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Objective. To investigate the relationship between IGF-I and the nutritional status of West-African children hospitalised for nutritional rehabilitation.Patients and methods. A cohort study was performed in two centres for nutritional rehabilitation and education (CREN) in Burkina Faso. Children were followed and the anthropometric data as well as the capillary blood samples were taken on the 7th and on the 14th days after their admission. IGF-I levels were determined from dried blood spots on filter paper on IGF-I RIA, after separation of the IGF-I from its binding proteins, using Sep-Pak chromatography.Results. A total of 59 children was included in the cohort. The IGF-I mean geometric values (SD) were 6.3 (1.4)μg/L on admission, 8.6 (1.8)μg/L at day 7 and 13.6 (2.0)μg/L at day 14. The differences between these values were statistically significant (P<.001). There is a significant correlation between the changes of IGF-I with the change of weight for height Z-score (P= .01).Conclusion. These results suggest that IGF-I can be considered as a potential marker to follow the nutritional status of children admitted in hospital for protein and energy malnutrition.

The aims of this study were to validate the use of filter paper to measure insulin-like growth factor-I (IGF-I) and to establish normal levels of IGF-I in children appearing healthy, from birth to 5 years of age in an African population.We determined IGF-I from blood collected on filter paper. We validated this method by comparing the IGF-I values from dried blood spots on filter paper (kept at 4 degrees C and ambient temperature) and from serum among 13 children under 5. IGF-I were measured by the classical IGF-I RIA, after separation of the IGF-I from its binding proteins, using Sep-Pak chromatography. To establish normal levels of IGF-I, we conducted a cross-sectional study and collected blood samples with filter paper among 360 children in Ouagadougou (Burkina Faso).IGF-I determined from dried blood spots on filter paper were in good agreement with IGF-I levels obtained from blood serum, whether the filter papers were kept at 4 degrees C or at ambient temperature. The results of IGF-I-levels in apparently healthy children showed that geometric mean IGF-I ranged from 27 microg/l in boys younger than five months to 31 microg/l in 5-year-old boys. In girls, mean IGF-I ranged from 29 microg/l for girls younger than five months to 45 microg/l at the age of 5. From birth to 24 months, IGF-I decreased by 0.32+/-0.08 microg/l/month in boys and by 0.27+/-0.06 microg/l/month in girls and these decreases were not significantly different (p=0.95). After the age of 24 months, there was an increase in IGF-I of 4.9+/-1.3 microg/l/year in boys and of 8.4+/-0.8 microg/l/year in girls. This increase was indeed significantly different (p0.001).Reference values of IGF-I for African boys and girls were determined. They will be used for endocrine evaluations and nutritional monitoring.

Risk factors for Buruli ulcer (BU) are poorly understood. We conducted a case-control study in southern Benin to investigate the association between haemoglobin variants S or C and BU, and particularly the association between haemoglobinopathies HbSS/SC and BU osteomyelitis. We compared the haemoglobin genotype of 179 patients with BU and 44 with BU osteomyelitis to that of 242 community controls. We found no evidence of an increased risk of BU according to the presence of haemoglobin variants S and/or C [odds ratio adjusted for sex, age, region of residence and ethnicity: 1.24 (95% CI: 0.80-1.93), P = 0.34]. Haemoglobin variants S and C are unlikely to play a role in the BU burden. However, haemoglobinopathies HbSS/SC were more frequent among BU osteomyelitis patients than among controls (6.8% vs. 1.0%, Fisher's exact P-value = 0.045), which may suggest that those disorders facilitate growth of Mycobacterium ulcerans in the bone matrix.

BCG remains the only possible prophylactic intervention against Buruli ulcer (BU). Estimating its public health impact on BU control is an important issue. We conducted a case-control study to investigate the vaccine effectiveness of routine BCG vaccine against BU in southern Benin. From August 2002 to August 2003, BCG vaccination status was obtained for 279 clinically diagnosed BU cases and 988 age- and sex-matched neighborhood controls. BCG coverage, which was estimated by the presence of a scar or a vaccination record, was 64.5% in cases and 67.2% in controls. There was no evidence of a protective effect of routine BCG vaccination against BU in southern Benin (vaccine effectiveness adjusted for socioeconomic status = 12%, 95% confidence interval = -24% to 37%).

OBJECTIVE: To investigate the possible association between the body burden of dioxin-like compounds and endometriotic disease. DESIGN: Case-control study. SETTING: Gynecology ward in a university hospital. PATIENT(S): Seventy-one women with peritoneal endometriosis (n = 25) or deep endometriotic (adenomyotic) nodules (n = 25) and controls (n = 21). INTERVENTION(S): Collection of 200 mL of blood (fasted) and face-to-face interview. MAIN OUTCOME MEASURE(S): Assessment of dioxin (PCDD), furan (PCDF), and dioxin-like PCB serum concentrations (picograms toxic equivalent [TEQ]/g lipids). RESULT(S): Age and body mass index were traced by linear multiple regression as determinants of total TEQ levels. After standardization for these variables (30 years and 22.5 kg/m2), the mean TEQ levels were 24.21 (controls), 30.62 (peritoneal endometriosis), and 37.60 (deep endometriotic [adenomyotic] nodules) pg TEQ/g lipids. Logistic regression analysis indicated a significantly increased risk of deep endometriotic (adenomyotic) nodules (odds ratio [OR], 3.3; 95% confidence interval [CI], 1.4-7.6) for an increment of 10 pg in total TEQ levels/g lipids. An increased risk was also found for peritoneal endometriosis (OR, 1.9; 95% CI, 0.9-3.8) for total TEQ levels and for dioxins alone (OR, 3.2; 95% CI, 1.0-9.9). CONCLUSION(S): The results provide the first epidemiological evidence of an association between increased PCDD/PCDF and PCB body burden and endometriosis.

OBJECTIVE: A lack of global cardiovascular (CV) risk approach is often observed in the clinical practice. Having conceived a clinical strategy aimed at helping general practitioners (GPs) to assess and manage global CV risk in the daily practice, we wanted to evaluate the impact of a training promoting this strategy. METHODS: Randomised controlled trial involving GPs registered in a continual medical education (CME) group. The intervention and control arms included 7 (123 GPs) and 13 (220 GPs) groups, respectively. The intervention was a training in CV prevention provided during a CME meeting. GPs answered a questionnaire four months after the training. The main outcome was the use of a global CV risk assessment tool. Secondary outcomes were the GPs' awareness of the CV diseases burden, knowledge of the CV risk factors, and CV therapeutic attitudes. RESULTS: More trained GPs (76% vs. 52%) used a global CV risk assessment tool (p = 0.003). Significant differences were also observed for secondary outcomes: (a) awareness of CV diseases burden: more trained GPs were aware of the lethality from myocardial infarction (37% vs. 21%, p = 0.047) and considered it as the main cause of sudden death in adults (78% vs. 59%, p = 0.018); (b) knowledge of risk factors: more trained GPs considered familial CV history (89% vs. 73%, p = 0.021) and HDL-cholesterol (82% vs. 62%, p = 0.013) as important CV risk factors; (c) therapeutic attitudes: fewer trained GPs used to prescribe a lipid-lowering drug based on a total cholesterol value without considering the other risk factors (44% vs. 65%, p = 0.013). CONCLUSIONS: The global CV risk approach in the general practice was favourably influenced by this training provided during a CME meeting. The impact of the training on patients' outcomes should be addressed in a prospective trial.

OBJECTIVES: To investigate the virological outcome of chronic hepatitis B (CH-B) in children who received interferon alpha (IFN) compared with no treatment. METHODS: Seventy-four children with CH-B (median age, 6.1 years; 44 boys) selected from a cohort of 158 cases were included and divided into two groups: IFN-treated (n = 37) and control (n = 37). The controls were matched with the treated children by baseline alanine aminotransferase (ALT) levels, sex and age. The Kaplan-Meier method was performed to estimate the time to clearance of hepatitis B e antigen (HbeAg) and hepatitis B surface antigen (HbsAg). RESULTS: Mean duration of follow-up was comparable in two groups (5.2 +/- 3.8 years in treatment group versus 5.2 +/- 3.7 years in control group, NS). HBeAg and HBsAg loss occurred in 20 (54.1%) and three treated children versus 13 (35.1%) and one untreated children (NS), respectively. The 7-year cumulative HBeAg and HBsAg clearance rates were 47.5% and 8.9% after the first visit in the treatment group versus 33.5% and 4.0% in untreated children (NS), respectively. Elevated baseline ALT (two times upper limit of normal) had a significant effect on the long-term cumulative rate of HBeAg seroconversion in treated patients (P = 0.01) but not in the untreated group. CONCLUSIONS: These findings show that the overall long-term virological outcome does not differ significantly between IFN-treated and untreated children but that a significant benefit of treatment on the long term rate of HBeAg seroconversion is obtained in children with higher baseline ALT levels.

Environmental chemicals with oestrogen-like activity are suspected aetiological factors of endometriosis. In animal experiments, cadmium was recently shown to possess oestrogen-like properties. In the frame of a case-control study designed to investigate environmental risk factors for endometriosis, we compared cadmium urinary excretion (CdU) and blood concentration in 59 patients with peritoneal endometriosis, deep endometriotic (adenomyotic) nodules of the recto-vaginal septum and controls. After standardisation for age (30 years) and smoking status, the mean levels of cadmium in urine were (geometric mean [geometric S.D.]) 0.25 [1.50], 0.29 [1.76] and 0.26 [1.46] microg/g creatinine, respectively. Cadmium concentrations in blood did not differ among the three groups. These data, therefore, do not support a role for cadmium in the onset or the growth of endometriosis or deep endometriotic (adenomyotic) nodules of the recto-vaginal septum.

Background: Factors determining lipoprotein concentrations in the fetus are not yet fully understood. We postulated that an important factor is the genetic make-up of the mother. In the present study, we examined the associations between the cord blood concentrations of lipoproteins of 525 newborns and the polymorphisms present in their mothers on the genes of apolipoprotein E (APOE*E2, *E3, *E4), apolipoprotein C-III (APOC3*C3238G also called APOC3*S2) and lipoprotein lipase (LPL*S447X). Results: Newborns born of mothers with APOE*E2 allele had significantly lower cord blood LDL-C (P < 0.01) and apoB (P < 0.001) and significantly higher cord blood HDL-C and apoA I (all P-values < 0.03) compared to those born of mothers with APOE*E3E3 genotype. These associations were independent of the presence of APOE*E2 allele in the newborns. Similarly, APOC3*S2 in mothers was associated with significantly lower (all P < 0.001) cord blood LDL-C, apoB, HDL-C and apoA1. In contrast, LPL*S447X in mothers lowered significantly cord blood LDL-C and apoB only when LPL*S447X was present in newborns. Most of the effects of these maternal polymorphisms on the newborns were independent of the changes of maternal lipoproteins generated by these polymorphisms. Conclusions: This is the first evidence that maternal genetic variations influence fetal lipoprotein concentrations, independent of the genetic status of the fetus and of the variations of maternal lipoprotein concentrations generated by these genetic variants. It suggests that proteic components of maternal lipoproteins strongly control the metabolism of maternal lipoproteins carried out at the surface of the placenta to assure the cholesterol delivery to the fetus. (C) 2003 Elsevier Ireland Ltd. All rights reserved.

BACKGROUND: Urban health is a fashionable topic which generates a bulk of research work most often focused on particularities of health problems in urban settings. This focus distracts from the importance of research on how local urban health systems are organized and managed. OBJECTIVE: To analyse the conceptual, managerial and technical problems faced by urban health system policy and organization in sub-Saharan Africa, in order to make recommendations. METHODS: We report here on a research programme carried out to review the available evidence on health system policy and organization in urban areas, and to learn lessons from a number of case studies. RESULTS: First, while the health district approach is usually regarded as a means of implementing primary health care in rural areas, we argue that it is likewise appropriate - theoretically and empirically - for the formulation and implementation of a coherent and effective health system in urban areas. Secondly, we concentrate on a number of contextual features that have to be taken into account in order to strengthen district organization and management in the urban context. Spatial, managerial and technical constraints which do not exist in rural areas, proliferation and fragmentation of uncontrolled health services in the private sector, lack of control over political power of the large national and university hospitals, insufficient governance and leadership of the urban health authorities are pointed out for attention. Having noted and thoroughly analysed these issues is not to suggest therefore that the health district approach has to be rejected but that it has to be modified and adapted in key respects. Thirdly, we outline district health system strengthening in the cities as a policy option less fashionable but more appropriate, including the World Bank agenda for reform, the sector-wide approaches for health development, the health promotion approaches based on the Ottawa Charter, and the poverty reduction approaches focusing on coping strategies of local actors. CONCLUSION: Greater achievements could be reached by urban health systems in sub-Saharan Africa if they were organized and structured according to a health district policy. Key elements of such an organizational and managerial strategy should be realistically understood and assessed so as to provide health managers with a suitable tool for the successful development of primary health care in urban settings. Given the identified contextual constraints, implementation of a district health system in an urban context appears to depend mainly on political will and decision. It calls only incidentally for technical solutions. The following are among the most important requirements that have to be taken into account: ensuring appropriate allocation of resources to a legitimate urban health authority responsible for effective co-ordination of the many actors involved in urban health, setting out key developmental guidelines for the big city hospitals and effective communication channels with these institutions, ensuring development regulation and good governance of the private health sector. The role of the state remains crucial in this perspective.

OBJECTIVE: To determine to what extent biochemical markers of the nutritional and inflammatory status of young children are related to subsequent growth retardation and morbidity. DESIGN: Population-based follow-up study of a cohort of children from admission to final survey round six months later. SETTING: Health area in Northern Kivu, Zaire. SUBJECTS: 842 children under two years of age of whom about one-third gave informed consent to capillary blood collection. MAIN OUTCOME MEASURES: Concentration of albumin, transferrin, transthyretin, alpha 1-acid glycoprotein, C-reactive protein, and complement component C3 at baseline, and three and six months later. Incremental growth per 1 month, 3 months and 6 months of follow-up. Cumulative incidence of disease per 1 month and 3 months interval. RESULTS: A high proportion of children was with low concentrations of transport proteins and high concentrations of acute-phase reactants. Weight growth and arm circumference growth did not vary significantly with respect to initial concentrations of biomarkers, but subsequent height growth was lower in children with high values of transferrin, alpha 1-acid glycoprotein, and complement component C3 at baseline. Cumulative incidence of malaria, respiratory illness, and diarrhoea was not significantly affected by the concentration of the biomarkers at baseline. CONCLUSIONS: In this part of central Africa performing biochemical measurements should not be encouraged as a means for risk scoring in non-hospitalized children.

The population of eastern Kivu, like that of Rwanda, has been surviving in critical conditions for many years. The Rwandan refugees of 1994 fled into an area with its own serious problems. The Zairean health services in the health districts of Rutshuru, Kirotshe and Masisi, in spite of the political and socioeconomic disintegration of the country, were still functioning, and the local hospitals and health centres, although overwhelmed, contributed to a large extent to the disaster response. Prominent among the major problems facing the local health services were their limited adaptability, the inadequate coordination and collaboration offered to them by the humanitarian aid agencies, and the discrimination between the direct and secondary victims of the emergency. The public health consequences of the Rwandan refugee crisis for the Zairean population constitute an integral part of the disaster.

A hospital-based follow-up study was conducted between 1986 and 1988 at Lwiro (South Kivu Province, Zaire). Of 1,129 children in the study, three of four were severely malnourished, and 17.4% died. This study analyzes the mortality in hospital; its objectives are to evaluate the prognostic power of edema and anthropometric and biologic indicators and to seek indices that perform better. Receiver operating characteristic curves were established for each parameter under study and for each index constructed. Areas under receiver operating characteristic curves were highest for biologic indicators, and simple indices, obtained by counting the number of risk factors present, performed best. In the absence of biologic parameters, the authors suggest classifying children as at risk of dying when they present with edema and/or with arm circumference of less than 115 mm. When biologic measurements are possible, in addition to edema and arm circumference, the authors suggest taking serum albumin and transthyretin into account. For serum albumin and transthyretin, mortality risk is defined in terms of values of less than 16 g/liter and 6.5 mg/dl, respectively. Children will be classified as at risk of dying when they present with at least two of the four risk factors. The resulting diagnostic test has a high sensitivity (91.2%) and positive and negative predictive values of 40.8% and 97.9%, respectively.

The sum of bulk polychlorobiphenyl levels was significantly higher in women with rectovaginal adenomyosis than in women with endometriosis and controls.

In July 1994, a stream of Rwandan refugees entered the southern part of North Kivu Region, Zaire. The public health consequences of this crisis for the host population and health services have not been analysed up to now. The lack of human and financial resources did not prevent Zairian health structures and personnel from taking care of the many refugees settled outside the camps, following their arrival. The public health consequences of the crisis for the local population should be considered an integral part of the disaster.

An important concern in surveys of the prevalence of endemic goitre is the possibility of inaccuracy that can occur when estimating thyroid enlargement by clinical examination. We report here the results of a study from central Africa that demonstrated the importance of interobserver variation in the assessment of goitre size among experts and participants attending an international training course on iodine deficiency disorders (IDD). Agreement among raters estimated by calculation of the kappa statistic was poor on average when the five-stage goitre classification recommended by WHO was used. As expected, agreement on a single category was slightly better, especially when the category of interest was visible goitre. Our results suggest that palpation alone is not a reliable method for assessing the severity of IDD endemia. Other sources of inaccuracies are discussed and recommendations are made for better data collection on IDD in Africa and other regions.

About one billion people worldwide are at risk for iodine deficiency. Despite existing programs of prophylaxis, the prevention of iodine deficiency is still a challenge throughout the developing world. We studied the efficacy of low doses of iodized oil in an area of severe iodine deficiency in Zaire., Clinical Trial, Journal Article, Randomized Controlled Trial, Research Support, Non-U.S. Gov't, SCOPUS: cp.j, info:eu-repo/semantics/published

In 1987 health workers followed 1096 501). 78% lived >5 minute walk from households with a low demand for water ( 5 minutes walk from the public standpipe was 2.2 episodes/child/year but fell to 1 episode/child/year for children living =or 501 of water daily (p 5 minute walk to a standpipe and household water use of =or> 501/day were positively associated with these same factors (p

Anthropometric data of 18,211 under‐fives were collected in three health districts in the Northern Kivu (Zaire). These data were compared with each other, the international reference data set, the local reference data set, and with other data from Zaire. Analysis produced evidence of severe nutritional problems which are a great cause of concern in the Kivu Highlands. Important implications of the study are that intra‐uterine growth and growth during the first three months of life are likely to be the most critical, and that early interventions should therefore be targeted on the mother‐and‐child pairs.

We investigated the association between Buruli ulcer and HIV by comparing the HIV-1/2 seroprevalence in a series of 426 Buruli ulcer patients and a sample of 613 residents of southern Benin. The overall HIV prevalence was 2.6% (11/426) among patients and 0.3% among controls (2/613), giving an odds ratio for the association between HIV and Buruli ulcer of 8.1 (95% confidence interval = 1.8-75; P = 0.003).

We conducted a case-control study to investigate the association between Buruli ulcer (BU) and environmental- and health-related behaviors in southern Benin. Hospital BU cases (N = 324) and sex- and age-matched neighborhood controls (N = 1,173) answered a questionnaire. Regular use of soap for washing, treating injuries with soap or antibiotic powder, and frequent contact with flowing water appeared protective against BU.

Peritoneal endometriosis (PE) and deep endometriotic nodules (DEN) are gynecological diseases recently shown to be associated with elevated serum concentrations of organochlorines. The objective of the present study was to compare risk factors associated with both forms of the disease, with a particular attention to potential sources of organochlorine exposure. This matched case-control study with prospective recruitment included 88 triads (PE-DEN-control). All women were face-to-face interviewed with a standardized questionnaire, and serum dioxin and polychlorinated biphenyl measurements were available for 58 of them. Alcohol consumption (odds ratio (OR): 5.82 [confidence interval at 95% (95%CI) 1.20-28.3]) in DEN and low physical activity at work for DEN (OR: 4.58 [95%CI 1.80-11.62]) and PE (OR: 5.61 [95%CI 1.90-16.60]) were traced as significant risk factors. Organochlorine-related factors (use of tampons, occupational or environmental exposure) were not related to the disease. The current consumption of foodstuffs that were more likely to contribute to organochlorine body burden did not differ among the groups. Only some of these fatty foodstuffs (marine fish, pig meat) were traced by multiple regression analysis as significant determinants of organochlorine body burden, explaining only a small fraction (20%) of the interindividual variation of organochlorine body burden. We conclude that PE and DEN share similar patterns of risk or protective factors.

OBJECTIVES: To describe the use of primary care services by a prisoner population so as to understand the great number of demands and therefore to plan services oriented to the specific needs of these patients. DESIGN: Retrospective cohort study of a sample of prisoners' medical records. SETTING: All Belgian prisons (n = 33). PATIENTS: 513 patients over a total of 182 patient years, 3328 general practitioner (GP) contacts, 3655 reasons for encounter. MAIN RESULTS: Prisoners consulted the GP 17 times a year on average (95%CI 15 to 19.4). It is 3.8 times more than a demographically equivalent population in the community. The most common reasons for encounter were administrative procedures (22%) followed by psychological (13.1%), respiratory (12.9%), digestive (12.5%), musculoskeletal (12%), and skin problems (7.7%). Psychological reasons for consultations (n = 481) involved mainly (71%) feeling anxious, sleep disturbance, and prescription of psychoactive drugs. Many other visits concerned common problems that in other circumstances would not require any physician intervention. CONCLUSION: The most probable explanations for the substantial use of primary care in prison are the health status (many similarities noted between health problems at the admission and reasons for consultations during the prison term: mental health problems and health problems related to drug misuse), lack of access to informal health services (many contacts for common problems), prison rules (many consultations for administrative procedures), and mental health problems related to the difficulties of life in prison.

Aims: To estimate the prevalence of psychiatric symptoms in the Kampong Cham province and to determine the association between these symptoms and an impaired social functioning. Methods: Cross-sectional cluster sample survey conducted among adults randomly selected within 50 clusters distributed over the province. Results: Of the respondents, 42.4% reported symptoms that met the Diagnostic and Statistical Manual of Mental Disorders, 4th edition criteria for depression, 53% displayed high anxiety symptoms and 7.3% met posttraumatic stress disorder (PTSD) criteria. Posttraumatic symptoms of intrusion and avoidance were present in 47.8% and 45.4% respectively. When reviewing comorbidities, 29.2% had depression and anxiety symptoms, 16.5% anxiety symptoms, 6.1% depression and 7.1% had triple comorbidity (PTSD, depression and anxiety). Regarding social functioning, 25.3% reported being socially impaired. Respondents with comorbid symptoms for depression, anxiety and PTSD were associated with an increased risk for social impairment compared with others. Being over 65 years and having experienced violent events were other factors associated with social impairment. Conclusion: Five years after the return of a more stable context in Cambodia, the prevalence of psychiatric symptoms in the community remains high. In addition, these symptoms are strongly associated with social impairment. This suggests that beyond psychosocial programs, the implementation of adapted clinical psychiatric care should be considered as a priority.

Urban health is a fashionable topic which generates a bulk of research work most often focused on particularities of health problems in urban settings. This focus distracts from the importance of research on how local urban health systems are organized and managed.To analyse the conceptual, managerial and technical problems faced by urban health system policy and organization in sub-Saharan Africa, in order to make recommendations.We report here on a research programme carried out to review the available evidence on health system policy and organization in urban areas, and to learn lessons from a number of case studies.First, while the health district approach is usually regarded as a means of implementing primary health care in rural areas, we argue that it is likewise appropriate - theoretically and empirically - for the formulation and implementation of a coherent and effective health system in urban areas. Secondly, we concentrate on a number of contextual features that have to be taken into account in order to strengthen district organization and management in the urban context. Spatial, managerial and technical constraints which do not exist in rural areas, proliferation and fragmentation of uncontrolled health services in the private sector, lack of control over political power of the large national and university hospitals, insufficient governance and leadership of the urban health authorities are pointed out for attention. Having noted and thoroughly analysed these issues is not to suggest therefore that the health district approach has to be rejected but that it has to be modified and adapted in key respects. Thirdly, we outline district health system strengthening in the cities as a policy option less fashionable but more appropriate, including the World Bank agenda for reform, the sector-wide approaches for health development, the health promotion approaches based on the Ottawa Charter, and the poverty reduction approaches focusing on coping strategies of local actors.Greater achievements could be reached by urban health systems in sub-Saharan Africa if they were organized and structured according to a health district policy. Key elements of such an organizational and managerial strategy should be realistically understood and assessed so as to provide health managers with a suitable tool for the successful development of primary health care in urban settings. Given the identified contextual constraints, implementation of a district health system in an urban context appears to depend mainly on political will and decision. It calls only incidentally for technical solutions. The following are among the most important requirements that have to be taken into account: ensuring appropriate allocation of resources to a legitimate urban health authority responsible for effective co-ordination of the many actors involved in urban health, setting out key developmental guidelines for the big city hospitals and effective communication channels with these institutions, ensuring development regulation and good governance of the private health sector. The role of the state remains crucial in this perspective.

STUDY OBJECTIVE—Comparison of children's nutritional status in refugee populations with that of local host populations, one year after outbreak refugee crisis in the North Kivu region of Democratic Republic of Congo. DESIGN—Cross sectional surveys. SETTING—Temporary and other settlements, in the town of Goma and surrounding rural areas. SUBJECTS—Anthropometric indicators of nutritional status and presence or absence of oedema were measured among 5121 children aged 6 to 59 months recruited by cluster sampling with probability proportional to size, between June and August 1995. RESULTS—Children in all locations demonstrated a typical pattern of growth deficit relative to international reference. Prevalence of acute malnutrition (wt/ht

Overweight and obesity prevalences increased during the 1980s and 1990s in the USA1 and in Europe.2 Belgium is no exception to this trend. Using a sub-sample of working men (aged 40–54), the Belgian Interuniversity Research on Nutrition and Health (BIRNH) study showed that prevalence of obesity rose from 9% in 1978 to 15% in 1993.2 Recent findings have shown that overweight and obesity differed in areas within a region or country,1 3 but that trend in the geographical inequality has not been assessed up to now. In this paper, we examine whether such unequal distribution has changed between 1979 and 1990 among young Belgian men. We used data from the Belgian Armed Forces Medical Examination Service, undertaking an annual clinical check of 45 000 men. Analysis was restricted to subjects aged 18–25 residing in 544 (out of 589) Belgian municipalities with at least 200 men having undergone medical examination over the entire period. Complete data were available for 98.7% of these men. Although military service was compulsory in Belgium at that time, only 62% of the male population aged 18–25 had been submitted to the Armed …

OBJECTIVE: To identify useful predictors of morbidity of young children in central Africa. METHOD: Population-based follow-up study in Northern Kivu, Congo, of 842 children under two years of age who completed weekly follow-up interviews and health examinations during three months. Main outcome measures were crude and adjusted effects of summary measures of nutritional status on one-month cumulative incidence of malaria, respiratory illness, and diarrhoea. RESULTS: Anthropometric indicators appeared to perform badly in predicting morbidity. In contrast, non-anthropometric variables such as growth as judged by the caretaker, child's diet at the time of examination, and occurrence of disease in the month preceding the interval of observation were useful. CONCLUSIONS: In the context of the 'Sick Child Initiative', simple tests and diagnostic tools to improve quality of both prevention and cure in first-level facilities need to be identified. Focusing on non-anthropometric indicators should be encouraged to offer a comprehensive appraisal of health status to all children.

Ten years of Safe Motherhood Initiative notwithstanding, many developing countries still experience maternal mortality levels similar to those of industrialized countries in the early 20th century. This paper analyses the conditions under which the industrialized world has reduced maternal mortality over the last 100 years. Preconditions appear to have been early awareness of the magnitude of the problem, recognition that most maternal deaths are avoidable, and mobilization of professionals and the community. Still, there were considerable differences in the timing and speed of reduction of maternal mortality between countries, related to the way professionalization of delivery care was determined: firstly, by the willingness of the decision-makers to take up their responsibility; secondly, by making modern obstetrical care available to the population (particularly by encouragement or dissuasion of midwifery care); and thirdly, by the extent to which professionals were held accountable for addressing maternal health in an effective way. Reduction of maternal mortality in developing countries today is hindered by limited awareness of the magnitude and manageability of the problem, and ill-informed professionalization strategies focusing on antenatal care and training of traditional birth attendants. These strategies have by and large been ineffective and diverted attention from development of professional first-line midwifery and second-line hospital delivery care.

After 19 years of civil war and the total collapse of health services, disabled people are numerous in Afghanistan. Injuries caused by landmines are a major cause of disability,1 but data on other causes of disability are lacking. We assessed locomotor disability, rehabilitation needs, and coverage of oral polio vaccine in Kandahar province, a heavily mined area in south west Afghanistan.2 A multistage random cluster sampling was performed in four districts of Kandahar province (population 428 390). A disabled person was defined as someone unable to walk normally without help or unable to move their hands or arms properly for a reason other than age. Poliomyelitis was defined as recommended by the World Health Organisation for lameness surveys.3 Coverage of oral polio vaccine was measured by standard WHO methods for children aged 12–59 months.4 Data were collected …

We conducted a locomotor disability survey on a heavily mined Taliban-controlled province of Afghanistan to document the problem of locomotor disability and to assess the need for orthopaedic rehabilitation devices in a study population of 12065. Global prevalence of locomotor disability was 23/1000 (95% CI: 20-26). )War-related injuries were the leading cause of disability, affecting almost exclusively adult males. Leading causes of disability among women and children were medical and poliomyelitis. Devices most needed were lower limb ortheses (8.2 devices/1000 people; 95% CI: 5.9-10.4) and orthopaedic shoes (6.0/1000; 95% CI:4.1-8.0). The need for lower limb prostheses was less frequent (2.0/1000; 95% CI: 1.1-2.8). Most lower limb amputees (mainly victims of landmine injuries) were fitted with an artificial leg, while rehabilitation needs for other types of disability remained largely unmet. We estimated that it would take at least 3 years to provide enough orthopaedic shoes and 10 years for ortheses, whereas the need for lower limb prostheses could be met in less than 4 months. None of the 27 women with lower limb disability were equipped with an orthopaedic device, although this was the case for 31 of 89 men (35%). The problem of landmines should not divert attention from other causes of disability such as poliomyelitis or from other rehabilitation requirements. Immunization programmes and restoration of the public health infrastructure should be given high priority; rehabilitation services are largely insufficient and should be developed. Extreme gender difference in needs coverage is a matter of concern. Researching culturally sensitive strategies to tackle this problem should be a priority for donors and implementing agencies.

The Expanded Program on Immunization (EPI) aims through immunization to protect children against at least tuberculosis poliomyelitis diphtheria tetanus pertussis and measles. To ensure protection each child must receive at least three doses of oral poliomyelitis vaccine (OPV) three doses of combined diphtheria/tetanus/pertussis (DTP) vaccine and one dose of measles vaccine. The first dose of OPV should be given together with the first dose of DTP vaccine. The same holds true for the second and third doses of the two vaccines. Finally measles vaccine should be given along with the fourth dose of OPV. In actual field settings however often only one antigen is available to administer at any given time. Childrens personal immunization cards should therefore be designed so that the date of each dose of vaccine received can be recorded. These cards in Afghanistan and Burkina Faso have only one box in which to record the dates for the administration of the two vaccines together. Personal immunization cards must instead reflect what is actually delivered in the field and not the ideal. EPI managers and international agencies such as UNICEF and the World Health Organization are urged to ensure that well-designed cards are used in all countries.

Biological markers were used in an attempt to predict mortality in children admitted to the hospital in Kivu, Zaire, for protein energy malnutrition. Data for 39 children who died (16.4%) showed significantly lower levels of albumin (1.61 vs. 2.53 g/dl; p < 0.001), transferrin (82.1 vs. 167.7 mg/dl; p < 0.001), and transthyretin (6.49 vs. 9.87 mg/dl; p < 0.001), but not or retinol-binding protein, than for the 199 survivors. Since albumin and transferrin were correlated, a Cox model was used to see whether albumin or transferrin has a significant predictive value independent of transthyretin. The relative risk predicted by each indicator was of the same order of magnitude, approximately 4. We conclude that specific biological markers help to discriminate among hospitalized subjects at risk and to identify those in need of more intensive nutritional support to prevent early death.

OBJECTIVE--To measure the prognostic value of clinical, anthropometric, and biological indicators of protein energy malnutrition in hospitalised children. DESIGN--Hospital based follow up study from admission to discharge or death of a cohort of children. SETTING-Paediatric hospital in Zaire. SUBJECTS--1129 children consecutively admitted between August 1986 and October 1988. MAIN OUTCOME MEASURES--Height, weight, arm circumference, skinfold thicknesses, serum albumin concentration, and mortality. RESULTS--Mortality was higher in wasted children and in those with a mid-upper arm circumference < 125 mm, a serum albumin concentration < 16 g/l, and oedema. After multivariate analysis, serum albumin concentration was the best predictor of subsequent risk of dying. Mid-upper arm circumference and oedema, however, still contributed considerably to evaluation of mortality. CONCLUSIONS--In this specific environment of central Africa an isolated clinical sign such as oedema is not enough to detect children with a high risk of dying among those admitted to paediatric wards with severe protein energy malnutrition. Measurement of additional indicators such as arm circumference and serum albumin concentration seems to be of crucial importance.

To compare two methods of measurement of oestrogen receptor (ER)-expression in invasive breast cancer tissue. Sections from 299 breast cancer cases were stained for the ER by immunocytochemical assay (ICA), using mouse monoclonal antibody (MAb) NCL-ER-6SF11, and by the dextran-coated charcoal assay (DCC). Concordant results were observed in 230 of the 299 cases (77%), 69 patients had discordant results (kappa=0.537). We found a moderate concordance between ICA and DCC for ER measurement in breast cancer tissue. If we change the golden standard from DCC to ICA, 23% of patients would receive a different therapeutic approach.