A tension exists between objectives of health policy makers to achieve high quality standards of care on one hand, and district multi-crisis reality in sub-Saharan Africa on the other hand where sheer survival of the (public) health system is questioned. The collapsing health services as well as the deteriorating living conditions affect the health status of the population and contribute to an increase in (health) inequalities both nationally and internationally. Constraints and some examples of achievements in district health management in two districts in Northern Province, Zambia, are presented. A strong focus on community-based health care, partnership with communities and accelerated health-system support via strengthening of on-site supervision is advocated. Decentralization and self-reliance are potential tools in flexible crisis management, but require continuity in human resource development and appropriate 'care for the carers'. In order to increase operational efficiency, the need is expressed to conceptualize a practical approach of 'minimum primary health care'.
Serum hepatitis B surface antigen (HBsAg) status and ferritin levels were measured in three groups of Nigerian subjects: Group A (n = 14) with non-neoplastic disease (CNLD); Group B (n = 14) with primary hepatocellular carcinoma (PHC); and Group C (n = 14) of healthy matched controls. Serum ferritin values were lowest in Group C, intermediate in Group A, and highest in the Group B patients (all p < 0.05). About 79% of the patients with PHC, 43% of those with CNLD, and none (0%) of the healthy controls had hyperferritinemia (serum ferritin > 400 ng/ml). Hyperferritinemia and HBsAg positivity coexisted in 15% and 73% of the patients with CNLD and PHC, respectively. Hyperferritinemia and HBsAg were significantly positively related in the patients with PHC (chi 2 5.09, p < 0.05). The predictive indices of hyperferritinemia in chronic liver disease appeared superior for PHC than for CNLD, and became somewhat enhanced with coexisting HBsAg positivity. These results suggest that serum ferritin could be useful as a tumor marker for PHC in Nigerian patients with established chronic liver disease.
In order to define characteristics that would help differentiate a centipede bite from a viper bite, we designed a prospective study using the data collection. system of a Poison Control Center, The clinical goal is to rapidly distinguish envenomations for which antitoxin may be indicated (viper) from those for which palliative care only is appropriate (centipede). During a year period, 31 cases, including two cases receiving double bites in each event, were reported, Centipede lengths were estimated to range from 3 to 20 cm, Ninety-two per cent of the bite marks were pointed in shape, A local reaction developed at the bitten site, but usually remaining localized to a 10 X 10 cm area of involvement, The length of the biting animal, the bite mark characteristics, the presence of haemorrhagic vesicles, the wound size and the progression of focal reactions are useful in the rapid clinical differentiation between centipede bites and viper bites.
The effect of nylon-netting wall-curtains impregnated with 0.5 g permethrin/m(2) upon the biting rate of malaria vectors (Anopheles gambiae s.l, and An. funestus) and on the Plasmodium falciparum parasite rate, and morbidity due to malaria in children under five and between five and fourteen years was tested in the Maputo area. The curtains significantly lowered biting rates of both vector species inside curtained houses, but reduced inside resting and outside biting only in An. funestus. The percentage of children with falciparum parasitaemia fell significantly in curtained houses, and among their neighbours. However, parasite load and malaria morbidity in under fives was unaffected but malaria morbidity fell throughout the experimental area in 5 to 14-year olds. This led to the speculation that malaria vectors inhibited from feeding in the vicinity of the curtains might have gone to feed in the adjacent control area.
[NANP](19)-5.1 is a recombinant Plasmodium falciparum vaccine consisting of 19 repeats of the sporozoite surface protein [NANP] and the schizont export antigen 5.1. In a previous study, an experimentally infected subject (with a history of malaria exposure and an elevated pre-immunization lymphocyte stimulation index to antigen 5.1) showed parasitaemia but no signs of clinical malaria, In an attempt to find a comparable partially immune population, we tested the vaccine in 194 schoolchildren (6 to 12 years, vaccine and placebo groups of equal size), who already possessed a certain degree of immunity It was hoped that this immunity would be boosted by the vaccine. During the 12 weeks of observation, no child developed clinical malaria. Analysis of serum taken before and after immunization revealed that, except for eight children, all had considerable levels of antibodies to both antigens. We conclude that the trial should be repeated in younger children who are still vulnerable to clinical malaria.
Sera from patients with visceral leishmaniasis (VL) (n = 26), healthy residents of Mogadishu (n = 157), inhabitants of a village in an endemic area (n = 276) and healthy Swedes (n = 60) were examined using the direct agglutination test (DAT), immunofluorescence (IF) and ELISA for antibodies against Leishmania donovani. The study was carried out in order to provide baseline data for antibody responses in visceral leishmaniasis as existing in Somalia and to explore which one of these methods would be most suitable for diagnosis of clinical cases as well as for epidemiological population studies in Somalia. All patients had high levels of circulating antibodies, however, lower values were recorded in the early stages of the disease. High reactivity in ELISA was seen first after one year. All three tests distinguished well between sera from VL patients and healthy controls. Approximately 10% of the sera from villagers were reactive above the cut-off levels in the three tests. DAT is the simplest to perform and does not require much equipment. ELISA can be made simple and economic if performed in one serum dilution and read visually. IF requires more expensive and specialized equipment and is not suitable for large scale examination of sera. A complete evaluation of the three tests should also include the analysis of sera from various stages and manifestations of the disease.
Rupture of the urinary bladder which is not associated with instrumental or external trauma is uncommon, Two cases of spontaneous bladder perforation were seen in a district general hospital in the Ashanti region, Ghana, Both cases presented with the primary clinical picture of an acute abdomen suggestive of a ruptured viscus, At laparotomy pin-point perforations of the bladder were found to exist, The literature is reviewed with Particular reference to the Possible pathogenesis within a tropical setting.
In a countrywide survey of amoebiasis, a total of 12,457 persons in 97 communities was stool examined by formal-ether concentration technique. The overall prevalences of Entamoeba histolytica infections, as measured by rate of cyst passers, in schoolchildren and non-school communities were 15.0% and 3.5%, respectively. Slightly more females (18.4%) than males (14.2%) were infected among schoolchildren (p<0.05) but the difference was not significant among non-school communities (P>0.05), There was a tendency but not a statistically significant decline of cyst-excretion with increasing age. So far as our survey goes, the influence of altitude on the prevalence of amoebiasis appeared not to be significant. Health education, improvement of sanitation and personal hygiene are suggested as realistic measures to reduce the transmission of this parasite.
The pattern of adult medical deaths in Queen Elizabeth Central Hospital, Blantyre, Malawi was documented over a 12 month period between April 1992 and March 1993. Results were compared with mortality data collected from the same wards in the pre-AIDS era in 1973. Tuberculosis and AIDS together accounted for 49% of all medical deaths in 1992-93. Eighty-two per cent of deaths occurred in the age group 13-49 years; tuberculosis, AIDS, gastroenteritis, pneumonia, pyogenic meningitis and septicaemia were the most important causes of death in these young patients. These findings are very different to those observed in the same wards 20 years previously when tuberculosis was responsible for 13% of deaths and there were no deaths due to AIDS. The predicted upsurge in AIDS-related deaths in sub-Saharan Africa in the 1990s will have grave consequences not only for the health sector, but for the social and economic fabric of the countries concerned.
Caring for persons with HIV infection is particularly difficult in resource-poor countries. In order to improve the quality of care we first have to evaluate how such care is presently organized. We need a better assessment of the needs and demands of persons with HIV infection as well as their families. Care for persons with HIV/AIDS should be decentralized and home-based care in a non-stigmatizing way should be promoted. The fight against discrimination of persons with HIV should be intensified. A lot can be achieved by reorganizing and strengthening existing health care systems, by better listening to patients and families and by promoting solidarity among communities.
A case-control study was carried out among 225 cases and 450 controls aged below 60 months between July and September 1991, with the aim of determining measles vaccine effectiveness (VE) under field conditions in Tabora region, Tanzania. VE was found to be 84% (95% confidence interval (CI) 61-93%) among children vaccinated between 9 and 59 months, and 73% (95% CI: 11-92%) in children vaccinated at the age of 6 to 8 months. Loosening the diagnostic criteria and/or establishing vaccination status from vaccine registers rather than Road to Health cards, lowered vaccine effectiveness results. The protective effectivity among children vaccinated from 6 months and above and those vaccinated from 9 months and above, was 79% (95% CI: 55-90%) and 84% (95% CI: 61-93%) respectively. A relatively higher VE was found in children vaccinated at rural health centres and hospitals, 89% (95% CI: 56-97%) compared with dispensaries, 70% (95% CI: 22-88%). It is high time for the current age at vaccination to be reviewed in the country. It should be noted, however, that the present observations and conclusions are based on a study of limited numbers of persons. Repetition at a large scale would seem indicated.
The objective of this research was to assess the barriers to cataract surgical acceptance by blind rural Malawians recognized and referred for surgical correction at district hospitals. Cataract blind recognized and referred for surgery by the ophthalmic assistants in Chikwawa and Nsanje Districts were interviewed 9-12 months after enrolment to determine if they had undergone cataract surgery and to assess factors associated with surgical acceptance. There were significant gender-specific baseline differences between men and women presenting to the ophthalmic assistants. Patients living near the district hospital were also most likely to present to the ophthalmic assistant. Men with lower socioeconomic status were more likely to accept surgery than men with higher socioeconomic status. Men and women who either talked to someone about cataract surgery or knew another aphakic patients were more likely to accept surgery. The best approaches to improving cataract acceptance given existing resources might be to encourage patients undergoing cataract surgery to educate and motivate others to accept surgery and to train existing village level health staff in cataract recognition and referral. Economic barriers and lack of family support are likely to continue to impede improved cataract surgical acceptance, especially among women.
Though the World Health Organization (WHO) has acted to reduce the price of anti-HIV assays for developing countries, the cost of the large-scale testing to be done may still be prohibitive to the health budget of these countries. GACPAT, a modified commercial particle assay, is ten times cheaper than the WHO price of ELISAs. In this study GACPAT was introduced in three district hospital laboratories (DHL) in Tanzania, and the results compared with those on the same sera in a reference laboratory (RL). Sensitivity and specificity were 92.6% and 98.7%, respectively at DHL. It is concluded that GACPAT is a valid, feasible and cheap alternative for ELISA anti-HIV-testing also at district hospital laboratory level.
The manufacturing of quinine in The Netherlands began shortly after 1820; large scale production started with the foundation of the Amsterdam Chinine Factory in 1881. The quantity of sold quinine in the Province of North-Holland leads retrospectively to the conclusion that an epidemic of malaria had occurred around 1880. At the start of a new epidemic in 1899, it was demonstrated that quinine killed the bloodforms of tertian malaria immediately. However, 50% of the patients experienced a relapse, particularly after interruption of treatment. The length--f the course did not change the chance of relapse. With the beginning of another epidemic in 1919, scientific work and education of the people started in an organized fashion and patients were urged to use quinine only at the prescription of physicians. Because of the inability to prevent relapses, an alternative to quinine was badly needed. In 1930 plasmochin became available, which proved to be useful in combination with quinine. It was not until 1934 that the asymptomatic carriers were recognized as a problem for control because their unobserved parasitic relapses were considered a major source of infection for mosquitoes. In 1939 it was proposed to apply autumnal quininization, which meant a scrupulous screening of the population. The early forties brought yet another major epidemic. Both quinine and Quiniplex were used until the fifties, when endemic malaria disappeared. The new schizonticidal drugs came too late to challenge the primate of quinine in the era of temperate zone Plasmodium vivax in The Netherlands.
The impact of selective treatment with praziquantel (40 mg/kg) on Schistosoma mansoni prevalence and intensity of infection in two annual follow up examinations was measured, The target population was the entire rural area of the northern Nile Delta Governorate, Kafr El Sheikh, from which a probability sample was drawn, The sample included 44 villages and hamlets (ezba), Baseline prevalence was determined by the Examination of stool by two Kato slides and all infected persons treated and reexamined one year later, Those found infected in the second round were treated and examined again one year later, The prevalence and geometric mean egg count declined across all ages in each follow-up (Prevalence: 39.3% (SE +/- 3.3), 28.4% (SE +/- 2.6), and 22.4% (SE +/- 2.3), respectively; and GMEC: 72.9 (SE +/- 7.3), 52.5 (SE +/- 4.5), and 41.9 (SE +/- 2.4), respectively), Reduction in prevalence varied considerably by village and ezba and was strongly related to the proportion of the village or ezba population that was infected and treated (r(2) = 0.29), This latter observation provides a rationale for the maximum application of chemotherapy in the endemic Nile Delta community.
The study aimed to examine the general contribution of motor traffic accidents (MTAs) to the total number of deaths in Dar es Salaam city from 1985 to 1991, and the number of people impaired by MTAs in 1991. Data of deaths from all causes, deaths caused by MTAs and of people impaired by MTAs was collected. In seven years the contribution of MTAs to the total number of deaths was more or less constant (24 to 21 people per 1,000 deaths), with the exception of 1985 (48 per 1,000 deaths). In 1991, a total of 1,829 MTAs were recorded in Muhimbili Medical Centre and these claimed 113 human lives on the spot and impaired 2,834 who had to attend medical services for injuries. The victims were in their prime years (11-40 years). The problem of MTAs in Dar es Salaam reflects those of other urban centres in Africa.
Liquid crystal thermometer (LCT) readings of skin temperatures were compared with mercury thermometer (MT) rectal temperature readings to assess the reliability of LCTs. Temperatures of 498 children were measured at two points in time. LCT skin temperature readings of children 0 to 52 months were on average 0.50 degrees C and 1.97 degrees C lower than MT rectal temperature readings. A strong correlation between temperature differences and LCT readings indicated that the greatest differences occurred at the lower LCT readings. These conclusions indicate LCT skin readings undermeasure temperature. Some of these differences were due to MTs not measuring temperatures below 35 degrees C. Children under 1 year of age had significantly greater differences than any other age group. Their LCT readings were, on average, 1.65 degrees C lower than their MT readings. Using MTs as a standard, LCTs were 100% sensitive and 92% specific for detecting children with hypothermia. LCTs were 38.5% sensitive and 100% specific for detecting fevers. These results suggest that LCTs leave undetected a large proportion of children who have fevers. However, they are sensitive for identifying children with hypothermia. A knowledge, attitude and practice (KAP) study indicated that local mothers can be identified who understand principles and procedures of LCTs, and accept them for health care of their child.
