Cost of Cholera for Households and Health Facilities, Somalia.

INTRODUCTION: Cholera remains a substantial public health challenge in Somalia. Ongoing droughts in the country have caused significant outbreaks which have negatively affected the lives of many individuals and overwhelmed health facilities. We aimed to estimate the costs associated with cholera cases for households and health facilities in Somalia. METHODS: This cost-of-illness study was conducted in five cholera treatment centres in Somalia and 400 patients treated in these facilities. Data collection took place during October and November 2023. Given that a significant portion of the patients were children, we interviewed their caregivers to gather cost data. We interviewed staff at the centres and the patients. The data obtained from the household questionnaire covered direct (medical and non-medical) and indirect (lost wages) costs, while direct costs were estimated for the health facility (personnel salaries, drugs and consumables used to treat a patient, and utility expenses). All costs were calculated in US dollars (USD), using 2023 as the base year for the estimation. RESULTS: The average total cost of a cholera episode for a household was US$ 33.94 (2023 USD), with 50.4% (US$ 17.12) being direct costs and 49.6% (US$ 16.82) indirect costs. The average total cost for a health facility to treat an episode of cholera was US$ 82.65. The overall average cost to households and health facilities was US$ 116.59. The average length of stay for a patient was 3.08 days. In the households, patients aged 41 years and older incurred the highest mean total cost (US$ 73.90) while patients younger than 5 years had the lowest cost (US$ 21.02). Additionally, 61.8% of households had to use family savings to cover the cost of the cholera episode, while 14.5% had to borrow money. Most patients (71.8%) were younger than 16 years- 45.3% were 5 years or younger- and 94.0% had never received a cholera vaccine. CONCLUSION: Our study suggests that preventing one cholera episode in Somalia could avert substantial losses for both the households and cholera treatment centres. The findings shed light on the expenses associated with cholera that extend beyond healthcare, including substantial direct and indirect costs borne by households. Preventing cholera cases could lead to a decrease in this economic burden, consequently our study supports the need for preventive measures.

Modelling testing and response strategies for COVID-19 outbreaks in remote Australian Aboriginal communities.

BACKGROUND: Remote Australian Aboriginal and Torres Strait Islander communities have potential to be severely impacted by COVID-19, with multiple factors predisposing to increased transmission and disease severity. Our modelling aims to inform optimal public health responses. METHODS: An individual-based simulation model represented SARS-CoV2 transmission in communities ranging from 100 to 3500 people, comprised of large, interconnected households. A range of strategies for case finding, quarantining of contacts, testing, and lockdown were examined, following the silent introduction of a case. RESULTS: Multiple secondary infections are likely present by the time the first case is identified. Quarantine of close contacts, defined by extended household membership, can reduce peak infection prevalence from 60 to 70% to around 10%, but subsequent waves may occur when community mixing resumes. Exit testing significantly reduces ongoing transmission. Concurrent lockdown of non-quarantined households for 14 days is highly effective for epidemic control and reduces overall testing requirements; peak prevalence of the initial outbreak can be constrained to less than 5%, and the final community attack rate to less than 10% in modelled scenarios. Lockdown also mitigates the effect of a delay in the initial response. Compliance with lockdown must be at least 80-90%, however, or epidemic control will be lost. CONCLUSIONS: A SARS-CoV-2 outbreak will spread rapidly in remote communities. Prompt case detection with quarantining of extended-household contacts and a 14 day lockdown for all other residents, combined with exit testing for all, is the most effective strategy for rapid containment. Compliance is crucial, underscoring the need for community supported, culturally sensitive responses.

Can we study the family environment through census data? A comparison of households, dwellings, and domestic units in rural Mali.

Are 'statistical households', as defined in national censuses, able to describe the family environment in Africa? Do they correspond to the family units that individuals identify with? To address this issue, we build on a follow-up survey in south-east Mali, which links national censuses with local censuses at the individual level (N ≈ 28,000 census observations). Three cross-sectional snapshots of family arrangements are compared: households recorded in national censuses, and family economic units and residential units recorded by local censuses. The national census household data appear poorly suited to documenting family living arrangements. They do not account for family economic units or residential units, but are highly conditioned by a normative representation centred on the nuclear family. Therefore, they fail to describe the complexity and diversity of people's living spaces, making particular types of living arrangements invisible and increasing the likelihood of omitting individuals who do not fit into a nuclear model.

Exploring family home food environments: Household resources needed to utilise weekly deliveries of free fruits and vegetables.

AIM: An adapted ethnographic approach was used to explore household factors that influence family fruit and vegetable consumption when access and cost barriers are removed. 'Structural' barriers, such as food affordability and accessibility, are likely to influence fruit and vegetable consumption in disadvantaged households, but households may require additional resources (human and social) to increase consumption. METHODS: Five low-income and five high-income households with children (N = 39 individuals) were observed in their home environment for three months. Including both advantaged and disadvantaged families allowed exploration of socioeconomic factors influencing these households. Each household received a free box of fresh fruit and vegetables each week for 10-12 weeks, delivered to their home, and were home-visited twice a week by a researcher (40+ hours per household). An inductive analysis of rich observational and discussion data revealed themes describing factors influencing household fruit and vegetable consumption. RESULTS: Household food cultures were dynamic and influenced by available resources. Even when free produce was delivered to homes, these households required human resource (personal drivers influenced by early life exposure and household dynamics) and external social networks to make use of them. When household finances and/or labour were limited, there was greater dependence on external organisations for tangible support. CONCLUSIONS: Even when structural barriers were removed, disadvantaged families needed a range of resources across the life course to improve eating behaviours, including sufficient, motivated and skilled labour and harmonious family relationships. Strategies targeting these households must consider structural, social, cultural and intra-familial influences on food choice.

The impacts of rapid demographic transition on family structure and income inequality in Brazil, 1981-2011.

This study analysed the impact of changing family structure on income distribution. Specifically, it analysed how changes in the proportions of different categories of family in the population contributed to increases in the income of the richest and poorest social strata in Brazil, and the consequent impacts on income inequality. Rural and urban families were compared in order to understand how these dynamics had different impacts on more developed (urban) and less developed (rural) areas. The results emphasize how changes observed in family structure are more pronounced among the richest families, contributing to an increase in (i) the income of the richest families and (ii) income inequality between the richest and poorest families, as well as between urban and rural areas.

Gendered power dynamics and HIV risk in drug-using sexual relationships.

This study illustrates how a sample (n = 63) of Scottish drug-using women's patterns of injecting and needle sharing were strongly influenced by the nature and type of their sexual relationships. Our data shows that 12 out of the 13 drug-using couples were sharing needles and 33 out of 41 drug-using women who had ever been in a sexual relationship with a male injector had been predominately injected by their partner whilst in that relationship. For the most part, these women placed significant importance on and investment in their heterosexual relationships. These dynamics clearly impacted on the women's HIV risk taking and risk management and the implications of these findings are discussed.

AIDS activists take South African government to court.

PIP: In South Africa, AIDS activists are taking legal action against their government because of its refusal to provide HIV-positive women with drugs to prevent mother-to-child transmission of HIV. The Treatment Action Campaign gave the health department an ultimatum to make moves to change policy on treating infected mothers; however, since the department had not responded, the legal process was set to begin. Mark Heywood, the Campaign's spokesman, said that the campaign is pushing for the implementation of programs on a phased basis to provide zidovudine or nevirapine at facilities where it is possible. It is noted that the government has remained steadfast in its opposition to an expansion of the program to all HIV-positive women attending state health services. Although Health Minister Mantho Tshabalala Msimang said that the drug regulatory authority is reviewing results of studies on nevirapine use, with a view to possible registration of the drug, Heywood argues that such an action continues to question the efficacy of antiretrovirals since these tests have already been done.^ieng

Hope for prevention of mother-to-child transmission of HIV.

PIP: During the 13th International AIDS Conference in Durban, South Africa, investigators of trials in several countries reported success with simple, cheap regimens of nevirapine given to mothers and newborn infants. Results from the South African Intrapartum Nevirapine Trial confirmed that nevirapine is safe and effective in reducing mother-to-child transmission of HIV. In addition, preliminary findings of long-term follow-up of a trial in Uganda indicated that the benefits of this drug are maintained at 18 months. However, the investigators also recorded a seven-fold increase in HIV infection at 4-8 weeks in breast-fed infants. Loss of efficacy may be explained through a high number of infection in breast-fed children, with breast-feeding doubling the risk at 18 months. Moreover, Anna Coutsoudis of the University of Natal, South Africa, suggested that the culture of breast-feeding in this region contribute to this loss of efficacy. She explained that adding foods into the child's diet at an early stage introduces allergens or contaminants to the gut, which in turn led to an inflammatory response. The resulting damage to the gut might allow the virus to enter the baby's system.^ieng

Bolivia 1998: results from the Demographic and Health Survey.

PIP: This document presents the results of the Bolivia Demographic and Health Survey (DHS), or Encuesta Nacional de Demografia y Salud 1998, conducted by the Instituto Nacional de Estadistica, La Paz, Bolivia, within the framework of the DHS Program of Macro International. Data were collected from 12,109 households and complete interviews were conducted with 11,187 women aged 15-49. A male survey was also conducted, which collected data from 3780 men aged 15-64. The information collected include the following: 1) general characteristics of the population, 2) fertility, 3) fertility preferences, 4) current contraceptive use, 5) contraception, 6) marital and contraceptive status, 7) postpartum variables, 8) infant mortality, 9) health: disease prevention and treatment, and 10) nutritional status: anthropometric measures.^ieng

Adolescents' reports of reproductive health education, 1988 and 1995.

CONTEXT: Reproductive health education is a key strategy for promoting safe sexual behavior among teenagers. In the last decade, new initiatives in response to AIDS and growing interest in abstinence education may have changed the prevalence, content or timing of the reproductive health education provided by schools and parents. METHODS: Formal reproductive health education and communication with parents about reproductive health among males aged 15-19 were analyzed using data from the 1988 and 1995 National Surveys of Adolescent Males. Young men's reports of formal instruction were compared with reports by adolescent females from the 1995 National Survey of Family Growth. RESULTS: Between 1988 and 1995, formal reproductive health education became nearly universal among adolescent males: In 1988, 93% of teenage males received some formal instruction, compared with 98% in 1995. The percentage of teenage males who received instruction about AIDS increased from 73% to 97% and the proportion who received instruction about how to say no to sex increased from 58% to 75%. Adolescent males who had dropped out of school received significantly less reproductive health education than those who had stayed in school, however. In addition, the median age at initial instruction decreased from age 14 to 13. Many males did not receive instruction prior to first intercourse, with non-Hispanic blacks being significantly less likely than other males to receive education prior to first intercourse. In 1995, 54% of black males had received reproductive health education before they first had sex, compared with 68% of Hispanic males and 76% of non-Hispanic white males. A smaller share of adolescent males than females received reproductive health education, and males were less likely than females to receive instruction prior to first intercourse. CONCLUSIONS: During the last decade, many types of formal reproductive health education for adolescents expanded. Further efforts should focus on assuring access to timely, comprehensive and high-quality reproductive health education for all teenagers and reducing gaps in access related to race, gender and school attendance.

No sexuality education is sexuality education.

PIP: Although many parents realize the importance of educating their children about sexuality, many of them find themselves unable to address the subject comfortably. In addition to their own discomfort, parents are concerned about how their children would feel about discussing sex with them. Parents who are unwilling or unable to discuss this important and sensitive part of life with their children present sexuality in a negative way and as a taboo rather than a natural part of being human. The author states that ¿no sexuality education is sexuality education,¿ and the message received from this lack of education may be a negative one. As a consequence, children who receive a negative message of sexuality from their parents are unlikely to turn to their parents to discuss sexual matters as they get older. On the other hand, positive communication about sexual information with children leads to ongoing discussions as they mature. Establishing an environment conducive to open and comfortable communication is therefore highly critical. The following are some tips for parents when educating their children about sexuality: 1) be approachable, 2) be accepting, 3) discuss issues and answer questions simply, and 4) discuss issues and answer questions honestly. Programs sponsored by local schools, civic organizations or religious groups can help narrow the gap that exists between parents and their children concerning human sexuality.^ieng

Mother-to-child transmission of hepatitis C virus: evidence for preventable peripartum transmission.

BACKGROUND: Little information is available about the timing of mother-to-child transmission of hepatitis C virus (HCV), and no interventions to decrease transmission rates have been identified. We examined the effect of risk factors, including mode of delivery, on the vertical transmission rate. METHODS: Data from HCV-infected women and their infants from three hospitals in Ireland and from a British Paediatric Surveillance Unit study of infants born to HCV-infected mothers were used to estimate the vertical transmission rate and risk factors for transmission. We used a probabilistic model using methods that simultaneously estimated the time to HCV-antibody loss in uninfected infants and the diagnostic accuracy of PCR tests for HCV RNA. FINDINGS: 441 mother-child pairs from the UK (227) and Ireland (214) were included. 50% of uninfected children became HCV-antibody negative by 8 months and 95% by 13 months. The estimated specificity of PCR for HCV RNA was 97% (95% CI 96-99) and was unrelated to age; sensitivity was only 22% (7-46) in the first month but rose sharply to 97% (85-100) thereafter. The vertical transmission rate was 6.7% (4.1-10.2) overall, and 3.8 times higher in HIV coinfected (n=22) than in HIV-negative women after adjustment for other factors (p=0.06). No effect of breastfeeding on transmission was observed, although only 59 women breastfed. However, delivery by elective caesarean section before membrane rupture was associated with a lower transmission risk than vaginal or emergency caesarean-section delivery (odds ratio 0 [0-0.87], p=0.04, after adjustment for other factors). INTERPRETATION: The low sensitivity of HCV RNA soon after birth and the finding of a lower transmission rate after delivery by elective caesarean section suggest that HCV transmission occurs predominantly around the time of delivery. If the findings on elective caesarean section are confirmed in other studies, the case for antenatal HCV testing should be reconsidered.

How do rural households perceive and prioritise malaria and mosquito nets? A study in five communities of Nigeria.

The aim of this study was to determine households' levels of prioritization and perception of malaria, ordinary mosquito nets and insecticide-treated nets (ITNs). A cross-sectional survey was conducted in five malaria holo-endemic communities in Enugu State, South-eastern Nigeria. The household heads or the representatives from randomly selected households were interviewed, using a pre-tested interviewer-administered questionnaire. The majority of the respondents had a good knowledge about malaria and the use of ordinary mosquito nets to prevent malaria. However, few knew about the existence of ITNs. Most respondents also stated that malaria was a priority problem and perceived some risk of contracting it. Despite the high level of knowledge about the use of mosquito nets, only 14.0%, 15.7%, 9.6% and 8.0% of the respondents from four of the communities had ever purchased any type of mosquito nets, except in Orba where the proportion was 50.3%. However, more than 80% in all the communities expressed a desire to buy insecticide-treated mosquito nets for the prevention of mosquito bites. There was considerable knowledge about malaria and the use of mosquito nets to prevent it. There were also high levels of prioritization of the disease, mosquito nets and ITNs which signalled the possibility of establishing sustainable community-based ITN programmes, especially as households wanted to buy the ITNs.

Antiretroviral interventions to reduce mother-to-child transmission of human immunodeficiency virus: challenges for health systems, communities and society.

This paper examines the ethical, economic and social issues that should be considered when antiretroviral interventions are being planned to reduce mother-to-child transmission of the human immunodeficiency virus. Interventions aiming to reduce mother-to-child transmission should be concerned with the rights of both the child and the mother. Women should not be seen as vectors of transmission but as people entitled to adequate health care and social services in their own right. For women accepting mother-to-child transmission interventions it is important to consider their medical and emotional needs and to ensure that they are not stigmatized or subjected to abuse or abandonment following voluntary counselling and testing. Seropositive women who do not wish to continue with pregnancy should have access to facilities for safe termination if this is legal in the country concerned. Problems arise in relation to the basic requirements for introducing such interventions via the health services in developing countries. A framework is given for making decisions about implementation of interventions in health care systems with limited resources where there is a relatively high prevalence of human immunodeficiency virus infection among pregnant women.

Role of education in reducing child labour: evidence from rural Bangladesh.

This paper explores the hypothesis that the level of education of children and their parents plays a major role in reducing child labour. Data were generated from a sample survey of 3809 children aged 10-14 years living in 150 villages in two rural districts of Bangladesh. A significant inverse relationship was found between child labour and years of schooling. Age and education of children, parental education, land ownership of household and fathers' occupation were the determinants of child labour force participation. Child's years of schooling is the variable that has most influence on the probability of participation in the labour force, followed by father's and mother's education.

Intimate partner violence among men and women--South Carolina, 1998.

Few studies provide population-based estimates of intimate partner violence (IPV) for men and women, especially at the state level. IPV may result in adverse health effects for victims and perpetrators (1-3). To estimate the lifetime incidence of IPV by type of violence (e.g., physical, sexual, and perceived emotional abuse) and to explore demographic correlates of reporting IPV among men and women, the South Carolina Department of Health and Environmental Control and the University of South Carolina conducted a population-based random-digit-dialed telephone survey of adults in the state. This report summarizes the results of the survey, which indicated that approximately 25% of women and 13% of men have experienced some type of IPV during their lifetime. Although women were significantly more likely to report physical and sexual IPV, men were as likely as women to report emotional abuse without concurrent physical or sexual IPV.

PIP: This report summarizes the results of the survey conducted by the South Carolina Department of Health and Environmental Control and the University of South Carolina. The purpose of the survey was to estimate the lifetime incidence of intimate partner violence (IPV) by type of violence (e.g., physical, sexual, and perceived emotional abuse) and to explore demographic correlates of reporting IPV among men and women. Data were collected using a population-based random-digit-dialed telephone survey of adults in the state. Overall, findings revealed that approximately 25% of women and 13% of men surveyed have experienced some type of IPV during their lifetime. Although women were significantly more likely to report physical and sexual IPV, men were as likely as women to report emotional abuse without concurrent physical or sexual IPV.

Transmission of HIV from injecting drug users to their wives in India.

We aimed to identify factors associated with transmission of human immunodeficiency virus (HIV) from injecting drug users (IDUs) to their wives in Manipur, northeast India, where the prevalence of HIV among IDUs is 80% via a case-control study. One hundred and sixty-one HIV-infected IDUs and their wives were recruited from September 1996 to August 1997 inclusive. HIV status was determined by enzyme-linked immunosorbent assay (ELISA) plus Western blot, Interviews were administered anonymously. Regression analysis identified factors associated with transmission of HIV from IDU husbands to their non-injecting wives. Seventy-two wives (45%) were HIV-positive. Only 15% of the couples reported regular usage of condoms during intercourse. On multivariate analysis, a sexually transmitted disease (STD) in either member, reported by the husband, estimated duration of HIV in the husband for >8 years, and a history of blood transfusions were associated with infection in the wife. In conclusion, STDs are associated with transmission of HIV from husband to wife. Improved control of STDs, condom promotion, and improved blood screening are urgently needed in Manipur.

Teaching mothers to provide home treatment of malaria in Tigray, Ethiopia: a randomised trial.

BACKGROUND: No satisfactory strategy for reducing high child mortality from malaria has yet been established in tropical Africa. We compared the effect on under-5 mortality of teaching mothers to promptly provide antimalarials to their sick children at home, with the present community health worker approach. METHODS: Of 37 tabias (cluster of villages) in two districts with hyperendemic to holoendemic malaria, tabias reported to have the highest malaria morbidity were selected. A census was done which included a maternity history to determine under-5 mortality. Tabias (population 70,506) were paired according to under-5 mortality rates. One tabia from each pair was allocated by random number to an intervention group and the other was allocated to the control group. In the intervention tabias, mother coordinators were trained to teach other local mothers to recognise symptoms of malaria in their children and to promptly give chloroquine. In both intervention and control tabias, all births and deaths of under-5s were recorded monthly. FINDINGS: From January to December 1997, 190 of 6383 (29.8 per 1000) children under-5 died in the intervention tabias compared with 366 of 7294 (50.2 per 1000) in the control tabias. Under-5 mortality was reduced by 40% in the intervention localities (95% CI from 29.2-50.6; paired t test, p<0.003). For every third child who died, a structured verbal autopsy was undertaken to ascribe cause of mortality as consistent with malaria or possible malaria, or not consistent with malaria. Of the 190 verbal autopsies, 13 (19%) of 70 in the intervention tabias were consistent with possible malaria compared with 68 (57%) of 120 in the control tabias. INTERPRETATION: A major reduction in under-5 mortality can be achieved in holoendemic malaria areas through training local mother coordinators to teach mothers to give under-5 children antimalarial drugs.

Effect of improved stoves on prevalence of acute respiration infection and conjunctivitis among children and women in a rural community in Kenya.

OBJECTIVES: To estimate the effect of improved stoves on the prevalence of ARI and conjunctivitis among children aged below five years and women aged between 15 and 60 years. METHOD: A field trial or intervention study design, in which cluster and random sampling were used to recruit households with improved stoves. Nearest households with traditional three-stone stoves were recruited as controls. Prevalence of ARI and conjunctivitis among the study subjects was estimated by clinical evaluation and physical observation, and by history (including clinical and socioeconomic information), and compared between the two study groups. RESULTS: The prevalence of ARI among children aged below five years and among women aged between 15 and 60 years were significantly higher in households with the traditional three-stone stoves than in those with the improved stove chi 2 = 31.45 rho = 0.00000, relative risk = 2.6, C.I. 1.86,3.63, and chi 2 = 30.13, rho = 0.00000, Relative Risk = 2.8, C.I. 1.93, 4.06, respectively). Similarly the prevalence of conjunctivitis among children aged below five years and among women aged between 15 and 60 years were significantly higher in households with traditional three-stone stoves than in those with the improved stoves (c2 = 24.18, p = 0.00000, Relative Risk = 3.3, C.I. 2.05,5.32, and chi 2 = 7.6, rho = 0.0057, Relative Risk = 3, C.I. 1.38, 6.54, respectively). CONCLUSION: Prevalence of ARI and conjunctivitis among children aged below five years and also among women aged between 15 and 60 years in households with the traditional three-stone stoves was significantly higher than that in households with improved stoves.