Condom Access in South African Schools: Law, Policy, and Practice

Juliana Han and Michael L. Bennish discuss their experience developing a policy on condom distribution for Mpilonhle, a South African nongovernmental organization involved in HIV prevention in schools

Effect on longitudinal growth and anemia of zinc or multiple micronutrients added to vitamin A: a randomized controlled trial in children aged 6-24 months

<p>Abstract</p> <p>Background</p> <p>The benefits of zinc or multiple micronutrient supplementations in African children are uncertain. African children may differ from other populations of children in developing countries because of differences in the prevalence of zinc deficiency, low birth weight and preterm delivery, recurrent or chronic infections such as HIV, or the quality of complementary diets and genetic polymorphisms affecting iron metabolism.</p> <p>The aim of this study was to ascertain whether adding zinc or multiple micronutrients to vitamin A supplementation improves longitudinal growth or reduces prevalence of anemia in children aged 6-24 months.</p> <p>Methods</p> <p>Randomized, controlled double-blinded trial of prophylactic micronutrient supplementation to children aged 6-24 months. Children in three cohorts - 32 HIV-infected children, 154 HIV-uninfected children born to HIV-infected mothers, and 187 uninfected children born to HIV-uninfected mothers - were separately randomly assigned to receive daily vitamin A (VA) [n = 124], vitamin A plus zinc (VAZ) [n = 123], or multiple micronutrients that included vitamin A and zinc (MM) [n = 126].</p> <p>Results</p> <p>Among all children there were no significant differences between intervention arms in length-for-age Z scores (LAZ) changes over 18 months. Among stunted children (LAZ below -2) [n = 62], those receiving MM had a 0.7 Z-score improvement in LAZ versus declines of 0.3 in VAZ and 0.2 in VA (P = 0.029 when comparing effects of treatment over time). In the 154 HIV-uninfected children, MM ameliorated the effect of repeated diarrhea on growth. Among those experiencing more than six episodes, those receiving MM had no decline in LAZ compared to 0.5 and 0.6 Z-score declines in children receiving VAZ and VA respectively (P = 0.06 for treatment by time interaction). After 12 months, there was 24% reduction in proportion of children with anemia (hemoglobin below 11 g/dL) in MM arm (P = 0.001), 11% in VAZ (P = 0.131) and 18% in VA (P = 0.019). Although the within arm changes were significant; the between-group differences were not significant.</p> <p>Conclusions</p> <p>Daily multiple micronutrient supplementation combined with vitamin A was beneficial in improving growth among children with stunting, compared to vitamin A alone or to vitamin A plus zinc. Effects on anemia require further study.</p> <p>Trial registration</p> <p>This study is registered with ClinicalTrials.gov, number .NCT00156832.</p

Zinc or Multiple Micronutrient Supplementation to Reduce Diarrhea and Respiratory Disease in South African Children: A Randomized Controlled Trial

Prophylactic zinc supplementation has been shown to reduce diarrhea and respiratory illness in children in many developing countries, but its efficacy in children in Africa is uncertain.To determine if zinc, or zinc plus multiple micronutrients, reduces diarrhea and respiratory disease prevalence.Randomized, double-blind, controlled trial.Rural community in South Africa.THREE COHORTS: 32 HIV-infected children; 154 HIV-uninfected children born to HIV-infected mothers; and 187 HIV-uninfected children born to HIV-uninfected mothers.Children received either 1250 IU of vitamin A; vitamin A and 10 mg of zinc; or vitamin A, zinc, vitamins B1, B2, B6, B12, C, D, E, and K and copper, iodine, iron, and niacin starting at 6 months and continuing to 24 months of age. Homes were visited weekly.Primary outcome was percentage of days of diarrhea per child by study arm within each of the three cohorts. Secondary outcomes were prevalence of upper respiratory symptoms and percentage of children who ever had pneumonia by maternal report, or confirmed by the field worker.Among HIV-uninfected children born to HIV-infected mothers, median percentage of days with diarrhea was 2.3% for 49 children allocated to vitamin A; 2.5% in 47 children allocated to receive vitamin A and zinc; and 2.2% for 46 children allocated to multiple micronutrients (P = 0.852). Among HIV-uninfected children born to HIV-uninfected mothers, median percentage of days of diarrhea was 2.4% in 56 children in the vitamin A group; 1.8% in 57 children in the vitamin A and zinc group; and 2.7% in 52 children in the multiple micronutrient group (P = 0.857). Only 32 HIV-infected children were enrolled, and there were no differences between treatment arms in the prevalence of diarrhea. The prevalence of upper respiratory symptoms or incidence of pneumonia did not differ by treatment arms in any of the cohorts.When compared with vitamin A alone, supplementation with zinc, or with zinc and multiple micronutrients, did not reduce diarrhea and respiratory morbidity in rural South African children.ClinicalTrials.gov NCT00156832

What the Future Holds for Resistance in Developing Countries

The challenge to controlling antimicrobial resistance in coming years is to put into practice recent policy and programmatic advances. Increasing attention to the problem of antimicrobial resistance, and how resistance in developing countries can affect industrialized countries, has led to increased attention to the problem of resistance in developing countries. Efforts, however, have lagged behind good intentions. Inappropriate use of antimicrobials, thought to be the major driver of resistance, remains the norm rather than the exception in most of the developing world, as well as in many industrialized countries. Enhanced educational outreach to both consumers and health-care providers to change the pattern of antimicrobial use is crucial and methods to do this effectively have been developed. There is an urgent need for greater regulation of antimicrobial distribution and sale so that private shops staffed by untrained owners and employees are no longer a common source of antimicrobials. Greater management capacity is required to ensure adherence to regulations, to audit prescribing in both the public and the private sectors, and to control corrupt practices and the proliferation of counterfeit or sub-standard drugs. Implementing and sustaining resistance surveillance systems that will alert the medical and public health communities to changes in resistance is also crucial. Development and introduction of rapid techniques to determine infecting pathogens and their susceptibility should enhance both surveillance and care. The substantial funding that is now flowing to targeted diseases - HIV and AIDS, tuberculosis, and malaria, all three of which have substantial problems with antimicrobial resistance - can in the coming years be both a boon (if funds are used to enhance infrastructure to manage all diseases of public health concern) and a detriment (if efforts remain narrowly focused on these diseases) to controlling resistance. Efforts to reduce disease burden - through health interventions such as immunizations and improved socioeconomic conditions - have the potential to have profound effects on the burden of resistance. Ultimately, control of resistance will depend on an integrated, multidimensional effort, the components of which can be implemented if the commitment, political will, and resources are made available

Antimicrobial Resistance in Vibrio

Vibrio infections potentially requiring antimicrobial therapy fall into three distinct clinical syndromes; cholera caused by either Vibrio cholerae O1 or O139 and rarely other V. cholerae serogroups; less severe non-cholera diarrhea caused by non-01 or O139 V. cholerae or other Vibrio species; and soft-tissue infections and sepsis caused by halophilic, marine vibrios.Infections with V. cholerae O1 or the currently much less frequently identified O139 serogroup occur almost exclusively in poor countries where access to clean water and proper sanitation is uncommon. Diarrhea with non-cholera vibrios and tissue invasive infections and sepsis occur wherever marine or seafood exposure takes place. Cholera and non-cholera diarrhea occur in otherwise healthy hosts, and most commonly in children in endemic areas; serious tissue-invasive infections and sepsis with halophilic vibrios is most common in immunocompromised hosts, especially those with hepatic impairment. Acquired multidrug resistance to V. cholerae O1 and O139 is now common and firmly established wherever infections occur.Acquired resistance in V. cholerae O1and O139 is primarily from acquisition of transmissible genetic elements, including conjugative plasmids, integrons, or integrative conjugative elements that carry genes encoding resistance.Circulating strains can both gain and lose resistance during the course of an epidemic, and surveillance of resistance patterns is essential. Because onset of disease is rapid, and disease can be rapidly fatal without appropriate fluid and antimicrobial therapy, antimicrobials should be administered empirically to patients with clinical cholera based on the known prevalence of resistance.In addition, cholera is usually treated in settings where isolation of the infecting organism and susceptibility testing are not routinely available. Thus surveillance programs that monitor resistance, and report to peripheral clinics where cholera patients are cared for, are essential for the management of this disease.. Resistance is not as common in halophilic Vibrios as it is in V. cholerae. Although there are a number of agents that remain active in-vitro against these organisms, because of the relative rarity of infections, and the absence of clinical trials, choice of therapy is predicated upon in-vitro and animal studies, and limited clinical experience

Gastrointestinal and extra-intestinal manifestations of childhood shigellosis in a region where all four species of Shigella are endemic.

To determine the clinical manifestations and outcome of shigellosis among children infected with different species of Shigella.We identified all patients <15 years infected with Shigella admitted to the icddr, b Dhaka hospital during one year. Study staff reviewed admission records and repeated the physical examinations and history of patients daily.Of 792 children with shigellosis 63% were infected with S. flexneri, 20% with S. dysenteriae type 1, 10% with S. boydii, 4% with S. sonnei, and 3% with S. dysenteriae types 2-10. Children infected with S. dysenteriae type 1, when compared to children infected with other species, were significantly (P<0.05) more likely to have severe gastrointestinal manifestations: grossly bloody stools (78% vs. 33%), more stools in the 24 h before admission (median 25 vs. 11), and rectal prolapse (52% vs. 15%)--and extra-intestinal manifestations--leukemoid reaction (22% vs. 2%), hemolytic-uremic syndrome (8% vs. 1%), severe hyponatremia (58% vs. 26%) and neurologic abnormalities (24% vs. 16%). The overall fatality rate was 10% and did not differ significantly by species. In a multiple regression analysis young age, malnutrition, hyponatremia, lesser stool frequency, documented seizure, and unconsciousness were predictive of death.Both severe intestinal disease and extra-intestinal manifestations of shigellosis occur with infection by any of the four species of Shigella, but are most common with S. dysenteriae type 1. Among these inpatient children, the risk of death was high with infection of any of the four Shigella species

Cefixime is ineffective in shigellosis in adults

Pivamdinocillin may be a better treatment for a Shigella bacterial infection in adults than cefixime. Doctors treated 30 adult males with diarrhea caused by a Shigella infection with either a daily 400 milligram (mg) dose of cefixime or four daily 400 mg doses of pivamdinocillin. Cefixime treatment was successful in only 8 of 15 patients while pivamdinocillin treatment was successful in all 15 patients. Patients treated with cefixime had more bloody stools for a longer period of time and their fever lasted significantly longer than those patients treated with pivamdinocillin. The Shigella bacteria were no longer present in 87% of the patients' stools after 2 days of pivamdinocillin treatment. This was the case in only 40% of the patients treated with cefixime.Professiona

Admission Clinical Characteristics of 792 Inpatients <15 Years by Species of <i>Shigella.</i>

<p>Values are n (%) unless noted.</p>*<p>P<0.020: <i>S. dysenteriae</i> type 1 versus <i>S. flexneri</i>, <i>S. boydii</i>, or <i>S. sonnei</i>; <i>S. dysenteriae</i> types 2–10 versus <i>S. flexneri</i>, <i>S. boydii</i> or <i>S. sonnei</i>; <i>S. flexneri</i> versus <i>S. sonnei</i>. P<0.008: <i>S. dysenteriae</i> type 1 versus non-<i>S. dysenteriae</i> type 1.</p>†<p>Duration of illness data were missing for 2/157 patients in the <i>S. dysenteriae</i> type 1 group, 5/504 patients in the <i>S. flexneri</i> group, and 1/77 patient in the <i>S. boydii</i> group.</p>‡<p>P<0.009: <i>S. dysenteriae</i> types 2–10 versus <i>S. dysenteriae</i> type 1, <i>S. flexneri</i>, <i>S. boydii</i> or <i>S. sonnei.</i></p>§<p>P<0.007: <i>S. dysenteriae</i> type 1 versus <i>S. flexneri or S. boydii</i>; <i>S. flexneri</i> versus <i>S. boydii.</i></p>||<p>Weight-for-age was calculated as a percentage of the United States National Center for Health Statistics median weight-for-age^17.</p>¶<p>Weight-for-age data were missing for 5/157 patients in the <i>S. dysenteriae</i> type 1 group, 1/24 patient in the <i>S. dysenteriae</i> type 2–10 group, and 11/504 patients in the <i>S. flexneri</i> group.</p>**<p>P<0.002: <i>S. dysenteriae</i> type 1 versus <i>S. flexneri or S. boydii</i>; <i>S. dysenteriae</i> types 2–10 versus <i>S. flexneri</i> or <i>S. boydii.</i></p

Intestinal Manifestation of Shigellosis in 792 Inpatients <15 Years by Species of <i>Shigella</i>.

<p>Values are n (%), unless noted.</p>*<p>Stool character data were missing for 1/157 patient in the <i>S. dysenteriae</i> group, 1/504 in the <i>S. flexneri</i> group, and 1/77 in the <i>S. boydii</i> group.</p>†<p>P<0.001:<i>S. dysenteriae</i> type 1 versus <i>S. dysenteriae</i> type 2–10, <i>S. flexneri</i>, <i>S. boydii</i> or <i>S. sonnei.</i></p>‡<p>Stool frequency data were missing for 3/157 patients in the <i>S. dysenteriae</i> type 1 group, 9/504 patients in the <i>S. flexneri</i> group, 5/77 patients in the <i>S. boydii</i> group, and 1/30 patient in the <i>S. sonnei</i> group.</p>§<p>P<0.001: <i>S. dysenteriae</i> type 1 versus <i>S. dysenteriae</i> type 2–10, <i>S. flexneri</i>, <i>S. boydii</i>, or <i>S. sonnei.</i></p>||<p>Rectal prolapse data were missing for 6/157 patients in the <i>S. dysenteriae</i> type 1 group, 13/504 patients in the <i>S. flexneri</i> group, 3/77 patients in the <i>S. boydii group</i>, and 1/30 patient in the <i>S. sonnei</i> group.</p>¶<p>P<0.040: <i>S. dysenteriae</i> type 1 versus <i>S. dysenteriae</i> type 2–10, <i>S. flexneri</i>, <i>S. boydii</i>, or <i>S. sonnei</i>; <i>S. flexneri</i> versus <i>S. boydii.</i></p>**<p>P = 0.006, <i>S. flexneri</i> versus <i>S. boydii.</i></p>††<p>P<0.015: <i>S. dysentereriae</i> type 1 versus <i>S. flexneri, S. boydii</i>, or <i>S. sonnei.</i></p>‡‡<p>Stool leukocyte count data were missing for 11/157 patients in the <i>S. dysenteriae</i> type 1 group, 1/24 patient in the <i>S. dysenteriae</i> type 2–10 group, 48/504 patients in the <i>S. flexneri</i> group, 10/77 patients in the <i>S. boydii</i> group, and 6/30 patients in the <i>S. sonnei</i> group.</p>§§<p>P<0.020: <i>S. dysenteriae</i> type 1 versus <i>S. flexneri</i>, <i>S. boydii</i>, or <i>S. sonne</i>; <i>S. dysenteriae</i> type 2–10 versus <i>S. boydii</i>; <i>S. flexneri</i> versus <i>S. boydii</i>, or <i>S. sonnei</i>; <i>S. boydii</i> versus <i>S.sonnei.</i></p>§§<p>Stool erythrocyte count data were missing for 11/157 patients in the <i>S. dysenteriae</i> type 1 group, 1/24 patient in the <i>S. dysenteriae</i> type 2–10 group, 46/504 patients in the <i>S. flexneri</i> group, 10/77 patients in the <i>S. boydii</i> group, and 6/30 patients in the <i>S. sonnei</i> group.</p>|| ||<p>P<0.050: <i>S. dysenteriae</i> type 1 versus <i>S. dysenteriae</i> type 2–10, <i>S. flexneri</i>, <i>S. boydii</i>, or <i>S. sonnei</i>; <i>S. dysenteriae</i> type 2–10 versus <i>S. sonnei</i>; <i>S. flexneri</i> versus <i>S. boydii</i>, or <i>S. sonnei</i>; <i>S. boydii</i> versus <i>S.sonnei.</i></p