From targeted "black spots" to area-wide pedestrian safety.

OBJECTIVE: To describe and illustrate the geographic distribution of pedestrian crash sites in an urban setting (Montreal, Canada) with an alternative data source. METHODS: Data on pedestrian victims were extracted for a 5-year period (1999-2003) from ambulance services information systems. The locations of crash sites and pedestrian victim density were mapped using a geographic information system. Pedestrian "black spots" were defined as sites where there had been at least eight pedestrian victims. RESULTS: The 22 identified black spots represent only 1% of all city intersections with at least one victim and 4% of all injured pedestrians, whereas 5082 victims were injured at >3500 different crash sites. The number and population rates of injured pedestrians are greater in central boroughs. Accordingly, the density of pedestrian victims is much higher in central boroughs. Over the 5-year period, in some central boroughs, pedestrian crashes occurred in up to 26% of intersections. CONCLUSIONS: Ambulance information systems were relevant to map pedestrian crash sites. Most pedestrians were injured at locations that would have been missed by the black spot approach. This high-risk preventive strategy cannot substantially reduce the total number of injured or the insecurity that many pedestrians experience when walking. Considering the large number and widespread occurrence of pedestrian crashes in Montreal, prevention strategies should include comprehensive environmental measures such as global reduction of traffic volume and speed.

Health trends among drug users attending needle exchange programmes in Switzerland (1994-2000).

As a part of an assessment of the Swiss drug harm-reduction policy, cross-sectional surveys were conducted in 1994, 1996 and 2000 among attenders of all needle exchange programmes (NEP) in Switzerland to assess changes in specific aspects of their health related to drug use. Data were gathered in each NEP over one week, using a questionnaire completed partly with an interviewer and partly self administered. The questionnaire covered socio-demographic characteristics, drug consumption, risk, prevention behaviour and state of health. Over a 6-year period (1994-2000), the average age of NEP attenders rose by 4 years. The prevalence of reported HIV remained fairly stable at around 10%. Reported level of Hepatitis C prevalence was high (59%). Incidence of used injection equipment sharing during the last 6 months was low and stable (9% in 1994, 12% in 2000); however, other forms of risk behaviour linked to intravenous drug use, such as sharing spoons, cotton or water, were more frequently reported. The HIV epidemic among NEP attenders seems to be contained, but this is not the case with Hepatitis C, and more attention should be paid to its prevention.

Acute lower respiratory infections among children hospitalized in Bangui, Central African Republic: toward a new case-management algorithm.

To measure the performance of the current WHO algorithm in identifying children at higher risk of death, children aged 2-59 months who presented with cough and/or difficult breathing and were admitted into the paediatric hospital of Bangui (Central African Republic) during a 1-year period (1996/97) were investigated. Among children with subcostal indrawing, mortality and severity of oxygen desaturation were identical whether or not they also had tachypnoea. Among children with a 'severe pneumonia', those who also fulfilled the 'very severe disease' definition had a higher risk of death (31/132, 23.5%) than those who did not (12/106, 11.3%, P = 0.02). However, this 'very severe disease' definition did not predict death when used in children who did not have severe pneumonia. To identify variables that would better predict death, combinations of symptoms and signs were examined among the subgroup of children with indrawing. Nine combinations had both a sensitivity and specificity over 60%. 'Grunting and/or nasal flaring' had a sensitivity of 72% and a specificity of 66% in predicting death, and might be easier to use by primary health care personnel than other combinations. A new algorithm is proposed for the management of children aged 2-59 months presenting with cough and/or difficult breathing. The definition of pneumonia would be unchanged (tachypnoea). Severe pneumonia would remain defined on indrawing regardless of respiratory rate, except that indrawing should be lower chest wall and/or intercostal. In health facilities where intravenous antibiotics, chloramphenicol and/or oxygen are available, entry into a 'very severe pneumonia' category would be based on 'grunting and/or nasal flaring' among children with indrawing. In our study population, the mortality rates in the categories based on these definitions were 0.8% (1/127) in children with no pneumonia, 0.9% (1/116) in children with pneumonia, 7.7% (12/156) in children with severe pneumonia and 31.1% (33/106) in children with very severe pneumonia.

Aetiology of urethral discharge in Bangui, Central African Republic.

OBJECTIVES: To determine the aetiology of urethritis in Bangui, Central African Republic. METHODS: 410 men presenting with urethral discharge and 100 asymptomatic controls were enrolled. Urethral swabs were obtained and processed by gonococcal culture and polymerase chain reaction for the detection of Neisseria gonorrhoeae, Chlamydia trachomatis, Mycoplasma genitalium, Trichomonas vaginalis, and Ureaplasma urealyticum. RESULTS: In multivariate analyses, M genitalium and C trachomatis were significantly associated with urethral discharge when comparing cases of non-gonococcal urethritis (NGU) with controls. T vaginalis was also more common in cases than in controls, but this reached statistical significance only among cases in whom N gonorrhoeae was also detected. U urealyticum was not associated with urethritis. The gonococcus was found in 69% of cases of urethral discharge. M genitalium was the predominant pathogen in patients with NGU, being found in 42% (53/127) of such patients while C trachomatis was found in only 17% (22/127). T vaginalis was found in 18% (23/127) of patients with NGU, but also in 15% (43/283) of patients with gonococcal urethritis, and two thirds of patients with T vaginalis also had the gonococcus. Multiple infections were common. M genitalium caused a syndrome similar to chlamydial urethritis, with a less severe inflammation than in gonococcal infection. No behavioural or clinical characteristic could discriminate between the various aetiological agents. CONCLUSIONS: M genitalium is more prevalent than C trachomatis and is the most common cause of NGU in BANGUI: It causes a syndrome similar to chlamydial urethritis. T vaginalis is weakly associated with urethritis, and is often found along with other pathogens.

Quality of sexually transmitted disease treatments in the formal and informal sectors of Bangui, Central African Republic.

BACKGROUND: Interventions for upgrading sexually transmitted disease (STD) management in sub-Saharan Africa have focused on the public sector, and to a much lower extent on private medical practitioners and pharmacies. However, in most African cities there is a large informal sector that provides care to many patients with STD symptoms. GOAL: To compare the quality of treatments offered to patients with major STD syndromes in the public sector, pharmacies, and the informal sector of the same city. STUDY DESIGN: Healthcare providers in health centers, pharmacies, private laboratories, and market drug peddlers in Bangui, Central African Republic, were asked to complete a short form for every patient consulting them with genital complaints. The treatments they ordered were evaluated for their potential efficacy against the major etiologic agents of the syndrome for which the patient consulted. RESULTS: The majority of male patients with STDs preferred to seek care in pharmacies and in the informal sector. The STD treatments offered to patients with urethral discharge or genital ulcers in pharmacies and in the informal sector tended to focus on a single etiologic agent. The quality of STD treatments offered by drug peddlers and private laboratories was poor, apart from adequate coverage of syphilis in patients with genital ulcers and of candidiasis in women with vaginal discharge. For instance, 41% and 34% of patients with urethral discharge managed by drug peddlers and private laboratories did not receive a drug active against either Neisseria gonorrhoeae or Chlamydia trachomatis, whereas this proportion was 22% in pharmacies and 14% in health centers. For patients with genital ulcers, the proportion offered a drug active against Haemophilus ducreyi was 2% if seen by drug peddlers, 0% in laboratories, 10% in pharmacies, and 25% in health centers. For each syndrome and each category of provider, between one fourth and two thirds of patients had already received another ineffective treatment elsewhere. CONCLUSION: National STD and HIV control programs will have to improve STD management in pharmacies and in the informal sector if they are to have any impact on the dynamics of HIV infection in urban centers.

Risk factors for mortality among children hospitalized because of acute respiratory infections in Bangui, Central African Republic.

BACKGROUND: Acute respiratory infections are the most common cause of death in children in developing countries. Little information is available on risk factors for mortality among African children presenting with symptoms compatible with acute respiratory infections. OBJECTIVE: To identify risk factors for death among children hospitalized for respiratory complaints who satisfy the WHO clinical definition for pneumonia or severe pneumonia. METHODS: Children <5 years of age who presented with cough and/or difficult breathing and were hospitalized in Bangui during a 1-year period were investigated for risk factors for mortality. The study population consisted of 395 children who satisfied the WHO clinical definition for pneumonia/severe pneumonia. The associations between death and demographic, nutritional, socioeconomic, laboratory and clinical variables were examined. RESULTS: Of the 49 (12.4%) children who died, all but one had had indrawing of the chest which, in univariate analysis, was the risk factor most strongly associated with death [odds ratio, 22.99; 95% confidence interval (CI), 3.81 to 935.2]. In a multivariate model the independent risk factors for death were indrawing of the chest [adjusted odds ratio (AOR) 8.35, CI 1.04 to 66.82], hepatomegaly (AOR 6.72, CI 2.35 to 19.21), age between 2 and 11 months (AOR 6.37, CI 2.18 to 18.59), grunting (AOR 4.53, CI 1.96 to 10.45), a moderate/severe alteration of general status (AOR 3.23, CI 1.17 to 8.94) and acute malnutrition (AOR 2.74, CI 0.96 to 7.78). CONCLUSIONS: These findings could be used in flow charts for the management of children with respiratory complaints to identify children at increased risk of death who need to receive aggressive therapy.