Tuesday, 31 May 2011

TUBERCULOSIS: History: Iceland

Sigurdsson S.
Laeknabladid. 2005 Jan;91(1):69-102.

Because of signs of tuberculous lesions in old skeletons it can be stated with certainty that tuberculosis has occurred in the country shortly after the settlement. From that time and up to the seventeenth century, little or nothing is known about the occurrence of the disease. A few preserved descriptions of diseases and deaths indicate that tuberculosis has existed in the country before the advent of qualified physicians in 1760. On the basis of papers and reports from the first physicians and the first tuberculosis registers the opinions is set forth that the disease has been rare up to the latter part of the nineteenth century. During the two last decades of that century the disease began to spread more rapidly and increased steadily up to the turn of the century. Although reporting of the disease was started in the last decade of the nineteenth century the reporting was first ordered by law with the passage of the first tuberculosis Act in the year 1903. With this legislation official measures for tuberculosis control work really started in the country. The first sanatorium was built in 1910. In 1921 the tuberculosis Act was revised and since then practically all the expenses for the hospitalization and treatment of tuberculous cases has been defrayed by the state. In the year 1935 organized tuberculosis control work was begun and a special physician appointed to direct it. From then on systematic surveys were made, partly in health centers i.e. tuberculosis clinics, which were established in the main towns, and partly by means of transportable X ray units in outlying rural areas of the country. In 1939 the tuberculosis Act was again revised with special reference to the surveys and the activities of the tuberculosis clinics. This act is still in force. Some items of it are described. The procedure of the surveys and the methods of examination are described. The great majority of subjects were tuberculin tested and all positive reactors X rayed. Furthermore, X ray examination was made in all cases where tuberculin examination had not been made or was incomplete. The negative reactors were not X rayed. The tuberculin tests were percutaneous, cutaneous and intracutaneous. The X ray examination during the first years was performed by means of fluoroscopy and roentgenograms were made in all doubtful cases. In 1945 when the survey of the capital city of Reykjavík was made and comprised a total of 43,595 persons photoroentgenograms were made. After 1948 only this method together with tuberculin testing was used in all the larger towns in the country. During the period 1940-1945 such surveys were carried out in 12 medical districts, or parts thereof and included 58,837 persons or 47 percent of the entire population. The attendance in these surveys ranged from 89.3 percent to 100 percent of those considered able to attend. In the capital city, Reykjavík, the attendance was 99.32 percent. The course and prevalence of tuberculosis in Iceland from 1911 to 1970 are traced on the basis of tuberculosis reporting registers, mortality records which were ordered by law in 1911, tuberculin surveys and post mortem examinations. The deficiencies of these sources are pointed out. Since 1939 the morbidity rates are accurate. The number of reported cases of tuberculosis increases steadily up to the year 1935, when 1.6 percent of the population is reported to have active tuberculosis at the end of that year. Thereafter it begins to decline gradually the first years but abruptly in 1939, then without doubt because of the revision of the tuberculosis legislation and more exact reporting regulations. After that year the fall is almost constant with rather small fluctuations as regards new cases, relapses and total number of reported cases remaining on register at the end of each year. In 1950 the new cases are down to 1.6 per thousand and at the end of the year the rate for those remaining on register is 6.9 per thousand. In the year 1954 there is a noteworthy drop both in new cases and the total number reported, doubtless because of the new specific medication which began in 1952. In 1960 the new cases are down to 0.4, relapses 0.2 and the rate for those remaining on register at the end of the year 2.4 per thousand. And in 1970 the rate for the same categories are: new 0.2, relapses 0.06, and remaining at the end of the year 0.5 per thousand. At the beginning of the period, when registration of deaths was initiated, tuberculosis mortality was found to be about 150 per 100,000 population. During the next two decades it increases, irregularly but persistently, to reach a peak of 217 in 1925. It remained high for the next seven years, dropped suddenly to 154 in 1933, and then, apart from a slight temporary increase during the years of the second world war, continued to fall rapidly reaching 20 per 100,000 population in 1950. In the period from 1930-50 the tuberculous death rate thus dropped a little over 90 percent. In the year 1952, when specific tuberculosis medical treatment was initiated (streptomycin, isoniazid and PAS) the death rate dropped to 14 per 100,000 population and the next year further down to 9 and since 1956 it never exceeded 5 per 100,000. From the year 1962 the tuberculosis mortality has never been over 2 per 100,000 population. The mortality rates have been broken down to reveal the role of age and sex specific death rates over some selected five year periods. Also the rates are shown according to different forms of the disease, pulmonary, meningeal and other forms. The highest proportionate mortality (60%) was observed in the 15-19 year age group between 1926 and 1930. From 1911 to 1930 tuberculous meningitis caused a remarkably high number of deaths, fluctuating between 20 and 50 per 100,000 population. Since 1956 not a single death from this form of the disease has occurred. Up to that year the highest meningitis death-rate consistently occurred in infancy and early childhood. Sex-specific tuberculosis death rates indicate that in every age-group the disease is more dangerous to women. Between 1941 and 1945, when the combined mortality-rate began to drop sharply, it was the rate for the males, which was first affected. Due to the very steep decline in tuberculosis mortality especially from 1952 tuberculosis mortality figures can no longer be considered the right criterion for the spread and course of the disease. The infection and morbidity rates are from then on the best measures of the prevalence and course of the disease. Tuberculosis infection-rates obtained through tuberculin testing on a comparatively broad scale, especially in school children 7-13 years of age, show a progressive reduction in tuberculosis infection in the country as a whole. These tuberculin surves on school children were initiated by the district health officers in the second decade of the century and therefore now extend over 60 years. The procedure of the tuberculin surveys and the methods used are mentioned. The shortcomings of these surveys and their importance are discussed. The value of the surveys is considered doubtful as long as the examinations are performed without any guidance or coordination. About the year 1930 the total percentage tuberculin tested in the age group 7-13 years was a little over 10 percent. In the year 1935 the director of tuberculosis control sent all the health officers instructions on how to perform the tuberculin testing together with some encouragement to perform such surveys. That year about 43 percent of the 7-13 years population was tested and in 1945 the percentage was 75. Between 1965 and 1970 the attendance percentage was 85. The tested 7-13 years age group showed in 1935 26.1 percent positive reaction, in 1945 10.1 percent, in 1955 5.3 percent and in 1970 0.7 percent. In 1970 0.2 percent of the 7 years old children reacted positively and 1.1 percent of those 13 years of age. the decline of the infection rate in this age group is remarkable. The very few BCG vaccinated children were excluded from the surveys. In the tuberculosis surveys made in the years 1940-1945, which covered 12 medical districts or parts thereof, extensive tuberculin examinations were performed. The results of these surveys showed that the infection rate was higher among male adults than females. This difference was notable after the age of 15 and especially in isolated and thinly populated rural districts. In urban and more thickly populated rural districts the infection rate was much higher. BCG vaccination was first used in Iceland in 1945. Only few persons were vaccinated in the first two years. In 1948 a systematic vaccination was proposed in the country to supplement the tuberculosis-control plan. The vaccination was particularly meant for the age group 12-29 where the risk of infection appeared to be greatest. However, at the end of the year 1950 a total of only about 6,900 persons had been vaccinated mostly groups of school children, young adults and contacts of tuberculosis cases. Most of the children and adults were born between the years 1929 and 1936 but in none of these years did the vaccination exceed 15 percent of those born in any one of the years concerned. Because of the rapid decline in the tuberculosis infection rate, morbidity and mortality in the country this vaccination plan was abandoned and changed at the end of the year 1950. After that only few groups of people were vaccinated, i.e. tuberculosis contacts, medical students, student nurses, adults studying abroad and persons who asked for vaccination. Between 1950 and 1970 only about 7,000 people have been vaccinated. So the total number of BCG vaccinations up to the end of 1970 has not exceeded 14,000 in the country. Therefore it seems most unlikely that the relatively few BCG vaccinations, given in recent years can be expected to have had much influence in speeding up the downward trend of the disease in the country. (ABSTRACT TRUNCATED)

PMID: 16155306 [PubMed - indexed for MEDLINE]

POVERTY: Rising food prices increase squeeze on poor

31 May 2011
Wheat grains 
The price of key crops could rise by up to 180%, Oxfam says Continue reading the main story

Rising food prices are tightening the squeeze on populations already struggling to buy adequate food, demanding radical reform of the global food system, Oxfam has warned.
By 2030, the average cost of key crops could increase by between 120% and 180%, the charity forecasts.
It is the acceleration of a trend which has already seen food prices double in the last 20 years.
Half of the rise to come will be caused by climate change, Oxfam predicts.
It calls on world leaders to improve regulation of food markets and invest in a global climate fund.
"The food system must be overhauled if we are to overcome the increasingly pressing challenges of climate change, spiralling food prices and the scarcity of land, water and energy," said Barbara Stocking, Oxfam's chief executive.

Women and children
World food prices have already more than doubled since 1990, according to Food and Agricultural Organization (FAO) figures, and Oxfam predicts that this trend will accelerate over the next 20 years.
In its report, Growing a Better Future, Oxfam says predictions suggest the world's population will reach 9bn by 2050 but the average growth rate in agricultural yields has almost halved since 1990.
According to the charity's research, the world's poorest people now spend up to 80% of their incomes on food - with those in the Philippines spending proportionately four times more than those in the UK, for instance - and more people will be pushed into hunger as food prices climb.

The report highlights four "food insecurity hotspots", areas which are already struggling to feed their citizens:
Guatemala, where 865,000 people are said to be at risk of food insecurity because of a lack of state investment in smallholder farmers who are highly dependent on imported food
India, where people spend more than twice the proportion of their income on food than UK residents
Azerbaijan, where wheat production fell 33% last year because of poor weather, forcing the country to import grains from Russia and Kazakhstan; food prices were 20% higher in December 2010 than the same month in 2009
East Africa, where eight million people currently face chronic food shortages because of drought, with women and children among the hardest hit
Among the many factors continuing to drive rising food prices in the coming decades, Oxfam predicts that climate change will have the most serious impact.
Ahead of the UN climate summit in South Africa in December, it calls on world leaders to launch a global climate fund, "so that people can protect themselves from the impacts of climate change and are better equipped to grow the food they need".
The World Bank has also warned that rising food prices are pushing millions of people into extreme poverty.
In April, it said food prices were 36% above levels of a year ago, driven by problems in the Middle East and North Africa.

'Minority profiting'
In its report, Oxfam says a "broken" food system causes "hunger, along with obesity, obscene waste, and appalling environmental degradation".
It says "power above all determines who eats and who does not", and says the present system was "constructed by and on behalf of a tiny minority - its primary purpose to deliver profit for them".
It highlights subsidies for big agricultural producers, powerful investors "playing commodities markets like casinos", and large unaccountable agribusiness companies as destructive forces in the global food system.

Oxfam wants nations to agree new rules to govern food markets, to ensure the poor do not go hungry.
It said world leaders must:
increase transparency in commodities markets and regulate futures markets
scale up food reserves
end policies promoting biofuels
nvest in smallholder farmers, especially women

"We are sleepwalking towards an avoidable age of crisis," said Ms Stocking. "One in seven people on the planet go hungry every day despite the fact that the world is capable of feeding everyone."

'Market works'
However, the report's emphasis on the importance of small farmers was challenged by Nicola Horlick, a leading British investment fund manager who has invested in farmland in Brazil, in a debate with Ms Stocking on the BBC's Today programme.
She said large mechanised farms still provided some job opportunities for local workers and created spin-off industries.
"You cannot reply on a whole lot of smallholders to feed the world - it's not going to work," she said.
"It is really important in my view that we have more investment going into farmland. There are huge tracts of farmland... that aren't being farmed."
She said the market worked because shortages increased potential profits from investing in food, which would in time being supply and demand back into balance.

How donors performed in 2010

DAKAR, 31 May 2011 (IRIN)
Summary of aid successes and shortfalls among major donors in 2010.
European Union (EU) member states made pledges to provide 0.56 percent of gross national income (GNI) as official development aid by 2010, with a view to increasing to 0.7 percent by 2015. Together, they missed this target by US$21 billion; delivering just under four fifths of the commitment.

The UK met the 0.56 percent goal, putting US$8.5 billion towards development aid in 2010; Germany gave 0.38 percent at $7.8 billion; and the US $18.5 billion - or 0.21percent of GNI.

The worst EU aid performers in terms of the proportion of GNI are Italy, Greece, Portugal, Austria and Germany. Best-performing are Sweden, Denmark, Luxembourg, Netherlands and Belgium.

G8 and EU aid to sub-Saharan Africa was the highest on record in 2010 at US$18.2 billion; but lower than commitments pledged by G8 leaders in 2005.

Assistance to sub-Saharan Africa has increased by $19.6 billion since 2000 - $15.6 billion of it coming from G7 countries (France, Germany, Italy, Japan, UK, USA and Canada).

The G7 delivered 60 percent of the increase they promised to sub-Saharan Africa in 2005 - largely because the USA, Japan and Canada surpassed their targets, and the UK delivered 86 percent of its commitment, with an increase of $2.55 billion.

Italy, Germany and France are mainly responsible for the shortfall. Italy’s aid to sub-Saharan Africa has declined by $78million since 2004.

(Sources: 2011 World Bank global monitoring report; ONE Data Report 2011, AidWatch)


Monday, 30 May 2011

POVERTY: AID POLICY: New mechanism to boost food security

JOHANNESBURG, 30 May 2011 (IRIN) -

 Photo: Manoocher Deghati/IRIN
Communities need help to get back on their feet

Since April the humanitarian community has been gearing up to deploy a new mechanism aimed at combining expertise on food aid and agricultural assistance to boost food security and make food insecure communities hit by a disaster more resilient.
A 2010 evaluation of the “cluster approach” conducted by the Global Public Policy Institute (GPPI) and Groupe Urgence, Réhabilitation, Développement (URD) recommended the setting up of a new global food security mechanism or “cluster”, to support disaster-affected food insecure communities.
Its coordinator, Graham Farmer, said the new cluster is led jointly by the UN Food and Agriculture Organization (FAO) and the World Food Programme (WFP).
One of the tools deployed by aid workers in emergency responses to such things as floods, droughts or earthquakes is the “cluster approach”, first implemented in 2005. A “cluster” consists of groupings of UN agencies, NGOs and other international organizations around a sector or service provided during a humanitarian crisis.
The cluster approach currently encompasses 11 clusters or sectors such as logistics, water and sanitation, early recovery and nutrition. Agriculture as a separate cluster will cease to exist under the new scheme.
GPPI’s Julia Steets explained the rationale behind the December 2010 decision to set up the new cluster: “Everybody in the field agrees that one of the greatest challenges [during a humanitarian crisis] is implementing a proper `early recovery’ approach - introducing recovery and development aspects into relief work as early as possible and strengthening transition.”
This is especially true of food assistance, where short-term food interventions, if not managed properly, can undermine long-term ones, she added, creating dependency and slowing recovery.
This is especially true of food assistance, where short-term food interventions, if not managed properly, can undermine long-term ones, she added, creating dependency and slowing recovery
The global food security cluster will ensure there are “no missed opportunities” - for example by distributing seeds at the same time as food aid if disaster strikes just before the planting season.
“It could be the implementation of a cash-for-work programme [as an emergency response] which involves repairing agriculture infrastructure such as dams or roads damaged during a crisis to get the community prepared for the next planting cycle,” said Farmer.
The agricultural cluster is normally one of the most under-funded, thus adversely affecting prospects for recovery, said Steets. Bundling agriculture with food aid, “usually by far the best funded”, would help increase support and funding for long-term solutions, she added.
Almost 80 percent of the population in developing countries, which are most susceptible to natural disasters, depend on agriculture for food and income.

Tapping into local knowledge
Generally, the role of global clusters is to strengthen preparedness and build capacity of the aid response, explained Farmer, and “that is what we intend to do”. The national or local level clusters make sure response to a crisis is effective and that all NGOs are on the same page.
But the most innovative aspect of the new global food security cluster could be that, unlike other clusters, it will choose its priorities according to the needs of existing local and national clusters, said Steets. In doing so it will endorse a bottom-up approach - something the GPPI/URD evaluation called for.
The GPPI/URD evaluation said the exclusion of national and local NGOs - and often the failure to link with, build on, or support existing coordination and response mechanisms - was a major failing of the cluster system.
This was largely because of insufficient analysis of local structures and lack of “clear transition and exit criteria and strategies”, said the evaluation report. “As a result, the introduction of clusters has in several cases weakened national and local ownership and capacities,” it pointed out.

In many countries, the food security clusters "were actually among the best attended and most concrete clusters of all, precisely because they reacted to demand, rather than being imposed from above," said Steets. "Yet, the poor people who managed those clusters were often overwhelmed, because they had no formal time allocated for this task and had no support structure, etc."
Steets said the new global food security cluster “can from the very beginning draw on a local structure and respond to its needs. And this is absolutely the way the global cluster should go: Start by talking to existing local food security [or similar] clusters - both at national and at local level - and find out what kind of support they would need, be it in terms of policy-making, guidance, training, surge capacity, pre-positioning or what have you.
“It would be a real disaster if they missed this opportunity and went ahead creating tools and guidance that could end up being irrelevant to the field.”
Farmer said they did intend to consult. The global food security cluster will be holding its Inception Meeting on 30-31 May.

TUBERCULOSIS: History: England: Roman York Skeleton Could Be Early TB Victim

May 27, 2011

The skeleton of a man discovered by archaeologists in a shallow grave on the site of the University of York’s campus expansion could be that of one of Britain’s earliest victims of tuberculosis.
Radiocarbon dating suggests that the man died in the fourth century. He was interred in a shallow scoop in a flexed position, on his left side.
The man, aged 26–35 years, suffered from iron deficiency anaemia during childhood and at 162 centimetres (5ft 4in), was a shorter height than average for Roman males.
The first known case of TB in Britain is from the Iron Age (300 BC) but cases in the Roman period are fairly rare, and largely confined to the southern half of England. TB is most frequent from the 12th century AD in England when people were living in urban environments. So the skeleton may provide crucial evidence for the origin and development of the disease in this country.
The remains were discovered during archaeological investigations on the site of the University’s £500 million expansion at Heslington East. Archaeologists unearthed the skeleton close to the perimeter of the remains of a late–Roman masonry building discovered on the site, close to the route of an old Roman road between York and Barton–on–Humber.
The burial site is on part of the campus that will not be built on. The University is developing plans for community archaeology and education visits once the investigations are complete.
Detailed analysis of the skeleton by Malin Holst, of York Osteoarchaeology Ltd, revealed that a likely cause of death was tuberculosis which affected the man’s spine and pelvis. She says that it is possible that he contracted the disease as a child from infected meat or milk from cattle, but equally the infection could have been inhaled into the lungs. The disease then lay dormant until adulthood when the secondary phase of the disease took its toll.
Heslington East Fieldwork Officer Cath Neal, of the University’s Department of Archaeology, said: "This was a remarkable find and detailed study of this skeleton will provide us with important clues about the emergence of tuberculosis in late-Roman Britain, but also information about what life was like in York more than 1,500 years ago.
"A burial such as this, close to living quarters, is unusual for this period when most burials were in formal cemeteries. It is possible that the man was buried here because the tuberculosis infection was so rare at the time, and people were reluctant to transport the body any distance."
Malin Holst added: "There were signs of muscular trauma and strong muscle attachments indicating that the individual undertook repeated physical activity while he was in good health. There was some intensive wear and chipping on his front teeth which may have been the result of repeated or habitual activity. There was evidence for infection of the bone in both lower limbs but this appeared to be healing at death."
Investigation of the remains is continuing — Professor Charlotte Roberts, of Durham University, with Professor Terry Brown at Manchester University, is now studying DNA from the skeleton as part of National Environmental Research Council funded research into the origin, evolution and spread of the bacteria that causes TB in Britain and parts of Europe.

TUBERCULOSIS: Denmark: Incidence, risk factors and mortality of tuberculosis in Danish HIV patients 1995-2007.

Gry Assam Taarnhoj et al. : Source: BMC Pulmonary Medicine 2011, 11:26

Human Immunodeficiency Virus (HIV) infection predisposes to tuberculosis (TB). We described incidence, risk factors and prognosis of TB in HIV-1 infected patients during pre (1995-1996), early (1997-1999), and late Highly Active Antiretroviral Therapy (HAART) (2000-2007) periods.

We included patients from a population-based, multicenter, nationwide cohort.
We calculated incidence rates (IRs) and mortality rates (MRs). Cox's regression analysis was used to estimate risk factors for TB infection with HAART initiation included as time updated variable.
Kaplan-Meier was used to estimate mortality after TB.

Among 2,668 patients identified, 120 patients developed TB during the follow-up period. The overall IR was 8.2 cases of TB/1,000 person-years of follow-up (PYR).
IRs decreased during the pre-, early and late-HAART periods (37.1/1000 PYR, 12.9/1000 PYR and 6.5/1000 PYR respectively). African and Asian origin, low CD4 cell count and heterosexual and injection drug user route of HIV transmission were risk factors for TB and start of HAART reduced the risk substantially.
The overall MR in TB patients was 34.4 deaths per 1,000 PYR (95% Confidence Interval: 22.0-54.0) and was highest in the first two years after the diagnosis of TB.

Incidence of TB still associated with conventional risk factors as country of birth, low CD4 count and route of HIV infection while HAART reduces the risk substantially. The mortality in this patient population is high in the first two years after TB diagnosis.

TUBERCULOSIS: Italy: Epidemiological Study

Anna Odone et al. : Credits/Source: BMC Public Health 2011, 11:376
Epidemiology of Tuberculosis in a low-incidence Italian region with high immigration rates: differences between not Italy-born and Italy-born TB cases

Emilia Romagna, a northern Italian region, has a population of 4.27 million, of which 9.7% are immigrants. The objective of this study was to investigate the epidemiology of tuberculosis (TB) during the period 1996-2006 in not Italy-born compared to Italy-born cases.

Data was obtained from the Regional TB surveillance system, from where personal data, clinical features and risk factors of all notified TB cases were extracted.

5377 TB cases were reported.
The proportion of immigrants with TB, over the total number of TB cases had progressively increased over the years, from 19.1% to 53.3%. In the not Italy-born population, TB incidence was higher than in Italians (in 2006: 100.7 cases per 100 000 registered not Italy-born subjects and 83.9/100 000 adding 20% of estimated irregular presences to the denominators.
TB incidence among Italians was 6.5/100 000 Italians). A progressive rise in the not Italy-born incident cases was observed but associated with a decline in TB incidence.
Not Italy-born cases were younger compared to the Italy-born cases, and more frequently classified as "new cases"(OR 2.0 95%CI 1.61-2.49 for age group 20-39); 60.7% had pulmonary TB, 31.6% extra pulmonary and 7.6% disseminated TB. Risk factors for TB in this population group were connected to lower income status (homeless: OR 149.9 95%CI 20.7-1083.3 for age group 40-59).

In low-incidence regions, prevention and control of TB among sub-groups at risk such as the foreign-born population is a matter of public health concern.
In addition, increasing immigration rates may affect TB epidemiology. TB among immigrants is characterized by particular clinical features and risk factors, which should be analyzed in order to plan effective action.

TUBERCULOSIS: Pakistan: Over 10,500 cases of tuberculosis reported in one month

PPI :  May 26, 2011
ISLAMABAD: As many as 10,831 new cases of tuberculosis have been reported at state-run healthcare facilities in 35 districts across Pakistan during February 2011. This alarming number is a cause of serious concern for the government particularly in the Punjab province that accounted for 86% of the reported cases in 18 districts.
According to FAFEN’s monthly Health Scan, the number of confirmed cases of TB reported in February 2011 is double than the 4,910 cases of the disease reported a month earlier in 37 districts.
FAFEN Monitors collected the data of disease cases from district health offices in 64 districts for February 2011. Executive District Officer (EDO)/Health offices in 24 districts of Punjab, 18 districts in Khyber Pakhtunkhwa (KP), 13 districts in Sindh and seven districts in Balochistan, as well as the office of the Agency Surgeon Health (ASH) in FR Peshawar, and that of the office of Health Management Information System (HMIS) in ICT shared the requested information with FAFEN Monitors.

Malaria decrease
Incidence of malaria decreased in February as compared to the preceding month, but it continued to be the most-recorded disease. Malaria constituted 92% of the total 80,367 reported cases of viral diseases in the country in February 2011.
This means that overall cases of viral diseases can be significantly reduced if malaria is controlled. Although a reprieve can be expected due to the extreme heat of the coming summer months in many parts of the country, preventive measures such as mosquito nets, repellants, and insecticides should still be used to keep it at bay. Malaria was most notable in February 2011 in Sindh, where 13 districts reported 57% of all malaria cases recorded nationwide.

The number of reported cases of probable poliomyelitis has also jumped from the previous month. The disease has been reported in monitored districts of Punjab for the first time since November 2010. A total of 47 cases of probable poliomyelitis were reported – 37 in Khushab and eight in DG Khan districts of Punjab, and two in Umerkot district of Sindh.
The most commonly observed diseases in the country were also those whose transmission is aided by particular conditions of environment and hygiene, such as TB and malaria. In line with trends observed in previous months, acute respiratory infections (ARIs) were the most reported set of diseases, making 63% of all reported cases of disease followed by diarrhea and dysentery taken together (12%), scabies (11%), malaria (5%) and gastroenteritis (4%).


TUBERCULOSIS: Zimbabwe: Struggles to Slow Mounting Incidence

Sandra Nyaira : 25 May 2011
Dr. Charles Sandy said his Health Ministry department is decentralizing care, especially in rural communities, and distributing motorcycles to ensure rural health staff can reach people who cannot get to hospitals.
The tuberculosis epidemic in Zimbabwe has become one of the worst in the world, according to international health consultant Population Services International.
The country registered the second highest number of deaths from the communicable disease, which in Zimbabwe is closely related to the spread of HIV/AIDS.
Nearly 72,000 new cases were recorded in 2007, the most recent year for which data was available, for an incidence rate of 539 cases per 10,000 people.
The fight against TB has been hampered by limited access to diagnostic centers and the lack of quick, accurate tests, Population Services International said.
The World Health Organization has recommended that Zimbabwean health officials step up surveillance for HIV in tuberculosis cases, given the close link.
Health Minister Henry Madzorera told VOA reporter Sandra Nyaira that Zimbabwe is in the process of acquiring advanced equipment to help deal with the epidemic.
He said Zimbabwe is not yet diagnosing or treating drug-resistant tuberculosis as other countries in the region are doing for lack of the medical testing equipment needed to detect strains of tuberculosis that resist standard treatments.
Dr. Charles Sandy, deputy director of AIDS and tuberculosis programs at the Health Ministry, is in charge of the country’s TB treatment centers.
He said his department is decentralizing care, especially in rural communities, and distributing motorcycles to ensure rural health staff can reach the many people needing care who are unable to get to hospitals.


TUBERCULOSIS: France: growing number of cases in the country in recent years

PARIS, May 25 (UPI) -- Tuberculosis is making a comeback in France, where doctors say they are concerned about the growing number of cases in the country in recent years.

While most cases are treated in pulmonology hospital wards, France's one remaining TB sanatorium in Paris is still operating and not likely to be closed any time soon, Radio France Internationale reported Wednesday.
At the Petit Fontainebleau sanatorium where more than 60 patients are being treated, some have developed drug-resistant TB, which is hard to cure, RFI reported.
"This type of TB is difficult to treat because it needs other drugs which are less tolerated," Dr. Mathilde Jachym said, and "we have to give patients this drug for a long time."
In the 1980s many health experts thought TB would disappear in France thanks to better living conditions and medicine, but there has been a slight increase in the number of cases in the 21st century, doctors said.
Tuberculosis is linked to poor living conditions, Jachym said.
"People who have social problems tend to postpone going to the doctor," she said. "So tuberculosis can grow and grow. And when they come to the doctor, they often have developed very severe case of tuberculosis."
Maka Traore, a Petit Fontainebleau patient from Mali, is an undocumented worker and said he is not looking forward to leaving the sanatorium.
"I don't have a home and I don't have any work," he said. "I wanted to work here to send money to my family back home. It's very difficult to find work."


Sunday, 29 May 2011

POVERTY: CHAD-LIBYA: Agencies prepare for more migrants

DAKAR, 25 May 2011 (IRIN)

 Photo: Kate Holt/IRIN
The inhospitable terrain in Western Chad

As thousands of Chadian returnees continue to cross from Libya into Chad - via Niger - villagers near the arrival points face a “double burden” with remittances drying up and their scarce resources overstretched, said International Organization for Migration (IOM) operations officer Craig Murphy.
Some 25,000 Chadians have returned since the conflict in Libya began, according to IOM. Most arrive in the small village of Zouarké, 600km northwest of the town of Faya from where returnees find transport to return to their home villages and towns.
There are now many more migrants than residents in Faya, which is usually home to 15,000, said Felix Léger, head of the NGO International Rescue Committee (IRC) in Chad.
Though no one can estimate how many more migrants are on their way, according to Murphy 1,566 turned up in Faya in just two days - on 23 and 24 May - and there is no sign of the number abating.
While the immediate concern is to get food, water, and health care to returnees, in the long term they will need assistance in finding work, said Murphy. “It [the influx of returnees] puts a strain on all these towns - a lot of them are dependent on remittances and those have dried up. Now they have to support them, which is a double burden,” he told IRIN.
IOM is starting by profiling migrants to assess what they did and what they earned in Libya, with a view to perhaps assisting them in re-starting work in Chad, said Murphy.
According to IOM, 90 percent of the returnees are young men who have worked for years as manual labourers, farmers, and guards in Libya; the rest are women and children.
Tensions have risen in Zouarké, usually home to just a couple of hundred people, where there is one well which must now serve thousands. Murphy saw 1,000 people trying to access the well in one day.

 Photo: Reliefweb

Following arduous journeys of about 30 days with minimal food or water on overloaded trucks, migrants arrive in Zouarké and Faya exhausted, hungry and sick. Common illnesses include advanced dehydration; respiratory illnesses; diarrhoea; and about 20 cases of measles - mainly among adolescents and children, according to IRC.
To stem the spread of measles, the organization will launch a one-week vaccination campaign in Faya targeting 10,000 people. It also screens incoming migrants for health problems, sending them to the local hospital if they need treatment.
Due to severe staff shortages at the hospital, IRC has put in place one doctor and two nurses.
In the immediate term, in Zouarké, IOM is sending food, and will set up a water tank to enable returnees to access well-water from a second point. Meanwhile, in Faya it is registering returnees, providing food, and helping find transport so they can return home.
Migrants in Faya are receiving more or less enough help, said the IRC’s Léger, but the response must be scaled up in Zouarké and along the roadside in Niger - both before migrants arrive in Chad and once they have left Faya, he said, adding that IRC is considering setting up medical “way stations” on busy migrant routes.


*Kenya: Chase for Profit Hampers Malaria Drugs Subsidy *
On the streets of Nairobi, James Odhiambo goes from one pharmacy to he next in search of anti-malarial drugs marked with the Global Fund's logo of a green leaf. He is looking for this specific brand because he understands that it is more than 10 times cheaper than the same drug produced by different manufacturers.

* Nigeria: Edo Govt Tasks Women on Malaria Scourge *
Edo State Government has advised women in the state to utilise the insecticide treated mosquito nets that had been freely provided by the government to fight the malaria scourge.

* Nigeria: Malaria - Yobe to Distribute 1,300 Mosquitoe Nets *
In its bid to control malaria, Yobe State Government is to distribute more than 1,300 Mosquito Nets to the 17 local governments in the state next month.

* Tanzania: Malaria Test Success Drives Up Antibiotic Use *
Antibiotic misuse has soared in an African capital as an unforeseen consequence of improving the diagnosis of malaria, according to a study.

* Tanzania: Anti-Malarial Therapy Not to Sell Above Tsh 1000 *
The Government has subsidized the costs for the combine therapy anti-malarial drugs by more than 93 percent. Now its full dose will only cost Tsh 1000.

* Ghana: Join War On Malaria - Minister Tells Sports Personalities *
The Minister for Youth and Sports, Hon. Clement Kofi Humado, has called on all sporting associations in the country to join the war on malaria to make the quest towards achieving the Roll Back Malaria
(RBM) of near zero death by 2015 a success.

* Nigeria: Govt to Ban Mono-Therapy Malaria Drugs *
The Federal Government has hinted that in the nearest future, it would ban all mono-therapy drugs used in malaria treatment in Nigeria as they are no longer effective following resistance of the drugs by Nigerians.

* Kenya: Marginal Profits Hamper Malaria Drug Subsidy *
On the streets of Nairobi, James Odhiambo goes from one pharmacy to the next in search of anti-malarial drugs marked with the Global Fund's logo of a green leaf. He is looking for this specific brand because he understands that it is more than ten times cheaper than the same drug produced by different manufacturers.

* Angola: Tomboco Registers Over 5000 Cases of Malaria *
About 5,575 cases of malaria, registered from January to March this year, were notified by the health authorities in Tomboco District, northern Zaire Province.

* Angola: New Malaria Fight Strategy Reduces Death *
The health services in central Huambo province recorded a drop in the rate of death caused by malaria in the first quarter of this year from 222 in 2010 to 58, as a result of new strategies in the fight against the disease.

* Angola: Technicians Finish Training on Rapid Malaria Test *
About sixteen laboratory technicians from the northern Uige Province finished on Thursday, in this city, a training programme on handling new equipment for testing malaria, ANGOP has learnt.

* Nigeria: Demystify Malaria Diagnosis And Treatment, Local Experts Urged *
Nigerian medical experts have been urged to demystify the diagnosis and treatment of malaria as part of strategies to reduce the burden of the disease in the country.

* Kenya: Pneumonia And Malaria Rated Top Killers Last Year *
Preventable malaria defied sustained government efforts meant to keep it at bay to kill the highest number of people last year.

* Nigeria: Lasg, NGOs Walk Against Malaria *
As part of activities to mark this year's World Malaria Day, the Lagos State Ministry of Health in collaboration with health related NGOs held a walk and free malaria screening/awareness creation exercise
which took off from Maryland and culminated at Kosofe Local Government Area Headquarters.

* East Africa: Official Calls for Harmonisation of Policies on Malaria *
Member states of the East African Community are urged to harmonise policies to ensure elimination of malaria in the region.

MALARIA: Precaution and funding of vector control must be based on evidence

Richard Tren & Donald Roberts : 18 May 2011
Malaria Journal
In their paper "Status of pesticide management in the practice of vector control: a global survey in countries at risk of malaria or other major vector-borne diseases," van den Berg et al. make some generally accepted and valid arguments about the need for improved management of public health insecticides (PHIs). Given the importance of vector control, it would be beneficial for malaria control program managers and staff to be trained in proper insecticide use and management, if only to slow the spread of insecticide resistance. However the authors reveal an anti-insecticide bias and an ideological approach to disease control that could potentially undermine disease prevention efforts.
In stating "All chemical pesticides are inherently toxic to humans and precaution is required to minimize exposure and adverse health effects," the authors are creating opportunities for scaremongering. The needs for research and for improved procedures to minimize exposures to both disease-carrying insects and insecticides are self-evident. Yet, invoking "precaution" at the level of warning residents their houses are being sprayed with a harmful chemical to minimize adverse health effects should be based on proof of such adverse effects. Such proof does not exist, as exemplified by the circular logic displayed by the first author in another paper in which he and co-authors argue residents should be warned of possible harm from DDT exposures. In that paper the authors trumpeted "precaution" by justifying a claim of adverse health effects with the statement, "The very fact that there are so many precautions built into the WHO guidelines shows that IRS chemicals are considered hazardous." Such rationalizations reveal clear intent to expand the precautionary principle to restrain PHI use in disease control programs. Reasonable people know existence of safety measures (which often result from mere claims of potential dangers) does not imply IRS chemicals are dangerous. On the other hand, reasonable people accept that prudent safety standards are important. Warning residents that DDT and other PHIs are dangerous is neither prudent nor good public health policy because it would result in spraying refusals, an outcome that would increase risks of malaria transmission.
The authors conclude with the statement that support for vector control by donors and funding agencies should be contingent on them pursuing an IVM approach. We disagree strongly. Support for vector control programs should be based on the evidence of disease control efficacy. If a program that relies heavily on IRS delivers the best results in terms of disease reduction, then that is what should be supported. Though IVM should embrace effective methods of malaria control, such as IRS, we believe that IVM is far too often interpreted as adopting any and every vector control method except the spraying of insecticides. This is proven by the highly biased track record of funding malaria control programs without PHIs by the UN Environment Programme and Global Environment Facility. Making IVM a condition of funding elevates ideology above evidence and has no place in disease control programs.
In summation, the authors reveal intent to invoke the precautionary principle over disease control programs and use power of the purse strings to pressure governments away from critically important uses of PHIs to control malaria and other insect-borne diseases. The disease control community must continue to resist the anti-PHI agenda.

POVERTY: Another reason to improve small farm output

May 24, 2011
A lot of emphasis has been put on small farmers in the aid world lately, and for good reason. Small farmers grow food for themselves, but any surplus they can later sell to market for extra income. When their yields are bad they can't make any money from their work; or worse yet, they will not be able to feed their families for the year. United Nations International Fund for Agricultural Development says that two billion people depend on the crops coming from 500 million small farms.
So the aid world has put a focus on improving the technology, the seeds used and more in hopes to end hunger. We discovered another reason why this is important today from a post at the From Poverty to Power blog. Writer Duncan Green introduces us to a small farmer in Tanzania by the name of Thelezia Salula. She says that it is important to improve the yield and income of small farmers so that future generations can be attracted to farming as a vocation. Without such improvements, they will instead migrate to the cities for work.
More farmers arrive and we move to the partial shade of a leafless tree. The conversation turns to their hopes for their children. Most of them, like poor farmers everywhere, want their kids to study and escape from farming to a ‘good job’ in an office, or for the government. ‘The world is changing, but if they stay in farming their lives won’t change.’ None of their children want to be farmers: ‘no-one will farm when I am old and I will suffer the consequences’, says Thelezia ‘My children will have to pay for labourers to work the farm.’ Farming, it seems, is the last resort when you fail your exams.
But one woman, Salome Luboja, does want her kids to be farmers, and sets out three things that would have to change for that to happen. Firstly, education and knowledge about modern farming methods; second irrigation to safeguard farmers from the vagaries of the newly unreliable rains, and third improved markets and prices. I’m not convinced – towns are just so much more fun than farms, especially for young people – but the women insist that if the facilities were there, the work would not be such a grind, and if the incomes were higher than in the town, the kids would stay on the farm.
I still think many of them will chose to migrate, but if governments and aid donors invest properly in small farmers like Thelezia, (which is one of the things Oxfam is pushing for in the impending Grow campaign, launching on 1 June) at least her children will have a dignified and genuine choice between staying and leaving. That’s only the start though: the flatness of this plain, under a huge sky and scorching sun, seems especially vulnerable to the whims of an increasingly harsh climate. Unless climate change can be controlled too, and people helped to adapt to it, any progress is likely to be short-lived.

POVERTY: FOOD: Prices and perceptions

LONDON, 25 May 2011 (IRIN)

 Photo: Siegfried Modola/IRIN

 Banu Bibi's shopping basket is becoming emptier. When she goes shopping in Dhaka, Bangladesh, she spends more than a year ago, but that money buys less. In 2010, for 134 taka (US$1.80), she could afford lentils and laundry soap, and the family's favourite fish. This year she has to spend 185 taka ($2.50) just for the basics: more rice to make up for the lack of other food, and cheaper vegetables.
Banu Bibi lives in one of eight communities picked by a research team from the Institute of Development Studies in the UK to track the effects of rising food and fuel prices. For three years, with the help of partner organizations in Bangladesh, Indonesia, Zambia and Kenya, they have been talking to people in selected rural and urban communities about how rising prices affect their lives.
Banu Bibi's experience is fairly typical. Her family is not starving; they still have food, but it is not the food they like and is not as nutritious as it could be. They certainly ate more and ate better before the food price shock and financial crisis of 2008. And across the world, homemakers are having to work harder, spending more time shopping or looking for food, and planning more carefully to stretch their budgets to feed their families.
A woman in Lango Baya, Kenya, spoke for many when she told the researchers: "You go to a shop to buy something with the same amount as you paid the previous day, only to be told that prices have risen."
Although food and fuel prices did fall after the initial spike in 2008, they never went back to their previous levels, and this year they have jumped again. Only one of the four countries studied has experienced some respite this year - Zambia, where the price of maize, the staple food, has not increased.

Local locus
While the two previous studies concentrated on the mechanisms people used to cope with the rising prices, this time the researchers decided to ask some more political questions - why did people think prices were so high? Who was to blame? And what should be done about it?
"It was an interesting time, with the Arab Spring and unrest around the world, and we wanted to ask how people felt about the food and fuel price rises," the research team leader, Naomi Hossain, told an audience at the University of Sussex, recently.
Her presentation coincided with the publication of a report into the global causes of rising prices by the British charity, Christian Aid. It analyzed recent movements on commodity markets, and concluded that much-vilified hedge funds were not the real culprits, instead singling out pension funds. They have very large pots of money, and have been pulling out of volatile stocks and shares and investing in funds linked to a basket of commodity prices, forcing fund managers to protect their positions by buying commodity futures on such a scale that they move the market.
But although commodity price rises are now an international phenomenon, extensively reported in the media, the people Hossain and her colleagues spoke to only looked for causes within their own country, citing hoarding and speculation, changing climate and environmental problems in their own area, and - overwhelmingly - their governments' failure to care about the poor.
One interviewee in Bangladesh told them, "I don't believe in this global market story at all. It is just an excuse for the government not to do anything."
Hossain describes "a real failure of global civil society to get people to see how their livelihoods are connected to the global economy. I am not surprised people prefer local causes. It gives people a sense of agency; if it's a global problem, then what can they do?"

Moral focus
But she has a certain sympathy for governments. There are more social protection schemes in place, for instance, than at the time of the first survey, despite governments having their budgets squeezed, but even so they get little credit.
Those who believe the government should "do something", suggest banning exports, controlling prices, punishing hoarders and subsidizing basic foodstuffs. The researchers found a sense that it was the moral duty of a government to provide for its people, sometimes linked to notions of democracy. A woman in Kenya told them, "In the new constitution, we have the right to be provided [with] food by the government."
The moral sense also extended to the business community. A rural doctor in Bangladesh said, "The businessmen should get some moral teaching. If they were afraid of Allah and conducted business honestly, the situation would improve."
All in all, says Hossain, "There is a popular consensus about what is legitimate, about social norms and obligations. People set moral limits to the freedom of the markets."
High food prices are not bad news for everyone. Another IDS research fellow, Xavier Cirera, pointed out that the rises followed a long period of low food prices, which had been very hard on farmers. "We always have to ask the question, what is the real price of food? And how can governments ensure better safety nets for the poor while ensuring that traders pass the benefits of price increases back to the producers? The evidence is that farmers are getting some benefit and are responding. But they are not realizing the full benefit of higher prices."

POVERTY: AFRICA: Sleeping sickness in cattle


 Photo: Chris/Flickr
Hardier Zebu in the not too distant future

New research on sleeping sickness in African cattle is holding out the possibility that in the not too distant future Africa could start seeing the introduction of cattle resistant to sleeping sickness - a disease which kills billions of dollars worth of livestock every year.
The research claims to have isolated two genes critical in the development of disease-resistant cattle.
Harry Noyes, lead author of a paper on this published in the Proceedings of the National Academy of Sciences of the USA (PNAS) on 16 May, told IRIN their research had been prompted by the fact that while East African humped cattle breeds are susceptible to trypanosome parasites which cause sleeping sickness, the N’Dama, a humpless West African breed, is not seriously affected by the disease.
African animal trypanosomosis - also known as `nagana’ (Zulu: "to be depressed") or tryps - is transmitted through the bite of an infected species of the tsetse fly and is endemic from Senegal to Tanzania, and Chad to Zimbabwe (an area almost the size of the USA).
“The humped cattle [zebu] originated in India, where the tsetse fly is not found, while N’Dama, which probably had been exposed to [the] trypanosome parasite for thousands of years had developed a mechanism to control the impact of the disease,” explained Noyes, a senior researcher at Liverpool University.
Over the past two decades the researchers found at least 10 genes which control the impact of the disease in the N’ Dama breed.
This, of course, does not mean that poor farmers will soon have cattle that are resistant to sleeping sickness
“Out of those resistant genes we isolated what we feel are the two most significant ones for our purposes,” said Steve Kemp, a geneticist with the Nairobi-based International Livestock Research Institute (ILRI), who also collaborated on the study.
Now that the scientists know what they are looking for, they have embarked on the task of isolating humped cattle breeds which also carry the two genes.
Over the next three years, ILRI intends to breed humped cattle varieties with at least one of the genes. The humped cattle breeds produce more milk than the N’Dama.

Decades away?
“This, of course, does not mean that poor farmers will soon have cattle that are resistant to sleeping sickness,” said Kemp. ILRI scientists will only be able to test resistance in the humped cattle after three years.
Thereafter it will take decades before sleeping sickness resistant breeds find their way down the chain to small farmers, the researchers believe.
“We can make the sperm and semen available for dissemination,” said Noyes, adding, however, that it was up to governments and extension services to make it accessible to all farmers.
Developing a resistant breed is critical as most of the drugs claiming to offer immunity to the disease are proving ineffective as new and drug-resistant strains of the disease evolve, according to the researchers. Furthermore, many of the new drugs are unaffordable for poor farmers.
In the week the discovery was published, the Global Alliance for Livestock Veterinary Medicines (GALVmed), announced a five-year plan to help livestock keepers in Africa access better drugs, diagnostics and maybe even a vaccine to deal with the disease.
Initially, the programme will identify ongoing research which could help livestock farmers.
At least three million cattle die from the disease in Africa every year, according to GALVmed. An estimated 50 million cattle and 70 million sheep and goats are at risk of tryps every year. Although best known for causing human sleeping sickness, the trypanosome parasite’s most devastating blow to human welfare comes when farmers have sick, unproductive cattle, said PNAS in a press release.

POVERTY: SRI LANKA: Women "key" to water projects

POLONNARUWA, 27 May 2011 (IRIN) -

 Photo: Amantha Perera/IRIN
Women bear the brunt of collecting water

Women could prove key to the success of Sri Lanka's rural water and sanitation projects, experts and villagers say.
As a five-year project to reduce time spent collecting water and to ensure safe drinking water jointly launched by the Asian Development Bank (ADB) and Sri Lankan government comes to a close, its leaders are reflecting on the lasting benefits of their decision to incorporate women in an unprecedented way.
"Usually women are in the backseat, but in this [project] we were right in front," Indrani Silva, who heads the women's association at Lanka Pokuna village in the north-central Polonnaruwa District, one of five rural areas involved in this US$263 million undertaking, told IRIN.
Projects took place in eastern Batticaloa and Trincomalee, north-central Anuradhapura and Polonnaruwa and southern Hambantota districts.
Upon completion at the end of 2011, an estimated 900,000 people will have benefited, and those involved say it is largely because the project's policies took into account the importance of gaining the trust and involvement of local women.
"[Women] understand the value of safe water. On top of that, they bear the traditional responsibility of collecting water, cleaning and cooking. You need them to be involved for any such project to have a chance," Mookiah Thiruchelvam, ADB's senior project officer overseeing the project, explained.
At the level of initial discussions with potential beneficiaries, 50 percent of participants and at least 25 percent of the government officials from the Water Supply and Drainage Board were women. This is not usual, Silva said.
"Usually these types of big projects will have no major involvement from the community, except for taking part in meetings. Even then the lead role is taken by men. Now this is our project; without the village women, this will not succeed," she said.
Attanayke Mundiyanse Senevirathana, chief sociologist working on improving access to water in the Polonnaruwa District, says the men were primarily farmers and did not have the time to play a big role, let alone collect water.
"It is the women who used to spend hours and walk miles to collect the water," Senevirathana said.
In Talpotha, a village in Polonnaruwa, the women's association is central to managing water distribution from a new pumping station and water-tank.
A member of the association does a monthly round of the 172 new connections, tabulating usage and collecting payment. But during the dry season their role becomes even more important.
"We go around requesting users to limit usage," said Sheila Herath, the chairwoman of the association. "All of them are our members and we can easily convince them."

Economic benefits
ADB's Thiruchelvam feels the next step is to use the time saved on collecting water to increase the income of the beneficiaries.

 Photo: Amantha Perera/IRIN :
A woman draws water from a well in Batticaloa

"The women have regained three hours every day that were spent on collecting water," he said.
Among some rural villages, women's associations have also proven to be effective in promoting new income generation.
A loan from a local women's association has helped Liyaduruge Siriyawathie, 45, to earn an additional Rs10,000 ($100) every month. She uses the time freed from walking kilometres to collect water to draw portraits and other designs that are sold. "For over two decades I did not have time to draw," she said.
Thiruchelvam said future water projects should take advantage of women's roles and, importantly, the freed hours that used to be spent on collecting water. "We don't calculate the productivity [gained]. It is time we started doing that."
Meanwhile, experts believe similar water and sanitation initiatives involving women could prove instrumental in the conflict-affected north, where access to piped water after two decades of war remains problematic.
On average, only three out of 10 people have access to piped water in all the districts that fall within the Vanni, an area encompassing the two districts of Kilinochchi and Mullaithivu and parts of Mannar and Vavuniya districts in the north, according to the National Water Supply Board.
The ADB and the Sri Lankan government are implementing a comparable project, with a high focus on women, in the Vanni and Jaffna valued at $164 million, Thiruchelvam says.

MALARIA: Africa trial questions hypovolaemic shock treatment for children

BBC: 27 May 2011

The trial found that children who were given fluid more slowly recovered better
A trial in East Africa has raised questions about an internationally accepted emergency treatment for children suffering from shock.
It involves injecting a large volume of fluid rapidly, through a drip, and is used widely in Europe and the US.
But researchers say it could be linked to additional deaths of children with severe infections like malaria.
They called for a rethink of UN World Health Organization guidelines that recommend the "fluid bolus" treatment.
'Not safe'
The Fluid Expansion as Supportive Therapy (Feast) trial, published in the New England Journal of Medicine, studied 3,170 children in hospitals across Uganda, Kenya and Tanzania.... http://www.bbc.co.uk/news/world-africa-13580838

The role of fluid resuscitation in the treatment of children with shock and life-threatening infections who live in resource-limited settings is not established.
We randomly assigned children with severe febrile illness and impaired perfusion to receive boluses of 20 to 40 ml of 5% albumin solution (albumin-bolus group) or 0.9% saline solution (saline-bolus group) per kilogram of body weight or no bolus (control group) at the time of admission to a hospital in Uganda, Kenya, or Tanzania (stratum A); children with severe hypotension were randomly assigned to one of the bolus groups only (stratum B). Children with malnutrition or gastroenteritis were excluded. The primary end point was 48-hour mortality; secondary end points included pulmonary edema, increased intracranial pressure, and mortality or neurologic sequelae at 4 weeks.
The data and safety monitoring committee recommended halting recruitment after 3141 of the projected 3600 children in stratum A were enrolled. Malaria status (57% overall) and clinical severity were similar across groups. The 48-hour mortality was 10.6% (111 of 1050 children), 10.5% (110 of 1047 children), and 7.3% (76 of 1044 children) in the albumin-bolus, saline-bolus, and control groups, respectively (relative risk for saline bolus vs. control, 1.44; 95% confidence interval [CI], 1.09 to 1.90; P=0.01; relative risk for albumin bolus vs. saline bolus, 1.01; 95% CI, 0.78 to 1.29; P=0.96; and relative risk for any bolus vs. control, 1.45; 95% CI, 1.13 to 1.86; P=0.003). The 4-week mortality was 12.2%, 12.0%, and 8.7% in the three groups, respectively (P=0.004 for the comparison of bolus with control). Neurologic sequelae occurred in 2.2%, 1.9%, and 2.0% of the children in the respective groups (P=0.92), and pulmonary edema or increased intracranial pressure occurred in 2.6%, 2.2%, and 1.7% (P=0.17), respectively. In stratum B, 69% of the children (9 of 13) in the albumin-bolus group and 56% (9 of 16) in the saline-bolus group died (P=0.45). The results were consistent across centers and across subgroups according to the severity of shock and status with respect to malaria, coma, sepsis, acidosis, and severe anemia.
Fluid boluses significantly increased 48-hour mortality in critically ill children with impaired perfusion in these resource-limited settings in Africa. (Funded by the Medical Research Council, United Kingdom; FEAST Current Controlled Trials number, ISRCTN69856593.)


MALARIA: Genetic Basis Discovered For Key Parasite Function In Malaria

Anne A. Oplinger : NIH/National Institute of Allergy and Infectious Diseases

27 May 2011
Snug inside a human red blood cell, the malaria parasite hides from the immune system and fuels its growth by digesting hemoglobin, the cell's main protein. The parasite, however, must obtain additional nutrients from the bloodstream via tiny pores in the cell membrane. Now, investigators from the National Institute of Allergy and Infectious Diseases (NIAID), part of the National Institutes of Health, have found the genes that malaria parasites use to create these feeding pores.
The research was led by Sanjay A. Desai, M.D., Ph.D., of NIAID's Laboratory of Malaria and Vector Research. In 2000, Dr. Desai co-discovered the primary type of feeding pore on parasite-infected blood cells, an ion channel known as the plasmodial surface anion channel (PSAC). Ion channels are pore-forming proteins that allow the movement of calcium, sodium and other particles into or out of the cell. A report of the team's new findings, which build on this original discovery, is now online in Cell.
"Despite recent progress in controlling malaria worldwide, the disease continues to kill more than 700,000 people, primarily young children, every year," said NIAID Director Anthony S. Fauci, M.D. "Dr. Desai and his colleagues have discovered the genetic basis of a fundamental aspect of malaria parasite biology, and in doing so, they have opened up potential new approaches to developing antimalarial drugs."
Scientists have known for decades that malaria-infected red blood cells have greater nutrient uptake than non-infected cells, presumably to support parasite survival and growth, noted Dr. Desai. But, he added, "It was debated whether the parasite co-opts existing human channels or uses its own proteins to remodel the red blood cell membrane."
To answer this question, the NIAID team screened nearly 50,000 chemicals for their ability to block nutrient uptake by cells infected with either of two genetically distinct lines of Plasmodium falciparum malaria parasites, HB3 and Dd2. Most chemicals were equally active against the two lines, but one, ISPA-28, stood out because it was 800 times more active against the nutrient channels of Dd2-infected red blood cells than against those of HB3-infected cells.
If the PSAC protein is made by the parasite, the scientists reasoned, the strikingly different effects of ISPA-28 on the two lines may reflect genetic differences. To explore this possibility, the investigators measured how well ISPA-28 inhibited PSAC activity in daughter parasites resulting from a genetic cross between the HB3 and Dd2 lines. They found that most daughter parasites made channels that were identical to those of one or the other parent, indicating that parasite genes play an important role. The inheritance pattern of ISPA-28 action on channels led the researchers to chromosome 3, where they found two parasite genes, clag3.1 and clag3.2, that appear to encode the PSAC protein.
This genetic evidence was bolstered when they showed that individual parasites express either the clag3.1 gene or the clag3.2 gene, but not both simultaneously. They found that switching between the two genes produced changes in PSAC behavior that could be predicted. Malaria parasites use gene switching as a way to protect essential proteins from attack by the immune system, Dr. Desai explained.
"We were surprised to discover a role for clag genes in PSAC activity," said Dr. Desai. This family of genes, which do not look like other ion channel genes, was previously thought to be involved in helping infected cells adhere to the inner lining of blood vessels. Clag genes are found in all species of malaria parasites, noted Dr. Desai, and this fact, along with the discovery that the parasites can choose between one of two channel genes to ensure nutrient uptake, strongly suggest that PSAC is required for parasite survival within red blood cells.
The discovery of parasite genes required for PSAC activity opens up several new research directions, said Dr. Desai. For example, development of antimalarial drugs that target these channels could be accelerated. The NIAID team has already found PSAC inhibitors that kill malaria parasites. Dr. Desai's team also is exploring how the PSAC protein is transported from the parasite to the red blood cell membrane, as preventing this transport may be another way to kill malaria parasites.

In addition to funding from NIAID's Division of Intramural Research, this study was supported by Medicines for Malaria Venture, a not-for-profit public-private partnership headquartered in Switzerland.
W Nguitragool et al. Malaria parasite clag genes determine nutrient uptake channel activity on infected red blood cells. Cell DOI: 10.1016/j.cell.2011.05.002 (2011).
SA Desai et al. A voltage-dependent channel involved in nutrient uptake by red blood cells infected with the malaria parasite. Nature 406:1001-05 (2000).

Tuesday, 24 May 2011

MALARIA: Comparative evaluation of two rapid field tests for malaria diagnosis: Partec Rapid Malaria Test(R) and Binax Now(R) Malaria Rapid Diagnostic Test.

Bernard Nkrumah et al. BMC Infectious Diseases 2011, 11:143 

About 90% of all malaria deaths in sub-Saharan Africa occur in children under five years. Fast and reliable diagnosis of malaria requires confirmation of the presence of malaria parasites in the blood of patients with fever or history suggestive of malaria; hence a prompt and accurate diagnosis of malaria is the key to effective disease management. Confirmation of malaria infection requires the availability of a rapid, sensitive, and specific testing at an affordable cost. We compared two recent methods (the novel Partec Rapid Malaria Test(R) (PT) and the Binax Now(R) Malaria Rapid Diagnostic Test (BN RDT) with the conventional Giemsa stain microscopy (GM) for the diagnosis of malaria among children in a clinical laboratory of a hospital in a rural endemic area of Ghana.

Blood samples were collected from 263 children admitted with fever or a history of fever to the pediatric clinic of the Agogo Presbyterian Hospital. The three different test methods PT, BN RDT and GM were performed independently by well trained and competent laboratory staff to assess the presence of malaria parasites. Results were analyzed and compared using GM as the reference standard.

In 107 (40.7%) of 263 study participants, Plasmodium sp. was detected by GM. PT and BN RDT showed positive results in 111 (42.2%) and 114 (43.4%), respectively. Compared to GM reference standard, the sensitivities of the PT and BN RDT were 100% (95% CI: 96.6-100) and 97.2% (95% CI: 92.0-99.4), respectively, specificities were 97.4% (95% CI: 93.6-99.3) and 93.6% (95% CI: 88.5-96.9), respectively. There was a strong agreement (kappa) between the applied test methods (GM vs PT: 0.97; p <0.001 and GM vs BN RDT: 0.90; p <0.001). The average turnaround time per tests was 17 minutes.

In this study two rapid malaria tests, PT and BN RDT, demonstrated a good quality of their performance compared to conventional GM. Both methods require little training, have short turnaround times, are applicable as well as affordable and can therefore be considered as alternative diagnostic tools in malaria endemic areas. The species of Plasmodium cannot be identified.


POVERTY: Sanitary energy thru toilets

May 23, 2011

2.5 billion people throughout the world don't have access to their own toilet. This leaves 2.5 billion people vulnerable to diseases such as cholera, diarrhea. These diseases are spread thru contaminated water as people are forced to use the outdoors instead of toilets to relive themselves.
Some non-profits and some social entrepreneurs have looked at ways of solving the problem by providing sanitation solutions to the poor. A team of engineers at the Massachusetts Institute of Technology have found a way make a business venture out of the human waste. Instead of selling inexpensive toilets to the poor, they have found away to convert the waste into energy that can be sold back into the grid.
From Forbes Magazine blogs, writer Elmira Bayrasli introduces us to Sanergy founded by MIT grads David Auerbach and Ani Vallabhaneni.
Auerbach and Vallabhaneni knew what they didn’t know. What they didn’t know was that they couldn’t draft up a sanitation solution in Boston – without the insights and input of those in the developing world. Committed to launching a start-up that would truly work for the poor, the two, along with a team of MIT classmates traveled to Kenya for the answers. Kenya, with eight million without access to proper sanitation but a university filled with bright and eager minds to help solve the problem, was an ideal testing ground. In January 2010 the team, in collaboration with the University of Nairobi, conducted a user survey among Kenya’s urban poor, inquiring about their lives. “It was important to us that we found a solution that fit into their lives, not our imagination of their lives,” Auerbach says.
What they found was that Kenya’s poor were interested in having compact stalls that could fit into the tight spaces of their usually one-room homes, rather than large community outhouses. They wanted a “permanent” feel to the stalls rather than the flimsy feel of a porta-potty. As a result, Auerbach, Vallabhaneni and their Sanergy team that includes engineers, architects and designers drew up plans for a 3×5 toilet made out of thin shell cement that is locally produced for $200 per unit. Each toilet is designed for a 100 uses per day. They are units, which also collect waste in double-sealed 30L containers, rather than pits, or septic tanks “that are then drained into waterways.” It is this waste collection that is key.
More than where to go to the bathroom, how to dispose of human waste is, as Auerbach points out, a primary reason that no one touches the issue of toilets. That was Sanergy’s opportunity. Recognizing that, though “messy,” human waste can be converted through anaerobic digestion to produce fertilizer or electricity. It is also where the Sanergy team recognized that it could generate revenue.
Sanergy produces toilets that are franchised to local operators who charge around $0.06 per use. Currently the company has two toilets serving approximately 150 each day. One is at Bridge International school (a for-profit school supported by the Omidyar Network), the other in Kibera, Kenya’s largest slum. These local operators keep all revenues. That, Auerbach says, is an incentive for them to clean, maintain and “market” the toilets. The operators then work with groups who collect the waste daily and bring it to facilities where it is converted to energy. “The waste from each toilet generates Sanergy revenues of $1250 per year.” The waste from 10 million creates a potential market of $178 million per year. Brown gold.

Monday, 23 May 2011

POVERTY: Randomized trials of antipoverty efforts

NICHOLAS D. KRISTOF :  May 18, 2011

One cost of the uproar over Greg Mortenson, and the allegations that he fictionalized his school-building story in the best-selling book “Three Cups of Tea,” is likely to be cynicism about whether aid makes a difference.
 Damon Winter/The New York Times : Nicholas D. Kristof

But there are also deeper questions about how best to make an impact — even about how to do something as simple as get more kids in school. Mortenson and a number of other education organizations mostly build schools. That seems pretty straightforward. If we want to get more kids in school around the world, what could make more sense than building schools?

How about deworming kids?
But, first, a digression: a paean to economists.
When I was in college, I majored in political science. But if I were going through college today, I’d major in economics. It possesses a rigor that other fields in the social sciences don’t — and often greater relevance as well. That’s why economists are shaping national debates about everything from health care to poverty, while political scientists often seem increasingly theoretical and irrelevant.
Economists are successful imperialists of other disciplines because they have better tools. Educators know far more about schools, but economists have used rigorous statistical methods to answer basic questions: Does having a graduate degree make one a better teacher? (Probably not.) Is money better spent on smaller classes or on better teachers? (Probably better teachers.)
And, yes, I’m getting to deworming. Hold your horses!
Now we reach a central question for our age: How can we most effectively break cycles of poverty? For decades, we had answers that were mostly anecdotal or hot air. But, increasingly, we are now seeing economists provide answers that are rigorously field-tested, akin to the way drugs are tested in randomized controlled trials, yielding results that are particularly credible and persuasive.
Prof. Michael Kremer, a Harvard economist, helped pioneer randomized trials in antipoverty work. In the 1990s, Kremer began studying how to improve education in Africa, trying different approaches in randomly selected batches of schools.
One intervention he tried was deworming kids — and bingo! In much of the developing world, most kids have intestinal worms, leaving them sick, anemic and more likely to miss school. Deworming is very cheap (a pill costing a few pennies), and, in the experiment he did with Edward Miguel, it resulted in 25 percent less absenteeism. Even years later, the kids who had been randomly chosen to be dewormed were earning more money than other kids.
Kremer estimates that the cost of keeping a kid in school for an additional year by building schools or by subsidizing school uniforms is more than $100, while by deworming kids, the cost drops to $3.50. (In a pinch, kids can usually go to “school” in a church or mosque without a uniform.)
Look, school buildings are important, too. My wife and I built a school in Cambodia, and whether it’s our school or one of Greg Mortenson’s, they can make a big difference. My point is that for years people have been arguing until they were blue in the face about how to help people — and, finally, we’re getting some reliable data suggesting how to do that.
Another example: What’s the most cost-effective way to prevent H.I.V. transmission in Africa? Most liberals focus on condoms and conservatives on abstinence-only programs. But one program that proved particularly cost-effective in randomized testing in Kenya was simply an initiative to warn teenage girls against “sugar daddies.”
This cost less than $1 per girl reached. The result was not that the girls engaged in less sex, but that they slept with boys their age rather than with older men (who, according to prevalence surveys, were more likely to have H.I.V.).
Randomized trials are the hottest thing in the fight against poverty, and two excellent new books have just come out by leaders in the field. One is “Poor Economics,” by Abhijit Banerjee and Esther Duflo, and the other is “More Than Good Intentions,” by Dean Karlan and Jacob Appel.
For years, we’ve seen a sterile debate about whether humanitarian aid works. (Sometimes yes, sometimes no.) These terrific books move the debate to the crucial question: What kind of aid works best?
For those who want to be sure that to get the most bang for your buck, there is also a “proven impact fund” (www.poverty-action.org/provenimpact/fund). It supports interventions like deworming or microsavings that have proved to be cost-effective in rigorous trials.
I’ve been worried that the “Three Cups of Tea” uproar would lead people to give up on helping others. That would be a tragedy because, over the last decade, we’ve actually gotten much smarter at figuring out how to make a difference. Increasingly, we have a good idea what works — if people still are trusting enough to try to help.

POVERTY: The new Gates Charitable Foundation half billion dollars headquarters

May 23, 2011 : By Kristi Heim

The Bill & Melinda Gates Foundation's philanthropy is literally reshaping Seattle, from the new headquarters opening across from Seattle Center to the burgeoning corridor of biotech and health institutes in nearby South Lake Union.

An atrium with four stories of glass is a central meeting place for Bill & Melinda Gates Foundation employees and visiting groups. The new headquarters is flooded with window light, a design feature intended to save energy and inspire creativity.  STEVE RINGMAN / THE SEATTLE TIMES
An atrium with four stories of glass is a central meeting place for Bill & Melinda Gates Foundation employees and visiting groups. The new headquarters is flooded with window light, a design feature intended to save energy and inspire creativity.

  The new Bill and Melinda Gates Foundation headquarters
Gates campus

In 2006, a team from Seattle's NBBJ architecture firm met with Melinda Gates to review drawings of buildings for a new Bill & Melinda Gates Foundation headquarters the architects had created according to her specifications. Melinda Gates had taken the lead in planning the $500 million campus. For inspiration, she toured a host of notable buildings, from the Wellcome Trust charity in London to biotech giant Genzyme in Cambridge, Mass., and the Finnish Embassy in Washington, D.C.
She envisioned the new headquarters as a model of durability, green design and workplace efficiency. But when NBBJ's plans for a set of unassuming rectangular buildings were unveiled, Gates thanked the team for delivering what she had asked for. Then she sent them back to the drawing board.
"The first one kind of looked like a traditional office building," Gates said, recalling her reaction. "It was kind of a yawner. Even the neighbors kind of went, 'Well, that's it?' "
The space Gates once envisioned as "humble and mindful" needed to be bold. It needed to make a statement reflective of the foundation's own expansive ambitions.
Its goals include eradicating age-old scourges such as malaria and polio, producing the first HIV vaccine and preparing every student in the U.S. to graduate from high school ready for college and a career.
The new campus, which will be showcased in a series of opening events in early June, has two dramatic, glass-walled structures that curve like boomerangs, with arms stretching out in different directions.
"I wanted something that's rooted in the Northwest," Gates said. But it also needed "to be iconic and represent the work we do. And the work we do is global; it reaches out to the world."

From family to global
The foundation has made a dramatic transition from a small family philanthropy run from Bill Gates Sr.'s basement into the world's largest charitable foundation. With its own $37 billion endowment and a long-term gift pledged by investor Warren Buffett, its coffers have grown to more than $60 billion — more than the market value of Boeing. Now its philanthropy is literally reshaping Seattle, from the brand-new headquarters across from Seattle Center to the burgeoning corridor of biotech and health institutes in nearby South Lake Union.
Part of nearly $3 billion the foundation gives away each year has fed the growth of more than a dozen local institutes devoted to researching malaria, HIV and tuberculosis and developing vaccines. About 30 percent of the grants goes toward U.S. programs, including education and addressing homelessness in the Pacific Northwest.
But most of the funded work ultimately takes place far from Seattle, aimed at diseases and conditions that affect poor people in South Asia and Africa. Gates said the new campus is her personal project, a kind of coming-out party to show the foundation's global mission is not remote from the local community.

Low-profile history
Over the past 10 years the foundation has been operating from a nondescript office building in Eastlake without any sign of its name outside, later expanding into four other generic-looking buildings nearby.
As the organization grew, it took on some of the fortresslike corporate culture and heavy public-relations messaging of its founders' Microsoft roots, which grantees and others say can be difficult to penetrate.
At the same time, the foundation has just three trustees, Bill and Melinda Gates and Warren Buffett, and no board of directors. Instead, it operates advisory panels with a handful of outside experts for each of its three main programs — global health, global development and U.S. education — but the meetings and reports are not made public. Despite its humanitarian intentions, its power to influence policy without a public process has raised concern.
The Gates Foundation says it's trying to be more transparent, posting more information about its work on its website and using blogs and social media.

Center-stage location
That change of mindset is reflected in the new headquarters. Melinda Gates said she chose a location in the heart of the city to be more visible and to help connect the campus with the surrounding neighborhood. Some foundation events, including its annual meeting, will be held across the street at Seattle Center.
The campus entrance along Fifth Avenue includes nearby benches, bike racks, an outdoor screen for video art and a viewing pavilion for the public to look in on the inner campus. "We really wanted the foundation to feel transparent to people when they came here," Gates said. "The idea was to have a place where people could understand our work but also understand what they could do."
A museum-style visitor's center will open this year with hands-on exhibits about clean water and other global issues, a kind of tourist destination for do-gooders. Visitors will get a chance to lift two buckets and experience what it's like for millions of women and children in the developing world to carry water.

Talk about a contrast
From the Space Needle, the building invites comparison with Microsoft co-founder Paul Allen's Experience Music Project
Science Fiction Museum, just up the street, said Knute Berger, a local writer and editor-at-large of Seattle Magazine.
"If you ever wanted to get a quick contrast between Bill Gates and Paul Allen, look down at this thing that looks like a crushed Coke can," he said. "It's such a contrast with the clean, sharp lines of the Gates paper-clip place across the way. One is very button-down. One is very rock and roll."
Almost 50 years after the Seattle World's Fair marked the jet age and the dawn of other new technology, the campus echoes the scientific initiative the fair embodied, Berger said.
Between the Space Needle and the biotech hub of South Lake Union, "the Gates Foundation is an actualization of those aspirations," he said.

Gold-plated charity?
Some have questioned whether it's right for the foundation to spend $500 million on office space for 1,500 workers when the 3 billion people the foundation aims to serve live on less than $2 a day.
Adding a visitor's center, striving to achieve environmentally sustainable design, and cleaning up the site, formerly a bus-refueling station, contributed to the higher cost, Gates said.
The city of Seattle sold the property to the foundation for about $54 million and helped pay for some of the cleanup, add a new parking garage and relocate some facilities, finally netting about $32 million.
The Gateses gave $350 million more of their own money to the foundation in 2009 to cover most of the building cost. They have contributed $28 billion to the philanthropy so far. In the end, "Everything from the foundation is going back to the world," Gates said. "You can imagine in some form that building will go back to the world."

Built to last
While typical commercial buildings change hands every seven years, this one was built to last for a century, said NBBJ Managing Partner Steve McConnell.
The thick facade of natural Jura limestone, imported from Germany, even has marine fossils in it. The floors are only half as wide as in a typical downtown high-rise, placing employees no more than 30 feet from daylight and promoting face-to-face interaction.
A 1.2 million-gallon storage pool underneath the plaza holds enough rainwater to supply toilets and irrigate plants, reducing the foundation's demand for city water by more than 70 percent. A 750,000-gallon tank chills water at night to cool the buildings during the day, cutting back on electricity use.
The upfront investment the foundation made in energy-efficient buildings will pay for itself in less than 30 years, according to Arup, the project's lead engineering firm.

Center of global impact
The new campus opens at a time the Gates Foundation's size, scope and influence are shaping global and national agendas. The largest private philanthropy in history, it is making a mark not only by mobilizing unprecedented assets but also by trying risky approaches and tracking results.
It's shaping Seattle by meshing the region's core of expertise in life sciences with its own mission and money. Local institutes funded by Gates are creating low-cost diagnostic devices and designing new vaccines.
Researchers at the nonprofit Seattle Biomed are testing one of the world's first malaria-vaccine candidates on volunteers in Seattle.
Two blocks away, global-health nonprofit PATH expanded into a gleaming office tower after receiving $1.1 billion in Gates grants over the past decade to develop low-cost vaccines and other health solutions. Last year, it introduced a meningitis vaccine for children that reduced the cost from $50 a dose to 50 cents and offers better protection.
The Gates Foundation helped create a new Department of Global Health at the University of Washington to train students, and a UW Institute of Health Metrics and Evaluation to analyze the effectiveness of funding.
Adding a philanthropy headquarters as a central part of the landscape makes a statement about Seattle's identity, says McConnell, of NBBJ.
"For the foundation to become visible," he said, "may awaken the public about the significance and the commitment behind these ambitious programs to create a better world."
Gates said she hopes to help the foundation's employees, who hail from 37 countries, do their best work.
"If having a space where people can collaborate better leads to that, then I think we've achieved our mission."

Kristi Heim: 206-464-2718 or kheim@seattletimes.com