A contextual exploration of healthcare service use in urban slums in Nigeria.

INTRODUCTION: Many urban residents in low- and middle-income countries live in unfavorable conditions with few healthcare facilities, calling to question the long-held view of urban advantage in health, healthcare access and utilization. We explore the patterns of healthcare utilization in these deprived neighborhoods by studying three such settlements in Nigeria. METHODS: The study was conducted in three slums in Southwestern Nigeria, categorized as migrant, indigenous or cosmopolitan, based on their characteristics. Using observational data of those who needed healthcare and used in-patient or out-patient services in the 12 months preceding the survey, frequencies, percentages and odds-ratios were used to show the study participants' environmental and population characteristics, relative to their patterns of healthcare use. RESULTS: A total of 1,634 residents from the three slums participated, distributed as 763 (migrant), 459 (indigenous) and 412 (cosmopolitan). Residents from the migrant (OR = 0.70, 95%CI: 0.51 to 0.97) and indigenous (OR = 0.65, 95%CI: 0.45 to 0.93) slums were less likely to have used formal healthcare facilities than those from the cosmopolitan slum. Slum residents were more likely to use formal healthcare facilities for maternal and perinatal conditions, and generalized pains, than for communicable (OR = 0.50, 95%CI: 0.34 to 0.72) and non-communicable diseases (OR = 0.61, 95%CI: 0.41 to 0.91). The unemployed had higher odds (OR = 1.45, 95%CI: 1.08 to 1.93) of using formal healthcare facilities than those currently employed. CONCLUSION: The cosmopolitan slum, situated in a major financial center and national economic hub, had a higher proportion of formal healthcare facility usage than the migrant and indigenous slums where about half of families were classified as poor. The urban advantage premise and Anderson behavioral model remain a practical explanatory framework, although they may not explain healthcare use in all possible slum types in Africa. A context-within-context approach is important for addressing healthcare utilization challenges in slums in sub-Saharan Africa.

Antimicrobial use by WHO methodology at primary health care centers: a cross sectional study in Punjab, Pakistan.

BACKGROUND: To investigate the antimicrobial (AM) use and prescribing patterns at primary health care centers (PHCCs) in Punjab, Pakistan. METHODS: A cross-sectional study was designed according to the World Health Organization (WHO) methodology for AM usage from January, 2017 to June, 2017. Standard data collection forms designed by the WHO were used to collect the data from 32 PHCCs (16 rural healthcare centers (RHCs) and 16 basic health units (BHUs)) in Punjab province of Pakistan. PHCCs were randomly selected from 8 main cities. The study sample consisted of prescription records of 6400 outpatients (200 prescriptions records from each PHCC) and 800 inpatients (25 inpatient records from each PHCC). Data of the year 2016 were collected retrospectively by using systematic random sampling technique and analyzed through SPSS. RESULTS: Among the hospital indicators, standard treatment guidelines (STGs) regarding the infectious diseases were not available in PHCCs. Number of days during which key AMs were out of stock was 12.1 days per month (range = 3.1-19.2). Out of total PHCC medicines costs, expenditures on AMs were 26.2% (range = 17.1-39.0). In case of prescribing indicators, the average number of AMs per prescription was 1.4 (range = 1.1-1.7), percentage of prescriptions prescribed with AMs was 81.5% (range = 68.9-89.1) and duration of AM treatment on average was 5.1 days per patient (range = 3.3-6.4). Average cost of prescribed AMs per patient was 1.3 USD (range = 0.6-4.3). The PHCCs prescribed a median of 5 (range = 3-9) types of AMs, including 10 (range = 5-15) individual agents. Out of 79.3% prescriptions of outpatients prescribed with AMs, only 16.4% were properly prescribed. Out of 100% prescriptions of inpatients prescribed with AMs, 12.1% were properly prescribed. Out of all the AM prescriptions 23.6% contained penicillins, 20.1% contained cephalosporins and 19.4% contained fluoroquinolones Metronidazole (18.0%), ciprofloxacin (16.5%) and co-amoxiclav (14.3%) were most commonly prescribed AMs. CONCLUSIONS: In PHCCs, AMs were prescribed more frequently. However large proportions of these prescriptions were inappropriate. Continuous education and training of medical staff and cost effective policies could play an important role in promotion of rational use of AMs.

Multivariate time series analysis on the dynamic relationship between Class B notifiable diseases and gross domestic product (GDP) in China.

The surveillance of infectious diseases is of great importance for disease control and prevention, and more attention should be paid to the Class B notifiable diseases in China. Meanwhile, according to the International Monetary Fund (IMF), the annual growth of Chinese gross domestic product (GDP) would decelerate below 7% after many years of soaring. Under such circumstances, this study aimed to answer what will happen to the incidence rates of infectious diseases in China if Chinese GDP growth remained below 7% in the next five years. Firstly, time plots and cross-correlation matrices were presented to illustrate the characteristics of data. Then, the multivariate time series (MTS) models were proposed to explore the dynamic relationship between incidence rates and GDP. Three kinds of MTS models, i.e., vector auto-regressive (VAR) model for original series, VAR model for differenced series and error-correction model (ECM), were considered in this study. The rank of error-correction term was taken as an indicator for model selection. Finally, our results suggested that four kinds of infectious diseases (epidemic hemorrhagic fever, pertussis, scarlet fever and syphilis) might need attention in China because their incidence rates have increased since the year 2010.

Trends in Infectious Disease Hospitalizations in US Children, 2000 to 2012.

BACKGROUND: Although infectious diseases (IDs) remain a major public health problem in US children, there have been no recent efforts to examine comprehensively the change in epidemiology of ID hospitalizations. METHODS: A serial cross-sectional analysis using the Kids' Inpatient Database 2000, 2003, 2006, 2009, and 2012. We identified children ≤19 years of age with a primary diagnosis of IDs. Outcomes were national rate of ID hospitalizations, in-hospital mortality, length-of-stay and hospitalization-related direct costs. Negative binomial and multivariable logistic models were constructed to test the change in hospitalization rate and in-hospital mortality, respectively. RESULTS: We identified 3,691,672 weighted hospitalizations for IDs, accounting for 24.5% of all pediatric hospitalizations. From 2000 to 2012, the rate of overall ID hospitalizations decreased from 91.0 to 75.8 per 10,000 US children (P < 0.001). The most frequently listed ID subgroup was lower respiratory infections (42.8% of all ID hospitalizations in 2012). Although the hospitalization rate for most ID subgroups decreased, the hospitalization rate for skin infections significantly increased (67.6% increase; P < 0.001). The multivariable model demonstrated a significant decline in in-hospital mortality (odds ratio for comparison of 2012 with 2000, 0.63; 95% confidence interval, 0.51-0.79). From 2000 to 2012, there was no significant change in the median length-of-stay (2 days in 2000 to 2 days in 2012; Ptrend = 0.33). The median direct cost for ID hospitalization increased from $3452 in 2003 to $3784 in 2012 (P = 0.007), with the nationwide direct cost of $4.4 billion in 2012. CONCLUSIONS: We found a statistically significant decline in overall ID hospitalization rate among US children from 2000 to 2012, whereas skin infections statistically significantly increased. In addition, the median direct cost per ID hospitalization increased by 10% during the study period.

Infectious Disease-related Emergency Department Visits Among Children in the US.

BACKGROUND: Although most research on infectious diseases (IDs) has focused on hospitalizations, this provides an incomplete picture of healthcare utilization. We describe the burden and epidemiologic features of ID-related emergency department (ED) visits among U.S. children. METHODS: We conducted a cross-sectional analysis of the Nationwide Emergency Department Sample, a nationally representative sample of ED patients. We identified children who presented to the ED with a primary diagnosis of ID. Outcome measures were ID-related ED visits, hospitalizations through the ED and ED charges. RESULTS: During 2011, we identified 1,914,509 ID-related ED visits among U.S. children, corresponding to a weighted estimate of 8,524,357 ED visits. This accounted for 28% of all ED visits by children. The frequency of ID-related ED visits was 10,290 visits per 100,000 children. The most common diagnoses were upper respiratory infection (41%), otitis media (18%) and lower respiratory infection (14%). Overall, 62% of ID-related ED visits were made by children with Medicaid; 35% were by those in the lowest income quartile. Among the ID-related ED visits, 424,725 (5%) resulted in hospitalization, with 513 hospitalizations per 100,000 children. The most common reason for hospitalization was lower respiratory infection, which accounted for 40% of all ID-related hospitalizations from the ED. Median charge per ED visit was $718, with total annual charges of $9.6 billion. CONCLUSIONS: The public health burden of IDs, as measured by ED visits, subsequent hospitalizations and associated charges, was substantial. We also found that children with markers of lower socioeconomic status comprised a disproportionately high proportion of ID-related ED visits.

Engaging new migrants in infectious disease screening: a qualitative semi-structured interview study of UK migrant community health-care leads.

Migration to Europe - and in particular the UK - has risen dramatically in the past decades, with implications for public health services. Migrants have increased vulnerability to infectious diseases (70% of TB cases and 60% HIV cases are in migrants) and face multiple barriers to healthcare. There is currently considerable debate as to the optimum approach to infectious disease screening in this often hard-to-reach group, and an urgent need for innovative approaches. Little research has focused on the specific experience of new migrants, nor sought their views on ways forward. We undertook a qualitative semi-structured interview study of migrant community health-care leads representing dominant new migrant groups in London, UK, to explore their views around barriers to screening, acceptability of screening, and innovative approaches to screening for four key diseases (HIV, TB, hepatitis B, and hepatitis C). Participants unanimously agreed that current screening models are not perceived to be widely accessible to new migrant communities. Dominant barriers that discourage uptake of screening include disease-related stigma present in their own communities and services being perceived as non-migrant friendly. New migrants are likely to be disproportionately affected by these barriers, with implications for health status. Screening is certainly acceptable to new migrants, however, services need to be developed to become more community-based, proactive, and to work more closely with community organisations; findings that mirror the views of migrants and health-care providers in Europe and internationally. Awareness raising about the benefits of screening within new migrant communities is critical. One innovative approach proposed by participants is a community-based package of health screening combining all key diseases into one general health check-up, to lessen the associated stigma. Further research is needed to develop evidence-based community-focused screening models - drawing on models of best practice from other countries receiving high numbers of migrants.

Impact on and use of an inner-city London Infectious Diseases Department by international migrants: a questionnaire survey.

BACKGROUND: The UK has witnessed a considerable increase in immigration in the past decade. Migrant may face barriers to accessing appropriate health care on arrival and the current focus on screening certain migrants for tuberculosis on arrival is considered inadequate. We assessed the implications for an inner-city London Infectious Diseases Department in a high migrant area. METHODS: We administered an anonymous 20-point questionnaire survey to all admitted patients during a 6 week period. Questions related to sociodemographic characteristics and clinical presentation. Analysis was by migration status (UK born vs overseas born). RESULTS: 111 of 133 patients completed the survey (response rate 83.4%). 58 (52.2%) were born in the UK; 53 (47.7%) of the cohort were overseas born. Overseas-born were over-represented in comparison to Census data for this survey site (47.7% vs 33.6%; proportional difference 0.142 [95% CI 0.049-0.235]; p = 0.002): overseas born reported 33 different countries of birth, most (73.6%) of whom arrived in the UK pre-1975 and self-reported their nationality as British. A smaller number (26.4%) were new migrants to the UK (< or =10 years), mostly refugees/asylum seekers. Overseas-born patients presented with a broad range and more severe spectrum of infections, differing from the UK-born population, resulting in two deaths in this group only. Presentation with a primary infection was associated with refugee/asylum status (n = 8; OR 6.35 [95% CI 1.28-31.50]; p = 0.023), being a new migrant (12; 10.62 [2.24-50.23]; p = 0.003), and being overseas born (31; 3.69 [1.67-8.18]; p = 0.001). Not having registered with a primary-care physician was associated with being overseas born, being a refugee/asylum seeker, being a new migrant, not having English as a first language, and being in the UK for < or =5 years. No significant differences were found between groups in terms of duration of illness prior to presentation or duration of hospitalisation (mean 11.74 days [SD 12.69]). CONCLUSION: Migrants presented with a range of more severe infections, which suggests they face barriers to accessing appropriate health care and screening both on arrival and once settled through primary care services. A more organised and holistic approach to migrant health care is required.

Toxic neutrophils in cats: clinical and clinicopathologic features, and disease prevalence and outcome--a retrospective case control study.

Toxic neutrophils exhibit a variety of nuclear and cytoplasmic abnormalities in Romanowsky-stained blood smears, and are associated with inflammation and infection. The purpose of the retrospective study reported here was to investigate the association of toxic neutrophils with clinicopathologic characteristics, diseases, and prognosis in cats. Cats with toxic neutrophils (n = 150) were compared with negative-control cats (n = 150). Statistical analyses included Fisher exact, independent t-, nonparametric Mann-Whitney, and chi-squared tests. Cats with toxic neutrophils had significantly (P < .05) higher prevalence of fever, icterus, vomiting, diarrhea, depression, dehydration, weakness, and cachexia, as well as leukocytosis, neutrophilia, left shift, neutropenia, anemia, hypokalemia, and hypocalcemia. The prevalence of shock, sepsis, panleukopenia, peritonitis, pneumonia, and upper respiratory tract diseases was significantly higher among these cats, as were infectious (viral and bacterial) and metabolic disorders. Control cats had a significantly higher prevalence of feline asthma, as well as allergic, idiopathic, and vascular disorders. Hospitalization duration and treatment cost were significantly (P < .001) higher in cats with toxic neutrophils. In 53 and 47% of the cats with toxic neutrophils, the leukocyte and neutrophil counts were normal, respectively, whereas in 43%, both abnormalities and left shift were absent, and toxic neutrophils were the only hematologic evidence of inflammation or infection. In conclusion, toxic neutrophils were found to be associated with certain clinicopathologic abnormalities, and when present, may aid in the diagnosis, as well as the assessment of hospitalization duration and cost. The evaluation of blood smears for toxic neutrophils provided useful clinical information.

The study of infectious intestinal disease in England: socio-economic impact.

To assess the socio-economic impact of infectious intestinal disease (IID) on the health care sector, cases and their families, cases of IID ascertained from a population cohort component and those presenting to general practices were sent a socio-economic questionnaire 3 weeks after the acute episode. The impact of the illness was measured and the resources used were identified and costed. The duration, severity and costs of illness linked to viruses were less than those linked to bacteria. The average cost per case of IID presenting to the GP was Pound Sterling253 and the costs of those not seeing a GP were Pound Sterling34. The average cost per case was Pound Sterling606 for a case with salmonella, Pound Sterling315 for campylobacter, Pound Sterling164 for rotavirus and Pound Sterling176 for SRSV. The estimated cost of IID in England was Pound Sterling743m expressed in 1994/5 prices. The costs of IID are considerable and the duration of the illness was found to be longer than previous reports have suggested.

An assessment of health and disease in the prehistoric inhabitants of the Mariana Islands.

Using a variety of skeletal and dental stress indicators, an assessment of the health and disease of the indigenous inhabitants of the Mariana Islands, the Chamorro, is made. The major hypothesis to be tested is that the Chamorro were relatively healthy and that deviations from the expected, as well as inter-island variation, may reflect environmental, ecological, and cultural differences. The major skeletal series surveyed include sites on Guam (N = 247 individuals), Rota (N = 14), Tinian (N = 20), and Saipan (N = 102). The majority of the specimens are from the transitional pre-Latte (AD 1-1000) and Latte (AD 1000-1521) periods. These data derive primarily from unpublished osteological reports. The indicators of health and disease surveyed include mortality and paleodemographic data, stature, dental paleopathology, cribra orbitalia, limb bone fractures, degenerative osteoarthritis, and infectious disease (including treponemal infection). Where appropriate, tests of significance are calculated to determine the presence of any patterning in the differences observed within and between the skeletal series. Information recorded in prehistoric Hawaiians provides a standard for external comparisons. Several of the larger skeletal series surveyed have paleodemographic features that are consistent with long-term cemetery populations. Females and subadults are typically underrepresented. Most subadult deaths occur in the 2-5 year age interval. Life expectancy at birth ranges from 26.4 to 33.7 years. A healthy fertility rate is indicated for these series. The prehistoric inhabitants of the Mariana Islands were relatively tall, exceeding living Chamorros measured in the early part of the present century. The greater prevalence of developmental defects in the enamel suggests that the Chamorro were exposed to more stress than prehistoric Hawaiians. The low frequency of cribra orbitalia further indicates iron deficiency anemia was not a problem. There are generally low frequencies of dental pathology in the remains from the Mariana Islands. Betel-nut staining is relatively common in all series which may help to explain the relatively low prevalence of dental pathology. Healed limb bone fractures are rare in these skeletal series; the frequency and patterns of fractures suggest accidental injury as the main cause. Greater physical demands involving the lower back region are indicated by a high frequency of spondylolysis, or stress fracture in the lumbar vertebrae in the Chamorro. Likewise, advanced degenerative bone changes, while of low occurrence, are significantly greater in the Chamorro than Hawaiians. The prevalence of skeletal and dental indicators of stress was generally higher in the smaller islands of the Mariansas chain (e.g., Rota), islands with fewer resources to buffer environmental catastrophe. Bony changes suggestive of treponemal (probably yaws) disease are common in most of these Marianas Islands skeletal series.