Use of the Automated Disaster and Emergency Planning Tool in developing district level public health emergency operating procedures in three East African countries.

BACKGROUND: Sub-Saharan Africa is vulnerable to several natural and man-made disasters. We used the CDC Automated Disaster and Emergency Planning Tool (ADEPT) to develop all-hazards disaster management plans at district level in three eastern African countries. METHODS: During July 2008-February 2011, we used the automated disaster and emergency planning tool to conduct training on disaster planning and management in the three east African countries namely Kenya, Tanzania and Uganda. We trained district disaster teams per country. We held 7 trainings in Tanzania, 8 in Uganda and 10 in Kenya respectively. The district disaster management teams trained comprised five district administrative personnel and a national Red Cross officer. The training took 5 days. RESULTS: A total of 100 districts teams (40 in Uganda and 35 in Kenya and Tanzania respectively) were trained using the ADEPT and consequently 100 district disaster response plans were developed during 2008-2011. A total 814 district disaster team members from these districts were trained. Our experience has shown that the Automated Disaster Emergency Planning Tool is a relatively quick, easy, practical, participatory and inexpensive approach to developing emergency operating plans at the sub-national (district) level. CONCLUSIONS: The ADEPT can be used relatively easily, quickly and inexpensively at the sub-national levels to develop emergency operating procedures to improve disaster management. Although the ADEPT enables district disaster response teams to generate their disaster response plans, the use of the ADEPT may be hampered by lack of computer skills and knowledge of MS computer programme by district personnel in resource limited settings.

Regional approach to building operational level capacity for disaster planning: the case of the Eastern Africa region.

BACKGROUND: The Eastern Africa region is regularly affected by a variety of disasters ranging from drought, to human conflict and population displacement. The magnitude of emergencies and response capacities is similar across the region. In order to strengthen public health disaster management capacities at the operational level in six countries of the Eastern Africa region, the USAID-funded leadership project worked through the HEALTH Alliance, a network of seven schools of public health from six countries in the region to train district-level teams. OBJECTIVES: To develop a sustainable regional approach to building operational level capacity for disaster planning. METHODS: This project was implemented through a higher education leadership initiative. Project activities were spear-headed by a network of Deans and Directors of public health schools within local universities in the Eastern Africa region. The leadership team envisioned a district-oriented systems change strategy. Pre-service and in-service curricula were developed regionally and district teams were formed to attend short training courses. Project activities began with a situational analysis of the disaster management capacity at national and operational levels. The next steps were chronologically the formation of country training teams and training of trainers, the development of a regional disaster management training curriculum and training materials, the cascading of training activities in the region, and the incorporation of emerging issues into the training curriculum. An evaluation model included the analysis of preparedness impact of the training program. RESULTS: The output from the district teams was the creation of individual district-level disaster plans and their implementation. This 4-year project focused on building operational level public health emergency response capacity, which had not previously been part of any national program. Use of the all-hazard approach rather than a scenario-based contingency planning led to the development of a standardized curriculum for training both in-service and pre-service personnel. Materials developed during the implementation phases of the project have been incorporated into public health graduate curricula in the seven schools. This systems-based strategy resulted in demonstrable outcomes related to district preparedness and university engagement in disaster management. CONCLUSION: University partnerships are an effective method to build district-level disaster planning capacity. Use of a regional network created a standardized approach across six countries.

Iodine fortification is related to increased weight-for-age and birthweight in children in Asia.

Severe iodine deficiency causes stunting and mental retardation in utero, but the relation between mild deficiency and child growth is not well known. The use of iodated salt in relation to anthropometric data was examined from recent survey data. After potential confounding factors had been controlled for, significant associations were seen in Bangladesh, India, Nepal, and Sri Lanka. The use of iodated salt was related to increased weight-for-age and mid-upper-arm circumference, most strongly in the second year of life, mainly affecting soft tissue (thinness). The relation with weight-for-age was greater among children of mothers with lower body mass index. The use of iodated salt was related to birthweight in Sri Lanka and in the Philippines, where iodized oil capsules given during pregnancy had a negative effect when used with high levels of iodine in salt. The associations generally were concentrated in large geographic areas, possibly because of interactions with other environmental factors (e.g., selenium and arsenic). The apparent growth response to iodine may reflect functional effects of mild deficiency, which is widespread, possibly including effects on brain development.

Certain immune markers are not good indicators of mild to moderate biotin deficiency in rats.

To assess the effects of marginal biotin deficiency on immune function and thereby evaluate immune function as a potential marker for impaired biotin status, we investigated immune function in a rat model during progression from sufficiency to moderate biotin deficiency. As immune function indicators, we assessed the IgG response to a vaccine and the cytokine responses and relative proportions of lymphocyte subpopulations in the immunocytes in blood, spleen and thymus. Neither phenotype nor organ redistribution of lymphocytes differed between biotin-deficient and biotin-sufficient rats. Assessment of immune function by mitogen T cell proliferation, mitogen-induced interferon-gamma and interleukin-4 levels, IgG antibody responses and natural killer cell activity were not significantly different in mild to moderately biotin-deficient rats compared with biotin-sufficient controls. The absence of effects on immune function was not attributable to failure to induce biotin deficiency; the rats exhibited unequivocal evidence of biotin deficiency, including reduced hepatic biotin and impaired leucine metabolism resulting from deficiency of the biotin-dependent enzyme methylcrotonyl-CoA carboxylase. We conclude that the immune markers examined are not promising candidates as indicators of mild to moderate deficiency in humans.

The impact of the AFDC and Food Stamp programs on child nutrition: empirical evidence from New Orleans.

This study tests the hypotheses that the participation in the Aid to Families with Dependent Children (AFDC) and Food Stamp programs has a positive impact on children's nutritional status, after controlling for other potentially important household- and individual-level characteristics. The analysis is based on the responses of a health facility survey of 246 pairs of low-income mothers and children in New Orleans. The results indicate that participation in the AFDC and Food Stamp programs is associated with increased anthropometric status of children, but the foods consumed by children in families receiving welfare benefits were of significantly lower nutritional value than foods consumed by other children. Among the study's conclusions are the following: (1) in this low-income setting, AFDC and Food Stamp benefits are associated with higher food expenditures, higher anthropometric levels, but inferior diets, and (2) female-headed households spend more on food expenditures than other households, after controlling for other individual- and household-level characteristics.

Measuring hunger in the Russian Federation using the Radimer/Cornell hunger scale.

Compared in the study are the results obtained using the Radimer/Cornell hunger scale to measure the prevalence of hunger in random samples of mothers and their households in the Russian Federation and in the USA in 1993. The 12 items in the scale measured hunger at three levels: household, women, and children. If the mother answered positively to one of the four items at a particular level, hunger was established for that level. The prevalence of hunger in the Russian Federation was very high: approximately 77% of the women surveyed, 70% of the households, and 32% of the children were classified as hungry. The corresponding estimated prevalences of hunger in New York State in 1993 were 46.8%, 25.9% and 18.3%. In both surveys, children were the least likely to be classified as hungry and, if they were, their mothers and households were almost always hungry. In both surveys, the hunger scale proved to have criterion-related validity. Basic indicators of household socioeconomic and demographic well-being were highly related to the three levels of hunger. The higher level of hunger in the Russian survey can be explained by the very low incomes. Further study of the nutritional status of the Russian population is recommended.

Disturbances in biotin metabolism in children undergoing long-term anticonvulsant therapy.

BACKGROUND: In subjects undergoing long-term therapy with carbamazepine and/or phenytoin, reduced plasma concentrations of biotin have been reported. However, the diagnostic value of plasma biotin is unclear, in part because of the presence of significant plasma concentrations of biotin metabolites. Pathologic organic aciduria has also been reported with long-term anticonvulsant therapy, suggesting biotin deficiency, but no mechanism leading to deficiency has yet been determined. METHODS: In the current study, we sought to determine whether biotin catabolism was accelerated in children receiving long-term treatment with certain anticonvulsants and to assess biotin status as judged by urinary excretion of biotin and 3-hydroxyisovaleric acid, an organic acid that is an indicator of deficiency of a biotin-dependent enzyme. Seven children treated with carbamazepine and/or phenytoin and six treated with phenobarbital provided untimed urine samples. Sixteen healthy children receiving no anticonvulsants served as controls. Biotin and biotin metabolites were determined by high-performance liquid chromatography/avidin-binding assay. Urinary excretion of 3-hydroxyisovaleric acid was determined using gas chromatography/mass spectrometry. RESULTS: Bisnorbiotin excretion was increased significantly in the carbamazepine/phenytoin group and in the phenobarbital group. Biotin sulfoxide excretion was significantly increased in the carbamazepine/phenytoin group but not in the phenobarbital group. 3-Hydroxyisovaleric acid excretion was increased significantly in the carbamazepine/phenytoin group. However, only one child (carbamazepine/phenytoin group) had a decreased urinary excretion of biotin. CONCLUSION: These data provide evidence that long-term administration of some anticonvulsants can accelerate biotin catabolism, but the indicators of biotin status conflict.

Biotin biotransformation to bisnorbiotin is accelerated by several peroxisome proliferators and steroid hormones in rats.

Bisnorbiotin and biotin sulfoxide are the major catabolites of biotin for humans, swine, and rats. Increased urinary excretion of bisnorbiotin, biotin sulfoxide, or both have been observed during pregnancy and in patients treated with certain anticonvulsants. We sought more insight into the sites and mechanisms of biotin catabolism by exposing rats in vivo to compounds known to induce classes of enzymes that were candidates to catalyze the biotransformations. Rats were treated with the anticonvulsants phenytoin, phenobarbital, and carbamazepine, the steroid hormones dexamethasone and dehydroepiandrosterone, and the peroxisome proliferators clofibrate and di(2-ethylhexyl)phthalate. [14C]Biotin was injected intraperitoneally at physiologic doses in treated rats and control rats; HPLC and radiometric flow detection were used to specifically identify and quantify [14C]biotin and its metabolites in urine. Treatment effects were assessed by the change in the urinary excretion of [14C]bisnorbiotin and [14C]biotin sulfoxide in response to administration of [14C]biotin. No significant changes resulted from treatment with any of the anticonvulsants. With the steroid hormones and the peroxisome proliferators, [14C]bisnorbiotin excretion increased significantly. These results indicate that biotin is converted into bisnorbiotin in the liver and that this conversion likely occurs in peroxisomes or mitochondria or both via beta-oxidative cleavage, and, in contrast to responses in humans, the enzymes responsible for the formation of biotin sulfoxide in rats are not induced by the anticonvulsants examined here.

Concentrations of biotin metabolites in human milk.

Because estimates of the biotin requirement for infants currently are based on the biotin concentration in human milk, we sought to determine whether inactive biotin metabolites are present. Samples were collected for 7 weeks post partum from 15 healthy women. Biotin and the inactive metabolites bisnorbiotin and biotin sulfoxide were measured by means of a high-performance liquid chromatography avidin-binding assay. At 8 days post partum the proportion of biotin was 44%, bisnorbiotin 48%, and biotin sulfoxide 8%. Although biotin content increased post partum (p < 0.003), the metabolites remained an important portion of the total providing evidence that accurate measurement of biotin in human milk requires an assay that is specific for biotin.

Biotin status assessed longitudinally in pregnant women.

This study assessed biotin nutritional status longitudinally during pregnancy as judged by urinary excretion of biotin and biotin metabolites and by serum concentration of biotin. 3-Hydroxyisovaleric acid excretion was also assessed because increased excretion of that acid reflects decreased tissue activity of the biotin-dependent enzyme, methylcrotonyl-CoA carboxylase. Thirteen women provided untimed urine samples during both early and late pregnancy. Twelve nonpregnant women served as controls. Biotin and metabolites were determined by a combined HPLC/avidin-binding assay. 3-Hydroxyisovaleric acid was determined by gas chromatography/mass spectrophotometry. Significance of changes from early to late pregnancy was tested by paired t test; to compare nonpregnant controls with early and late pregnancy, ANOVA was used. During early pregnancy, biotin excretion was not significantly different than controls; however, 3-hydroxyisovaleric acid excretion was significantly increased relative to controls (P < 0.0001) and was greater than the upper limit of normal in 9 of 13 women. From early to late pregnancy, biotin excretion decreased in 10 of 13 women (P < 0.01); by late pregnancy, biotin excretion was less than normal in six women. During late pregnancy, 3-hydroxyisovaleric acid remained significantly increased relative to controls (P < 0.0001). Serum concentrations of biotin were significantly greater than those of controls during early pregnancy (P < 0.0001) and decreased in each woman from early to late pregnancy (P < 0.0001). These data provide evidence that biotin status decreases during pregnancy.

Increased urinary excretion of 3-hydroxyisovaleric acid and decreased urinary excretion of biotin are sensitive early indicators of decreased biotin status in experimental biotin deficiency.

To assess the utility of various indicators of biotin status, marginal biotin deficiency was induced experimentally in normal adults. Ten subjects consumed a diet that contained enough avidin to bind seven times more biotin than that in the diet. Blood and 24-h urine samples were collected before the diet began and twice weekly thereafter for 20 d. The urinary excretion and serum concentration of biotin and its two principal inactive metabolites bisnorbiotin and biotin sulfoxide were determined after HPLC separation with an avidin-binding assay. The urinary concentration of 3-hydroxyisovaleric acid, an indicator of reduced activity of a biotin-dependent enzyme, was quantitated by gas chromatography-mass spectrometry. The urinary excretion of 3-hydroxyisovaleric acid increased significantly (P < 0.0001). For all subjects, the urinary excretion of both biotin and bisnorbiotin decreased significantly (P < 0.0001 for each). In contrast, the mean serum concentration of biotin did not decrease significantly (P = 0.06). These data provide evidence that the urinary excretion of 3-hydroxyisovaleric acid and the urinary excretion of biotin are early and sensitive indicators of biotin deficiency and that the serum concentration of biotin is not.

Serum concentrations of bisnorbiotin and biotin sulfoxide increase during both acute and chronic biotin supplementation.

In addition to the pharmacokinetic interest, serum concentrations of biotin and biotin metabolites are important because biotin in serum might interfere with assays that use avidin-biotin detection systems. With acute and chronic oral administration of biotin the serum concentration of biotin increases. Because of limited specificity of bioassays or avidin-binding assays used in previous studies, the proportion of the increase attributable to biotin metabolites (if any) remains unknown. To address these questions 15 adults consumed 1,200 microg biotin daily for 14 days. Blood samples were obtained before biotin ingestion and at 3 hours after biotin ingestion on the first day ("acute supplementation") and the fourteenth day ("chronic supplementation"). Biotin, bisnorbiotin, and biotin sulfoxide were measured with a chemically specific high-pressure liquid chromatography/avidin-binding assay. Serum concentrations of biotin, bisnorbiotin, and biotin sulfoxide increased approximately fiftyfold with acute supplementation of biotin; each increased further with chronic supplementation. With acute supplementation the proportion of the total attributable to metabolites did not decrease significantly, suggesting that pathways for biotin catabolism are not easily saturated. With chronic supplementation the proportion of the total attributable to metabolites did not increase significantly, suggesting that biotin catabolism was not substantially induced. We conclude that on a mole basis the contribution of biotin metabolites is important, and we provide an estimate of the biotin and biotin metabolite concentration that might be encountered in individuals who self-select large biotin supplements.

The impact of primary health care services on under-five mortality in rural Niger.

BACKGROUND: Despite large investments in basic primary health care in sub-Saharan Africa over the past two decades, quantifying the contribution of national programme efforts to the reduction of infant/child mortality in the region has proven difficult. This study takes advantage of the phased implementation of the national Rural Health Improvement Program in Niger and conveniently timed survey data to reassess programme impact on under-five mortality during the 1980-1985 period. METHODS: Health service use and under-five mortality rates for children born in the 5 years prior to the 1985 survey are compared for three groups of villages: villages served by a dispensary, villages served by village health teams (VHT), and villages without access to modern primary care services. Multi-level regression analyses using both household- and community-level variables are undertaken in estimating the magnitude of effects. RESULTS: Children residing in villages proximate to health dispensaries were approximately 32% less likely to have died during the study period than children without access to modern health services. Village health teams were not, however, associated with significantly lower mortality probabilities. Formal test for endogeneity indicated that these effects were not the result of non-uniform/non-random allocation of resources. CONCLUSIONS: The findings are largely supportive of the key premise underlying selective primary health care interventions - that packages of basic services can be effectively mounted nationally in poor countries and have a significant impact over a short time period. In Niger, less than optimal implementation of VHT appears to have reduced the magnitude of the impact achieved.

PIP: The phased implementation of Niger's Rural Health Improvement Program, in conjunction with a 1985 Ministry of Health survey, facilitated quantification of the contribution of primary health care interventions to the reduction of infant and child mortality. During 1978-84, over 8000 health workers were trained and deployed to unserved villages; in addition, 45% of rural villages were provided with primary care services through dispensaries or village health teams. The 35 rural clusters covered in the survey were grouped into three categories: 1) villages located 5 km or less from a dispensary; 2) those located over 5 km from a dispensary, but with a village health team; and 3) villages located more than 5 km from a dispensary and with no health team. Mothers residing near a dispensary were two to five times more likely than their counterparts in the other two groups to have received prenatal care for the most recent birth, had the delivery attended by trained health personnel, received nutrition and health education, and know how to prepare oral rehydration solution. Children in the dispensary-proximate villages were three times more likely to have been at least partially immunized and to have a health card and twice as likely to have had their most recent diarrhea episode treated by a health worker. The unadjusted proportions of infants and children who died in the five years preceding the survey were 0.191 in villages served by a dispensary, 0.203 in villages served by a health team, and 0.267 in villages with neither resource. Multivariate analyses indicated that significantly lower mortality was associated with the presence of a dispensary, maternal literacy, and the existence in the community of farm machinery or access to seeds to plant the next crop. Overall, these findings confirm the significance of primary health care services, especially treatment of infantile diarrhea and tetanus, to reducing under-five mortality in sub-Saharan Africa.

Cultural response to mental illness in Senegal: reflections through patient companions--Part II. Statistical correlates.

Patient records from the Thiaroye Psychiatric Hospital in Senegal were studied to see if analysis of patterns of persons accompanying patients to the hospital could help to portray the community's response to mental illness. A systematic sample of 935 records of initial out-patients visits were examined. Patterns of patient companionship were found to strongly correlate with specific patient sociodemographic and clinical characteristics. Interpretation of these findings helped to clarify both prevailing attitudes toward the mentally ill and the social response and management of mental illness. The first article in this series presented the study setting, methods, sociodemographic and clinical characteristics of the patients, and characteristics of patient companions. The current article examines the statistical associations of companion number, gender and kinship relationship with patient sociodemographic and clinical characteristics.

Health and nutrition in children under 2 years of age in three areas of the Russian Federation.

The study objectives were to determine the nutritional status of children under 2 years of age in selected areas of the Russian Federation, to estimate the proportion of children potentially at risk for nutritional problems, and to characterize such a vulnerable group in terms of demographic variables. A cross-sectional sample of children under 2 years of age was used. Six areas-Moscow, St Petersburg, Ekaterinburg, and their surrounding oblasts-were sampled, and data were collected for approximately 800 children in each area between July and December 1993. A low prevalence of children with a weight-for-age Z-score below -2 was found, indicating that at the time of the survey protein-energy malnutrition was not a serious problem for this age group. However, other survey results indicating high morbidity, low immunization rates, the possibility of food insecurity, and poor infant-feeding practices imply that children's health could easily deteriorate. Therefore, food security and children's nutrition should be monitored to avoid serious consequences in the future. The results also show that there is ample scope for public health interventions that encourage more effective immunization coverage, emphasize prevention of childhood diseases, and promote proper infant-feeding practices.

PIP: Cross-sectional data were collected on approximately 800 children under age 2 years in Moscow, St. Petersburg, Ekaterinburg, and each of the cities' surrounding provinces during July-December 1993 in a study to determine young children's nutritional status, to estimate the proportion of children potentially at risk for nutritional problems, and to characterize such a vulnerable group in terms of demographic variables. The prevalence of protein-energy malnutrition, as indicated by low weight-for-age, was not elevated by comparison with international reference standards. The prevalence of malnutrition was low and relatively constant across the different age groups. However, the survey found high morbidity, low immunization rates, the possibility of food insecurity, and poor infant-feeding practices. In such a context, child health status could easily deteriorate. Food security and children's nutrition should be monitored to avoid serious adverse consequences in the future. There is also considerable scope for public health interventions which encourage more effective immunization coverage, emphasize the prevention of childhood diseases, and promote proper infant-feeding practices.

Biotin accounts for only half of the total avidin-binding substances in human serum.

In studies using an avidin-binding assay to measure the serum or plasma concentration of biotin, biotin is sometimes assumed to be equal to the avidin-binding substances detected. To provide a range of values for serum concentrations of biotin, bisnorbiotin, and biotin sulfoxide, HPLC was used to separate avidin-binding substances in human serum, and the chromatographic fractions were assayed for avidin-binding substances (biotin and biotin metabolites). In sera from 15 normal fasting adults, substantial concentrations of avidin-binding substances other than biotin were detected. Two of the principal substances were identified as bisnorbiotin and biotin sulfoxide based on their chromatographic properties. The serum concentrations of bisnorbiotin and biotin sulfoxide varied widely among the individuals. In three subjects, the concentration of bisnorbiotin exceeded that of biotin. The presence of avidin-binding substances in addition to biotin may have confounded previous measurements of the concentration of biotin in serum, plasma, and blood when avidin-binding assays were used. Because bioassay methods for biotin sometimes use organisms for which one or more of these biotin metabolites are growth factors, measurements of biotin in blood using some bioassays are likely to overestimate the concentrations of biotin.

Requirements for biotin are not affected by the combination of copper deficiency and fructose feeding.

OBJECTIVE: The objective of the present study was to establish whether copper (Cu)-deficient rats fed a diet containing fructose as their sole carbohydrate source require more biotin than the recommended 2 mg/kg diet when egg-white serves as the dietary protein. METHODS: Eighty weanling male Sprague-Dawley rats were randomly divided into 8 groups according to type of dietary carbohydrate (starch or fructose), level of Cu (0.6 micrograms Cu/g diet or 6.0 micrograms Cu/g diet) and level of biotin (2 mg/kg diet or 10 mg/kg diet). RESULTS: Regardless of the level of dietary biotin, Cu-deficient rats fed a fructose-containing diet exhibited growth retardation, anemia, atrophied pancreata, enlarged hearts and similar death rates. The remaining Cu-deficient rats fed fructose were emaciated and sick regardless of dietary biotin levels. The concentration of biotin in serum and biotin content of liver of rats fed fructose were higher than corresponding values from rats fed starch. CONCLUSION: Cu-deficient rats fed fructose are not deficient in biotin compared to published normal values. Supplementation of 10 mg/biotin/kg diet did not improve morbidity or mortality and therefore was not beneficial.

Prevalence and differentials of low birth weight in Niamey, Niger.

This study provides population representative data on live births occurring in Niamey, Niger during the period 1980 to 1985. A total of 5097 live births were systematically sampled from maternity registers over the study period. Due to legislation and incentives to register all live births, between 90 and 95 per cent of all live births are represented in this study. The data here suggest that low birth weight (LBW) prevalence may be lower in this urban area than it is in the region as a whole; and that the demographic risk factors are similar to those found in other developing countries. Finally, in many developing countries, maternity coverage of attended births may be quite high, suggesting that record or prospective studies examining trends in LBW and risk factors for perinatal outcomes might be convenient and implemented at very low cost.