Characterising injuries and pathologies of common dolphin Delphinus delphis mortalities in the South Australian Sardine Fishery.

Mortality of dolphins in fishing operations is often under-estimated, as shown by studies of beach-washed carcasses. Linking evidence obtained during necropsies with fishing method is fundamental to understanding the extent of mortality and the manner in which animals die. The South Australian Sardine Fishery (SASF) has operated a purse-seine industry since 1991. This study characterised injuries, pathological changes and life history of 49 dead dolphins collected from SASF during 2006-2019. Histology examination was conducted on 25 animals. Neonates, calves and juveniles accounted for 63% of the sample. Of mature females (n = 14), 11 were pregnant or lactating, with cryptic mortality estimated to be 20% of dolphins studied. Body condition was robust in 48 dolphins. Net marks were seen on 82%, mostly on the head, trunk and peduncle. Broken/missing teeth were noted in 63%. All dolphins had subdermal haemorrhage (moderate to severe in 96%), particularly around the head. Deep haemorrhage was common, including around occipital and flipper condyles, and organs. Copious fluid was present in the thoracic (pleural) and abdominal (ascites) cavities of half of the dolphins. Within the lungs, watery fluid and froth were observed in 100 and 39%, respectively. Recent bone fractures were documented in 43% of dolphins, mostly associated with haemorrhage. Severe blunt trauma appeared to be the primary cause of death, and 10 dolphins also had other significant pathologies. Visceral organ congestion and mild cardiomyopathy were observed. Stomachs contained prey remains in 75% of cases. The results of this study may help identify unreported purse-seine mortalities washed up in South Australia and elsewhere.

A balancing act: sex selection after pre-implantation genetic testing for aneuploidy for first versus second baby.

STUDY QUESTION: How often do patients undergoing frozen embryo transfer (FET) after preimplantation genetic testing for aneuploidy (PGT-A) choose to select for sex and do sex selection rates differ before and after successful delivery of a first baby? SUMMARY ANSWER: When a choice was available between male and female embryos, patients selected the sex more frequently when trying to conceive the second child (62%) as compared to the first child (32.4%) and most commonly selected for the opposite sex of the first child. WHAT IS KNOWN ALREADY: Sex selection is widely available in US fertility clinics. However, the rate of sex selection for patients undergoing FET after PGT-A is unknown. STUDY DESIGN, SIZE, DURATION: This is a retrospective cohort study of 585 patients that took place between January 2013 and February 2021. PARTICIPANTS/MATERIALS, SETTING, METHODS: The study took place at a single, urban academic fertility center in the USA. Patients were included if they had a live birth after single euploid FET and returned for at least one subsequent euploid FET. The primary outcomes were the rates of sex selection for first versus second baby. Secondary outcomes were rate of selection for same versus opposite sex as first live birth and overall rate of selection for males versus females. MAIN RESULTS AND THE ROLE OF CHANCE: Five hundred and eighty-five patients underwent a total of 1560 single euploid FETs resulting in either one or two live births. A choice between male and female euploid embryos was available for 919 FETs (first child: 67.5% (519/769) versus second child: 50.6% (400/791), P < 0.01). When a choice was available, patients selected the sex more frequently when trying to conceive the second child (first child: 32.4% (168/519) versus second child: 62.0% (248/400), P < 0.01). When sex was selected after first live birth, the opposite sex of the first child was selected 81.8% (203/248 FETs) of the time. Of transfers that involved sex selection, rates of male and female selection were similar for the first child, but selection for females was greater for the second child (first child: 51.2% (86/168) male versus 48.9% (82/168) female, second child: 41.1% (102/248) male versus 58.9% (146/248) female, P < 0.04). LIMITATIONS, REASONS FOR CAUTION: The study was performed at one urban academic medical center in the Northeastern US, which may limit generalizability to other settings where PGT-A may be performed less frequently, or sex selection may be limited or not permitted. In addition, we could not reliably account for whether patients or their partners had prior children and if so, of what sex. WIDER IMPLICATIONS OF THE FINDINGS: Patients undergoing PGT-A with both male and female euploid embryos were more likely to select for sex when attempting a second child and usually selected for the opposite sex of their first child. These findings highlight the potential for family balancing for patients who undergo PGT-A in settings where sex selection is permitted. STUDY FUNDING/COMPETING INTEREST(S): This study received no funding. The authors have no conflicts of interest to declare. TRIAL REGISTRATION NUMBER: N/A.

Increasing facility delivery through maternity waiting homes for women living far from a health facility in rural Zambia: a quasi-experimental study.

OBJECTIVE: To report on the effectiveness of a standardised core Maternity Waiting Home (MWH) model to increase facility deliveries among women living >10 km from a health facility. DESIGN: Quasi-experimental design with partial randomisation at the cluster level. SETTING: Seven rural districts in Zambia. POPULATION: Women delivering at 40 health facilities between June 2016 and August 2018. METHODS: Twenty intervention and 20 comparison sites were used to test whether MWHs increased facility delivery for women living in rural Zambia. Difference-in-differences (DID) methodology was used to examine the effectiveness of the core MWH model on our identified outcomes. MAIN OUTCOME MEASURES: Differences in the change from baseline to study period in the percentage of women living >10 km from a health facility who: (1) delivered at the health facility, (2) attended a postnatal care (PNC) visit and (3) were referred to a higher-level health facility between intervention and comparison group. RESULTS: We detected a significant difference in the percentage of deliveries at intervention facilities with the core MWH model for all women living >10 km away (DID 4.2%, 95% CI 0.6-7.6, P = 0.03), adolescent women (<18 years) living >10 km away (DID 18.1%, 95% CI 6.3-29.8, P = 0.002) and primigravida women living >10 km away (DID 9.3%, 95% CI 2.4-16.4, P = 0.01) and for women attending the first PNC visit (DID 17.8%, 95% CI 7.7-28, P < 0.001). CONCLUSION: The core MWH model was successful in increasing rates of facility delivery for women living >10 km from a healthcare facility, including adolescent women and primigravidas and attendance at the first PNC visit. TWEETABLE ABSTRACT: A core MWH model increased facility delivery for women living >10 km from a health facility including adolescents and primigravidas in Zambia.

Impact of chlorhexidine baths on suspected sepsis and bloodstream infections in hospitalized neonates in Zambia.

INTRODUCTION: Sepsis is the leading cause of infectious morbidity and mortality among hospitalized neonates. In high-resource pediatric and adult intensive care units, use of aqueous chlorhexidine (CHG) solution has been associated with reduced risk of bloodstream infections (BSI). OBJECTIVES: To assess the impact of bathing of neonates with 2% CHG on BSI, suspected sepsis, and mortality in a low-income country neonatal care unit. METHODS: We conducted a secondary analysis of data from the Sepsis Prevention in Neonates in Zambia (SPINZ) study, a prospective observational cohort study performed at a large public referral hospital in Lusaka, Zambia. The SPINZ study assessed the impact of an infection control bundle (consisting of alcohol hand rub, SMS hygiene reminders, enhanced environmental cleaning, and CHG baths for babies ≥1.5 kg) on sepsis, BSI, and all-cause mortality. Episodic shortages in study staffing resulted in some enrolled babies not receiving a CHG bath. Using Longitudinal Targeted Maximum Likelihood Estimation and Cox proportional hazards regression to adjust for observed confounding, we estimated the causal effect of receiving a CHG bath within the first 3 days of life on suspected sepsis, BSI, and death among inborn babies enrolled during the study implementation and intervention phases. RESULTS: The majority of inborn, enrolled babies ≥1.5 kg received a CHG bath within 3 days of NICU admission (864 of 1233, 70%). We found that CHG bathing reduced the hazard rate of BSI among inborn babies ≥1.5 kg by a factor of 0.58 (p = 0.10, 95% CI: 0.31, 1.11), corresponding to an absolute risk reduction of 9.6 percentage points within a week of admission (p = 0.002, 95% CI: 3.4-15.7 percentage points). We did not find a statistically significant effect of CHG bathing on culture-negative sepsis (p = 0.54) or death (p = 0.85). CONCLUSION: In our single center study, CHG bathing at admission was associated with a reduced risk of BSI due to a pathogenic organism after adjusting for potential confounding. Our results suggest that CHG may be an effective intervention for preventing neonatal sepsis in high-risk, low-income country settings.

Convergence of marine megafauna movement patterns in coastal and open oceans.

The extent of increasing anthropogenic impacts on large marine vertebrates partly depends on the animals' movement patterns. Effective conservation requires identification of the key drivers of movement including intrinsic properties and extrinsic constraints associated with the dynamic nature of the environments the animals inhabit. However, the relative importance of intrinsic versus extrinsic factors remains elusive. We analyze a global dataset of ∼2.8 million locations from >2,600 tracked individuals across 50 marine vertebrates evolutionarily separated by millions of years and using different locomotion modes (fly, swim, walk/paddle). Strikingly, movement patterns show a remarkable convergence, being strongly conserved across species and independent of body length and mass, despite these traits ranging over 10 orders of magnitude among the species studied. This represents a fundamental difference between marine and terrestrial vertebrates not previously identified, likely linked to the reduced costs of locomotion in water. Movement patterns were primarily explained by the interaction between species-specific traits and the habitat(s) they move through, resulting in complex movement patterns when moving close to coasts compared with more predictable patterns when moving in open oceans. This distinct difference may be associated with greater complexity within coastal microhabitats, highlighting a critical role of preferred habitat in shaping marine vertebrate global movements. Efforts to develop understanding of the characteristics of vertebrate movement should consider the habitat(s) through which they move to identify how movement patterns will alter with forecasted severe ocean changes, such as reduced Arctic sea ice cover, sea level rise, and declining oxygen content.

Spatial Distribution of Epidemiological Cases of Dengue Fever in Suriname, 2001-2012.

OBJECTIVE: To characterize the frequency, incidence and severity of dengue fever in Suriname and to detect historic clusters of disease by integrating epidemiological data into a spatial visualization platform. METHODS: The frequency, incidence and severity of all reported dengue fever (DF) and dengue haemorrhagic fever (DHF) cases in Suriname from 2001 to 2012 were calculated and stratified by demographic factors. Using a geographic information systems (GIS) platform, we visualized the distribution of DF cases and used Moran's I to detect autocorrelation. Furthermore, a retrospective spatial Poisson probability model was used to identify local clusters of DF within Suriname. Local clusters were divided into neighborhoods and individual DF cases were mapped to the street level. RESULTS: In Suriname, cases of DF emerge in cyclical patterns (three to five years) with seasonal peaks following the short and the long rainy season. Chi-square analysis indicated a statistically significant (p < 0.05) difference between age group, ethnicity and district and the onset of DHF. The spatial analysis detected spatial autocorrelation and four statistically significant (p < 0.05) clusters were identified in the two most populated districts of Paramaribo and Wanica. CONCLUSION: In Suriname, identification of demographic and environmental risk factors that contribute to the development of DHF is essential to determine how preventive action can be more effectively allocated. The integration of epidemiological data into a GIS platform allowed for the identification of historic epidemiological clusters of dengue which will be used to guide environmental health studies in Suriname.

Mobile health technology-enabled community health workers as pesticide interventionists in rural Suriname

OBJECTIVE: To bolster access for vulnerable communities to urgent pesticide-related health information and services using a mobile health technology-enabled community health worker (CHW) strategy. DESIGN AND METHODS: The project was designed to demonstrate the effectiveness of mobile health technology–enabled CHWs in promoting safe pesticide use in pesticide-induced suicide-prone communities in Suriname. The team focused on three interconnected components: message mapping, validation, and delivery testing. The text messages were tested to assess content, literacy, and the ability to solicit a recipient response to determine the effectiveness of mobile technology as a health intervention tool. RESULTS: Thirty-nine text messages addressed the following key themes: pesticide miss/overuse, pesticide accessibility contributing to its use as an attempted or successful suicide strategy, and pesticide handling and disposal. For each of these themes, at least three messages were developed. Most text messages emphasized safe pesticide handling as the root cause of both misuse and access. (The pesticide awareness and education campaign will be expanded country-wide.) CONCLUSION: The mobile health technology- enabled CHWs functioning as pesticide interventionists demonstrated that bidirectional text messaging was a promising awareness and education intervention strategy. Focusing on safe handling was a reasonable target for intervention in the absence of a comprehensive national pesticide policy governing import, distribution, access, handling, and disposal. Of note is that none of the messages to date directly focused on suicide, confirming the strategy to address suicide prevention as a holistic public health issue under a safe pesticide use “umbrella” rather than as an isolated, stigma-provoking problem.

Evaluation of the QBC Star centrifugal three-part differential haematology system.

The QBC Star haematology system includes the QBC Star centrifugal analytical analyser and the QBC Star tube system. Together, they are capable of producing a haematology profile on venous or capillary whole blood. The aim of this study is to compare full blood count (FBC) including differential white cell count performance between the QBC Star analyser and a gold standard Sysmex XE-2100 haematology analyser. The FBC performance was evaluated according to the National Committee for Clinical Laboratory Standards (NCCLS) document H20-A. Imprecision, correlation and linearity studies all showed excellent results. Overall, the haemoglobin, haematocrit, white cell count (WCC) and platelet count parameters showed excellent correlation. Mean corpuscular haemoglobin concentration (MCHC) results showed poor comparability. The white cell differential parameters showed good correlation within certain clinically significant limits. Imprecision for haemoglobin, haematocrit, WCC, MCHC and platelet count was considered acceptable. The re-read function was found to be stable over the five-hour testing period under the authors' laboratory environmental conditions. The subjective assessment by biomedical scientist staff demonstrated that the system was user friendly, required little maintenance, and no user calibration was required. Staff considered the user manual to be excellent. Overall, the QBC Star appears to be an excellent point-of-care (POC) dry haematology analyser that delivers clinically significant nine-parameter complete blood count and will make a good POC analyser for use in field hospitals, research, screening programmes, GP surgeries as well as in emergency and intensive care units. It is a health and safety-friendly analyser considering the fact that it uses dry haematology reagents instead of the bulky wet reagents that are often associated with liquid biohazard waste.

Thermal protection of the newborn in resource-limited environments.

Appropriate thermal protection of the newborn prevents hypothermia and its associated burden of morbidity and mortality. Yet, current global birth practices tend to not adequately address this challenge. Here, we discuss the pathophysiology of hypothermia in the newborn, its prevention and therapeutic options with particular attention to resource-limited environments. Newborns are equipped with sophisticated mechanisms of body temperature regulation. Neonatal thermoregulation is a critical function for newborn survival, regulated in the hypothalamus and mediated by endocrine pathways. Hypothermia activates cellular metabolism through shivering and non-shivering thermogenesis. In newborns, optimal temperature ranges are narrow and thermoregulatory mechanisms easily overwhelmed, particularly in premature and low-birth weight infants. Hyperthermia most commonly is associated with dehydration and potentially sepsis. The lack of thermal protection promptly leads to hypothermia, which is associated with detrimental metabolic and other pathophysiological processes. Simple thermal protection strategies are feasible at community and institutional levels in resource-limited environments. Appropriate interventions include skin-to-skin care, breastfeeding and protective clothing or devices. Due to poor provider training and limited awareness of the problem, appropriate thermal care of the newborn is often neglected in many settings. Education and appropriate devices might foster improved hypothermia management through mothers, birth attendants and health care workers. Integration of relatively simple thermal protection interventions into existing mother and child health programs can effectively prevent newborn hypothermia even in resource-limited environments.

Prevention of vaginal SHIV transmission in macaques by a live recombinant Lactobacillus.

Most human immunodeficiency virus (HIV) transmissions in women occur through the cervicovaginal mucosa, which is coated by a bacterial biofilm including Lactobacillus. This commensal bacterium has a role in maintaining a healthy mucosa and can be genetically engineered to produce antiviral peptides. Here, we report a 63% reduction in transmission of a chimeric simian/HIV (SHIV(SF162P3)) after repeated vaginal challenges of macaques treated with Lactobacillus jensenii expressing the HIV-1 entry inhibitor cyanovirin-N. Furthermore, peak viral loads in colonized macaques with breakthrough infection were reduced sixfold. Colonization and prolonged antiviral protein secretion by the genetically engineered lactobacilli did not cause any increase in proinflammatory markers. These findings lay the foundation for an accessible and durable approach to reduce heterosexual transmission of HIV in women, which is coitally independent, inexpensive, and enhances the natural protective effects of the vaginal microflora.

Clinical manifestations and outcome in HIV-infected young infants presenting with acute illness in Durban, South Africa.

OBJECTIVES: In young infants, early development of symptomatic HIV infection increases the risk of morbidity and mortality. A prospective study was conducted over a 1-year period in a region with a high burden of HIV in order to describe the clinical presentation of HIV infection in infants aged between 0 and 59 days on attendance at hospital and the factors associated with the need for urgent hospital management. METHODS: Sick young infants presenting to the King Edward VIII Hospital, Durban between February 2003 and January 2004 were enrolled. After systematic evaluation by a primary health worker, an experienced paediatrician determined the primary diagnosis and need for urgent hospital management. Comparisons of these assessments were stratified by HIV status. Children were classified as HIV-uninfected (HIV ELISA-negative), HIV-exposed-but-uninfected (HIV ELISA-positive and HIV RNA PCR-negative), HIV-infected (HIV ELISA-positive and HIV viral load >400 copies/ml). RESULTS: Of 925 infants enrolled, 652 (70·5%) had their HIV status determined: 70 (10·7%) were HIV-infected, 271 (41·6%) HIV-exposed-but-uninfected, and 311 (47·7%) HIV-uninfected. Factors associated with an increased probability of being HIV-infected included if the mother had children from more than one sexual partner, if the infant had had contact with a tuberculosis-infected person or if the HIV-infected mother and/or her exposed infant failed to receive nevirapine prophylaxis. Signs of severe illness were more frequently encountered in HIV-infected than in HIV-exposed-but-uninfected infants, including the prevalence of chest in-drawing (20·3% vs 8·8%, p = 0·004) and severe skin pustules (18·6% vs 8·6%, p = 0·01). Among infants requiring urgent hospital management, observed or reported feeding difficulties and severe skin pustules were more common in HIV-infected than uninfected infants. More HIV-infected infants (12·9%) required hospitalisation than those who were HIV-exposed-but-uninfected (7·7%) or uninfected (7·4%). Primary diagnoses of pneumonia, sepsis or oral thrush were more frequently seen in HIV-infected than exposed-but-uninfected or HIV-uninfected children. CONCLUSION: Early recognition and triaging of infants suspected of having HIV infection provides an opportunity for early diagnosis and treatment which could prevent the adverse impact of rapidly progressive HIV disease.

Alternative treatment for septic tank sludge: co-digestion with municipal solid waste in bioreactor landfill simulators.

Co-disposal of septic tank sludge had a positive effect on the municipal solid waste (MSW) stabilisation process in Bioreactor Landfill simulators. Co-disposal experiments were carried out using the Bioreactor Landfill approach aiming to solve the environmental problems caused by indiscriminate and inadequate disposal of MSW and especially of septic tank sludge. The simulator receiving septic tank sludge exhibited a 200 days shorter lag-phase as compared to the 350 days required by the control simulator to start the exponential biogas production. Additionally, the simulator with septic sludge apparently retained more moisture (>60% w/w), which enhanced the overall conversion of organic matter hence increasing the biogas production (0.60 m3 biogas kg(-1)VS(converted)) and removal efficiency of 60% for VS from the simulator. Alkaline pH values (pH>8.5) did not inhibit the biogas production; moreover it contributed to reduce partially the negative effects of NH(4)(+) (>2 g L(-1)) due to NH(3) volatilisation thus reducing the nitrogen content of the residues. Associated risks and hazards with septage disposal were practically eliminated as total coliform and faecal coliform contents were reduced by 99% and 100%, respectively at the end of the experiment. These results indicate that co-disposal has two direct benefits, including the safe and environmentally sound disposal of septic tank sludge and an improvement of the overall performance of the Bioreactor Landfill by increasing moisture retention and supplying a more acclimatised bacterial population.

Control measures for malaria in pregnancy in India.

The purpose of this paper is to examine the current status of malaria in pregnancy (MiP) in India and review current control measures, programmes and interventions that work, and to suggest areas that need to be addressed. MiP can have serious health consequences for both the mother and infant, and thus presents a major public health challenge. Roll Back Malaria (RBM), a supporting agency of the World Health Organization (WHO), recommends reducing the burden of MiP through the following control measures: insecticide treated nets (ITNs), intermittent preventive therapy (IPTp), and effective case management. Even though India has a comprehensive national malaria programme, specific control measures aimed at decreasing the burden of MiP are limited in availability or are not adequately available. Components of the national malaria programme, which may serve to alleviate the MiP burden include the integration of malaria control with general health services and use of indoor residual spraying (IRS). These control strategies are beneficial because they reduce overall malaria exposure, both for pregnant women and the general population. However, there are several challenges and issues that India still faces regarding MiP. Major among them are the lack of ITNs, socio-cultural issues, growing resistance to antimalarials and insecticides, a new, yet to be fully implemented drug policy, and a highly centralized malaria control programme. A review of the current control measures for MiP in India indicates that these challenges and issues must be addressed in order to alleviate the MiP situation in India.

Acceptability of micronutrient fortified school meals by schoolchildren in rural Himalayan villages of India.

This cross-sectional randomized controlled study assessed the social acceptability of micronutrient fortified cooked lunch meals by schoolchildren in rural Himalayan villages of India, in a program where the cooking and the micronutrient fortification were done at school. Subjects were randomly assigned to treatment (91) and control (90) groups. The treatment group consumed a weighed amount of cooked lunch meals fortified with locally produced multi-micronutrient premix and the control group consumed a weighed amount of the same meals but without added micronutrient premix. After having eaten, subjects were asked to rate, on a 3-point Likert scale using "smiley" faces, the pleasantness of smell, taste, and overall satisfaction with the food. The mean age of study children was 7.96 +/- 1.64 y and 48.6% were males. The average amounts of food consumed by the treatment and control groups were 345 +/- 114 and 360 +/- 102.4 g, respectively. Addition of the multi-micronutrient premix to school meals did not significantly affect the mean amount of food consumed by the schoolchildren (P > 0.05; independent sample t-test). No significant differences were seen between treatment and control groups in terms of ratings for taste, smell, and the general acceptance of the micronutrient fortified or the unfortified school meals. In conclusion, the addition of a multiple micronutrient premix to school meals was well liked by schoolchildren and did not adversely affect their food consumption.

Health facility and health worker readiness to deliver new national treatment policy for malaria in Kenya.

OBJECTIVE: To evaluate health facility and health worker readiness to deliver new artemether-lumefantrine (AL) treatment policy for uncomplicated malaria in Kenya. DESIGN: Cross-sectional survey. SETTING: Health facilities in four sentinel districts in Kenya. PARTICIPANTS: All government facilities in study districts (n = 211) and all health workers performing outpatient consultations (n = 654). MAIN OUTCOME MEASURES: Availability of antimalarial drugs on the survey day, stock-outs in past six months, presence of AL wall charts, health worker's exposure to in-service training on AL and access to new national malaria guidelines. RESULTS: The availability of any tablets of AL, sulfadoxine-pyrimethamine and amodiaquine was nearly universal on the survey day. However, only 61% of facilities stocked all four weight-specific packs of AL. In the past six months, 67% of facilities had stock-out of at least one AL tablet pack and 15% were out of stock for all four packs at the same time. Duration of stock-out was substantial for all AL packs (median range: 27-39% of time). During the same period, the stock-outs of sulfadoxine-pyrimethamine and amodiaquine were rare. Only 19% of facilities had all AL wall charts displayed, AL in-service training was provided to 47% of health workers and 59% had access to the new guidelines. CONCLUSION: Health facility and health worker readiness to implement AL policy is not yet optimal. Continuous supply of all four AL pack sizes and removal of not recommended antimalarials is needed. Further coordinated efforts through the routine programmatic activities are necessary to improve delivery of AL at the point of care.

Effects of revised diagnostic recommendations on malaria treatment practices across age groups in Kenya.

OBJECTIVE: The recent change of treatment policy for uncomplicated malaria from sulfadoxine-pyrime-thamine to artemether-lumefantrine (AL) in Kenya was accompanied by revised malaria diagnosis recommendations promoting presumptive antimalarial treatment in young children and parasitological diagnosis in patients 5 years and older. We evaluated the impact of these age-specific recommendations on routine malaria treatment practices 4-6 months after AL treatment was implemented. METHODS: Cross-sectional, cluster sample survey using quality-of-care assessment methods in all government facilities in four Kenyan districts. Analysis was restricted to the 64 facilities with malaria diagnostics and AL available on the survey day. Main outcome measures were antimalarial treatment practices for febrile patients stratified by age, use of malaria diagnostic tests, and test result. RESULTS: Treatment practices for 706 febrile patients (401 young children and 305 patients > or =5 years) were evaluated. 43.0% of patients > or =5 years and 25.9% of children underwent parasitological malaria testing (87% by microscopy). AL was prescribed for 79.7% of patients > or =5 years with positive test results, for 9.7% with negative results and for 10.9% without a test. 84.6% of children with positive tests, 19.2% with negative tests, and 21.6% without tests were treated with AL. At least one antimalarial drug was prescribed for 75.0% of children and for 61.3% of patients > or =5 years with a negative test result. CONCLUSIONS: Despite different recommendations for patients below and above 5 years of age, malaria diagnosis and treatment practices were similar in the two age groups. Parasitological diagnosis was under-used in older children and adults, and young children were still tested. Use of AL was low overall and alternative antimalarials were commonly prescribed; but AL prescribing largely followed the results of malaria tests. Malaria diagnosis recommendations differing between age groups appear complex to implement; further strengthening of diagnosis and treatment practices under AL policy is required.

Impact of human immunodeficiency virus infection on Streptococcus pneumoniae colonization and seroepidemiology among Zambian women.

Nasopharyngeal colonization with Streptococcus pneumoniae precedes invasive pneumococcal disease. Human immunodeficiency virus (HIV) infection increases rates of invasive pneumococcal disease, and its effect on colonization is unknown. In a longitudinal cohort of Zambian mothers with or without HIV infection, HIV infection increased the risk of colonization (risk ratio [RR], 1.9; 95% confidence interval [CI], 1.3-2.8) and repeat colonization (RR, 2.4; 95% CI, 1.1-5.3) and reduced the time to new colonization (P = .01). Repeat colonization with homologous sero/factor types occurred only among HIV-positive mothers. Pediatric serotypes 6, 19, and 23 accounted for excess colonization among HIV-positive mothers. HIV infection significantly increases the risk of pneumococcal colonization. Increased rates of colonization by pediatric serotypes suggest a potential role for the 7-valent pneumococcal vaccine in HIV-infected adults.

Changes in Na+/K+-ATPase activity, unsaturated fatty acids and metallothioneins in gills of the shore crab Carcinus aestuarii after dilute seawater acclimation.

We have assessed the activity of Na(+)/K(+)-ATPase, cAMP, free fatty acids (FFA) and metallothionein (MT) in the posterior gills of the brackish water shore crab Carcinus aestuarii during acclimation to 10 ppt dilute seawater (DSW). Following 3-18 days acclimation in DSW specific activity of Na(+)/K(+)-ATPase in native gill homogenates and partially purified membrane vesicles was progressively increased, from 1.7- to 3.9-fold. After short-term acclimation of crabs in DSW with added sucrose to make media isosmotic with the haemolymph the specific Na(+)/K(+)-ATPase activity in homogenates was not increased, relative to SW enzyme activity. Moreover, hyposmotic conditions led to depletion of cAMP in gills. In partially purified membrane vesicles isolated from posterior gills, fatty acids with compositions 16:0, 18:0, 18:1, 20:4 and 20:5 dominated in both SW- and DSW-acclimated Carcinus. During a year in which the metabolic activity of crabs was increased, the arachidonic/linoleic acids ratio (ARA/LA) for DSW-acclimated crabs was markedly increased relative to that in SW. Increased Na(+)+K(+)-ATPase activity under hyposmotic stress may be modulated at least partially by the changed proportion of fatty acids in the purified membranes of posterior gills. Long-term acclimation of shore crabs to DSW resulted in a 2.6-fold increase in cytosolic metallothionein (MT) content in posterior gills over those in SW crabs. Assuming an antioxidant role of MT associated with intracellular zinc partitioning, the observed MT induction in posterior gills may be considered an adaptive response of C. aestuarii to hyposmotic stress.

Clinico-epidemiological profile and predictors of severe illness in young infants (0-59 days) in Ghana.

BACKGROUND: Young infant mortality has remained high and relatively unchanged compared with deaths of older infants. Strategies to reduce infant mortality, however, are mostly targeted at the older child. OBJECTIVES: To describe the clinical profile of sick young infants presenting to a hospital and to define important signs and symptoms that will enable health workers to detect young infants with severe illness requiring hospital admission. METHODS: Young infants aged 0-59 days presenting to a paediatric out-patient clinic were evaluated by a nurse using a standardised list of signs and symptoms. A paediatrician independently evaluated these children and decided whether they needed hospitalisation. RESULTS: A total of 685 young infants were enrolled, 22% of whom were <7 days of age. The commonest reasons for seeking care were jaundice in the 0-6-day group, skin problems in the 7-27-day group and cough in the 28-59-day group. The primary clinical diagnoses for admissions were sepsis in the 0-6- and 7-27-day groups and pneumonia in the 28-59-day group. Clinical signs and symptoms predicting severe illness requiring admission were general (history of fever, difficult feeding, not feeding well and temperature >37.5 degrees C) and respiratory (respiratory rate > or =60/min, severe chest in-drawing). CONCLUSION: General and respiratory signs are important predictors for severe illness in young infants. Training peripheral health workers to recognise these signs and to refer to hospital for further assessment and management might have a significant impact on young infant mortality.

Translation of artemether-lumefantrine treatment policy into paediatric clinical practice: an early experience from Kenya.

OBJECTIVE: To describe the quality of outpatient paediatric malaria case-management approximately 4-6 months after artemether-lumefantrine (AL) replaced sulfadoxine-pyrimethamine (SP) as the nationally recommended first-line therapy in Kenya. METHODS: Cross-sectional survey at all government facilities in four Kenyan districts. Main outcome measures were health facility and health worker readiness to implement AL policy; quality of antimalarial prescribing, counselling and drug dispensing in comparison with national guidelines; and factors influencing AL prescribing for treatment of uncomplicated malaria in under-fives. RESULTS: We evaluated 193 facilities, 227 health workers and 1533 sick-child consultations. Health facility and health worker readiness was variable: 89% of facilities stocked AL, 55% of health workers had access to guidelines, 46% received in-service training on AL and only 1% of facilities had AL wall charts. Of 940 children who needed AL treatment, AL was prescribed for 26%, amodiaquine for 39%, SP for 4%, various other antimalarials for 8% and 23% of children left the facility without any antimalarial prescribed. When AL was prescribed, 92% of children were prescribed correct weight-specific dose. AL dispensing and counselling tasks were variably performed. Higher health worker's cadre, in-service training including AL use, positive malaria test, main complaint of fever and high temperature were associated with better prescribing. CONCLUSIONS: Changes in clinical practices at the point of care might take longer than anticipated. Delivery of successful interventions and their scaling up to increase coverage are important during this process; however, this should be accompanied by rigorous research evaluations, corrective actions on existing interventions and testing cost-effectiveness of novel interventions capable of improving and maintaining health worker performance and health systems to deliver artemisinin-based combination therapy in Africa.