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Lokangaka A, Ramani M, Bauserman M, Patterson J, Engmann C, Tshefu A, Cousens S, Qazi SA, Ayede AI, Adejuyigbe EA, Esamai F, Wammanda RD, Nisar YB, Coppieters Y. Incidence of possible serious bacterial infection in young infants in the three high-burden countries of the Democratic Republic of the Congo, Kenya, and Nigeria: A secondary analysis of a large, multi-country, multi-centre clinical trial. J Glob Health 2024; 14:04009. [PMID: 38299777 PMCID: PMC10832543 DOI: 10.7189/jogh.14.04009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2024] Open
Abstract
Background Neonatal infections are a major public health concern worldwide, particularly in low- and middle-income countries, where most of the infection-related deaths in under-five children occur. Sub-Saharan Africa has the highest mortality rates, but there is a lack of data on the incidence of sepsis from this region, hindering efforts to improve child survival. We aimed to determine the incidence of possible serious bacterial infection (PSBI) in young infants in three high-burden countries in Africa. Methods This is a secondary analysis of data from the African Neonatal Sepsis (AFRINEST) trial, conducted in the Democratic Republic of the Congo (DRC), Kenya, and Nigeria between 15 March 2012 and 15 July 2013. We recorded baseline characteristics, the incidence of PSBI (as defined by the World Health Organization), and the incidence of local infections among infants from 0-59 days after birth. We report descriptive statistics. Results The incidence of PSBI among 0-59-day-old infants across all three countries was 11.2% (95% confidence interval (CI) = 11.0-11.4). The DRC had the highest incidence of PSBI (19.0%; 95% CI = 18.2-19.8). Likewise, PSBI rates were higher in low birth weight infants (24.5%; 95% CI = 23.1-26.0) and infants born to mothers aged <20 years (14.1%; 95% CI = 13.4-14.8). The incidence of PSBI was higher among infants delivered at home (11.7%; 95% CI = 11.4-12.0). Conclusions The high burden of PSBI among young infants in DRC, Kenya, and Nigeria demonstrates the importance of addressing PSBI in improving child survival in sub-Saharan Africa to reach the Sustainable Development Goals (SDGs). These data can support government authorities, policymakers, programme implementers, non-governmental organisations, and international partners in reducing preventable under-five deaths. Registration Australian New Zealand Clinical Trials Registry: ACTRN12610000286044.
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Affiliation(s)
- Adrien Lokangaka
- Kinshasa School of Public Health, Université de Kinshasa, Kinshasa, Democratic Republic of the Congo
- School of Public Health, Université Libre de Bruxelles, Brussels, Belgium
| | - Manimaran Ramani
- University of Alabama at Birmingham, Birmingham, Alabama, USA
- University of South Alabama, Birmingham, Alabama, USA
| | - Melissa Bauserman
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jackie Patterson
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Cyril Engmann
- University of Washington, Seattle, Washington, USA
- PATH Organization, Seattle, Washington, USA
| | - Antoinette Tshefu
- Kinshasa School of Public Health, Université de Kinshasa, Kinshasa, Democratic Republic of the Congo
| | - Simons Cousens
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine (LSHTM), London, United Kingdom
| | | | - Adejumoke Idowu Ayede
- Department of Paediatrics, College of Medicine, University of Ibadan, and University College Hospital, Ibadan, Nigeria
| | - Ebunoluwa A Adejuyigbe
- Department of Paediatrics and Child Health, Obafemi Awolowo University, Ile-Ife, Nigeria
| | - Fabian Esamai
- Department of Child Health and Paediatrics, School of Medicine, Moi University, Eldoret, Kenya
| | - Robinson D Wammanda
- Department of Paediatrics, Ahmadu Bello University Teaching Hospital, Ahmadu Bello University, Zaria, Nigeria
| | - Yasir Bin Nisar
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Yves Coppieters
- School of Public Health, Université Libre de Bruxelles, Brussels, Belgium
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2
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Cousens S, Yeung M, Zepf M, Dromey B. Electron trajectories associated with laser-driven coherent synchrotron emission at the front surface of overdense plasmas. Phys Rev E 2020; 101:053210. [PMID: 32575346 DOI: 10.1103/physreve.101.053210] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 04/21/2020] [Indexed: 11/07/2022]
Abstract
We present an in-depth analysis of an ultrafast electron trajectory type that produces attosecond electromagnetic pulses in both the reflected and forward directions during normal incidence, relativistic laser-plasma interactions. Our particle-in-cell simulation results show that for a target which is opaque to the frequency of the driving laser pulse the emission trajectory is synchrotronlike but differs significantly from the previously identified figure-eight type which produces bright attosecond bursts exclusively in the reflected direction. The origin and characteristics of this trajectory type are explained in terms of the driving electromagnetic fields, the opacity of the plasma, and the conservation of canonical momentum.
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Affiliation(s)
- S Cousens
- Centre for Plasma Physics, Department of Physics and Astronomy, Queen's University Belfast, Belfast BT7 1NN, United Kingdom
| | - M Yeung
- Centre for Plasma Physics, Department of Physics and Astronomy, Queen's University Belfast, Belfast BT7 1NN, United Kingdom
| | - M Zepf
- Institut für Optik und Quantenelektronik, Friedrich-Schiller-Universität Jena, Max-Wien-Platz 1, 07743 Jena, Germany.,Helmholtz Institut Jena, Fröbelstieg 3, 07743 Jena, Germany
| | - B Dromey
- Centre for Plasma Physics, Department of Physics and Astronomy, Queen's University Belfast, Belfast BT7 1NN, United Kingdom
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3
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Salam RA, Cousens S, Welch V, Gaffey M, Middleton P, Makrides M, Arora P, Bhutta ZA. Mass deworming for soil-transmitted helminths and schistosomiasis among pregnant women: A systematic review and individual participant data meta-analysis. Campbell Syst Rev 2019; 15:e1052. [PMID: 37131518 PMCID: PMC8356523 DOI: 10.1002/cl2.1052] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
The objective of the review is to use individual participant data (IPD) meta-analysis to explore the effect of mass deworming during pregnancy. We developed a search strategy and searched the databases till March 2018. We included individually randomised controlled trials; cluster randomised controlled trials and quasi randomised studies providing preventive or therapeutic deworming drugs for soil transmitted helminthiases and schistosomiasis during pregnancy. All IPD were assessed for completeness, compared to published reports and entered into a common data spreadsheet. Out of the seven trials elgible for IPD, we received data from three trials; out of 8,515 potential IPD participants; data were captured for 5,957 participants. Findings from this IPD suggest that mass deworming during pregnancy reduces maternal anaemia by 23% (Risk ratio [RR]: 0.77, 95% confidence intreval [CI]: 0.73-0.81; three trials; 5,216 participants; moderate quality evidence). We did not find any evidence of an effect of mass deworming during pregnancy on any of the other outcomes. There was no evidence of effect modification; however these findings should be interpreted with caution due to small sample sizes. The quality of evidence was rated as moderate for our findings. Our analyses suggest that mass deworming during pregnancy is associated with reducing anaemia with no evidence of impact on any other maternal or pregnancy outcomes. Our analyses were limited by the availability of data for the impact by subgroups and effect modification. There is also a need to support and promote open data for future IPDs.
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Affiliation(s)
- R. A. Salam
- Healthy Mother, Babies and Children ThemeSouth Australian Health and MedicalResearch InstituteAdelaideAustralia
- Paediatrics and Reproductive HealthUniversity of AdelaideAdelaideAustralia
| | - S. Cousens
- Maternal Adolescent Reproductive & Child Health (MARCH) CentreLondon School of Hygiene and Tropical MedicineLondonUK
| | - V. Welch
- School of Epidemiology, Public Health and Preventive MedicineUniversity of OttawaOttawaCanada
| | - M. Gaffey
- Centre for Global Child HealthThe Hospital for Sick ChildrenTorontoCanada
| | - P. Middleton
- Healthy Mother, Babies and Children ThemeSouth Australian Health and MedicalResearch InstituteAdelaideAustralia
- Robinson Research InstituteUniversity of AdelaideAdelaideAustralia
| | - M. Makrides
- Healthy Mother, Babies and Children ThemeSouth Australian Health and MedicalResearch InstituteAdelaideAustralia
| | - P. Arora
- Dalla Lana School of Public HealthUniversity of TorontoTorontoCanada
| | - Z. A. Bhutta
- Centre for Global Child HealthThe Hospital for Sick ChildrenTorontoCanada
- Centre of Excellence in Women and Child HealthThe Aga Khan UniversityKarachiPakistan
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4
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Sarrassat S, Meda N, Badolo H, Ouedraogo M, Somé H, Cousens S. Distance to care, care seeking and child mortality in rural Burkina Faso: findings from a population-based cross-sectional survey. Trop Med Int Health 2018; 24:31-42. [PMID: 30347129 PMCID: PMC6378618 DOI: 10.1111/tmi.13170] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Objective Although distance has been identified as an important barrier to care, evidence for an effect of distance to care on child mortality is inconsistent. We investigated the association of distance to care with self‐reported care seeking behaviours, neonatal and post‐neonatal under‐five child mortality in rural areas of Burkina Faso. Methods We performed a cross‐sectional survey in 14 rural areas from November 2014 to March 2015. About 100 000 women were interviewed on their pregnancy history and about 5000 mothers were interviewed on their care seeking behaviours. Euclidean distances to the closest facility were calculated. Mixed‐effects logistic and Poisson regressions were used respectively to compute odds ratios for care seeking behaviours and rate ratios for child mortality during the 5 years prior to the survey. Results Thirty per cent of the children lived more than 7 km from a facility. After controlling for confounding factors, there was a strong evidence of a decreasing trend in care seeking with increasing distance to care (P ≤ 0.005). There was evidence for an increasing trend in early neonatal mortality with increasing distance to care (P = 0.028), but not for late neonatal mortality (P = 0.479) and post‐neonatal under‐five child mortality (P = 0.488). In their first week of life, neonates living 7 km or more from a facility had an 18% higher mortality rate than neonates living within 2 km of a facility (RR = 1.18; 95%CI 1.00, 1.39; P = 0.056). In the late neonatal period, despite the lack of evidence for an association of mortality with distance, it is noteworthy that rate ratios were consistent with a trend and similar to or larger than estimates in early neonatal mortality. In this period, neonates living 7 km or more from a facility had an 18% higher mortality rate than neonates living within 2 km of a facility (RR = 1.18; 95%CI 0.92, 1.52; P = 0.202). Thus, the lack of evidence may reflect lower power due to fewer deaths rather than a weaker association. Conclusion While better geographic access to care is strongly associated with increased care seeking in rural Burkina Faso, the impact on child mortality appears to be marginal. This suggests that, in addition to improving access to services, attention needs to be paid to quality of those services.
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Affiliation(s)
- S Sarrassat
- Centre for Maternal Adolescent Reproductive and Child Health (MARCH), London School of Hygiene and Tropical Medicine, London, UK
| | - N Meda
- Centre Muraz, Bobo Dioulasso, Burkina Faso
| | - H Badolo
- Centre Muraz, Bobo Dioulasso, Burkina Faso
| | | | - H Somé
- Africsanté, Bobo Dioulasso, Burkina Faso
| | - S Cousens
- Centre for Maternal Adolescent Reproductive and Child Health (MARCH), London School of Hygiene and Tropical Medicine, London, UK
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5
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Moorthie S, Blencowe H, Darlison MW, Lawn J, Morris JK, Modell B, Bittles AH, Blencowe H, Christianson A, Cousens S, Darlison MW, Gibbons S, Hamamy H, Khoshnood B, Howson CP, Lawn J, Mastroiacovo P, Modell B, Moorthie S, Morris JK, Mossey PA, Neville AJ, Petrou M, Povey S, Rankin J, Schuler-Faccini L, Wren C, Yunnis KA. Estimating the birth prevalence and pregnancy outcomes of congenital malformations worldwide. J Community Genet 2018; 9:387-396. [PMID: 30218347 PMCID: PMC6167261 DOI: 10.1007/s12687-018-0384-2] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 08/29/2018] [Indexed: 12/22/2022] Open
Abstract
Congenital anomaly registries have two main surveillance aims: firstly to define baseline epidemiology of important congenital anomalies to facilitate programme, policy and resource planning, and secondly to identify clusters of cases and any other epidemiological changes that could give early warning of environmental or infectious hazards. However, setting up a sustainable registry and surveillance system is resource-intensive requiring national infrastructure for recording all cases and diagnostic facilities to identify those malformations that that are not externally visible. Consequently, not all countries have yet established robust surveillance systems. For these countries, methods are needed to generate estimates of prevalence of these disorders which can act as a starting point for assessing disease burden and service implications. Here, we describe how registry data from high-income settings can be used for generating reference rates that can be used as provisional estimates for countries with little or no observational data on non-syndromic congenital malformations.
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Affiliation(s)
| | - Hannah Blencowe
- Centre for Maternal, Adolescent, Reproductive, and Child Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Matthew W Darlison
- Centre for Health Informatics and Multiprofessional Education (CHIME), University College London, London, UK.
| | - Joy Lawn
- Centre for Maternal, Adolescent, Reproductive, and Child Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Joan K Morris
- Centre for Environmental and Preventive Medicine, Wolfson Institute of Preventive Medicine, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Bernadette Modell
- Centre for Health Informatics and Multiprofessional Education (CHIME), University College London, London, UK
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6
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Cousens S, Reville B, Dromey B, Zepf M. Temporal Structure of Attosecond Pulses from Laser-Driven Coherent Synchrotron Emission. Phys Rev Lett 2016; 116:083901. [PMID: 26967416 DOI: 10.1103/physrevlett.116.083901] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Indexed: 06/05/2023]
Abstract
The microscopic dynamics of laser-driven coherent synchrotron emission transmitted through thin foils are investigated using particle-in-cell simulations. For normal incidence interactions, we identify the formation of two distinct electron nanobunches from which emission takes place each half-cycle of the driving laser pulse. These emissions are separated temporally by 130 as and are dominant in different frequency ranges, which is a direct consequence of the distinct characteristics of each electron nanobunch. This may be exploited through spectral filtering to isolate these emissions, generating electromagnetic pulses of duration ∼70 as.
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Affiliation(s)
- S Cousens
- Centre for Plasma Physics, Department of Physics and Astronomy, Queen's University Belfast, Belfast BT7 1NN, United Kingdom
| | - B Reville
- Centre for Plasma Physics, Department of Physics and Astronomy, Queen's University Belfast, Belfast BT7 1NN, United Kingdom
| | - B Dromey
- Centre for Plasma Physics, Department of Physics and Astronomy, Queen's University Belfast, Belfast BT7 1NN, United Kingdom
| | - M Zepf
- Centre for Plasma Physics, Department of Physics and Astronomy, Queen's University Belfast, Belfast BT7 1NN, United Kingdom
- Helmholtz Institut Jena, Fröbelstieg 3, 07743 Jena, Germany
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7
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Yeung M, Bierbach J, Eckner E, Rykovanov S, Kuschel S, Sävert A, Förster M, Rödel C, Paulus GG, Cousens S, Coughlan M, Dromey B, Zepf M. Noncollinear Polarization Gating of Attosecond Pulse Trains in the Relativistic Regime. Phys Rev Lett 2015; 115:193903. [PMID: 26588384 DOI: 10.1103/physrevlett.115.193903] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Indexed: 06/05/2023]
Abstract
High order harmonics generated at relativistic intensities have long been recognized as a route to the most powerful extreme ultraviolet pulses. Reliably generating isolated attosecond pulses requires gating to only a single dominant optical cycle, but techniques developed for lower power lasers have not been readily transferable. We present a novel method to temporally gate attosecond pulse trains by combining noncollinear and polarization gating. This scheme uses a split beam configuration which allows pulse gating to be implemented at the high beam fluence typical of multi-TW to PW class laser systems. Scalings for the gate width demonstrate that isolated attosecond pulses are possible even for modest pulse durations achievable for existing and planned future ultrashort high-power laser systems. Experimental results demonstrating the spectral effects of temporal gating on harmonic spectra generated by a relativistic laser plasma interaction are shown.
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Affiliation(s)
- M Yeung
- Helmholtz-Institut Jena, Fröbelstieg 3, 07743 Jena, Germany
| | - J Bierbach
- Helmholtz-Institut Jena, Fröbelstieg 3, 07743 Jena, Germany
- Friedrich-Schiller-Universität Jena, Max-Wien-Platz 1, 07743 Jena, Germany
| | - E Eckner
- Helmholtz-Institut Jena, Fröbelstieg 3, 07743 Jena, Germany
- Friedrich-Schiller-Universität Jena, Max-Wien-Platz 1, 07743 Jena, Germany
| | - S Rykovanov
- Helmholtz-Institut Jena, Fröbelstieg 3, 07743 Jena, Germany
| | - S Kuschel
- Helmholtz-Institut Jena, Fröbelstieg 3, 07743 Jena, Germany
- Friedrich-Schiller-Universität Jena, Max-Wien-Platz 1, 07743 Jena, Germany
| | - A Sävert
- Helmholtz-Institut Jena, Fröbelstieg 3, 07743 Jena, Germany
- Friedrich-Schiller-Universität Jena, Max-Wien-Platz 1, 07743 Jena, Germany
| | - M Förster
- Friedrich-Schiller-Universität Jena, Max-Wien-Platz 1, 07743 Jena, Germany
| | - C Rödel
- Helmholtz-Institut Jena, Fröbelstieg 3, 07743 Jena, Germany
- Friedrich-Schiller-Universität Jena, Max-Wien-Platz 1, 07743 Jena, Germany
- SLAC National Accelerator Laboratory, 2575 Sand Hill Road, Menlo Park, California 94025, USA
| | - G G Paulus
- Helmholtz-Institut Jena, Fröbelstieg 3, 07743 Jena, Germany
- Friedrich-Schiller-Universität Jena, Max-Wien-Platz 1, 07743 Jena, Germany
| | - S Cousens
- Department of Physics and Astronomy, Queen's University Belfast, BT7 1NN, United Kingdom
| | - M Coughlan
- Department of Physics and Astronomy, Queen's University Belfast, BT7 1NN, United Kingdom
| | - B Dromey
- Department of Physics and Astronomy, Queen's University Belfast, BT7 1NN, United Kingdom
| | - M Zepf
- Helmholtz-Institut Jena, Fröbelstieg 3, 07743 Jena, Germany
- Friedrich-Schiller-Universität Jena, Max-Wien-Platz 1, 07743 Jena, Germany
- Department of Physics and Astronomy, Queen's University Belfast, BT7 1NN, United Kingdom
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8
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Bin JH, Ma WJ, Wang HY, Streeter MJV, Kreuzer C, Kiefer D, Yeung M, Cousens S, Foster PS, Dromey B, Yan XQ, Ramis R, Meyer-ter-Vehn J, Zepf M, Schreiber J. Ion Acceleration Using Relativistic Pulse Shaping in Near-Critical-Density Plasmas. Phys Rev Lett 2015; 115:064801. [PMID: 26296119 DOI: 10.1103/physrevlett.115.064801] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/01/2015] [Indexed: 06/04/2023]
Abstract
Ultraintense laser pulses with a few-cycle rising edge are ideally suited to accelerating ions from ultrathin foils, and achieving such pulses in practice represents a formidable challenge. We show that such pulses can be obtained using sufficiently strong and well-controlled relativistic nonlinearities in spatially well-defined near-critical-density plasmas. The resulting ultraintense pulses with an extremely steep rising edge give rise to significantly enhanced carbon ion energies consistent with a transition to radiation pressure acceleration.
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Affiliation(s)
- J H Bin
- Fakultät für Physik, Ludwig-Maximilians-Universität München, D-85748 Garching, Germany
- Max-Planck-Institute für Quantenoptik, D-85748 Garching, Germany
| | - W J Ma
- Fakultät für Physik, Ludwig-Maximilians-Universität München, D-85748 Garching, Germany
- State Key Laboratory of Nuclear Physics and Technology and Key Lab of High Energy Density Physics Simulation, CAPT, Peking University, Beijing 100871, People's Republic of China
| | - H Y Wang
- Fakultät für Physik, Ludwig-Maximilians-Universität München, D-85748 Garching, Germany
- Max-Planck-Institute für Quantenoptik, D-85748 Garching, Germany
- State Key Laboratory of Nuclear Physics and Technology and Key Lab of High Energy Density Physics Simulation, CAPT, Peking University, Beijing 100871, People's Republic of China
| | - M J V Streeter
- The John Adams Institute for Accelerator Science, Blackett Laboratory, Imperial College, London SW7 2AZ, United Kingdom
| | - C Kreuzer
- Fakultät für Physik, Ludwig-Maximilians-Universität München, D-85748 Garching, Germany
| | - D Kiefer
- Fakultät für Physik, Ludwig-Maximilians-Universität München, D-85748 Garching, Germany
| | - M Yeung
- Department of Physics and Astronomy, Centre for Plasma Physics, Queens University, Belfast BT7 1NN, United Kingdom
| | - S Cousens
- Department of Physics and Astronomy, Centre for Plasma Physics, Queens University, Belfast BT7 1NN, United Kingdom
| | - P S Foster
- Department of Physics and Astronomy, Centre for Plasma Physics, Queens University, Belfast BT7 1NN, United Kingdom
- Central Laser Facility, STFC Rutherford Appleton Laboratory, Chilton, Didcot, Oxon 0X11 0QX, United Kingdom
| | - B Dromey
- Department of Physics and Astronomy, Centre for Plasma Physics, Queens University, Belfast BT7 1NN, United Kingdom
| | - X Q Yan
- State Key Laboratory of Nuclear Physics and Technology and Key Lab of High Energy Density Physics Simulation, CAPT, Peking University, Beijing 100871, People's Republic of China
| | - R Ramis
- E.T.S.I Aeronáuticos, Universidad Politécnica de Madrid, E-28040 Madrid, Spain
| | - J Meyer-ter-Vehn
- Max-Planck-Institute für Quantenoptik, D-85748 Garching, Germany
| | - M Zepf
- Department of Physics and Astronomy, Centre for Plasma Physics, Queens University, Belfast BT7 1NN, United Kingdom
- Helmholtz-Institut-Jena, Fröbelstieg 3, 07743 Jena, Germany
| | - J Schreiber
- Fakultät für Physik, Ludwig-Maximilians-Universität München, D-85748 Garching, Germany
- Max-Planck-Institute für Quantenoptik, D-85748 Garching, Germany
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9
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Ma WJ, Bin JH, Wang HY, Yeung M, Kreuzer C, Streeter M, Foster PS, Cousens S, Kiefer D, Dromey B, Yan XQ, Meyer-ter-Vehn J, Zepf M, Schreiber J. Bright subcycle extreme ultraviolet bursts from a single dense relativistic electron sheet. Phys Rev Lett 2014; 113:235002. [PMID: 25526132 DOI: 10.1103/physrevlett.113.235002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Indexed: 06/04/2023]
Abstract
Double-foil targets separated by a low density plasma and irradiated by a petawatt-class laser are shown to be a copious source of coherent broadband radiation. Simulations show that a dense sheet of relativistic electrons is formed during the interaction of the laser with the tenuous plasma between the two foils. The coherent motion of the electron sheet as it transits the second foil results in strong broadband emission in the extreme ultraviolet, consistent with our experimental observations.
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Affiliation(s)
- W J Ma
- Fakultät für Physik, Ludwig-Maximilians-University, Am Coulombwall 1, D-85748 Garching, Germany
| | - J H Bin
- Fakultät für Physik, Ludwig-Maximilians-University, Am Coulombwall 1, D-85748 Garching, Germany and Max-Planck-Institute of Quantum Optics, Hans-Kopfermann-Strasse 1, D-85748 Garching, Germany
| | - H Y Wang
- Max-Planck-Institute of Quantum Optics, Hans-Kopfermann-Strasse 1, D-85748 Garching, Germany and State Key Laboratory of Nuclear Physics and Technology & Center of Applied Physics and Technology, Peking University, Beijing 100871, China
| | - M Yeung
- Department of Physics and Astronomy, Queen's University Belfast, Belfast BT7 1NN, United Kingdom and Helmholtz Institute Jena, 07743 Jena, Germany
| | - C Kreuzer
- Fakultät für Physik, Ludwig-Maximilians-University, Am Coulombwall 1, D-85748 Garching, Germany
| | - M Streeter
- Blackett Laboratory, Imperial College London, London SW7 2AZ, United Kingdom
| | - P S Foster
- Department of Physics and Astronomy, Queen's University Belfast, Belfast BT7 1NN, United Kingdom and Central Laser Facility, STFC Rutherford Appleton Laboratory, Chilton, Didcot OX11 0QX, United Kingdom
| | - S Cousens
- Department of Physics and Astronomy, Queen's University Belfast, Belfast BT7 1NN, United Kingdom
| | - D Kiefer
- Fakultät für Physik, Ludwig-Maximilians-University, Am Coulombwall 1, D-85748 Garching, Germany
| | - B Dromey
- Department of Physics and Astronomy, Queen's University Belfast, Belfast BT7 1NN, United Kingdom
| | - X Q Yan
- State Key Laboratory of Nuclear Physics and Technology & Center of Applied Physics and Technology, Peking University, Beijing 100871, China
| | - J Meyer-ter-Vehn
- Max-Planck-Institute of Quantum Optics, Hans-Kopfermann-Strasse 1, D-85748 Garching, Germany
| | - M Zepf
- Department of Physics and Astronomy, Queen's University Belfast, Belfast BT7 1NN, United Kingdom and Helmholtz Institute Jena, 07743 Jena, Germany
| | - J Schreiber
- Fakultät für Physik, Ludwig-Maximilians-University, Am Coulombwall 1, D-85748 Garching, Germany and Max-Planck-Institute of Quantum Optics, Hans-Kopfermann-Strasse 1, D-85748 Garching, Germany
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10
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Yeung M, Dromey B, Cousens S, Dzelzainis T, Kiefer D, Schreiber J, Bin JH, Ma W, Kreuzer C, Meyer-ter-Vehn J, Streeter MJV, Foster PS, Rykovanov S, Zepf M. Dependence of laser-driven coherent synchrotron emission efficiency on pulse ellipticity and implications for polarization gating. Phys Rev Lett 2014; 112:123902. [PMID: 24724650 DOI: 10.1103/physrevlett.112.123902] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/08/2013] [Indexed: 06/03/2023]
Abstract
The polarization dependence of laser-driven coherent synchrotron emission transmitted through thin foils is investigated experimentally. The harmonic generation process is seen to be almost completely suppressed for circular polarization opening up the possibility of producing isolated attosecond pulses via polarization gating. Particle-in-cell simulations suggest that current laser pulses are capable of generating isolated attosecond pulses with high pulse energies.
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Affiliation(s)
- M Yeung
- Department of Physics and Astronomy, Queen's University Belfast, Belfast BT7 1NN, United Kingdom
| | - B Dromey
- Department of Physics and Astronomy, Queen's University Belfast, Belfast BT7 1NN, United Kingdom
| | - S Cousens
- Department of Physics and Astronomy, Queen's University Belfast, Belfast BT7 1NN, United Kingdom
| | - T Dzelzainis
- Department of Physics and Astronomy, Queen's University Belfast, Belfast BT7 1NN, United Kingdom
| | - D Kiefer
- Max-Planck-Institut für Quantenoptik, Hans-Kopfermann-Straße 1, D-85748 Garching, Germany and Fakultät für Physik, Ludwig-Maximilians-Universität München, D-85748 Garching, Germany
| | - J Schreiber
- Max-Planck-Institut für Quantenoptik, Hans-Kopfermann-Straße 1, D-85748 Garching, Germany and Fakultät für Physik, Ludwig-Maximilians-Universität München, D-85748 Garching, Germany
| | - J H Bin
- Max-Planck-Institut für Quantenoptik, Hans-Kopfermann-Straße 1, D-85748 Garching, Germany and Fakultät für Physik, Ludwig-Maximilians-Universität München, D-85748 Garching, Germany
| | - W Ma
- Max-Planck-Institut für Quantenoptik, Hans-Kopfermann-Straße 1, D-85748 Garching, Germany and Fakultät für Physik, Ludwig-Maximilians-Universität München, D-85748 Garching, Germany
| | - C Kreuzer
- Fakultät für Physik, Ludwig-Maximilians-Universität München, D-85748 Garching, Germany
| | - J Meyer-ter-Vehn
- Max-Planck-Institut für Quantenoptik, Hans-Kopfermann-Straße 1, D-85748 Garching, Germany
| | - M J V Streeter
- Blackett Laboratory, Imperial College London, London SW7 2BZ, United Kingdom
| | - P S Foster
- Central Laser Facility, STFC Rutherford Appleton Laboratory, Chilton, Didcot OX11 0QX, United Kingdom
| | - S Rykovanov
- Fakultät für Physik, Ludwig-Maximilians-Universität München, D-85748 Garching, Germany
| | - M Zepf
- Department of Physics and Astronomy, Queen's University Belfast, Belfast BT7 1NN, United Kingdom and Helmholtz-Institut Jena, Fröbelstieg 3, 07743 Jena, Germany
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Lawn JE, Kinney MV, Black RE, Pitt C, Cousens S, Kerber K, Corbett E, Moran AC, Morrissey CS, Oestergaard MZ. Newborn survival: a multi-country analysis of a decade of change. Health Policy Plan 2013. [DOI: 10.1093/heapol/czt008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Meda N, Sarrassat S, Ouedraogo M, Head R, Cousens S, Murray J. Promotion de la santé de l’enfant au Burkina Faso : place des radios communautaires. Rev Epidemiol Sante Publique 2013. [DOI: 10.1016/j.respe.2013.07.409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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13
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Yeung M, Dromey B, Adams D, Cousens S, Hörlein R, Nomura Y, Tsakiris GD, Zepf M. Beaming of high-order harmonics generated from laser-plasma interactions. Phys Rev Lett 2013; 110:165002. [PMID: 23679609 DOI: 10.1103/physrevlett.110.165002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2012] [Indexed: 06/02/2023]
Abstract
Beam divergences of high-order extreme ultraviolet harmonics from intense laser interactions with steep plasma density gradients are studied through experiment and Fourier analysis of the harmonic spatial phase. We show that while emission due to the relativistically oscillating mirror mechanism can be explained by ponderomotive surface denting, in agreement with previous results, the divergence of the emission due to the coherent wake emission mechanism requires a combination of the dent phase and an intrinsic emission phase. The temporal dependence of the divergences for both mechanisms is highlighted while it is also shown that the coherent wake emission divergence can be small in circumstances where the phase terms compensate each other.
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Affiliation(s)
- M Yeung
- Department of Physics and Astronomy, Queen's University Belfast, BT7 1NN Belfast, United Kingdom
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14
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Abstract
Reducing neonatal mortality remains a challenge with an estimated 3.0 million neonatal deaths in 2011, three-quarters of these in sub-Saharan Africa and Southern Asia. The leading causes of neonatal death globally are complications of preterm birth, intrapartum-related causes and infections. While post-neonatal, under-5 deaths fell by 47% between 1990 and 2011, neonatal deaths only fell by 32% and they now account for 43% of all under-5 child deaths. This article reviews the progress in reducing neonatal deaths in high-burden countries and presents an overview of known effective interventions to reduce neonatal mortality and the challenges faced in implementing these in high-burden settings. Effective action is possible to reduce neonatal mortality, but innovative approaches to implementation will be required if these preventable deaths are to be avoided.
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Affiliation(s)
- H Blencowe
- London School of Hygiene and Tropical Medicine, London, UK.
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15
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Diallo AH, Meda N, Ouédraogo WT, Cousens S, Tylleskar T. A prospective study on neonatal mortality and its predictors in a rural area in Burkina Faso: can MDG-4 be met by 2015? J Perinatol 2011; 31:656-63. [PMID: 21372798 PMCID: PMC3183235 DOI: 10.1038/jp.2011.6] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To measure the neonatal mortality rate (NMR) and investigate its predictors in a rural area of Burkina Faso. STUDY DESIGN A cohort of infants born in 24 villages in Banfora region was followed until the children were 6 months old. We estimated the risk of neonatal death and used logistic regression to identify its predictors. RESULT Among 864 live births followed to day 28, there were 40 neonatal deaths, a NMR of 46.3 per 1000 live births (95% confidence intervals (CI): 22 to 70). Multivariable regression identified twin birth (OR=11.5, 95% CI: 4.5 to 29.8), having a nulliparous mother (odds ratio (OR)=4.3, 95% CI: 1.5 to 12.1), and birth into a polygynous household (OR=2.1, 95% CI: 1.0 to 4.7) as main predictors of neonatal death. CONCLUSION The burden of neonatal mortality in rural Burkina Faso is very high and the observed NMRs in a predominantly rural country suggest that it is unlikely Burkina will meet fourth Millennium Development Goal (MDG-4) by 2015.
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Affiliation(s)
- A H Diallo
- Centre MURAZ Research Institute, Ministry of Health/Burkina Faso, Bobo-Dioulasso, Burkina Faso.
| | - N Meda
- Centre MURAZ Research Institute, Ministry of Health/Burkina Faso, Bobo-Dioulasso, Burkina Faso
| | - W T Ouédraogo
- Centre MURAZ Research Institute, Ministry of Health/Burkina Faso, Bobo-Dioulasso, Burkina Faso
| | - S Cousens
- London School of Hygiene and Tropical Medicine, Infectious Diseases Epidemiology Unit (IDEU), London, United Kingdom
| | - T Tylleskar
- Centre for International Health (CIH), University of Bergen, Arstadveien 21, Bergen, Norway
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Gabrysch S, Cousens S, Cox J, Campbell O. O4-3.1 Distance and quality of care strongly influence choice of delivery place in rural Zambia: a study linking national data in a geographic information system. Br J Soc Med 2011. [DOI: 10.1136/jech.2011.142976b.19] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Gabrysch S, Cousens S, Cox J, Campbell O. The influence of distance and level of care on health facility delivery in rural Zambia: A study linking national data in a Geographic Information System. Gesundheitswesen 2010. [DOI: 10.1055/s-0030-1266179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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18
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Nebie I, Diarra A, Ouedraogo A, Tiono AB, Konate AT, Gansane A, Soulama I, Cousens S, Leroy O, Sirima SB. Humoral and cell-mediated immunity to MSP3 peptides in adults immunized with MSP3 in malaria endemic area, Burkina Faso. Parasite Immunol 2009; 31:474-80. [PMID: 19646212 PMCID: PMC2759983 DOI: 10.1111/j.1365-3024.2009.01130.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We performed a single-blind, randomized phase 1 trial of the long synthetic peptide (LSP) of merozoite surface protein-3 (MSP3) in adults living in Burkina Faso. Thirty eligible volunteers were randomized to receive either the MSP3-LSP candidate vaccine or tetanus toxoid vaccine as a control. A dose of each vaccine was administered on days 0, 28 and 112 and the vaccine was formulated with aluminium hydroxide. Humoral immune responses were assessed by ELISA at days 0, 28, 56, 112, 140, 252 and 365 and cell-mediated immune responses by lymphoproliferation assay and by ELISA on days 0, 56 and 140. IgG responses to four peptides of MSP3 were similar in both vaccine groups. Higher IgG concentrations were recorded after the beginning of malaria high transmission season in both vaccine groups. The lymphocyte proliferation and the production of IFN-γ in response to stimulation with the four overlapping peptides increased following vaccination in the MSP3-LSP vaccine group, but did not change appreciably in the control group. In contrast to natural infection, MSP3-LSP did not boost humoral responses to the four overlapping peptides of MSP3 to any detectable degree in our semi-immune adult. MSP3-LSP may be more immunogenic in young children with little or no acquired immunity.
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Affiliation(s)
- I Nebie
- Centre National de Recherche et de Formation sur le Paludisme, Ouagadougou, Burkina Faso, West Africa.
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Cousens S, Hargreaves J, Bonell C, Armstrong B, Thomas J, Kirkwood BR, Hayes R. Alternatives to randomisation in the evaluation of public-health interventions: statistical analysis and causal inference. J Epidemiol Community Health 2009; 65:576-81. [PMID: 19666633 DOI: 10.1136/jech.2008.082610] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND In non-randomised evaluations of public-health interventions, statistical methods to control confounding will usually be required. We review approaches to the control of confounding and discuss issues in drawing causal inference from these studies. METHODS Non-systematic review of literature and mathematical data-simulation. RESULTS Standard stratification and regression techniques will often be appropriate, but propensity scores may be useful where many confounders need to be controlled, and data are limited. All these techniques require that key putative confounders are measured accurately. Instrumental variables offer, in theory, a solution to the problem of unknown or unmeasured confounders, but identifying an instrument which meets the required conditions will often be challenging. Obtaining measurements of the outcome variable in both intervention and control groups before the intervention is introduced allows balance to be assessed, and these data may be used to help control confounding. However, imbalance in outcome measures at baseline poses challenges for the analysis and interpretation of the evaluation, highlighting the value of adopting a design strategy that maximises the likelihood of achieving balance. Finally, when it is not possible to have any concurrent control group, making multiple measures of outcome pre- and postintervention can enable the estimation of intervention effects with appropriate statistical models. CONCLUSION For non-randomised designs, careful statistical analysis can help reduce bias by confounding in estimating intervention effects. However, investigators must report their methods thoroughly and be conscious and critical of the assumptions they must make whenever they adopt these designs.
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Affiliation(s)
- S Cousens
- Infectious Disease Epidemiology Unit, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK.
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Bonell CP, Hargreaves J, Cousens S, Ross D, Hayes R, Petticrew M, Kirkwood BR. Alternatives to randomisation in the evaluation of public health interventions: design challenges and solutions. J Epidemiol Community Health 2009; 65:582-7. [PMID: 19213758 DOI: 10.1136/jech.2008.082602] [Citation(s) in RCA: 131] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND There has been a recent increase in interest in alternatives to randomisation in the evaluation of public health interventions. We aim to describe specific scenarios in which randomised trials may not be possible and describe, exemplify and assess alternative strategies. METHODS Non-systematic exploratory review. RESULTS In many scenarios barriers are surmountable so that randomised trials (including stepped-wedge and crossover trials) are possible. It is possible to rank alternative designs but context will also determine which choices are preferable. Evidence from non-randomised designs is more convincing when confounders are well-understood, measured and controlled; there is evidence for causal pathways linking intervention and outcomes and/or against other pathways explaining outcomes; and effect sizes are large. CONCLUSION Non-randomised trials might provide adequate evidence to inform decisions when interventions are demonstrably feasible and acceptable, and where evidence suggests there is little potential for harm, but caution that such designs may not provide adequate evidence when intervention feasibility or acceptability is doubtful, and where existing evidence suggests benefits may be marginal and/or harms possible.
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Affiliation(s)
- C P Bonell
- Public and Environmental Health Research Unit, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK.
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Nebie I, Tiono AB, Diallo DA, Samandoulougou S, Diarra A, Konate AT, Cuzin-Ouattara N, Theisen M, Corradin G, Cousens S, Ouattara AS, Ilboudo-Sanogo E, Sirima BS. Do antibody responses to malaria vaccine candidates influenced by the level of malaria transmission protect from malaria? Trop Med Int Health 2008; 13:229-37. [PMID: 18304269 DOI: 10.1111/j.1365-3156.2007.01994.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To examine whether the humoural response to malaria vaccine candidate antigens, Plasmodium falciparum [circumsporozoite repetitive sequence (NANP)(5) GLURP fragments (R0 and R2) and MSP3] varies with the level of malaria transmission and to determine whether the antibodies (IgG) present at the beginning of the malaria transmission season protect against clinical malaria. METHODS Cross-sectional surveys were conducted to measure antibody response before, at the peak and at the end of the transmission season in children aged 6 months to 10 years in two villages with different levels of malaria transmission. A cohort study was performed to estimate the incidence of clinical malaria. RESULTS Antibodies to these antigens showed different seasonal patterns. IgG concentrations to any of the four antigens were higher in the village with high entomological inoculation rate. Multivariate analysis of combined data from the two villages indicated that children who were classified as responders to the selected antigens were at lower risk of clinical malaria than children classified as non-responders [(NANP)(5) (incidence rate ratio (IRR) = 0.65, 95% CI: 0.46-0.92; P = 0.016), R0 (IRR = 0.69, 95% CI: 0.48-0.97; P = 0.032), R2 (IRR = 0.73, 95% CI: 0.50-1.06; P = 0.09), MSP3 (IRR = 0.52, 95% CI: 0.32-0.85; P = 0.009)]. Fitting a model with all four antibody responses showed that MSP3 looked the best malaria vaccine candidate (IRR = 0.63; 95% CI: 0.38-1.05; P = 0.08). CONCLUSION Antibody levels to the four antigens are affected by the intensity of malaria transmission and associated with protection against clinical malaria. It is worthwhile investing in the development of these antigens as potential malaria vaccine candidates.
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Affiliation(s)
- I Nebie
- Centre National de Recherche et de Formation sur le paludisme, Ouagadougou, Burkina Faso.
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Scott S, Moss WJ, Cousens S, Beeler JA, Audet UA, Mugala N, Quinn TC, Griffin DE, Cutts FT. The Influence of HIV-1 Exposure and Infection on Levels of Passively Acquired Antibodies to Measles Virus in Zambian Infants. Clin Infect Dis 2007; 45:1417-24. [DOI: 10.1086/522989] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2007] [Accepted: 08/05/2007] [Indexed: 11/03/2022] Open
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Sidibé T, Sangho H, Doumbia S, Sylla M, Keita M, Tékété I, Cousens S, Keita D, Keita HD, Keita AS, Belemou B, Diakité B. [Knowledge, attitude and practices (KAP) of community health center staff on birth asphyxia in Kolokani (Mali)]. Mali Med 2007; 22:9-14. [PMID: 19434987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Most newborn deaths are associated with birth asphyxia (40%), low birth weigt and prematurity (25%) and infections (20%). In Mali, in the Community Health Centers (CSCOM) exercises a staff composed of the nurse chief of health centers (ICPM) assuring the supervision of the matrons that is charged in pregnancy and the newborn. An investigation KAP (Knowledge, Attitudes and Practises) initiated in order to assess the knowledge and the practices of the community health centers agents on birth asphyxia. The survey was cross-sectional and that took place in September 2004. Have been included in the study the matrons, the nurse chief available at the time of the survey. The multiplicity of the names mentioned among which Ninakili dégou (27,3%) and Niominè (15,2%) are the most frequent and show the necessity of a qualitative investigation to find a name. Prolonged labor more than 12 hours (73,3%) and the stained amniotic liquid (63,3%) are the most recognized signs during labor making fear the birth asphyxia. In our survey the prolonged labor (63,7%), the infection/malaria of mother (60,7%) and the Dystocic delivery (45,5%) were the mostly reported causes of birth asphyxia. The pale or bluish coloration (69,7%), the irregular or lack of breath (69,7%), the lack of cry (63,6%) were known as the main signs of birth asphyxia. We noted some good practices as aspirating with a bulb (69,7%) and clearing upper ways with a finger covered with gauze (30,3% ); doing the mouth to mouth (51,5%); stimulating the newborn (66,7%). The improvement of the neontatal mortality requires the training of the staff and the equipment of the centers in small simple materials of resuscitation.
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Affiliation(s)
- T Sidibé
- Centre de Recherche d'Etudes et de Documentation pour la Survie de l'Enfant (CREDOS), BP E 5675.
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Abstract
PURPOSE To assess the effect of an intervention comprising training in optic disc assessment, explicit referral criteria and ophthalmologist feedback on referred patients, on the number of optometrist referrals for suspected glaucoma seen at a referral site and the positive predictive value of those referrals. METHODS Optometric practices routinely referring to the Ealing Hospital Eye Clinic were randomly divided into two groups taking into consideration those practices, which shared an optometrist (a cluster) and the number of optometrist days worked per week. One group of practices acted as controls, while the other practices were invited to receive the intervention. Data on 397 new patients referred and presenting to Ealing Hospital with suspected glaucoma were collected over a 20-month period. The data on patients who had failed to attend their appointment were collected over 7 months of this period. The number of referrals seen, the positive predictive value of those referrals, and the attendance rate were calculated. Optometrist's opinions of the intervention were assessed qualitatively. Data relating to optometrist compliance with the intervention were also collected. RESULTS The number of glaucoma referrals presenting to Ealing Hospital from the intervention practices was almost double that from the control practices (210 vs 119). When cluster randomisation, the number of optometrist days per cluster and the number of assessed referrals in the preintervention period are taken into consideration, it is estimated that the intervention is associated with a 52% increase in the number of referrals reaching Ealing Hospital. However, the design effect resulting from the cluster randomisation was unexpectedly high (of the order of 13-14)and so the confidence intervals around the estimate of 52% are very wide (95% c.i. 35% decrease to 253% increase, P = 0.34). There was no evidence of an association between optometrist compliance with the intervention and the number of referrals seen at Ealing Hospital. The positive predictive value (PPV)of referrals was similar for the intervention(0.49 (95% c.i. 0.42, 0.55)) and control groups(0.46 (95% c.i. 0.33, 0.60)). Optometrist opinions of the intervention were largely favourable. All expressed a willingness to participate in future programmes. CONCLUSION A large difference in the number of referrals between the practice groups was observed. Since the PPV of referral was unchanged, the potential impact of the intervention in terms of numbers of new cases of glaucoma detected in the community is substantial. However, because of its large design effect, this trial does not provide conclusive evidence of an impact of the intervention on referral numbers. A considerably larger trial will be required to produce conclusive evidence of an effect.
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Affiliation(s)
- J Theodossiades
- Department of Epidemiology and International Eye Health, Institute of Ophthalmology, and Moorfields Eye Hospital, London, UK.
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Abstract
BACKGROUND Variant Creutzfeldt-Jakob disease (vCJD) is a novel human prion disease caused by infection with the agent of bovine spongiform encephalopathy (BSE). Epidemiological evidence does not suggest that sporadic CJD is transmitted from person to person via blood transfusion, but this evidence may not apply to vCJD. We aimed to identify whether vCJD is transmissible through blood transfusion. METHODS The national CJD surveillance unit reported all cases of probable or definite vCJD to the UK blood services, which searched for donation records at blood centres and hospitals. Information on named recipients and donors was provided to the surveillance unit to establish if any matches existed between recipients or donors and the database of cases of vCJD. Recipients were also flagged at the UK Office of National Statistics to establish date and cause of death. FINDINGS 48 individuals were identified as having received a labile blood component from a total of 15 donors who later became vCJD cases and appeared on the surveillance unit's register. One of these recipients was identified as developing symptoms of vCJD 6.5 years after receiving a transfusion of red cells donated by an individual 3.5 years before the donor developed symptoms of vCJD. INTERPRETATION Our findings raise the possibility that this infection was transfusion transmitted. Infection in the recipient could have been due to past dietary exposure to the BSE agent. However, the age of the patient was well beyond that of most vCJD cases, and the chance of observing a case of vCJD in a recipient in the absence of transfusion transmitted infection is about 1 in 15000 to 1 in 30000.
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Affiliation(s)
- C A Llewelyn
- National Blood Service, Cambridge Centre, Cambridge CB2 2PT, UK
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Abstract
Current best practice for primary open-angle glaucoma case-finding comprises history-taking, disc examination, intraocular pressure measurement and suprathreshold visual field analysis (SVFA). An alternative case-finding technique was formulated replacing SVFA with computerised quantitative disc assessment, using the Heidelberg retinal tomograph II (HRT II). Each approach was adopted by four optometrists who screened 29 POAG and 37 normal patients. Average sensitivities and specificities were similar in the two groups [sensitivity 71% (SVFA) vs 69% (HRT II); specificity 94% both groups]. Our inclusion of pre-perimetric glaucoma cases limited the sensitivity of the optometrists in this study. There was evidence to suggest that the optometrists tended to miss early changes at the optic disc such as disc haemorrhage, nerve fibre layer defects and subtle neuroretinal thinning.
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Affiliation(s)
- A Ieong
- Moorfields Eye Hospital, City Road, London, UK.
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27
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Abstract
BACKGROUND Traditionally, blindness surveys have modelled themselves on the "gold standard" of a census and examination of a whole population. Blindness, however, is a relatively rare condition even in badly affected communities; hence, large sample sizes are required to gain adequate estimates of prevalence, particularly by cause. METHODS Three assessments of blindness prevalence and aetiology in the same communities are reported. One involved asking individuals questions concerning their visual status during a census (perceived visual status, PVD), one involved examination of all ostensibly visually disabled people presenting to a central point within each community (examination of the visually disabled, EVD), and the final assessment involved a gold standard examination of the whole population (whole community examination, WCE). RESULTS In a population of 8139 the blindness prevalence was 2.7% PVS, 3.6% EVD, and 3.1% WCE. Attributed causes of blindness were not representative in the PVS except for cataract. The END yielded cause specific estimates not far from those found at WE except for a relative under-representation of glaucoma and optic atrophy. CONCLUSION Since cataract is, by a significant margin, the most common cause of blindness in the world such a simple method as asking individuals if they are blind and what they believe to be the cause may yield adequate estimates of the problem for planning eye care strategies for this condition. Alternatively, an ophthalmologist visiting villages and examining allcomers for visual disability may provide reasonably accurate cause specific prevalence estimates without the expense of a major blindness survey.
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Yang YF, Cousens S, Murdoch IE, Babalola OE, Abiose A, Jones B. Intraocular pressure and gonioscopic findings in rural communities mesoendemic and nonendemic for onchoceriasis, Kaduna State, Nigeria. Eye (Lond) 2001; 15:756-9. [PMID: 11826997 DOI: 10.1038/eye.2001.244] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE To report on glaucoma-related ocular parameters, namely intraocular pressure and peripheral anterior synechiae, in the presence of onchocercal infection. METHODS Two computer-generated random samples of individuals were drawn from communities mesoendemic and nonendemic for onchocerciasis respectively. Applanation tonometry and gonioscopy were carried out on these individuals. RESULTS Four hundred and thirty-six and 319 individuals from the mesoendemic and nonendemic communities were examined respectively. The mean intraocular pressure was 1.58 mmHg lower in the individuals from the mesoendemic communities compared with those from the nonendemic communities (p < 0.001) despite the prevalence of peripheral anterior synechiae being higher in the mesoendemic communities. In these communities, there was strong evidence that the prevalence of peripheral anterior synechiae increased with increasing microfilarial load. CONCLUSIONS Onchocercal infection produces a low-grade inflammatory process, which may result in a lowering of intraocular pressure despite the formation of peripheral anterior synechiae. Glaucomatous optic nerve damage may therefore not be the primary cause of visual loss in ocular onchocerciasis as this occurs late and is probably preceded by other blinding onchocercal pathology.
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Affiliation(s)
- Y F Yang
- Moorfields Eye Hospital, London, UK.
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Cousens S, Smith PG, Ward H, Everington D, Knight RS, Zeidler M, Stewart G, Smith-Bathgate EA, Macleod MA, Mackenzie J, Will RG. Geographical distribution of variant Creutzfeldt-Jakob disease in Great Britain, 1994-2000. Lancet 2001; 357:1002-7. [PMID: 11293592 DOI: 10.1016/s0140-6736(00)04236-7] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
BACKGROUND Geographical variation in the distribution of variant Creutzfeldt-Jakob disease (vCJD) might indicate the transmission route of the infectious agent to man. We investigated whether regional incidences of vCJD were correlated with regional dietary data. METHODS The National CJD Surveillance Unit prospectively identified 84 people with vCJD up to Nov 10, 2000, in Great Britain. Their lifetime residential histories were obtained by interviews with a close relative. Cumulative incidences of vCJD by standard region were calculated. Grid references for places of residence in 1991 were identified and evidence of geographical clusters were sought. Data on diet in the 1980s were analysed for regional correlations with vCJD incidence. The socioeconomic status of the places of residence of people with vCJD was compared with that of the general population. FINDINGS vCJD incidence was higher in the north of Great Britain than the south. The rate ratio (north vs south) was 1.94 (95% CI 1.27-2.98). The mean Carstairs' deprivation score for areas of residence of people with vCJD was -0.09 (-0.73 to 0.55), which is close to the national average of zero. Regional rates of vCJD were correlated with consumption of other meat or meat products as classified and recorded by the Household Food Consumption and Expenditure Survey (r=0.72), but not with data from the Dietary and Nutritional Survey of British Adults. Five people with vCJD in Leicestershire formed a cluster (p=0.004). INTERPRETATION Regional differences in vCJD incidence are unlikely to be due to ascertainment bias. We had difficulty determining whether regional variations in diet might cause these differences, since the results of dietary analyses were inconsistent.
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Affiliation(s)
- S Cousens
- Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, UK.
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Curtis V, Kanki B, Cousens S, Diallo I, Kpozehouen A, Sangaré M, Nikiema M. Evidence of behaviour change following a hygiene promotion programme in Burkina Faso. Bull World Health Organ 2001; 79:518-27. [PMID: 11436473 PMCID: PMC2566434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2023] Open
Abstract
OBJECTIVES To determine whether a large, 3-year hygiene promotion programme in Bobo-Dioulasso, Burkina Faso, was effective in changing behaviours associated with the spread of diarrhoeal diseases. The programme was tailored to local customs, targeted specific types of behaviour, built on existing motivation for hygiene, and used locally appropriate channels of communication. METHODS Two population surveys recorded the coverage of the programme among target audiences (mothers of children aged 0-35 months). Four surveys were carried out: three prior to the programme and one in 1998 (after the programme had been running for 3 years), using structured observation of hygiene behaviours in the participants' homes to document changes in target behaviours. FINDINGS After the programme had run for 3 years, three-quarters of the mothers targeted had had contact with programme activities. Half could cite the two main messages of the programme correctly. Although the safe disposal of children's stools changed little between 1995 and 1998 (80% pre-intervention, 84% post-intervention), hand-washing with soap after cleaning a child's bottom rose from 13% to 31%. The proportion of mothers who washed their hands with soap after using the latrine increased from 1% to 17%. CONCLUSION Hygiene promotion programmes can change behaviour and are more likely to be effective if they are built on local research and use locally appropriate channels of communication repeatedly and for an extended time.
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Affiliation(s)
- V Curtis
- Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, England.
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Fraser-Hurt N, Bailey RL, Cousens S, Mabey D, Faal H, Mabey DC. Efficacy of oral azithromycin versus topical tetracycline in mass treatment of endemic trachoma. Bull World Health Organ 2001; 79:632-40. [PMID: 11477966 PMCID: PMC2566466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2023] Open
Abstract
OBJECTIVE To compare the impact of mass treatment with oral azithromycin and topical tetracycline on the prevalence of active trachoma. METHODS A total of 1803 inhabitants from 106 households of eight Gambian villages were randomized, in pairs, to receive either three doses of azithromycin at weekly intervals, or daily topical tetracycline over 6 weeks. Ocular examinations were conducted before treatment, and 2, 6 and 12 months after treatment. FINDINGS Prior to treatment, 16% of the study participants had active trachoma. Two months after treatment, the prevalence of trachoma was 4.6% and 5.1% in the azithromycin and the tetracycline groups, respectively (adjusted odds ratio (OR) = 1.09; 95% confidence interval (CI) = 0.53, 2.02). Subsequently, the prevalence rose to 16% in the tetracycline group, while remaining at 7.7% in the azithromycin group (adjusted OR at 12 months = 0.52; 95% CI = 0.34, 0.80). At 12 months post-treatment, there were fewer new prevalent cases in the azithromycin group, and trachoma resolution was significantly better for this group (adjusted OR = 2.02; 95% CI = 1.42, 3.50). CONCLUSION Oral azithromycin therefore appears to offer a means for controlling blinding trachoma. It is easy to administer and higher coverages may be possible than have been achieved hitherto.
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Affiliation(s)
- N Fraser-Hurt
- Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine (LSHTM), London, England
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Zeidler M, Sellar RJ, Collie DA, Knight R, Stewart G, Macleod MA, Ironside JW, Cousens S, Colchester AC, Hadley DM, Will RG, Colchester AF. The pulvinar sign on magnetic resonance imaging in variant Creutzfeldt-Jakob disease. Lancet 2000; 355:1412-8. [PMID: 10791525 DOI: 10.1016/s0140-6736(00)02140-1] [Citation(s) in RCA: 237] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND There is a need for an accurate non-invasive diagnostic test for variant Creutzfeldt-Jakob disease (vCJD). We investigated the sensitivity and specificity of bilateral pulvinar high signal on magnetic resonance imaging (MRI) for the diagnosis of vCJD. METHODS MRI from patients with vCJD and controls (patients with suspected CJD) were analysed. Scans were reviewed on two separate occasions by two neuroradiologists and scored for the distribution of changes, and likely final diagnosis. Scans from vCJD cases were reassessed to reach a consensus on all abnormalities. FINDINGS We analysed 36 patients and 57 controls. vCJD patients were correctly identified based on bilateral pulvinar high signal in 29 of 36 and 32 of 36 cases on the first assessment by the two radiologists, and 32 of 36 and 31 of 36 on their second assessment. Bilateral increased pulvinar signal was identified in one of 57 and one of 57 controls on the first assessment and two of 57 and three of 57 controls on the second assessment. These reported changes in controls were graded as minimal/equivocal in six of seven patients and moderate in one (<0.5% of all control assessments). 80% of the assessments in vCJD cases were graded as moderate or substantial. On consensus review, 28 of 36 cases and none of 57 controls had prominent bilateral pulvinar signal-sensitivity 78% (95% CI 60-90%) and specificity 100% (95% CI 94-100%). Other common MRI features of vCJD were medial thalamic and periaqueductal grey matter high signal, and the notable absence of cerebral atrophy. Pulvinar high signal correlated with histological gliosis. INTERPRETATION In the appropriate clinical context the MRI identification of bilaterally increased pulvinar signal is a useful non-invasive test for the diagnosis of vCJD.
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Affiliation(s)
- M Zeidler
- National Creutzfeldt-Jakob Disease Surveillance Unit, Western General Hospital, Edinburgh, UK.
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Hayes R, Alexander N, Bennett S, Cousens S. Design and analysis issues in cluster-randomized trials of interventions against infectious diseases. Stat Methods Med Res 2000. [DOI: 10.1191/096228000670953670] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Fox NC, Cousens S, Scahill R, Harvey RJ, Rossor MN. Using serial registered brain magnetic resonance imaging to measure disease progression in Alzheimer disease: power calculations and estimates of sample size to detect treatment effects. Arch Neurol 2000; 57:339-44. [PMID: 10714659 DOI: 10.1001/archneur.57.3.339] [Citation(s) in RCA: 278] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVE To evaluate the rate of brain atrophy calculated from serial magnetic resonance imaging (MRI) registration as a surrogate marker of disease progression for use in clinical trials in Alzheimer disease (AD). METHODS Eighteen patients with mild to moderate AD and 18 age-matched normal controls underwent 2 MRI brain scans separated by a 12-month interval. Each individual's later scan was registered to their first scan, and the volume of cerebral tissue loss calculated directly from the registered and subtracted MRI scan pairs. The mean and SD of the rate of brain volume changes were used to estimate the sample sizes that would be needed in a clinical trial with a drug anticipated to modify disease progression by varying degrees. Comparable sample size estimates were performed with data for other methods of monitoring rates of brain atrophy, extracted from published papers. RESULTS The mean (SD) rate of brain atrophy for the patients with AD was 2.37% (1.11%) per year, while in the control group it was 0.41% (0.47%) per year. Based on these figures, to have 90% power to detect a drug effect equivalent to a 20% reduction in the rate of atrophy, 207 patients would be needed in each treatment arm. This assumes a 1-year placebo-controlled trial with a 10% patient dropout rate, and that 10% of scan pairs are unusable. CONCLUSION Registration of serial MRI volume images provides a powerful method of quantification of brain atrophy that can be used to monitor progression of AD in clinical trials.
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Affiliation(s)
- N C Fox
- Department of Clinical Neurology, Institute of Neurology, London, England
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Meda HA, Diallo B, Buchet JP, Lison D, Barennes H, Ouangré A, Sanou M, Cousens S, Tall F, Van de Perre P. Epidemic of fatal encephalopathy in preschool children in Burkina Faso and consumption of unripe ackee (Blighia sapida) fruit. Lancet 1999; 353:536-40. [PMID: 10028981 DOI: 10.1016/s0140-6736(99)01088-0] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND On March 21, 1998, the Regional Health Authority of Bobo-Dioulasso, Burkina Faso, asked the Centre Muraz to investigate an unexplained outbreak of epidemic fatal encephalopathy (EFE). We aimed to identify the cause of this epidemic. METHODS We identified cases retrospectively through review of health-service records and interviews of family members, village chiefs, and local healers. Active surveillance was started in administrative divisions within the study area in April, 1998, to identify further EFE cases. We did a case-control study of households to investigate the risk from various environmental and health factors. Blood and urine samples were collected if possible and urine dicarboxylic acid concentrations measured by gas chromatography. FINDINGS 29 cases of EFE were identified from January to May, 1998. Estimated age-specific attack rates (2-6 years) ranged from 31 to 847 per 100,000 population (p<0.001). The most common symptoms were hypotonia, vomiting, convulsions, and coma. All children died in 2-48 h. The only factor associated with EFE was the presence of ackee trees (Blighia sapida) within 100 m of households (odds ratio 5.1 [95% CI 1.8-14.7] p=0.001). Poisoning with unripe ackee fruits was suggested by urine concentrations of dicarboxylic acids four to 200 times higher in cases (n=2) than in controls (n=3). CONCLUSION Consumption of unripe ackee fruit probably caused this epidemic and may lead to a substantial number of unexplained deaths in preschool children in west Africa every year. Educational campaigns have the potential to prevent these deaths.
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Affiliation(s)
- H A Meda
- Centre Muraz/OCCGE, Bobo-Dioulasso, Burkina Faso.
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Meda N, Dao Y, Touré B, Yameogo B, Cousens S, Graham W. [Assessing severe maternal anemia and its consequences: the value of a simple examination of the coloration of palpebral conjunctiva]. Sante 1999; 9:12-7. [PMID: 10210797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
The aims of this study were: (1) to investigate the relationship between pre-delivery hemoglobin (Hb) concentration and the outcome of the pregnancy for the mother and child and (2) to assess the extent to which the pallor of the conjunctiva indicates severe anemia in pregnancy (Hb < 7 g/dl). We carried out a prospective study in 1995, in the maternity department of the National Sourô Sanou Hospital (Bobo-Dioulasso, Burkina Faso). Women arriving to give birth at the maternity unit gave verbal consent and underwent a physical examination including the assessment of conjunctiva coloration. Finger-prick blood samples were taken from all the women selected and Hb was determined with a portable hemoglobin meter (HemoCue AB, Sweden). For each woman, information about age, obstetric history, the condition of mother and child at admission and delivery and any post-delivery complications in the first 48 hours was collected before discharge from the maternity unit, 3 to 5 days after the delivery. Women with multiple pregnancies were excluded from the study and 247 women were included overall. Endometriosis was observed in only three cases. Three women died, two due to septic shock. The third woman died from hypovolemic shock. The Hb concentrations of these women were 8 g/dl, 10.2 g/dl and 2.6 g/dl respectively. The mean Hb concentration for our population was 10.1 g/dl (SD = 2.08), with 165 women (67%) having less than 11 g Hb/dl. Forty-one women (17%) had less than 9 g Hb/dl and 16 (6%) had less than 7 g Hb/dl. Severe maternal anemia and pallor of the conjunctiva were significantly associated with pre-term delivery and perinatal death, but not with low birth weight. The sensitivity of the pallor of the conjunctiva for detection of severe maternal anemia was 87%, and its specificity was 88%. We found no evidence that maternal Hb levels of 9 to 10.9 g/dl were associated with a high risk of poor pregnancy outcome for either the mother or the child, although women with such levels of Hb are classed as anemic by the World Health Organization criteria. These results show that poor pregnancy outcome is associated with severe maternal anemia. Examination of the coloration of the conjunctiva is a suitable and affordable screening method for the detection of severe anemia. Mothers with severe anemia present with signs and symptoms of anemia and could therefore be given iron treatment to improve their health. This demonstrates the importance of nutritional intervention during pregnancy.
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Affiliation(s)
- N Meda
- Centre MURAZ, OCCGE, 01 BP 153 Bobo-Dioulasso 01, Burkina Faso
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Manun'Ebo M, Cousens S, Haggerty P, Kalengaie M, Ashworth A, Kirkwood B. Measuring hygiene practices: a comparison of questionnaires with direct observations in rural Zaïre. Trop Med Int Health 1997; 2:1015-21. [PMID: 9391503 DOI: 10.1046/j.1365-3156.1997.d01-180.x] [Citation(s) in RCA: 137] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
To date questionnaire surveys have been the most commonly used instruments to measure hygiene behaviours related to water and sanitation. More recently, a number of studies have used structured observations to study practices related to diarrhoea. During a trial of a hygiene education intervention to reduce diarrhoea among young children in Bandundu, Zaire, both instruments were used to measure the disposal of child faeces and various hand-washing practices. Three hundred families were observed and follow-up interviews performed with 274 (91%) mothers. At the individual level, agreement between observed and reported behaviour was little better than might be expected by chance. There was evidence of over-reporting of hand-washing before food preparation (44% vs 33%; P = 0.03), hand-washing before eating (76% vs 60%; P < 0.001) and disposal of the child's faeces in a latrine (75% vs 40%; P < 0.001). On the other hand, hand-washing before feeding the child was reported less often than it was observed (7% vs 64%; P < 0.001). Our data are consistent with the hypothesis that, in general, mothers over-report 'desirable' behaviours. At the same time, our data indicate that open questions may lead to under-reporting of certain behaviours. The repeatability of observations at both the individual and population levels remains to be established.
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Affiliation(s)
- M Manun'Ebo
- Maternal and Child Epidemiology Unit, London School of Hygiene and Tropical Medicine, UK
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Bruce ME, Will RG, Ironside JW, McConnell I, Drummond D, Suttie A, McCardle L, Chree A, Hope J, Birkett C, Cousens S, Fraser H, Bostock CJ. Transmissions to mice indicate that 'new variant' CJD is caused by the BSE agent. Nature 1997; 389:498-501. [PMID: 9333239 DOI: 10.1038/39057] [Citation(s) in RCA: 1304] [Impact Index Per Article: 48.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
There are many strains of the agents that cause transmissible spongiform encephalopathies (TSEs) or 'prion' diseases. These strains are distinguishable by their disease characteristics in experimentally infected animals, in particular the incubation periods and neuropathology they produce in panels of inbred mouse strains. We have shown that the strain of agent from cattle affected by bovine spongiform encephalopathy (BSE) produces a characteristic pattern of disease in mice that is retained after experimental passage through a variety of intermediate species. This BSE 'signature' has also been identified in transmissions to mice of TSEs of domestic cats and two exotic species of ruminant, providing the first direct evidence for the accidental spread of a TSE between species. Twenty cases of a clinically and pathologically atypical form of Creutzfeldt-Jakob disease (CJD), referred to as 'new variant' CJD (vCJD), have been recognized in unusually young people in the United Kingdom, and a further case has been reported in France. This has raised serious concerns that BSE may have spread to humans, putatively by dietary exposure. Here we report the interim results of transmissions of sporadic CJD and vCJD to mice. Our data provide strong evidence that the same agent strain is involved in both BSE and vCJD.
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Affiliation(s)
- M E Bruce
- Institute for Animal Health, BBSRC/MRC Neuropathogenesis Unit, Edinburgh, UK.
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Pagnoni F, Convelbo N, Tiendrebeogo J, Cousens S, Esposito F. A community-based programme to provide prompt and adequate treatment of presumptive malaria in children. Trans R Soc Trop Med Hyg 1997; 91:512-7. [PMID: 9463653 DOI: 10.1016/s0035-9203(97)90006-7] [Citation(s) in RCA: 93] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
A community-based programme to ensure prompt and adequate treatment of presumptive episodes of clinical malaria in children has been established in a rural province of Burkina Faso. The implementation strategy was based on training a core group of mothers in every village and supplying community health workers with essential antimalarial drugs specially packed in age-specific bags containing a full course of treatment. Drugs were sold under a cost-recovery scheme. The programme was run in 1994 by the national malaria control centre (CNLP), and in 1995 it was developed to the provincial health team (PHT). Knowledge and awareness of malaria increased with the intervention. Drug consumption by age group was compatible with the distribution of disease, and no major problem of misuse emerged. The actual implementation costs of the intervention were US$ 0.06 per child living in the province. An evaluation of the impact of the intervention on the severity of malaria, using routine data from the health information system and taking as an indicator the proportion of malaria cases which were recorded as severe in health centres, was performed. In 1994, when the intervention was implemented on a provincial scale by CNLP, this proportion was lower than the average of the 4 preceding years (3.7% vs. 4.9%). In 1995, when the programme was implemented by the PHT, the proportion of severe cases was lower in health centres achieving a programme coverage of > or = 50% in their catchment area compared with the others (4.2% vs. 6.1%). Our experience shows that a low-cost, community-based intervention aimed at providing children with prompt and adequate treatment of presumptive episodes of clinical malaria is feasible, and suggests that it may lead to a reduction in the morbidity from severe malaria.
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Affiliation(s)
- F Pagnoni
- Centre National de Lutte contre le Paludisme, Ministère de la Santé, Burkina Faso
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Abstract
Investment in the promotion of better hygiene for the prevention of diarrhoeal diseases and as a component of water and sanitation programmes is increasing. Before designing programmes capable of sustainably modifying hygiene behaviour in large populations, valid answers to a number of basic questions concerning the site and the intended beneficiaries have to be obtained. Such questions include 'what practices favour the transmission of enteric pathogens?', 'what advantages will be perceived by those who adopt safe practices?' and 'what channels of communication are currently employed by the target population?' A study of hygiene and diarrhoea in Bobo-Dioulasso, Burkina Faso, used a mixture of methods to address such questions. This paper draws on that experience to propose a plan of preliminary research using a variety of techniques which could be implemented over a period of a few months by planners of hygiene promotion programmes. The techniques discussed include structured observation, focus group discussions and behavioural trials. Modest investment in such systematic formative research with clear and limited goals is likely to be repaid many times over in the increased effectiveness of hygiene promotion programmes.
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Affiliation(s)
- V Curtis
- Maternal and Child Epidemiology Unit, London School of Hygiene and Tropical Medicine, UK
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Anglaret X, Diagbouga S, Mortier E, Meda N, Vergé-Valette V, Sylla-Koko F, Cousens S, Laruche G, Ledru E, Bonard D, Dabis F, Van de Perre P. CD4+ T-lymphocyte counts in HIV infection: are European standards applicable to African patients? J Acquir Immune Defic Syndr Hum Retrovirol 1997; 14:361-7. [PMID: 9111479 DOI: 10.1097/00042560-199704010-00009] [Citation(s) in RCA: 49] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
CD4+ lymphocyte count (CD4+ LC) is a widely used marker of Human Immunodeficiency Virus (HIV) immune impairment. Physiological lymphocytosis is frequently encountered in Africans. Therefore, we tried to determine if given CD4+ LC levels are of similar significance in European versus African HIV-infected individuals. Lymphocyte phenotyping of 750 HIV-infected adults was retrospectively analyzed. Three hundred and seventy patients were consecutively selected in Paris, France; 185 in Abidjan, Côte d'Ivoire; and 195 in Bobo-Dioulasso, Burkina Faso. In the three settings, lymphocyte phenotyping was performed by flow cytometry using similar protocols. Data from Abidjan and Bobo-Dioulasso were combined on the basis of geographic proximity and contrasted with those from Paris. Geometric mean levels of Total Lymphocyte Count (TLC), CD4+ LC, CD8+ lymphocyte count (CD8+ LC), and CD4:CD8 ratio, adjusted for percentage of CD4+ T-cells (%CD4+), were compared between Africans and Europeans. For a given %CD4+, TLC and CD4+ LC but not CD8+ LC tended to be about one third higher in West African than in French adults (p < 0.0001). Approximate equivalencies of absolute CD4+ counts in French and West African HIV-infected adults suggest that where thresholds of 200 and 500 CD4+ cells/microliter are applied in Europe, it might be appropriate to apply a threshold of approximately 250 and 700 CD4+ cells/microliter in West Africa, respectively. Establishing indicators of progression of HIV infection with locally appropriate thresholds may represent important steps toward improvement of HIV disease management in Africa.
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Affiliation(s)
- X Anglaret
- CeDReS, CHU de Treichville, Abidjan, Côte d'Ivoire
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Murdoch IE, Jones BR, Cousens S, Liman I, Babalola OE, Dauda J, Abiose A. Visual field constriction as a cause of blindness or visual impairment. Bull World Health Organ 1997; 75:141-6. [PMID: 9185366 PMCID: PMC2486930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Reported are the results of a study of onchocerciasis in communities mesoendemic for savanna onchocerciasis in Kaduna State, northern Nigeria. The study involved 6831 individuals aged > or = 5 years who underwent an extensive screening examination for visual function including Friedmann field analysis. A total of 185 (2.7%) were bilaterally blind by acuity and an additional 28 (0.4%) were blind by visual field constriction. Also 118 (1.7%) individuals were visually impaired by acuity criteria. No criteria for visual impairment by field constriction have been established, and we therefore investigated three potential criteria. As a result, a further 60 (0.9%) individuals were identified with significant visual impairment due to field loss by the various definitions. Small islands of remaining peripheral field occurred in 50 individuals, while 40 individuals had marked reduction of binocular visual field below the horizontal meridian. Concentric visual field constriction to < 20 degrees was found in seven individuals. The WHO definition of blindness currently includes visual field damage criteria for blindness but not for visual impairment. Visual field loss is recognized as a major disability. We hope that these findings stimulate international discussion leading to the development of satisfactory definitions for visual impairment by visual field constriction.
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Affiliation(s)
- I E Murdoch
- Department of Ophthalmology, Ahmadu Bello University Teaching Hospital, Kaduna, Nigeria
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Abstract
If interventions promoting improved hygiene behaviour to prevent childhood diarrhoea are to be implemented and evaluated, valid methods for measuring this behaviour will be required. This paper presents findings from a study to investigate the use of structured observations to measure hygiene behaviour in Burkina Faso. Two hundred mothers with young children (2-36 months) were observed on several occasions, with particular attention focused on events/behaviour surrounding defaecation. Child defaecation occurred most often in a potty (67% of occasions). Stools were most often disposed of into a latrine (79%). Following defaecation the child's bottom was usually rinsed using water alone with a bare hand (76%). Subsequent hand washing by the mother/caretaker was much rarer (29%). None of these behaviours appeared "reactive" to the presence of the observer. Less common behaviors showed some evidence of reactivity. The frequency of child defaecation in the yard increased over the course of three observations (5% to 16%; P = 0.01) and the proportion of occasions on which the child was observed to be cleaned after defaecation declined (95% to 85%; P = 0.01). Mothers usually took with them to the latrine a water recipient (91%). Hand washing after leaving the latrine was observed on 30% of occasions. This proportion declined from 36% to 22% over three observations (P = 0.05). Defaecation by older siblings (aged 3-5 years) was usually into a potty (48%) or directly in a latrine (30%). There was no evidence that this behaviour was reactive. The repeatability of behaviours at the individual level was generally low. The site of index child defaecation (kappa = 0.27), how the child's bottom was cleaned (kappa = -0.01) and whether the caretaker washed her hands afterwards (kappa = 0.26) all showed low repeatability. The method of stool disposal was more repeatable (kappa = 0.73). Hand washing by mothers after using the latrine showed moderate repeatability (kappa = 0.40). Older sibling's defaecation behavior had excellent repeatability (kappa = 0.90). Our findings suggest that, in studies which aim to measure behaviour at the population level, structured observations may provide a useful tool. Studies which investigate links between hygiene behaviour and diarrhoea incidence at the individual level will require repeated observations of mothers and children since measuring behaviour during a single observation will lead to misclassification of exposure status, resulting in bias which could mask any underlying association. This is likely to be very costly.
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Affiliation(s)
- S Cousens
- Department of Epidemiology and Population Sciences, London School of Hygiene and Tropical Medicine, UK
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Meda N, Cousens S, Kanki B. Anaemia among women of reproductive age in Burkina Faso. World Health Forum 1996; 17:369-372. [PMID: 9060233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
The control of anaemia among women of reproductive age (15-49 years) is one of the priorities of the Safe Motherhood initiative. This article presents the results of a study that was carried out to provide some of the information needed for an effective and sustainable programme to control anaemia in women of this age group in Burkina Faso.
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Affiliation(s)
- N Meda
- Centre hospitalier national Sourô Sanou, Bobo-Dioulasso, Burkina Faso
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Abstract
Stool disposal practices have been shown to be associated with childhood diarrhoea. However, efforts to promote improved hygiene behaviour are hampered by a lack of understanding of what determines those behaviours. Data from 2793 household interviews with mothers of children from the town of Bobo-Dioulasso in Burkina Faso were analyzed to examine what differentiated mothers who reported using safer stool disposal practices from those who did not. Three 'outcomes' were considered: where the child was reported to defaecate; where the mother reported disposing of the child stools; and whether excreta were observed in the compound. Regression models were developed to identify those factors with the strongest independent associations with the outcomes. There was a consistent association between the source of water and the outcomes. Mothers with access to a tap in the yard reported using safe hygiene practices three times more often than mothers using wells outside the compound and twice as often as mothers who used public standpipes or wells within the yard. The source of water showed a similar pattern of association with observations of faecal matter in the environment. Improved sources of water may contribute to safer stool hygiene by reducing the time spent on water collection or by encouraging mothers to conform to higher standards of hygiene. Other factors which played a role in predicting the hygiene behaviour of mothers were the husbands' occupation, the number of health education sessions that she had attended, her zone of residence and family ownership of certain valuable objects. These factors are likely to be related and to be, to some extent, proxies for the real determinants of her behaviour. A model of the cultural, psycho-social and infrastructural proximate determinants of hygiene behaviour is proposed. Data from focus group discussions suggested that the main purpose of hygienic behaviour is to conform to existing norms of social etiquette. Trials of interventions based on changing such norms are needed to test whether this is an effective means of promoting of safer hygiene practices.
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Affiliation(s)
- V Curtis
- Maternal and Child Epidemiology Unit, London School of Hygiene and Tropical Medicine/Centre Muraz, Bobo-Dioulasso, Burkina Faso
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Murdoch I, Abiose A, Babalola O, Bird A, Cousens S, Evans J, Jones B. Ivermectin and onchocercal optic neuritis: short-term effects. Eye (Lond) 1994; 8 ( Pt 4):456-61. [PMID: 7821473 DOI: 10.1038/eye.1994.108] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
In 1982 the macrocyclic lactone, ivermectin, was first tested in human patients with onchocerciasis. It has since undergone phase I to IV trials and is now being widely distributed in onchocercal areas. The previous microfilaricide, diethylcarbamazine citrate (DEC), is known to precipitate or exacerbate active optic neuritis in some onchocercal patients, as part of a wider inflammatory response (the Mazzotti reaction). Ivermectin may also cause a mild reaction, especially in people with high microfilarial loads. Few data are available concerning the effect of ivermectin on active optic neuritis. A large, randomised, double-masked, phase IV trial is reported. Individuals were screened for evidence of optic nerve disease (OND), and those identified as possible cases of OND underwent detailed ophthalmic examination, including fluorescein angiography, before being dosed with ivermectin or placebo. A total of 6831 persons were screened of whom 856 (13%) underwent angiography prior to dosing. At 7-14 days after dosing an attempt was made to re-examine 50% of adults over the age of 20 years, including all those with OND. Six hundred and eighty-eight repeat or new angiograms were performed. During this period, 5 new cases of active optic neuritis and one case of exacerbation of existing optic neuritis were identified. Five of these individuals had received placebo and one ivermectin. Two individuals with optic neuritis before dosing had improved after 7-14 days. One had received placebo, the other ivermectin. Ivermectin does not appear to precipitate or exacerbate optic neuritis at a period of 7-14 days.
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Affiliation(s)
- I Murdoch
- Department of Ophthalmology, Ahmadu Bello University Teaching Hospital, Kaduna, Nigeria
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Traoré E, Cousens S, Curtis V, Mertens T, Tall F, Traoré A, Kanki B, Diallo I, Rochereau A, Chiron JP. Child defecation behaviour, stool disposal practices, and childhood diarrhoea in Burkina Faso: results from a case-control study. J Epidemiol Community Health 1994; 48:270-5. [PMID: 8051526 PMCID: PMC1059958 DOI: 10.1136/jech.48.3.270] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To investigate the association between where young children defecate, where stools are disposed of, and the presence of human stools on the ground in the compound and the rate of hospital admission with diarrhoea. DESIGN This was a case-control study with two control groups. SETTING The study took place in Bobo-Dioulasso, the second city of Burkina Faso in West Africa. PARTICIPANTS Three groups of children aged 36 months and under, and living in Bobo-Dioulasso were studied. Cases were 757 children admitted to hospital with symptoms of diarrhoea or dysentery. The first control group comprised 757 neighbourhood control children approximately matched on age and date of recruitment, and the second, 631 children admitted to the same hospital without symptoms of diarrhoea or dysentery. MAIN RESULTS There was no evidence of any association between where the child was reported to defecate and hospital admission with diarrhoea or dysentery (odds ratio = 1.10; 95% confidence interval (CI) 0.78, 1.57, cases v neighbourhood controls; odds ratio = 0.84; 95% CI 0.60, 1.18, cases v hospital controls). There was evidence of an association between where the mother reported disposing of the child's stools and hospital admission with diarrhoea or dysentery (odds ratio = 1.50; 95% CI 1.09, 2.06, cases v neighbourhood controls; odds ratio = 1.31; 95% CI 0.96, 1.79, cases v hospital controls). Human stools were more frequently observed in the yards of cases than controls (odds ratio = 1.38; 95% CI 0.98, 1.95, cases compared with neighbourhood controls; odds ratio = 1.33; 95% CI 0.96, 1.84, cases compared with hospital controls). CONCLUSIONS The findings suggest that it is not where the child defecates that matters but how the mother then deals with the child's stools.
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Affiliation(s)
- E Traoré
- Ministère de la Santé, de l'Action Sociale et de la Famille, Bobo-Dioulasso, Burkina Faso
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Tall FR, Valian A, Curtis V, Traore A, Nacro B, Cousens S, Diallo I, Traore E, Mertens TH. [Acute respiratory infections in pediatric hospital at Bobo-Dioulasso (Burkina Faso)]. Arch Pediatr 1994; 1:249-54. [PMID: 7994332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Acute lower respiratory tract infections are the primary cause of morbidity in developing countries. POPULATION AND METHODS Six hundred and sixty seven children (379 boys, 288 girls, aged 0-30 months) admitted for lower respiratory tract infections from January 1990 to March 1991 were included in the study. Immediate medical history was collected from the mother. The weight, height, temperature and clinical manifestations, plus the results of chest X-rays, parasitologic and bacteriological examination of stools, and blood smear for malaria were recorded for each patient. Sero-immunologic study for HIV infection of 473 of the patients aged 12-36 months and their mothers also took part in a sero-immunological study for HIV infection. RESULTS Lower respiratory tract infections were the second major cause of admission (16.8%) after malaria (28.7%). Infections peaked between 6 and 11 months of age (29.5%). The main diseases were pneumonia and bronchial pneumonia (54%) followed by bronchiolitis (21.7%). Almost half the patients were admitted during the hot, dry season. Two hundred and eighty seven patients (43.4%) were referred only after they had been suffering from the disease for 3 to 9 days, partly explaining the high level of mortality. One hundred and twenty one patients (20.9%) died; the main cause of death was staphylococcal pneumonia (57.9%), followed by pneumonia and bronchial pneumonia (29.3%). Some criteria for severity could be identified, based on pulmonary signs and symptoms and associated manifestations (dehydration, malnutrition, convulsions, anemia). Twenty two patients were positive for HIV-1 infection. CONCLUSIONS This study confirms that acute lower respiratory tract infections remain a public health problem. Early diagnosis and treatment are necessary to reduce mortality.
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Affiliation(s)
- F R Tall
- Service de pédiatrie, centre hospitalier national Souro-Sanou, Bobo-Dioulasso, Burkina Faso
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Abiose A, Murdoch I, Babalola O, Cousens S, Liman I, Onyema J, Evans J, Gregory W, Jones B. Distribution and aetiology of blindness and visual impairment in mesoendemic onchocercal communities, Kaduna State, Nigeria. Kaduna Collaboration for Research on Onchocerciasis. Br J Ophthalmol 1994; 78:8-13. [PMID: 8110711 PMCID: PMC504682 DOI: 10.1136/bjo.78.1.8] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
During a field trial of ivermectin in Kaduna State, 6831 people age 5 years and above, living in 34 mesoendemic onchocercal communities in Kaduna State, northern Nigeria, were examined for ocular disease. Visual function assessments included tests of visual acuity and visual fields. A total of 185 individuals (2.7%) were bilaterally blind by acuity criteria with a further 28 blind by field constriction. The overall prevalence of blindness was 3.1%. A further 118 individuals were visually impaired by WHO criteria. Examination for the cause of blindness revealed that 43% of eyes in bilaterally blind patients were blind due to onchocerciasis. A further 11% were blind from optic atrophy much of which was probably onchocercal in origin. Glaucoma was the next most common cause of blindness in the bilaterally blind (11%). Only 6% of eyes were blind from cataract as the primary cause. In the visually impaired population cataract was the most common primary cause of impaired/blind eyes (31%), followed by onchocerciasis (19%) [corrected].
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Affiliation(s)
- A Abiose
- Department of Ophthalmology, Ahmadu Bello University Teaching Hospital, Kaduna, Nigeria
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Murdoch ME, Hay RJ, Mackenzie CD, Williams JF, Ghalib HW, Cousens S, Abiose A, Jones BR. A clinical classification and grading system of the cutaneous changes in onchocerciasis. Br J Dermatol 1993; 129:260-9. [PMID: 8286222 DOI: 10.1111/j.1365-2133.1993.tb11844.x] [Citation(s) in RCA: 96] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Although onchocerciasis is one of the most important diseases of the skin and eye in the tropical world, to date there has been no formal consensus regarding the description and terminology of skin lesions. Furthermore, the contribution of cutaneous pathology to the morbidity and socio-economic effects of the disease has been largely neglected. We present a clinical classification and grading system for recording the cutaneous changes of onchocerciasis, and propose that this system be used as a standard method of description to convey clinical information between workers in all endemic areas to assist local and comparative research.
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Affiliation(s)
- M E Murdoch
- Department of Ophthalmology, Ahmadu Bello University Teaching Hospital, Kaduna, Nigeria
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