional, it is necessary to describe methods of self-destruction, in order to facilitate preventive measures. METHODS: The French Army operated a surveillance system to record all instances of suicide and attempted suicide. Under this surveillance system, all suicidal acts and attempts must be reported through an anonymous standard form completed by a military physician. This form records demographic data, the circumstances and known motives. For the epidemiological analysis, we used the chi square test and the Student test. A method of indirect standardization was employed to enable comparisons between military suicides and those within the general French population in 1996. We chose a risk of error of 5%. RESULTS: During the course of 1998, 145 forms were gathered for professional armed forces. Of these, 40 were recorded as actual suicides and 105 as attempted suicides. The suicide rate corresponded to 14p 100,000. Suicides were limited exclusively to males, the average age at death was 36. Comparisons with the French male population at large (using the indirect method of standardization) showed a standardized mortality rate of 0.43 (p > 0.05). Methods of self-destruction employed were mostly hanging and using firearms. Attempted suicide rate was 31.5 p 100,000, with a relatively even balance between males and females. The average age was 30. Methods of self-destruction employed were mostly drug ingestion and laceration. Difficulties with personal relationships were the principal motive recorded, whilst instances of psychiatric diseases were rare. Previous suicide attempts were known in 21% of recorded suicide attempts in 1998 and in 10% of actual suicide. There was no suicidal act during or linked to an outside army operation. The ratio suicide-attempted suicide was 0.38. DISCUSSION: The fact that the rate of suicide in the French Army is lower than the national average could be explained by the medical criteria used to select army personnel on active duty. These results should be interpreted with caution: our data only covers a single year. Moreover, there is a certain bias in the surveillance system used. Measures in the French Army to prevent suicide are based on a significant medical component within units, particularly during operational tours where there is sometimes a psychiatrist. Although the military physician is constrained by professional secrecy, he must execute his duty as an advisor to the commanding officer to signal human factors that need to be taken into account. Responsibility for knowing men and living conditions lies with the commanding officer. Epidemiological surveillance is a key element of analyzing the risks of suicidal. Its contributing role should be regularly reevaluated.

[Cost-benefit ratio of tick-borne encephalitis vaccination of French troops based in Kosovo]. / Etude coût-bénéfice de la vaccination contre l'encéphalite à tique chez les militaires français au Kosovo.

BACKGROUND: French military troops based in Kosovo are exposed to Tick-Borne Encephalitis (TBE) biorisk. An efficacious vaccine is available to prevent this disease, burdened by high morbidity and mortality. The epidemiologic features of TBE in Kosovo are unprecise. To help the French Department of Defense to make a decision about immunization against TBE, we performed a cost-benefit analysis. METHODS: By a Bayes'analysis decision, we have estimated the net benefits for a three-injection vaccine program versus absence of vaccination, for all French military troops based in Kosovo. Time expectancy was 4 years. Through the review of several medical reports, we have estimated the useful parameters for this study: morbidity incidence rate, mortality rate, sequelae rate, efficacy vaccine and side effects. We have chosen as initial hypothesis a sero-conversion rate of 1,080 per 100,000 men-by-year. Human life was valorized in francs, by calculating the allowance paid by Department of Defense to the family in case of death or for sequelae. RESULTS: Net benefits arised to 2.17 millions of francs. The vaccine program cost was 25.0 millions of francs. 140 cases of encephalitis viruses were saved by vaccination. Nevertheless a sensibility analysis has shown that results are well reliable with TBE incidence rate. CONCLUSION: The break even point being close to the incidence rate of the initial assumption, the decision to vaccine all French military troops depends at the same time on a better knowledge of the incidence of the disease in Kosovo, but also of the number of potentially avoided cases of tick-borne encephalitis and of the programs of vaccination concerning this disease of the other countries forming the United Nations Organization forces.

[Acute acoustic trauma in military personnel. Evaluation of 1 year epidemiologic surveillance]. / Traumatismes sonores aigus en population militaire. Bilan d'une année de surveillance épidémiologique.

OBJECTIVES: Acute acoustic trauma (AAT) refers to damage to sensitive cochlear structures caused by excessive exposure to impulse noise. The aim of this study was to 1) assess the incidence of ATT in French soldiers and 2) to clarify the circumstances under which AAT occurs. PATIENTS AND METHODS: We carried out a prospective study of AAT events reported to medical officers in 1998. RESULTS: The incidence of AAT was 156 per 100,000 person-years (150-161). It was higher in conscripts and in soldiers aged under 31 years. Fifty-seven percent were wearing hearing protectors when the accident took place. CONCLUSION: According to these results, specific preventive programs were planned and should be assessed by epidemiological surveillance of exposed populations.

[Anesthesia practices in Yaounde (Cameroon)]. / Pratiques anesthésiques à Yaoundé (Cameroun).

This descriptive and prospective study, carried out during a 6-month period at Yaounde (Cameroon), assessed work practices relating to anaesthesia in public and private health care institutions, the incidence and causes of complications, and considers possible means for improving security of the anaesthetized patient. This study included 1,103 patients, aged 12 days to 89 years. Main surgical indications were gynaecology-obstetrics (33.3% of cases) and emergency surgery (28.6% of cases). Anaesthetic practices were characterized by an unsuitable and non systematic use of procedures which are essential parts of a safe anaesthetic. Pre-anaesthetic assessment was carried out in 71.4% of cases, premedication in 78.4% of cases and management in recovery room in 24% of cases only. Patients were anaesthetized by nurses in 78.6% of cases (40% of them had been trained on-the-job only). The anaesthesia equipment of operating room was poor in most places, especially with respect to physiological monitors. The rate of complications, 476 in 321 patients (29.1% of cases), was similar to the incidence registered in 1977 (30%). Twenty-four deaths occurred (overall mortality rate of 2.2%). Besides the shortage of equipment, this study underlines the necessity for producing and adhering to guidelines for safe practice of anaesthesia, adapted for developing countries.

La surveillance epidemiologique; mode d'emploi

L'objet de cette note pedagogique est de rappeler l'importance de la surveillance epidemiologique pour les systemes de sante et les grands principes qui lui permettent d'etre utile. Certaines attitudes inadequates; generalement non formulees mais sous jacentes sont ensuite enoncees et discutees

[Perception of the Central Hospital by the urban population of Yaoundé: quantitative and qualitative methods]. / Perception de i'Hôpital central par la population de la ville de Yaoundé: approches quantitative et qualitative.

Two studies, using different methods, were used to assess the opinions of the local population on Yaounde Central Hospital (YCH), the changes made as part of a restructuring program and use of health care facilities. The study population comprised YCH patients and the urban population of Yaounde as a whole. One study used personal interviews, according to standard epidemiological survey methods (1,267 inhabitants). The other used focus group discussions involving 8 to 12 people each (10 groups). There was no significant difference in the results recorded by these two methods. Focus group discussions are cheaper and easier to implement and are thus valuable for use alone or prior to more extensive studies using questionnaires. Classic epidemiological survey methods produce results which are reproducible and suitable for statistical analysis, and will make it possible to follow the progress of the new working policies of the YCH.

[Prevention and control of malaria in pregnant women in an urban setting (Yaoundé, Cameroun)]. / Prévention et lutte contre le paludisme chez les femmes enceintes en milieu urbain (Yaoundé, Cameroun).

The aim of this study was to evaluate the methods of preventing malaria (chemoprophylaxis, vector control) and of fever management (presumptive treatment of malaria) used for pregnant women in Yaounde, Cameroon and to identify the most important factors for assessing these practices. The 221 women studied were selected by cluster sampling. All had made extensive use of health services during pregnancy and 77% were using chemoprophylaxis. The number of febrile episodes in pregnant women who claimed to have used chemoprophylaxis was not significantly different to that in the women who did not use it. However, the mean birth weight of the babies of women who had used chemoprophylaxis was significantly higher. The women did not systematically use vector control measures; 21% used insect repellents (electric plaques, coil burners) and 20% used aerosol insecticides. Only 10% of the women slept under simple, untreated mosquito nets and none used mosquito nets impregnated with insecticide. Fifty per cent of the women had at least one episode of fever during pregnancy and 77% were treated for presumed malaria. However, the treatment was not standardized and was unsuitable in a third of cases. Possible changes in the chemoprophylaxis strategy are discussed.

[Legal format and costs of prescriptions at the Central Hospital in Yaounde, Cameroon]. / Forme légale et coût des prescriptions à l'Hôpital Central de Yaoundé, Cameroun.

Prescribing treatment is the last act of a medical visit. A prescription is a written document that engages the medical and legal responsibility not only of the physician but of all those subsequently involved in its execution. In countries with weaker economies and more limited health care insurance the costs of filling a prescription can place a heavy financial burden on the families. In the present study we analyzed 285 prescriptions written in the Emergency Room and Outpatient Clinic of Central Hospital in Yaounde, Cameroon. In most cases prescribers were in compliance with legal requirements regarding their identity, but in 20 to 30% of cases neither the name nor function of the prescriber was mentioned. Most prescriptions were written legibly and coherently for both paramedical personnel and the patient. The number of products prescribed ranged from 2 to 5 depending on the issuing department. Practitioners in the outpatient clinic prescribed few brand-name products from the public outlet of the hospital pharmacy (16% of the prescriptions). In 68% of the cases a generic replacement was available. Practitioners in the emergency room were more apt to prescribe brand-name products (73% of the prescriptions). Five classes of drugs accounted for two thirds of prescriptions, i.e. analgesics-antipyretics, usual antibiotics, antimalarials, non-steroid anti-inflammatory drugs, and vitamins. Lawfully required information (drug presentation, route of administration, dose unit, directions and duration of treatment) was stated on 85% of prescriptions from the outpatient clinic and 50% from the emergency room. Although there were large variations, the mean cost of filling a prescription at the town pharmacy was identical in the two groups, i.e. 9500 CFA francs. The cost was 50% lower at the hospital pharmacy. All prescribers and in particular medical students should receive instruction in prescription writing. Careful selection of brand and non-brand-name drugs in agreement with practitioners should achieve further reductions in the cost of filling a prescription in hospital pharmacy.

[Part of health costs related to malaria in a Cameroon enterprise]. / Part des dépenses de santé liée au paludisme dans une entreprise camerounaise en 1994.

In 1995 a survey was conducted in a metallurgical company in Cameroon to determine the percentage of health-related costs attributed to malaria. Both direct (consultation, hospitalizations, laboratory tests, and drugs) and indirect (sick pay, overtime, and lost production) costs were included. Total annual health-related expenditures were 4,125,000 FF. The average amount spent was 5,800 FF per family or 900 FF per eligible person. Malaria accounted for 1,272,000 FF or 31% of these expenditures. Thus the average amount spent for malaria was 1780 FF per family and 275 FF per eligible person. These figures indicate that a prevention program based mainly on use of impregnated mosquito nets, would be a highly cost-effective approach especially within the context of a well-organized health care system, a stable local population, a high mosquito biting nuisance, a good awareness of this nuisance, the possibility of social upheaval, and probable company support. Since a malaria-prevention program running at 50% efficiency would only decrease the malaria-related costs by about 12.5% of overall annual health expenditures, careful monitoring of cost-effectiveness would be necessary.

[Knowledge, attitudes and practice of populations faced with culicidae nuisances: results of 6 surveys taken in Cameroon in 1994]. / Connaissances, perceptions et pratiques des populations face aux nuisances culicidiennes: résultats de six enquêtes menées au Cameroun en 1994.

In 1994, six KAP studies were carried out in Cameroon to assess the importance of protective methods used by different population groups against culicine nuisance. The objective of these surveys was to evaluate the importance of the use of preventive measures by family against the parasite. The results show that in spite of a strongly resistant parasite in a hyperendemic malaria zone, the use of average protection remains very heterogeneous. Mosquito nets, identified as efficient protection, are used to varying degrees depending on the sites. In Douala, mosquito nets were found in 47% of households visited, with 65% of the inhabitants regularly using them. These figures rose to 75% and 82% respectively in a particularly exposed area of the city. In rural areas very few mosquito nets were identified with an average of one inhabitant per residence using them. The report of the study on the free distribution of mosquito nets and the reimpregnation of the nets six months later in Mbebe-Kikot village, showed that three years after the distribution of the nets, only 68% of the residences still had one mosquito net. In addition, only 9% of these nets were still in good condition. The results of these surveys showed that mosquito nets are more widely used in urban areas, with a higher number of inhabitants per household sleeping under them. They also showed that the free distribution of nets alone does not improve the protection of the population as they are not educated on the maintenance and care of the nets. So we can suggest to use different promotion and distribution strategies in urban area, where lot of people has got the experience of bed nets, and in rural area.

[Surveillance of the in vivo sensitivity of Plasmodium falciparum to antimalarial agents: the results of initial tests of the OCEAC Malaria Network]. / Surveillance de la sensibilité in vivo de Plasmodium falciparum aux anti-malariques: résultat des premiers tests du réseau paludisme OCEAC.

The Malaria Control Division of the Organization for Endemic Disease Control in Central Africa (OCEAC) has developed a standardized method to measure the in vivo sensitivity of Plasmodium falciparum to antimalarial drugs. Between May 1996 and February 1997, a first series of tests using this method was carried out to determine the sensitivity of Plasmodium falciparum to chloroquine and amodiaquine in infected school children in four capital cities: Yaoundé, Brazzaville, Malabo, and Libreville. As expected, only children presenting more than 100 parasites per 1000 leucocytes were enrolled. Results showed variable degrees of in vivo resistance to chloroquine and amodiaquine at each location: 25% and 13% respectively in Yaoundé, 19% and 11% in Malabo, 23% and 43% in Brazzaville, and 29% and 0% in Libreville. Overall results concerning chloroquine of this test series were similar to recent data in comparable populations and confirmed the idea that the situation has stabilized in Central Africa. Findings concerning amodiaquine raise the need for further study to validate and explain the contrasting findings in Libreville (0%) and Brazzaville (43%). This first experience shows that the method is simple and quick and that it can be used with minimal means. Results could provide important early warning data for national health officials.

[Evaluation of patient recruitment at the Yaounde Central Hospital]. / Evaluation du recrutement des patients de l'Hôpital Central de Yaoundé.

A rehabilitation project at Yaounde Central Hospital (YCH) under way since 1990 will soon reach completion with renovation of the maternity ward. In May 1996 three surveys designed to assess recruitment were carried out in 660 patients admitted to the Outpatient Clinic (n = 241), Emergency Room (n = 183), and other departments (n = 236). The study questionnaire focused on familial, educational, and socio-economic background, home living conditions, reasons for admission, and treatment conditions. The findings of these studies indicated that the YCH is at the top-ranked treatment facility with recruitment covering the entire city and beyond. For people living in nearby areas the YCH is also the first care provider especially since income is low. Information campaigns for users, physicians, and health care workers are needed to reinforce confidence in the YCH. The YCH must do more to promote proper management, selection, and transport of patients from upstream facilities and continue its emphasis on wide access to health facilities for the population.

[Evaluation of the risks of sexually transmitted diseases and HIV infection in a rural region of Senegal in 1991]. / Evaluation en 1991 des risques de MST et d'infection par VIH en zone rurale sénégalaise.

This study was performed in the Sereer region 150 km to the east of Dakar, the capital of Senegal. The population of the region is characterised by large seasonal migration, a high divorce rate (41% of marriages end in divorce) and frequent polygamy (1.8 married women per married man). We organised the medical centres in the region to monitor actively the epidemiology of HIV infection. Three populations were targeted: pregnant women presenting for their first prenatal consultation; patients presenting with STD; and people with chronic (more than three weeks) cough. The patients consulting for STD were recruited two ways: those presenting spontaneously and those identified during home interviews by the team performing a parallel sociological study of behaviour. Overall, the prevalence of HIV seropositivity was 0.2% of the women and 1.3% of the men (the difference is not significant). The seropositive individuals identified were 2 pregnant women and 5 patients (3 of 409 women and 2 of 84 men) with STD. There was no significant difference between the sex, age, marital status, or type of recruitment (spontaneous or identified by the sociological survey) of the HIV seropositive and seronegative individuals. The prevalence of treponema antibodies was 1.8% among pregnant women, 2% among STD patients and 2.4% among patients with chronic cough. There was no significant difference according to age, sex, marital status or motivation for consultation. More than half the patients consulting for STD presented biomedical disease. The majority of the STD patients were women: 70% of those spontaneous consulting; 90% of those identified by the survey; and 92% of those with biomedical disease were women.(ABSTRACT TRUNCATED AT 250 WORDS)

[Endotracheal intubation under propofol with or without vecuronium]. / Intubation endotrachéale sous propofol avec ou sans vécuronium.

OBJECTIVE: In order to test the hypothesis that under the association propofol-alfentanil-IV lidocaine the trachea could be intubated easily without an additional muscle relaxant, this study compared the intubation conditions when this association was combined or not with vecuronium. STUDY DESIGN: Randomized comparative trial. PATIENTS: The study included 152 young adults classified as ASA physical class I and Mallampati presentation grade 1, randomly allocated either into Vecu+ group or Vécu0 group, depending on whether vecuronium was co-administered or not. METHODS: All patients received midazolam 0.05 mg.kg-1 i.v., one minute before induction. Those of group Vecu0 were given successively within two minutes: alfentanil 0.03 mg.kg-1, lidocaine 1.5 mg.kg-1 i.v. and propofol 2.5 mg.kg-1. Patients of group Vecu+ received similar doses of alfentanil and propofol as well as vecuronium 0.08 mg.kg-1. The endotracheal tube was inserted one minute after induction in the patients of Vecu0 group, and after three minutes in those of the Vecu+ group. During intubation, scores of mouth opening, glottis opening and coughing were established, in order to assess intubation conditions. RESULTS: Similar convenient intubating conditions were obtained in both groups (in 97% of patients in Vecu+ group vs 95% of those in Vecu0 group). In the latter, the glottis opening was less pronounced. CONCLUSIONS: In young healthy adults, without anaesthetic risk (emergency, full stomach) and without foreseen difficult intubation, the endotracheal tube can be inserted in convenient conditions without a muscle relaxant, under the association propofol-alfentanil-lidocaine iv.

L'evaluation des tests de diagnostic : quels indices peut-on calculer?

L'evaluation de tests diagnostiques se pose en termes differents selon que l'on dispose ou non au depart de certitudes sur le statut des sujets vis-a-vis de la maladie. Si l'on dispose d'un test de reference permettant de distinguer les malades des non malades; l'evaluation est relativement simple et l'on peut calculer facilement les principaux indices descriptifs de la performance diagnostique du test etudie. Si l'on ne dispose pas de test de reference ou si le nouveau test est destine a devenir la reference; l'evaluation consistera a comparer entre eux ces deux tests car les indices classiques ne peuvent plus etre interpretes facilement

Comment superviser le programme national de lutte contre la tuberculose?

La supervision du Programme National de Lutte contre la Tuberculose est une activite indispensable pour s'assurer que les objectifs du programme sont realises selon les criteres de qualite et en respectant les echeances. Elle doit etre reguliere et periodique et n'oublier aucune formation sanitaire. Elle doit employer des indicateurs sensibles; fiables; et toujours les memes pour juger de l'evolution de la qualite du travail. Enfin et surtout; la supervision doit etre concue plus comme un soutien et une aide aux personnels engages dans l'action de sante que comme un controle

Le laboratoire dans la lutte contre la tuberculose

Au sein du Programme National de Lutte contre la Tuberculose; le laboratoire joue un role determinant: le diagnostic de la tuberculose et la surveillance en cours de traitement reposent quasi-exclusivement sur l'examen microscopique des crachats. Le role du technicien de laboratoire dans la bonne marche du programme est donc primordial. Aussi est-il indispensable que le technicien soit conscient de ses responsabilites; forme a tous les aspects du travail; encadre et soutenu par le programme au niveau de la formation et du controle de qualite par le laboratoire de reference; de la supervision de son travail; de l'approvionnement en materiel et fourniture

Fiche medicaments : les antituberculeux

La Rifampicine; le plus actif et le plus recent antituberculeux a ete decouvert en 1965. son arrivee sur le marche a permis la mise au point de protocoles therapeutiques courts en association avec des produits comme le Pyrazinamide et l'Ethambutol. Ces protocoles tres efficaces ont permis une regression importante de la maladie dans le monde occidental. Malheureusement; dans les pays en developpement et en particulier en Afrique subsaharienne; la maladie connait depuis 10 ans une tres forte recrudescence due a la gestion parfois difficile des programmes nationaux de lutte contre la maladie et la pandemie du SIDA

Situation de la trypanosomiase humaine en Afrique centrale en 1994 : interpretation programmatique des donnees

L'Afrique Centrale; en tant qu'espace geographique ou sevit la trypanosomiase humaine africaine (THA) a Trypanosoma brucei gambiense represente dix etats : quatre ou la THA est un probleme majeur (Zaire; Soudan; Angola et Ouganda) et les six etats de l'OCEAC (Cameroun; Congo; Gabon; Guinee-Equatoriale; Republique Centrafricaine et Tchad). Dans ces dix etats; on arrive a ce paradoxe d'une situation de plus en plus preoccupante dans de nombreux foyers alors que les capacites a decrire l'importance epidemiologique de la maladie sont de plus en plus limitees. Les raisons sont multiples parmi lesquelles l'absence de moyens ou de volonte politique; les desordres socio-economiques; la guerre civile parfois. Les auteurs presentent ici les donnees declarees depuis quinze ans en utilisant une methodologie essayant de tenir compte de leur caractere imparfait