Household socio-economic status, social support and infant and child growth in urban South Africa: a cohort study from 1990

The rapid political, economic and social changes experienced by South Africans from 1991, combined with socio-economic inequalities ingrained in South African society at this time, made the early 1990s a unique and well-suited period to investigate child growth inequalities. Furthermore, recent estimates of low birth weight and stunting (≤ 3 years), showing prevalence of 15% (Chen et aI., 2006) and 25.5% (Labadarios, 1999) respectively, indicate that poor intrauterine and postnatal growth patterns continue to represent considerable public health issues in this setting. This study aimed to investigate associations of birth measures of household SES and social support with infant/child growth in urban South Africa. Anthropometric, demographic, socioeconomic and social support data for quantitative analyses were obtained from the 1990 Bt20 cohort (n=3275). [Continues.

Measuring implementation strength: lessons from the evaluation of public health strategies in low- and middle-income settings.

Evaluation of strategies to ensure evidence-based, low-cost interventions reach those in need is critical. One approach is to measure the strength, or intensity, with which packages of interventions are delivered, in order to explore the association between implementation strength and public health gains. A recent systematic review suggested methodological guidance was needed. We described the approaches used in three examples of measures of implementation strength in evaluation. These addressed important public health topics with a substantial disease burden in low-and middle-income countries; they involved large-scale implementation; and featured evaluation designs without comparison areas. Strengths and weaknesses of the approaches were discussed. In the evaluation of Ethiopia's Health Extension Programme, implementation strength scoring for each kebele (ward) was based on aggregated data from interviews with mothers of children aged 12-23 months, reflecting their reports of contact with four elements of the programme. An evaluation of the Avahan HIV prevention programme in India used the cumulative amount of Avahan funding per HIV-infected person spent each year in each district. In these cases, a single measure was developed and the association with hypothesised programme outcomes presented. In the evaluation of the Affordable Medicines Facility-malaria, several implementation strength measures were developed based on the duration of activity of the programme and the level of implementation of supporting interventions. Measuring the strength of programme implementation and assessing its association with outcomes is a promising approach to strengthen pragmatic impact evaluation. Five key aspects of developing an implementation strength measure are to: (a) develop a logic model; (b) identify aspects of implementation to be assessed; (c) design and implement data collection from a range of data sources; (d) decide whether and how to combine data into a single measure; and, (e) plan whether and how to use the measure(s) in outcome analysis

Methicillin-resistant Staphylococcus aureus Colonization in Veterinary Personnel

TOC Summary: Prevalence of colonization was 6.5%, and employment within a large-animal practice was a significant risk factor

Correlates of the Women's Development Army strategy implementation strength with household reproductive, maternal, newborn and child healthcare practices: a cross-sectional study in four regions of Ethiopia.

BACKGROUND: To address the shortfall in human resources for health, Ethiopia launched the Health Extension Program (HEP) in 2004, establishing a health post with two female health extension workers (HEWs) in every kebele (community). In 2011, the Women's Development Army (WDA) strategy was added, using networks of neighboring women to increase the efficiency of HEWs in reaching every household, with one WDA team leader for every 30 households. Through the strategy, women in the community, in partnership with HEWs, share and learn about health practices and empower one another. This study assessed the association between the WDA strategy implementation strength and household reproductive, maternal, newborn and child health care behaviors and practices. METHODS: Using cross-sectional household surveys and community-level contextual data from 423 kebeles representing 145 rural districts, an internal comparison group design was applied to assess whether HEP outreach activity and household-level care practices were better in kebeles with a higher WDA density. The density of active WDA leaders was considered as WDA strategy implementation strength; higher WDA density in a kebele indicating relatively high implementation strength. Based on this, kebeles were classified as higher, moderate, or lower. Multilevel logit models, adjusted for respondents' individual, household and contextual characteristics, were used to assess the associations of WDA strategy implementation strength with outcome indicators of interest. RESULTS: Average numbers of households per active WDA team leader in the 25th, 50th and 75th percentiles of the kebeles studied were respectively 41, 50 and 73. WDA density was associated with better service for six of 13 indicators considered (p < 0.05). For example, kebeles with one active WDA team leader for up to 40 households (higher category) had respectively 7 (95% CI, 2, 13), 11 (5, 17) and 9 (1, 17) percentage-points higher contraceptive prevalence rate, coverage of four or more antenatal care visits, and coverage of institutional deliveries respectively, compared with kebeles with one active WDA team leader for 60 or more households (lower category). CONCLUSION: Higher WDA strategy implementation strength was associated with better health care behaviors and practices, suggesting that the WDA strategy supported HEWs in improving health care services delivery

Evaluating the effectiveness of IPTi on malaria using routine health information from sentinel health centres in southern Tanzania

BACKGROUND\ud \ud Intermittent preventive treatment of malaria in infants (IPTi) consists of the administration of a treatment dose of sulphadoxine-pyrimethamine (SP) at the time of routine vaccinations. The use of routine Health Management and Information Services (HMIS) data to investigate the effect of IPTi on malaria, anaemia, and all-cause attendance in children aged 2-11 months presenting to 11 health centres in southern Tanzania is described.\ud \ud METHODS\ud \ud Clinical diagnosis of malaria was confirmed with a positive blood slide reading from a quality assurance laboratory. Anaemia was defined using two thresholds (mild [Hb<11 g/dL], severe [Hb<8 g/dL]). Incidence rates between IPTi and non-implementing health centres were calculated using Poisson regression, and all statistical testing was based on the t test due to the clustered nature of the data.\ud \ud RESULTS\ud \ud Seventy two per cent of infants presenting in intervention areas received at least one dose of IPTi--22% received all three. During March 2006-April 2007, the incidence of all cause attendance was two attendances per person, per year (pppy), including 0.2 episodes pppy of malaria, 0.7 episodes of mild and 0.13 episodes of severe anaemia. Point estimates for the effect of IPTi on malaria varied between 18% and 52%, depending on the scope of the analysis, although adjustment for clustering rendered these not statistically significant.\ud \ud CONCLUSIONS\ud \ud The point estimate of the effect of IPTi on malaria is consistent with that from a large pooled analysis of randomized control trials. As such, it is plausible that the difference seen in health centre data is due to IPTi, even thought the effect did not reach statistical significance. Findings draw attention to the challenges of robust inference of effects of interventions based on routine health centre data. Analysis of routine health information can reassure that interventions are being made available and having desired effects, but unanticipated effects should trigger data collection from representative samples of the target population

Severe Acute Respiratory Syndrome–associated Coronavirus in Lung Tissue

Efforts to contain severe acute respiratory syndrome (SARS) have been limited by the lack of a standardized, sensitive, and specific test for SARS-associated coronavirus (CoV). We used a standardized reverse transcription-polymerase chain reaction assay to detect SARS-CoV in lung samples obtained from well-characterized patients who died of SARS and from those who died of other reasons. SARS-CoV was detected in all 22 postmortem lung tissues (to 109 viral copies/g) from 11 patients with probable SARS but was not detected in any of the 23 lung control samples (sample analysis was blinded). The sensitivity and specificity (95% confidence interval) were 100% (84.6% to 100%) and 100% (85.1% to 100%), respectively. Viral loads were significantly associated with a shorter course of illness but not with the use of ribavirin or steroids. CoV was consistently identified in the lungs of all patients who died of SARS but not in control patients, supporting a primary role for CoV in deaths

Uptake, Accuracy, Safety, and Linkage into Care over Two Years of Promoting Annual Self-Testing for HIV in Blantyre, Malawi: A Community-Based Prospective Study

Background Home-based HIV testing and counselling (HTC) achieves high uptake, but is difficult and expensive to implement and sustain. We investigated a novel alternative based on HIV self-testing (HIVST). The aim was to evaluate the uptake of testing, accuracy, linkage into care, and health outcomes when highly convenient and flexible but supported access to HIVST kits was provided to a well-defined and closely monitored population. Methods and Findings Following enumeration of 14 neighbourhoods in urban Blantyre, Malawi, trained resident volunteer-counsellors offered oral HIVST kits (OraQuick ADVANCE Rapid HIV-1/2 Antibody Test) to adult (≥16 y old) residents (n = 16,660) and reported community events, with all deaths investigated by verbal autopsy. Written and demonstrated instructions, pre- and post-test counselling, and facilitated HIV care assessment were provided, with a request to return kits and a self-completed questionnaire. Accuracy, residency, and a study-imposed requirement to limit HIVST to one test per year were monitored by home visits in a systematic quality assurance (QA) sample. Overall, 14,004 (crude uptake 83.8%, revised to 76.5% to account for population turnover) residents self-tested during months 1–12, with adolescents (16–19 y) most likely to test. 10,614/14,004 (75.8%) participants shared results with volunteer-counsellors. Of 1,257 (11.8%) HIV-positive participants, 26.0% were already on antiretroviral therapy, and 524 (linkage 56.3%) newly accessed care with a median CD4 count of 250 cells/μl (interquartile range 159–426). HIVST uptake in months 13–24 was more rapid (70.9% uptake by 6 mo), with fewer (7.3%, 95% CI 6.8%–7.8%) positive participants. Being “forced to test”, usually by a main partner, was reported by 2.9% (95% CI 2.6%–3.2%) of 10,017 questionnaire respondents in months 1–12, but satisfaction with HIVST (94.4%) remained high. No HIVST-related partner violence or suicides were reported. HIVST and repeat HTC results agreed in 1,639/1,649 systematically selected (1 in 20) QA participants (99.4%), giving a sensitivity of 93.6% (95% CI 88.2%–97.0%) and a specificity of 99.9% (95% CI 99.6%–100%). Key limitations included use of aggregate data to report uptake of HIVST and being unable to adjust for population turnover. Conclusions Community-based HIVST achieved high coverage in two successive years and was safe, accurate, and acceptable. Proactive HIVST strategies, supported and monitored by communities, could substantially complement existing approaches to providing early HIV diagnosis and periodic repeat testing to adolescents and adults in high-HIV settings

The Impact of an Intervention to Improve Malaria Care in Public Health Centers on Health Indicators of Children in Tororo, Uganda (PRIME): A Cluster-Randomized Trial.

Optimizing quality of care for malaria and other febrile illnesses is a complex challenge of major public health importance. To evaluate the impact of an intervention aiming to improve malaria case management on the health of community children, a cluster-randomized trial was conducted from 2010-2013 in Tororo, Uganda, where malaria transmission is high. Twenty public health centers were included; 10 were randomized in a 1:1 ratio to intervention or control. Households within 2 km of health centers provided the sampling frame for the evaluation. The PRIME intervention included training in fever case management using malaria rapid diagnostic tests (mRDTs), patient-centered services, and health center management; plus provision of mRDTs and artemether-lumefantrine. Cross-sectional community surveys were conducted at baseline and endline (N = 8,766), and a cohort of children was followed for approximately 18 months (N = 992). The primary outcome was prevalence of anemia (hemoglobin < 11.0 g/dL) in children under 5 years of age in the final community survey. The intervention was delivered successfully; however, no differences in prevalence of anemia or parasitemia were observed between the study arms in the final community survey or the cohort. In the final survey, prevalence of anemia in children under 5 years of age was 62.5% in the intervention versus 63.1% in control (adjusted risk ratio = 1.01; 95% confidence interval = 0.91-1.13; P = 0.82). The PRIME intervention, focusing on training and commodities, did not produce the expected health benefits in community children in Tororo. This challenges common assumptions that improving quality of care and access to malaria diagnostics will yield health gains