Improving private practitioner care of sick children: testing new approaches in rural Bihar.

Private practitioners are a major source of care for childhood illnesses in developing countries, but the care they provide is often of poor quality. This study tested the effectiveness of two new methods for improving the quality of private practitioner care of sick children: the verbal case review (VCR) and INFECTOM. The VCR is a method for evaluating private providers' quality of care based on mothers' reports and INFECTOM is a package of interventions for improving private providers' quality of care. The study was conducted in 110 villages of Bihar State, India, by three local non-governmental organizations (NGOs). First, the VCR was used for interviews with mothers of approximately 600 children sick with diarrhoea, ARI or fever in the past 2 weeks. The VCR identified practitioners consulted for the treatment of the sick children and recorded providers' case management practices as reported by the mothers. Based on the results of the VCR, the INFECTOM intervention was carried out. This consisted of INformation sessions for the providers regarding standard case management guidelines for ARI, diarrhoea and fever, FEedback to providers on their performance based on the results of the VCR, ConTracting with practitioners to gain their commitment to practice specific guidelines, and Ongoing Monitoring of practitioners' practices with feedback of the results to the practitioners and the community. Seven months after the interventions were initiated, another cross-sectional VCR survey of approximately 300 sick children was carried out to evaluate the impact of the activities on practitioners' case management practices. The results of the study show statistically significant improvements in private practitioners' history taking, examination and counselling practices for ARI, diarrhoea and fever. It was concluded that the VCR and INFECTOM were feasible for implementation by community-based NGOs, and were effective in improving the technical quality of care provided by private health practitioners in rural India.

Feeding, feedback and sustenance of primary health care.

PIP: The neglect of nutrition in primary health care is widespread despite the severity of malnutrition in the world today. Some of the reasons for this situation include a lack of definition, i.e. nutrition is considered a continuous daily need, not a health intervention; it is often a difficult task to solicit participation from the mothers; nutrition is often not an acutely felt need, thus there is no demand; nutrition requires continuous action on a daily basis, but produces no visible results; and finally actions aimed at malnutrition or even its prevention often do not seem to work. Nutrition interventions often do not work because the interventions come too late, often when permanent stunting of the child's growth has already occurred. Since inadequate nutrition can not be seen in the early stages, growth monitoring can be used as a feedback mechanism to stimulate appropriate feeding responses. For a mother to become involved in growth monitoring 4 elements are necessary: 1) she must be aware of the problem or situation, 2) she must be motivated to respond, 3) she must have the knowledge and skills of how to feed, what to feed, and when to feed, and 4) She must have the means to act, i.e. food must be available to give the child. Many growth monitoring programs have failed because the mother was not involved, and never perceives the problem, therefore she never acts. If growth monitoring is integrated into the primary health care system, it also becomes a regular time for health education in other topics. Disease and death are more often found in children who are malnourished, thus primary health care interventions are likely to be more effective in the presence of effective nutrition interventions.^ieng

BioPrep. A premedical program for rural high school students.

To address physician maldistribution in Alabama and the Southeast region. The University of Alabama established the Biomedical Sciences Preparation Program (BioPrep) in five rural high schools. Its purpose is to help rural, disadvantaged high school students develop academically and socially so that they will be motivated and able to enroll in and progress successfully through college, specifically in pre-health professional curricula. It aims to develop their desire to return eventually to rural areas of Alabama as professionals. Project students are compared with two control groups. Performance on the American College Testing Program college entrance examination revealed significantly higher achievement by the project students. The project students also chose professional careers earlier and more frequently than matched high school students not receiving this special program, but similar to medical students and premedical students. The implications of the project for increasing the size of the rural, disadvantaged student applicant pool are discussed.

Taking science where the diarrhoea is.

With attack rates exceeding two episodes per year in the young diarrhoea with attendant dehydration is by far the major single killer in the developing world. An invariable accompaniment of the more insidious and chronic protein-energy malnutrition (PEM), diarrhoea is itself an acute form of malnutrition: fluid-electrolyte malnutrition (FEM). Scientific attention to FEM has focused heavily on mechanisms of pathogenesis and disordered physiology, often to the neglect of preventive and effective control measures. A notable exception was the huge step from the short-circuit chamber to the cholera ward which carried the science of coupled transport to the field. Glucose-electrolyte solutions provide effective prevention and treatment of dehydration and, where combined with early proper feeding, an interruption of the FEM-PEM cycle. Wider use of this simple technology awaits greater understanding and interact-on with the social systems that determine the ecology of diarrhoeal disease.

Vi antigen from Salmonella typhosa and immunity against typhoid fever. 11. Safety and antigenicity in humans.

Safety and antigenicity of a purified preparation of Salmonella typhosa Vi antigen was evaluated in human volunteers. Dosages of Vi antigen at 25, 50, and 100 mug were less toxic than U.S. standard typhoid vaccine (lot 6A) containing 5 X 10(8) bacteria per dosage. Vi antigen in comparison with the standard typhoid vaccine induced higher hemagglutinating antibody but lower bactericidal antibody responses.

Vi antigen from Salmonella typhosa and immunity against typhoid fever. I. Isolation and immunologic properties in animals.

The role of Vi antigen in human immunity against typhoid fever has been debated for decades. Circumstantial evidence indicates that Vi antigen may play a role in pathogenicity and immunity. A Vi preparation was isolated from Salmonella typhosa, the causative organism in human typhoid fever, by a mild precipitation method. It was significantly more potent in animal studies than preparations from Citrobacter used in the past for human study and less toxic than conventional typhoid vaccines. With this antigen, the role of Vi antigen in human protection is now being investigated.

In vitro susceptibility of El Tor and classical Vibrio cholerae strains to trimethoprim and sulfamethoxazole.

Trimethoprim and sulfamethoxazole were tested individually and in combination against El Tor and classical biotype strains of Vibrio cholerae. Determinations of the minimal inhibitory concentration in liquid media and by an agardilution method showed that classical strains were uniformly more resistant to sulfamethoxazole than were El Tor strains. In agar-dilution studies, trimethoprim was equally active against both biotypes. Combination of the agents produced a synergistic action against all strains tested. Testing for susceptibility to sulfonamide is suggested as a possible method for differentiating between El Tor and classical biotypes of V. cholerae.