Bulletin of the World Health Organizationhttps://scielosp.org/feed/bwho/2000.v78n8/2016-01-01T00:02:00ZUnknown authorVol. 78 No. 8 - 2000WerkzeugIn This Month's BulletinS0042-968620000008000012016-01-01T00:02:00Z2001-01-28T00:08:00ZEliminating measles - no quick fixS0042-968620000008000022016-01-01T00:02:00Z2001-01-28T00:08:00ZGay, Nigel J.
<em>Gay, Nigel J.</em>;
<br/><br/>
Pattern of susceptibility to measles in ItalyS0042-968620000008000032016-01-01T00:02:00Z2001-01-28T00:08:00ZSalmaso, StefaniaGabutti, GiovanniRota, Maria CristinaGiordano, CristinaPenna, CleoniceMandolini, DonatellaCrovari, Pietro
<em>Salmaso, Stefania</em>;
<em>Gabutti, Giovanni</em>;
<em>Rota, Maria Cristina</em>;
<em>Giordano, Cristina</em>;
<em>Penna, Cleonice</em>;
<em>Mandolini, Donatella</em>;
<em>Crovari, Pietro</em>;
<br/><br/>
On the basis of seroprevalence and incidence data we describe the distribution of individuals susceptible and immune to measles in Italy in 1996-97. In regions where vaccination coverage was at least 70%, approximately 10% of 3-year-old children were susceptible to measles, whereas 40% were in this category in regions with lower vaccination coverage. Seroprevalence among children older than 4 years was similar for the two groups of regions; in the age group 20-39 years it was approximately 95%. During 1990-96 in the regions with lower vaccination coverage the incidence was highest among children aged 4-6 years, and the median age of cases was 7 years; in the regions with higher vaccination coverage, however, the incidence remained at around 5% for the age group 4-16 years, and the overall median age was 10 years. These data confirm the partial reduction in measles incidence in Italy, although transmission has still not been interrupted. The size and geographical distribution of the current pool of susceptible individuals can be expected to present an obstacle to measles elimination if appropriate vaccination strategies, such as catch-up campaigns, are not adopted.Unsafe injections and the transmission of hepatitis B and C in a periurban community in PakistanS0042-968620000008000042016-01-01T00:02:00Z2001-01-28T00:08:00ZKhan, Aamir J.Luby, Stephen P.Fikree, FariyalKarim, AnitaObaid, SaimaDellawala, SalimaMirza, ShaperMalik, TariqFisher-Hoch, SueMcCormick, Joseph B.
<em>Khan, Aamir J.</em>;
<em>Luby, Stephen P.</em>;
<em>Fikree, Fariyal</em>;
<em>Karim, Anita</em>;
<em>Obaid, Saima</em>;
<em>Dellawala, Salima</em>;
<em>Mirza, Shaper</em>;
<em>Malik, Tariq</em>;
<em>Fisher-Hoch, Sue</em>;
<em>Mccormick, Joseph B.</em>;
<br/><br/>
Following reports of frequent deaths associated with jaundice and chronic liver disease among adults in a periurban community of Karachi, Pakistan, an investigation was conducted to evaluate the relationship between injections and viral hepatitis infections, to identify the reasons why patients received frequent injections, and to observe the injection practices employed in clinics. Two hundred and three adult patients were interviewed as they left each of the 18 area clinics. Practitioners were interviewed and three consecutive injections were observed at each clinic. Eighty-one per cent of patients received an injection on the day of the interview. Of the 135 patients who provided a serum sample, 59 (44%) had antibodies against hepatitis C virus and 26 (19%) had antibodies against hepatitis B virus. Patients who received more injections were more likely to be infected with hepatitis C. If oral and injected medications were equally effective, 44% of patients preferred injected medication. None of the practitioners knew that hepatitis C could be transmitted by injections. Non-sterile syringes and needles that had been used earlier in the day on other patients were used for 94% of the observed injections. Interventions to limit injections to those which are safe and clinically indicated are needed to prevent injection-associated infections in Pakistan and other low-income countries.Low-cost technology for screening uterine cervical cancerS0042-968620000008000052016-01-01T00:02:00Z2001-01-28T00:08:00ZParashari, AdityaSingh, VeenaSehgal, AshokSatyanarayana, LabaniSodhani, PushpaGupta, Madan M.
<em>Parashari, Aditya</em>;
<em>Singh, Veena</em>;
<em>Sehgal, Ashok</em>;
<em>Satyanarayana, Labani</em>;
<em>Sodhani, Pushpa</em>;
<em>Gupta, Madan M.</em>;
<br/><br/>
We report on an illuminated, low-cost (Rs 1500 (US$ 36)) magnifying device (Magnivisualizer) for detecting precancerous lesions of the uterine cervix. A total of 403 women attending a maternal and child health care clinic who had abnormal vaginal discharge and related symptoms were referred for detailed pelvic examination and visual inspection by means of the device after the application of 5% (v/v) acetic acid. Pap smears were obtained at the same time. The results were compared with those obtained using colposcopy and/or histology. The Magnivisualizer improved the detection rate of early cancerous lesions from 60%, for unaided visual inspection, to 95%. It also permitted detection of 58% of cases of low-grade dysplasia and 83% of cases of high-grade dysplasia; none of these cases were detectable by unaided visual inspection. For low-grade dysplasia the sensitivity of detection by means of the Magnivisualizer was 57.5%, in contrast with 75.3% for cytological examination. However, the two methodologies had similar sensitivities for higher grades of lesions. The specificity of screening with the Magnivisualizer was 94.3%, while that of cytology was 99%. The cost per screening was approximately US$ 0.55 for the Magnivisualizer and US$ 1.10 for cytology.American cutaneous leishmaniasis: use of a skin test as a predictor of relapse after treatmentS0042-968620000008000062016-01-01T00:02:00Z2001-01-28T00:08:00ZPassos, Valéria M.A.Barreto, Sandhi M.Romanha, Alvaro J.Krettli, Antoniana U.Volpini, Ângela C.Costa, Maria Fernanda F. Lima e
<em>Passos, Valéria M.a.</em>;
<em>Barreto, Sandhi M.</em>;
<em>Romanha, Alvaro J.</em>;
<em>Krettli, Antoniana U.</em>;
<em>Volpini, Ângela C.</em>;
<em>Costa, Maria Fernanda F. Lima E</em>;
<br/><br/>
While relapses following clinical cure of American cutaneous leishmaniasis are frequent, no test has been described until now to predict such relapses. A cohort of 318 American cutaneous leishmaniasis patients was followed up for two years after treatment with meglumine antimoniate, during which time 32 relapses occurred, 30 in the first year and two in the second (accumulated risk: 10.5%). No association was found between these relapses and the parasite-specific antibody response before and after treatment, or between the relapses and stratification by sociodemographic and clinical characteristics. However when Leishmania was used as antigen, patients with a negative skin test at the time of diagnosis presented a 3.4-fold higher risk (hazard risk = 3.4; 95% confidence interval, 1.7-7.0) of American cutaneous leishmaniasis relapse, compared with patients with a positive response. This result shows that the skin test can be a predictor of American cutaneous leishmaniasis relapse after treatment.Validation of spot-testing kits to determine iodine content in saltS0042-968620000008000072016-01-01T00:02:00Z2001-01-28T00:08:00ZPandav, Chandrakant S.Arora, Narendra K.Krishnan, AnandSankar, RajanPandav, SmitaKarmarkar, Madhu G.
<em>Pandav, Chandrakant S.</em>;
<em>Arora, Narendra K.</em>;
<em>Krishnan, Anand</em>;
<em>Sankar, Rajan</em>;
<em>Pandav, Smita</em>;
<em>Karmarkar, Madhu G.</em>;
<br/><br/>
Iodine deficiency disorders are a major public health problem, and salt iodization is the most widely practised intervention for their elimination. For the intervention to be successful and sustainable, it is vital to monitor the iodine content of salt regularly. Iodometric titration, the traditional method for measuring iodine content, has problems related to accessibility and cost. The newer spot-testing kits are inexpensive, require minimal training, and provide immediate results. Using data from surveys to assess the availability of iodized salt in two states in India, Madhya Pradesh and the National Capital Territory of Delhi, we tested the suitability of such a kit in field situations. Salt samples from Delhi were collected from 30 schools, chosen using the Expanded Programme on Immunization (EPI) cluster sampling technique. A single observer made the measurement for iodine content using the kit. Salt samples from Madhya Pradesh were from 30 rural and 30 urban clusters, identified by using census data and the EPI cluster sampling technique. In each cluster, salt samples were collected from 10 randomly selected households and all retailers. The 15 investigators performing the survey estimated the iodine content of salt samples in the field using the kit. All the samples were brought to the central laboratory in Delhi, where iodine content was estimated using iodometric titration as a reference method. The agreement between the kit and titration values decreased as the number of observers increased. Although sensitivity was not much affected by the increase in the number of observers (93.3% for a single observer and 93.9% for multiple observers), specificity decreased sharply (90.4% for a single observer and 40.4% for multiple observers). Due to the low specificity and resulting high numbers of false-positives for the kit when used by multiple observers (‘‘real-life situations’’), kits were likely to consistently overestimate the availability of iodized salt. This overestimation could result in complacency. Therefore, we conclude that until a valid alternative is available, the titration method should be used for monitoring the iodine content of salt at all levels, from producer to consumer, to ensure effectiveness of the programme.A critical examination of summary measures of population healthS0042-968620000008000082016-01-01T00:02:00Z2001-01-28T00:08:00ZMurray, Christopher J.L.Salomon, Joshua A.Mathers, Colin
<em>Murray, Christopher J.l.</em>;
<em>Salomon, Joshua A.</em>;
<em>Mathers, Colin</em>;
<br/><br/>
In the past decade, interest has been rising in the development, calculation and use of summary measures of population health, which combine information on mortality and non-fatal health outcomes. This paper reviews the issues and challenges in the design and application of summary measures and presents a framework for evaluating different alternatives. Summary measures have a variety of uses, including comparisons of health in different populations and assessments of the relative contributions of different diseases, injuries and risk factors to the total disease burden in a population. Summary measures may be divided into two broad families: health expectancies and health gaps. Within each family, there are many different possible measures, but they share a number of inputs, including information on mortality, non-fatal health outcomes, and health state valuations. Other critical points include calculation methods and a range of conceptual and methodological issues regarding the definition, measurement and valuation of health states. This paper considers a set of basic criteria and desirable properties that may lead to rejection of certain summary measures and the development of new ones. Despite the extensive developmental agenda that remains, applications of summary measures cannot await the final resolution of all methodological issues, so they should focus on those measures that satisfy as many basic criteria and desirable properties as possible.Why aircraft disinsection?S0042-968620000008000092016-01-01T00:02:00Z2001-01-28T00:08:00ZGratz, Norman G.Steffen, RobertCocksedge, William
<em>Gratz, Norman G.</em>;
<em>Steffen, Robert</em>;
<em>Cocksedge, William</em>;
<br/><br/>
A serious problem is posed by the inadvertent transport of live mosquitoes aboard aircraft arriving from tropical countries where vector-borne diseases are endemic. Surveys at international airports have found many instances of live insects, particularly mosquitoes, aboard aircraft arriving from countries where malaria and arboviruses are endemic. In some instances mosquito species have been established in countries in which they have not previously been reported. A serious consequence of the transport of infected mosquitoes aboard aircraft has been the numerous cases of ‘‘airport malaria’’ reported from Europe, North America and elsewhere. There is an important on-going need for the disinsection of aircraft coming from airports in tropical disease endemic areas into nonendemic areas. The methods and materials available for use in aircraft disinsection and the WHO recommendations for their use are described.Through Mintzberg’s glasses: a fresh look at the organization of ministries of healthS0042-968620000008000102016-01-01T00:02:00Z2001-01-28T00:08:00ZUnger, Jean-PierreMacq, JeanBredo, FrançoisBoelaert, Marleen
<em>Unger, Jean-Pierre</em>;
<em>Macq, Jean</em>;
<em>Bredo, François</em>;
<em>Boelaert, Marleen</em>;
<br/><br/>
In 1987, district health care policies were officially adopted by a majority of developing countries. Many operational problems constraining implementation of such policies have subsequently been identified, most of which are attributable to well-known characteristics of less developed countries. However, the policy of operational and administrative decentralization has often been critically obstructed by inappropriate organizational structures in ministries of health. By applying Mintzberg’s analytical framework to several ministries of health, we identify structural deficiencies that make systems unfit to match their policy environment and yield the expected outcomes of functional and decentralized services. We propose a typology likely to elicit strategies for decentralizing health care administration. Our analysis is based on the following steps: - a description of Mintzberg’s concepts of organizational structure, generic components (strategic apex, technostructure, supporting structure, middle line, operational core) and functions (horizontal and vertical integration, liaison devices, vertical and horizontal decentralization) applied to health systems; - a discussion of divisionalized adhocracy as a suitable configuration for health organizations with a need for a high degree of regional autonomy, community participation, medical staff initiative, action research and operational research, and continuous evaluation; - a discussion of the organizational features of a number of health ministry systems and a consideration of strategies for transforming configurations towards divisionalized adhocracy.New contraceptive eligibility checklists for provision of combined oral contraceptives and depot-medroxyprogesterone acetate in community-based programmesS0042-968620000008000112016-01-01T00:02:00Z2001-01-28T00:08:00ZStang, AmandaSchwingl, PamelaRivera, Roberto
<em>Stang, Amanda</em>;
<em>Schwingl, Pamela</em>;
<em>Rivera, Roberto</em>;
<br/><br/>
Community-based services (CBS) have long used checklists to determine eligibility for contraceptive method use, in particular for combined oral contraceptives (COCs) and the 3-month injectable contraceptive depot-medroxyprogesterone acetate (DMPA). As safety information changes, however, checklists can quickly become outdated. Inconsistent checklists and eligibility criteria often cause uneven access to contraceptives. In 1996, WHO produced updated eligibility criteria for the use of all contraceptive methods. Based on these criteria, new checklists for COCs and DMPA were developed. This article describes the new checklists and their development. Several rounds of expert review produced checklists that were correct, comprehensible and consistent with the eligibility requirements. Nevertheless, field-testing of the checklists revealed that approximately half (48%) of the respondents felt that one or more questions still needed greater comprehensibility. These findings indicated the need for a checklist guide.In March 2000, WHO convened a meeting of experts to review the medical eligibility criteria for contraceptive use. The article reflects also the resulting updated checklist.Resource allocation and budgetary mechanisms for decentralized health systems: experiences from Balochistan, PakistanS0042-968620000008000122016-01-01T00:02:00Z2001-01-28T00:08:00ZGreen, AndrewAli, B.Naeem, A.Ross, D.
<em>Green, Andrew</em>;
<em>Ali, B.</em>;
<em>Naeem, A.</em>;
<em>Ross, D.</em>;
<br/><br/>
This paper identifies key political and technical issues involved in the development of an appropriate resource allocation and budgetary system for the public health sector, using experience gained in the Province of Balochistan, Pakistan. The resource allocation and budgetary system is a critical, yet often neglected, component of any decentralization policy. Current systems are often based on historical incrementalism that is neither efficient nor equitable. This article describes technical work carried out in Balochistan to develop a system of resource allocation and budgeting that is needs-based, in line with policies of decentralization, and implementable within existing technical constraints. However, the development of technical systems, while necessary, is not a sufficient condition for the implementation of a resource allocation and decentralized budgeting system. This is illustrated by analysing the constraints that have been encountered in the development of such a system in Balochistan.Antiretroviral interventions to reduce mother-to-child transmission of human immunodeficiency virus: challenges for health systems, communities and societyS0042-968620000008000132016-01-01T00:02:00Z2001-01-28T00:08:00ZBaggaley, Rachelvan Praag, Eric
<em>Baggaley, Rachel</em>;
<em>Van Praag, Eric</em>;
<br/><br/>
This paper examines the ethical, economic and social issues that should be considered when antiretroviral interventions are being planned to reduce mother-to-child transmission of the human immunodeficiency virus. Interventions aiming to reduce mother-to-child transmission should be concerned with the rights of both the child and the mother. Women should not be seen as vectors of transmission but as people entitled to adequate health care and social services in their own right. For women accepting mother-to-child transmission interventions it is important to consider their medical and emotional needs and to ensure that they are not stigmatized or subjected to abuse or abandonment following voluntary counselling and testing. Seropositive women who do not wish to continue with pregnancy should have access to facilities for safe termination if this is legal in the country concerned. Problems arise in relation to the basic requirements for introducing such interventions via the health services in developing countries. A framework is given for making decisions about implementation of interventions in health care systems with limited resources where there is a relatively high prevalence of human immunodeficiency virus infection among pregnant women.Use of business planning methods to monitor global health budgets in TurkmenistanS0042-968620000008000142016-01-01T00:02:00Z2001-01-28T00:08:00ZEnsor, TimAmannyazova, Bakhtigul
<em>Ensor, Tim</em>;
<em>Amannyazova, Bakhtigul</em>;
<br/><br/>
After undergoing many changes, the financing of health care in countries of the former Soviet Union is now showing signs of maturing. Soon after the political transition in these countries, the development of insurance systems and fee-for-service payment systems dominated the discussions on health reform. At present there is increasing emphasis on case mix adjusted payments in larger hospitals and on global budgets in smaller district hospitals. The problem is that such systems are often mistrusted for not providing sufficient financial control. At the same time, unless further planned restructuring is introduced, payment systems cannot on their own induce the fundamental change required in the health care system. As described in this article, in Tejen etrap (district), Turkmenistan, prospective business plans, which link planned objectives and activities with financial allocations, provide a framework for setting and monitoring budget expenditure. Plans can be linked to the overall objectives of the restructuring system and can be used to ensure sound financial management. The process of business planning, which calls for a major change in the way health facilities examine their activities, can be used as a vehicle to increase awareness of management issues. It also provides a way of satisfying the requirement for a rigorous, bottom-up planning of financial resources.Overlooked opportunities for investing in health research and developmentS0042-968620000008000152016-01-01T00:02:00Z2001-01-28T00:08:00ZFraser, David W.
<em>Fraser, David W.</em>;
<br/><br/>
In 1996, an Ad Hoc Committee on Health Research Relating to Future Intervention Options (formed under the auspices of the World Health Organization) described a model for setting priorities in research funding. This model, however, as presented in the Ad Hoc Committee’s report entitled Investing in health research and development, fails in the following important situations: (i) when there is a health problem about which little is known; (ii) when current control measures are unsustainable; (iii) when there are complex risk factors, like ‘‘social factors’’, which affect many different diseases; and (iv) when the disease burden and resources for control vary greatly from one place to another. In situations of uncertainty or complexity, a method of priority-setting that emphasizes certainty and simplicity may actually mislead. A transparent, matrix-based process - illustrated with an example of priority-setting for malaria - may permit such uncertainty and complexity to be better taken into account in setting health research priorities.Florida court awards US$ 145 billion in damages against US tobacco companiesS0042-968620000008000162016-01-01T00:02:00Z2001-01-28T00:08:00ZCharatan, Fred
<em>Charatan, Fred</em>;
<br/><br/>
Up to one third of malaria deaths in Africa occur in countries affected by complex emergenciesS0042-968620000008000172016-01-01T00:02:00Z2001-01-28T00:08:00ZWhyte, Barry
<em>Whyte, Barry</em>;
<br/><br/>
Deficiencies in immunization campaigns highlighted in new UNICEF reportS0042-968620000008000182016-01-01T00:02:00Z2001-01-28T00:08:00ZGottlieb, Scott
<em>Gottlieb, Scott</em>;
<br/><br/>
More than 13 000 reported ill in Japan after drinking milk productsS0042-968620000008000192016-01-01T00:02:00Z2001-01-28T00:08:00ZWatts, Jonathan
<em>Watts, Jonathan</em>;
<br/><br/>
The world health report 2000 - Health systems: improving performanceS0042-968620000008000202016-01-01T00:02:00Z2001-01-28T00:08:00ZReinhardt, Uwe E.Cheng, Tsung-mei
<em>Reinhardt, Uwe E.</em>;
<em>Cheng, Tsung-Mei</em>;
<br/><br/>
Abortion in the developing worldS0042-968620000008000212016-01-01T00:02:00Z2001-01-28T00:08:00ZLee, Ellie
<em>Lee, Ellie</em>;
<br/><br/>
Health equity gaugesS0042-968620000008000222016-01-01T00:02:00Z2001-01-28T00:08:00ZEvans, TimothyWirth, MegVega, Jeannette
<em>Evans, Timothy</em>;
<em>Wirth, Meg</em>;
<em>Vega, Jeannette</em>;
<br/><br/>