Michael J. Toole

Keeping clean water clean in a Malawi refugee camp: a randomized intervention trial.

OBJECTIVE This study was undertaken to assess the ability of a water container with a cover and a spout to prevent household contamination of water in a Malawian refugee camp. METHODS A randomized trial was conducted in a refugee population that had experienced repeated outbreaks of cholera and diarrhoea and where contamination of water in the home was found to be a significant cause of cholera. Four hundred Mozambican refugee households were systematically identified and followed over a 4-month period, one fourth of the households were randomly assigned to exclusively use the improved container for water collection. FINDINGS Water flowing from the source wells had little or no microbial contamination although the water collectors quickly contaminated their water, primarily through contact with their hands. Analysis of water samples demonstrated that there was a 69% reduction in the geometric mean of faecal coliform levels in household water and 31% less diarrhoeal disease (P = 0.06) in children under 5 years of age among the group using the improved bucket. Regression models examining diarrhoea among under 5-year-olds confirmed the protective effect of the bucket and found that visible faeces in the family latrine and the presence of animals were significantly associated with an increased diarrhoeal incidence in children. CONCLUSION Household contamination of drinking-water significantly contributed to diarrhoea in this population. Proper chlorination is a less expensive and more effective means of water quality protection in comparison with the improved bucket, but was unpopular and rarely utilized by the camp inhabitants.

Mortality rates in displaced and resident populations of central Somalia during 1992 famine

Famine and civil war have resulted in high mortality rates and large population displacements in Somalia. To assess mortality rates and risk factors for mortality, we carried out surveys in the central Somali towns of Afgoi and Baidoa in November and December, 1992. In Baidoa we surveyed displaced persons living in camps; the average daily crude mortality rate was 16.8 (95% CI 14.6-19.1) per 10,000 population during the 232 days before the survey. An estimated 74% of children under 5 years living in displaced persons camps died during this period. In Afgoi, where both displaced and resident populations were surveyed, the crude mortality rate was 4.7 (3.9-5.5) deaths per 10,000 per day. Although mortality rates for all displaced persons were high, people living in temporary camps were at highest risk of death. As in other famine-related disasters, preventable infectious diseases such as measles and diarrhoea were the primary causes of death in both towns. These mortality rates are among the highest documented for a civilian population over a long period. Community-based public health interventions to prevent and control common infectious diseases are needed to reduce these exceptionally high mortality rates in Somalia.

The Prevalence of Sexually Transmitted Infections in Papua New Guinea: A Systematic Review and Meta-Analysis

Background The potential for an expanded HIV epidemic in Papua New Guinea (PNG) demands an effective, evidence-based and locally-appropriate national response. As sexually transmitted infections (STIs) may be important co-factors in HIV transmission nationally, it is timely to conduct a systematic review of STI prevalences to inform national policy on sexual health and HIV/STI prevention. Methodology/Principal Findings We undertook a systematic review and meta-analysis of HIV and STI prevalences in PNG, reported in peer-reviewed and non-peer-reviewed publications for the period 1950–2010. Prevalence estimates were stratified by study site (community or clinic-based), geographic area and socio-demographic characteristics. The search strategy identified 105 reports, of which 25 studies (10 community-based; 10 clinic-based; and 5 among self-identified female sex workers) reported STI prevalences and were included in the systematic review. High prevalences of chlamydia, gonorrhoea, syphilis and trichomonas were reported in all settings, particularly among female sex workers, where pooled estimates of 26.1%, 33.6%, 33.1% and 39.3% respectively were observed. Pooled HIV prevalence in community-based studies was 1.8% (95% CI:1.2–2.4) in men; 2.6% (95% CI:1.7–3.5) in women; and 11.8% (95% CI:5.8–17.7) among female sex workers. Conclusions/Significance The epidemiology of STIs and HIV in PNG shows considerable heterogeneity by geographical setting and sexual risk group. Prevalences from community-based studies in PNG were higher than in many other countries in the Asia-Pacific. A renewed focus on national STI/HIV surveillance priorities and systems for routine and periodic data collection will be essential to building effective culturally-relevant behavioural and biomedical STI/HIV prevention programs in PNG.

Are war and public health compatible

A public health assessment during March, 1993, in Bosnia-Herzegovina and in the areas of Serbia and Montenegro hosting Bosnian refugees, revealed extensive disruption to basic health services, displacement of more than 1 million Bosnians, severe food shortages in Muslim enclaves in eastern Bosnia, and widespread destruction of public water and sanitation systems. War-related violence remains the most important public health risk; civilians on all sides of the conflict have been intentional targets of physical and sexual violence. The impact of the war on the health status of the population has been difficult to document; however, in the central Bosnian province of Zenica, perinatal and child mortality rates have increased twofold since 1991. The crude death rate in one Muslim enclave between April, 1992, and March, 1993, was four times the pre-war rate. Prevalence rates of severe malnutrition among both adults and children in central Bosnia have been increasing since November, 1992. Major epidemics of communicable diseases have not been reported; however, the risk may increase during the summer of 1993 when the effects of disrupted water and sanitation systems are more likely to promote enteric disease transmission. Economic sanctions against Serbia and Montenegro may lead to declining health care standards in those republics if basic medical supplies cannot effectively be exempted.

Low back pain in rural Tibet

In a baseline assessment of 30 rural villages surrounding Shigatse City, Tibet, many people, especially women, identified low back pain as a serious health problem. Consequently, we aimed to establish the prevalence of such pain and to develop appropriate interventions. We did a cross-sectional study of the prevalence of low back pain and related functional disability using two-stage random cluster sampling. We included 499 adults aged at least 15 years from 19 villages. The point prevalence of low back pain was 34.1% (95% CI 27.9-40.3% [170 people]); the 12-month prevalence was 41.9% (35.5-48.3% [209 people]). 100 (20%) villagers had substantial functional disability associated with low back pain. Low back pain is likely to be an important and under recognised problem in rural societies like Tibet.

HIV prevalence and risk behaviour among men who have sex with men in Vientiane Capital, Lao People's Democratic Republic, 2007.

Background:Men who have sex with men are at high risk for HIV infection. Here we report the results of the first assessment of HIV prevalence and risk behaviour in this group in Vientiane, Lao Peoples Democratic Republic. Methods:Between August and September 2007, 540 men were enrolled from venues around Vientiane, using venue-day-time sampling. Men of Lao nationality, 15 years and over, reporting oral or anal sex with a man in the previous 6 months were eligible for participation. Demographic and socio-behavioural information was self-collected using hand-held computers. Oral fluid was tested for HIV infection. Logistic regression was used to evaluate risk factors for prevalent HIV infection. Results:The median age of participants was 21 years; the HIV prevalence was 5.6%. Of participants, 39.6% reported exclusive attraction to men and 57.6% reported sex with women. Of those who reported having regular and nonregular sexual partner(s) in the past 3 months, consistent condom use with these partners was 14.4 and 24.2%, respectively. A total of 42.2% self-reported any sexually transmitted infection symptoms and 6.3% had previously been tested for HIV. Suicidal ideation was reported by 17.0%, which was the only variable significantly and independently associated with HIV infection in multivariate analysis. Conclusion:Although the HIV prevalence is low compared with neighbouring countries in the region, men who have sex with men in Lao Peoples Democratic Republic are at high behavioural risk for HIV infection. To prevent a larger HIV epidemic occurrence and transmission into the broader community, higher coverage of HIV prevention interventions is required.

The Association Between Inadequate Rations, Undernutrition Prevalence, and Mortality in Refugee Camps: Case Studies of Refugee Populations in Eastern Thailand, 1979–1980, and Eastern Sudan, 1984–1985

A review was conducted of nutrition and mortality data collected among Tigrayan refugees in Eastern Sudan (1984-85) and Cambodian refugees in Thailand (1979-80) 2 populations of comparable size. The Cambodian refugee population showed a rapid decline in mortality rates during the acute phase of the emergency--from 10/1000/month to 1/1000/month within 1 month. These changes were associated with rapid improvement in nutritional status and the provision of adequate rations soon after the arrival of the refugees in Thailand. By contrast mortality rates in the Tigrayan refugee population in late 1984 and 1985 were unusually high (14-24/1000/month) and prolonged. The high mortality was associated with persistently high prevalence rates of undernutrition (14-50%) among children 5 years of age. Inadequate amounts of food (1360-1870 kcal/person/day) were distributed to this population during the 1st 5 months after their arrival; in addition a severe measles outbreak in the camps added to the high mortality. The reported high undernutrition prevalence in the Tigrayan refugee camps persisted despite supplementary feeding programs for which enrollment and attendance rates among identified undernourished children were low. The close association of mortality with undernutrition leads us to conclude that refugee relief programs should give highest priority to ensuring that adequate rations are distributed. This requires better anticipation of and more timely response to refugee movements by international relief agencies. (authors)

Planning STI/HIV Prevention Among Refugees and Mobile Populations: Situation Assessment of Sudanese Refugees

This article reflects an investigation of knowledge, attitudes and behaviours and HIV/STI prevalence of Sudanese refugees and Ethiopian sex workers in 1992. It represents one of the earliest such investigations within an African refugee population. The investigation took place in the Dimma refugee settlement in south-western Ethiopia and study participants included Sudanese refugee men and women and Ethiopian female sex workers. Methods used for this investigation included focus group discussions, behavioural surveys and serologic testing. The main outcome measures of the investigation were HIV/STI knowledge, attitudes and behaviours and biological markers for HIV, syphilis and herpes simplex 2. The study findings indicate that in the early 1990s, knowledge about AIDS and condom use was low among Sudanese refugee women and not one reported having ever used a condom. Furthermore, sexual contact between refugee men and sex workers was frequent during the time of this study and the prevalence of HIV and other STIs was high. The results confirm a widely held assumption that highly mobile and transient populations in Africa are susceptible to STIs and HIV, in large part due to their knowledge, attitudes and behaviours.

DOTS-based tuberculosis treatment and control during civil conflict and an HIV epidemic, Churachandpur District, India.

OBJECTIVE To pilot the WHO guidelines on DOTS for tuberculosis (TB) among displaced people affected by conflict in Churachandpur District, Manipur State, north-east India, which has endured an HIV epidemic, injecting drug use, civil unrest, high levels of TB, and poor TB treatment and prevention services for many years. METHODS Prerequisites for TB control programmes were established. WHO guidelines and protocols were adapted for local use. Outreach workers were appointed from each ethnic group involved in the conflict, and training was conducted. Quality control and evaluation processes were introduced. FINDINGS TB was diagnosed in 178 people between June and December 1998. Of the 170 with pulmonary disease, 85 were smear-positive. Successful outcomes were recorded in 91% of all patients and in 86% of smear-positive cases of pulmonary TB. The default rate and the mortality rate were low at 3% each. HIV positive serostatus was the only factor associated with a poor treatment outcome. CONCLUSION TB treatment and control were possible in a conflict setting and WHO targets for cure were attainable. The factors associated with the success of the programme were strong local community support, the selection of outreach workers from each ethnic group to allow access to all areas and patients, the use of directly observed therapy three times a week instead of daily in the interest of increased safety, and the limiting of distances travelled by both outreach workers and patients.

Understanding male sexual behaviour in planning HIV prevention programmes: lessons from Laos, a low prevalence country.

Methods: Focus group discussions were conducted with a range of young men in Vientiane, Laos; interviews were conducted with male sex workers. A questionnaire survey was conducted with a purposive sample of 800 young men. Results: Most young men initiate sex at an early age and have multiple sex partners. Married men are more likely to pay for sex and most sex for money is negotiated in non-brothel settings. Despite high reported condom use for last intercourse with a casual partner, decisions on condom use are subjective. Many men have extramarital sex when their partner is pregnant and post partum. 18.5% of men report having had sex with another man; most of these men also report having sex with women. Moreover, more men report having had anal sex with a woman than with a man. Conclusions: Although not a probability sample survey, this study of a broad range of young men in Vientiane reveals sexual behaviours that could lead to accelerated HIV transmission. Education should emphasise the need to use condoms in all sexual encounters outside the primary relationship. This needs special emphasis when the partner is pregnant or post partum. Advice on safe sex with other men needs to be integrated into all sexual health education for young men.