University of Zambia Medical Library


ZAMBIA HEALTH INFORMATION DIGEST

Volume 5 Number 2 April-June 1998

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THE UNIVERSITY OF ZAMBIA MEDICAL LIBRARY

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THE MINISTRY OF HEALTH, ZAMBIA
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[ZHID Table of Contents]

EDITORIAL BOARD:
Dr. J.C. L. Mwansa, Microbiologist: University Teaching Hospital
Dr. Andrew L.Mbewe, Consultant Paediatrician: Kitwe Central Hospital
Dr. Oliver Bowa, Surgical Anatomist: University of Zambia Surgery Department
Ms. Regina Shakakata, Health Information & Promotions Officer: World Health Organisation-Zambia
Dr. Katele Kalumba: Minister of Health, Zambia
Dr. Mannasseh Phiri, Chief Medical Officer: Company Clinic, Kitwe
Mrs. Norah Mumba, Medical Librarian (Ag): University of Zambia Medical Library

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The Zambia Health Information Digest is produced to provide current information to health workers who have little access to current health related publications and information.

SOURCE:
The abstracts of journal articles published in this quarterly Digest are obtained from the MEDLINE databases provided by the Dreyfus Health Foundation of New York. Abstracts are also selected from a database of Zambian health articles, which is continually being compiled at the UNZA Medical Library. Readers are encouraged to send in their work for inclusion in this Zambian health information database.
Computer equipment has been supplied through a grant from the IBM Corporation. Subjects that are prominently reflected on the Medical Library's MEDLINE search requests and information on prevalent health conditions seen in Zambia are published. Other health related subjects are also included.
The Health Sciences Centre Library of the University of Florida, our cooperating partners, will supply photocopies of the full text articles to the University Medical Library on request, which in turn will be supplied to readers on request. When available in the library, articles will be photocopied at a nominal cost.
Production costs are supported by The Dreyfus Health Foundation of New York. Full articles on unsafe abortion are provided by courtesy of Commonwealth Regional Health Community Secretariat for East, Central and Southern Africa (CRHCS), who have also contributed generously to the expansion of the Digest. We encourage readers to submit requests for articles highlighted in the Digest.

CUSTOM SEARCHES:
Using the MEDLINE compact disc databases, custom searches can be done on any health issue to obtain the most up-to-date information available. Readers are encouraged to submit requests for searches on relevant health problems which they face. Requests should be sent to the Medical Library, attention Norah Mumba.

TABLE OF CONTENTS:

EDITORIAL:

SCHISTOSOMIASIS : PUBLIC HEALTH IMPORTANCE

 Schistosomiasis is one of the most widespread of all human parasitic diseases, ranking second only to malaria in terms of its socioeconomic and public health importance in tropical and subtropical areas. It is also the most prevalent of the waterborne diseases and one of the greatest risks to health in rural areas of developing countries.

In 1996 schistosomiasis was reported to be endemic in 74 tropical countries and over 200 million people living in rural and agricultural areas were estimated to be infected. Between 500 and 600 million people were considered at risk of becoming infected.

As a mainly rural, often occupational disease, schistosomiasis principally affects people who are unable to avoid contact with water, either because of their profession(agriculture, fishing) or because of a lack of reliable source of safe water for drinking, washing and bathing. As a result of a low level of resistance and intensive water contact when playing and swimming, children aged between 10 and 15 years are the most heavily infected. Increased population movements help to spread the disease, and schistosomiasis is now occurring increasingly in peri urban areas.

Although most people in areas of endemicity have light infections with no symptoms, the effects of schistosomiasis on a country's health and economy are serious. In several areas(e.g., north-eastern Brazil, Egypt, Sudan) the working ability of the rural inhabitants is severely reduced as a result of the weakness and lethargy caused by the disease.

SCHISTOSOMIASIS (CURRENT ABSTRACTS OF JOURNAL ARTICLES -- MEDLINE)

Schistosomiasis in the Isoka District

The opinion has long been held that only by treating cases individually could diseases be controlled or eradicated. This view has been adopted from time immemorial and has failed miserably in, for instance, the control of schistosomiasis. This paper presents views of the head teachers on the prominence of schistosomiasis in the Isoka district, Zambia, as a step towards their involvement in a community mediated programme for the control of schistosomiasis. Information was sought on the importance of schistosomiasis in the district by means of two questionnaires, one distributed to head teachers, and the other to school children. Lack of clean water was considered to be the leading factor by 71 (82.6%) teachers. Generally, schistosomiasis was not considered to be a prominent disease in the district. Nevertheless, teachers from highly infected areas ranked schistosomiasis as a health problem higher than those teachers from schools with lower prevalences (P = 0.002). The implications of these results to implementing a district wide schistosomiasis control programme covering both infected and uninfected areas are discussed.
Siziya S. Mushanga M. Importance of schistosomiasis in the Isoka district of Zambia: a prerequisite for its control using community participation.
Social Science & Medicine. 42(3):431-5, 1996 Feb.

Questionnaire for identifying high risk communities

A comparative study was conducted in northern Zambia in order to compare both the economical and diagnostic performance of a questionnaire with that of the chemical reagent strip test in diagnosing urinary schistosomiasis with a view to replacing the more economically expensive reagent strip test with the questionnaire in the identification of high risk communities.

A total of 57 schools participated in the study and each school was considered as a community. Among the symptoms and conditions of blood in urine, pain when passing urine and bilharzia for urinary schistosomiasis, blood in the urine was the best predictor for urinary schistosomiasis with 73.9 pc (95 pc CI 56.0 to 91.9 pc) sensitivity, 82.4 pc (95 pc CI 69.5 to 95.2 pc) specificity and 78.9 pc (95 pc CI 68.4 to 89.5 pc) diagnostic efficiency in the identification of schools with high levels of infection. A diagnostic questionnaire for urinary schistosomiasis was two times cheaper than the reagent strip test in economical terms. The questionnaire approach in identifying high risk communities for urinary schistosomiasis is promising and should be tried in other endemic areas.
Siziya S. Mushanga M. Marufu T. Mudyarabikwa O. Diagnostic and cost comparisons of a questionnaire against a chemical reagent strip test in identifying high risk communities for Schistosoma haematobium infection in northern Zambia.
Central African Journal of Medicine. 42(2):40-2, 1996 Feb.

Urban schistosomiasis in Lusaka

A preliminary survey was conducted in Lusaka, Zambia to determine the extent of schistosomiasis transmission in the city. Stool and urine samples were collected from 240 children from seven schools selected to give a cross-sectional representation of the various socio-economic neighbourhoods of the city. In addition to the parasitological examination, students were questioned with respect to their knowledge of the disease and other epidemiological factors. In addition, water bodies near the schools were examined for the presence of snail hosts. Results of the survey suggest that schistosomiasis is actively transmitted within Greater Lusaka. An overall prevalence of 20.9% for S. haematobium was observed, but only one case of S. mansoni was detected. Prevalence rates for S. haematobium in individual schools ranged from 7.5 to 37.5%.
Mungomba LM. Michelson EH. Urban schistosomiasis in Lusaka, Zambia: a preliminary study.
Journal of Tropical Medicine & Hygiene. 98(3):199-203, 1995 Jun.

Schistosomiasis & use of indigenous plant molluscicides

In the last decade plant molluscicides have received considerable attention in the search for cheaper alternatives to chemotherapy and synthetic molluscicides in schistosomiasis control. The attraction of a locally grown molluscicidal plant is based on the development of a philosophy of self-reliance and community involvement. This approach is dependent on community recognition of the infection as a public health problem and their acceptance of proposed control measures. The objectives of this study were: (i) firstly, to assess the knowledge of schistosomiasis in a rural community and their attitude to the use of indigenous plant molluscicides; (ii) secondly, to assess the prevalence and intensity of infection in relation to its severity as perceived within the community.

Study sites were located at Mtwalume (KwaZulu-Natal, South Africa). Sixty-nine community members were interviewed during six focus-group interviews and two depth interviews. Urine and stool samples (354 and 306, respectively) from children and young adults (2-25 years old) were analysed for Helminth and Protozoal infections. Results indicate that despite a poor understanding of schistosomiasis, it is a primary health concern for those dependent on river-water for their water requirements. Concern for schistosomiasis is indeed matched by a prevalence of 75.14% for Schistosoma haematobium. Oral antischistosomal drugs are inaccessible primarily due to the cost of transport and secondarily, due to the cost of treatment. The concept of molluscicidal control, as an alternative, was enthusiastically received by all respondents.
Clark TE. Appleton CC. Kvalsvig JD. Schistosomiasis and the use of indigenous plant molluscicides: a rural South African perspective.
Acta Tropica. 66(2):93-107, 1997 Aug.

Cerebral schistosomiasis

After returning from Africa, a 54-year-old man began to have episodes of headache and nausea, then a cerebral convulsion. Clinical and laboratory findings and response to chemotherapy indicated the diagnosis of cerebral schistosomiasis. Three lesions were seen on CT and MR studies: two appeared to be subacute intracerebral hematomas, one in the right parietal lobe and one in the frontal lobe; the third lesion, in the cortex of the left occipital lobe, appeared to be a cyst. These lesions could represent small granulomatous tissue reactions with secondary hemorrhages.
Preidler KW. Riepl T. Szolar D. Ranner G. Cerebral schistosomiasis: MR and CT appearance.
Ajnr: American Journal of Neuroradiology. 17(8):1598-600, 1996 Sep.

A serosurvey of waterborne pathogens amongst canoeists

Certain health risks have been associated with recreational exposure to faecally polluted water. Canoeing in certain South African waters is considered to be a high risk activity with regard to schistosomiasis, gastroenteritis and possibly hepatitis. In a cross-sectional study, aserosurvey was conducted amongst canoeists to ascertain whether or not they had a higher seroprevalence to hepatitis A virus, Norwalk virus and Schistosoma spp. than non-canoeists.

In comparisons between the two groups, a significant association could not be demonstrated between canoeing and antibody response to hepatitis A and Norwalk viruses (P-values for age-adjusted chi 2 were 0.083 and 0.219 respectively), but a significant association could be demonstrated between canoeing and the antibody response to Schistosoma spp. (P < 0.001; age-adjusted).
Taylor MB. Becker PJ. Van Rensburg EJ. Harris BN. Bailey IW. Grabow WO. A serosurvey of water-borne pathogens amongst canoeists in South Africa.
Epidemiology & Infection. 115(2):299-307, 1995 Oct.

The case for a schistosomiasis vaccine

Cost-effectiveness analysis has been widely used in the health sector toguide decisions about where scarce resources aimed at disease prevention or control should be invested. It has rarely been used to guide decisions about what type of health research should be funded. In addition, the validity of the behavioural assumptions underlying the economic analysis is rarely considered explicitly.

This paper explores the use of cost-effectiveness analysis to set priorities for research using thedevelopment of a schistosomiasis vaccine as an example. It then explicitly considers behavioural factors which might affect the accuracy of the calculations. A 'product profile' for the new technology is derived which can be used by developers as a target to aim at. To ensure that the vaccine would be more cost-effective than the currently preferred option for the control of schistosomiasis, chemotherapy based on praziquantel, researchers need a vaccine which has sufficient duration of protection tobe delivered as part of the regular childhood immunization programme. The cost of adding it to existing vaccination schedules should not be more than US$4.30 per child in excess of the cost of one round of chemotherapy. It should, ideally, have an efficacy over 80%.

These results, however, depend on a number of cultural and behavioural factors which are often ignored in cost-effectiveness studies. For example, low rates of school attendance would increase the cost of contacting children for a chemotherapy programme and increase the relative attractiveness of a vaccine. For chemotherapy to be effective, children also need to comply each year for a number of years. Falling rates of compliance over time would reduce the effectiveness of chemotherapy and increase the attractiveness of a vaccine. But on the other hand, even though a vaccine may still be more cost-effective than chemotherapy at relatively low levels of vaccine efficacy, if mothers perceived the vaccine to be ineffective and refused to bring their children for vaccination, the success of the entire childhood immunization programme could be threatened.
Evans DB. Guyatt HL. Human behaviour, cost-effectiveness analysis and research and development priorities: the case of a schistosomiasis vaccine.
Tropical Medicine & International Health. 2(11):A47-54, 1997 Nov.

Potential long term consequences of vaccination programmes

Potential long term consequences of vaccination programmes Fields trials of new schistosomiasis vaccines are anticipated within the next few years, but there remains great uncertainty regarding the optimal design of vaccination programmes. Mathematical models are used here to explore the potential long-term consequences of vaccination, assuming that the vaccines provide partial protection for a limited period.

The analysis suggests that vaccines acting to reduce infection rates or egg output will have a similar impact on levels of infection, that this impact may be highly sensitive to the duration as well as the degree of protection, that it may take several decades for the full impact to become apparent, and that one consequence will be peak levels of infection occurring in older age classes. In terms of lowering levels of infection there may be advantages in delaying vaccination until children reach school age, especially if the vaccine gives short-lived protection, or to repeat vaccination. The short-term advantages can be greatly increased by combining the introduction of a vaccination programme with initial mass chemotherapy. Continuous combined vaccination and chemotherapy programmes may also be more effective than either intervention alone. More research is needed on the consequences of vaccinating previously vaccinated, infected, and infected and treated individuals and the importance of natural boosting of vaccine-induced immunity.
Chan MS. Woolhouse ME. Bundy DA. Human schistosomiasis: potential long-term consequences of vaccination programmes.
Vaccine. 15(14):1545-50, 1997 Oct.

Schistosomiasis & social conditions in Egypt

A probability sample (n = 2000) of primary and preparatory school children (6-15 years old) in a rural area, in the eastern part of Nile Delta, Egypt, were examined for S. haematobium eggs using the sedimentation technique. A sub-sample, consisting of all children whose urine samples were positive, was subjected to short interview and urine examination for egg counting using the modern monofilament polyamide (Nytrel) filters.

The overall prevalence of S. haematobium was 5.5% with significant (P < 0.05) Difference between males (7.9%) and females (3.1%). The sample mean egg count was 163 eggs/10 ml urine, while those of males and females were 625 and 52, respectively (P < 0.001). The age category 9-12 years old had the highest prevalence rate and mean egg count. Also, these patients had highest frequency distributions in the severe grade of infection intensity. Significant relationships were detected between fathers' occupation and mothers' education on one hand and mean egg counts and intensity grade of infection on the other hand.
Farag MK. Handoussa AE. el-shazly AM. Salama MM. Morsy TA. Prevalence and intensity of schistosomiasis haematobium among school children in respect of family social conditions in a village in Dakahlia Governorate, Egypt.
Journal of the Egyptian Society of Parasitology. 27(1):101-11, 1997 Apr.

Parasitic infections in Pemba Island school children

Intestinal helminths, schistosomiasis and malaria have been recognised for decades to be major public health problems in Zanzibar, Tanzania. During the evaluation of the impact of the Zanzibar Helminth Control Programme, baseline parasitological data on 3,605 school children were collected in Pemba Island.

Prevalence of intestinal helminth infections was 72%, 94% and 96% for Ascaris lumbricoides, Trichuris trichiura and hookworm, respectively. Thirty one percent of children tested positive for haematuria, a reliable indicator of urinary schistosomiasis in the study area. Malaria parasites were found in 61% of children. Hookworm infections and haematuria were more prevalent in boys. Sixty seven percent of the children were infected with all the three helminths, and 28% harboured double infection.

No association was found between intestinal helminths and schistosomiasis or malaria. Children living in rural areas were more heavily infected with hookworms, schistosomiasis and malaria compared to children in towns. Results from this study provided relevant information for designing a "plan of action" for the integrated control of filariasis, intestinal helminths, malaria and schistosomiasis in Zanzibar.
Albonico M. Chwaya HM. Montresor A. Stolfzfus RJ. Tielsch JM. Alawi KS. Savioli L. Parasitic infections in Pemba Island school children.
East African Medical Journal. 74(5):294-8, 1997 May.

Control of urinary schistosomiasis in schools

A school- and chemotherapy-based urinary schistosomiasis and intestinal helminth infection control programme was conducted in Matuga Division, Kwale District, Coast Province with teachers taking care of diagnosis, treatment and health education. More than 12,000 children in 36 primary schools were included in the 2-year programme.

Results for 20 evaluation schools are presented. Children with haematuria were treated with praziquantel (40 mg/kg) once a year. Within 2 years, the prevalence of haematuria in the schools was reduced from 28% (range 8-68%) to 11.4% (range 3-23%). More than 80% of the schoolchildren were infected with one or more intestinal helminths at baseline.

After one year with levamisole mass chemotherapy, single dose (2.5 mg/kg) three times a year (once per school term), the prevalence of Ascaris infection was reduced by 83% from 18% to 3%, but there was no change in pretreatment prevalences of hookworm (57%) and Trichuris (56%) infections. In the second year of the programme, albendazole 600 mg once every six months was administered to the children in 10 randomly selected schools. This resulted in 52% and 23% reductions in prevalences of hookworm and Trichuris infections, respectively, in these schools and a reduction in mean intensity of infection of 52.8% and 50.3%, respectively.
Magnussen P. Muchiri E. Mungai P. Ndzovu M. Ouma J. Tosha S. A school-based approach to the control of urinary schistosomiasis and intestinal helminth infections in children in Matuga, Kenya: impact of a two-year chemotherapy programme on prevalence and intensity of infections.
Tropical Medicine & International Health. 2(9):825-31, 1997 Sep.

Schistosomiasis in relation to the ABO blood groups

The study aimed to establish if there was any relationship between the blood group of the human host and schistosomiasis prevalence, intensity, incidence and related organ pathology. Urine and stool specimens were collected from the 735 school children attending a rural school in Zimbabwe to determine the Schistosoma haematobium and S. mansoni infection status of the children. The parasitology results were used to calculate prevalence and intensity of schistosomiasis infection. All the children, irrespective of infection status, were examined for signs of organ damage using ultrasonography before those that were infected were treated using a single dose of praziquantel. A blood specimen was taken from each child for blood group determination.

Exactly 1 year later, parasitology was repeated to allow calculation of annual incidence of schistosomiasis infection. Of the children studied, 212 (28.8%) were of blood group 'A', 156 (21.2%) were of blood group 'B' while 367 (49.9%) belonged to blood group 'O'. The prevalence of S. haematobium was 59.6% (n = 438) while that of S. mansoni was 15.60% (n = 115). S. haematobium infection was detected among 129 (60.8%) children belonging to blood group 'A': 225 (61.30%) of blood group 'O' and 84 (53. 80%) of those belonging to blood group 'B'. S. mansoni infection was detected among 65 (30.70%) blood group 'A' children while 37 (10.10%) blood group 'O' and 13 (8.30%) blood group 'B' children were infected. Intensity, annual incidence of S. haematobium infection and related organ pathology was significantly higher among children of blood group 'A' and lowest among blood group 'O' children (P < 0.01, F-value = 6.13). Similarly, S. Mansoni intensity and incidence of infection and related liver lesions were highest among children of blood group 'A' (P <0.005, F-value = 11.45).
Ndamba J. Gomo E. Nyazema N. Makaza N. Kaondera KC. Schistosomiasis infection in relation to the ABO blood groups among school children in Zimbabwe.
Acta Tropica. 65(3):181-90, 1997 May 30.

Female genital schistosomiasis

A total of 51 women with urinary schistosomiasis haematobium were examined in order to identify diagnostic indicators for female genital schistosomiasis (FGS). Patients were selected at random from the outpatient department of the Mangochi District Hospital, Malawi. The medical histories were recorded according to a pre-designed questionnaire and the women were subjected to a thorough gynaecological examination including colposcopy and photographic documentation of lesions.

Microscopy of genital biopsies revealed that 33 of the 51 women had S. haematobium ova in cervix, vagina and/or vulva in addition to the presence of ova in urine. The most sensitive diagnostic procedure was beside microscopic examination of a wet cervix biopsy crushed between two glass slides, which revealed 25 of the 33 genital infections. There was a significant correlation between the size of genital lesions and the number of ova counted per mm2 of crushed tissue. Women with FGS had significantly more tumours in the vulva than women with schistosomiasis limited to the urinary tract. Most of the observed genital pathology could easily be identified by the naked eye, but colposcopic examination yielded valuable additional information like the demonstration of neovascularisation around cervical sandy patches.

Few of the symptoms previously regarded as indicators for FGS could be linked to the presence of schistosome ova in genital tissue. Husbands of infertile women with FGS had children with other women significantly more often than husbands of women who only had urinary schistosomiasis. This, together with the finding that the majority of the divorced women had FGS, indicates that the manifestation of this disease may have implications for the marital and sexual life of the affected women.
Kjetland EF. Poggensee G. Helling-Giese G. Richter J. Sjaastad A. Chitsulo L. Kumwenda N. Gundersen SG. Krantz I. Feldmeier H. Female genital schistosomiasis due to Schistosoma haematobium. Clinical and parasitological findings in women in rural Malawi.
Acta Tropica. 62(4):239-55, 1996 Dec 30.

Schistosomiasis control in schools

There has been a recent revival of interest in school-based health programmes in developing countries as a means of reducing the morbidity observed in school-aged children, of improving their physical growth and cognitive development, and of controlling transmission of disease in the community at large. This study used data collected from a large epidemiological survey of schistosomiasis in Egypt to examine what proportion of infected children missed treatment from an established national school-based schistosomiasis control programme simply because they did not attend school.

It showed that children who were not enrolled in school had a higher prevalence of infection and were more intensely infected than children who attended school. At the extreme, over 80% of infected girls in one part of Egypt could not be treated by the existing school programme because they did not attend school. If these trends are similar in other countries where school-based programmes are being developed, school-based delivery may exacerbate existing inequalities in society and ways of expanding services to children who do not attend school regularly need to be explored.
Husein MH. Talaat M. El-Sayed MK. El-Badawi A. Evans DB. Who misses out with school-based health programmes? a study of schistosomiasis control in Egypt.
Transactions of the Royal Society of Tropical Medicine & Hygiene. 90(4):362-65, 1996 Jul-Aug.

Human behaviour & schistosomiasis transmission

A study of the social, environmental and parasitological factors involved in the transmission of schistosomiasis among 1834 residents of a small settlement within an agricultural establishment near Yola, Nigeria, was carried out between June 1991 and May 1992.

Water-contact rates and the prevalences of urinary schistosomiasis and intestinal schistosomiasis (40.0% of all contacts, 98% and 79%, respectively) were highest among children of 5-12 years, who were also the major contributors to the contamination of the Lake Geriyo environment with faeces and urine. The frequency and duration of water contact followed a seasonal pattern and seemed to be influenced by physiological and social needs such as defecation, urination and avoidance of harsh weather conditions. The interplay between a need for water contact, sanitation, freshwater snails and a supportive environment ensures a recycling of parasites within the studied community. This, in turn, helps to maintain a parasite bank from which infection is probably spread to other areas of the state. The present study is part of a series, on the dynamics of schistosomiasis transmission, which began with a study of the ecology of the freshwater snails in the same area.
Akogun OB. Akogun MK. Human behaviour, water usage and schistosomiasis transmission in a small settlement near Yola, Nigeria.
Annals of Tropical Medicine & Parasitology. 90(3):303-11, 1996 Jun.

Indicators of infection


Friis H. Ndhlovu P. Kaondera K. Sandstrom B. Michaelsen KF. Vennervald BJ. Christensen NO. Serum concentration of micronutrients in relation to schistosomiasis and indicators of infection: a cross-sectional study among rural Zimbabwean schoolchildren.
European Journal of Clinical Nutrition. 50(6):386-91, 1996 Jun.

Schistosomiasis & gender diffrences in growth of schoolchildren

Light or moderate intensity infection with Schistosoma mansoni may contribute to growth deficits. We report on the effects of treatment for S. mansoni on growth and development in Brazilian schoolchildren.

Anthropometric measurements were taken from 539 S. mansoni-infected children and their age- and sex-matched egg-negative controls between the ages of 7 and 15 years. The children as a whole exhibited chronic malnutrition, with growth retardation in height evident in 21% of the population. Infected children, however, were significantly smaller in height, weight, mid upper arm circumference (UAC), tricep skinfold (TSF), and subscapular skinfold (SSF) measurements than control children (P <0.05).

These differences were due primarily to a greater disparity between infected and egg-negative girls in height (P < 0.01), weight (P = 0.01), UAC (P = 0.O2), and TSF (P < 0.01). Nevertheless, girls demonstrated a better level of development and nutrition compared with boys. While infected boys were shorter and weighed less than controls, these differences were not significant. Growth and development in girls was negatively correlated with intensity of infection. Coinfection with S. mansoni and Trichuris appeared to act synergistically in the development of malnutrition.
Parraga IM. Assis AM. Prado MS. Barreto ML. Reis MG. King CH. Blanton RE. Gender differences in growth of school-aged children with schistosomiasis and geohelminth infection. American Journal of Tropical Medicine & Hygiene. 55(2):150-6, 1996 Aug.

Control of urinary schistosomiasis

A preliminary investigation was conducted into factors that may bring about control of morbidity due to endemic urinary schistosomiasis in rural communities. A Knowledge, Attitudes, Practices and Beliefs (KAPB) study was conducted among primary schoolchildren (those with more than four years elementary education) in Ogbagba village, Osun State, Nigeria, from October 1990 to December 1993, to ascertain their understanding of urinary schistosomiasis. The study further assessed the potential of subjective haematuria, i.e. asking children with haematuria in the recent past to so indicate, in detecting urinary schistosomiasis. It was established that subjective haematuria is both sensitive and specific for detecting urinary schistosomiasis in endemic communities. The study also established that subjective haematuria offers a valid, easy to recognize target for morbidity control in endemic situation. It is proposed that with appropriate health education; availability of safe, effective, easy-to-administer drugs, such as praziquantel, morbidity control of urinary schistosomiasis is feasible within the primary health care system with the lower cadre health worker or even a volunteer village health worker (VVHW) at the centre of the control effort.
Onayade AA. Abayomi IO. Fabiyi AK. Urinary schistosomiasis: options for control within endemic rural communities: a case study in south-west Nigeria. Public Health. 110(4):221-7, 1996 Jul.

Control of transmission

Despite the success of control programmes, schistosomiasis is still a serious public health problem in the world. More than 70 countries where 200 million individuals are evaluated to be infected of a total 600 million at risk. Though there have been important local success in the control of transmission, globally the infection has increased. Economic constrains in developing countries, environmental changes associated with migration and water resources development have been blocking the progress. The main objective of schistosomiasis control is to achieve reduction of disease due to schistosomiasis. We discussed the control measures like: health education, diagnosis and chemotherapy, safe water supplies, sanitation and snail control. We emphasized the need to give priority to school-age children and the importance of integrating the measures of control into locally available systems of health care. The control of schistosomiasis is directly related to the capacity of the preventive health services of an endemic country. The strategy of control requires long-term commitment from the international to the local level.
Dias LC. Marcal Junior. Glasser CM. Control of schistosomiasis transmission.
Memorias do Instituto Oswaldo Cruz. 90(2):285-8, 1995 Mar-Apr.

FACT-ESTABLISHING SCHISTOSOMIASIS SURVEY FOLLOWING A REPORTED OUTBREAK IN KAFUE AND MAGOYE BY A LABORATORY TEAM FROM UTH, UNZA, NCSR.

 Objectives:
Material and Methods:
Three schools in the Kafue area were established as centres for the parasitological survey, these were Lishilo basic school, Kapongo primary school and Muchuto Primary schools. Urine specimens were collected from these centres and taken to the laboratory in Kafue fro processing. The syringe filtration technique(quantitative) and sedimentation (qualitative ) were used fro processing urine. For stool specimens are Kato/Katz technique (qualitative) and formal-ether method (qualitative) were used.

The qualitative methods were used on sub-samples because of limited supplies of the consumables required. Excretion of blood and protein in urine was investigated as the specific urinary schistosomiasis they related morbidity. Urinanalysis for the two parameters was therefore done using multistix.

The parasitological record form also included questions to the subjects investigating whether they excreted blood, their knowledge of bilharzia and sites they used for water contact activities. Basic demographic information was also collected on the same forms.

Results: Kafue area

LABORATORY TEAM FROM UTH, UNZA, NCSR:
Dr. L.M. Mungomba PhD - Parasitologist UNZA
Dr. J.C.L. Mwansa PhD - Microbiologist U.T.H.
Dr. Shehata PhD - NCSR Kitwe
Mr. Darlingtone Mwenya - Snr. Technologist U.T.H.
Mr. Sandie Sianomgo - Snr Technologist U.T.H.
Mr. Malon Banda - Snr Technologist UNZA

SCHISTOSOMIASIS: PUBLIC HEALTH IMPORTANCE

Schistosomiasis is one of the most widespread of all human parasitic diseases, ranking second only to malaria in terms of its socioeconomic and public health importance in tropical and subtropical areas. It is also the most prevalent of the waterborne diseases and one of the greatest risks to health in rural areas of developing countries.

In 1996 schistosomiasis was reported to be endemic in 74 tropical countries and over 200 million people living in rural and agricultural areas were estimated to be infected. Between 500 and 600 million people were considered at risk of becoming infected.

As a mainly rural, often occupational disease, schistosomiasis principally affects people who are unable to avoid contact with water, either because of their profession(agriculture, fishing) or because of a lack of reliable source of safe water for drinking, washing and bathing. As a result of a low level of resistance and intensive water contact when playing and swimming, children aged between 10 and 15 years are the most heavily infected. Increased population movements help to spread the disease, and schistosomiasis is now occurring increasingly in peri urban areas.

Although most people in areas of endemicity have light infections with no symptoms, the effects of schistosomiasis on a country's health and economy are serious. In several areas(e.g., north-eastern Brazil, Egypt, Sudan) the working ability of the rural inhabitants is severely reduced as a result of the weakness and lethargy caused by the disease.

Major forms and distribution of schistosomes:
Five species of the trematode parasite are responsible for the major forms of human schistosomiasis. In 1996 intestinal schistosomiasis caused by Schistosoma mansoni was reported from 52 countries in Africa, the eastern Mediterranean, the Caribbean and South America. Oriental or Asiatic intestinal schistosomiasis, caused by S. Japonicum or S. Mekongi, was reported to be endemic in seven Asian countries. Another from of intestinal schistosomiasis caused by S. Intercalatum was reported from 10 central African countries. Urinary(or vesical) schistosomiasis, caused by S. Haematobium, was reported to be endemic in 54 countries in Africa and the eastern Mediterranean.

Life cycle and transmission:
On reaching water, the eggs excreted by an infected person hatch to release a tiny parasite( a miracidium) that swims actively through the water by means of the fine hairs(cilia) covering its body. The miracidium survives for about 8-12 hours, during which time it must find and penetrate the soft body of a suitable freshwater snail in order to develop further(figs 8.5 and 8.6)

Once inside the snail, the miracidium reproduces many times asexually until thousands of new forms(cercariae) break out of the snail into the water. Depending on the species of snail and parasite, and on environmental conditions, this phase of development may take 3 weeks in hot areas, and 4-7 weeks or longer elsewhere. The fork-tailed cercariae can live for up to 48 hours outside the snail. Within that time they must penetrate the skin of a human being in order to continue their life cycle.

As the cercaria penetrate the skin, it loses its tail. Within 48 hours it penetrates the skin completely to reach the blood vessels. This process sometimes causes itching, but most people do not notice it.

Within seven weeks the young parasite mature into an adult male or female worm. Eggs are produced only by mated females. Male and female adult worms remains joined together for life, a period of less than five years on a average but 20 years has been recorded. The more slender female is held permanently in a groove in the front of the male's body. Once eggs are produced, the cycle started again.

In intestinal schistosomiasis the worms attach themselves to the blood vessels that line the intestines; in urinary schistosomiasis, they live in the blood vessels of the bladder. Only about half of the eggs leave the body in the faeces (intestinal schistosomiasis ) or urine (urinary schistosomiasis ); the rest remain embedded in the body where they cause damage to organs.

Clinical signs and symptoms:
Reactions occur to schistosome eggs that are not passed out in the urine or stools but become lodged in body tissues. The symptoms are related to the number and location of the eggs.

In urinary schistosomiasis (caused by S.haematobium) the eggs cause damage to the urinary tract and blood appears in the urine. Enlargement of the liver and spleen may occur in people with untreated intestinal schistosomiasis. Urination becomes painful and there is progressive damage to the bladder, ureters and kidneys. Bladder cancer is common in advanced cases.

Intestinal schistosomiasis (caused by S. Mansoni, S. Japonicum and S. Mekongi) develops more slowly. There is progressive enlargement of the liver and spleen(fig 8.7) as well as damage to the intestine, cause by fibrotic lesions around the schistosome eggs lodged in these tissues and hypertension of the abdominal blood vessels. Repeated bleeding from these vessels leads to blood in the stools and can be fatal. S. Intercalatum infects the lower intestinal tract.

Swimmer's itch:
Human skin can be penetrated by cercariae that normally develop in bird. The larvae die in the skin causing a allergic reaction known as swimmer's itch. This problem is seen in many temperate areas, in people who bathe in fresh, brackish and salt water, where infected aquatic birds shed faeces in water populated by appropriate snail hosts.

Diagnosis:
Modern techniques for detecting schistosome eggs the microscope are simple and inexpensive. A simple syringe filtration technique (using filter paper, polycarbonate or nylon filters) is recommended for quantitative diagnosis of urinary schistosomiasis. This technique allows urinary egg counts to be performed on up to 130 samples per hour.

Researchers using this technique on children in Ghana, Kenya, Liberia, Niger, the United Republic of Tanzania and Zambia reported that children with more than 50 S. haematobuim eggs per 10ml of urine often have blood in their urine (haematuria). This sign is evidence of bladder disease caused by urinary schistosomiasis, and can be used by primary health care workers to identify children needing treatment. Urine sedimentation is also a simple and effective method for detecting Schistosome eggs.

The diagnosis of intestinal schistosomiasis by counting the eggs in fetal specimen has also been simplified. A small amount of faeces, pressed through a fine nylon or steel screen to remove large debris, and placed under a peace of cellophane soaked in glycerol (Karo technique) or between glass slides (glass sandwich technique) can be quickly examined by trained microscopists.

Treatment:
All people are susceptible to infection. Children have a higher rate of reinfection after treatment than adult. Immunization is of great research interest but the probability of success is remote.

Three safe, effective drugs that can be taken orally are now available to treat schistosomiasis. Praziquantel, oxamniquine and metrifonate are all included in the WHO Model List of Essential Drugs (1). Praziquantel is effective in a single dose against all forms of schistosomiasis. Previously irreversible damage caused by Schistosoma infections can now be successfully treated with praziquantel.

Oxamniquine is used exclusively to treat intestinal schistosomiasis in Africa and South America, although S. Mansoni is less susceptible to oxamniquine in Africa than in South America. Metrifonate, which was originally developed as an insecticide, has now proved to be safe and effective for the treatment of urinary schistosomiasis.

Fear of many doctors that reinfection would quickly eliminate any benefit from treatment have proved too pessimistic. Rapid identification and prompt treatment of infected people immediately reduce in the number of cases is maintained for a year and a half without further intervention, but in areas of continuing transmission certain age group (schoolchildren) may be reinfected within 4-6 months. Even if reinfection occurs morbidity may be reduced for a much longer time, because it usually results from prolonged infection with large numbers of parasites.

Prevention and control:
Individual protection from infection e.g. in travellers) can in principle be achieved by avoiding contact with unsafe water. However this requires an understanding of the risk of contact with water and a knowledge of the sites where infected snails are likely to occur. For people living in areas of endemicity, contact is often unavoidable (farmer in irrigated agricultural areas, fishermen) or difficult to prevent (playing children).

Control of the disease in known foci of transmission is possible by using one or a combination of the following measures: improved detection and treatment of sick people; improvement of sanitary facilities for safe and acceptable disposal of human excreta; provision of safe drinking-water; reduction of contact with contaminated water; and snail control.

In areas with low to medium prevalence of schistosomiasis and good health services, improved case detection and treatment of report cases of illness may be the most cost-effective approach to control. In areas where the disease is highly endemic, special schistosomiasis control campaigns, involving snail control measures, might be an additional cost-effective solution (2) . Long-term sustainable improvements have to be based on safe water supply and improvements in sanitation and hygiene. Health education is essential for community understanding and participation in the proper used and continuous maintenance of sanitary and water supply facilities.

Schistosomiasis control in water resources development projects The increasing numbers of water resources projects, essential fro industrial and agricultural expansion in development countries are a matter of great concern to schistosomiasis experts. Water impoundments of all sizes, including man-made and irrigation systems, provide excellent habitats for freshwater snails and encourage close and frequent contact between people and infected water.

Schistosomiasis and other waterborne disease, whether introduced or spread by water development projects, can have a severe impact in economic terms (Loss of labour, cost of treatment) and as regards the quality of life, and can delay the completion of projects if construction workers or the local population becomes infected. However, it is now possible to institute control measures from the moment such a project is planned. Examination and treatment of the population in the project area, of all employees of the development project and their families, and of potential migrant populations reduce the risk of schistosomiasis becoming a major public health problem. Good water management practices, where necessary supplemented by regular applications of molluscicide, may limit the distribution of snails. The lower the potential for transmission from the start, the smaller is the chance that serious disease will develop.

From: Vector control: methods for use by individuals and communities. Geneva: WHO, 1997

QUOTES & MISCELLANEA

DONNY'S MEDICAL TERMS H : M

HangnailCoat hook
High ColonicJewish religious holiday
ImpotentDistinguised; well known
Labour PainGetting Hurt at Work
Medical StaffDoctor's cane
MorbidHigher offer

An engineer dies and reports to the pearly gates. St. Peter checks his dossier and says, "Ah, you're an engineer -- you're in the wrong place." So the engineer reports to the gates of hell and is let in. Pretty soon, the engineer gets dissatisfied with the level of comfort in hell, and starts designing and building improvements. After a while, they've got air conditioning and flush toilets and escalators, and the engineer is a pretty popular guy.

One day God calls Satan up on the telephone and says with a sneer, "So, how's it going down there in hell?" Satan replies, "Hey, things are going great. We've got air conditioning and flush toilets and escalators, and there's no telling what this engineer is going to come up with next."

God replies, "What??? You've got an engineer? That's a mistake -- he should never have gotten down there; send him up here." Satan says, "No way. I like having an engineer on the staff, and I'm keeping him." God replies "Send him back up here or I'll sue." Satan laughs uproariously and answers, "Yeah, right, sue me. And just where are YOU going to get a lawyer from?"

An old man and woman were married for years even though they hated each other. When they had a confrontation, screams and yelling could be heard deep into the night. A constant statement was heard by the neighbors who feared the man the most. "When I die I will dig my way up and out of the grave to come back and haunt you for the rest of your life!"

They believed he practiced black magic and was responsible for missing cats and dogs, and strange sounds at all hours. He was feared and enjoyed the respect it garnished. He died abruptly under strange circumstances and the funeral had a closed casket. After the burial, the wife went straight to the local bar and began to party as if there was no tomorrow.

The gaiety of her actions were becoming extreme while her neighbors approached in a group to ask these questions: Are you not afraid? Concerned? Worried? that this man who practiced black magic and stated when he died he would dig his way up and out of the grave to come back and haunt you for the rest of your life?
The wife put down her drink and said..."let the old bastard dig. I had him buried upside down."

There was once a Scotsman and an Englishman who lived next door to each other. The Scotsman owned a hen and each morning would look in his garden and pick up one of his hen's eggs for breakfast.

One day he looked into his garden and saw that the hen had laid an egg in the Englishman's garden. He was about to go next door when he saw the Englishman pick up the egg. The Scotsman ran up to the Englishman and told him that the egg belonged to him because he owned the hen. The Englishman disagreed because the egg was laid on his property. They argued for a while until finally the Scotsman said, "In my family we normally solve disputes by the following actions: I kick you in the balls and time how long it takes you to get back up, then you kick me in the balls and time how long it takes for me to get up, whoever of us gets up quicker wins the egg."

The Englishman agreed to this and so the Scotsman found his heaviest pair of boots and put them on, he took a few steps back, then ran toward the Englishman and kicked as hard as he could in the balls. The Englishman fell to the floor clutching his nuts howling in agony for 30 minutes.

Eventually the Englishman stood up and said, "Now it's my turn to kick you. "The Scotsman said, "Keep the damn egg man."

BRUNDTLAND: NEW DIRECTOR GENERAL FOR WHO

Dr. Gro Harlem Brundtland: Director General, The World Health Organization
Speech to the 51st World Health Assembly Geneva, 13 May 1998 (Excerpt)

 Mr President,
This is a special moment of responsibility. You have given me confidence and I feel responsible towards all of you and to the peoples that you represent. Since I made my basic choices in life I have thought of myself a doctor who wanted to heal and who wanted to change. Not least to change the causes of suffering and injustice.

I believed that societies can be changed and that poverty can be fought. That people working together can achieve impressive results. This I still think and know. We can harness the resources. We can mobilize the will. We can inspire the extra effort. I feel that I can ask for, and that the peoples of the United Nations have the right to count on your support and active participation in the future work of the World Health Organization. That support will be needed. There is hard work ahead.

I may ask for more than you have been used to being asked. You represent the owners of WHO, the shareholders and the stakeholders, all those who need us to succeed. We need political guidelines from this Assembly. We depend on how members states follow up at home. We depend on how they live up to the imperative of equity and social justice, expressed in health for all.

The challenge goes to all of us. WHO can and must change. It must become more effective, more accountable, more transparent and more receptive to a changing world. Member states must take responsibility for the targets they set and provide resources. They must practice what they preach from this rostrum. I believe we can forge stronger relations with member states. Keeping you better informed of how WHO develops, seeking your advice and when needed asking you for an extra contribution.

Without a sense of partnership between the organization and its owners, our work will prove exceedingly difficult. With a unity of purpose we can unleash real momentum for health. That momentum will be needed as we approach a new century where WHO must cope with complex processes of transition.. The transition from one century to another sees changes which will be faster and more dramatic from an economic, social and health perspective.

The 20th century gave the world more health advances than in the entire previous history of mankind. Still we are faced with daunting challenges. Above all they are linked to the persistence of poverty. The imbalances are striking. People in developing countries carry over 90 per cent of the disease burden, yet have access to only 10 per cent of the resources used for health. This is unacceptable. This has to change.

Wealthier countries will benefit by contributing and they have the moral obligation. Governments in poorer countries must acknowledge their responsibility, they have a moral obligation to give priority to health and to equitable distribution of health services.

We have another transition, the transition from the communicable to the non-communicable diseases. They can not be seen as competing tasks. They are complementary. We need to fight both. The burden of disease is the burden of unfulfilled human development.

I hear some say that infectious disease is becoming yesterday's problem. But is that correct? I don't believe so. There is an unfinished agenda of eradication and rolling back diseases. No one should underestimate childhood infections, HIV/AIDS, TB, malaria, polio and the other new and emerging diseases. They may hit us all in this small world - but above all they keep ravaging the lives of the poor.

WHO must be an enduring advocate in the fight against infectious diseases. And WHO must help governments face the daunting challenge from the new epidemic of non-communicable diseases, now spreading in the low- and middle-income countries. We need to anchor health in a broad setting. Globalization is opening up new opportunities for growth and progress. But the benefits are not adequately distributed. Globalization has also brought new and critical threats to health and the environment.

We have to reach out to new arenas critical for the health of billions. The next century may well be one of great environmental crises. But it need not be. We still have the opportunity to make timely decisions before we have to pay the bills of overburdening the capacity of the planet, its resources and most importantly - the health of its people.

World trade, environmental changes, lifestyles and culture; in all these fields we must be able to analyze the driving forces and speak out for health and development. The world is in transition. So accordingly WHO must be in transition. Looking ahead. Our constitution provides us with a broad and impressive mandate. But a mandate is no roadmap. It must be made according to the needs - of the people, the communities and the nations we are meant to serve. We need to focus our work.

Poverty is the greatest threat to people's health. Ill-health leads to poverty - and poverty breeds ill-health. Governments must take it seriously. Childhood diseases, malnutrition, spreading infections and excess fertility, we know the results.

Only a broad alliance can manage this critical task. WHO must be the health component of that alliance - impatient and ready to lead when required, our special contribution being to fight ill-health.

In this process of transition - what is our key mission? I see our role as being the moral voice and the technical leader in improving the health of the people of the world. Ready and able to give advice - not on every issue - but on the key issues that can unleash development and alleviate suffering. I see our purpose to be combating disease and ill-health - promoting sustainable and equitable health systems in all countries.

What should be our motivation? My answer is short: Making a difference. We should measure our work in full transparency - sharing and learning from successes and failures - our own and those of others.

There are two roads we must follow: One road leads to our work on the ground. We must combat disease, premature death and disability. We must give advice on best practices to achieve equity and quality, set standards and norms. We must encourage, support and trigger the best research and development.

The other road leads to the levels of political decision making where the broader agenda for development is set. We must speak out for health in development, bringing health to the core of the development agenda. That is where it belongs, as the key to poverty reduction and development underpinned by the values of equity, human dignity and human rights.

This is why I wish to focus the technical support and normative work of the World Health Organization and at the same time bring the organization more firmly into the political arena. I wish to organize our programmes and activities around key functions that tell a clear story of what business we are in. I wish to concentrate our resources in a way which enables us to do fully what we decide to do - and to let go what we decide not to do - either because others do it better or because we simply can't do all. In the reorganization - which I intend to start implementing from the very first day - I will focus on four areas of concern:

To succeed in this endeavor we must be able to say: WHO is one. Not two - meaning one financed by the regular budget and one financed by extrabudgetary funds. Not seven - meaning Geneva and the six regional offices. Not more than fifty - meaning the individual programmes.

WHO must be one: Setting its priorities as one, raising additional financial resources as one, speaking out as one. And then - but only then - can we act effectively in our decentralized diversity through skilled presence at the country level, through regional guidance by the regional offices and through global direction by the headquarters and the governing bodies. With this structure and spirit in place I am ready to give a short answer when asked about my priorities: The World Health Organization is my priority.

A WHO that can engage where the needs are greatest. A WHO that is trusted to maximize its resources. A WHO with excellence. A WHO that can truly make a difference. With this structure and spirit in place WHO will be the lead agency in world health. But we need a change in attitude. We cannot point to our Constitution and say: We have the right to be the lead agency. We must earn our leadership. We must demonstrate through the way we plan, structure and carry out our work that we make a difference that we and others can measure.

To succeed there are a few basic requirements:

WHO, UNICEF, UNAIDS ANNOUNCE GUIDELINES ON INFANT FEEDING AND HIV

 Here the final press release of the 20-22 March meeting at WHO:
In a concerted effort to stop the mother-to-child transmission of HIV, the Joint United Nations Programme on HIV/AIDS (UNAIDS) and its co-sponsors the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) have developed a comprehensive set of guide-lines that support the use of alternatives to breastfeeding for in- fants born to women infected with HIV, the virus that causes AIDS.

The guidelines are intended to help governments devise national poli- cies to reduce the risk of HIV transmission through breastfeeding and to assist health care managers in providing services and support to this end. The guidelines stress the importance of protecting, pro- moting and supporting breastfeeding as the best method of feeding for infants whose mothers are HIV-negative or who do not know their HIV status. But at the same time, they recognize the need to support al- ternatives to breastfeeding for mothers who test positive for the hu- man immunodeficiency virus.

Implementation of the guidelines was the subject of an intensive two- day meeting recently hosted by WHO in Geneva. The meeting was at- tended by: experts from WHO, UNICEF and UNAIDS; government officials responsible for maternal and child health, nutrition and HIV/AIDS programmes; representatives of nongovernmental organizations; and scientists with expertise in infant feeding and HIV/AIDS.

The Right to Know and Choose: The guidelines emphasize the need to support HIV-positive mothers in their right to know their HIV status, through voluntary counselling and testing, and to choose an infant feeding method appropriate to their needs. They stress that those mothers who decide not to breast- feed their children must be ensured access to sufficient quantities of nutritionally adequate breastmilk substitutes. WHO, UNICEF and UNAIDS agree that there is an urgent need for the resources and in- formation required to enable women to prepare these substitutes as safely as possible.

Breastfeeding to be Protected:
"These guidelines bring together two important goals: reducing mother-to-child HIV transmission, and affirming the benefits of breastfeeding, which is the optimal source of nutrition for most in- fants", said Dr Tomris Tuermen, Executive Director, Family and Repro- ductive Health, WHO.

WHO, UNICEF and UNAIDS also endorse the need to implement measures to prevent breastfeeding from being undermined among HIV-negative women and among those whose HIV status is unknown. There is a consensus that methods for procuring, distributing and making available re-placements for breastmilk must comply with the International Code of Marketing of Breastmilk Substitutes, and subsequent resolutions of the World Health Assembly.

Three Million Children Infected Worldwide:
HIV can be transmitted vertically from an infected mother to her baby: if breastfed, children born to HIV-positive mothers have a one- in-three chance of contracting the virus. Of those infected, one- third acquire the virus through breastmilk, with the other two-thirds infected in utero or during birth.

To date, three million children worldwide have been infected with HIV, and the rapid and accelerating spread of the virus has rein- forced predictions that HIV/AIDS is becoming a major killer of chil- dren, especially in the developing world. In 1997 alone, more than half a million children were infected globally.

Offering a Solution:
Ways now exist of helping women to reduce the HIV risk to their in- fants both before and after birth. Recent results from a study con- ducted in Thailand among non-breastfed infants showed a 50% reduction in HIV transmission when women were given a short-course regimen of AZT (zidovudine) during pregnancy and delivery. Participants at a meeting convened by UNAIDS in March 1998, reviewed issues related to the implementation of effective interventions in developing coun- tries, particularly those involving the short-course AZT regimen.

For short-course AZT to confer its full benefits, it should logically be coupled with measures after birth to help reduce the HIV risk through breastmilk. As the HIV infant feeding guidelines state, this means giving HIV-positive mothers better access to alternatives to breastfeeding. The guidelines stress the need to improve women's access to voluntary and confidential HIV counselling and testing, be- fore and during pregnancy, and to proper counselling on infant feed- ing. And they emphasize the importance of health care and social sup- port for HIV-positive mothers and their children as they cope with HIV-related illness and with possible stigma or discrimination.

Health care services, especially in developing countries, are a pri- ority for WHO, UNICEF and UNAIDS. Unless reproductive and child health services in particular are strengthened, they will not be able to help prevent HIV infection in women and reduce mother-to-child transmission of HIV.

UNAIDS and its two cosponsors underline that the best prevention ap- proach is to help women of childbearing age to remain free of HIV, and they will continue working toward this goal.

Working Together to Prevent HIV/AIDS:
As a result of a consensus at both the March and April meetings, a working group will be established to facilitate and support acceler- ated action on the part of the United Nations agencies and organiza- tions, UNAIDS and others. This working group will move as quickly as possible to implement interventions to reduce mother-to-child trans- mission, including adequate infant feeding alternatives.

NEWSWORTHY!

 Zambia Medical Association 1998 EXECUTIVE:

President - Dr Sekelani Banda
V/president - Dr Charles Ngoma
General Secretary - Dr Hilda Mutayabarwa
Treasurer - Dr Jacqueline Mulundika
Administrator - Dr. Nkandu Mushikita
Chairman -Publications Board - Dr. Patrick Matondo
Chairman -Medical Education & Research Board - Dr Rueben Mbewe
Chairman -Health & Environment Board - Dr Moses Sakala
Chairman Medical Council Board - Dr Lackson Kasonka

6TH BIENNIAL CONGRESS AND GENERAL ASSEMBLY
LUSAKA, ZAMBIA 14 - 18 SEPTEMBER, 1998

 The theme of the 1998 Congress is:
HEALTH PROMOTION THROUGH INFORMATION DISSEMINATION - A STRATEGY FOR THE FUTURE

Introduction:
The Association for Health Information and Libraries in Africa (AHILA) was established as a consortium of African Medical Librarians in 1980 at the Belgrade meeting with support from the World Health Organization. In 1982, the Nairobi, Kenya meeting of the consortium named the association African Medical Library Association (AMLA). The first Congress & General Assembly was held in 1987 in Dakar, Senegal. Ever since, the Association has been meeting regularly once every two years. In 1989, at a meeting in Brazzaville, Congo the organisation name changed to the Association for Health Information and Libraries in Africa (AHILA), a broader designation embracing, among others, non-medical librarians who work in the area of health information.

The objectives of the Association are to:

Membership of AHILA constitutes institutions providing medical and allied scientific information in Africa as well as persons who are actively engaged in providing health related information services or who hold recognised professional qualifications in librarianship or related field.

Sub-Themes:

Workshops:
Objectives of the Congress: General
The objective of AHILA 6 is to follow on the AHILA constitutional obligation to hold the meeting biennially and to strategise on how to promote health in Africa through information dissemination, the theme of the Congress.

Specific:
The more specific objectives are - Consolidate the African Index Medicus project. Get AHILA members and partners to focus on promotion of health through information dissemination. Strengthen collaboration among health information producers, providers, health sciences librarians, media, new information and communications technologies and partners for better dissemination of health information. Strategise on continuing education and information/ communication technologies skills training for health sciences librarians and information providers.

Opportunities for health promotion:
AHILA offers several opportunities to health sciences librarians and information providers to do the following - Share experiences with partners. Continuing education. Building indigenous African health literature data bases. Building partnerships with colleagues abroad. Access to health sciences literature which is normally not easy to get in Africa. Responding to challenges to use the Internet to harness and disseminate health information.

Expected outcome:
AHILA 6 is expected to come up with strategies for the 21st Century for health promotion through information dissemination. Specifically AHILA 6 is expected to come up with strategies in the following areas - Information and Communication Technologies Skills. Training for Health Sciences Librarians and Information Providers. Continuing Education for Health Sciences Librarians. Global Communications Networks for Harnessing Health Information for Africa. Partnerships in Health Information, Mobilisation and Promotion.

The importance of AHILA 6 lies in the fact that it will be the last AHILA in the second millenium. Further, it will provide an opportunity for AHILA members to learn about CONVERGE 2000, a global meeting of medical librarians which will take place in London, United Kingdom, at the close of this century, in the year 2000. The strategies that will come out of this year's meeting will be crucial for a visualisation of the future role of AHILA in the promotion of health.

AFRICA'S INFANT MORTALITY RATE UNACCEPTABLE:

 May 6, 1998: HARARE, Zimbabwe (Pan African News Agency)
Experts from 12 African countries have called on governments on the continent to draw up realistic and feasible reproductive health policies and provide sufficient funds for the implementation of the World Health Organization (WHO) reproductive health strategy for Africa.

The strategy aims to reverse Africa's current unacceptably high maternal and infant morbidity and mortality rates. This was one of the recommendations made by the reproductive health experts at the end of the first inter-country meeting on the implementation of the reproductive health strategy held at Kadoma in Zimbabwe from April 20 to 24.

Participants at the meeting included national directors and managers of reproductive health and related programmes and WHO representatives from 11 southern African countries and Cape Verde. Others were WHO reproductive health programme managers from the organisation's African regional office, now temporarily based in Harare, its headquarters in Geneva, and experts from United Nations Population Fund and the Joint UN Programme on AIDS (UNAIDS).

The meeting reviewed various aspects of reproductive health in Africa and made recommendations on how to improve the situation through the implementation of the new strategy. The participants recommended that African countries must ensure that their reproductive health policies and other related policies are realistic and feasible, taking into consideration each country's specific needs and available resources. The plans, they advised, should be used as bases for mobilising internal resources and for negotiations with interested donors.

African countries were also urged to strengthen their district health systems within their health sector reforms and allocate appropriate and sufficient resources for the implementation of the reproductive health strategy. In addition, they proposed that countries should strengthen their overall health systems, ensure capacity building in all areas of reproductive health and involve the media in efforts to promote reproductive health.

Addressing participants at the close of the meeting, the WHO Regional Director for Africa, Ebrahim Malick Samba, called for vigorous implementation of the newly-launched reproductive health strategy. He pointed out that it was unacceptable that 250,000 mothers died due to complications related to pregnancy and childbirth and three million children died within the first week of life in Africa each year. This is unacceptable, he emphasised, adding that urgent action must be taken to end the situation through the implementation of the reproductive health strategy.

Countries represented at the meeting were: Angola, Botswana, Cape Verde, Lesotho, Malawi, Mauritius, Namibia, South Africa, Swaziland, Zambia and Zimbabwe. The meeting was the first in a series of four workshops organised to discuss the implementation of the WHO reproductive health strategy for the Africa region which was launched early this month. Other workshops will be held soon in Uganda, Mali and Gabon.

PROBLEM SOLVING FOR BETTER HEALTH (PSBH):

 Problem Solving for Better Health (PSBH) began in 1989 with one specific goal: to generate action to improve health. It is a sister programme to Communication for Better Health (CBH) under which the Dreyfus Health Foundation sponsors production of the Zambia Health Information Digest.

This program is based on the fundamental belief that answers to health problems, like most other problems, can be found locally, by looking within, rather than waiting for solutions from the outside.

Unlike meetings that "tell" people what their problems are and how best to solve them, this approach invites people to actively participate, placing the responsibility for change on the individual. PSBH participants identify their own problems and are encouraged to work through them both individually and as members of a team. Following a structured process over the course of a 2-3 day workshop, they strengthen their abilities to verbalize and define strategies to resolve their problems. The end result of this process is the empowerment of individuals.

PSBH is about new ways of looking at and approaching existing health problems. One of the most commonly voiced problems is the lack of resources to address issues of concern. Rather than focus on what they lack, PSBH participants are challenged to take a new look at the resources which are actually available to them from colleagues and facilities to information and professional networks. Making better use of available resources is an underlying principle of this program - a principle clearly taught by the Foundation's long experience with phenytoin.

Critical to the entire effort is the development of local leadership and ownership of the PSBH process. From the earliest stages, the emphasis is on the local team; they are aware of and involved with community issues that affect health for all its members. Their task is not only the identification of participants but the long-term maintenance of the PSBH process. The local team is the backbone of the program and the key to its success.

PSBH programs are active in over one dozen countries around the world, resulting in the development of an international PSBH "family". For each workshop, representatives from several of the participating countries serve as facilitators. They are paired with a member of the local team and together guide participants through the PSBH process. A spirit of goodwill is generated by this international exchange and participants are encouraged to learn that colleagues from other countries are also working towards the same goals.

Another dynamic element of this program is the diversity among the participants. Approximately fifty people from a wide variety of professional backgrounds are invited to a workshop, with each having different skills to offer and lessons to learn from one another. This approach, as basic as it sounds, is very novel and can meet with some resistance initially. The mixture of people is really at the heart of this process, since it creates the energy and vitality necessary to stimulate a true exchange of experiences.

Since the goal of the PSBH program is action, the participants are expected to create a work plan that can be implemented after the workshop has ended. Thus, from a group of 50 participants, there is potential for 50 active projects, which conceivably can improve the health of thousands of people.

The Dreyfus Health Foundation also encourages strengthening partnerships among its international collaborators. Having reached the five year mark of the PSBH program, DHF invited representatives from each country where there are active programs to come together and reflect on their experiences. This group spent three days together assessing their programs, evaluating lessons learned and making recommendations for the future. One result of this meeting was the development and publication of DHF's international newsletter, Connections. The newsletter further strengthens the international network by raising awareness of the many efforts and activities taking place around the world.

PSBH Zambia - Update by Ruth Chikasa:
In Zambia, PSBH is managed by the Foundation for Better Health - Zambia. The Secretariat is in Ndola (see address below). Most of our PSBH members are busy working on their projects.

Elijah Mwaba of Luanshya Girls' Sec School (Teenage Pregnancy Project) will be conducting two workshops (with the help of Ruth), one on Tuesday 26th August for Peer Educators and another one on Thursday 28th August for Teachers, PTA members and other interested members of the public like the church leaders, health workers, etc. It is hoped that after these two workshops, satelite projects will be started in different schools in Luanshya.

Victor Masafwa of Ndola Lime Company (Malaria Control Project) has continued on his project and has reported a significant drop in cases of Malaria from 175 cases in December 1997 to 100 cases in March 1998.

Coming Up:
Facilitators' Workshop in Kabwe 2 - 4 October
Follow up Workshop in Ndola 6 - 8 November

In the next issue, background information on PSBH - Zambia and an insight into what participants are engaged in.

Contact Address for Foundation for Better Health - Zambia:

Ruth Mulenga Chikasa
FBH-Zambia
P O Box 70721, Ndola, Zambia
Tel/Fax: +260-2-621097

AUTHOR INDEX:

 Abayomi, IO.19
Akogun, MK.17
Akogun, OB.17
Alawi, KS.12
Albonico, M.12
Appleton, CC.8
Assis, AM.18
Bailey, IW.9
Barreto,ML.18
Becker,PJ.9
Blanton,RE.18
Bundy,DA.11
Chan,MS.11
Chitsulo,L.15
Christensen,NO.17
Chwaya,HM.12
Clark,TE.8
Dias,LS.20
EL-Badawi,A.16
EL-Sayed,MK.16
el-shazly,AM.11
Evans,DB.10, 16
Fabiyi,AK.19
Farag,MK.11
Feldmeier,H.15
Friss,H.17
Glasser,CM.20
Gomo,E.14
Grabow,WO.9
Gundersen,SG.15
Guyatt,HL.10
Handoussa,AE.11
Harris,BN.9
Helling-Giese,G..15
Husein,MH.16
Kaondera,K.17
Kaondera,KC.14
King, CH.18
Kjetland,EF.15
Krantz,I.15
Kumwenda,N.15
Kvalsvig,JD.8
Magnussen,P.13
Makaza,N.14
Marcal Junior.20
Marufu,T
Michaelsen,KF.17
Michaelson,EH.7
Montresor,A.12
Morsy,TA.11
Muchiri,E.13
Mudyarabikwa,O
Mungomba,LM.7
Mungai,P.13
Mushanga,M.6
Ndamba,J.14
Ndhlovu,P..17
Ndzovu,M.13
Nyazema,N.14
Ouma, J.13
Parraga, IM.18
Poggensee, G.15
Prado, MS.18
Preidler, KW.9
Ranner, G.9
Reis, MG.18
Richter, J.15
Reipl, I.9
Salama, MM.11
Sandstrom, B.17
Savioli, I.12
Siziya, S.6
Sjaastad, A.15
Stolfzfus, RJ.12
Szolar, D.9
Talaat, M.16
Taylon, MB.9
Tielsch, JM.12
Tosha, S.13
Van Rensburg,EJ.9
Vennervald,BJ.17
Woolhouse,ME.11

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Last updated October 29, 1998