Using timeliness metrics for household contact tracing and TB preventive therapy in the private sector, India

BACKGROUND

Although screening of household contacts (HHCs) of TB patients and provision of TB preventive therapy (TPT) is a key intervention to end the TB epidemic, their implementation globally is dismal. We assessed whether introducing a '7-1-7' timeliness metric was workable for implementing HHC screening among index patients with pulmonary TB diagnosed by private providers in Chennai, India, between November 2022 and March 2023.

METHODS

This was an explanatory mixed-methods study (quantitative-cohort and qualitative-descriptive).

RESULTS

There were 263 index patients with 556 HHCs. In 90% of index patients, HHCs were line-listed within 7 days of anti-TB treatment initiation. Screening outcomes were ascertained in 48% of HHCs within 1 day of line-listing. Start of anti-TB treatment, TPT or a decision to receive neither was achieved in 57% of HHC within 7 days of screening. Overall, 24% of screened HHCs in the '7-1-7' period started TPT compared with 16% in a historical control (P < 0.01). Barriers to achieving '7-1-7' included HHC reluctance for evaluation or TPT, refusal of private providers to prescribe TPT and reliance on facility-based screening of HHCs instead of home visits by health workers for screening.

CONCLUSIONS

Introduction of a timeliness metric is a workable intervention that adds structure to HHC screening and timely management..

Annual consumption of parenteral antibiotics in a tertiary hospital of Nepal, 2017-2019: a cross-sectional study

SETTING

Patan Hospital, a tertiary care hospital in Lalitpur District, Nepal.

OBJECTIVES

To describe the annual parenteral antibiotic consumption in 1) defined daily dose (DDD) and DDD per 100 admissions; 2) calculate DDD per 100 admissions and proportions by pharmacological subgroup, chemical subgroup and AWaRe categories; and 3) describe patient expenditure on parenteral antibiotics as a proportion of the total patient expenditure on drugs and consumables between 2017 and 2019.

DESIGN

This was a cross-sectional study.

RESULTS

Total DDD of parenteral antibiotics increased by 23% from 39,639.7 in 2017 to 48,947.7 in 2019. DDD per 100 admissions increased by 10% from 172.1 in 2017 to 190.2 in 2019. Other beta-lactam antibacterials comprised the most frequently consumed pharmacological subgroup. The chemical substance most often consumed was ceftriaxone, with an increasing trend in the consumption of vancomycin and meropenem. Parenteral antibiotics in 'Watch' category were the most consumed over the study period, with a decreasing trend in 'Access' and increasing trend in 'Reserve' categories.

CONCLUSION

We aimed to understand the consumption of parenteral antibiotics at a tertiary care hospital and found that Watch antibiotics comprised the bulk of antibiotic consumption. Overconsumption of antibiotics from the 'Watch' and 'Reserve' categories can promote antimicrobial resistance; recommendations were therefore made for their rational use.

Surgical antibiotic prophylaxis administration practices

SETTING

A referral hospital in Kavre, Nepal.

OBJECTIVES

To assess 1) compliance with National Antibiotic Treatment Guidelines (NATG), specifically, whether the administration of surgical antibiotic prophylaxis (SAP) (initial dosing and redosing) was in compliance with NATG for patients who were and were not eligible, and 2) development of surgical site infections (SSIs) among patients who underwent surgery in the Department of General Surgery (July-December 2019).

DESIGN

This was a retrospective cohort analysis.

RESULTS

The analysis included 846 patients, of which 717 (85%) patients were eligible for SAP and 129 (15%) were ineligible. Of those eligible, 708 (99%) received the initial dose; while 65 (50%) of the ineligible did not receive any dose. Of those who received the initial dose, 164 (23%) were eligible for redosing. Of these, only 23 (14%) received at least one redosing and 141 (86%) did not receive it. Overall compliance with NATG was achieved in 75% (632/846) of patients. SSIs occurred in 23 (3%) patients, 8 (35%) of whom did not have SAP administered according to NATG.

CONCLUSION

A relatively high overall compliance with NATG for SAP administration was reported. Recommendations were made to improve compliance among those who were ineligible for SAP and those who were eligible for redosing.

Building the capacity of public health programmes to become data rich, information rich and action rich

Good quality, timely data are the cornerstone of health systems, but in many countries these data are not used for evidence-informed decision making and/or for improving public health. The SORT IT (Structured Operational Research and Training Initiative) model has, over 8 years, trained health workers in low- and middle-income countries to use data to answer important public health questions by taking research projects through to completion and publication in national or international journals. The D2P (data to policy) training initiative is relatively new, and it teaches health workers how to apply 'decision analysis' and develop policy briefs for policy makers: this includes description of a problem and the available evidence, quantitative comparisons of policy options that take into account predicted health and economic impacts, and political and feasibility assessments. Policies adopted from evidence-based information generated through the SORT IT and D2P approaches can be evaluated to assess their impact, and the cycle repeated to identify and resolve new public health problems. Ministries of Health could benefit from this twin-training approach to make themselves 'data rich, information rich and action rich', and thereby use routinely collected data in a synergistic manner to improve public health policy making and health care delivery.

Effect of increased ART-CPT uptake on tuberculosis outcomes and associated factors, Burundi, 2009-2013

We retrospectively examined 3579 records of human immunodeficiency virus infected tuberculosis (TB) patients diagnosed from January 2009 to June 2013 in 55 TB treatment facilities in Burundi, to demonstrate whether improvement of combined cotrimoxazole preventive therapy and antiretroviral therapy (ART) uptake was accompanied by improvement of treatment outcomes, and to describe associated factors. Treatment success rates increased from 71% to 80% (P < 0.001). While loss to follow-up and transfer-out rates declined significantly, death rates decreased modestly, and remained high, at 14%. ART uptake was worse in suburban areas and private for-profit institutions. World Health Organization targets could be achieved if peripheral health facilities were prioritised.

Building operational research capacity in the Pacific

Operational research (OR) in public health aims to investigate strategies, interventions, tools or knowledge that can enhance the quality, coverage, effectiveness or performance of health systems. Attention has recently been drawn to the lack of OR capacity in public health programmes throughout the Pacific Islands, despite considerable investment in implementation. This lack of ongoing and critical reflection may prevent health programme staff from understanding why programme objectives are not being fully achieved, and hinder long-term gains in public health. The International Union Against Tuberculosis and Lung Disease (The Union) has been collaborating with Pacific agencies to conduct OR courses based on the training model developed by The Union and Médecins Sans Frontières Brussels-Luxembourg in 2009. The first of these commenced in 2011 in collaboration with the Fiji National University, the Fiji Ministry of Health, the World Health Organization and other partners. The Union and the Secretariat of the Pacific Community organised a second course for participants from other Pacific Island countries and territories in 2012, and an additional course for Fijian participants commenced in 2013. Twelve participants enrolled in each of the three courses. Of the two courses completed by end 2013, 18 of 24 participants completed their OR and submitted papers by the course deadline, and 17 papers have been published to date. This article describes the context, process and outputs of the Pacific courses, as well as innovations, adaptations and challenges.

Do non-monetary incentives for pregnant women increase antenatal attendance among Ethiopian pastoralists?

In a pastoralist setting in Ethiopia, we assessed changes in attendance between the first and subsequent antenatal care (ANC) visits following the implementation of non-monetary incentives in a primary health care centre over a 3-year period from October 2009 to September 2012. Incentives included the provision of a bar of soap, a bucket, a mosquito net, sugar, cooking oil, a jerrycan and a delivery kit. The first ANC visits increased by 48% in the first year to 60% in the second. Subsequent visits did not show a similar pattern due to ruptures in incentive stocks. Incentives appear to increase ANC attendance; however, ruptures in stock should be avoided to sustain the effect.

The Structured Operational Research and Training Initiative for public health programmes

In 2009, the International Union Against Tuberculosis and Lung Disease (The Union) and Médecins sans Frontières Brussels-Luxembourg (MSF) began developing an outcome-oriented model for operational research training. In January 2013, The Union and MSF joined with the Special Programme for Research and Training in Tropical Diseases (TDR) at the World Health Organization (WHO) to form an initiative called the Structured Operational Research and Training Initiative (SORT IT). This integrates the training of public health programme staff with the conduct of operational research prioritised by their programme. SORT IT programmes consist of three one-week workshops over 9 months, with clearly-defined milestones and expected output. This paper describes the vision, objectives and structure of SORT IT programmes, including selection criteria for applicants, the research projects that can be undertaken within the time frame, the programme structure and milestones, mentorship, the monitoring and evaluation of the programmes and what happens beyond the programme in terms of further research, publications and the setting up of additional training programmes. There is a growing national and international need for operational research and related capacity building in public health. SORT IT aims to meet this need by advocating for the output-based model of operational research training for public health programme staff described here. It also aims to secure sustainable funding to expand training at a global and national level. Finally, it could act as an observatory to monitor and evaluate operational research in public health. Criteria for prospective partners wishing to join SORT IT have been drawn up.

Open access for operational research publications from low- and middle-income countries: who pays?

Open-access journal publications aim to ensure that new knowledge is widely disseminated and made freely accessible in a timely manner so that it can be used to improve people's health, particularly those in low- and middle-income countries. In this paper, we briefly explain the differences between closed- and open-access journals, including the evolving idea of the 'open-access spectrum'. We highlight the potential benefits of supporting open access for operational research, and discuss the conundrum and ways forward as regards who pays for open access.

Sex, drugs and prisons: HIV prevention strategies for over 190 000 clients in Ukraine

SETTING

One hundred and forty non-governmental organisations implementing human immunodeficiency virus (HIV) prevention programmes among clients, including people who inject drugs, prisoners, female sex workers, men who have sex with men and street children in Ukraine, 2010-2011.

OBJECTIVE

Among enrolled clients, to assess factors associated with HIV testing, HIV retesting within a year of initial testing and HIV seroconversion.

DESIGN

Retrospective cohort study involving record reviews.

RESULTS

Of 192 487 clients, 42 109 (22%) underwent an initial HIV test (22% were positive). Among HIV-negative clients at baseline, 10 858 (27%) were retested within a year: 317 (3%) of these were HIV-positive. HIV testing and retesting rates were lower among prisoners (0.3%) and others (street children and partners of those in risk groups, 6%), and those who did not receive counselling or services such as condom and needle distribution. Individuals who were not counselled were more likely to seroconvert.

CONCLUSIONS

In this large cohort of high-risk groups from Eastern Europe, HIV testing was low and HIV sero-conversion was high. This is of public health concern, bringing into question the overall quality of counselling and how well it is tailored to the specific needs of various risk groups. Qualitative studies to understand the reasons for non-testing are urgently required for designing client-specific interventions.

Are sputum samples of retreatment tuberculosis reaching the reference laboratories? A 9-year audit in Tanzania

SETTING

One reference and three zonal laboratories and 500 health facilities managing retreatment tuberculosis (TB) patients in Tanzania.

OBJECTIVES

The National Tuberculosis and Leprosy Programme (NTLP) requires that all notified cases of retreatment TB in Tanzania have sputum samples sent for culture and drug susceptibility testing (DST). This study determined 1) if the number of annually notified retreatment patients corresponded to the number of sputum samples received by the reference laboratories, and 2) the number of culture-positive samples and the number of cases undergoing DST.

DESIGN

Nine-year audit of country-wide programme data from 2002 to 2010.

RESULTS

Of the 40 940 retreatment TB patients notified by the NTLP, 3871 (10%) had their sputum samples received at the reference and zonal laboratories for culture and DST. A total of 3761 (97%) sputum samples were processed for culture, of which 1589 (42%) were found to be culture-positive and 1415 (89%) had DST performed.

CONCLUSIONS

There is a >90% shortfall between notified retreatment cases and numbers of sputum samples received, cultured and assessed for DST at reference and zonal laboratories. Steps needed to address this problem are discussed.

Poor treatment outcomes among multidrug-resistant tuberculosis patients in Gomel Region, Republic of Belarus

SETTINGS

Tuberculosis (TB) health facilities in the Gomel Region, Republic of Belarus-settings with a high burden of multidrug-resistant TB (MDR-TB) and human immunodeficiency virus (HIV) infection.

OBJECTIVE

To determine treatment outcomes among MDR-TB patients diagnosed in 2009-2010 and factors associated with unsuccessful outcomes (death, failure and loss to follow-up).

DESIGN

Retrospective cohort study involving a review of an electronic patient database maintained under the National Tuberculosis Control Programme.

RESULTS

Of 517 patients diagnosed, 78 (15%) did not start treatment. Among 439 patients who started treatment (84% males, median age 45 years, 15% HIV-infected), 291 (66%) had unsuccessful outcomes (35% deaths, 18% treatment failure and 13% lost to follow-up). Multivariate regression analysis showed that patients aged ⩾45 years (aRR 1.2, 95%CI 1.1-1.3), HIV-infected patients and those not receiving antiretroviral therapy (ART) (aRR 1.5, 95%CI 1.4-1.6) and those with a previous history of anti-tuberculosis treatment (aRR 1.2, 95%CI 1.1-1.4) had significantly higher risk of unsuccessful outcomes.

CONCLUSION

Treatment outcomes among MDR-TB patients were poor, with high rates of death, failure and loss to follow-up (including pre-treatment loss to follow-up). Urgent measures to increase ART uptake among HIV-infected MDR-TB patients, improved access to second-line anti-tuberculosis drug susceptibility testing and comprehensive patient support measures are required to address this grim situation.

Non-adherence to standard treatment guidelines in a rural paediatric hospital in Sierra Leone

SETTING

A rural paediatric hospital in Bo, Sierra Leone.

OBJECTIVES

To assess the level of adherence to standard treatment guidelines among clinicians prescribing treatment for children admitted with a diagnosis of malaria and/or lower respiratory tract infection (LRTI), and determine the association between (non) adherence and hospital outcomes, given that non-rational use of medicines is a serious global problem.

DESIGN

Secondary analysis of routine programme data.

RESULTS

Data were collected for 865 children admitted with an entry diagnosis of malaria and 690 children with LRTI during the period January to April 2011; some patients were classified in both categories. Non-adherence to guidelines comprised use of non-standard drug regimens, dosage variations, non-standard frequency of administration and treatment duration. Cumulative non-adherence to guidelines for LRTI cases was 86%. For malaria, this involved 12% of patients. Potentially harmful non-adherence was significantly associated with an unfavourable hospital outcome, both for malaria and for LRTI cases.

CONCLUSIONS

Overall non-adherence to standard treatment guidelines by clinicians in a routine hospital setting is very high and influences hospital outcomes. This study advocates for the implementation of routine measures to monitor and improve rational drug use and the quality of clinical care in such hospitals.

Prevalence of anaemia, syphilis and hepatitis B in pregnant women in Nausori, Fiji

SETTING

An antenatal clinic serving a population of 47 604 in Nausori, Fiji.

OBJECTIVE

1) To estimate the prevalence of anaemia, syphilis and hepatitis B in pregnant women attending their first antenatal visit; and 2) to estimate the uptake of treatment for syphilis and for the prevention of hepatitis B transmission in affected individuals.

DESIGN

Retrospective review of the clinic register and patient records for the year 2011.

RESULTS

The prevalence of anaemia, hepatitis B and syphilis were respectively 22%, 2% and 5%. Among women with syphilis, 78% of those for whom data were available received a complete course of three doses of penicillin during their pregnancy, and 83% of babies born to women with hepatitis B received hepatitis B immunoglobulin.

CONCLUSION

The prevalence of anaemia in pregnant women has declined but remains high, and further research is required to identify the major causes of this condition in Fiji. The prevalence of syphilis has remained static, while hepatitis B has decreased over the past decade. There are some gaps in the implementation of effective interventions to manage these conditions in pregnant women.

Performance of decentralised facilities in tuberculosis case notification and treatment success in Armenia

We assessed the performance of decentralised tuberculosis (TB) out-patient centres in tuberculosis (TB) case notification and treatment success in Armenia. An average threshold case notification of ⩾37/100 000 was seen in centres that had higher numbers of presumptive TB patients, where more TB was diagnosed by in-patient facilities and where TB contacts were examined. The number of doctors and/or TB specialists at centres did not influence case notification. Onsite smear microscopy was significantly associated with a treatment success rate of ⩾85% for new TB patients. Addressing specific characteristics of TB centres associated with lower case notification and treatment success and optimising their location may improve performance.

Risk factors associated with loss to follow-up among multidrug-resistant tuberculosis patients in Georgia

SETTING

Georgia, a country with a high-burden of multi-drug-resistant tuberculosis (MDR-TB).

OBJECTIVE

To determine the proportion of loss to follow-up (LFU) among MDR-TB patients treated nationwide from 2009 to 2011, and associated risk factors.

DESIGN

Retrospective cohort study involving a review of the National Tuberculosis Programme electronic surveillance database. A Cox proportional hazards model was used to assess risk factors for time to LFU.

RESULTS

Among 1593 patients, 458 (29%) were lost to follow-up. A total of 1240 MDR-TB patients were included in the final analysis (845 treatment success, 395 LFU). Over 40% of LFU occurred during the first 8 months of MDR-TB treatment; 40% of patients had not achieved culture conversion at the time of LFU. In multivariate analysis, the factors associated with LFU included male sex, illicit drug use, tobacco use, history of previous anti-tuberculosis treatment, site of TB disease, and place and year of initiating treatment.

CONCLUSION

LFU was high among MDR-TB patients in Georgia and posed a significant public health risk, as many were culture-positive at the time of LFU. A multi-pronged approach is needed to address the various patient- and treatment-related characteristics associated with LFU.

Treatment outcomes among drug-susceptible tuberculosis patients in Latvia, 2006-2010

SETTING

Latvia, an Eastern European country with a high burden of tuberculosis (TB).

OBJECTIVE

To describe treatment outcomes among new drug-susceptible TB patients and assess the association of treatment outcomes with selected social determinants and risk factors.

DESIGN

A retrospective cohort study of patients aged ⩾15 years registered during 2006-2010, with a review of records in the National Tuberculosis Registry.

RESULTS

Of 2476 patients, 1704 (69%) were male; the median age was 42 years. About two thirds of patients were unemployed or retired, 7% were human immunodeficiency virus (HIV) positive and 35% had a history of alcohol use. Treatment success was achieved in 2167 (88%) patients. Older age, unemployment, HIV infection and alcohol use were found to be independently associated with unsuccessful treatment (death, loss to follow-up, failure, transfer out and other). For many variables, including HIV infection, diabetes mellitus and tobacco use, it was not possible to distinguish between 'not recorded' and 'not present' in the registry.

CONCLUSION

The treatment success rate among new drug-susceptible TB patients exceeded the 85% global target for TB control. Additional attention and support is required for most vulnerable patients, such as those who are unemployed or retired, HIV infected and alcohol users. The National TB Registry should be revised to improve definitions and staff should be trained for proper data collection and recording.

How well are asthma treatment cards filled out in public health centres in Gazeera State, Sudan?

SETTING

Four public district hospitals offering asthma treatment in Gazeera State, Sudan. Incomplete recording of patient data directly affects the quality of asthma care and the evaluation of asthma management programmes.

OBJECTIVE

To assess the completeness of filling out of treatment cards and accuracy of calculating peak expiratory flow (PEF) for confirming diagnosis and grading severity of asthma.

DESIGN

Cross-sectional audit of asthma treatment cards from asthma centres, 2006-2012.

RESULTS

Of 959 patient cards assessed, completeness ranged from 47% to 98%. Six of 13 variables had an unsatisfactory grade of completeness (<80% complete). Calculated PEF was indicated in 885 (92%) cards, but was correct in only 609 (69%). PEF variability was recorded in 835 (87%) cards, but was correctly calculated in 442 (53%). A scheduled follow-up visit was attended by only 359 (37%) patients, indicating 63% loss to follow-up. Contact telephone numbers were missing from 453 (47%) cards.

CONCLUSION

This is the first study in Africa to assess the data completeness and integrity of asthma patient cards, identifying important shortcomings. This affects quality of management of asthma patients and programme evaluation. Steps to rectify this situation are urgently needed.

Childhood immunisation in Bungoma County, Kenya, from 2008 to 2011: need for improved uptake

Uptake of immunisations in children aged 1-2 years in Bungoma County, Kenya, was determined as part of the 6-monthly Health and Demographic Surveillance System surveys. A total of 2699 children were assessed between 2008 and 2011. During this time period, full immunisation declined significantly from 84% to 58%, and measles vaccine declined uptake from 89% to 60% (P < 0.001). Each year there was a significant fall-off for the third doses of the oral polio and pentavalent vaccines (P < 0.001). These findings are of concern, as low immunisation coverage may lead to vaccine-preventable disease outbreaks. Further investigations into the reasons for declining immunisation trends are required.

High loss to follow-up following obstetric fistula repair surgery in rural Burundi: is there a way forward?

SETTING

Gitega Fistula Centre (GFC), a dedicated obstetric fistula repair centre providing comprehensive care at the Gitega District Hospital, rural Burundi.

OBJECTIVES

To describe 1) the proportion who returned for scheduled 3- and 6-month follow-up visits and 2) outcomes (fistula closure rates and continence status) at discharge from hospital and after 3 and 6 months among patients who underwent fistula repair surgery.

DESIGN

Retrospective cohort analysis using programme data from April 2010 to December 2011.

RESULTS

A total of 475 women with obstetric fistula underwent surgical repair. At discharge from hospital, 415 (87%) had a closed fistula, of whom 318 (77%) were continent of urine and/or faeces, while 97 (23%) remained incontinent despite closure. Of the 415 patients with closed fistula, only 244 (59%) were followed up at 3 months and 73 (18%) at 6 months (χ(2) for linear trend 576, P < 0.0001). This indicates progressive loss to follow-up, reaching 82% by 6 months.

CONCLUSION

Women undergoing obstetric fistula repair surgery at GFC achieve good hospital exit outcomes. Thereafter, substantial and progressive loss to follow-up hinder the ability to judge programme success over time. Steps to address this operational problem are discussed.

Nurses graduating in Fiji between 2001 and 2010: sufficient supply for Fiji's health service demands?

SETTING

Fiji's schools of nursing and government health services, 2001-2010.

OBJECTIVES

To report on 1) the number and characteristics of nurses who graduated in Fiji, 2) the proportion of vacant nursing positions in the government health services and 3) attrition among nurses.

DESIGN

Descriptive study involving a retrospective record review of Ministry of Health annual reports and nursing registers.

RESULTS

Over the period 2001-2010, a total of 1500 nurses graduated, with the overall trend being a gradual increase in newly qualified nurses year on year. Available data from 2007 onwards showed relatively low vacancy rates (range 0.4-2%), with a sharp rise to 15% in 2009. Complete data on nurse attrition were available only from 2007 onwards, with rates of attrition ranging from 4% to 10%; the most common reason for attrition was resignation.

CONCLUSION

While it was unable to directly assess whether Fiji's supply of nursing graduates has been meeting the country's health service demands, this study provides a series of baseline data on Fiji's nurse graduate and nursing workforce. In addition, it identifies some of the challenges and gaps that need to be considered to better assess and address nursing staff shortages.

Diagnosis of pulmonary tuberculosis in a pastoralist population in Ethiopia: are three sputum specimens needed?

OBJECTIVE

To assess the number of sputum specimens necessary for a reliable diagnosis of pulmonary tuberculosis (PTB) in a pastoralist population in Ethiopia.

METHOD

Using routine data from Ethiopia, where three sputum specimens are currently recommended for the diagnosis of PTB, we documented, (i) the proportion of persons with suspected, PTB who submitted a first, second and third sputum specimen for smear examination and (ii) the incremental smear-positive yield from the first, to the second and third specimens.

RESULTS

Of 505 persons with suspected PTB, 107 (22%) failed to submit three samples. Of 60 patients who submitted three sputum samples with at least one smear-positive sample, the first sputum sample was smear positive in 56 (93%) cases; the second sputum sample was the first to be positive in 3 (5%) cases and in only one case was the third sample the first to be smear positive (additional yield 2%).

CONCLUSION

In a pastoralist setting, a reliable diagnosis of PTB can be achieved with two sputum specimens and PTB diagnosis may be adequate with just one sputum specimen. However, if this more radical approach was adopted, ways of increasing diagnostic sensitivity should be explored.

Primary school compliance with school canteen guidelines in Fiji and its association with student obesity

SETTING

Childhood obesity is of growing public health concern in Fiji. The study setting was primary schools in Fiji's Western Division.

OBJECTIVE

1) To assess primary schools' compliance with national school canteen guidelines, 2) to understand reasons for non-compliance, and 3) to assess the relationship between compliance with the guidelines and students' body mass index (BMI).

DESIGN

Cross-sectional analysis of data collected in 2010 by public health dieticians of the Ministry of Health on annual visits to primary schools.

RESULTS

Among 230 schools, 33 (14%) had no canteen data. Of the 197 schools with data, only 31 (16%) were fully compliant with national school canteen guidelines, while the remaining 166 (84%) did not fully comply with the guidelines. This was irrespective of school location or whether the canteen was school or commercially operated. In a random sample (n = 44 schools), overweight and obesity were more common among children in non-compliant schools than in fully compliant schools (40% vs. 32%, P < 0.001).

CONCLUSION

Most primary schools in Fiji's Western Division did not comply with school canteen guidelines, which is worrying given the increasing rates of overweight children. Given the association between non-compliance and student overweight/obesity, further action is needed to ensure that these guidelines are implemented.

Household crowding index: a correlate of socioeconomic status and inter-pregnancy spacing in an urban setting

OBJECTIVES

This paper examines the effect of household crowding on inter-pregnancy spacing and its association with socioeconomic indicators, among parous mothers delivered in an urban environment.

DESIGN

Cross sectional survey.

METHODS

Sociodemographic data were obtained on 2466 parous women delivering at eight hospitals in Greater Beirut over a one year period. Statistical methodology comprised Pearson chi(2) test and logistic regression analysis.

MAIN RESULTS

A significant inverse relation was observed between household crowding and socioeconomic status, defined as education and occupation of women and their spouses. Inter-pregnancy spacing increased with higher levels of crowding. Further analysis suggested that this positive association was confounded by maternal demographic characteristics.

CONCLUSIONS

These data have shown that household crowding, a correlate of low parental socioeconomic status, is associated with longer birth intervals. This association, however, seems to be largely explained by maternal age and parity.

Low socioeconomic status and neonatal outcomes in an urban population in a developing country

OBJECTIVE

To investigate the effect of low socioeconomic status indicators, specifically parental educational and occupational characteristics on neonatal health outcomes.

METHODS

Analysis of 3372 newborn infants admitted to five National Collaborative Perinatal Neonatal Network centers (1 February 2000 to 31 January 2002). Outcomes included birth weight, gestational age, admission to the neonatal intensive care unit (NICU) and length of hospital stay. The independent effects of mother's education and occupation as well as father's occupation on health outcomes were assessed by means of stepwise logistic regression analysis.

RESULTS

A total of 271 (8.0%) infants were of low birth weight, 306 (9.1%) were preterm, 410 (12.2%) had NICU admissions and 240 (7.1%) were hospitalized for more than a week. After adjusting for maternal gravidity, age, smoking during pregnancy and pregnancy-related complications, parental socioeconomic characteristics had no significant impact on low birth weight or preterm birth. NICU admission and prolonged hospitalization were significantly correlated with skilled, semi-skilled and unskilled paternal occupations. Illiterate mothers had nearly 3-5 times the risk of NICU admission and prolonged hospitalization.

CONCLUSION

Both father's occupation and mother's education play an important role as determinants of neonatal morbidity characteristics.

Routine urinalysis of patients in hospital in Lebanon: how worthwhile is it?

OBJECTIVES

To examine the impact of routine urinalysis at admission on inpatient care at a hospital in Lebanon, where physicians perceive it to be a valuable diagnostic tool, in a country where preventive services are underdeveloped and where the epidemiology of kidney diseases possibly differs from that of the western world.

SETTING

American University Hospital, a tertiary teaching hospital in Beirut, Lebanon.

METHODS

A retrospective medical record review of all adult patients admitted over 2 weeks to the medicine and surgery wards of the American University Hospital. Outcomes measured were frequency of routine urinalysis versus urinalysis for a clinical indication, investigation of abnormal test results, and implications of test results on clinical management.

RESULTS

367 (79%) of 462 study patients underwent urinalysis. 266 (73%) patients had routine urinalysis. Abnormal results were found in 97(37%) routine tests and 67 (66%) of those clinically indicated urinalysis (p<0.001). Abnormalities were investigated in 21 (22%) of the abnormal routine urinalyses and 45 (67%) of the abnormal clinically indicated urinalyses (p<0.001). Logistic regression analysis showed no factors to correlate positively with investigation of abnormal urinalysis. Treatment was given to two (1%) patients who had had routine urinalysis and 26 (26%) of all those tested because of a clinical indication (p<0.001).

CONCLUSIONS

Clinical response to any abnormal urinalysis is more likely when a urine test is done for a clinical indication. In this study setting, impact of routine admission urinalysis on patient care was negligible. Despite physicians' perception of routine urinalysis being a valuable case finding tool, in this study its true value remains questionable.

Treatment of pediatric Hodgkin's disease with chemotherapy alone or combined modality therapy

Optimal treatment for Hodgkin's disease during childhood is unknown. We report the treatment outcome of patients with Hodgkin's disease <13 years of age seen at the American University of Beirut Medical Center (AUBMC) between 1980 and 1996. A retrospective review of the medical records of 24 children treated for HD at AUBMC was performed. Treatment consisted of chemotherapy alone (n = 15) or chemotherapy plus involved field radiotherapy (n = 9). Chemotherapy consisted of COPP, ABVD, or alternating cycles of each for a total of 6 to 12 cycles, depending on clinical and radiological response; three patients received MOPP. Five patients in the chemotherapy group had clinical stage (CS) I and II and 10 had CS III disease. In the combined modality group, eight patients had CS I and II and one had CS IV disease. At a median follow-up of 5 years, the event-free survival (EFS) for the combined modality group was 100% and the overall survival (OS) 100%. For the chemotherapy alone group, the EFS was 56% and the OS was 79%. Four patients (27%) in the chemotherapy alone group who had Stage IIIB disease relapsed. Mean time to relapse was 4.3 years. In our experience, six cycles of COPP or (COPP plus ABVD) alone were suboptimal for the treatment of Stage IIIB Hodgkin's disease patients, especially those with involvement of lower abdominal nodes (III2B), extensive pulmonary disease, or mixed cellularity histology. Radiation therapy or additional chemotherapy courses are required for these patients.

Prevalence of asthma and asthma symptoms in children in urban Lebanon

Full text is available as a scanned copy of the original print version.

Drug-related hospitalization at a tertiary teaching center in Lebanon: incidence, associations, and relation to self-medicating behavior

OBJECTIVE

In Lebanon there is very limited restriction on drug use. Accordingly, self-medication is highly prevalent. This study examined the influence of these factors on the development of drug-related illnesses that lead to hospitalization.

METHODS

Patients admitted to the medical and pediatric wards of a tertiary teaching center in Beirut, Lebanon, over a period of 6 months were interviewed and their charts were reviewed. Admissions attributable to adverse drug reactions or therapeutic failures were identified and characterized with respect to demographic factors, medical history, drug intake, and self-medicating behavior. The influence of these variables on the development of drug-related illnesses was examined by logistic regression.

RESULTS

Of 1745 adults and 457 children, there were 177 (10.2%) and 36 (7.9%) drug-related illnesses, respectively. Adverse drug reactions accounted for 7.0% and 5.7% and therapeutic failures for 3.2% and 2.2% of adult and pediatric admissions, respectively. Self-medication was commonly practiced (52.6% of adults and 41.6% of children). Logistic regression analysis revealed that female sex increased the risk of adverse drug reaction in adults, whereas self-medication decreased the risk. In children, the risk of adverse drug reaction was increased in lower socioeconomic groups, whereas the risk of therapeutic failure was increased by a positive history of atopy or drug reaction.

CONCLUSIONS

These results provide the first detailed analysis of the problem of drug-related illnesses in a developing country and identify a number of related or risk factors. Despite the lack of regulation of drug dispensing and the unchecked access to drugs in Lebanon, the incidence of drug-related illnesses is not different from that in Western nations. This finding may have relevance to policies of drug regulation in other countries.

Managing diabetes mellitus in a Lebanese primary care centre. Working towards change

OBJECTIVES

Demand for medical care in Lebanon is dominated by diseases, such as diabetes. Quality of documentation of care given to these patients in a primary care centre, prior to and after introducing a diabetes initiative (DI) is reported.

METHODS

Chart audit of diabetic patients attending an inner city health centre in Beirut, during 1/6/94-30/8/96 was conducted. DI was introduced in 1/1/97, and audit repeated six months later.

RESULTS

First and second audits identified 213 and 162 patients respectively. Audit I showed poor recording for almost all parameters; example: family history (3%), smoking status (11%), hypertension (9%), dyslipidaemia (4%), BMI (nil), blood pressure (46%), foot exam (16%), HbA1c (nil), serum cholesterol and triglyceride (27%) and urine analysis (12%). Audit II revealed an improvement in the recording of most parameters, risk factors such as: smoking status, hypertension, hyperlipidaemia (98-99%), physical examination: BMI (39%), foot and peripheral circulation (91-92%), blood pressure (87%). Over half the patients had undergone a complete metabolic workup.

CONCLUSION

Over the short period of time, there appears to have been an important improvement in the documentation of medical care for these diabetic patients. Effects of this change in terms of clinical outcomes is currently being assessed.

Pathophysiology of bleeding in heat stress: an experimental study in sheep

Widespread hemorrhagic manifestations commonly occur in patients with severe heat stroke. The pathogenesis of hemostatic disorders in these patients is not fully understood, although it is believed to be multifactorial in origin. The present investigation was designed to study the changes in blood platelets caused by heat stress in an experimental model of five merino sheep. The experiments were performed in two groups of five merino sheep each. In one group the sheep were subjected to a combination of heat (elevated environmental temperature) and exertional stress, and allowed to proceed throughout the experiment until a state of near collapse was reached (Task A). In the other group (Task B) the animals were heated in the same manner as those in Task A and also subjected to exertional heat; however, when the temperature reached 43.6 +/- 0.2 degrees C, the critical core temperature (CCT), they were subjected to evaporative cooling in a climatic chamber. Serial changes in the platelet counts and platelet functions were measured throughout the duration of the experiments. At the core temperature (CT) of 42.1 degrees C and above there was a significant impairment of adhesion of platelets to glass beads. During the early phases of elevation of CT, platelets showed hyperaggregation in the presence of different agonists (such as, collagen, ADP, ristocetin); this was followed by hypoaggregation when the CCT was raised above 43.6 +/- 0.2 degrees C. However, these impairments of platelet functions occurring at elevated CT and CCT were found to reverse to normal within 24 hours after the animals were cooled to 39 degrees C. It was also found that the hyperaggregation of platelets to different agonists induced by raised CT could be partially prevented by prior in vitro treatment of platelets with apyrase, a known enzyme destroying of ADP. The results of these experiments indicate that heat stress induced by exposing merino sheep to elevated controlled temperature directly activates the platelets. This may be an important contributing factor in causing altered hemostasis in heat stroke activated directly by heat. This mechanism may be operating in altered hemostasis in heat stroke.

Known type 2 diabetes mellitus among the Kuwaiti population. A prevalence study

The reported prevalence of type 2 diabetes among the Kuwaiti population varied from one source to another. This study was undertaken to define the magnitude of the problem and to suggest plans for future diabetic care. All type 2 Kuwaiti diabetic subjects registered and continuing to attend regularly in two health areas Mubarak Health Area (MHA) and Farwania Health Area (FHA)] were selected for the study. There were 3222 in MHA and 5114 in FHA among the Kuwaiti population aged 20 years and above, accounting for a total crude prevalence of 7.6% in both health areas and for a prevalence rate of 5.6% in MHA and 10.0% in FHA. The age-specific prevalence of type 2 diabetes in both areas combined rose from 2.639 per 100 population in the age group 20-39 years to 15.350% and 26.252% in the age groups 40-59 and 60 and above, respectively. The female to male ratio was 1.7, 1.6, 1.1, respectively, in MHA and 1.7, 2.0, 0.9 in FHA for the age groups 20-39, 40-59, and 60 and above. This study shows that type 2 diabetes is a major public health problem in Kuwait, with a female preponderance. Obesity is a characteristic feature of the population studied, with a mean body mass index of 31.8 +/- 6.3 and 28.5 +/- 5.1 in women and men, respectively. A positive family history of diabetes mellitus was reported in 63% of the diabetic subjects. There is a need to standardize methods of reporting and to plan a national screening survey.

Data from a public school health project in Beirut

The health status of 2778 elementary students enrolled in twenty-five government schools in Beirut was evaluated. Parents completed special forms relating to demographic information, socioeconomic status, the students' medical and vaccination history, and the presence of certain medical conditions in the family. A complete physical examination of each student was carried out. Seventy-six percent of the children belonged to families with a monthly income between US $118-237. The most common medical problems encountered were poor dentition (53%), incomplete immunization (22-63%) for the various vaccines, enuresis (9%), pediculosis (8%), and defective vision (6%). It was also noticed that 72% of the students have at least one member in the family who smokes. The data presented in this study show the need for fluoridation of public water; provision of accessible and affordable medical and dental care; carrying vaccination campaigns and introducing health education in elementary schools in Lebanon.

Height and lung function in preadolescent children of Kuwaitis and European origin: a pilot survey on health effects of gas cooking in the Middle East

Spirometric testing, including forced vital capacity (FVC), forced expiratory volume in .5 s (FEV0.5), FEF25-75%, and peak expiratory flow resistance (PEFR), was conducted among 130 10-y-old children (67 Kuwaitis, 63 Europeans) who lived with their parents in the same area in Kuwait city. Lung function of children who lived in houses with gas stoves were compared with those who lived in homes supplied with electric cookers. The FEV0.5 for children who lived in households with gas stoves was significantly lower (average difference, 94 ml; p = .05; corrected to height and sex). Other lung function indices, i.e., FVC, FEF25-75%, and PEFR, were also lower but, after accounting for confounders, were not statistically significant. Children from households that were equipped with gas cookers were approximately 3 cm shorter than children who lived in homes with electric cookers. These findings suggest that children who live in a very hot and dry climate--even with efficient air conditioning systems--are susceptible to the same environmental hazards to which children from other climatic zones are exposed. This susceptibility may be more pronounced before or at the onset of puberty.

Epidemiology of multiple sclerosis in Arabs in Kuwait: a comparative study between Kuwaitis and Palestinians

On December 31, 1988 there were 201 registered multiple sclerosis patients in Kuwait, an overall prevalence rate (PR) of 10.2 per 100,000; among them were 186 Arabs, of whom 72 were Palestinians and 51 Kuwaitis. Comparison of these two subgroups, who had a similar age distribution revealed that the disease was 2 1/2 times more frequent among Palestinians (PR 23.8/100,000) than among Kuwaitis (PR 9.5/100,000). Palestinians also showed significant differences from Kuwaitis in eye color, blood group distribution and HLA-DR and HLA-DQW epitopes frequency. This suggests that genetic rather than environmental factors might be the underlying cause for the high susceptibility to develop MS among Arabs originating from the Eastern Mediterranean basin.

Effect of hyperthermia on brain auditory evoked potentials in the conscious sheep

To assess the effect of hyperthermia on brain function of conscious sheep, auditory evoked potentials (AEPs) were studied. Auditory brain-stem potentials (BAEPs) and mid-latency potentials (MLPs) to monaural rarefaction click stimuli were recorded as the potential difference between midline skull screws and mastoid electrodes. Hyperthermia was induced by a combined passive heat and work stress in a climatic chamber. Brain temperature was monitored with a thermistor in the parietal lobe. Hyperthermia resulted in a progressive decrease in the absolute latencies of the BAEPs up to the time of heat-induced collapse. There was a similar decrease in the latencies of MLPs up to a brain temperature of 42.0 degrees C +/- 0.3 degrees C (mean +/- S.D.), while there was prolongation of latencies at higher brain temperatures. The wave form of the BAEPs (I-V) persisted up to the time of heat-induced collapse. In contrast those of MLPs showed reproducible changes in the form of flattening or splitting of the Pa wave at a brain temperature of 41.8 degrees C +/- 0.7 degrees C, reversible with cooling. That temperature was also associated with behavioural changes reversible with cooling. A complete loss of the MLP waves occurred at a brain temperature of 42.9 degrees C +/- 0.6 degrees C which was not reversed with whole body cooling and immediately preceded the heat-induced collapse. This study demonstrates that hyperthermia in the conscious sheep produces potentially damaging effects on the central nervous system once a critical brain temperature (41.8 degrees C +/- 7.0 degrees C) is exceeded and that the MLPs are more sensitive indicators of this damage than BAEPs.

The nature of human brucellosis in Kuwait: study of 379 cases

Three hundred seventy-nine Kuwaiti patients with brucellosis were admitted to Adan General Hospital, Kuwait, during the period 1984-1985. Of these 231 were males and 148 were females. Diagnosis was based on symptoms and signs compatible with the disease and on the detection of significantly elevated antibody titer and/or positive blood culture. The primary means of exposure were the consumption of raw milk and contact with goats, sheep, or camels. Patients most frequently presented with fever (91%), chills (40%), sweats (39%), gastrointestinal symptoms (30%), headache (23%), respiratory symptoms (23%), and musculoskeletal symptoms (22%). The major signs were osteoarticular involvement (37%), hepatosplenomegaly (27%), and lymphadenopathy (9%). Different regimens of treatment were used, but the highest rate of cure was achieved with triple therapy--tetracycline, streptomycin, and rifampin.

Brucellosis in Kuwait: a clinico-epidemiological study

The 160,000 population in Adan area, Kuwait, is served by Adan Regional Hospital. During the 6 months period mid-December, 1983 to mid-June, 1984, 68 cases of brucellosis were admitted to the hospital, an annual incidence of 85/100,000 population. Of these, 84% were Kuwaitis and Bedouins. The mean age was 32 years, range 12-70 years. The male female ratio was 1.4:1. 55 patients gave histories of consuming raw milk and 4 had close contact with animals. The highest incidence of the disease coincided with the animal delivery season and the desert camping period of Kuwaiti families. It appears that air transmission of contaminated soil is one of the main routes of Brucella infections in Kuwait.

Circulatory changes associated with heat stroke: observations in an experimental animal model

1. Although heat stroke is a frequent cause of death in both humans and animals as a result of climatic or exercise-imposed stress, underlying mechanisms are understood poorly. In order to develop more effective strategies for prevention and treatment of this cause of death and suffering, controlled experiments were conducted on a small number of sheep to examine cardiovascular involvement in the thermoregulatory failure of heat stroke. 2. Sheep were studied in a hot environment at rest and then during exercise until collapse. 3. With exercise, mean arterial pressure (MAP) increased slightly, cardiac output (CO) increased markedly and total peripheral resistance (TPR) decreased slightly. As collapse was imminent, MAP increased but CO and TPR did not change significantly. On collapse, MAP and TPR increased markedly and CO decreased markedly. 4. Radioactive microsphere measurements demonstrated during exercise a redistribution of blood flow (BF) away from abdominal viscera and torso skin, to muscles involved in exercise, respiratory muscles, myocardium, fat, limb skin and nasobuccal tissues. With progressively increasing heat stress and exercise, BF increased in exercise muscles and decreased in limb skin and fat. As collapse was imminent, there were sharp increases in BF in exercise muscles, brain and spinal cord. On collapse, BF decreased markedly in exercise and respiratory muscles and fat. 5. It is concluded that collapse and ultimately heat stroke are not due primarily to cardiovascular 'failure' but, rather, to consequences of high body temperatures resulting from thermoregulatory failure attributable to demands for blood pressure regulation dominating requirements for body temperature regulation.