Italian survey on the use of a multidisciplinary approach for age assessment of UAM

Issue

Many methods are used to assess the age of unaccompanied foreign minors (UAM). In Italy, in the frame of a new legislative asset, a multidisciplinary protocol has been adopted in July 2020 with the aim of ensuring that all UAMs are assessed uniformly throughout the country when their age is in doubt. The assessment is based on a multidisciplinary - social, psychological and physical - evaluation performed by a team of specialists. The local health authorities (ASL) carry out the assessment when requested by the Juvenile Court.

Description

One year after the establishment of the protocol, INMP launched a national survey, through an online questionnaire, to investigate the formal adoption of the protocol by the ASL and their adherence in practice. The survey started on 10 January 2022 and closed on 8 March 2022.

Results

Out of 118 ASL that were asked to participate, 102 (85%) answered. 37 declared to have a multidisciplinary team for age assessment. Of them, 18 use the formal protocol, 11 use an approach “in line” with the protocol and 8 have a forensic team, out of the rules of the protocol. Of the 65 that did not set up the team, 22 declared that they were ready to do so. 846 age assessment requests were reported and 687 were carried out. 398 migrants were recognized as minors, 222 migrants were not recognized as minors, and the age of 67 migrants remained uncertain.

Lessons

The pandemic period prevented the effective adoption of the protocol by the ASL, that were strongly engaged in the COVID 19 response. There is still great variability in the way the age assessment of UAMs is conducted and in order to counteract the use of inadequate/outdated practices, it is necessary to actively promote and support the adoption of the protocol. In addition, a continuous comparison/dialogue between the multidisciplinary teams, the Juvenile Court, and the Police Headquarters is also needed, so that the procedure is requested only when necessary and carried out properly.

Key messages

• In case of doubt, the age of all UAM has to be assessed in a uniform manner throughout the country.

• The adoption of the multidisciplinary protocol has to be actively promoted and supported to counter the use of inadequate or outdated assessment practices.

The Italian Roma, Sinti and Travellers Health Project for equity in access to care

Issue

In 2015, Italy approved the National Action Plan for Health for and with Roma, Sinti and Travellers (RSC); however, it is still not fully applied at a local level. The INMP (funded by the National Operational Programme for Social Inclusion), implemented the “Health Project - Promotion of strategies and tools for equity in access to health care for RSC”, aimed to support the implementation of the Plan by Local Health Authorities (ASL).

Description

The project lasted from March 2019 to December 2021. INMP worked with 7 ASL to design interventions and develop tools to address RSC health needs. The SODA (Strategic Options Development and Analysis) method as a participatory process aimed at identifying strategies and models for the execution of the Plan among relevant stakeholders was used. Moreover, RSC communities’ engagement strategies and a community-based Proximity Public Health (PPS) approach were adopted in designing and developing health promotion interventions.

Results

INMP performed 38 interviews with ASL health operators highlighting barriers and strategies in the local implementation of the Plan. Tools orienting to social and health services and health education materials for hard-to-reach groups were produced. A training course for 14 RSC facilitators and 5 training courses attended by over 200 NHS operators have been organized. ASL were supported in developing health promotion initiatives, based on the engagement of both local RSC communities and third sector entities.

Lessons

The project has enabled the ASL to develop local protocols for the implementation of the Action Plan. In line with this capacity-building activity, the project trained both health operators and RSC facilitators fostering the dissemination of the PPS culture in designing and providing care for hard-to-reach groups. Given the positive results obtained, INMP is still collaborating with both ASL and the Third Sector on additional activities related to the Project in 2022.

Key messages

Very High Fascioliasis Intensities in Schoolchildren from Nile Delta Governorates, Egypt: The Old World Highest Burdens Found in Lowlands

Quantitative coprological analyses of children were performed in Alexandria and Behera governorates, Egypt, to ascertain whether individual intensities in the Nile Delta lowlands reach high levels as those known in hyperendemic highland areas of Latin America. Analyses focused on subjects presenting intensities higher than 400 eggs per gram of faeces (epg), the high burden cut-off according to WHO classification. A total of 96 children were found to shed between 408 and 2304 epg, with arithmetic and geometric means of 699.5 and 629.07 epg, respectively. Intensities found are the highest hitherto recorded in Egypt, and also in the whole Old World. A total of 38 (39.6%) were males and 58 (60.4%) were females, with high intensities according to gender following a negative binomial distribution. The high burden distribution shows a peak in the 7-10 year-old children group, more precocious in females than males. Results showed high burdens in winter to be remarkably higher than those known in summer. The fascioliasis scenario in Egyptian lowlands shows similarities to highlands of Bolivia and Peru. Diagnostic methods, pathogenicity and morbidity in high burdens should be considered. The need for an appropriate quantitative assessment of heavy infected children to avoid post-treatment colic episodes is highlighted.

District health planning at a time of transition: a critical review and lessons learnt from the implementation of regional planning in Uganda

A quarter of a century after the Harare Declaration on Strengthening District Health Systems Based on Primary Health Care (1987) was conceived, district health teams (DHTs) are facing a markedly changed situation. Rapid population growth, urbanization, a rapidly developing private sector, and the increasing role of vertical programs and global initiatives have marginalized the planning process and weakened the entire district health system (DHS). The Ugandan Ministry of Health (MoH) responded to these challenges by beginning a review of district planning: a key action point of the Harare Declaration. The first step was a critical review of relevant literature, then central and district health staff were engaged with to provide their input in developing the new strategy. Through a field experiment started in 2012-13, and still underway, the MoH is developing an innovative regional approach to health planning, which aims to encompass the complexity of the new context of health care provision and coordinate all new actors (private health providers, projects and local government staff from other sectors) operating in the health sector. A strategic revision of the planning process represents an opportunity to develop an appropriate 'Theory of Change', intended as a broader approach of thinking about the entire DHS and the relative role and functions of the DHT. Leadership and stewardship capacities of MoH staff, at central and peripheral level, must be strengthened and supported to achieve the expected changes and results.

Description of two measles outbreaks in the Lazio Region, Italy (2006-2007). Importance of pockets of low vaccine coverage in sustaining the infection

BACKGROUND

Despite the launch of the national plan for measles elimination, in Italy, immunization coverage remains suboptimal and outbreaks continue to occur. Two measles outbreaks, occurred in Lazio region during 2006-2007, were investigated to identify sources of infection, transmission routes, and assess operational implications for elimination of the disease.

METHODS

Data were obtained from several sources, the routine infectious diseases surveillance system, field epidemiological investigations, and molecular genotyping of virus by the national reference laboratory.

RESULTS

Overall 449 cases were reported, sustained by two different stereotypes overlapping for few months. Serotype D4 was likely imported from Romania by a Roma/Sinti family and subsequently spread to the rest of the population. Serotype B3 was responsible for the second outbreak which started in a secondary school. Pockets of low vaccine coverage individuals (Roma/Sinti communities, high school students) facilitated the reintroduction of serotypes not endemic in Italy and facilitated the measles infection to spread.

CONCLUSIONS

Communities with low vaccine coverage represent a more serious public health threat than do sporadic susceptible individuals. The successful elimination of measles will require additional efforts to immunize low vaccine coverage population groups, including hard-to-reach individuals, adolescents, and young adults. An enhanced surveillance systems, which includes viral genotyping to document chains of transmission, is an essential tool for evaluating strategy to control and eliminate measles.

[A cross-sectional survey on childhood immunization coverage and reasons of non-compliance in Lazio Region, Italy (2007)]

During 2007, Laziosanità conducted a cross-sectional survey on childhood immunization coverage in Lazio Region. The survey, implemented in collaboration with the 12 LHUs of the Region, aimed at assessing immunization coverage among children, with 24 months of age or older, at regional and district level. In addition, the survey assessed reliability of the routine surveillance system and immunization records at peripheral level. Finally, delay in immunization schedule, and major reasons for non-compliance, as reported by the mothers, were analyzed. The survey results allowed to identify weakness in the routine surveillance system, low coverage levels for specific LHUs, and strategies for improvement of immunization coverage.

Incidence of bacterial meningitis (2001-2005) in Lazio, Italy: the results of a integrated surveillance system

Background

Monitoring the incidence of bacterial meningitis is important to plan and evaluate preventive polices. The study's aim was to estimate the incidence of bacterial meningitis by aetiological agent in the period 2001–2005, in Lazio Italy (5.3 mln inhabitants).

Methods

Data collected from four sources – hospital surveillance of bacterial meningitis, laboratory information system, the mandatory infectious diseases notifications, and hospital information system – were combined into a single archive.

Results

944 cases were reported, 89% were classified as community acquired. S. pneumoniae was the most frequent aetiological agent in Lazio, followed by N. meningitis. Incidence of H. influenzae decreased during the period. 17% of the cases had an unknown aetiology and 13% unspecified bacteria. The overall incidence was 3.7/100,000. Children under 1 year were most affected (50.3/100.000), followed by 1–4 year olds (12.5/100,000). The percentage of meningitis due to aetiological agents included in the vaccine targets, not considering age, is 31%. Streptococcus spp. was the primary cause of meningitis in the first three months of life. The capture-recapture model estimated underreporting at 17.2% of the overall incidence.

Conclusion

Vaccine policies should be planned and monitored based on these results. The integrated surveillance system allowed us to observe a drop in H. influenzae b meningitis incidence consequent to the implementation of a mass vaccination of newborns.

Acute hepatitis B 14 years after the implementation of universal vaccination in Italy: areas of improvement and emerging challenges

BACKGROUND

Italy had intermediate-level endemicity for hepatitis B virus (HBV) infection in the 1970s and 1980s. In 1991, vaccination of infants and adolescents became mandatory. We report the impact of universal vaccination 14 years after its beginning.

METHODS

We performed a case-control study within a population-based surveillance for acute viral hepatitis. The incidence of acute hepatitis B (AHB) was estimated for the time since 1991, and the association between AHB and the considered risk factors was analyzed for the period 2001-2005.

RESULTS

The incidence of AHB progressively decreased from 1991 to 2005, mainly for persons in the age groups targeted by the universal vaccination campaign: there was a 24-fold and 50-fold decrease in the 15-24-year and 0-14-year age groups, respectively; for the > or =25-year age group, the incidence halved. Owing to the persons' ages, approximately 3% of total AHB cases should have been the target of vaccination campaign. In 2004-2005, foreigners accounted for 14% of total cases and for 57% of persons who should have been targets for vaccination. Missed opportunities for immunization were documented for approximately 50% of patients with AHB who reported cohabitation with HBV carriers and for 70% of those who reported injection drug use. The strongest associations with AHB were found for blood transfusion (adjusted odds ratio [OR(adj)], 8.4; 95% confidence interval [CI], 2.7-26), cohabitation with HBV carriers (OR(adj), 5.3; 95% CI, 3.6-7.7), injection drug use (OR(adj), 3.8; 95% CI, 2.5-5.8), and unsafe sexual practices (OR(adj), 2.8; 95% CI, 1.9-4.2).

CONCLUSION

Universal vaccination has contributed to a decreasing AHB incidence in Italy, especially by reducing the risk of infection among persons aged 15-24 years. Most infections occur in persons aged > or =25 years in association with injection drug use, unsafe sexual activity, percutaneous treatment, and iatrogenic exposure. Improvement of vaccine coverage in high-risk groups and adherence to infection control measures during surgery and percutaneous treatment are needed. The high risk still associated with blood transfusion needs to be further investigated, with consideration of occult HBV infection in blood donors. The potential spread of HBV infection from the immigrant population deserves adequate health policy prevention programs.

HIV incidence estimate among non-nationals in Italy

We estimated the incidence of new HIV infections among non-nationals living in Italy for the period 1992-2004, calculated as the number of new diagnoses among legally and illegally residing non-nationals out of the number of new residence permits (which does not include illegal non-nationals). This incidence was compared to that among Italians by calculating the standardized incidence ratio (SIR) by age and gender. There were 17,309 new diagnoses; 19.0% were among non-nationals. The incidence of new diagnoses among non-nationals was 69 cases per 100,000 residence permits, compared to 8.7 per 100,000 population among Italians. The SIR confirmed the marked difference between the two populations, with the incidence being six times higher among non-nationals, compared to Italians. This difference increased over time: in 1992-1994, it was five times higher among non-nationals, compared to Italians, whereas it was eight times higher in 2002-2004. Although the incidence of infection among non-nationals seems to have decreased in the past 10 years, it is still high if compared to that among Italians, suggesting that non-nationals constitute a population subgroup with a high circulation of HIV. Furthermore, HIV is mainly transmitted through the sexual route among non-nationals, prevalently affecting younger persons and women. Access to testing, treatment, and care needs to be facilitated for non-nationals.

Human fascioliasis infection: gender differences within school-age children from endemic areas of the Nile Delta, Egypt

Several studies have reported a higher prevalence of infection for human fascioliasis among girls than among boys. To investigate this aspect further a sufficiently large data set was assembled comprising of 21,477 subjects with 932 positive cases. Subjects were primary school children covered by a control programme implemented by the Egyptian Ministry of Health and Population in the Nile Delta from 1988 to 2002. Stool analyses were performed by the Kato-Katz thick smear technique for a quantitative diagnosis on the intensity of infection. Both prevalence and intensity of infection, indirectly measured as mean number of eggs per gram of faeces, were significantly higher among girls than boys. The higher level of infection in girls was consistent across different years and in different survey areas. Co-infection with Schistosoma mansoni was present and associated with fascioliasis, but schistosomiasis was significantly more prevalent among boys. In Egypt rural girls are often involved in household and farm work and are exposed more than boys to infected foci. The lower school attendance for girls in rural areas appears to be an important factor increasing risk of infection. The precise mode of transmission and behavioural risk factors for human infection need to be investigated further to identify those related to gender.

Acute hepatitis delta virus infection in Italy: incidence and risk factors after the introduction of the universal anti-hepatitis B vaccination campaign

BACKGROUND

Updates on the incidence of and risk factors for acute hepatitis delta virus infection in Italy, as well as in other countries, are lacking, and the impact of the mandatory anti-hepatitis B vaccination has not been evaluated.

METHODS

We performed a case-control study within a population-based surveillance for acute viral hepatitis.

RESULTS

During 1993-2004, 344 cases of acute hepatitis delta virus infection were reported. After a peak in 1993 (2.8 cases per 1 million population), the incidence decreased from 1.7 to 0.5 cases per 1 million population. Coinfections were prevalent. The decrease in incidence particularly affected young adults, and it paralleled the decrease in incidence of acute hepatitis B. In 1993, being an injection drug user (adjusted odds ratio [OR(adj)], 67.9; 95% confidence interval [CI], 18.1-254.5) or being a member of a household with a carrier of hepatitis B surface antigen (OR(adj,) 14.8; 95% CI, 3.0-72.9) were the only independent predictors of infection. During 1994-2004, being an injection drug user (OR(adj), 36.8; 95% CI, 20.7-65.4), cohabitation with an injection drug user (OR(adj), 4.2, 95% CI, 1.7-12.3), hospitalization (OR(adj), 3.5; 95% CI, 1.9-6.6), receipt of dental therapy (OR(adj), 2.3; 95% CI, 1.4-3.6), promiscuous sexual activity (OR(adj), 2.2; 95% CI, 1.4-3.6), and receipt of beauty treatment (OR(adj), 2.0; 95% CI, 1.3-3.2) were independently associated with infection.

CONCLUSIONS

Incidence of acute hepatitis delta infection is markedly decreasing in Italy. Undergoing invasive medical procedures, engaging in promiscuous sexual activity, and receiving beauty treatments are emerging, in addition to injection drug use, as important risk factors for infection. Further efforts are needed to increase vaccine coverage in high-risk groups and to implement the safety of invasive procedures performed both inside and outside health care facilities.

Cluster of measles cases in the Roma/Sinti population, Italy, June-September 2006

Three clusters of measles cases occurred between June and September 2006, in the Roma/Sinti populations in three different Italian regions: the Bolzano-South Tyrol in northern Italy; Lazio in central Italy; and the island of Sardinia in the southwest.

Cost-effectiveness of vaccinating for invasive pneumococcal disease in the elderly in the Lazio region of Italy

Pneumococcal vaccination among the elderly is currently recommended in several western countries. We estimated the cost-effectiveness of a hypothetical vaccination campaign of 65+ year olds in the Lazio region (Italy). Baseline net costs per event averted and life-year gained, at 2001 prices, were euro 34,681 (95%CI: euro 28,699 to euro 42,929) and euro 23,361, respectively (95%CI: euro 16,419 to euro 38,297). Lower bacteraemic pneumonia incidence and vaccine effectiveness increased the net cost per life-year gained (ICER) to euro 53,899 and euro 74,313, respectively; in the best-case scenario the ICER was euro 4249. The case definition of invasive pneumococcal disease and, consequently, vaccine effectiveness are major uncertainties in countries with low incidence of pneumonia.

Streptococcus pneumoniae in western Europe: serotype distribution and incidence in children less than 2 years old

We did a systematic search and synthesis of evidence on the incidence of invasive pneumococcal disease, symptomatic disease, and circulating Streptococcus pneumoniae serotypes in western Europe. Using data from studies published between 1992 and 2005 we calculated a weighted mean invasive pneumococcal disease and pneumococcal meningitis incidence rate per 100,000 children aged 2 years or younger within 95% confidence intervals, together with the prevalence of S. pneumoniae serotypes and resistance to penicillin. Invasive pneumococcal disease incidence was 27.03 cases per 100,000 children under 2 years (95% CI 21.85-33.43) [corrected] Heptavalent conjugate vaccine serotypes account for 43.18-75.32% of isolates among people aged under 18 years of age. 11% of isolates in individuals aged under 18 years were penicillin resistant. The incidence of invasive pneumococcal disease appeared consistently lower in western European countries compared with studies from the USA. Thus the use of studies of vaccine effectiveness based on the US population may lead to an overestimation of the benefits of its introduction in Europe.

First cases of rubella infection during pregnancy detected by new reporting system in Italy

On 1 January 2005, rubella infection during pregnancy and congenital rubella syndrome/infection were made statutorily notifiable in Italy, as recommended by the national plan for the elimination of measles and congenital rubella

Control of human fascioliasis by selective chemotherapy: design, cost and effect of the first public health, school-based intervention implemented in endemic areas of the Nile Delta, Egypt

Human fascioliasis is becoming a serious public health problem with a number of endemic areas identified in different countries. The viability of humans as definitive hosts has been experimentally demonstrated, and there is now a need to control the human infection along with the veterinary infection. In 1998, following reports on high prevalence among children in the Nile Delta, the Egyptian Ministry of Health and Population launched the first public health, school-based intervention to control human fascioliasis. An innovative selective treatment approach, with chemotherapy targeted to specific high risk age groups and villages, was adopted. First, high prevalence districts were identified by a regional baseline survey, then screening and selective treatment of all schoolchildren took place in high prevalence villages within those districts. From 1998 to 2002 the programme screened almost 36000 schoolchildren, in six districts, treating 1280 cases of human fascioliasis. Prevalence in the endemic area was reduced from 5.6 to 1.2%. The control intervention is described in detail, including data on cost. The targeted, selective chemotherapy approach was appropriate in addressing low prevalence infection, effective in reducing prevalence rates and transmission of the disease, and in the present situation, more cost-effective than mass distribution.

Anaemia among schoolchildren in Qena Governorate, Upper Egypt

A study was carried out during January/February 2001 in Deshna and Armant Districts of Qena Governorate, Upper Egypt, to establish the prevalence of anaemia among schoolchildren aged 6 to 11 years and define appropriate control interventions in the area. Haemoglobin levels were measured directly in schools using a portable spectrophotometer. The mean (SD) level of haemoglobin in 1844 schoolchildren in 37 schools was 12.79 (1.15) g/dL. Only 12% of children were below the WHO cut-off for anaemia for this age group (< 11.5 g/dL) and no cases of severe anaemia (< 7.0 g/dL) were detected. The low prevalence of mild to moderate anaemia indicates that mass iron supplementation is not justifiable, but routine monitoring of haemoglobin levels should be part of the public health activities in the schools.

Anaemia among schoolchildren in Qena Governorate, Upper Egypt

A study was carried out during January/February 2001 in Deshna and Armant Districts of Qena Governorate, Upper Egypt, to establish the prevalence of anaemia among schoolchildren aged 6 to 11 years and define appropriate control interventions in the area. Haemoglobin levels were measured directly in schools using a portable spectrophotometer. The mean [SD] level of haemoglobin in 1844 schoolchildren in 37 schools was 12.79 [1.15] g/dL. Only 12% of children were below the WHO cut-off for anaemia for this age group [< 11.5 g/dL] and no cases of severe anaemia [< 7.0 g/dL] were detected. The low prevalence of mild to moderate anaemia indicates that mass iron supplementation is not justifiable, but routine monitoring of haemoglobin levels should be part of the public health activities in the schools

Distribution of human fascioliasis by age and gender among rural population in the Nile Delta, Egypt

The number of cases of human fascioliasis reported in Egypt, has increased drastically during the past years. Most of the newly infected cases were children and adolescents. In the year 2000, the Egyptian Ministry of Health and Population implemented a cross-sectional survey in four endemic foci of Behera Governorate, in the Nile Delta. The aim of the study was to define prevalence and intensity of human fascioliasis, by age and gender, in order to plan appropriate control measures in endemic areas. The field assessments involved 1331 subjects and utilized the Kato-Katz thick-smear technique, on a double preparation, for quantitative diagnosis of intestinal helminths. A total of 72 positive cases were detected, the majority of them (n = 51, 71 per cent) in subjects below 19 years of age. The highest prevalence and intensity of infection was reported in the 9-11 years age group. Women were more affected then men, but not at a significant level. Primary schoolchildren appeared to be more at risk of contracting the infection and should be considered the main target for control measures. Further studies are needed to identify new ways of infections and possible risk factors responsible for the higher transmission among schoolchildren and women.

Hyperendemic fascioliasis associated with schistosomiasis in villages in the Nile Delta of Egypt

Coprologic surveys were carried out in villages of the Behera Governorate in the Nile Delta region of Egypt to characterize the epidemiologic features of human fascioliasis caused by Fasciola hepatica and F. gigantica in this lowland endemic area by comparison with fascioliasis caused by only F. hepatica in areas hyperendemic for human disease in the Andean highlands of South America. The fascioliasis prevalences detected (range = 5.2-19.0%, mean = 12.8%) are the highest obtained in Egypt. The comparison with previous results suggests that in the Nile Delta, fascioliasis is spreading from an original situation of sporadic human cases in well-known endemic foci for animal disease to an endemic distribution in humans, which may be characterized as a mesoendemic region that includes several hyperendemic areas for human disease. As in Andean countries, a relationship with sex was found, although in Egypt prevalences, but not intensities, appeared to be significantly higher in females. All ages appear to be susceptible to liver fluke infection, with prevalences and intensities being lower before and after school age, a situation that is consistent with that detected in Andean countries, although the peak in the 9-11-year-old age group appears less pronounced in Egypt. The intensities were very high when compared with those found in subjects sporadically infected in areas endemic for animal disease, but relatively low for a hyperendemic situation, although the intensities may not be conclusive because of the transmission seasonality of fascioliasis in the Nile Delta. The marked similarities in the qualitative and quantitative spectrums of protozoans and helminths, multiparasitisms, and associations between liver flukes and other parasitic species suggest physiographic-hydrographic and behavioral-social characteristics similar in all areas hyperendemic for human fascioliasis, which are independent of other factors such as climate, altitude, and cultural or religious features. The significant positive association between liver fluke infection and schistosomiasis mansoni detected in one locality has never been described elsewhere, and must be considered relevant from clinical, pathologic, diagnostic, and therapeutic points of view. Interestingly, the relationships of schistosomiasis prevalences and intensities with sex and age follow patterns similar to those found in fascioliasis.

Performance of Sahli and colour scale methods in diagnosing anaemia among school children in low prevalence areas

Our aim was to compare the performance of the Sahli and Colour Scale methods in diagnosing anaemia in school children, where the prevalence of anaemia is low and the haemoglobin level ranges from mild to moderate (8-11 g/dl). The study was conducted in February 2001, in Qena Governorate, Upper Egypt. The haemoglobin level measured by the two methods in each child were compared with the result obtained by using a portable haemoglobin photometer 'HemoCue'. A total of 149 school children were included in the study. Using HemoCue, 17.4% children were anaemic; using the Sahli method (SM), 66.4% children were anaemic; and using the Haemoglobin Colour Scale (HCS) method, 57.7% children were anaemic. Neither method detected any cases of severe anaemia (Hb < 7 g/dl). Both the Sahli and Colour Scale methods are sensitive but have low specificity, giving a high rate of false positive results. Both methods perform perform very similarly in haemoglobin measurement; they fulfil many of the criteria for their use at primary health care level and detect almost all cases of anaemia in a given population, even if the level of anaemia is mild. Standards for collection, handling and disposal of blood samples are guaranteed more easily by the HCS than the SM. Moreover, lay people can easily manage the HCS with success after brief training. We suggest to gradually replace the SM by the HCS method in primary health care (PHC) centres. Where anaemia levels are moderate to mild, the use of SM and HCS as tools to define anaemia prevalence might be limited, as they often label healthy individuals as anaemic. Both methods remain a useful diagnostic tool to confirm the diagnosis of clinically suspected anaemia in areas where the prevalence of anaemia is low and the haemoglobin level ranges from mild to moderate.

The School Health Programme in Behera: an integrated helminth control programme at Governorate level in Egypt

School Health Programmes offer the opportunity to deliver public health interventions to a great number of beneficiaries at a relatively low cost and are seen with growing interest by policy makers in developing countries and the donors' communities. In Egypt a pilot School Health Programme has been implemented for the past 6 years in Behera, the largest and most populous Governorate of the Nile Delta. The Programme integrated additional activities for the control of soil-transmitted helminthiasis, human fascioliasis and anaemia in the National Schistosomiasis Control Programme (NSCP), implemented in Egypt since 1988 by the Ministry of Health and Population (MoHP). To facilitate planning and direct actions, a strong monitoring system was also developed, that generated useful information for the schistosomiasis control programme. The practical steps adopted to develop the programme are presented and discussed. Results from three rounds of monitoring (2000, 2001, 2002) are analysed and compared with baseline data conducted in 1996, together with the cost of each activity. On the basis of the experience gained by the Behera School Health Programme a number of operational recommendations are formulated.

Clinical signs and household characteristics associated with human fascioliasis among rural population in Egypt: a case-control study

The symptomatology associated with human fascioliasis has been studied mostly in hospitalised subjects. Very little is known about clinical signs and symptoms associated with infections in human endemic zones, as well as on possible new ways of transmission which might be responsible for the increased number of human cases reported in recent years. This information is of great importance to facilitate diagnosis and plan effective control measures. With the objective to identify clinical signs, blood tests, household characteristics and hygienic habits associated with human fascioliasis, a cross-sectional case-control study was implemented among the rural population of three endemic foci in the Nile Delta, Egypt. Clinical history was collected from 53 cases of fascioliasis and the same number of individually matched controls. They received a complete clinical examination and a range of blood tests was performed on them. Information on socio-economic conditions, dietary and hygienic habits was also collected. The most important complaints, associated with the infection, were right abdominal pain (Odds Ratio 20, P = 0.005), epigastric burning (o.r. 16, P = 0.007) and nausea (o.r. 8, P = 0.05). Blood analyses reported a marked increase in blood eosinophils (o.r 1.3, P = 0.001) among cases. The presence of cows (o.r 3.2), buffaloes (o.r 3.0) and goats (o.r 2.6) in the household was closely associated with the infection together with the habit to bring those animals to the canal for bathing and/or drinking (o.r. 3.2). Among dietary habits investigated, eating raw seeds was more common in cases than controls (o.r. 9, P = 0.03) and emerged as a possible new way of infection.

Anaemia among young male workers in Alexandria, Egypt

In a cross-sectional survey, we investigated exposure to and the presence of factors associated with anaemia, such as socioeconomic conditions, dietary habits, intestinal parasitic infections and lead among 355 young male workers [7-19 years of age]employed in private workshops. Of the total study sample, 44.5% [158 participants]were found to be anaemic. The major risk factors for anaemia were multiple parasitic infection, high intensity of parasitic [Ascaris lumbricoides]infection and drinking tea soon after a meal. A significantly lower prevalence of anaemia was noted after Ramadan; it appeared to be the main factor associated with the presence or absence of anaemia and warrants further attention.

Anaemia among young male workers in Alexandria, Egypt

In a cross-sectional survey, we investigated exposure to and the presence of factors associated with anaemia, such as socioeconomic conditions, dietary habits, intestinal parasitic infections and lead among 355 young male workers (7-19 years of age) employed in private workshops. Of the total study sample, 44.5% (158 participants) were found to be anaemic. The major risk factors for anaemia were multiple parasitic infection, high intensity of parasitic (Ascaris lumbricoides) infection and drinking tea soon after a meal. A significantly lower prevalence of anaemia was noted after Ramadan; it appeared to be the main factor associated with the presence or absence of anaemia and warrants further attention.

Prevalence of xerophthalmia among children in Beheira governorate, Egypt

A survey was conducted on a sample representative of the entire Beheira governorate to identify high-risk areas of vitamin A deficiency [VAD] and assess xerophthalmia prevalence. The study also tested the reliability of a household cluster survey for assessing xerophthalmia prevalence. A trained ophthalmologist examined 10, 664 children. The results showed that VAD was present in the region, but did not appear to be a public health problem. Ocular signs of VAD were more prevalent among older children, suggesting an improvement in socioeconomic conditions and health care over the past few years. The household cluster survey appeared to be a reliable method for assessing xerophthalmia prevalence in the region

Prevalence of xerophthalmia among children in Beheira governorate, Egypt

A survey was conducted on a sample representative of the entire Beheira governorate to identify high-risk areas of vitamin A deficiency (VAD) and assess xerophthalmia prevalence. The study also tested the reliability of a household cluster survey for assessing xerophthalmia prevalence. A trained ophthalmologist examined 10,664 children. The results showed that VAD was present in the region, but did not appear to be a public health problem. Ocular signs of VAD were more prevalent among older children, suggesting an improvement in socioeconomic conditions and health care over the past few years. The household cluster survey appeared to be a reliable method for assessing xerophthalmia prevalence in the region.

An analysis of individual, household, and environmental risk factors for intestinal helminth infection among children in Qena Governorate, Upper Egypt

During 1994 a cross-sectional survey was carried out on a sample representative of the population in Qena Governorate, Upper Egypt, to investigate the relationship between intestinal helminthic infection among children and a wide range of variables (demographic, behavioural, cultural, socioeconomic, and environmental). Data were collected by direct observation and by administering a questionnaire to mothers in charge of the household in a sample of 768 households representative of the entire population in the governorate. A stool sample survey was conducted at the same time on all children 2-12 years of age living in the selected households (n = 2657). Diagnosis of intestinal helminths was made on the basis of the Kato-Katz thick-smear technique. After univariate analyses, conducted to define associations among individual, familial, and community variables and prevalence of infection, the relevant variables were included in a multivariate logistic model to assess the importance of each factor as an independent determinant of infection. Several factors were independently associated with increased risk of intestinal helminth infection. In particular, the age of the child (between 4 and 5 years) (individual), the age of marriage for the mother (cultural), type of garbage disposal (household), and type of settlement (environmental) gave the highest predictive value for infection. The present results are consistent with those of former studies and highlight the importance of a multisectorial approach in the control of intestinal helminth infection.

Anaemia and intestinal parasitic infections among school age children in Behera Governorate, Egypt. Behera Survey Team

Anaemia is considered a serious public health problem in Egypt, although updated population-based data are lacking. Similarly, data on prevalence and intensity of infection with intestinal parasites, which are considered one possible cause of anaemia, are available only from small, unrepresentative sample surveys. The present research was implemented on an entire Governorate representative sample. The aim of the study was to assess the prevalence of anaemia and intestinal parasites in the area and to evaluate the role of each parasite in the epidemiology of anaemia among school age children. At the end of the survey, results of faecal analyses from direct smear and the Kato-Katz examination techniques were available from 1844 and 1783 children respectively, as well as haemoglobin levels measured by spectrophotometer from 1238 children aged 6-12 years. The prevalence of anaemia in the area was high (90 per cent), but very few serve forms were detected (< 2 per cent). Prevalence of intestinal parasites was high only for protozoa (Giardia intestinalis 24.7 per cent Entamoeba histolytica 17.5 per cent) and Schistosoma mansoni (20.7 per cent). From analysis of the results, Fasciola infection appeared to be highly endemic, even among children (3 per cent), and emerged as the factor most strongly correlated with low levels of haemoglobin (p < 0.0001). The effect of Fasciola on haemoglobin levels was related to the intensity of infection with this parasite. The role of S. mansoni as a risk factor for anaemia was supported by the present study. Among the protozoa, G. intestinalis was significantly correlated with low haemoglobin levels (p < 0.05). The present results substantiated similar findings from smaller studies. In future research, the relationship between Fasciola infection and anaemia needs to be studied with a well-controlled longitudinal design.

Knowledge, perceptions and behaviour of mothers toward intestinal helminths in Upper Egypt: implications for control

Operational research was conducted in Qena Governorate, Upper Egypt, to gather the information needed to design an integrated control programme for intestinal helminths in the area. To this aim, qualitative and quantitative techniques were used on a sample representative of the entire governorate. Mothers were questioned about their knowledge and perception of intestinal helminths, their hygienic habits and health-seeking behaviour. At the same time, a coprological survey was conducted on all the children 2 to 12 years of age living in the selected households (n = 2657) to provide baseline data on the prevalence of infection with these parasites. The survey results showed that intestinal helminth infections were more prevalent in rural areas and in three of the 12 Governorate districts. Almost all the respondents considered worms harmful and were aware of the need for treatment. More than adequate knowledge was present on ways to prevent infection. Good hygienic practices were associated with a low prevalence of infection in the household. Practical recommendations were formulated to design a helminth control programme tailored to the local situation and to prioritize allocation of resources. Passive case detection appeared to be appropriate to the level of infection in Qena (< 15%). The intervention should target areas and districts where prevalence of infection was higher, and all children below 12 years of age. Health education, besides encouraging mothers to refer their children to the health units for treatment, should focus on improving hygienic behaviour. While schools might be the best channel to contact children, the use of informal channels of communication, such as television, should be promoted to reach the mostly illiterate mothers. The research highlights the importance of gathering information on mothers' perceptions and behaviour in the design and implementation of a community-based intestinal helminths control programme.

Different patterns of intestinal helminth infection among young workers in urban and rural areas of Alexandria Governorate, Egypt

The process of urbanisation taking place in most developing countries is creating favourable conditions for an increase in prevalence of infections, especially with intestinal parasites, in the marginal areas of the towns. The present study was implemented in 1996 to assess the varying prevalence and intensity of infection among young workers in urban and rural areas of the same Governorate (Alexandria, Egypt). The sample comprised 408 male subjects, 8 to 19 years of age, in various occupations: 308 from urban areas, 67 from an industrialised village close to the desert, and 33 from a rural village. A quantitative diagnosis of intestinal helminth infections was made using the Kato-Katz technique, with a double reading of each slide. The results showed a higher prevalence (> 50%) and intensity of infection (indirectly measured as number of eggs per gram of faeces) than in previous studies. Furthermore, a higher prevalence and intensity of infection with Ascaris lumbricoides and Trichuris trichiura was detected in urban districts, as compared to rural areas. This difference was statistically significant. High crowding index, latrine shared with other families and no piped water inside the household, were more common in urban areas as compared with rural settlements and also associated with a higher intensity of infection by soil-transmitted helminths. The trend toward urbanisation seems to have caused deterioration of living conditions and sanitation standards in some areas of Alexandria city, with the most vulnerable people experiencing an increase in intestinal parasitic infections.

Nutrition education and mega-dose vitamin A supplementation in Nepal

Two approaches to improve vitamin A nutriture are compared: nutrition education and mega-dose capsule distribution. The impact of these programmes on vitamin A deficiency (VAD), wasting malnutrition, and excessive childhood mortality are compared for approximately 40,000 children who were assigned to either intervention cohorts or a control group from 75 sites within seven districts in two ecological settings (Terai, or lowland, and hills) of Nepal. Twenty-four months after the implementation of the project, the reduction of risk of xerophthalmia was greater among children of mothers who were able to identify vitamin A-rich foods [relative risk (RR) = 0.25; 95% CI = 0.10-0.62] than among children who received mega-dose capsules (RR = 0.59; 95% CI = 0.41-0.84). The risk of mortality at two years was reduced for both the nutrition education cohort (RR = 0.64; 95% CI = 0.48-0.86) and capsule distribution cohort (RR = 0.57; 95% CI = 0.42-0.77). The nutrition education program, however, was more expensive to deliver than the capsule distribution programme. High rates of participation in the supplementation programme were achieved within a short period. The nutrition education message spread rapidly throughout the study population, although practice was slower to change. Where maternal literacy was low and channels of communication were limited, the capsule programme appeared to be more cost-effective. However, economies of scale for nationwide programmes exist for nutrition education programmes that do not exist for capsule distribution programmes. A comprehensive national programme requires both dietary supplementation and nutrition education.

Lead toxicity among working children and adolescents in Alexandria, Egypt

A substantial number of children and adolescents work and are exposed to different occupational and environmental hazards. In order to identify the prevalence of lead toxicity and related risk factors, a study was conducted of 408 working children and adolescents in Alexandria. In 20.1% of those sampled, the blood lead level was >/= 25 mg/dl. For children working in battery workshops in El-Gomrouk and Mina El-Bassal districts, anaemia and smoking were found to be significantly associated with a higher risk of lead toxicity. Thus, more attention should be paid to the problem of lead toxicity in working children, particularly in industrialized urban cities with heavy traffic and an unprotected work environment

Impact of nutrition education and mega-dose vitamin A supplementation on the health of children in Nepal

The impact on vitamin A deficiency (VAD), wasting malnutrition, and excessive childhood mortality of two alternative approaches-nutrition education and mega-dose capsule distribution (6-12-month-olds: 100,000 IU; 1-5-year-olds: 200,000 IU)-in communities in Nepal are compared. Approximately 40,000 children from 75 locations in seven districts in two ecological settings (lowland and hills) took part in the study and were randomly allocated to intervention cohorts or a control group. At 24 months after the implementation of the project the reduction of risk for xerophthalmia was greater among children whose mothers were able to identify vitamin-A-rich foods (relative risk (RR) = 0.25; 95% confidence interval (CI) = 0.10-0.62) than among the children who received mega-dose capsules (RR = 0.59; 95% CI = 0.41-0.84). The risk of mortality at 2 years was reduced for both the nutrition education (RR = 0.64; 95% Cl = 0.48-0.86) and capsule distribution (RR = 0.57; 95% CI = 0.42-0.77) cohorts. The nutrition education programme was, however, more expensive to deliver than the capsule distribution programme. High rates of participation for children in the supplementation programme were achieved quickly. The nutrition education messages also spread rapidly throughout the study population (regardless of intervention cohort assignment). Practices, however, were slower to change. In communities where maternal literacy was low and channels of communication were limited the capsule distribution programme appeared to be more economical. However, there are economies of scale for nationwide education programmes that do not exist for capsule distribution programmes. Although nutrition education provides economies of scale and the promise of long-term sustainability, a comprehensive national programme requires both dietary supplementation and nutrition education components.

Selective treatment and targeted chemotherapy: effect on prevalence and intensity of infection for two intestinal helminths in Nepalese children

The study examines the effect of mebendazole distribution (2 x 100 mg x 3 days) either as mass chemotherapy targeted to children 1 to 10 years old, or selective treatment of heavily infected children, over a two year period in sixteen rural villages of Nepal. Eight villages were covered with six monthly mass chemotherapy, provided by Community Health Volunteers, other eight with yearly selective treatment of heavily infected children based on clinical signs. Prevalence and intensity of infection, indirectly measured as the number of eggs per gram of faeces, were measured for A. lumbricoides and hookworms utilising the Kato thick-smear technique. At the end of two year intervention, the effect of both activities was similar on worm prevalence with a slightly significant difference (p < 0.05) on worm load in favour of mass chemotherapy. Furthermore a greater effect of mebendazole was reported, regardless of the type of intervention, on hookworms present at baseline with a lower prevalence (23.4%) than A. lumbricoides (47.6%). The study suggests that clinical diagnosis of heavily infected children may be a feasible way to direct selective treatment. Baseline prevalence seems to influence effectiveness of control programs. Further studies are needed to substantiate these observations.

Intestinal helminths and xerophthalmia in Nepal. A case-control study

The study reports on 25 cases of xerophthalmia among children 6-120 months of age and single controls for which faecal egg counts were available as proxy for hookworm and Ascaris lumbricoides infection. The selection of cases and controls was performed by ophthalmic assistants. Controls were healthy children matched for sex, age, and neighbourhood of residence. Faecal analyses were performed by Kato thick-smear technique, recording the number of eggs of hookworm and A. lumbricoides. The xerophthalmia cases had a significantly higher prevalence (P < 0.05) and intensity (P < 0.01) of infection, as expressed by the presence and number of A. lumbricoides eggs per gram of faeces, respectively, compared with the control group. Hookworm eggs were not detected in the faecal specimens of any of the cases or controls. This study demonstrates the importance of A. lumbricoides as a risk factor for ocular signs of vitamin A deficiency. Reduction of prevalence and intensity of A. lumbricoides infection may reduce the incidence of xerophthalmia in the community with its potential sequels of blindness, morbidity, and mortality.

Improving skills and utilization of community health volunteers in Nepal

The study analyses the effects of a Nutrition Education Intervention (NEI), specifically designed to reduce vitamin A deficiency, on skills and utilization of Community Health Volunteers (CHVs) in rural Nepal. The intervention, which included preventive and curative activities, was carried out through the existing Primary Health Care (PHC) structure, utilizing CHVs trained by the Ministry of Health and already working in the villages. At the end of two years implementation, the CHVs associated with the NEI showed an improved ability to detect and treat a range of common diseases (diarrhoea, night blindness, malnutrition and acute respiratory infections) as compared with the CHVs not associated with the intervention program. Community utilization of CHVs increased significantly while the use of traditional healers and consultations at private pharmacies decreased. The utilization of health posts and referral to hospitals remained constant. Coverage for all activities carried out by the CHVs was higher among the population within the NEI area. The intervention did not utilize cash incentives. Its operational input consisted mainly of more frequent training, added supervision and increased and regular drug supply. The inclusion of curative activities among the CHVs' responsibilities seems to be a key factor in increasing motivation of volunteers and their acceptance within the community. This study indicated some possible adjustments to improve productivity and utilization of health volunteers in rural communities of Nepal, with a positive return for all PHC activities.

Ascariasis, hookworm infection and serum retinol amongst children in Nepal

The study reports on the association between serum retinol levels and prevalence of two intestinal helminths in a random sample of 592 children, 6-120 months of age. Faecal analyses were performed by Kato thick-smear technique, recording the presence of hookworm and Ascaris lumbricoides eggs. Serum retinol levels were determined by high pressure liquid chromatography (HPLC) and expressed in micrograms/dl. The presence of Ascaris lumbricoides eggs was associated with lower levels of serum retinol in children below 60 months of age (p < 0.05). The presence of hookworm eggs was not associated with lower levels of serum retinol in any age group. In addition children who received at least one course of mebendazole during the past 12 months recorded higher serum retinol levels than children who did not receive it (p < 0.01).

Intestinal helminths and risk of anaemia among Nepalese children

Relationships between hookworm, A. lumbricoides and anaemia were studied utilising egg count in faecal specimens and haemoglobin levels from a cross-sectional sample of 641 Nepalese children, 6 to 120 months of age. Additional analyses were performed to assess the level of risk by age and worm load. Kato thick-smear technique was used to perform faecal analyses, recording the number of hookworm eggs and A. lumbricoides eggs in each sample of 50 mg of faeces. Haemoglobin levels were assessed by the Sahli method. The presence of eggs for each parasite was significantly associated with lower levels of haemoglobin (P < 0.001). Children infected with both parasites or hookworm alone presented higher depletion of haemoglobin. The presence of A. lumbricoides was more closely related with anaemia in the age group 72 to 119 months and for an intensity of infection higher than 8000 eggs per gram of faeces. Hookworm, correlated with lower levels of haemoglobin, affected less than 4% of the children in the sample and appear to be a serious risk factor at the individual level. A. lumbricoides, present in 51% of the children, was associated with moderate anaemia and represents a more important risk factor at the community level, especially if coupled with inadequate food and iron intake. Any public health intervention aimed at reducing anaemia prevalence in Nepal should consider effective measures for the control of soil-transmitted helminths.