Multiple methods for workshop evaluation.

Evaluation is a necessary component of all training, including workshops. Evaluation can provide information about the teaching and learning that occur during a workshop and document the extent to which long-term objectives were achieved after a workshop. Multiple methods for evaluating the process and outcomes of a regional workshop on Program Planning and Management for Malaria Control were developed and implemented by an evaluation team composed of African program managers and technical assistance partners, all of whom served as workshop trainers. Among the five methods used to assess the process of workshop implementation and participant satisfaction, a questionnaire administered at the close of the two-week workshop was found least useful in improving the training. Much more useful were the results of daily trainers' meetings and of two qualitative evaluation methods: large group feedback sessions and focused group discussions. Among the three methods used to evaluate the workshop outcomes, a review of the quality of the pre- and post-workshop national malaria control program plans by a panel of experts was found to be the most useful in providing information about the extent to which learning objectives were achieved. The involvement of trainers in evaluation activities permitted immediate action based on results. Our experience suggests that during brief workshops, evaluation should not compete with training activities for time and resources but must be considered an essential part of the curriculum. Effective and efficient workshop evaluation will require advance planning by trainers, support and training in evaluation methods for all members of the evaluation team, and advance consideration of how evaluation results will be summarized and translated into action.

Plasmodium falciparum-associated anemia in children at a large urban hospital in Zaire.

Chloroquine-resistant Plasmodium falciparum malaria and human virus (HIV) infection through blood transfusions used to treat malaria-associated anemia are causes of increasing morbidity and mortality among children in Africa. To evaluate the role of malaria and other risk factors for pediatric anemia, we conducted a study of children brought to the emergency ward of a large urban hospital in Kinshasa, Zaire. A total of 748 children ages six through 59 months were enrolled; 318 (43%) children were anemic (hematocrit < 33%), including 74 (10%) who were severely anemic (hematocrit < 20%). Plasmodium falciparum parasites were detected in 166 children (22%); hematocrits for these children (mean 25.8%) were significantly lower than for aparasitemic children (mean 33.7%; P < 10(-6)). Fever with splenomegaly (odds ratio [OR] = 6.5, P = 0.02), parasitemia (OR = 3.5, P < 0.001), lower socioeconomic status (OR = 2.0, P = 0.004), and malnutrition (OR = 1.8, P = 0.06) were independently associated with anemia in a multivariate model. Recent antimalarial therapy was also associated with a lower hematocrit, suggesting that chloroquine may have aggravated the anemia. A reassessment of the effectiveness of strategies to diagnose and treat malaria and malnutrition is necessary to decrease the high prevalence of anemia and the resultant high rate of blood transfusions in areas endemic for malaria and HIV.

Human monkeypox: confusion with chickenpox.

Human monkeypox is a zoonosis occurring sporadically in the tropical rain forest of western and central Africa. The exact incidence and geographical distribution are unknown, since many cases are not recognized. Special surveillance was established in three regions in Zaire in 1981 that led to a substantial increase in reported cases. The question arose as to the possibility that clinical diagnostic errors cause some cases of monkeypox to be misdiagnosed as other eruptive diseases. This paper presents the results of a study assessing the extent of and reasons for these clinical diagnostic errors in areas where health staff as well as the general public are aware of human monkeypox. In Zaire in the period 1981-1986, 977 persons with skin eruption not clinically diagnosed as human monkeypox were laboratory tested. 3.3% of human monkeypox cases were found among 730 patients diagnosed as cases of chickenpox, 7.3% among cases diagnosed as "atypical chickenpox" and 6.1% among cases with skin rash for which clinical diagnosis could not be established. The diagnostic difficulties were mainly based on clinical features characteristic of chickenpox: regional pleomorphism (in 46% of misdiagnosed cases), indefinite body-distribution of skin eruptions (49%), and centripetal distribution of skin lesions (17%). Lymph-node enlargement was observed in 76% of misdiagnosed patients. In the absence of smallpox, the main clinical diagnostic problem is the differentiation of human monkeypox from chickenpox. The presence of lymphadenopathy, pre-eruptive fever and slower maturation of skin lesions are the most important clinical signs supporting correct diagnosis of monkeypox.

Human monkeypox: disease pattern, incidence and attack rates in a rural area of northern Zaire.

Human monkeypox is a zoonosis that occurs sporadically in the tropical rainforest of western and central Africa. This article presents the results of epidemiological features of 91 monkeypox patients reported in Bumba zone in northern Zaire during the period 1981 to 1985. Their age ranged from 7 months to 29 years (93% below 15 years of age). 11% of patients had visible smallpox vaccination scars. Deaths occurred sporadically; the overall case-fatality rate was 9%. 91 patients arose in 61 separate outbreaks; 42 of them consisted of only a single case. The source of infection was suspected to be animal for 70 cases, and human for the remaining 21 cases. The illness occurred in all months of the year. There was a considerable clustering of cases in the northern part of the zone. The average annual incidence rate in the observed zone was 0.63 cases per 10,000 population with marked differences in age, time and place. The average annual primary attack rate among unvaccinated individuals (1.7/10,000) sharply contrasted with those vaccinated (0.04/10,000). The secondary attack rate for contacts without vaccination scar (4.3%) differed significantly from those who had been vaccinated in past (0.7%). Many unvaccinated contacts living under conditions of maximal exposure to index cases escaped not only the disease but also infection. The low incidence rate of human monkeypox indicates its limited public health importance even in a well-known enzootic area.

Malaria infection in pregnant women in Zaire: the effects and the potential for intervention.

In five maternity centres in urban and rural Zaire we evaluated the maternal prevalence of Plasmodium falciparum parasitaemia and recorded fever, the frequency of abortions and stillbirths, newborn birth weights and the feasibility of delivering antimalarial chemoprophylaxis. Women in their first and second pregnancy, compared to others (greater than or equal to third pregnancies), had a higher frequency of parasitaemia (38 v. 15%, respectively, P less than 0.001), higher parasite densities (geometric mean densities 927 per mm3 v. 277 per mm3, respectively, P = 0.01), higher rates of stillbirths and low birth weight babies (24% v. 6.4%, P less than 0.001). On average, pregnant women first attended prenatal clinics in the sixth to seventh month of gestation and made three to four visits before delivery. In these areas of Zaire, antimalarial interventions during pregnancy would have the largest impact if they were targeted to women in their first and second pregnancy. In the study areas, maternal attitudes and prenatal care-seeking behaviours do not appear to be barriers to providing an antimalarial intervention.

Response of children with Plasmodium falciparum to chloroquine and development of a national malaria treatment policy in Zaire.

In vivo sensitivity of Plasmodium falciparum to chloroquine was evaluated in 4 of 9 regions of Zaire in 1985 to develop a national strategy for treatment of malaria. Children less than 5 years of age were treated with either a single dose of chloroquine base, 10 mg/kg, or a dose of 25 mg/kg given over 3 d. A modified 7-day World Health Organization in vivo test was used with follow-up 2, 3 and 7 d after the start of treatment. 339 children were studied. In Bwamanda 92% of children were aparasitaemic 7 days after chloroquine, 10 mg/kg, but in Kinshasa only 44% were free of parasites after 25 mg/kg chloroquine. The mean drop in parasite density among those who did not clear parasites by day 7 was greater than 98% of the initial value. Although the parasite density decreased markedly, the failure of most subjects to become aparasitaemic indicated a marked decrease in parasite sensitivity since 1983. Only one child of 51 who were initially febrile remained febrile, although 14 (28%) of these had resistant parasites. The decrease in parasitaemia and temperature, even among children with resistant strains, led the Ministry of Health to recommend 25 mg/kg chloroquine as first line treatment for fever/malaria in their national malaria control plan. The plan includes drug sensitivity surveillance and a referral system for patients who do not respond to chloroquine treatment.

Clinico-epidemiological features of monkeypox patients with an animal or human source of infection.

Clinical and laboratory examinations were carried out on a total of 338 monkeypox patients in Zaire from 1981 to 1986. An animal source of infection was suspected in 245 (72%) and interhuman transmission for the remaining 93 patients. Among those whose infection was presumably acquired from an animal source, the most affected groups were children aged 3-4 years (27%) and 5-6 years (20%), while only 4% of cases were over 15 years old; there was a considerable preponderance of males (58%) over females (42%), especially in the age group 5-14 years. Among those presumably infected by person-to-person transmission, the age distribution was more uniform, adult patients tending to be relatively more common, and there were more females (57%) than males (43%).Based on comparisons of the frequency and intensity of clinical signs and symptoms among patients infected from an animal source and those who were infected by another patient, there was no evidence that the disease becomes more severe and the transmitted virus more virulent or more easily transmissible from person to person after one or more passages through human hosts.

Human monkeypox: secondary attack rates.

Data on human monkeypox collected in Zaire during the six years 1981-86 were analysed to assess the extent of interhuman transmission of monkeypox virus. Among the 2278 persons who had close contact with 245 monkeypox patients infected from an animal source, 93 fell ill and were presumed to have been infected from the known human source: 69 of these were spread in the first generation, 19 in the second generation, and the remaining five cases in the third and fourth generation.The secondary attack rates were correlated with the age, sex, place of residence, and vaccination status of the contacts. There was an overall 3% probability of becoming ill following infection from a known human source. The affected household was the main focal point for interhuman transmission of monkeypox virus. The highest attack rate (11.7%) occurred among unvaccinated household contacts in the age group 0-4 years. However, the majority of susceptible persons who had been close to patients in the confined space of poorly ventilated huts failed to develop illness. There was no evidence of an increase in the secondary attack rate between 1970-80 and 1981-86.The inefficient spread from person to person, even in conditions of maximum exposure, supports the concept that monkeypox virus is poorly adapted for sustained transmission between humans and that such transmission does not pose a significant health problem.

Clinco-epidemiological features of monkeypox patients with an animal or human source of infection

Clinical and laboratory examinations were carried out on a total of 388 monkeypox patients in Zaire from 1981 to 1986. An animal sources of infections was suspected in 245 (72 percent) and interhuman transmission for the remaining 93 patients. Among those whose infection was presumably acquired from an animal source, the most affected groups were children aged 3-4 years (27 percent) and 5-6 years (20 percent), while only 4 percent of cases were over 15 years old; there was a considerable preponderance of males (58 percent) over females (42 percent), especially in the age group 5-14 years. Among those presumably infected by person-to-person transmission, the age distribution was more uniform, adult patients tending to be relatively more common, and there were more females (57 percent) than males (43 percent). Based on comparisons of the frequency and intensity of clinical signs and symptoms among patients infected from an animal source and those who were infected by another patient, there was no evidence that the disease becomes more severe and the transmitted virus more virulent or more easily transmissible from person to person after one or more passages through human hosts

Human monkeypox: Secondary attack rates

Data on human monkeypox collected in Zaire during the six years 1981-86 were analysed to assess the extent of interhuman transmission of monkeypox virus. Among the 2278 persons who had close contact with 245 monkeypox patients infected from an animal sources, 93 fell ill and were presumed to have been infected from the known human sources: 69 of these were spread in the first generation, 19 in the second, and the remaining five cases in the third and fourth generation. The secondary attack rates were correlated with the age, sex, place of residence, and vaccination status of the contacts. There was an overall 3 percent probability of becoming ill following infection from a know human source. The affected household was the main focal point for interhuman transmission of monkeypox virus. The highest attack rate (11.7 percent) occurred among unvaccinated household contacts in the age group 0-4 years. However, the majority of susceptible persons who had been close to patients in the confined space of poorly ventilated huts failed to develop illness. There was no evidence of an increase in the secondary attack rate between 70-80 and 81-86. The inefficient spread from person to person, even in conditions of maximum exposure, supports the concept that monkeypox virus is poorly adapted for sustained transmission between humans and that such transmission does not pose a significant health problem

Human monkeypox: clinical features of 282 patients.

We present the clinical features and course of 282 patients with human monkeypox in Zaire during 1980-1985. The ages of the patients ranged from one month to 69 years; 90% were less than 15 years of age. The clinical picture was similar to that of the ordinary and modified forms of smallpox. Lymphadenopathy, occurring in the early stage of the illness, was the most important sign differentiating human monkeypox from smallpox and chickenpox. The symptoms, signs, and the course of the disease in patients who had been vaccinated against smallpox differed significantly from those in unvaccinated subjects. Pleomorphism and "cropping" similar to that in chickenpox occurred in 31% of vaccinated and 18% of unvaccinated patients. The prognosis depended largely on the presence of severe complications. No deaths occurred among vaccinated patients. In unvaccinated patients the crude case-fatality rate was 11% but was higher among the youngest children (15%).

Human monkeypox: a study of 2,510 contacts of 214 patients.

A study of 2,510 contacts of 214 patients with human monkeypox was conducted in Zaire from 1980 to 1984. Among the contacts of 130 primary cases of human monkeypox, a further 22 co-primary and 62 secondary cases were detected, and an additional fourteen people who had no evidence of clinical disease had positive serological results. A majority of the clinical and subclinical cases of monkeypox occurred in children less than 10 years of age. Immunity in vaccinated persons now appears to be waning because 16 overt cases occurred in contacts who had been vaccinated. The overall attack rate for contacts without a vaccination scar (7.2%) differed significantly from the attack rate for those who had been vaccinated in the past (0.9%). The attack rate for household contacts was significantly higher than that for other contacts, among both unvaccinated (four times higher) and vaccinated (seven times higher) household contacts. Many unvaccinated contacts living in the same household as the index case under conditions of maximum exposure, however, escaped not only the disease but also infection.

Human tanapox in Zaire: clinical and epidemiological observations on cases confirmed by laboratory studies.

Human tanapox, a mild disease characterized by a short febrile illness associated with one or more skin lesions, is important because of its possible confusion with smallpox. The article describes clinical and epidemiological features of 264 laboratory-confirmed tanapox cases observed in a geographically limited area in northern Zaire over the period 1979-83.