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PubMed2005

Misoprostol use for labor induction in developing countries: a prospective study in Guinea.

BACKGROUND: The purpose of this study was to assess the efficacy, side effects and cost of misoprostol regimens in various obstetrical situations frequently occurring in developing countries. STUDY DESIGN: One hundred and four parturient women with indications for labor induction received different regimens of misoprostol in the range of 50-800 microg according to their gestational age. Misoprostol was administered by the vaginal route, every 6h without exceeding four doses. RESULTS: All indications for labor induction concerned women with a gestational age of more than 30 weeks, except in the intrauterine death cases. The mean overall duration of labor was 7.8 h (+/-4.6 h). The mean amount of misoprostol used was 226 microg (+/-196 microg). The difference in the mean labor duration between the four indications for induction was statistically significant (P<0.01). It was also significant for the mean total dose of misoprostol used. Total dose of misoprostol and Bishop score were inversely proportional. Two caesarean deliveries and two uterine ruptures were recorded, but no maternal deaths. The mean Apgar score was 8.0 (+/-1) at 1 min and 9.5 (+/-0.8) at 5 min. In our series, four fetal deaths occurred. The mean cost of misoprostol for labor induction was around US$ 1, with a range of 0.05-4. CONCLUSIONS: The use of vaginal misoprostol appears to be relevant in developing countries in cases where labor induction is indicated. Nevertheless, the advantages of misoprostol (low cost, facility of storage) are counter-balanced by side-effects (C-section, uterine rupture) which can be harmful for the mother and also for the newborn.

Administration, Intravaginal↗

PubMed2004

Introducing new vaccines in developing countries: concepts and approaches to estimating burden of Haemophilus influenzae type b-associated disease.

In the past 30 years, great strides have been made in immunizing infants and children routinely in developing countries under the Expanded Programme on Immunization. Despite this, the introduction of Haemophilus influenzae type b (Hib) vaccines has progressed rather slowly compared to previously-introduced vaccines for infant immunizations. This slower uptake has been attributed partly to the need for data on the burden of invasive Hib disease. To understand this need, conceptual underpinnings and prerequisites were explored for Hib disease-burden studies. Methodological approaches were also reviewed for conducting Hib disease-burden studies that may be considered in developing countries. Potential studies span a range of designs that provide varying levels of clinical, laboratory and epidemiologic evidence of the burden of invasive Hib disease. Carefully-conducted studies can lay the foundation for complementary studies of long-term disability due to invasive Hib disease, national economic analysis, and field evaluations of vaccine. Studies done in collaboration with national agencies and clinical investigators will maximize study value and provide critical data for national decision-makers who make choices regarding the introduction of Hib vaccines.

Child, Preschool↗

PubMed1998

Mortality impact of the AIDS epidemic: evidence from community studies in less developed countries.

BACKGROUND: The AIDS epidemic is now more than a decade old and direct evidence of mortality impact has become measurable, as indicated by an increasing number of publications presenting empirical data from less developed countries. METHODS: This review focuses on the evidence of mortality impact among adults and children in community studies. The majority of these studies are located in Africa, particularly eastern Africa, where the AIDS epidemic is conjectured to be older than in other less developed countries. RESULTS: Community studies show a two- to threefold increase in total adult mortality with an even larger increase in mortality among young adults in communities with adult HIV prevalence levels below 10%. Mortality amongst HIV-infected adults ranges from 5 to 11% per year, and more than half of all adult deaths can be attributed to HIV. HIV-infected women die at an earlier age than men and thereby lose significantly more productive years of life. Follow-up studies of incident cases are few, but population-based data indicate that the median survival time is substantially longer than originally thought on the basis of mortality amongst HIV-infected commercial sex workers. Tuberculosis incidence is on the increase, but evidence of additional impact on mortality is hitherto limited. Infant and early child mortality among children of HIV-infected mothers is two to five times higher than among children of HIV-negative mothers in follow-up studies of maternity-based and community samples. CONCLUSION: There is now empirical evidence of the mortality impact of HIV/AIDS from several community studies. The large increase in adult mortality and moderate increase in child mortality lead to dramatic falls in life expectancy. For instance, in a rural area of Uganda, which has an HIV prevalence of 8%, life expectancy has dropped from just under 60 years to 42.5 years.

Acquired Immunodeficiency Syndrome↗

PubMed1993

Technology transfer to the developing world: does new technology have any relevance for developing countries?

Technology is not limited to equipment and commodities but includes know-how, understanding and the ability to control and exploit underlying principles and processes. Diverse technologies, not only those termed 'biomedical', affect the incidence and control of all diseases including tuberculosis. 'New technology' implies something recently developed, but any technology is new to those without prior experience. For developing countries, technologic novelty is far less important than relevance, which encompasses, among other things: direct application to reducing risk of infection and disease; affordability and cost-effectiveness; saving foreign exchange; satisfying public demand with political benefit to the government; and promotion of social equity. The value of health gained by the new technology should exceed its cost, but this is difficult to measure. It is usually presumed that industrial countries are eager to export technologies, but intellectual property and patient regulations of the importing country may inhibit such transfers. Similarly, ethical issues involving protection of human subjects and informed consent may complicate clinical trials and technology assessment in the developing country environment.

Cost-Benefit Analysis↗

PubMed1993

Evaluation of two staging systems for HIV infection for use in developing countries.

OBJECTIVE: To evaluate the clinical axis of the World Health Organization (WHO) clinical staging system and the modified WHO staging system proposed by Montaner et al. using the lymphocyte strata > 1500, 1500-1000 and < 1000 cells x 10(6)/l. DESIGN: Cross-sectional study. PATIENTS: Four hundred and fifteen consecutive patients with HIV infection attending three HIV reference centres in Belgium. METHODS: Absolute CD4 lymphocyte counts were compared between stages within the two staging systems. RESULTS: Median CD4 lymphocyte counts decreased with increasing stage of disease in both staging systems. Differences in median CD4 lymphocyte counts between stages of each staging system were statistically significant (Kruskal-Wallis one-way analysis of variance, P < 0.001). The WHO clinical stage 1 and the modified WHO stage I had positive predictive values of 56 and 58%, respectively, for identifying patients with CD4 lymphocyte levels > 500 cells x 10(6)/l. The WHO clinical stage 4 and the modified WHO stage IV had positive predictive values of 79 and 80%, respectively, for identifying patients with CD4 lymphocyte levels < 200 cells x 10(6)/l. CONCLUSIONS: The WHO clinical staging system or a modified version of this system using lymphocytes stratification may be a good alternative in developing countries to the CD4 lymphocyte count-based HIV staging system used in the developed world. Cohort studies in developing countries are needed to assess their prognostic value.

CD4-Positive T-Lymphocytes↗

PubMed2004

Assessing the feasibility of single lifetime PAP smear evaluation between 41-50 years of age as strategy for cervical cancer control in developing countries from our 32 years of experience of hospital-based routine cytological screening.

In view of the huge expenditure involved in mass cytological screening as well as lack of cytology manpower in the developing countries, single lifetime screening at 45 yr of age has been suggested as feasible strategy for control of cervical cancer. The present study is aimed at testing this hypothesis in a broader prospective, accommodating women between 41 and 50 yr of age from the data derived from the ongoing long-term hospital-based routine cervicovaginal cytology at Queen Mary's Hospital, Lucknow, India. The cervical smears of 31,032 women have been evaluated cytologically during a span of 32 yr (April 1971-March 2003) for early detection of carcinoma cervix and sexually transmitted diseases (STDs). The incidence of squamous intraepithelial lesions (SIL) was found to be 6.1% while frank malignancy was seen in 0.5% of cases. The following observations were made from the accumulated cytological data: (a) approximately 30% of the total cancer cases was in the age group of 41-50 yr; (b) the maximum number of SIL cases was detected in women between 41 and 50 yr of age (35% of the total SIL cases), and adequate management of these SIL cases would prevent cancer cases from occurring in later years, thus minimizing the maximum incidence of 1.3% observed in women beyond 50 yr of age; (c) the incidence of human papillomavirus (HPV) infection also was found quite high in women between 41 and 50 yr old, the adequate management of which would prevent onset/progression of any premalignant changes in the cervix. Our experience of 32 yr of cytological screening substantiates the hypothesis of single lifetime screening between 41 and 50 yr of age as an effective strategy for control of carcinoma cervix in developing countries like ours.

Adolescent↗

PubMed2006

Quantitative microbial risk assessment to estimate health risks attributable to water supply: can the technique be applied in developing countries with limited data?

In the 3rd edition of its Guidelines for Drinking-Water Quality (2004) (GDWQ) the World Health Organization (WHO) promotes the use of risk assessment coupled with risk management for the control of water safety in drinking water supplies. Quantitative microbial risk assessment (QMRA) provides a tool for estimating the disease-burden from pathogenic microorganisms in water using information about the distribution and occurrence of the pathogen or an appropriate surrogate. This information may then be used to inform decisions about appropriate management of the water supply system. Although QMRA has been used to estimate disease burden from water supplies in developed countries, the method has not been evaluated in developing countries where relevant data may be scarce. In this paper, we describe a simplified risk assessment procedure to calculate the disease burden from three reference pathogens--pathogenic Escherichia coli, Cryptosporidium parvum and rotavirus--in water supplies in Kampala, Uganda. The study shows how QMRA can be used in countries with limited data, and that the outcome can provide valuable information for the management of water supplies.

Animals↗

PubMed2006

Systematic review of the effectiveness of mass communication programs to change HIV/AIDS-related behaviors in developing countries.

This review systematically examined the effectiveness of 24 mass media interventions on changing human immunodeficiency virus (HIV)-related knowledge, attitudes and behaviors. The intervention studies were published from 1990 through 2004, reported data from developing countries and compared outcomes using (i) pre- and post-intervention data, (ii) treatment versus control (comparison) groups or (iii) post-intervention data across levels of exposure. The most frequently reported outcomes were condom use (17 studies) and knowledge of modes of HIV transmission (15), followed by reduction in high-risk sexual behavior (eight), perceived risk of contracting HIV/acquired immunodeficiency syndrome (AIDS) (six), interpersonal communication about AIDS or condom use (six), self-efficacy to negotiate condom use (four) and abstaining from sexual relations (three). The results yielded mixed results, and where statistically significant, the effect size was small to moderate (in some cases as low as 1-2% point increase). On two of the seven outcomes, at least half of the studies did show a positive impact of the mass media: knowledge of HIV transmission and reduction in high-risk sexual behavior. Further rigorous evaluation on comprehensive programs is required to provide a more definitive answer to the question of media effects on HIV/AIDS-related behavior in developing countries.

Communication↗

PubMed1998

Intensive care use in a developing country: a comparison between a Tunisian and a French unit.

OBJECTIVES: To compare the variations in intensive care (ICU) outcome in relation to variations in resources utilization and costs between a developed and a developing country with different medical and economical conditions. DESIGN AND SETTING: Prospective comparison between a 26-bed French ICU and an 8-bed Tunisian ICU, both in university hospitals. PATIENTS: Four hundred thirty and 534 consecutive admissions, respectively, in the French and Tunisian ICUs. MEASUREMENTS: We prospectively recorded demographic, physiologic, and treatment information for all patients, and collected data on the two ICU structures and facilities. Costs and ICU outcome were compared in the overall population, in three groups of severity indexes and among selected diagnostic groups. RESULTS: Tunisian patients were significantly younger, were in better health previously and were less severely ill at ICU admission (p < 0.01). French patients had a lower overall mortality rate (17.2 vs 22.5%; p < 0.01) and received more treatment (p < 0.01). In the low severity range, the outcome and costs were similar in the two countries. In the highest severity range, Tunisian and French patients had similar mortality rates, while the former received less therapy throughout their ICU stays (p < 0.05). Conversely, in the mid-range of severity, mortality was higher among Tunisian patients, and a difference in management was identified in COPD patients. CONCLUSION: Although the Tunisian ICU might appear more cost-effective than the French one in the highest severity group of patients, most of this difference appeared in relation to shorter lengths of ICU stay, and a poorer efficiency and cost-effectiveness was suggested in the mid-range severity group. Differences in economical constraints may partly explain differences in ICU performances. These results indicate where resource allocation could be directed to improve the efficiency of ICU care.

Adult↗

PubMed1977

[Water resources and health problems in developing countries].

The rapidly increasing use of water for agricultural and hydroelectric development in developing countries is causing serious health problems. These can be divided into two categories; the diseases whose transmission depends on water; and the changes in the life style of the population. We review briefly the principal health problems and analyze the principles to be followed in solving them, and the reasons of the success or failure of health programs. Among the topics we consider, are the development versus health, the collaboration of health service personnel with the rest of the personnel participating in water development schemes, the necessity of ensuring a multidisciplinary approach to the solutions of these health problems, the necessity of integration of the public health component within the administrative and budgetary levels and the coordination of public health measures with the development of project from the planning phase through the completion and maintenance phases, the purely medical aspects of the health problems involved appearing as being of secondary importance. Common sense, and the use of simple, cheap methods adapted to the local conditions, and applied focaly, provide better solutions than the sophisticated, more general and expensive approaches. The time and budget accorded for surveys and research, usually excessive, should be limited. It is necessary to adhere to a disciplined use of water. Ambitions and utopian dreams and strategies of disease eradication should, in general, give way to more limited, but accessible objectives, whose attainment would lead to a decrease of the clinical and socioeconomic gravity of the health problems to a "reasonable" level.

Adult↗

PubMed1986

An appropriate approach to orthopaedics in developing countries.

Gifts of high technology and expensive buildings can constitute a disservice to a poor country when not accompanied by funding for the maintenance and running costs, since they will divert limited resources from more essential needs. The orthopaedic surgery that should be practised in many developing countries differs greatly from that in the contemporary Western world because of a different spectrum of disease, the consequences of uncontrolled disease processes and the less satisfactory conditions in which to function. Training in the home country is therefore essential and circumvents frustration and the brain drain from these countries. Poverty in material resources is not matched by poverty of intellect or resourcefulness, and we have much to learn from developing countries. Different cultures result in the needs of patients being quite different. Orthoses and prostheses need to be based on local crafts and resources, and some of these are illustrated. The Western world can best assist by having surgeons working, teaching and learning in the Developing World, using inexpensive means to treat the many and not to pamper the few.

Africa↗

PubMed1990

Urbanisation and health: methodological difficulties in undertaking epidemiological research in developing countries.

Rapid urbanisation has historically resulted in complex societal changes which have had both beneficial and adverse effects on the health of communities. Recently, it has been recognised that the urban poor in developing countries are at greatest risk for several adverse health effects. The epidemiologist has a key role to play in planning to meet current and future health needs of urban communities. Epidemiological research needs to focus on understanding the relationship between the changes that occur with urbanisation and their impact on health, in order to identify those at greatest risk, to identify the important risk factors that are amenable to intervention, and to evaluate the effectiveness of interventions aimed at improving the health of urban communities. This paper addresses several methodological difficulties in conducting epidemiological research on urbanisation and health in developing countries, with particular reference to Southern Africa. These relate to the definition of urban areas and residence thereof, the comparability across areas of exposure and outcome information, the identification of intra-urban variability, selection bias in cross-sectional studies, associating outcomes with specific urban exposures in analytic studies, and determining appropriate interventions and means of evaluation. Ways of overcoming these difficulties are suggested. Epidemiologists need to address these issues in order to make a valuable contribution to the improvement of health in urban communities.

Bias↗

PubMed2004

Vitamin A for acute respiratory infection in developing countries: a meta-analysis.

AIM: To determine the efficacy of intervention with high-dose vitamin A as an adjunct to standard treatment on outcome in acute lower respiratory tract infection in children in developing countries. METHODS: A systematic review of double-blinded, randomized, controlled intervention studies of high-dose vitamin A or placebo in children aged between 1 mo and 6 y presenting with acute non-measles lower respiratory tract infection. RESULTS: Five studies fulfilling the criteria were identified and included a total of 2177 children (1067 intervention, 1110 control). The main outcome measures were time to normalization of fever, respiratory rate and oxygen dependence, time to discharge, and mortality. On meta-analysis, there were no significant differences in any of the recovery measures or mortality between the intervention and control groups. Pooled results for recovery times are given showing difference in days to recovery days and 95% confidence intervals. Positive summary measures indicate faster recovery in the vitamin A group and negative in the placebo: fever: 0.03 (-0.10 to 0.17); oxygen requirement: -0.08 (-0.31 to 0.16); raised respiratory rate: -0.09 (-0.38 to 0.19); hospital stay: -0.06 (-0.52 to 0.40). Mortality was below 2% in both groups, with a non-significantly higher risk in the intervention group (odds ratio 1.16, 95% CI: 0.61-2.21). CONCLUSION: There is no evidence from this meta-analysis that intervention with high-dose vitamin A improves recovery from pneumonia in children in developing countries aged from 1 mo to 6 y.

Acute Disease↗

PubMed2003

Teaching clinical skills in developing countries: are clinical skills centres the answer?

CONTEXT: There is growing international interest in teaching clinical skills in a variety of contexts, one of which is Clinical Skills Centres. The drivers for change making Skills Centres an important adjunct to ward and ambulatory teaching come both from within and outside medical education. Educationally, self-directed learning is becoming the accepted norm, encouraging students to seek and maximize learning opportunities. There are global changes in health care practice, increased consumerism and increasing student numbers. In some countries, professional recommendations influence what is taught. Increasingly, core skills curricula and outcome objectives are being defined. This explicit definition encourages assessment of the core skills. In turn, all students require equal opportunities to learn how to practise the skills safely and competently. The moves towards interprofessional education make joint learning in a"neutral" setting, like a Clinical Skills Centre, appear particularly attractive. OBJECTIVE: To discuss the potential role of Clinical Skills Centres in skills training in developing countries and to consider alternative options. DISCUSSION: Many developing countries seek to establish Clinical Skills Centres to ensure effective and reliable skills teaching. However, the model may not be appropriate,because fully equipped Clinical Skills Centres are expensive to set up, staff; and run. They are not the only way to achieve high quality clinical teaching. Suggested options are based on the philosophy and teaching methods successfully developed in Clinical Skills Centres that may fulfil the local needs to achieve low cost and high quality clinical teaching which is reflective of the local health needs and cultural expectations.

Clinical Competence↗

PubMed2003

Classification of perinatal death in a developing country.

OBJECTIVES: To evaluate and compare the three most commonly used perinatal death classification systems: (1) the Nordic-Baltic; (2) the Aberdeen; and (3) the Wigglesworth, and assess their applicability in a developing country (Sudan) with a high perinatal mortality rate, and their justification for practical use in quality assurance and audit activities. METHODS: At Omdurman Maternity Hospital (OMH), Khartoum, Sudan, 166 perinatal deaths were prospectively assessed during a 3-month period (May-August 2000) with a total of 2260 births. Narratives of 166 perinatal deaths were prepared for the purpose of audit. A panel of two Danish and one Sudanese obstetrician categorized the cases according to: (1) the Nordic-Baltic; (2) the Aberdeen; and (3) the Wigglesworth classification. RESULTS: By all three classifications a similar fraction of cases (approx. 85%) were allocated to one category only, and in 15% of cases the assessors were in doubt into which of two categories the cases should be allocated. The necessary information is often not available, giving at least 40% classified as 'unknown' in the Aberdeen classification, whereas the Wigglesworth classification results in an even larger group of unspecified asphyxia. CONCLUSION: Classification of perinatal deaths in developing countries is associated with problems regarding application, validity and usefulness. The Nordic-Baltic classification seems to be most suitable for appropriate stratification using routinely recorded variables and providing categories associated with specific levels of care.

Cause of Death↗

PubMed1983

Homicide death rates in childhood in 23 developed countries: U.S. rates atypically high.

World Health Organization vital statistics data were used to compare U.S. homicide death rates with those in 23 other developed countries. Using rank ordering and comparison with mean and median rates for the other countries, U.S. homicide rates for the general population were found to be exceptionally high among developed countries. Similarly, U.S. homicide death rates for infants and for 1-4-year-olds were atypically high. The U.S. infant homicide rates were also unusual because of a male predominance. After infancy, high female homicide rates in the U.S. were more unusual than the male rates. The atypically high homicide risk in the U.S. apparently begins in early childhood, affecting particularly male infants and females after infancy. The data and other cited information suggest that features of U.S. society may promote homicide in childhood. The scope and nature of the U.S. childhood homicide problem warrants a focused effort to develop specific preventive approaches.

Age Factors↗

PubMed1992

AIDS/HIV crisis in developing countries: the need for greater understanding and innovative health promotion approaches.

Epidemiologic data on morbidity and mortality have shown that the acquired immunodeficiency syndrome/human immunodeficiency virus (AIDS/HIV) epidemic is relatively widespread in the developing countries of the world, especially in the already economically deprived regions of Sub-Saharan Africa. Africa is estimated to have approximately 5 million seropositive individuals, and by the year 2000, this number is expected to include 10 million HIV-infected children. Improved control over this epidemic can only come through a greater understanding of the specifics of the disease and, eventually, the introduction of more effective and innovative health promotion campaigns targeted at medical personnel, traditional healers, families, and persons with AIDS. Comprehensive health promotion campaigns, carefully using mass media strategies in addition to more community-based programs, all operating under "decentralized" AIDS control programs, are reasoned to be the most efficacious approach that African and other developing countries can use to successfully contain the AIDS/HIV epidemic. Given the reality of the following factors: Pattern II (ie, transmission of AIDS via heterosexual sexual activity) is the main mode of HIV transmission in Africa, the traditional dominant roles males have in sexual relations, and the positive relationship between sexually transmitted diseases and AIDS, health promotion campaigns must focus specifically on addressing at-risk culturally related sexual values and behaviors in African communities. Failure to address these and other related factors will certainly lead to an escalation of the AIDS/HIV epidemic in Africa and, therefore, concomitant devastation in the human and societal realms of the region.

Acquired Immunodeficiency Syndrome↗

PubMed2000

The long-term reinfection rate and the course of duodenal ulcer disease after eradication of Helicobacter pylori in a developing country.

OBJECTIVE: The aim of this study was to evaluate the effect of Helicobacter pylori (H. pylori) eradication on the natural history of duodenal ulcer disease and the reinfection rate after treatment in a developing country. METHODS: A total of 111 H. pylori-infected patients with duodenal ulcer were treated with either omeprazole or famotidine plus two antibiotics for 2 wk. Those failed to respond to treatment were retreated with bismuth-based triple therapy. RESULTS: The radication rate was 76% (95% CI: 67-83%). Eventually, H. pylori was eradicated in 96 of the 111 patients (86%), who were followed-up clinically and endoscopically for a mean of 37.2 months. The cumulative reinfection rate after eradication (Kaplan-Meier) was 8%+/-3% in yr 1, 11%+/-4% in yr 2, and 13%+/-4% in yr 3. Nine of the 12 reinfections occurred during yr 1. Recurrence of duodenal ulcer was detected in five patients (5.2%), all of them during yr 1 of follow-up. Histologically, gastritis scores (according to the Sydney system) improved significantly after eradication. CONCLUSIONS: In a high prevalence setting, H. pylori eradication and early reinfection rates after treatment are similar to rates observed in a low prevalence environment, whereas the late reinfection rate seems to be higher. However, up to 3 yr after treatment, most treated patients are free of H. pylori infection and/or ulcer activity. Even longer follow-up studies are necessary to determine whether specific retreatment policies are necessary to maintain long term eradication in developing countries.

Adolescent↗