Perception of Health-Care Professionals on Presumed Consent in Formulation of Proper Organ Transplantation Regulatory System

Background

Owing to the advancement in organ transplantation, treating an individual with organ failure in today's world has become possible. However, organ transplantation is lagging in the absence of adequate organ donations. Shortage of organs for transplantation is a challenge to developing countries like Nepal and developed countries like the USA and UK. Despite various efforts to increase the rate of organ donation, the problem persists. The primary reason for the failure to accomplish adequacy in organ do-nation is the immediate dependency on an available donor. On top of that, reluctance to decide on organ donation after death, regarded as an onerous moment, at least by the general public, has another impact on the subject. Some countries have shifted while some are planning to change from an informed consent system to a presumed consent system, in which if an individual does not make any decision during life-time, it is presumed that his/her organ can be removed for organ transplantation after death.

Objective

To perceive the perception of healthcare professionals of the tertiary care centre of eastern Nepal regarding the presumed consent system.

Methods

Purposive sampling of 221 health care professionals (Faculties, Nursing In-charges, Lab-technicians, and Radiology technicians) participated in the study.

Results

Most healthcare professionals (90.5%) support using a presumed consent system in Nepal and agree on considering the family's opinion in the decision-making for cadaveric organ donation.

Conclusion

Most healthcare professionals have shown their perception in favors of presumed consent to support the increasing organ donation rate.

Safety and immunogenicity of a killed bivalent (O1 and O139) whole-cell oral cholera vaccine in adults and children in Vellore, South India

This open-label study assessed the safety and immunogenicity of two doses (14 days apart) of an indigenously manufactured, killed, bivalent (Vibrio cholerae O1 and O139), whole-cell oral cholera vaccine (SHANCHOL; Shantha Biotechnics) in healthy adults (n = 100) and children (n = 100) in a cholera endemic area (Vellore, South India) to fulfill post-licensure regulatory requirements and post-World Health Organization (WHO) prequalification commitments. Safety and reactogenicity were assessed, and seroconversion rates (i.e. proportion of participants with a ≥ 4-fold rise from baseline in serum vibriocidal antibody titers against V. cholerae O1 Inaba, O1 Ogawa and O139, respectively) were determined 14 days after each vaccine dose. No serious adverse events were reported during the study. Commonly reported solicited adverse events were headache and general ill feeling. Seroconversion rates after the first and second dose in adults were 67.7% and 55.2%, respectively, against O1 Inaba; 47.9% and 45.8% against O1 Ogawa; and 19.8% and 20.8% against O139. In children, seroconversion rates after the first and second dose were 80.2% and 68.8%, respectively, against O1 Inaba; 72.9% and 67.7% against O1 Ogawa; and 26.0% and 18.8% against O139. The geometric mean titers against O1 Inaba, O1 Ogawa, and O139 in both adults and children were significantly higher after each vaccine dose compared to baseline titers (P < 0.001; for both age groups after each dose versus baseline). The seroconversion rates for O1 Inaba, O1 Ogawa, and O139 in both age groups were similar to those in previous studies with the vaccine. In conclusion, the killed, bivalent, whole-cell oral cholera vaccine has a good safety and reactogenicity profile, and is immunogenic in healthy adults and children. Trial Registration: ClinicalTrials.gov NCT00760825; CTRI/2012/01/002354.

Performance of lemongrass (Cymbopogon citrates) oil as growth promoter in broiler

An attempt was taken to study the growth performance of lemongrass oil (Cymbopogon citraturs) as a growth promoter on the broiler production. A total of 180day-old broiler chicks were procured from private hatchery (Shivam Hatchery Birgung, Parsa, Nepal) and were allocated following Completely Randomized Design (CRD) into four treatment groups (each treatment with 3 replications and each replication with 15 birds); T1= control, T2= containing lemongrass oil 200 ml/100 kg feed, T3= containing lemongrass oil 400 ml/100 kg feed and, T4= containing lemongrass oil 600 ml/100 kg feed. The study was carried out for 36 days at Avian Research Unit, Regional Agriculture Research Station, Parwanipur, Bara, Nepal. Concentrate mixture and lemongrass oil were procured from Shakti Feed Industry, Birgung; Herbs Processing Plant of Ministry of Forest and Soil Conservation, Jadibuti, Kathmandu, respectively. Experimental birds were provided ad libitum amount of starter feed from 0 to 21 days and finisher feed from 22 to 36 days. Feed intake was recorded daily and body weight gain was measured in 7 days interval. The study revealed that the cumulative feed intake per bird was found higher in T3 (3443.17g) followed by T4 (3377.33g) and T2 (3354.04g), respectively, and were statistically non-significant among the diet groups. The FCR was highest in T3 (1:1.44 kg) and lowest in T4 (1:1.51 kg), and differed insignificantly among the diet groups. Similarly, the total weight gain of the experimental bird was found to be higher in T3 (2385.13g) followed by T1 (2279.46g) and T2 (2271.86g), respectively.  The average daily gain of experimental birds noted higher in T3 (66.25g) followed by T1 and T2 (63.31g) and (63.1g), respectively. The experiment suggested that inclusion of lemongrass oil could be considered as an alternative to antibiotic growth promoter in broiler diet to enhance the production performance. Bang. J. Anim. Sci. 2018. 47 (2): 85-91

Benefit of 18F-fluorocholine PET imaging in parathyroid surgery

OBJECTIVES

To assess the additional diagnostic value of ¹⁸F-fluorocholine PET imaging in preoperative localization of pathologic parathyroid glands in clinically manifest hyperparathyroidism in case of negative or conflicting ultrasound and scintigraphy results.

METHODS

A retrospective, single-institution study of 26 patients diagnosed with hyperparathyroidism. In cases where ultrasound and scintigraphy failed to detect the location of an adenoma in order to allow a focused surgical approach, an additional ¹⁸F-fluorocholine PET scan was performed and its results were compared with the intraoperative findings.

RESULTS

A total of 26 patients underwent ¹⁸F-fluorocholine PET/CT (n = 11) or PET/MRI (n = 15). Adenomas were detected in 25 patients (96.2%). All patients underwent surgery, and the location predicted by PET hybrid imaging was confirmed intraoperatively by frozen section and adequate parathyroid hormone drop after removal. None of the patients needed revision surgery during follow-up.

CONCLUSIONS

These results demonstrate that ¹⁸F-fluorocholine PET imaging is a highly accurate method to detect parathyroid adenomas even in case of previous localization failure by other imaging examinations.

KEY POINTS

• With ¹⁸ F-fluorocholine PET imaging, parathyroid adenomas could be detected in 96.2%. • ¹⁸ F-fluorocholine imaging is a highly accurate method to detect parathyroid adenomas. • We encourage its use, where ultrasound fails to detect an adenoma.

Non-Surgical Pneumoperitoneum

Pneumoperitoneum is mostly caused by visceral perforation and surgical intervention; however non-surgical pneumoperitoneum has been reported without evidence of visceral disease. Blunt chest trauma causing an abrupt rise in thoracic pressure can leak air through the microscopic diaphragmatic defects or the mediastinum along perivascular connective tissue and cause pneumoperitoneum. We hereby present a case of non-surgical pneumoperitoneum after blunt chest trauma that was brought to the emergency department of college of medical sciences teaching hospital with features of bilateral pneumothorax with subcutaneous emphysema and abdominal distension which was diagnosed and managed promptly with bilateral chest drain and other supportive treatments.

Development of a Valid and Reliable Questionnaire to Identify Professional Opinion Regarding Organ Transplantation System

BACKGROUND

Currently, the Nepalese law permits organ donation by an individual who falls into the category of a "close relative" of the recipient. There is a need for expansion of the live organ donor pool beside close relatives. Different systems of organ transplantation are followed by several countries and the professional opinions that underpin these systems need to be studied.

OBJECTIVE

To generate a questionnaire related to different organ transplant systems and validate it so that it can be used to collect mass professional opinions.

METHODS

Item generation, item reduction, item scaling, and pretesting were used to develop a questionnaire. The final version of the questionnaire was reviewed by experts for its content validity and then was used twice for participants at a 20-day interval to calculate Cronbach's alpha for testing its internal consistency and Intra-class correlation for testing its test and retest reliability.

RESULTS

The questionnaire was found to be valid and reliable with an overall Cronbach's alpha of 0.701. Intra-class correlation scores for each question in both test and retest were correlated.

CONCLUSION

A valid and reliable questionnaire was developed that can be used to collect mass professional opinions to assist policy makers to establish a better organ transplant system.

Uptake during an oral cholera vaccine pilot demonstration program, Odisha, India

Approximately 30% of reported global cholera cases occur in India. In 2011, a household survey was conducted 4 months after an oral cholera vaccine pilot demonstration project in Odisha India to assess factors associated with vaccine up-take and exposure to a communication and social mobilization campaign. Nine villages were purposefully selected based on socio-demographics and demonstration participation rates. Households were stratified by level of participation and randomly selected. Bivariate and ordered logistic regression analyses were conducted. 517/600 (86%) selected households were surveyed. At the household level, participant compared to non-participant households were more likely to use the local primary health centers for general healthcare (P < 0.001). Similarly, at the village level, higher participation was associated with use of the primary health centers (P < 0.001) and private clinics (p = 0.032). Also at the village level, lower participation was associated with greater perceived availability of effective treatment for cholera (p = 0.013) and higher participation was associated with respondents reporting spouse as the sole decision-maker for household participation in the study. In terms of pre-vaccination communication, at the household level verbal communication was reported to be more useful than written communication. However written communication was perceived to be more useful by respondents in low-participating villages compared to average-participating villages (p = 0.007) These data on participation in an oral cholera vaccine demonstration program are important in light of the World Health Organization's (WHO) recommendations for pre-emptive use of cholera vaccine among vulnerable populations in endemic settings. Continued research is needed to further delineate barriers to vaccine up-take within and across targeted communities in low- and middle-income countries.

An Estimation of Private Household Costs to Receive Free Oral Cholera Vaccine in Odisha, India

BACKGROUND

Service provider costs for vaccine delivery have been well documented; however, vaccine recipients' costs have drawn less attention. This research explores the private household out-of-pocket and opportunity costs incurred to receive free oral cholera vaccine during a mass vaccination campaign in rural Odisha, India.

METHODS

Following a government-driven oral cholera mass vaccination campaign targeting population over one year of age, a questionnaire-based cross-sectional survey was conducted to estimate private household costs among vaccine recipients. The questionnaire captured travel costs as well as time and wage loss for self and accompanying persons. The productivity loss was estimated using three methods: self-reported, government defined minimum daily wages and gross domestic product per capita in Odisha.

FINDINGS

On average, families were located 282.7 (SD = 254.5) meters from the nearest vaccination booths. Most family members either walked or bicycled to the vaccination sites and spent on average 26.5 minutes on travel and 15.7 minutes on waiting. Depending upon the methodology, the estimated productivity loss due to potential foregone income ranged from $0.15 to $0.29 per dose of cholera vaccine received. The private household cost of receiving oral cholera vaccine constituted 24.6% to 38.0% of overall vaccine delivery costs.

INTERPRETATION

The private household costs resulting from productivity loss for receiving a free oral cholera vaccine is a substantial proportion of overall vaccine delivery cost and may influence vaccine uptake. Policy makers and program managers need to recognize the importance of private costs and consider how to balance programmatic delivery costs with private household costs to receive vaccines.

Treatment of Chronic Venous Ulcers Using New Four Layers Compressive Bandage Dressing

INTRODUCTION

Lower-extremity ulcers represent the largest group of ulcers presenting to an outpatient department. It is a cumbersome, difficult to treat disease, which causes high morbidity and huge cost for the patient and healthcare system. Current standard treatment includes compression therapy.  However, majority of patients need long term treatment with minimal efficacy. Aim of our study is to evaluate efficacy of four layers compressive bandages for the management of chronic venous ulcers.

METHODS

In Group A, we have prospectively included 20 patients with chronic venous ulcers on lower limbs for four layers hosiery bandage using Velfour bandage. Other 15 patients, Group B, were treated with conventional wound dressing. Velfour and crepe bandage were done once weekly for three weeks.

RESULTS

DVT was cause of chronic venous ulcer in 70% patient in group A and in 73.3% in Group B. Majority of patients were having left sided chronic venous ulcers. The mean duration of the ulcers was 15.6 vs 10.86 months (group A vs. group B). At the end of 3rd week, in 55% wounds in Group A were healed except few big and deep wounds remained. Most of these wounds also became smaller with minimal discharge. Size of wounds significantly decreased in Group A vs. Group B patients (0.7±0.81 cm vs. 1.73±0.77 cm, p<0.00031). However, cost of treatment in group A remained higher than group B.

CONCLUSIONS

Our study has shown that four layer compressive bandage using Velfour is an easy, effective, and reproducible method of treatment for the chronic venous ulcer.

A case report of Traumatic Asphyxia

Traumatic asphyxia is a condition presenting with cervicofacial cyanosis and edema, subconjunctival hemorrhage, and petechial hemorrhages of the face, neck, and upper chest that occurs due to a compressive force to the thoracoabdominal region.In this case report a 52 years old lady who was brought to the mortuary because of death due to traumatic asphyxia as a result of being stampeded by her own cows upon her chest was discussed. Congestion on both the conjunctiva, cyanosis on chin and adjacent upper left side of neck found with a well demarcated area observed between the cyanosed area over face and the normal area of neck. Hematoma was present in the chin and the adjacent neck region.Apart from quickly eliminating organ pathologies and initiation of supportive therapy in a case of traumatic asphyxia, possibility of formation of hematoma in neck after few hours of getting injured should also be considered, as this type of hematoma may contribute to the cause of death.Journal of College of Medical Sciences-Nepal, 2014, Vol-10, No-3, 51-55

Effectiveness of an oral cholera vaccine campaign to prevent clinically-significant cholera in Odisha State, India

BACKGROUND

A clinical trial conducted in India suggests that the oral cholera vaccine, Shanchol, provides 65% protection over five years against clinically-significant cholera. Although the vaccine is efficacious when tested in an experimental setting, policymakers are more likely to use this vaccine after receiving evidence demonstrating protection when delivered to communities using local health department staff, cold chain equipment, and logistics.

METHODS

We used a test-negative, case-control design to evaluate the effectiveness of a vaccination campaign using Shanchol and validated the results using a cohort approach that addressed disparities in healthcare seeking behavior. The campaign was conducted by the local health department using existing resources in a cholera-endemic area of Puri District, Odisha State, India. All non-pregnant residents one year of age and older were offered vaccine. Over the next two years, residents seeking care for diarrhea at one of five health facilities were asked to enroll following informed consent. Cases were patients seeking treatment for laboratory-confirmed V. cholera-associated diarrhea. Controls were patients seeking treatment for V. cholerae negative diarrhea.

RESULTS

Of 51,488 eligible residents, 31,552 individuals received one dose and 23,751 residents received two vaccine doses. We identified 44 V. cholerae O1-associated cases and 366 non V. cholerae diarrhea controls. The adjusted protective effectiveness for persons receiving two doses was 69.0% (95% CI: 14.5% to 88.8%), which is similar to the adjusted estimates obtained from the cohort approach. A statistical trend test suggested a single dose provided a modicum of protection (33%, test for trend, p=0.0091).

CONCLUSION

This vaccine was found to be as efficacious as the results reported from a clinical trial when administered to a rural population using local health personnel and resources. This study provides evidence that this vaccine should be widely deployed by public health departments in cholera endemic areas.

Mass vaccination with a new, less expensive oral cholera vaccine using public health infrastructure in India: the Odisha model

Introduction

The substantial morbidity and mortality associated with recent cholera outbreaks in Haiti and Zimbabwe, as well as with cholera endemicity in countries throughout Asia and Africa, make a compelling case for supplementary cholera control measures in addition to existing interventions. Clinical trials conducted in Kolkata, India, have led to World Health Organization (WHO)-prequalification of Shanchol, an oral cholera vaccine (OCV) with a demonstrated 65% efficacy at 5 years post-vaccination. However, before this vaccine is widely used in endemic areas or in areas at risk of outbreaks, as recommended by the WHO, policymakers will require empirical evidence on its implementation and delivery costs in public health programs. The objective of the present report is to describe the organization, vaccine coverage, and delivery costs of mass vaccination with a new, less expensive OCV (Shanchol) using existing public health infrastructure in Odisha, India, as a model.

Methods

All healthy, non-pregnant residents aged 1 year and above residing in selected villages of the Satyabadi block (Puri district, Odisha, India) were invited to participate in a mass vaccination campaign using two doses of OCV. Prior to the campaign, a de jure census, micro-planning for vaccination and social mobilization activities were implemented. Vaccine coverage for each dose was ascertained as a percentage of the censused population. The direct vaccine delivery costs were estimated by reviewing project expenditure records and by interviewing key personnel.

Results

The mass vaccination was conducted during May and June, 2011, in two phases. In each phase, two vaccine doses were given 14 days apart. Sixty-two vaccination booths, staffed by 395 health workers/volunteers, were established in the community. For the censused population, 31,552 persons (61% of the target population) received the first dose and 23,751 (46%) of these completed their second dose, with a drop-out rate of 25% between the two doses. Higher coverage was observed among females and among 6–17 year-olds. Vaccine cost at market price (about US$1.85/dose) was the costliest item. The vaccine delivery cost was $0.49 per dose or $1.13 per fully vaccinated person.

Discussion

This is the first undertaken project to collect empirical evidence on the use of Shanchol within a mass vaccination campaign using existing public health program resources. Our findings suggest that mass vaccination is feasible but requires detailed micro-planning. The vaccine and delivery cost is affordable for resource poor countries. Given that the vaccine is now WHO pre-qualified, evidence from this study should encourage oral cholera vaccine use in countries where cholera remains a public health problem.

Cholera – an acute life-threatening diarrheal illness – continues to disrupt public health in resource poor countries. The devastating outbreaks in Haiti and Zimbabwe – to name just two of many occurrences – calls for the use of available oral cholera vaccines as an additional tool in the arsenal of cholera control measures. An oral cholera vaccine (Shanchol) has been licensed in India since 2009; however, there has only been limited use of this vaccine in government public health programs. A vaccination campaign using 2 doses of Shanchol was conducted in Odisha, India, during May and June, 2011, where 31,552 persons (61% of the target population) received the first dose and 23,751 of them completed their second dose. The vaccine delivery cost was $0.49 per dose. Through our findings and experience, we discuss the organization of the cholera vaccination campaign in Odisha, the challenges met for conducting the campaign and the strategies designed to overcome those challenges, and the delivery costs incurred in the use of this vaccine, the first of its kind, in a public health setting. We believe that evidence from this study is of significant interest and use to policymakers from countries where cholera remains a public health problem.

Risk map of cholera infection for vaccine deployment: the eastern Kolkata case

BACKGROUND

Despite advancement of our knowledge, cholera remains a public health concern. During March-April 2010, a large cholera outbreak afflicted the eastern part of Kolkata, India. The quantification of importance of socio-environmental factors in the risk of cholera, and the calculation of the risk is fundamental for deploying vaccination strategies. Here we investigate socio-environmental characteristics between high and low risk areas as well as the potential impact of vaccination on the spatial occurrence of the disease.

METHODS AND FINDINGS

The study area comprised three wards of Kolkata Municipal Corporation. A mass cholera vaccination campaign was conducted in mid-2006 as the part of a clinical trial. Cholera cases and data of the trial to identify high risk areas for cholera were analyzed. We used a generalized additive model (GAM) to detect risk areas, and to evaluate the importance of socio-environmental characteristics between high and low risk areas. During the one-year pre-vaccination and two-year post-vaccination periods, 95 and 183 cholera cases were detected in 111,882 and 121,827 study participants, respectively. The GAM model predicts that high risk areas in the west part of the study area where the outbreak largely occurred. High risk areas in both periods were characterized by poor people, use of unsafe water, and proximity to canals used as the main drainage for rain and waste water. Cholera vaccine uptake was significantly lower in the high risk areas compared to low risk areas.

CONCLUSION

The study shows that even a parsimonious model like GAM predicts high risk areas where cholera outbreaks largely occurred. This is useful for indicating where interventions would be effective in controlling the disease risk. Data showed that vaccination decreased the risk of infection. Overall, the GAM-based risk map is useful for policymakers, especially those from countries where cholera remains to be endemic with periodic outbreaks.

Clinical outcome following the first-line, single lesion microfracture at the knee joint

CASE SERIES

Level of evidence, 4.

BACKGROUND

Arthroscopic microfracture of chondral defects across the knee joint is a frequent treatment modality. There is only limited information on the clinical outcome in patients without previous surgery and single lesions.

PURPOSE

Evaluation of clinical outcome following microfracture in patients without previous surgery and single lesions and identification of prognostic factors.

METHODS

Inclusion criteria were patients with single-lesion knee joint first-line microfracturing at minimum 2 years postoperatively. Charts were reviewed to identify patient and defect characteristics. Clinical outcome was evaluated by IKDC and Lysholm knee scores, Tegner activity scale and a numeric analogue scale (NAS) for function and pain (10 = highest possible function, no pain).

RESULTS

Totally, 145 patients (age at operation 47.92 ± 15.7) met inclusion criteria. Average defect size was 2.7 ± 1.9 cm(2). Postoperatively, IKDC was 73.1 ± 18.5, Lysholm 77.6 ± 19.1, Tegner 4.5 ± 1.7, NAS pain 6.5 ± 2.6 and NAS function 6.4 ± 2.3. Significantly better clinical outcome was observed in male patients than in female patients. Regression analysis including all patient and defect characteristics highlighted that singly the parameter shorter symptom duration (P = 0.018) significantly predicted an improved postoperative clinical outcome.

CONCLUSION

Microfracturing results in a satisfying clinical outcome, but no full recovery in patients without previous surgery and single lesions. Specific parameters facilitate outcome prognosis and therefore may aid in indicating surgery.

Herd protection by a bivalent killed whole-cell oral cholera vaccine in the slums of Kolkata, India

BACKGROUND

We evaluated the herd protection conferred by an oral cholera vaccine using 2 approaches: cluster design and geographic information system (GIS) design.

METHODS

Residents living in 3933 dwellings (clusters) in Kolkata, India, were cluster-randomized to receive either cholera vaccine or oral placebo. Nonpregnant residents aged≥1 year were invited to participate in the trial. Only the first episode of cholera detected for a subject between 14 and 1095 days after a second dose was considered. In the cluster design, indirect protection was assessed by comparing the incidence of cholera among nonparticipants in vaccine clusters vs those in placebo clusters. In the GIS analysis, herd protection was assessed by evaluating association between vaccine coverage among the population residing within 250 m of the household and the occurrence of cholera in that population.

RESULTS

Among 107 347 eligible residents, 66 990 received 2 doses of either cholera vaccine or placebo. In the cluster design, the 3-year data showed significant total protection (66% protection, 95% confidence interval [CI], 50%-78%, P<.01) but no evidence of indirect protection. With the GIS approach, the risk of cholera among placebo recipients was inversely related to neighborhood-level vaccine coverage, and the trend was highly significant (P<.01). This relationship held in multivariable models that also controlled for potentially confounding demographic variables (hazard ratio, 0.94 [95% CI, .90-.98]; P<.01).

CONCLUSIONS

Indirect protection was evident in analyses using the GIS approach but not the cluster design approach, likely owing to considerable transmission of cholera between clusters, which would vitiate herd protection in the cluster analyses.

CLINICAL TRIALS REGISTRATION

NCT00289224.

The global burden of cholera

OBJECTIVE

To estimate the global burden of cholera using population-based incidence data and reports.

METHODS

Countries with a recent history of cholera were classified as endemic or non-endemic, depending on whether they had reported cholera cases in at least three of the five most recent years. The percentages of the population in each country that lacked access to improved sanitation were used to compute the populations at risk for cholera, and incidence rates from published studies were applied to groups of countries to estimate the annual number of cholera cases in endemic countries. The estimates of cholera cases in non-endemic countries were based on the average numbers of cases reported from 2000 to 2008. Literature-based estimates of cholera case-fatality rates (CFRs) were used to compute the variance-weighted average cholera CFRs for estimating the number of cholera deaths.

FINDINGS

About 1.4 billion people are at risk for cholera in endemic countries. An estimated 2.8 million cholera cases occur annually in such countries (uncertainty range: 1.4-4.3) and an estimated 87,000 cholera cases occur in non-endemic countries. The incidence is estimated to be greatest in children less than 5 years of age. Every year about 91,000 people (uncertainty range: 28,000 to 142,000) die of cholera in endemic countries and 2500 people die of the disease in non-endemic countries.

CONCLUSION

The global burden of cholera, as determined through a systematic review with clearly stated assumptions, is high. The findings of this study provide a contemporary basis for planning public health interventions to control cholera.

Efficacy of a low-cost, inactivated whole-cell oral cholera vaccine: results from 3 years of follow-up of a randomized, controlled trial

BACKGROUND

Killed oral cholera vaccines (OCVs) have been licensed for use in developing countries, but protection conferred by licensed OCVs beyond two years of follow-up has not been demonstrated in randomized, clinical trials.

METHODS/PRINCIPAL FINDINGS

We conducted a cluster-randomized, placebo-controlled trial of a two-dose regimen of a low-cost killed whole cell OCV in residents 1 year of age and older living in 3,933 clusters in Kolkata, India. The primary endpoint was culture-proven Vibrio cholerae O1 diarrhea episodes severe enough to require treatment in a health care facility. Of the 66,900 fully dosed individuals (31,932 vaccinees and 34,968 placebo recipients), 38 vaccinees and 128 placebo-recipients developed cholera during three years of follow-up (protective efficacy 66%; one-sided 95%CI lower bound = 53%, p<0.001). Vaccine protection during the third year of follow-up was 65% (one-sided 95%CI lower bound = 44%, p<0.001). Significant protection was evident in the second year of follow-up in children vaccinated at ages 1-4 years and in the third year in older age groups.

CONCLUSIONS/SIGNIFICANCE

The killed whole-cell OCV conferred significant protection that was evident in the second year of follow-up in young children and was sustained for at least three years in older age groups. Continued follow-up will be important to establish the vaccine's duration of protection.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00289224.

Paperless registration during survey enumerations and large oral cholera mass vaccination in Zanzibar, the United Republic of Tanzania

PROBLEM

Field trials require extensive data preparation and complex logistics. The use of personal digital assistants (PDAs) can bypass many of the traditional steps that are necessary in a paper-based data entry system.

APPROACH

We programmed, designed and supervised the use of PDAs for a large survey enumeration and mass vaccination campaign.

LOCAL SETTING

The project was implemented in Zanzibar in the United Republic of Tanzania. Zanzibar is composed of two main islands, Unguja and Pemba, where outbreaks of cholera have been reported since the 1970s.

RELEVANT CHANGES

PDAs allowed us to digitize information at the initial point of contact with the respondents. Immediate response by the system in case of error helped ensure the quality and reliability of the data. PDAs provided quick data summaries that allowed subsequent research activities to be implemented in a timely fashion.

LESSONS LEARNT

Portability, immediate recording and linking of information enhanced structure data collection in our study. PDAs could be more useful than paper-based systems for data collection in the field, especially in impoverished settings in developing countries.