Outbreak of gastroenteritis caused by Yersinia pestis in Afghanistan.

Plague, which is most often caused by the bite of Yersinia pestis-infected fleas, is a rapidly progressing, serious disease that can be fatal without prompt antibiotic treatment. In late December 2007, an outbreak of acute gastroenteritis occurred in Nimroz Province of southern Afghanistan. Of the 83 probable cases of illness, 17 died (case fatality 20·5%). Being a case was associated with consumption or handling of camel meat (adjusted odds ratio 4·4, 95% confidence interval 2·2-8·8, P<0·001). Molecular testing of patient clinical samples and of tissue from the camel using PCR/electrospray ionization-mass spectrometry revealed DNA signatures consistent with Yersinia pestis. Confirmatory testing using real-time PCR and immunological seroconversion of one of the patients confirmed that the outbreak was caused by plague, with a rare gastrointestinal presentation. The study highlights the challenges of identifying infectious agents in low-resource settings; it is the first reported occurrence of plague in Afghanistan.

Cesarean delivery surveillance system at a maternity hospital in Kabul, Afghanistan.

OBJECTIVE: To use an active facility-based maternal and newborn surveillance system to describe cesarean delivery practices and outcomes in a resource-poor setting. METHODS: Using data from operating room logbooks, 392 cesarean deliveries were evaluated between April 1 and June 30 2006 at a large public maternity hospital in Kabul, Afghanistan. RESULTS: The perinatal mortality rate was 89 per 1000 births: 57% antepartum and 37% intrapartum stillbirths. Fetuses with normal birth weight comprised 85% of intrapartum stillbirths. Obstructed labor, uterine rupture, and malpresentation accounted for more than 50% of perinatal deaths. The cesarean delivery rate was 10.2% and there were 2 maternal deaths. CONCLUSION: The high percentage of intrapartum stillbirths among normal birth weight fetuses suggests a need for improved labor monitoring and surgical obstetric practices. The use of a facility-based perinatal surveillance system is critical in guiding such quality assurance initiatives.

Scaling up TB DOTS in a fragile state: post-conflict Afghanistan.

SETTING: Afghanistan. OBJECTIVE: To describe the results of rapid expansion of the DOTS strategy in a post-conflict environment, with a focus on the experience of the Rural Expansion of Afghanistan's Community-based Healthcare (REACH) Program. RESULTS: Despite the destruction of the National Tuberculosis Program (NTP) and basic health services by war and an uncertain security situation, the NTP, with assistance from many partners and REACH, increased the number of patients receiving DOTS by 136% in 4 years (from 9261 cases in 2001 to 21851 in 2005), with an 86% treatment success rate. By focusing on rapidly expanding the number of facilities capable of providing tuberculosis (TB) diagnostic and treatment services and involving community health workers in case detection, referrals and home-based DOTS, REACH showed a 10-fold rise in the number of facilities providing TB services and a 380% increase in the number of sputum smear-positive pulmonary TB cases detected in 2 years (from 251/month in 2004 to 818/month in 2006) in 13 provinces. CONCLUSION: At the current rate of expansion, case detection and successful treatment of TB cases in Afghanistan will continue to expand rapidly. The NTP and REACH have demonstrated that expansion of TB services in Afghanistan is possible despite the challenges.

Towards sustainable delivery of health services in Afghanistan: options for the future.

Disruption caused by decades of war and civil strife in Afghanistan has led many international and national nongovernmental organizations (NGOs) to assume responsibility for the delivery of health services through contracts with donor agencies. Recently the Afghan Government has pursued the policy of contracting for a basic package of health services (BPHS) supported by funds from three major donors - the World Bank, the United States Agency for International Development (USAID) and the European Commission. With the gradual strengthening of the public health ministry, options for the future include pursuing the contracting option or increasing public provision of health services. Should contracting with NGOs be pursued, a clear strategy is required that includes developing accreditation instruments, better contracting mechanisms and a system for monitoring and evaluating the entire process. Should the government opt for an increasing role, problems to be solved include securing the transition to public provision, obtaining guarantees that appropriate financing will be provided and reconfiguration of the public health delivery system. Large-scale contracting with the private for-profit sector cannot be recommended at this stage, although this option could be explored via subcontracting by larger NGOs or small-scale trial contracts initiated by the public health ministry. Irrespective of the option chosen, an important challenge remaining is the recalcitrant problem of high out-of-pocket payments. Sustainable delivery of health services in Afghanistan can only be achieved with a clear national strategy in which all stakeholders have roles to play in the financing, regulation and delivery of services.

Towards sustainable delivery of health services in Afghanistan: options for the future.

Disruption caused by decades of war and civil strife in Afghanistan has led many international and national nongovernmental organizations (NGOs) to assume responsibility for the delivery of health services through contracts with donor agencies. Recently the Afghan Government has pursued the policy of contracting for a basic package of health services (BPHS) supported by funds from three major donors-the World Bank, the United States Agency for International Development (USAID) and the European Commission. With the gradual strengthening of the public health ministry, options for the future include pursuing the contracting option or increasing public provision of health services. Should contracting with NGOs be pursued, a clear strategy is required that includes developing accreditation instruments, better contracting mechanisms and a system for monitoring and evaluating the entire process. Should the government opt for an increasing role, problems to be solved include securing the transition to public provision, optining guarantees that appropriate financing will be provided and reconfiguration of the public health delivery system. Large-scale contracting with the private for-profit sector cannot be recommended at this stage, although this option could be explored via subcontracting by larger NGOs or small-scale trial contracts initiated by the public health ministry. Irrespective of the option chosen, an important challenge remaining is the recalcitrant problem of high out-of-pocket payments. Sustainable delivery of health services in Afghanistan can only be achieved with a clear national strategy in which all stakeholders have roles to play in the financing, regulation and delivery of services.

The role of vitamin A in enhancing humoral immunity produced by antirabies vaccine.

We tested the effects of vitamin A supplementation on the antibody titre of 40 healthy volunteers (age range: 10-35 years), who had received a complete course of antirabies vaccine (5 injections over 30 days). After determining the baseline serum vitamin A status of 80 volunteers, 20 pairs were matched for serum vitamin A level, body mass index, age, sex and socioeconomic status. One person from each pair was randomly assigned to an experimental or control group. The experimental group received vitamin A and antirabies vaccine. Controls received only the vaccine. The experimental group had significantly greater (2.1 times) serum antirabies titre than controls. This finding is an important step towards improving the economy of dosage of antirabies vaccines.

The role of vitamin A in enhancing humoral immunity produced by antirabies vaccine

We tested the effects of vitamin A supplementation on the antibody titre of 40 healthy volunteers [age range: 10-35 years], who had received a complete course of antirabies vaccine [5 injections over 30 days]. After determining the baseline serum vitamin A status of 80 volunteers, 20 pairs were matched for serum vitamin A level, body mass index, age, sex and socioeconomic status. One person from each pair was randomly assigned to an experimental or control group. The experimental group received vitamin A and antirabies vaccine. Controls received only the vaccine. The experimental group had significantly greater [2.1 times] serum antirabies titre than controls. This finding is an important step towards improving the economy of dosage of antirabies vaccines

The consequence of land mines on public health.

An estimated 110 million land mines scattered in 64 countries continue to terrorize people and destroy human lives long after wars and fighting have ceased. Despite efforts to clear these devices, their numbers continue to increase and their presence constitutes a substantial threat to public health in affected countries. Direct consequences include both the physical and emotional injuries from the impact, flying debris, and structural collapse associated with their detonation. Indirect consequences include increases in the incidence of waterborne diseases, diarrhea, malnutrition, infectious diseases, and spread of the human immunodeficiency virus associated with the increased use of blood. Those at highest risk of these later consequences are mostly the disadvantaged poor, especially children. Psychiatric disorders, such as post-traumatic stress disorder, occur in those not directly injured as well as those physically wounded by the explosion. Besides efforts to ban production, stockpiling and export of land mines, a comprehensive and integrated health program aimed at the prevention, treatment, and rehabilitation of those injured directly or indirectly by land mines is needed urgently. Strategies should include mine-awareness programs, enhanced transport of those directly injured, training the villagers in first aid, augmenting the capacity and quality of treatment facilities, improving the psychological support and treatment capabilities, development of rehabilitation programs, and the institution and enhancement of public-health programs directed at the indirect consequences associated with the presence of land mines. Land mines constitute a major public health problem in the world that must be addressed.

Aspects of the rationale for the Women's Health Trial.

A 5.5-fold range in breast cancer incidence rates in 21 countries shows strong correlation with national estimates of per capita intake of dietary fat, but not with other caloric sources (proteins and carbohydrates). It is argued that certain breast cancer and hormone factors may contribute little to the explanation of such international variations in incidence of this neoplasm. It is further argued that experimental studies in animals support a specific role for dietary fat in the promotion of mammary tumors, but the effects of calories alone seem to be largely restricted to tumor initiation. Finally, data from international, migrant-population, and analytic epidemiologic investigations are used to motivate the basic relative risk assumption of study designs thus far proposed for the Women's Health Trial, and some continuing motivations for a dietary intervention (low-fat diet) trial are discussed.

Non-contraceptive estrogen use and the risk of gallstone disease in women.

We interviewed 102 women, ages 41-74 years who underwent gallstone surgery between January 1979 and September 1980, and 98 controls selected from the membership files of a large prepaid health care plan in Western Washington, about their past use of certain medications, reproductive history, and physical and demographic characteristics. The risk of gallstone disease among women who used estrogens for at least one year prior to diagnosis of their condition, relative to that of other women, was 1.18 (95% CI: 0.65-2.13). Standardization for the effects of age, race, obesity, parity, thiazide use, and history of high blood pressure did not alter appreciably the estimate of relative risk. Among estrogen users, the duration of use was similar in cases and controls. Our findings suggest that if non-contraceptive estrogen use is a risk factor for gallstone disease (requiring surgery) in women, its effect is very small.

Thiazide use and the risk of cholecystectomy in women.

As part of a case-control study of gallstone disease conducted among the female members of Group Health Cooperative of Puget Sound, the authors investigated the possible etiologic role of prior use of thiazide diuretics. One hundred fifty-three women who underwent gallstone surgery between January 1979 and September 1980, and 156 controls selected from membership files, were interviewed about their past use of certain medications, their reproductive history, and physical and demographic characteristics. The risk of gallstone disease which required surgery among women who had used thiazides relative to those who had not used this drug, after controlling for age, race, pregnancy, and body mass index, was 1.9 (95% confidence interval (CI) = 1.0-3.7). However, this association was present only among women who were not overweight, i.e., those with body mass index less than or equal to 36, for whom the relative risk was 5.0 (95% CI = 1.8-13.5). Among overweight women, the relative risk was 1.0 (95% CI = 0.5-2.2). Among women who were not overweight, there was no further increase in risk with increasing duration or recency of thiazide use. These data fail to agree with data from earlier studies which show a possible thiazide-gallstone disease association. The results of the present study suggest that if thiazide use has any influence on the occurrence of gallstone disease in women, that influence exists primarily in those who are not overweight.