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Background: Hospital-acquired occipital pressure injuries are a preventable cause of morbidity and mortality in the perioperative setting., Purpose: To find the occipital cushion/pillow with the lowest measured peak pressures and the highest measured surface area using pressure mapping technology., Materials and Methods: A quality improvement project involving 3 operating room staff volunteers was conducted using pressure mapping. Five different pillows were tested based on what the study location commonly used and had available. The pillows included: standard pillow with pillowcase, non-powered fluidized positioner, medium-sized (17 × 17 × 1.5 inches) static seat cushion placed under the shoulders and head, pediatric-sized (13 × 13 × 2 inches) static air cushion placed under the head, and foam donut., Results: The non-powered fluidized positioner had the highest average pressure and peak pressure for all 3 volunteers. The medium static air seat cushion had the lowest average and peak pressures for 2 out of 3 volunteers. None of the head cushions consistently demonstrated a larger surface area of pressure distribution., Conclusions: The medium-sized static air seat cushion, placed under the shoulders and head, demonstrated the most favorable pressure redistribution properties. The non-powered fluidized positioner demonstrated the least favorable pressure redistribution properties.

This closed cohort study aimed to identify the associations between dairy calf management practices and herd-level perinatal calf mortality risk. From February 2020 to June 2021, predominantly Holstein dairy farms in Québec (n = 1,832) and New Brunswick (n = 52), Canada, that were registered in the dairy herd improvement program were visited once. A questionnaire covering all aspects of precalving, calving, and colostrum management was administered. Data regarding perinatal mortality were retrieved from the dairy herd improvement program database for each farm for 2021. Perinatal mortality was calculated for each farm as the proportion of calves dead at birth or dying within 24 h after birth. A multivariable negative binomial model was used to assess herd-level factors associated with the risk of perinatal mortality. The final model included the lying surface in the calving area, the typical time to first colostrum intake, typical cow-calf contact time, the proportion of males born, the proportion of assisted calvings, and herd size. Herd-level perinatal mortality risk ranged from 0% to 38.1% (mean ± SE = 7.6% ± 0.1%). A greater proportion of males born, a higher proportion of assisted calvings, and delayed colostrum feeding were associated with increased herd-level perinatal mortality. Factors associated with a decreased herd-level perinatal mortality risk were having a typical cow-calf contact time between 7 and 12 h after calving compared with reduced cow-calf contact time, soft lying surfaces in the calving area compared with concrete and mat-lying surfaces, and an increased number of calvings per year. Our results show that although some of the significant risk factors are not well understood (i.e., calving area lying surface, typical cow-calf contact time), Canadian farmers could focus on the factors under their control (i.e., time to first colostrum feeding, proportion of difficult calvings, males born, and calvings per year) to reduce the risk of perinatal mortality. Future work should focus on qualitative research to understand the dairy farmer motivations and limitations to implementing practices identified in this and other studies to reduce perinatal mortality., (The Authors. Published by Elsevier Inc. on behalf of the American Dairy Science Association®. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).)

Objective: To compare pressure injury (PI) incidence based on repositioning intervals and support surfaces in acute care settings., Methods: This pragmatic, quasi-experimental trial recruited a total of 251 critically ill patients who were at low or moderate risk for PI development. Participants were assigned to three interventions: a 2-hour repositioning interval using an air mattress, a 2-hour repositioning interval using a foam mattress, or a 3-hour repositioning interval using a foam mattress. Data were collected by nurses every shift over the course of 14 days. Pressure injury incidence was analyzed using a χ2 test., Results: There were no statistically significant differences in PI incidence between the groups with a 2-hour repositioning interval. However, the PI incidence in the group using a foam mattress with a 3-hour repositioning interval was significantly lower than in the group using an air mattress with a 2-hour repositioning interval (odds ratio, 0.481; 95% confidence interval, 0.410-0.565)., Conclusions: The findings showed that PIs decreased when the repositioning interval was extended from every 2 hours to every 3 hours while using foam mattresses. This study suggests that a 3-hour repositioning interval using a foam mattress could be applied to reduce the risk of PI development for patients at low or moderate risk., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Many hospital settings are adopting a zero-tolerance policy towards pressure injury (PI) development; this requires good planning and the implementation of care, as the incidence of PIs reflects the quality of care given in a hospital or facility., Aim: To identify common contributing factors towards the development of PIs in a geriatric rehabilitation hospital and improve patient safety through the reduction of hospital-acquired PIs., Method: This was done using root cause analysis (RCA). All patients who developed a Stage 3 or 4 deep tissue injuries or unstageable hospital-acquired PI between December 2017 and April 2018 PIs were investigated using RCA. The RCA was facilitated through the use of a contributing framework developed by the National Pressure Ulcer Advisory Panel which guides investigations of different areas of care. Qualitative and quantitative data was collected from several sources and placed in a timeline to reconstruct the series of events. The investigator then identified if the PI was avoidable or not by comparing the evidence with pre-set criteria. Content analysis was further used to analyse the themes retrieved., Results: A variety of root causes were common amongst all the cases. These included both flaws in the system, such as poor equipment and inadequate educational programmes, as well as human factors such as a lack of basic routine care. No skin assessment was being performed (n = 0) apart from the assessment done on admission. Documentation of action planning when it comes to PI prevention was also missing (n = 0). It was identified that 7 patients were mobilized on admission while the others (n = 3) had a delay in mobilisation, due to some fragmentation in care. There was no documentation of patient and relative education on the prevention of PIs (n = 0). All the patients were provided with the right pressure redistributing mattress however, some mattresses were bottoming out. Some causes overlapped, with system defects like lack of protocols, equipment and tools pushing human errors to occur. This created a series of events leading to the adverse event. The identification of these factors helped to provide an understanding of the changes that are needed to reduce future harm and improve patient safety., Conclusion: Recommendations were proposed to reduce contributing factors to the development of hospital-acquired PIs. These include audits to reinforce adherence to hospital guidelines, streamlining of the documentation system, investment in new equipment and improvements to educational programmes. The recommendations implemented resulted in a decreased incidence rate of HAPIs., (Copyright © 2021 Tissue Viability Society. Published by Elsevier Ltd. All rights reserved.)

Introduction: The lying and rumination behavior of dairy cows is internationally used as an animal welfare indicator. Dairy cow housing in Switzerland is subordinated to detailed legal requirements. It is particularly described that the lying area for cows must be covered with a sufficient amount of bedding. In the current study, we investigated whether bedding depth influences the lying and rumination behavior and thus, the animal welfare of healthy dairy cows housed in tie stalls. Bedding depth was categorized as ≤ 2 cm and > 2 cm. The lying and rumination behavior of 145 cows from 33 farms was recorded and analyzed considering farm effects; 105 cows were housed on ≤ 2 cm bedding, and 40 cows on > 2 cm bedding. Cows on > 2 cm bedding had on average a one hour longer daily lying time compared with cows on ≤ 2 cm bedding (mixed-effects linear regression: mean difference [cows on > 2 cm bedding - cows on ≤ 2 cm bedding] = 60,7 min/d; standard error = 28,6 min/d; p-value = 0,037). The odds of a cow to lie while ruminating were significantly higher in cows on > 2 cm bedding against cows on ≤ 2 cm bedding (mixed-effects logistic regression: Odds ratio = 1,27; CI95% [1,17-1,38]; p-value  2 cm can make a significant difference in the lying and rumination behavior of healthy dairy cows housed in tie stalls. Consequently, the animal welfare of dairy cows in tie stalls is improved by providing at least 2 cm of bedding.

Bedding material or litter is an important requirement of meat chicken production which can influence bird welfare, health, and food safety. A substantial increase in demand and cost of chicken bedding has stimulated interest in alternative bedding sources worldwide. However, risks arising from the use of alternative bedding materials for raising meat chickens are currently unknown. Organic chemicals, elemental, and biological contaminants, as well as physical and management hazards need to be managed in litter to protect the health of chickens and consequently that of human consumers. This requires access to information on the transfer of contaminants from litter to food to inform risk profiles and assessments to guide litter risk management. In this review, contaminants and hazards of known and potential concern in alternative bedding are described and compared with existing standards for feed. The contaminants considered in this review include organic chemical contaminants (e.g., pesticides), elemental contaminants (e.g., arsenic, cadmium, and lead), biological contaminants (phytotoxins, mycotoxins, and microorganisms), physical hazards, and management hazards. Reference is made to scientific literature for acceptable levels of the above contaminants in chicken feed that can be used for guidance by those involved in selecting and using bedding materials., (Copyright © 2020. Published by Elsevier Inc.)

Background: Frequent patient handling activities present numerous challenges to healthcare workers. A variety of products are available to assist with in-bed positioning but few comparative studies have been completed to ascertain turning effectiveness., Methods: The purpose of this study was to compare two turning devices (air-powered positioning system with wedges versus ceiling lift with pillows) for in-bed repositioning and turning effectiveness. The study took place at a large community hospital in the Midwestern USA and used a prospective, four-group crossover study design to compare devices., Results: The two turning groups were not significantly different for any of the demographic variables. The use of an air-powered positioning system with wedges achieved a greater degree of turn and maintained that turn after an hour better than the lift device with pillows. There were no hospital acquired pressure injuries in either group., Conclusion: The devices used demonstrated significant differences in turn angle achieved and ability to maintain the turn at one hour. Future studies need to further delineate the ideal method for turning and compare devices to identify best practice and equipment. An effective turning method would integrate ease of use with the ability to achieve an optimal degree of turn in order to prevent hospital acquired pressure injuries while also decreasing caregiver injuries., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Purpose: To evaluate if a Full Access Underbody (FAU) blanket used preoperatively and intraoperatively in patients undergoing major spinal surgery prevents hypothermia compared with current practice and to explore patients' experiences of comfort., Design: A nonrandomized controlled trial., Methods: Sixty patients were included, 30 in each group. Temperature was assessed on arrival, after connecting to the bladder catheter, and at the start and end of surgery. In the FAU group, comfort was evaluated at arrival and after 10 minutes of prewarming., Findings: The incidence of hypothermia at the start of surgery was significantly lower (relative risk [95% confidence interval], 0.28 [0.13 to 0.59]). Before prewarming, 77% felt comfortable, 20% cold, and 3% hot. After prewarming 60% felt comfortable, 37% hot, and 3% very hot., Conclusions: Patients using the FAU blanket had a 72% lower incidence of hypothermia at the start of the operation. Attention to thermal comfort during surgery is important., (Copyright © 2019 American Society of PeriAnesthesia Nurses. Published by Elsevier Inc. All rights reserved.)

Purpose: The present study aimed to evaluate the impact of warming on physiological indices of patients undergoing laparoscopic cholecystectomy., Design: The study was a three-group randomized controlled clinical trial., Methods: In the present study, 96 patients were assigned to three groups: forced-air warming system group; warmed intravenous fluid group; and control group. The intervention was performed immediately after the anesthesia induction. Physiological indices (core body temperature, blood pressure, and heart rate) were evaluated at 15-minute intervals, and postoperative shivering was also recorded., Findings: The mean systolic blood pressure and the mean heart rate were significantly different in each warming group before, during, and after surgery, but the three groups had no significant differences in terms of physiological indices at any time (P > .05). Postoperative shivering was not seen in any group., Conclusions: Both interventions had similar effects on physiological indices. Therefore, the recommendation is to use the warming method according to patient's other conditions., (Copyright © 2018 American Society of PeriAnesthesia Nurses. Published by Elsevier Inc. All rights reserved.)

Purpose: To prevent perioperative hypothermia, forced air warming blanket was compared with a passive insulation suit., Design: Prospective, open, randomized controlled trial., Methods: Thirty patients were scheduled for orthopedic spinal surgery. The intervention group (group TS) received the thermal suit T-Balance before premedication and throughout the perioperative period, whereas the control group (group C) received forced air warming (FAW) during surgery., Findings: No statistically significant difference (ns) was found between the groups for core temperature 30 minutes after induction of general anesthesia. Perioperative hypothermia occurred in 10 (66.7%) patients in group TS and 6 (40%) in group C (ns). For hypothermic patients, re-establishment of normothermia took significantly longer in group TS, mean 108 ± 111 minutes, than in group C, 33 ± 59.5 minutes (P = .03)., Conclusions: The thermal suit did not prevent hypothermia in this study. FAW was significantly more efficient in re-establishing normothermia., (Copyright © 2019 American Society of PeriAnesthesia Nurses. Published by Elsevier Inc. All rights reserved.)

Objective: Numerous studies have reported that various environmental factors during early life are key determinants for developing allergic disease. Herein, we aimed to investigate the impact of environmental factors on allergic rhinitis., Methods: This cross-sectional study was conducted in a single university in Japan (from April to June, in 2015 and 2016). Students voluntarily answered online questionnaires regarding their allergic rhinitis symptoms and their exposure to various environmental factors during preschool-age., Results: Overall, 3075 students participated the questionnaire. After excluding those with incomplete datasets, 3016 students were eligible. Of these, 49% had allergic rhinitis symptoms. Female sex was associated with a lower risk of allergic rhinitis symptoms (odds ratio [OR], 0.82; 95% confidence interval [CI], 0.68-0.99). Comorbidity of asthma or atopic dermatitis and a family history of allergy (asthma, atopic dermatitis, or allergic rhinitis) were associated with higher risks of allergic rhinitis symptoms. Regarding the number of household members, compared with subjects with <3 people, those with 5 (OR, 0.74; 95% CI, 0.57-0.97) and ≥6 people (OR, 0.66; 95% CI, 0.49-0.88) in their household showed lower incidences of allergic rhinitis symptoms. No other environmental factors, including birth order, number of siblings, living environment, passive smoking, furry pet ownership, housing, bedding, breastfeeding, dairy product intake, preschool setting, and starting age of preschool, was associated with the incidence of allergic rhinitis symptoms., Conclusion: Sex, current asthma and atopic dermatitis symptoms, family history of allergies, and the number of people in the household at preschool-age were associated with the incidence of allergic rhinitis symptoms., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Introduction: Actively warming hypothermic patients or preventing hypothermia is critical in optimising outcomes in patients with traumatic injuries. Our aim was to investigate the effect of ambient oxygen concentration on the rate and change in temperature of the TechTrade Ready-Heat II exothermic (oxygen-activated) warming blanket, to evaluate safety and ascertain the risk of thermal injury., Methods: A mannequin covered with an exothermic blanket was placed in a sealed oxygen tent. An ambulance blanket was placed between the TechTrade Ready-Heat II exothermic blanket and the mannequin. Two temperature probes were placed directly on the surface of the mannequin; one on the torso away from the heating packs and the other directly beneath the exothermic heating pack. The mannequin was exposed to increasing oxygen concentrations at 10% increments, starting at 21%. The experiment was conducted nine times, each time using a new blanket. Maximum temperature of the mannequin 'skin' and rate of rise were recorded from both temperature sensors., Results: In room air (21% oxygen), the mannequin surface reached 52°C after 60 min, matching manufacturer specifications. At 30% oxygen concentration, the temperature directly beneath the exothermic heating pack exceeded the 65°C threshold at which rapid thermal burns occur, reaching 72.5°C, with minimal change in overall torso temperature., Conclusion: The supplemental use of oxygen in patients with traumatic injuries that increases ambient oxygen levels in the presence of exothermic warming devices may represent a significant risk to the patient. We suggest that prehospital care providers remain highly vigilant of heat when using high-flow oxygen and the subsequent fire risk, while manufacturers of exothermic blankets should consider ways to improve safety., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Passengers' behavioral adjustments warrant greater attention in thermal comfort research in aircraft cabins. Thus, a field investigation on 10 commercial aircrafts was conducted. Environment measurements were made and a questionnaire survey was performed. In the questionnaire, passengers were asked to evaluate their thermal comfort and record their adjustments regarding the usage of blankets and ventilation nozzles. The results indicate that behavioral adjustments in the cabin and the use of blankets or nozzle adjustments were employed by 2/3 of the passengers. However, the thermal comfort evaluations by these passengers were not as good as the evaluations by passengers who did not perform any adjustments. Possible causes such as differences in metabolic rate, clothing insulation and radiation asymmetry are discussed. The individual difference seems to be the most probable contributor, suggesting possibly that passengers who made adjustments had a narrower acceptance threshold or a higher expectancy regarding the cabin environment. Local thermal comfort was closely related to the adjustments and significantly influenced overall thermal comfort. Frequent flying was associated with lower ratings for the cabin environment., (© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

In 2014, Japanese Ministry of Health, Labour and Welfare published the guideline on the policy of the psychiatric hospitals. We executed a survey to the members of "The Japanese Society of Psychiatry and Neurology" about the impression of this guideline, especially about "The functional differentiation of psychiatric hospital beds". Nine questions were notified on the home page of the society. 862 answers (5.3% of the members) were corrected by website from 1st to 30th of May in 2015. Attribution of the answers : doctors working at the psychiatric hospitals (70.9%), the psychiatric clinics (20%), the others (9.1%). The questions which more than 80% of the answers agreed were "The reduction of the psychiatric beds should be stepwise under the rule of check & balance in the improvement of the psychiatric community treatment", "Improve the function of the recovery phase treatment" and "The adequate treat- ment for the patients of the severe and chronic phases". The questions more than 55% of the answers agreed were "The reduction of the chronic phase beds for the improvement of the function of the acute phase beds". The questions which opposites exceeded (almost 47%) were "The assessment of the psychiatric symptoms in the patients of the chronic phase should be done by the third party" and "The facility for social skill treatment should be placed in the community". We could know the mind of the members about the revolution of the psychiatric.

Household crowding can place young children at risk for respiratory infections which subsequently provoke asthma symptoms. However, crowding might also protect against asthma, in accordance with the hygiene hypothesis. We tested if parent-infant bed-sharing, an important dimension of household crowding, increases or decreases the risk for asthma. In a population-based prospective cohort (N = 6160) we assessed bed-sharing at 2 and 24 months; wheezing between 1 and 6 years of age; and asthma at 6 years of age. Generalised estimating equation models were used to assess repeated measures of wheezing and asthma. We found no association between bed-sharing in early infancy and wheezing or diagnosis of asthma. By contrast, we found a positive association between bed-sharing in toddlerhood and both wheezing (OR 1.42, 95% CI 1.15-1.74) and asthma (OR 1.57, 95% CI 1.03-2.38). Wheezing was not associated with bed-sharing when using cross-lagged modelling. This study suggests that bed-sharing in toddlerhood is associated with an increased risk of asthma at later ages, and not vice versa. Further studies are needed to explore the underlying causal mechanisms., (Copyright ©ERS 2015.)

Background: Children in developing countries continue to suffer mortality and morbidity from a number of illnesses, among which are malaria and non-malarial febrile illnesses, which epidemiologically overlap. We examined the spatial pattern and risk factors of co-morbidity of malaria and non-malarial febrile illness among children aged 6-59 months in Nigeria., Method: Using data from the 2010 Nigeria Malaria Indicator Survey, we considered the co-morbidity of malaria and non-malarial febrile illness among the children as multicategorical and selected a mixed multinomial logit model capable of incorporating covariates of different types. Inference was Bayesian, based on multicategorical linear mixed-model representation., Results: We found that the risk of co-morbidity of malaria and non-malarial febrile illness increases as a child advances in age while the risk of non-malarial fever reduces after about 32 months of age. Area of residence (urban or rural), wealth index and type of roofing material used in the dwelling are other important risk factors for the co-morbidity found in this study. Further, children from four of Nigeria's 37 states are at high risk of malaria., Conclusions: Disease preventive measures need to be intensified, with more focus on rural areas and the poor. Campaigns for use of insecticide-treated bed nets need be more aggressive in all Nigerian states., (© The Author 2014. Published by Oxford University Press on behalf of Royal Society of Tropical Medicine and Hygiene. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Pododermatitis, often called 'sore hocks', is a chronic, granulomatous, ulcerative dermatitis which most commonly affects the plantar aspect of the caudal metatarsal and tarsal areas. Pododermatitis is a common clinical finding in the pet rabbit population, but no data is available regarding the actual prevalence of this condition in the UK pet rabbit population or possible husbandry-related factors which may predispose pet rabbits to development of this condition. It was the aim of this study to determine the prevalence of pododermatitis within a sample pet rabbit population, and study possible correlations with husbandry, sex, breed and origin of the rabbits. Findings suggested that young rabbits are at a lower risk of pododermatitis compared with older rabbits; female domestic rabbits are more predisposed to pododermatitis than males; and 100 per cent of the neutered females examined showed clinical evidence of pododermatitis. The effect that different types of bedding may have on the prevalence of pododermatitis was also investigated. This study also produced a scoring system which can be used to score clinical cases. Our study is of clinical importance because it helps to recognise many of the factors which predispose pet rabbits to pododermatitis, representing the first step towards increased awareness of this extremely common problem.

This research has been conducted continuously since 2009 as part of a cohort of studies examining relationships between asthma and genetic factors, dietary habits, and environmental factors. Based on data from environmental research on house dust mites and endotoxins, which are widely known as pollutants in bedding that cause asthma in pregnant women and children, this work was conducted to obtain basic data that can be used in future cohort studies that analyze links between distribution of biological hazards and physical features of residential environments. The detection rates of house dust mite allergens, Der p1 and Der f1, were 52.7 and 86.5%, respectively, indicating that Der f1 is a dominant species in domestic indoor environments. According to comparisons between concentrations of house dust mites and endotoxins in bedding of pregnant women and children, Der p1 and endotoxins showed significantly lower concentrations in bedding of pregnant women compared with those in bedding of children, whereas Der f1 showed no significant difference in concentration according to bedding.

Veterinary practices in the United Kingdom were surveyed to compare their surgical draping practices with Royal College of Veterinary Surgeons (RCVS) accreditation tier and other surgery-related factors. Using descriptive statistics and logistic or ordinal regression analysis (where appropriate), the relationships between draping material and accreditation tier and other surgery-related factors were assessed. Procedures were categorised as short or long. Two hundred and sixty-nine surveys were completed. Reusable drapes were used in 66 per cent of practices. Antibiotics were administered routinely in 38 per cent of short and 93 per cent of long procedures. Practices accredited as a Veterinary Hospital (VH) were 6.3-7.2 (short and long surgeries, respectively) times more likely to use disposable drapes, when compared with non-accredited practices. Use of dedicated surgical attire, draping the whole animal/table, and routine antibiotic usage were also positively correlated with disposable drape usage. Fifty-one per cent of practices rated infection rate as most important when choosing drape material. 'Best practice' techniques are associated with lower importance given to infection rate, and higher importance given to financial cost, when choosing drape material. Disposable drape use correlates with RCVS accreditation and with other aspects of surgical technique. Importance ratings awarded correlate with best practice procedures. Clinical relevance 'Best practice' draping procedures, that are not governed by RCVS accreditation scheme, are also more frequently performed in accredited VHs.

Background: The elimination of malaria in Zanzibar is highly dependent on sustained effective coverage of bed-nets to avoid malaria resurgence. The Health Belief Model (HBM) framework was used to explore the perceptions of malaria and bed-net use after a noticeable reduction in malaria incidence., Methods: Nineteen in-depth interviews were conducted with female and male caretakers of children under five in North A district, Zanzibar. Deductive content analysis was used to identify meaning units that were condensed, coded and assigned to pre-determined elements of the HBM., Results: Awareness of malaria among caretakers was high but the illness was now seen as easily curable and uncommon. In addition to the perceived advantage of providing protection against malaria, bed-nets were also thought to be useful for avoiding mosquito nuisance, especially during the rainy season when the malaria and mosquito burden is high. The discomfort of sleeping under a net during the hot season was the main barrier that interrupted consistent bed-net usage. The main cue to using a bed-net was high mosquito density, and children were prioritized when it came to bed-net usage. Caretakers had high perceived self-efficacy and did not find it difficult to use bed-nets. Indoor Residual Spraying (IRS), which was recognized as an additional means of mosquito prevention, was not identified as an alternative for bed-nets. A barrier to net ownership was the increasingly high cost of bed-nets., Conclusions: Despite the reduction in malaria incidence and the resulting low malaria risk perceptions among caretakers, the benefit of bed-nets as the most proficient protection against mosquito bites upholds their use. This, in combination with the perceived high self-efficacy of caretakers, supports bed-net usage, while seasonality interrupts consistent use. High effective coverage of bed-nets could be further improved by reinforcing the benefits of bed-nets, addressing the seasonal heat barrier by using nets with larger mesh sizes and ensuring high bed-net ownership rates through sustainable and affordable delivery mechanisms.

Background: Knowledge of the domestic mite fauna and allergen levels is important for a correct diagnosis and treatment of mite allergy. Our objectives were to describe the domestic mite fauna in the region of Murcia, Spain, to quantify mite allergens in dust samples obtained from mattresses of this area and to assess the influence of geographical, climatic and dwelling factors., Methods: Dust samples were collected in a transversal descriptive study from mattresses of 51 patients who went to the Allergology Service, and from mattress of 81 neighbours or family members of these patients. A questionnaire about home environment was filled in and obtained by all participants. Mite identification was done by light microscopy and allergen determinations (Der p 1 and Der f 1) by monoclonal antibodies., Results: Sixteen mite species were identified in the 132 dust samples collected. The most frequent species were Dermatophagoides farinae (36% of the samples), Dermatophagoides pteronyssinus (32%) and Tyrophagus putrescentiae (5.3%). There were significant differences among climatic regions. The coastal sector had greater mite abundance, being D. pteronyssinus more frequent and abundant than D. farinae. In inland areas D. farinae was the predominant mite species. Allergen levels correlated with the concentration of Dermatophagoides, with higher levels detected in coastal regions. Average annual temperature was the main outdoor factor that correlated with higher mite concentrations. Indoor main predictor of higher levels of mites was the presence of obvious signs of humidity in the home., Conclusion: This study demonstrates the existence of a mite fauna dominated by D. pteronyssinus and D. farinae with a strong influence of climatic factors and residential characteristics., (Copyright © 2010 SEICAP. Published by Elsevier Espana. All rights reserved.)

We evaluated the effectiveness of installing the Olyset® Net on the ceiling in preventing the invasion of malaria vectors. This study was conducted in houses in western Kenya. The number of resting mosquitoes inside the houses reduced when the ceiling and eaves of the houses were covered with the net. The mosquito densities remained low for 9 months, until the nets were removed.

Background: After a national voucher scheme in 2004 provided pregnant women and infants with highly subsidized insecticide-treated nets (ITNs), use among children under five years (U5s) in mainland Tanzania increased from 16% in 2004 to 26.2% in 2007. In 2008, the Ministry of Health and Social Welfare planned a catch-up campaign to rapidly and equitably deliver a free long-lasting insecticidal net (LLIN) to every child under five years in Tanzania., Methods: The ITN Cell, a unit within the National Malaria Control Programme (NMCP), coordinated the campaign on behalf of the Ministry of Health and Social Welfare. Government contractors trained and facilitated local government officials to supervise village-level volunteers on a registration of all U5s and the distribution and issuing of LLINs. The registration results formed the basis for the LLIN order and delivery to village level. Caregivers brought their registration coupons to village issuing posts during a three-day period where they received LLINs for their U5s. Household surveys in five districts assessed ITN ownership and use immediately after the campaign., Results: Nine donors contributed to the national campaign that purchased and distributed 9.0 million LLINs at an average cost of $7.07 per LLIN, including all campaign-associated activities. The campaign covered all eight zones of mainland Tanzania, the first region being covered separately during an integrated measles immunization/malaria LLIN distribution in August 2008, and was implemented one zone at a time from March 2009 until May 2010. ITN ownership at household level increased from Tanzania's 2008 national average of 45.7% to 63.4%, with significant regional variations. ITN use among U5s increased from 28.8% to 64.1%, a 2.2-fold increase, with increases ranging from 22.1-38.3% percentage points in different regions., Conclusion: A national-level LLIN distribution strategy that fully engaged local government authorities helped avoid additional burden on the healthcare system. Distribution costs per net were comparable to other public health interventions. Particularly among rural residents, ITN ownership and use increased significantly for the intended beneficiaries. The upcoming universal LLIN distribution and further behaviour change communication will further improve ITN ownership and use in 2010-2011.

Background: The use of insecticidal bed nets is found to be an effective public health tool for control of malaria, especially for under-five children and pregnant women. BRAC, an indigenous Bangladeshi non-governmental development organization, started working in the East African state of Uganda in June 2006. As part of its efforts to improve the health and well-being of its participants, BRAC Uganda has been distributing long lasting insecticide-treated bed nets (LLIN) at a subsidized price through health volunteers since February 2008. This study was conducted in March-April 2009 to examine how equitable the programme had been in consistence with BRAC Uganda's pro-poor policy., Methodology/principal Findings: Information on possession of LLINs and relevant knowledge on its proper use and maintenance was collected from households either with an under-five child and/or a pregnant woman. The sample included three villages from each of the 10 branch offices where BRAC Uganda's community-based health programme was operating. Data were collected by trained enumerators through face-to-face interviews using a hand-held personal digital assistant (PDA). Findings reveal that the study population had superficial knowledge on malaria and its transmission, including the use and maintenance of LLINs. The households' rate of possession of bed nets (41-59%), and the proportion of under-five children (17-19%) and pregnant women (25-27%) who reported sleeping under an LLIN were not encouraging. Inequity was observed in the number of LLINs possessed by the households, in the knowledge on its use and maintenance, and between the two programme areas., Conclusions/significance: The BRAC Uganda's LLINs distribution at a subsidized price appeared to be inadequate and inequitable, and BRAC's knowledge dissemination is insufficient for initiating preventive actions such as proper use of LLINs to interrupt malaria transmission. Findings contribute to the on-going debate on LLINs distribution in Africa and make a strong case for its free distribution.

Background: This study evaluated the progress in the treatment and prevention of hypothermia in combat wounded since the October 2, 2006 Joint Theater Trauma System Clinical Practice Guideline (CPG) publication and evaluated the frequency of use and effectiveness of the methods described in the CPG., Methods: The authors used data obtained from the Joint Trauma Theater Trauma Registry maintained by the US Army Institute of Surgical Research for our analysis., Results: The issuance of the CPG was associated with a decrease in the incidence of hypothermia (p value = <0.0001). None of the thermoregulatory methods were associated with significantly higher overall temperatures when compared with the others (p value = 0.1062-0.3686) or with hypothermia (p value = 0.1367-0.7992); however, lack of entered prehospital data resulted in a suboptimal number of patients for evaluation in this portion of the study. The wool blanket was the most commonly used thermoregulatory method (prehospital, 72%; interfacility, 49%)., Conclusions: (1) The incidence of hypothermia decreased after the issuance of the JTTS CPG. (2) The standard Army wool blanket is the most commonly used thermoregulatory method during transport in theater. (3) This study did not find a significant difference in the capability of maintaining temperatures between the different thermoregulatory methods used in theater during either prehospital or interfacility transport, or in the incidence of hypothermia between patients presenting from the site of injury or from interfacility transport. (4) Data collected before a Level III facility is not consistently entered into the Joint Theater Trauma Registry.

Background: Insecticide-treated nets (ITN) and long-lasting insecticidal treated nets (LLIN) are important means of malaria prevention. Although there is consensus regarding their importance, there is uncertainty as to which delivery strategies are optimal for dispensing these life saving interventions. A targeted mass distribution of free LLINs to children under five and pregnant women was implemented in Zanzibar between August 2005 and January 2006. The outcomes of this distribution among children under five were evaluated, four to nine months after implementation., Methods: Two cross-sectional surveys were conducted in May 2006 in two districts of Zanzibar: Micheweni (MI) on Pemba Island and North A (NA) on Unguja Island. Household interviews were conducted with 509 caretakers of under-five children, who were surveyed for socio-economic status, the net distribution process, perceptions and use of bed nets. Each step in the distribution process was assessed in all children one to five years of age for unconditional and conditional proportion of success. System effectiveness (the accumulated proportion of success) and equity effectiveness were calculated, and predictors for LLIN use were identified., Results: The overall proportion of children under five sleeping under any type of treated net was 83.7% (318/380) in MI and 91.8% (357/389) in NA. The LLIN usage was 56.8% (216/380) in MI and 86.9% (338/389) in NA. Overall system effectiveness was 49% in MI and 87% in NA, and equity was found in the distribution scale-up in NA. In both districts, the predicting factor of a child sleeping under an LLIN was caretakers thinking that LLINs are better than conventional nets (OR = 2.8, p = 0.005 in MI and 2.5, p = 0.041 in NA), in addition to receiving an LLIN (OR = 4.9, p < 0.001 in MI and in OR = 30.1, p = 0.001 in NA)., Conclusions: Targeted free mass distribution of LLINs can result in high and equitable bed net coverage among children under five. However, in order to sustain high effective coverage, there is need for complimentary distribution strategies between mass distribution campaigns. Considering the community's preferences prior to a mass distribution and addressing the communities concerns through information, education and communication, may improve the LLIN usage.

Background: The promotion of insecticide-treated net (ITN) can be a key approach towards the reduction of morbidity and mortality from malaria., Objective: To determine the proportion of mothers using insecticide treated nets for their children and reasons for nonuse., Study Design: Prospective hospital-based study., Method: Consecutive mothers attending the children's out patient clinic of UNTH, Ituku-Ozalla, Enugu, whose children presented with fever without localizing focus were interviewed with the aid of an open-ended structured questionnaire., Results: Awareness of ITN was found in 184 (80%) of the 230 mothers interviewed, while only 48 (26.1%) use it for their children. There was statistically significant difference in terms of ITN awareness between the highly educated mothers and those with lower educational qualification (p = 0.000) but, in terms of ITN usage, there was no significant difference between the two groups (p = 0.40). Socio economic class did not influence the use of ITN (p = 0.153). A greater number; 56 (41.2%) have no reason for non-use. Reasons for nonuse include use of windows and door nets 22 (16.2%) and not convenient to spread 18 (13.2%)., Conclusion: There was a high awareness of ITN, which did not influence usage.

Medical waste is a necessary by-product of any hospital environment; however, the majority of regulated medical waste is produced in the OR from the use of disposable surgical supplies (eg, drapes, gowns, basins, gloves, sponges). We conducted a concept comparison project in the ORs of two large medical centers in Bethesda, Maryland, and Washington, DC, to evaluate the effects of using reusable surgical basins, gowns, and table and Mayo stand covers in place of disposable products. Survey results indicated that surgeons and surgical technologists found the reusable products to be preferable to the disposable products currently in use. In addition, using reusable products provided a means to decrease regulated medical waste generated in the OR by an average of 65% as well as reduce the cost of waste disposal. AORN recommends evaluating the environmental effects of using reusable, reposable, and disposable products; our findings provide evidence that may be useful to surgical facilities that seek to adopt a "green" approach., (Copyright 2010 AORN, Inc. Published by Elsevier Inc. All rights reserved.)

Background: In the 1990s, the experience of eliminating malaria from Aneityum Island, Vanuatu is often given as evidence for the potential to eliminate malaria in the south-west Pacific. This experience, however, cannot provide a blueprint for larger islands that represent more complex social and environmental contexts. Community support was a key contributor to success in Aneityum. In the context of disappearing disease, obtaining and maintaining community participation in strategies to eliminate malaria in the rest of Tafea Province, Vanuatu will be significantly more challenging., Method: Nine focus group discussions (FGDs), 12 key informant interviews (KIIs), three transect walks and seven participatory workshops were carried out in three villages across Tanna Island to investigate community perceptions and practices relating to malaria prevention (particularly relating to bed nets); influences on these practices including how malaria is contextualized within community health and disease priorities; and effective avenues for channelling health information., Results: The primary protection method identified by participants was the use of bed nets, however, the frequency and motivation for their use differed between study villages on the basis of the perceived presence of malaria. Village, household and personal cleanliness were identified by participants as important for protection against malaria. Barriers and influences on bed net use included cultural beliefs and practices, travel, gender roles, seasonality of mosquito nuisance and risk perception. Health care workers and church leaders were reported to have greatest influence on malaria prevention practices. Participants preferred receiving health information through visiting community health promotion teams, health workers, church leaders and village chiefs., Conclusion: In low malaria transmission settings, a package for augmenting social capital and sustaining community participation for elimination will be essential and includes: 'sentinel sites' for qualitative monitoring of evolving local socio-cultural, behavioural and practical issues that impact malaria prevention and treatment; mobilizing social networks; intersectoral collaboration; integration of malaria interventions with activities addressing other community health and disease priorities; and targeted implementation of locally appropriate, multi-level, media campaigns that sustain motivation for community participation in malaria elimination.

Background: Despite Vietnam's success in reducing malaria mortality and morbidity over the last decade, malaria persists in the forested and mountainous areas of the central and southern provinces, where more than 50% of the clinical cases and 90% of severe cases and malaria deaths occur., Methods: Between July 2005 and September 2006, a multi-method study, triangulating a malariometric cross-sectional survey and qualitative data from focused ethnography, was carried out among the Ra-glai ethnic minority in the hilly forested areas of south-central Vietnam., Results: Despite the relatively high malaria burden among the Ra-glai and their general awareness that mosquitoes can transmit an unspecific kind of fever (84.2%), the use of bed nets, distributed free of charge by the national malaria control programme, remains low at the farmers' forest fields where the malaria risk is the highest. However, to meet work requirements during the labour intensive malaria transmission and rainy season, Ra-glai farmers combine living in government supported villages along the road with a second home or shelter at their slash and burn fields located in the forest. Bed net use was 84.6% in the villages but only 52.9% at the forest fields; 20.6% of the respondents slept unprotected in both places. Such low use may be explained by the low perception of the risk for malaria, decreasing the perceived need to sleep protected. Several reasons may account for this: (1) only 15.6% acknowledged the higher risk of contracting malaria in the forest than in the village; (2) perceived mosquito biting times only partially coincided with Anopheles dirus ss and Anopheles minimus A true biting times; (3) the disease locally identified as 'malaria' was hardly perceived as having an impact on forest farmers' daily lives as they were unaware of the specific kind of fevers from which they had suffered even after being diagnosed with malaria at the health centre (20.9%)., Conclusions: The progressive confinement of malaria to minority groups and settings in the Greater Mekong sub-region implies that further success in malaria control will be linked to research into these specific socio-cultural contexts. Findings highlight the need for context sensitive malaria control policies; not only to reduce the local malaria burden but also to minimize the risk of malaria spreading to other areas where transmission has virtually ceased.

Background: Plasmodium falciparum is the major species responsible for malaria transmission on the island of Príncipe, in the Republic of São Tomé and Príncipe (STP). Indoor residual spraying (IRS) has been intensively deployed on the island, since 2003. Other measures included intermittent preventive therapy (IPT), since 2004, as well as artemisinin-based therapy (ACT) and long-lasting insecticidal nets (LLINs) from 2005. The work was coordinated by the Ministry of Health of STP through their Centro Nacional de Endemias (CNE) and the impact of such an integrated control programme on the prevalence and epidemiology of malaria in Príncipe was evaluated., Methods: The scaling-up of preventive strategies included IRS, LLINs, IPT for pregnant women, as well as early diagnosis and prompt treatment with ACT. Regular implementation of an island-wide IRS programme was carried out yearly in 2003-2005, and later in 2008. Malaria incidence and prevalence were estimated based on passive case detection and active case detection, respectively. Slide positivity rate (SPR) was used as an indicator of any increase of malaria cases during and after the control programme was initiated., Results: Regular IRS achieved a coverage of 85-90% for each of the four annual cycles (2003-2005, annually and one spraying in 2008) while usage of LLINs was never superior to 50% from 2006-2009. Coverage of IPT steadily increased from 50% in 2004 to 80% in 2008. Since 2006, over 90% of uncomplicated malaria patients received ACT treatment. Severe malaria cases were hospitalized and treated with quinine. Monthly trends of SPR were constantly over 50% in 2003, but steadily decreased below 10% in 2006. SPR has been below 5% since 2007, but an increase to up to 15% was noted in June 2009 when 16 imported cases were detected. A steep decline by 99% of malaria incidence was observed between 2003 and 2008, with an incidence risk of the population of five per thousand, in 2008. No malaria mortality has been reported since 2005. Species shift from falciparum to non-falciparum malaria was noted after a five-year intensive control programme. Cross-sectional country-wide active surveillances showed malaria prevalences of 1.1%, 0.7%, and 0.9% in June 2006, Oct 2007, and July 2009, respectively, of which over 90% were asymptomatic., Conclusion: The effective measures of the combination of four major control methods have produced a rapid decline in malaria morbidity and mortality on the island of Príncipe. The combination of IRS, IPT, and active surveillance with ACT treatment seemed to have played important roles to achieve a present status of low and stable malaria on the island. In low transmission settings, any increase of malaria morbidity indicates potential epidemics and assumes that current control strategies were interrupted. Active surveillance should be reinforced to follow and monitor all asymptomatic carriers and imported cases. Consolidation and a shift to elimination phase demands the sustainability of such integrated programmes.

This textual analyses on Social marketing, Insecticide Treated Nets (ITNs) and Population Services International (PSI) were undertaken to achieve two objectives: (a) to contribute to the continuing debate and search for a better strategy for combating malaria in sub-Saharan Africa; and (b) to contribute to theory building on social marketing. The analyses revealed that Malaria has reached an epidemic proportion and despite major inroads by PSI in combating malaria on the principles of social marketing, the strategies of pricing and segmentation of the clients are not appropriate for Sub-Saharan African countries that are mired in absolute poverty where majority of the rural communities eke a living on less than a dollar per day and the health sector does not receive priority attention from policy makers and politicians. The descriptive statistics and a one sample t test for the sampled countries suggest that sub-Saharan countries have not even met the hypothesized 5% investment of their GDP on health, compared to their counterparts, the developed countries, who are all above this figure. The null hypothesis that there is no significant different between the population and the sample means of both developed and a developing country in their investments in the health sector was also tested and rejected. Though the elements in some of the existent models and theories of social marketing such as Health Belief Model, Theory of Reasoned Action, Social Cognitive Theory and Trans-theoretical Models all attempt to advocate for elimination of constraints and barriers to effective access to a service or product, PSI is adamant to these and try to generalize these principles in all contexts, including in Sub-Saharan Africa. The African scenario, where about 90% of Malaria related deaths cases in the world occur, demands more than what these theories present. Accordingly, it was concluded that however good intentioned social marketing is, in the case of ITNs in this region, it is counter productive as the pricing de-motivates clients who usually have other pressing needs to address and segmentation limits coverage. Social marketing is thus more relevant to developed economies where absolute poverty no longer exist and people can afford to pay for health services. Malaria in sub-Saharan Africa needs a "carpet bombing" strategy. It was also concluded that for Sub-Saharan countries to effectively address the MDG six on malaria, and implement the Abuja Summit and the Roll Back Malaria partnership declarations, it requires a high degree of political commitment, amongst others, to enable the vulnerable communities have access to free malaria treatment related drugs. Partners in the fight against malaria such as PSI should adopt a more eclectic intervention strategy, and be cognizant of the fact that the strategy that works for Africa should be that which is based on strict equity and stimulates demand for ITNs. The paper concludes by agreeing with Professors Curtis and Sachs that comprehensive malaria control in Africa is achievable by 2010, at the minimal cost if sound principles of public health and economics are observed. Millions of lives can be saved and Africa will be given vital help in escaping from the viscous circle of poverty and diseases that continue to grip the continent. The target for all intervention efforts should be to eliminate the cost factor and ensure free distribution of all malaria related treatment products.

In developing strategies to control malaria vectors, there is increased interest in biological methods that do not cause instant vector mortality, but have sublethal and lethal effects at different ages and stages in the mosquito life cycle. These techniques, particularly if integrated with other vector control interventions, may produce substantial reductions in malaria transmission due to the total effect of alterations to multiple life history parameters at relevant points in the life-cycle and transmission-cycle of the vector. To quantify this effect, an analytically tractable gonotrophic cycle model of mosquito-malaria interactions is developed that unites existing continuous and discrete feeding cycle approaches. As a case study, the combined use of fungal biopesticides and insecticide treated bednets (ITNs) is considered. Low values of the equilibrium EIR and human prevalence were obtained when fungal biopesticides and ITNs were combined, even for scenarios where each intervention acting alone had relatively little impact. The effect of the combined interventions on the equilibrium EIR was at least as strong as the multiplicative effect of both interventions. For scenarios representing difficult conditions for malaria control, due to high transmission intensity and widespread insecticide resistance, the effect of the combined interventions on the equilibrium EIR was greater than the multiplicative effect, as a result of synergistic interactions between the interventions. Fungal biopesticide application was found to be most effective when ITN coverage was high, producing significant reductions in equilibrium prevalence for low levels of biopesticide coverage. By incorporating biological mechanisms relevant to vectorial capacity, continuous-time vector population models can increase their applicability to integrated vector management.

Background: Insecticide treated nets (ITNs) have been identified as a key strategy in addressing malaria problem among young children and pregnant women. Their utilisation among under fives, however, have been found to be low in some areas., Objective: To identify factors affecting net utilisation (sleeping under insecticide treated net) among caregivers of under fives in Makueni District in Kenya., Design: A cross-sectional, descriptive study., Setting: Eight sub-locations in Wote division Makueni district., Subjects: Four hundred caregivers of children aged five years and below., Results: The results indicated that 88.5% of caregivers were aware of ITNs. The proportion of households with children below five years that owned mosquito net were found to be 46.2%, and only 32.0% had at least a treated net. Slightly more than half of treated nets were used by under fives (52.2%) compared to 47.8% used by children over five years including adults. The main reason cited by majority of caregivers as a hindrance to net utilisation was lack of treated nets in households (72.3%). Utilisation of ITNs by under five children was found to be positively associated with knowledge of ITNs (p = 0.024), marital status (p = 0.018) and occupation (p = 0.043)., Conclusion: Utilisation of ITNs by under fives was low despite high level of awareness among caregivers. Factors such as awareness of ITNs, marital status and occupation significantly affected ITNs utilisation. Although the government with support from other stakeholders has recently embarked on large scale distribution of nets in high risky districts, more interventions from various stakeholders are needed to increase availability and accessibility of subsidised permanently treated nets, including interventions to address non-compliance to proper utilisation of nets. There is also need for intensive education emphasising on their proper and consistent use. Scaling up proper use of ITNs along with other initiatives can contribute significantly in reducing malaria.

Background: Malaria is one of the most serious public health problems in Kenya. Pregnant women are among the groups with the highest risk of malaria. Use of insecticide treated bed nets (ITNs) is a cost-effective method of controlling malaria. Despite this, there is low utilisation of ITNs among pregnant women in Kilifi district which is an endemic malaria zone., Objective: To determine knowledge, attitude and practice on the use of ITNs in the prevention of malaria among pregnant women in Kilifi district., Design: A descriptive cross-sectional study., Setting: The district hospital and the five health centres in Kilifi district, Subjects: Two hundred and twenty pregnant women attending antenatal clinics (ANC) between October and December 2007., Results: Knowledge on malaria illness and ITNs was high with majority of pregnant women having adequate level of knowledge (86.9%). There was significant association between level of education and adequate knowledge (P-value = 0.010). Good attitude on ITNs use was low. There was no association between good attitude and any of the socio-demographic variables. The majority of pregnant women attending ANC owned ITNs (75.4%). ITNs usage was high (70.5%). There was significant association between religion and good practice (p-value = 0.050). Although adequate level of knowledge on malaria and protective role of ITNs was high, there was no association between knowledge with practice and attitude., Conclusion: Before any malaria preventive intervention is implemented in an area, different socio-cultural factors must be considered when behavioural interventions for malaria control are designed and implemented. Targeted health education should be disseminated to the community to remove stigma and misconceptions associated with ITNs. Community concerns and fears should be addressed.

Efforts to control malaria have been boosted in the past few years with increased international funding and greater political commitment. Consequently, the reported malaria burden is being reduced in a number of countries throughout the world, including in some countries in tropical Africa where the burden of malaria is greatest. These achievements have raised new hopes of eradicating malaria. This paper summarizes the outcomes of a World Health Organization's expert meeting on the feasibility of such a goal. Given the hindsight and experience of the Global Malaria Eradication Programme of the 1950s and 1960s, and current knowledge of the effectiveness of antimalarial tools and interventions, it would be feasible to effectively control malaria in all parts of the world and greatly reduce the enormous morbidity and mortality of malaria. It would also be entirely feasible to eliminate malaria from countries and regions where the intensity of transmission is low to moderate, and where health systems are strong. Elimination of malaria requires a re-orientation of control activity, moving away from a population-based coverage of interventions, to one based on a programme of effective surveillance and response. Sustained efforts will be required to prevent the resurgence of malaria from where it is eliminated. Eliminating malaria from countries where the intensity of transmission is high and stable such as in tropical Africa will require more potent tools and stronger health systems than are available today. When such countries have effectively reduced the burden of malaria, the achievements will need to be consolidated before a programme re-orientation towards malaria elimination is contemplated. Malaria control and elimination are under the constant threat of the parasite and vector mosquito developing resistance to medicines and insecticides, which are the cornerstones of current antimalarial interventions. The prospects of malaria eradication, therefore, rest heavily on the outcomes of research and development for new and improved tools. Malaria control and elimination are complementary objectives in the global fight against malaria.

Background: A key to making insecticide-treated nets (ITNs) a long-term, sustainable solution to the spread of malaria is understanding what drives their purchase and use. Few studies have analysed the determinants of demand for bed nets for malaria prevention at the household level, and in particular, how demand for nets compares with demand for other mosquito prevention methods., Methods: This study uses a household survey to assess the determinants of demand for bed nets in an area of endemic malaria transmission in rural, southern Mozambique. The study looks at willingness to pay (WTP) for bed nets, net ownership, usage, and past purchase behaviour, alongside expenditure and frequency of use of alternate methods for malaria prevention., Results: While overall net ownership in the sample is low, the evidence fails to suggest that poorer households are less likely to own bed nets, when controlling for covariates, nor does the likelihood of receiving a free net depend on socioeconomic status (SES). Formal schooling and market knowledge seem to indicate higher average willingness to pay, while use of alternate methods for malaria prevention, and receipt of Indoor Residual Spraying (IRS) are found to decrease demand for bed nets., Conclusion: For long-term sustainability of ITNs to be realized, results suggest that either full or partial subsidies may be necessary in some contexts to encourage households to obtain and use nets. Given the possible substitution effects of combined malaria control interventions, and the danger of not taking into consideration household preferences for malaria prevention, successful malaria control campaigns should invest a portion of their funds towards educating recipients of IRS and users of other preventive methods on the importance of net use even in the absence of mosquitoes.

Background: In March 2008, the Solomon Islands and Vanuatu governments raised the goal of their National Malaria Programmes from control to elimination. Vector control measures, such as indoor residual spraying (IRS) and long-lasting insecticidal bed nets (LLINs) are key integral components of this programme. Compliance with these interventions is dependent on their acceptability and on the socio-cultural context of the local population. These factors need to be investigated locally prior to programme implementation., Method: Twelve focus group discussions (FGDs) were carried out in Malaita and Temotu Provinces, Solomon Islands in 2008. These discussions explored user perceptions of acceptability and preference for three brands of long-lasting insecticide-treated bed nets (LLINs) and identified a number of barriers to their proper and consistent use., Results: Mosquito nuisance and perceived threat of malaria were the main determinants of bed net use. Knowledge of malaria and the means to prevent it were not sufficient to guarantee compliance with LLIN use. Factors such as climate, work and evening social activities impact on the use of bed nets, particularly in men. LLIN acceptability plays a varying role in compliance with their use in villages involved in this study. Participants in areas of reported high and year round mosquito nuisance and perceived threat of malaria reported LLIN use regardless of any reported unfavourable characteristics. Those in areas of low or seasonal mosquito nuisance were more likely to describe the unfavourable characteristics of LLINs as reasons for their intermittent or non-compliance. The main criterion for LLIN brand acceptability was effectiveness in preventing mosquito bites and malaria. Discussions highlighted considerable confusion around LLIN care and washing which may be impacting on their effectiveness and reducing their acceptability in Solomon Islands., Conclusion: Providing LLINs that are acceptable will be more important for improving compliance in areas of low or seasonal mosquito nuisance and malaria transmission. The implications of these findings on malaria elimination in Solomon Islands are discussed.

Background: Studies show that the burden of malaria remains huge particularly in low-income settings. Although effective malaria control measures such as insecticide-treated nets (ITNs) have been promoted, relatively little is known about their equity dimension. Understanding variations in their use in low-income settings is important for scaling up malaria control programmes particularly ITNs. The objective of this paper is to measure the extent and causes of inequalities in the ownership and utilisation of bed nets across socioeconomic groups (SEGs) and age groups in Tanga District, north-eastern Tanzania., Methods: A questionnaire was administered to heads of 1,603 households from rural and urban areas. Households were categorized into SEGs using both an asset-based wealth index and education level of the household head. Concentration indices and regression-based measures of inequality were computed to analyse both vertical and horizontal inequalities in ownership and utilisation of bed nets. Focus Group Discussions (FGDs) were used to explore community perspectives on the causes of inequalities., Results: Use of ITNs remained appallingly low compared to the RBM target of 80% coverage. Inequalities in ownership of ITNs and all nets combined were significantly pro-rich and were much more pronounced in rural areas. FGDs revealed that lack of money was the key factor for not using ITNs followed by negative perceptions about the effect of insecticides on the health of users. Household SES, living within the urban areas and being under-five were positively associated with bed net ownership and/or utilisation., Conclusion: The results highlight the need for mass distribution of ITN; a community-wide programme to treat all untreated nets and to promote the use of Long-Lasting Insecticidal nets (LLINs) or longer-lasting treatment of nets. The rural population and under-fives should be targeted through highly subsidized schemes and mass distribution of free nets. Public campaigns are also needed to encourage people to use treated nets and mitigate negative perceptions about insecticides.

Objective: This study aims to provide a better understanding of the amounts spent on different malaria prevention products and the determinants of these expenditures., Methods: 1,601 households were interviewed about their expenditure on malaria mosquito nets in the past five years, net re-treatments in the past six months and other expenditures prevention in the past two weeks. Simple random sampling was used to select villages and streets while convenience sampling was used to select households. Expenditure was compared across bed nets, aerosols, coils, indoor spraying, using smoke, drinking herbs and cleaning outside environment., Findings: 68% of households owned at least one bed net and 27% had treated their nets in the past six months. 29% were unable to afford a net. Every fortnight, households spent an average of US $0.18 on nets and their treatment, constituting about 47% of total prevention expenditure. Sprays, repellents and coils made up 50% of total fortnightly expenditure (US$0.21). Factors positively related to expenditure were household wealth, years of education of household head, household head being married and rainy season. Poor quality roads and living in a rural area had a negative impact on expenditure., Conclusion: Expenditure on bed nets and on alternative malaria prevention products was comparable. Poor households living in rural areas spend significantly less on all forms of malaria prevention compared to their richer counterparts. Breaking the cycle between malaria and poverty is one of the biggest challenges facing malaria control programmes in Africa.

Background: Distribution of insecticide-treated nets (ITNs) has recently been incorporated into comprehensive care strategies for HIV-positive people in malaria-endemic areas. WHO now recommends free or low-cost distribution of ITNs to all persons in malaria-endemic areas, regardless of age, pregnancy and HIV status. Knowledge about and appropriate use of ITNs among HIV-positive ITN recipients and their household members has not been well characterized., Methods: 142 randomly selected adults were interviewed in July-August 2006 to assess knowledge, retention, and appropriate use of ITNs they had received through a PEPFAR-funded comprehensive HIV care programme in rural Uganda., Results: Among all participants, 102 (72%, CI: 65%-79%) reported they had no ITNs except those provided by the programme. Of 131 participants who stated they were given >or= 1 ITN, 128 (98%, CI: 96%-100%) stated they still possessed at least one programme-provided ITN. Reported programme-ITN (pITN) use by participants was high: 119 participants (91%, CI: 86%-96%) reported having slept under pITN the night prior to the survey and 115 (88%, CI: 82%-94%) reported sleeping under pITN seven days per week. Being away from home and heat were the most common reasons given for not sleeping under an ITN. A sub-study of thirteen random home visits demonstrated concordance between participants' survey reports and actual use of ITNs in homes., Conclusion: There was excellent self-reported retention and appropriate use of ITNs distributed as a part of a community-based outpatient HIV care programme. Participants perceived ITNs as useful and were unlikely to have received ITNs from other sources.

Background: There is no clear consensus on the most sustainable and effective distribution strategy for insecticide treated bed nets (ITNs). Tanzania has been a leader in social marketing but it is still not clear if this can result in high and equitable levels of coverage., Methods: A cluster-randomized survey of ITN and bed net ownership and use was conducted in a rural area exposed to intense Plasmodium falciparum transmission in NE Tanzania where ITN distribution had been subject to routine delivery of national strategies and episodic free distribution through local clinics. Data were collected on household assets to assess equity of ITN coverage and a rapid diagnostic test for malaria (RDT) was performed in all ages., Results: Among 598 households in four villages the use of any or insecticidal bed nets in children less than five years of age was 71% and 54% respectively. However there was a 19.8% increase in the number of bed nets per person (p < 0.001) and a 13.4% increase in the number of insecticidal nets per person (p < 0.001) for each quintile increase in household asset score. The odds of being RDT-positive were reduced by more than half in the least poor compared to the poorest households (OR 0.49, 95% CI 0.35-0.70). Poorer households had paid less for their nets and acquired them more recently, particularly from non-commercial sources, and bed nets in the least poor households were less likely to be insecticidal compared to nets in the poorest households (OR 0.44, 95% CI 0.26-0.74)., Conclusion: Marked inequity persists with the poorest households still experiencing the highest risk of malaria and the lowest ITN coverage. Abolition of this inequity within the foreseeable future is likely to require mass or targeted free distribution, but risks damaging what is otherwise an effective commercial market.

Background: Use of insecticide-treated nets (ITNs) continues to offer potential strategy for malaria prevention in endemic areas. However their effectiveness, sustainability and massive scale up remain a factor of socio-economic and cultural variables of the local community which are indispensable during design and implementation stages., Methods: An ethnographic household survey was conducted in four study villages which were purposefully selected to represent socio-economic and geographical diversity. In total, 400 households were randomly selected from the four study villages. Quantitative and qualitative information of the respondents were collected by use of semi-structured questionnaires and focus group discussions., Results: Malaria was reported the most frequently occurring disease in the area (93%) and its aetiology was attributed to other non-biomedical causes like stagnant water (16%), and long rains (13%). Factors which significantly caused variation in bed net use were occupant relationship to household head (chi2 = 105.705; df 14; P = 0.000), Age (chi2 = 74.483; df 14; P = 0.000), village (chi2 = 150.325; df 6; P = 0.000), occupation (chi2 = 7.955; df 3; P = 0.047), gender (chi2 = 4.254; df 1; P = 0.039) and education levels of the household head or spouse (chi2 = 33.622; df 6; P = 0.000). The same variables determined access and conditions of bed nets at household level. Protection against mosquito bite (95%) was the main reason cited for using bed nets in most households while protection against malaria came second (54%). Colour, shape and affordability were some of the key potential factors which determined choice, use and acceptance of bed nets in the study area., Conclusion: The study highlights potential social and economic variables important for effective and sustainable implementation of bed nets-related programmes in Sub-Saharan Africa.

Introduction: Malaria in pregnancy is a formidable misery in Africa and contributes significantly to maternal death in Nigeria. The use of insecticide treated mosquito bed nets is one of the strategies of the Roll Back Malaria initiative. It is a form of vector control measure but there exists discordance between awareness and utilization of insecticide treated nets in Nigeria. This study set out to assess the level of awareness and utilization of insecticide treated nets among pregnant mothers attending antenatal clinic., Methods: Using a structured questionnaire, a cross sectional study of 250 consecutive pregnant mothers attending antenatal booking clinic in Usmanu Danfodiyo University Teaching Hospital Sokoto between January and March 2008 was conducted., Results: Seventy four percent of the clients were aware of Insecticide treated nets. Awareness of insecticide treated nets was significantly higher in clients with post primary education (66.8%) compared to those with at most primary education (33.2%); p < 0.05. Thirteen percent of the clients were using insecticide treated nets while 67.6% were not. The main reason for non-utilization of insecticide treated nets were non availability of the nets (58.8%) and inconvenience of the barrier to the clients (29.4%)., Conclusion: There is high level of awareness of insecticide treated nets among the study population but very low utilization largely due to non availability. For Nigeria to achieve the millennium development goal target in combating the menace of malaria in pregnancy, more effort is required to increase the availability of insecticide treated nets. In addition, proper education on the benefits of insecticide treated nets may increase its utilization.

Impact of insecticide-treated bednets (ITNs) on preventing malaria may be minimized if they are not used by vulnerable populations. Among ITN-owning households from 15 standardized national surveys from 2003 to 2006, we identify factors associated with ITN use among children younger than 5 years of age and make comparisons of ITN use among children and pregnant women across countries. Within ITN-owning households, many children and pregnant women are still not using them. Between-country analysis with linear regression showed child ITN use increases as intra-household access to ITNs increases (P = 0.020, R2 = 0.404), after controlling for season and survey year. Results from within-country logistic regression analyses were consistent with between-country analysis showing intra-household access to ITNs is the strongest and most consistent determinant of use among children. The gaps in ITN use and possession will likely persist in the absence of achieving a ratio of no more than two people per ITN.

Background: An increasing number of malaria-endemic African countries are rapidly scaling up malaria prevention and treatment. To have an initial estimate of the impact of these efforts, time trends in health facility records were evaluated in selected districts in Ethiopia and Rwanda, where long-lasting insecticidal nets (LLIN) and artemisinin-based combination therapy (ACT) had been distributed nationwide by 2007., Methods: In Ethiopia, a stratified convenience sample covered four major regions where (moderately) endemic malaria occurs. In Rwanda, two districts were sampled in all five provinces, with one rural health centre and one rural hospital selected in each district. The main impact indicator was percentage change in number of in-patient malaria cases and deaths in children < 5 years old prior to (2001-2005/6) and after (2007) nationwide implementation of LLIN and ACT., Results: In-patient malaria cases and deaths in children < 5 years old in Rwanda fell by 55% and 67%, respectively, and in Ethiopia by 73% and 62%. Over this same time period, non-malaria cases and deaths generally remained stable or increased., Conclusion: Initial evidence indicated that the combination of mass distribution of LLIN to all children < 5 years or all households and nationwide distribution of ACT in the public sector was associated with substantial declines of in-patient malaria cases and deaths in Rwanda and Ethiopia. Clinic-based data was a useful tool for local monitoring of the impact of malaria programmes.

Background: Insecticide-treated bednets (ITNs) provide a means to improve child survival across Africa. Sales figures of these nets and survey coverage data presented nationally mask inequities in populations at biological and economic risk, and do not allow for precision in the estimation of unmet commodity needs. We gathered subnational ITN coverage sample survey data from 40 malaria-endemic countries in Africa between 2000 and 2007., Methods: We computed the projected ITN coverage among children aged less than 5 years for age-adjusted population data that were stratified according to malaria transmission risks, proximate determinants of poverty, and methods of ITN delivery., Findings: In 2000, only 1.7 million (1.8%) African children living in stable malaria-endemic conditions were protected by an ITN and the number increased to 20.3 million (18.5%) by 2007 leaving 89.6 million children unprotected. Of these, 30 million were living in some of the poorest areas of Africa: 54% were living in only seven countries and 25% in Nigeria alone. Overall, 33 (83%) countries were estimated to have ITN coverage of less than 40% in 2007. On average, we noted a greater increase in ITN coverage in areas where free distribution had operated between survey periods., Interpretation: By mapping the distribution of populations in relation to malaria risk and intervention coverage, we provide a means to track the future requirements for scaling up essential disease-prevention strategies. The present coverage of ITN in Africa remains inadequate and a focused effort to improve distribution in selected areas would have a substantial effect on the continent's malaria burden.

Objective: To determine whether long lasting insecticide treated bed nets (LLINs) distributed free of charge to pregnant women at their first antenatal clinic visit in Kinshasa, DRC are used from the time of distribution to delivery and 6 months after delivery., Methods: Women were enrolled into a cohort study at their first antenatal care (ANC) visit and provided LLINs free of charge. Reported use of these nets was then measured at the time of delivery (n = 328) and in a random sample of women (n = 100) 6 months post-delivery using an interviewer administered, structured questionnaire., Results: At baseline, only 25% of women reported having slept under a bed net the night before the interview. At the time of delivery, after being provided an LLIN for free, this increased to 79%. Six months post-delivery (n = 100), 80% of women reported sleeping under a net with a child under the age of 5 the night before the interview., Conclusions: Freely distributed bed nets are acceptable, feasible and result in high usage. Free distribution of bed nets during antenatal clinic visits may be a highly effective way to rapidly increase the use of bed nets among both pregnant women and their newborn infants in areas with high levels of ANC attendance.