Göran Tomson

Meeting the challenge of antibiotic resistance.

A concerted global response is needed to tackle rising rates of antibiotic resistance, say Otto Cars and colleagues

Using the three delays model to understand why newborn babies die in eastern Uganda

Objectives  To investigate causes of and contributors to newborn deaths in eastern Uganda using a three delays audit approach.

SELF-PRESCRIBING BY WAY OF PHARMACIES IN THREE ASIAN DEVELOPING COUNTRIES

The pattern of advice given and drugs dispensed at 75 Asian pharmacies in response to the presentation of a fictitious infant with diarrhoea were studied. Only 16 of the 75 pharmacies gave the appropriate advice--oral rehydration or consultation with a health worker. 19 of 25 pharmacies in Bangladesh, 16 of 25 in Sri Lanka, and 24 of 25 in Yemen Arab Republic dispensed drugs, with or without oral rehydration solution. Fixed-dose combinations of antibiotics and antidiarrhoeal drugs were common. The results are discussed in relation to national drug and diarrhoeal control policies. After further development of the method it might become a useful monitoring instrument.

Antibiotic medication and bacterial resistance to antibiotics: a survey of children in a Vietnamese community.

Summary objective  To investigate antibiotic use and antibiotic susceptibility of respiratory tract pathogens in children aged 1–5 years in Bavi, Vietnam.

Malaria rapid testing by community health workers is effective and safe for targeting malaria treatment: randomised cross-over trial in Tanzania.

Background Early diagnosis and prompt, effective treatment of uncomplicated malaria is critical to prevent severe disease, death and malaria transmission. We assessed the impact of rapid malaria diagnostic tests (RDTs) by community health workers (CHWs) on provision of artemisinin-based combination therapy (ACT) and health outcome in fever patients. Methodology/Principal Findings Twenty-two CHWs from five villages in Kibaha District, a high-malaria transmission area in Coast Region, Tanzania, were trained to manage uncomplicated malaria using RDT aided diagnosis or clinical diagnosis (CD) only. Each CHW was randomly assigned to use either RDT or CD the first week and thereafter alternating weekly. Primary outcome was provision of ACT and main secondary outcomes were referral rates and health status by days 3 and 7. The CHWs enrolled 2930 fever patients during five months of whom 1988 (67.8%) presented within 24 hours of fever onset. ACT was provided to 775 of 1457 (53.2%) patients during RDT weeks and to 1422 of 1473 (96.5%) patients during CD weeks (Odds Ratio (OR) 0.039, 95% CI 0.029–0.053). The CHWs adhered to the RDT results in 1411 of 1457 (96.8%, 95% CI 95.8–97.6) patients. More patients were referred on inclusion day during RDT weeks (10.0%) compared to CD weeks (1.6%). Referral during days 1–7 and perceived non-recovery on days 3 and 7 were also more common after RDT aided diagnosis. However, no fatal or severe malaria occurred among 682 patients in the RDT group who were not treated with ACT, supporting the safety of withholding ACT to RDT negative patients. Conclusions/Significance RDTs in the hands of CHWs may safely improve early and well-targeted ACT treatment in malaria patients at community level in Africa. Trial registration ClinicalTrials.gov NCT00301015

Informed choices for attaining the Millennium Development Goals: towards an international cooperative agenda for health-systems research

Health systems constraints are impeding the implementation of major global initiatives for health and the attainment of the Millennium Development Goals (MDGs). Research could contribute to overcoming these barriers. An independent task force has been convened by WHO to suggest areas where international collaborative research could help to generate the knowledge necessary to improve health systems. Suggested topics encompass financial and human resources, organisation and delivery of health services, governance, stewardship, knowledge management, and global influences. These topics should be viewed as tentative suggestions that form a basis for further discussion. This article is part of a wide-ranging consultation and comment is invited. The potential agenda will be presented at the Ministerial Summit on Health Research in November, 2004, and revised in the light of responses. Subsequently, we hope that resources will be committed to generate the evidence needed to build the equitable, effective, and efficient health systems needed to achieve the MDGsHealth systems constraints are impeding the implementation of major global initiatives for health and the attainment of the Millennium Development Goals (MDGs). Research could contribute to overcoming these barriers. An independent task force has been convened by WHO to suggest areas where international collaborative research could help to generate the knowledge necessary to improve health systems. Suggested topics encompass financial and human resources, organisation and delivery of health services, governance, stewardship, knowledge management, and global influences. These topics should be viewed as tentative suggestions that form a basis for further discussion. This article is part of a wide-ranging consultation and comment is invited. The potential agenda will be presented at the Ministerial Summit on Health Research in November, 2004, and revised in the light of responses. Subsequently, we hope that resources will be committed to generate the evidence needed to build the equitable, effective, and efficient health systems needed to achieve the MDGs.

STD management by private pharmacies in hanoi: practice and knowledge of drug sellers.

Background: Prompt treatment of sexually transmitted infections may reduce the incidence of HIV/AIDS infections. With health sector reforms private pharmacies are increasingly the first and only contact with health delivery services. Objectives: To find out how patients with STDs are treated at private pharmacies in Hanoi, and what drug sellers know about STD management. Methods: Five simulated clients were taught to adopt a scenario stating that their friend had a urethral discharge. They visited 60 randomly selected private pharmacies in urban Hanoi and noted all questions asked, advice offered, and treatment given. Afterwards interviewers administered a semistructured questionnaire to all people working in the 60 pharmacies. Results: Drug treatment was given in 84% of the 297 encounters averaging 1.5 drugs and 1.2 antibiotics per encounter. Quinolones were given 188 times. No dispensing was adequate for chlamydia or was in accordance with the national guidelines. No questions were asked in 55% of encounters and no advice was given in 61%. Questions on sexual activity were asked in 23% (69) of cases and about the health of the partner twice (1%). Advice to practise safe sex was given in 1% of encounters and for the partner to seek treatment only once. Of 69 questionnaires administered 51% said they would refer to a doctor, 16% said they would ask about the sexual activity 1% said they would ask about the health of the partner, 7% said they would advise using a condom, and 1% advised telling the partner to seek treatment. Even after prompting, 61% would ask no questions and 80% would give no advice. Conclusions: Even though 74% of pharmacists and drug sellers know that they should not treat STD patients, 84% actually did. None gave syndromically correct treatment. In both the questionnaire and during the simulated client methods, numbers advising on partner notification and condom use were very poor. Educational or peer awareness interventions are urgently needed among private pharmacists in Vietnam.

Determinants of delay in care-seeking for febrile children in eastern Uganda.

Objective  To explore factors associated with delay in seeking treatment outside the home for febrile children under five.

Local understanding, perceptions and reported practices of mothers/guardians and health workers on childhood malaria in a Tanzanian district--implications for malaria control.

Knowledge on local understanding, perceptions and practices of care providers regarding management of childhood malaria are needed for better malaria control in urban, peri-urban and rural communities. Mothers of under five children attending five purposively selected public health facilities in the Kibaha district, Tanzania, were invited to participate in 10 focus group discussions (FGDs). The health workers of these facilities were included in six other FGDs to elicit their professional views. Analysis was done using interpretative and qualitative approaches. Both health workers and all mothers were clear about the signs and symptoms of homa ya malaria, a description consistent with the biomedical definition of mild malaria. Although most of the mothers related this to mosquito bites, some did not. Mothers also described a severe childhood illness called degedege, consistent with convulsions. Most of the mothers failed to associate this condition with malaria, believing it is caused by evil spirits. Urinating on or fuming the child suffering from degedege with elephant dung were perceived to be effective remedies while injections were considered fatal for such condition. Traditional healers were seen as the primary source of treatment outside homes for this condition and grandmothers and mother in-laws are the key decision makers in the management. Our findings revealed major gaps in managing severe malaria in the study communities. Interventions addressing these gaps and targeting mothers/guardians, mother in-laws, grandmothers and traditional healers are needed.

An open letter to The BMJ editors on qualitative research

Seventy six senior academics from 11 countries invite The BMJ ’s editors to reconsider their policy of rejecting qualitative research on the grounds of low priority. They challenge the journal to develop a proactive, scholarly, and pluralist approach to research that aligns with its stated mission