Can estimates of antimalarial efficacy from field studies be improved?

Monitoring therapeutic efficacy of antimalarial drugs is important because treatment failure rates are the primary basis for changing antimalarial treatment policy. An important aspect of efficacy studies is the use of PCR genotyping to distinguish recrudescent from new infections. The conclusions reached using this technique might be misleading if there is insufficient parasite diversity or a non-uniform haplotype frequency distribution in the study area. Statistical techniques can be used to overcome this problem, but only when data describing the haplotype frequency distribution are available. Therefore, assessing haplotype frequency and distribution should form an integral part of all studies investigating the therapeutic efficacy of antimalarial treatment regimes.

Herpes simplex 2 risk among women in a polygynous setting in rural West Africa

OBJECTIVES: To determine risk factors for herpes simplex 2 (HSV2) infection in women in a polygynous rural Gambian population. METHODS: Data from women who participated in a cross-sectional survey of reproductive health were matched to their own and, for women who had been or were married (ever-married), their spouses' data collected in a cross-sectional survey of fertility interests, including information on marital histories. RESULTS: Data were available on 150 never-married and 525 ever-married women. HSV2 prevalence was 16% amongst never-married women and 36% amongst ever-married women. For ever-married women, their own personal characteristics (age, ethnicity and genital cutting status) and events from their husbands' marriage history were important determinants of HSV2 infection. Women whose husbands married for the first time over age 35 were at greater risk than women whose husbands married by age 24 [odds ratio (OR) 2.72, 95% confidence interval (CI) 1.20-6.10]. Women whose husband reported interest in a new marriage were more likely to be HSV2 positive (OR 1.91, 95% CI 1.18-3.09). Women whose husbands were currently monogamous but had had previous marriages (OR 2.76, 95% CI 1.30-5.88) and women in currently polygynous marriages (OR 2.88, 95% CI 1.66-5.01) were three times as likely to be HSV2 positive as women who were their husband's only wife ever. CONCLUSION: Much transmission of HSV2 in this setting occurs within marriage where opportunity for personal protection is limited. High levels of transmission within marriage may undermine the impact of sexual behaviour change programmes aiming to reduce HSV2 and HIV incidence and complicate their evaluation.

Systematic Review Protocol : "Are community-based interventions effective in identifying and responding to emerging zoonotic infectious diseases?"

Review question/objective The objective of this review is to identify the effectiveness of surveillance systems and community-based interventions in identifying and responding to emerging and re-emerging zoonotic infections in Southeast Asia (SE Asia). More specifically the research questions are: 1. What is the effectiveness of community-based surveillance interventions designed to identify emerging zoonotic infectious diseases? 2. What is the effectiveness of non-pharmaceutical community-based interventions designed to prevent transmission of emerging zoonotic infectious diseases? 3. How do factors related to the emergence and management of emerging zoonotic infectious diseases impact the effectiveness of interventions designed to identify and respond to them?

Slaving and release in co-infection control

Background Animal and human infection with multiple parasite species is the norm rather than the exception, and empirical studies and animal models have provided evidence for a diverse range of interactions among parasites. We demonstrate how an optimal control strategy should be tailored to the pathogen community and tempered by species-level knowledge of drug sensitivity with use of a simple epidemiological model of gastro-intestinal nematodes. Methods We construct a fully mechanistic model of macroparasite co-infection and use it to explore a range of control scenarios involving chemotherapy as well as improvements to sanitation. Results Scenarios are presented whereby control not only releases a more resistant parasite from antagonistic interactions, but risks increasing co-infection rates, exacerbating the burden of disease. In contrast, synergisms between species result in their becoming epidemiologically slaved within hosts, presenting a novel opportunity for controlling drug resistant parasites by targeting co-circulating species. Conclusions Understanding the effects on control of multi-parasite species interactions, and vice versa, is of increasing urgency in the advent of integrated mass intervention programmes.

Health education and the control of intestinal worm infections in China : a new vision

Background: The transmission of soil-transmitted helminths (STHs) is associated with poverty, poor hygiene behaviour, lack of clean water and inadequate waste disposal and sanitation. Periodic administration of benzimidazole drugs is the mainstay for global STH control but it does not prevent re-infection, and is unlikely to interrupt transmission as a stand-alone intervention. Findings: We reported recently on the development and successful testing in Hunan province, PR China, of a health education package to prevent STH infections in Han Chinese primary school students. We have recently commenced a new trial of the package in the ethnically diverse Xishuangbanna autonomous prefecture in Yunnan province and the approach is also being tested in West Africa, with further expansion into the Philippines in 2015. Conclusions: The work in China illustrates well the direct impact that health education can have in improving knowledge and awareness, and in changing hygiene behaviour. Further, it can provide insight into the public health outcomes of a multi-component integrated control program, where health education prevents re-infection and periodic drug treatment reduces prevalence and morbidity.

School based youth health nurses and attrition : the reasons for moving on

Like the UK, Australia has a number of school nursing models and programmes. The School Based Youth Health Nurse Program (SBYHNP) is a new and unique model of school nursing in Queensland, Australia. The SBYHNP represents a philosophical and structural shift from traditional school nursing programmes. The purpose of this qualitative case study is to explore the reasons School Based Youth Health Nurses (SBYHN) leave school nursing. Sixteen in-depth interviews were conducted with participants who practiced as SBYHN and left the SBYHNP. This case study reveals six themes: The politics’: Navigating the organisational divide, 'Unconditional positive regard’: Surviving without team cohesion, 'Absolutely exhausted’: Maintaining physical and emotional strength, ‘Definitely geographical’: Managing the tyranny of time and distance, ‘If things fell into place’: Thinking about what could have been, and ‘A stepping stone’: Moving on to the next nursing position. This case study suggests nurses considering school nursing as a specialty should seek opportunity to understand this complex role, ensure realistic expectations and ndertake relevant qualifications. This approach may secure the investment made by nurses and schools and create demand for a highly sort after position.

Abundance and prevalence of Aedes aegypti immatures and relationships with household water storage in rural areas in southern Viet Nam

Since 2000, the Government of Viet Nam has committed to provide rural communities with increased access to safe water through a variety of household water supply schemes (wells, ferrocement tanks and jars) and piped water schemes. One possible, unintended consequence of these schemes is the concomitant increase in water containers that may serve as habitats for dengue mosquito immatures, principally Aedes aegypti. To assess these possible impacts we undertook detailed household surveys of Ae. aegypti immatures, water storage containers and various socioeconomic factors in three rural communes in southern Viet Nam. Positive relationships between the numbers of household water storage containers and the prevalence and abundance of Ae. aegypti immatures were found. Overall, water storage containers accounted for 92–97% and 93–96% of the standing crops of III/IV instars and pupae, respectively. Interestingly, households with higher socioeconomic levels had significantly higher numbers of water storage containers and therefore greater risk of Ae. aegypti infestation. Even after provision of piped water to houses, householders continued to store water in containers and there was no observed decrease in water storage container abundance in these houses, compared to those that relied entirely on stored water. These findings highlight the householders’ concerns about the limited availability of water and their strong behavoural patterns associated with storage of water. We conclude that household water storage container availability is a major risk factor for infestation with Ae. aegypti immatures, and that recent investment in rural water supply infrastructure are unlikely to mitigate this risk, at least in the short term.

Prevalence and predictors of advance directives in Australia

Background Advance care planning is regarded as integral to better patient outcomes yet little is known about the prevalence of advance directives in Australia. Aims To determine the prevalence of advance directives (ADs) in the Australian population. Methods A national telephone survey about estate and advance planning. Sample was stratified by age (18-45 and >45 years) and quota sampling occurred based on population size in each State and Territory. Results Fourteen percent of the Australian population has an AD. There is State variation with people from South Australia and Queensland more likely to have an AD than people from other states. Will making and particularly completion of a financial enduring power of attorney are associated with higher rates of AD completion. Standard demographic variables were of limited use in predicting whether a person would have an AD. Conclusions Despite efforts to improve uptake of advance care planning (including ADs), barriers remain. One likely trigger for completing an AD and advance care planning is undertaking a wider future planning process (e.g. making a will or financial enduring power of attorney). This presents opportunities to increase advance care planning but steps are needed to ensure that planning which occurs outside the health system is sufficiently informed and supported by health information so that it is useful in the clinical setting. Variations by State could also suggest that redesign of regulatory frameworks (such as a user-friendly and well publicised form backed by statute) may help improve uptake of ADs.

Doctors' knowledge of the law on withholding and withdrawing life-sustaining medical treatment

Objectives To examine the level of knowledge of doctors about the law on withholding and withdrawing life-sustaining treatment from adults who lack decision-making capacity, and factors associated with a higher level of knowledge. Design, setting and participants Postal survey of all specialists in emergency medicine, geriatric medicine, intensive care, medical oncology, palliative medicine, renal medicine and respiratory medicine on the AMPCo Direct database in New South Wales, Victoria and Queensland. Survey initially posted to participants on 18 July 2012 and closed on 31 January 2013. Main outcome measures Medical specialists’ levels of knowledge about the law, based on their responses to two survey questions. Results Overall response rate was 32%. For the seven statements contained in the two questions about the law, the mean knowledge score was 3.26 out of 7. State and specialty were the strongest predictors of legal knowledge. Conclusions Among doctors who practise in the end-of-life field, there are some significant knowledge gaps about the law on withholding and withdrawing life-sustaining treatment from adults who lack decision-making capacity. Significant consequences for both patients and doctors can flow from a failure to comply with the law. Steps should be taken to improve doctors’ legal knowledge in this area and to harmonise the law across Australia.

Malaria rapid diagnostic test performance : results of WHO product testing of malaria RDTs : round 5 (2013)

WHO estimates that half the world’s population is at risk of malaria. In 2012, there were an estimated 207 million cases (with an uncertainty range of 135 million to 287 million) and an estimated 627 000 deaths (with an uncertainty range of 473 000 to 789 000). Approximately 90% of all malaria deaths occur in sub-Saharan Africa, and 77% occur in children under 5 years. Malaria remains endemic in 104 countries, and, while parasite-based diagnosis is increasing, most suspected cases of malaria are still not properly confirmed, resulting in over-use of antimalarial drugs and poor disease monitoring (1)...

Prevalence of asymptomatic malaria and bed net ownership and use in Bhutan, 2013 : a country earmarked for malaria elimination

Background With dwindling malaria cases in Bhutan in recent years, the government of Bhutan has made plans for malaria elimination by 2016. This study aimed to determine coverage, use and ownership of LLINs, as well as the prevalence of asymptomatic malaria at a single time-point, in four sub-districts of Bhutan. Methods A cross-sectional study was carried out in August 2013. Structured questionnaires were administered to a single respondent in each household (HH) in four sub-districts. Four members from 25 HH, randomly selected from each sub-district, were tested using rapid diagnostic tests (RDT) for asymptomatic Plasmodium falciparum and Plasmodium vivax infection. Multivariable logistic regression models were used to identify factors associated with LLIN use and maintenance. Results All blood samples from 380 participants tested negative for Plasmodium infections. A total of 1,223 HH (92.5% of total HH) were surveyed for LLIN coverage and use. Coverage of LLINs was 99.0% (1,203/1,223 HH). Factors associated with decreased odds of sleeping under a LLIN included: washing LLINs nine months compared to washing LLINs every six months; HH in the least poor compared to the most poor socio-economic quintile; a HH income of Nu 5,001-10,000 (US$1 = Nu 59.55), and Nu >10,000, compared to HH with income of

Preventing infections following caesarean section

Surgical site infections following caesarean section are a serious and costly adverse event for Australian hospitals. In the United Kingdom, 9% of women are diagnosed with a surgical site infection following caesarean section either in hospital or post-discharge (Wloch et al 2012, Ward et al 2008). Additional staff time, pharmaceuticals and health supplies, and increased length of stay or readmission to hospital are often required (Henman et al 2012). Part of my PhD investigated the economics of preventing post-caesarean infection. This paper summarises a review of relevant infection prevention strategies. Administering antibiotic prophylaxis 15 to 60 minutes pre-incision, rather than post cordclamping, is probably the most important infection prevention strategy for caesarean section (Smaill and Gyte2010, Liu et al 2013, Dahlke et al 2013). However the timing of antibiotic administration is reportedly inconsistent in Australian hospitals. Clinicians may be taking advice from the influential, but out-dated RANZCOG and United States Centers for Disease Control and Prevention guidelines (Royal Australian and New Zealand College of Obstetricians and Gynaecologists 2011, Mangram et al 1999). A number of other important international clinical guidelines, including Australia's NHMRC guidelines, recommend universal prophylactic antibiotics pre-incision for caesarean section (National Health and Medical Research Council 2010, National Collaborating Centre for Women's and Children's Health 2008, Anderson et al 2008, National Collaborating Centre for Women's and Children's Health 2011, Bratzler et al 2013, American College of Obstetricians and Gynecologists 2011a, Antibiotic Expert Group 2010). We need to ensure women receive preincision antibiotic prophylaxis, particularly as nurses and midwives play a significant role in managing an infection that may result from sub-optimal practice. It is acknowledged more explicitly now that nurses and midwives can influence prescribing and administration of antibiotics through informal approaches (Edwards et al 2011). Methods such as surgical safety checklists are a more formal way for nurses and midwives to ensure that antibiotics are administered pre-incision (American College of Obstetricians and Gynecologists 2011 b). Nurses and midwives can also be directly responsible for other infection prevention strategies such as instructing women to not remove pubic hair in the month before the expected date of delivery and wound management education (Ng et al 2013). Potentially more costly but effective strategies include using a Chlorhexidine-gluconate (CHG) sponge preoperatively (in addition to the usual operating room skin preparation) and vaginal cleansing with a povidone-iodine solution (Riley et al 2012, Rauk 2010, Haas, Morgan, and Contreras 2013).

Effect of the increase in "alcopops" tax on alcohol-related harms in young people : a controlled interrupted time series

Objective: To measure alcohol-related harms to the health of young people presenting to emergency departments (EDs) of Gold Coast public hospitals before and after the increase in the federal government "alcopops" tax in 2008. Design, setting and participants: Interrupted time series analysis over 5 years (28 April 2005 to 27 April 2010) of 15-29-year-olds presenting to EDs with alcohol-related harms compared with presentations of selected control groups. Main outcome measures: Proportion of 15-29-year-olds presenting to EDs with alcohol-related harms compared with (i) 30-49-year-olds with alcohol-related harms, (ii)15-29-year-olds with asthma or appendicitis, and (iii) 15-29-yearolds with any non-alcohol and non-injury related ED presentation. Results: Over a third of 15-29-year-olds presented to ED with alcohol-related conditions, as opposed to around a quarter for all other age groups. There was no significant decrease in alcohol-related ED presentations of 15-29-year-olds compared with any of the control groups after the increase in the tax. We found similar results for males and females, narrow and broad definitions of alcoholrelated harms, under-19s, and visitors to and residents of the Gold Coast. Conclusions: The increase in the tax on al copops was not associated with any reduction in alcohol-related harms in this population in a unique tourist and holiday region. A more comprehensive approach to reducing alcohol harms in young people is needed.

A time series analysis of presentations to Queensland health facilities for alcohol-related conditions, following the increase in 'alcopops' tax

Objective: In response to concerns about the health consequences of high-risk drinking by young people, the Australian Government increased the tax on pre-mixed alcoholic beverages ('alcopops') favoured by this demographic. We measured changes in admissions for alcohol-related harm to health throughout Queensland, before and after the tax increase in April 2008. Methods: We used data from the Queensland Trauma Register, Hospitals Admitted Patients Data Collection, and the Emergency Department Information System to calculate alcohol-related admission rates per 100,000 people, for 15 - 29 year-olds. We analysed data over 3 years (April 2006 - April 2009), using interrupted time-series analyses. This covered 2 years before, and 1 year after, the tax increase. We investigated both mental and behavioural consequences (via F10 codes), and intentional/unintentional injuries (S and T codes). Results: We fitted an auto-regressive integrated moving average (ARIMA) model, to test for any changes following the increased tax. There was no decrease in alcohol-related admissions in 15 - 29 year-olds. We found similar results for males and females, as well as definitions of alcohol-related harms that were narrow (F10 codes only) and broad (F10, S and T codes). Conclusions: The increased tax on 'alcopops' was not associated with any reduction in hospital admissions for alcohol-related harms in Queensland 15 - 29 year-olds.

Development and validation of the ankle fracture outcome of rehabilitation measure (A-FORM)

Study Design Delphi panel and cohort study. Objective To develop and refine a condition-specific, patient-reported outcome measure, the Ankle Fracture Outcome of Rehabilitation Measure (A-FORM), and to examine its psychometric properties, including factor structure, reliability, and validity, by assessing item fit with the Rasch model. Background To our knowledge, there is no patient-reported outcome measure specific to ankle fracture with a robust content foundation. Methods A 2-stage research design was implemented. First, a Delphi panel that included patients and health professionals developed the items and refined the item wording. Second, a cohort study (n = 45) with 2 assessment points was conducted to permit preliminary maximum-likelihood exploratory factor analysis and Rasch analysis. Results The Delphi panel reached consensus on 53 potential items that were carried forward to the cohort phase. From the 2 time points, 81 questionnaires were completed and analyzed; 38 potential items were eliminated on account of greater than 10% missing data, factor loadings, and uniqueness. The 15 unidimensional items retained in the scale demonstrated appropriate person and item reliability after (and before) removal of 1 item (anxious about footwear) that had a higher-than-ideal outfit statistic (1.75). The “anxious about footwear” item was retained in the instrument, but only the 14 items with acceptable infit and outfit statistics (range, 0.5–1.5) were included in the summary score. Conclusion This investigation developed and refined the A-FORM (Version 1.0). The A-FORM items demonstrated favorable psychometric properties and are suitable for conversion to a single summary score. Further studies utilizing the A-FORM instrument are warranted. J Orthop Sports Phys Ther 2014;44(7):488–499. Epub 22 May 2014. doi:10.2519/jospt.2014.4980