Simple and practical screening approach to identify HIV-infected individuals with depression or at risk of developing depression.

OBJECTIVES: Studies have shown that depression and other mental illnesses are under-diagnosed among HIV-infected individuals. The aim of this study was to evaluate the use of mental health history and questionnaire-based screening instruments to identify HIV-infected individuals at risk of depression. METHODS: The Beck Depression Inventory II (BDI-II) was used to assess the prevalence and severity of depressive symptoms among HIV-infected individuals attending two out-patient clinics in Denmark. HIV-infected individuals with a BDI-II score ≥ 20 were offered a clinical evaluation by a consultant psychiatrist. The BDI-II score was compared to the outcome of mental health history review, and to results obtained using the European AIDS Clinical Society (EACS) two-item depression screening tool. RESULTS: A total of 501 HIV-infected individuals were included in the study. Symptoms of moderate/major depression (BDI-II score ≥ 20) were observed in 111 patients (22%); 65 of these patients consulted a psychiatrist, of whom 71% were diagnosed with a co-existing disorder. The BDI-II score was compared to the outcome of a mental health history review, and to results obtained using the European AIDS Clinical Society (EACS) two-item depression screening tool. The two questions showed a sensitivity and specificity of 95% and 68%, respectively, for diagnosis of current depression or risk of depression. A previous psychiatric history and substance abuse were independently associated with an increased risk of depression. CONCLUSIONS: We suggest that the mental health of HIV-infected individuals should be reviewed and a "risk-flag" three-step approach should be used (1) to screen routinely with the two verbal questions suggested by the EACS, (2) to identify whether there is a risk of depression and then screen with the BDI-II, and (3) to identify whether there is still a risk and then perform a full evaluation and obtain an accurate psychiatric diagnosis by a psychiatrist.

Factors associated with risk of depression and relevant predictors of screening for depression in clinical practice: a cross-sectional study among HIV-infected individuals in Denmark.

OBJECTIVES: Depression and psychiatric disorders are frequent among HIV-infected individuals. The aim of this study was to determine the prevalence of depression and describe the psychiatric history of HIV-infected individuals in an out-patient clinic in Denmark and to identify factors of clinical importance that may be used to identify patients at risk of depression. METHODS: In 2013, 212 HIV-infected patients were included in a questionnaire study. We used the Beck Depression Inventory II (BDI-II) to assess the prevalence and severity of depressive symptoms. Patients with a BDI-II score ≥ 20 were offered a clinical evaluation by a consultant psychiatrist. Logistic regression was used to determine predictors associated with risk of depression. RESULTS: Symptoms of depression (BDI-II score ≥ 14) were observed in 75 patients (35%), and symptoms of moderate to major depression (BDI-II score ≥ 20) in 55 patients (26%). There was also a high prevalence of co-occurring mental illness. In a multivariate model, self-reported stress, self-reported perception that HIV infection affects all aspects of life, self-reported poor health, not being satisfied with one's current life situation, previous alcohol abuse, nonadherence to antiretroviral therapy and previously having sought help because of psychological problems were independently associated with risk of depression. CONCLUSIONS: Symptoms of depression and co-occurring mental illness are under-diagnosed and under-treated among HIV-infected individuals. We recommend that screening of depression should be conducted regularly to provide a full psychiatric profile to decrease the risk of depression and improve adherence and quality of life in this population.

Infant twin mortality and hospitalisations after the perinatal period - a prospective cohort study from Guinea-Bissau.

OBJECTIVE: To examine mortality and hospitalisations among infant twins and singletons after the perinatal period in Guinea-Bissau. METHODS: The study was conducted from September 2009 to November 2012 by the Bandim Health Project (BHP). Newborn twins and unmatched singleton controls were included at the National Hospital Simão Mendes in the capital Bissau. Children were examined clinically at enrolment. Maternal, pregnancy and obstetric information was collected and HIV testing offered at birth. Follow-up occurred at home at 2, 6 and 12 months and through linkage with the paediatric admission register at the National Hospital. RESULTS: About 495 twins and 333 singletons were alive on day 7 after birth. In total, 36 twins and 12 singletons died during follow-up, the post-perinatal infant mortality rate being 91/1000 person-years for twins and 42/1000 for singletons (HR = 2.11, 95% CI: 1.09-4.07). In a multivariable analysis among twins only, birth weight <2000 g [3.32, (1.36-8.07)], death of the cotwin perinatally [2.54, (1.16-5.57)] and severe maternal illness during pregnancy [2.35, (1.00-5.51)] were significant risk factors for twin death. In the subgroup with available HIV status, maternal HIV infection was strongly associated with twin mortality [3.16, (1.24-8.05)]. Death occurred at home for 60% of twins and 67% of singletons. During follow-up, 90 first-time hospital admissions were registered, with similar rates observed for twins (139/1000) and singletons (143/1000) [0.97, (0.61-1.52)]. CONCLUSION: The post-perinatal infant mortality rate of twins was double that of singletons. No excess in twin hospitalisations was observed, possibly implying obstacles to hospital admission for twins in case of severe illness.

Decline in overall, smear-negative and HIV-positive TB incidence while smear-positive incidence stays stable in Guinea-Bissau 2004-2011.

OBJECTIVE: To calculate Tuberculosis (TB) incidence rates in Guinea-Bissau over an 8-year period. METHODS: Since 2003, a surveillance system has registered all TB cases in six suburban districts of Bissau. In this population-based prospective follow-up study, 1205 cases of pulmonary TB were identified between January 2004 and December 2011. Incidence rates were calculated using census data from the Bandim Health and Demographic Surveillance System (HDSS). RESULTS: The overall incidence of pulmonary TB was 279 per 100,000 person-years of observation; the male incidence being 385, and the female 191. TB incidence rates increased significantly with age in both sexes, regardless of smear or HIV status. Despite a peak with unknown cause of 352 per 100,000 in 2007, the overall incidence of pulmonary TB declined over the period. The incidence of HIV infected TB cases declined significantly from 108 to 39 per 100,000, while the incidence of smear-positive TB cases remained stable; the overall figure was 188 per 100,000. CONCLUSIONS: Overall incidence of pulmonary TB in Guinea-Bissau has declined from 2004 to 2011. The decline was also seen in the subgroups of smear-negative and HIV-positive TB cases, probably due to antiretroviral treatment. Smear-positive TB incidence remains stable over the period.

Tuberculosis awareness in Gezira, Sudan: knowledge, attitude and practice case-control survey.

This case-control study aimed to assess tuberculosis (TB) awareness and its associated sociodemographic characteristics in Gezira, Sudan. New smear-positive TB patients registered in Gezira in 2010 (n = 425) and age-matched controls who attended the same health facilities for other reasons (n = 850) formed the study sample. Awareness was measured using a modified standard World Health Organization TB knowledge, attitude and practice instrument. There was no significant difference between TB cases and the controls in overall levels of TB awareness. About two-thirds of TB cases and controls had good TB awareness. Respondents' sex was associated with awareness among the controls. Age, level of education, type of residence and type of occupation were significantly associated with TB awareness, whereas marital status had no effect. The good level of TB awareness found among TB cases and controls is a baseline for further TB awareness-raising among the Gezira population.

HIV-infected individuals with high coping self-efficacy are less likely to report depressive symptoms: a cross-sectional study from Denmark.

OBJECTIVES: Having effective ways to cope helps HIV-infected individuals maintain good psychological and physical well-being. This study investigated the relationship between coping self-efficacy levels, as determined by the Coping Self-Efficacy Scale (CSE), HIV status disclosure, and depression in a Danish cohort. METHODS: In 2008, the CSE was administered to 304 HIV-infected individuals to measure their confidence in their ability to cope with HIV infection. HIV status disclosure was assessed on a three-point scale: living openly with the disease, partly openly, or secretly. The Beck Depression Inventory (BDI) was used to assess depression prevalence and severity. RESULTS: The CSE score was significantly related to depression (Spearman's rho = -0.71; the test of H0: BDI and coping, probability >t=0.0001). There was a significant relationship between higher CSE scores and living openly with HIV. The risk of depression was four times higher in HIV-infected individuals who did not disclose their HIV status (i.e. who lived 'secretly'; odds ratio = 4.1) than in individuals who lived openly. CONCLUSION: Those with low CSE scores were more likely to report living secretly with HIV and to be depressed. Disclosing HIV may constitute a social stressor, and a lack of coping self-efficacy may increase the likelihood of non-disclosure and depression. Interventions that enhance self-efficacy may help in managing the demands of daily life with HIV, increase disclosure, and reduce depression.

Tuberculosis awareness in Gezira, Sudan:knowledge, attitude and practice case-control survey

This case control study aimed to assess tuberculosis [TB]awareness and its associatedsociodemographic characteristics in Gezira, Sudan.New smear-positive TB patients registered in Gezira in 2010 [n - 425]and age-matched controls who attended the same health facilities for other reasons [n = 850]formed the study sample.Awareness was measured using a modified standard World Health Organization TB knowledge, attitude and practice instrument.There was no significant difference between TB cases and the controls in overall levels of TB awareness.About two-thirds of TB cases and controls had good TB awareness.Respondents' sex was associated with awareness among the controls.Age, level of education, type of residence and type of occupation were significantly associated with TB awareness, whereas marital status had no effect.The good level of TB awareness found among TB cases and controls is a baseline for further TB awareness-raising among the Gezira population

تهدف دراسة الحالات والشواهد هذه إلى تقييم مدى الوعي بالسل، والسمات الاجتماعية والديموغرافية المصاحبة له في الجزيرة بالسودان. واعتمدت عينة الدراسة على مرضى السل الجدد إيجابيي اللطاخة المسجلين في ولاية الجزيرة بالسودان في عام 2010 [العدد = 425]والشواهد الذين يضاهون الحالات في السن ممن حضروا إلى المرافق الصحية نفسها لأسباب أخرى [العدد = 850]. وتم قياس مدى الوعي باستخدام المقياس المعدل لمنظمة الصحة العالمية لقياس المعارف والمواقف والممارسات. ولم يكن هناك أي فروق يعتد بها بين حالات السل والشواهد من حيث المستوى الكلي للوعي بالسل. ولقد اتضح أن ثلثي حالات السل والشواهد لديها مستوى جيد من الوعي بالسل. وأن جنس المستجيب للدراسة يؤثر على مدى الوعي بين الشواهد. فالسن، ومستوى التعليم ونمط الإقامة ونوع المهنة كلها من الأمور التي ترتبط بشكل كبير بمدى الوعي بالسل، في حين نجد أن الحالة الزواجية لم يكن لها أي أثر. ومن ثم فإن مستوى الوعي الجيد بالسل لدى الحالات المصابة به ولدى الشواهد تمثل خط الأساس لإذكاء المزيد من الوعي بالسل لدى سكان ولاية الجزيرة

La présente étude cas-témoin visait à évaluer la sensibitisation à la tubercutose et les caractéristiques sociodémographiques associées dans l'état de Gézira [Soudan]. L'échantillon de l'étude était compose de nouveaux patients a frottis positifs pour la tuberculose au Gézira en 2010 [n = 425]et de témoins appariés pour l'âge qui consultaient dans les mêmes établissements de santé pour d'autres motifs [n = 850]. Le degré de sensibilisation à la maladie a été mesuré à l'aide de l'instrument standard modifié de l'Organisation mondiale de la Santé évaluant les connaissances, les attitudes et les pratiques en matière de tuberculose.Aucune différence significative n'a été observée entre les patients tuberculeux et les témoins dans les niveaux généraux de sensibilisation à la tuberculose.Environ deux tiers des patients tuberculeux et des témoins avaient un niveau de sensibilisation à la tuberculose satisfaisant.Dans le groupe des témoins, les hommes et les femmes n'avaient pas le même niveau de sensibilisation à la question.L'âge, le niveau d'études, le type de résidence et la profession étaient des facteurs nettement corrélés à la sensibilisation à la tuberculose, contrairement à la situation matrimoniale.Le niveau satisfaisant de sensibilisation à la tuberculose observé chez les patients atteints de tuberculose est un point de départ pour l'augmentation de la sensibilisation à cette maladie dans la population du Gézira

Impact of tuberculosis treatment on CD4 cell count, HIV RNA, and p24 antigen in patients with HIV and tuberculosis.

OBJECTIVES: To describe HIV RNA levels during tuberculosis (TB) infection in patients co-infected with TB and HIV. Moreover, to examine the p24 antigen profile during TB treatment. METHODS: We examined the changes in CD4 cell count, HIV RNA, and p24 levels during anti-tuberculous therapy in a group of TB/HIV-1 co-infected and HIV-untreated patients from Guinea-Bissau. RESULTS: A total of 365 TB patients were enrolled, of whom 76 were co-infected with HIV-1 and 19 were dually infected with HIV-1 + HIV-2. No significant changes in CD4, HIV RNA, or p24 levels were found during 8 months of TB treatment. HIV RNA levels correlated well with p24 (Spearman's R(2)=0.52, p<0.00001) and both markers were strong predictors of mortality. Initial HIV RNA levels correlated with a clinical TB severity index--the TBscore (Spearman's R(2)=0.23, p=0.02)--and the TBscore decreased dramatically during TB treatment although HIV RNA levels remained unchanged. CONCLUSION: We found no significant changes in CD4, HIV RNA, or p24 antigen levels during 8 months of TB treatment among TB/HIV co-infected individuals, who did not receive antiretroviral treatment. The markers were unaffected by a strong improvement in TBscore and all three markers showed predictive capacity for mortality risk.

Tuberculosis stigma in Gezira State, Sudan: a case-control study.

OBJECTIVE: To evaluate the prevalence of tuberculosis (TB) stigma and to determine the relation between socio-demographic characteristics and TB stigma among TB cases and their controls in Gezira State, Sudan. METHODS: A case-control study design was used. New smear-positive TB patients registered in Gezira State in 2010 (n = 425) and controls who attended the same health facility for other reasons (n < 850) formed the study population. Stigma was measured using a standard modified World Health Organization TB KAP (knowledge, attitudes, practice) instrument. RESULTS: TB stigma did not differ between TB cases and controls; mild stigma was found in both groups. The higher degree of stigma among both groups was significantly associated with higher age, lower level of education, residence in rural areas, unemployment and poor TB awareness, while sex had no association with the degree of stigma in either group. CONCLUSION: Although TB stigma among the Gezira population was found to be mild, it can affect treatment adherence. Empowering both TB patients and communities by increasing their knowledge through proper education programmes could effectively contribute to the effort of controlling TB in the state.

Mid-upper-arm-circumference and mid-upper-arm circumference z-score: the best predictor of mortality?

BACKGROUND/OBJECTIVE: Mid-upper-arm circumference (MUAC) is a simple method of assessing nutritional status in children above 6 months of age. In 2007 World Health Organization (WHO) introduced a MUAC z-score for children above 3 months of age. We evaluated whether MUAC or MUAC z-score had the best ability to identify children with high short-term mortality risk in Guinea-Bissau. SUBJECTS/METHODS: The Bandim Health Project visits children 3-monthly until 3 years of age. MUAC is measured and deaths are registered. We studied a high-mortality cohort of children born in 1995-96 and a lower mortality cohort of children born in 2005-06. The prognostic ability of MUAC and MUAC z-score to predict mortality within 1 and 3 months after the MUAC assessment were compared by area under the receiver operating characteristic curve, sensitivity and positive predictive value. RESULTS: Compared with MUAC z-score, MUAC identified as malnourished more girls than boys (prevalence ratio (PR)=1.74 (1.52;2.01)) and more children aged 6-11 months than children aged 12-35 months (1.59 (1.38;1.82)). There was no difference in the prognostic ability of MUAC and MUAC z-score to predict mortality for children aged 6-35 months. The prognostic ability was higher when mortality was lower. MUAC performed well in the youngest infants. CONCLUSION: In the age group 6-35 months, MUAC and MUAC z-score had the same prognostic ability to predict short-term mortality. As MUAC is easier to use in field settings, there is no need to use MUAC z-score to identify children with a high-mortality risk.

Depression in patients with HIV is under-diagnosed: a cross-sectional study in Denmark.

BACKGROUND: International studies suggesting that 20-37% of HIV-positive patients have diagnosable depression may underestimate the prevalence of this condition. The aim of this study was to investigate the prevalence of depression among HIV-positive patients in an out-patient clinic in Denmark and to detect factors of importance for the development of depression. METHODS: In 2005, a population of 205 HIV-positive patients was included in a questionnaire-based study. The Beck Depression Inventory II (BDI-II) was used to assess the prevalence and severity of depressive symptoms. Patients with a BDI score of 20 or above were offered a clinical evaluation by a consultant psychiatrist. RESULTS: Symptoms of depression (BDI>14) were observed in 77 (38%) patients and symptoms of major depression (BDI>or=20) in 53 (26%). Eighteen patients subsequently started treatment with anti-depressants. In a reduced logistic regression model, self-reported stress, loneliness, constant thoughts about HIV and being in a difficult financial situation were associated with risk of depression. Patients at risk of major depression were nearly six times more likely to have missed at least one dose of highly active antiretroviral therapy (HAART) in the 4 days prior to assessment (odds ratio 5.7, 95% confidence interval 1.7-18.6). There was a dose-response trend in relation to unsafe sex (P=0.03). CONCLUSIONS: The study found that depression was under-diagnosed among HIV-positive patients and was associated with stress, loneliness, a difficult financial situation, low adherence and unsafe sex. Screening for depression should be conducted regularly to provide full evaluation and relevant psychiatric treatment. This is particularly important at the time of diagnosis and before initiating HAART.

Antibiotic treatment interruption of suspected lower respiratory tract infections based on a single procalcitonin measurement at hospital admission--a randomized trial.

Recent studies have suggested that procalcitonin (PCT) is a safe marker for the discrimination between bacterial and viral infection, and that PCT-guided treatment may lead to substantial reductions in antibiotic use. The present objective was to evaluate the effect of a single PCT measurement on antibiotic use in suspected lower respiratory tract infections (LRTIs) in a Danish hospital setting. In a randomized, controlled intervention study, 223 adult patients admitted to the hospital because of suspicion of LRTI were included with 210 patients available for analysis. Patients were randomized to either PCT-guided treatment or standard treatment. Antibiotic treatment duration in the PCT group was based on the serum PCT value at admission. The cut-off point for recommending antibiotic treatment was PCT > or =0.25 microg/L. Physicians could overrule treatment guidelines. The mean duration of hospital stay was 5.9 days in the PCT group vs. 6.7 days in the control group (p 0.22). The mean duration of antibiotic treatment during hospitalization in the PCT group was 5.1 days on average, as compared to 6.8 days in the control group (p 0.007). In a subgroup analysis of chronic obstructive pulmonary disease patients, the mean length of stay was reduced from 7.1 days in the control group to 4.8 days in the PCT group (p 0.009). It was concluded that the determination of a single PCT value at admission in patients with suspected LRTIs can lead to a reduction in the duration of antibiotic treatment by 25% without compromising outcome. No effect on the length of hospital stay was found.

Evaluation of tuberculosis control programme in Khartoum State for the year 2006.

BACKGROUND: Tuberculosis (TB) is among the top ten causes of global mortality. Sudan is among the countries with high TB prevalence; with an estimated incidence of 90/100,000 smear-positive cases. In 1993, the Khartoum State tuberculosis control programme was established. Since its establishment, however, the programme has never been adequately assessed. AIM: To evaluate and describe the tuberculosis control programme in Khartoum State, Sudan in 2006; to find out if the programme achieved its global targeted goals; and to identify the challenges and needs for performing a good standard tuberculosis control programme. METHODS: A descriptive cross-sectional and retrospective study design was used. The study population was tuberculosis control departments at the levels of the state (n = 1), localities (n = 7), health areas (n = 19) and health facilities (n = 42). Records review and group interviews were used to collect the required data. RESULTS: The study found that the TB control programme in Khartoum State achieved a 77.2% case detection rate of the smear-postive cases, and 73.5% treatment success rate, and a case fatality rate of 2.2%, treatment failure rate of 2.2%, and default rate of 14.1%. There was no system to detect the prevalence of MDR-TB (multi-drug resistant TB) or HIV (human immunodeficiency virus) among the TB cases. The programme was not well implemented at locality or health area levels. Conversely, drugs and laboratory supply systems were functioning well. CONCLUSIONS: The tuberculosis control programme in Khartoum State is centralized, not updated, and does not achieve the targeted goals.

DC-SIGN (CD209), pentraxin 3 and vitamin D receptor gene variants associate with pulmonary tuberculosis risk in West Africans.

We investigated the role of DC-SIGN (CD209), long pentraxin 3 (PTX3) and vitamin D receptor (VDR) gene single nucleotide polymorphisms (SNPs) in susceptibility to pulmonary tuberculosis (TB) in 321 TB cases and 347 healthy controls from Guinea-Bissau. Five additional, functionally relevant SNPs within toll-like receptors (TLRs) 2, 4 and 9 were typed but found, when polymorphic, not to affect host vulnerability to pulmonary TB. We did not replicate an association between SNPs in the DC-SIGN promoter and TB. However, we found that two polymorphisms, one in DC-SIGN and one in VDR, were associated in a nonadditive model with disease risk when analyzed in combination with ethnicity (P=0.03 for DC-SIGN and P=0.003 for VDR). In addition, PTX3 haplotype frequencies significantly differed in cases compared to controls and a protective effect was found in association with a specific haplotype (OR 0.78, 95% CI 0.63-0.98). Our findings support previous data showing that VDR SNPs modulate the risk for TB in West Africans and suggest that variation within DC-SIGN and PTX3 also affect the disease outcome.

Knowing a medical doctor is associated with reduced mortality among sick children consulting a paediatric ward in Guinea-Bissau, West Africa.

BACKGROUND: To examine equity in access to public health services in Guinea-Bissau. METHODS: The study was conducted in 2000-2001 at the emergency clinic of the only paediatric ward in Bissau. Mothers of all children from the study area were interviewed about previous care seeking and relations with anybody working in the health sector. All management actions in the emergency clinic were registered. In-hospital and subsequent community mortality was ascertained through community surveillance. The measured outcome was mortality risk within 30 days of first consultation. RESULTS: We followed 1572 children with a first consultation. Of these, 8.2% died within 30 days. Acquaintance with a physician reduced 30-day mortality risk by 48% (95% CI: 18-66). The effect was strongest among post-neonatal children (54%; 95% CI: 18-74). Mortality within 30 days of consultation was also independently predicted by consultation after 7 PM, nurse team on duty, day of week and young mother. In a multivariate model, socioeconomic status and school education were not associated with 30-day mortality when acquaintance with a medical doctor was taken into account. CONCLUSION: Favouritism may be a significant factor for quality of care and child mortality in developing countries. Interventions to improve hospital and health worker performance should be given high priority.

Reduced case fatality among hospitalized children during a war in Guinea-Bissau: a lesson in equity.

BACKGROUND: During a recent armed conflict in Guinea-Bissau, we observed a marked decline in the case fatality among hospitalized children at the only paediatric department in the country. AIM: To analyse the causes behind the observed fall in case fatality. MATERIAL: All children hospitalized at the only paediatric department in the capital of Guinea-Bissau. The war cohort comprised all children hospitalized during the war, which lasted from June 1998 to May 1999, and the peace cohort comprised all children hospitalized in the year preceding the war. As part of a longitudinal community study, we also registered all children being hospitalized from the Bandim Health Project's study area, including routinely collected information on socio-economic background factors. METHODS: The war cohort was compared with the peace cohort in terms of determinants for hospital case fatality. Through information in the community register, we examined post-hospital mortality in the 2 wk after discharge as well as socio-economic differences in recruitment during the war. Hospital case fatality was estimated by odds ratios and compared by multiple logistic regression. Community mortality risk was estimated by deaths per person years. RESULTS: The case fatality among children aged 0-14 y fell during the war (age-adjusted OR = 0.58; 95% CI: 0.50-0.68). There was a uniform reduction in case fatality among children hospitalized less than 7 d, while we observed no decline among children hospitalized longer. There were more children per bed during the war and mean hospitalization time was shorter, and post-discharge mortality also fell (mortality ratio (MR) = 0.57; 95% CI: 0.40-0.83). Adjustment for socio-economic confounders in recruitment during the war period made no difference to the estimated decline in case fatality. The decline in case fatality at the hospital was not explained by a general decline in mortality. Compared with the preceding year, the mortality ratio was 1.34 (1.20-1.51) in the Bandim Health Project's study area during the war. Adjusted for age, the decline in case fatality at the hospital was most marked for disadvantaged groups. For example, the general reduction in case fatality was 42% (95% CI: 11-63); however, children of mothers without any schooling experienced a reduction of 73% (95% CI: 27-90%), whereas the reduction was only 33% (95% CI: 14-61%) for children of mothers with school education. CONCLUSION: The decline in case fatality could be explained neither by a general decline in childhood mortality nor by changes in recruitment or discharge policy. The decline was therefore most likely due to improved treatment as a result of better availability of drugs funded by humanitarian aid and the presence of dedicated staff, which was offered relief food as compensation. Interventions improving case management may have a proportionately larger effect for poor families.

Termination of breastfeeding after 12 months of age due to a new pregnancy and other causes is associated with increased mortality in Guinea-Bissau.

BACKGROUND: As part of an assessment of breastfeeding and child health in Guinea-Bissau, we investigated the impact of mother's reason for weaning on subsequent child mortality. METHODS: Children were identified and followed by the demographic health surveillance system of the Bandim Health Project in Guinea-Bissau. Breastfeeding status and survival were ascertained by 3-monthly follow-up home visits. At termination of breastfeeding mothers were interviewed about her reasons for weaning. In all, 1423 children who terminated breastfeeding after 12 months of age were followed to 3 years of age. RESULTS: Median length of breastfeeding was 22 months. Following termination of breastfeeding, 66 children died before 36 months of age. In all, 62% (879/1423) were weaned because they were 'healthy'. Compared with the 'healthy' children, all other causes of weaning were associated with a higher mortality (mortality ratio [MR] = 2.97, 95% CI: 1.54-5.73). For 237 children weaned due to a new pregnancy the MR was 3.25 (95% CI: 1.45-7.30). Seventy-five children weaned because of illness had a 2.98 (95% CI: 0.95-9.39) fold excess mortality compared with children considered healthy. Excess deaths in the 'non-healthy' group accounted for 44% (29/66) of post-weaning deaths. Median length of spacing between an index child and a new sibling was 28 months irrespective of whether the index child survived or died before 3 years of age. The majority of the deaths occurred before birth of the new sibling. CONCLUSION: Popular rationalizations of abstinence during breastfeeding emphasizes, as we observed, that weaning due to new pregnancy of the mother is associated with higher mortality. This was not due to a shorter breastfeeding period of the child weaned due to a new pregnancy. Generally children weaned for other reasons than 'being healthy' had higher mortality. The mother's reason for weaning could potentially be used as screening criteria in child monitoring programmes in areas with high mortality.

Seven years' experience with Cryptosporidium parvum in Guinea-Bissau, West Africa.

In community-based studies conducted from 1991 to 1997 in Guinea-Bissau, West Africa, stool specimens from children aged less than 5 years with diarrhoea were routinely examined for enteric parasites. Cryptosporidium parvum, found in 7.7% of 4,922 samples, was the second most common parasite, exceeded only by Giardia lamblia which was found in 14.8% of the samples. The highest prevalence of cryptosporidium was found in children aged 6-11 months, whereas the prevalence of other enteric parasites increased with age. Cryptosporidiosis showed a marked seasonal variation, with peak prevalences found consistently at the beginning of or just before the rainy seasons, May through July. By contrast, no seasonality was found for the enteric parasites Giardia lamblia or Entamoeba histolytica. We conclude that Cryptosporidium parvum is an important pathogen in children with diarrhoea.

Episode-specific risk factors for progression of acute diarrhoea to persistent diarrhoea in west African children.

The aim of the present study, carried out in Guinea-Bissau, West Africa, was to identify episode-specific risk factors for persistent diarrhoea (PD) related to clinical observations and management efforts. We followed 319 episodes of childhood diarrhoea by repeated household interviews until the episode stopped or after 14 days with diarrhoea. Children who still had diarrhoea after 14 days (n = 40, 12.5% of episodes) were regarded as suffering from PD. Clinical signs, perceived by the mother, were recorded together with care-seeking behaviour and management actions. Tired and rapid breathing prior (OR = 6.52 (95% CI 1.69-25.1)), mother had to force breast feeding (OR = 8.01 (2.99-21.5)) and current infection with Cryptosporidium (OR = 5.53 (2.10-14.6)) were the most important independent risk factors for the development of PD. Late consultation (> 48 h) was associated with PD, reflecting that these episodes initially were less acute. Use of oral rehydration salts did not have an impact on development of PD, whereas home medication tended to increase the risk of PD. Our study confirms the close association between systemic illness and PD as well as the importance of cryptosporidiosis as a cause of PD. We were unable to identify management factors with a significant influence on the risk of developing PD.

Malaria parasitemia and childhood diarrhea in a peri-urban area of Guinea-Bissau.

To examine the association between diarrhea in early childhood and malaria parasitemia, we conducted a nested case-control study in Guinea-Bissau of 297 children with diarrhea and a similar number of children without diarrhea matched for age, season, and residential area. There were no associations between diarrhea and parasite rate, parasite density, or clinical malaria. However, anti-malarials were easily available and frequently used, which was reflected by a 0.7% prevalence of children with a parasite density > 100/200 leukocytes. Thus, the findings do not preclude that diarrhea may be a sign of clinical malaria or high-parasite density in endemic areas with lower use of antimalarials.