Establishment and development of the National Tuberculosis Control Programme in Vietnam.

OBJECTIVE: To describe the establishment and development of the National Tuberculosis Control Programme (NTP) of Vietnam. METHODS: Data were obtained from the surveillance system established by the new NTP in 1986 and based on the principles now described as the WHO DOTS strategy. RESULTS: The proportion of districts covered by the NTP increased from 40% in 1986 to almost 100% in 2000. The proportion of communes applying NTP guidelines increased from 18% in 1986 to 99.8% in 2000. The total number of tuberculosis cases notified increased from 8737 in 1986 to 89 792 in 2000. Most of these are new smear-positive cases. Based on WHO estimations of the incidence rate, the proportion of new smear-positive cases detected and put on short-course treatment has been over 70% since 1996. Reported cure rates with short-course chemotherapy are consistently over 85%. CONCLUSIONS: DOTS is feasible in a low-income, high-burden country. The main reasons for success were political commitment, a well-functioning health network, integration of tuberculosis control into the general health service at district level, a continuous supply of drugs and effective external support. Major challenges are long-term financial support, expansion to remote areas and vulnerable groups, definition of the role of the private sector, and future developments of the HIV epidemic and multidrug resistance.

Co-factors related to the causal relationship between human papillomavirus and invasive cervical cancer in Honduras.

BACKGROUND: A case-control study was conducted in Honduras to identify co-factors in the carcinogenic pathway by which human papillomavirus (HPV) causes invasive cervical cancer. METHODS: Ninety-nine cases aged 23-65 (median 47) years participated. Two controls were matched to each case by age and clinic where they first presented for cytological screening; controls had no cervical abnormalities. Information on risk factors was obtained by personal interviews in the clinics regarding sociodemographic, reproductive and behavioral characteristics. Human papillomavirus was detected in cervical scrapes by general primer-mediated polymerase chain reaction (PCR) followed by sequence analysis to identify the different types present. RESULTS: All cases had squamous cell tumours and most were FIGO (International Federation of Gynecologists and Obstetricians) class II or higher; HPV was strongly associated with cervical cancer (odds ratio [OR] = 7.66, 95% CI : 3.88-15.1). Among HPV-positive women, dose-response relationships were observed for education, age at first intercourse and exposure to wood smoke that persisted after adjustment for previous screening. Among HPV-negative women, the number of sexual partners and parity were associated with cervical cancer. The protective effect of previous cytological screening operated independently of HPV. CONCLUSIONS: Our findings speak for the powerful role that both primary and secondary education plays in fostering a lifestyle that reduces the risk of invasive cervical cancer. The data suggest that important elements of such a lifestyle include later age at first sexual intercourse, a limited number of pregnancies, greater likelihood of undergoing cytological screening and reduced exposure to carcinogens in the household environment.

Where health care has no access: the nomadic populations of sub-Saharan Africa.

Nomadic and seminomadic pastoralists make optimal use of scarce water and pasture in the arid regions south of the Sahara desert, spreading from Mauretania in the west to Somalia in East Africa. We attempted to summarize the fragmentary evidence from the literature on the health status of these populations and to assess the best ways to provide them with modern health care. Infant mortality is higher among nomadic than among neighbouring settled populations, but childhood malnutrition is less frequent. Nomads often avoid exposure to infectious agents by moving away from epidemics such as measles. Trachoma is highly prevalent due to flies attracted by cattle. The high prevalence of tuberculosis is ascribed to the presence of cattle, crowded sleeping quarters and lack of health care; treatment compliance is generally poor. Guinea worm disease is common due to unsafe water sources. Helminth infections are relatively rare as people leave their waste behind when they move. Malaria is usually epidemic, leading to high mortality. Sexually transmitted diseases spread easily due to lack of treatment. Leishmaniasis and onchocerciasis are encountered; brucellosis occurs but most often goes undetected. Drought forces nomads to concentrate near water sources or even into relief camps, with often disastrous consequences for their health. Existing health care systems are in the hands of settled populations and rarely have access to nomads due to cultural, political and economic obstacles. A primary health care system based on nomadic community health workers is outlined and an example of a successful tuberculosis control project is described. Nomadic populations are open to modern health care on the condition that this is not an instrument to control them but something they can control themselves.

Human papillomavirus infection, cervical dysplasia and invasive cervical cancer in Honduras: a case-control study.

A substantial body of evidence has confirmed human papillomavirus (HPV) infection as the central etiological agent in human cervical carcinogenesis. In Honduras, cervical cancer is the most common cancer among women, with a high annual incidence. We conducted a population-based, case-control study of 229 patients with different grades of CIN and invasive cervical cancer and 438 matched controls. A structured questionnaire was used to investigate known and probable risk factors for cervical cancer. Cervical scrapes were tested for the presence of different HPV types using a general primer-mediated PCR followed by PCR-based sequencing. HPV DNA was detected in 87% of all cancer in situ and invasive cancer cases, and 95% of invasive cases could be attributed to high-risk types. In control women, 39% were positive for HPV DNA sequences. HPV 16 prevalence ranked highest in all stages of cervical dysplasias, invasive cancers and controls. A statistically significant association with HPV was observed for CIN II, CIN III and invasive cancer, showing an upward trend to more severe lesions and being more pronounced for HPV 16 and related types. The OR for HPV 16- and 18-related invasive cancer cases was 14.88 (95% CI 5.12-43.25) and 74.66 (95% CI 7.77-717.62), respectively. Our results confirm a central role of HPV as the cause of cervical cancer in Honduras and provide information as to the type distribution of HPVs in the country.

The National Leprosy Control Programme of Zimbabwe a data analysis, 1983-1992.

Prevalence and detection rates of leprosy in Zimbabwe as well as patient characteristics were reported by the National Leprosy Control Programme over the 10-year period 1983-1992. The control programme made a new start in 1983 when multidrug therapy was introduced. Prevalence per 10,000 population declined steeply from 3.78 in 1983 to 0.52 in 1987. Prevalence continued to decline to 0.22 in 1992 and was highest in the north-eastern provinces. After an initial increase, the detection rate per 10,000 had declined from 0.19 in 1985 to 0.08 in 1992. The proportion of refugees among new cases had gradually increased since 1988 and amounted to one third in 1991 and 1992. An analysis of records of 802 cases who were newly detected from 1983 to 1992 showed that 51% were of the multibacillary (MB) type, 33% had visible disabilities at detection, 5% were under 15 years of age while the average delay time was 2.6 years. Patients with disabilities reported a longer delay time, were more often men and had more often the MB type of leprosy. The data suggest that transmission of leprosy is low but that cases are not diagnosed early enough to prevent transmission altogether.

Alcohol consumption in the rural population of Misungwi subdistrict in Mwanza Region, Tanzania.

OBJECTIVE: This study was undertaken to investigate the frequency and quantity of alcohol consumption in four villages on the southern shores of Lake Victoria, Tanzania. METHOD: Study participants were 148 men and 162 women selected by cluster sampling from the population (N = 9,243) of four villages in Misungwi subdistrict, Mwanza Region, Tanzania. Interviews on self-reported alcohol consumption were conducted at the participants' home in Kiswahili using a standardized questionnaire. RESULTS: Fifty-five percent of the men and 33% of the women had consumed alcohol at least once during the year prior to the interview; 24% of the men and 6% of the women had consumed alcohol on six or more occasions during the past month. The quantity of alcohol consumed at the last sitting and in the month prior to the interview was twice as high among male compared to female respondents. The frequency and quantity of alcohol consumption per month increased with age for men but not for women. The large majority of respondents consumed locally produced alcoholic beverages. CONCLUSIONS: Alcohol consumption in this area was low compared to estimates from other parts of Tanzania and national data. Drinking patterns suggested that traditional rules and regulations concerning alcohol were still adhered to.

A sero-epidemiological study of the relationship between sexually transmitted agents and cervical cancer in Honduras.

To investigate a possible cause-and-effect relationship between sexually transmitted diseases and cervical cancer, we performed a sero-epidemiological study on the presence of antibodies against a number of sexually transmitted agents (STAs) in patients with cervical cancer and their matched controls. In this study, we used serological techniques to investigate the presence of antibodies to cytomegalovirus, herpes simplex virus type 2, human immunodeficiency virus, Chlamydia trachomatis, Treponema pallidum and human papillomavirus (HPV) early protein E7 in sera from patients with cervical cancer, cervical intra-epithelial neoplasia and individually matched, healthy controls. The presence of antibodies to infectious agents other than HPV appeared not to be associated with risk of cervical neoplasia in either univariate or multivariate analysis. After adjustment for cytology, schooling and presence of HPV DNA in cervical scrapes, there was a significantly higher prevalence of antibodies to HPV-16 E7 protein in sera from patients with cervical cancer (OR = 3.6, 95% CI 1.0-12.9) than in healthy controls. The highest antibody prevalence was found among HPV-16 DNA-positive cervical cancer patients (33%). Our results indicate that in these study groups past infections with the STA considered seems to be of no apparent relevance for cervical carcinogenesis and that the HPV-16 anti-E7 response appears to be associated with cervical cancer.

Typhoid fever in Ujung Pandang, Indonesia--high-risk groups and high-risk behaviours.

We performed a hospital-based case-control study to identify high risk groups and routes of transmission of typhoid fever in the city of Ujung Pandang on the island of Sulawesi, Indonesia. The annual incidence of this disease in southern Sulawesi is estimated at 3.1/1000 and the case fatality at 5.1% Cases were 50 patients over 13 years of age admitted to Stella Maris Hospital with a diagnosis of typhoid fever between June and September 1991. Diagnosis was made on clinical grounds and in 90% of cases confirmed by a Widal test. Controls were 42 patients admitted for non-infectious disorders during the same period and individually matched by age and sex. Controls did not have a history of typhoid fever. Interviews took place in hospital. Analysis was by unconditional logistic regression. High-risk groups consisted of those who were single, unemployed and those who had a university education. Median age of cases was 22 years. Consumption of food from warungs (food stalls in the street) was strongly associated with risk (OR = 45). Both cases and controls washed hands after use of the toilet and before meals, but cases used soap significantly less often (OR = 30). The results of this study can be used to take preventive measures against this severe disease of educated and single young adults by targetting them for IEC-activities emphasizing the importance of thorough hand-washing and the need to take care in the selection of street-foods.

Association of infections with human immunodeficiency virus and human papillomavirus in Honduras.

The etiologic role of the oncogenic types of human papillomavirus (HPV) in the development of cervical cancer has been widely proven. Since this cancer occurs more frequently in immunosuppressed individuals, we sought to evaluate the prevalence of HPV infection among human immunodeficiency virus (HIV)-infected and HIV-noninfected prostitutes in Tegucigalpa, Honduras. Cervical scrapes were collected from 23 HIV-seropositive and 28 HIV-seronegative prostitutes for HPV DNA detection by the polymerase chain reaction. Fifty-six percent of the HIV-seropositive women and only 18% of the seronegative women were HPV DNA positive (odds ratio = 6.0). In addition, there was a significant association between seropositivity for HIV with a history of sexually transmitted diseases (P < 0.01). Our data confirm the association between infections with HIV and HPV.

PIP: Numerous studies have revealed a higher prevalence of human papillomavirus (HPV)--etiologically linked to the development of cervical cancer--in women infected with HIV. This study investigated the association of HPV and HIV among 51 prostitutes in Tegucigalpa, Honduras. 23 were HIV-positive. All participants were in their early thirties, had had at least one pregnancy, and experienced their first pregnancy at a mean age of 16 years. Polymerase chain reaction identified HPV DNA in cervical scrapes from 13 (56.5%) HIV-positive women compared with only 5 (18%) HIV-negative prostitutes (odds ratio, 6.0; 95% confidence interval, 1.5-26.7). In addition, there was a significant association between HIV and a history of other sexually transmitted diseases (p 0.01). Since the progression to invasive cervical disease is more aggressive in HIV-infected women, prostitutes and other women at risk of both these infections should receive frequent cytologic screening and counseling.

HIV-1 incidence and HIV-1 associated mortality in a cohort of urban factory workers in Tanzania.

OBJECTIVE: To determine HIV-1 incidence and HIV-1 associated mortality in a prospective cohort study. To determine whether the cohort is suitable for studies aiming to determine the impact of interventions on HIV-1 incidence. METHODS: The study population was a cohort of 1772 urban factory workers (1478 men and 294 women) in northwest Tanzania. The study took place from October 1991 to September 1993. Outcome measures were HIV-1 seroconversion and death. RESULTS: HIV-1 incidence was 1.2 (95% CI 0.7-2.0) per 100 person-years (pyr). Crude annual mortality was 4.9 per 100 pyr in those with and 0.3 in those without HIV-1 infection, giving an age and sex adjusted mortality ratio of 12.9 (95% CI 5.4-30.7). Of all deaths, 62% were attributable to HIV-1 infection. CONCLUSION: HIV-1 infection was a major public health problem, being the major cause of death in this adult population. At an HIV-1 incidence of 1.2 per 100 pyr, a large cohort size would be required to evaluate the impact of interventions on HIV-1 incidence.

PIP: The objectives were to determine HIV-1 incidence and HIV-1 associated mortality in a prospective cohort study and to determine whether the cohort is suitable for studies attempting to determine the impact of interventions on HIV-1 incidence. The study population was a cohort of 2038 urban factory workers in northwest Tanzania of whom 1772 workers (1478 men or 87% and 294 women or 89%) had enrolled in the study during October 1991 to September 1993. 471 (27%) of the total study population were lost to follow-up by the end of the study period. Outcome measures were HIV-1 seroconversion and death. At intake, 153 of 1478 (10.4%) men and 52 of 294 (17.7%) women were infected with HIV-1. In the study period, 17 seroconversions took place in 1365.9 person years of follow-up giving an HIV-1 incidence rate of 1.2/100 person-years of follow-up. No association was found between seroconversion and age or sex. The crude annual mortality rate was 4.9/100 person-years in those with and 0.3/100 person-years in those without HIV-1 infection, giving an age- and sex-adjusted mortality ratio of 12.9. The age- and sex-adjusted population attributable risk was 0.5/100 person-years, and of all deaths, 62% were attributable to HIV-1 infection. Of the 14 HIV-1 infected people who died, 9 met the criteria of the 1987 revised Centers for Disease Control/World Health Organization AIDS case definition: one had cryptococcal meningitis and eight HIV wasting syndrome. Two others had had weight loss and fever, but the evidence was inadequate to make or reject the diagnosis of AIDS. The remaining three without an AIDS diagnosis had pulmonary tuberculosis, diarrhea, and pyomyositis, respectively. HIV-1 infection was a major cause of death in this adult population. At an HIV-1 incidence of 1.2/100 person-years, a large cohort size would be required to evaluate the impact of interventions on HIV-1 incidence.

Sexual partner change and condom use among urban factory workers in northwest Tanzania.

OBJECTIVE: To describe sexual partner change and condom use at the intake of a cohort study of urban factory workers in Tanzania. METHODS: From October 1991 to March 1992, 926 male and 170 female factory workers were interviewed using a structured, pre-coded questionnaire. Questionnaire reliability was assessed by pre-testing and comparison with results of unstructured interviews and carrying out repeat questionnaires on a sub-sample. RESULTS: Almost half of both men and women had had sexual intercourse by their 17th birthday. The period of premarital sex had an interquartile range of 2 to 10 years in men and 0 to 2.5 years in women. Having had sexual intercourse in the past month with more than one partner was reported by 22% of the men and 5% of the women. Factors associated with multiple partners in men were being born in or near Mwanza Region, having low education and low income, and being married. Condoms had been used in the past month by 3% only, mainly with casual partners. Condom use in men was associated with being young, living in town, being born in Kagera Region, high education and high income, being circumcised, and having causal or steady (non- martial) partners. CONCLUSION: Information, education and communication (IEC) on sexual relationships and condom use should start at an early age, and include education at primary schools. Much sexual partner change appears to occur through steady (non-marital) partnerships, indicating the need for IEC to be expanded beyond groups such as commercial sex workers and their clients.

PIP: A cohort study of urban workers was initiated in a factory in Mwanza Municipality, Tanzania, October 1991 to March 1992, in order to identify risk factors for HIV-1 seroconversion and for contracting other STDs. All respondents were interviewed for 30-45 minutes in Kiswahili using a structured and pre-coded questionnaire that was slightly different for men and women. In the first 19 weeks 1096 workers (926 male, 170 female) were enrolled. Participants were more likely to be under 25 years old. By the 15th birthday 16% of male and 6% of female respondents reported having had sexual intercourse; by the 17th birthday these percentages were 44% and 33%, respectively. In those who had ever married, the median period of having had premarital sexual intercourse was 5 years (interquartile range 2-10 years) in men and 1 year (interquartile range 0-2.5 years) in women. Marriage survival was slightly longer for men than for women (0.05 p 0.1). 724/926 (78%) of male and 76/170 (45%) of the female factory workers were married and living together with their spouse. Of the 724 married men 45 (6%) had 2 wives, the others had 1 wife only. Among the married respondents 607/717 (85%) of the men and 71/76 (93%) of the women reported having had sex with their spouse in the past 4 weeks (men: median 4 times, women: median 5 times). Having had more than one sexual partner in the past month was reported by 205/926 (22%) of men and 8/170 (5%) of women. Factors associated with having had multiple sexual partners in the past month were: being born in Mwanza or the neighboring Mara or Shinyanga Regions, having had less education or having a low income, and being married. Having had more than one sexual partner in the past month was also associated with having ever had a genital discharge. Overall, 141/924 (15%) of men and 30/170 (18%) of women had ever used a condom. Only 28/924 (3%) of men and 5/170 (3%) of women had used a condom in the past month.

Intake of a cohort study of urban factory workers in northwest Tanzania. Risk factors for HIV-1 infection.

A cohort study has been started of urban factory workers and their spouses in Tanzania, in order to 1) identify risk factors for HIV-1 seroconversion, and 2) document changes over time in risk behaviour, in particular condom use and partner change, and determine whether these are associated with a reduced incidence of HIV-1 and other sexually transmitted diseases. We report findings at intake from October 1991 to March 1992. Study participants were interviewed, examined, and screened for HIV-1 and syphilis. HIV-1 prevalence was 91/926 (10%) in males and 36/217 (17%) in females. Statistically significant risk factors for HIV-1 infection in males were age group, region of birth, not being married for more than 5 years, being uncircumcised, having had a genital ulcer in the past four months, and having received injections from medical staff in the past four months. HIV-1 incidence in this group is expected to be between 1% and 2% per year. It is concluded that a longitudinal study is needed to assess the importance of partner change. This cohort appears to be suitable for such a study as HIV-1 incidence is expected to be fairly high, HIV-1 prevalence and risk factors are comparable to those of the general population and cooperation of the factory workers is good.

Estimating gallstone incidence from prevalence data.

Because incidence data for gallstones are generally unavailable, we have used a previously described epidemiologic method to estimate age-specific incidence rates from published gallstone prevalence data in seven populations. Yearly incidence rates ranged from a low of 1 in 1000 for the younger men to 19 in 1000 for the oldest women. An overall pattern of increasing incidence of disease with increasing age was observed. Rate-ratios for oldest versus youngest subjects ranged from 4.0 in German women to 9.4 in Italian men: mean rate-ratio = 5.9; 95% CI = 4.0-7.8. For all centers, age-specific female incidence rates exceeded comparable age-specific male rates at all ages (mean female to male rate-ratio = 1.85; 95% CI = 1.7-2.0). No differences were observed in the sex-specific incidence of gallstones for subjects of similar age in the various centers (P = > 0.10). For Denmark our estimates resemble recently published incidence data obtained by re-surveying the original population.

Malaria morbidity and mortality in children under three years of age on the coast of Benin, West Africa.

Malaria morbidity and mortality were measured in a population of 1500 children under 3 years of age from April to December 1989. During monthly home visits, an average of 26 children in 1000 had fever, of whom 15 had parasitaemia. Children less than 6 months old had significantly fewer fever episodes, whether associated with parasitaemia or not. Overall, prevalence of fever with parasitaemia rose steadily from April to August, then decreased but reached a second peak in November. Peaks coincided with the 2 rainy seasons in April to June and September to October. Comparison with a control group demonstrated that children with parasitaemia exceeding 1000 infected red blood cells per microliter of blood had fever significantly more often than children with lower levels of parasitaemia. The average number of fever episodes per child per year was 2.4, and 33% of these were estimated to be caused by malaria. All cause mortality was 26/1000/year and the malaria mortality rate was 8/1000/year. Malaria deaths were most frequent in the second year of life.

Childhood mortality among users and non-users of primary health care in a rural west African community.

To evaluate the effectiveness of primary health care (PHC) interventions implemented through the Pahou PHC Project, the utilization of PHC by 74 children aged 4 to 35 months who died in 1986 or 1987 was compared to that of 230 controls who survived and were individually matched by date of birth, sex and place of residence. The crude death rate was 35.9/1000/year. Measles vaccination before the first birthday significantly reduced the risk of mortality (Relative Risk/RR = 0.4). Children with less than 75% weight for age early in 1986 had an increased risk (RR = 4.3). Children who died had had significantly fewer contacts with the village health worker (VHW) in the last six months prior to death (RR = 0.3). A similar association was not observed for periods more than six months prior to death. Children who had more regular contact with the VHW throughout life were better protected than children for whom contact had been less systematic. We conclude that VHWs contribute to a better survival of young children through regular personal contact with the household.

PIP: Researchers analyzed the relationship between use of primary health care services and child mortality in 16 villages in the communes of Pahou and Avlekete on the Atlantic coast of Benin. The case control study included 74 4-35 month old children who died in 1986-1987 and 230 controls who survived. Overall child mortality stood at 35.9/1000/year. Fever and convulsions, presumably malaria, were the most likely cause of the majority of deaths (38 cases). No protective effect of a village health worker (VHW) visit in the 6 months before death occurred between fever and convulsion cases and other causes of death cases, however. VHWs had visited considerably more controls than cases in the 6 months prior to death (RR ..3; p.05). Indeed the greatest protective effect occurred in children who has been seen by VHWs had visited 71% of all children for a median of 4 visits each. Poor children were only slightly more likely to die than nonpoor children. Children whose weight for age was 75% of the standard for their age has a 4.26 relative risk (RR) of mortality (p.05). Further, when the researchers excluded cases who died within 3 months of the weight measurement, the RR remained high (2.9) and the association significant (p=.08). Measles vaccination between 9-12 months old significantly protected children against mortality (RR .36; p.05). On the other hand, diphtheria, tetanus, and pertussis vaccination did not have a significant protective effect. In conclusion, personal and household contact with a VHW and measles vaccination between 9-12 months improves child survival for 4-35 month old children.