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Author(s): Lorenz von Seidlein 1,2,*, Jacqueline L. Deen 3 The technology for a killed oral cholera vaccine (OCV) was developed by Jan Holmgren and colleagues in Sweden in the 1970s [...]

OBJECTIVE: To investigate the problems, benefits, feasibility, and sustainability of implementation of WHO guidelines on management of severe malnutrition. METHODS: A postal survey invited staff from 12 African hospitals to participate in the study. Five hospitals were evaluated and two were selected to take part in the study: a district hospital in South Africa and a mission hospital in Ghana. At an initial visit, an experienced paediatrician reviewed the situation in the hospitals and introduced the principles of the guidelines through a participatory approach. During a second visit about six months later, the paediatrician reviewed the feasibility and sustainability of the introduced changes and helped find solutions to problems. At a final visit after one year, the paediatrician reassessed the overall situation. FINDINGS: Malnutrition management practices improved at both hospitals. Measures against hypoglycaemia, hypothermia, and infection were strengthened. Early, frequent feeding was established as a routine practice. Some micronutrients for inclusion in the diet were not locally available and needed to be imported. Problems were encountered with monitoring of weight gain and introducing a rehydration solution for malnutrition. CONCLUSION: Implementation of the main principles of the WHO guidelines on severe malnutrition was feasible, affordable, and sustainable at two African hospitals. The guidelines could be improved by including suggestions on how to adapt specific recommendations to local situations. The guidelines are well supported by experience and published reports, but more information is needed about some components and their impact on mortality.

To the Editor: We wish to thank Date et al. for their clear discussion of the arguments against the use of oral cholera vaccines (OCVs) in Haiti in 2010-11 (7). [...]

Objective To define mortality patterns in an urban slum in Kolkata, India, in the context of a cholera and typhoid fever project. Methods In a well-defined population that was under surveillance for 18 months, we followed a dynamic cohort of 63 788 residents whose households were visited monthly by community health workers to identify deaths. Trained physicians performed verbal autopsies and experienced senior physicians assigned the primary cause of death according to the International classification of diseases, 10th edition. We tabulated causes of death in accordance with Global Burden of Disease 2000 categories and assessed overall and cause-specific mortality rates per age group and gender. Findings During 87 921 person-years of follow-up, we recorded 544 deaths. This gave an overall mortality rate of 6.2 per 1000 person-years. We assigned a cause to 89% (482/544) of the deaths. The leading causes of death, in descending order, were cardiovascular diseases (especially among adults aged over 40 years), cancer, respiratory ailments and digestive disorders. Most deaths in children under 5 years of age were caused by tuberculosis, respiratory infections and diarrhoeal diseases. Conclusion Although the most common causes of death in children were infectious, non-communicable diseases were predominant among adults. There is a need for continuing interventions against infectious diseases in addition to new and innovative strategies to combat non-infectious conditions. Objectif Definir des modeles de mortalite dans un quartier urbain pauvre de Kolkata en Inde, dans le contexte d'un projet cholera et fievre typhoide. Methodes Au sein d'une population bien definie, surveillee pendant 18 mois, nous avons suivi une cohorte dynamique de 63788 residents dont les foyers ont ete visites chaque mois par des professionnels communautaires de la sante pour identifier les deces. Des medecins competents ont realise des autopsies verbales et des professeurs experts ont reference la cause primaire du deces a partir de la Classification internationale des maladies, 10e edition. Nous avons mis en tableau les causes de deces conformement aux categories du <> et nous avons evalue les taux de mortalite generaux et pour cause specifique par tranche d'age et par sexe. Resultats Au cours des 87921 personnes-annees de suivi, nous avons enregistre 544 deces. Cela donne un taux de mortalite total de 6,2 par 1 000 personnes-annees. Nous avons attribue une cause a 89% (482/544) des deces. Les principales causes de deces, par ordre decroissant, etaient des maladies cardio-vasculaires (surtout parmi les adultes ages de 40 ans et plus), des cancers, des maladies respiratoires et des troubles digestifs. La plupart des deces chez les enfants de moins de 5 ans ont ete causes par la tuberculose, des infections respiratoires et des maladies diarrheiques. Conclusion Alors que les causes de deces les plus communes chez les enfants etaient d'origine infectieuse, les maladies non transmissibles ont ete predominantes chez les adultes. Des interventions en continu sont necessaires contre les maladies infectieuses, conjointement a ales strategies nouvelles et innovatrices pour combattre les conditions non infectieuses. Objetivos Definir los patrones de mortalidad en un barrio urbano pobre de Kolkata, India, dentro dei contexto de un proyecto contra el colera y la fiebre tifoidea. Metodos En una poblacion bien definida y sometida a vigilancia durante 18 meses se realizo el seguimiento de un conjunto de 63 788 residentes, cuyos hogares recibieron visitas mensuales, dei personai sanitario comunitario para identificar las defunciones. Las entrevistas con los familiares y allegados de las personas fallecidas fueron realizadas por medicos expertos, y los directores medicos atribuyeron la causa principal de la muerte siguiendo la Clasificacion Intemacional de Enfermedades, 10.a edicion. Las causas de la muerte se clasificaron segun las categorias de la Carga Mundial de Morbilidad dei 2000 y se evaluaron las tasas de mortalidad general y especifica de cada caso en funcion dei grupo de edad y dei sexo. Resultados Se registraron 544 muertes durante el seguimiento de 87921 anos-persona. Estos datos generaron una tasa de mortalidad de 6,2 por 1000 anos-persona. En el 89% de las muertes (482/544) se asigno una causa. Las principales causas de defuncion, en orden descendente, fueron: las enfermedades cardiovasculares (fundamentalmente, entre los adultos mayores de 40 anos), el cancer, las enfermedades respiratorias y los trastornos digestivos. La mayoria de las muertes acaecidas en ninos menores de cinco anos se debieron a la tuberculosis, las infecciones respiratorias y las enfermedades diarreicas. Conclusion Aunque las causas mas frecuentes de muerte infantil fueron las infecciosas, en los adultos predominaron las enfermedades infecciosas no contagiosas. Es necesario continuar con las intervenciones contra las enfermedades infecciosas, asi como iniciar estrategias nuevas e innovadoras para luchar contra las enfermedades no infecciosas., Introduction Mortality data are important indicators of population health and are crucial for setting priorities for health interventions and research. However, in areas with scanty resources little reliable information is [...]

ABSTRACT Background The burden of shigellosis is greatest in resource-poor countries. Although this diarrheal disease has been thought to cause considerable morbidity and mortality in excess of 1,000,000 deaths globally [...]

The New-generation, orally administered cholera vaccines are promising tools for the control of cholera in Mozambique, where Cholera is an endemic from January to June during rainy season. One such vaccine that consists of recombinant cholera-toxin B subunit and kills whole cells (rBs-WC) is shown to confer protection against endemic cholera and is internationally licensed.

Abstract Background Typhoid fever remains a significant health problem in many developing countries. A rapid test with a performance comparable to that of blood culture would be highly useful. A rapid diagnostic test for typhoid fever, Tubex®, is commercially available that uses particle separation to detect immunoglobulin M directed towards Salmonella Typhi O9 lipopolysaccharide in sera. Methods We assessed the sensitivity and specificity of the Tubex test among Tanzanian children hospitalized with febrile illness using blood culture as gold standard. Evaluation was done considering blood culture confirmed S. Typhi with non-typhi salmonella (NTS) and non - salmonella isolates as controls as well as with non-salmonella isolates only. Results Of 139 samples tested with Tubex, 33 were positive for S. Typhi in blood culture, 49 were culture-confirmed NTS infections, and 57 were other non-salmonella infections. Thirteen hemolyzed samples were excluded. Using all non - S. Typhi isolates as controls, we showed a sensitivity of 79% and a specificity of 89%. When the analysis was repeated excluding NTS from the pool of controls we showed a sensitivity of 79% and a specificity of 97%. There was no significant difference in the test performance using the two different control groups (p > 0.05). Conclusion This first evaluation of the Tubex test in an African setting showed a similar performance to those seen in some Asian settings. Comparison with the earlier results of a Widal test using the same samples showed no significant difference (p > 0.05) for any of the performance indicators, irrespective of the applied control group.

Abstract Background The diagnosis of typhoid fever is confirmed by culture of Salmonella enterica serotype Typhi (S. typhi). However, a more rapid, simpler, and cheaper diagnostic method would be very useful especially in developing countries. The Widal test is widely used in Africa but little information exists about its reliability. Methods We assessed the performance of the Widal tube agglutination test among febrile hospitalized Tanzanian children. We calculated the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of various anti-TH and -TO titers using culture-confirmed typhoid fever cases as the "true positives" and all other febrile children with blood culture negative for S. typhi as the "true negatives." Results We found that 16 (1%) of 1,680 children had culture-proven typhoid fever. A single anti-TH titer of 1:80 and higher was the optimal indicator of typhoid fever. This had a sensitivity of 75%, specificity of 98%, NPV of 100%, but PPV was only 26%. We compared our main findings with those from previous studies. Conclusion Among febrile hospitalized Tanzanian children with a low prevalence of typhoid fever, a Widal titer of ≥ 1:80 performed well in terms of sensitivity, specificity, and NPV. However a test with improved PPV that is similarly easy to apply and cost-efficient is desirable.

Little is known about the causes of enteric fever in Asia. Most cases are believed to be caused by Salmonella enterica serovar Typhi and the remainder by S. Paratyphi A. [...]

To the Editor: Cholera outbreaks caused by toxigenic Vibrio cholerae serogroup O1 frequently occur in many sub-Saharan African countries. The serogroup O1 is classified into two biotypes, classical and El [...]

Cholera: A Continuing Public Health Threat The emergence of cholera in Haiti highlighted the difficulties in containing cholera outbreaks with only safe water, sanitation, hygiene, and appropriate case management. In [...]

Abstract Background: Exposure of the individual to contaminated food or water correlates closely with the risk for enteric fever. Since public health interventions such as water improvement or vaccination campaigns are implemented for groups of individuals we were interested whether risk factors not only for the individual but for households, neighbourhoods and larger areas can be recognised? Methods: We conducted a large enteric fever surveillance study and analyzed factors which correlate with enteric fever on an individual level and factors associated with high and low risk areas with enteric fever incidence. Individual level data were linked to a population based geographic information systems. Individual and household level variables were fitted in Generalized Estimating Equations (GEE) with the logit link function to take into account the likelihood that household factors correlated within household members. Results: Over a 12-month period 80 typhoid fever cases and 47 paratyphoid fever cases were detected among 56,946 residents in two bustees (slums) of Kolkata, India. The incidence of paratyphoid fever was lower (0.8/1000/year), and the mean age of paratyphoid patients was older (17.1 years) than for typhoid fever (incidence 1.4/1000/year, mean age 14.7 years). Residents in areas with a high risk for typhoid fever had lower literacy rates and economic status, bigger household size, and resided closer to waterbodies and study treatment centers than residents in low risk areas. Conclusion: There was a close correlation between the characteristics detected based on individual cases and characteristics associated with high incidence areas. Because the comparison of risk factors of populations living in high versus low risk areas is statistically very powerful this methodology holds promise to detect risk factors associated with diseases using geographic information systems.

Abstract This is a correction of an earlier published article.

Abstract Background In the conduct of epidemiological studies in less developed countries, while great emphasis is placed on study design, data collection, and analysis, often little attention is paid to data management. As a consequence, investigators working in these countries frequently face challenges in cleaning, analyzing and interpreting data. In most research settings, the data management team is formed with temporary and unskilled persons. A proper working environment and training or guidance in constructing a reliable database is rarely available. There is little information available that describes data management problems and solutions to those problems. Usually a line or two can be obtained in the methods section of research papers stating that the data are doubly-entered and that outliers and inconsistencies were removed from the data. Such information provides little assurance that the data are reliable. There are several issues in data management that if not properly practiced may create an unreliable database, and outcomes of this database will be spurious. Results We have outlined the data management practices for epidemiological studies that we have modeled for our research sites in seven Asian countries and one African country. Conclusion Information from this model data management structure may help others construct reliable databases for large-scale epidemiological studies in less developed countries.

Abstract Background Early detection of cholera outbreaks is crucial for the implementation of the most appropriate control strategies. Methods The performance of an immunochromatographic dipstick test (Institute Pasteur, Paris, France) specific for Vibrio cholerae O1 was evaluated in a prospective study in Beira, Mozambique, during the 2004 cholera season (January-May). Fecal specimens were collected from 391 patients with acute watery nonbloody diarrhea and tested by dipstick and conventional culture. Results The overall sensitivity and specificity of the rapid test compared to culture were 95% (95% confidence interval [CI]: 91%–99%) and 89% (95% CI: 86%–93%), respectively. After stratification by type of sample (rectal swab/bulk stool) and severity of diarrhea, the sensitivity ranged between 85% and 98% and specificity between 77% and 97%. Conclusion This one-step dipstick test performed well in the diagnosis of V. cholerae O1 in a setting with seasonal outbreaks where rapid tests are most urgently needed.

Abstract Background In preparation of vaccines trials to estimate protection against shigellosis and cholera we conducted a two-year community-based surveillance study in an impoverished area of North Jakarta which provided updated information on the disease burden in the area. Methods We conducted a two-year community-based surveillance study from August 2001 to July 2003 in an impoverished area of North Jakarta to assess the burden of diarrhoea, shigellosis, and cholera. At participating health care providers, a case report form was completed and stool sample collected from cases presenting with diarrhoea. Results Infants had the highest incidences of diarrhoea (759/1 000/year) and cholera (4/1 000/year). Diarrhea incidence was significantly higher in boys under 5 years (387/1 000/year) than girls under 5 years (309/1 000/year; p < 0.001). Children aged 1 to 2 years had the highest incidence of shigellosis (32/1 000/year). Shigella flexneri was the most common Shigella species isolated and 73% to 95% of these isolates were resistant to ampicillin, trimethoprim-sulfamethoxazole, chloramphenicol and tetracycline but remain susceptible to nalidixic acid, ciprofloxacin, and ceftriaxone. We found an overall incidence of cholera of 0.5/1 000/year. Cholera was most common in children, with the highest incidence at 4/1 000/year in those less than 1 year of age. Of the 154 V. cholerae O1 isolates, 89 (58%) were of the El Tor Ogawa serotype and 65 (42%) were El Tor Inaba. Thirty-four percent of patients with cholera were intravenously rehydrated and 22% required hospitalization. V. parahaemolyticus infections were detected sporadically but increased from July 2002 onwards. Conclusion Diarrhoea causes a heavy public health burden in Jakarta particularly in young children. The impact of shigellosis is exacerbated by the threat of antimicrobial resistance, whereas that of cholera is aggravated by its severe manifestations.

The present article identifies, for children living in developing countries, the major causes of ill-health that are inadequately covered by established health programmes. Injuries and noncommunicable diseases, notably asthma, epilepsy, dental caries, diabetes mellitus and rheumatic heart disease, are growing in significance. In countries where resources are scarce it is to be expected that increasing importance will be attached to the development and implementation of measures against these problems. Their control may benefit from the application of elements of programmes directed against infectious, nutritional and perinatal disorders, which continue to predominate., Voir page 523 le resume en francais. En la pagina 523 figura un resumen en espanol. Introduction Disease patterns have been changing in recent decades because of socioeconomic developments. Low-income [...]