The disease profile of poverty: morbidity and mortality in northern Uganda in the context of war, population displacement and HIV/AIDS.

The population of Gulu District (northern Uganda) has been severely incapacitated by war, epidemics and social disruption. This study is aimed at describing disease patterns and trends in this area through a retrospective analysis of discharge records for 155205 in-patients of Lacor Hospital in the period 1992-2002. The burden of infectious diseases in childhood is overwhelming, with malaria accounting for the steepest increase in admissions. Admissions for war-related injuries and malnutrition fluctuated with the intensity of the war and the severity of famine. Emerging and re-emerging infections, such as HIV/AIDS, tuberculosis and Ebola, accounted for a heavy disease burden; however, there has been a trend for admissions related to HIV/AIDS and tuberculosis to decrease since the implementation of community-based services. Vulnerable groups (infants, children and women) accounted for 79.8% of admissions. Long-term war, population displacement, the collapse of social structures and the breakdown of the health system place people at a much greater risk of persistent, emerging and re-emerging infectious diseases, malnutrition and war-related injuries, shaping the 'disease profile of poverty'. Most of the disease burden results from infectious diseases of childhood, whose occurrence could be dramatically reduced by low-cost and effective preventive and curative interventions.

The increasing burden of infectious diseases on hospital services at St Mary's Hospital Lacor, Gulu, Uganda.

To evaluate the impact of infectious diseases on hospital services in Northern Uganda, a retrospective analysis of discharge records concerning 70,304 inpatients admitted to the Lacor Hospital (Gulu, Uganda) during the period 1992-1997 was performed. Children less than five years old represented 46.5% of the admissions, and the burden of infectious diseases on pediatric admissions increased over time, especially due to malaria and measles. Infectious diseases accounted for 7 of the 10 leading causes of admission. The most frequent cause was malaria (21.8% of total). The second leading infectious disease resulting in admission was respiratory tuberculosis (6.2%); given the long hospital stay, this is the most important disease in terms of hospital bed days (24.6%). Infectious diseases have represented a progressively heavy burden on hospital services, mostly due to pediatric admissions. Respiratory tuberculosis and malaria represent nearly one-third of the overall burden in terms of hospital bed days.

Impact of insecurity, the AIDS epidemic, and poverty on population health: disease patterns and trends in Northern Uganda.

A retrospective analysis of the discharge records of 186,131 inpatients admitted to six Ugandan hospitals during 1992-1998 was performed to describe the disease patterns and trends among the population of Northern Uganda. In all hospitals, malaria was the leading cause of admission and the frequency of admissions for malaria showed the greatest increase. Other conditions, such as malnutrition and injuries, mainly increased in the sites affected by civil conflict and massive population displacement. Tuberculosis accounted for the highest burden on hospital services (approximately one-fourth of the total bed-days), though it showed a stable trend over time. A stable trend was also observed for acquired immunodeficiency syndrome (AIDS), which is in contrast to the hypothesis that AIDS patients have displaced other patients in recent years. In conclusion, preventable and/or treatable communicable diseases, mainly those related to poverty and poor hygiene, represent the leading causes of admission and death, reflecting the socioeconomic disruption in Northern Uganda.

Trend in HIV-1 prevalence in an antenatal clinic in North Uganda and adjusted rates for the general female population.

OBJECTIVES: To estimate HIV-1 prevalence among women attending an antenatal clinic in the Gulu District (North Uganda) and, based on these data, among the district's female population. METHODS: Anonymous HIV-1 screening was performed for 8555 antenatal clinic attendees aged 15-39 years in the period 1993-1997. The results were used to estimate the prevalence among the district's female population, accounting for differences in fertility rates by HIV-1 serostatus. RESULTS: Among antenatal clinic attendees, HIV-1 prevalence showed a significant linear decrease (P < 0.001), from 26.0% in 1993 [95% confidence Interval (CI), 23.2-29.0%] to 16.1% in 1997 (95% CI, 14.8-17.5%). This decrease was mostly due to a marked decrease until 1995 (14.3%; 95% Cl, 12.7-16.0%) and was more pronounced among women aged under 30 years (P < 0.001), from both urban and rural areas (P < 0.001). The risk of being infected was higher among women from urban areas (Gulu Municipality), both over the entire period (adjusted prevalence proportion ratio = 1.54; 95% CI, 1.40-1.68) and by individual year. The estimated prevalence for the 15-39-year-old female population, standardized by age and area of residence, decreased from 25.4% in 1993-1994 to 17.8% in 1996-1997; these rates were 1.22 and 1.28 times higher, respectively, than those among antenatal clinic attendees. CONCLUSIONS: The trend of decrease among young women, for whom changes in HIV-1 prevalence more closely reflect incidence, could be partially due to a reduction in risk behaviour and a consequent decreasing incidence. Differences in fertility rates by HIV-1 serostatus should be addressed when using antenatal clinic data to estimate prevalence among the general female population.

'Killer' canines: the morbidity and mortality of ebino in northern Uganda.

In northern Uganda, unerupted primary canine teeth are commonly extracted because they are believed to cause diarrhoea, vomiting, and fever. This practice, known as ebino, is performed under very crude conditions often using unclean tools. To evaluate the morbidity and mortality of complications related to ebino, we retrospectively analysed discharge records from the paediatric ward of Lacor Hospital, Gulu. In the period 1992-98, ebino-related complications, mainly sepsis and anaemia, were among the leading causes of admission (n = 740) and hospital death (n = 156, case fatality rate = 21.1%, proportional mortality rate = 3.3%). Discouraging the adoption of deeply rooted traditional practices that are potentially hazardous to health should be a public health priority in northern Uganda. This could be done by educating not only the general public, but also traditional healers and community and religious leaders, who could convey the knowledge to their people.

Distribution of onchocerciasis in selected river basins of four west African countries.

Detailed epidemiological mapping of eight river basins was conducted in four West African countries as part of an effort to identify the communities at risk of onchocercal blindness to guide a programme of large scale ivermectin distribution, attempting control of eye disease. The results show a surprising variability of pattern in the geographical distribution of intensity of onchocerciasis infections in the communities of the river basins investigated. These patterns were at time very different from what was expected on the basis of the available entomological and demographic information. The technique of detailed mapping proved very useful in achieving an excellent coverage of the communities at risk of onchocercal blindness where, so far, satisfactory treatment coverage has been attained for four consecutive yearly treatments.

Distribution and severity of onchocerciasis in southern Benin, Ghana and Togo.

The Onchocerciasis Control Programme in West Africa has recently extended its operation in southern Benin, Ghana and Togo. To estimate the number of people infected and blinded by onchocerciasis and to describe the distribution and severity of the disease in the extension area, 99 villages were selected, using a stratified random sampling procedure, and surveyed. All the ecological and entomological information available was used in the sampling procedure and in the selection of 87 non-representative villages surveyed to confirm the findings. The study estimated that 590,468 people are infected and 11,715 blind from onchocerciasis out of a rural population of 1,878,234. The Pru, Asukawkaw and Mono river basins were areas with high risk of onchocercal blindness. The Oueme and Zou river basins in Benin and the mountainous areas between Ghana and Togo were classified as areas with medium risk of onchocercal blindness. The other parts of the study area presented low or no risk of onchocercal blindness. By detecting the river basins where villagers are at risk of onchocercal disease this study permits the selection of populations for disease control based on mass distribution of ivermectin, a microfilaricide.

[Significance of the bacterial flora in the etiology of apical periodontitis. Qualitative, quantitative and topographical aspects]. / Significato della flora batterica nell'eziologia delle periodontiti apicali. Aspetti qualitativi, quantitativi e topografici.

In the international literature it is shown the central role of root canal infection in the etiology of periapical lesions. As a matter of fact it has been proved (13) that sterile necrotic pulp tissue is completely unable to cause inflammatory reactions at the periapex. Infection of endodontic origin extends to the supporting tissues of the tooth only in the case of their acute inflammation (e.g. acute apical periodontitis, acute alveolar abscess, phoenix abscess). On the other hand in chronic inflammation bacteria remain confined in the endodontic space. Only few exceptions to this general rule have been experimentally proved. In endodontics we deal with a mixed infection which is composed by obligate anaerobes and by facultative anaerobes. The most frequently found obligate anaerobes are Bacteroides sp. and Fusobacterium sp. (Gram- rods) Anaerobic Diphtheroides (Gram+ rods) Peptostreptococcus sp. (Gram+ cocci) and Veilonella sp. (Gram- cocci). Actinomyces sp., Lactobacillus sp., Streptococcus sp., and Staphilococcus sp. are the facultative anaerobes most frequently found.

[Morpho-functional characteristics of bacterial species of major importance in endodontic infections]. / Caratteristiche morfo-funzionali dei ceppi batterici di maggiore importanza nelle infezioni endodontiche.

Most of the bacteria involved in the endodontic infection can be considered as "highly specific", for they appear to be almost irrelevant in the large field of the other human disease from infection. Namely the most important anaerobia responsible for endodontic infection are: Bacteroides, Fusobacterium, Peptostreptococcus, and Veillonella. The group of Bacteroides is composed by several species with different metabolic and genetic characteristics. They are Gram-, non-motile, non-spore-forming rods. Fusobacterium are spindle-shaped, Gram-, non motile, non-spore-forming bacilli. Peptostreptococci are round-shaped, Gram+, non-motile cocci. Veillonella are small, Gram-, non-motile cocci.

[Mixed infection: specific canal aspects]. / L'infezione mista: aspetti specifici a livello canalare.

The fundamental feature of the bacteriologic flora that causes endodontic lesions is its mixed nature. It has been demonstrated that a mixed flora can more easily give rise to both acute and chronic inflammatory reactions. The coexistence of different families of bacteria within the same environment is based upon a very delicate balance given by the interplay of the various mechanisms of bacterial relationships: mutualism (symbiosis and commensalism), antagonism and synergism. The metabolic needs (nutritive and respiratory) of the different types of bacteria which cause endodontic infections are so specific that these organisms are strictly dependent on each other for their own survival in the radicular canal system and for their pathogenicity.

Adverse reactions after large-scale treatment of onchocerciasis with ivermectin: combined results from eight community trials.

Eight community trials were carried out by the Onchocerciasis Control Programme in West Africa to determine the safety of the new microfilaricide ivermectin during large-scale treatment of onchocerciasis. The trial areas were located in eight different countries and varied greatly in endemicity level; a total of 50,929 persons were treated and monitored for 72 hours. Overall treatment coverage was 60% of the census population, the main reasons for non-treatment being the exclusion criteria. Of those treated, 9% reported with adverse reactions, 2.4% with moderate reactions, and 0.24% with severe reactions. Most reactions were reported during the first day of follow-up, the most frequent severe reaction being severe symptomatic postural hypotension (in 49 cases). Three cases of severe dyspnoea were life-threatening but their relationship with ivermectin treatment is uncertain. The incidence of adverse reactions was directly related to skin microfilarial load and was highest in the foci with the highest endemicity levels. Treatment resulted in 98% reductions in mean microfilarial loads at all endemicity levels. The benefit of treatment largely compensated for the discomfort due to adverse reactions, which were all transient and managed successfully. Ivermectin thus appears to be sufficiently safe for large-scale treatment but monitoring by resident nurses for at least 36 hours is recommended.

Adverse reactions after large-scale treatment of onchocerciasis with ivermectin: combined results from eight community trials

Eight community trials were carried out by the Onchocerciasis Control Programme in West Africa to determine the safety of the new microfilaricide ivermectin during large-scale treatment of onchocersiasis. The trial areas were located in eight different countries and varied greatly in endemicity level; a total of 50,929 persons were treated and monitored for 72 hours. Overall treatment coverage was 60 percent of the census population, the main reasons for non-treatment being the exclusion criteria. Of those treated, 9 percent reported with adverse reactions, 2.4 percent with moderate reactions, and 0.24 percent with severe reactions. Most reactions were reported during the first day of follow-up, the most frequent severe reaction being severe symptomatic postural hypotension (in 49 cases). Three cases of severe dyspnoea were life-threatening but their relationship with ivermectin treatment is uncertain. The incidence of adverse reactions was directly related to skin microfilarial load and was highest in the foci with the highest endemicity levels. Treatment resulted in 98 percent reductions in mean microfilarial loads at all endemicity levels. The benefit of treatment largely compensated for the discomfort due to adverse reactions, which were all transient and managed successfully. Ivermectin thus appears to be ...(AU)