key: cord-0042179-3g688ond
authors: nan
title: Oral Presentations
date: 2011-10-03
journal: Trop Med Int Health
DOI: 10.1111/j.1365-3156.2011.02859.x
sha: 45266e0c86812f8eb39b2bc3fddffdc7f7e6363f
doc_id: 42179
cord_uid: 3g688ond

nan

Introduction Malaria programs co-financed by the Global Fund had distributed 160 million insecticide-treated bednets (ITNs), and delivered 170 million malaria treatments, in low-and middle-income countries by end-2010.

Methods We evaluate country progress toward ITN coverage and case and death reduction targets of Millennium Development Goal (MDG) 6 and Roll Back Malaria. Assessments use WHO estimates of households owning Y1 ITNs for sub-Saharan Africa (SSA, 37 supported countries), and case incidence and deaths for all 79 endemic countries with malaria grants. For SSA, malaria cases and deaths are estimated by applying endemicity-specific morbidity and mortality levels from demographic surveillance, to population endemicity maps, adjusting for country-specific ITN coverage. Outside SSA, estimates use case and death notifications adjusted for treatment seeking patterns and reporting completeness.

Results ITN coverage in SSA increased from 3% (2000) to 45% (2009). Case incidence decreased from 293 to 234 per 1000 person-years in SSA, and from 16 to 13 in other supported countries. Malaria mortality decreased from 1.5 to 1.0 per 1000 person-years in SSA, and from 0.023 to 0.017 in other supported countries. ITN coverage increases and case and death declines were larger in the 20 countries with the highest per-capita malaria disbursements than in other supported countries. Similar associations were observed for progress relative to countries' overall level of international malaria funding, including other donors.

Conclusions Global Fund grants are associated with accelerating progress towards MDG 6 malaria targets. To meet the targeted 75% reductions in malaria case and death rates by 2015 from the 2000 baseline, ITN distribution should further accelerate, especially in SSA. Improvement of progress esti-mates will depend on regular household surveys measuring population uptake of ITNs and artemisin-based treatment, and improved surveillance data, notably in large, high-endemic countries with recent scale-up such as Nigeria and Congo Democratic Republic.

Moving towards malaria elimination: the need for innovative, multi-faceted regional approaches to reach mobile and migrant populations Introduction Significant progress has been achieved in the Greater Mekong Subregion (GMS) in the reduction of malaria morbidity and mortality over recent decades. The geographical and epidemiological landscape for malaria in the GMS has undergone tremendous changes due a number of factors including intense deforestation, rapid expansion of development projects, and a highly mobile population. Much of the malaria risk remains along the forested border areas in the GMS and particularly among mobile and migrant workers. As countries re-orientate their programmes towards malaria pre-elimination and elimination, it is even more critical that robust surveillance systems are in place to allow for adequate monitoring for and response to malaria foci among a highly mobile population.

analyses on mobile and migrant populations are often limited and fragmented, especially ensuring adequate responses to this information. Efforts are ongoing to improve the evidence base for migrant populations including extensive bibliographic reviews of migration, innovative vector control and community-based behavior change communications strategies, qualitative research targeting migrant populations, and adapting malaria indicator surveys to obtain utilization and coverage of interventions among migrant populations.

Results Addressing migrant populations is identified as a priority in the strategies to contain artemisinin resistance along the Thai-Cambodia border (including the Global Plan for Artemisinin Resistance Containment). Difficult to define, mobile and migrant populations are heterogeneous, and require specialized surveys and surveillance tools. Adapting national malaria indicator surveys in Cambodia did not allow adequate estimations of coverage and utilization of long-lasting insecticide nets (LLINs), and alternative sampling methodologies were required. Introduction In compliance with WHO recommendations, African countries have discontinued chloroquine(CQ) and now promote artemisinin-based combination therapy (ACT), as firstline treatment for uncomplicated malaria. Faced with an average CQ treatment failure of 25%, Senegal changed its national malaria policy in 2003 from CQ to amodiaquine (AQ)+sulfadoxinepyrimethamine and in 2006, to AQ+artesunate. Studying travelers returning from a specific region, collectively infected by a wide variety of strains of Plasmodium falciparum (Pf), could be an effective tool for detecting the evolution of resistance onsite. The aim of the study is to describe the evolution of CQ resistance in Senegal after a decrease of drug pressure, through imported cases from the country.

Introduction The International Master in medical and veterinary Entomology (IME) is a teaching programme for 2nd year Master students on vector systematics, biology and ecology, population genetics, genomics and control. The IME's objective is to prepare future researchers in areas of public health, veterinary science, teaching and research.

Materials and MethodsCandidates must have a Bachelor of Science (BSc) or equivalent. CVs and applications are evaluated by a scientific committee. The IME consists of three parts: (i) theoretical courses delivered by top-notch experts from each field in Ouidah, Benin; (ii) laboratory and field-work practices in endemic regions of West Africa; (iii) a 5-month research training at IME-collaborating laboratories mainly in Africa and Europe. A written report on the research training is presented at the end of the academic year.

Introduction Past and present uses of dichlorodiphenyltrichloroethane (DDT) as indoor residual spraying (IRS) for malaria vector control, may lead to human exposure to this compound and its metabolites (DDE and DDD). Breast feeding is the primary source of early life infant nutrition and is also a feasible way of Tropical Medicine and International Health volume 16 suppl 1 pp 55-96 october 2011

Introduction Malaria in pregnancy has serious consequences for mother and infant, possibly increased by concurrent HIV infection. Cotrimoxazole prophylaxis given to HIV-infected pregnant women (PW) for the prevention of opportunistic infections is also protective against malaria. Alternatively, intermittent preventive treatment (IPT) with three doses of sulfadoxinepyrimethamine is recommended. As resistance increases rapidly, other molecules have to be tested. We have already assessed the safety and efficacy of mefloquine (MQ) IPT in HIV-negative PW. The PACOME trial evaluates the efficacy of cotrimoxazole vs. MQ IPT in HIV-positive PW.

The PACOME randomized controlled non inferiority trial was started in Benin in December 2009. HIV-positive PW receive insecticide-treated bednets. In the cotrimoxazole treatment arm, daily cotrimoxazole is prescribed. In the IPT treatment arm, 15 mg/kg MQ is given three times, cotrimoxazole is associated in case of low CD4 cell count or advanced HIV disease. PW are followed until delivery and their infants until 4-6 months of life. Combined antiretroviral therapy is prescribed for the prevention of mother-to-child transmission of HIV. The target sample size to judge treatment efficacy as placental malaria prevalence is 500. In May 2011, 295 PW were enrolled, 212 had reached the end of pregnancy. At enrolment, mean CD4 cell count was 364/mm 3 , malaria prevalence was 5%. Malaria incidence during pregnancy was 5/100 person-year. At delivery, 22% of live singleton infants had low birth weight. Of the 170 placental blood smears available, one showed placental malaria (0.6% prevalence). Minor side effects following MQ intake were reported by 65% of PW, mostly dizziness, vomiting, and nausea.

Conclusions Mid-term results show low prevalence and incidence of malaria overall, suggesting good efficacy of the two prevention strategies. They will be compared at the end of the trial. MQ tolerance appears comparable to that observed in HIVnegative women.

Objective Young children with severe malarial anaemia in Africa are at high risk of re-admission or dying within the first 6 months after discharge due to a combination of factors delaying adequate haematological recovery, including reinfections with malaria . We aimed to assess whether chemoprevention from malaria for 3 months could reduce post-discharge hospitalisation and morbidity.

Methods A two-arm randomized placebo controlled multicentre trial of Intermittent Preventive Therapy post-discharge (IPTpd) was conducted in four hospitals in southern Malawi involving 1414 transfused children aged 4-59 months admitted for severe malarial anaemia. Convalescent children received artemether-lumefantrine (AL) on discharge, and IPTpd with either placebo or AL at 1 and 2 month post-discharge, providing approximately 1 and 3 month(s) chemoprevention respectively. Children were followed for 6 months. We compared rates using Cox regression with robust methods. Method and ResultsMSF was alerted by an unusual increase in the number of malaria patients in Burundi's northern provinces of Kayanza and Ngozi in December 2009. The decision to intervene in this epidemic prone region has been based on quantitative and qualitative grounds: observations in the health care structures, analysis of the malaria data and the history of an unusual rain pattern as potential trigger. During the emergency intervention between January and July 2010, 74% of the more than 120 000 patients with fever tested positive on a rapid diagnostic test (RDT). The intervention consisted of offering better access to diagnosis and treatment through fixed and mobile clinics, support to hospitals and prevention through the targeted distribution of 82 000 bednets. Further analysis of the data showed that the number of monthly cases exceeded already the proposed alert threshold in September 2009 and exceeded the proposed epidemic threshold in October 2009. These thresholds were defined as the monthly average of the previous years plus one standard deviation and plus two standard deviations.

Conclusion Considering the increasing risk of malaria epidemics, data collection and monitoring should be reinforced. Precalculated alert and epidemic thresholds, based on the data from previous years, are imperfect but relevant tools and have to be interpreted together with the RDT positivity rate and qualitative information such as an unusual overload of medical structures, and the presence of risk or triggering factors. The generalized use of RDT's will allow more reliable malaria data for future epidemiological monitoring.

Imported submicroscopic Malaria: can it be a risk for re-emergence in Europe?

Introduction Submicroscopic malaria (SMM) can be defined as low-density infections of Plasmodium that are unlikely to be detected by conventional microscopy. Such submicroscopic infections only occasionally cause acute disease, but they are capable of infecting mosquitoes and contributing to transmission. This entity is frequent in endemic countries; however, little is known about imported SMM. The goals of this study were twofold: (i) To determine the frequency of imported SMM, and (ii) to describe epidemiological, laboratorial and clinical features of imported SMM.

Methods A retrospective study based on review of medical records was performed. The study population consisted of patients Discussion Results from this study suggest that imported SMM should be considered in some patients attending at tropical medicine units. Although it is usually asymptomatic, it may be responsible of fever, or laboratorial abnormalities in patients coming from endemic areas.

Results The association of malaria incidence with land cover around 12 villages in the Ashanti Region, Ghana, was assessed in 1988 children <15 years of age. The median malaria incidence was 85.7 per 1000 children and year (range 28.4-272.7). Swampy areas and banana/plantain production in the proximity of villages were strong predictors of a high malaria incidence. An increase of 10% of swampy area coverage in the 2 km radius around a village led to a 43% higher incidence [relative risk (RR) = 1.43, P < 0.001]. Each 10% increase of area with banana/plantain production around a village tripled the risk for malaria (RR = 3.25, P < 0.001). An increase in forested area of 10% was associated with a 47% decrease of malaria incidence (RR = 0.53, P = 0.029). In a next step, mapping of GPS positions of each household will enable to determine individual risk and to confirm and to improve the validity of the model. Methods This 18-cluster (nine intervention clusters in villages;

nine control), randomized, single-center, controlled, parallel, prospective study will evaluate the impact of systematic treatment of asymptomatic carriers (ACs) of asexual forms of P. falciparum with artemether 20 mg-lumefantrine 120 mg (AL, Coartem/ Coartem Dispersible, BID for 3 consecutive days) in approximately 9000-14 000 subjects (male/female adults, children, and infants) from a community setting in Africa. The primary objectives are to evaluate whether treatment of P. falciparum ACs is associated with a lower number of symptomatic malaria episodes, RDT confirmed per person-year over a 12-month follow-up period and an improvement in hemoglobin levels after 28 days. Subjects will be excluded from receiving AL if they have severe malaria, known disturbances of electrolyte balance, history of congenital QTc prolongation or sudden death, body weight <5 kg, hypersensitivity to AL, or if they are in the first trimester of pregnancy. Those subjects will be treated with alternative drugs per current national guidelines. Responsibilities of the investigator's central site include microscopy, data entry, source data archiving, and supervision of the Demographic Surveillance System (DSS). DSS will monitor each cluster population every 2 months during the study for births, deaths, and in/out migrations; and provide an up-to-date demographic status of the study population. A mobile team supervised by the principal investigator will be supported by community healthcare workers (CHWs), a lead CHW, and a local healthcare facility for different study procedures.

Conclusions A unique permanent identification number will be assigned to each inhabitant. If the reduction of ACs and disease burden is confirmed, policymakers may consider this approach in the surveillance strategies being implemented by malaria control programs across Africa.

Differential diagnosis of fever in malaria endemic areas: Co-morbidities, co-infections and alternative diagnoses Impact of community case management of malaria and pneumonia on clinical outcome and rational use of drugs: results from a multi-country study in Sub-Saharan Africa Background Integrated community case management (iCCM) of malaria and pneumonia is a recommended approach to reduce childhood mortality and attain MDGs. However, evidence regarding its impact on the clinical outcome of fever episodes and drug use is scanty. To address this, WHO/TDR funded a multicountry, cluster-randomised study in Ghana, Burkina Faso and Uganda.

Methods In intervention clusters (ICs) community health workers (CHWs) tested febrile children with rapid diagnostic tests (RDTs) for malaria and by counting respiratory rates (RR) to detect acute respiratory infection. Treatment with artemisinin combination therapy (ACT), antibiotics (AB), ACT + AB, or antipyretics alone depended on test results. In control clusters (CCs) all children were treated with ACT without diagnostic tests. Outcome variables were temperature (T) > 37.5°C at D3 and D7 in ICs and CCs, and the proportion of correct use of ACT and AB in ICs. In Uganda, training and supervision of CHWs was particularly intensive with fortnightly visits, peer support and use of cell phones. 

The design was a controlled noninferiority study. Enrolled children aged 2-59 months with any illness were managed either by a study clinician using the new Almanach algorithm (two intervention health facilities), or clinicians using standard practice, including RDT (two control HF). At day 7 and day 14, all patients were reassessed. Patients who were ill in between or not cured at day 14 were followed until recovery or death. Primary outcome was rate of complications, secondary outcome rate of antibiotic prescriptions. According to IMCI+, 6% didn't receive antibiotics when they should have and 19% received antibiotics when they should not have. Re-attendance rates within 14 days after LRTI was 9% when children received antibiotics compared to 8% when they did not (P = 0.44), rates for gastroenteritis were respectively 8% and 9% (P = 0.51). No differences were found in the incidence of non-malarial illnesses between the placebo and IPTI intervention arms (AQ -SP and AS-SP).

Conclusion IMCI+ results in a high accuracy of malaria diagnosis, while the syndromic diagnosis of LRTI is insufficiently accurate to adequately guide treatment. Inappropriate use of antibiotics is common. However, their usage seems not to change the outcome of children with LRTI and GI. Better strategies for the identification of diseases that require antibiotics are needed. Although effective in preventing malaria, IPTi had no impact on other common causes of morbidity in infancy.

Plasmodium vivax (CRESIB-iVAX)

Relapses are contributing significantly to risk of P. vivax infection and disease in Papua New Guinean children 1-5 years of age receive a directly observed treatment with Artesunate (7d, ART) plus primaquine (14d, PQ), ART alone or no treatment (Control), we found that radical treatment with ART-PQ reduced the incidence of P. vivax malaria at 9 months of follow-up by 38% (P = 0.005) and 32% (P = 0.026) against the control and ART arms, respectively. The effect was strongest in the first 3 months after treatment (ART-PQ vs. control: Incidence rate ratios (IRR) = 0.39, P = 0.002; ART-PQ vs. ART: IRR = 0.52, P = 0.04) with little effect thereafter. The reduction in incidence of clinical disease went in line with significantly longer times to first infection in the ART-PQ compared to the ART arm (light microscopy (LM): hazard ratio (HR) = 0.43, P < 0.001; PCR: HR = 0.66, P = 0.002). Intriguingly, the ART-PQ treatment also resulted in a significant reduction in the incidence of P. falciparum malaria (ART-PQ vs. control: IRR = 0.48, P = 0.002, ART-PQ vs. ART: IRR = 0.64, P = 0.07) albeit not significantly delaying time to first P. falciparum infection. These data confirm that P. vivax relapse contribute significantly to the high burden of P. vivax infection and disease in young PNG children living in an area of high transmission.

Pre-exposure prophylaxis for HIV prevention Methods A cohort analysis was conducted among 116 discordant couples attending the IDI clinic. The couples routinely receive interventions to limit seroconversion and these include disclosure of serostatus, STI screening and treatment, condom promotion, timed conception trials, HAART (if eligible by national guidelines) as well as quarterly peer support meetings. Seronegative partners undergo regular (6 monthly) HIV testing. These data are routinely entered in a clinic database. We performed a database analysis to determine the rate of seroconversion. Methods This prospective cohort study was carried out in a tertiary care hospital over 5 years. HIV patients with TB being put on ATT and ART concurrently were enrolled as subjects. They were followed up for a minimum of 12 months (m) after initiating ATT-ART. SO-CD4 was defines as a CD4 count rise of <100/mm 3 from baseline at 12 m after starting ATT-ART. Statistical analysis was done using R 2.11-1. Fischer¢s exact; Rank sum and Chi squared tests were used as required. Results 105 plasma data were available out of 113 participants recruited for the study. Fifty patients had TB without comorbidity, 26 had co-existent DM and 29 had co-existent HIV. Unexpectedly, the time to peak concentration (Tmax) was 6 h (slow absorber) instead of 2 h (fast absorber) for 61 patients (62.2%). The median peak concentration (C max ) was significantly higher in fast than in slow absorbers (5.4 vs. 4 mg/l; P = 0.04). Rifampicin C max was significantly lower in male than in female patients (median 3.6 vs. 6.6 mg/l; P < 0.001). Neither slow nor fast absorbers with co-morbidities (DM or HIV) had significantly different C max Results compared to TB patients without co-morbidities. In the fast absorber group, 10 patients (27.0%) had C max < 4 mg/l, 23 (62.2%) had C max between 4-8 mg/l and only 4 (10.8%) had acceptable therapeutic levels. In slow absorbers, 31 (50.8%) had <4 mg/l, 20 (32.8%) had levels between 4-8mg/l and 10 patients (16.3%) had therapeutic levels.

Conclusions In the majority of this Peruvian population we found altered rifampicin pharmacokinetics with delayed absorption and low drug levels.

Progress toward millennium development goal 6 in global fund-supported tuberculosis programs Introduction Treatment of latent Mycobacterium tuberculosis infection is an essential component of tuberculosis (TB) control and elimination. Isoniazid for 9 months is efficacious but limited by low treatment completion rates and liver toxicity.

We conducted an open-label, randomized non-inferiority trial comparing 3 months of directly-observed once-weekly rifapentine 900 mg plus isoniazid 900 mg (3HP) vs. 9 months of self-administered daily isoniazid 300 mg (9H). Participants at high risk of developing TB were enrolled from the United States, Canada, Brazil, and Spain and followed for 33 months. The primary endpoint was confirmed TB and the non-inferiority margin was 0.75%.

In the modified intention-to-treat analysis there were 3986 persons in the 3HP arm, of whom seven developed TB (cumulative TB rate 0.19%) and 3745 in the 9H arm, of whom 15 developed TB (cumulative TB rate 0.43%). The rate difference was -0.24% with an upper bound of the 95% CI of the difference of 0.01%. Treatment completion was 82% in the 3HP arm and 69% in the 9H arm (P < 0.0001). Permanent drug discontinuation due to an adverse event was 4.7% in the 3HP arm and 3.6% in the 9H arm (P = 0.01). Rates of drug-related hepatotoxicity were 0.5% and 2.7%, respectively (P < 0.0001).

Conclusions In low to medium TB incidence settings, 3HP

was as effective as 9H in preventing TB, had higher treatment 

IgM antibody response in symptomatic (Visceral Leishmaniasis) and asymptomatic (indeterminate initial infection) human leishmania (L.) infantum chagasi-infection in Amazonian Brazil Results All 14 samples tested negative in the III profile, contradicting the expected IgM reactivity in asymptomatic III profile. In contrast all seven SI profiles with up to 2 months of disease tested positive (160-320 IgM), as did 26.7% (4/15) of those with more than 2 months (80-160 IgM); thus, there 50% (11/22) IgM reactivity in the SI profile.

Conclusion These results strongly suggest that IgM response might only be evidenced at the time-point when the asymptomatic infection (III) has converted to a symptomatic one (SI profile), just when the infection has evaded the macrophage microbicidal action and amplified the parasite load at the mononuclear phagocyte system, providing a suitable antigenic stimulation capable of exacerbating the humoral response, with high IgG production and in lower scale IgM.

Exploring the salivary gland contents of Phlebotomus perniciosus by a proteomic approach Introduction Sand fly salivary proteins are species-specific. As a consequence, identifying antigenic salivary proteins of different leishmaniasis vectors has currently become a major task in the field of anti-Leishmania vaccine development. Salivary protein contents of Phlebotomus perniciosus, the main proven vector of leishmaniasis in Spain, were investigated through two-dimensional electrophoresis.

Materials and Methods Salivary glands from adult reared female flies were dissected under a stereoscopic microscope. After disrupting the glands, the salivary gland homogenate was subjected to isoelectric focusing using 11 cm IPG-strips of different pH range (3-10, 4-7, 7-10 and 7-11). 15% polyacrylamide gels were employed for the second dimension electrophoresis. Silver stained spots were analyzed by MALDI-TOF/TOF and database searching was done using MASCOT software. In order to obtain sera with anti-saliva antibodies, mice and hamsters were immunized against salivary proteins through the bite of uninfected P. perniciosus. ELISA tests were performed to ensure that sera of the immunized animals had generated specific anti-saliva IgG. In addition, pooled sera were employed to detect antigenic salivary proteins by western blotting.

Results Proteomic 2D electrophoresis revealed a reproducible protein profile that matched the classic SDS-PAGE pattern. More spots rather than protein bands were visualized suggesting either protein isoforms or post-translational modifications presence. Pooled sera of immunized animals showed elevated anti-saliva IgG levels and recognized by western blot salivary antigens such as SP03, SP03B, SP01, SP01B, SP08, SP04, SP04B among others.

Conclusions This work is assumed to be the first attempt to establish a proteomic map of P. perniciosus saliva. All spots were identified as salivary proteins confirming this technology as an interesting tool to improve sand fly salivary knowledge. This work was supported by the Spanish Ministry of Science and Innovation (Project no. AGL2008-01592).

CD4+ memory T cell assessment in individuals with active cutaneous leishmaniasis: differential distribution of immunoregulatory potential Introduction Human cutaneous leishmaniasis is a devastating tropical disease that affects millions globally and for which no effective vaccine exists . While there are effective treatments, problems with toxicity, treatment compliance and resistance are serious issues that point to the need for the development of new therapies and vaccines. The immunoregulatory environment in individuals actively infected with L. braziliensis is a key factor associated with resolution of disease, and development of more serious forms of disease like mucosal and disseminated leishmaniasis. Understanding the cellular and molecular aspects of the cellular immune response associated with each clinical from of disease is key for development of effective therapeutics or vaccines. While much has been learned about the cellular response in human cutaneous leishmaniasis (CL), our understanding of the balance between memory cell compartments in active disease is not well understood.

Objective and Method We report findings designed to define the immunoregulatory balance between three CD4+ T cell compartments: central memory (CM), effector memory (EM) and naïve T cell compartments as defined by a series of surface markers using multiparameter flow cytometer in a group of 13 well defined CL patients following overnight cultures in media, with soluble Leishmania antigen (SLA) or polyclonal stimuli (anti-CD3/CD28). We defined the CD4+ T cell subpopulations based on the expression of CD45RA and CCR7, in following way: central memory (CD45RA), CCR7+); effector memory (CD45RA); CCR7)), and naïve (CD45RA+; CCR7+). The frequency of cells in each subpopulation producing key immunoregulatory/functional molecules such as cytokines and granzyme was determined.

In active disease the relative distribution of these subpopulations was on average approximately; 30% CM, 45% EM and 20% naïve. Significant increases in the frequency of cells expressing CD69, and the functional cytokines; IFN-gamma and TNF-alpha, were seen within the EM cell population in SLA stimulated cultures, with no differences between subpopulation in the media alone cultures. 

We identified a Leishmania donovani-specific 12.6-kDa (BHUP3) soluble promastigote antigen through sensitive western blot technique. The identified protein was partially purified from sodium dodecyl sulfate-polyacrylamide gel electrophoresis and the antigenic response of eluted protein was determined by western blot with different groups of individual sera. The diagnostic potential was further validated by enzyme-linked immunosorbent assay using serum of 100 VL patients, 93 nonendemic healthy control individuals, 110 endemic healthy control individuals, and 110 disease control individuals. Further, it was characterized by two-dimensional gel electrophoresis followed by matrix-assisted laser desorption/ionization-time-of-flight analysis.

Results On blotting, antibody against this protein was recognized by all (9/9) VL patient's sera, but it was absent in every control group (nonendemic healthy control and endemic healthy control). Sensitivity of the enzyme-linked immunosorbent assay was 88% (89/101), whereas the specificity for endemic healthy, nonendemic healthy, and different disease groups was 96% (106/ 110), 100% (93/93), and 97% (107/110), respectively. The twodimensional gel electrophoresis showed a single spot, and matrixassisted laser desorption/ionization-time-of-flight analysis revealed that it is a 113 amino-acid-long putative uncharacterized protein of 12.6-kDa anamorsin homolog matched completely with Leishmania major (GenBank accession number: Q4QIS1).

Conclusion Despite marginally lower sensitivity of BHUP3, excellent specificity warrants its further development as a tool for diagnosis of VL.

Comparative evaluation of immunogenicity and protective efficacy of parenteral and oral GP63 single antigen and polytope DNA vaccines against visceral leishmaniasis in mouse model Introduction The polytope approach of genetic immunization is a promising gene therapy for the prevention of infectious disease, as it is capable of generating effective cell mediated immunity by delivering the T-cell epitopes assembled in series. We used this approach for the preparation of DNA vaccines against visceral The overall response to the outbreak was organized as a multi-sector approach to promote the integration and coordination between health, nutrition, food security, shelter and water/sanitation/hygiene sectors by all partners. This multisectoral approach has positively impacted the treatment outcome and reduction of case fatality rate due to visceral leishmaniasis. Introduction In the hyperendemic state of Bihar, India, the cure rate of antimonial compounds in the treatment of visceral leishmaniasis (VL) has declined over the past 30 years from over 85% to <50% and resistance in parasites has been demonstrated. Since arsenic and antimony are metalloids which share many structural and chemical properties, we hypothesise that chronic exposure of the population of Bihar to arsenic contaminated groundwater, accessed via tubewells, contributed to the dramatic decrease in efficacy of antimonials in this region.

Methods A literature and internet based search was performed to assess the historical, epidemiological, parasitological and biochemical feasibility of this hypothesis.

The following key facts were ascertained: Antimony resistance in Leishmania parasites has been induced experimentally by exposure to stepwise increasing concentrations of sublethal concentrations of trivalent arsenite in culture. The emergence of decreased antimonial efficacy in the treatment of VL in Bihar occurred in the years directly after the large scale insertion of shallow tubewells across Asia in the early 1970s. There are 10 VL endemic districts in Bihar where both significant arsenic contamination of the groundwater and antimonial resistance have been reported. High levels of accumulated hepatic arsenic, capable of inducing antimonial resistance have been demonstrated experi-mentally in laboratory exposed animals and in liver biopsies of chronically arsenic exposed patients. Long term stability of resistant laboratory strains and superior fitness of clinical resistant strains has been demonstrated which would explain dissemination of resistant strains.

Conclusion If individuals chronically exposed to arsenic are infected with Leishmania, the parasites would be exposed to arsenic within organs of the lymphoreticular system. This could lead to the development of arsenic-resistant Leishmania strains that would be cross-resistant to antimonial therapy. In vitro and in vivo laboratory work, together with epidemiological studies, is being performed to explore this hypothesis further. [1999] [2000] [2001] [2002] [2003] [2004] [2005] [2006] [2007] [2008] . Monthly averages of cases ranged from 149 to 309, highest peak in March-April and another one in July. Monthly VL incidence was associated positively to rainfall and negatively to relative humidity and the numbers of VL cases in the previous month.

Interpretation The number of cases reported to the public health sector allowed the describing of spatial distribution and temporal variations in the Muzaffarpur from 1990 to 2008. However, to assess the actual VL burden, as well as the efficacy of the control measures applied in the district, reporting from private practices and NGOs should be encouraged. patient data. We conducted survival analyses for cyst response defined as inactive (CE4 or CE5 by the ultrasound based World Health Organizsation (WHO) classification scheme) or as disappeared. We collected data from 711 treated patients with 1308 cysts from six centres (five countries). Analysis was restricted to 1159 liver and peritoneal cysts. Overall, 1-2 years after initiation of benzimidazole treatment 50-75% of active CE1 cysts were classified as inactive/disappeared compared to 30-55% of CE2 and CE3 cysts. Further in analyzing the rate of inactivation/ disappearance with regard to cyst size, 50-60% of cysts <6 cm responded to treatment after 1-2 years compared to 25-50% of cysts >6 cm. However, 25% of cysts reverted to active status within 1.5 to 2 years after having initially responded and multiple relapses were observed; after the second and third treatment 60% of cysts relapsed within 2 years. We estimated that 2 years after treatment initiation 40% of cysts are still active or become active again. The overall efficacy of benzimidazoles has been overstated in the past. There is an urgent need for a pragmatic randomized controlled trial that compares standardized benzimidazole therapy on responsive cyst stages with the other treatment modalities.

Re-visiting the 'Del Brutto diagnostic criteria' for the diagnosis of neurocysticercosis Introduction Neurocysticercosis (NCC) is the most common cause of acquired epilepsy in Taenia solium endemic areas, primarily situated in low-income countries. Diagnosis is largely based upon the 'Del Brutto diagnostic criteria' using the definitive/ probable/ no NCC diagnosis 'approach'. Neuro-imaging and specific T. solium cysticercosis antibody detection results are at the mainstay of this diagnosis, while antigen detection in serum is not included. This study aimed at evaluating the addition of antigen detection as a major diagnostic criterion, especially in areas where neuro imaging is absent.

Methods Retrospective B158/B60 monoclonal antigen ELISAs were carried out on serum samples collected during a hospital based study from 25 people without epilepsy and 83 people with epilepsy (PWE) living in a T. solium endemic area.

The addition of antigen results as a major criterion allowed the correct diagnosis of definitive NCC in 10/17 patients (0/17 could be diagnosed without antigen results) in the absence of neuro-imaging. A sensitivity of 1 and specificity of 0.84 were determined for the diagnosis of active NCC by antigen ELISA.

Conclusions Taking into account its limitations for diagnosis of inactive NCC, antigen detection can be of added value for diagnosing NCC in PWE by assisting in diagnostic and treatment decisions, as it can determine the presence/absence of viable cysts and thereby improve the diagnostic potential, especially in areas where neuro-imaging is absent. Therefore, we suggest a revision of the 'Del Brutto diagnostic criteria' with the inclusion of serum antigen detection as a major criterion.

A multicenter, open label, phase III study of therapeutic use of the co-administration of nifurtimox and eflornithine (NECT) for human African trypanosomiasis (NECT field): safety profile in children during initial hospitalization The NECT FIELD study assesses the clinical tolerability, feasibility and effectiveness of NECT co-administration in adults as well as children and pregnant or breastfeeding women, to treat human African trypanosomiasis (HAT) (stage 2 T.b. gambiense) in real-life conditions. The trial is ongoing in six centres in Democratic Republic of Congo. Only in-hospital safety is reported here. 2. 630 stage 2 HAT patients were included. They received 400 mg/kg/day of eflornithine as IV infusion for 7 days and 15 mg/kg/day of oral nifurtimox for 10 days. Median hospitalization duration was 16 days (range 5-46). 3. 629 patients were analyzed (ITT). 100 were children <12 years of age (median 6 years), 13 were pregnant women and 33 breastfeeding women. At baseline children showed similar symptoms than adults with the exception of fever that was more frequent and headache less reported. As primary outcome measure, all children left the hospital alive in contrast to 10 adults (1.6%) who died. The same proportion of adults and children (92%) had at least one adverse event (mean 4/patient). 2 SAEs were reported in children: one developed convulsions, considered as possibly related and the other had an abdominal infection, unlikely to be related with the treatment. In general, children presented fewer digestive symptoms (46%) than pregnant/breastfeeding women (74%) or other adults (64%) and more fever (44% children vs. 39% pregnant/breastfeeding women vs. 26% other adults). 4. Inhospital safety of NECT treatment was overall similar for children and adults. NECT therefore appears as safe in children as in adults.

Effectiveness of short vs. long treatment schedules with pentamidine in first-stage HAT: a large field cohort study Introduction Across the world, schistosomiasis afflicts over 207 million people in 74 countries but the disease is perhaps of greatest significance in sub-Saharan Africa (SSA) . During the last decade, with substantial donor support, control of schistosomiasis is very firmly on the international health agenda. In SSA several national control programmes have delivered praziquantel to millions of children and adults and now, with extensive WHO advocacy, the control of several of the most common neglected tropical diseases (NTDs), including schistosomiasis, in co-endemic areas is achieved by integrated preventive chemotherapy.

Materials and methods A systematic review of the literature between 2002 and 2011 was conducted using key terms: schistosomiasis, integration, neglected tropical diseases and the name of endemic countries in SSA. A total of 402 papers were assembled, reviewed to highlight commonalities and progression in co-themed topics. Tables were constructed to compare the direction of previous actions for schistosomiasis control and the evidence of integrated control with other NTDs.

Results Spatial distribution and predictive risk mapping were important topics of research and several studies demonstrated impact of praziquantel treatment on parasitological dynamics and host morbidity (using anaemia, liver function, and haematuria as primary indicators). Furthermore, coverage of treatment for school age children was reported as the main indicator of control programme success. While many papers highlighted the future benefits of integrated control of NTDs, few studies have substantiated these claims in terms of cost effectiveness, efficacy, sustainability, capacity building and socioeconomic impact, particularly on the integration of schistosomiasis control with other NTD control programs.

Conclusions There is a clear need to increase operational research on programmatic issues, especially in the context of integration of schistosomiasis control with other NTDs. With the current increased support in the fight against NTDs in SSA, there is a new important opportunity to explore the challenges and benefits of integration. To do so fully, however, additional support to develop a more comprehensive research agenda based upon pragmatic in-country experiences is needed.

Immunological and genetical analysis of combined therapy with artemisinin-praziquantel in Schistosoma mansoni in vivo Introduction Schistosomiasis is caused by digenetic trematodes of the genus Schistosoma. For the treatment of this disease Praziquantel (PZQ) is mostly the drug of choice. However, its extensive use in mass treatment for schistosomiasis control potentiates increased tolerance to the drug. The use of combination therapy may be an alternative to improve cure rates, thus eventually delaying the permanent establishment of drug resistance. One of the drugs that has been suggested to be used in combination with PZQ is Artemisinin (ART).

Methods and MaterialsThe rodent model of Schistosoma mansoni was divided into three groups of mice infected with S. mansoni and were treated with (i) 40 mg/kg/single dose of PZQ, the standard curative dose in humans; (ii) 60 mg/kg/single dose of PZQ; (iii) 30 mg/kg/single dose of ART, (iv) combined therapy of PZQ (40 mg/kg/single dose) and ART (30 mg/kg/single dose).

Mice not infected were negative controls and mice infected but not treated were positive controls. Mice were followed up weekly for 60 days post drug administration, parasite load was measured and sera was collected MicroELISAs were performed to detect antibody (IgG or IgM)-S. mansoni antigen complexes with rabbit hyper immune serum or to detect mice anti-Schistosoma IgG or IgM. DNA was extracted from S. mansoni adult worms at day 60 and amplified through RAPD-PCR.

Results and ConclusionsThe combination therapy led to more sustained parasite load control than PZQ alone, however no statistically significant differences were observed for IgG and IgM profiles along the infection periods when comparing PZQ, ART and ART+PZQ groups, which will be discussed. Different RAPD profiles were also observed between different drug groups but also between male and female parasites. The well-studied schistosome antigen detection ELISA (CAA-ELISA) was transformed into a ultra-sensitive UCP lateral flow based assay (CAA-UCP). The objective of the study presented here was to demonstrate and improve robustness and sensitivity of this assay under field conditions. Data showed: (i) the development of dry-reagent assays with extended shelf life allowing shipping and storage at ambient temperature; (ii) usage of portable readers; (iii) simplification and increase of sensitivity by modification of serum sample handling; (iv) large scale application in a routine laboratory setting in South-Africa. The conclusion is that the assay is robust, suitable for use in low-resource settings, ultra-sensitive and specific, and has significant potential to be developed into a Gold Standard diagnostics for schistosomiasis. Referring to in vitro Although great reductions in human schistosomiasis have been observed after praziquantel (PZQ) mass drug administration (MDA), some individuals remain infected after multiple treatments. Many MDA programmes now require monitoring for drug efficacy as a key component. No molecular tools for PZQ-resistance identification currently exist, and ED50 investigations present ethical, logistical, and temporal restraints. We characterized the full behavioural repertoire of Schistosoma mansoni miracidia and assessed the feasibility and accuracy of a rapid, inexpensive in vitro PZQ test, in the laboratory and directly in the field in Uganda under MDA, in conjunction with highly detailed infection intensity, clearance and reinfection data as well as corresponding genetic diversity and population structure microsatellite data. This test strongly differentiated between subsequently cleared and uncleared human infections, as well as differences between parasite populations pre-and post-PZQ treatments, advocating its use for on-thespot monitoring of PZQ efficacy in natural foci. In the laboratory an enhanced dispersal potential and a greater proportion of erratic swimming behaviours were associated with increased praziquantelsusceptibility and in vitro praziquantel concentration. The use of this expanded behavioural repertoire could enhance in vitro tests used to detect praziquantel-resistance in natural foci. After only a few treatments, uncleared parasites from human infections were identified to be phenotypically different from drug-sensitive parasites, emphasizing the urgent need for monitoring of these repeatedly PZQ-treated populations. 

We undertook a series of independent randomized double blind trials in lab and field to determine the protective efficacy resulting from co-immunization of buffaloes with S. japonicum triose-phosphate isomerase (SjCTPI) or 23 kDa integral membrane protein [SjC23 fused to heat shock protein 70 (SjCTPI-Hsp70) plasmid and interleukin-12 (IL-12)] DNA vaccines followed by challenge infection with Chinese strain S. japonicum. In each trial, forty-five 8-10 monthold water buffaloes from a non endemic area were divided into three treatment groups with 15 animals each.

Results and ConclusionsLaboratory results showed that, compared with the control group (pVAX), vaccination with SjCTPI-Hsp70 and SjCTPI plasmids resulted in a worm reduction rate of 51.2% and 41.5%, fecal egg reduction of 52.1% and 38.3% and liver egg reduction of 61.5% and 42.0%; vaccination with SjC23-Hsp and SjC23 plasmids resulted in a worm reduction rate of 50.9% and 45.5%, fecal egg reduction of 48.0% and 40.2%. A small pilot study was carried out in four endemic villages and showed that co-immunization with SjCTPI-Hsp70/ SjC23-Hsp70 and IL-12 DNA vaccines induces significant protective immunity against S. japonicum in water buffaloes. An extensive field assessment in 12 endemic villages in Dongting Lake has commenced in 2009 and the outcome of this study will determine whether this vaccine can be used in a national control program or not.

Introduction A major reason why Strongyloides stercoralis is highly neglected, even in studies dedicated to the epidemiology and control of other clinically relevant Soil Transmitted Helminths (STH), is the fact that infections are simply missed in commonly used diagnostic procedures such as Kato-Katz stool slide examination. Recent studies showed specific detection and quantification of Strongyloides DNA by real-time multiplex PCR to be a sensitive and highly specific diagnostic method. In the present study we compare prevalence and intensity of Strongyloides infection in different geographical regions in the tropics, using the same standardized procedure of species specific DNA detection.

Method In total more than 4000 stool samples were collected in eight tropical countries at three different continents. All samples originated from rural or semi-urban populations and were collected in order to study the epidemiology of helminths within communities. DNA isolation and specific detection and quantification of four different STH-species were performed similarly for all different stool collections. Using a multiplex PCR format, Results were obtained for Ascaris lumbricoides, Necator americanus, Ancylostoma duodenale and Strongyloides stercoralis, of which only the latter will be presented here.

The percentage of S. stercoralis specific DNA stool positive individuals ranged from <1% in Senegal to 10% in Ghana and more than 40% in Mozambique and Peru. In those settings where extensive and Strongyloides-dedicated microscopy, i.e. Baermann and copro-culture procedure, was used PCR-based findings were confirmed by the detection of L3-larvae.

Conclusion Our data shows a high variation in prevalence and intensity of S. stercoralis infection in different communities, ranging from almost absent to extremely high transmission levels.

In comparison to microscopy, multiplex real-time PCR was found to be a reliable and relatively simple high throughput procedure to monitor Strongyloides infections during cross sectional surveys, as well to compare the epidemiology between different geographical regions. Introduction The published literature is replete with empirical evidence from endemic areas around the globe on the differential occurrence of the soil-transmitted helminth (STH) infections of Ascaris, hookworm and Trichuris -between girls and boys and between women and men. Although many of these studies have methodological limitations, there remains an ongoing debate on the respective roles of gender and sex in the acquisition and transmission of STH infection, and on the affected individual's response to infection.

appraisal of the scientific and grey literature was conducted to identify all reported potential determinants of STH infection and morbidity. The determinants were then classified as being biological (sex) or behavioural (gender), modifiable or non-modifiable, and organized into a comprehensive framework.

The proposed framework details gender-specific behaviours, expectations and roles which contribute to differential acquisition, transmission and response to STH infection and morbidity. Not only may gender-specific behaviours lead to differential determinants for STH infection (e.g. through environmental exposures, access to and utilization of health services and preventive measures, and knowledge and perception of health and disease), but they may also affect response to disease (e.g. utilization of health services, detection of disease, care during illness, perception and symptoms of disease) and consequences of STH infection (e.g. length and intensity of disease, impact on work and family, economic consequences, recovery and treatment).

Conclusions The importance of gender in relation to the acquisition and response to STH infection must be fully understood and appreciated in order to develop the most appropriate interventions. A framework is proposed which outlines the role of gender in STH infection and which can be used to guide gendersensitive interventions to more effectively and efficiently reduce the disease burden associated with STH infection.

Single-dose azithromycin vs. penicillin G benzathine for the treatment of yaws Introduction Yaws, an endemic treponematosis and as such a neglected tropical disease (NTD), is currently making a comeback. Injectable long acting penicillin remains the drug of choice for the treatment of yaws. However, on the basis of successful experience with venereal syphilis in large-scale studies, oral azithromycin has emerged as a potential alternative that overcomes the major medical and logistic disadvantages of the current regimen.

Materials and methods This randomized clinical trial was conducted in Lihir Medical Centre, Papua New Guinea. The sample size was calculated to detect a non-inferiority margin of 14%. Children <15 years of age with a confirmed diagnosis of yaws were randomly assigned to receive 30 mg/kg (maximum 2 g) of azithromycin orally or 50 000 units/kg (maximum 2.4 MU) of penicillin-G-benzathine intramuscularly. The primary outcome was treatment efficacy, with cure defined serologically (a decline in the VDRL titer of at least two dilutions by 6 months after treatment) and, in primary yaws, also by epithelialization of ulcers within 2 weeks.

Results A total of 176 subjects, 74 (42.0%) with primary and 102 (58.0%) with secondary yaws, were enrolled in the trial. The average age of participants was 9.49 years, and 100 (56.8%) were male. After 6 months of follow up, cure rates were 93.0% (80/86) in the azithromycin group and 91.1% (82/90) in the penicillin-G-benzathine group (95% CI for the difference, -6.7-10.5%), achieving pre-specified criteria for equivalence. Cure rates were also similar 3 months after treatment in the azithromycin and penicillin groups, 83.7% and 84.4% respectively. The incidence of worsening ulcers that required re-treatment after 2 weeks (2.3-2.2%) did not differ significantly between treatment arms.

Conclusions Single-dose oral azithromycin is effective in treating yaws, avoids the need for injection equipment and medically trained personnel, and may be a more accessible treatment to enable yaws control through mass drug administration programs. Results 8709 people were involved in the MDA program and average drug coverage rates were around 70%. The overall prevalence of filariasis fell from an initial 17.91% to 3.76% after round 5 (P < 0.001). Viewed on a village by village basis, 12/27 (44%) villages achieved success whereas it failed in the remaining 15 (55%). In multivariate analysis, low baseline prevalence was the only factor predicting both success in reducing infection rates (OR 19, 26 CI 95% 1, 12 to 331, 82) and success in preventing new infections (OR 27, 44; CI 95% 1, 05 to 719, 6). Low vector density and the use of an optimal vector control strategy were also associated with success in reducing infection rates, but this did not reach statistical significance.

Our results provide the data that support the recommendation that high endemic areas may require longer duration MDA programs, or alternative control strategies.

Prevention and control of vector borne diseases: surveillance and vector control Conclusion This is the first report of arthropods carrying C.

burnetii from the Arabian Gulf region suggesting that ticks may play a significant role in the transmission of coxiellosis among wild vertebrates in this region. The ticks left on the offshore oil wellhead tower by cormorants frequently bite workers and thus create the possibility of human infection transmitted via a tick bite. Human diseases have been reported from the region rarely, which, however, could be due to the lack of clinical awareness. Result We estimate an overall reproduction number of 3.25 for the whole municipality. The R0 by health area ranges from 2 to 7. Within each genotype, viral strains collected in SPICs grouped within a particular cluster. By analyzing the genetic mutations on the E gene, we observed that most of the mutations appeared during the first epidemic/endemic period. In addition, we found that specific amino acid substitutions on the E protein were rapidly acquired and then conserved on all DENV strains later collected in the region, thus reflecting a founder effect. Furthermore, our findings lead to the identification of the main routes of DENV distribution between the SPICs and should contribute to the improvement of dengue surveillance in the region.

Clinical profile pre-hospitalization of severe Dengue fever: a household case-control study Introduction In 2008, Rio de Janeiro city experienced its fourth large dengue epidemic, when many severe cases of dengue fever were recorded, with high hospitalization and death rates, especially among younger individuals. The role of the ineffectiveness of diagnostic and therapeutic interventions for the severity of this epidemic became a matter of debate. Recognition of clinical warning signs as predictors of bad prognosis is essential to prompt treatment that might reduce risk of death Objective To compare the evolution of clinical signs before hospitalization between severe and mild cases of dengue fever, in order to identify bad prognostic signals.

Methods A case-control study in a sample of 88 severe dengue cases admitted at four hospitals over the 2008 epidemic and 367 controls living in the vicinity of the cases' residence. A questionnaire including daily evolution of the disease was applied both to cases and to controls with mild dengue fever. Pearson's Chi-square test was used to compare the frequency of clinical signs between groups.

Results The frequency of fever and abdominal pain on the third and fourth day of the disease were significantly higher in the severe cases group, as well as breathing difficulty on the third day and drowsiness or irritability on the fourth and fifth day of onset symptoms (P-value <0.05).

The results suggest the importance of these symptoms as predictors of poor prognosis of the disease. The concomitant presence of these signs with fever suggests that symptomatic manifestations of gravity may occur before the end of the period of defervescence, around the third day of illness. An educational campaign could be developed, if results are confirmed in other studies and places, to give the children presenting those signs and symptoms earlier medical assistance.

Introduction Vaccination is the single most effective preventive strategy against yellow fever, a severe, often fatal, hemorrhagic disease. Yellow fever vaccine is a live vaccine comprising the 17D attenuated strain of yellow fever virus. The immunologic basis of the long-term, possibly lifelong, immunity provided by 17D vaccine is not known but has been speculated to be related either to persistent antigen stimulation or to a particular innate immune response signature. The 17D vaccine strain is normally cleared from blood during the first 4-6 days after vaccination. Recently, it has been shown that 17D vaccine genome could be found in the urine of healthy vaccines during the first week and up to 25 days post-vaccination in people with suspected vaccine-associated adverse events. To further explore the possible persistence of yellow fever vaccine virus in urine we tested urine samples from healthy yellow fever vaccine recipients at varying times up to 1 year after vaccination. Conclusions These results suggest that yellow fever vaccine virus might persist for at least 6 months after vaccination in some people. A larger study is ongoing to determine the frequency and duration of persistence of yellow fever vaccine viral RNA in urine of healthy vaccine recipients. Methods We describe the clinical signs, symptoms, and basic laboratory features in 1916 confirmed dengue patients recruited to a prospective observational study that took place in recognised centres of excellence in seven endemic countries across two continents. All patients were followed daily throughout the evolution of their illness by trained physicians using a single comprehensive case report form. All patients were subsequently categorised according to the revised (2009) WHO dengue classification scheme.

Results Detailed information on fever duration, common symptoms such as abdominal pain, mucosal bleeding, hepatomegaly etc will be presented comparing Results across age groups and by continent, as well as according to disease severity. Overall, the clinical epidemiology was similar across the two continents. The majority of severe patients had severe plasma leakage without being severe by bleeding or organ dysfunction (213/271). Hospitalized adults in Asia seemed to be more likely to have bleeding manifestations than hospitalized children. The prevalence of mucosal bleeding in non-severe disease for adults was in the same range as for children with severe disease (10-30%, over day of illness 3-7). Information on daily laboratory parameters will be shown, indicating characteristic patterns over time, particularly in the platelet count and haematocrit values. Finally, Results of a principal components analysis of clinical signs and symptoms according to day of illness will be presented, stratified by age group and geography.

Conclusions Despite the ongoing geographical spread into regions with different immuno-epidemiological backgrounds dengue appears to be a single disease entity. Plasma leakage is the leading cause of severity and can be documented in a considerable number of cases without other severity markers.

The global aetiology and epidemiology of paediatric diarrhoeal disease Methods We conducted a prospective study in 12 hospitals in Lima, Peru. E. coli strains were isolated from bacteremia cases in hospitalized children younger than 5 years of age. Five E. coli colonies/sample were studied by a multiplex real-time PCR to identify the presence of virulence genes asociated with DEC: Enterotoxigenic (lt, st), Enteropathogenic (eaeA), Shiga toxinproducing (stx1, stx2), Enteroinvasive (IpaH), Enteroaggregative (AggR), and Diffusely Adherent E. coli (daaD). Additionally, a triplex PCR was used to classify the phylogenetic groups by Clermont's method; and susceptibility testing was performed by disc diffusion.

We analyzed 70 E. coli strains. Virulence genes associated with DEC were identified in seven bacteremia-positive children (10%), including: four AggR-positive (6%), three daaDpositive (4%), one eaeA-positive (1%) and one st-positive (1%). Two children were positive to AggR and daaD simultaeneously. The most comom phylogenetic groups among samples (n = 70) were D (49%), A (29%), B1 (20%) and B2 (3%). Antibiotic resistance was common: ampicillin 90%, cefotaxime 50% and gentamicin 47%. Resistance to multiple antibiotics was most frequent in phylogenetic groups A and D.

Conclusions To our knowledge this is the first description of virulence genes associated with DEC in E. coli strains isolated from bacteremia in children. Further studies are needed in a larger number of samples to determine the relevance of these findings.

Pregnancy and cholera; pregnancy outcomes from specialized cholera treatment unit for pregnant women in Leogane, Haiti Introduction Cholera in pregnancy is associated with high risk of stillbirth or abortion. Reported fetal loss, in the limited literature available, varies between 13.5% and 53%. Since October 2010, Haiti is confronted with an important cholera outbreak. A specialized cholera isolation unit for pregnant women was set-up inside the MSF hospital compound in Leogane, Haiti. All women received intensive intravenous re-hydration for prevention and cure of dehydration during the whole hospitalization. All received antibiotics and preventive treatment for hypoglycemia. Fetal status was monitored during hospitalization, clinically and with ultrasound. Treatment for obstetric complications was available, including C-section and specialized neonatal care. We present the outcome of the pregnancy from the routinely collected data in this center. Methods We collected demographic and clinical data regarding the pregnancy and the cholera episode. Data were entered in Excel and analyzed with SPSS.

pregnant women were admitted in the cholera treatment unit: 14 (13.7%) were in 1st, 50 (49%) in 2nd and 38 (37.3%) in the 3rd trimester of pregnancy. No maternal death occurred during admission in the unit. Of the 102 pregnant women, 81 (79.4%) preserved their pregnancy and seven delivered a live newborn (6.9%). Fetal loss was reported for 14 women (13.7%), of which seven occurred before admission. Of the seven women with fetal loss after admission, 6 (85.7%) had severe or moderate dehydration and 1 (14.3%) had mild dehydration, whereby of women with a positive outcome 44 (48.3%) had severe or moderate dehydra- Giardia duodenalis infection is common in animals and humans.

Giardia duodenalis presents seven genotypes or assemblages (A-G), two of which (A and B) are mainly found in humans. Although giardiosis is considered an important zoonotic disease, there are specific assemblages related to different animal species. The aim of the present study was to determine the prevalence of G. duodenalis in domestic animals (dog and cat) in Madrid, and to genotype the isolates. A total of 604 and 144 faecal samples from dogs and cats, respectively, were analyzed by microscopy. The prevalence of G. duodenalis was 16.4% in dogs and 4.2% in cats. Selected G. duodenalis-positive samples (n = 100) were genotyped using previously described primers targeting the glutamate dehydrogenase (gdh) gene and the b-giardin gene. Of the 100 faecal samples selected for genotyping, 57 samples yielded a good amplification for one or both of the targeted genes. Thirty two isolates were characterizated using ß-giardin gene, being the assemblages: 

Introduction The mucosal interface of the body is the most important entry route for pathogenic organisms, as well as the site of multiple colonisations. However, the interactions taking place during the most critical initial hours of infection or colonization, adhesion, invasion etc. are still poorly understood. Today there are only few models available and especially the internal mucous membranes such as stomach or gut are very difficult to study in vivo.

The presented new setup is based on a custom-built reusable organ chamber compatible with standard microscopes. Luminal and basal side of the explanted mucosa are connected to separate channels for optimized incubation. Oxygen is provided via a specially constructed membrane oxygenation device. Dynamic imaging with confocal microscopy permits a detailed analysis of the dynamics of pathogen-host cell interactions at the mucosal interface and the neighbouring tissue at high resolution. Data can be complemented by parallel cytokine measurements.

We performed imaging studies of an ex-vivo infection of the washed mouse caecum with Entamoeba histolytica HK9 in the described setup. We could demonstrate that pre-incubation with labelled wheat germ agglutinin is an easy and new method to live-stain E. histolytica in various colors. Further, this technique is stable in confocal imaging setup for extended periods of time.

Using transgenic mice with eGFP labelled phagocytes and membrane dye as well as DAPI staining we could demonstrate multicolor high resolution imaging of E. histolytica on the mouse caecum. Invasion and interactions with the mucosal surface could be visualized and provide insight into time depended processes of Entamoeba infection in the gut. C t values were used to provide semi-quantitative viral loads.

Of 1005 febrile children enrolled, 623 (62%) had respiratory symptoms (URTI in 66%, bronchiolitis in 7% and clinical pneumonia in 27%); 156 (16%) had febrile illness that remained of unspecified etiology and 226 (22%) had other infectious diseases and no ARI (62 malaria, 56 gastroenteritis, 36 urinary tract and 72 others). The proportions of patients with at least one respiratory virus were 70%, 61% and 47% (Pvalue < 0.001) in these three groups. When excluding picornavirus and adenovirus these proportions were 48%, 24% and 26% (P-value < 0.001). Apart from picornavirus and adenovirus, influenza A and B viruses were the most frequent followed by coronavirus and RSV. The proportion of children with presumably high viral titers (C t < 25) was higher in the group with respiratory symptoms (31%) than in the two other groups (21% and 16%). Influenza genotyping revealed strains that were similar to the ones circulating elsewhere in the world.

Conclusion In African children with febrile illness, the prevalence of respiratory viruses, especially influenza A and B, is high particularly in the presence of respiratory symptoms, but also, although less so, in those with unspecified etiology or other infectious diseases. This highlights that these viruses are commonly circulating in Tanzanian children. Objectives The aim of this study was to describe the epidemiology, aetiology and clinical characterization of clinical severe pneumonia (as defined by WHO) among children under 5 years of age admitted to a tertiary hospital in Rabat, Morocco, over a 12month period.

Methods All children fulfilling the WHO criteria for severe pneumonia and whose parents signed a written informed consent were recruited to the study. A standardised questionnaire assessing sociodemographic, clinical and laboratory data was completed for all children, and a chest X ray performed. Blood samples were obtained for blood cultures, haemogram, biochemistry (including procalcitonine and C-Reactive Protein) and Zinc determinations. Nasopharyngeal aspirates were obtained and processed for bacterial culture and viral diagnosis using a commercial PCRbased multiplex panel. Finally, bacterial isolates were studied to assess antimicrobial sensitivity.

We will present the preliminary results of this study. Background A recently-identified group of human rhinoviruses (HRV), HRV-C, has been associated with more frequent and severe acute lower respiratory infection (ALRI) in children.

Previous studies have reported that Aboriginal Australian children have more respiratory infections than non-Aboriginal (n-A) children. Therefore, we investigated the hypothesis that HRV-C infection will be more common in Aboriginal children from a rural community than in n-A children from a rural or urban setting.

(Kalgoorlie-Boulder) or urban (Perth) Western Australia were tested for respiratory viruses including HRV groups. HRV-C prevalence was compared between (i) rural Aboriginal children (n= 103), (ii) rural n-A children (rn-A) (n= 94), (iii) urban n-A healthy controls (un-Ah) (n= 44), (iv) urban n-A siblings of group v (un-As) (n=45), and (v) urban n-A children with an ALRI (un-AALRI) (n= 232). For HRV strain identification, RNA was extracted and cDNA prepared and used for a two-step PCR amplification of the 5¢ non-coding region, followed by DNA sequencing and phylogenetic analysis.

Results HRV was identified in 23.6% rural Aboriginal, 16.5% of rn-A, 22.2% of un-Ah, 37% of un-As and 70.9% of un-AALRI children. Of the typed specimens, HRV-C was identified in 6.2% of rural Aboriginal, 5.1% rn-A, 0% un-Ah, 22.2% of un-As and 44% un-AALRI children. HRV was identified more often in rural Aboriginal than in rn-A children (P < 0.05). HRV-C was identified more often in rural Aboriginal and rn-A children than in un-Ah children (P < 0.001). HRV and HRV-C were more commonly found in un-As and un-AALRI children than all other groups (P < 0.001).

Conclusions Rural Aboriginal children have higher rates of HRV infection than rural non-Aboriginal children, but lower rates than children with a severe ALRI and their siblings. HRV-C was more common in rural than urban children, but much lower than in children with an ALRI and their siblings.

Introduction The development and spread of antimicrobial resistance is a major public health , especially in developing countries where antibiotic armamentarium is limited. Differences in antibiotic resistance levels among pathogenic vs. commensal bacteria give us information about the antibiotic use in clinic and community respectively. The objective was to describe the antibiotic resistance levels in commensal and enteroaggregative Conclusion High antibiotic resistance levels have been found in the area, being especially noticeable among the antibiotics most used in this geographical area. The differences in resistance levels among EAEC and commensal isolates suggests that antimicrobial resistance development is mainly associated with clinical practices than to other sources, such as the food chain or the communitarian use.

African setting before and after the introduction of ciprofloxacin Methods We conducted a case control study and compared 38 returnees from the tropics and subtropics with S. aureus positive skin and soft tissue infections (SSTI) and 124 control patients with other travel associated disorders. We collected information on travel characteristics, the clinical outcome of SSTI, and the antibiotic sensitivity pattern and genotype of S. aureus strains isolated from skin lesions and the nares.

Results Staphylococcus aureus positive SSTI was associated with travel duration and purpose and was most common in returnees from Africa (OR 4.2, P = 0.005). PVL+ S. aureus was frequent in lesional and nasal isolates from travelers with SSTI but could not be found in the nares of control patients. Presence of PVL in S. aureus from travelers was associated with complicated disease, reduced antibiotic susceptibility and secondary spread. Genotypes of PVL+ S. aureus from returnees were reported as endemic at the visited destination but often rarely described in Europe. Results A total of 1136 (605 males, 531 females) specimens were collected during the period. The median age of the subjects was 10 ± 14.0 years (range, 4 months-75 years) and 28.8% cases were under 5 years of age. Median age of Pandemic H1 positive subjects was higher (11.0 ± 11.9 years) than that of seasonal influenza positive subjects (10.0 ± 14.2 years). Of the collected samples, influenza virus was detected in 177, 59.9% (106/177) were Pandemic H1. After detection of the first case of Pandemic H1 in August 2009, it reached its peak activity in October-November and June-July and declined gradually to disappear in the month of December 2010 from the community. The Pandemic H1 completely displaced the existing circulating influenza viruses over a period of 2 months (Fig-1) and after a period of sixteen months it disappeared gradually with reappearance of seasonal influenza in the community. Introduction Staphylococcus aureus causes a broad variety of infections, ranging from skin infections to sepsis. Worldwide emergence and spread of methicillin-resistant S. aureus (MRSA) compromises anti-staphylococcal therapy. Thus far, only one study has been published reporting sporadic community-acquired MRSA in Mozambique and arguing that its emergence is of great concern. This study was designed to determine the current antimicrobial resistance patterns of community-acquired S. aureus (CA-SA) and hospital-acquired S. aureus (HA-SA) isolates in Beira, Mozambique. 

November 2010 was diagnosed with melioidosis in Geneva, Switzerland. Burkholderia pseudomallei was identified in blood cultures 24 h after first medical contact, by use of mass spectrometry (MALDI-TOF). He developed rapidly progressive respiratory failure and despite maximal intensive care support and treatment with high-dose imipenem-cilastin, the patient died 48 h after admission. Information about this case was communicated within 2 days following the patient's hospital admission to the local clinicians in Martinique, national health authorities and international travel medicine networks. Following this, two additional patients were diagnosed with melioidosis in Martinique, one with severe pneumonia-sepsis and the other with acute prostatitis. Thanks to the information, antibiotic therapy was rapidly adapted.

Discussion Modes of transmission include percutaneous inoculation of contaminated surface water or inhalation of soil dust. As the evolution of melioidosis is sometimes fulminant, specific treatment should be initiated as soon as possible. Clusters of cases are known to occur mainly in hyperendemic countries, but following natural disasters (storms, tsunamis) they are also seen in areas of lower endemicity. Two weeks before the travel of the index case, Martinique was affected by hurricane Tomas; resultant flooding probably explains the cluster.

Conclusion As clusters of melioidosis are known to occur, local medical authorities and international travel medicine networks should rapidly be informed when a case is diagnosed. This could be particularly critical when the contaminated area is a touristic location where the disease is rarely reported. Prompt reporting facilitates the investigation of possible additional cases. Results Across the sites, a range of factors influenced timing of ANC attendance: although accessibility (transport and healthcare costs, and distance to healthcare facilities) played a role, ideas about ANC and its benefits -shaped by context-specific understandings of pregnancy care and risk, interactions with healthcare providers and the perspectives of relatives -were also key themes.

In western Kenya and southern Malawi, to reduce the number of trips to healthcare facilities, women often attended ANC in the third trimester. However, this was not simply a result of poor accessibility. As women were largely unaware of specific interventions and viewed checking the pregnancy's progress and obtaining the ANC card as priorities, they had little reason to attend in early pregnancy. Furthermore, after ANC visits, healthcare workers scheduled monthly follow-ups, and fearful of being refused care for non-compliance, women viewed follow-ups as obligatory. In addition, three Kenyan women attending ANC in the first trimester were told by healthcare staff to return when their pregnancy was visible.

Conclusions This qualitative research highlights the role interactions between healthcare workers and pregnant women can play in influencing timing of ANC. This relationship is therefore a potentially important focus for future interventions aimed at promoting early ANC attendance.

Improving quality of maternal and newborn care in selected districts in 3 sub-saharan countries: baseline quality assessment Methods Quality assessment was conducted in each research country in 12 primary health care (PHC) facilities located in two rural districts. Quality of MNC is addressed by a quantitative study assessing: (i) availability of material and human resources through a health facility survey (12 facilities/country); (ii) women's experience of care through a satisfaction survey (63 women/ facility); and, (iii) actual care given through direct observation study (35 observations/facility), review of patient records (35 records/facility), and review of routinely collected data. National guidelines on pregnancy and childbirth serve as standard for good quality of care. Antenatal and childbirth care is assessed separately. Quality scores reflecting availability of resources, client satisfaction and quality of actual care given were calculated and compared along PHC facilities and districts.

Results Preliminary results show that scores for availability of material resources are good however in most facilities no vacuum extractor is available which implies that basic EmOC services cannot be provided. Inter-personal performance and counselling (part of technical-professional performance) have the lowest scores as well in the satisfaction survey as in the observation study.

Conclusion Quality assessment show there is little difference in the MNC quality between PHC facilities inside the study countries and there is need to improve MNC especially access to basic EmOC services, counselling practices and inter-personal performance.

Community skilled birth attendants: are they making a difference? Results Data show that on average CSBAs perform four deliveries monthly, far less than the anticipated 10-12 births per month. When deemed necessary, they were, however, successful in referring women to emergency care facilities. While services should be free, CSBAs were collecting an unofficial cash income when they assisted births. CSBAs stated that community members still prefer to deliver with traditional birth attendants, who are often family members and believed to have extensive experience. Other obstacles included lack confidence in performing deliveries, being overburdened with other work requirements, facing problems traveling at night, and being viewed as too young to assist childbirth. Data also suggest that CSBAs are not supervised or accountable for the number of deliveries they conduct. Instead, those who perform a high number of deliveries are often criticized by supervisors or colleagues for being too focused on assisting childbirth.

Conclusions Data suggest that community-based birth attendants are making a limited contribution to the recent increase in use of skilled birth attendance in Bangladesh. Maternal health programmes and policy makers need to reassess the CSBA program and reconsider their roles and responsibilities.

Prevention of mother-to-child transmission of HIV: adherence to combination prophylaxis is difficult to achieve in a peripheral Tanzanian setting Background Combination prophylaxis for prevention of mother-to-child-transmission of HIV (PMTCT) according to 2008 Tanzanian guidelines requires drug administration during pregnancy, delivery and the postpartum period, involving self-administering and hospital-based components. Adherence to the regimen is decisive for intervention effectiveness. We aimed at following-up women and newborns throughout all intervention stages in rural Tanzania to assess achieved adherence levels.

Methods A cohort of 122 pregnant women willing to start combination prophylaxis, comprising antenatal AZT, intrapartum sdNVP and AZT/3TC, postpartum AZT/3TC for women, and sdNVP and AZT for newborns, were enrolled in an observational study in Kyela District Hospital. Adherence, defined as women's pre-delivery drug collection and intra/ postpartum drug administration by health staff, was assessed through medication possession ratio or total numbers of correctly dispensed drug doses. Adherence levels for different drugs and intervention stages were calculated, using a 95% adherence cutoff level for analysis.

Of 122 women, 36 (29.5%) did not take AZT in pregnancy at all while 43 (35.3%) took AZT, but remained below 95% adherence. Of 43 (35.3%) achieved 95% predelivery adherence. Average adherence among the 86 who took AZT was 77%. Of 74 women returning to hospital in the intra/ postpartum period, correct sdNVP intake was registered for >90% of mothers and newborns. For postpartum drugs directly administered by nurses during hospitalisation, only 19% of infants and 37.5% of mothers achieved 95% adherence. At hospital discharge, take-home postpartum tails were correctly handed out to >80% of mother-child-pairs. Only one mother-child-pair achieved 95% adherence for all drugs in all intervention stages.

Conclusions Adhering to combination prophylaxis throughout all PMTCT intervention stages seemed to be very difficult in our rural study setting. To avoid reduced effectiveness in complex regimens due to suboptimal adherence, close supervision of PMTCT clients and consideration of hospital-based barriers to drug adherence are strongly suggested.

Emergence of minor drug-resistant HIV-1 variants in Tanzanian women after TRIPLE antiretroviral prophylaxis using zidovudine, lamivudine and nevirapine for the prevention of mother-to-child-transmission of HIV-1 Background WHO-guidelines for the prevention of mother-tochild transmission (PMTCT) of HIV in resource-limited settings recommend triple antiretroviral prophylaxis starting with zidovudine (AZT) monotherapy during pregnancy followed by nevirapine single-dose (NVP-SD) at labor onset and AZT/lamivudine (3TC) for 7 days. AZT monotherapy lasting over months and the low genetic barrier of 3TC and NVP could select for resistant HIV-1 variants. Therefore we analyzed the emergence of minor drugresistant variants against the three antiretrovirals.

Method Of 50 HIV-1 infected pregnant Tanzanian women participated in a PMTCT intervention using triple antiretroviral prophylaxis at Kyela District Hospital. AZT was started from pregnancy week 28 onwards. Blood samples were collected before the start of prophylaxis, at birth and 2-4 weeks, 4-6 weeks and 12-17 weeks after delivery, respectively. Allele-specific real-time PCR assays (ASPCR) specific for HIV-1 subtypes A, C and D were applied to quantify key resistance mutations of AZT (K70R, T215Y and T215F), NVP (K103N and Y181C) and 3TC (M184V) at a detection limit of <1%.

The median duration of AZT-intake during pregnancy was 53.9 days (IQR 38.8-64.3); all women ingested NVP-SD and 86% took 3TC. Drug-resistant HIV-1 was detected in 20/50 women (40%). AZT-resistant variants were found in 9/50 women (18%), 3TC-resistant variants in 4/50 women (8%) and NVPresistant variants in 7/50 women (14%). HIV-1 variants with resistance to more than one antiretroviral were selected by three women (6%). Drug-resistant minor populations representing <5% of the total HIV-population were present in 14/20 mothers (70%) with resistance formation.

Conclusion Although the triple antiretroviral prophylaxis diminished NVP-associated resistance compared to NVP-SD alone, drug-resistant HIV-1 emerged in a substantial proportion of women. In most women, the drug-resistant viral population existed as minor population only. The impact of these minor drug-resistant variants on future prophylaxis regimens and longterm antiretroviral treatment is unknown and needs to be assessed. Introduction Despite overall increases in family planning practice, disparities in use still remain in many low-and middleincome countries. Rapidly developing peri-urban areas may be particularly vulnerable as health service expansion may fail to keep up with population growth in these districts. This study examined knowledge and practices of family planning in mothers of young children living in a poor peri-urban area in the Dominican Republic.

Methods Data were drawn from a structured interview conducted with mothers of young children. Participants came from three sources: admissions to a nutrition rehabilitation program for children with malnutrition, attendees at a paediatric clinic (who did not have malnutrition), and a community sample from a nearby neighbourhood. A follow-up interview was conducted with a subsample of participants at approximately 3 months.

Of 408 participants completed at least one interview.

High knowledge levels were found (96% of participants could name two or more family planning methods). Seventy three per cent of the sample reported regular use of a family planning method. However, 21% of mothers who did not want any more children were not currently using a family planning method. The oral-contraceptive pill was the most common method (24%) followed by sterilization (18%). More years of education, older age, and knowledge of more methods remained significantly related to family planning use in a multivariate model.

Frequency of use reported in this study was similar to findings in the 2007 Demographic and Health Survey for the Dominican Republic. However, further analyses of subsamples are required to better examine potential disparities. Further research should also explore why some women who do not want any more children are not currently using any method of family planning.

Meeting the benchmark, yet missing the goal? assessing indicators for access to emergency obstetric care using data from Zambia and Sri Lanka Introduction Indicators of Emergency Obstetric Care (EmOC) access are valuable but underused tools for tracking progress towards Millennium Development Goal 5 (MDG5). We seek to promote them by illustrating their use, while questioning current formulations.

Methods We examined indicator inconsistencies due to different metrics (per birth and per population) and to different assumptions (on facility size and need) and examined their association with maternal mortality. We then compared national and subnational density of health facilities, EmOC facilities and health professionals against current benchmarks for a high maternal mortality setting (Zambia) and a low one (Sri Lanka). For Zambia, we also examined geographic accessibility by linking health facility data to population data.

The currently used formulation of EmOC facilities per population is not associated with maternal mortality. The UN guidelines require fewer EmOC facilities than the World Health Report (WHR) 2005, and do not specify capacity for deliveries or staffing levels. Both countries failed the WHR 2005 EmOC benchmarks and met (or almost met) the UN ones. In Zambia, the benchmarks for doctors and midwives were met overall, but distribution between provinces was highly unequal. Sri Lanka overshot the suggested benchmarks by three times for midwives and over 30 times for doctors. Geographic access in Zambia was poor; less than half of the population lived within 15 km of an EmOC facility.

Conclusion Current health-system output indicators and benchmarks on EmOC need revision to enhance consistency and discriminatory power, and should be adapted for different population densities. Subnational disaggregation and assessing geographic access can identify gaps in EmOC provision and should be routinely considered. Increased use of an improved set of output indicators is crucial for guiding international efforts towards MDG5.

Introduction Alterations of blood glucose homeostasis are common in critically ill children but may remain undetected in tropical health facilities . Hypoglycaemia is a well known feature of severe malaria associated with poor prognosis. Emerging evidence suggests that sublingual sugar is a feasible and effective therapy for correction of hypoglycemia in children, and should be considered where intravenous glucose is delayed or impossible. Hyperglycaemia prevalence and prognosis had rarely been assessed in the tropics. The Integrated Management of Childhood Illness (IMCI) is a decision algorithm that helps performing a triage of illchildren. We assessed the prevalence of alterations of glycemia homeostasis at admission of children in a paediatric university hospital in Madagascar and measured the outcome related to IMCI severity.

Methods All children (1 months-15 years of age) admitted to the paediatric service were eligible from March to June 2010. After informed consent 0.6 ml of blood was collected once through finger prick to measure the blood glucose concentration (Accu-Check Ò Performa glucometers, Roche laboratory). Children were classified into four blood glucose categories and IMCI classification.

Of 420 children, 48.1% were severely ill, 3.1% had severe hypoglycemia, 20% moderate, 65.9% normoglycaemia, 10.9% hyperglycemia. Of the 28 children who died, 60.7% had glycemic dysregulation (OR: 3.2, 95% CI 1.3-7.9). Children with hypoglycaemia had the highest risk of death (OR13.0, 95% CI: 3.5-43.7), but hyperglycemia children had a non-negligible risk of death compared to euglycemic children (OR: 3.6, 95% CI: 1-11.3).

Conclusion Hypoglycaemia but also hyperglycemia are asso- Objective Our objective was to evaluate the HBV immunization coverage and its impact on the HBV infection in hospitalized children between 4 months and 6 years of age. Sera were systematically tested for anti-HBs and anti-HBc, and for AgHBs and HBV-DNA in case of anti-HBs) /anti-HBc+. Anti-HBs as single marker 10 mIU/ml) was considered a marker of efficient vaccination. Anti-HBc+ after 18 months of age was considered reflective of HBV exposure.

Results Among the 1759 children recruited, overall vaccine coverage was 53%. Cameroon presented significantly higher coverage (73%) than CAR (17%) and Senegal (54%). Among vaccinated children, only 64% had anti-HBs+ in Senegal compared to 90% in Cameroon (P < 0.001), and the proportion of responders in Senegal varied significantly over time (43% in 2006-2007, 73% in 2008-2009 (P < 0.001)). A high rate of HBV exposure was found in CAR (27%) compared to Cameroon (9%) and Senegal (14%). CAR showed the highest level of HBV infection (5%) in comparison with Cameroon (0.7%) and Senegal (0.2%).

Conclusion Five years after the integration of HBV vaccine in EPI, we found that the proportion of children with HBV exposure or infection was significantly lower in Cameroon and Senegal than in CAR. Nevertheless, HBV immunization coverage still remains insufficient in Cameroon and in Senegal, and response to vaccination has fluctuated dramatically over time in Senegal. Although our results indicate HBV vaccine's positive impact, they highlight the necessity of strengthening the EPI program and monitoring vaccination quality.

Introduction Global Fund-supported HIV/AIDS and malaria programs in low and middle-income countries delivered 160 million insecticide-treated bednets, 170 million malaria treatments, 1 million courses of antiretroviral prophylaxis to prevent motherto-child transmission of HIV and several other services benefiting child health. Conclusions Global Fund HIV and malaria financing is associated with increasing progress towards MDG 4, but ongoing declines are not sufficient to achieve MDG 4 by 2015. Improved malaria and HIV control will contribute to accelerate child survival gains, but overall progress will likely depend on strengthening maternal, neonatal and child care, and health systems in general. in DRC reveal the importance of considering past gaps and weaknesses in immunization activities (EPI, SIAs) in planning outbreak response strategies. The different age distribution of measles cases in these settings shows two different dynamics. In Malawi, a majority of cases were above 5 years (58%) indicative of a longstanding immunization programme, while in DRC the overwhelming majority of cases are among children aged <5 years.

To respond to outbreaks effectively, it is essential to consider local epidemiology to tailor the response strategy. The age distribution in cases should be part of the risk assessment in the planning stage to guide resource allocation for supplemental vaccination activities. In contexts like DRC, where measles is endemic, vaccination should aim to reach the most highly affected age groups as a priority. In contexts like Malawi, with a wide age-range of cases, the vaccination response should consider both local epidemiology and national level needs as reducing transmission requires a comprehensive country-wide approach.

Introduction For prevention of mother-to-child-transmission (PMTCT) of HIV-1, national Tanzanian guidelines recommend combination prophylaxis including zidovudine (AZT) monotherapy during pregnancy in addition to single-dosed nevirapine at labor onset and 1-4 weeks postpartum AZT/lamivudine. As drug toxicities in infants pose a relevant concern, we assessed hematological alterations in AZT-exposed infants.

Methods and Materials A cohort of infants born to HIV-1 positive women having received antenatal AZT 4 weeks (n= 43, group 1), and infants whose mothers did not utilize PMTCT services and thus had not taken antenatal AZT (n= 62, group 2) was established at Kyela District Hospital, Tanzania. According to Tanzanian guidelines, infants of group 1 received AZT for 1 week postpartum whereas infants of group 2 were given a prolonged 4-week AZT tail. Complete blood counts were evaluated at birth, week 4-6 and week 12.

Results At birth, group 1 infants with prenatal AZT exposure showed significantly lower mean hemoglobin (13.2 vs. 15.0 g/dl, P < 0.001 t-test) and red blood count (3.7 vs. 4.5, P < 0.001 t-test) levels than group 2 infants. At birth, frequency of anaemia (45% group 1 vs. 14% group 2, P = 0.002 Fischer's exact test) and neutropenia (53% group 1 vs. 30% group 2, P < 0.05 Fischer's exact test) was higher in infants with antenatal AZT-exposure. However, 4-6 weeks after birth, mean neutrophil granulocyte counts were lower in group 2 infants with prolonged postpartum AZT intake (2.1 vs. 3.3/mm 3 in group 1, P < 0.01 t-test) and neutropenia was more frequent in group 2 infants (33% vs. 12% in group 1; P = 0.06 Fischer's exact test). Twelve weeks after birth, no haematological differences between the 2 groups could be observed.

Conclusions AZT-exposure during and after pregnancy entailed significant haematological alterations in infants. Further research involving larger cohorts is needed to further analyse the impact of AZT-containing regimens on infant health outcomes.

Introduction Bangladesh now has 5.7 million people living in urban slums and the number will grow rapidly . Slums are characterized by adverse living conditions, inadequate healthcare services, and poor health outcomes. In an attempt to ensure safe maternal, neonatal and child health services for the slum dwellers BRAC started a programme, known as MANOSHI, in 2007 with an aim to cover all the slums in Bangladesh by 2012. The programme was supported by research to make the service effective and the experience reproducible. This paper reports the causes of maternal and neonatal deaths and discusses the implications for service delivery programmes as that of MANOSHI. 

Maternal anaemia at first antenatal visit: prevalence and aetiology in a West African malaria endemic area Introduction Anaemia in pregnancy remains a public health concern in developing countries . This multifactorial syndrome involves micronutrient deficiencies, infections and hemoglobinopathies although their respective contributions are unclear. In this study, we investigated the relationship between micronutrients, mainly iron, and maternal anaemia in Beninese pregnant women, before the administration of haematinics or antimalarials.

Material and Methods Study design: A cross-sectional survey was carried out at enrolment from January 2010 to May 2011 as part of a cohort study of pregnant women and their babies to assess the aetiologies of anaemia in pregnancy and its consequences in infants up to the age of 1 year. This cohort survey is an ancillary study to a multi-centre randomized trial of IPTp (MiPPAD) procedures: For each participant, socio-socioeconomic and demographic data, parity, gestational age, anthropometric measurements and medical history were recorded. Malaria, iron, folate and vitamin B12 deficiencies, inflammation, syphilis, hemoglobin rate and genotype, HIV status and intestinal helminths were also checked. Statistical analysis: multiple logistic regression was used to study the relationships between anaemia and risk factors. A P value £ 0.05 was considered statistically significant. Results Antibody responses were detected to all P. falciparum

and P. vivax antigens tested. In general, levels of antibodies were greater in non-pregnant women compared to pregnant women, except in the case of three vir genes. Preliminary analyses indicate that parity or age may not affect the magnitude of antibody responses, neither at recruitment nor at delivery. The association between levels of IgG against P. falciparum and P. vivax and anemia or infant birth weight, adjusting for confounding variables like infection status, parity and age, will be presented.

Conclusions Women in PNG have high levels of antibodies against most P. falciparum and P. vivax antigens tested, including five vir proteins with unknown function. Pregnancy appears to affect the magnitude of response to Plasmodium parasites in adult women exposed to malaria infection since birth. Further statistical analysis is ongoing to determine the association between antibody responses and poor delivery outcomes.

Consequence of malaria during pregnancy on immunological responses of the newborn: a study of regulatory t cells belonging to the natural pool of CD25+ CD4+ T cells play a major role in the maintenance of peripheral tolerance to self-antigens, and in the regulation of adaptive and innate immune responses against pathogens by controlling inflammatory responses and lymphocyte homeostasis. Treg are characterized by the phenotype CD4+ CD25+ CD127) Foxp3+. Treg prevalence was observed to be higher in cord blood from a P. falciparum infected placenta, compared to uninfected placenta, with an effect on cellular immune responses, suggesting in utero stimulation on Treg by soluble P. falciparum antigens with altered pro-inflammatory responses. Our objective is to evaluate the impact of malaria during pregnancy and during the first year of life on the profile of Treg at birth, and at 3, 6 and 12 month of age. Our hypothesis is that in utero contact with P. falciparum soluble antigens may modify the profile of Treg and we questioned the consequences of those changes on outcomes of infection during the first year of life. This study is part of the STOPPAM project that conducted a clinical and parasitological follow up of 1000 women during pregnancy and 200 infants during the first year of life in Comé, southwestern Benin. Immunophenotyping of Treg cells has been evaluated using flow cytometry in 200 infants in cord blood and again in peripheral blood at 3, 6 and 12 months of age in 200 neonates from mothers with different malaria histories during prengancy. Statistical analysis is on going and results will be presented.

Keywords Regulatory T cell, P. falciparum, newborn, proinflammatory responses

Introduction Plasmodium falciparum (Pf) infection in pregnancy can lead to congenital malaria which has detrimental health consequences for the infant. We hypothesized that HIV might increase congenital malaria by decreasing maternal antibodies specific for Pf. Conclusions This study shows that HIV-infected women can transmit Pf to their babies more frequently than uninfected women due to impairment of antibody responses by viral infection. Results Antibody levels were significantly affected by exposure to Pf, age, season and neighbourhood of residence, and in general were not associated with reduced malaria incidence, except for anti-EBA-175 IgG in year 2. Antigen-specific TH1 (IL-2, IL-12, IFN-) and TH2 (IL-4, IL-5) cytokines were significantly lower at 24 months in children receiving chemoprofilaxis during the first year compared to control; this was not observed for proinflammatory or immunoregulatory cytokines, or at any other time point.

Conclusions Overall, antibodies were markers of Pf exposure rather than protection. Different Pf exposure in the first 10 months resulted in a different pattern of cytokines at age 2 years, which appears to be an inflexion point in the acquisition on immunity.

Background The association between placental malaria (PM) and first peripheral parasitemias in early infancy was assessed in Tori Bossito, a rural area of Benin with careful assessment of transmission factors at an individual level.

Methodology Statistical analysis was performed on 550 infants followed weekly from birth to 12 months. Malaria transmission was assessed by Anopheles human landing catches every 6 weeks in 36 sampling houses and season defined by rainfall. Each child was located by GPS and assigned to the closest Anopheles sampling house. Data were analysed by survival Cox models, stratified on the possession of insecticide-treated mosquito nets (ITNs) at enrolment.

Principal Findings Among infants sleeping in a house with an ITN, PM was found to be highly associated to first malaria infections, after adjusting on season, number of anopheles, antenatal care (ANC) visits and maternal severe anaemia. Infants born from a malaria infected placenta had a 2.13 fold increased risk to present a first malaria infection than those born from a non infected placenta [(1.24-3.67), P < 10-2] when sleeping in a house with an ITN. The risk to present a first malaria infection was increased by 3.2-6.5, according to the level of Anopheles exposure (moderate or high levels, compared to the absence of Anopheles). Methods Of 272 Mozambican women participating in an intermittent preventive treatment in pregnancy (IPTp) trial with sulfadoxine-pyrimethamine (SP) were selected at delivery, based on the presence of real time PCR-detected infection in at least one of the two compartments (peripheral blood and/or placenta) (n= 122). A random selection of negative women was also included (n= 150). Infection was diagnosed by an histidine-rich protein 2 (HRP2)-based rapid diagnostic test (RDT), microscopy, placental histology and real time PCR. The use of RDT on plasma was validated by comparing its performance with the RDT on whole blood and with detection of HRP2 by ELISA.

The agreement between RDT and HRP2-ELISA performed in peripheral plasma was 90%, and reached 98% between RDTs in plasma and in whole blood. Sensitivities of PCR and RDT in periphery, using peripheral blood microscopy as reference standard, were 100% and 91%, and specificities 75% and 92%, respectively. Sensitivities of placental microscopy, placental PCR and peripheral RDT compared to placental histology were 67%, 89%, 78%, and specificities 97%, 75% and 93%, respectively. RDT on peripheral plasma misses 60% of the maternal infections detected by PCR. Women with PCR-detected infections but negative by optical examination had a higher risk of anemia than PCR-negative women.

Conclusions Microscopy, RDT and placental histology miss a significant proportion of infections detected by PCR. These undetected infections have a clinical impact in pregnant women, suggesting the necessity of more accurate methods to detect malaria in pregnancy. We previously demonstrated that current m-phones can be easily used, without any additional devices, to photograph from a microscope and send images via MMS to a reference center for a remote second opinion. We then tested the method in different conditions, including in Uganda and Bangladesh, in order to verify the easiness, as well as the feasibility and appropriateness of the approach in remote limited-resource settings, both for diagnostic and capacity-building purposes. The experience is comprehensively reviewed. Over the period 2009-2011, eighty individuals participated in the testing. In Italy, 20 randomly chosen people, completely foreign to microscopy where asked to take pictures on the sole basis of simple written instructions. In both Uganda and Bangladesh, a total of 60 health workers and laboratory technicians -all with very basic previous laboratory training -where involved through 'on the job' training. Only locally available materials and technology were used, including microscopes and mphones. With few standardized instructions all participants rapidly learned to use m-phones to take quality pictures from the microscope and send them via MMS. The possibility of jointly observing and discussing images of the microscopic field on the mphone screen and eventually on wider portable PC screen enhanced learning speed and health workers involvement and interest. Images shared on a web-based platform allowed distant diagnosis and both clinical and educational support from experts overseas, including timely response over SMS. Country-specific health system architecture, telecommunication protocols and distant support dynamics, represent determinants to be further studied for a wider scale implementation.

Impact of pocket-ultrasound in diagnosis and patient management at remote areas Background The focus on determinants of the quality of health services in low-income countries is increasing. Health workers' motivation has emerged as important in this context. The main objective of this article is to explore health workers' experience of working conditions, linked to motivation to work. Working conditions have been pointed out as a key factor in ensuring a motivated and well performing staff. The empirical focus is on rural public health services in Tanzania. The study aims to situate the results in a broader historical context in order to enhance our understanding of the health worker discourse on working conditions.

The study was qualitative to elicit detailed information on health workers' experience of their working conditions. Data comprise focus group discussions (FGDs) and in-depth interviews (IDIs) with administrators, clinicians and nursing staff in the public health services in a rural district in Tanzania. The study has an ethnographic backdrop based on earlier long-term fieldwork in the same part of Tanzania.

Results Experiences of unsatisfactory working conditions and a perceived lack of fundamental fairness dominated the FGDs and IDIs. Informants reported unfairness with reference to factors such as salary, promotion, recognition of work experience, allocation of allowances and access to training as well as to human resource management. The study also revealed that many health workers lack information or knowledge about factors that influence their working conditions.

Our results call for attention to the importance of locating the discourse of unfairness of working conditions in a broader historical/political context. Such a historic contextualisation enhances our understanding of the strong sentiments of unfairness revealed in this study and assists us in considering potential ways forward. Methods and Materials A description of the process of policy change is made, with identification of key elements and moments, organisational changes required, operational consequences and impact on interventions and health status. During the eighties and nineties, co-payment was accepted in most public health services supported by MSF, if certain pre-conditions and implementation modalities to assure equitable access were present. After increasing problem reporting in terms of accessibility, affordability and perverse effects on quality of care, a policy change was formalised in 2003. This policy paper stated the abolition of direct patient payments in all MSF supported health care.

The following tools proved useful in the process:

Systematic review of accessibility situation in MSF supported health services to obtain an objective measure of the degree of problems, practical support during implementation in terms of organisation and planning of additional resources; monitoring tools were provided; intensive briefings and discussions were conducted to obtain organisational buy in at all levels. At project and country level, briefs and scientific literature were provided for use with health authorities and other organisations. Lessons learned from the process: Population based measurement of access was key to obtaining a realistic perspective of access, as the only way to measure non-use of available health services. The usual classification based on crisis situation showed its limitations. Postconflict contexts showed prolonged high mortality and financial access problems, but so called 'stable' areas, without any history of conflict were revealed as equally bad under five mortality indicators. Many assessments focus on affordability of care in terms of willingness to pay or avoiding catastrophic health expenses. MSF's experience showed the importance of exclusion/ deterrence from utilisation and the important financial obstacles linked to relatively small fees for primary health care. Increased utilisation rates allowed better assessment of the real disease burden in the community. Several population assessments postabolition of user fees show a significant reduction in general and child mortality.

Conclusions For international organisations that support existing public health services, assurance of financial access is crucial, as it is key to reach those people most in need of care. Without this, additional resources mobilised by or through the organisation, are trapped in inaccessible health facilities, channelled to the better off. For reasons of medical quality, effectiveness at population level and accountability, abolition of user fees is an important policy decision for international health organisations. 

Of 312 (25%) of the 1244 individuals in the 408 families had experienced a health problem over the last month. Of 157 episodes were acute problems: mainly fever (36%), headache (36%), respiratory infection (31%), pain (19%) and diarrhea (11%). Of 155 were aggravations of chronic ailments: mainly hypertension (36%), asthma (25%), arthritis (16%) and diabetes (14%). Persons with acute and chronic problems, respectively, undertook the following actions (possibly combined): 5% and 7% do nothing, 38% and 39% self-medication, 42% and 32% consult the family doctor, 10% and 16% attend the policlinic, 24% and 26% go to hospital 73% and 65% of people with acute and chronic problems, respectively, consulted a health service. Patient flow analysis revealed that the family doctor was the entry point in 57% and 48%, respectively. Alternative entry points were (the emergency services of) the policlinic (13% and 20%) and the hospital (30% and 32% respectively).

The percentage of patients using the family doctor as the entry point to health care is relatively low.

Reinforcing the entry-point function of the first level of care could further strengthen continuity and comprehensiveness of care.

Introduction Aging of the population will be faster in Africa more than in the rest of the world . Africa will face aging before being rich. In that sense, aging will be a menace for African development. In Africa, the demographic transition is accompanied by the epidemiological transition, marked by chronicity of illness and increased functional disability in older people. This increase of dependents elders will occur in a context of inadequate health care system. So, it is imperative for Africa to prepare the management of this situation by preventing disability and organizing support to elderly. One of the conditions is to identify elders with disabilities. This is the objective of the study reported in this paper.

Methods This is a descriptive transversal study, which took place in Bobo-Dioulasso. We used a systematic random sample of elders. Each participant was interviewed using the questionnaire ''PRISMA7'' which identify elderly people with functional disability. To describe disabilities, elders who obtained 4 or more than 4 score with ''PRISMA7'' were interviewed with the questionnaire ''SMAF''. Data analysis was performed using Stata. The study protocol obtained the approval of the Burkina Faso National Ethics Committee for Health Research.

Results A sample of 362 people older than 60 year was interviewed. The demographic characteristics of respondents are similar to those of the elderly in urban areas of Burkina Faso or the population of Bobo-Dioulasso. The prevalence of functional disability (measured by PRISMA7) was estimated at 42%. This proportion varied between 23% for mobility, to 41% for activities of daily living. The SMAF score mean is 20% and 60% of these people had a moderate or severe disability.

Conclusion These Results show that in Burkina Faso, many older people (42%) live with at least one type of disability and that the majority of them (60%) presented moderate or severe disabilities. It is time that Africa begin to improve its social and health policy for the prevention and treatment of these disabilities. Objectives To draft a conceptual model that includes the specific political, social and cultural determinants in the framework of the new health care model that would recognize dying as a life stage and communitarian based palliative care as a feasible strategy to diminish suffering. To discuss the notion of 'environments of care' as social support model that involves community, health providers and decision makers and propose global strategies that could be adapted locally in order to go from the discourse into the practice. To analyze how this approach could transform the medical training system from a 'technology' paradigm to a 'person focus' paradigm.

Methods Conceptual analysis of a social model.

Several aspects have to be taken in account in order to draft a prescriptive social support model that aims to diminish collective suffering and empower communities to care for their own members in dying, death and bereavement issues. Global primary health care and health promotion values should be discussed in the local context in order to suit the specific needs and to create 'environments of care' that shorten the gap between the needs of the population, the offering services and the perception of professionals. The ideology, understood as a system of ideas and values among physicians, plays an important role in the understanding of suffering, the Introduction Access to health care is low in developing countries. Poor people are less likely to seek care than those who are better off . Community-based health insurance (CBI) aims to improve health care utilization by removing financial barriers. The objective is to describe the changes in utilization of health services that occurred among the poor after enrolment to health insurance and associated factors.

Methods Community-based insurance has been offered to a district in Burkina Faso, comprising 74 000 people who lived in 41 villages and the district capital of Nouna since 2004. Community self assessment of poverty was used to identify the poorest quintile of households who were subsequently offered insurance at half the usual premium rate. Utilization was compared in the different groups using households' panel data and CBI's registers in the health facilities. The probability of choice of health care provider was assessed using multinomial logistic regression.

Results Among the poorest, the annual enrolment increased Conclusion Benefits of CBI are not equally enjoyed by all socioeconomic groups, there is first a need to subsidize the premium to favour the enrolment of the very poor but measures are also needed to maximize the population's capacity to enjoy the benefits of insurance once insured. Patient empowerment and information about health and their rights are particularly needed. Conclusions Changes of NCMS increased the service utilization generally. Inpatient service utilization increased, while outpatient care played a lesser role for improving access. A balance between outpatient care and inpatient benefit is needed.

Regional platform to reinforce capacity for clinical trials in human african trypanosomiasis (hat platform): 5 years contributing to improved research With the main objective of building capacity and improving methodologies for research in HAT endemic countries, the specific objectives are to develop appropriate methods for HAT Clinical trials; overcome administrative and regulatory barriers; reinforce clinical research capacities (human resources, infrastructure, and material); exchange information and support communication among endemic countries. Since its inception, the HAT platform has organized several Ethic Committees' training for member countries (140 participants), as well as Clinical Monitors training (13 participants), training for doctors and lab technicians (25 participants), and training in pharmacovigilance (40 participants). The HAT Platform held five scientific meetings (the last one together with EANETT, an East African Platform) and published eight newsletters. The HAT Platform was a key element in the support of three clinical trials: NECT, DB289, and NECT Field. The dynamics and synergy created among the members brings an opportunity to improve and simplify research in the most endemic countries, saving efforts, time, and energy to all research institutions acting in clinical research for human African trypanosomiasis and supporting the long-term WHO goal of disease control and elimination.

Global access to care for women and children

Brief Introduction Access to high quality health services is essential for youth. The formal system is often not geared to respond to the special needs of adolescents particularly on sexuality matters. Even though Adolescent Friendly Health Services (AFHS) were developed at 700 sub-districts, evidence suggests that when in need, most adolescents do not seek care from AFHS. Lack of confidentiality was one of important underlying reason.

The study used qualitative methods whose objective is to gain deep information on confidentiality at Adolescent Friendly Health Services (AFHS).

Material This study involved Adolescent who had been treated in AFHS as informants. Providers and policy makers were key informants in Primary Health Care 'Y' and 'X' South Jakarta in 2009.

Results AFHS was not as friendly as its name. The schedules of AFHS were unfriendly, being open when young people were supposed to be in school. Services did not have special rooms for AFHS, which is one of elements to make the services more confidential. No special training was provided to improve skill and knowledge for health facility staff before implementation of AFHS. There was a gap on perception and definition of confidentiality between adolescents, provider and policy officers.

The standard and implementation of confidentiality at AFHS differed widely. Periodical monitoring and evaluation and confidentiality training for AFHS workers are needed. A standard of services including ethics and attitude on AFHS services, and a more suitable time schedule for adolescents must be established.

What are the challenges for European networks in pre and post travel medicine?

Analysing health systems to make them stronger The attention for Health Systems Strengthening (HSS) has reemerged in the frontlines of global debate. Views continue to evolve, both in reaction to transitions in the world and inspired by new contacts and fresh ideas. We present a framework for description and analysis on health systems development. We followed a consultative process that consisted of a literature review on models and frameworks on HSs and HSS and consecutive discussions with health systems' experts. The editorial team wrote out the paper's drafts, which were circulated for comments, before finalizing it. The framework developed is useful for the analysis of any Health System at national, intermediate or local level and can be loaded with specific values and principles and contribute to strategic action. The framework includes the six basic building blocks of the WHO health systems framework, but goes beyond them by stressing four issues: (i) a focus on outcomes and goals; (ii) the importance of underlying values and principles; (iii) service delivery as the core building block, which needs unpacking (not a black box); and (iv) health systems interactions with the population and with the specific contexts in which they are embedded. HSS starts from an understanding of the health systems reality. It involves a root cause analysis of problems and an analysis of the power and interests of important actors in relation to the issues at stake. Guiding principles for HSS are: (i) strengthen the most important capacities first, these being governance, the health workforce component and service delivery; (ii) coordination of efforts based on a coherent policy and long-term view, linked with goals and values; (iii) recognition of the need for continuity in time and creation of structures to ensure institutionalisation of processes; (iv) alignment and coordination through dialogue and other steering mechanisms; and (v) continuous interaction with and adaptation to context. Results Participation rate was 38.0%. 11.8% had been resident for <3 years, 32.9% for ‡3-5.9 years, and 55.3% for ‡6 years. As migrants live in Catalonia for longer, they are more likely to be married [P-value for trend (P) = 0.0004], economically active (P = 0.03), have an employment contract (P < 0.001), have permanent residence status (P < 0.001) and be registered in the National Health Service (P = 0.0004). They were significantly more likely to report poor general health (P = 0.007), insomnia (P = 0.04), depression (P = 0.009), and consume psychiatric drugs (P = 0.007). These associations remained significant after adjusting by sex, age and country of origin. Length of residence was not associated with tobacco (P = 0.99), alcohol (P = 0.62) or drug consumption (P= 0.76), ever having been tested for HIV (P= 0.69) and ever having had a cytology (P= 0.76).

The linear trend in improving socio-economic circumstances for migrants does not parallel a better health outcome or changes in health behaviour. We cannot rule out the possibility that migrants may be using health services more frequently, increasing the likelihood that conditions affecting their self-reported health status are diagnosed. However, results for screening services use seem to be inconsistent with this hypothesis and suggest that migrants' need for preventive healthcare may be unmet. Cultural perception of illness and high expectations of the health system may also have an influence in self-reported health.

Severe acute maternal morbidity (SAMM) among migrant women in Germany Background In previous studies on severe acute maternal morbidity (SAMM) in several Western countries migrant women were at high risk for these conditions. The objective of our study was to compare the risks of SAMM between migrant women and German women, adjusting for socio-demographic, behavioral and health-related confounders.

We conducted a retrospective cohort study using data from maternity wards in Lower Saxony, Germany. We analyzed perinatal data of n= 441,199 mothers who had singletons in 2001-2007 collected prospectively during pregnancy and up to 7 days post partum. We ran chi-squared tests, bivariate and multivariable logistic regression analyses. The outcome measures were unplanned peripartal hysterectomy, hemorrhage <1000 ml, eclampsia and sepsis. We treated maternal age, parity, occupational and marital status, smoking, obesity, adequacy of prenatal care, status after assisted infertility treatment and chronic conditions as potential confounders. Conclusion Marked disparities in maternal morbidity among women of different heritages were confirmed in this sample from Germany. The sociodemographic, behavioral and health-related confounders we examined mostly did not explain these observed inequalities. Monitoring maternal morbidity among migrant women is an important task and is a key to improving maternal health. A multidisciplinary approach is required to further our understanding of migrant women's health care needs. The screening test included complete red blood cell examination. At that time, pediatricians were alerted to a possible high risk of rickets in those children, and recommendations about prevention were made. We evaluated the evolution of the number of cases detected in the last 8 years.

Of 34/147 children had abnormal biochemical results suggestive of rickets (23%). After careful physical and X-ray examination, 14 (9.5%) were finally diagnosed with nutritional rickets, and 20 children (13.6%) with abnormal blood results alone were classified as having subclinical rickets. Adding the 11 cases previously detected, clinical and biochemical findings of the whole 25-case rickets group (A) are described, and compared to the group of 20 subclinical rickets cases (B) and to those 113 with normal Ca-P results (C). Sixty eight per cent of rachytic patients showed ferropenic anemia. The number of rickets decreased 50% between the two halves of the last 8-year period.

Conclusions Nutritional rickets is prevalent in children and adolescents of migrant families, and appears in different forms including a subclinical form which should be looked for especially in black breast fed infants. In our environment, making paediatricians aware of preventive measures has been weakly effective for the last 8 years, as rickets has still been diagnosed, though less often. 

Brazil; 3 Programa de Computaçã o Científica-PROCC/FIO-CRUZ, Rio de Janeiro-Brazil; 4 Instituto de Pesquisa Clínica Evabdro Chagas-IPEC/FIOCRUZ, Rio de Janeiro-Brazil; 5 Laborató rio de Imunologia Viral-IOC/FIOCRUZ

Hospital Clinic/Institut d'Investigacions Biomèdiques August Pi i Sunyer

Alonso 1,2 and J. Ruiz 1 1 CRESIB

Medical Mission Institute, Wuerzburg, Germany; 6 Goettingen International Health Network, Germany Prevalence and prognosis of blood glucose homeostasis alterations in critically ill children in tropical settings H

Institut de Recherche pour le Developpement (IRD)

Centro International de Vacunas (CIV)/Instituto de Inmunología, Calí, Colombia

Alonso 1,2 1 Centre de Recerca en Salut Internacional de Barcelona (CRESIB), Hospital Clínic

Faculté de Pharmacie

UMR204 IRD/Montpellier1/Montpellier2/Sup-Agro, Prévention des malnutritions et des pathologies associees Simulation of running cost needs for a rural district hospital in DRC: based on real life cost data

Vos 3 and P. Van der Stuyft 3 1 National Institute of Hygiene

Epidemiology and Disease Control Unit, Public Health Department

Association Sida Ka Taa

Belgique interiorization of death and their relationship to patients with terminal illnesses and their families

Changes in utilization of health services among the poor: is health insurance benefitting the poorest households?

Sie 2 and R. Sauerborn 1 1 Institute of Public Health

Burkina Faso Confidentiality on adolescent-friendly reproductive health services: a challenge in Indonesia J

Bisoffi 1 1 Centre for Tropical Diseases

Introduction Chagas disease (CD) and strongyloidosis (S) are , without age restriction. Diagnosis of CD was based on positivity of two tests: recombinant ELISA (BIOELISA Ò , Biokit) plus either an immune-chromatographic test (Rapid Test Chagas Ò , Cypress) or a crude-antigen ELISA (Test ELISA Chagas III Ò ; BioChile). S was diagnosed with an in-house IFAT, 97

Patients proceeded mainly from Cochabamba department (61.3%), followed by Santa Cruz (17.1%) and Chuquisaca (7.7%). Overall prevalence for CD and S was 25

Senperforto: determinants for effective prevention and response actions of SGBV perpetration and victimization in the European asylum reception system

Greek Refugee Council; 3 Jesuit Refugee Service for Malta; 4 ICRH

The global challenge of Influenza pandemics Monitoring of human influenza virus activity in northeast India with a focus on Pandemic H1N1/2009

Introduction Low birth weight (LBW) prevalence is high in low-income countries. Although economic evaluations of interventions to reduce this burden are of critical relevance to guide health policies, there is insufficient information on costs associated with LBW. This study aims to estimate household and health system costs, and Disability Adjusted Life Years (DALYs) arising from infant deaths associated with LBW death in Southern Mozambique.

Costs incurred by the households were collected through exit surveys. Health system costs were obtained from published information in addition to data obtained onsite. DALYs due to death of LBW babies were based on local estimates of prevalence of LBW (12%), very low birth weight (VLBW) (1%) and of case fatality rate for LBW (15%) and VLBW (80%). Costs associated with LBW excess morbidity were calculated on the incremental number of hospital admissions between LBW and normal weight babies.

costs for routine health care were 24.12 US$ (CI 95% 21.51; 26.26). An increase in birth weight of 100 g would lead to a 53% decrease in these costs. Direct and indirect household costs for hospital admissions were 8.50 US$ (CI 95% 6.33; 10.72). Health system costs (routine health care and excess morbidity) and DALYs per 3322 live births occurred in the area in 1 year at the time of the study were 169 957.61 US$ (CI 95% 144 900.00; 195 500.00) and 2746.06, respectively. This first economic evaluation of LBW in a low-income country shows that reducing the prevalence of LBW would translate into important cost savings to the health system and the household. These results are of relevance for similar settings and should serve to promote interventions aimed at improving maternal care.Hematological changes in infants exposed to AZT-containing prophylaxis for prevention of mother-to-child-transmission of HIV-1 in Tanzania Characterization of the factors linked to the higher susceptibility of newborns to P. falciparum infection is a priority for the validation of any anti-malarial . Regulatory T cells (Treg) Conclusions We found a high prevalence of CD and S in the Bolivian community screened. Difficult access to diagnosis and scarce awareness of these NTDs contribute to potential underestimation of their burden. Our estimate of the magnitude of the two NTDs in a targeted population showed relevant data for public health control and health resource planning. 

Network component to take part in various research activities on the basis of specific responsibilities; different structures (research institutes, government institutions, public buildings, non-governmental organization, voluntary associations) and the intervention area within which the professional is committed (prevention, diagnosis, treatment and care).

The Italian NFP interdisciplinary collaboration has been working in the following areas: psycho-social characteristics and behavior of migrants with a diagnosis of HIV infection; HIV/AIDS counselling in a cross-cultural context; definition of an operational model for the communication of the diagnosis and care of immigrants with infectious disease. The results from the different project areas have highlighted the need to both monitor and study the migrant population health determinants in the specific field of infectious diseases. Data have also shown how to protect the health of migrants through the establishment of an effective working and human relationship with those people coming from different cultural realities. The work done by the Italian NFP and the practical partnerships between the different professionals has led to the development of different targeted interventions and health promotion actions for a population which is characterized by heterogeneous areas of origin, multiple motivational forces behind any personal migration project, social and personal characteristics and different legal status.Oral communications on global migration, conflicts and population health Health status, health behaviour and healthcare use according to length of residence among migrants in Catalonia Sexual and gender-based violence (SGBV) is a global public health issue and a violation of human rights. Although asylum seekers are considered as particularly vulnerable, so far no cross-national studies assessed the patterns between SGBV experience and prevention knowledge, attitudes, practices and needs within the European reception system. Hence, this study explores which determinants in SGBV perpetration and victimization within the EU reception system are decisive for 'desirable prevention'. Applying community-based participatory research from a socioecological perspective; 599 interviews were conducted with professionals working and residents staying at reception facilities in Belgium, Greece, Hungary, Ireland, Malta, the Netherlands, Portugal and Spain. They reported 660 violence cases in the year prior to the interview. SPSS and R were used for analysis of quantitative data. Our results indicate that both professionals and residents are vulnerable to victimization and/or perpetration of psychological (n= 362) as well as sexual violence (n= 68) regardless of age, sex or residence status. Undocumented migrants are more likely to be victimized physically compared to others (OR 2.23; P< 0.012). Young age (<30 years) (OR 1.90; P< 0.001) and being a close peer of the victim (OR 1.93; P < 0.0304) are associated to higher probabilities of perpetrating physical violence (n= 359). Finally, perpetration of socio-economical violence (n= 68) is linked to older age (>30: OR 3.8; P< 0.001), to group aggression (OR: 2.55; P< 0.001) and to be committed by national citizens (OR: 14; P< 0.001). Thus, in order to be effective, it is paramount for SGBV prevention and response actions within the European reception sector, to mainstream for sexual and psychological violence. However, as for physical and socio-economical violence it is a prerequisite to differentiate according to age, residence status and social network. In support of this, the Senperforto project group developed a Frame of Reference on SGBV prevention and response for the European asylum and reception sector.Equitable access to quality maternal and child health care: an external evaluation for a pilot project to deliver a new service model for rural-to-urban migrants in three districts of China Methods An external evaluation of the project was conducted to understand its implementation and impact on policy, and to summarize the experience and benefit for rural-to-urban migrants. Of 85 stakeholders and actors were interviewed via in-depth interview or in focus group discussions.Results New MCH service models for rural-to-urban migrants were delivered in the project districts, including identification of previously unregistered pregnant women and children at community level through multi-sectoral efforts, referring them to health centers for registration, providing basic pre-natal or child health care at a discounted rate, subsidising institutional childbirth for the poor and free post-natal care visits. The project drove a transition from awareness to action among the local government and health providers. Consequently, multi-sectoral cooperation and an information sharing mechanism was established; a migrant MCH service package was developed and implemented; the medical financial aid was made available to migrants and clinical outcomes improved. An emergency referral system was established. The project also raised the awareness and motivation of the migrants to use and improved uptake of MCH services through participatory communication. Moreover, project experience was scaled up province wide and adopted by province health bureau.Conclusions The new service model could improve rural-tourban migrants' equitable access to quality maternal and child health care.Screening of imported diseases among migrant populations: results from a tropical unit in Barcelona 

Of 927 immigrants were included in this study. Of 537 were male and 390 female. The median age was 34 years old (range 16-78 years old). The median time living in our country was 3.5 years (range 1 month to 30 years). Of 470 (50%) came from central and South America, 362 (39.1%) came from sub-Saharan Africa, 52 (5.6%) from Asia, 24 (2.6%) from Eastern Europe and 21 (2%) from Northern Africa. In most of the cases (55.1%) no diseases were found, and 87.9% of all diseases that were found were infections. Among sub-Saharan immigrants, 43.6% had latent tuberculosis infection, 14.9% were infected with Hepatitis B virus, 7.1% with Hepatitis C virus and 7.5% had latent syphilis. Among Latin-American immigrants 25% had Chagas disease, 22.5% had latent tuberculosis infection, 3% had latent syphilis and fewer than 3% were infected with Hepatitis B or C virus. Sixteen HIV infections were also diagnosed, 14 in sub Saharan immigrants and 2 in Latin-Americans. Hepatitis B infections, latent tuberculosis infection and syphilis were more prevalent in sub Saharan immigrants (P < 0.005).Conclusions The immigrant population faces health situations that are different from those of the general population. Incorporating screening strategies allows early diagnosis and treatment, avoiding the development of latent diseases with a bigger personal and macroeconomical cost.