Journal Search

Journal Search - July 2003


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Paul Worley1
-, Editor-in-Chief


* Jennifer Richmond


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31 July 2003 Volume 3 Issue 3


RECEIVED: 31 July 2003

ACCEPTED: 31 July 2003


Worley P.  Journal Search - July 2003. Rural and Remote Health 2003; 3: 233.


© Paul Worley 2003 A licence to publish this material has been given to Deakin University,

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Journal Search brings Rural and Remote Health users a selection of relevant recent abstracts from MEDLINE. This month's themes are rural maternal and child health; and malaria.

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Journal Search - July 2003

J Rural Health 2003; 19: 269-78
Children's agricultural health: traumatic injuries and hazardous inorganic exposures
Perry MJ
Occupational Health Program, Harvard School of Public Health, 665 Huntington Ave., Boston, MA 02115, USA.

CONTEXT: Farming is one of the most hazardous occupational industries in the USA, and farms pose numerous health risks for youth visiting, living in, or working in the farm environment. PURPOSE: This review discusses both potential traumatic injuries and hazardous inorganic exposures that are common in agricultural settings. FINDINGS: An estimated 2 million youth under the age of 20 currently live or work on US farms. Approximately 103 farm fatalities occur in this age group each year; over 32,000 nonfatal youth injuries occurred on farms in 1998. Children working in US agriculture make up only 8% of the population of working minors overall, yet they account for 40% of work-related fatalities among minors. Farm children and youth are also exposed to potentially harmful chemicals, such as pesticides and solvents, and many of these exposures go undetected. The long-term health effects of exposure to pesticides or solvents are not known, but the developmental vulnerabilities of children and youth are of particular concern. CONCLUSIONS: Clinical and epidemiologic research in pediatric populations is needed to expand the empirical data, particularly for inorganic and organic exposures, musculoskeletal trauma, skin disorders, occupation-induced hearing loss, and psychosocial stress. Rural health professionals can work to reduce these risks to farm youth by becoming more aware of the problem, by conducting clinical and epidemiologic research, and by engaging in advocacy at state and local levels.

Chemosphere 2003; 50: 529-35
A method to determine residue levels of persistent organochlorine pesticides in human milk from Indonesian women
Burke ER, Holden AJ, Shaw IC
Department of Environmental Management, University of Central Lancashire, Preston PR1 2HE, UK

A method has been developed for the analysis of organochlorine pesticides in human milk using solvent extraction, Florisil solid phase extraction clean-up and analysis by gas chromatography with an electron capture detector. The recovery of analytes from spiked milk samples was in the range 53 +/- 1% to 109 +/- 7% (n = 9). A small number of samples were obtained from women in a rural and an urban area of Indonesia and analysed using the developed method. The results are reported on a milk fat basis. All samples contained detectable residues of p,p'-DDT (urban mean 0.11 +/- 0.18 mgkg(-1) (n = 5), rural mean 0.07 +/- 0.03 mg kg(-1) (n = 5)) and p,p'-DDE (urban mean 0.05 +/- 0.04 m kg(-1) (n = 5), rural mean 0.76 +/- 1.46 mg kg(-1) (n = 5)). Residues of HCB, betaHCH, alpha-endosulfan and dieldrin were also detected in some samples. There was no significant difference (at the 95% confidence level) in levels of pesticides between urban and rural areas. The levels of organochlorine pesticides in milk from Indonesian women were lower than those reported from Indonesian women exposed to DDT through malaria eradication schemes and were similar to levels reported from UK and Japan.

Appl Occup Environ Hyg 2003; 18: 418-29
Characterization of agricultural tasks performed by youth in the keokuk county rural health study
Park H, Reynolds SJ, Kelly KM, Stromquist AM, Burmeister LF, Zwerling C, Merchant JA
College of Public Health, The University of Iowa, Iowa City, Iowa

Injury and illness among youth working on farms are important problems. The types of farm tasks performed by children and the ages at which they begin these activities have not been well characterized. This cross-sectional study characterized agricultural work performed by adolescents in a rural Iowa county to better understand the patterns and extent of exposures to agricultural risk factors. This information will help to develop prevention strategies for agriculture-related injury and illnesses for children working on farms. The Keokuk County Rural Health Study is a prospective cohort study of randomly selected households in Iowa. In Round 2, all youth, aged 12 to 17 years participating in this population-based study, were asked about their use of farm machinery, work with livestock, pesticide handling, and other farm activities. The age at which they actually began these activities, the age they believed youth should start these activities, and sources of health and safety training they received were also ascertained. Adults in the study were asked the same questions about youth. Matched parental reports and opinions were compared to their children's reports and opinions using McNemar's chi-square tests. A total of 143 youth and 684 adults with farming experience completed the interviews. There were 118 pairs of parents and youth. Fifty percent of male youth, and 18 percent of females had performed agricultural work at some time in their life. Twenty-five percent of all male youth, and 5 percent of females were currently working on farms. Close to 30 percent had driven tractors, all-terrain vehicles, and pick-up trucks. Despite the legal prohibition of hazardous work by children under age 16, several younger children reported that they had driven a self-propelled combine, worked in silos, or handled and applied fertilizers in the past 12 months. Youth began riding on tractors at a mean age of 7. The mean ages for driving tractors and all-terrain vehicles were 11 and 10, respectively. The mean age for driving a self-propelled combine was 13. Children began applying or handling fertilizers at the age of 12. There were discrepancies between parent and youth reports regarding the frequencies, starting age, and opinions relative to performing agricultural tasks. These results suggest the need for implementing guidelines, particularly for age appropriate agricultural tasks.

Pediatrics 2003; 111(5 Pt 1): 956-63
Health services use by children of migratory agricultural workers: exploring the role of need for care
Weathers A, Minkovitz C, O'Campo P, Diener-West M
Department of Maternal and Child Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599-7445, USA.

OBJECTIVE: For migrant children: 1). to assess the determinants of health services use among users and nonusers of health services; 2). to evaluate the association between health status and health services use, while controlling for potential confounders. DESIGN: A cross-sectional household survey using multistage, partially random sampling to identify migrant families in eastern North Carolina. PARTICIPANTS: Adult caretakers of 1 randomly selected child under 13 years old. RESULTS: Forty-four percent of children (N = 300) visited a doctor in the preceding 3 months. Those visiting a doctor disproportionately reported having less than very good health (29% vs 10%), insurance (46% vs 11%), interpreters (45% vs 27%), a family member receiving Special Supplemental Nutrition Program for Women, Infants, and Children (50% vs 16%), and a legal caretaker (30% vs 18%). Compared with those without a doctor visit, a larger proportion of children visiting a doctor were 6 years or younger in age (71% vs 35%), born in the United States (51% vs 15%), female (64% vs 45%), and had not moved in 6 or more months (19% vs 10%). Controlling for enabling resource and sociodemographic confounders, children with less than very good health were 2.4 times more likely than those in very good health to have visited a doctor (95% confidence interval [1.1-5.2]). CONCLUSIONS: Migrant children using health services are distinct from nonusers with regards to sociodemographic factors, enabling resources, and need for care. Health services use is associated with less than very good perceived health, despite resource barriers and sociodemographic disadvantages. More efforts are needed to improve access to health care for migrant children.

Arch Dis Child 2003; 88: 621-5
Abnormal blood glucose concentrations on admission to a rural Kenyan district hospital: prevalence and outcome
Osier FH, Berkley JA, Ross A, Sanderson F, Mohammed S, Newton CR
Kenya Medical Research Institute (KEMRI), Centre for Geographic Medicine Research, Coast, Kilifi District Hospital, PO Box 230, Kilifi, Kenya.

AIMS: To determine the prevalence, clinical characteristics, and outcome of hypoglycaemia on admission in children at a rural Kenyan district hospital. METHODS: Observational study of 3742 children (including 280 neonates) in Kilifi District Hospital, Kenya. Main outcome measures: hypoglycaemia (blood glucose <2.2 mmol/l) and hyperglycaemia (blood glucose >10.0 mmol/l). RESULTS: Non-neonates: the prevalence of hypoglycaemia on admission was 7.3%. Severe illness, malnutrition, last meal >12 hours ago, and a positive malaria slide were independently associated with hypoglycaemia. Overall, mortality in hypoglycaemic children was 20.2% compared to 3.8% in normoglycaemic children (p < 0.001). The brunt of mortality in hypoglycaemic children was borne by those who were severely ill or malnourished (31.8%) as opposed to those who were neither severely ill nor malnourished (9.0%). Neonates: 23.0% of neonates were hypoglycaemic on admission. Inability to breast feed and weight <2500 g were independently associated with hypoglycaemia. Mortality was 45.2% compared to 19.6% in normoglycaemic neonates (p < 0.001). Hyperglycaemia was present in 2.7% of children and was associated with a higher mortality than normoglycaemia, 14.0% versus 3.8% respectively (p < 0.001). CONCLUSIONS: Hypoglycaemia is common in children admitted to a rural Kenyan district hospital and is associated with an increased mortality. Apart from features of severe illness and poor feeding, clinical signs have a low sensitivity and specificity for hypoglycaemia. Where diagnostic facilities are lacking, presumptive treatment of severely ill children is recommended. For other children, the continuation of feeding (by nasogastric tube if necessary) should be part of standard management.

Trop Med Int Health 2003; 8: 67-72
Health and nutritional status of orphans <6 years old cared for by relatives in western Kenya
Lindblade KA, Odhiambo F, Rosen DH, DeCock KM
Division of Parasitic Diseases, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, USA.

One of the consequences of the HIV/AIDS epidemic in sub-Saharan Africa is the increase in the number of orphans, estimated to have reached 6-11% of children <15 years old in 2000. Orphans who stay in their communities may be at increased risk for poor health due to reduced circumstances and loss of parental care. We have used data from a population-based study in rural western Kenya to compare basic health and nutritional indicators between non-orphaned children <6 years old and children who lost either or both of their parents. In June 2000, all children <6 years old who had been recruited for a cross-sectional survey in 60 villages of Rarieda Division, western Kenya, in June 1999 were invited to return for a follow-up survey. Basic demographic characteristics, including the vital status of the child's parents, and health histories were requested from all 1190 participants of the follow-up survey, along with a finger-prick blood sample for determination of malaria parasite status and haemoglobin (Hb) levels. Height-for-age (H/A) and weight-for-height (W/H) Z-scores were also calculated from anthropometric measurements. Overall, 7.9% of the children had lost one or both their parents (6.4% had lost their father, 0.8% had lost their mother and 0.7% had lost both parents). While there was no difference between orphans and non-orphans regarding most of the key health indicators (prevalence of fever and malaria parasitaemia, history of illness, Hb levels, H/A Z scores), W/H Z-scores in orphans were almost 0.3 standard deviations lower than those of non-orphans. This association was more pronounced among paternal orphans and those who had lost a parent more than 1 year ago. These results suggest that the health status of surviving orphans living in their community is similar to that of the non-orphan population, but longitudinal cohort studies should be conducted to determine better the overall impact of orphanhood on child health.

Am J Trop Med Hyg 2003; 68: 94-9
Prevalence and severity of malnutrition in pre-school children in a rural area of western Kenya
Kwena AM, Terlouw DJ, de Vlas SJ, Phillips-Howard PA, Hawley WA, Friedman JF, Vulule JM, Nahlen BL, Sauerwein RW, ter Kuile FOCentre for Vector Biology and Control Research, Kenya Medical Research Institute, Kisumu, Kenya

We determined the nutritional status of children less than five years of age in an area in rural western Kenya with intense malaria transmission, a high prevalence of severe anemia and human immunodeficiency virus, and high infant and under-five mortality (176/1,000 and 259/1,000). No information is available on the prevalence of malnutrition in this area. Three cross-sectional surveys were conducted between 1996 and 1998 to monitor the effect of insecticide-treated bed nets on child morbidity. Anthropometric indices are presented for 2,103 children collected prior to and during intervention (controls only). The prevalence of stunting (Z-scores for height-for-age [HAZ] <-2), wasting (Z-scores for weight-for-height [WHZ] <-2) and being underweight (Z-scores for weight-for-age [WAZ] <-2) was 30%, 4%, and 20%, respectively. This was severe (Z-score <-3) in 12% (stunting), 1% (wasting), and 5% (underweight) of the children. Few children less than three months of age were malnourished (<2%), but height-for-age and weight-forage deficits increased rapidly in children 3-18 months of age, and were greatest in children 18-23 months old (44% stunted and 34% underweight). While the mean HAZ and WAZ stabilized from 24 months of age onwards, they still remained substantially below the reference median with no evidence of catch-up growth. Malnutrition is likely to interact with infectious diseases, placing children 3-24 months of age at high risk of premature death in this area.

Am J Trop Med Hyg 2003; 68: 30-7
Comparison of government statistics and demographic surveillance to monitor mortality in children less than five years old in rural western Kenya
Arudo J, Gimnig JE, ter Kuile FO, Kachur SP, Slutsker L, Kolczak MS, Hawley WA, Orago AS, Nahlen BL, Phillips-Howard PA
Centre for Vector Biology and Control Research, Kenya Medical Research Institute, Centers for Disease Control and Prevention, Kisumu, Kenya

Estimates of mortality in children less than five years old using government civil registration statistics (passive surveillance) were compared against statistics generated by active demographic surveillance during a randomized controlled trial of permethrin-treated bed nets (ITNs) in western Kenya. Mortality rates were two-fold lower when estimated through civil registration compared with active prospective surveillance (rate ratio [RR] = 0.51, 95% confidence interval [CI] = 0.44-0.59). While civil registration underestimated deaths, particularly in the neonatal period, the age distribution of deaths in children 1-59 months of age was the same as with active surveillance. Seasonal mortality trends were also similar. There was no agreement between cause of death recorded by active and passive surveillance. Verbal autopsy estimated that half of all deaths were associated with malaria and pneumonia, but civil registration markedly under-reported these illnesses; incidence RR (95% CI) = 0.18 (0.14-0.24), and 0.05 (0.03-0.08), respectively, while over-reporting deaths due to measles (RR = 15.5 [95% CI = 7.3-33.2]). Government statistics under-represent mortality, particularly neonatal mortality, in children less than five years of age in rural areas of Kenya. They can provide accurate information on the age-distribution of deaths among children 1-59 months old, and on seasonal trends, but not on disease-specific mortality.

BJOG 2003; 110: 616-23
Avoidable stillbirths and neonatal deaths in rural Tanzania
Hinderaker SG, Olsen BE, Bergsjo PB, Gasheka P, Lie RT, Havnen J, Kvale G
Centre for International Health, University of Bergen, Norway

To determine the causes of stillbirths and neonatal deaths in the community in rural Tanzania and to evaluate whether the deaths were avoidable under the prevailing circumstances.Review of stillbirths and neonatal deaths.Rural northern Tanzania, Mbulu and Hanang districts.One hundred and nineteen stillbirth and neonatal deaths identified in a prospective cohort of antenatal attendees and 21 stillbirths and neonatal deaths identified retrospectively in a household survey in seven rural communities.Verbal autopsy was done to reach a diagnosis, in many cases supplemented with information from antenatal records and hospital records. The avoidability of deaths under the prevailing circumstances was assessed for each case. An account of risk factors detectable at antenatal clinic was done and compared with the woman's recall of the risk assessment and recall of being referred.Avoidability of stillbirths and neonatal deaths.There were 60 stillbirths, 49 early neonatal deaths and 27 late neonatal deaths. Infection-related deaths were most common (n = 53), followed by asphyxia-related deaths (n = 32) and immaturity-related deaths (n = 20). Malaria was the most common infectious agent observed (21 children and 20 mothers). Twenty-one deaths (15%) were probably avoidable and 13 (10%) were possibly avoidable. A patient-oriented avoidable factor was identified in 17 (51%) and a provider-oriented avoidable factor was identified in 22 cases (65%). Twenty-six of the 34 avoidable deaths had risk factors, but only two of the women were aware of it and only one recalled being referred to a hospital for the risk factor. There were eight deaths among the 133 mothers who experienced a perinatal death.Our data indicate that prevention and adequate treatment of infections and asphyxia in the newborn should have high priority in low-income settings. The relatively low proportion of avoidable stillbirths and neonatal deaths may be partly due to accessible emergency obstetric care in the area. Future efforts should emphasise improving the communication between midwife and women at the antenatal clinics, preparing the women-and their families-for the delivery and to be ready for complications.

J Trop Pediatr 2003; 49: 28-32
Percentage, bacterial etiology and antibiotic susceptibility of acute respiratory infection and pneumonia among children in rural Senegal
Echave P, Bille J, Audet C, Talla I, Vaudaux B, Gehri M
Department of Pediatrics, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland

Acute respiratory infections (ARI) are still a major health problem in most developing countries. So far no study has evaluated the importance of childhood ARI in rural Senegal. We prospectively studied ARI, the percentage of pneumonia and related mortality, as well as the bacterial composition of nasopharyngeal flora using nasopharyngeal aspirates in 114 children, aged 2-59 months, presenting at Ndioum's pediatric ward. Excluded from the trial were those children that had had antimicrobial therapy in the previous 2 weeks. The Kirby-Bauer method was used to determine antibiotic resistance throughout the study. The percentage of ARI and pneumonia among the population tested was 24 per cent and 11 per cent respectively. Streptococcus pneumonia was often resistant to cotrimoxazole (31 per cent) but only 9 per cent were resistant to chloramphenicol and 14 per cent to penicillin. Haemophilus influenzae (HI) was uniformly sensitive to ampicillin, and only 4 per cent were resistant to chloramphenicol and 11 per cent to cotrimoxazole. We conclude that SP and HI resistance to cotrimoxazole is important and warrants larger clinical trials using chloramphenicol. Information campaigns and intense management of comorbidities are desirable in this type of population. Comorbidities (tuberculosis, malaria, HIV-AIDS, severe malnutrition) are determinant variables in many ARI cases and carry a high negative prognosis value.

Am J Clin Nutr 2003; 77: 242-9
Titers of antibody to common pathogens: relation to food-based interventions in rural Kenyan schoolchildren
Siekmann JH, Allen LH, Watnik MR, Nestel P, Neumann CG, Shoenfeld Y, Peter JB, Patnik M, Ansari AA, Coppel RL, Gershwin ME
Department of Nutrition, University of California, Davis 95616, USA

BACKGROUND: Undernutrition is widely perceived to affect the development of an effective immune system. OBJECTIVE: We used a mini-analysis system to quantitate antibody titers and evaluate the sera of 200 Kenyan schoolchildren for antibodies to Helicobacter pylori [isotypes of immunoglobulins A (IgA), G (IgG), and M (IgM)], hepatitis A virus, rotavirus, tetanus toxoid (IgG), and a panel of recombinant malarial antigens (MSP1(19), MSP2, Ag512, MSP4, and MSP5). DESIGN: Children participated in a school-based feeding intervention with meat, milk, or nonanimal-source foods or in a nonintervention control group. Microvolumes (200 mL) of sera were analyzed at baseline and after 1 y. RESULTS: Nearly all children had elevated titers of antibody to H. pylori, hepatitis A virus, rotavirus, and malaria at the outset, despite a high prevalence of apparent biochemical micronutrient deficiencies and stunting, but many had titers of tetanus toxoid IgG antibodies below the protective concentration. Children with low hemoglobin had a greater proportion of elevated H. pylori IgM antibody titers at baseline, which suggests that current infection with H. pylori may be associated with anemia. Compared with the control subjects, only the group eating meat had a significant increase in H. pylori IgM antibodies during the intervention (P = 0.019). No other group comparisons with the control subjects were statistically significant. The additional finding that the sera of some children showed inadequate tetanus-protective antibodies, despite immunization, suggests that the vaccination program was suboptimal. CONCLUSIONS: A large battery of immune assays can be performed on microvolumes of sera. Furthermore, despite evidence of malnutrition, children do develop significant antibody-mediated responses to common pathogens.

Trop Med Int Health 2003; 8: 507-11
The association between protein-energy malnutrition, malaria morbidity and all-cause mortality in West African children
Muller O, Garenne M, Kouyate B, Becher H
Department of Tropical Hygiene and Public Health, Ruprecht-Karls-University, Heidelberg, Germany.

Both malaria and protein-energy malnutrition (PEM) are highly prevalent in young children of sub-Saharan Africa, and the association between PEM and malaria continues to be discussed controversially. We analysed the association between PEM, malaria morbidity and all-cause mortality in a cohort of 709 children aged 6-30 months in a malaria holoendemic rural area of Burkina Faso. Study children were followed over the main malaria transmission period (June-December) in 1999 through longitudinal malaria surveillance complemented by three cross-sectional clinical surveys. There was no association between PEM and malaria morbidity, but malnourished children had a more than two-fold higher risk of dying than non-malnourished children.

Lancet Infect Dis 2003; 3: 349-58
Measurement of trends in childhood malaria mortality in Africa: an assessment of progress toward targets based on verbal autopsy
Korenromp EL, Williams BG, Gouws E, Dye C, Snow RW
Malaria Control Department of WHO, Geneva, Switzerland

Reduction of deaths associated with malaria in children is a primary goal of malaria control programmes in Africa, but there has been little discussion about how changes in mortality will be measured. This paper assesses recent historical changes in the contribution of malaria to child survival in Africa by examining data from demographic surveillance systems (DSS) in 25 mainly rural settings. The data were adjusted for the varying sensitivity and specificity of verbal autopsies (VA) in different ranges of malaria mortality and for varying parasite prevalences. Average malaria mortality in the DSS sites in west Africa was 7.8 per 1000 child-years between 1982 and 1998; the rate did not change significantly over this period. In the sites in east and southern Africa combined, malaria mortality was 6.5 per 1000 child-years between 1982 and 1989, but it increased to 11.9 per 1000 child-years between 1990 and 1998. All-cause child mortality and non-malaria mortality, by contrast, decreased significantly over time in both regions; consequently, the proportion of deaths due to malaria rose from 18% to 23% in west African sites and from 18% to 37% in east and southern African sites between 1982-89 and 1990-98. If malaria mortality fell at a rate consistent with the Roll Back Malaria target of halving malaria mortality by the year 2010, an individual DSS of a total population of 63 500 could with adequate VA adjustment detect this reduction after 7 years.

Trop Med Int Health 2003; 8: 431-8
Attitude of women in western Uganda towards pre-packed, unit-dosed malaria treatment for children
Kilian AH, Tindyebwa D, Gulck T, Byamukama W, Rubaale T, Kabagambe G, Korte R
GTZ Gesellschaft fur Technische Zusammenarbeit GmbH, Dept. Health, Education, Social Security, Eschborn, Germany.

In the context of a larger study on malaria related knowledge, attitudes, practices and beliefs in western Uganda 813 women aged 15-49 years were shown a sample of a pre-packed, unit-dosed malaria treatment for children, its use was explained and attitudes of the women were investigated. Of all women, 90.5% (86% urban, 92% rural) said they would prefer the pre-packed over the conventional type of treatment and 93.9% of these were willing to pay between 0.17 (rural) and 0.29 (urban) US dollars more for this treatment. Two-thirds (67.8%) thought that they would not have to ask their spouses before making a decision on the kind of treatment and 59.5% said they would rather stock the treatment at home than buy it when a child gets sick. The most mentioned reason for preferring pre-packs was their safety and cleanliness, while ease of application, dosing and compliance were secondary. We conclude that pre-packed, unit-dosed malaria treatment is accepted by the caretakers of children in the area studied and that they readily understand and accept its concept. This indicates a high potential for this approach to improve the home management of malaria fevers and reduce malaria-related morbidity and mortality if adequate coverage can be achieved and if the intervention is embedded into an appropriate programme of behavioural change communication and provider training.

Trop Med Int Health 2003; 8: 427-30
Treatment failure of pyrimethamine-sulphadoxine and induction of Plasmodium falciparum gametocytaemia in children in western Kenya
Bousema JT, Gouagna LC, Meutstege AM, Okech BE, Akim NI, Githure JI, Beier JC, Sauerwein RW
Department of Medical Microbiology, University Medical Centre St Radboud, Nijmegen, The Netherlands.

Sub-Saharan Africa faces increasing levels of resistance of Plasmodium falciparum parasites to the first-line drug pyrimethamine-sulphadoxine (SP). Successful treatment with SP is reported to induce gametocytes and drug resistance may further increase gametocytaemia after treatment. Treatment success, gametocyte prevalence and gametocyte density were determined in 224 asymptomatic children in western Kenya on day 7 after treatment with SP. Treatment failure (R2 or R3 resistance) was observed in 22% of the children. The relative risk to show gametocytes on day 7 after treatment in children with treatment failure was 4.1 (95% CI 1.4-11.6) times higher compared to children with a sensitive infection, after adjustment for age and trophozoite density at the start of treatment. In addition, the gametocyte density was also higher upon SP treatment failure. These findings are reason for concern, as the increased gametocyte prevalence and density after SP treatment failure may increase the spread of SP-resistant strains in the population.

Trop Med Int Health 2003; 8: 12-16
Seizure disorders among relatives of Kenyan children with severe falciparum malaria
Versteeg AC, Carter JA, Dzombo J, Neville BG, Newton CRFaculty of Medicine, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands

PURPOSE: The cause of seizures in children with falciparum malaria is unclear. In malaria endemic areas, children who develop severe falciparum malaria with seizures may have a genetically higher risk of epilepsy or febrile seizures. We used the history of seizures in relatives of children previously admitted with malaria to determine if there is evidence for a familial predisposition of seizures in children admitted with malaria and seizures or cerebral malaria. METHODS: Family history of seizures were obtained from the parents/guardians of 81 children (35 children previously admitted with severe malaria and 46 children matched for age who had not been admitted with severe malaria). Data were collected on frequency, duration, age of onset, presence of fever and causes of seizures. RESULTS: The prevalence of seizures in the relatives of children not admitted with severe malaria was 4.3%, of whom 2.2% had a history of seizures compatible with febrile seizures, and 1.1% with epilepsy. Overall the odds ratio (OR) for relations of children admitted with malaria, to have a seizure disorder was 1.41 [95% confidence interval (CI) 1.06-1.88]. There was a significant risk of the relatives dying if they had epilepsy [relative risk 1.88 (95% CI 1.11-3.19)], but not for other seizure disorders (i.e. febrile, single or unclassifiable seizures). CONCLUSION: Relatives of children admitted with severe falciparum malaria are more likely to have a seizure disorder compared with controls, but it is unclear if this is because of a genetic propensity or caused by exogenous factors such as malaria.

Bull World Health Organ 2003; 81: 261-8
Self-treatment of malaria in rural communities, Butajira, southern Ethiopia
Deressa W, Ali A, Enqusellassie F
Department of Community Health, Faculty of Medicine, Addis Ababa University, Ethiopia.

OBJECTIVES: To quantify the use of self-treatment and to determine the actions taken to manage malaria illness. METHODS: A cross-sectional study was undertaken in six peasant associations in Butajira district, southern Ethiopia, between January and September 1999. Simple random sampling was used to select a sample of 630 households with malaria cases within the last six months. FINDINGS: Overall, 616 (>97%) of the study households acted to manage malaria, including the use of antimalarial drugs at home (112, 17.8%), visiting health services after taking medication at home (294, 46.7%), and taking malaria patients to health care facilities without home treatment (210, 33.3%). Although 406 (64.5%) of the households initiated treatment at home, the use of modern drugs was higher (579, 92%) than that of traditional medicine (51, 8%). Modern drugs used included chloroquine (457, 73.5%) and sulfadoxine-pyrimethamine (377, 60.6%). Malaria control programmes were the main sources of antimalarials. In most cases of malaria, treatment was started (322, 52.3%) or health services visited (175, 34.7%) within two days of the onset of symptoms. Cases of malaria in the lowland areas started treatment and visited health services longer after the onset of malaria than those in the midland areas (adjusted odds ratio, 0.44; 95% confidence interval (CI), 0.30-0.64; and adjusted odds ratio, 0.37; 95% CI, 0.25-0.56, respectively). Similarly, those further than one hour's walk from the nearest health care facility initiated treatment later than those with less than one hour's walk (adjusted odds ratio, 0.62; 95% CI 0.43-0.87). This might be because of inaccessibility to antimalarial drugs and distant health care facilities in the lowland areas; however, statistically insignificant associations were found for sex, age, and religion. CONCLUSION: Self-treatment at home is the major action taken to manage malaria. Efforts should be made to improve the availability of effective antimalarials to communities in rural areas with malaria, particularly through the use of community health workers, mother coordinators, drug sellers, and shop owners.

Parasitol Res 2003; 89: 252-8
Individual cases of autochthonous malaria in Evros Province, northern Greece: entomological aspects
Kampen H, Proft J, Etti S, Maltezos E, Pagonaki M, Maier WA, Seitz HM
Institute for Medical Parasitology, University of Bonn, Sigmund-Freud-Strasse 25, 53105 Bonn, Germany.

Prompted by four autochthonous cases of malaria in 1994 and 1995 in Evros Province, northern Greece, we conducted an entomological study between 1997 and 1999 in Nipsa and Chandras, rural locations where two of the four cases had occurred, and in Feres where two additional autochthonous malaria cases had been diagnosed in 1998. In Nipsa and Chandras, we identified 29 Anopheles breeding sites and characterized them by physicochemical parameters. Larvae were collected both at these sites and in a brackish water breeding site near Feres in the Evros River delta. Adults were caught in sheds at all three locations. Morphology was used to classify larvae and adults as A. superpictusor as species belonging to the A. claviger or A. maculipennis species complexes. The latter were further identified by PCR as being A. maculipennis s.s., A. melanoon and A. sacharovi. Of the A. maculipennis complex larvae collected inland, approximately 94% were A. maculipennis s.s. and 6% A. melanoon, whereas all larvae collected in the coastal region were A. sacharovi. In contrast, the A. maculipennis adults were A. maculipennis s.s. and A. melanoon (both 47%), and A. sacharovi (6%). In the coastal region, no A. maculipennis s.s. adults were caught. The ratio of A. melanoon adults collected to A. sacharovi was about 3:1. As shown by a bloodmeal ELISA, only 5 of 266 fed females (1.9%) had ingested human blood, whereas 232 (87%) had fed on goats. Of the mosquitoes containing human blood, two were A. melanoon, one A. sacharovi and one A. maculipennis s.s. One human blood specimen could no longer be assigned to a particular mosquito.

Soc Sci Med 2003; 57: 155-65
Willingness to pay and determinants of choice for improved malaria treatment in rural Nepal
Morey ER, Sharma VR, Mills A
Department of Economics, University of Colorado, Campus Box 256, 80309-0256, Boulder, CO, USA

A logit model is used to estimate provider choice from six types by malaria patients in rural Nepal. Patient characteristics that influence choice include travel costs, income category, household size, gender, and severity of malaria. Income effects are introduced by assuming the marginal utility of money is a step function of expenditures on the numeraire. This method of incorporating income effects is ideally suited for situations when exact income data is not available. Significant provider characteristics include wait time for treatment and wait time for laboratory results. Household willingness to pay (wtp) is estimated for increasing the number of providers and for providing more sites with blood testing capabilities. Wtp estimates vary significantly across households and allow one to assess how much different households would benefit or lose under different government proposals.

Ethiop Med J 2003; 41: 25-34
Beliefs and traditional treatment of malaria in Kishe settlement area, southwest Ethiopia
Adera TD
Assela Hospital, Assela, P.O. Box 105, Arsi, Ethiopia

Kishe settlement area southwest Ethiopia, is endemic for malaria, and malaria-related morbidity and mortality are important public health problems. Malaria beliefs and practices are often related to culture, and can influence the effectiveness of control strategies. This study assessed attitude and practices relative to causation, treatment, prevention and control of malaria, and documented traditional malaria treatment practices and remedies, in order to provide baseline data for control program planning and further investigation. A cross-sectional study was conducted in December 1997 by interviewing 254 randomly selected study subjects 85 indigenous and 169 settlers. Eighty three percent of 254 respondents attributed the cause of malaria infection to dirt and rubbish. Ranking of vector control measures was poor, with 77% prioritizing cleaning dirt and rubbish, while only 36% mentioned drainage of swampy areas. Ninety eight percent accepted Dichlorodiphenyltrichlroethane (DDT) house spraying. The prevalence of clinical malaria attacks was 77% and communities had good knowledge about malaria morbidity and mortality. Forty three percent had used traditional medicine for malaria, for reasons including greater accessibility (82%), low cost (48%), lack of awareness about modern medicine (25%) and belief that traditional medicine is better (7%). Most are well informed about malaria morbidity and mortality, understood about the use of DDT spraying and have good treatment seeking behavior but practice of prevention and concept about causation prevention, and control of malaria is poor. It is wise to put emphasis on health education particularly on preventive aspects. Malaria control technicians and environmental health technicians, who closely interact with the community could be used for this purpose. The common traditional treatments for malaria could be further investigated for their effects on malaria parasites and/or symptomatic relief of clinical illness.

Trop Med Int Health 2003; 8: 459-70
Living in the paddies: a social science perspective on how inland valley irrigated rice cultivation affects malaria in Northern Cote d'Ivoire
De Plaen R, Geneau R, Teuscher T, Koutoua A, Seka ML.
International Development Research Centre, Ottawa, Canada.

The potential impact of irrigated agriculture on water-related vector-borne diseases has been an increasing source of concern for researchers from the bio-medical sector. While most research on the potential impacts of irrigation on the health of local populations focuses on vector densities, levels of exposures, health services and technologies (prophylaxis, mosquito nets), we argue that it is essential to enlarge the scope of investigation and consider the complex mechanisms by which factors such as agriculture-generated changes in ecosystems, gender repositioning in the family organization as a result of access to new crops, and production activities combine together in increasing disease risks and producing new scenarios in the management of disease. This paper presents the results of an investigation of how transformations induced on the local society by the intensification of inland valley irrigated rice cultivation influence malaria health care systems and modulate risks to the health of local populations, within well-defined geographical boundaries in northern Cote d'Ivoire. Our results indicate that socio-economic transformations and gender repositioning induced, or facilitated, by the intensification of inland valley irrigated rice cultivation lead to a reduction of the capacity of women to manage disease episodes, contributing therefore to increase malaria incidence among farming populations.

Trop Med Int Health 2003; 8: 518-24
Self-reported compliance with last malaria treatment and occurrence of malaria during follow-up in a Brazilian Amazon population
Duarte EC, Gyorkos TW
Pan American Health Organization, Special Program for Health Analysis/Health Analysis and Information System, 525 23rd Street N.W., Washington DC 20037, USA

The objective of this study was to describe the association between self-reported compliance with last malaria treatment (CMT) and occurrence of malaria during follow-up, controlling for current risk factors. We conducted a prospective open cohort study in Leonislandia, a rural area of Peixoto de Azevedo City, in the Amazon region of Mato Grosso, Brazil. A total of 414 individuals were interviewed at baseline regarding CMT and followed-up for either 8 or 4 months to assess malaria incidence. The associations between CMT and occurrence of malaria were examined through multiple linear regression (when the outcome was malaria episode frequency) or Cox regression (when the outcome was time to malaria onset). Poor CMT (prior to baseline) was identified as an important predictor of the occurrence of subsequent malaria episodes during follow-up among individuals with an indication of being less immune - those whose first malaria episode was relatively recent or those who had an increased number of malaria episodes during the last 2 years. Moreover, surprisingly, it seems that for individuals who are probably more immune (individuals who had experienced their first malaria episode more than 4.5 years previously or those with few or no malaria episodes during the last 2 years), CMT was found to be a poor predictor of increased risk of subsequent malaria. These findings provide compelling evidence for the need to further study CMT and its effect on malaria outcomes.

Rev Inst Med Trop Sao Paulo 2003; 45: 29-34
Clinical and laboratory findings of Plasmodium vivax malaria in Colombia, 2001
Echeverri M, Tobon A, Alvarez G, Carmona J, Blair S
Grupo Malaria, Universidad de Antioquia, Carrera 51D #62-29, Medellin, Colombia

A descriptive study was carried out in 104 patients with Plasmodium vivax malaria, from the region of Turbo (Antioquia, Colombia). Clinical features and levels of hemoglobin, glycemia, serum bilirubin, alanine-aminotransferase (ALT), aspartate-aminotransferase (AST), creatinine and complete blood cell profile were established. 65% of the studied individuals were men and their mean age was 23. Of all individuals 59% had lived in the region for > 1 year and 91% were resident in the rural area. 42% were farmers and 35% had a history of malaria. The mean parasitaemia was 5865 parasites/mm3. The evolution of the disease was short (average of 4.0 days). Fever, headache and chills were observed simultaneously in 91% of the cases while the most frequent signs were palmar pallor (46%), jaundice (15%), hepatomegaly (17%), and spleen enlargement (12%). Anemia was found in 39% of the women and in 51% of the men, 8% of individuals had thrombocytopaenia and 41% had hypoglycemia.

Am J Trop Med Hyg 2003; 68: 624-8
Performance of the OptiMAL test for malaria diagnosis among suspected malaria patients at the rural health centers
Iqbal J, Muneer A, Khalid N, Ahmed MA
Department of Microbiology, Faculty of Medicine, Kuwait University, Safat, Kuwait.

The OptiMAL test detects both Plasmodium falciparum and P. vivax malaria infections. In this study, we evaluated the performance of the OptiMAL test at the Basic Health Units (BHUs) and the District Health Quarter (DHQ) Center in rural villages of Punjab, Pakistan that provide minimal health services. Two sets of blood specimens obtained from 930 suspected malaria patients attending these BHUs were tested at BHUs and the DHQ Center by microscopy and the OptiMAL test. At the BHUs, 231 (25%) of the patients were positive by microscopy and 278 (30%) patients tested positive by the OptiMAL test. At the DHQ Center, microscopic analysis of a second set of specimens from the same patients confirmed the malaria infection in 386 (42%) patients and the OptiMAL test result was positive in 300 (32%) patients. To determine the performance of OptiMAL test at the BHUs and the DHQ Center, all data were compared with microscopy results obtained at the DHQ Center. The OptiMAL test results for P. falciparum at the BHUs were comparable to those of the OptiMAL test at the DHQ Center. However, the sensitivity, positive predictive value (PPV), and negative predictive value (NPV) of the OptiMAL test were considerably lower for P. vivax infections than for P. falciparum infections, irrespective of whether the test was performed at the BHUs or at the DHQ Center (P. falciparum: sensitivity = 78-85%, PPV = 89-97%, NPV = 96-98%; P. vivax: sensitivity = 61-76%, PPV = 88-95%, NPV = 90-93%). The OptiMAL test also detected a number of false-positive and false-negative results at both the BHUs and the DHQ Center. The false-positive results ranged from 1% to 2%; however, the number of false-negative results was much higher (BHUs: P. falciparum = 22%, P. vivax = 39%; DHQ Center: P. falciparum = 15%, P. vivax = 24%). In conclusion, these results, when combined with other advantages of the OptiMAL test, suggest that this test can be used by relatively inexperienced persons to diagnose malaria infection in rural areas where facilities for microscopy are not available.

Trop Med Int Health 2003; 8: 536-43
Malaria dipsticks beneficial for IMCI in Cambodia
Rimon MM, Kheng S, Hoyer S, Thach V, Ly S, Permin AE, Pieche S.
Paediatric Research Centre, Tampere University Hospital, Tampere, Finland.

OBJECTIVES: The Integrated Management of Childhood Illness (IMCI) approach and new clinical treatment guidelines to control malaria among children less than 5 years old were introduced recently in Cambodia. This study was conducted to finalize the malaria part of the national IMCI fever chart. METHODS: A total of 323 sick children 2-59 months old were studied at rural health centres in northern Cambodia from February to April 2000. Cases with fever (by axillary temperature or history) or anaemia (by palmar pallor) were tested with dipsticks for Plasmodium falciparum and Plasmodium vivax in high and low malaria risk areas and, if positive, treated with anti-malarials. RESULTS: The draft IMCI chart identified children with malaria safely and effectively (sensitivity 14 of 15, approximately 93% and specificity 292 of 308, approximately 95%). The study confirmed the potential of malaria dipsticks as a part of IMCI case management. CONCLUSION: The Cambodian Ministry of Health will use the studied malaria chart during the Early Implementation Phase of IMCI. Dipsticks able to detect P. falciparum and P. vivax with high sensitivity and acceptable cost will be needed for this purpose. To promote the rational use of dipsticks, the National Centre for Malaria Control, Parasitology and Entomology (Centre National de Malaridogie, Parasitologie et Entomologie, CNM) should list all known malaria risk areas in the country and prepare detailed local maps guiding case management especially in transitional zones.

Trop Med Int Health 2003; 8: 512-17
Changes in house design reduce exposure to malaria mosquitoes
Lindsay SW, Jawara M, Paine K, Pinder M, Walraven GE, Emerson PM
Institute of Ecosystem Science, School of Biological and Biomedical Sciences, University of Durham, UK.

House design may affect an individual's exposure to malaria parasites, and hence to disease. We conducted a randomized-controlled study using experimental huts in rural Gambia, to determine whether installing a ceiling or closing the eaves could protect people from malaria mosquitoes. Five treatments were tested against a control hut: plywood ceiling; synthetic-netting ceiling; insecticide-treated synthetic-netting ceiling (deltamethrin 12.5 mg/m2); plastic insect-screen ceiling; or the eaves closed with mud. The acceptability of such interventions was investigated by discussions with local communities. House entry by Anopheles gambiae, the principal African malaria vector, was reduced by the presence of a ceiling: plywood (59% reduction), synthetic-netting (79%), insecticide-treated synthetic-netting (78%), plastic insect-screen (80%, P <0.001 in all cases) and closed eaves (37%, ns). Similar reductions were also seen with Mansonia spp., vectors of lymphatic filariasis and numerous arboviruses. Netting and insect-screen ceilings probably work as decoy traps attracting mosquitoes into the roof space, but not the room. Ceilings are likely to be well accepted and may be of greatest benefit in areas of low to moderate transmission and when used in combination with other malaria control strategies.

Infect Genet Evol 2003; 2: 185-92
Metapopulation concepts applied to falciparum malaria and their impacts on the emergence and spread of chloroquine resistance
Ariey F, Duchemin JB, Robert V
Groupe de Recherche sur le Paludisme, Institut Pasteur de Madagascar, BP 1274, Antananarivo 101, Madagascar.

Studying the structure of metapopulations is a new concept in population genetics of infectious diseases that is particularly adapted to the analysis of parasite populations. We considered one application of this theory focusing on Plasmodium falciparum populations. Our study consisted of three main steps: the relevance of the approach, the proposal of a simplified model using metapopulation concepts, and the exploration of the consequences on antimalarial drug resistance. Our main result concerns the metapopulation structure that is appropriate in some real situations. In intertropical rural Africa, parasite populations can be considered to be patchy, comparable to the panmictic situation in which a high transmission rate associated with a high prevalence (generally higher than 50%) implies that no diferenciation occurs between sub populations. In contrast, in Asia and South America, there are great variations in endemicity (with prevalences ranging from 0 to 100%) consistent with a typical metapopulation dynamic structure and a high probability of differentiation between patches. These findings agree with the observed emergence of chloroquine resistance in south-east Asia and South American but not in Africa, and with its rapid spread following its introduction.

Trop Med Int Health 2003; 8: 118-24
Reduced prevalence of Plasmodium falciparum infection and of concomitant anaemia in pregnant women with heterozygous G6PD deficiency
Mockenhaupt FP, Mandelkow J, Till H, Ehrhardt S, Eggelte TA, Bienzle U
Institut fur Tropenmedizin Berlin, Charite, Humboldt-Universitat zu Berlin, Germany.

Glucose-6-phosphate dehydrogenase (G6PD) deficiency confers protection against malaria in children, yet its role in malaria in pregnancy is unknown. In a cross-sectional study among 529 pregnant Ghanaian women, Plasmodium falciparum infection, anaemia and G6PD genotypes were assessed. Of these, 30.4% were heterozygous and 2.6% were homozygous for G6PD deficiency. The prevalence of P. falciparum infection decreased from 66% in G6PD-normal women to 58% in heterozygotes, and to 50% in individuals with homozygous G6PD deficiency (Chi2(trend) = 4.4, P = 0.04). Multivariate analysis revealed that in multigravid women but not in primigravidae, heterozygous G6PD deficiency was associated with a reduced risk of P. falciparum infection (Odds ratio (OR), 0.6; 95% confidence interval (95% CI), [0.4-0.9]). This protection against infection was limited to the third trimenon of pregnancy. In addition, heterozygous G6PD deficiency was associated with a reduced risk of anaemia among infected multigravidae (OR, 0.5 [0.3-1.0]). Pregnancy is a period of high vulnerability to malaria. The results of this study provide evidence for protection against malaria in pregnancy caused by heterozygous G6PD deficiency. This advantage, even if confined to multigravid women, may contribute to the selection of G6PD variants in malaria-endemic regions.

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