Multidisciplinary Studies of Disease Burden in the Diseases of the Most Impoverished Programme

With limited healthcare resources, rational prioritization of healthcare interventions requires knowledge and analysis of disease burden. In the absence of actual disease-burden data from less-developed countries, various types of morbidity and mortality estimates have been made. Besides having questionable reliability, these estimates do not capture the full burden of a disease since they provide only the number of cases and deaths. The modelling methods that include disability are more comprehensive but are difficult to understand, and their reliability is affected by baseline approximations. To provide policy-makers with information needed for rational decision-making, the Diseases of the Most Impoverished (DOMI) Programme of the International Vaccine Institute has used a multidisciplinary approach to describe the burden of disease due to typhoid fever, shigellosis, and cholera. Recognizing the relative advantages and disadvantages of various methodologies, the programme employs passive clinic-based surveillance in defined communities to provide prospective data. The prospective data are complemented with retrospectively-collected information from existing sources, frequently less accurate and complete but readily available for the whole population over extended periods. To create a more complete picture, economic and qualitative studies specific to each disease are incorporated in these prospective studies. The goal is to achieve a more complete and realistic picture by combining the results of these various methodologies, acknowledging the strengths and limitations of each. These projects also build in-country capacity in terms of treatment, diagnosis, epidemiology, and data management

Old age is associated with decreased wealth in rural villages in Mtwara, Tanzania: findings from a cross‐sectional survey

Objective: In many countries housing is used for wealth accumulation and provides financial security in old age. We tested the hypothesis that household wealth, measured by housing quality and ownership of durable assets, would increase with age of the household head. Methods: e conducted a survey of household heads in 68 villages surrounding Mtwara town, Tanzania and recorded relevant demographic, housing, and social characteristics for each household. The primary analysis assessed the relationship between age of the household head, quality of the house structure and socio‐economic score (SES) using multivariate analysis. Principal Components Analysis (PCA) was used as a data reduction tool to estimate the social‐economic status of subjects based on relevant variables that are considered as proxy for SES. Results: 13,250 household heads were surveyed of whom 49% were male. Those at least 50 years old were more likely to live in homes with an earth floor (86%) compared to younger household heads (80%; p<0.0001), wattle and daub walls (94% vs. 90%; p<0.0001) and corrugated iron roofs (56% vs. 52%; p<0.0001). Wealth accumulation in the villages included in the study tends to be an inverted V‐relationship with age. Housing quality and SES rose to a peak by 50 years and then rapidly decreased. Households with a large number of members were more likely to have better housing than smaller households. Conclusions: Housing plays a critical role in wealth accumulation and socio‐economic status of a household in rural villages in Tanzania. Households with a head under 50 years were more likely to live in improved housing and enjoyed a higher SES, than households with older heads. Larger families may provide protection against old age poverty in rural areas. Assuring financial security in old age, specifically robust and appropriate housing would have wide‐ranging benefits

Comparisons of predictors for typhoid and paratyphoid fever in Kolkata, India

BACKGROUND: Exposure of the individual to contaminated food or water correlates closely with the risk for enteric fever. Since public health interventions such as water improvement or vaccination campaigns are implemented for groups of individuals we were interested whether risk factors not only for the individual but for households, neighbourhoods and larger areas can be recognised? METHODS: We conducted a large enteric fever surveillance study and analyzed factors which correlate with enteric fever on an individual level and factors associated with high and low risk areas with enteric fever incidence. Individual level data were linked to a population based geographic information systems. Individual and household level variables were fitted in Generalized Estimating Equations (GEE) with the logit link function to take into account the likelihood that household factors correlated within household members. RESULTS: Over a 12-month period 80 typhoid fever cases and 47 paratyphoid fever cases were detected among 56,946 residents in two bustees (slums) of Kolkata, India. The incidence of paratyphoid fever was lower (0.8/1000/year), and the mean age of paratyphoid patients was older (17.1 years) than for typhoid fever (incidence 1.4/1000/year, mean age 14.7 years). Residents in areas with a high risk for typhoid fever had lower literacy rates and economic status, bigger household size, and resided closer to waterbodies and study treatment centers than residents in low risk areas. CONCLUSION: There was a close correlation between the characteristics detected based on individual cases and characteristics associated with high incidence areas. Because the comparison of risk factors of populations living in high versus low risk areas is statistically very powerful this methodology holds promise to detect risk factors associated with diseases using geographic information systems

Community Participation in Two Vaccination Trials in Slums of Kolkata, India: A Multi-level Analysis

This study aims at understanding the individual and community-level characteristics that influenced participation in two consecutive vaccine trials (typhoid and cholera) in urban slums of Kolkata, India. The study area was divided into 80 geographic clusters (communities), with 59,533 subjects aged ≥2 years for analysis. A multi-level model was employed in which the individuals were seen nested within the cluster. Rates of participation in both the trials were nearly the same; those who participated in the initial trial were likely to participate in the subsequent cholera vaccine trial. Communities with predominantly Hindu population, lower percentage of households with an educated household head, or lower percentage of households owning a motorbike had higher participation than their counterparts. At individual scale, higher participation was observed among younger subjects, females, and individuals from households with a household head who had no or minimal education. Geographic patterns were also observed in participation in the trials. The results illustrated that participation in the trial was mostly influenced by various individual and community-level factors, which need to be addressed for a successful vaccination campaign

Knowledge gaps in the construction of rural healthy homes: A research agenda for improved low-cost housing in hot-humid Africa

Lorenz von Seidlein and colleagues discuss improving house designs in rural Africa to benefit health

Organizational aspects and implementation of data systems in large-scale epidemiological studies in less developed countries

BACKGROUND: In the conduct of epidemiological studies in less developed countries, while great emphasis is placed on study design, data collection, and analysis, often little attention is paid to data management. As a consequence, investigators working in these countries frequently face challenges in cleaning, analyzing and interpreting data. In most research settings, the data management team is formed with temporary and unskilled persons. A proper working environment and training or guidance in constructing a reliable database is rarely available. There is little information available that describes data management problems and solutions to those problems. Usually a line or two can be obtained in the methods section of research papers stating that the data are doubly-entered and that outliers and inconsistencies were removed from the data. Such information provides little assurance that the data are reliable. There are several issues in data management that if not properly practiced may create an unreliable database, and outcomes of this database will be spurious. RESULTS: We have outlined the data management practices for epidemiological studies that we have modeled for our research sites in seven Asian countries and one African country. CONCLUSION: Information from this model data management structure may help others construct reliable databases for large-scale epidemiological studies in less developed countries

Understanding reticence to occupy free, novel-design homes: A qualitative study in Mtwara, Southeast Tanzania.

IntroductionThe population of Africa set to reach 2 billion by 2050. There is therefore great demand for housing across the continent. Research on modified novel designs for housing is a priority to ensure that these homes are not sites of infection for diseases transmission such as malaria. One trial to assess the protection afforded by novel design houses is underway in Mtwara Region, southeastern Tanzania. After constructing 110 of such homes across 60 villages, project staff encountered a certain reticence of the target population to occupy the homes and were faced with accusations of having nefarious intentions. This article explores these accusations, their impacts on home occupancy and lessons for future housing studies.MethodsThis qualitative study drew on in-depth interviews and focus group discussions with ten occupants of the intervention homes, six community leaders and a further 24 community members. Interviews were recorded, transcribed verbatim and translated to English for qualitative content analysis.ResultsIn communities around the Star Homes, during construction and handover, project staff were widely associated with 'Freemasons', a term used to practices, secrecy, and other conspiracy theories in rural Tanzania. These connections were attributed to other community members and explained in terms of knowledge deficit or envy, with others hoping to be allocated the home. The stories were embedded in assumptions of reciprocity and suspicions about study motives, linked to limited experience of research. The relationship between the accusations of freemasonry and reticence to occupy the houses was not straightforward, with project staff or relatives playing a role in decisions. The stakes were high, because the recipients of Star Homes were the poorest families in targeted communities.ConclusionThe results indicate the need for long-term and proactive community engagement, which focuses on building relationships and providing information through recognizable voices and formats. Given the stakes at play in housing interventions, research teams should be prepared for the social upheaval the provision of free new housing can cause

Replacing paper data collection forms with electronic data entry in the field: findings from a study of community-acquired bloodstream infections in Pemba Zanzibar

BackgroundEntering data on case report forms and subsequently digitizing them in electronic media is the traditional way to maintain a record keeping system in field studies. Direct data entry using an electronic device avoids this two-step process. It is gaining in popularity and has replaced the paper-based data entry system in many studies. We report our experiences with paper- and PDA-based data collection during a fever surveillance study in Pemba Island, Zanzibar, Tanzania.MethodsData were collected on a 14-page case report paper form in the first period of the study. The case report paper forms were then replaced with handheld computers (personal digital assistants or PDAs). The PDAs were used for screening and clinical data collection, including a rapid assessment of patient eligibility, real time errors, and inconsistency checking.ResultsA comparison of paper-based data collection with PDA data collection showed that direct data entry via PDA was faster and 25% cheaper. Data was more accurate (7% versus 1% erroneous data) and omission did not occur with electronic data collection. Delayed data turnaround times and late error detections in the paper-based system which made error corrections difficult were avoided using electronic data collection.ConclusionsElectronic data collection offers direct data entry at the initial point of contact. It has numerous advantages and has the potential to replace paper-based data collection in the field. The availability of information and communication technologies for direct data transfer has the potential to improve the conduct of public health research in resource-poor settings