Anti-Black discrimination in primary health care: a qualitative study exploring internalized racism in a Canadian context

OBJECTIVES

A growing body of evidence points to persistent health inequities within racialized minority communities, and the effects of racial discrimination on health outcomes and health care experiences. While much work has considered how anti-Black racism operates at the interpersonal and institutional levels, limited attention has focused on internalized racism and its consequences for health care. This study explores patients' attitudes towards anti-Black racism in a Canadian health care system, with a particular focus on internalized racism in primary health care.

DESIGN

This qualitative study employed purposive maximal variation and snowball sampling to recruit and interview self-identified Black persons aged 18 years and older who: (1) lived in Montréal during the COVID-19 pandemic, (2) could speak English or French, and (3) were registered with the Québec health insurance program. Adopting a phenomenological approach, in-depth interviews took place from October 2021 to July 2022. Following transcription, data were analyzed thematically.

RESULTS

Thirty-two participants were interviewed spanning an age range from 22 years to 79 years (mean: 42 years). Fifty-nine percent of the sample identified as women, 38% identified as men, and 3% identified as non-binary. Diversity was also reflected in terms of immigration experience, financial situation, and educational attainment. We identified three major themes that describe mechanisms through which internalized racism may manifest in health care to impact experiences: (1) the internalization of anti-Black racism by Black providers and patients, (2) the expression of anti-Black prejudice and discrimination by non-Black racialized minority providers, and (3) an insensitivity towards racial discrimination.

CONCLUSION

Our study suggests that multiple levels of racism, including internalized racism, must be addressed in efforts to promote health and health care equity among racialized minority groups, and particularly within Black communities.

Strengthening health service delivery and governance through institutionalizing 'Urban Health Atlas'-A geo-referenced Information Communication and Technology tool: Lessons learned from an implementation research in three cities in Bangladesh

INTRODUCTION

Urban health governance in Bangladesh is complex as multiple actors are involved and no comprehensive data are currently available on infrastructure, services, or performance either in public and private sectors of the healthcare system. The Urban Health Atlas (UHA)-a novel and interactive geo-referenced, web-based visualization tool was developed in Bangladesh to provide geospatial and service information to decision makers involved in urban health service planning and governance. Our objective was to study the opportunities for institutionalization of the UHA into government health systems responsible for urban healthcare delivery and document the facilitators and barriers to its uptake.

METHODS

This implementation research was carried out during 2017-2019 in three cities in Bangladesh: Dhaka, Dinajpur and Jashore. During the intervention period, six hands-on trainings on UHA were provided to 67 urban health managers across three study sites. Thirty in-depth and twelve key informant interviews were conducted to understand user experience and document stakeholder perceptions of institutionalizing UHA.

RESULTS

Capacity building on UHA enhanced understanding of health managers around its utility for service delivery planning, decision making and oversight. Findings from the IDIs and KIIs suggest that UHA uptake was challenged by inadequate ICT infrastructure, shortage of human resources and lack of ICT skill among managers. Motivating key decision makers and stakeholders about the potential of UHA and engaging them from its inception helped the institutionalization process.

CONCLUSION

While uptake of UHA by government health managers appears possible with dedicated capacity building initiatives, its use and regular update are challenged by multiple factors at the implementation level. A clear understanding of context, actors and system readiness is foundational in determining whether the institutionalization of health ICTs is timely, realistic or relevant.

Food systems determinants of nutritional health and wellbeing in urban informal settlements: A scoping review in LMICs

INTRODUCTION

Increasing food and nutritional inequities are apparent in urban settings across Low- and Middle-Income Countries (LMICs), along with nutrition transition towards ultra-processed diets high in fat, sugar, and salt. In urban informal settlements, characterized by insecurity and inadequate housing and infrastructure, food systems dynamics and their nutritional implications are poorly understood.

OBJECTIVES

This paper explores the food system determinants of food and nutrition security in urban informal settlements in LMICs with the goal of identifying effective approaches and entry points for policy and program.

METHODS

Scoping review. Five databases were screened spanning the period 1995 to 2019. A total of 3748 records were assessed for inclusion based on title and abstract followed by 42 full text reviews. At least two reviewers assessed each record. Twenty-four final publications were included, coded, and synthesized.

RESULTS

Factors influencing food security and nutrition in urban informal settlements can be organized into three interconnected levels. Macro-level factors include globalization, climate change, transnational food corporations, international treaties and regulations, global and national policies such as SDGs, insufficient social aid programs, and formalization or privatization. Meso-level factors include gender norms, inadequate infrastructure and services, insufficient transportation, informal food retailers, weak municipal policies, marketing strategies, and (lack of) employment. Micro-level factors comprise gender roles, cultural expectations, income, social networks, coping strategies, and food (in) security.

CONCLUSIONS

Greater policy attention should focus at the meso-level, with priority investments in services and infrastructure within urban informal settlements. The role and engagement of the informal sector is an important consideration in improving the immediate food environment. Gender is also crucial. Women and girls have a central role in food provisioning but are more vulnerable to various forms of malnutrition. Future research should include context-specific studies in LMIC cities as well as promoting policy change using a participatory and gender transformative approach.

Telemedicine perceptions and experiences of socially vulnerable households during the early stages of the COVID-19 pandemic: a qualitative study

BACKGROUND

Early in the COVID-19 pandemic, efforts to decrease risk of viral transmission triggered an abrupt shift from ambulatory health care delivery toward telemedicine. In this study, we explore the perceptions and experiences of telemedicine among socially vulnerable households and suggest strategies to increase equity in telemedicine access.

METHODS

Conducted between August 2020 and February 2021, this exploratory qualitative study involved in-depth interviews with members of socially vulnerable households needing health care. Participants were recruited from a food bank and primary care practice in Montréal. Digitally recorded telephone interviews focused on experiences and perceptions related to telemedicine access and use. In our thematic analysis, we employed the framework method to facilitate comparison, and the identification of patterns and themes.

RESULTS

Twenty-nine participants were interviewed, 48% of whom presented as women. Almost all sought health care in the early stages of the pandemic, 69% of which was received via telemedicine. Four themes emerged from the analysis: delays in seeking health care owing to competing priorities and perceptions that COVID-19-related health care took precedence; challenges with appointment booking and logistics given complex online systems, administrative inefficiencies, long wait times and missed calls; issues around quality and continuity of care; and conditional acceptance of telemedicine for certain health problems, and in exceptional circumstances.

INTERPRETATION

Early in the pandemic, participants report telemedicine delivery did not accommodate the diverse needs and capacities of socially vulnerable populations. Patient education, logistical support and care delivery by a trusted provider are suggested solutions, in addition to policies supporting digital equity and quality standards to promote telemedicine access and appropriate use.

Sex and Gender Determinants of Vascular Disease in the Global Context

Globally, vascular diseases are a leading cause of morbidity and mortality. Many of the most significant risk factors for vascular disease have a gendered dimension, and sex differences in vascular diseases incidence are apparent, worldwide. In this narrative review, we provide a contemporary picture of sex- and gender-related determinants of vascular disease. We illustrate key factors underlying sex-specific risk stratification, consider similarities and sex differences in vascular disease risk and outcomes with comparisons of data from the global North (ie, developed high-income countries in the Northern hemisphere and Australia) and the global South (ie, regions outside Europe and North America), and explore the relationship between country-level gendered inequities in vascular disease risk and the United Nation's gender inequality index. Review findings suggest that the rising incidence of vascular disease in women is partly explained by an increase in the prevalence of traditional risk factors linked to gender-related determinants such as shifting roles and relations related to the double burden of employment and caregiving responsibilities, lower educational attainment, lower socioeconomic status, and higher psychosocial stress. Social isolation partly explained the higher incidence of vascular disease in men. These patterns were apparent across the global North and South. Study findings emphasize the necessity of taking into account sex differences and gender-related factors in the determination of the vascular disease risk profiles and management strategies. As we move toward the era of precision medicine, future research is needed that identifies, validates, and measures gender-related determinants and risk factors in the global South.

Making doctors stay: Rethinking doctor retention policy in a contracted-out primary healthcare setting in urban Bangladesh

BACKGROUND

"Contracting Out" is a popular strategy to expand coverage and utilization of health services. Bangladesh began contracting out primary healthcare services to NGOs in urban areas through the Urban Primary Health Care Project (UPHCP) in 1998. Over the three phases of this project, retention of trained and skilled human resources, especially doctors, proved to be an intractable challenge. This paper highlights the issues influencing doctor's retention both in managerial as well as service provision level in the contracted-out setting.

METHODOLOGY

In this qualitative study, 42 Key Informant Interviews were undertaken with individuals involved with UPHCP in various levels including relevant ministries, project personnel representing the City Corporations and municipalities, NGO managers and doctors. Verbatim transcripts were coded in ATLAS.ti and analyzed using the thematic analysis. Document review was done for data triangulation.

RESULTS

The most cited problem was a low salary structure in contrast to public sector pay scale followed by a dearth of other financial incentives such as performance-based incentives, provident funds and gratuities. Lack of career ladder, for those in both managerial and service delivery roles, was also identified as a factor hindering staff retention. Other disincentives included inadequate opportunities for training to improve clinical skills, ineffective staffing arrangements, security issues during night shifts, abuse from community members in the context of critical patient management, and lack of job security after project completion.

CONCLUSIONS

An adequate, efficient and dedicated health workforce is a pre-requisite for quality service provision and patient utilization of these services. Improved career development opportunities, the provision of salaries and incentives, and a safer working environment are necessary actions to retain and motivate those serving in managerial and service delivery positions in contracting out arrangements.

Using the Flipped Classroom Model in Surgical Education: Efficacy and Trainee Perception

OBJECTIVE

To describe the feasibility, efficacy, and learner perception of the flipped classroom model for teaching conferences within surgical training programs.

DESIGN

For the flipped classroom conferences, video lectures were prepared by a faculty member, and sent to all attendees at least 2 days prior to lecture. The conference time was then spent going over cases and questions, rather than traditional lecture. We conducted a qualitative survey to assess learner's perceptions and pre-lecture quizzes to assess trainee preparedness.

SETTING

The comparison of pre-conference quizzes between flipped classroom and traditional models was carried out at Brooke Army Medical Center (BAMC) in San Antonio, TX, a tertiary care facility with a general surgery residency program. The survey was conducted at BAMC and within the Complex General Surgical Oncology fellowship program at University of Texas MD Anderson Cancer Center, where a flipped classroom model was similarly employed.

PARTICIPANTS

Surgical residents BAMC participated in pre-lecture quizzes. BAMC residents and MD Anderson fellows were invited to complete the online survey.

RESULTS

Lecture videos did not increase mean preparation time (1.53 vs. 1.46 hours without vs. with video, p = 0.858), but did increase mean quiz scores from 67% to 80% (p = 0.031) with 32/35 learners utilizing videos. Videos increased the proportion of learners who self-reported preparing at all from 42% to 95% (p = 0.28), and preparing for at least one hour for conference from 23% to 49% (p = 0.014). Of survey respondents, 90% said videos were very helpful, 90% would use them weekly if available, and 90% prefer this format to traditional lecture.

CONCLUSIONS

Utilization of a flipped classroom method was well received and preferred by surgical trainees, and it increased performance on pre-conference quizzes without increasing preparation time. Although creation of video lectures is work-intensive for lecturers, these results suggest it is more effective for learner preparation. These results could be generalizable to surgical residents nationwide as technology utilization increases in surgical education.

Modelling improved efficiency in healthcare referral systems for the urban poor using a geo-referenced health facility data: the case of Sylhet City Corporation, Bangladesh

Background

An effective referral system is critical to ensuring access to appropriate and timely healthcare services. In pluralistic healthcare systems such as Bangladesh, referral inefficiencies due to distance, diversion to inappropriate facilities and unsuitable hours of service are common, particularly for the urban poor. This study explores the reported referral networks of urban facilities and models alternative scenarios that increase referral efficiency in terms of distance and service hours.

Methods

Road network and geo-referenced facility census data from Sylhet City Corporation were used to examine referral linkages between public, private and NGO facilities for maternal and emergency/critical care services, respectively. Geographic distances were calculated using ArcGIS Network Analyst extension through a “distance matrix” which was imported into a relational database. For each reported referral linkage, an alternative referral destination was identified that provided the same service at a closer distance as indicated by facility geo-location and distance analysis. Independent sample t-tests with unequal variances were performed to analyze differences in distance for each alternate scenario modelled.

Results

The large majority of reported referrals were received by public facilities. Taking into account distance, cost and hours of service, alternative scenarios for emergency services can augment referral efficiencies by 1.5–1.9 km (p < 0.05) compared to 2.5–2.7 km in the current scenario. For maternal health services, modeled alternate referrals enabled greater referral efficiency if directed to private and NGO-managed facilities, while still ensuring availability after working-hours. These referral alternatives also decreased the burden on Sylhet City’s major public tertiary hospital, where most referrals were directed. Nevertheless, associated costs may be disadvantageous for the urban poor.

Conclusions

For both maternal and emergency/critical care services, significant distance reductions can be achieved for public, NGO and private facilities that avert burden on Sylhet City’s largest public tertiary hospital. GIS-informed analyses can help strengthen coordination between service providers and contribute to more effective and equitable referral systems in Bangladesh and similar countries.

Healthcare seeking for chronic illness among adult slum dwellers in Bangladesh: A descriptive cross-sectional study in two urban settings

Introduction

Accompanying rapid urbanization in Bangladesh are inequities in health and healthcare which are most visibly manifested in slums or low-income settlements. This study examines socioeconomic, demographic and geographic patterns of self-reported chronic illness and healthcare seeking among adult slum dwellers in Bangladesh. Understanding these patterns is critical in designing more equitable urban health systems and in enabling the country’s goal of Universal Health Coverage by 2030.

Methods

This descriptive cross-sectional study compares survey data from slum settlements located in two urban sites in Bangladesh, Tongi and Sylhet. Reported chronic illness symptoms and associated healthcare-seeking strategies are compared, and the catastrophic impact of household healthcare expenditures are assessed.

Results

Significant differences in healthcare-seeking for chronic illness were apparent both within and between slum settlements related to sex, wealth score (PPI), and location. Women were more likely to use private clinics than men. Compared to poorer residents, those from wealthier households sought care to a greater extent in private clinics, while poorer households relied more on drug shops and public hospitals. Chronic symptoms also differed. A greater prevalence of musculoskeletal, respiratory, digestive and neurological symptoms was reported among those with lower PPIs. In both slum sites, reliance on the private healthcare market was widespread, but greater in industrialized Tongi. Tongi also experienced a higher probability of catastrophic expenditure than Sylhet.

Conclusions

Study results point to the value of understanding context-specific health-seeking patterns for chronic illness when designing delivery strategies to address the growing burden of NCDs in slum environments. Slums are complex social and geographic entities and cannot be generalized. Priority attention should be focused on developing chronic care services that meet the needs of the working poor in terms of proximity, opening hours, quality, and cost.

The influence of corruption and governance in the delivery of frontline health care services in the public sector: a scoping review of current and future prospects in low and middle-income countries of south and south-east Asia

BACKGROUND

The dynamic intersection of a pluralistic health system, large informal sector, and poor regulatory environment have provided conditions favourable for 'corruption' in the LMICs of south and south-east Asia region. 'Corruption' works to undermine the UHC goals of achieving equity, quality, and responsiveness including financial protection, especially while delivering frontline health care services. This scoping review examines current situation regarding health sector corruption at frontlines of service delivery in this region, related policy perspectives, and alternative strategies currently being tested to address this pervasive phenomenon.

METHODS

A scoping review following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) was conducted, using three search engines i.e., PubMed, SCOPUS and Google Scholar. A total of 15 articles and documents on corruption and 18 on governance were selected for analysis. A PRISMA extension for Scoping Reviews (PRISMA-ScR) checklist was filled-in to complete this report. Data were extracted using a pre-designed template and analysed by 'mixed studies review' method.

RESULTS

Common types of corruption like informal payments, bribery and absenteeism identified in the review have largely financial factors as the underlying cause. Poor salary and benefits, poor incentives and motivation, and poor governance have a damaging impact on health outcomes and the quality of health care services. These result in high out-of-pocket expenditure, erosion of trust in the system, and reduced service utilization. Implementing regulations remain constrained not only due to lack of institutional capacity but also political commitment. Lack of good governance encourage frontline health care providers to bend the rules of law and make centrally designed anti-corruption measures largely in-effective. Alternatively, a few bottom-up community-engaged interventions have been tested showing promising results. The challenge is to scale up the successful ones for measurable impact.

CONCLUSIONS

Corruption and lack of good governance in these countries undermine the delivery of quality essential health care services in an equitable manner, make it costly for the poor and disadvantaged, and results in poor health outcomes. Traditional measures to combat corruption have largely been ineffective, necessitating the need for innovative thinking if UHC is to be achieved by 2030.

Supporting the role and enabling the potential of community health workers in Bangladesh’s rural maternal and newborn health programs: a qualitative study

Background

In the global journey towards Universal Health Coverage (UHC), strong primary healthcare systems are essential. This includes the frontline health workers, the bedrock of which are community health workers (CHWs). In Bangladesh, this largely female workforce plays a critical role in health promotion and linking communities with the formal health care system. With the launch of the new national strategy on CHWs, and its ambitions around the implementation of harmonized systems of financing, certification, job harmonization, performance assessment and supportive supervision, it is important to reference the perceptions, experiences, needs and aspirations of CHWs themselves.

Methods

This qualitative exploratory study examines three UNICEF supported maternal and newborn health (MNH) programs in rural Bangladesh, with two districts sampled for each program. In-depth interviews were conducted with CHWs, community members, other health workers, and program managers. Data were analyzed using a thematic analysis approach, with a particular focus on the voice and experience of CHWs and the programmatic features that support them in serving their communities.

Results

Across all three programs, CHWs function as critical local agents for health promotion and referral whose recruitment from and support by the community, enhances their effectiveness. Regular communication and collaboration between CHWs and public-sector frontline workers were perceived as important in enabling their role in increasing the coverage of essential services. Support for structured systems of training, supervision and monitoring which encompass the support of referral decisions, was also apparent. Of particular note were the needs and aspirations of CHWs regarding work-life balance, job satisfaction and desire for professional development. These concerns emphasize the importance of flexibility in how the CHW workforce is configured such that roles, responsibilities and remuneration are keyed to experience and qualifications, and the dynamic needs and aspirations of CHWs over the life course.

Conclusions

As Bangladesh pursues its UHC agenda, CHWs are pivotal in linking underserved communities to the formal health system. Flexibility in the scope of CHW roles and responsibilities, as well as supportive supervision, regular training and fair remuneration, will optimize their contributions towards UHC and better MNH outcomes.

Impact of traffic variability on geographic accessibility to 24/7 emergency healthcare for the urban poor: A GIS study in Dhaka, Bangladesh

Ensuring access to healthcare in emergency health situations is a persistent concern for health system planners. Emergency services, including critical care units for severe burns and coronary events, are amongst those for which travel time is the most crucial, potentially making a difference between life and death. Although it is generally assumed that access to healthcare is not an issue in densely populated urban areas due to short distances, we prove otherwise by applying improved methods of assessing accessibility to emergency services by the urban poor that take traffic variability into account. Combining unique data on emergency health service locations, traffic flow variability and informal settlements boundaries, we generated time-cost based service areas to assess the extent to which emergency health services are reachable by urban slum dwellers when realistic traffic conditions and their variability in time are considered. Variability in traffic congestion is found to have significant impact on the measurement of timely access to, and availability of, healthcare services for slum populations. While under moderate traffic conditions all slums in Dhaka City are within 60-minutes travel time from an emergency service, in congested traffic conditions only 63% of the city's slum population is within 60-minutes reach of most emergency services, and only 32% are within 60-minutes reach of a Burn Unit. Moreover, under congested traffic conditions only 12% of slums in Dhaka City Corporation comply with Bangladesh's policy guidelines that call for access to 1 health service per 50,000 population for most emergency service types, and not a single slum achieved this target for Burn Units. Emergency Obstetric Care (EmOC) and First Aid & Casualty services provide the best coverage, with nearly 100% of the slum population having timely access within 60-minutes in any traffic condition. Ignoring variability in traffic conditions results in a 3-fold overestimation of geographic coverage and masks intra-urban inequities in accessibility to emergency care, by overestimating geographic accessibility in peripheral areas and underestimating the same for central city areas. The evidence provided can help policy makers and urban planners improve health service delivery for the urban poor. We recommend that taking traffic conditions be taken into account in future GIS-based analysis and planning for healthcare service accessibility in urban areas.

Contracting-out urban primary health care in Bangladesh: a qualitative exploration of implementation processes and experience

BACKGROUND

Contracting-out (CO) to non-state providers is used widely to increase access to health care, but it entails many implementation challenges. Using Bangladesh's two decades of experience with contracting out Urban Primary Health Care (UPHC), this paper identifies contextual, contractual, and actor-related factors that require consideration when implementing CO in Low- and Middle- Income Countries.

METHODS

This qualitative case-study is based on 42 in-depth interviews with past and present stakeholders working with the government and the UPHC project, as well as a desk review of key project documents. The Health Policy Triangle framework is utilized to differentiate among multiple intersecting contextual, contractual and actor-related factors that characterize and influence complex implementation processes.

RESULTS

In Bangladesh, the contextual factors, both intrinsic and extrinsic to the health system, deeply impacted the CO process. These included competition with other health projects, public sector reforms, and the broader national level political and bureaucratic environment. Providing free services to the poor and a target to recover cost were two contradictory conditions set out in the contract and were difficult for providers to achieve. In relation to actors, the choice of the executing body led to complications, functionally disempowering local government institutions (cities and municipalities) from managing CO processes, and discouraging integration of CO arrangements into the broader national health system. Politics and power dynamics undermined the ethical selection of project areas. Ultimately, these and other factors weakened the project's ability to achieve one of its original objectives: to decentralize management responsibilities and develop municipal capacity in managing contracts.

CONCLUSIONS

This study calls attention to factors that need to be addressed to successfully implement CO projects, both in Bangladesh and similar countries. Country ownership is crucial for adapting and integrating CO in national health systems. Concurrent processes must be ensured to develop local CO capacity. CO modalities must be adaptable and responsive to changing context, while operating within an agreed-upon and appropriate legal framework with a strong ethical foundation.

Factors enabling comprehensive maternal health services in the benefits package of emerging financing schemes: A cross-sectional analysis from 1990 to 2014

INTRODUCTION

Maternal delivery is the costliest event during pregnancy, especially if a complicated delivery occurs that requires emergency hospital services. A health financing scheme or program that covers comprehensive maternal services, including specialized hospital services in the benefits health package, enhances maternal survival and improves financial risk protection.

OBJECTIVES

The objective of this study is to identify factors that enable the inclusion of comprehensive maternal services in the benefits package of emerging health financing schemes in low and middle-income countries across selected world regions. Comprehensive care is presumed if, in addition to normal delivery, primary health care, and secondary or tertiary hospital care are included.

METHODS

Multilevel regression analysis is performed on 220 health financing schemes and programs initiated during the period 1990-2014, in 40 countries in Sub-Saharan Africa, Asia, and Latin America.

FINDINGS

About two-thirds of emerging health financing schemes explicitly include maternal care in the benefits package, and less-than-half cover comprehensive maternal services. Provision of any type of maternal services and comprehensive services is significantly associated with the presence of donors/philanthropies as funders, and beneficiaries possessing an ID card that links them to entitled services. Other enabling factors are prepayment and risk pooling. However, private and community insurances are negatively associated with covering comprehensive maternal services, because they are subject to market failures, such as adverse and risk selection.

CONCLUSIONS

Emerging health financing schemes in low and upper-middle-income countries lag in coverage of maternal care. Advancing financial protection of these services in the health package needs policy attention, including government oversight and mandatory regulations. The enabling factors identified can enrich the ongoing discourse on Universal Health Coverage.

Impact of fortified biscuits on micronutrient deficiencies among primary school children in Bangladesh

BACKGROUND

Micronutrient deficiencies can compromise the development potential of school-aged children, and their later health and productivity as adults. School feeding and school-based fortification approaches have been utilized globally to redress nutritional deficiencies in this age group.

OBJECTIVE

We explored the acceptability and micronutrient impact of a Bangladesh Government supported school-based micronutrient fortification program for children attending rural primary schools in 10 disadvantaged sub-districts.

METHODS

We applied a mixed methods approach. The quantitative component assessed the impact of micronutrient fortification on 351 children aged 6-11 years using a cohort pre-post research design with a control group. The qualitative component explored the acceptability of the intervention using focus group discussions, body mapping and semi-structured interviews with teachers, school-going children and school authorities.

RESULTS

Daily consumption of fortified biscuits by primary school children had a significant positive impact on mean levels of iron, folic acid, vitamin B12, retinol and vitamin D controlling for sex, baseline deficiency status, CRP, and H. pylori. Levels of anemia and vitamin D deficiency were also significantly reduced. Qualitative findings indicated the widespread acceptability of the daily biscuit. Teachers perceived students to be more attentive in class, less tired, and some attributed better school performance to biscuit consumption. Children reported similar improvements in concentration and energy levels.

CONCLUSIONS

This study is among the first in Bangladesh to comprehensively assess a school-based fortification program in terms of its acceptability and impact on micronutrient status of children aged 6-11 years of age. While results strongly support this modality of school feeding, research on the cognitive impacts of micronutrient fortified biscuits will help clarify the case for scaled-up investments in school- based feeding program in Bangladesh and other low and middle income countries.

Who serves the urban poor? A geospatial and descriptive analysis of health services in slum settlements in Dhaka, Bangladesh

In Bangladesh, the health risks of unplanned urbanization are disproportionately shouldered by the urban poor. At the same time, affordable formal primary care services are scarce, and what exists is almost exclusively provided by non-government organizations (NGOs) working on a project basis. So where do the poor go for health care? A health facility mapping of six urban slum settlements in Dhaka was undertaken to explore the configuration of healthcare services proximate to where the poor reside. Three methods were employed: (1) Social mapping and listing of all Health Service Delivery Points (HSDPs); (2) Creation of a geospatial map including Global Positioning System (GPS) co-ordinates of all HSPDs in the six study areas and (3) Implementation of a facility survey of all HSDPs within six study areas. Descriptive statistics are used to examine the number, type and concentration of service provider types, as well as indicators of their accessibility in terms of location and hours of service. A total of 1041 HSDPs were mapped, of which 80% are privately operated and the rest by NGOs and the public sector. Phamacies and non-formal or traditional doctors make up 75% of the private sector while consultation chambers account for 20%. Most NGO and Urban Primary Health Care Project (UPHCP) static clinics are open 5–6 days/week, but close by 4–5 pm in the afternoon. Evening services are almost exclusively offered by private HSDPs; however, only 37% of private sector health staff possess some kind of formal medical qualification. This spatial analysis of health service supply in poor urban settlements emphasizes the importance of taking the informal private sector into account in efforts to increase effective coverage of quality services. Features of informal private sector service provision that have facilitated market penetration may be relevant in designing formal services that better meet the needs of the urban poor.

The influence of travel time on emergency obstetric care seeking behavior in the urban poor of Bangladesh: a GIS study

Background

Availability of Emergency Obstetric Care (EmOC) is crucial to avert maternal death due to life-threatening complications potentially arising during delivery. Research on the determinants of utilization of EmOC has neglected urban settings, where traffic congestion can pose a significant barrier to the access of EmOC facilities, particularly for the urban poor due to costly and limited transportation options. This study investigates the impact of travel time to EmOC facilities on the utilization of facility-based delivery services among mothers living in urban poor settlements in Sylhet, Bangladesh.

Methods

A cross-sectional EmOC health-seeking behavior survey from 39 poor urban clusters was geo-spatially linked to a comprehensive geo-referenced dataset of EmOC facility locations. Geo-spatial techniques and logistic regression were then applied to quantify the impact of travel time on place of delivery (EmOC facility or home), while controlling for confounding socio-cultural and economic factors.

Results

Increasing travel time to the nearest EmOC facility is found to act as a strong deterrent to seeking care for the urban poor in Sylhet. Logistic regression results indicate that a 5-min increase in travel time to the nearest EmOC facility is associated with a 30 % decrease (0.655 odds ratio, 95 % CI: 0.529–0.811) in the likelihood of delivery at an EmOC facility rather than at home. Moreover, the impact of travel time varies substantially between public, NGO and private facilities. A 5-min increase in travel time from a private EmOC facility is associated with a 32.9 % decrease in the likelihood of delivering at a private facility, while for public and Non-Government Organizations (NGO) EmOC facilities, the impact is lower (28.2 and 28.6 % decrease respectively). Other strong determinants of delivery at an EmOC facility are the use of antenatal care and mother’s formal education, while Muslim mothers are found to be more likely to deliver at home.

Conclusions

Geospatial evidence points to the need to strengthen referral and emergency transport systems in order to reduce urban travel time, and establish or relocate EmOC facilities closer to where the poor reside. However, female education and antenatal care coverage remain the most important determinants of facility delivery.

Innovation for universal health coverage in Bangladesh: a call to action

A post-Millennium Development Goals agenda for health in Bangladesh should be defined to encourage a second generation of health-system innovations under the clarion call of universal health coverage. This agenda should draw on the experience of the first generation of innovations that underlie the country's impressive health achievements and creatively address future health challenges. Central to the reform process will be the development of a multipronged strategic approach that: responds to existing demands in a way that assures affordable, equitable, high-quality health care from a pluralistic health system; anticipates health-care needs in a period of rapid health and social transition; and addresses underlying structural issues that otherwise might hamper progress. A pragmatic reform agenda for achieving universal health coverage in Bangladesh should include development of a long-term national human resources policy and action plan, establishment of a national insurance system, building of an interoperable electronic health information system, investment to strengthen the capacity of the Ministry of Health and Family Welfare, and creation of a supraministerial council on health. Greater political, financial, and technical investment to implement this reform agenda offers the prospect of a stronger, more resilient, sustainable, and equitable health system.

Explaining equity gains in child survival in Bangladesh: scale, speed, and selectivity in health and development

By disaggregating gains in child health in Bangladesh over the past several decades, significant improvements in gender and socioeconomic inequities have been revealed. With the use of a social determinants of health approach, key features of the country's development experience can be identified that help explain its unexpected health trajectory. The systematic equity orientation of health and socioeconomic development in Bangladesh, and the implementation attributes of scale, speed, and selectivity, have been important drivers of health improvement. Despite this impressive pro-equity trajectory, there remain significant residual inequities in survival of girls and lower wealth quintiles as well as a host of new health and development challenges such as urbanisation, chronic disease, and climate change. Further progress in sustaining and enhancing equity-oriented achievements in health hinges on stronger governance and longer-term systems thinking regarding how to effectively promote inclusive and equitable development within and beyond the health system.

Drosophila female precopulatory behavior is modulated by ecdysteroids

The effect of ecdysteroid signaling on Drosophila female precopulatory behavior was investigated using two types of mutants with either globally reduced ecdysteroid availability or reduced expression of ecdysone receptors in fruitless neurons, known to control sexual behavior. While being courted by males, mutant females performed significantly less full ovipositor extrusion behavior to reject male copulation attempts. Ecdysteroid depleted females (ecdysoneless(1)) performed male-like courtship behaviors, including unilateral wing extension and song production with patterns very similar to male courtship song. These results support the hypothesis that ecdysteroids modulate female sexual behavior, perhaps acting as a regulator of sexual motivation, and as a component affecting the performance of sex specific behavior patterns.

Wnt/β-catenin pathway regulates bone morphogenetic protein (BMP2)-mediated differentiation of dental follicle cells

BACKGROUND AND OBJECTIVE

Bone morphogenetic protein 2 (BMP2)-induced osteogenic differentiation has been shown to occur through the canonical Wnt/βcatenin pathway, whereas factors promoting canonical Wnt signaling in cementoblasts inhibit cell differentiation and promote cell proliferation in vitro. The aim of this study was to investigate whether putative precursor cells of cementoblasts, dental follicle cells (murine SVF4 cells), when stimulated with BMP2, would exhibit changes in genes/proteins associated with the Wnt/β-catenin pathway.

MATERIAL AND METHODS

SVF4 cells were stimulated with BMP2, and the following assays were carried out: (i) Wnt/β-catenin pathway activation assessed by western blotting, β-catenin/transcription factor (TCF) reporter assays and expression of the lymphoid enhancer-binding factor-1 (Lef1), transcription factor 7 (Tcf7), Wnt inhibitor factor 1 (Wif1) and Axin2 (Axin2) genes; and (ii) cementoblast/osteoblast differentiation assessed by mineralization in vitro, and by the mRNA levels of runt-related transcription factor 2 (Runx2), osterix (Osx), alkaline phosphatase (Alp), osteocalcin (Ocn) and bone sialoprotein (Bsp), determined by quantitative PCR after treatment with wingless-type MMTV integration site family, member 3A (WNT3A) and knockdown of β-catenin.

RESULTS

WNT3A induced β-catenin nuclear translocation and up-regulated the transcriptional activity of a canonical Wnt-responsive reporter, suggesting that the Wnt/β-catenin pathway functions in SVF4 cells. Activation of Wnt signaling with WNT3A suppressed BMP2-mediated induction of cementoblast/osteoblast maturation of SVF4 cells. However, β-catenin knockdown showed that the BMP2-induced expression of cementoblast/osteoblast differentiation markers requires endogenous β-catenin. WNT3A down-regulated transcripts for Runx2, Alp and Ocn in SVF4 cells compared with untreated cells. In contrast, BMP2 induction of Bsp transcripts occurred independently of Wnt/β-catenin signaling.

CONCLUSION

These data suggest that stabilization of β-catenin by WNT3A inhibits BMP2-mediated induction of cementoblast/osteoblast differentiation in SVF4 cells, although BMP2 requires endogenous Wnt/β-catenin signaling to promote cell maturation.

Drosophila male courtship behavior is modulated by ecdysteroids

Temperature-dependent induction of ecdysteroid deficiency in the ecdysoneless mutant ecd(1) adult Drosophila melanogaster results in altered courtship behavior in males. Ecdysteroid deficiency brings about significantly elevated male-male courtship behavior including song production resembling that directed toward females. Supplementation with dietary 20-hydroxyecdysone reduces male-male attraction, but does not change motor activity, courtship patterns or attraction to females. These observations support the hypothesis that reduced levels of ecdysteroids increase the probability that male fruit flies will display courtship behaviors to male stimuli.

Measurement and repeatability of interrupter resistance in unsedated newborn infants

Interrupter resistance (R(int)) is a useful measure of airway caliber in young children, but has not been well characterized in infants-in whom there are concerns about the accurate measurement of driving pressure. This study aimed to assess the feasibility and repeatability of measuring R(int) in unsedated newborn infants, and to explore alternative algorithms for calculating driving pressure. R(int) measurement was attempted in 28 healthy term newborn infants during natural sleep using the MicroRint device. Paired R(int) measurements were achieved in 24 infants, but after screening of waveforms only 15 infants had at least 5 technically acceptable waveforms on both measurements. R(int) values obtained were comparable with reported values for airflow resistance in newborns using other methods. However, the repeatability coefficient (CR) was much higher than reported values in preschool children using standard back-extrapolation algorithms, with CR 2.47 KPa L(-1) sec (unscreened) and 2.93 KPa L(-1) sec (screened). Other algorithms gave only marginally better repeatability, with all CR values over 50% of the mean R(int) value. Using current commercially available equipment, R(int) is too poorly repeatable to be a reliable measurement of airflow resistance in newborn infants. Lower deadspace equipment is needed, but anatomical and physiological factors in the infant are also important.

Comparative analysis of antisense oligonucleotide sequences for targeted skipping of exon 51 during dystrophin pre-mRNA splicing in human muscle

Duchenne muscular dystrophy (DMD) is caused by mutations in the dystrophin gene that result in the absence of functional protein. In the majority of cases these are out-of-frame deletions that disrupt the reading frame. Several attempts have been made to restore the dystrophin mRNA reading frame by modulation of pre-mRNA splicing with antisense oligonucleotides (AOs), demonstrating success in cultured cells, muscle explants, and animal models. We are preparing for a phase I/IIa clinical trial aimed at assessing the safety and effect of locally administered AOs designed to inhibit inclusion of exon 51 into the mature mRNA by the splicing machinery, a process known as exon skipping. Here, we describe a series of systematic experiments to validate the sequence and chemistry of the exon 51 AO reagent selected to go forward into the clinical trial planned in the United Kingdom. Eight specific AO sequences targeting exon 51 were tested in two different chemical forms and in three different preclinical models: cultured human muscle cells and explants (wild type and DMD), and local in vivo administration in transgenic mice harboring the entire human DMD locus. Data have been validated independently in the different model systems used, and the studies describe a rational collaborative path for the preclinical selection of AOs for evaluation in future clinical trials.

Knockdown of the Dnmt1s transcript using small interfering RNA in primary murine and bovine fibroblast cells

RNA interference (RNAi) has rapidly developed into one of the most widely applied technologies in molecular and cellular research, and although young, is now an essential experimental tool. The versatility of RNAi, especially in mammalian species, lends to its potential applications in a wide array of fields. Without having to genetically manipulate the genome, the ability to selectively reduce the level of a specific transcript using small interfering RNA (siRNA) molecules has great appeal in studying reprogramming issues in somatic cell nuclear transfer (SCNT) embryos. In such embryos, the aberrant expression of the somatic isoform of Dnmt1 (Dnmt1s), the enzyme responsible for maintaining DNA methylation in all somatic cells, has been implicated as one factor in the improper reprogramming of the donor genome. In the present study, the ability to develop a method allowing for the knockdown, or reduction, of Dnmt1s in primary fibroblast cells, like those commonly used as karyoplast donors in SCNT studies, was investigated in primary murine and bovine fibroblast cells as well as in a compromised cell line (NIH/3T3). Two Dnmt1s-specific siRNA candidates were designed and tested. Using optimized conditions, these siRNAs were transiently transfected into the cells with total RNA and nuclear protein being collected. A 56.5% knockdown in Dnmt1s was achieved in the compromised and primary murine cells whereas Dnmt1s was reduced by 15.4% in the primary bovine cells. A reduction in Dnmt1s mRNA did not correspond to a reduction in protein as determined by immunodetection of Western blots. Overall, this study demonstrated the ability of siRNA to knockdown Dnmt1s mRNA in primary fibroblast donor cells. In order to substantially increase the efficiency while decreasing the anomalies seen in SCNT, novel techniques, like the one proposed, are needed to assist the oocyte's ability to reprogram a differentiated genome.

Changing health-seeking behaviour in Matlab, Bangladesh: do development interventions matter?

It is generally assumed that socioeconomic development interventions for the poor will enhance their material and social capacities to prevent ill health and to seek appropriate and timely care. Using cross-sectional data from surveys undertaken in 1995 and 1999 as part of the BRAC-ICDDR,B Joint Research Project in Matlab, Bangladesh, this paper explores patterns of health-seeking behaviour over time, with the hypothesis that exposure to integrated socioeconomic development activities will enhance gender equity in care-seeking and the use of qualified medical care. While there is tentative evidence of greater gender equity in treatment choice among households benefiting from development interventions, a preference for qualified medical care is not apparent. Findings reveal a striking and generalized rise in self-treatment over the 4-year period that is attributed to the economic repercussions of a major flood in 1998, and greater heath awareness due to the density of community health workers in Matlab. Also noteworthy is the substantial reliance on informal and often unqualified practitioners (over 20%) such as pharmacists and itinerant drug sellers. Factors associated with the type of health care sought were identified using logistic regression. Self-care is associated with female gender, the absence of low cost health services and illnesses of relatively short duration. Medical care, on the other hand, is positively predicted by male gender, geographic location, greater socioeconomic status and serious illness of long duration. The paper concludes by emphasizing the importance of enhancing local capacities to determine whether self-treatment is indicated, to self-treat appropriately, or in cases where health care is sought, to judge provider competence and evaluate whether treatment costs are justified. The provision of pharmaceutical training to the full spectrum of health care providers is also recommended.

Women's social power, child nutrition and poverty in Mali

While the macro-level association between poverty and child malnutrition is well-established, the concept of 'poverty' and its operationalization in terms of measures of socioeconomic status shed little or no light on the mechanisms through which malnutrition is created and/or prevented. This paper investigates a woman's social power, one such mechanism that may mediate the impact of poverty on childhood nutrition. This micro-level factor is examined using survey data on 402 children 5 years of age and younger and their 261 Fulbe mothers in rural Mali. A conceptual model of social power is developed and used to test the hypothesis that a mother's social power can predict her child's nutritional status.

Comparison of patient dose from imaging protocols for dental implant planning using conventional radiography and computed tomography

OBJECTIVES

To compare the radiation doses from imaging protocols for dental implant planning either using conventional radiography only (dental panoramic radiography (DPR), cephalometry and linear cross-sectional tomography) or involving computed tomography (CT).

METHODS

Organ absorbed doses were measured using a female Rando anthropomorphic phantom loaded with lithium fluoride thermoluminescent dosemeters (TLD). Standard mandibular protocols for dental implant planning were followed using either a conventional dental radiographic unit (PM 2002 CC Planmeca, Helsinki, Finland) or CT scanner (Excel Twin Elscint, Haifa, Israel). Organ absorbed and effective doses were calculated. Effective dose was calculated using two approaches, one based on the ICRP method which excludes the salivary tissue from the remainder organs (designated E(exc)), and the other with its inclusion (E(inc)).

RESULTS

The greatest individual organ doses for any examination were measured in the salivary tissue. E(exc) for panoramic, cephalometric and cross-sectional tomography using DPR was 0.004 mSv, 0.002 mSv and 0.002 mSv, respectively, whereas with CT it was 0.314 mSv. The value of E(inc) calculated using these data was between two and five times E(exc).

CONCLUSIONS

E(inc) greatly increases the apparent radiation burden, especially with high dose procedures. CT techniques can provide excellent images, but at the cost of increased radiation detriment. DPR with a cross-sectional tomography facility may give adequate clinical information at a greatly reduced dose.

Women's social networks and child survival in Mali

This paper explores the influence of women's social networks on child survival through a comparative investigation of two ethnic groups in Mali, West Africa. Data are drawn from a study of women's social networks and health conducted during the period 1996-97. Separate samples of 500 ever-married women aged 15-49 were surveyed at two geographically distinct sites representing Bamanan and Fulbe populations respectively. Consistent with known differences in economic risk, household structure, and cultural norms, descriptive analysis reveals a greater probability of child death among the Fulbe, and a larger mean size of total, material, practical and cognitive networks among the Bamanan. Cox regression models are used to examine the association between social network size, function and composition and the odds of child death (1-5 years). Among the various biological, household and community-level variables tested in the basic model, spacing exerts an expected negative effect on the odds of child death in both groups, while household SES predicts child survival only among Fulbe children. When variables representing the educational and psychosocial attributes of the mother are included, no effects are detected in either group. Controlling for these factors, the size of total, practical, cognitive and emotional networks are found to significantly increase the odds of child survival among the Fulbe only. Compositional variables, such as the extent to which natal kin, non-kin or husbands figure in a woman's network, nor the degree to which networks are located within household yield any significant results for the Fulbe. Among Bamanan women, however, the higher the proportion of network members living in the household, the lower the odds of child death. The paper concludes by discussing the methodological, conceptual and practical implications of these findings.

Comparison of patient dose from imaging protocols for dental implant planning using conventional radiography and computed tomography

OBJECTIVES

To compare the radiation doses from imaging protocols for dental implant planning either using conventional radiography only (dental panoramic radiography (DPR), cephalometry and linear cross-sectional tomography) or involving computed tomography (CT).

METHODS

Organ absorbed doses were measured using a female Rando anthropomorphic phantom loaded with lithium fluoride thermoluminescent dosemeters (TLD). Standard mandibular protocols for dental implant planning were followed using either a conventional dental radiographic unit (PM 2002 CC Planmeca, Helsinki, Finland) or CT scanner (Excel Twin Elscint, Haifa, Israel). Organ absorbed and effective doses were calculated. Effective dose was calculated using two approaches, one based on the ICRP method which excludes the salivary tissue from the remainder organs (designated E(exc)), and the other with its inclusion (E(inc)).

RESULTS

The greatest individual organ doses for any examination were measured in the salivary tissue. E(exc) for panoramic, cephalometric and cross-sectional tomography using DPR was 0.004 mSv, 0.002 mSv and 0.002 mSv, respectively, whereas with CT it was 0.314 mSv. The value of E(inc) calculated using these data was between two and five times E(exc).

CONCLUSIONS

E(inc) greatly increases the apparent radiation burden, especially with high dose procedures. CT techniques can provide excellent images, but at the cost of increased radiation detriment. DPR with a cross-sectional tomography facility may give adequate clinical information at a greatly reduced dose.

Evaluation of a new percutaneous dilatational tracheostomy set apparatus

Percutaneous tracheostomy is a well established technique used primarily to assist weaning from mechanical ventilation on many intensive care units. We report our experiences of a total of 36 procedures performed with the new Blue Rhino Percutaneous Tracheostomy Introducer Set developed by Ciaglia. The technique was successful in all cases and was simpler and quicker to perform than with the earlier Ciaglia percutaneous tracheostomy set. Difficulties were encountered when using Shiley tracheostomy tubes. Significant complications included one posterior wall tear and one tracheal cartilage ring fracture.

Risk perception and communication: recent developments and implications for anaesthesia

This review begins by outlining the history of probability theory, exposing cultural differences between scientists and lay people in the way risks are viewed. The basic principles of the science of risk perception are described, and the various methods of communicating risk in health care, both verbal and numerical, are then discussed critically. These concepts are then applied to the practice of anaesthesia. Risk perception may affect anaesthetists' choice of career and may be involved in the genesis and evolution of critical incidents; we also discuss possibilities for training in risk perception issues. The place of risk communication in informed consent and its ethical implications are discussed.

Gender, socioeconomic development and health-seeking behaviour in Bangladesh

In efforts to reduce gender and socioeconomic disparities in the health of populations, the provision of medical services alone is clearly inadequate. While socioeconomic development is assumed important in rectifying gender and socioeconomic inequities in health care access, service use and ultimately, outcomes, empirical evidence of its impact is limited. Using cross-sectional data from the BRAC-ICDDR,B Joint Research Project in Matlab, Bangladesh, this paper examines the impact of membership in BRAC's integrated Rural Development Programme (RDP) on gender equity and health-seeking behaviour. Differences in health care seeking are explored by comparing a sample of households who are BRAC members with a sample of BRAC-eligible non-members. Individuals from the BRAC member group report significantly less morbidity (15-day recall) than those from the non-member group, although no gender differences in the prevalence of self-reported morbidity are apparent in either group. Sick individuals from BRAC member households tend to seek care less frequently than non-members. When treatment is sought, BRAC members rely to a greater extent on home remedies, traditional care, and unqualified allopaths than non-member households. While reported treatment seeking from qualified allopaths is more prevalent in the BRAC group, non-members use the para-professional services of community health care workers almost twice as frequently. In both BRAC member and non-member groups, women suffering illness report seeking care significantly less often than men. The policy and programmatic implications of between group and gender differences in care seeking are discussed with reference to the literature.

Natural transfer of helminths of marine origin to freshwater fishes with observations on the development of Diphyllobothrium alascense

Infective stages of helminths of 5 species that occur as adults in marine mammals were found in burbot, Lota lota (L.) (Gadidae), from the lower Kuskokwim River (southwestern Alaska): Diphyllobothrium alascense Rausch et Williamson, 1958; Pyramicocephalus phocarum (Fabricius, 1780); Corynosoma strumosum (Rudolphi, 1801); Corynosoma semerme (Forsell, 1904); and Pseudoterranova decipiens (Krabbe, 1878). Some larval stages were obtained also from smelt, Osmerus mordax dentex Steindachner, an anadromous fish important as prey of burbot. Burbot, which are freshwater fish, could become paratenic hosts of those helminths by means of at least 3 interactions: by consuming marine fishes in brackish waters at river mouths, by feeding on marine fishes that enter lower reaches of rivers, or by preying on anadromous fishes as they migrate up rivers. Consumption of burbot by people may result in infection by helminths of marine origin; of those recorded, only P. decipiens may be significantly pathogenic. Attempts to rear P. phocarum in dogs were unsuccessful. Plerocercoids of D. alascense, of very small size and found only in the gastric lumen of burbot, readily infected dogs. For study of their development, strobilae were obtained at intervals of 48 hr to 32 days postinfection. In heavy infections, some strobilae developed slowly, while others underwent rapid development.

Limitations in working memory: implications for language development

In this study, the proposal that individual differences in spoken language acquisition may be due to limitations in short-term memory abilities was investigated within a working memory framework. The relationship speech production skills and working memory abilities was examined in two groups of 4-year-old children, matched for non-verbal ability but who had either relatively good or poor non-word repetition skills. Children with better non-word repetition skills produced speech that comprised a wider repertoire of words, on average longer utterances and a greater range of syntactic constructions than did children with relatively poor non-word repetition skills. The significant association found between these indices of language development and verbal short-term memory span assessed with non-spoken recall, suggested that this relationship was not merely due to the common output requirements of the language and memory tasks. Inconsistent associations between language performance and two tasks of visuo-spatial short-term memory precluded firm conclusions being drawn regarding the specificity of the relationship to the phonological domain. Cognitive mechanisms that may underlie the association between spoken language development and working memory skills are discussed.

An oligonucleotide-ligation assay for the differentiation between Cyclospora and Eimeria spp. polymerase chain reaction amplification products

An oligonucleotide-ligation assay (OLA) was developed and compared to a restriction fragment length polymorphism (RFLP) test for distinguishing between 294-bp polymerase chain reaction (PCR) amplification products of the 18S rRNA gene from Cyclospora and Eimeria spp. The PCR/OLA correctly distinguished between three Cyclospora, three E. tenella, and one E. mitis strains and the ratio of positive to negative spectrophotometric absorbance (A490) values for each strain ranged from 4.086 to 15.280 (median 9.5). PCR/OLA provides a rapid, reliable, spectrophotometric alternative to PCR/RFLP.

Survival of Anisakis simplex in microwave-processed arrowtooth flounder (Atheresthes stomias)

The purpose of this study was to define the relationship between survival and temperature of nematodes of the species Anisakis simplex in microwave-processed arrowtooth flounder (Atheresthes stomias). Ten fillets (each 126 to 467 g, 0.5 to 1.75 cm thick), with an average of five larvae of Anisakis simplex per fillet, were processed to target temperatures on high (100%) power using a commercial 700-W microwave oven. Fillets were neither covered nor rotated and had a temperature probe inserted to two-thirds depth into the thickest portion. After the fillet was digested using a 1% pepsin solution, the viability of nematodes was determined by viewing them under a dissecting microscope. Survival rates were 31% at 140 degrees F (60 degrees C), 11% at 150 degrees F (65 degrees C), 2% at 160 degrees F (71 degrees C), 3% at 165 degrees F (74 degrees C), and 0% at 170 degrees F (77 degrees C). Microwave processing of standardized fillet "sandwiches," 14 cm long, 4.5 cm wide, and approximately 1.75 cm high, each of which was preinoculated with 10 live nematodes, resulted in no survival at either 160 degrees F or 170 degrees F. Using ultraviolet light to detect both viable and nonviable nematodes in fillet sandwiches as an alternative method to pepsin digestion resulted in survival rates of 1% at 140 degrees F (60 degrees C), 3% at 145 degrees F (63 degrees C), and 0% at 150 degrees F (65 degrees C). Smaller fillet sandwiches, which most likely had fewer cold spots during microwave processing, required 150 degrees F (65 degrees C), whereas larger whole fillets required 170 degrees F (77 degrees C) to kill larvae of Anisakis simplex. The parasites were most likely inactivated by a thermal mechanism of microwave treatment. Damage to the nematodes was often evident from ruptured cuticles that were no longer resistant to digestive enzymes. The high hydrostatic pressure and low chloride content of the pseudocoelomic fluid probably contributed greatly to the damage incurred by the larvae.

Template preparation for PCR and RFLP of amplification products for the detection and identification of Cyclospora sp. and Eimeria spp. Oocysts directly from raspberries

Raspberries were epidemiologically associated with cyclosporiasis outbreaks during 1996 and 1997. The 18S rRNA genes of Cyclospora cayetanensis and several species of a closely related genus, Eimeria, were sequenced and primers for a nested PCR developed in a previous study. The ability to distinguish amplified products of Cyclospora sp. from those of Eimeria spp. is important for testing food and environmental samples. Therefore, an RFLP analysis of amplified products was used to differentiate Cyclospora cayetanensis from Eimeria spp. PCR inhibitors and the low levels of Cyclospora oocysts present in raspberries make template preparation for PCR challenging. Several approaches for PCR template preparation from raspberry samples were evaluated. Template preparation methods using various washing and concentration steps, oocyst disruption protocols, resin matrix treatment, DNA precipitation, and/or the addition of nonfat dried milk solution to a PCR using modified primers were evaluated first with oocysts of Eimeria tenella then refined with oocysts of C. cayetanensis. Approximately 10 E. tenella oocysts per PCR or approximately 19 C. cayetanensis oocysts per PCR were detected with the optimized template preparation method. The addition of 20 microliters of raspberry wash sediment extract and nonfat dried milk solution did not inhibit the amplification of DNA from as few as 10 E. tenella and 25 C. cayetanensis oocysts in a 100-microliter PCR. The nucleotide sequences of C. cayetanensis and the Eimeria spp. are 94 to 96% similar in the amplified region, but the amplification products from the two genera were distinguished using an RFLP analysis with the restriction enzyme MnlI.

Occurrence and morphological comparisons of Campula oblonga (Digenea: Campulidae), including a report from an atypical host, the thresher shark, Alopias vulpinus

New host records for Campula oblonga Cobbold, 1858 from the common dolphin, Delphinus delphis L., and from the thresher shark, Alopias vulpinus (Bonnaterre), are reported herein. Campulids have not been reported previously from a host that was not a marine mammal. The excellent condition and small size of the gravid specimen and the diet and natural history of the thresher shark lead us to conclude that the digene was acquired from the consumption of infected fish. Specimens of C. oblonga from these 2 hosts and from harbor porpoises, Phocoena phocoena (L.), and from Dall's porpoises, Phocoenoides dalli (True), are compared, and a wide variation in ranges and values for characters is noted. The synonymy of Campula folium Ozaki, 1935 with C. oblonga is further supported by the apparent effect of the host on the size of the trematodes. Due to the degree of variation in measurements and the numerous factors that may impact these values, we recommend the use of qualitative morphologic characters for the identification of C. oblonga.

Parasites of fish and risks to public health

A multitude of parasites have been reported in fish, but only a few species are capable of infecting humans. The most important of the helminths acquired by humans from fish are the anisakid nematodes (particularly Anisakis simplex and Pseudoterranova decipiens), cestodes of the genus Diphyllobothrium and digenetic trematodes of the families Heterophyidae, Opisthorchiidae and Nanophyetidae. Seafood-associated infections by acanthocephalans are rarely reported in humans. All of the helminths mentioned above are associated with social-cultural and behavioural factors, in particular the consumption of raw or undercooked seafood. Measures can be taken during harvesting, processing or post-processing (e.g., by the consumer) to mitigate the risks of infection. The seafood industry and government authorities can apply various programmes to reduce these risks, including good manufacturing practices (GMPs) and hazard analysis and critical control point (HACCP) systems. Such measures may include avoiding particular harvest areas, sizes of fish, or even particular species of fish. The method of capture, handling and storage of the catch can directly affect the quality of the seafood with regard to the presence and numbers of parasites. The extent of processing--including heading and gutting, candling and trimming--and the type of product derived (fresh, frozen, salted or pickled) can all contribute to the control of the risks posed by helminths. The most effective means of killing the parasites are either freezing or heat inactivation.