The ALERT MDT Field Evaluation Study (AMFES): a descriptive study of leprosy in Ethiopia. Patients, methods and baseline characteristics.

The ALERT MDT Field Evaluation Study (AMFES) is a long-term prospective study of 650 patients (594 new cases and 56 relapses after dapsone monotherapy), treated with fixed-duration multiple-drug therapy (MDT), as recommended by WHO. Follow-up has continued for up to 11 years from the start of treatment. This paper presents the methodology of the study and the baseline characteristics of the cohort, while accompanying papers examine the incidence of, and possible risk factors for, the various complications of leprosy, including relapse, reactions and nerve function impairment. The methods of diagnosis, classification and treatment with MDT are described; nerve function was assessed at every visit to the clinic using a standardized methodology, so that reactions and new impairment could be detected early and treated. Eighty-four per cent of new case had at least one thickened nerve, with the ulnar nerve most commonly involved. Seventy-seven per cent of cases completed treatment and only one adverse reaction to the MDT drugs was noted. Twenty-eight per cent of all patients were given steroids at one time or another, almost always for new nerve function impairment, and 3% of these developed significant complications of steroid treatment. Twenty-nine patients (5%) received hospital care, including 14 patients who underwent major surgery. Sixty-one per cent of the women over 19 years of age had at least one pregnancy, but pregnancies were much less common after leprosy was diagnosed.

Guidelines for anal cytology--to make cytological diagnosis and follow up much more reliable.

Anal intraepithelial neoplasia is a difficult diagnostic and management problem, particularly when it occurs in women with synchronous or metachronous genital intraepithelial neoplasia. Diagnosis and follow up by colposcopy is too specialized for widespread use, and although anal cytology has been used before it has been thought of as too inconsistent for practical application. This study standardized collection of specimens and investigated interobserver variation. The aim of the study was to determine whether observers could reliably distinguish high grade anal intraepithelial neoplasia from other conditions. Standardized collection of anal preparations was achieved in the host centre. A meeting of experienced cytopathologists was convened to agree guidelines for anal cytology. These guidelines were sent to the panel of six observers who were subsequently circulated with 30 cytopathological preparations in random order and asked to report them all. The results were collected and processed centrally. Four individuals were in complete agreement about those preparations which were inadequate for reporting, but two others had a lower threshold for rejecting preparations as inadequate. There was agreement between the observers in over 95% of cases in distinguishing high grade intraepithelial neoplasia from other cytological conditions. Kappa values range from 0.66 to 1.00. This study demonstrates that the provision of guidelines for the interpretation of anal cytopathological preparations can result in a high degree of interobserver agreement about the clinically important distinction between high grade anal intraepithelial neoplasia and other conditions. Anal cytology is a more useful technique for diagnosis and follow up of 'at risk' individuals than has previously been suggested, and should be utilized more widely in this group of patients.

A one-year community study of under-fives in rural Ethiopia: health and behavioural determinants of morbidity.

Based on a one-year weekly home surveillance study, morbidity patterns of 1,304 children under five years of age in a rural Ethiopian community were measured, together with nutritional and health behavioural determinants. Using Poisson regression models, the study showed that nutritional and health care factors make a significant impact on under-five morbidity. Gastroenteritis was particularly associated with child care factors, while acute respiratory infections were particularly associated with nutritional factors. Lack of immunization, low birthweight and pre-term delivery (more than one month early) were not found to have any independent effect on morbidity. Breast feeding was universal, but the introduction of supplementary foods was found to protect from excess morbidity. The study concludes by discussing possible applications of the results in intervention programmes.

PIP: In southern central Ethiopia, weekly interviews with mothers of 1315 children aged 0-5 years over a period of one year were conducted so public health workers could analyze child health and nutritional and obstetric determinants of the under-five population in the Butajira Rural Health Project. 99.4% of the children were breast fed at birth. By age 4 months, only 0.8% of them had stopped. Introduction of supplementary foods appeared to protect from excess morbidity. The median age for termination of breast feeding was 27 months. Children receiving care from a public health service facility had slightly lower morbidity rates than those receiving assistance from a pharmacy, community health agent, or a traditional herbalist. Less than 50% of mothers sought medical care from local health facilities. Birth order and variables associated with prenatal care and delivery did not affect subsequent morbidity independently of other variables. The presence and involvement in child care of both parents had a beneficial effect on morbidity. In terms of morbidity, children benefited from sleeping with adults. Fully immunized children were at lower risk of morbidity than those not fully immunized. Gastroenteritis was particularly associated with child care factors (health care source, parents, sleeping, immunization, and sunshine exposure). On the other hand, acute respiratory infections (ARI) were particularly associated with nutritional factors (breast feeding, cow's milk, formula milk, porridge, cereal, meat, vegetable protein, and fruit and vegetables). Lack of immunization, low birth weight, and pre-term delivery (1 month early) did not have an independent effect on morbidity. These findings will be used to prepare for an intervention study on ARI.

The relationship between anthropometric measurements and measurements of iron status and susceptibility to malaria in Gambian children.

Anthropometric measurements were made and serum iron and ferritin levels determined in a group of Gambian children at the beginning of the rainy season and these findings were related to the malaria experience of the children during the following malaria transmission season. Susceptibility to malaria was not correlated with prior weight-for-age, height-for-age, weight-for-height or serum albumin, or with serum iron, serum iron binding capacity nor serum ferritin. Thus, our findings do not provide any support for the view that poor nutritional status, as assessed by anthropometric measurements, or iron deficiency protect against malaria infection. Children who developed a clinical attack of malaria accompanied by a high level of parasitaemia tended to have a higher mean weight-for-age at the beginning of the rainy season than did children who had a clinical attack accompanied by a low level of parasitaemia, but the difference between groups was not statistically significant. However, they had a significantly higher mean serum ferritin level (P less than 0.01).

Cellular immune responses to Plasmodium falciparum antigens in children receiving long term anti-malarial chemoprophylaxis.

Fifty-two Gambian children who had received fortnightly chemoprophylaxis with maloprim, (pyrimethamine and dapsone), and 45 receiving placebo, were studied. Cellular immune responses to malaria antigens, measured by lymphoproliferative responses and interferon production, were higher in children who had received prophylaxis than in controls, although the anti-malarial antibody levels were lower. During a one-year period after termination of prophylaxis, there was no increase in the frequency of clinical episodes of malaria in the children who had received Maloprim. These results suggest that chemoprophylaxis for 3 years may lower malaria antibody levels, but does not interfere with the development of protective immunity, perhaps by enhancing cell-mediated immune responses to malaria in protected children.

Immunity to malaria in young Gambian children after a two-year period of chemoprophylaxis.

A cohort of 48 Gambian children was protected against malaria by fortnightly administration of Maloprim (pyrimethamine and dapsone) for 2 years between their 3 and 5 birthdays. A matched cohort of 47 children received placebo. During the year following the termination of prophylaxis there was no increase in the frequency of clinical attacks of malaria in the protected children compared with the control children. Antibody levels to circumsporozoite protein were measured by a radioimmunoassay and that to blood-stage antigens by a variety of techniques including an ELISA to whole blood-stage Plasmodium falciparum antigen, immunofluorescent assays (IFAT) to acetone fixed, glutaraldehyde fixed and unfixed parasites, a merozoite inhibition test and an opsonizing assay. Antibody levels were, in general, lower in protected than in control children and several differences between the two groups were statistically significant. When antibody levels were measured by ELISA and IFAT at the end of the following rainy season, when malaria transmission was intense, those in protected children had increased to comparable levels to those found in control children. Our findings suggest that chemoprophylaxis given for 2 years lowers malaria antibody levels but that it does not interfere with the development of protective immunity.

A prospective survey of the outcome of pregnancy in a rural area of the Gambia.

PIP: Pregnancy outcome was studied in 672 women over a 1-year period in a rural area of Gambia where medical resources were very limited, prior to the introduction of a primary health care program. Maternal mortality was quite high (22/1000), primarily the result of postpartum hemorrhage and infections. Stillbirth and neonatal death rates were also very high (35 and 65/1000); prematurity and infections were the primary causes of neonatal deaths. First or late pregnancies, either prior to age 20 or after age 40, and multiple pregnancies were all associated with a poor pregnancy outcome. Women in these groups should therefore be encouraged by traditional birth attendants and by the staff of rural antenatal clinics to deliver at a health center or hospital.^ieng