Estimating the burden of disease in one Swiss canton: what do disability adjusted life years (DALY) tell us?

BACKGROUND: Examining life expectancy and general mortality rates, the health of the population of Geneva can be described as one of the best in the world. However, in some areas Geneva fares worse than the rest of Switzerland or Europe. To re-appraise the current health priorities of the Genevan population, we analysed the relative importance of specific diseases and injuries calculating DALYs. METHODS: We followed the procedures developed for the Global Burden of Disease (GBD) study to ensure comparability. Some adaptations were made for mortality coding. Disability was estimated based on data for countries classified as Established Market Economies (EME) in the GBD study. RESULTS: Non-communicable diseases accounted for 79% of the disability adjusted life years (DALY), injuries represented 12%, and communicable diseases and other disorders 9%. Ischaemic heart disease was the largest single contributor to DALY, followed by unipolar major depression. Neuropsychiatric disorders and mental health accounted for more than 23% of DALY. CONCLUSIONS: Some of the most important problems identified-depression, osteoarthritis and alcohol abuse-would have been overlooked in an analysis based solely on mortality data. The most striking finding is the importance of mental health problems. The main limitation is the lack of morbidity data for Geneva.

Setting health priorities in a Swiss canton: what do different methods tell us?

STUDY OBJECTIVE: Despite excellent mortality indicators, there is clear evidence that the health status of the population of Geneva could be improved if more attention and resources were devoted to prevention strategies. To identify a set of robust health priorities an original approach was used triangulating results between three methods. METHODS: The study calculated potential years of life lost, disability adjusted years of life lost, and conducted a Delphi survey to gather the opinion of health professionals and the general public. MAIN RESULTS: Several health conditions were unanimously selected by all three methods as top priorities: cardiovascular diseases, AIDS, respiratory cancer, breast cancer for women, suicide and traffic accidents. In addition, two determinants-alcohol abuse and tobacco abuse-for which a clear conceptual link could be established between all methods were chosen. Connections between priorities identified through the DALY and the Delphi method lead to further inclusion of chronic back pain and depression. Some issues solely identified through the Delphi survey were included as they were consistently considered important by professionals and the lay public alike-violence in the family, unemployment, social exclusion. CONCLUSIONS: These results indicate that health priorities, and by extension health care priorities, would benefit from using a mix of quantitative and qualitative research methods. The triangulation of results allows for a broader perspective and makes results more acceptable.

Research on AIDS interventions in developing countries: state of the art.

This paper reviews achievements of past and current research on AIDS interventions in developing countries, and identifies three major issues. (1) Several areas of research have been severely neglected, namely transmission from mother to infant, the impact of treating curable STD and transmission in health care settings. (2) AIDS intervention research is mainly concerned with behavioral changes in a very intimate part of human lives, namely sexual relationships. This makes it difficult to design studies that are at the same time ethically acceptable and scientifically sound. A more creative mix of methodologies is needed, that goes hand in hand with a close collaboration between researchers from the social sciences and health sciences field. (3) Counseling is a major aspect of any targeted AIDS intervention program. However, there is no evidence yet for the effectiveness of specific messages and particular forms of counseling. Investigation in this area is urgently needed.

Sexual behaviors relevant to HIV transmission in a rural African population. How much can a KAP survey tell us?

KAP surveys have been proposed as a means to gather quantitative information on AIDS-related sexual behaviors, but the validity of survey results has not been tested. The validity of data gathered during a KAP survey in a rural district in Northern Uganda (N = 1486) was examined analyzing expected behavioral patterns, agreement of partner reports, and concordance of number of sexual contacts across gender. Patterns of sexual behavior and age trends are as expected. More men (50%) than women (18.5%) reported premarital sex. The likelihood of sexual intercourse before marriage increases with age at first marriage and with education. Women marry 5 years earlier than men, and the number of marriages increases with age. Peak incidence of casual sex occurs before age 25. The male/female ratio of casual sex is 4, as compared to about 3 in other African surveys. Single men are 2.5 times more likely to engage in casual sex than married males. Agreement of partner reports was examined for 392 couples selected by chance. 86% of the couples agreed on being polygamous or monogamous. On average men reported 1.3 (SD = 0.7) wives as compared to women reporting 1.5 (SD = 0.89) wives (P < 0.001). 16.8% of women declared more, and 2.8% less cowives than their husband (r = 0.65). Self-reports on frequency of sexual intercourse in the past month were examined for 256 monogamous couples. Mean frequencies differ (5.24 +/- 5.1 for men, 4.43 +/- 4.7 for women, P < 0.001). 42.8% of couples are in agreement within +/- 1 unit (r = 0.44). The total number of extra-marital and marital sex acts, as well as the total number of partners reported by each gender are similar. There is, however, a striking gender difference in reporting of casual partners in the past year. Data were found to be accurate at the aggregate level. However, accuracy of reporting at the individual level was found to be low. The gender difference in reporting of casual partners may be due to female underreporting, to not having captured prostitutes or to a different perception of the meaning of casual partnership. All KAP surveys should include a validity analysis, so as to provide a sense of the accuracy of the surveys and allow for comparison of the quality of different KAP surveys. There is an urgent need for a standardized approach to validating the findings from AIDS-related KAP surveys. Some of the indirect methods described here could be relevant for further use.

When providers and community leaders define health priorities: the results of a Delphi survey in the canton of Geneva.

The Delphi method was used to determine the health priorities in one Swiss canton. The opinion of various groups concerned, either as health professionals or as representatives of the general population, was gathered to identify the health determinants and health problems perceived as most important, to clarify the reasons for these choices, and to recommend interventions to be undertaken in order to improve the situation in the identified priority areas. Five panels, including health professionals as well as selected leaders of community groups with no direct involvement in health, were given the opportunity to reply to two rounds of questionnaires. There was a high convergence of opinion on health determinants and problems to be given priority between panels and between the first and second round. Priorities identified are mainly physical problems (cardiovascular disease, respiratory and breast cancer, AIDS, injuries due to road accidents, chronic back pain), psychosocial disorders (depression, suicide, violence in the family, stress), and problems of substance abuse (alcohol and tobacco). Unemployment and social isolation were chosen because of their perceived impact on health. Very few interventions were proposed in the medical technical or research areas. This may be due partly to the fact that good quality care is widely available and accessible in Geneva, whereas preventive programmes have not received enough attention in the past. Through the identified priorities and the proposed activities, a new vision of health emerges which gives more importance to psychosocial problems and the social environment. In this context, health promotion is seen as essential, acknowledging that sustained change in individual behaviours can only occur if the social and cultural context is taken into consideration. In conclusion, the results of this survey show that the Delphi method is a useful tool to reach consensus on health priorities and corresponding activities among a variety of actors.

Variation in estrus-related odors in the cow and its dependency on the ovary.

Urine samples were collected from 10 cows during the estrous cycle (Day 0=day of observed estrus) and investigated for pheromone activity using a quantitative rat bioassay. Pheromone activity in this assay was given in impulses/45 sec. Progesterone was measured in milk fat to verify the stage of cycle. The maximal response of rats was found on Day -1 (20.0 +/- 3.5 impulses/45 sec; x +/- SEM), and impulse rates were clearly higher (P

Care for AIDS patients in developing countries: a review.

As an ever increasing number of HIV-infected persons develop AIDS, treating the manifestations associated with HIV infection has become a new challenge to health sectors in developing countries. Given resource constraints of health systems before the AIDS epidemic, there is an urgent need to start examining ways in which health care can be delivered to the large number of AIDS patients, without infringing on other primary health care activities. This paper reviews current experience with AIDS patient care management in developing countries and determines some of the areas where further research is crucial. The main issues identified are: (1) that reliable data on standardized treatment schemes for AIDS patients are scarce; (2) that there is an urgent need for research on low-cost supportive treatment of AIDS patients, comparing costs and outcomes; (3) that outpatient and home-based care can be a valuable alternative to hospital-based care, but that cost-efficiency of these alternative treatment strategies should be examined more closely; and finally, that (4) the potential benefit of using HIV/AIDS patients to promote prevention of HIV transmission should be acknowledged.

PIP: The current experience of developing countries in dealing with AIDS patient care management are reviewed and areas where further research is needed are identified. WHO estimates that since the beginning of the pandemic, at least 8-10 million adults and 1 million children worldwide have become infected with HIV, most of whom will eventually develop AIDS. While ample research on treatment and care for AIDS patients in developed countries exists, there is little information available from developing countries, whose health care systems already suffer serious constraints. Current care practices for AIDS patients include clinical management (diagnosis, antiretroviral treatment, and treatment and prevention of opportunistic infections), nursing and palliative care, counseling, and support. Many of the treatments used in developed countries, however, man not be realistic for developing countries, given the differences in available resources and the presence of different opportunistic infections. The impact of the AIDS epidemic so far on developing countries' health system is examined. Issues discussed include health services utilization, human resources, drugs, cost of care, and financial resources. 2 commonly cited models for patient care in developing countries are also discussed: the specialized outpatient clinic and home-based care. The following areas where further research is crucial are identified: 1) standardized treatment schemes for AIDS patients, 2) low-cost supportive treatment of AIDS patients, and 3) the cost-efficiency of outpatient and home-based care. It is suggested that the potential benefit of using HIV/AIDS patients to promote HIV prevention should be acknowledged.

Health maintenance organizations in developing countries: what can we expect?

Health maintenance organizations (HMOs) are a relatively new and alternative means of providing health care, combining a risk-sharing (insurance) function with health service provision. Their potential for lowering costs has attracted great interest in the USA and elsewhere, and has raised questions regarding their applicability to other settings. Little attention, however, has been given to critically reviewing the experience with HMOs in other countries, particularly concerning their introduction to settings other than the USA. This paper first reviews the current experience of HMOs in low- and middle-income countries, including Argentina, Bolivia, Brazil, Colombia, Ecuador, Uruguay, Chile and Indonesia. Secondly, the paper reviews the USA experience with HMOs: prerequisites for the establishment of HMOs in the USA are identified and discussed, followed by a review of the performance of HMOs in terms of cost containment, integration of care and quality of care for the elderly and poor. The analysis concludes that difficulties may arise when implementing HMOs in developing countries, and that potential adverse effects on the overall health care delivery system may occur. These should be avoided by careful analyses of a nation's health care system.

Investigations on the occurrence of non-extractable residues of trienbolone acetate in cattle tissues in respect to their bioavailability and immunological reactivity.

3H-trienbolone acetate (TBA) was injected/implanted in cattle and the distribution of radioactivity in liver and muscular tissue was determined, applying rigorously standardized organic or aqueous extraction procedures, either directly or following enzymatic hydrolysis and proteolytic procedures. These steps yielded almost 100% recovery of the radioactivity and indicated that only between 5% and 15% of the total residues present was extractable with organic solvents. The remaining radioactivity was either soluble in aqueous media or stayed bound to tissue structures. Similarly processed liver tissue from a calf treated with 3500 mg TBA 68 days prior to slaughter was examined by applying radioimmunoassay for the determination of TBA/trienbolone (TBOH). Indications of the presence of trienic-steroid type residues were only obtained for fractions containing residues extractable with organic solvents.

Contribution of individual compartments of the genital tract to oestrogen and testosterone concentrations in ejaculates of the boar.

The investigation of steroids in compartments of the genital tract of boars revealed that in the tubular fluid a pattern apparently exists which is unique in this compartment. It is characterized by high concentrations of unconjugated testosterone (35 ng/ml) and even higher amounts of oestradiol-17 beta (42.6 ng/ml) whereas in other compartments oestrone is the predominant oestrogen. At least in the ejaculate half of the total amount of oestrogens is bound to sperms and it is concluded that sperms act as a carrier for oestrogens. The accessory sex glands contribute to ejaculate concentrations to a varying degree (unconjugated testosterone 55%, conjugated testosterone 20%, unconjugated oestrogens 22%, conjugated oestrogens 12%) as could mainly be demonstrated by vasectomy with and without administration of hCG. Increasing the frequencies of ejaculations (up to three times a day) shows that the steroid transfer into the ejaculate is a rapid process.

Country watch. Uganda.

PIP: In 1991, Medecins sans Frontieres initiated an HIV/AIDS prevention program in Moyo District, Uganda, with the goal of gradually transferring responsibility for it to local people through the training of AIDS control advisors (ACA). Informational pamphlets were developed along with an action plan for a village-based information campaign, followed by the insertion of 8 women and 22 men into a two-week training course in Moyo Town on prevention measures and communication. The ACAs were evaluated monthly both qualitatively and quantitatively with an overall evaluation conducted in January 1992. All villages had been visited several times in the first five months, with the ACAs meeting 50,000 people and distributing 45,000 pamphlets and 40,000 condoms. Community collaboration was excellent, although condoms were distributed to only adults and older teenagers in response to local cries that condom distribution encouraged immorality. Some language difficulties were also encountered. ACAs continued to distribute condoms upon request over the period February-August 1992, but concentrated upon drivers, beer brewers and their customers, traders, musicians, soldiers, barmaids, fishermen, teachers and school children, traditional healers and birth attendants, and religious leaders. Subsequent to this period, the advisors received a week of training on conducting KAP surveys. Refinements were made later in the program with the Ugandan assistant manager ultimately taking over field responsibility in May 1993. Although the ACA team was reduced from 30 to 10 people, it continues to work closely with all district authorities.^ieng

Application of Synovex-H in veal calves: steroid release and residues.

Four experiments were carried out with veal calves which were implanted subcutaneously with Synovex-H. Testosterone in blood plasma and also total oestrogens in plasma, urine and faeces during the trial and in liver, kidney and muscle after slaughter (62-75 days after implantation) were determined. Prepurification methods and radioimmunoassays for faeces and tissue samples were elaborated and validated. Variables between or within the trials were the sex, the dose (four pellets versus eight pellets; 25 mg testosterone propionate + 2.5 mg 17 beta-oestradiol-3-benzoate per pellet) and the implantation site (either on the base of the ear or on the middle of the pinna). Results from the blood plasma and the excreta showed that using four pellets implanted in the middle of the pinna guaranteed a continuous release in order that oestrogen levels were maximally doubled in comparison to controls. On the other hand, application of the same dose at the base of the ear was characterized by an accentuated burst during the first three days (10-fold elevation over controls). In plasma and excreta of male controls, higher oestrogen concentrations were measured as compared to the corresponding substrates of females. Comparing all groups, untreated males showed the highest testosterone levels. In all animals, residues of total oestrogens were of the same order of magnitude (kidney and liver 0.1-1.5 ng/g; muscle 0-32 pg/g) with somewhat higher means in the treated groups. Since all results are within the physiological scope, no risk for the consumer is visible after correct use of Synovex-H.

Seasonal effect on steroids in blood plasma and seminal plasma of boars.

Unconjugated testosterone (T), 5a-androst-16-en-3-one (delta-16), dihydrotestosterone (DHT), unconjugated (u Oe) and conjugated oestrogens (c Oe) were determined weekly in the peripheral blood plasma and seminal plasma of 8 boars for a period of 15 months. Four of the boars were kept under natural daylength fluctuations (8-17 h), and 4 boars on a light programme which shifted these fluctuations by half a year. In peripheral plasma of all boars the highest concentrations were found for c Oe (17 ng/ml) followed by delta-16 (7.3), T (2.2) DHT (0.75) and u Oe (0.24). In seminal plasma of all boars (with an average volume of 172 ml) the highest concentrations were again found for c Oe (5.9 ng/ml) followed by delta-16 (1.1), u Oe (0.73), T (0.28) and DHT (0.1). This shows that u Oe reach higher concentrations in seminal plasma than in blood plasma. In boars under the influence of natural daylight steroids fluctuated with season. Maximum concentrations were present from October till December. Minimum concentrations were about 1/10 of the maximum concentrations. All steroids measured in blood and semen were similarly affected and all were highly correlated. In boars on an artificial light programme the off-season depression during the summer was completely restored. This indicates that daylight fluctuations are the main reason for seasonal changes of testicular function in the domestic boar.

Seasonal changes of steroid concentrations in seminal plasma of a European wild boar.

The influence of season on testicular steroid production as a parameter of testicular function has been studied in a wild boar. Semen was collected once weekly while it served the dummy. In seminal plasma concentrations of the following steroids were determined by radioimmunoassay: unconjugated testosterone, conjugated testosterone, unconjugated total oestrogens, conjugated total oestrogens and 5 alpha-androst-16-en-3-one ('boar-taint steroid'). All steroids showed a clear seasonal pattern with highest concentrations in autumn and early winter and low levels from January to July. Maxima during the rutting season were 10-25 times greater than average values out of season. During a 2-month-period (mid-July until mid-September) libido was abolished and the wild boar refused to mount the dummy. These results indicate that the seasonal variation in testicular steroid production by the wild boar, regulated by photoperiod, are similar to those of the domestic boar.

Seminal oestrogens in the boar: origin and functions in the sow.

The boar produces considerable amounts of oestrogens in the Leydig-cells also occurring in semen. Very high oestrogen concentrations are measurable in the fluid of the tubuli, which contribute the main part of seminal oestrogens. Additionally, the accessory sex glands add 22% of the unconjugated oestrogens and 12% of conjugated oestrogens to the ejaculate. Concentrations vary considerably according to season and individuals. So far a maximum of 15.3 micrograms was measured in one ejaculate. Infusion of oestrogens (simulation of the oestrogen content of an ejaculate) at oestrus through a catheter into the uterus lumen leads to an increase of the myometrial contraction-frequency for 3 h. Additionally "inseminations" with oestradiol-17 beta (Oe 2), oestrone (Oe 1), and oestrone-sulfate (Oe 1-S) (naturally occurring in the ejaculate) in 10-micrograms amounts at oestrus may lead to an increase of PGF2 alpha concentrations in the uterine veins within a few minutes. This increase may be found after "insemination" with each of the three steroids but not after saline. A parallel rise of the "inseminated" oestrogen is measurable in the uterine vein plasma and may reach concentrations up to several thousand pg/ml. This rise also leads to significantly increased concentrations in peripheral plasma for about 30 min after the "insemination" of Oe 2 (increase of Oe 2 and Oe 1-S) and Oe 1 (Oe 1 and Oe 1-S). Consequences of seminal oestrogens for sperm transport and the timing of ovulation are discussed.

Village-based AIDS prevention in a rural district in Uganda.

OBJECTIVE: To design, implement and evaluate a village-based AIDS prevention programme in a rural district in north-western Uganda. A baseline KAP survey of the general population was carried out to design a district-wide information campaign and condom promotion programme. Eighteen months later the impact achieved was measured through a second KAP survey, using the same methodology. METHODS: Anonymous structured interviews were conducted in March 1991 and October 1992 with 1486 and 1744 randomly selected individuals age 15-49, respectively. RESULTS: At 18 months, 60% of respondents had participated in an information session in the past year (47% women, 71% men) and 42% had received a pamphlet about AIDS (26% women, 58% men). Knowledge about AIDS, high initially (94%), reached 98%. More respondents knew that the incubation period is longer than one year (from 29% to 40%), and were willing to take care of a PWA (from 60% to 77%). Knowledge about condoms increased from 26 to 63% in women and 57 to 91% in men. Ever use of condoms among persons having engaged in casual sex in the past year increased from 6 to 33% in women, and 27 to 48% in men. Fifty per cent of condom users criticized lack of regular access to condoms. CONCLUSIONS: This is the first documented example of the impact a village-based AIDS prevention programme can achieve in a rural African community. Critical areas to be improved were identified, such as: women must be given better access to information, more attention must be paid to explain the asymptomatic state of HIV infection in appropriate terms, and condom social marketing must be developed.

PIP: A population-based knowledge, attitude and practice (KAP) survey was carried out as the first step in designing and implementing an AIDS prevention program. The design and implementation of an AIDS information campaign and condom promotion program following the results of the first KAP survey is described. Anonymous interviews on knowledge, attitudes, and practices related to AIDS were conducted in February-March 1991 on a representative sample of the adult population of the district. A 3-stage cluster sampling procedure (parish, village, household) was applied to 800 randomly selected households. In each household 1 man and 1 woman in the 15-49 age range were randomly selected and interviewed. A total of 1486 interviews (753 women, 733 men) were completed. More than 90% of respondents had heard of AIDS, and of these 90% knew that the disease is sexually transmitted and not curable. During September 1991-January 1992 of the information campaign, an estimated 50,000 people attended the village-based information sessions, and 45,000 pamphlets and 40,000 condoms were distributed. A second KAP survey was carried out during September-October 1992 to evaluate the impact of the AIDS prevention program. A total of 1744 questionnaires (874 women, 870 men) were completed and analyzed. Knowledge about the prevention of AIDS had improved substantially, from 40% to almost 70% of the respondents. Overall 39% of respondents knew that the time between infection and disease is more than one year, as compared to 26% at baseline. The proportion of respondents willing to take care of a family member suffering from AIDS had increased from 60% to 77% (p 0.001) between 1991 and 1992. In addition, the proportion of respondents who had ever used condoms increased from 23% to 46% among those who had engaged in casual sex in the past year. However, the overall proportion of respondents who had ever used a condom had remained at 3%. About half of the condom users complained about lack of access to condoms.