An epidemic of spastic paraparesis of unknown aetiology in Northern Mozambique.

This case study is based on a real-life outbreak investigation undertaken in Mozambique in 1981. This case study describes and promotes one particular approach to unknown disease outbreak investigation. Investigational procedures, however, may vary depending on location and outbreak. It is anticipated that the epidemiologist investigating an unknown disease outbreak will work within the framework of a "multidisciplinary investigation team". It is through the collaborative efforts of this team, with each member playing a critical role, that outbreak investigations are successfully completed. Some aspects of the original outbreak and investigation have, however, been altered to assist in meeting the desired teaching objectives and to allow completion of the case study in less than 3 hours.

Ebola and Its Control in Liberia, 2014-2015.

The severe epidemic of Ebola virus disease in Liberia started in March 2014. On May 9, 2015, the World Health Organization declared Liberia free of Ebola, 42 days after safe burial of the last known case-patient. However, another 6 cases occurred during June-July; on September 3, 2015, the country was again declared free of Ebola. Liberia had by then reported 10,672 cases of Ebola and 4,808 deaths, 37.0% and 42.6%, respectively, of the 28,103 cases and 11,290 deaths reported from the 3 countries that were heavily affected at that time. Essential components of the response included government leadership and sense of urgency, coordinated international assistance, sound technical work, flexibility guided by epidemiologic data, transparency and effective communication, and efforts by communities themselves. Priorities after the epidemic include surveillance in case of resurgence, restoration of health services, infection control in healthcare settings, and strengthening of basic public health systems.

The joy of facts and figures by Fiona Fleck.

Hans Rosling tells Fiona Fleck why it's easy to make health statistics interesting but difficult to persuade people to accept a fact-based view of the world.

Estimating the capacity for ART provision in Tanzania with the use of data on staff productivity and patient losses.

BACKGROUND: International targets for access to antiretroviral therapy (ART) have over-estimated the capacity of health systems in low-income countries in Sub-Saharan Africa. The WHO target for number on treatment by end 2005 for Tanzania was 10 times higher than actually achieved. The target of the national Care and Treatment Plan (CTP) was also not reached. We aimed at estimating the capacity for ART provision and created five scenarios for ART production given existing resource limitations. METHODS: A situation analysis including scrutiny of staff factors, such as available data on staff and patient factors including access to ART and patient losses, made us conclude that the lack of clinical staff is the main limiting factor for ART scale-up, assuming that sufficient drugs and supplies are provided by donors. We created a simple formula to estimate the number of patients on ART based on availability and productivity of clinical staff, time needed to initiate vs maintain a patient on ART and patient losses using five different scenarios with varying levels of these parameters. FINDINGS: Our scenario assuming medium productivity (40% higher than that observed in 2002) and medium loss of patients (20% in addition to 15% first-year mortality) coincides with the actual reported number of patients initiated on ART up to 2008, but is considerably below the national CTP target of 90% coverage for 2009, corresponding to 420,000 on ART and 710,000 life-years saved (LY's). Our analysis suggests that a coverage of 40% or 175,000 on treatment and 350,000 LY's saved is more achievable. CONCLUSION: A comparison of our scenario estimations and actual output 2006-2008 indicates that a simple user-friendly dynamic model can estimate the capacity for ART scale-up in resource-poor settings based on identification of a limiting staff factor and information on availability of this staff and patient losses. Thus, it is possible to set more achievable targets.

Foreign field hospitals in the recent sudden-onset disasters in Iran, Haiti, Indonesia, and Pakistan.

INTRODUCTION: Foreign field hospitals (FFHs) may provide care for the injured and substitute for destroyed hospitals in the aftermath of sudden-onset disasters. PROBLEM: In the aftermath of sudden-onset disasters, FFHs have been focused on providing emergency trauma care for the initial 48 hours following the sudden-onset disasters, while they tend to be operational much later. In addition, many have remained operational even later. The aim of this study was to assess the timing, activities, and capacities of the FFHs deployed after four recent sudden-onset disasters, and also to assess their adherence to the essential criteria for FFH deployment of the World Health Organization (WHO). METHODS: Secondary information on the sudden-onset disasters in Bam, Iran in 2003, Haiti in 2004, Aceh, Indonesia in 2004, and Kashmir, Pakistan in 2005, including the number of FFHs deployed, their date of arrival, country of origin, length of stay, activities, and costs was retrieved by searching the Internet. Additional information was collected on-site in Iran, Indonesia, and Pakistan through direct observation and key informant interviews. RESULTS: Basic information was found for 43 FFHs in the four disasters. The first FFH was operational on Day 3 in Bam and Kashmir, and on Day 8 in Aceh. The first FFHs were all from the militaries of neighboring countries. The daily cost of a bed was estimated to be US$2,000. The bed occupancy rate generally was < 50%. None of the 43 FFHs met the first WHO/Pan-American Health Organization (PAHO) essential requirement if the aim is to provide emergency trauma care, while 15% followed the essential requirement if follow-up trauma and medical care is the aim of deployment. DISCUSSION: A striking finding was the lack of detailed information on FFH activities. None of the 43 FFHs arrived early enough to provide emergency medical trauma care. The deployment of FFHs following sudden-onset disasters should be better adapted to the main needs and the context and more oriented toward substituting for pre-existing hospitals, rather than on providing immediate trauma care.

Socioeconomic determinants of infant mortality: a worldwide study of 152 low-, middle-, and high-income countries.

BACKGROUND: To reach the Millennium Development Goals for health, influential international bodies advocate for more resources to be directed to the health sector, in particular medical treatment. Yet, health has many determinants beyond the health sector that are less evident than proximate predictors. AIM: To assess the relative importance of major socioeconomic determinants of population health, measured as infant mortality rate (IMR), at country level. METHODS: National-level data from 152 countries based on World Development Indicators 2003 were used for multivariate linear regression analyses of five socioeconomic predictors of IMR: public spending on health, GNI/capita, poverty rate, income equality (Gini index), and young female illiteracy rate. Analyses were performed on a global level and stratified for low-, middle-, and high-income countries. RESULTS: In order of importance, GNI/capita, young female illiteracy, and income equality predicted 92% of the variation in national IMR whereas public spending on health and poverty rate were non-significant determinants when adjusted for confounding. In low-income countries, female illiteracy was more important than GNI/capita. Income equality (Gini index) was an independent predictor of IMR in middle-income countries only. In high-income countries none of these predictors was significant. CONCLUSIONS: The relative importance of major health determinants varies between income levels, thus extrapolating health policies from high- to low-income countries is problematic. Since the size, per se, of public health spending does not independently predict health outcomes, functioning health systems are necessary to make health investments efficient. Potential health gains from improved female education and economic growth should be considered in low- and middle-income countries.

Clinic entrance interviews: a new method to assess needs after a sudden impact disaster.

BACKGROUND: After a Sudden impact disasters (SID), relief workers and coordinators require information on the size and location of the affected population as well as the character and magnitude of their immediate needs. METHODS: The study was performed in the mountainous Bagh district, a part of the autonomous state of Azad Jammu and Kashmir in Pakistan. Semi-structured interviews were conducted daily at either of the three health centres or the district hospital in which MSF was working. RESULTS: The MSF facility-based survey results on mortality and injury in Bagh Tehsil corresponded to those from the community-based Army survey. This indicates that regular selection of consecutive arrivals at the entrance of a health facility may provide a fairly geographically representative population sample in a SID context. Our findings suggest that the sample was large enough to provide useful estimates on the main pattern of post-earthquake needs in the study area.

Economic burden on families of childhood type 1 diabetes in urban Sudan.

The aims of this study were to estimate the direct costs of childhood diabetes in a low income country, Sudan, and to assess the effectiveness of care paid for by the families. For this purpose, socio-economic and demographic data on families were obtained from the parents of 147 children with type 1 diabetes, attending public or private clinics in Khartoum State, Sudan. The median annual income of the families of diabetic children was US dollars (US$) 1222 (range 0-14,338) of which 16% was received as financial help from relatives and friends. The median annual expenditure of diabetes care was US$ 283 per diabetic child of which 36% was spent on insulin. Of the family expenditure on health, 65% was used for the diabetic child. Families of diabetic children who were attending private clinics had a significantly higher total expenditure on health and home blood glucose monitoring than those who were attending the public clinics. However, there was no difference in total income between the two groups and glycaemic control was poor in 86% of the patients, regardless of whether care was being given by private or public clinics. The occurrence of the disease and its poor control appeared to exert a negative impact on the school performance of the diabetic child. In conclusion, the low direct costs reflect the minimal care given to the diabetic patients. Under the present economic conditions, families pay a considerable part of their income to sponsor the health of their diabetic children and receive little support other than that from relatives and friends. The present organization of diabetes care does not provide the patient with empowerment, knowledge and self-care ability. Well-trained diabetic teams and education programs may improve this situation.

Attempted suicide in Hanoi, Vietnam.

BACKGROUND: Attempted suicide is a key predictor of suicide, which is among the dominant causes of young people's deaths worldwide. Very little is known about the characteristics of suicide attempters in Asia, especially in Vietnam. METHODS: Medical records of 509 patients (515 attempted-suicide events) admitted to Bach Mai General Hospital in Hanoi, Vietnam from 1 January 1999 to 30 April 2001 were analysed according to the criteria of the WHO Multicentre Study of Attempted Suicide. RESULTS: The suicide attempters' mean age was 28.3+/-12.9 years. Nearly half (48.7%) were aged 15-24. The female-to-male ratio of patients living in urban areas (2.1:1) was higher than in rural areas (1.2:1). In urban areas, students (32 %) and homeworkers (28%) and, in rural areas, farmers (56 %) and students (17%) were the salient occupational categories. Acute life stressors were the main causes (73.8%) of suicide attempts. Only in some 6% of cases had a psychiatric illness been diagnosed before the suicide attempts. As a means of attempting suicide, intoxication with analgesics and antipyretics (e. g. paracetamol) with low medical lethality scores was a frequent method among the urban patients, the majority of whom (81%) consequently stayed in hospital less than 24 h. Pesticide and rat poison, more commonly (57.2%) used by attempters in rural areas, had higher medical lethality scores and also necessitated more prolonged hospital treatment. CONCLUSIONS: Some suicide-preventive strategies used in the West for young people may be applicable in Vietnam. Reducing access to pesticides and rat poison is comparable to western efforts to make paracetamol or firearms less freely available. Skills in resolving family and other conflicts can be taught in schools according to WHO's suicide-prevention resources for teachers.