Estimating the number of HIV transmissions through reused syringes and needles in the Mbeya Region, Tanzania.

OBJECTIVE: HIV infection attributable to medical injections is suspected to be low, although case-control studies have not provided definite results. This study aims to determine the number of HIV infections caused by the reuse of syringes and needles in the Mbeya Region, Tanzania. METHODS: The direct identification or detection of HIV in syringes and needles under field conditions was not appropriate, therefore a surrogate marker consisting of two components for possible HIV transmission was used: insufficient sterilization, and blood remaining from a previous patient. The assumption was that HIV infection can only occur if both markers are positive. Samples were collected in nine health-care facilities. All syringes and needles prepared for use in these facilities were collected without prior notification. The samples were rinsed and the resulting fluid was cultured for bacteria. Traces of blood were detected by urine stick test for haemoglobin volumes > 0.0015 microliters. RESULTS: Bacterial contamination was found in 32.8% of the total 1219 syringes and needles; 67% was caused by improper handling of the equipment after sterilization. Blood was detected in 12.5% of the samples. In the following three sampling strata, both contamination criteria were positive either on the syringe or the needle: wards/outpatient departments (OPD), 1.39%; laboratories, 7.45%; expanded programme on immunization (EPI), < 0.1%. We calculated that from 1.1 million patients injected in wards/OPD in any 1 year, fewer than 13 become infected, in laboratories fewer than 12 (160,000 blood-taking procedures), and less than one child in the EPI (850,000 vaccinations). CONCLUSION: With an established AIDS intervention programme supporting the health system, less than 0.4% of the total annual incidence of 4500-8500 is attributable to medical injections in the Mbeya Region.

Risk of transfusion-associated HIV transmission in Kinshasa, Zaire.

Between 5 March and 12 April 1990, we assessed transfusion practices and the risk of transfusion-associated HIV transmission in all the hospitals and medical centres in Kinshasa, Zaire. Of the 733 hospitals and medical centres surveyed, 62 (8.5%) transfuse blood. Of 3741 units of blood transfused in February 1990, 1045 (27.9%) were not screened for HIV infection. Eighteen out of 62 centres (29%) received HIV test kits on a regular basis. Twenty of the centres (32.3%) recorded HIV test results. Major blood group cross-matching was done by 9.7% (six out of 62) of the centres. Bacteriological results indicated contamination in 17% (four out of 23) of stocked blood units, 6.4% (four out of 62) of solutions for disinfections, and 22% (13 out of 59) of sterilized instruments (possessed by 59 centres only). Transfusion practices in Kinshasa are associated with considerable health risks. The establishment and appropriate supervision of HIV screening facilities should be integrated into primary health-care programmes in order to increase safe transfusions in Kinshasa.

PIP: Between March 5-April 12, 1990, the authors assessed transfusion practices and the risk of transfusion-associated HIV transmission in all of the hospitals and medical centers in Kinshasa, Zaire. Of the 733 hospitals and medical centers surveyed, 62 (8.5%) transfuse blood. Of 3741 units of blood transfused in February 1990, 1045 (27.9%) were not screened for HIV infection. 18 of 62 centers (29%) received HIV test kits on a regular basis. 20 of the centers (32.3%) recorded HIV test results. Major blood group cross-matching was done by 9.7% (6 of 62) of the centers. Bacteriological results indicated contamination in 17% (4 of 23) of stocked blood units, 6.4% (4 of 62) solutions for disinfections, and 22% (13 of 59) of sterilized instruments (possessed by only 59 centers). Transfusion practices in Kinshasa are associated with considerable health risks. The establishment and appropriate supervision of HIV screening facilities should be integrated into primary healthcare programs in order to increase safe transfusions in Kinshasa.

Lack of neuroprotection by an ACTH (4-9) analogue. A randomized trial in patients treated with vincristine for Hodgkin's or non-Hodgkin's lymphoma.

PURPOSE: This randomized, double-blind, placebo-controlled study evaluates the effect of the corticotropin (4-9) analogue Org 2766 on the neuropathy-free interval in patients receiving vincristine (VCR) containing chemotherapy for Hodgkin's or non-Hodgkin's lymphoma. PATIENTS AND METHODS: In a longitudinal design, 150 patients were evaluated by interview, neurological examination, and neurophysiological techniques. Patients with an expected cumulative VCR dose of at least 8 mg received a single dose of Org 2766 or placebo before and after each intravenous VCR injection and 3-4 weeks after cessation of VCR. The final patient assessment was performed 1 month after discontinuation of study medication. The neuropathy-free interval as the major end point of this study was defined as the first occurrence of bilateral paresthesias and expressed as the administered cumulative VCR dose. This bi-center study represents the largest cohort of patients monitored for the effect of an ACTH-analogue on VCR neurotoxicity. RESULTS: A total of 147 patients were included in the final analysis. No significant differences were observed between the placebo and actively treated group for the major and secondary endpoints. CONCLUSION: Contrary to a single previous pilot study in patients receiving VCR-based chemotherapy, in our study the ACTH (4-9) analogue Org 2766 did not provide protection from VCR-induced neuropathy.

Resistance in vivo of Plasmodium falciparum to co-trimoxazole in western Uganda.

In the context of the 'integrated management of childhood illnesses' (IMCI) programme the World Health Organization recommends treating children in malarious areas presenting with fever and respiratory symptoms with co-trimoxazole. In order to verify its effectiveness in uncomplicated Plasmodium falciparum malaria we carried out a study in vivo in western Uganda: 180 children under 5 years old were enrolled and treated with 40/8 mg/kg/d co-trimoxazole over 5 d, and 159 could be followed on days 3, 7 and 14. Effectiveness of treatment was found to be significantly different in various parts of the study area. In Bundibugyo District, bordering République Democratique du Congo (Zaire), 59.1% (39/66) of children were clinically cured after 14 d and 56.1% were parasitologically cured. In the east of Kabarole District (43 children), the figures were 76.7% and 65.1%, respectively. In western Kabarole (50 children) the rates were 96.0% and 90.0%, respectively. We conclude that, in view of the high level of clinical failures in parts of the study area, co-trimoxazole should not be used in the IMCI programme for combined treatment of malaria and pneumonia in the region. Assessment of therapeutic effectiveness of antimalarial drugs needs to consider the microepidemiology of resistance.

Development of the optokinetic system in macaque monkeys.

Optokinetic nystagmus in response to horizontal movement of a whole field random dot pattern was measured in infant macaque monkeys from the first week to about 5 months after birth using electrooculography. During monocular and binocular viewing conditions stimulus velocities were varied between 10 and 120 degrees/s. Monocular stimulation in the temporonasal direction yielded slow phase gain of the optokinetic system which was relatively constant for a given stimulus velocity over the whole period of observation. Gain during nasotemporal stimulation was also clearly present but significantly lower at early stages and increased during further development. This asymmetry of monocular horizontal optokinetic nystagmus (OKN) clearly depended on the stimulus velocity. At lower stimulus velocities (10-20 degrees/s) OKN was largely symmetrical at 2-5 weeks of age. At higher stimulus velocities (40 degrees/s) symmetry was reached at about 12 weeks of age or even much later (80-120 degrees/s).

Primary health workers in north east Brazil.

One approach to providing primary health care in developing countries is to implement programs which rely on minimally trained primary health workers (PHWs). Originally, such programs were primarily designed for rural areas with intact social structures--where a community--based PHW could easily establish a link between the community and the conventional health services (delivery programs). However, faced with increasing migration of the rural population to urban centers in developing countries, the present need for elementary health care in urban slums raises the question of whether PHWs can also provide health assistance to the population there. This paper deals with the issue of whether PHWs in North East Brazil can improve health care delivery and the health situation of the poor population in rural and urban areas. The investigations covered both PHWs and the population. Questionnaire-guided interviews and participant observation were used as research tools. The conclusion is drawn that the PHW-program there has succeeded, if the PHWs have increased the coverage of the health service delivery and also the level of health-related knowledge, attitudes and practices (KAP) in the population--although with significant differences between rural and urban areas (higher coverage and higher KAP in rural areas). The quality of training and supervision and the characteristics of the area and local framework were also found to influence the quality of the work (performance) of the PHWs.

Financing health services in Sub-Saharan Africa: options for decision makers during adjustment.

The financing of health services has become an increasingly critical and urgent issue in many developing countries particularly in Sub-Saharan Africa. This paper analyses options available to policy makers. The possible effects and side effects of strategies are described based on the experience from different countries. The dangers of simplistic solutions are discussed. A cautious approach is recommended taking into consideration the lessons learned in other regions accompanied by a careful ongoing evaluation especially regarding the ability to pay of the poorer sections of the population. Providing for equity in health care should be an important guiding principle. It therefore appears to be necessary to find an appropriate mix of public and private sector interventions with elements of cost-sharing for services and drugs, insurance schemes and more efficient use of available resources.

The role of research in a technical assistance agency: the case of the 'German Agency for Technical Co-operation'.

Technical assistance agencies have a sustainable impact on the health systems of the countries they are operating in. As well as policy-makers at the national level, technical assistance agencies see themselves confronted that their interventions should be based on evidence, usually meaning the results of research. This study has the aim to analyse role of research in the implementation of technical assistance. We sent a questionnaire to all health project managers of the 'German Agency for Technical Co-operation' and performed a qualitative case study in one of the health projects. Forty-seven of 80 (58.8%) of the questionnaires were completed and sent back. The managers considered publications of International Organisations (IOs), scientific articles and local research as most important for their work. The case study showed application problems in the daily work. Research use not only depends on the relevance of the data but also on analytical skills, linguistic barriers and technical access to research by the potential users. The role of knowledge and information management has to be clearly defined in an organisation of technical assistance. The specific needs at the different levels have to be analysed so that skills and resources can be allocated adequately.

Spontaneous pulmonary neoplasms in cynomolgus monkeys (Macaca fascicularis)--a report of two cases.

The first lung tumour-bearing animal was a 7 years and 3 months old cynomolgus monkey. Microscopic examination revealed a neoplastic mass under the pleura that consisted of squamous islands with little keratinization, multifocal mineralization of the keratin, inflammatory cell and foreign body-type giant cell infiltration. It was classified as pulmonary squamous cell carcinoma. In a second cynomolgus monkey (2 years and 10 months old) a lung mass was observed at necropsy. Microscopically the tumour consisted of numerous islands of cartilage with glandular structures lined by a cuboidal epithelium between them. The neoplasm was classified as cartilaginous hamartoma.

[Obstetrics in the Third World]. / Geburtshilfe in der Dritten Welt.

PIP: According to the World Health Organization, between 1980 and 1985 the total fertility rate was 2.0 in the wealthy countries and 4.1 in the less developed countries. The highest rate was found in Kenya with 8.1. The risk of maternal mortality in connection with pregnancy and childbirth was 1/10,000 in Northern Europe, but 1/21 in Africa. Every year about 500,000 women die because of complications before, during, or after delivery. The maternal mortality rate (30/100,000 live births in Europe) is still 500-800/100,000 in the developing countries, although Tanzania has succeeded in cutting its rate from 450/100,000 to 170/100,000. The main causes of maternal mortality are: 1) unrecognized obstructed labor, 2) postpartum bleeding that could be managed by massaging the uterus, administration of oxytocin or by the manual removal of the placenta, 3) postpartum infections that could be treated by timely administration of antibiotics, 4) preeclampsia that could be detected and treated, and 5) abortion complications requiring effective treatment. Among indirect causes of death is anemia: 66% of pregnant women in developing countries are anemic, compared to 14% in industrialized countries. So far the cause of the reduction of partial immunity against malaria parasites in primiparas has not been explained. A significant percentage of deaths (11-47%) can be traced to unqualified and negligent personnel, especially in the slums and rural areas. Only 52% of deliveries are attended by well-trained health personnel, although in 10% of pregnancies complications arise. Young age is another factor: in 1989 in Tanzania the first pregnancy occurred on the average at age 17.6 years compared to 27 years in England. In the beginning of the 1990s there were an estimated 3 million HIV-infected women, therefore maternal mortality as a consequence of AIDS is going to increase. In high prevalence areas the population growth rate will decline from 3% to 2.4%. Traditional birth attendants could be trained and used effectively to reduce maternal mortality by 3-11% as part of a functioning referral system.^ieng

Protein versus energy in Papua New Guinea.

Protein deficiency has in the past generally been considered the main nutritional problem in the world. This has unduly detracted attention from the need for an adequate energy intake. Using surveys from different areas in Papua New Guinea, it is shown that deteiled investigations are needed to determine actual nutritional needs. In the Sepik a severe energy deficiency was found to be the principal problem. In some Highland areas, on the other hand, a distinct protein deficiency was observed, compounded by a low energy intake in the under 5-years age group. These distinct dietary patterns require a vastly different approach to nutrition intervention. It is shown that nutritional needs in the Sepik could in principle be met by increasing the availability of staple foods. An emphasis on protein would be a misdirected effort for most areas there. In the Highlands emphasis should be placed on legumes particularly those with a high energy value. This could close the protein gap and help to meet the caloric needs of young children.