Evaluation of a pre-existing, 3-year household water treatment and handwashing intervention in rural Guatemala

Background The promotion of household water treatment and handwashing with soap has led to large reductions in child diarrhoea in randomized efficacy trials. Currently, we know little about the health effectiveness of behaviour-based water and hygiene interventions after the conclusion of intervention activities. Methods We present an extension of previously published design (propensity score matching) and analysis (targeted maximum likelihood estimation) methods to evaluate the behavioural and health impacts of a pre-existing but non-randomized intervention (a 3-year, combined household water treatment and handwashing campaign in rural Guatemala). Six months after the intervention, we conducted a cross-sectional cohort study in 30 villages (15 intervention and 15 control) that included 600 households, and 929 children <5 years of age. Results The study design created a sample of intervention and control villages that were comparable across more than 30 potentially confounding characteristics. The intervention led to modest gains in confirmed water treatment behaviour [risk difference = 0.05, 95% confidence interval (CI) 0.02-0.09]. We found, however, no difference between the intervention and control villages in self-reported handwashing behaviour, spot-check hygiene conditions, or the prevalence of child diarrhoea, clinical acute lower respiratory infections or child growth. Conclusions To our knowledge this is the first post-intervention follow-up study of a combined household water treatment and handwashing behaviour change intervention, and the first post-intervention follow-up of either intervention type to include child health measurement. The lack of child health impacts is consistent with unsustained behaviour adoption. Our findings highlight the difficulty of implementing behaviour-based household water treatment and handwashing outside of intensive efficacy trial

Intervention to Lower Household Wood Smoke Exposure in Guatemala Reduces ST-Segment Depression on Electrocardiograms

Background: A large body of evidence suggests that fine particulate matter (PM) air pollution is a cause of cardiovascular disease, but little is known in particular about the cardiovascular effects of indoor air pollution from household use of solid fuels in developing countries. RESPIRE (Randomized Exposure Study of Pollution Indoors and Respiratory Effects) was a randomized trial of a chimney woodstove that reduces wood smoke exposure. Objectives: We tested the hypotheses that the stove intervention, compared with open fire use, would reduce ST-segment depression and increase heart rate variability (HRV). Methods: We used two complementary study designs: a) between-groups comparisons based on randomized stove assignment, and b) before-and-after comparisons within control subjects who used open fires during the trial and received chimney stoves after the trial. Electrocardiogram sessions that lasted 20 hr were repeated up to three times among 49 intervention and 70 control women 38–84 years of age, and 55 control subjects were also assessed after receiving stoves. HRV and ST-segment values were assessed for each 30-min period. ST-segment depression was defined as an average value below –1.00 mm. Personal fine PM [aerodynamic diameter ≤ 2.5 μm (PM$_{2.5}$)] exposures were measured for 24 hr before each electrocardiogram. Results: PM$_{2.5}$ exposure means were 266 and 102 μg/m$^3$ during the trial period in the control and intervention groups, respectively. During the trial, the stove intervention was associated with an odds ratio of 0.26 (95% confidence interval, 0.08–0.90) for ST-segment depression. We found similar associations with the before-and-after comparison. The intervention was not significantly associated with HRV. Conclusions: The stove intervention was associated with reduced occurrence of nonspecific ST-segment depression, suggesting that household wood smoke exposures affect ventricular repolarization and potentially cardiovascular health

Effi cacy and safety of single-dose liposomal amphotericin B for visceral leishmaniasis in a rural public hospital in Bangladesh: a feasibility study

Background To rapidly reduce the burden of visceral leishmaniasis for national elimination programmes, an acceptable, safe, and eff ective treatment is needed that can be delivered at primary health-care centres. We aimed to assess the tolerability, safety, and cure rate of single-dose liposomal amphotericin B (AmBisome, Gilead, USA) for visceral leishmaniasis treatment in such a setting in Bangladesh. Methods We enrolled patients who had been diagnosed with visceral leishmaniasis at Muktagacha upazila (subdistrict) hospital, Bangladesh. Eligible participants were at least 5 years old and had a history of fever for more than 2 weeks, splenomegaly, rK39 rapid test positivity, and haemoglobin concentrations of at least 50 g/L. Participants were provided a one-off intravenous infusion of liposomal amphotericin B (10 mg/kg bodyweight). Clinical assessments were done during treatment, before hospital discharge, and on days 30 and 180 after treatment. Cure was defi ned as resolution of fever, decrease in spleen size, and an increase in haemoglobin by 10% compared with baseline or to at least 100 g/L. We estimated effi cacy in terms of initial cure (at day 30) and fi nal cure (at 6 months), and safety in all patients who were enrolled (intention-to-treat analysis). We also assessed effi cacy in all patients who completed treatment and 6 month follow-up after treatment with or without visceral leishmaniasis relapse (per protocol analysis). We assessed acceptability in terms of proportion of patients who consented to treatment. This study was registered with the Australian New Zealand Clinical Trial Registry, number CTRN12612000367842. Findings Between March 5, and Aug 14, 2012, 329 (55%) of 594 cases of suspected visceral leishmaniasis were confi rmed. Of these cases, fi ve patients did not consent to treatment and 24 were ineligible for treatment. In the intention-to-treat analysis, 261 (87%) of 300 patients achieved initial cure and 290 (97%) achieved fi nal cure. In the per-protocol analysis, 260 (88%) of 296 patients achieved initial cure and 289 (98%) achieved fi nal cure. One patient did not start treatment owing to an allergic reaction to liposomal amphotericin B. During treatment or within 2 h afterwards, 79 (26%) patients developed fever, 109 (36%) had fever with rigor, and 56 (19%) had hypotension. No patients needed referral to a tertiary hospital for management of adverse events. Interpretation Treatment of visceral leishmaniasis in a primary health-care facility with single-dose liposomal amphotericin B could safely and eff ectively be adopted by the national visceral leishmaniasis elimination programme in Bangladesh

Visceral Leishmaniasis Clinical Management in Endemic Districts of India, Nepal, and Bangladesh

Background. National VL Elimination Programs in India, Nepal and Bangladesh face challenges as home-based Miltefosine treatment is introduced. Objectives. To study constraints of VL management in endemic districts within context of national elimination programs before and after intervention. Methods. Ninety-two and 41 newly diagnosed VL patients were interviewed for clinical and provider experience in 2009 before and in 2010 after intervention (district training and improved supply of diagnostics and drugs). Providers were assessed for adherence to treatment guidelines. Facilities and doctor-patient consultations were observed to assess quality of care. Results. Miltefosine use increased from 33% to 59% except in Nepal where amphotericin was better available. Incorrect dosage and treatment interruptions were rare. Advice on potential side effects was uncommon but improved significantly in 2010. Physicians did not rule out pregnancy prior to starting Miltefosine. Fever measurement or spleen palpation was infrequently done in Bangladesh but improved after intervention (from 23% to 47%). Physician awareness of renal or liver toxicity as Miltefosine side effects was lower in Bangladesh. Bio-chemical monitoring was uncommon. Patient satisfaction with services remained low for ease of access or time provider spent with patient. Health facilities were better stocked with rK39 kits and Miltefosine in 2010

Route map for the discovery and pre-clinical development of new drugs and treatments for cutaneous leishmaniasis.

Although there have been significant advances in the treatment of visceral leishmaniasis (VL) and several novel compounds are currently in pre-clinical and clinical development for this manifestation of leishmaniasis, there have been limited advances in drug research and development (R & D) for cutaneous leishmaniasis (CL). Here we review the need for new treatments for CL, describe in vitro and in vivo assays, models and approaches taken over the past decade to establish a pathway for the discovery, and pre-clinical development of new drugs for CL. These recent advances include novel mouse models of infection using bioluminescent Leishmania, the introduction of PK/PD approaches to skin infection, and defined pre-clinical candidate profiles

Harmonized clinical trial methodologies for localized cutaneous leishmaniasis and potential for extensive network with capacities for clinical evaluation

International audienceINTRODUCTION: Progress with the treatment of cutaneous leishmaniasis (CL) has been hampered by inconsistent methodologies used to assess treatment effects. A sizable number of trials conducted over the years has generated only weak evidence backing current treatment recommendations, as shown by systematic reviews on old-world and new-world CL (OWCL and NWCL).MATERIALS AND METHODS: Using a previously published guidance paper on CL treatment trial methodology as the reference, consensus was sought on key parameters including core eligibility and outcome measures, among OWCL (7 countries, 10 trial sites) and NWCL (7 countries, 11 trial sites) during two separate meetings.RESULTS: Findings and level of consensus within and between OWCL and NWCL sites are presented and discussed. In addition, CL trial site characteristics and capacities are summarized.CONCLUSIONS: The consensus reached allows standardization of future clinical research across OWCL and NWCL sites. We encourage CL researchers to adopt and adapt as required the proposed parameters and outcomes in their future trials and provide feedback on their experience. The expertise afforded between the two sets of clinical sites provides the basis for a powerful consortium with potential for extensive, standardized assessment of interventions for CL and faster approval of candidate treatments

Diseño de la red de distribución de agua potable a la aldea Santo Domingo Los Ocotes y diseño de mercado municipal, municipio de San Antonio la Paz, departamento de el Progreso.

El municipio de San Antonio La Paz, departamento de El Progreso, presenta un crecimiento poblacional notable, por el cual en el presente trabajo de investigación se diagnosticaron, analizaron y priorizaron necesidades de servicios básicos y de infraestructura, aportando soluciones de carácter técnico a dos de ellas, las cuales están contenidas en las fases de investigación y de servicio técnico profesional. A través de la investigación monográfica y de diagnóstico de necesidades de servicios básicos y de infraestructura de la población, se determinaron como prioritarias el diseño de la red de distribución de agua potable a la aldea Santo Domingo Los Ocotes y diseño del mercado municipal del municipio de San Antonio La Paz, departamento de El Progreso. Con este trabajo busca disminuir enfermedades intestinales por el estado en que se encuentra el agua que consumen

Análisis de la estructura orgánica funcional por procesos y su incidencia en las funciones administrativas de la gobernación de la Provincia de Santa Elena, año 2015.

El objetivo de la investigación es analizar la relación entre las variables: estructura orgánica por procesos y funciones administrativas, el estudio permite determinar la efectividad o deficiencia con la que se aplican los procesos de planeación, organización, dirección y control dentro de la gobernación de Santa Elena. En la metodología de investigación se utilizaron los métodos: documental y de campo. Mediante el método documental se analizaron las disposiciones emitidas por el Ministerio del Interior a través del Estatuto Orgánico Funcional, en la investigación de campo realicé una entrevista al representante de la organización y se conoció los aspectos referentes a la incidencia que tiene la estructura orgánica en el desarrollo de las funciones administrativas de la gobernación. Para el diagnostico situacional se plantearon dos variables, la independiente denominada “estructura orgánica” y la dependiente llamada “funciones administrativas”. Se realizó la encuesta a los 67 funcionarios de la institución, las preguntas fueron diseñadas en base a la escala de Likert con la finalidad de obtener información acerca de las funciones administrativas que se llevan a cabo en la organización. Para la comprobación de la hipótesis mediante el método de Chi Cuadrado, se utilizó el programa IBM.SPSS.Statistics.v20.x86-x64.Multilingual-EQUiNOX, los resultados permitieron establecer una relación entre la variable independiente y dependiente, aceptando la hipótesis planteada. A su vez, se pudo elaborar las correspondientes y recomendaciones del estudio. En conclusión, la investigación realizada permitió comprobar que las teorías y técnicas aplicadas fueron efectivas ya que se logró establecer la relación directa que tiene la inexistencia de una estructura orgánica funcional por procesos en el desarrollo de las funciones administrativas de la Gobernación de Santa Elena

Introducing single dose liposomal amphotericin B for the treatment of visceral leishmaniasis in rural bangladesh: feasibility and acceptance to patients and health staff.

Background. For the treatment of visceral leishmaniasis in Bangladesh, single dose liposomal amphotericin B (ambisome) is supposed to be the safest and most effective treatment. Specific needs for application and storage raise questions about feasibility of its implementation and acceptance by patients and health staff. Methods. The study was carried out in the most endemic district of Bangladesh. Study population includes patients treated with ambisome or miltefosine, hospital staff, and a director of the national visceral leishmaniasis program. Study methods include direct observation (subdistrict hospitals), open interviews (heath staff and program personnel), structured questionnaires, and focus group discussions (patients). Results. Politicalcommitment for ambisome is strong; the general hospital infrastructure favours implementation but further strengthening is required, particularly for drug storage below 25°C (refrigerators), back-up energy (fuel for generators), and supplies for ambisome administration (like 5% dextrose solution). Ambisome created high satisfaction in patients and hospital staff, less adverse events, and less income loss for patients compared to miltefosine. Conclusions. High political commitment, general capacities of subdistrict hospitals, and high acceptability favour the implementation of ambisome treatment in Bangladesh. However, strengthening of the infrastructure and uninterrupted supplies of essential accessories is mandatory before introducing sLAB in Bangladesh