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Objectives To assess hypertension prevalence and the extent and associated factors of hypertension diagnosis, follow‐up, treatment and control gaps in low‐income urban Medellin, Colombia. Methods We randomly sampled 1873 adults aged 35 or older. Unaware hypertensive individuals were defined as those without previous diagnosis whose average blood pressure was equal to or above 140/90 mmHg. For aware hypertensive patients, control was delimited as average blood pressure below 140/90 if under 59 years old or diabetic, and as less than 150/90 otherwise. We used logistic regression to identify care gap‐associated factors. Results Hypertension prevalence was 43.5% (95% CI 41.2–45.7). We found 28.2% aware and 15.3% unaware hypertensive individuals, which corresponds to a 35.1% (95% CI 31.9–38.5) underdiagnosis. This gap was determined by age, sex, education and lifestyle factors. 14.4% (95% CI 11.6–17.6) of aware hypertensive patients presented a follow‐up gap, 93.4% (95% CI 90.9–95.2) were prescribed antihypertensive drugs, but 38.9% (95% CI 34.7–43.3) were not compliant. The latter was strongly associated with follow‐up. The hypertension control gap in aware hypertensive patients, 39.0% (95% CI: 34.9–43.2), was associated with being older, having diabetes, weakly adhering to pharmacological treatment and receiving poor non‐pharmacological advice. Overall, 60.4% (95% CI 57.0–63.8) of aware and unaware hypertensive participants had either diagnosed but uncontrolled or undiagnosed hypertension. Conclusions We found high hypertension prevalence coupled with, from an international perspective, encouraging awareness and control figures. Still, there remains ample room for improvement. Our findings can assist in designing integrated primary healthcare measures that further strengthen equitable and effective access to hypertension care and control.

Objectives: Our aims were to examine AMR‐specific and AMR‐sensitive factors associated with antibiotic consumption in Nepal between 2006 and 2016, to explore health care‐seeking patterns and the source of antibiotics. Methods: Cross‐sectional data from children under five in households in Nepal were extracted from the 2006, 2011 and 2016 Demographic Health Surveys (DHS). Bivariable and multivariable analyses were carried out to assess the association of disease prevalence and antibiotic use with age, sex, ecological location, urban/rural location, wealth index, household size, maternal smoking, use of clean fuel, sanitation, nutritional status, access to health care and vaccinations. Results: Prevalence of fever, acute respiratory infection (ARI) and diarrhoea decreased between 2006 and 2016, whilst the proportion of children under five receiving antibiotics increased. Measles vaccination, basic vaccinations, nutritional status, sanitation and access to health care were associated with antibiotic use. Those in the highest wealth index use less antibiotics and antibiotic consumption in rural areas surpassed urban regions over time. Health seeking from the private sector has overtaken government facilities since 2006 with antibiotics mainly originating from pharmacies and private hospitals. Adherence to WHO‐recommended antibiotics has fallen over time. Conclusions: With rising wealth, there has been a decline in disease prevalence but an increase in antibiotic use and more access to unregulated sources. Understanding factors associated with antibiotic use will help to inform interventions to reduce inappropriate antibiotic use whilst ensuring access to those who need them.

Suicide by pesticide self-poisoning is a major public health challenge in low- and middle-income countries. While effectiveness studies are required to test alternative prevention approaches, economic evidence is lacking to inform decision-making in research priority setting. Therefore, this study aimed to estimate the costs of a shop-based gatekeeper training programme for pesticide vendors seeking to prevent pesticide self-poisoning in rural Sri Lanka and assess its potential for cost-effectiveness.Ex-ante cost and cost-effectiveness threshold (CET) analyses were performed from a governmental perspective based on a three-year analytic horizon, using 'no programme' as a comparator. A programme model targeting all 535 pesticide shops in the North Central Province and border areas was applied. Total programme costs (TPC) were estimated in 2019 USD using an ingredients approach and 3% annual discounting. The Sri Lankan gross domestic product per capita and life years saved were used as CET and effectiveness measure, respectively. Sensitivity analyses were performed.TPC were estimated at 31 603.03 USD. TPC were sensitive to cost changes of training material and equipment and the programme lifetime. The programme needs to prevent an estimated 0.23 fatal pesticide self-poisoning cases over three years to be considered cost-effective. In the sensitivity analyses, the highest number of fatal cases needed to be prevented to obtain cost-effectiveness was 4.55 over three years.From an economic perspective, the programme has a very high potential to be cost-effective. Research assessing its effectiveness should therefore be completed, and research analysing its transferability to other settings prioritised.Le suicide par auto-intoxication par les pesticides est un défi majeur de santé publique dans les pays à revenu faible ou intermédiaire. Bien que des études d'efficacité soient nécessaires pour tester d'autres approches de prévention, les données économiques manquent pour informer la prise de décision dans les priorités de recherche. Par conséquent, cette étude visait à estimer les coûts d'un programme de formation des vendeurs dans les magasins de pesticides visant à prévenir l'auto-intoxication par les pesticides dans les régions rurales du Sri Lanka et à évaluer son potentiel de rentabilité. MÉTHODES: Les analyses ex-ante des coûts et des seuils de rentabilité (SR) ont été réalisées dans une perspective gouvernementale sur la base d'un horizon analytique de trois ans, en utilisant «l’absence de programme» comme comparateur. Un modèle de programme ciblant les 535 magasins de pesticides de la province du Centre-Nord et des zones frontalières a été appliqué. Les coûts totaux du programme (CTP) ont été estimés en USD 2019 en utilisant une approche d’ingrédients et une remise annuelle de 3%. Le produit intérieur brut sri-lankais par habitant et les années de vie sauvées ont été utilisés comme SR et mesure d'efficacité, respectivement. Des analyses de sensibilité ont été effectuées. RÉSULTATS: le CTP a été estimé à 31.603,03 USD. Le CTP était sensible aux changements de coût du matériel et de l'équipement de formation et de la durée de vie du programme. Le programme devrait prévenir environ 0,23 cas d'auto-intoxication mortelle par des pesticide sur trois ans pour être considéré comme rentable. Dans les analyses de sensibilité, le plus grand nombre de cas mortels à prévenir pour obtenir une rentabilité était de 4,55 sur trois ans.D'un point de vue économique, le programme a un potentiel très élevé pour être rentable. La recherche évaluant son efficacité doit donc être complétée et la recherche analysant sa transférabilité à d'autres contextes doit être priorisée.

Ethiopia's HIV prevalence has decreased by 75% in the past 20 years with the implementation of antiretroviral therapy, but HIV transmission continues in high-risk clusters. Identifying the spatial and temporal trends, and epidemiologic correlates, of these clusters can lead to targeted interventions.We used biomarker and survey data from the 2005, 2011 and 2016 Ethiopia Demographic and Health Surveys (DHS). The spatial-temporal distribution of HIV was estimated using the Kulldorff spatial scan statistic, a likelihood-based method for determining clustering. Significant clusters (P 0.05) were identified and compared based on HIV risk factors to non-cluster areas.In 2005, 2011 and 2016, respectively, 219, 568 and 408 individuals tested positive for HIV. Four HIV clusters were identified, representing 17% of the total population and 43% of all HIV cases. The clusters were centred around Addis Ababa (1), Afar (2), Dire Dawa (3) and Gambella (4). Cluster 1 had higher rates of unsafe injections (4.9% vs. 2.2%, P 0.001) and transactional sex (6.0% vs. 1.6%, P 0.001) than non-cluster regions, but more male circumcision (98.5% vs. 91.3%, P 0.001). Cluster 2 had higher levels of transactional sex (4.9% vs. 1.6%, P 0.01), but lower levels of unsafe injections (0.8% vs. 2.2%, P 0.01). Cluster 3 had fewer individuals with 1 sexual partner (0% vs. 1.7%, P 0.001) and more male circumcision (100% vs. 91.3%, P 0.001). Cluster 4 had less male circumcision (59.1% vs. 91.3%, P 0.01).In Ethiopia, geographic HIV clusters are driven by different risk factors. Decreasing the HIV burden requires targeted interventions.La prévalence du VIH en Ethiopie a diminué de 75% au cours des 20 dernières années avec l’implémentation du traitement antirétroviral, mais la transmission du VIH se poursuit dans les grappes à haut risque. L'identification des tendances spatiales et temporelles et des corrélations épidémiologiques de ces grappes peut mener à des interventions ciblées. MÉTHODES: Nous avons utilisé des biomarqueurs et des données d'enquête provenant des Surveillances Démographiques et de Santé (SDS) en Ethiopie de 2005, 2011 et 2016. La distribution spatiotemporelle du VIH a été estimée à l'aide de la statistique de balayage spatial de Kulldorff, une méthode basée sur la probabilité de déterminer des regroupements. Des grappes significatives (P 0.05) ont été identifiées et comparées sur base des facteurs de risque du VIH dans les zones sans regroupements. RÉSULTATS: En 2005, 2011 et 2016, respectivement, 219, 568 et 408 personnes ont été testées positives pour le VIH. Quatre grappes de VIH ont été identifiées, représentant 17% de la population totale et 43% de tous les cas de VIH. Les grappes étaient centrées sur Addis-Abeba (1), Afar (2), Dire Dawa (3) et Gambella(4). La grappe 1 avait des taux plus élevés d'injections à risque (4,9% contre 2,2%, P 0.001) et de rapports sexuels transactionnels (6,0% contre 1,6%, P 0.001) que les régions sans regroupement, mais plus de circoncisions masculines (98,5% contre 91,3%, p0,001). La grappe 2 avait des taux plus élevés de rapports sexuels transactionnels (4,9% contre 1,6%, P 0.01), mais des taux inférieurs d'injections à risque (0,8% contre 2,2%, P 0.01). La grappe 3 avait moins d'individus avec1 partenaire sexuel (0% contre 1,7%, P 0.001) et plus de circoncisions masculines (100% contre 91,3%, P 0.001). La grappe 4 avait moins de circoncisions masculines (59,1% contre 91,3%, P 0.01).En Ethiopie, les grappes géographiques du VIH sont guidées par différents facteurs de risque. La réduction de la charge du VIH nécessite des interventions ciblées.

To describe socioeconomic inequalities in the utilisation of hypertension and type 2 diabetes (T2D) management services in the Indonesian population and to determine whether education level and geographical location contribute to inequalities.Cross-sectional study using data from the 2014 Indonesia Family Life Survey (N = 30 762 for hypertension; N = 6758 for T2D). Socioeconomic status was measured by household consumption. The prevalence of hypertension and T2D was determined using internationally standardised clinical measurement, while disease management was defined by participation in screening and current use of medication. The relative index of inequality (RII) was used to estimate inequalities, adjusted to education level and geographical location.For all household consumption quintiles, we observed low rates of screening participation for T2D and low medication use in both hypertension and T2D. We found socioeconomic inequalities in screening participation for hypertension (RII 2.68, 95% CI 2.42-2.96) and T2D (RII 7.30, 95% CI 5.48-9.72) and also for medication use in hypertension (RII 3.09, 95% CI 2.28-4.18) and T2D (RII 2.81, 95% CI 1.09-7.27). Education level contributed to socioeconomic inequalities in screening utilisation for both hypertension and T2D. Geographical location contributed to inequalities in screening utilisation and medication use for T2D. Socioeconomic inequalities in medication use for hypertension and T2D were larger among men than women.Large socioeconomic inequalities were found in the utilisation of hypertension and T2D management services in Indonesia. Improving affordability, availability and approachability of services is crucial to reduce such inequalities.INÉGALITÉS SOCIOÉCONOMIQUES DANS L'UTILISATION DES SERVICES DE PRISE EN CHARGE DE L'HYPERTENSION ET DU DIABÈTE DE TYPE 2 EN INDONÉSIE: OBJECTIFS: Décrire les inégalités socioéconomiques dans l'utilisation des services de prise en charge de l'hypertension et du diabète de type 2 (DT2) au sein de la population indonésienne et déterminer si le niveau d’éducation et la localisation géographique contribuent aux inégalités. MÉTHODES: Etude transversale utilisant les données de l'enquête 2014 sur la vie de famille en Indonésie (N = 30.762 pour l'hypertension; N = 6.758 pour le DT2). Le statut socioéconomique a été mesuré par la consommation des ménages. La prévalence de l'hypertension et du DT2 a été déterminée à l'aide de mesures cliniques standardisées à l’échelle internationale, tandis que la prise en charge de la maladie était définie par la participation au dépistage et à l'utilisation courante de médicaments. L'indice relatif d'inégalité (RII) a été utilisé pour estimer les inégalités, ajustées à l’échelle de l’éducation et à la localisation géographique. RÉSULTATS: Pour tous les quintiles de consommation des ménages, nous avons observé de faibles taux de participation au dépistage du DT2 et une faible utilisation de médicaments dans l'hypertension et le DT2. Nous avons constaté des inégalités socioéconomiques dans la participation au dépistage de l'hypertension (RII= 2,68; IC95%: 2,42 à 2,96) et du DT2 (RII= 7,30; IC95%: 5,48 à 9,72), ainsi que de l'utilisation de médicaments pour l'hypertension (IIR= 3,09; IC95%: 2,28 à 4.18) et pour le DT2 (RII= 2,81; IC95%: 1,09-7,27). Le niveau d’éducation a contribué aux inégalités socioéconomiques dans l'utilisation du dépistage pour l'hypertension et le DT2. La localisation géographique a contribué aux inégalités dans l'utilisation du dépistage et de l'utilisation de médicaments pour le DT2. Les inégalités socioéconomiques dans l'utilisation des médicaments contre l'hypertension et le DT2 étaient plus importantes chez les hommes que chez les femmes. CONCLUSIONS: De grandes inégalités socioéconomiques ont été constatées dans l'utilisation des services de prise en charge de l'hypertension et du DT2 en Indonésie. Améliorer l'aspect abordable, la disponibilité et l'accessibilité des services est crucial pour réduire ces inégalités.

Reduction in maternal and newborn mortality requires that women deliver in high quality health facilities. However, many facilities provide sub-optimal quality of care, which may be a reason for less than universal facility utilisation. We assessed the impact of a quality improvement project on facility utilisation for childbirth.In this cluster-randomised experiment in four rural districts in Tanzania, 12 primary care clinics and their catchment areas received a quality improvement intervention consisting of in-service training, mentoring and supportive supervision, infrastructure support, and peer outreach, while 12 facilities and their catchment areas functioned as controls. We conducted a census of all deliveries within the catchment area and used difference-in-differences analysis to determine the intervention's effect on facility utilisation for childbirth. We conducted a secondary analysis of utilisation among women whose prior delivery was at home. We further investigated mechanisms for increased facility utilisation.The intervention led to an increase in facility births of 6.7 percentage points from a baseline of 72% (95% Confidence Interval: 0.6, 12.8). The intervention increased facility delivery among women with past home deliveries by 18.3 percentage points (95% CI: 10.1, 26.6). Antenatal quality increased in intervention facilities with providers performing an additional 0.5 actions across the full population and 0.8 actions for the home delivery subgroup.We attribute the increased use of facilities to better antenatal quality. This increased utilisation would lead to lower maternal mortality only in the presence of improvement in care quality.La réduction de la mortalité maternelle et néonatale exige que les femmes accouchent dans des établissements de santé de haute qualité. Cependant, de nombreux établissements offrent une qualité de soins sous-optimale, ce qui peut expliquer l'utilisation moins généralisée des établissements. Nous avons évalué l'impact d'un projet d'amélioration de la qualité sur l'utilisation des établissements pour l'accouchement. MÉTHODES: Dans cet essai randomisé en grappes mené dans quatre districts ruraux de Tanzanie, 12 cliniques de soins primaires et leurs zones de recrutement ont bénéficié d'une intervention d'amélioration de la qualité consistant en une formation au cours du service, une supervision par un encadrement et un accompagnement, un appui en infrastructure et des relations avec les pairs tandis que 12 établissements et leur zone de recrutement ont servi de contrôles. Nous avons procédé à un recensement de tous les accouchements dans la zone de recrutement et utilisé une analyse de la différence des différences pour déterminer l'effet de l'intervention sur l'utilisation des établissements pour l'accouchement. Nous avons effectué une analyse secondaire de l'utilisation chez les femmes dont l'accouchement précédent avait eu lieu à domicile. Nous avons également investigué les mécanismes permettant d'accroître l'utilisation des établissements. RÉSULTATS: L'intervention a entraîné une augmentation du nombre de naissances dans les établissements de 6,7 points de pourcentage par rapport à une de référence base de 72% (intervalle de confiance à 95%: 0.6-12.8). L'intervention a augmenté de 18.3 points de pourcentage l'accouchement dans un établissement pour les femmes ayant accouché à domicile précédemment (IC 95%: 10.1-26.6). La qualité prénatale a augmenté dans les établissements d'intervention, les prestataires effectuant 0.5 action supplémentaire sur l'ensemble de la population et 0.8 action pour le sous-groupe des accouchements à domicile.Nous attribuons l'utilisation accrue des établissements à une meilleure qualité prénatale. Cette utilisation accrue ne ferait baisser la mortalité maternelle que si la qualité des soins s'améliorait.

Objective Although distance has been identified as an important barrier to care, evidence for an effect of distance to care on child mortality is inconsistent. We investigated the association of distance to care with self‐reported care seeking behaviours, neonatal and post‐neonatal under‐five child mortality in rural areas of Burkina Faso. Methods We performed a cross‐sectional survey in 14 rural areas from November 2014 to March 2015. About 100 000 women were interviewed on their pregnancy history and about 5000 mothers were interviewed on their care seeking behaviours. Euclidean distances to the closest facility were calculated. Mixed‐effects logistic and Poisson regressions were used respectively to compute odds ratios for care seeking behaviours and rate ratios for child mortality during the 5 years prior to the survey. Results Thirty per cent of the children lived more than 7 km from a facility. After controlling for confounding factors, there was a strong evidence of a decreasing trend in care seeking with increasing distance to care (P ≤ 0.005). There was evidence for an increasing trend in early neonatal mortality with increasing distance to care (P = 0.028), but not for late neonatal mortality (P = 0.479) and post‐neonatal under‐five child mortality (P = 0.488). In their first week of life, neonates living 7 km or more from a facility had an 18% higher mortality rate than neonates living within 2 km of a facility (RR = 1.18; 95%CI 1.00, 1.39; P = 0.056). In the late neonatal period, despite the lack of evidence for an association of mortality with distance, it is noteworthy that rate ratios were consistent with a trend and similar to or larger than estimates in early neonatal mortality. In this period, neonates living 7 km or more from a facility had an 18% higher mortality rate than neonates living within 2 km of a facility (RR = 1.18; 95%CI 0.92, 1.52; P = 0.202). Thus, the lack of evidence may reflect lower power due to fewer deaths rather than a weaker association. Conclusion While better geographic access to care is strongly associated with increased care seeking in rural Burkina Faso, the impact on child mortality appears to be marginal. This suggests that, in addition to improving access to services, attention needs to be paid to quality of those services.

Objective WHO recommends optimisation of available interventions to reduce deaths of under‐five children with diarrhoea and dehydration (DD). Clinical networks may help improve practice across many hospitals but experience with such networks is scarce. We describe magnitude and patterns of changes in processes of care for children with DD over the first 3 years of a clinical network. Methods Observational study involving children aged 2–59 months with DD admitted to 13 hospitals participating in the clinical network. Processes of individual patient care including agreement of assessment, diagnosis and treatment according to WHO guidelines were combined using the composite Paediatric Admission Quality of Care (PAQC) score (range 0–6). Results Data from 7657 children were analysed and improvements in PAQC scores were observed. Predicted mean PAQC score for all the hospitals at enrolment was 59.8% (95% CI: 54.7, 64.9) but showed a wide variation (variance 10.7%, 95% CI: 5.8, 19.6). Overall mean PAQC score increased by 13.8% (95% CI: 8.7–18.9, SD between hospitals: ±8.2) in the first 12 months, with an average 0.9% (95% CI: 0.3–1.5, SD ± 1.0) increase per month and plateaued thereafter, and changes were similar in two groups of hospitals joining the network at different times. Conclusion Adherence to guidelines for children admitted with DD can be improved through participation in a clinical network but improvement is limited, not uniform for all aspects of care and contexts and occurs early. Future research should address these issues.

Objective Environmental Enteric Dysfunction (EED) can be assessed by faecal biomarkers such as Myeloperoxidase (MPO), Neopterin (NEO) and Alpha‐1 anti‐trypsin (AAT). We aimed to test the association of intestinal pathogens with faecal markers of EED among slum‐dwelling children in first 2 years of life. Methods The MAL‐ED birth cohort data of Bangladesh site were used to conduct this analysis. Multivariable analyses using Generalized Estimating Equations (GEE) were performed to test the association between intestinal pathogens and faecal markers of EED. Results Giardiasis, ascariasis and trichuriasis were the most frequent parasitic infections and Campylobacter spp., Enteroaggregative Escherichia coli (EAEC) and Enterotoxigenic Escherichia coli (ETEC) were the common bacterial pathogens observed in stool samples of the children. Overall, 71%, 97% and 58% of stool samples were above values considered normal in non‐tropical settings for MPO, NEO and AAT respectively. Giardiasis was found to be significantly associated with MPO (Coefficient = 0.55; 95% CI = 0.15, 0.95; P‐value = 0.008) and AAT concentrations (Coefficient = 0.34; 95% CI = 0.04, 0.63; P‐value = 0.03). A significant association was found between trichuriasis and NEO (Coefficient = 0.90; 95% CI = 0.19, 1.61; P‐value = 0.01). Trichuriasis (Coefficient = 1.71; 95% CI = 0.32, 3.11; P‐value = 0.02) and giardiasis (Coefficient = 1.51; 95% CI = 0.79, 2.23; P‐value

Objective To examine the levels, inequalities, and factors associated with health insurance coverage in Kenya. Methods We analyzed secondary data from the Kenya Demographic and Health Survey (KDHS) conducted in 2009 and 2014. We examined the level of health insurance coverage overall, and by type, using an asset index to categorize households into 5 socio-economic quintiles with quintile 5 (Q5) being the richest and quintile 1 (Q1) being the poorest. The high-low ratio (Q5/Q1 ratio), concentration curve, and concentration index (CIX) were employed to assess inequalities in health insurance coverage, and logistic regression to examine correlates of health insurance coverage. Results Overall health insurance coverage increased from 8.17% to 19.59% between 2009 and 2014. There was high inequality in overall health insurance coverage, even though this inequality decreased between 2009 (Q5/Q1 ratio of 31.21, CIX=0.61, 95% CI 0.52-0.0.71) and 2014 (Q5/Q1 ratio 12.34, CIX=0.49, 95% CI 0.45-0.52). Individuals that were older, employed in the formal sector, married, exposed to media, male, belonged to a small household, had a chronic disease, and belonged to rich households, had increased odds of health insurance coverage. Conclusion Health insurance coverage in Kenya remains low and is characterized by significant inequality. In a context where over 80% of the population is in the informal sector, and close to 50% live below the national poverty line, achieving high and equitable coverage levels with contributory, and voluntary health insurance mechanism is problematic. Kenya should consider a universal, tax-funded mechanism that ensures revenues are equitably and efficiently collected, and everyone (including the poor and those in the informal sector) is covered. This article is protected by copyright. All rights reserved.

Objectives Evaluation of a novel index case-finding and linkage-to-care program to identify and link HIV-infected children (1-15 years) and young adults (>15-24 years) to care. Methods HIV-infected patients enrolled in HIV services were screened and those who reported untested household members (index cases) were offered home or facility-based HIV testing and counseling (HTC) of their household by a community health worker (CHW). HIV-infected household members identified were enrolled in a follow-up program offering home and facility-based follow-up by CHWs. Results Of the 1567 patients enrolled in HIV services, 1030 (65.7%) were screened and 461 (44.8%) identified as index cases. 93.5% consented to HIV testing of their households and of those, 279 (64.7%) reported an untested child or young person. CHWs tested 711 children and young adults, newly diagnosed 28 HIV-infected persons (yield 4.0%; 95% CI: 2.7-5.6), and identified an additional two HIV-infected persons not enrolled in care. Of the 30 HIV-infected persons identified, 23 (76.6%) were linked to HIV services. 18 of the 20 eligible for ART (90.0%) were initiated. Median time (IQR) from identification to enrollment into HIV services was 4 days (1-8) and from identification to ART start was 6 days (1-8). Conclusions Almost half of HIV-infected patients enrolled in treatment services had untested household members, many of whom were children and young adults. Index case-finding, coupled with home-based testing and tracked follow-up is acceptable, feasible, and facilitates the identification and timely linkage to care of HIV-infected children and young adults. This article is protected by copyright. All rights reserved.

Objective To determine modifiable risk factors of ocular surface squamous neoplasia (OSSN) in Kenya using disease‐free controls. Methods Adults with conjunctival lesions were recruited at four eye care centres in Kenya and underwent excision biopsy. An equal number of controls having surgery for conditions not affecting the conjunctiva and unrelated to ultraviolet light were group‐matched to cases by age group, sex and eye care centre. Associations of risk factors with OSSN were evaluated using multivariable logistic regression to estimate odds ratios (ORs) and 95% confidence intervals (95% CIs). Continuous variables were compared using the t‐test or the Wilcoxon–Mann–Whitney U‐test depending on their distribution. Results A total of 131 cases and 131 controls were recruited. About two‐thirds of participants were female, and the mean age of cases and controls was 42.1 years and 43.3 years, respectively. Risk factors for OSSN were HIV infection without antiretroviral therapy (ART) use (OR = 48.42; 95% CI: 7.73–303.31) and with ART use (OR = 19.16; 95% CI: 6.60–55.57), longer duration of exposure to the sun in the main occupation (6.9 h/day vs. 4.6 h/day, OR = 1.24; 95% CI: 1.10–1.40) and a history of allergic conjunctivitis (OR = 74.61; 95% CI: 8.08–688.91). Wearing hats was protective (OR = 0.22; 95% CI: 0.07–0.63). Conclusion Measures to prevent and control HIV, reduce sun exposure such as wearing hats and control allergic conjunctivitis are recommended.

To explore associations of environmental and demographic factors with diarrhoea and nutritional status among children in Rusizi district, Rwanda. We obtained cross-sectional data from 8,847 households in May-August 2013 from a baseline survey conducted for an evaluation of an integrated health intervention. We collected data on diarrhoea, water quality, and environmental and demographic factors from households with children

Objective Fatigue is a common complaint worldwide and associated with disability and high health service use costs. We tested the hypothesis that maternal fatigue would be associated independently with maternal common mental disorder (‘maternal CMD’) in a rural, low‐income country setting. Methods The analysis was conducted using data from a population‐based cohort located in the Butajira demographic surveillance site, Ethiopia. A total of 1065 women were recruited in pregnancy and followed up to 2.5 (n = 1009; 94.7%) and 3.5 years post‐partum (n = 989; 92.9%). Maternal CMD symptoms were measured using a locally validated version of the Self‐Reporting Questionnaire and fatigue was measured using a dichotomised item from the Patient Health Questionnaire‐15. Physical health indicators included haemoglobin level, body mass index and illness episodes. Generalised estimating equations were used to conduct hypothesis‐driven and exploratory multivariable analyses in the panel at 2.5 and 3.5 years. Results The prevalence of maternal fatigue was 8.3% at 2.5 years and 5.5% at 3.5 years post‐partum. Psychological symptoms of maternal CMD were associated independently with complaints of fatigue after adjusting for anaemia, body mass index, physical ill health, poverty and other confounding variables: adjusted odds ratio (aOR), 1.46; 95% confidence interval (CI), 1.28–1.66 for each one point increase in SRQ score. In the multivariable model, only psychosocial factors (CMD and stressful life events) and self‐reported physical ill health were associated significantly with complaints of fatigue. Conclusion Complaints of fatigue are associated strongly with maternal CMD and other psychosocial risk factors in this rural, low‐income country setting with a high burden of undernutrition and infectious disease. Fatigue should be understood as a potential indicator of CMD in primary care to improve detection and treatment.

OBJECTIVES: The objectives were to assess the quality of health management information system (HMIS) data needed for assessment of local area variation in pregnancy induced hypertension (PIH) incidence and to describe district and regional variations in PIH incidence. METHODS: A retrospective review of antenatal and delivery records of 2,682 pregnant women in ten district hospitals in the Greater Accra and Upper West regions of Ghana was conducted in 2013. Quality of HMIS data was assessed by completeness of reporting. The incidence of PIH was estimated for each district. RESULTS: Key variables for routine assessment of PIH such as blood pressure at antenatal visits, weight and height were 95% to 100% complete. Fundal height, gestational age and blood pressure at delivery were not consistently reported. The incidence of PIH differed significantly between Greater Accra region (6.1%) and Upper West region (3.2%). Prevalence of obesity among pregnant women in Greater Accra region (13.9%) was significantly higher than that of women in Upper West region (2.2%). CONCLUSIONS: More attention needs to be given to understanding local area variations in PIH and possible relationships with urbanization and lifestyle changes that promote obesity, to inform maternal and newborn health policy. This can be done with good quality routine HMIS data. This article is protected by copyright. All rights reserved.

Objective In sub-Saharan Africa, the use of malaria rapid diagnostic tests (mRDT) has raised awareness of alternative fever causes in children but few studies have included adults. To address this gap, we conducted a study of mRDT-negative fever aetiologies among children and adults in Tanzania. Methods A total of 1028 patients aged 3 months to 50 years with a febrile illness and negative mRDT were enrolled from a Tanzanian hospital outpatient department. All had a physical examination and cultures from blood, nasopharynx/throat and urine. Patients were followed on Days 7 and 14 and children meeting WHO criteria for pneumonia were followed on Day 2 with chest radiology. Results Respiratory symptoms were the most frequent presenting complaint, reported by 20.3% of adults and 64.0% (339/530) of children. Of 38 X-rayed children meeting WHO pneumonia criteria, 47.4% had a normal X-ray. Overall, only 1.3% of 1028 blood cultures were positive. Salmonella typhi was the most prevalent pathogen isolated (7/13, 53.8%) and S. typhi patients reported fever for a median of 7 days (range 2–14). Children with bacteraemia did not present with WHO symptoms requiring antibiotic treatment. Young children and adults had similar prevalences of positive urine cultures (24/428 and 29/498, respectively). Conclusion Few outpatient fevers are caused by blood stream bacterial infection, and most adult bacteraemia would be identified by current clinical guidelines although paediatric bacteraemia may be more difficult to diagnose. While pneumonia may be overdiagnosed, urinary tract infection was relatively common. Our results emphasise the difficulty in identifying African children in need of antibiotics among the majority who do not.

OBJECTIVE: Universal coverage with insecticide-treated bed nets is a cornerstone of modern malaria control. Mozambique has developed a novel bed net allocation strategy, where the number of bed nets allocated per household is calculated on the basis of household composition and assumptions about who sleeps with whom. We set out to evaluate the performance of the novel allocation strategy. METHODS: 1,994 households were visited during household surveys following two universal coverage bed net distribution campaigns in Sofala and Nampula Provinces in 2010-2013. Each sleeping space was observed for the presence of a bed net, and the sleeping patterns for each household were recorded. The observed coverage and efficiency were compared to a simulated coverage and efficiency had conventional allocation strategies been used. A composite indicator, the product of coverage and efficiency, was calculated. Observed sleeping patterns were compared with the sleeping pattern assumptions. RESULTS: In households reached by the campaign, 93% (95% CI: 93-94%) of sleeping spaces in Sofala and 84% (82-86%) in Nampula were covered by campaign bed nets. The achieved efficiency was high, with 92% (91-93%) of distributed bed nets in Sofala and 93% (91-95%) in Nampula covering a sleeping space. Using the composite indicator, the novel allocation strategy outperformed all conventional strategies in Sofala and was tied for best in Nampula. The sleeping pattern assumptions were completely satisfied in 66% of households in Sofala and 56% of households in Nampula. The most common violation of the sleeping pattern assumptions was that male children 3-10 years of age tended not to share sleeping spaces with female children 3-10 or 10-16 years of age. CONCLUSIONS: The sleeping pattern assumptions underlying the novel bed net allocation strategy are generally valid, and net allocation using these assumptions can achieve high coverage and compare favorably with conventional allocation strategies. This article is protected by copyright. All rights reserved.

Objective Paediatric laboratory reference intervals used in Africa and Asia may be derived from historical intervals of predominantly Caucasian infants in Europe or North America. These intervals may therefore not be compatible with the range of normality for developing country populations. We aimed to compare haematology and biochemistry parameters in healthy South African infants with local laboratory reference intervals. Methods We compared the baseline haematology and biochemistry results of 634 (316 male and 318 female) HIV-unexposed infants, aged 3–6 months, living in a rural area of the Western Cape Province, South Africa, against laboratory reference intervals supplied by the South African National Health Laboratory Services (NHLS). We calculated the percentage of observed values out of bound (in terms of lower and upper limits) compared to laboratory reference intervals. Results Of the 634 healthy infants screened, 316 (49.84%) were male and 318 (50.16%) female. A majority (91.05%) had platelet counts above the laboratory reference interval upper limit (350 9 109cells/l), while over half, 54.85% and 56.98% had mean corpuscular volume (MCV) and mean corpuscular haemoglobin (MCH) values below the lower limits of 77.0–105.0 fl and 26.0–34.0 pg, respectively. A small proportion were outside the reference limits for haematocrit, namely 15.71% below and 7.14% above the normal limits of 0.31–0.38 l/l. For male and female infants, 33.65% and 18.04% of alkaline phosphatase (ALP) values and 7.01% and 14.56% of alanine transaminase (ALT) values were above the upper limits, respectively. For male infants, 10.83% of gamma-glutamyl transferase (GGT) values, and for female infants, 31.11% of GGT values were below the lower limits of 12 U/l for males and 15 U/l for females. We observed no significant deviations (>10% out of bound) from NHLS reference intervals in the remaining haematology and biochemistry parameters measured. Conclusions Haematology and biochemistry parameters in apparently healthy South African infants deviate frequently from national laboratory reference intervals, including abnormalities consistent with subclinical hypochromic microcytic anaemia. It is important that clinical laboratory reference intervals for children are derived locally, rather than being adopted from Caucasian norms in developed countries, because clinical trials of vaccines, drugs and diagnostics are increasingly conducted in sub-Saharan Africa.

Objectives To characterise the differences in care seeking behaviour and dispensing outcomes between adults and children purchasing drugs for malaria at retail shops in Nigeria. Methods In Nasarawa State, retail drug shops were enumerated and a subset of those stocking antimalarials were selected as study sites and surveyed. Customers exiting shops after purchasing antimalarial drugs were surveyed and tested with a malaria rapid diagnostic test. Sick adults and caregivers accompanying sick children were eligible, but individuals purchasing drugs for a sick person that was not present were excluded. Multivariate regression analysis was used to identify the correlates of care seeking and the quality of interaction at the shop. Results Of 737 participants, 80% were adults and 20% were children (under age 18). Caregivers of sick children were more likely to obtain a prescription prior to attending a drug retailer than adults seeking care for themselves and waited a shorter time before seeking care. Caregivers of sick children were also more likely than sick adults to have been asked about symptoms by the retailer, to have been given an examination, and to have purchased an ACT. Fewer than half of respondents had purchased an ACT. Only 14% of adults, but 27% of children were RDT-positive; RDT-positive children were more likely to have had an ACT purchased for them than RDT-positive adults. Conclusions Children with suspected malaria tend to receive better care at drug retailers than adults. The degree of overtreatment and prevalence of dispensing non-recommended antimalarials emphasise the need for routine diagnosis before treatment to properly treat both malaria and non-malaria illnesses. Objectifs Caracteriser les differences dans le comportement de recherche de soins et les resultats des prestations entre les adultes et les enfants achetant des medicaments contre le paludisme dans les boutiques de detaillants au Nigeria. Methodes Dans l’etat de Nasarawa, les commerces au detail de medicaments ont ete denombres et un sous-ensemble de ceux stockant des antipaludeens a ete choisi comme site d’etude et investigue. Les clients sortant des magasins apres l'achat de medicaments antipaludiques ont ete interroges et depistes avec un test de diagnostic rapide du paludisme. Les adultes malades et les soignants accompagnant des enfants malades etaient admissibles, mais les personnes achetant des medicaments pour une personne malade qui n’etait pas presente ont ete exclues. L'analyse de regression multivariee a ete utilisee pour identifier les correlats dans la recherche de soins et la qualite de l'interaction avec la boutique. Resultats Sur 737 participants, 80% etaient des adultes et 20% des enfants (de moins de 18 ans). Les soignants d'enfants malades etaient plus susceptibles d'obtenir une ordonnance avant de visiter un detaillant de medicaments que les adultes en quete de soins pour eux-memes et tardaient moins avant de rechercher des soins. Les soignants d'enfants malades etaient egalement plus susceptibles que les adultes malades d'avoir ete interroges sur les symptomes par le detaillant, d'avoir ete examines et d'avoir achete un traitement a base d'artemisinine (ACT). Moins de la moitie des repondants avaient achete un ACT. Seuls 14% des adultes mais 27% des enfants ont ete trouve positifs au test rapide; les enfants positifs au test rapide etaient plus susceptibles d'avoir un ACT achete que les adultes positifs. Conclusions Les enfants suspectes de paludisme ont tendance a recevoir de meilleurs soins chez les detaillants de medicaments que les adultes. Le degre de surtraitement et la prevalence de delivrance d'antipaludiques non recommandes soulignent la necessite du diagnostic de routine avant le traitement afin de traiter correctement a la fois le paludisme et les maladies non paludiques. Objetivos Caracterizar las diferencias en el comportamiento de busqueda de cuidados y los resultados en la dispensacion entre los adultos y ninos que compraron medicamentos para malaria en farmacias de venta al por menor en Nigeria. Metodos En el estado de Nasarawa, se enumeraron las farmacias de venta al por menor y se seleccionaron como lugares de estudio un subgrupo de ellas que tenia antimalaricos entre sus existencias. A los clientes que salian de las farmacias despues de haber comprado antimalaricos se les realizo la encuesta y se les hizo una prueba de diagnostico rapido de malaria. Los adultos enfermos y los cuidadores de ninos enfermos eran elegibles, pero se excluyeron los individuos que compraban medicamentos para una persona enferma que no estaba presente. Se utilizo un analisis de regresion multivariante para identificar las asociaciones entre la busqueda de cuidados y la calidad de la interaccion en la farmacia. Resultados De 737 participantes, un 80% eran adultos y un 20% eran ninos (menores de 18). Los cuidadores de ninos enfermos tenian una mayor probabilidad de obtener una prescripcion antes de ir a la farmacia que los adultos que buscaban cuidar de si mismos, y esperaban un menor periodo de tiempo para buscar la ayuda. Los cuidadores de ninos enfermos tenian mas posibilidad que los adultos enfermos de que en la farmacia se les hubiese preguntado por los sintomas, se les hubiese realizado alguna prueba y que hubiesen comprado ACT. Menos de la mitad de quienes respondian habian comprado un ACT. Solo un 14% de los adultos, pero un 27% de los ninos daban positivo en las pruebas de diagnostico rapido (PDR). Los ninos con PDR positiva tenian una mayor posibilidad de que se les comprase un ACT que los adultos con una PDR positiva. Conclusiones Los ninos con una sospecha de malaria tienden a recibir mejores cuidados en las farmacias que los adultos. El nivel de sobretratamiento y la prevalencia de dispensacion de antimalaricos no recomendados enfatizan la necesidad de un diagnostico rutinario antes del tratamiento para manejar adecuadamente tanto la malaria como otras enfermedades.

Objectives Rates of first-line treatment failure and switches to second-line therapy are key indicators for national HIV programmes. We assessed immunological treatment failure defined by WHO criteria in the Tanzanian national HIV programme. Methods We included adults initiating first-line therapy in 2004–2011 with a pre-treatment CD4 count, and ≥6-months of follow-up. We assessed subhazard ratios (SHR) for immunological treatment failure, and subsequent switch to second-line therapy, using competing risks methods to account for deaths. Results Of 121 308 adults, 7% experienced immunological treatment failure, and 2% died without observed immunological treatment failure, over a median 1.7 years. The 6-year cumulative probability of immunological treatment failure was 19.0% (95% CI 18.5, 19.7) and of death, 5.1% (4.8, 5.4). Immunological treatment failure predictors included earlier year of treatment initiation (P

Objective To explore the chronic disease services in Uganda: their level of utilisation, the total service costs and unit costs per visit. Methods Full financial and economic cost data were collected from 12 facilities in two districts, from the provider's perspective. A combination of ingredients‐based and step‐down allocation costing approaches was used. The diseases under study were diabetes, hypertension, chronic obstructive pulmonary disease (COPD), epilepsy and HIV infection. Data were collected through a review of facility records, direct observation and structured interviews with health workers. Results Provision of chronic care services was concentrated at higher‐level facilities. Excluding drugs, the total costs for NCD care fell below 2% of total facility costs. Unit costs per visit varied widely, both across different levels of the health system, and between facilities of the same level. This variability was driven by differences in clinical and drug prescribing practices. Conclusion Most patients reported directly to higher‐level facilities, bypassing nearby peripheral facilities. NCD services in Uganda are underfunded particularly at peripheral facilities. There is a need to estimate the budget impact of improving NCD care and to standardise treatment guidelines.

Objective To examine the association between travel (recency of travel, transmission intensity at destination compared to origin and duration of travel) and confirmed malaria in Uganda. Methods Health facility-based case–control study in highland (~2200 m), and highland fringe (~1500 m) areas with adjustment for other covariates. Results In the highland site, patients who had travelled to areas of higher transmission intensity than their home (origin) areas recently were nearly seven times more likely to have confirmed malaria than those who had not (OR 6.9; P = 0.01, 95% CI: 1.4–33.1). In the highland fringe site, there was also a statistically significant association between travel and malaria (OR 2.1; P = 0.04, 95% CI: 1.1–3.9). Conclusions For highland areas, or areas of low malaria transmission, health authorities need to consider internal migrants when designing malaria control programs. Control interventions should include information campaigns reminding residents in these areas of the risk of malaria infection through travel and to provide additional mosquito nets for migrants to use during travel. Health authorities may wish to improve diagnosis in health facilities in highland areas by adding travel history to malaria case definitions. Where routine monitoring data are used to evaluate the impact of interventions on the malaria burden in highland areas, health authorities and donors need ensure that only cases from the local area and not ‘imported cases’ are counted. Objectif Examiner l'association entre le voyage (recence du voyage, intensite de la transmission au lieu de destination par rapport a l'origine et la duree du voyage) et les cas confirmes de paludisme en Ouganda. Methodes Etude cas-temoins dans les etablissements de sante dans les regions montagneuses (~2200 m), et a l'oree des ces regions (~1500 m) avec ajustement pour d'autres covariables. Resultats Dans le site de montagne, les patients qui avaient recemment voyage dans des regions d'intensite de transmission plus elevee que les zones du domicile etaient pres de sept fois plus susceptibles d'avoir un paludisme confirme que ceux qui n'avaient pas voyage (OR = 6,9; p = 0,01, IC 95%: 1,4–33,1). Dans la zone a l'oree des regions montagneuse, il y avait une association statistiquement significative entre le voyage et le paludisme (OR = 2,1; p = 0,04, IC95%: 1,1 a 3,9). Conclusions Pour les zones montagneuses, les autorites sanitaires doivent tenir compte des migrants lors de la conception des programmes de lutte contre le paludisme. Les interventions de lutte devraient inclure des campagnes d'information rappelant les residents dans ces zones du risque d'infection du paludisme suite au voyage et fournir des moustiquaires supplementaires pour les migrants a utiliser lors du voyage. Les autorites sanitaires pourraient ameliorer le diagnostic dans les etablissements de sante dans les zones montagneuses en ajoutant l'histoire de voyage dans les definitions de cas de paludisme. Lorsque les donnees de surveillance de routine sont utilisees pour evaluer l'impact des interventions sur la charge du paludisme dans les zones montagneuses, les autorites sanitaires et les donateurs devraient veiller a ce que seuls les cas de la region et non les «cas importes» sont comptes. Objetivo Examinar la asociacion entre el viajar (cuan reciente habia sido el viaje, la intensidad de transmision en el lugar de destino comparada con la del origen, y duracion del viaje) y malaria confirmada en Uganda. Metodos Estudio casos control basado en la comunidad en areas de tierras altas (~2200 m), y areas limitrofes (~1500 m) con ajuste para otras covariables. Resultados En las tierras altas, los pacientes que habian viajado recientemente a areas con una intensidad de transmision mas alta que la del area de sus hogares tenian casi 7 veces mas probabilidad de tener una malaria confirmada que aquellos que no habian viajado (OR 6.9; p = 0.01, IC 95%: 1.4–33.1). En las areas limitrofes a las zonas altas existia una asociacion estadistica significativa entre el viaje y la malaria (OR 2.1; p = 0.04, IC 95%: 1.1–3.9). Conclusiones En el caso de las areas en tierras altas, las autoridades sanitarias deberian tener en cuenta a los emigrantes cuando disenan los programas de control de malaria. Las intervenciones de control deberian incluir campanas de informacion que recuerden a los residentes en estas areas del riesgo de infeccion por malaria al viajar y proveer redes mosquiteras adicionales para que los emigrantes utilicen durante el viaje. Las autoridades sanitarias podrian mejorar el diagnostico en los centros sanitarios anadiendo el historial de viajes a las definiciones de caso de malaria. En donde se utilicen datos rutinarios de monitorizacion para evaluar el impacto de las intervenciones sobre la carga de malaria en tierras altas, las autoridades sanitarias y los donantes deben asegurarse de que solo se tienen en cuenta los casos de locales y no los “importados”.

Objectives To examine the prevalence of seizures, epilepsy and seropositivity to cysticercosis in rural villagers (cysticercosis-endemic setting), rural-to-urban migrants into a non-endemic urban shanty town and urban inhabitants of the same non-endemic shanty town. Methods Three Peruvian populations (n = 985) originally recruited into a study about chronic diseases and migration were studied. These groups included rural inhabitants from an endemic region (n = 200), long-term rural-to-urban migrants (n = 589) and individuals living in the same urban setting (n = 196). Seizure disorders were detected by a survey, and a neurologist examined positive respondents. Serum samples from 981/985 individuals were processed for cysticercosis antibodies on immunoblot. Results Epilepsy prevalence (per 1000 people) was 15.3 in the urban group, 35.6 in migrants and 25 in rural inhabitants. A gradient in cysticercosis antibody seroprevalence was observed: urban 2%, migrant 13.5% and rural group 18% (P