Geneva Health Forum Archive

Browse and download abstracts, posters, documents and videos from past editions of the GHF

Detecting Malaria in Refugees living in Non-Endemic Area: South Africa

Author(s) Joyce Tsoka-Gwegweni1, Uchenna Okafor2.
Affiliation(s) 1Public Health Medicine, University of KwaZulu-Natal, Durban, South Africa, 2Public Health Medicine, University of KwaZulu-Natal, Durban, South Africa.
Country - ies of focus South Africa
Relevant to the conference tracks Infectious Diseases
Summary The study presents findings from a research conducted in a refugee population in South African city known to be non-endemic to malaria transmission.
Background It is reported that 64% of malaria cases in South Africa are imported. This is expected given the high influx of refugees into the cities and reports by United Nations High Commission for Refugees that South Africa carries the highest number of asylum seekers globally. Although South Africa has planned to eliminate malaria by 2018, current interventions and research only take place in malaria endemic areas, which are remote and rural.
Objectives The aim of this study is to determine prevalence of malaria infection among a refugee population living in a malaria non-endemic city of KwaZulu-Natal province, South Africa.
Methodology After obtaining relevant approvals and consent, adult refugee participants were recruited from a faith-based facility offering social services in a city of KwaZulu-Natal province. The participants were screened for malaria using rapid diagnostic tests and confirmed with microscopy. Demographic data for the participants were obtained using a closed ended questionnaire.
Results Data were obtained for 303 participants consisting of 52% females and 48% males ranging from 19 to 64 years old. Of these 303 participants, 289 originated from different African countries, mainly central Africa. Two hundred and ninety participants provided a blood sample for screening of malaria. Of these, 3.8% tested positive for rapid diagnostic test and 5.2% for microscopy. The majority of malaria infections were due to Plasmodium falciparum.
Conclusion The study confirms important findings that include the prevalence of asymptomatic malaria infections detected in a refugee population and residing in an urban area of KwaZulu-Natal province that is not endemic for malaria. These findings have important implications for both public health and malaria control in South Africa, particularly since the country has decided to eliminate malaria by 2018. To achieve this goal, South Africa needs to expand research, surveillance and elimination activities to include non-endemic areas and marginalized communities. The findings further emphasize the importance of integrating services such as malaria surveillance into other public health intervention programmes, and provide refugees with full access to public health services. Other implications of the findings and possible challenges threating the success of the malaria elimination process and health service provision in South Africa are discussed.

Towards The Elimination Of New Pediatric HIV Infections.

Author(s) Olatunji Adetokunboh1.
Affiliation(s) 1Community Health, Stellenbosch University, Cape Town, South Africa.
Country - ies of focus South Africa
Relevant to the conference tracks Infectious Diseases
Summary In 2009, UNAIDS called for the virtual elimination of Mother to Child Transmission. In 2011, the Global Plan started and it covers all low and middle-income countries, but focuses on the 22 countries with the highest estimated numbers of pregnant women living with HIV. The data used were obtained from 2012 progress reports submitted by countries to UNAIDS and Spectrum software 2012 country files were used in monitoring the progress of these countries. From this study, Kenya, Namibia, South Africa, Swaziland and Zambia were the top progressing countries while India, Congo Democratic Republic, Nigeria, Angola, Chad and Mozambique were in the rear.
Background In 2009, the Joint United Nations Programme on HIV/VIGS (UNAIDS) called for the virtual elimination of Mother to Child Transmission, a call that has since been embraced by many agencies, regional coordinating bodies and national governments.
In 2011, at the United Nations General Assembly High Level Meeting on AIDS, global leaders made commitment with a plan towards the elimination of new HIV infections among children by 2015 and to keeping their mothers alive. This plan covers all low and middle-income countries, but focuses on the 22 countries with the highest estimated numbers of pregnant women living with HIV.
Objectives The objective of this study was to access the progress of the priority countries involved in Global Plan towards the elimination of new HIV infections in children and keeping their mothers alive.
Methodology Research question:
What is the progress made by the priority countries towards the elimination of new HIV infections in children and keeping their mothers alive.Methods:
The data used were obtained from 2012 progress reports submitted by countries to UNAIDS and Spectrum software 2012 country files. The study looked at the overall target 1 which is geared towards reducing the number of new HIV infections among children by 90%. The study also looked at Prong 3: Targets 3.1 - reducing mother-to-child transmission of HIV to 5% , Target 3.2 - having 90% of mothers receiving Perinatal antiretroviral therapy or prophylaxis and Target 3.3 - having 90% of breastfeeding infant-mother pairs receiving antiretroviral therapy or prophylaxis. The 2009 data serves as the baseline for this study.
Results For the overall target 1, the countries were categorized into 3 categories with 8 countries achieving rapid decline ( > 30%), 7 countries had moderate decline (20 -30%) while 5 countries had slow or no decline (10%) The percentage difference in reduction of mother-to-child transmission rate (%) (2009-2011), 9 countries (5 - 10%) and 5 countries (90%, 50-90% and < 50% in 3, 12 and 7 countries respectively.
By 2011, the percentages of mother-infant pairs receiving antiretroviral drugs to reduce transmission during breastfeeding were >50%, 21-50% and ≤20% in 3, 6 and 11 countries respectively. From this study, Kenya, Namibia, South Africa, Swaziland and Zambia were the top progressing countries while India, Congo Democratic Republic, Nigeria, Angola, Chad and Mozambique were in the rear. Notably, by 2009 Botswana had achieved some of the targets. Some of the countries did not provide adequate data for proper assessment.
Conclusion There was some level of progress among the priority countries in different areas geared towards reaching the elimination of new HIV infections in children, however some countries are still far behind. The performance in the area of mother - infant pairs receiving antiretroviral drugs is generally not encouraging. There is need for more drastic measures in the slowly progressing countries and keeping pace with the others. This research will be published in open access journals and presented to the research communities.

HIV Risk Perception among Injecting Drug Users in Egypt.

Author(s) Doaa Oraby1
Affiliation(s) 1Self employed, Self employed, Cairo, Egypt.
Country - ies of focus Egypt
Relevant to the conference tracks Infectious Diseases
Summary Egypt has low HIV prevalence (below 0∙02 %) among the general population mostly attributed to conservative culture. In 2010, transmission through injecting drug use represented around 5∙1% of reported cases and the 2010 second round biological/behavioral surveillance survey (Bio-BSS) conducted in some governorates revealed concentrated epidemic among male injecting drug users. The aim of the current study was to assess HIV risk perception among IDUs; to what extent is that risk perception attributable to the nature of HIV, the characteristics of the IDUs population and cultural considerations in Egypt in addition to identifying possible interventions to mitigate HIV infections among IDUs.
Background Egypt has low HIV prevalence (below 0∙02 %) among the general population mostly attributed to conservative culture. In 2010, transmission through injecting drug use represented around 5∙1% of reported cases and the 2010 second round biological/behavioral surveillance survey (Bio-BSS) conducted in some governorates revealed concentrated epidemic among male injecting drug users (IDUs). IDUs face the risks of HIV through the sharing of contaminated needles and other drug paraphernalia, and engaging in unprotected sex sometimes occurring under the effect of, or in exchange for drugs. Additionally, because of their legal status, IDUs are put in prison, where clean needles are harder to find, thereby raising the threat of HIV. Through sharing injection equipment, IDUs are also at particular risk for acquiring hepatitis C virus (HCV). HCV is one of the major health threats and leading causes of death in Egypt. The 2008 Egyptian Demographic Health Survey tested a representative sample of both urban and rural populations in the entire country for HCV antibody and the overall prevalence positive for antibody to HCV was 14.7 %. The current harm reduction interventions do not tackle HCV and only focus on HIV.
Objectives The aim of the current study was to assess HIV risk perception among IDUs; to what extent is that risk perception attributable to the nature of HIV, the characteristics of the IDUs population and cultural considerations in Egypt in addition to identifying possible interventions to mitigate HIV infections among IDUs.
Methodology The assessment included in-depth interviews with 50 IDUs (45 males and 5 females, who were very hard to locate as they are poorly connected compared to male IDUs) who were reached using respondent driven sampling technique. The interviews were structured around the themes of HIV transmission, how IDUs perceive their own risk of contracting HIV and their knowledge of the protective role of safe sex and safe injection practices, in addition to exploring the barriers that keep them from abiding to safe sex and injection behaviors. The study was conducted late in 2012. Informed consent was obtained from all interviewees after explaining the purpose of the study, asking permission to record the interview and assuring voluntary participation and confidentiality. Analysis was based on grounded-theory.
Results For most interviewed IDUs were poor and unemployed, and getting high is their only escape from the hardships they face daily so they inject drugs. Some tried to quit but failed. The majority of the interviewed sample reported that they never perceived HIV as a threat because they do not deal with HIV patients, HIV is uncommon in their communities and they do not go to the countries famous for the high rate of HIV infection. This is contrary to HCV which they perceive as a high threat prevalent among themselves. None of the interviewed IDUs could list all the correct methods of HIV transmission; the majority stated sexual contact as the mode of transmission and some stated infected blood but none mentioned syringes apart from them leading to abscess if frequently used. Interviewed IDUs stated sharing needles, syringes or paraphernalia at least once in the 3 months preceding the interviews. Sharing needles, syringes and paraphernalia when probed was affirmed as a mode of transmission of HCV, yet they do not consider they have an alternative. IDUs clarified that although syringes are cheap and available in pharmacies yet they share syringes rather than buying new ones because IDUs fear being detained as carrying syringes, particularly if drug contaminated, is a sufficient excuse for arrest by policemen who easily identify IDUs. Male IDUs revealed that under the influence of drugs they engage in sexual relations sometimes with the same sex though they are heterosexuals while few female IDUs admitted that they exchanged sex for drugs. Both admitted that in such impromptu encounters, using condom never crosses their minds. All interviewed male IDUs knew about condoms, some use condoms when not under the influence of drugs but not on regular basis while others hate condoms because they reduce pleasure. On the other hand, female IDUs stated that using condoms is not their decision. None of the interviewed IDUs linked non-use/irregular use of condoms to the possibility of contracting HIV but did link non-use to urinary discharge, itching and other genital manifestations.
IDUs revealed that owing to the sensitivity and stigma of drug use in Egypt conservative culture they fear disclosing their sexual and drug injection practices. Hence, they resort to self-treatment rather than going to doctors in case of abscess development or sexually transmitted infections which are common ailments among IDUs. When probed, IDUs stated that if acceptance by service providers, in addition to maintained  confidentiality was guaranteed, they would access health services in the case of aliments.
Conclusion Approaches that address the perceived benefits of safe injecting and safe sex and barriers to behavioral change among IDUs are needed with regard to HIV. Listening to IDUs enabled better understanding of HIV-related knowledge and perceptions which may contribute to the innovation of HIV prevention interventions for IDUs that could also lead to benefits regarding HCV which is currently a public health priority in Egypt. Addressing HIV and HCV simultaneously through competent trained providers will increase IDUs acceptability and commitment to the delivered interventions.

Clinical features to diagnose pneumonia in children under 5: A systematic review

Author(s) Clotilde Rambaud-Althaus1, Amani Shao2, Blaise Genton3, Valerie Dacremont 4
Affiliation(s) 1Epidemiology and Public Health department, Swiss Tropical and Public Health institute, Basel, Switzerland, Geneva, Switzerland, 2Amani research center, National Institute of Medical Research, Dar es Salaam, Tanzania, Dar es Salaam, Tanzania, 3Department of Ambulatory Care and Community Medicine – Infectious Disease Service, University Hospital, Lausanne, Switzerland, Lausanne, Switzerland, 4Epidemiology and Public Health department, Swiss Tropical and Public Health institute, Basel, Switzerland, Lausanne, Switzerland.
Country - ies of focus Global
Relevant to the conference tracks Infectious Diseases
Summary Pneumonia is the leading cause of child mortality. In low income countries only the clinical diagnosis is available. We undertook a systematic literature review to assess the diagnostic accuracy of WHO non-severe pneumonia case definition for children less than 5 years of age to identify which clinical features best predict pneumonia. Our preliminary results indicate that chest in-drawing and fast breathing appeared to be rule-in signs in the selected studies. The specificity of the WHO pneumonia case definition remained low, resulting in over-treatment of non-pneumonia cases.
Background Pneumonia is the leading cause of child mortality. Early identification and treatment of pneumonia in primary health care facilities is essential to decrease the number of deaths. In low income countries, primary care health workers have access to neither radiology nor laboratory support, and pneumonia diagnosis relies on simple clinical features. In the context of antibiotics resistance, the accuracy of the diagnosis is fundamental. The more accurate the diagnostic test will be, the more pneumonia cases will be identified and the less non-pneumonia conditions will be prescribed unnecessary antibiotics. The current WHO definition of pneumonia relies on cough, chest indrawing and fast breathing. Recent published studies suggest that antibiotics may not be beneficial to children with WHO non-severe pneumonia (cough + fast breathing), and that severe (but not very severe) pneumonia (cough + chest indrawing without general danger signs) may be safely managed at home with oral antibiotics.
Objectives Our aim was to review the accuracy of WHO non-severe pneumonia clinical case definition, and to identify which clinical features have value in predicting the diagnosis of pneumonia in children younger than 5 years presenting in outpatient facilities.
Methodology We undertook a systematic review, searching electronic databases (Medline, Embase, Cochrane database of systematic reviews) and reference lists of relevant studies. 1296 potentially relevant articles were identified. Studies were selected on the basis of 6 criteria: design (studies assessing diagnostic accuracy), targeted disease (pneumonia), participants (children aged 2 to 59 months), setting (ambulatory care), index tests assessed (clinical features), and sufficient data reported. Quality assessment was done using the Quality Assessment of Diagnostic Accuracy Studies criteria. In each individual study, we only considered for analyses the index tests that were not part of participants’ inclusion criteria. For each clinical feature, we calculated sensitivity, specificity, and positive and negative likelihood ratio (LR+ and LR-). Clinical features were considered as a rule-in sign if the positive likelihood ratio was above 5.0, and the rule-out sign was if the negative likelihood ratio was less than 0.2.
Results We included 14 studies in the analysis, assessing a total of 14 different clinical features. Likelihood ratios were highly varied in the included studies. Within the included studies, chest indrawing (1 study, LR+ 30.32), respiratory rate above 50 breaths/min in children aged 1 to 5 years (2 studies, LR+ 5.17 and 19.83), and caretaker reported breathlessness (1 study, LR+ 9.50) were identified as rule-in sign in individual studies. Only 2 studies reported clinical features with LR-
Conclusion No single clinical feature accurately predicted the diagnosis of pneumonia. The current WHO definition of non-severe pneumonia lead to substantial overtreatment of non-pneumonia cases, which is an issue with regards to the rapid spread of antibiotic resistance. Point-of-care tests identifying bacterial pneumonia are highly desirable to further improve diagnosis accuracy.

Institutional Complexity as a Challenge for a Coherent HIV Control Policy: Brussels.

Author(s) Christoph Schweikardt1, Yves Coppieters2.
Affiliation(s) 1School of Public Health, Université Libre de Bruxelles, Brussels, Belgium, 2School of Public Health, Université Libre de Bruxelles, Brussels, Belgium.
Country - ies of focus Belgium
Relevant to the conference tracks Infectious Diseases
Summary The Brussels Region is an example of the challenges in implementing global principles in the fight against HIV/AIDS locally. This is due to divided legal competencies between the Federal and the Federate (Communities, Regions) level resulting a complex legal and administrative structure and multiple coordination processes between governments. Growing Federal government commitment led to the preparation of a national plan HIV/AIDS which provides an opportunity to pass from confirmatory legislation to a new agreed HIV/AIDS action framework.
Background According to the Belgian Scientific Institute for Public Health (WIV-ISP), more than one third of HIV positive persons in Belgium, of whom the residence was known at the time of diagnosis, reside in the Brussels Region. In April 2004, the "Consultation on Harmonization of International AIDS Funding" recommended three general principles in the fight against HIV/AIDS. The first is an agreed AIDS action framework that provides the basis for coordinating the work of all partners, the second a national AIDS coordinating authority, with a broad-based multisectoral mandate; and thirdly an agreed country-level monitoring and evaluation system. The implementation of these principles poses serious challenges to countries with a complex distribution of legal competencies in health care such as Belgium. In Belgium, health care competencies are divided between the Federal level (treatment) and the sub-national Federate entities, the Regions and the Communities (prevention, health promotion). The Flemish and the French Communities exercise their legal competences concurrently in the Brussels Region, thereby increasing institutional complexity in Brussels. Furthermore, Federal legislation cannot overrule the legislation of the Communities and the Regions in their respective areas of competence.
Objectives The aim of this study is to describe the consequences of institutional complexity with regard to the different governments which are influential within the territory of the Brussels Region in the fight against HIV/AIDS and the role of Federal government as a key actor in this regard.
Methodology In order to elicit the cooperation between the different governments and the role of the Federal government, government publications and documents relating to HIV/AIDS prevention and control, such as policy statements and reports (Federal, Communities, Regions), the documentation of parliamentary debates and published personal statements of representatives were assessed, complemented by participation in the sub-workgroup "Test and treat" of the Belgian National Plan HIV/AIDS and also subsequent informal conversations with experts were carried out.
Results The legal competence of the Communities in the field of prevention led to cooperation arrangements with different parts of the Brussels government according to their competence of the Dutch- and French-language institutions, respectively. Federal government commitment increased since 2006 by:(1) taking over the financing of free and anonymous HIV testing from Doctors Without Borders (Médecins Sans Frontières, MSF) in Brussels after their decision to withdraw. This resulted in a Federal pilot programme of anonymous and free testing for the three Regions (Flanders, Wallonia, Brussels) in 2006 and subsequent legislation with the royal decree of December 28, 2006 as the initiating key document.

(2) taking the initiative for the National Plan HIV/AIDS by negotiating support from the Federate entities in the inter-ministerial conference in 2012 and chairing its preparation until the following year. Experts and workers in the field from all Regions were appointed to workgroups / sub-workgroups on prevention, screening, and care of HIV-infected persons in order to work out recommendations by June 2013. These were taken up by the Federal government in order to negotiate potential future actions with the Federate entities before publishing the plan.

Conclusion The experience of the Brussels governments indicates that institutional complexity is unlikely to be reduced in the short run.  The limits of civil society engagement concerning HIV testing in Brussels prompted Federal government into action. The National Plan HIV/AIDS provides an opportunity for a new agreed AIDS action framework and for passing from confirmatory to pro-active legislation. In this regard, the strong point of the approach of Federal government was that it chose a step by step approach that involved decision-making bodies and practitioners in order to obtain as high a commitment as possible. The process shows how a government can exploit its scope of action notwithstanding legislative limitations and institutional complexity.

Community Case Management of Malaria in Trained Role Model Caregivers of Under Fives, Kaduna Northwestern Nigeria

Author(s) Aisha Ahmed Abubakar1, Kabir Sabitu2, Andreas Jansen3, Nykiconia Preacely 4, Mu'awiyya Sufiyan 5, Suleman Hadejia Idris6, Ikeoluwapo Ajayi7.
Affiliation(s) 1Department of Community Medicine, Faculty of Medicine, , Ahmadu Bello University/ African Program for Advanced Research Epidemiology Training, Zaria, Nigeria, 2Department of Community Medicine, Ahmadu Bello University, Zaria, Nigeria, 3Scientific Advice Co-ordination Section, European Centre for Disease Control and Prevention, Stockholm, Sweden, 4Division of Global Health, Centres for Disease Control and Prevention, Atlanta, United States, 5Department of Community Medicine, Ahmadu Bello University, Zaria, Nigeria, 6Department of Community Medicine, Ahmadu Bello University Zaria, Zaria, Nigeria, 7Department of Epidemiology and Biostatistics, University of Ibadan, Ibadan, Nigeria.
Country - ies of focus Nigeria
Relevant to the conference tracks Infectious Diseases
Summary Use of Role Model Caregivers for Community Case Management of Malaria achieved the 80% treatment target of malaria within 24 hours of onset of symptoms. Continuing training and supervision are necessary for correct dosage to be given.
Background Malaria is Africa’s leading cause of under five mortality, constituting 10% of the overall disease burden. A major strategy for reducing the burden of malaria is prompt access to effective antimalarials. Community Case Management of malaria (CCMm) can be used to achieve the 80% treatment target of uncomplicated malaria within 24 hours of the onset of symptoms. CCMm aims to train selected community members to recognize symptoms of malaria and give appropriate early and prompt treatment.
Objectives This study was conducted to assess CCMm in trained Role Model caregivers (RMCs) of under fives in Kaduna state, Nigeria.
1. To assess knowledge of malaria amongst role model caregivers trained in CCMm trained in Kaduna state
2. To assess treatment practices of malaria in CCMm trained role model caregivers in Kaduna state
3. To assess the relationship between knowledge and treatment practices of malaria in CCMm trained role model caregivers in Kaduna state
Methodology • What is the current knowledge of malaria in Community Case Management of malaria trained role model caregivers in Kaduna state?
• What are the malaria treatment practices of CCMm trained role model caregivers in Kaduna state?A descriptive cross sectional survey was conducted in Kaduna state. A sample of 308 RMCs were selected by multistage sampling and interviewed using a standardized questionnaire. The questionnaire had questions on sociodemographics, malaria transmission and treatment. Focus Group Discussions with RMCs were also conducted.
Results Mean age of RMCs was 35.34 years (±8.67). Females were 294(95.5%) and 285(92.5%) were literate. Out of 308, 294 (95.5%) correctly identified malaria was transmitted by mosquitoes. Two hundred and sixty three (85.4%) RMCs had treated a child under five years in the two weeks preceding the survey. Age range of children treated for malaria was 4-59 months, mean 26.9 months (±12.41). Out of 263 children, 232 (88.2%) received the correct dose of antimalarials and 220(84.3%) were treated within 24 hours of onset of symptoms. Level of education and literacy level were not significantly found to affect receiving the correct dose of antimalarials.
Limitations
The baseline knowledge of the trained role model caregivers is not available so change in knowledge cannot be assessed
Conclusion Use of RMCs achieved the 80% treatment target of malaria within 24 hours of onset of symptoms. Continuing training and supervision are necessary for correct dosage to be given. The results would be disseminated to the Kaduna state Malaria Control Program and the Department of Public Health of the Kaduna state Ministry of Health.

Noma: the mask of poverty

Author(s) Angèle Gayet-Ageron1, Denise Baratti-Mayer2, Patrice François3, Brigitte Pittet-Cuenod 4, Alain Gervaix 5, Jacques Schrenzel6, Andrea Mombelli7, Didier Pittet8
Affiliation(s) 1Division of Clinical Epidemiology, University hospitals of Geneva, Geneva, Switzerland, 2Division of Plastic and Reconstructive Surgery, University hospitals of Geneva, Geneva, Switzerland, 3Genomic Research Laboratory and Clinical Microbiology Laboratory, University hospitals of Geneva, Geneva, Switzerland, 4Division of Plastic and Reconstructive Surgery, University hospitals of Geneva, Geneva, Switzerland, 5Department of Paediatrics, University hospitals of Geneva, Geneva, Switzerland, 6Department des laboratoires, University hospitals of Geneva, Geneva, Switzerland, 7Department of Periodontology and Oral Pathophysiology, School of Dental Medicine, University of Geneva Faculty of Medicine, Geneva, Switzerland, 8Direction médicale, University hospitals of Geneva, Geneva, Switzerland
Country - ies of focus Niger
Relevant to the conference tracks Infectious Diseases
Summary To the best of our knowledge, this study is the first to assess both epidemiological risk factors and microbiology with a case-control design. From a practical perspective, our data confirm the importance of pre-existing malnutrition and the role of poverty in children with noma. Our results showed no involvement of specific bacteria in the cause of the disease. Overall, these data suggest new areas of research and draw attention to potential new primary preventive strategies to be developed for the disease.
Background Noma is a poorly investigated disease affecting young children living in the most deprived regions of the world, particularly sub-Saharan Africa. The lesion originates in the mouth and extends rapidly to the face, often leading to death or severe disfigurement in a high proportion of children. Malnutrition and debilitating diseases, such as malaria or measles, have been recognized as possible risk factors, thus leading to the hypothesis that the aetiology could be bacterial. However, this hypothesis has never been assessed in a case-control study.
Objectives We aimed to identify the epidemiological and microbiological risk factors associated with noma disease.
Methodology We conducted a prospective, matched, case-control study in Niger to identify the epidemiological and microbiological risk factors for noma. All acute cases of noma in children less than 12 years were included and 4 controls were matched by age and village of residence for each child. Epidemiological data and biological samples were collected for both cases and controls. Conditional logistic regression models were used.
Results We included 82 cases and 327 controls between August 2001 and October 2006. Noma was independently associated with severe malnutrition, the presence of respiratory disease, diarrhoea or fever in the past three months, and social indicators of precarity. The microbiological analysis showed differences in the proportion of some oral bacteria (Fusobacterium, Capnocytophaga, Neisseria and Spirochaeta) between cases and controls, but no specific agent was clearly associated with noma.
Conclusion Noma is associated with severe malnutrition and oral bacterial imbalance. The predominance of specific bacterial commensals is indicative of a modification of the oral microbiota associated with reduced bacterial diversity.

Irregular migration: malaria re-introduction in elimination settings.

Author(s) Kolitha Wickramage1, Sharika Peiris 2.
Affiliation(s) 1Health Unit, International Organization for Migration, Sri Lanka, Sri Lanka, 2Health Unit, International Organization for Migration, Sri Lanka, Sri Lanka.
Country - ies of focus Sri Lanka
Relevant to the conference tracks Infectious Diseases
Summary Irregular migration in the form of human smuggling and human trafficking is recognized as a global public health issue. Beyond the criminality and human rights abuse, irregular migration plays an important, but often forgotten, pathway for malaria re-introduction. We describe 32 cases of Plasmodium falciparum that were detected in 534 irregular migrants returning to Sri Lanka via failed human smuggling routes from West Africa in 2012, who contributed to the largest burden of imported cases in Sri Lanka which had entered elimination phase. Active surveillance of the growing numbers of irregular migrant flows becomes an important strategy as Sri Lanka advances towards goals of malaria elimination.
Background Sri Lanka is heralded as a ‘success story’ for malaria control in Asia having succeeded in reducing malaria cases
by 99.9% since 1999 and is aiming to eliminate the disease entirely by 2014. Since the end of the protracted civil conflict in 2009, there have been an unprecedented number of migrants leaving Sri Lanka to countries such as Australia, Canada and the UK via ‘irregular migration’ routes. An irregular migrant is defined as someone who, owing to illegal entry or the expiry of his or her visa, lacks legal status in a transit or host country. Irregular migration takes many forms, ranging from human smuggling to trafficking of persons for purpose of exploitation. Globally, the numbers of undocumented cases have increased despite spending on enforcement measures at the major destination countries.
Objectives This report focuses on a migrant flow of major importance for malaria importation that, until recently, has received little attention from public health authorities.
Methodology From the end of 2011, local and international law enforcement authorities intercepted people-smuggling operations from Sri Lanka to Canada across nine West African nations: Togo, Benin, Guinea, Sierra Leone, Mali, Ghana, Senegal, and Mauritania. In close coordination and partnership with the Governments of Sri Lanka, Canada and West African nations, IOM assisted these irregular migrants who were intercepted or detained, and returned to their place of origin. From January to December 2012, all irregular migrants returning from West African countries were subjected to malaria screening upon arrival at the Bandaranayke International Airport (BIA) in Sri Lanka. Screening was conducted on site using the rapid diagnostic test kit CareStart™ Malaria HRP2/PLDH, with 98% sensitivity and 97.5% specificity for Plasmodium falciparum, and microscopic examination of blood smears, collected at the airport and performed at the national reference laboratory. Health personnel from the airport medical unit, Anti-Malaria Campaign (AMC) and IOM officials were involved in facilitating the on-arrival screening process. Under a directive from the Anti-Malaria Campaign, repeat RDTs were carried out for all returnees at the district level within one week of their arrival at home destination. This intensive follow-up was carried out with the collaborative efforts of both the AMC and IOM field staff.
Results Of the total number of returnees screened (n=534), 32 were positive for P. falciparum. Nearly two thirds (n=19) were identified at the point of entry at the BIA and 13 during district level follow-up. The total number of malaria cases from irregular migration routes accounted for 76% (32/42) of the total number of P. falciparum cases detected in Sri Lanka in 2012. This route contributed to 46% (32/70) of the total number of imported malaria cases in the same year. Imported cases overtook indigenously acquired cases of malaria for the first time in Sri Lankan in 2012, contributing to three-quarters of the total malaria burden (70/93). The largest number of irregular migrants (n=17) had returned to Jaffna district which has the highest API of >0.2 to 0.3 in comparison to other districts in Sri Lanka.
Conclusion Malaria incidence in returnees from source countries has proven to be a sensitive predictor of malaria risk, particularly where there is sub-national transmission. The fact that the largest number of migrants returned to districts with the highest API indexes reported nationally is also significant. Re-introduction and risk of spreading the parasites occurs when there is a long-term return into areas of endemicity with presence and prevalence of the mosquito vector. For this reasons the close follow up and monitoring performed by the AMC and IOM field based teams is an important strategy. Unlike other categories of inbound migrants, such as tourists, who may also import malaria to the country, returning Sri Lankan citizens from endemic areas are more likely to be exposed to mosquito bites and hence are more likely to contribute to the spread of malaria upon return to their homes within locally endemic regions. Other inbound migration categories include: returning Sri Lankan labour migrant workers, Sri Lankan armed forces personnel from UN peace keeping missions, and returning students. The attack rate for malaria in this migrant group using irregular modes of travel is considerably high (sixty cases per 1,000) when compared to the risk of contracting malaria for regular travellers returning from West Africa at three per 1,000. For the migrants themselves, their ‘illegal’ status and clandestine nature of movements enhanced health vulnerability, including having little or no access to health care in transit countries.

Abused and Resistant: Antibiotics in Rural and Urban Nigeria.

Author(s) Hamidu Oluyedun1.
Affiliation(s) 1Pharmaceutical Servicea, State Hospitlas Management Board, Ibadan, Nigeria.
Country - ies of focus Nigeria
Relevant to the conference tracks Infectious Diseases
Summary The development of effective and safe drugs to deal with bacterial infections has reduced morbidity and mortality from microbial disease. This study aimed at identifying specific cultural, demographic and institutional factors in rural and urban settings in Ibadan, Nigeria. The research showed that the rise of drug-resistant bacteria “superbugs” is mainly a consequence of the overuse, inappropriate use and misuse of antibiotics which occurs across geographical, economic and social boundaries in the two communities. Pharmaceutical care interventions are needed in the communities to safeguard the health of the populace against bacteria resistance.
Background The development of effective and safe drugs to deal with bacterial infections has reduced morbidity and mortality from microbial disease. Nevertheless, the emergence of drug-resistant organisms as a result of environmental flexibility and genetic adaptability has imposes serious constraints on the options available for the medical treatment of many bacterial infections. Bacteria can spread resistance in bacterial populations from person to person.
This is a world-wide problem, which is particularly serious in low-income countries where many of the affordable antibiotics have become powerless due to resistance, and also where the newer, broad-spectrum antibiotics are a financial burden for the poor who cannot afford good medical care and expensive new antibiotics. High numbers of patients, lack of time, small resources and lack of diagnostic laboratory test are all confounding factors in abuse of antibiotics. Disease-causing microbes that have become resistant to antibiotic drug therapy are an increasing public health problem. Bacteria and other microbes that cause infections are remarkably resilient and have developed several ways to resist antibiotics and other antimicrobial drugs
Objectives This study attempted to identify specific cultural, demographic and institutional factors in rural and urban setting in Ibadan, Nigeria that favor resistance to antibacterial drugs. This will help the public health workers and policy makers to safeguarding public health by putting in place strategic interventions.
Methodology In Ibadan, Oyo Nigeria the study was carried out in two communities settings, one rural the other urban. The two settings were selected through stratified sampling method.  Through the multistage sampling method ten households were picked for six weeks recall on the use of antibiotics. A hospital was chosen within each setting.
The study was non-experimental and employed descriptive research design to describe data. Also, context and ethnographic analysis was used to analyze the data. The survey employed 10 in-depth interviews with policy makers, medical practitioners and community based pharmacists. Ten key-informant interviews were conducted for Patent Proprietary Vendor License holders (PPMVL holder), Head of Household and Hospitals staff. Four focus group discussion (FGDs) were held with 2 groups of nurses and two groups of PPMVL holders and ante-natal women. Ten Household recalls were undertaken in both the communities for six weeks.
The key informant interviews and in-depth interviews were analyzed through context analysis and ethnographic summary. This involved verbatim quoting of respondents to buttress certain arguments that arose during the course of the study. Content analysis involved critical evaluation of the respondents’ position on any issue.
Results The household recall revealed that remnants of antibiotics were found in 80% of the respondents. The adherence to antibiotics usage was extremely low: 30% in the rural setting and 70% in the urban setting. Incomplete prescription filling accounted for 70% of abused use of antibiotics in rural setting, whereas, it accounted for 20% in the urban area. In both settings the male abuse was a ratio of 2: 1, and this is likely connected with male dominance within the community. In the rural community 60% of the respondents had been treated with antibiotics 6 weeks preceding the study, and within the hospital 90% of those surveyed were already on antibiotics prior to consultation. In the urban setting 80% used antibiotics prior to the study and 40% that visited the hospital were on antibiotics prior to consultation. The most commonly used antibiotics were beta-lactams ampicillin, amoxicillin, ciprofloxacin and co-trimoxazole. The urban setting respondents are now gradually moving towards third generation cephalosporin due to the failure of common antibiotics. It was discovered that most of the antibiotics were purchased from small private shops with unqualified personnel. The ability to correctly diagnose and treat was worse in the rural setting. Various case mismanagements were found in the rural setting. The majority of the respondents in both rural and urban settings consulted and purchased antibiotics from mega source. The health–seeking behaviour of the respondents is based upon personal decisions of what to buy, which is in turn influenced by the out-of-pockets payment, health literacy and previous experience. There is high rate of antibiotics used and over 50% of this use represented self–medication. The result revealed that health literacy had positive effect on self-care. The educated in both communities to non-educated was ratio 1:4 when it comes to antibiotics self medication. Also, financial power plays significant roles in the ability to fill prescriptions and buy the recommended dose of antibiotics. Non-adherence is 80% in the rural setting compare to 20% in urban. The community cannot be blamed for this because the entire local government of Oluyole, with over 100,000 residents, has only 23 health personnel in the state owned Health facilities compared to 557 in Ibadan North West,  an urban setting with four State owned Health facilities (MOH, 2009). The result revealed that pressure to use cheaper, proven drugs, led health care providers to over-prescribe antibiotics.
Conclusion The rise in drug-resistant bacteria “super-bugs” is mainly a consequence of the overuse, inappropriate, and misuse of antibiotics which occurs across geographical, economic and social boundaries in the two communities. The two communities are already reporting ineffectiveness and lack of confidence in the common antibiotics found in the communities. Pharmaceutical care interventions are needed in the communities to safeguard the health of the populace against bacteria resistance. The study revealed that there are discrepancies between knowledge and practice among healthcare providers and health literacy is poor in the two communities. In addition, there are no antibiotic prescription policies to guide prescribers and there is easy access in the community to antibiotics. The drug providers/vendors require regular training, monitoring and proper surveillance.

Economic Benefits of Antiretroviral Therapy for HIV/AIDS Patients in Nigeria.

Author(s) Kingsley Nnanna Ukwaja1.
Affiliation(s) 1Department of Medicine, , Federal Teaching Hospital, Abakaliki, Ebonyi State, Nigeria, Abakaliki, Ebonyi State, Nigeria 2
Country - ies of focus Nigeria
Relevant to the conference tracks Infectious Diseases
Summary Little is known about the economic benefits of antiretroviral therapy (ART) for HIV/AIDS-patients and their households. We conducted a descriptive study among 1176 HIV/AIDS patients on ART to assess their present status of employment, household poverty and its determinants. About 88% of the patients had stable jobs. Employment rates increased with duration on ART (P=0.033). Overall, poverty rates were 86% of households of HIV-patients ≤1 year on ART while 39% for HIV-patients >1 year on ART (P <0.001). Poverty rates decreased with increasing duration of ART use (P <0.001). ART use decreases poverty among households of HIV/AIDS patients in Nigeria.
Background Although clinical, immunologic, and virologic effects of antiretroviral therapy (ART) for people living with human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) are well-documented, far less is known about the economic benefits of treatment of HIV/AIDS for patients and their households. ART use has been shown to improve work performance, reduce absenteeism and increase employment rates following job loss due to HIV/AIDS. Furthermore, recent longitudinal studies indicated that ART use resulted in a rapid increase in employment and income for patients. The findings of these studies were limited by high attrition rates. Secondly, in low-income countries, ART is started after a substantial drop in the immunity of HIV patients. These studies mainly compared the economic indices of healthy ART-naïve HIV patients with those of immune-depressed patients on ART. Healthy ART-naïve HIV patients are more likely to be employed, maintain productivity, and decrease absenteeism, while ill HV-patients may require some time to become strong enough to work. Thus it is still not clear if these improvements in economic indices from ART and its sustained use in the long-term translate to poverty reduction among HIV/AIDS patients and their households.
Objectives The primary objective of this study was to investigate the rates of employment and poverty among HIV/AIDS patients receiving antiretroviral therapy and their households and to explore the relationships between household poverty and duration of antiretroviral therapy among HIV/AIDS patients in Nigeria.
Methodology A cross-sectional survey was conducted from April to May 2013 with 1,176 HIV/AIDS patients at a large tertiary hospital providing antiretroviral treatment services in South East, Nigeria. Socio-economic and clinical characteristics of the respondents were collected using in-depth interviews with structured questionnaires. Monthly household income was self-reported including all sources of each household member’s income such as salary, wages, pensions, relatives’ supports, interests and revenues. Other characteristics like patient employment status, duration on antiretroviral therapy, adherence to ART, e.t.c. were also obtained. Households earning below the national minimum wage were classified as poor. Also, the economic indices of HIV-patients on ART for one year or less were compared with those of patients who had been on ART for more than one year. Statistical analyses were conducted using Epi Info 3.5.2. Descriptive analyses were presented and multivariable logistic regression analysis was performed to identify independent determinants of household poverty.
Results We interviewed 1176 patients, accounting for 20% of total HIV patients in the study site. Mean age was 35.3 (standard deviation [SD] = 10) years, 71.4% were female, 92.9% had at least a formal education (six years of schooling), 53% were resident in the rural area, and the overall mean duration on ART was 33.2 (SD = 28.2) months. Almost 88% had stable jobs and the mean monthly household income was US$ 156 (SD = 183). The median duration on ART for HIV-patients was significantly associated with the likelihood of being employed (employed (31 months) versus unemployed (19months) using the Kruskal-Wallis test 4.56, P=0.033). Also 624 (53%) were from poor households. Overall 86% of households of HIV-patients who were one year or below on ART were poor, while 39% of households with HIV patients on ART for more than a year were poor (Chi-square 218; P
Conclusion Rates of employment increased and poverty rates decreased with increasing duration of ART among HIV/AIDS patients and their households in Nigeria. Integration of education about sustained use and improved ART adherence counselling, as well as social and financial protection services for HIV-patients belonging to the identified at risk-groups could further reduce poverty among their households and should be implemented. Overall, this study provides evidence that effective delivery of ART services in resource-constrained settings could improve employment rates of HIV patients and reduce poverty among their households. The study findings have important implications for policy. Low-income countries, especially those with high burden of HIV, must further decentralize HIV/AIDS care services to rural and remote communities, for example through integration with primary health care services as an intervention to reduce poverty in people living with HIV/AIDS. Future studies to assess the impact of these interventions are urgently needed in resource-limited settings.