Providing Hemodialysis in Unstable Areas: An Assessment and Framework for Effective Care.

Introduction: Providing hemodialysis to patients with kidney failure (KF) in conflict-affected areas poses a significant challenge. Achieving and sustaining reasonable quality hemodialysis operations in such regions necessitates a comprehensive approach. Methods: In the conflict area of Northwest (NW) Syria, a 3-phase project was initiated to address the quality of hemodialysis operations. The assessment phase involved the examination of infection prevention and control (IPC) protocols, staff training, medical protocols, individualized hemodialysis prescriptions, and laboratory testing capabilities. The second phase involved activities toward capacity building and implementing an action plan based on feasibility and sustainability. Results: The assessment phase revealed that only 7 of 14 centers had IPC protocols, and 8 centers provided IPC training for their staff. Furthermore, only 7 centers had medical protocols, and 5 used individualized hemodialysis prescriptions. Difficulties in testing for potassium was reported in 7 centers and the inability to perform hepatitis B and C serologies was reported in 3 centers. Only 2 centers adhered to machine and water treatment system maintenance guidelines, and 4 conducted daily water quality checks. Recommendations were formulated, and an action plan was developed for implementation in the second phase. The plan encompassed enhancements in IPC practices, medical protocols, record-keeping, laboratory testing, and equipment maintenance. Conclusion: This project underscores that hemodialysis services in conflict-affected areas do not meet the standards for quality care. It emphasizes the necessity of implementing a comprehensive framework that engages relevant stakeholders in defining and upholding quality care, a model that should be extended to other protracted conflict-affected regions.

Dilemmas and controversies within civilian and military organizations in the execution of humanitarian aid in Iraq: a review.

Civilian humanitarian assistance organizations and military forces are working in a similar direction in many humanitarian operations around the world. However, tensions exist over the role of the military in such operations. The purpose of this article is to review cultural perspectives of civilian and military actors and to discuss recent developments in civil-military humanitarian collaboration in the provision of health services in Iraq for guiding such collaborative efforts in postconflict and other settings in future. Optimal collaborative efforts are most likely to be achieved through the following tenets: defining appropriate roles for military forces at the beginning of humanitarian operations (optimally the provision of transportation, logistical coordination, and security), promoting development of ongoing relationships between civilian and military agencies, establishment of humanitarian aid training programs for Department of Defense personnel, and the need for the military to develop and use quantitative aid impact indicators for assuring quality and effectiveness of humanitarian aid.

Doctors leaving 12 tertiary hospitals in Iraq, 2004-2007.

Medical doctors leaving less developed countries are now part of a global labour market. This doctor migration has been extensively studied from economic and health systems perspectives. Seldom, however has the specific role of the conflict or the collapsing state been considered as a cause of migration. Using hospital staffing records we measured the changes in numbers of medical specialists at 12 Iraqi tertiary hospitals (in Baghdad, Basra, Erbil and Mosul) between 2004 and 2007. For doctors leaving their posts, we attempted to determine destinations and circumstances of departure. We counted 1243 specialists in the 12 hospitals on January 1, 2004. This declined to 1166 or 94% of the original number by late 2007. In Baghdad, specialists decreased to 78% by late 2007, Outside Baghdad, specialists numbered 134% of the original count by 2007. In Baghdad, replacements kept pace with losses until 2005, with loss rates peaking in 2006 at 29%. Outside Baghdad, gains exceeded losses each year. Violent event rates associated with the migration of doctors were estimated as: threats 30/1000 doctors; kidnappings 6.7/1000; violent deaths 16.5/1000, and any violent event 36.7/1000. Specialists who left Baghdad were 2.5 times more likely to experience a violent event than doctors elsewhere. Specialists departing teaching hospitals were 2.3 times more likely to experience a violent event than those in general hospitals. Of specialists leaving hospital posts for which data were available, 39% went elsewhere in Iraq and 61% left the country. These findings suggest a major loss of human capital from Iraq's hospital sector, a loss that is likely to require some years to fully replace.

Population-based tuberculin skin testing and prevalence of tuberculosis infection in Afghanistan.

OBJECTIVE: A tuberculin skin-test survey was conducted in eight provinces of Afghanistan to estimate the prevalence and annual risk of tuberculosis infection among the Afghan population. METHODS: A cluster survey in eight Afghan provinces, chosen based on population density and geographic distribution, was carried out between October and February 2006. Interviews were conducted and tuberculin skin tests were administered and read. FINDINGS: 11,413 individuals participated in the study. Using the international standard cut-off of >or= 10 mm, tuberculosis prevalence and annual risk of infection in the population were 15% (CI: 14.4-15.7) and 0.80 (CI: 0.76-0.84), respectively. Tuberculosis prevalence was higher in rural than in urban areas. Other risk factors included age, prior tuberculosis treatment or contact, productive cough or cough >3 weeks, no prior bacille Calmette Guérin (BCG) vaccination and a cooking fire in the sleeping room. CONCLUSIONS: The survey documented a lower prevalence and risk of tuberculosis infection than the 1978 national survey and a substantially lower estimate of incidence of new smear-positive tuberculosis cases than World Health Organization estimates. However, other findings suggest that active tuberculosis may remain widespread and undiagnosed, and indicate a need for both additional research and continued investment in tuberculosis treatment and prevention, and in health infrastructure.

Violence-related mortality and morbidity of humanitarian workers.

OBJECTIVES: (1) To determine the rate of violence-related deaths, medical evacuations, and hospitalizations occurring to national and expatriate staff of participating humanitarian organizations; (2) to describe the distribution of all-cause and cause-specific mortality and morbidity of humanitarian workers with regard to possible risk factors. DESIGN: Surveillance study of field-based humanitarian workers; data were regularly collected from headquarters of participating organizations via e-mail and telephone between September 2002 and December 2005. PARTICIPANTS: Eighteen humanitarian organizations reported on any death, medical evacuation, or hospitalization of any national or expatriate staff for any cause, in any field location during the study period. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Risk of violence-related events was calculated as the number of deaths, medical evacuations, and hospitalizations during the study period divided by the total number of field staff for organizations that had staff in those countries where events occurred to the staff of any participating organization. Distribution descriptions are presented as simple proportions. RESULTS: Risk of violence-related deaths, medical evacuations, and hospitalizations was six per 10,000 aid worker person-years. Fifty percent of intentional violence cases were lethal. Intentional violence accounted for 55 percent of all deaths reported, followed by coincidental illness (27 percent) and accidents (15 percent). CONCLUSIONS: Aid worker deaths in this group were more frequently caused by intentional violence than either accidents or coincidental illness. The rate of six intentional violence events per 10,000 person-years can be used as a baseline by which to track changes in risk over time.

Prevalence of human immunodeficiency virus infection, risk behavior, and HIV knowledge among tuberculosis patients in Afghanistan.

OBJECTIVES/GOAL: To assess prevalence and correlates of human immunodeficiency virus (HIV) infection, risk factors, and HIV knowledge among tuberculosis patients in Afghanistan. STUDY DESIGN: Adult participants undergoing treatment for tuberculosis in this cross-sectional study completed a questionnaire and HIV testing between November 2005 and February 2006. Prevalence of HIV and high-risk behaviors were calculated, with correlates of high-risk behavior and relevant knowledge assessed. RESULTS: Of 1163 participants, 2 (0.2%, 95% CI: 0.0-0.6) were HIV-infected. Known risk factors for HIV infection, such as paying women for sex or male to male sexual contact, were rarely reported, though receipt of injections from a nonmedical provider was common (38%). Symptoms suspicious for sexually transmitted infection were reported by 5% of the population and were significantly associated with young (<26 years) age (OR: 3.2, 95% CI: 1.7-6.0). Relatively, a few participants had ever heard of HIV (23%) or condoms (25%). Condom use was significantly more frequent among those 26 and older (OR: 2.9, 95% CI: 1.7-5.2) and among male participants (OR: 1.5, 95% CI: 1.0-2.2). CONCLUSIONS: HIV prevalence among tuberculosis patients in Afghanistan is currently quite low. However, lack of knowledge of HIV and engaging in high-risk practices, particularly regarding health, make this group vulnerable. Health education sessions regarding HIV, sexually transmitted infection, and blood-borne infections should be implemented for tuberculosis patients during the treatment course.

Discontinuation of cost sharing in Uganda.

OBJECTIVE: To assess the effects of ending cost sharing on use of outpatient services and how this was perceived by health workers and members of a health unit management committee. METHODS: From 10 districts across Uganda, 78 health facilities were selected. Attendance at these facilities was assessed for eight months before and 12 months after cost sharing ended. The data represented 1 966 522 outpatient visits. Perceptions about the impact of ending cost sharing were obtained from the 73 health workers and 78 members of the health unit management committee who were available. FINDINGS: With the end of cost sharing, the mean monthly number of new visits increased by 17 928 (53.3%), but among children aged <5 years the increase was 3611 (27.3%). Mean monthly reattendances increased by 2838 (81.3%) among children aged <5 years and 1889 (24.3%) among all people. Attendances for immunizations, antenatal clinics, and family planning all increased, despite these services having always been free. Health workers reported a decline in morale, and many health unit management committees no longer met regularly. CONCLUSION: Use of all services increased - even those that had never before been subject to fees. The loss of some autonomy by the health facility and diminished community governance of health facilities may have long term negative effects.

Quality design: a planning methodology for the integration of refugee and local health services, West Nile, Uganda.

In an emergency, the international community responds to the immediate health needs of refugees through the establishment of action-oriented, life-saving services. Healthcare delivery is often managed with limited, if any, coordination with local health management structures. In situations where refugees remain in the host country for many years, sustainability issues inevitably arise. Refugee-hosting governments may ultimately be called upon to assume the management and funding of refugee services. Planning for service integration, while protecting against declines in service quality, is a challenge in the typically resource-poor host environments. This paper discusses these issues by presenting the experience of the West Nile districts in northern Uganda, and describes quality design as a relevant planning methodology. Quality design is a systematic planning approach that documents and directly incorporates the service users' self-defined expectations and needs.