Adequate ventilation can reduce the transmission of infection in health-care settings. Natural ventilation can be one of the effective environmental measures to reduce the risk of spread of infections in health care. This guideline first defines ventilation and then natural ventilation. It explores the design requirements for natural ventilation in the context of infection control, describing the basic principles of design, construction, operation and maintenance for an effective natural ventilation system to control infection in health-care settings.
Equitable health services
Natural ventilation for infection control in health-care settings
Atkinson J, Chartier Y, Pessoa-Silva CL, Jensen P, Li Y and Seto W: World Health Organization, 2009
Packages of care for alcohol use disorders in low- and middle-income countries
Benegal V, Chand PK and Obot IS: Public Library of Science Medicine 6(10), 27 October 2009
Alcohol use disorders (AUDs) – conditions that range from hazardous and harmful alcohol use to alcohol dependence – are a low priority in low- and middle-income countries (LMICs), despite causing a large health burden. Most alcohol-related harm is attributable to hazardous/harmful drinkers who make disproportionate use of primary health care systems, but often go undetected and untreated for long periods, even though brief, easily delivered interventions are effective in this group of people. Health care systems in LMICs currently focus on providing tertiary care services for the treatment of dependence (where there is often a poor outcome). This study indicates that the focus needs to shift towards the cost-effective strategy of providing brief interventions for early AUDs. Effective evidence-based combinations of psychosocial and pharmacological treatments for AUDs are available in LMICs but are costly to implement. Policy makers need to ensure that people with AUDs are offered the most appropriate services using stepped-care solutions that start with simple, structured advice for risky drinkers and progress to specialist treatment services for more serious AUDs. LMICs also need to improve their implementation of proven population-level preventive measures to reduce the health burden due to AUDs. An international Framework Convention on Alcohol Control may help them do this.
Packages of care for dementia in low- and middle-income countries
Prince MJ, Acosta D, Castro-Costa E, Jackson J and Shaji KS: Public Library of Science Medicine 6(11), 3 November 2009
Two-thirds of people with dementia live in low- and middle-income countries (LMICs), where there are few services available and levels of awareness and help-seeking are low. After early diagnosis, the principal goals for management of dementia are optimising physical health, cognition, activity, and wellbeing; detecting and treating behavioural and psychological symptoms (BPSD); and providing information and long-term support to carers. This study recommends that routine packages of continuing care should comprise diagnosis coupled with information, regular needs assessments, physical health checks, and carer support, and where necessary carer training, respite care, and assessment and treatment of BPSD. Care can be delivered by trained primary care teams working in a collaborative care framework. Continuing care with practice-based care coordination, and community outreach are essential components of this model. Efficient care delivery in LMICs involves integrating dementia care with that of other chronic diseases and community-support programmes for the elderly and disabled.
Packages of care for depression in low- and middle-income countries
Patel V, Simon G, Chowdhary N, Kaaya S and Araya R: Public Library of Science Medicine 6(10), 6 October 2009
Depression is clearly a global health priority. Improving the recognition of this disorder in clinical populations in LMICs is aided by the successful adaption of depression-screening instruments from HIC settings into settings with few resources and weaker health systems. This review suggests that evidence-based treatments such as antidepressants and psychotherapy are effective in managing depression; it is important, however, that such treatments are adapted when used in LMICs to increase their acceptability, accessibility, and manage their costs. The review proposes two packages of care on the basis of the availability of mental health specialist resources. The delivery of these treatments should ideally be carried out through an integration of depression programmes into existing health services or community settings with task-shifting to non-specialist health workers to deliver front-line care and a supervisory framework of appropriately skilled mental health workers.
Packages of care for schizophrenia in low- and middle-income countries
Mari JJ, Razzouk D, Thara R, Eaton J and Thornicroft G: Public Library of Science Medicine 6(10), 20 October 2009
It is estimated that about 41.7 million people need treatment for schizophrenia and related disorders in low- and middle-income countries (LMICs). The majority of these cases are concentrated in Asia (70%) and Africa (16%). In countries with low resources, general physicians and primary health care workers can be trained to recognise and treat people with psychotic disorders in the community. This study found that health systems can scale up such interventions across all routine-care settings by training general physicians and primary health care workers to recognise and treat clients with schizophrenia with effective, evidence-based interventions. In addition, first- and second-generation antipsychotics (FGAs and SGAs) are similarly effective in the acute treatment of psychotic symptoms. In addition, a number of trials have shown the efficacy of psycho-educational strategies to improve adherence to antipsychotics, to decrease relapse and readmission rates, and to have a positive impact in social functioning of family members and patients. The study recommends a package of care combining low doses of conventional antipsychotics along with brief and simple psycho-educational interventions as an important strategy to decrease the treatment gap for schizophrenia in LMICs. The combination of FGAs and psycho-educational interventions are more cost-effective than the use of drugs alone.
Preventive health services are the future, says South African health minister
Thom A: Health-e News, 10 March 2010
South Africa’s health minister, Dr Aaron Motsoaledi, is reported as having called for South Africa’s health system to make a 180 turn away from the dominant curative health system, which is unsustainable and unaffordable, to a health system where prevention is the cornerstone. This and the primary health care approach is argued by the Minister to make the national health insurance system an affordable option and to improve equity and universal coverage.
TB treatment initiation and adherence in a South African community influenced more by perceptions than by knowledge of tuberculosis
Cramm JM, Finkenflügel HJM, Møller V and Nieboer AP: BMC Public Health 10(72), 17 February 2010
This study investigated knowledge of, perceptions of and access to tuberculosis (TB) treatment and adherence to treatment among an Eastern Cape population in South Africa. An area-stratified sampling design was applied. A total of 1,020 households were selected randomly in proportion to the total number of households in each neighbourhood. It found TB knowledge was fairly good among this community. A full 95% of those interviewed believe people with TB tend to hide their TB status out of fear of what others may say and therefore may not seek treatment. Regression analyses revealed that in this population young and old, men and women and the lower and higher educated share the same attitudes and perceptions, suggesting that the findings are likely to reflect the actual situation of TB patients in the population. Future interventions should be directed at improving attitudes and perceptions to potentially reduce stigma. This requires a patient-centred approach to empower TB patients and their active involvement in the development and implementation of stigma reduction programmes.
Unplanned ART treatment interruptions in southern Africa: What can we do to minimise the long-term risks?
Veenstra N, Whiteside A, Gibbs A and Lalloo D: Health Economics and AIDS Research Division (HEARD), University of KwaZulu-Natal, 2010
Adherence to antiretroviral therapy (ART) is important to optimise treatment outcomes and prevent the development of drug resistance. It is however compromised under a number of situations in the countries most heavily affected by HIV and AIDS. The question this paper is concerned with is: ‘How do we keep people on treatment?’ It proposes that the answer to this question is an improved understanding of why adherence is important; what levels of adherence are needed to ensure that treatment remains effective; how different types of crisis affect access to treatment; and how patients and service providers respond to difficulties. The paper considers the longer-term impact of unplanned ART treatment interruptions and offers suggestions as to how they might be avoided and managed in future. It considers three case studies, by looking at the problems with health system functioning and ART delivery during the 2007 public sector strike in South Africa, the ongoing political and economic crisis in Zimbabwe and the 2008 floods in Mozambique. It is based on a literature review and a relatively small number of interviews with health managers and clinicians in each country.
Cervical cancer screening in Zambia saves lives
Plus News: 18 February 2010
Cervical cancer is a leading killer among women living with HIV, but a low-cost screening programme developed in Zambia is proving that simple techniques can go a long way in saving lives. New research presented at the 17th Conference on Retroviruses and Opportunistic Infections (CROI) in San Francisco has shown that cervical cancer screening among HIV-positive women prevented one death for every 32 women screened. The research originated from a pilot study of about 6,600 HIV-positive women examined as part of the Cervical Cancer Prevention Programme in Zambia (CCPPZ), an ongoing low-cost screening project. More than half the women had abnormal results, and about 20% were diagnosed as having lesions at varying stages from pre-cancerous to advanced cancer. Screening by the programme's service costs about US$1 as compared to pap smears that cost about $15 and remain prohibitively expensive even in richer countries like South Africa. To keep costs this low, the programme enables health workers and nurses to carry out screening and treatment, allowing doctors - already in short supply - to perform other tasks. The screening programme has also drawn interest from other countries, including Botswana, Tanzania and Cameroon, which have sent delegations for training.
Effect of human rotavirus vaccine on severe diarrhea in African infants
Madhi SA, Cunliffe NA, Steele D, Witte D, Kirsten M, Louw C, Ngwira B, Victor JC, Gillard PH, Cheuvart BB, Han HH and Neuzil KM: New England Journal of Medicine 362(4): 289–298, 28 January 2010
This study took the form of a randomised, placebo-controlled, multicenter trial in South Africa and Malawi to evaluate the efficacy of a live, oral rotavirus vaccine in preventing severe rotavirus gastroenteritis. A total of 4,939 infants were enrolled and randomly assigned to one of the three groups: 1,647 infants received two doses of the vaccine, 1,651 infants received three doses of the vaccine, and 1,641 received placebo. Of the 4,417 infants included in the per-protocol efficacy analysis, severe rotavirus gastroenteritis occurred in 4.9% of the infants in the placebo group and in 1.9% of those in the pooled vaccine group. Vaccine efficacy was lower in Malawi than in South Africa (49.4% vs. 76.9%); however, the number of episodes of severe rotavirus gastroenteritis that were prevented was greater in Malawi than in South Africa (6.7 vs. 4.2 cases prevented per 100 infants vaccinated per year). Efficacy against all-cause severe gastroenteritis was 30.2%. In conclusion, human rotavirus vaccine significantly reduced the incidence of severe rotavirus gastroenteritis among African infants during the first year of life.