Julie Balen

Prevalence, intensity and associated morbidity of Schistosoma japonicum infection in the Dongting Lake region, China

OBJECTIVE To determine the prevalence and intensity of Schistosoma japonicum infection and associated morbidity, and to estimate the infected human and buffalo populations in the Dongting Lake region, Hunan province, China. METHODS We used data from the third national schistosomiasis periodic epidemiological survey (PES) of 2004. These included 47 144 human serological and 7205 stool examinations, 3893 clinical examinations and questionnaire surveys, and 874 buffalo stool examinations, carried out in 47 villages in Hunan province. Serological examinations were performed using the enzyme linked immunosorbent assay technique and human stool samples were examined by the Kato-Katz method. Stools from buffaloes and other domestic animals were examined for schistosome infection by the miracidial hatching test. FINDINGS Sero-prevalence was 11.9% (range: 1.3-34.9% at the village level), and the rate of egg-positive stools was estimated at 1.9% (0-10.9%) for the same population. The prevalence of infection among buffaloes was 9.5% (0-66.7%). Extrapolating to the entire population of the Dongting Lake region, an estimated 73 225 people and 13 973 buffaloes were infected. Most frequently reported symptoms were abdominal pain (6.2%) and bloody stools (2.7%). More than half of the clinically examined people reported having had at least one prior antischistosomal treatment. CONCLUSION There was a significant reduction in the number of humans infected with S. japonicum since the previous national PES carried out in 1995, partially explained by large-scale chemotherapy campaigns. However, a near-stable number of buffalo infections suggest continuing human re-infection, which may lead to future increases in human prevalence.

A randomized, double-blind, placebo-controlled trial of safety and efficacy of combined praziquantel and artemether treatment for acute schistosomiasis japonica in China

OBJECTIVE To evaluate the safety and efficacy of combining artemether (AM) and praziquantel (PZQ) in different regimens for treating acute schistosomiasis japonica. METHODS We undertook a randomized, double-blind, placebo-controlled trial within four specialized schistosomiasis hospitals in the Dongting Lake region, Hunan province, China, between May 2003 and December 2005. Study participants were randomized into one of four treatment regimes: group A received 60 mg/kg PZQ + 6 mg/kg AM; group B received 60 mg/kg PZQ + AM placebo; group C received 120 mg/kg PZQ + 6 mg/kg AM; and group D received 120 mg/kg PZQ + AM placebo. All participants were followed up over a 45-day period. The primary endpoint of the trial was human infection status (determined by positive stool examination). Secondary endpoints involved clinical observations and blood biochemistry, including monitoring haemoglobin and alanine aminotransferase levels over time. FINDINGS Treatment efficacies of the four different treatment regimens were 98.0%, 96.4%, 97.7% and 95.7% for group A, B, C, and D respectively (P > 0.05). The group B had a greater treatment efficacy (96.4%) than the group D (95.7%) (P > 0.05). Group A treatment was better for clearance of fever (P < 0.05) and resulted in a shorter hospitalization time (P < 0.05). CONCLUSION This is the first report of a randomized, double-blind, placebo-controlled trial for evaluating combined chemotherapy with AM and two different dosages (60 mg/kg and 120 mg/kg) of PZQ in the treatment of acute schistosomiasis japonica in China. The combination of AM and PZQ chemotherapy did not improve treatment efficacy compared with PZQ alone. PZQ given as a dosage of 60 mg/kg (1 day, 3 x 20 mg/kg doses at 4-5 hour intervals) may be as effective as a dosage of 120 mg/kg (6 days, 20 mg/kg for each day split into 3 doses at 4-5 hour intervals).

Risk factors for helminth infections in a rural and a peri-urban setting of the Dongting Lake area, People's Republic of China

Schistosomiasis japonica and soil-transmitted helminthiasis are endemic parasitic diseases in the Peoples Republic of China (PR China). As very few studies have reported on the distribution and interaction of multiple species helminth infections, we carried out a comparative study of households in a rural village and a peri-urban setting in the Dongting Lake area of Hunan province in November and December 2006 to determine the extent of single and multiple species infections, the underlying risk factors for infection, and the relationships with clinical manifestations and self-reported morbidity. In each household, stool samples were collected and subjected to the Kato-Katz method for identifying Schistosoma japonicum, Ascaris lumbricoides, hookworm and Trichuris trichiura infections. Clinical examinations were performed and questionnaire surveys conducted at both household and individual subject levels. Complete parasitological, clinical and questionnaire data were obtained for 1,298 inhabitants of the two settings. The overall prevalences of single infections of S. japonicum, A. lumbricoides, hookworm and T. trichiura were 6.5%, 5.5%, 3.0% and 0.8%, respectively; the majority of the infections were of light intensity. We found significant negative associations between wealth and infections with S. japonicum and A. lumbricoides. Clinical manifestations of splenomegaly, hepatomegaly and anaemia were prevalent (9.0%, 3.7% and 10.9%, respectively), the latter two being significantly (P<0.05) associated with schistosomiasis. Self-reported symptoms were more common among females but there was considerable under-reporting in both sexes when relying only on spontaneous recall. Our findings may guide the design and targeting of a more equitable, comprehensive and integrated parasitic disease control programme in Hunan province and in other areas of PR China.

A conceptual and analytical approach to comparative analysis of country case studies: HIV and TB control programmes and health systems integration.

Attempts to comparatively analyse large-scale communicable disease control programmes have, for the most part, neglected the wider health system contexts within which the programmes lie. In addition, many evaluations of the integration of vertical disease control programmes into health systems have focused on single case studies or on a limited number of cases, or, when large numbers of cases were drawn upon, have been presented as a compendium of monographs rather than a systematic cross-national comparison. One reason for this may be that appropriate theories and tools for comparative health systems analysis are rare and difficult to formulate. In this paper we propose a conceptual framework and an analytical methodology which might be used to comparatively analyse a series of case studies that explore health systems, communicable diseases programmes and concepts of integration in order to make systematic comparisons to offer novel insights, to test new theories and to offer new hypotheses. We illustrate through a preliminary analysis how this framework can be applied to compare the impact of health systems integration and HIV and TB programmes in four countries in South-East Asia that were the subject of cases studies.

Spatial distribution of human Schistosoma japonicum infections in the Dongting Lake Region, China.

Background The aim of this study was to spatially model the effect of demographic, reservoir hosts and environmental factors on human Schistosoma japonicum infection prevalence in the Dongting Lake area of Hunan Province, China and to determine the potential of each indicator in targeting schistosomiasis control. Methodology/Principal Findings Cross-sectional serological, coprological and demographic data were obtained from the 2004 nationwide periodic epidemiologic survey for Hunan Province. Environmental data were downloaded from the USGS EROS data centre. Bayesian geostatistical models were employed for spatial analysis of the infection prevalence among study participants. A total of 47,139 participants from 47 administrative villages were selected. Age, sex and occupation of residents and the presence of infected buffaloes and environmental factors, i.e. NDVI, distance to the lake and endemic type of setting, were significantly associated with S. japonicum infection prevalence. After taking into account spatial correlation, however, only demographic factors (age, sex and occupation) and the presence of infected buffaloes remained significant indicators. Conclusions/Significance Long established demographic factors, as well presence of host reservoirs rather than environmental factors are driving human transmission. Findings of this work can be used for epidemiologic surveillance and for the future planning of interventions in the Dongting Lake area of Hunan Province.

Magnetic beads for schistosomiasis diagnosis.

Research of Malcolm Jones on iron metabolism in schistosomes is funded by the National Health and Medical Research Council of Australia. The authors received no specific funding for this study.

Health access livelihood framework reveals potential barriers in the control of schistosomiasis in the Dongting Lake area of Hunan Province, China.

Background Access to health care is a major requirement in improving health and fostering socioeconomic development. In the Peoples Republic of China (P.R. China), considerable changes have occurred in the social, economic, and health systems with a shift from a centrally planned to a socialist market economy. This brought about great benefits and new challenges, particularly for vertical disease control programs, including schistosomiasis. We explored systemic barriers in access to equitable and effective control of schistosomiasis. Methodology Between August 2002 and February 2003, 66 interviews with staff from anti-schistosomiasis control stations and six focus group discussions with health personnel were conducted in the Dongting Lake area, Hunan Province. Additionally, 79 patients with advanced schistosomiasis japonica were interviewed. The health access livelihood framework was utilized to examine availability, accessibility, affordability, adequacy, and acceptability of schistosomiasis-related health care. Principal Findings We found sufficient availability of infrastructure and human resources at most control stations. Many patients with advanced schistosomiasis resided in non-endemic or moderately endemic areas, however, with poor accessibility to disease-specific knowledge and specialized health services. Moreover, none of the patients interviewed had any form of health insurance, resulting in high out-of-pocket expenditure or unaffordable care. Reports on the adequacy and acceptability of care were mixed. Conclusions/Significance There is a need to strengthen health awareness and schistosomiasis surveillance in post-transmission control settings, as well as to reduce diagnostic and treatment costs. Further studies are needed to gain a multi-layered, in-depth understanding of remaining barriers, so that the ultimate goal of schistosomiasis elimination in P.R. China can be reached.

The Holy See on sexual and reproductive health rights: conservative in position, dynamic in response

Abstract The Holy See has engaged extensively in United Nations negotiations on issues concerning sexual and reproductive health rights as they have emerged and evolved in a dynamic global agenda over the past two decades. A meta-narrative review of the mission’s official statements was conducted to examine the positions, discourses and tensions across the broad range of agendas. The Holy See represents a fundamentally conservative and stable position on a range of sexual and reproductive health rights concerns. However, the mission has been dynamic in the ways in which it has forwarded its arguments, increasingly relying upon secularised technical claims and empirical evidence; strategically interpreting human rights norms in ways consistent with its own position; and framing sexuality and reproduction in the context of “the family”. Seen in the broader context of a “religious resurgence” in international relations, and in light of the fact that the Holy See has frequently sought to form alliances with conservative State and non-State actors, these findings make an important contribution to understanding the slow progress as well as the potential obstacles that lie ahead in the battle to realise sexual and reproductive health rights in a changing global political environment. Résumé Le Saint-Siège s’est engagé largement dans des négociations aux Nations Unies sur les questions concernant les droits à la santé sexuelle et génésique à mesure qu’elles ont émergé et évolué dans un ordre du jour mondial dynamique ces vingt dernières années. Une étude des déclarations officielles de la mission a examiné sous forme de métanarration les positions, les discours et les tensions à travers un vaste éventail de préoccupations. Le Saint-Siège représente une position stable et fondamentalement conservatrice sur une palette de thèmes relatifs aux droits à la santé sexuelle et génésique. Néanmoins, la mission a fait preuve de dynamisme dans les moyens choisis pour avancer ses arguments, se fondant de plus en plus sur des revendications techniques sécularisées et des données empiriques ; en interprétant stratégiquement les normes des droits de l’homme conformément à sa propre position ; et en encadrant la sexualité et la procréation dans le contexte de « la famille ». Vues dans le contexte plus large d’une « résurgence religieuse » dans les relations internationales et à la lumière des alliances que le Saint-Siège a fréquemment cherché à nouer avec des acteurs étatiques et non étatiques conservateurs, ces conclusions sont fort utiles pour comprendre la lenteur des progrès ainsi que les obstacles potentiels qui attendent la lutte pour réaliser les droits à la santé sexuelle et génésique dans un environnement politique mondial en évolution. Resumen La Santa Sede ha participado extensamente en negociaciones con las Naciones Unidas sobre asuntos relacionados con salud y derechos sexuales y reproductivos según han ido surgiendo y evolucionando en una agenda mundial dinámica en las últimas dos décadas. Se realizó una revisión meta-narrativa de las declaraciones oficiales de la misión para examinar las posturas, discursos y tensiones en una amplia gama de agendas. La Santa Sede representa una postura fundamentalmente conservadora y estable frente a una variedad de asuntos inquietantes de salud y derechos sexuales y reproductivos. Sin embargo, la misión ha sido dinámica en las maneras en que ha presentado sus argumentos, dependiendo cada vez más de afirmaciones técnicas secularizadas y evidencia empírica; interpretando estratégicamente las normas de los derechos humanos en maneras que concuerdan con su postura; y definiendo la sexualiad y reproducción en el contexto de “la familia”. En un contexto más amplio de “resurgimiento religioso” en las relaciones internacionales, y en vista del hecho de que la Santa Sede frecuentemente ha procurado formar alianzas con actores conservadores Estatales y no Estatales, estos hallazgos nos permiten entender el lento progreso así como los posibles obstáculos en la batalla para hacer realidad la salud y los derechos sexuales y reproductivos en un ambiente político mundial que está cambiando.

Use of Information and Communication Technologies in the formal and informal health system responses to the 2015 Nepal earthquakes

Abstract Information and Communication Technologies (ICTs) are increasingly recognized for their potential contributions to health service delivery in Low‐and Middle‐Income Countries (LMICs). As well as playing a role in improving the provision of health services under everyday ‘normal’ circumstances, ICTs can also be important in preparing for, mitigating, responding to and recovering from disasters. This research explores the use of ICTs in a natural disaster situation in Nepal, a country affected by a series of strong earthquakes in 2015. In March and April 2016, in‐depth semi‐structured interviews (n = 24) and focus group discussions (n = 4) were conducted with key informants: those affected by the earthquake, and those forming part of the formal or informal health system responses. Data were collected and analysed across three levels, from the bottom ‘upwards’, namely: (1) village level; (2) district level and (3) central/national level. Perceptions of the role and value of ICTs varied greatly—as did patterns of use. While access and capability were found to be key barriers to use rurally, ICTs were nevertheless an important part of the informal response, helping people to gather information, express needs and cope emotionally. They also helped relief agencies in allowing for networking and coordination among actors. Use of ICTs in the formal health system response, however, was severely lacking in many areas, relying more on traditional methods of disaster management. This reflects a general deficiency in, and underuse of, ICTs in the pre‐earthquake Nepali healthcare system. We conclude by calling for a redoubling of efforts to improve and increase the adoption, diffusion, integration and regular use of ICTs within the Nepali health system—an approach that will assist with day‐to‐day service delivery but also provide a crucial platform upon which to build during future crises.