School non-enrollment and its relation with health and schistosomiasis knowledge, attitudes and practices in rural Egypt

Children who are not enrolled in school are deprived of schistosomiasis treatments delivered through school health programmes. We explored perceptions of barriers to school enrolment and health and schistosomiasis knowledge, attitude and practices among 58 enrolled and 41 non-enrolled children and 80 adults in a village in El-Fayoum governate, Egypt. Economic factors, cultural factors and the school system were perceived as barriers. Maternal education had a significant role in enrolment. Non-enrolled children were more anaemic and had more signs of vitamin deficiency. Enrolled children had better schistosomiasis knowledge and attitudes, but not practice; both groups had high Schistosoma mansoni infection rates (51.7% enrolled and 65.8% non-enrolled). Education and health policies should tackle perceived barriers. Introduction

Histological assessment of tissue repair after treatment of human schistosomiasis

Schistosomiasis is one of the main health problems hindering socio-economic development in Egypt. It affects millions at an early age, diminishing productivity and exerting a significant socio-economic impact. Schistosomiasis endemicity in Egypt varies in different areas. Schistosoma mansoni, with a prevalence generally ranging between 20 to 40%, has replaced Schistosoma haematobium in the Nile Delta, and the latter is now localized to upper Egypt with low endemicity levels (5-10%). The pathology of schistosomiasis consists essentially of a series of chronic inflammatory lesions produced in and around blood vessels by eggs or their products and sometimes by dead adult worms. If the ova continued to be deposited in sufficient numbers and over several years, they would ultimately lead to progressive fibrosis of the portal tracts and urinary bladder, or may be carried in blood and become trapped in the lungs, gastro-intestinal and genital tracts with only occasional association with other organs. The etiology of human pipe-stem fibrosis is still not understood. The host immune response and frequency of exposure and the time of re-infection interval appear to be involved in the overall process of fibrosis. Additional factors are probably involved in the human disease as genetic host susceptibility, malnutrition, repeated infections and repeated treatment, mixed infections including hepatitis, tuberculosis and typhoid. Reversibility of the fibrosis might be related to the proportion of the collagen types present. Immuno-histopathological demonstration of various types of collagen confirms the importance of time for administration of the treatment and period of follow-up. According to previous studies, the timing for treatment affects the reversibility of liver fibrosis emphasizing the importance of early treatment of schistosomiasis to prevent complications.

Pitfalls in the surgical management of cancer of the larynx and hypopharynx

This article is based on findings in 180 patients with cancer of the larynx and hypopharynx. Positive margins were found in 12.2% (22/180) of all tumors, 12.5% (8/64) of supraglottic tumors, 16% (4/25) of transglottic tumors, 5.3% (2/38) of glottic tumors, 11.1% (2/18) of pyriform fossa tumors, 50% (3/6) of posterior pharyngeal wall tumors, and 10.6% (3/29) of postcricoid tumors. The relationship between the inadequate surgical margins of the specimens, tumor spread, preoperative CT findings, and surgical procedures performed have been correlated.

The costs and coverage of a strategy to control schistosomiasis morbidity in non-enrolled school-age children in Egypt

Schistosomiasis still constitutes a major public health problem in some endemic parts of rural Egypt, particularly in school-aged children. The school-based health programme for schistosomiasis control adopted by the Egyptian Ministry of Health and Population (MOHP) focuses on treating enrolled schoolchildren. Children who are not enrolled or who do not attend regularly (out-of-school) do not have access to this service, in spite of evidence that the prevalence and intensity of infection are higher in these children than among children who attend school regularly. The aim of the present study was to test an intervention to extend the existing routinely applied school-based treatment to the out-of-school children. This paper reports on the costs and the coverage obtained by the intervention under 2 alternative delivery strategies: selective versus mass chemotherapy for out-of-school children. The intervention reached 88.5% of the out-of-school children at a relatively low cost per infected child of 2.29 L.E. (US$0.67) and 2.02 L.E. (US$0.59) for selective and mass chemotherapy, respectively. The calculations also suggest that, if the government were to implement such a programme, it would be more efficient to offer mass than selective chemotherapy at observed levels of prevalence. Sensitivity analysis showed that selective chemotherapy would be more cost-effective in areas where the prevalence of infection in out-of-school children was < 43%.

Epidemiology 1, 2, 3: study and sample design

Bad sample designs and selection bias have plagued studies on schistosomiasis, and as a result some believe that schistosomiasis is too focal, making it difficult to draw reliable samples. The Epidemiology 1, 2, 3 (EPI 1, 2, 3) sample design, although complex, demonstrates that sampling theory is readily applicable to epidemiologic studies of schistosomiasis. The EPI 1, 2, 3 sampling scheme was designed to achieve the smallest feasible standard errors given EPI 1, 2, 3 objectives and certain logistical constraints. The sample design is a multi-stage selection of villages (ezbas, which were stratified by size) and households within each of 9 purposely selected Egyptian governorates. Villages and households were systemically selected from census frames. The sampling of ezbas was especially difficult because of the lack of complete sampling frames and their wide variation in population size. Ultimately, ezbas were stratified by size and then randomly selected from each stratum. Sample sizes for villages and ezbas and individuals within ezbas were calculated based on EPI 1 and 2 objectives, respectively. No re-selection was made for non-respondents. A 20% subsample of the full sample was drawn for clinical and ultrasonographic examinations. The sample selected from individual governorates closely parallel the age structure of the 1986 census of the respective rural populations. Details of the study design and related methods are given below.

The epidemiology of schistosomiasis in Egypt: Qena governorate

Qena is the southernmost governorate of Egypt included in the Epidemiology 1, 2, 3 national study. A probability sample selected 17,822 individuals from 2,950 households in 34 ezbas and 10 villages from a total rural target population of 1,731,252 (based on the most recent 1986 census of the population by the Egyptian Central Agency for Public Mobilization And Statistics). Parasitologic examination of urine and stool were made for Schistosoma haematobium and S. mansoni, respectively, and physical and ultrasound examinations were made on a 20% subsample. The overall estimated prevalence of S. haematobium was 4.8 +/- 0.7% (+/-SE) and geometric mean egg count (GMEC) was 7.0 ova per 10 ml of urine. Considerable variation in prevalence was observed between the villages and ezbas, ranging from 0.0% to 20%, with the smaller ezbas having a slightly higher overall prevalence. The age- and sex-specific patterns of S. haematobium showed typical peak prevalence in early adolescence, with males having a higher prevalence than females. A history of hematuria was associated with current infection (odds ratio = 3.6, 95% confidence interval = 2.32-5.63). Hepatomegaly and splenomegaly determined by physical examination present in 7.9% and 3.0%, respectively. Ultrasonography-determined hepatomegaly of the left liver lobe was found in 10.1%. Ultrasonography-detected hepatomegaly in both the left and right lobes increased in prevalence from approximately 5% in children to 15-20% in adults. The prevalence of ultrasonography-detected splenomegaly increased slightly with age. Grade III periportal fibrosis was detected in only 2 individuals in the sample. Bladder wall lesions and obstructive uropathy were also very infrequent. Other associations with these measures are given. Most villages and ezbas had an S. mansoni prevalence of less than 1%. The exception was Nag'a El-Sheikh Hamad, where the prevalence was 10.3 +/- 0.5% (GMEC = 57.4 +/- 2.6). Two other communities also had a prevalence >1% (Ezbet Sarhan and Kom Heitin).

The epidemiology of schistosomiasis in Egypt: Assiut governorate

In the Assiut, Egypt Epidemiology 1, 2, 3 investigation, a sample of 14,204 persons in 10 villages, 31 ezbas (satellite communities), and 2,286 households was drawn from a rural population of 1,598,607. Parasitologic examination of urine and stool were made for Schistosoma haematobium and S. mansoni, and physical and ultrasound examinations were made on a 20% subsample. The overall estimated prevalence of S. haematobium was 5.2 +/- 0.5 (+/- SE). This varied considerably by village and ezba, ranging from 1.5% to 20.9%, with ezbas having a slightly higher overall prevalence than villages. The overall estimated geometric mean egg count was 6.6 +/- 0.5 eggs per 10 ml of urine and was consistently low throughout the communities. Infection with S. haematobium was associated with age (peak prevalence of 10.6 +/- 1.5% in 15-19-year-old age group) males, children playing in the canals, a history of blood in the urine, and reagent strip positivity for hematuria and proteinuria. The prevalence of either hepatomegaly or splenomegaly detected by physical examination was low (4.0% and 1.5%, respectively). The prevalence of hepatomegaly determined by ultrasonography was substantially higher, 24.1%. The prevalence of periportal fibrosis (PPF) was 12.0%, but grade II or III PPF was present in less than 1%. Ultrasonography-determined hepatomegaly, in both the midclavicular line and the midsternal line, increased by age to more than 30%. Periportal fibrosis was more common in the age groups in which infection rates were the highest. At the village and ezba level of analysis, the prevalence of hepatomegaly, splenomegaly, and PPF tended to be higher in communities having the highest prevalence of infection with S. haematobium.

Developing strategies to control schistosomiasis morbidity in nonenrolled school-age children: experience from Egypt

Schistosomiasis is a major health problem in school-age children in much of the tropical world. They harbour the most intense infections for both Schistosoma mansoni and S. haematobium. In Egypt, the Ministry of Health and Population (MOHP) has implemented a successful school-based treatment programme in which children are screened and those found to be infected treated with praziquantel. High nonenrolment rates in some rural areas have a negative impact on the coverage of this programme and on its ability to reduce transmission in the community. The main aim of our study was to introduce and test a simple intervention to extend treatment to nonenrolled children using the routine MOHP schistosomiasis treatment programme. Twenty villages or ezbas in Tamia district, Fayoum governorate, with 8 schools and 1901 nonenrolled children were targeted. 88.5% of nonenrolled children attended schools to avail themselves of treatment. Coverage rates were significantly higher for girls (P < 0.001). These results are important for countries where schistosomiasis is endemic. They suggest that offering interventions in schools may not only improve the health of school attendees but also be an affordable way of extending services to out-of-school children.

Emergence of Schistosoma mansoni infection in upper Egypt: the Giza governorate

We found an unexpectedly high prevalence of Schistosoma mansoni in a village in the Upper Egyptian governorate of Giza. Historically, S. mansoni is endemic in the northern Egyptian Nile Delta rather than in the southern Upper Egypt. This observation was made during an evaluation of a rural health care schistosomiasis surveillance program using a cross sectional survey for S. haematobium and S. mansoni in the village of El-Gezira El-Shakra El-Saf district in the Upper Egypt Giza Governorate. A 10% systematic random sample of households of the village was chosen. All persons in the selected houses were invited to submit urine and stool samples. All students from a primary school were also included in the study. Urine was screened by a polycarbonate filtration method and stool was examined using modified Kato-Katz technique. The prevalence of S. mansoni in the population sample and in the school children was 33.7% and 57.7%, respectively, whereas the prevalence of S. haematobium infection in the population sample and the school children was 7.4% and 10.6%, respectively. The prevalence of infection was highest in the younger age groups, and males were infected more than females. Review of Ministry of Health records showed that both species of vector snails, Bulinus truncatus and Biomphalaria alexandrina, were present from 1991 to 1995, and that B. alexandrina was more abundant than B. truncatus in the canals surrounding this village. The unexpected high prevalence of S. mansoni in this village indicates an urgent need to include training programs for S. mansoni surveillance in the primary health care facilities of Giza and to educate villagers to request examinations for S. mansoni as well as for S. haematobium infection.

A mass chemotherapy trial of praziquantel on Schistosoma haematobium endemicity in Upper Egypt

We evaluated the impact of mass chemotherapy using praziquantel (40 mg/kg of body weight) on Schistosoma haematobium endemicity in a typical village in Giza, Upper Egypt. The entire village population of 988, determined by census, was included in the study. At baseline all villagers were screened for S. haematobium and offered treatment with praziquantel regardless of their infection status. Infection was determined by nucleopore filtration and egg counts were reported per 10 ml of urine. Information on compliance to treatment or refusal to participate was also obtained at baseline. One month after treatment, all those who were found infected at baseline were re-examined for infection and re-treated if found positive. Baseline was conducted in late fall just prior to the low winter transmission season. Approximately one year after baseline, the entire village was requested to participate in an annual follow-up urine examination and treatment. The results showed that the baseline prevalence was reduced by 83.6% from 23.1% to 3.8%. Geometric mean egg counts decreased four-fold from 12.4 to 3.1. There was a 60-fold reduction in the estimated population egg count from 10,006 to 167. There were only eight cases of reinfection and five incident cases. The typical age specific prevalence curve was flattened, showing that those in the childhood age groups benefited the greatest reductions in endemicity. Treatment noncompliance was 30%, for which half had justifiable reasons. The others simply refused treatment many of whom were nevertheless examined for infection. Mass chemotherapy was found to be a feasible and an effective method to reduce measures of S. haematobium endemicity in Egypt.

Who misses out with school-based health programmes? a study of schistosomiasis control in Egypt

There has been a recent revival of interest in school-based health programmes in developing countries as a means of reducing the morbidity observed in school-aged children, of improving their physical growth and cognitive development, and of controlling transmission of disease in the community at large. This study used data collected from a large epidemiological survey of schistosomiasis in Egypt to examine what proportion of infected children missed treatment from an established national school-based schistosomiasis control programme simply because they did not attend school. It showed that children who were not enrolled in school had a higher prevalence of infection and were more intensely infected than children who attended school. At the extreme, over 80% of infected girls in one part of Egypt could not be treated by the existing school programme because they did not attend school. If these trends are similar in other countries where school-based programmes are being developed, school-based delivery may exacerbate existing inequalities in society and ways of expanding services to children who do not attend school regularly need to be explored.

Comparison of clinical evaluation and computed tomographic diagnostic accuracy for tumors of the larynx and hypopharynx

Ninety-five patients with laryngeal and hypopharyngeal cancer were examined and staged preoperatively by clinical evaluation (CE) and computed tomography (CT). The CE and CT staging were compared to each other and to the pathologic (PT) staging of the tumors. The CT staging showed high accuracy in staging transglottic (88%), supraglottic (68%), and oropharyngeal tumors invading the larynx (68%) when compared to the PT findings. The CT staging was less effective in evaluating glottic tumors (46%), both overstaging (12%) and understaging (20%) cases. Combined CE-CT evaluation showed higher accuracy in staging all tumors (84%) compared to CE alone (52%) or CT alone (68%). The findings suggest that combined CE-CT should be used to evaluate laryngeal and hypopharyngeal tumors.

Costs, benefits and operational implications of using quantitative techniques to screen for schistosomiasis haematobium in Egypt

The official strategy for schistosomiasis control in Egypt relies on individual case detection and treatment. Screening for Schistosoma haematobium has traditionally involved urine sedimentation which shows whether or not eggs are present in the urine, thereby providing only a qualitative assessment of infection status. Recently the Ministry of Health introduced the nucleopore filtration technique into a few villages to assess its applicability for broader use in areas where S. haematobium is endemic. This method gives an indirect quantitative measure of morbidity in terms of egg counts/10 ml urine. The overall purpose of this study was to provide rapid feedback to the Ministry on the likely implications of expanding the use of the filtration technique by examining the benefits, costs and operational problems that may be involved. From 2 villages in Giza Governorate, systematic random samples were taken from the general populations and from schools. Each selected person provided a urine specimen on which the two diagnostic techniques were performed. Filtration offered no additional benefits over sedimentation in terms of defining if a person was infected or not, with sensitivities ranging from 59.6%-75% for filtration and from 60%-73.1% for sedimentation. The additional non-labor costs of using the filtration technique in the two villages were calculated and showed that, if extended to all rural health units in Egypt, the Ministry would need to find an additional 31.6 million pounds (US$9.5 million) each year. A number of operational problems would also be involved in the wider application of the technique.

Use of Kato and nucleopore techniques for qualitative diagnosis of schistosomiasis

A comparison on qualitative basis, is attempted between merthiolate-iodine-formaldehyde concentration (MIFC) and Kato thick smear techniques for diagnosis of schistosome eggs in stools. As well, the centrifugation-sedimentation method was compared with the Nucleopore filtration technique for schistosome eggs in urine. Using MIFC and Kato techniques, 149 out of 185 subjects were found to have Schistosoma mansoni infection, 41 of them were diagnosed by Kato alone, while no case was solely MIFC positive. The sensitivity of MIFC compared to kato was 72.3% and both techniques were 100% specific. For diagnosis of S. haematobium infection, 78 out of 103 subjects were positive by centrifugation- sedimentation and/or Nucleopore techniques. 42 of them were diagnosed by Nucleopore alone and none was positive by centrifugation- sedimentation only. The sensitivity of the latter technique was 46.2% and both techniques were 100% specific. The study demonstrates that Kato thick smear and Nucleopore filtration are highly sensitive techniques that can be used for routine qualitative diagnosis of schistosomiasis. Under field conditions, they are qualitatively and quantitatively useful. The Kato technique besides its high sensitivity is very cheap. The only limitation for the Nucleopore technique is its relative high expenses.

Evaluation of urinalysis reagent strips versus microscopical examination of urine for Schistosoma haematobium

This study deals with the effectivecess of chemical reagent strips for detection of haematuria and proteinuria in selecting S. haematobium egg positive subjects as compared to microscopical examination of urine. Out of 222 students from primary and secondary rural schools, 191 were S. haematobium and 59 were parasitologically negative. 135 students had a count of less than 50 eggs/10 ml. urine and 56 had more than 50 eggs/10ml. The sensitivity of reagent strips in detecting haematuria was 10% and 36% for the groups with less than and more than 50 eggs/10 ml. of urine respectively. The correspondant microscope figures were 42% and 93% respectively. Proteinuria was detected in 11% and 29% of urines from the groups with less than and more than 50 eggs/10 ml. respectively. The specificity of strips and microscopical examination in detection of haematuria was 100%, while that for proteinuria was 97% as detected by strips. These results show that urinalysis strips cannot be used as an alternative to microscopic examination of urine for the presence of S. haematobium eggs.

Pull-through branchial fistulectomy: a technique for the otolaryngologist

The complete second branchial fistula consists of a superficial infrahyoid portion and a deep parapharyngeal portion. Through the present technique, the infrahyoid portion is dissected from the neck while the parapharyngeal segment is dissected through the mouth with or without tonsillectomy. Eventually, the whole fistula is pulled out through the mouth. This technique ensures complete fistulectomy and a low recurrence rate, is more cosmetic than the traditional technique, and allows simultaneous tonsillectomy. It may not be satisfactory if the fistula was the seat of repeated infections. This technique is suitable for the otolaryngologist, who is naturally well acquainted with microsurgery and tonsillectomy.

Apron tracheostome

Stenosis of the tracheostome following total laryngectomy is not an infrequent complication, either immediately postoperatively or years later, and it poses a common problem for head and neck surgeons. The opening becomes inadequate and the patient is uncomfortable and panicky. A secondary plastic operation is necessary in order to improve the airway, or a laryngectomy tube must be worn constantly. I have developed a satisfactory technique for tailoring the tracheostome during total laryngectomy so as to minimize postoperative stenosis even in irradiated cases and allow the patient to dispense with the laryngectomy tube. It may render the posterosuperior wall of the tracheostome more suitable for a tracheoesophageal puncture tract for voice restoration after total laryngectomy. These goals are achieved by interdigitating a small skin-thick superiorly based apron flap, raised from the lower midline of the front of the neck, into a similar recipient area at the upper posterior tracheal wall after removal of an equal mucosal apron.

Histologic and histochemical study of effects of anabolic steroids on the female larynx

The larynges of 30 unmated, mature female albino mice were examined histologically and histochemically after injecting them with 19-nandrolone phenylpropionate. Permanent irreversible changes, in the form of parakeratosis and squamous metaplasia of the epithelium, and hypertrophy of the muscle fibers, were observed together with persistence of increased alkaline phosphatase enzyme intensity in the endothelium of capillaries and increased activity of nonspecific esterase in the muscles. Similar changes may be responsible for the alteration in the human female's voice after prolonged treatment with anabolic steroids.

Submucous diathermy of the inferior turbinates in chronic hypertrophic rhinitis

Twenty patients, 10 allergic and 10 non-allergic, with chronic hypertrophic rhinitis and presenting mainly with bilateral nasal obstruction were subjected to submucosal diathermy of their inferior turbinates. There was significant post-operative improvement clinically, histopathologically and histochemically in the non-allergic group, while the improvement was less obvious in the allergic cases. The post-operative clinical improvement as regards rhinorrhea and sneezing was not as marked as that for nasal obstruction. Evaluation of the results showed that submucous diathermy of inferior turbinates is a good line of treatment for cases of chronic hypertrophic rhinitis, with better results in the non-allergic group of patients.

Relevance of the conventional Waters' view in evaluating chronic bacterial maxillary sinusitis

Considerable controversy exists as to whether X-ray examination of the sinuses is a reliable diagnostic guide or not, in cases of chronic bacterial maxillary sinusitis, as many factors apart from infection in the sinuses may produce radiographic signs on the X-ray film. With those facts in mind, it was decided to investigate the diagnostic reliability of Waters' view in these cases. The present work showed that radiographic signs of chronic maxillary sinusitis have different diagnostic and predictive reliabilities ranging from the almost complete inaccuracy of reduced translucency or 'veiling' of the sinus to the perfect validity of 'fluid levels' or polyps within the sinus. In general, while Waters' view undoubtedly yields valuable information regarding maxillary sinus pathology, nevertheless the presence of various sources of error while exposing and reading the film should make one appreciate that radiographic diagnosis is not absolute and should only be considered in the light of the clinical findings and possibly other investigations.

The human respiratory nasal mucosa in nasal syphilis. An ultra-microscopic study

The fine structure of the human tertiary syphilitic nasal mucosa was studied in 5 patients. The epithelium showed variations in thickness, loss of cilia, irregular cell contours, widened intercellular spaces, rare goblet cells. The seromucinous glands were in three forms. The arterioles and capillaries varied in relation to the pathology of the surrounding tissue. The venules were least affected. The stroma was infiltrated by macrophages, plasma cells with some areas having excessive fibrosis and others partially necrotic. These findings were correlated to the histochemical reactions. Scattered Treponema pallidum were seen, demonstrating the blood-borne dissemination and the infective nasal secretions.

Treatment of auricular hematoma using button technique

10 male patients suffering from auricular hematoma were treated by evacuation of the hematoma followed by suturing two buttons to the ear using through-and-through staying silk sutures, leaving them attached for 1 week. Not a single case of recurrence has been encountered as this technique eliminates the dead space and does not allow reaccumulation of the hematoma.