David Bishai

Emergency medical systems in low- and middle-income countries: recommendations for action

Emergency medical care is not a luxury for rich countries or rich individuals in poor countries. This paper makes the point that emergency care can make an important contribution to reducing avoidable death and disability in low- and middle-income countries. But emergency care needs to be planned well and supported at all levels--at the national, provincial and community levels--and take into account the entire spectrum of care, from the occurrence of an acute medical event in the community to the provision of appropriate care at the hospital. The mix of personnel, materials, and health-system infrastructure can be tailored to optimize the provision of emergency care in settings with different levels of resource availability. The misconception that emergency care cannot be cost effective in low-income settings is demonstrably inaccurate. Emergencies occur everywhere, and each day they consume resources regardless of whether there are systems capable of achieving good outcomes. With better planning, the ongoing costs of emergency care can result in better outcomes and better cost-effectiveness. Every country and community can and should provide emergency care regardless of their place in the ratings of developmental indices. We make the case for universal access to emergency care and lay out a research agenda to fill the gaps in knowledge in emergency care.

The Acceptability of Self-Collected Samples for HPV Testing vs. the Pap Test as Alternatives in Cervical Cancer Screening

OBJECTIVE To explore the acceptability of the self-collection of samples for human papillomavirus (HPV) testing in comparison with that of the Pap test. METHODS The study population consisted of 1069 women 20 years and older who were eligible for coverage through the Mexican Institute of Social Security (IMSS). These women were randomly selected among participants in a larger study to evaluate the use of HPV testing as an alternative in cervical cancer screening. All participants provided a self-collected vaginal sample for HPV testing according to explicit instructions and underwent a Pap test. Afterwards, each woman was interviewed about her experience and opinion regarding the two procedures. Acceptability was measured by a calculated score based on discomfort, pain, embarrassment, privacy, perception of personal treatment during the Pap test, and understanding of how to perform the self-sampling method. RESULTS Ninety-three percent of women experienced sufficient privacy with the Pap test, whereas 98% of women reported that privacy with the self-sampling procedure was acceptable. The Pap test consistently provoked more discomfort, pain, and embarrassment than self-sampling. Sixty-eight percent of the women who indicated a test preference chose self-sampling. Preference for this method was positively associated with monthly household income. Women reported a preference for self-sampling because it is more comfortable (71.2%) and causes less embarrassment (55.8%). CONCLUSIONS Self-sampling is more acceptable than the Pap test and could improve coverage rates of early detection programs. The incorporation of self-collected samples to detect HPV could encourage participation in screening programs among those women who reject the Pap test because of the necessary pelvic examination.

Comparison of HPV-based assays with Papanicolaou smears for cervical cancer screening in Morelos State, Mexico

Objective: To compare the performance of human papillomavirus (HPV) assays with conventional Pap cytology for cervical cancer (CC) screening in Mexico. Methods: Pap smears, self-collected vaginal specimens (SS) for HPV testing, and clinician-collected cervical specimens (CS) for HPV testing were obtained from 7868 women, aged 15–85 years old, attending CC screening at the Mexican Institute of Social Security (IMSS) between May and October, 1999. SS and CS specimens were screened for oncogenic HPV DNA by Hybrid Capture 2. Women who received cytological interpretations of atypical squamous cells of undetermined significance (ASCUS), and/or a positive HPV test were referred for colposcopy and histologic studies. The relative estimates for sensitivity, specificity and predictive values of each test were calculated using histological diagnoses of cervical intraepithelial neoplasia (CIN) grades 2 or 3, or CC histological diagnosis. Results: Oncogenic HPV detection rate was 11.6% for SS, and 9.3% for CS. Pap smear abnormalities were observed in 2.4% of the women. Of 1147 women who had at least one abnormal test result, 88.5% underwent colposcopy, and 101 biopsy-confirmed CIN2/3 or cancer cases were identified. The relative sensitivity estimates for the Pap test, SS and CS were 59.4% (95% CI: 49.2–68.9), 71.3% (95% CI: 61.3–79.6), and 93.1% (95% CI: 85.8–96.9), respectively, while the specificities were 98.3% (95% CI: 98.0–98.6), 89.2% (95% CI: 88.5–89.9), and 91.8% (95% CI: 91.2–92.4), respectively. The positive predictive values of Pap, SS and CS were 36.1, 9.1 and 14.9, the colposcopy referrals needed to detect a case of CIN2/3 or cancer were 2.8, 11.0 and 6.7, respectively. Discussion: Both HPV assays detected more cases of CIN2/3 or CC than Pap cytology alone. However, the HPV assays increased the number of colposcopy referrals. Our study suggests that HPV testing could be an effective way to improve the performance of CC screening.

HIV STATUS AND UNION DISSOLUTION IN SUB- SAHARAN AFRICA: THE CASE OF RAKAI, UGANDA*

Little is known about the impact of HIV infection on the disruption of families through separation, divorce, and widowhood. Using life tables and multinomial logistic regression, this research examined the influence of HIV status on the risk of separation or divorce and widowhood among women in Rakai, Uganda. The multivariate results revealed that dissolution is more common among HIV-infected women and that infected women in HIV-discordant couples are especially likely to face separation or divorce than women in other HIV-status couples. These results highlight women’s vulnerability to the social impact of HIV infection and the importance of dyadic studies of the disruption of unions.

Risk factors for juvenile onset recurrent respiratory papillomatosis

Background.Children born to condylomatous mothers are at risk for developing juvenile onset recurrent respiratory papillomatosis (JORRP). We inquired whether the triad of vaginal delivery, being firstborn and maternal age of <20 years are also risk factors for JORRP.Methods.Data for JORRP and adu

Success factors for reducing maternal and child mortality

Reducing maternal and child mortality is a priority in the Millennium Development Goals (MDGs), and will likely remain so after 2015. Evidence exists on the investments, interventions and enabling policies required. Less is understood about why some countries achieve faster progress than other comparable countries. The Success Factors for Womens and Childrens Health studies sought to address this knowledge gap using statistical and econometric analyses of data from 144 low- and middle-income countries (LMICs) over 20 years; Boolean, qualitative comparative analysis; a literature review; and country-specific reviews in 10 fast-track countries for MDGs 4 and 5a. There is no standard formula--fast-track countries deploy tailored strategies and adapt quickly to change. However, fast-track countries share some effective approaches in addressing three main areas to reduce maternal and child mortality. First, these countries engage multiple sectors to address crucial health determinants. Around half the reduction in child mortality in LMICs since 1990 is the result of health sector investments, the other half is attributed to investments made in sectors outside health. Second, these countries use strategies to mobilize partners across society, using timely, robust evidence for decision-making and accountability and a triple planning approach to consider immediate needs, long-term vision and adaptation to change. Third, the countries establish guiding principles that orient progress, align stakeholder action and achieve results over time. This evidence synthesis contributes to global learning on accelerating improvements in womens and childrens health towards 2015 and beyond.

Multiple Births Are a Risk Factor for Postpartum Maternal Depressive Symptoms

OBJECTIVE. The purpose of the study was to assess the relationship between multiple births and maternal depressive symptoms measured 9 months after delivery. METHODS. Data were derived from the Early Childhood Longitudinal Study-Birth Cohort, a longitudinal study of a nationally representative sample of children born in 2001. Depressive symptoms were measured at 9 months by using an abbreviated version of the Center for Epidemiologic Studies Depression Scale. Logistic regression analyses were conducted to study the association between multiple births and maternal depressive symptoms, with adjustment for demographic and household socioeconomic characteristics and maternal history of mental health problems. A total of 8069 mothers were included for analyses. RESULTS. The prevalence of moderate/severe depressive symptoms at 9 months after delivery was estimated to be 16.0% and 19.0% among mothers of singletons and multiple births, respectively. Only 27.0% of women who had moderate/severe depressive symptoms reported talking about emotional or psychological problems with a mental health specialist or a general medical provider within the 12 months before the interview. The proportions of women with depressive symptoms who were receiving mental health services did not vary according to plurality status. CONCLUSIONS. Mothers of multiple births had 43% greater odds of having moderate/severe, 9-month postpartum, depressive symptoms, compared with mothers of singletons. Greater attention is needed in pediatric settings to address maternal depression in families with multiple births.

The cost effectiveness of antiretroviral treatment strategies in resource-limited settings.

Background:Optimal resource allocation for antiretroviral treatment (ART) in developing countries requires assessment of different strategies for drug treatment and laboratory monitoring. Objectives:To compare costs and outcomes for 10 000 simulated HIV-infected patients followed every 6 months for 10 years in a limited-resource setting. Method:Five nested strategies, with and without the availability of a second-line treatment regimen, were simulated: (a) no ART (NO ART); (b) with ART but without any laboratory markers of HIV other than positive serology (ART ONLY); (c) ART plus total lymphocyte count (TLC); (d) ART plus CD4 cell counts (CD4); and (e) ART plus CD4 cell count plus viral load measurement (VL). Baseline prices of CD4 cell count and viral load measurements were

Cost-effectiveness of five strategies for gonorrhea and chlamydia control among female and male emergency department patients.

5.00 and

Association of Antiretroviral Therapy Adherence and Health Care Costs

25.00 per test, respectively. Results:With no second-line treatment available, treating 10 000 patients with ART ONLY compared with NO ART would cost