A participatory and systemic training approach for IPC improvement in Nigerian health facilities

Background

Health care-associated infections (HAI) are one of the most common adverse events in care delivery and a major public health problem. A large percentage of HAI in hospitals are preventable through effective infection prevention and control (IPC) measures. IPC trainings for health care personnel based only on technical content do not lead to sustainable improvement of IPC standard precautions. To address this problem, the Nigeria Centre for Disease Control (NCDC) in collaboration with the Robert Koch Institute (RKI) developed a multimodal training approach to facilitate the transfer of IPC competences into working routine in Nigerian health facilities.

Objectives

The training should foster the ability of health care workers to act and communicate participatory, analyze IPC problems systemically and to develop and perform tailored IPC activities in their health facilities. It should empower health care workers to initiate and promote sustainable IPC improvement locally.

Results

We developed a participatory training approach which focusses on the relational and organizational dimension of IPC. It addresses the human and infrastructural factors for IPC compliance in daily working routine. A variety of training methods offers practice tools in communication, systemic thinking and team work, and allows experiencing a participatory attitude. The training program consists of two face to face workshops and an interjacent field project. 28 Health care workers of 14 health facilities in Lagos State participated the first implementation of the training program in 2018. The training evaluation showed the high relevance of the training to the HCW. The field projects showed that the participants could apply the participatory approach for IPC improvement.

Conclusions

A participatory and systemic approach for IPC trainings enables health care workers to take action for IPC improvement locally.

Key messages

We developed and implemented a participatory training approach that addresses the relational and organizational dimension of IPC. Health care workers took tailored actions for IPC improvement locally.

Transmission of HIV Drug Resistance and the Predicted Effect on Current First-line Regimens in Europe

Transmitted human immunodeficiency virus drug resistance in Europe is stable at around 8%. The impact of baseline mutation patterns on susceptibility to antiretroviral drugs should be addressed using clinical guidelines. The impact on baseline susceptibility is largest for nonnucleoside reverse transcriptase inhibitors.

Background. Numerous studies have shown that baseline drug resistance patterns may influence the outcome of antiretroviral therapy. Therefore, guidelines recommend drug resistance testing to guide the choice of initial regimen. In addition to optimizing individual patient management, these baseline resistance data enable transmitted drug resistance (TDR) to be surveyed for public health purposes. The SPREAD program systematically collects data to gain insight into TDR occurring in Europe since 2001.

Methods. Demographic, clinical, and virological data from 4140 antiretroviral-naive human immunodeficiency virus (HIV)–infected individuals from 26 countries who were newly diagnosed between 2008 and 2010 were analyzed. Evidence of TDR was defined using the WHO list for surveillance of drug resistance mutations. Prevalence of TDR was assessed over time by comparing the results to SPREAD data from 2002 to 2007. Baseline susceptibility to antiretroviral drugs was predicted using the Stanford HIVdb program version 7.0.

Results. The overall prevalence of TDR did not change significantly over time and was 8.3% (95% confidence interval, 7.2%–9.5%) in 2008–2010. The most frequent indicators of TDR were nucleoside reverse transcriptase inhibitor (NRTI) mutations (4.5%), followed by nonnucleoside reverse transcriptase inhibitor (NNRTI) mutations (2.9%) and protease inhibitor mutations (2.0%). Baseline mutations were most predictive of reduced susceptibility to initial NNRTI-based regimens: 4.5% and 6.5% of patient isolates were predicted to have resistance to regimens containing efavirenz or rilpivirine, respectively, independent of current NRTI backbones.

Conclusions. Although TDR was highest for NRTIs, the impact of baseline drug resistance patterns on susceptibility was largest for NNRTIs. The prevalence of TDR assessed by epidemiological surveys does not clearly indicate to what degree susceptibility to different drug classes is affected.

Surveillance and Outbreak Response Management System (SORMAS) to support the control of the Ebola virus disease outbreak in West Africa

In the context of controlling the current outbreak of Ebola virus disease (EVD), the World Health Organization claimed that 'critical determinant of epidemic size appears to be the speed of implementation of rigorous control measures', i.e. immediate follow-up of contact persons during 21 days after exposure, isolation and treatment of cases, decontamination, and safe burials. We developed the Surveillance and Outbreak Response Management System (SORMAS) to improve efficiency and timeliness of these measures. We used the Design Thinking methodology to systematically analyse experiences from field workers and the Ebola Emergency Operations Centre (EOC) after successful control of the EVD outbreak in Nigeria. We developed a process model with seven personas representing the procedures of EVD outbreak control. The SORMAS system architecture combines latest In-Memory Database (IMDB) technology via SAP HANA (in-memory, relational database management system), enabling interactive data analyses, and established SAP cloud tools, such as SAP Afaria (a mobile device management software). The user interface consists of specific front-ends for smartphones and tablet devices, which are independent from physical configurations. SORMAS allows real-time, bidirectional information exchange between field workers and the EOC, ensures supervision of contact follow-up, automated status reports, and GPS tracking. SORMAS may become a platform for outbreak management and improved routine surveillance of any infectious disease. Furthermore, the SORMAS process model may serve as framework for EVD outbreak modeling.

Evidence for airborne infectious disease transmission in public ground transport – a literature review

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Evidence for airborne infectious disease transmission in public ground transport--a literature review

While guidelines on contact tracing (CT) after exposure to certain infectious pathogens during air travel exist, no guidance documents are available on CT in response to potential exposure on public ground transport. We reviewed scientific and non-scientific literature on transmission of airborne pathogens in public ground transport and on factors potentially influencing transmission. We identified 32 relevant publications (15 scientific and 17 non-scientific). Most of the selected studies dealt with transmission of tuberculosis. However, the relation between travel duration, proximity to the index case and environmental factors, such as ventilation, on disease transmission in public ground transport is poorly understood. Considering the difficulty and probably limited effectiveness of CT in ground transport, our results suggest that only exceptional circumstances would justify CT. This contrasts with the high level of attention CT in air travel seems to receive in international regulations and recommendations. We question whether the indication for CT should be revisited after a risk–benefit assessment that takes into account exposure in both ground and air transport.

Quantitative assessment of passenger flows in Europe and its implications for tracing contacts of infectious passengers

In contrast to air travel, there are no recommendations on tracing ground transport passengers exposed to infectious pathogens. We analysed European statistics on passenger transport in different conveyances and conducted expert workshops to discuss environmental conditions in ground transport, indications and minimal datasets required for contact tracing. Transport performance in the 27 countries of the European Union increased from 5.3x1012 passenger kilometres (pkm) in 1995 to 6.5x1012 pkm in 2007. Each resident generated on average 13,092 pkm in 2007, of which 2,062 pkm were public ground transport and 1,155 pkm in air transport. In the same year in Germany the total passenger volume in all different conveyances was 67,937 million. Public ground transport accounted for a passenger volume of 11,387 million (16.8%) and air transport for 129 million (0.2%). High efficiency particulate air (HEPA) filtration is frequently used in airplanes but not in ground transport vehicles. Therefore opportunities for disease transmission in public ground transport are not necessarily lower than in air travel. However, contact tracing is rarely conducted in these settings because of immense logistic challenges. Indication for contact tracing should be revisited, including all kinds of passenger transport.

Quantitative assessment of passenger flows in Europe and its implications for tracing contacts of infectious passengers

In contrast to air travel, there are no recommendations on tracing ground transport passengers exposed to infectious pathogens. We analysed European statistics on passenger transport in different conveyances and conducted expert workshops to discuss environmental conditions in ground transport, indications and minimal datasets required for contact tracing. Transport performance in the 27 countries of the European Union increased from 5.3 x 10(12) passenger kilometres (pkm) in 1995 to 6.5 x 10(12) pkm in 2007. Each resident generated on average 13,092 pkm in 2007, of which 2,062 pkm were public ground transport and 1,155 pkm in air transport. In the same year in Germany the total passenger volume in all different conveyances was 67,937 million. Public ground transport accounted for a passenger volume of 11,387 million (16.8%) and air transport for 129 million (0.2%). High efficiency particulate air (HEPA) filtration is frequently used in airplanes but not in ground transport vehicles. Therefore opportunities for disease transmission in public ground transport are not necessarily lower than in air travel. However, contact tracing is rarely conducted in these settings because of immense logistic challenges.Indication for contact tracing should be revisited, including all kinds of passenger transport.

Estimating vaccination coverage in the absence of immunisation registers--the German experience

Immunisation registers are regarded as an appropriate solution to measure vaccination coverage on a population level. In Germany, a decentralised healthcare system and data protection regulations constrain such an approach. Moreover, shared responsibilities in the process of immunisation and multiple providers form the framework for public health interventions on vaccination issues. On the national level, those interventions consist mainly of conceptualising immunisation strategies, establishing vaccination programmes, and issuing recommendations. This paper provides an overview on sources and methods for collecting appropriate coverage data at national level and their public health relevance in Germany. Methods of data collection and available information on immunisations are described for three approaches: school entrance health examination, population surveys and insurance refund claim data. School entrance health examinations allow regional comparisons and estimation of trends for a specific cohort of children and for all recommended childhood vaccinations. Surveys deliver population based data on completeness and timeliness of selected vaccinations in populations defined by age or socio-demographic parameters and on knowledge and attitudes towards vaccination. Insurance refund claim data inform continuously on immunisation status (e.g. of children aged two years) or on vaccination incidence promptly after new or modified recommendations. In a complex healthcare system, the German National Public Health Institute (Robert Koch Institute, RKI) successfully compiles coverage data from different sources, which complement and validate one another. With the German approach of combining different data sources in the absence of immunisation registers, it is possible to gain solid and reliable data on the acceptance of vaccination programmes and target groups for immunisation. This approach might be of value for other countries with decentralised healthcare systems.

[Teleconferences for national surveillance of infectious diseases and public health events in Germany. Evaluation after three quarters in 2009]

Public health threats are increasingly triggered by events which span across international, national and state level jurisdictions. Innovative surveillance methods are needed to ensure adequate and timely response to such threats. In January 2009 the Department of Infectious Disease Epidemiology at the Robert Koch Institute (RKI) established a system of weekly telephone conferences with all competent authorities of the German federal states to identify, discuss and respond to infectious disease events in real-time. A regular and structured platform was developed for use between participants from state level public health authorities, the military and the RKI. During the first three quarters, 46 infectious diseases were covered, including mandatory reports of measles and meningococcal meningitis and outbreaks of cowpox, which does not have to be notified in Germany. Results of a targeted evaluation and a consistently high attendance rate both indicate that the teleconference has met additional needs for supplemental information exchange among participants. The telephone conference has proven to be a useful resource for rapid and direct communication, coordination and evaluation of signals for public health events in Germany.

Pandemic influenza A(H1N1) 2009 breakthrough infections and estimates of vaccine effectiveness in Germany 2009-2010

During the 2009 influenza pandemic, a monovalent AS03-adjuvanted vaccine was almost exclusively used in Germany for immunisation against the 2009 pandemic influenza A(H1N1) virus. One-dose vaccination was recommended for all age groups. We applied the screening method for the rapid assessment of vaccine effectiveness (VE) based on reported data of vaccinated and unvaccinated pandemic influenza cases and vaccination coverage estimates. Preliminary results demonstrate excellent VE in persons aged 14-59 years (96.8%; 95% confidence interval (CI): 95.2-97.9) and moderately high VE in those 60 years or older (83.3%; 95% CI: 71.0-90.5).

Pandemic influenza A(H1N1) 2009 breakthrough infections and estimates of vaccine effectiveness in Germany 2009-2010

During the 2009 influenza pandemic, a monovalent AS03-adjuvanted vaccine was almost exclusively used in Germany for immunisation against the 2009 pandemic influenza A(H1N1) virus. One-dose vaccination was recommended for all age groups. We applied the screening method for the rapid assessment of vaccine effectiveness (VE) based on reported data of vaccinated and unvaccinated pandemic influenza cases and vaccination coverage estimates. Preliminary results demonstrate excellent VE in persons aged 14-59 years (96.8%; 95% confidence interval (CI): 95.2-97.9) and moderately high VE in those 60 years or older (83.3%; 95% CI: 71.0-90.5).

[Overview and assessment of available data sources to determine incidence of vaccine preventable diseases, vaccination coverage, and immune status in Germany]

The surveillance of vaccine preventable diseases and vaccination coverage is necessary in order to deliver epidemiological data with respect to national vaccination recommendations and control targets. The data available on the incidence of vaccine preventable diseases, vaccination coverage, and immune status of the population are fragmentary and do not allow the epidemiological situation to be fully assessed. Although the majority of vaccine preventable diseases are under surveillance nationwide (by statutory reporting or sentinel surveillance), data are not available for some diseases. In addition, data on vaccination coverage are not collected centrally. Nationwide data on vaccination coverage are only available for children at school entry. Use of secondary data such as data from health insurance companies or associations of statutory health insurance physicians provides an opportunity to close gaps in knowledge and to improve the surveillance of vaccine preventable diseases.

Implications of and perspectives on HIV surveillance using a serological method to measure recent HIV infections in newly diagnosed individuals: results from a pilot study in Berlin, Germany, in 2005-2007

OBJECTIVES

This cross-sectional study was designed to pilot the analysis of clinical data, knowledge about and attitudes towards HIV/AIDS, and prevention and risk behaviour in persons recently infected with HIV.

METHODS

Blood samples and demographic, laboratory, clinical and behavioural data were collected from patients with newly diagnosed HIV infections. The BED IgG-capture ELISA (BED-CEIA) was used to determine the recency of infection.

RESULTS

Recent HIV infections contributed 54% [95% confidence interval (CI) 45; 64%] of infections in men who have sex with men (MSM) and 16% (95% CI 0; 39%) of infections in patients with other transmission risks (P=0.041). Recently infected MSM were characterized by younger age and higher viral load as compared with MSM who had longstanding infections (P=0.011 and 0.005, respectively). Symptoms during primary infection and patients' assumptions with regard to time of infection were significantly correlated with test results indicating whether or not the HIV infection was recently acquired (P<0.001).

CONCLUSIONS

Cross-sectional surveillance of recent HIV infections proved to be relevant to the identification of current risks for acquiring HIV infection. The high proportion of recent HIV infections in MSM and the even higher proportion in MSM younger than 30 years indicate ongoing HIV transmission in this group. The method will be used in future national HIV surveillance in Germany.

Impact of transmission of drug-resistant HIV on the course of infection and the treatment success. Data from the German HIV-1 Seroconverter Study

BACKGROUND

Data on the clinical course of infection in patients with transmitted drug-resistant HIV before and after initiation of treatment are scarce.

PATIENTS AND METHODS

Genotypic resistance was analysed in 504 therapy-naïve individuals with a known date of infection. Resistance was predicted using the Stanford algorithm. Clinical parameters for 80 individuals with transmitted drug-resistant HIV and for 424 patients with susceptible virus were analysed.

RESULTS

In 16% of the individuals transmitted drug-resistant HIV was found. Detection of drug-resistant HIV was more likely in individuals with acute primary HIV infection [odds ratio (OR)=1.529; 95% confidence interval (95% CI) 1.001; 2.236]. At the time of infection patients with an acute infection with resistant HIV had lower viral loads. CD4 cell counts tended to be higher and the CD4 cell loss more pronounced in the group with resistant HIV. Suppression of the viral load below the detection limit was achieved in 64% of the group with resistant HIV and in 85% of the group with susceptible HIV 6 months after initiation of therapy (P=0.199). The majority of the group with resistant HIV (74%) received at least one compromised drug.

CONCLUSION

First-line treatment including drugs with predicted resistance can impair virological success in some patients. Factors influencing the decision to include compromised drugs need to be investigated.

Falldefinitionen für die Surveillance meldepflichtiger Infektionskrankheiten in Deutschland, Ausgabe 2007

The revised case definitions established by the Robert Koch Institute will become effective on 1 January 2007. The case definitions provide criteria for the reporting of mandatory notifiable infectious diseases according to the German infectious disease control act. The new case definitions take into account recent developments in laboratory methods. Furthermore in the new edition the criteria were updated and clarified if necessary. For each case definition a paragraph 'reference definition' is introduced and explained. If applicable additional information (e.g., vaccination history) to be reported was added. In this article, the major changes of the revised case definitions are described.

Enhanced Surveillance of Infectious Diseases : the 2006 FIFA World Cup experience, Germany

The 2006 FIFA World Cup was held in 12 German cities between 9 June and 9 July 2006. We identified a need to accelerate and sensitise the pre-existing surveillance system for infectious diseases in order to timely detect adverse health events during the World Cup. Enhanced surveillance, based on Germany’s pre-existing system of mandatory notifications was conducted between 7 June and 11July 2006 in the 12 World Cup cities by: accelerating frequency of electronic data transmission of case-definition based notifiable diseases from weekly to daily transmission, additional reporting of non-case definition-based infectious disease events, lay and expert press screening and intensifying communication between all stakeholders of the surveillance system. Median delay of notification data transmission from the community to the federal level was reduced from three days to one day. The enhanced reporting system detected a norovirus outbreak in the International Broadcast Centre in Munich with 61 epidemiologically linked cases within the first week after onset, as well as four single cases related to the World Cup, two of them with relevance for the International Health Regulations. After the World Cup, all surveillance stakeholders agreed that communication between local, state and federal levels had improved considerably. Unlike the majority of health planners of previous mass gatherings in the last decade we did not introduce syndromic surveillance. Nevertheless, enhancement of infectious disease surveillance successfully detected adverse health events in a timely manner during the FIFA World Cup. Additionally, it provided a valuable communication and networking exercise for potentially critical health-related events. We recommend continuing daily notification data transmission for routine infectious disease surveillance in Germany.

Leukocytosis and blood eosinophilia in a polyparasitised population in north-eastern Brazil

It has long been known that leukocytosis and blood eosinophilia are common in the tropical environment, but data derived from population-based studies are scarce. A study was undertaken in a fishing village in north-east Brazil where both intestinal helminthiases and parasitic skin diseases are common. Of 409 individuals studied, 128 (31.3%) were infected with one intestinal helminth or ectoparasite species, 93 (22.7%) with two, 61 (14.9%) with three, 25 (6.1%) with four and 11 (2.7%) with more than four species; no parasites were found in 91 (22.2%) individuals. Leukocyte counts ranged between 3,300 cells/microl and 16,100 cells/microl (median, 7,200 cells/microl) and eosinophil counts between 40 cells/microl and 5,460 cells/microl (median, 455 cells/microl). Eosinophilia (>500/microl) was detected in 44.7% of the individuals, and hypereosinophilia (>1,000/microl) in 12.9%. Thirty-six (8.8%) individuals showed leukocytosis. While 75% of individuals with normal eosinophil counts were considered parasite-free, only 14% with eosinophilia and 11% with hypereosinophilia did not have enteroparasites or ectoparasites. Multivariate regression showed that the probability of eosinophilia and hypereosinophilia, but not of leukocytosis, increased with the number of parasite species present. The data show that eosinophilia occurs in almost one-half of the individuals from a resource-poor setting and that it is significantly associated with the presence of intestinal helminths, but not with the presence of ectoparasites.

Enhanced surveillance of infectious diseases : the 2006 FIFA World Cup experience, Germany

The 2006 FIFA World Cup was held in 12 German cities between 9 June and 9 July 2006. We identified a need to accelerate and sensitise the pre-existing surveillance system for infectious diseases in order to timely detect adverse health events during the World Cup. Enhanced surveillance, based on Germany's pre-existing system of mandatory notifications was conducted between 7 June and 11 July 2006 in the 12 World Cup cities by: accelerating frequency of electronic data transmission of case-definition based notifiable diseases from weekly to daily transmission, additional reporting of non-case definition-based infectious disease events, lay and expert press screening and intensifying communication between all stakeholders of the surveillance system. Median delay of notification data transmission from the community to the federal level was reduced from three days to one day. The enhanced reporting system detected a norovirus outbreak in the International Broadcast Centre in Munich with 61 epidemiologically linked cases within the first week after onset, as well as four single cases related to the World Cup, two of them with relevance for the International Health Regulations. After the World Cup, all surveillance stakeholders agreed that communication between local, state and federal levels had improved considerably. Unlike the majority of health planners of previous mass gatherings in the last decade we did not introduce syndromic surveillance. Nevertheless, enhancement of infectious disease surveillance successfully detected adverse health events in a timely manner during the FIFA World Cup. Additionally, it provided a valuable communication and networking exercise for potentially critical health-related events. We recommend continuing daily notification data transmission for routine infectious disease surveillance in Germany.

Mother-to-child transmission of HIV and its prevention: awareness and knowledge in Uganda and Tanzania

Awareness and knowledge about HIV mother-to-child transmission (MTCT) and preventive measures in different population groups and health personnel were analysed in future intervention areas in western Uganda and southwestern Tanzania. In Uganda, a total of 751 persons (440 clients of antenatal and outpatient clinics, 43 health workers, 239 villagers, 29 traditional birth attendants) and in Tanzania, 574 persons (410 clients, 49 health workers, 93 villagers, 18 traditional birth attendants) were interviewed. When given options, knowledge on transmission during pregnancy and delivery in women was 93% and 67% in Uganda and Tanzania respectively, and 86% and 78% for transmission during breastfeeding. In Uganda 59% of male interviewees did not believe that HIV is transmitted during breastfeeding. Expressed acceptance of HIV testing was above 90% in men and women in both countries, but only 10% of the clients in Uganda and 14% in Tanzania had been tested for HIV infection. Health workers' knowledge regarding MTCT was acceptable, while traditional birth attendants' knowledge on both MTCT and preventive measures was extremely poor. Recom endations on infant feeding were not compatible with WHO recommendations for HIV-infected women. If prevention of MTCT (PMTCT) interventions are to be accepted by the population and promoted by health personnel, thorough orientation and training are mandatory.

[Recurrent strongyloidiasis as an indicator of HTLV-1 infection]

HISTORY AND CLINICAL FINDINGS

A 53-year-old West African man presented two years after a travel to Guinea because of severe headache, neck stiffnes, fever and pruritus. The patient had been in orthopedical treatment for the last five months.

INVESTIGATIONS

Stool microscopy revealed a high number of Strongyloides stercoralis larvae. Hematology, biochemistry and all other parasitology results were normal. HIV-1/2 testing was negative and CD4+-lymphocyte count was normal. Concomitant infection by Human T Cell lymphotropic virus type 1 (HTLV-1) was confirmed by serology and PCR. The phylogenetic analysis confirmed African origin of the virus.

TREATMENT

The infection responded to a five-day course of albendazol at 400 mg/d but during the following five years repeat recrudescences were observed inspite of high-dosage and prolonged antiparasitic treatments. Eventually, eradication of the infection was achieved by a four day course of ivermectin 0.2 mg/kg/d.

CONCLUSIONS

Although both strongyloidiasis and HTLV-1 infections occur most frequently in tropical areas, these may also be observed in temperate regions. Suppression of the immune system by HTLV-1 differs from that by HIV. CD4+-lymphocytes were rarely decreased. Prolonged treatment with ivermectin in a dosage exceeding the current recommendations may be required in HTLV-1 infected patients and was well tolerated. The unusual presentation of the infection with muscular symptoms contributed to the delay of the diagnosis. HTLV-1 positive patients must be monitored for years. They and their partners must be instructed how to prevent transmission of the virus.

Diagnosis of genital cervical schistosomiasis: comparison of cytological, histopathological and parasitological examination

Granulomatous inflammation of the cervix uteri is a common manifestation of infection with Schistosoma haematobium. In women the cervix is the most common site of infection by S. haematobium. Three methods were used to assess the performance of three different ways of detecting schistosome eggs in cervical tissue: cytological examination of a cervical smear, histological examination of a cervical biopsy, and direct examination of cervical tissue obtained by forceps biopsy (quantitative compressed biopsy technique [QCBT]). Of 228 women studied who lived in an S. haematobium endemic area in Tanzania, 112 (49%) had schistosome eggs detected in the cervix using QCBT. Histological examination detected eggs in 40 of 228 (18%). The cytological examination of cervical smears yielded only 6 positive results (3%). The median egg load in the cervical tissue of cases correctly diagnosed by histology was significantly higher than the egg load in the misclassified cases, indicating that the sensitivity of histological sectioning increases with egg density. We conclude that the QCBT is the diagnostic test of choice for schistosomiasis of the genital cervix.

Female genital schistosomiasis: facts and hypotheses

In this paper we summarise the parasitological, clinical and epidemiological characteristics of female genital schistosomiasis (FGS), a frequent manifestation of the infection with Schistosoma haematobium. Means to diagnose and treat lesions in the lower and upper genital tract are discussed. Based on clinical findings and available pathophysiological as well as immunological data it is conceivable that FGS of the cervix and vagina not only facilitates the infection with agents of sexually transmitted diseases, but presumably also alters the natural history of such infections. Two infectious agents are of particular concern: the Human Immunodeficiency Virus and the oncogenic Human Papilloma Viruses. Possible interactions and their consequences are discussed and research areas which should be addressed are outlined.

Seroepidemiology of TT virus, GBC-C/HGV, and hepatitis viruses B, C, and E among women in a rural area of Tanzania

The seroprevalence and determinants of hepatitis B, C, and E virus infection, and of GBV-C/hepatitis G virus and TT virus infection were investigated among women from a rural area of northeastern Tanzania. High seroprevalence rates were found for TTV (74%), HBV (74%), and GBV-C/HGV (35%), whereas 7% of the women had evidence of HCV and HEV infection. The majority of TTV DNA sequences in the study population belonged to the genotypes 1 or 2. One sequence seems to represent a new subtype of genotype 4. The GBV-C/HGV sequences either belonged to the genomic Group 1b or to the recently described Group 4. In multivariate analysis, the detection of TTV DNA was associated significantly with a larger number of children in the household and with older age. A history of injections of contraceptive hormones was an independent risk factor for HCV infection. The findings on TTV are consistent with fecal-oral transmission, and recurrent infections may occur in adults.

Seroepidemiology of TT virus, GBC-C/HGV, and hepatitis viruses B, C, and E among women in a rural area of Tanzania

The seroprevalence and determinants of hepatitis B, C, and E virus infection, and of GBV-C/hepatitis G virus and TT virus infection were investigated among women from a rural area of northeastern Tanzania. High seroprevalence rates were found for TTV (74%), HBV (74%), and GBV-C/HGV (35%), whereas 7% of the women had evidence of HCV and HEV infection. The majority of TTV DNA sequences in the study population belonged to the genotypes 1 or 2. One sequence seems to represent a new subtype of genotype 4. The GBV-C/HGV sequences either belonged to the genomic Group 1b or to the recently described Group 4. In multivariate analysis, the detection of TTV DNA was associated significantly with a larger number of children in the household and with older age. A history of injections of contraceptive hormones was an independent risk factor for HCV infection. The findings on TTV are consistent with fecal-oral transmission, and recurrent infections may occur in adults.

Female genital schistosomiasis of the lower genital tract: prevalence and disease-associated morbidity in northern Tanzania

Female genital schistosomiasis (FGS) is a neglected disease manifestation of schistosomiasis. A cross-sectional study was carried out to assess in a schistosomiasis-endemic area the proportion of women affected by FGS of the lower reproductive tract and to compare the frequency of symptoms and signs possibly associated with FGS between women with proven FGS (n=134), endemic referents (n=225, women living in an endemic site), and referents (n=75, women living in a nonendemic site). Urinary schistosomiasis was diagnosed in 36% (239/657) and FGS in 37% (134/359) of the women. Cervical lesions occurred in 75% of the FGS cases, in 48% of endemic referents, and in 36% of nonendemic referents. The high prevalence of FGS in all age groups and the high levels of pathologic cervical alterations such as swollen and disrupted epithelium support the hypothesis that FGS might be a risk factor for the transmission of human immunodeficiency virus.

Screening of Tanzanian women of childbearing age for urinary schistosomiasis: validity of urine reagent strip readings and self-reported symptoms

The screening of women of childbearing age for haematuria, leukocyturia and proteinuria to detect urinary schistosomiasis can be confounded by several factors such as menstruation, pregnancy and genitourinary infections. We therefore undertook a study in an area endemic for Schistosoma haematobium in the United Republic of Tanzania to carry out the following: assess the sensitivity, specificity and predictive values--in women of childbearing age--of indirect indicators of urinary schistosomiasis, as measured by urine reagent strip readings; assess the predictive values of self-reported symptoms; and finally to estimate the morbidity attributable to S. haematobium. A total of 303 women (128 and 175, respectively, living in high- and low-risk sites) participated in the study. Haematuria was more frequent among women excreting S. haematobium eggs than among those who did not (65% versus 32%). The predictive potential of all indirect disease markers was poor in the highly endemic site, while in the sites with low endemicity the negative predictive values were high. Among infected women, 54% of haematuria could be attributed to S. haematobium, but for patients with more than 10 eggs/10 ml the attributable fraction rose to 70%. Symptoms of "bloody urine" and "pain while urinating" were recalled significantly more often by women living in the highly endemic site. On a population level, one-third of the self-reported cases with bloody urine could be attributed to urinary schistosomiasis. Screening of women of childbearing age for urinary schistosomiasis using urine reagent strips can be biased in two directions. The prevalence of S. haematobium will be overestimated if other causes of haematuria, such as reproductive tract infections, are highly endemic. On the other hand, women with light or very light infections will be missed and will not be treated. This is of concern because genital schistosomiasis, a possible risk factor for the transmission of HIV, occurs among women even with light infections.

Schistosomiasis of the female genital tract: public health aspects

In this paper Gabriele Poggensee, Hermann Feldmeier and Ingela Krantz discuss the public health relevance of female genital schistosomiasis (FGS). Some of the stated hypotheses are supported only by clinical observations and/or circumstantial evidence as valid epidemiological and immunological data of this disease entity are still very scanty. Morbidity caused by the presence of schistosome eggs in the lower and upper genital tract have been almost completely neglected during the past two decades. This has been acknowledged by the WHO and, in 1997, the Gender Task Force of the WHO's Tropical Disease Research Programme (TDR) included FGS in a list of scientific areas that deserve high research priority.

Schistosomiasis of the lower reproductive tract without egg excretion in urine

The individual and public health impact of female genital schistosomiasis (FGS) has been studied and FGS as a risk factor for acquiring human immunodeficiency virus is discussed. In a community-based study in Tanzania, 40% of the women of child-bearing age (n=543) showed excretion of Schistosoma haematobium eggs in the urine (median=2.2 eggs/10 ml of urine) and 32% (n=263) had S. haematobium eggs in their cervical tissue. Urinary and genital schistosomiasis coexisted in 62% of the women, but S. haematobium eggs were found in the cervix without detectable egg excretion in the urine in 23%. Only 43% of the FGS cases had hematuria. Since FGS frequently exists in women with scanty or no egg excretion in the urine and because this disease manifestation is a considerable individual and public health hazard in S. haematobium-endemic areas, mass treatment targeted to women of child-bearing age should be considered.

Sonographic prediction of variceal bleeding in patients with liver fibrosis due to Schistosoma mansoni

Several studies have shown that the characteristic hepatic abnormalities induced by Schistosoma mansoni detectable by ultrasound correlate with the degree of oesophageal varices. So far the value of ultrasound for predicting variceal haemorrhage has not been assessed. Fifty Brazilian patients with schistosomal periportal fibrosis from Alagoas State, 18 of whom had already bled from oesophageal varices, were enrolled in a combined cross-sectional and longitudinal study and investigated clinically, by endoscopy and by ultrasound. Twenty-seven of the patients were monitored until another bleeding episode, death or for a minimum of 28 months. Eight of these patients could be followed up for a further three years. A sonographic score, which accounts for the degree of echogenic periportal thickening and of portal vein dilatation, was calculated for all patients. A highly significant correlation (P < 0.0001) existed between the sonographic score and the occurrence of previous variceal haemorrhage, paralleled by a similar correlation between the sonographic score and the degree of oesophageal varices (P < 0.001). In the 27 patients monitored longitudinally, the sonographic score indicated the risk of future variceal bleeding (P < 0.0001). The sonographic score reliably predicts the risk of variceal bleeding in individual patients with periportal fibrosis. Hence, the application of endoscopy, if available at all in endemic areas, may be restricted to the patients at risk of future variceal bleeding, as determined by ultrasound. Since portable devices can be carried even to remote areas, the application of the proposed score in community surveys could provide a new means for the identification of high-risk patients in S. mansoni-infected populations.

Schistosomiasis in women: manifestations in the upper reproductive tract

Female genital schistosomiasis (FGS) is a neglected disease entity which may give rise to considerable suffering among women of child-bearing age in areas where schistosomiasis (especially due to Schistosoma haematobium) is prevalent. The close relation between the vessels in genital organs and the urinary bladder enables the parasite to easily change location to virtually any organs in the female pelvic area. Symptoms concur with the anatomical location of worm pairs and their ova. Lesions of the lower female genital tract can easily be investigated by cytology, histology or direct demonstration of eggs in scrapings or biopsies whereas schistosomiasis of the upper genital tract is clinically indecipherable and less accessible for examination. In the literature there are references to FGS as a cause of infertility, complications of pregnancy, menstrual disorders, problems related to sexual intercourse, diagnostic similarities to STDs and cancer, unspecified complaints related to blood loss, chronic abdominal pain, social segregation and related psychological problems. The diagnosis of female upper genital schistosomiasis is difficult and the authors point out possible diagnostic procedures which might be helpful for further understanding of this complex entity.

Urine reagent strips for diagnosis of schistosomiasis haematobium in women of fertile age

Hematuria, proteinuria and leukocyturia were semiquantitatively assessed by reagent strips in single morning urine of women of fertile age visiting the outpatient department of the Mangochi district hospital, Malawi. This was part of a diagnostic approach to female genital schistosomiasis (FGS). In 51 women ova of Schistosoma haematobium were detected in urine by a filtration technique. In 33 of these women ova were also present in genital tissue as demonstrated by microscopic examination of biopsies. In 209 women no ova were found in the single urine filtered. There were significantly higher scores for hematuria, proteinuria and leukocyturia as well as of the combined reagent strip index (RSI) in egg-excreting than in egg-negative women. The sensitivity of a single hematuria, proteinuria and leukocyturia reading was 98, 84 and 73%, respectively. However, the respective specificity was only 24, 22 and 23%. The best prediction of urinary schistosomiasis was achieved by a +2 score for hematuria, of which the sensitivity was 94% and the specificity was 61%. The high false-positive rates can probably be explained by contamination of urine by vaginal secretion. Moreover, cases of schistosomiasis have probably been overlooked because only a single morning urine sample was examined. The total absence of hematuria, proteinuria and leukocyturia, however, may be used to rule out heavy infections in community surveys. There was no difference in reagent strip scores between women with genital and urinary schistosomiasis as compared with those with urinary tract lesions alone. Thus urine analysis reagent strip readings do not help to discriminate between S. haematobium infected women with and without FGS.

Reversibility of lower reproductive tract abnormalities in women with Schistosoma haematobium infection after treatment with praziquantel--an interim report

Little is known whether and to what extent antiparasitic treatment cures female genital schistosomiasis (FGS). Using a standard protocol, of twenty-one women with FGS nine were re-examined at two to nine weeks after they had been treated with praziquantel at a single dose of 40 mg/kg. Symptoms related to pathology of the urinary tract and to a lesser extent of genital pathology subsided in most patients. Schistosoma haematobium ova were no longer detectable in urine of any of the patients post-treatment. Efficiency of chemotherapy against adult worms was confirmed by the disappearance of circulating anodic antigen (CAA) in serum. Sandy patches showed resolution in two of four cases after chemotherapy. Papillomata due to schistosomiasis alone improved, but persisted in mixed infection with human papilloma virus (HPV) or when HPV was the only underlying cause. In one patient ulcera could not be related with certainty to schistosomiasis at admission, but resolved after treatment with parziquantel. Leukoplakia (two cases) was not influenced by chemotherapy, or even increased during follow-up, regardless of whether ova had been detected or not. Although the follow-up period was rather short, time intervals were not standardized, and a relatively small number of patients was investigated, it could be shown that genital pathology due to sequestered S. haematobium ova is, at least partially, reversible already two to nine weeks after killing the adult worms by praziquantel. This is paralleled by a normalization of inflammatory immune responses detectable in histological sections and vaginal lavage.

Female genital schistosomiasis (FGS): relationship between gynecological and histopathological findings

Schistosomiasis of the lower female reproductive tract manifests itself in a broad spectrum of clinical features. However, clinical and histopathological findings have never been studied in a synoptic manner. Based on the assumption that any type of pathology present in the female reproductive tract is the expression of a complex pathophysiological reaction towards eggs sequestered in the genital tissues, we decided to analyze colposcopic and histopathological findings in a comprehensive manner. Thirty-three women in Malawi with urinary and genital schistosomiasis were examined parasitologically and gynecologically. A thorough colposcopic examination with photodocumentation was performed and biopsies were taken from the cervix, the vagina and/or the vulva for histological sectioning and immunohistochemistry. The predominant colposcopic findings were sandy patches on the cervical surface similar to those seen in the bladder and polypous/papillomatous tumors with irregular surface on the vaginal wall and in the vulvar area. The histopathological sections of sandy-patch-like lesions demonstrated only a small cellular reaction around S. haematobium eggs in various stages of disintegration. In contrast, in the case of polyps the histology revealed a more pronounced immunological reaction characterized by a heavy cellular infiltrate. One case of invasive squamous cell carcinoma of the cervix was diagnosed. We conclude that colposcopy is a useful tool in the detection of FGS related pathology in the lower female reproductive tract and that the synoptic assessment of surface and of corresponding histological sections helped to understand the pathophysiology of S. haematobium associated disease in genital tissue.

Female genital schistosomiasis due to Schistosoma haematobium. Clinical and parasitological findings in women in rural Malawi

A total of 51 women with urinary schistosomiasis haematobium were examined in order to identify diagnostic indicators for female genital schistosomiasis (FGS). Patients were selected at random from the outpatient department of the Mangochi District Hospital, Malawi. The medical histories were recorded according to a pre-designed questionnaire and the women were subjected to a thorough gynaecological examination including colposcopy and photographic documentation of lesions. Microscopy of genital biopsies revealed that 33 of the 51 women had S. haematobium ova in cervix, vagina and/or vulva in addition to the presence of ova in urine. The most sensitive diagnostic procedure was beside microscopic examination of a wet cervix biopsy crushed between two glass slides, which revealed 25 of the 33 genital infections. There was a significant correlation between the size of genital lesions and the number of ova counted per mm2 of crushed tissue. Women with FGS had significantly more tumours in the vulva than women with schistosomiasis limited to the urinary tract. Most of the observed genital pathology could easily be identified by the naked eye, but colposcopic examination yielded valuable additional information like the demonstration of neovascularisation around cervical sandy patches. Few of the symptoms previously regarded as indicators for FGS could be linked to the presence of schistosome ova in genital tissue. Husbands of infertile women with FGS had children with other women significantly more often than husbands of women who only had urinary schistosomiasis. This, together with the finding that the majority of the divorced women had FGS, indicates that the manifestation of this disease may have implications for the marital and sexual life of the affected women.

Diagnosis of female genital schistosomiasis by indirect disease markers: determination of eosinophil cationic protein, neopterin and IgA in vaginal fluid and swab eluates

Based on assumptions about the pathophysiology of egg-related lesions in the lower reproductive tract, putative indirect disease markers were investigated in vaginal fluids from 54 Malawi adolescent girls and women infected with S. haematobium. These women received a careful gynecological examination during which biopsies were taken from the cervix, and, if present, also from suspicious lesions in the vagina and the vulva. If the biopsies, either in wet crushed preparations or in histological sections, contained eggs the patients were considered to have female genital schistosomiasis (FGS; n = 33). The remainder (n = 21) were classified as having urinary schistosomiasis only. Eosinophil cationic protein (ECP), a cytotoxic granule protein of eosinophils, neopterin, a second messenger molecule generated during the activation of macrophages, and IgA as an indicator of local B-cell activation were quantitatively determined in vaginal fluid. To clarify the origin of ECP, this protein was also looked for in histological sections by an immunohistochemical method. In order to explore whether such disease markers can be detected after absorption to a tampon-like material, ECP and IgA were also assessed after elution from a non-porous, polypropylene fibre web impregnated with vaginal fluid. The concentration of ECP in vaginal fluid and the degree of immunohistochemical staining in histological sections were significantly higher in patients with FGS than in women with urinary schistosomiasis only. The amount of ECP detected in histological sections correlated to the number of eggs/mm2 of compressed genital tissue (rho = 0.36, P = 0.02), and the concentration of ECP in vaginal fluid correlated to the concentration of neopterin as well as to that of IgA (rho = 0.52, P = 0.004 and rho = 0.37, P = 0.02, respectively). Median neopterin concentration in vaginal fluid was also higher in the FGS group, but the difference was not statistically significant. ECP could also be detected in eluates from impregnated fibre webs, but the concentration was approximately one power of 10 less than in the original vaginal fluid. These results demonstrate that indicators of immunological mechanisms related to the egg-granuloma might be useful as indirect disease markers for women with FGS if assessed in vaginal washings or swab eluates.

Female genital schistosomiasis. New challenges from a gender perspective

Female genital schistosomiasis has been neglected as a disease entity during a period when considerable progress has been achieved for schistosomiasis as such. The pathophysiology and immunology are imperfectly understood, appropriate diagnostic tools are not at hand, therapeutic rationales do not exist, the natural history is not well known and women's perception of their illness has never been studied. Based on the findings of a systematic analysis, made by an inventory of research needs on women and tropical diseases, it has been possible to highlight individual and public health hazards of female genital schistosomiasis, such as the disease being a possible cofactor for te spread of the human immunodeficiency virus. This paper gives an example of how a gender perspective on a well-known parasitic disease can bring new challenges to the research community and the public health sector.

Female genital schistosomiasis as a risk-factor for the transmission of HIV

Sexually transmitted diseases increase the probability for HIV transmission, presumably through lesions in the genital mucosa. Female genital schistosomiasis, a special form of urinary schistosomiasis due to infection with Schistosoma haematobium, may be another risk-factor for transmission of HIV. From published data there seem to be pathophysiological, immunological and epidemiological evidence for an association between genital ulcer disease due to S. haematobium and HIV-infection in women. Female genital schistosomiasis could be seen as an example of how an interaction between a parasitic disease and HIV facilitates the propagation of the latter. As long as the prevalence of HIV is low in the general population, interventions targeted to high risk groups will significantly delay, or even prevent, widespread dissemination of the HIV infection in the rest of the population. If female genital schistosomiasis is a risk factor for the spread of HIV like other genital ulcer diseases, there should be interesting ways to intervene from the public health point of view.