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The Impact of HIV of infectiousness of pulmonary tuberculosis: a community study in Zambia.Elliot AM; Hayes RJ; Halwiindi B; Luo N; Tembo G; Pobee JO; Nunn PP; McAdam KPSchool of Medicine, University of Zambia, Lusaka.AIDS (UNITED STATES) July 1993, 7(7) p981-7, ISSN 0269-9370Journal Code: AIDLanguages: ENGLISHDocument Type: Journal articleOBJECTIVE: To examine the impact of HIV on infectiousness of pulmonary tuberculosis (TB). DESIGN: A cross-sectional tuberculin survey carried out among household contacts of HIV-1 positive and negative patients with bacteriology confirmed pulmonary TB. Contacts were also examined for active TB. SETTING: Index cases were recruited from patients attending the University Teaching Hospital in Lusaka, Zambia and household contacts were examined during visits to their homes within Lusaka. PATIENTS, PARTICIPANTS: A total of 207 contacts 43 HIV-positive patients, and 141 contacts of 28 HIV-negative patients with pulmonary TB were examined. MAIN OUTCOME MEASURES: Proportion of contacts of HIV-positive and negative index cases with a positive tuberculin response (diameter of induration > or = 5 mm to a dose of 2 tuberculin units). RESULTS: Fifty-two per cent of contacts of HIV-positive pulmonary TB patients had a positive tuberculin response compared with 71% of contacts of HIV-negative patients (odds ratio, 0.43; 95% CI, 0.26-0.72; P< 0.001). This difference persisted after allowing for between-household variations in the tuberculin response. Tuberculin response in the contact was related to age of contract, intimacy with the index case and crowding in the household. However, the effect of HIV status of the index case was not confounded by these variables. Tuberculin response in the contact was also related to the number of bacilli seen in the sputum smear of the index case, which partially explained the effect of HIV status of the index case. Active TB was diagnosed in 4% of contacts of HIV-positive and 3% of contacts of HIV-negative cases, respectively (P = 0.8). CONCLUSIONS: HIV-positive patients with pulmonary TB may be less infectious than their HIV-negative counterparts and this may partly be explained by lower bacillary load in the sputum.---------------------------------------
A single 210-mumol oral dose of retinol does not enhance the immune response in children with measles
Rosales FJ, Kjolhede C
Department of International Health, Johns Hopkins School of Hygiene and Public Health, Baltimore, MD 21205.
J Nutr 1994 Sep: 124(9):1604-14
-Nine-year follow-up study of a plasma-derived hepatitis B vaccine in a rural African setting.Tabour E; Cairns J; Gerety RJ; Bayley ACNational Cancer Institute, National Institutes of Health, Bethesda, MD 20892.J Med Virol (UNITED STATES) July 1993, 40 (3) p240-9, ISSN 0146-6615 Journal Code: 19NLanguages: EnglishDocument Type: CLINICAL TRIAL; JOURNAL ARTICLEOne hundred and one of 255 recipients of a plasma-derived hepatitis B vaccine were evaluated in 1990, 9 years after the first vaccine dose in a study in Zambia to evaluate the efficacy of one, two or three doses. In 1983, 2 years after the first vaccine dose, antibody to the hepatitis B surface antigen (anti-HBs) had been detectable in 90 of those 101 participants (89%). In 1990, anti-HBs was still detectable in 72 of 101 (71%), and was present at a protective level (> or = 10 mlU/mL) in 68 of 101 (67%). Although the original vaccine study elicited a protective level of antibody in a greater percentage of children and adolescents than in adults, there were no significant differences among the three groups at 9 years. (in 1990, anti-HBs was still detectable in 52 of 70 [74%] who had no serologic markers of the hepatitis B virus in 1981, and a protective level was detected in 47 of 70 [67%]). A protective level of anti-HBs was detected in 1990 in 26 of 36 (72%) recipients of three doses and in 23 of 31 (74%) recipients of two doses; the slightly lower prevalence among recipients of one dose (19 of 34 [56%]) was not statistically significant. (ABSTRACT
Human immunodeficiency virus type-1 infection in Zambian children with tuberculosis: changing seroprevalence and evaluation of a thioacetazone-free regimen
Luo C, Chintu C, Bhat G, Raviglione M, Diwan V, DuPont HL, Zumla A
Department of Paediatrics, University Teaching Hospital, Lusaka, Zambia
Tuber Lung Dis 1994 Apr;75(2):110-5
Seroprevalence of human immunodeficiency virus type 1 infection in Zambian children with tuberculosis.Chintu C; Bhat G; Luo C; Raviglione M; Diwan V; Dupont HL; Zumla ADepartment of Paediatrics, University Teaching Hospital, Lusaka, Zambia.Pediatr Infect Dis J (UNITED STATES) June 1993, 12 (6) p499-504, ISSN 0891-3668 Journal Code: OXJContract/Grant No.: RO1A131356-01A2Languages: EnglishDocument Type: JOURNAL ARTICLEDescriptions in the medical literature of human immunodeficiency virus type 1 (HIV-1) in children with tuberculosis (TB) are scanty. This study determined the seroprevalence of HIV-1 in 237 hospitalized children between the ages of 1 month and 14 years with a clinical diagnosis of TB (125 males and 112 females) and in 242 control children (149 males and 93 females). The overall HIV-1 seroprevalence rate in patients with TB was 37% (88 of 237) compared with 10.7% (26 of 242) among the control group (P < 0.00001: odds ratio 5.37, 95% confidence interval = 3.21 < 5.37 < 9.47). HIV-1 seropositivity in children with TB ranged from 53% (31 of 58) in the 12- to 18-month age group to 14% (9 of 61) in the 10- to 14-year olds. The risk of TB attributable to HIV infection was 29%. The predominant clinical presentation in both seronegative (84.6%) and seropositive (89.7%) groups was that of pulmonary TB and there were no significant differences in clinical presentation between the two groups of patients. Only 54.8% of the patients attended follow-up clinics regularly whereas 32% were lost to follow up within 3 months. Bacillus Calmette-Guerin vaccination coverage was 87.3% among TB patients and 90.5% in the controls. No significant differences in B. Calmette-Guerin vaccination rates between the seronegative and seropositive children were seen. Coinfection with HIV and TB in children is now one of the major public health problems in Zambian children
Cutaneous reactions to thiacetazone in Zambia--implications for tuberculosis treatment strategies
Kelly P, Buve A, Foster SD, McKenna M, Donnelly M, Sipatunyana G
Monze District Hospital, Zambia
Trans R Soc Trop Med Hyg 1994 Jan-Feb; 88(1):113-5
Cutaneous hypersensitivity reactions due to thiacetazone in the treatment of tuberculosis in Zambian children infected with HIV-1.Chintu C; Luo C; Bhat G; Raviglione M; DuPont H; Zumla ADepartment of Paediatrics, University Teaching Hospital, Lusaka, Zambia.Arch Dis Child (ENGLAND) May 1993, 68 (5) p665-8, ISSN 0003-9888Journal Code: 6XGContract/Grant No.: NIAID RO1 A1 31356-01A2, A1, NIAIDLanguages: ENGLISHDocument type: JOURNAL ARTICLETuberculosis is one of the most common infections in Zambian adults and children infected with HIV. In Africa, cutaneous hypersensitivity reactions attributed to thiacetazone during treatment of tuberculosis in adults infected with HIV-1 have been well documented. This study monitored adverse drug reactions during treatment for tuberculosis over an 18 month period (1 April 1990 to 31 October 1991) in 237 children with a clinical diagnosis of tuberculosis (125 boys and 112 girls; 88/237 (37%) infected with HIV-1) and 242 control children (149 boys and 93 girls; 26/242 (11%) infected with HIV-1). Twenty-two (9%) of the 237 children with tuberculosis developed hypersensitivity skin reactions during the course of treatment. Adverse skin reactions were seen more often in children infected with HIV than in those who were not (odds ratio 11.65, 95% confidence interval 3.07 to 34.88). These represented 19 (21%) of 88 children infected with HIV and three (2%) of 149 children not infected with HIV. These skin reactions occurred after a period of treatment ranging between two and four weeks among 14 children receiving the HST (isoniazid, streptomycin, thiacetazone) regimen and eight children receiving the HSTR (isoniazid, streptomycin, thiacetazone, rifampicin) regimen. Twelve (55%) of the 22 children who reacted adversely to treatment developed the Stevens-Johnson syndrome. All 12 of these children with the Stevens-Johnson syndrome were infected with HIV. The mortality among these children who developed the Stevens-Johnson syndrome was 91% (11 of 12 died within three days of the onset of the reaction).
Cutaneous hypersensitivity reactions due to thiacetazone in the treatment of tuberculosis in Zambian children infected with HIV-I
Chintu C, Luo C, Bhat G, Raviglione M, DuPont H, Zumla A
Department of Paediatrics, University Teaching Hospital, Lusaka, Zambia
Arch Dis Child 1993 May;68(5):665-8
Case definitions for paediatric AIDS: the Zambian experience.Chintu C; Malek A; Nyumbu M; Luo C; Masona J; DuPont HL; Zumla ADepartment of Paediatrics, University Teaching Hospital, Lusaka, Zambia.Int J STD AIDS (ENGLAND) Mar-Apr 1993, 4 (2) p83-5, ISSN 0956-4624Journal Code: A16Contract/Grant No.: RO1A131356-01A2Languages: EnglishDocument type: JOURNAL ARTICLEFor the purpose of surveillance of the acquired immunodeficiency syndrome (AIDS) in developing countries, the World Health Organization (WHO) has recommended criteria for the clinical case definition of AIDS in adults and children. In a preliminary examination of children in Zambia a number of patients with obvious AIDS did not fit the published WHO case definition for paediatric AIDS. Based on this the Zambia National AIDS Surveillance Committee designed local criteria for the clinical case definition of paediatric AIDS. We compared the Zambian criteria with the WHO criteria for the diagnosis of paediatric AIDS by studying 134 consecutively admitted children to one of the paediatric wards at the University Teaching Hospital in Lusaka. Twenty-nine of the patients were HIV-1 seropositive and 105 were HIV-1 seronegative. Among the 29 HIV-seropositive and 105 were HIV-1 seronegative. Among the 29 HIV-seropositive patients, the Zambian criteria identified 23, and the WHO criteria identified 20 children as having AIDS. The 105 HIV-seronegative children were classified as having AIDS in 9 cases by the Zambian criteria and in 38 cases by the WHO criteria. These results give the Zambian criteria for the diagnosis of AIDS sensitivity of 79.3%, a specificity of 91.4% and a positive predictive value of 86.8% compared to a sensitivity of 69%, specificity of 64% and a positive predictive value of 38% for the WHO criteria. The current WHO criteria are inadequate for the diagnosis of paediatric AIDS. The need to refine the WHO criteria for the diagnosis of paediatric AIDS is discussed.
Delayed-type hypersensitivity test for assessing tick-immune status of cattle in Zambia
Smith RE, Mwase ET, Heller-Haupt A, Trinder PK, Pegram RG, Wilsmore AJ, Varma,MG
Royal Veterinary College, London.
Vet Rec 1989 Jun 3;124(22):583-4
Low and Stable HIV seroprevalence in pregnant women in Shaba province, Zaire.Magazani K; Laleman G; Perriens JH; Kizonde K; Mukendi K; Mpungu M; Badibanga N; Piot PJ Acquir Immune Defic Sydro (UNITED STATES) Apr 1993, 6 (4) p419-23Languages: ENGLISHDocument Type: JOURNAL ARTICLESentinel serosurveillance for HIV infection has been carried out in Shaba province, Zaire, among consecutive pregnant women attending antenatal clinics from 1989 to 1991. There were four surveillance cities (three urban and one semiurban), at which a total of 13 surveillance studies were made of 4,205 women. Overall, 3.1% were HIV seropositive. There were no significant differences in HIV seroprevalence between surveillance sites, and HIV seroprevalence did not increase at any of the surveillance sites during the 2-year period of study. Since changes in the population studied did not occur between surveillance studies, it is believed that the observed stable trend reflects stable HIV seroprevalence rates in the general adult population of the surveillance sites. Collateral HIV seroprevalence data were available from 8,725 blood donors at 20 sites (six urban, 14 rural) in the province, who had an overall HIV seroprevalence of 4.6%. The higher HIV seroprevalence rate among blood donors was probably due to selection bias, since HIV seroprevalence rates in two blood banks, which relied nearly exclusively on replacement donors, were 2.7 and 2.8%, our best estimate for HIV seroprevalence in the three cities where blood banks exists and where no surveillance studies were carried out. The stable and relatively low HIV seroprevalence rates in Shaba province are in sharp contrast with the rapidly increasing and much higher rates in neighboring Zambia and other East African cities. Reasons for this discrepancy are unclear, and their elucidation may yield critical information for HIV prevention programs
Cutaneous manifestations of human immunodeficiency virus in Lusaka, Zambia
Hira SK, Wadhawan D, Kamanga J, Kavindele D, Macuacua R, Patil PS, Ansary MA, Macher AM, Perine PL
University Teaching Hospital, Lusaka, Zambia
J Am Acad Dermatol 1988 Sep;19(3):451-7
Chemotherapy of African AIDS diarrhoea: a preliminary study.Kelly P; Buve AMonze District Hospital, Zambia.AIDS (UNITED STATES) Jan 1993, 7 (1) p91-3Journal Code: AIDLanguages: ENGLISHOBJECTIVE: To determine whether combined chemotherapy with tinidazole, thiabendazole and cotrimoxazole is more effective than placebo in treatment of AIDS diarrhoea in Zambia. DESIGN: Single-blind prospective comparison in consecutive patients, randomized alternately to placebo or chemotherapy.SETTING: A district hospital in Zambia. PATIENTS: Sixty-four HIV-seropositive patients with chronic diarrhoea were considered for inclusion in the study. Of these, 25 patients were not eligible for randomization (in 13 cases because of spontaneous remission); 11 were randomized, but excluded from the analysis (seven failed to attend for a scheduled visit and four died), leaving 28 patients who completed the study. MAIN OUTCOME MEASURES: Proportion of diarrhoea-free days in the 7 days following treatment, as determined by daily stool counts. RESULTS: There were 38 diarrhoea-free days out of 89 (43%) in the placebo group, and 39 out of 72 (54%) in the chemotherapy group; this difference was not statistically significant. CONCLUSIONS: The high level of spontaneous remission probably indicates a natural fluctuation in stool frequency and demonstrates the need for placebo-controlled studies in any assessment of therapy for AIDS diarrhoea. Our findings do not allow us
Cutaneous manifestations of human immunodeficiency virus in Lusaka, Zambia
Hira SK, Wadhawan D, Kamanga J, Kavindele D, Macuacua R, Patil PS, Ansary MA, Macher AM, Perine PL
University Teaching Hospital, Lusaka, Zambia
J Am Acad Dermatol 1988 Sep;19(3):451-7
Prophylaxis for opportunistic infections in patients with HIV Infection Gallant J E, Moore R D, Chaisson R E. 1994 Jun 1. Prophylaxis for opportunistic infections in patients with HIV infection. Annals of Internal Medicine 120(1): pp. 932-944. Author's objective To review the efficacy of chemoprophylaxis for opportunistic infections in persons infected with human immunodeficiency virus (HIV). Type of intervention Treatment/prevention Specific interventions included in the review. The prophylactic use of anti-microbial agents in patients with HIV infection. Participants included in the review All patients who were HIV positive. Outcomes assessed in the review Incidence of infection in patients receiving prophylactic treatment. Organisms studied included pneumocystis carinii, toxoplasma gondii, various fungal infections, mycobacterium avium complex, mycobacterium tuberculosis, herpes simplex virus and several other bacterial infections. Study designs of evaluations included in the review Controlled clinical trials, uncontrolled trials, retrospective studies and prospective observational studies. What sources were searched to identify primary studies? Medline 1985-1993, English language. Relevant abstracts from the International Conferences on AIDS, the Inter-science Conferences on Antimicrobial Agents and Chemotherapy and the National Conference on Human Retroviruses and Related Diseases. Criteria on which the validity (or quality) of studies was assessed Importance was given in descending order to controlled trials, uncontrolled trials and retrospective studies and prospective observational studies. Results of the review Seven groups of infections are discussed separately. Include a synthesis of data into a detailed table of treatment recommendations. Indications for primary prevention for other infections such as M.avium complex should be considered in relation to the progression of HIV and CD4 counts. A discussion of interaction of a number of the treatment regimens is included in the narrative. Was any cost information reported? Some cost benefit analysis are reported. Included in the synthesis of the data are recommendations related to the efficacy and cost effectiveness of utilising a primary prophylactic approach for some infections (eg: Pneumocystis carinii) as opposed to the treatment of acquired infections such as the majority of fungal infections. Author's conclusions A growing number of infections related to acquired immunodeficiency syndrome are preventable with currently available agents. Issues of drug interactions, toxicity, and cost-effectiveness will become increasingly important in the management of patients with advanced HIV diseaseCutaneous manifestations of human immunodeficiency virus in Lusaka, Zambia
Hira SK, Wadhawan D, Kamanga J, Kavindele D, Macuacua R, Patil PS, Ansary MA, Macher AM, Perine PL
University Teaching Hospital, Lusaka, Zambia
J Am Acad Dermatol 1988 Sep;19(3):451-7.----------------------------------------School-based programs to reduce sexual risk behaviors: a review of effectiveness Kirby D, Short L, Collins J, Rugg D, Kolbe L, Howard M, Miller B, Sonenstein F, Zabin LS. 1994. School-based programs to reduce sexual risk behaviors: a review of effectiveness. Public Health Reports 109(3): pp.339-360. Objective 1. To synthesise, in a qualitative way, research on the effectiveness of school based programmes to reduce sexual risk behaviours. 2. To identify the distinguishing characteristics of effective programmes. 3. To identify important research questions to be addressed in the future Type of intervention/Prevention. Specific interventions included in the review School based programmes to reduce sexual risk behaviours. Participants included in the review. Males and females of school age. Outcomes assessed in the review Reported sexual or contraceptive behaviour or their outcomes (pregnancy rates, birth rates or sexually transmitted disease (STD) rates). Study designs of evaluations included in the review Experimental or quasi-experimental studies and national surveys. What sources were searched to identify primary studies? Computer searches of appropriate data bases; review of journals commonly publishing articles on this topic, and contact with other researchers in the field. Only research that had appeared or had been accepted for publication in a peer-reviewed journal was considered. Criteria on which the validity (or quality) of studies was assessed Not stated. How were the inclusion criteria applied? Decision were made by a panel of experts established for the review. How were judgements of validity (or quality) made? Results of the review National surveys (7 studies): 1. Initiation of sexual activities. Studies show inconsistent results and suggest that the impact of sex education instruction might vary with the topics covered and the age of the students. 2. Use of contraception. Results varied both with the particular study and with the time interval of contraceptive measure. Four of the five survey data sets produced some positive significant relationships between participation in a sex or AIDS education program and either contraceptive use or specifically condom use, while the fifth data set revealed a possible indirect effect through greater knowledge Specific Program evaluation (16 studies): 1. Abstinence programmes. There is insufficient evidence to determine whether school-based programs that focus only upon abstinence delay the onset of intercourse or affect other sexual or contraceptive behaviours. 2. Sexuality and AIDS-STD education programmes. 2a. Initiation of intercourse (5 evaluations). There is no evidence that programmes significantly hasten the onset of intercourse and some programmes can delay the initiation of sexual activity. 2b. Frequency of sexual activity (4 studies). These measured the impact of the programme upon frequency of sexual activity, among those who had already initiated intercourse. None of the programmes significantly increased or decreased the frequency of intercourse. 2c. Use of contraceptives (8 studies). Some, but not all, programmes increased contraceptive use. Only two programmes increased contraceptive use. Only two of the eight programmes significantly increased contraceptive use among all sexually experienced youths. Five studies combined education and reproductive health services (close to or with the schools). The presence of reproductive health services was found to: 1. Neither hasten the onset of intercourse or increase the frequency, 2. Have mixed effects on contraceptive use, 3. Be less critical than the presence of a strong educational component. It is unclear whether school-based or school-linked reproductive health services, either by themselves or in addition to education programmes, significantly decrease pregnancy or birth rates. In order to understand which characteristics are necessary for behavioural change the characteristics of the 8 effective programmes were compared with the characteristics of the ineffective programmes: Effective Programme Characteristics: 1. Had a narrow focus on reducing sexual risk-taking behaviours that may lead to HIV-STD infection or unintended pregnancy. 2. Used social learning theories as a foundation for programme development. These programmes went beyond cognitive level: they focused on recognising social influences, changing individual values, changing group norms and building social skills. 3. Provided basic, accurate information about the risks of unprotected intercourse and methods of avoiding unprotected intercourse through experimental activities designed to personalise this information. 4. Included activities that address social or media influences on sexual behaviours. 5. Reinforced clear and appropriate values to strengthen individual values and group norms against unprotected sex. 6. Provided modelling and practice in communication and negotiation skills. Author's conclusions The programmes reviewed did not hasten intercourse in older students, while evidence for younger students is less consistent. Some programmes can increase the use of condoms or other contraceptives. The curricula that effectively delayed the onset of intercourse, increased the use of condoms or contraception and reduced sexual risk behaviours had six common characteristics as listed above. The published literature does not provide any good evidence indicating whether programmes focusing only on abstinence delay the onset of intercourse or reduce the frequency of intercourse. There is insufficient direct evidence to determine whether any of these educational or clinic programmes actually decreased pregnancy rates, birth rates or incidence of STD or HIV infections. There is evidence from two studies that some programmes delayed the onset of intercourse, reduced the number of sexual partners and reduced the frequency of intercourse or increased the use of protection.Cutaneous manifestations of human immunodeficiency virus in Lusaka, Zambia
Hira SK, Wadhawan D, Kamanga J, Kavindele D, Macuacua R, Patil PS, Ansary MA, Macher AM, Perine PL
University Teaching Hospital, Lusaka, Zambia
J Am Acad Dermatol 1988 Sep;19(3):451-7----------------------------------------Sexual health education interventions for young people: a methodological review Oakley A, Fullerton D, Holland J, Arnold S, France-Dawson M, Kelley P, McGrellis S . Jan 21 1995.Sexual health education interventions for young people: a methodological review. British Medical Journal 310: 158-62. Author's objective To locate reports of sexual health education interventions for young people, assess the methodological quality of evaluations, identify the subgroup with a methodologically sound design and assess the evidence with respect to the effectiveness of different approaches to promoting young people's sexual health. Type of intervention Prevention Specific interventions included in the review Sexual health education/information Participants included in the review Young people aged 0 to 19 years, which included high school students, university students and runaway adolescents at a residential shelter. Outcomes assessed in the review The methodological quality of evaluations was assessed along with the study outcomes, which were changes in knowledge, attitudes or sexual behaviour. Study designs of evaluations included in the review Controlled trials What sources were searched to identify primary studies? The following databases were searched from 1982 to 1994: Social Science Citation Index (BIDS) MEDLINE Psychlit Eric Health Education Authority's Unicorn database National HIV/AIDS Prevention Information Service database. Hand searches from 1982 to 1994 of the following journals were carried out: Health Education Research Health Education Journal Health Education Quarterly AIDS Education and Prevention, The Journal of School Health Family Planning Perspectives bibliographies of located studies were searched and contact with other researchers in the area were made. Criteria on which the validity (or quality) of studies was assessed There were 8 methodological quality criteria, which the studies were rated on: clear definition of aims; a description of the intervention package and design sufficiently detailed to allow replication; inclusion of a randomly allocated control group; provision of data on number of participants recruited to the study and control groups; provision of pre-intervention data for the study and control groups; provision of post-intervention data for the study and control groups; attrition rates reported for the study and control groups; findings reported for each outcome measure as described in the aims of the study. However, evidence on effectiveness generated by studies meeting 4 core criteria was assessed. The 4 core criteria were: employing randomly allocated control groups or control groups shown to be equivalent to the study groups before intervention on sociodemographic characteristics and measures used as outcome variables; providing pre-intervention data; providing post-intervention data; reporting on all outcomes; How were the inclusion criteria applied? Not stated How were judgements of validity (or quality) made? Two reviewers with backgrounds in quantitative social science independently assessed each study. Any disagreements were discussed and resolved with a third reviewer and by discussion with the members of the study's steering group. How were the data extracted from primary studies? Not stated Number of studies included 73 outcome evaluations (of which only 12 were controlled trials and met the core quality criteria) How were the studies combined? A narrative review How were differences between studies investigated? Not stated Results of the review Of the 73 reports of evaluations of sexual health interventions examining the effectiveness of these interventions examining the effectiveness of these interventions in changing knowledge attitudes or behavioural outcomes, 65 were separate outcome evaluations. Of these 65 studies 45 (69%) lacked random control groups, 44 (68%) failed to present pre-intervention data and 38 (59%) failed to present post-intervention data, 26 (40%) omitted to discuss the relevance of loss of data caused by drop outs. Only 12 (18%) of the 65 outcome evaluations were judged to be methodologically sound. Only 3 of the methodologically sound evaluations were (judged by the reviewers to be) effective in showing an impact on young peoples' sexual behaviour. Was any cost information reported? No Author's conclusions The design of evaluations in sexual health intervention needs to be improved so that reliable evidence of the effectiveness of different approaches to promoting young people's sexual health may be generated. CRD commentary This review presents information about the methodology needed to evaluate health education interventions and so judge the effectiveness of sexual health education. What are the implications of the review Evaluations of sexual health interventions need to be improved in order to obtain reliable evidence about the effectiveness of different interventions. Record status This record is a structured abstract written by CRD reviewers. The review has met a set of quality criteria. Index terms
ASTHMA IN CHILDREN
FEMALE CONDOM ACCEPTABILITY IN ZAMBIAGladys Nkama and Tamara FettersZambia has a high prevalence of STDs including HIV/AIDS. Sentinel surveillance statistics in Lusaka in 1994 indicated 27% of urban antenatal clinic attendees were HIV+. In order to assess the acceptability and demand for female condoms in Zambia, CARE international in Zambia carried out a study from November 1995 to June 1996. A female-controlled barrier method would offer Zambian women another option, besides the male condom, to control their own fertility and their health status.Research, design and methodologyA cross-sectional acceptability study was conducted in three public sector clinics in the capital city of Lusaka. The family planning unit of each clinic used a specially designed female condom log book to register its motivated clients. After counseling clients on all available family planning methods, providers asked women if they would like to use the female condom and gave the acceptors three to six female condoms as an initial supply. Women could come back for a re-supply at any time during the regular clinic hours.After three months, a random sample of initial acceptors who never returned for re-supply ("discontinuers") and initial acceptors who returned for re-supply at least once ("continuers") were asked to participate in separate focus group discussions. In addition, 10 partners of female condom users were invited for individual in-depth interviews.Motivation to try the female condomContinuers expressed several reasons for trying the female condom. Around half were on oral contraceptives, but negative side-effects like heavy bleeding and dizziness put them off and caused them to consider the female condom. Most of the women who came back at least once found the female condom to be clean, safe and good protection against STDs. Continuing or not with the female condom correlated highly with their partners' appreciation of the method. Most of the discontinuers were apparently not self-motivated: 70% of them said the nurses told them to try it for various reasons. Some had an STD, while others were encouraged to try it as an interim method whilst breastfeeding or awaiting the provision of long-term contraceptives like the Norplant implant.Advantages of the female condomThe users said they liked the female condom because it offers double protection, against pregnancy and STDs, and it is safer than the male condom because it is stronger and protects better against STDs, covering the "lips of the vagina". Most women were pleased because they finally had a method they could control, and, unlike other family planning methods, the female condom has no side-effects. Women also appreciated the female condom because it was not messy; the ejaculate remains in the condom and can be removed after intercourse.A few also said that its "lightness" increased sexual sensitivity and they thought it might be possible to re-use it. Some women preferred the female condom because it made their vaginas feel warm, making sex very pleasurable. Some users experienced an unexpected prolonged male orgasm.The partners of the continuers were positive about the method: they said it was better than the male condom because it "it now was the responsibility of the woman to ensure that the condom was in place before sex". They also liked it because it was strong and they thought it could be re-used and was a good method for family planning and prevention of STDs.Problems and disadvantages of the female condomBoth continuers and discontinuers reported problems with the condom. Sixty-five percent of the continuers said sex was just as enjoyable, but some said the inner ring was uncomfortable on insertion, but all right once in place. Others said the ring caused the woman to be conscious and made intercourse less enjoyable. The outer ring also caused some discomfort, because it pushed inside the vagina during intercourse.Unlike the injectable and oral contraceptives that can be taken secretly, the female condom required the male partner's consent, and some women felt this could be a problem. As men in this culture frequently prefer "dry sex" over wet sex, some women felt their partners might not like the female condom because it had too much lubrication. (In dry sex, women use herbs and other substances to dry up the vagina.) The major reason why women discontinued use was their partners' disapproval: 60% of them said their partners complained, because it would encourage women to be promiscuous and they would not be able to trust them, so that it was a method only for prostitutes. Some male partners thought the condom was ugly, too big an uncomfortable. Many women said their partners enjoyed "skin to skin sex" but with the labia covered and no skin contact, sex was less enjoyable. Some also found the female condom to be quite noisy, causing uneasiness.Conclusions and recommendationsThe study in Zambia revealed interest, even excitement, in the female condom. By incorporating the female condom into CARE's normal method mix, more than 200 women and their partners opted to try the female condom as an interim, experimental or primary family planning and disease prevention choice. Nearly half of these people came back to the clinics for more condoms, indicating a relatively high level of acceptance. Male condom use did not seem to be a necessary precondition for initial acceptance of the female condom. 49% of the new acceptors of the female condom had never used a barrier method before. All of the women in the focus group sessions and the men who were interviewed felt the female condom would be a welcome method choice in Lusaka, even those people who tried it only once.Recommendations for follow-up research include the further exploration of continuation rates and women's use patterns. For instance, are women using the female condom as dual protection against STDs? If so, are they doing this with their regular partners or only outside of their conjugal relationships?These findings show that attitudes towards the female condom are sometimes based on gender beliefs about who holds the responsibility for contraception, social stigma surrounding women's use of contraception encouraging promiscuity or who should be allowed sexual pleasure.Still, the strongest reason for discontinuation was the unwillingness of the male partner. If this method is to be widely introduced, its introduction should be accompanied by an education campaign to combat social stigma already associated with male and female condoms, especially in men.Gladys Nkhama and Tamara Fetters, CARE International Zambia,P.O. Box 36238,Lusaka,Zambia.E-mail: care@zamnet.zmSexual Health Exchange1999/1
CURRENT CONCEPTS IN THE MANAGEMENT OF GENITAL HERPES
DIARRHOEAL DISEASES1. What are diarrhoeal diseases?Diarrhoeal diseases are dangerous diseases, which make a person pass watery stools three times or more in a day. They make the body lose water fast and may lead to death if not treated. They are most common among children under 5 years of age.Diarrhoeal diseases include diarrhoea, dysentry and cholera.In addition to making a person pass frequent watery stools, different diarrhoeal diseases have different characteristics.(I) When the watery stools start suddenly and continue for several days, what the child has is acute diarrhoea.(ii) When the watery stools last for more than 2 weeks, it is persistent diarrhoea.(iii) When the diarrhoea comes with blood in the stool, it is dysentry.(iv) When it is sudden, serious and comes with vomiting, it is cholera.2. What are the causes of diarrhoeal diseases?A major cause of diarrhoeal diseases is dirty living conditions, which allow dangerous germs to get into a person's stomach or intestine. The germs which cause diarrhoeal diseases can get into someone:(I) if he touches the stool or vomit of a sick person with his hand and eats later without washing the hand;(ii) through food that is cooked or kept in dirty pots;(iii) through food that is spoiled;through food which is not well-cooked;(v) through food or water that is served or kept in dirty pots, buckets, bottles, plates, pans, cups or other dirty containers;(vi) through shortage of water which promotes the spread of germs.How can we prevent diarrhoea?Obey the following simple rules of hygiene:(I) Food(a) Prepare food in a clean place, using clean pots and other utensils.(b) Eat or serve cooked food while still hot. If it is cold, heat it well again before serving or eating it.© Wash uncooked food, such as fruits, in clean water before serving or eating it.(ii) Feeding childrenMothers should:(a) wash their hands with soap before preparing food for their children;(b) wash their hands with soap before feeding the children.© wash their hands after stooling(d) breast-feed babies for at least 2 years (Breast milk is best for the child. It helps to prevent and stop diarrhoea and other infections)
BASELINE SURVEY ON PREVALENCE AND AETIOLOGY OF IRON DEFICIENCY ANAEMIA IN ZAMBIA
Background
The World Health Organization, United Nations Childrens Education Fund (UNICEF) and Opportunities for Micronutrient Initiatives (OMNI) funded a baseline survey on the prevalence and aetiology of Iron Deficiency Anaemia (IDA) in Zambia in March 1998. The survey was carried out by the National Food and Nutrition Commission in collaboration with the University Teaching Hospital, Central Statistical Office, National Council for Scientific Research, and the Natural Resources Development College. What is Iron Deficiency Anaemia?
Iron Deficiency Anaemia (IDA) is the commonest nutritional problem in the world, affecting about 2 billion people. IDA occurs when the dietary intake or absorption is not sufficient to meet the bodys needs. This situation can be due to the following factors:
If IDA is un-corrected it leads to the following:
- An inadequate dietary intake.
- A poor iron absorption or low dietary biovailability.
- An increased need for iron.
- Chronic blood loss (for example in parasitic infections such as malaria and helminths).
- A reduced work capacity.
- A reduced learning ability.
- A greater susceptibility to infection.
- Increased maternal mortality.
Other nutritional deficiencies such as folic acid, Vitamin C, and Vitamin A deficiency can also contribute to anaemia. Parasitic infections such as hookworm and malaria contribute to anaemia in areas where these infections including HIV and genetic conditions such as thalassemia and sickle cell may also cause anaemia.
Who is at Risk?
The Situation of IDA in Zambia
Infants, pre-school children, adolescents and women of child bearing age especially pregnant women are of greatest risk of iron deficiency anaemia. Adult males may also be at risk, especially if their dietary intake of iron is very low or if they have chronic parasitic infections.
Until recently the prevalence of IDA in Zambia was not known. Today IDA is known to be a major health problem in the country. This is due to the existence of the following factors which are largely responsible for IDA:
- Low food security.
- Low dietary intake of animal foods.
- High prevalence of malaria and other parasitic infections.
In order to develop and advocate for interventions to combat IDA, it is necessary to understand the extent of the problem. It was therefore decided to execute a baseline survey on the prevalence and aetiology of IDA in the country.
The IDA Baseline Survey
The baseline survey was conducted in March 1998. The objectives of the study were as follows:
- To establish the prevalence and aetiology of IDA in the country.
- To provide District Health Management Teams with information on anaemia and anaemia aetiology in both urban and rural areas of Zambia, which they could use when planning to allocate their resources to appropriate anaemia interventions.
- To assess current iron programmes and mothers knowledge and perceptions of iron deficiency in selected areas.
- To provide baseline information on IDA prevalence and associated factors to collaborative partners already working in nutrition and to identify partners who are interested in supporting interventions in Zambia.
The Design of the Survey
The survey was intended to collect data which was representative of the situation of the prevalence and aetiology of IDA in the contry. Therefore a total of thirty districts were randomly selected to be used for data collection during the survey. In each district, a random sample was made comprising children, women and men from 25 households.The following indicators of IDA were checked for every sample population that was selected: Haemoglobin levels, Malaria and other parasites. Other variables which were taken into account in the study incude sex, age, weight, feeding patterns, educational status, occupation, parity, obstetric history iron supplementation during pregnancy etc. An assessment of knowledge, attitude and practices relating to anaemia were also conducted with health providers and mothers in the community.
Preliminary Findings and Analysis
Preliminary data revealed the following:-\
- 65% of children (500 of the 970) were anaemic. The prevalence of anaemia in children from rural areas was higher than that of urban children 72.4% compared to 56% respectivelty.
- The prevalence of anaemia in women of the reproductive age group was found to be 42%. In contrast to the findings with children, this prevalence was irrespective of whether the woman was from a rural or urban area with the respective 41% and 40.5%.
- The prevalence of anaemia in men was lower than that found in children and women, e.g. 25%. As in children, the rural men seemed to be more affected compared to the men from the urban areas.
Annoek, Van Den Wijngaart
Associate Professional Officer, Nutrition WHO/NFNC
CO-TRIMOXAZOLE FOR MALARIA
en compared in India for vivax malaria. Both were effective, but chloroquine cleared the blood more quickly. Using twice the normal dose of co-trimoxazole gave better results, but caused crystalluria.LAL, H.
A comparative trial of oral chloroquine and oral co-trimoxazole in vivax malaria in children.
Am J Trop Med Hyg 1982; 31:38-40
COPING WITH TUBERCULOSIS
What is Tuberculosis?
Tuberculosis (TB) is a disease caused by a germ called K.B. It makes someone cough, get weak and become thin. It is a contagious disease (passes from person to person easily.) It usually attacks the lungs, but also affect other organs of the body.How does someone get tuberculosis?
When the sick person coughs out, he/she releases into the air thousands of TB germs. People around him/she then breathe in the air with the germs. Those of them whose bodies can not fight off and kill the germs then get the disease.How can we control and prevent tuberculosis?
- People with TB must be treated promptly.
- Give BCG vaccination to all babies at birth or soon after birth, and to other children.
- Cover your mouth when coughing and nose when sneezing.
- Seek medical advice for any TB symptoms.
- TB treatment should be fully supervised by a health care provider.
- Dont spit on the ground.
- Avoid sleeping in overcrowded rooms.
- Observe the rules of hygiene.
What are the signs of TB?
- Coughing and spitting almost all the time and for more than 3 weeks.
- Chest pains
- Difficulty in breathing.
- Getting thinner and thinner.
- Mild fever in the afternoon and sweat at night.
- Poor appetite.
- Coughing blood in some cases.
What anyone should do if they have signs of TB?
The TB patient should:
Go to the health centre or hospital to have your sputum (spit) to be examined in the laboratory. If you have TB, take medicine until you are cured.
- Cover his/her mouth when he/she coughs.
- Avoid spitting on the floor.
- Eat plenty of good food.
- Have a lot of rest and enough sleep.
What should family members, co-workers, classmates or roommates of the sick person do?
- They should see the doctor or health worker to be examined and, if necessary, treated.
- The children should be vaccinated.
- They should give support to the patient.
- Ensure that the patient takes all the medicines until he/she is completely cured.
If lung tuberculosis is not treated promptly, what are the effects?
- It can damage the persons lungs.
- The coughing becomes more serious and he/she may start to cough out blood.
- The chest pain becomes more intense.
- Breathing becomes more difficult.
- The person gets weaker and weaker and
- He/she may die.
(Extracted from the health information package, ZAMPAC, Coping with common diseases).
10 FACTS ABOUT TB
- One-third of Africas population is infected with TB bacillus.
- Left untreated, a person with active TB can infect between 10 and 15 people in one year.
- Eighty percent of victims are between 15 and 49 years of age the most economically productive years of their lives.
- A patient who is not diagnosed or treated loses on average a full year of work.
- This year, over half a million people in the African Region will die of TB. Almost all TB deaths are preventable.
- For every US$10 spent on health care in developing countries, only US$0.02 goes to TB control.
- Someone who is HIV-positive and infected with TB is thirty times more likely to become sick with TB than someone who is HIV-negative.
- TB accounts for about 40% of AIDS deaths in Africa.
- TB is the single biggest killer of women.
- In some parts of Africa, the stigma attached to TB leads to isolation, the abandonment and divorce.
10 FACTS ABOUT DOTS (Directly Observable Treatment, Short Course)
- DOTS (Directly Observed Treatment, Shot Course) is the WHO recommended strategy for the detection and cure of TB.
- DOTS combines five elements: political commitment, microscopy services, drug supplies, a monitoring system and direct observation of treatment.
- DOTS can successfully and permanently cure at least 9 out of every 10 TB patients who complete their treatment. Every infectious patient cured reduces the risk to everyone of contracting TB.
- DOTS does not require that patients always stay in hospital; most patients can return to work soon after starting treatment
- DOTS prevents new infections and the development of Multi-Drug Resistant TB (MDR-TB).
- A six-month supply of drugs cost just US$11 per patient in some Member countries.
- Effective TB treatment is estimated to cost only US$3-US$7 for every healthy-year of life gained.
- DOTS can add two years of life to an HIV-positive person and 25-30 years to an HIV-negative person.
- Proper use of DOTS in South Africa, for instance, could save the country nearly US$5 thousand million over ten years, according to a 1994 cost analysis of TB in that country.
World Health Organisation
THE MANAGEMENT OF HIRSCHSPRUNGS DISEASE IN A RURAL HOSPITAL
H.A. HEIJ, St. Francis Hospital Private Katete, Zambia
Introduction
Hirschsprungs Disease (HD) is characterised by the absence of ganglionic cells in the submucous and intermuscular plexus of the intestinal wall. Consequently, the affected bowel does not propel its contents, which results in a functional obstruction. As HD is very amenable to treatment (which is always surgical), I present my personal experience in a rural hospital in the Eastern Province of Zambia, with the aim of increasing the awareness of doctors, midwives and clinical officers. Pathology and Epidemiology
As ganglionic cells migrate during embroyonic life in a caudal direction, the abnormality always involves a distal rectum and extends proximally for a variable distance. In 75% of the patients, the rectum and distal sigmoid are affected, in the other 25% a longer segment, sometimes including the small bowel, is affected. The disease occurs in 1 per 3500 newborns, an incidence that is similar in various parts of the world. There is a male preponderance in the rectosigmoid type, but in the long segment type, females are affected with the same frequency. Hereditary factors are involved, and the risk is increased in siblings and offspring of patients with HD. Clinical Presentation
Invariably, a child with HD has a delayed passage of meconium beyond the first 24 hours. The role of midwives, nurses and TBAs in this phase is very important: any child who does not pass meconium within 24 hours after delivery should be referred to a doctor. The child may present in the neonatal period with signs of acute intestinal obstruction: bilious vomiting, constipation and gross distension. Untreated, perforation of the dilated bowel leads to faecal peritonitis. Alternatively, enterocolitis and septicaemia may lead to the demise of the child. Later in infancy, the child may present with abdominal distension, constipation and failure to thrive. Some children present after infacy with periodic abdominal pain, distension and constipation. As chronic constipation in African children is very rare in comparison to Caucasian children, the index of suspicion should be very high. On physical examination, apart from the abdominal findings, the rectal examination is quite often diagnostic. The anus and sphincter are normal, the rectum is often filled with liquid stools, and when the finger is withdrawn, and explosion of foul-smelling faeces follows. It is a wise precaution not to stand at the foot-end of the child, so as to avoid this jet stream! Further Investigations
A plain abdominal X-ray, preferably erect, reveals dilated loops, often with gas-fluid levels. The distal rectum does not contain gas. Pneumoperitoneum will be visible if a perforation has occurred. On a burium enema, the aganlionic segment is seen as a narrow distal segment with proximal dilatation of the colon. The transitional zone is often best appreciated after removal of the canula. Twenty-four hours later, a plain X-ray will reveal that barium is still present in the colon, provided no rectal manipulations have been done. The diagnosis is our setting is made by histological examination of the distal rectal submucosa. A full thickness biopsy is taken from the dorsal rectal wall, and should include the submucosal and intermuscular layer. As gangllionic cells are not normally present below the dentate line, the biopsy should be taken above that level and prefarebly extend upwards for 2 centimeters. The specimen can be stored in formaldehyde and dispatched to a histological laboratory with experience in diagnosing HD. Differential Diagnosis
Neonatal septicaemia, e.g. from omphalitis, may present with abdominal distension, vomiting and constipation. The rectal examination will be normal and erect abdominal X-ray will show mild dilatation of loops, evenly distributed in the abdomen. Colonic atresia may present in newborns with similar clinical picture as HD. On rectal examination, there will be no faecal explosion, as the rectum is usually empty. Meconium ileus (associated with cystic fibrosis) is said not to occur in Africans. Management
Newborns and infants with acute presentation are very poor surgical risks. Therefore, the initial management consists of rectal canulation with repeated, careful lavage with small quantities (10-15ml) of warm water in order to decompress the bowel. Antibiotic (gentamicin and metronidazole) are given, and intravenous fluids if the child is dehydrated. After 24 hours, when the condition has improved, a right transverse colostomy is made. A loop colostomy is simply and quick to perform and satisfactory for decompression, although subsequent prolapse may be troublesome. In infants and older children with subacute presentations, a divided transverse colostomy can be made after investigations have been made the diagnosis HD likely. Definitive treatment consists of excision of the aganglionic bowel segment and restoration of the continuity. This can be achieved by endorectal pull through (Swenson, Soave), retorectal pull through (Duhamel) or low anterior resection with end-to end anastomosis (Rehbein). Personal experience with the Duhamel operation has shown that it is very satisfactory, also in a rural setting. The French paediatric surgeon Duhamel described this operation in 1956, using two Kocher clamps on the septum between the rectum and the pulled through colon. These clamps were left in the anus, causing considerable discomfort and anxiety, until they fall out after 5-7 days. Ravitch described the use of the stapling device, which produces an immediate anastomosis (1). As the price of staplers is prohibitive, I have used an umbilical clamp for this purpose, with good results (2). After 6-8 weeks, when the rectal anastomosis has healed, the colostomy is closed. Follow-up is advisable, as bouts of entercolitis may occur in all HD patients. Results
The Duhamel operation was performed in three patients: in two the Kocher clamps were used and in the third patient an umbilical clamp. In all three, the operation and postoperative period were uneventful, but the child with the umbilical clamp was obviously much more comfortable. After closure of the colostomy, bowel function was essentially normal, but with an increased frequency during the first weeks. Previous experience regarding the long-term outcome shows that a significant number for patients continue to have defaecation problems (3). Whether this is also true for African children remains to be established. It is advisable that children with HD remain under follow-up supervised by the paediatric surgeon. Conclusion
Surgical treatment for HD can be performed satisfactorily in a rural setting with limited means. A high index of suspension is required to identify these patients and refer them in time to a hospital for emergency rectal decompression and subsequent colostomy. Excision of the aganglionic bowel and restoration of the continuity can be performed later by a surgeon with experience in paediatric surgery. Zambia Journal of Medicine & Health Sciences
(Sept. Dec. 1998, Vol. 2 No. 3 & 4)
REPORT ON THE AFRICAN INDEX MEDICUS (AIM) WORKSHOP HELD AT THE
African Index Medicus (AIM) project is an international index to African health literature and information sources. Its objective is improve access to what has been published on health issues in African countries through the creation of regional index. This is done through the creation of national databases to feed into the regional database. This is a project funded by the World Health Organisation Africa Regional Office. From the 31st of May to the 4th of June 1999 the World Health Organisation Regional Office in collaboration with the School of Medicine conducted a workshop for its library staff. The objectives of the workshop course was to teach the participants in the following:
UNIVERSITY OF ZAMBIA MEDICAL LIBRARY FROM THE 31ST OF MAY 4TH JUNE 1999
- Introduction to the African Index Medicus database
- Installation of software
- CDS/ISIS overview/DOS and Windows
- Health Research Dissemination
- Data entry
- Principles of indexing
- Sorting and printing
- AIM project development, management and sustainability
The World Health Representative to Zambia and the Dean of the School of Medicine officially opened the workshop. After the workshop the medical library has been mandated to collect information on health in Zambia with the help of other participating institutions into a database that will input into the regional WHO regional database in Harare Zimbabwe.
It is our hope that access to what has been written and published o health issues in Zambia will become part of the larger wide Africa health information resource base. This project will also greatly feed into the International Training in Medical Informatics for Zambia project by making visible and accessible health information to users.
TREATING DEPRESSION CAN PAVE THE WAY TO A HEALTHIER HEART
Antidepressants not only treat depression, but can also help prevent heart disease. The scientists who have made this discovery think that improved mood makes the difference, rather than direct action by the drugs. People who suffer from severe depression are up to four times as likely to die from heart disease even allowing for classical risk factors such as smoking and high cholesterol levels. Infact, depression is a greater risk factor than smoking.New Scientist No.2187.
AUTHOR INDEX
Ansary, M. A.
Bhat, G.
Buchanan, D. J.
Buve, A.
Chintu, C.
Diwan, V.
Donnelly, M.
DuPont, H. L
Deiniaud F.
Heij, H. A.
Hillis, A.
Hira, S. K.
Foster, S. D.
Kamanga, J.
Kavindele, D.
Kelly, P.
Kjolhede, C.
Luo, C.
Macuacua, R.
Macher, A. M.
Mwase, E. T.
Patil, P. S.
Perine, P. L.
Pegram, R. G
Raviglione, M.
Rosales, F. J.
Sipatunyana, G.
Smith, R. E.
Trinder, P. K.
Van Den Wijngaart, A
Varma, M. G.
Wadham, D.
Williams, P. N.
Wilsmore, A. J.
Zumla, A.
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