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Affiliation(s)
| | - David Sack
- Johns Hopkins University, Baltimore, USA
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Abstract
In a Perspective, Lorenz von Seidlein and Jacqueline L. Deen discuss the implications of Andrew Azman and colleagues' accompanying study for management of cholera outbreaks.
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Affiliation(s)
- Lorenz von Seidlein
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Jacqueline L. Deen
- Institute of Child Health and Human Development, National Institutes of Health, University of the Philippines, Manila, Philippines
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von Seidlein L, Ikonomidis K, Mshamu S, Nkya TE, Mukaka M, Pell C, Lindsay SW, Deen JL, Kisinza WN, Knudsen JB. Affordable house designs to improve health in rural Africa: a field study from northeastern Tanzania. Lancet Planet Health 2017; 1:e188-e199. [PMID: 29851640 DOI: 10.1016/s2542-5196(17)30078-5] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 07/05/2017] [Accepted: 07/11/2017] [Indexed: 06/08/2023]
Abstract
BACKGROUND The population of sub-Saharan Africa is currently estimated to be 1245 million and is expected to quadruple by the end of the century, necessitating the building of millions of homes. Malaria remains a substantial problem in this region and efforts to minimise transmission should be considered in future house planning. We studied how building elements, which have been successfully employed in southeast Asia to prevent mosquitos from entering and cooling the house, could be integrated in a more sustainable house design in rural northeastern Tanzania, Africa, to decrease mosquito density and regulate indoor climate. METHODS In this field study, six prototype houses of southeast Asian design were built in in the village of Magoda in Muheza District, Tanga Region, Tanzania, and compared with modified and unmodified, traditional, sub-Saharan African houses. Prototype houses were built with walls made of lightweight permeable materials (bamboo, shade net, or timber) with bedrooms elevated from the ground and with screened windows. Modified and unmodified traditional African houses, wattle-daub or mud-block constructions, built on the ground with poor ventilation served as controls. In the modified houses, major structural problems such as leaking roofs were repaired, windows screened, open eaves blocked with bricks and mortar, cement floors repaired or constructed, and rain gutters and a tank for water storage added. Prototype houses were randomly allocated to village households through a free, fair, and transparent lottery. The lottery tickets were deposited in a bucket made of transparent plastic. Each participant could draw one ticket. Hourly measurements of indoor temperature and humidity were recorded in all study houses with data loggers and mosquitoes were collected indoors and outdoors using Furvela tent traps and were identified with standard taxonomic keys. Mosquitoes of the Anopheles gambiae complex were identified to species using PCR. Attitudes towards the new house design were assessed 6-9 months after the residents moved into their new or modified homes through 15 in-depth interviews with household heads of the new houses and five focus group discussions including neighbours of each group of prototype housing. FINDINGS Between July, 2014, and July, 2015, six prototype houses were constructed; one single and one double storey building with each of the following claddings: bamboo, shade net, and timber. The overall reduction of all mosquitoes caught was highest in the double-storey buildings (96%; 95% CI 92-98) followed closely by the reduction found in single-storey buildings (77%; 72-82) and lowest in the modified reference houses (43%; 36-50) and unmodified reference houses (23%; 18-29). The indoor temperature in the new design houses was 2·3°C (95% CI 2·2-2·4) cooler than in the reference houses. While both single and two-storey buildings provided a cooler indoor climate than did traditional housing, two-story buildings provided the biggest reduction in mosquito densities (96%, 95% CI 89-100). Seven people who moved into the prototype houses and seven of their neighbours (three of whom had their houses modified) participated in in-depth interviews. After living in their new prototype houses for 6-9 months, residents expressed satisfaction with the new design, especially the second-storey sleeping area because of the privacy and security of upstairs bedrooms. INTERPRETATION The new design houses had fewer mosquitoes and were cooler than modified and unmodified traditional homes. New house designs are an underused intervention and hold promise to reduce malaria transmission in sub-Saharan Africa and keep areas malaria-free after elimination. FUNDING Ruth W Jensens Foundation, Copenhagen and Hanako Foundation, Singapore.
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Affiliation(s)
- Lorenz von Seidlein
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.
| | | | | | - Theresia E Nkya
- The National Institute for Medical Research, Amani Medical Research Centre, Muheza, Tanzania
| | - Mavuto Mukaka
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Christopher Pell
- Centre for Social Science and Global Health, University of Amsterdam, Amsterdam, the Netherlands; Amsterdam Institute for Global Health and Development, Amsterdam, the Netherlands
| | - Steven W Lindsay
- School of Biological and Biomedical Sciences, Durham University, Durham, UK
| | - Jacqueline L Deen
- Institute of Child Health and Human Development, National Institutes of Health, University of the Philippines, Manila, Philippines
| | - William N Kisinza
- The National Institute for Medical Research, Amani Medical Research Centre, Muheza, Tanzania
| | - Jakob B Knudsen
- Ingvartsen Arkitekter, København K, Denmark; Det Kongelige Danske Kunstakademis Skoler for Arkitektur, Design og Konservering-Arkitektskolen, Copenhagen, Denmark
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Ali M, You YA, Kanungo S, Manna B, Deen JL, Lopez AL, Wierzba TF, Bhattacharya SK, Sur D, Clemens JD. Assessing different measures of population-level vaccine protection using a case-control study. Vaccine 2015; 33:6878-83. [PMID: 26364121 DOI: 10.1016/j.vaccine.2015.07.045] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2015] [Revised: 07/13/2015] [Accepted: 07/16/2015] [Indexed: 11/15/2022]
Abstract
BACKGROUND Case-control studies have not been examined for their utility in assessing population-level vaccine protection in individually randomized trials. METHODS We used the data of a randomized, placebo-controlled trial of a cholera vaccine to compare the results of case-control analyses with those of cohort analyses. Cases of cholera were selected from the trial population followed for three years following dosing. For each case, we selected 4 age-matched controls who had not developed cholera. For each case and control, GIS was used to calculate vaccine coverage of individuals in a surrounding "virtual" cluster. Specific selection strategies were used to evaluate the vaccine protective effects. RESULTS 66,900 out of 108,389 individuals received two doses of the assigned regimen. For direct protection among subjects in low vaccine coverage clusters, we observed 78% (95% CI: 47-91%) protection in a cohort analysis and 84% (95% CI: 60-94%) in case-control analysis after adjusting for confounding factors. Using our GIS-based approach, estimated indirect protection was 52% (95% CI: 10-74%) in cohort and 76% (95% CI: 47-89%) in case control analysis. Estimates of total and overall effectiveness were similar for cohort and case-control analyses. CONCLUSION The findings show that case-control analyses of individually randomized vaccine trials may be used to evaluate direct as well as population-level vaccine protection.
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Affiliation(s)
- Mohammad Ali
- International Vaccine Institute, Seoul, Republic of Korea; Johns Hopkins Bloomberg School of Public Health, Baltimore, USA.
| | - Young Ae You
- International Vaccine Institute, Seoul, Republic of Korea
| | - Suman Kanungo
- National Institute of Cholera and Enteric Diseases, Kolkata, India
| | - Byomkesh Manna
- National Institute of Cholera and Enteric Diseases, Kolkata, India
| | | | - Anna Lena Lopez
- University of the Philippines Manila, National Institutes of Health, Philippines
| | | | | | - Dipika Sur
- National Institute of Cholera and Enteric Diseases, Kolkata, India
| | - John D Clemens
- icddr,b, Dhaka, Bangladesh; UCLA Fielding School of Public Health, Los Angeles, USA
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Abstract
Anna Lena Lopez and colleagues give an overview of the cholera situation in Vietnam and discuss how an oral cholera vaccine was developed and used as a component of a public health strategy against the disease. Please see later in the article for the Editors' Summary
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Affiliation(s)
- Dang Duc Anh
- National Institute of Hygiene and Epidemiology, Hanoi, Vietnam
| | - Anna Lena Lopez
- University of the Philippines Manila-National Institutes of Health, Manila, Philippines
| | | | | | - Vu Dinh Thiem
- National Institute of Hygiene and Epidemiology, Hanoi, Vietnam
| | - Mohammad Ali
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Jacqueline L. Deen
- Menzies School of Health Research, Casuarina, Northern Territory, Australia
| | | | - David A. Sack
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
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You YA, Ali M, Kanungo S, Sah B, Manna B, Puri M, Nair GB, Bhattacharya SK, Convertino M, Deen JL, Lopez AL, Wierzba TF, Clemens J, Sur D. Risk map of cholera infection for vaccine deployment: the eastern Kolkata case. PLoS One 2013; 8:e71173. [PMID: 23936491 PMCID: PMC3732263 DOI: 10.1371/journal.pone.0071173] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Accepted: 06/25/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Despite advancement of our knowledge, cholera remains a public health concern. During March-April 2010, a large cholera outbreak afflicted the eastern part of Kolkata, India. The quantification of importance of socio-environmental factors in the risk of cholera, and the calculation of the risk is fundamental for deploying vaccination strategies. Here we investigate socio-environmental characteristics between high and low risk areas as well as the potential impact of vaccination on the spatial occurrence of the disease. METHODS AND FINDINGS The study area comprised three wards of Kolkata Municipal Corporation. A mass cholera vaccination campaign was conducted in mid-2006 as the part of a clinical trial. Cholera cases and data of the trial to identify high risk areas for cholera were analyzed. We used a generalized additive model (GAM) to detect risk areas, and to evaluate the importance of socio-environmental characteristics between high and low risk areas. During the one-year pre-vaccination and two-year post-vaccination periods, 95 and 183 cholera cases were detected in 111,882 and 121,827 study participants, respectively. The GAM model predicts that high risk areas in the west part of the study area where the outbreak largely occurred. High risk areas in both periods were characterized by poor people, use of unsafe water, and proximity to canals used as the main drainage for rain and waste water. Cholera vaccine uptake was significantly lower in the high risk areas compared to low risk areas. CONCLUSION The study shows that even a parsimonious model like GAM predicts high risk areas where cholera outbreaks largely occurred. This is useful for indicating where interventions would be effective in controlling the disease risk. Data showed that vaccination decreased the risk of infection. Overall, the GAM-based risk map is useful for policymakers, especially those from countries where cholera remains to be endemic with periodic outbreaks.
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Affiliation(s)
- Young Ae You
- International Vaccine Institute, Seoul, Republic of Korea
| | - Mohammad Ali
- International Vaccine Institute, Seoul, Republic of Korea
| | - Suman Kanungo
- National Institute of Cholera and Enteric Diseases, Kolkata, India
| | - Binod Sah
- International Vaccine Institute, Seoul, Republic of Korea
| | - Byomkesh Manna
- National Institute of Cholera and Enteric Diseases, Kolkata, India
| | - Mahesh Puri
- International Vaccine Institute, Seoul, Republic of Korea
| | | | - Sujit Kumar Bhattacharya
- National Institute of Cholera and Enteric Diseases, Kolkata, India
- Indian Council of Medical Research, New Delhi, India
| | - Matteo Convertino
- HumNat Lab, Department of Biological Systems Engineering, Virginia Tech, Blacksburg, Virginia, United States of America
- Bioinformatics Institute, Virginia Tech, Blacksburg, Virginia, United States of America
- Institute for Critical Technology and Applied Science, Virginia Tech, Blacksburg, Virginia, United States of America
| | - Jacqueline L. Deen
- Menzies School of Health Research, Casuarina, Northern Territory, Australia
| | - Anna Lena Lopez
- International Vaccine Institute, Seoul, Republic of Korea
- University of the Philippines Manila, National Institutes of Health, Manila, Philippines
| | | | - John Clemens
- International Vaccine Institute, Seoul, Republic of Korea
- University of California Los Angeles, School of Public Health, Los Angeles, United States of America
| | - Dipika Sur
- National Institute of Cholera and Enteric Diseases, Kolkata, India
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Ali M, Sur D, You YA, Kanungo S, Sah B, Manna B, Puri M, Wierzba TF, Donner A, Nair GB, Bhattacharya SK, Dhingra MS, Deen JL, Lopez AL, Clemens J. Herd protection by a bivalent killed whole-cell oral cholera vaccine in the slums of Kolkata, India. Clin Infect Dis 2013; 56:1123-31. [PMID: 23362293 DOI: 10.1093/cid/cit009] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND We evaluated the herd protection conferred by an oral cholera vaccine using 2 approaches: cluster design and geographic information system (GIS) design. METHODS Residents living in 3933 dwellings (clusters) in Kolkata, India, were cluster-randomized to receive either cholera vaccine or oral placebo. Nonpregnant residents aged≥1 year were invited to participate in the trial. Only the first episode of cholera detected for a subject between 14 and 1095 days after a second dose was considered. In the cluster design, indirect protection was assessed by comparing the incidence of cholera among nonparticipants in vaccine clusters vs those in placebo clusters. In the GIS analysis, herd protection was assessed by evaluating association between vaccine coverage among the population residing within 250 m of the household and the occurrence of cholera in that population. RESULTS Among 107 347 eligible residents, 66 990 received 2 doses of either cholera vaccine or placebo. In the cluster design, the 3-year data showed significant total protection (66% protection, 95% confidence interval [CI], 50%-78%, P<.01) but no evidence of indirect protection. With the GIS approach, the risk of cholera among placebo recipients was inversely related to neighborhood-level vaccine coverage, and the trend was highly significant (P<.01). This relationship held in multivariable models that also controlled for potentially confounding demographic variables (hazard ratio, 0.94 [95% CI, .90-.98]; P<.01). CONCLUSIONS Indirect protection was evident in analyses using the GIS approach but not the cluster design approach, likely owing to considerable transmission of cholera between clusters, which would vitiate herd protection in the cluster analyses. CLINICAL TRIALS REGISTRATION NCT00289224.
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Affiliation(s)
- Mohammad Ali
- International Vaccine Institute, Seoul, Republic of Korea.
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Hashim R, Khatib AM, Enwere G, Park JK, Reyburn R, Ali M, Chang NY, Kim DR, Ley B, Thriemer K, Lopez AL, Clemens JD, Deen JL, Shin S, Schaetti C, Hutubessy R, Aguado MT, Kieny MP, Sack D, Obaro S, Shaame AJ, Ali SM, Saleh AA, von Seidlein L, Jiddawi MS. Safety of the recombinant cholera toxin B subunit, killed whole-cell (rBS-WC) oral cholera vaccine in pregnancy. PLoS Negl Trop Dis 2012; 6:e1743. [PMID: 22848772 PMCID: PMC3404114 DOI: 10.1371/journal.pntd.0001743] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2012] [Accepted: 06/10/2012] [Indexed: 11/19/2022] Open
Abstract
Introduction Mass vaccinations are a main strategy in the deployment of oral cholera vaccines. Campaigns avoid giving vaccine to pregnant women because of the absence of safety data of the killed whole-cell oral cholera (rBS-WC) vaccine. Balancing this concern is the known higher risk of cholera and of complications of pregnancy should cholera occur in these women, as well as the lack of expected adverse events from a killed oral bacterial vaccine. Methodology/Principal Findings From January to February 2009, a mass rBS-WC vaccination campaign of persons over two years of age was conducted in an urban and a rural area (population 51,151) in Zanzibar. Pregnant women were advised not to participate in the campaign. More than nine months after the last dose of the vaccine was administered, we visited all women between 15 and 50 years of age living in the study area. The outcome of pregnancies that were inadvertently exposed to at least one oral cholera vaccine dose and those that were not exposed was evaluated. 13,736 (94%) of the target women in the study site were interviewed. 1,151 (79%) of the 1,453 deliveries in 2009 occurred during the period when foetal exposure to the vaccine could have occurred. 955 (83%) out of these 1,151 mothers had not been vaccinated; the remaining 196 (17%) mothers had received at least one dose of the oral cholera vaccine. There were no statistically significant differences in the odds ratios for birth outcomes among the exposed and unexposed pregnancies. Conclusions/Significance We found no statistically significant evidence of a harmful effect of gestational exposure to the rBS-WC vaccine. These findings, along with the absence of a rational basis for expecting a risk from this killed oral bacterial vaccine, are reassuring but the study had insufficient power to detect infrequent events. Trial Registration ClinicalTrials.gov NCT00709410 Pregnant women are more vulnerable to complications of cholera than other people. It would be helpful to include pregnant women in vaccination campaigns against cholera but pregnant women and their unborn children are highly vulnerable to the potential adverse effects of biological products such as vaccines. The safety of oral cholera vaccines in pregnant women has up to now not been evaluated. During a large mass cholera vaccination campaign in Zanzibar in 2009, women were advised not to participate if they thought they may be pregnant. The large majority (955 or 83%) of women residing in the study area who were to be pregnant during the 9 months following the vaccinations did not participate in the campaign. The remaining 196 (17%) women received the vaccine. A comparison between vaccine exposed and unexposed pregnancies did not reveal any significant differences in outcome between the two groups. The small number of miscarriages, infant deaths and ill infants was similarly distributed between the two groups. These findings are reassuring but continued monitoring of this vaccine when given during pregnancy is recommended.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Benedikt Ley
- International Vaccine Institute, Seoul, Korea
- Biocenter, University of Vienna, Vienna, Austria
| | | | | | | | | | | | - Christian Schaetti
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | | | | | | | - David Sack
- Johns Hopkins School of Public Health, Baltimore, Maryland, United States of America
| | - Stephen Obaro
- Michigan State University, East Lansing, Michigan, United States of America
| | | | - Said M. Ali
- Public Health Laboratory Ivo de Carneri, Chake-Chake, Zanzibar
| | - Abdul A. Saleh
- Ministry of Health and Social Welfare, Stonetown, Zanzibar
| | - Lorenz von Seidlein
- Menzies School of Health Research, Casuarina, Northern Territory, Australia
- * E-mail:
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von Seidlein L, Olaosebikan R, Hendriksen ICE, Lee SJ, Adedoyin OT, Agbenyega T, Nguah SB, Bojang K, Deen JL, Evans J, Fanello CI, Gomes E, Pedro AJ, Kahabuka C, Karema C, Kivaya E, Maitland K, Mokuolu OA, Mtove G, Mwanga-Amumpaire J, Nadjm B, Nansumba M, Ngum WP, Onyamboko MA, Reyburn H, Sakulthaew T, Silamut K, Tshefu AK, Umulisa N, Gesase S, Day NPJ, White NJ, Dondorp AM. Predicting the clinical outcome of severe falciparum malaria in african children: findings from a large randomized trial. Clin Infect Dis 2012; 54:1080-90. [PMID: 22412067 PMCID: PMC3309889 DOI: 10.1093/cid/cis034] [Citation(s) in RCA: 125] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Four predictors were independently associated with an increased risk of death: acidosis, cerebral manifestations of malaria, elevated blood urea nitrogen, or signs of chronic illness. The standard base deficit was found to be the single most relevant predictor of death. Background. Data from the largest randomized, controlled trial for the treatment of children hospitalized with severe malaria were used to identify such predictors of a poor outcome from severe malaria. Methods. African children (<15 years) with severe malaria participated in a randomized comparison of parenteral artesunate and parenteral quinine in 9 African countries. Detailed clinical assessment was performed on admission. Parasite densities were assessed in a reference laboratory. Predictors of death were examined using a multivariate logistic regression model. Results. Twenty indicators of disease severity were assessed, out of which 5 (base deficit, impaired consciousness, convulsions, elevated blood urea, and underlying chronic illness) were associated independently with death. Tachypnea, respiratory distress, deep breathing, shock, prostration, low pH, hyperparasitemia, severe anemia, and jaundice were statistically significant indicators of death in the univariate analysis but not in the multivariate model. Age, glucose levels, axillary temperature, parasite density, heart rate, blood pressure, and blackwater fever were not related to death in univariate models. Conclusions. Acidosis, cerebral involvement, renal impairment, and chronic illness are key independent predictors for a poor outcome in African children with severe malaria. Mortality is markedly increased in cerebral malaria combined with acidosis. Clinical Trial Registration. ISRCTN50258054.
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Affiliation(s)
- Lorenz von Seidlein
- Department of Global Health, Menzies School of Health Research, Casuarina, Northern Territory, Australia.
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Sur D, Kanungo S, Sah B, Manna B, Ali M, Paisley AM, Niyogi SK, Park JK, Sarkar B, Puri MK, Kim DR, Deen JL, Holmgren J, Carbis R, Rao R, Thu Van N, Han SH, Attridge S, Donner A, Ganguly NK, Bhattacharya SK, Nair GB, Clemens JD, Lopez AL. Efficacy of a low-cost, inactivated whole-cell oral cholera vaccine: results from 3 years of follow-up of a randomized, controlled trial. PLoS Negl Trop Dis 2011; 5:e1289. [PMID: 22028938 PMCID: PMC3196468 DOI: 10.1371/journal.pntd.0001289] [Citation(s) in RCA: 123] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2011] [Accepted: 07/09/2011] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Killed oral cholera vaccines (OCVs) have been licensed for use in developing countries, but protection conferred by licensed OCVs beyond two years of follow-up has not been demonstrated in randomized, clinical trials. METHODS/PRINCIPAL FINDINGS We conducted a cluster-randomized, placebo-controlled trial of a two-dose regimen of a low-cost killed whole cell OCV in residents 1 year of age and older living in 3,933 clusters in Kolkata, India. The primary endpoint was culture-proven Vibrio cholerae O1 diarrhea episodes severe enough to require treatment in a health care facility. Of the 66,900 fully dosed individuals (31,932 vaccinees and 34,968 placebo recipients), 38 vaccinees and 128 placebo-recipients developed cholera during three years of follow-up (protective efficacy 66%; one-sided 95%CI lower bound = 53%, p<0.001). Vaccine protection during the third year of follow-up was 65% (one-sided 95%CI lower bound = 44%, p<0.001). Significant protection was evident in the second year of follow-up in children vaccinated at ages 1-4 years and in the third year in older age groups. CONCLUSIONS/SIGNIFICANCE The killed whole-cell OCV conferred significant protection that was evident in the second year of follow-up in young children and was sustained for at least three years in older age groups. Continued follow-up will be important to establish the vaccine's duration of protection. TRIAL REGISTRATION ClinicalTrials.gov NCT00289224.
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Affiliation(s)
- Dipika Sur
- National Institute of Cholera and Enteric Diseases, Kolkata, India
| | - Suman Kanungo
- National Institute of Cholera and Enteric Diseases, Kolkata, India
| | - Binod Sah
- International Vaccine Institute, Seoul, Republic of Korea
| | - Byomkesh Manna
- National Institute of Cholera and Enteric Diseases, Kolkata, India
| | - Mohammad Ali
- International Vaccine Institute, Seoul, Republic of Korea
| | | | - Swapan K. Niyogi
- National Institute of Cholera and Enteric Diseases, Kolkata, India
| | - Jin Kyung Park
- International Vaccine Institute, Seoul, Republic of Korea
| | | | - Mahesh K. Puri
- International Vaccine Institute, Seoul, Republic of Korea
| | - Deok Ryun Kim
- International Vaccine Institute, Seoul, Republic of Korea
| | | | | | - Rodney Carbis
- International Vaccine Institute, Seoul, Republic of Korea
| | - Raman Rao
- Shantha Biotechnics, Hyderabad, India
| | | | - Seung Hyun Han
- International Vaccine Institute, Seoul, Republic of Korea
- Seoul National University, Seoul, Korea
| | | | - Allan Donner
- University of Western Ontario, London, Ontario, Canada
| | | | | | | | - John D. Clemens
- International Vaccine Institute, Seoul, Republic of Korea
- * E-mail:
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Ley B, Thriemer K, Ame SM, Mtove GM, von Seidlein L, Amos B, Hendriksen ICE, Mwambuli A, Shoo A, Kim DR, Ochiai LR, Favorov M, Clemens JD, Wilfing H, Deen JL, Ali SM. Assessment and comparative analysis of a rapid diagnostic test (Tubex®) for the diagnosis of typhoid fever among hospitalized children in rural Tanzania. BMC Infect Dis 2011; 11:147. [PMID: 21609455 PMCID: PMC3123569 DOI: 10.1186/1471-2334-11-147] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2011] [Accepted: 05/24/2011] [Indexed: 11/16/2022] Open
Abstract
Background Typhoid fever remains a significant health problem in many developing countries. A rapid test with a performance comparable to that of blood culture would be highly useful. A rapid diagnostic test for typhoid fever, Tubex®, is commercially available that uses particle separation to detect immunoglobulin M directed towards Salmonella Typhi O9 lipopolysaccharide in sera. Methods We assessed the sensitivity and specificity of the Tubex test among Tanzanian children hospitalized with febrile illness using blood culture as gold standard. Evaluation was done considering blood culture confirmed S. Typhi with non-typhi salmonella (NTS) and non - salmonella isolates as controls as well as with non-salmonella isolates only. Results Of 139 samples tested with Tubex, 33 were positive for S. Typhi in blood culture, 49 were culture-confirmed NTS infections, and 57 were other non-salmonella infections. Thirteen hemolyzed samples were excluded. Using all non - S. Typhi isolates as controls, we showed a sensitivity of 79% and a specificity of 89%. When the analysis was repeated excluding NTS from the pool of controls we showed a sensitivity of 79% and a specificity of 97%. There was no significant difference in the test performance using the two different control groups (p > 0.05). Conclusion This first evaluation of the Tubex test in an African setting showed a similar performance to those seen in some Asian settings. Comparison with the earlier results of a Widal test using the same samples showed no significant difference (p > 0.05) for any of the performance indicators, irrespective of the applied control group.
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Affiliation(s)
- Benedikt Ley
- Translational Research Division, International Vaccine Institute, Seoul, Korea.
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Reyburn R, Deen JL, Grais RF, Bhattacharya SK, Sur D, Lopez AL, Jiddawi MS, Clemens JD, von Seidlein L. The case for reactive mass oral cholera vaccinations. PLoS Negl Trop Dis 2011; 5:e952. [PMID: 21283614 PMCID: PMC3026767 DOI: 10.1371/journal.pntd.0000952] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2010] [Accepted: 12/29/2010] [Indexed: 11/18/2022] Open
Abstract
Introduction The outbreak of cholera in Zimbabwe intensified interest in the control and prevention of cholera. While there is agreement that safe water, sanitation, and personal hygiene are ideal for the long term control of cholera, there is controversy about the role of newer approaches such as oral cholera vaccines (OCVs). In October 2009 the Strategic Advisory Group of Experts advised the World Health Organization to consider reactive vaccination campaigns in response to large cholera outbreaks. To evaluate the potential benefit of this pivotal change in WHO policy, we used existing data from cholera outbreaks to simulate the number of cholera cases preventable by reactive mass vaccination. Methods Datasets of cholera outbreaks from three sites with varying cholera endemicity—Zimbabwe, Kolkata (India), and Zanzibar (Tanzania)—were analysed to estimate the number of cholera cases preventable under differing response times, vaccine coverage, and vaccine doses. Findings The large cholera outbreak in Zimbabwe started in mid August 2008 and by July 2009, 98,591 cholera cases had been reported with 4,288 deaths attributed to cholera. If a rapid response had taken place and half of the population had been vaccinated once the first 400 cases had occurred, as many as 34,900 (40%) cholera cases and 1,695 deaths (40%) could have been prevented. In the sites with endemic cholera, Kolkata and Zanzibar, a significant number of cases could have been prevented but the impact would have been less dramatic. A brisk response is required for outbreaks with the majority of cases occurring during the early weeks. Even a delayed response can save a substantial number of cases and deaths in long, drawn-out outbreaks. If circumstances prevent a rapid response there are good reasons to roll out cholera mass vaccination campaigns well into the outbreak. Once a substantial proportion of a population is vaccinated, outbreaks in subsequent years may be reduced if not prevented. A single dose vaccine would be of advantage in short, small outbreaks. Conclusions We show that reactive vaccine use can prevent cholera cases and is a rational response to cholera outbreaks in endemic and non-endemic settings. In large and long outbreaks a reactive vaccination with a two-dose vaccine can prevent a substantial proportion of cases. To make mass vaccination campaigns successful, it would be essential to agree when to implement reactive vaccination campaigns and to have a dynamic and determined response team that is familiar with the logistic challenges on standby. Most importantly, the decision makers in donor and recipient countries have to be convinced of the benefit of reactive cholera vaccinations. Cholera outbreaks have had catastrophic impact on societies for centuries. Despite more than half a century of advocacy for safe water, sanitation and hygiene, approximately 100,000 cholera cases and 5,000 deaths were reported in Zimbabwe between August 2008 and by July 2009. Safe and effective oral cholera vaccines have been licensed and used by affluent tourists for more than a decade to prevent cholera. We asked whether oral cholera vaccines could be used to protect high risk populations at a time of cholera. We calculated how many cholera cases could have been prevented if mass cholera vaccinations would have been implemented in reaction to past cholera outbreaks. We estimate that determined, well organized mass vaccination campaigns could have prevented 34,900 (40%) cholera cases and 1,695 deaths (40%) in Zimbabwe. In the sites with endemic cholera, Kolkata and Zanzibar, a significant number of cases could have been prevented but the impact would have been less dramatic. The barriers which currently prevent the implementation of mass vaccinations, including but not only the cost to purchase the vaccine, seem insurmountable. A concerted effort of donors and key decision makers will be needed to offer better protection to populations at risk.
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Affiliation(s)
- Rita Reyburn
- International Vaccine Institute (IVI), Seoul, Korea.
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Ley B, Mtove G, Thriemer K, Amos B, von Seidlein L, Hendriksen I, Mwambuli A, Shoo A, Malahiyo R, Ame SM, Kim DR, Ochiai LR, Clemens JD, Reyburn H, Wilfing H, Magesa S, Deen JL. Evaluation of the Widal tube agglutination test for the diagnosis of typhoid fever among children admitted to a rural hdospital in Tanzania and a comparison with previous studies. BMC Infect Dis 2010; 10:180. [PMID: 20565990 PMCID: PMC2898821 DOI: 10.1186/1471-2334-10-180] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2010] [Accepted: 06/22/2010] [Indexed: 11/16/2022] Open
Abstract
Background The diagnosis of typhoid fever is confirmed by culture of Salmonella enterica serotype Typhi (S. typhi). However, a more rapid, simpler, and cheaper diagnostic method would be very useful especially in developing countries. The Widal test is widely used in Africa but little information exists about its reliability. Methods We assessed the performance of the Widal tube agglutination test among febrile hospitalized Tanzanian children. We calculated the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of various anti-TH and -TO titers using culture-confirmed typhoid fever cases as the "true positives" and all other febrile children with blood culture negative for S. typhi as the "true negatives." Results We found that 16 (1%) of 1,680 children had culture-proven typhoid fever. A single anti-TH titer of 1:80 and higher was the optimal indicator of typhoid fever. This had a sensitivity of 75%, specificity of 98%, NPV of 100%, but PPV was only 26%. We compared our main findings with those from previous studies. Conclusion Among febrile hospitalized Tanzanian children with a low prevalence of typhoid fever, a Widal titer of ≥ 1:80 performed well in terms of sensitivity, specificity, and NPV. However a test with improved PPV that is similarly easy to apply and cost-efficient is desirable.
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Kanungo S, Tsuzuki A, Deen JL, Lopez AL, Rajendran K, Manna B, Sur D, Kim DR, Gupta VK, Ochiai RL, Ali M, von Seidlein L, Bhattacharya SK, Clemens JD. Use of verbal autopsy to determine mortality patterns in an urban slum in Kolkata, India. Bull World Health Organ 2010; 88:667-74. [PMID: 20865071 DOI: 10.2471/blt.09.073742] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2009] [Revised: 01/14/2010] [Accepted: 01/18/2010] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To define mortality patterns in an urban slum in Kolkata, India, in the context of a cholera and typhoid fever project. METHODS In a well-defined population that was under surveillance for 18 months, we followed a dynamic cohort of 63 788 residents whose households were visited monthly by community health workers to identify deaths. Trained physicians performed verbal autopsies and experienced senior physicians assigned the primary cause of death according to the International classification of diseases, 10th edition. We tabulated causes of death in accordance with Global Burden of Disease 2000 categories and assessed overall and cause-specific mortality rates per age group and gender. FINDINGS During 87 921 person-years of follow-up, we recorded 544 deaths. This gave an overall mortality rate of 6.2 per 1000 person-years. We assigned a cause to 89% (482/544) of the deaths. The leading causes of death, in descending order, were cardiovascular diseases (especially among adults aged over 40 years), cancer, respiratory ailments and digestive disorders. Most deaths in children under 5 years of age were caused by tuberculosis, respiratory infections and diarrhoeal diseases. CONCLUSION Although the most common causes of death in children were infectious, non-communicable diseases were predominant among adults. There is a need for continuing interventions against infectious diseases in addition to new and innovative strategies to combat non-infectious conditions.
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Affiliation(s)
- Suman Kanungo
- National Institute of Cholera and Enteric Diseases, Kolkata, India
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Mtove G, Amos B, von Seidlein L, Hendriksen I, Mwambuli A, Kimera J, Mallahiyo R, Kim DR, Ochiai RL, Clemens JD, Reyburn H, Magesa S, Deen JL. Invasive salmonellosis among children admitted to a rural Tanzanian hospital and a comparison with previous studies. PLoS One 2010; 5:e9244. [PMID: 20168998 PMCID: PMC2821934 DOI: 10.1371/journal.pone.0009244] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2009] [Accepted: 01/27/2010] [Indexed: 11/18/2022] Open
Abstract
Background The importance of invasive salmonellosis in African children is well recognized but there is inadequate information on these infections. We conducted a fever surveillance study in a Tanzanian rural hospital to estimate the case fraction of invasive salmonellosis among pediatric admissions, examine associations with common co-morbidities and describe its clinical features. We compared our main findings with those from previous studies among children in sub-Saharan Africa. Methodology/Principal Findings From 1 March 2008 to 28 Feb 2009, 1,502 children were enrolled into the study. We collected clinical information and blood for point of care tests, culture, and diagnosis of malaria and HIV. We analyzed the clinical features on admission and outcome by laboratory-confirmed diagnosis. Pathogenic bacteria were isolated from the blood of 156 (10%) children, of which 14 (9%) were S. typhi, 45 (29%) were NTS and 97 (62%) were other pathogenic bacteria. Invasive salmonellosis accounted for 59/156 (38%) bacteremic children. Children with typhoid fever were significantly older and presented with a longer duration of fever. NTS infections were significantly associated with prior antimalarial treatment, malarial complications and with a high risk for death. Conclusions/Significance Invasive salmonellosis, particularly NTS infection, is an important cause of febrile disease among hospitalized children in our rural Tanzanian setting. Previous studies showed considerable variation in the case fraction of S. typhi and NTS infections. Certain suggestive clinical features (such as older age and long duration of fever for typhoid whereas concomitant malaria, anemia, jaundice and hypoglycemia for NTS infection) may be used to distinguish invasive salmonellosis from other severe febrile illness.
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Affiliation(s)
- George Mtove
- National Institute for Medical Research-Amani Centre, Tanga, Tanzania.
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Sur D, Lopez AL, Kanungo S, Paisley A, Manna B, Ali M, Niyogi SK, Park JK, Sarkar B, Puri MK, Kim DR, Deen JL, Holmgren J, Carbis R, Rao R, Nguyen TV, Donner A, Ganguly NK, Nair GB, Bhattacharya SK, Clemens JD. Efficacy and safety of a modified killed-whole-cell oral cholera vaccine in India: an interim analysis of a cluster-randomised, double-blind, placebo-controlled trial. Lancet 2009; 374:1694-702. [PMID: 19819004 DOI: 10.1016/s0140-6736(09)61297-6] [Citation(s) in RCA: 191] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Oral cholera vaccines consisting of killed whole cells have been available for many years, but they have not been used extensively in populations with endemic disease. An inexpensive, locally produced oral killed-whole-cell vaccine has been used in high-risk areas in Vietnam. To expand the use of this vaccine, it was modified to comply with WHO standards. We assessed the efficacy and safety of this modified vaccine in a population with endemic cholera. METHODS In this double-blind trial, 107 774 non-pregnant residents of Kolkata, India, aged 1 year or older, were cluster-randomised by dwelling to receive two doses of either modified killed-whole-cell cholera vaccine (n=52 212; 1966 clusters) or heat-killed Escherichia coli K12 placebo (n=55 562; 1967 clusters), both delivered orally. Randomisation was done by computer-generated sequence in blocks of four. The primary endpoint was prevention of episodes of culture-confirmed Vibrio cholerae O1 diarrhoea severe enough for the patient to seek treatment in a health-care facility. We undertook an interim, per-protocol analysis at 2 years of follow-up that included individuals who received two completely ingested doses of vaccine or placebo. We assessed first episodes of cholera that occurred between 14 days and 730 days after receipt of the second dose. This study is registered with ClinicalTrials.gov, number NCT00289224. FINDINGS 31 932 participants assigned to vaccine (1721 clusters) and 34 968 assigned to placebo (1757 clusters) received two doses of study treatment. There were 20 episodes of cholera in the vaccine group and 68 episodes in the placebo group (protective efficacy 67%; one-tailed 99% CI, lower bound 35%, p<0.0001). The vaccine protected individuals in age-groups 1.0-4.9 years, 5.0-14.9 years, and 15 years and older, and protective efficacy did not differ significantly between age-groups (p=0.28). We recorded no vaccine-related serious adverse events. INTERPRETATION This modified killed-whole-cell oral vaccine, compliant with WHO standards, is safe, provides protection against clinically significant cholera in an endemic setting, and can be used in children aged 1.0-4.9 years, who are at highest risk of developing cholera in endemic settings. FUNDING Bill & Melinda Gates Foundation, Swedish International Development Cooperation Agency, Governments of South Korea, Sweden, and Kuwait.
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Affiliation(s)
- Dipika Sur
- National Institute of Cholera and Enteric Diseases, Kolkata, India
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Deen JL, von Seidlein L, Dondorp A. Therapy of uncomplicated malaria in children: a review of treatment principles, essential drugs and current recommendations. Trop Med Int Health 2008; 13:1111-30. [DOI: 10.1111/j.1365-3156.2008.02117.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
Dengue is an arthropod-borne infection caused by a flavivirus and spread by the Aedes mosquitoes. Many of the countries where dengue is endemic are popular tourist destinations and the disease is an increasingly important problem encountered by international travelers. Personal protection against the day-feeding dengue vectors is problematic, indicating the urgent need for a dengue vaccine. This review discusses the challenges of vaccine development, current vaccine strategies and the prospects for the availability of a vaccine for travelers in the future. Cost-effectiveness studies will need to take into account many factors, including the attack rate of dengue in travelers, the proportion of travelers who will need hospitalization, the cost of altered travel itineraries, the cost of the vaccine, duration of travel, destination and season. To be licensed as a travelers' vaccine, vaccine trials must address safety, immunogenicity, duration of protection, schedules and boosters in adults (in particular in immunologically naive adults), trials that may differ from those conducted in endemic countries. Vaccine schedules with long intervals would be a major obstacle to the uptake of the vaccine by travelers. Enhanced reactogenicity or interference with immunization must be effectively excluded for travelers with prior or concurrent vaccination against other flaviviruses, such as yellow fever or Japanese encephalitis. Licensing dengue as a travelers' vaccine poses unique challenges beyond the development of a vaccine for the endemic population.
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Affiliation(s)
- Annelies Wilder-Smith
- Travelers' Screening and Vaccination Clinic, National University of Singapore, Kent Ridge Road, 119076 Singapore.
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Von Seidlein L, Wang XY, Macuamule A, Mondlane C, Puri M, Hendriksen I, Deen JL, Chaignat CL, Clemens JD, Ansaruzzaman M, Barreto A, Songane FF, Lucas M. Is HIV infection associated with an increased risk for cholera? Findings from a case-control study in Mozambique. Trop Med Int Health 2008; 13:683-8. [DOI: 10.1111/j.1365-3156.2008.02051.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Deen JL, von Seidlein L, Sur D, Agtini M, Lucas MES, Lopez AL, Kim DR, Ali M, Clemens JD. The high burden of cholera in children: comparison of incidence from endemic areas in Asia and Africa. PLoS Negl Trop Dis 2008; 2:e173. [PMID: 18299707 PMCID: PMC2254203 DOI: 10.1371/journal.pntd.0000173] [Citation(s) in RCA: 129] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2007] [Accepted: 12/26/2007] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Cholera remains an important public health problem. Yet there are few reliable population-based estimates of laboratory-confirmed cholera incidence in endemic areas around the world. METHODS We established treatment facility-based cholera surveillance in three sites in Jakarta (Indonesia), Kolkata (India), and Beira (Mozambique). The annual incidence of cholera was estimated using the population census as the denominator and the age-specific number of cholera cases among the study cohort as the numerator. FINDINGS The lowest overall rate was found in Jakarta, where the estimated incidence was 0.5/1000 population/year. The incidence was three times higher in Kolkata (1.6/1000/year) and eight times higher in Beira (4.0/1000/year). In all study sites, the greatest burden was in children under 5 years of age. CONCLUSION There are considerable differences in cholera incidence across these endemic areas but in all sites, children are the most affected. The study site in Africa had the highest cholera incidence consistent with a growing impression of the large cholera burden in Africa. Burden estimates are useful when considering where and among whom interventions such as vaccination would be most needed.
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Thiem VD, Canh DG, Anh DD, Deen JL, von Seidlein L, Clemens JD, Holmgren J. Response to "questionable merits of the field trial of an oral killed whole cell cholera vaccine in Vietnam during 1998-2003" Vaccine 2007;25(8):1353-4. Vaccine 2007; 25:7981-3. [PMID: 17933443 DOI: 10.1016/j.vaccine.2007.06.069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2007] [Accepted: 06/01/2007] [Indexed: 10/22/2022]
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Ansaruzzaman M, Bhuiyan NA, Safa A, Sultana M, McUamule A, Mondlane C, Wang XY, Deen JL, von Seidlein L, Clemens JD, Lucas M, Sack DA, Balakrish Nair G. Genetic diversity of El Tor strains of Vibrio cholerae O1 with hybrid traits isolated from Bangladesh and Mozambique. Int J Med Microbiol 2007; 297:443-9. [PMID: 17475554 DOI: 10.1016/j.ijmm.2007.01.009] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2006] [Revised: 12/31/2006] [Accepted: 01/23/2007] [Indexed: 11/25/2022] Open
Abstract
Vibrio cholerae O1 strains that are hybrids between the classical and El Tor biotypes were isolated during two consecutive years (2004-2005) from diarrheal patients in Mozambique. Similar variants isolated in Bangladesh and recently isolated El Tor strains were analyzed for genetic diversity. Pulsed-field gel electrophoresis (PFGE) analysis using the restriction enzyme NotI, resulted in 18-21 bands showed five closely related PFGE patterns that were distributed similarly in both years (2004-2005) among the 80 strains tested in Mozambique. Overall based on the PFGE patterns the hybrids indicated an El Tor lineage. The restriction patterns of whole-chromosomal DNA grouped the hybrid strains from Mozambique into a separate cluster from Bangladeshi clinical and environmental hybrid strains. A high molecular weight band of 398kb that contain rstR allele of the classical type was detected from all hybrid strains, which was absent in all conventional classical and El Tor strains. This band could be designated as a marker for the hybrid strains. This study suggests that hybrid strains from Mozambique are closely related to each other, different from Bangladeshi hybrid strains that are diverse in nature and all hybrid strains differed markedly from conventional classical and El Tor strains.
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Affiliation(s)
- Mohammad Ansaruzzaman
- Laboratory Sciences Division, Centre for Health and Population Research, International Centre for Diarrhoeal Disease Research, Dhaka 1000, Bangladesh.
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Sur D, Ali M, von Seidlein L, Manna B, Deen JL, Acosta CJ, Clemens JD, Bhattacharya SK. Comparisons of predictors for typhoid and paratyphoid fever in Kolkata, India. BMC Public Health 2007; 7:289. [PMID: 17935611 PMCID: PMC2099435 DOI: 10.1186/1471-2458-7-289] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2007] [Accepted: 10/12/2007] [Indexed: 11/26/2022] Open
Abstract
Background: Exposure of the individual to contaminated food or water correlates closely with the risk for enteric fever. Since public health interventions such as water improvement or vaccination campaigns are implemented for groups of individuals we were interested whether risk factors not only for the individual but for households, neighbourhoods and larger areas can be recognised? Methods: We conducted a large enteric fever surveillance study and analyzed factors which correlate with enteric fever on an individual level and factors associated with high and low risk areas with enteric fever incidence. Individual level data were linked to a population based geographic information systems. Individual and household level variables were fitted in Generalized Estimating Equations (GEE) with the logit link function to take into account the likelihood that household factors correlated within household members. Results: Over a 12-month period 80 typhoid fever cases and 47 paratyphoid fever cases were detected among 56,946 residents in two bustees (slums) of Kolkata, India. The incidence of paratyphoid fever was lower (0.8/1000/year), and the mean age of paratyphoid patients was older (17.1 years) than for typhoid fever (incidence 1.4/1000/year, mean age 14.7 years). Residents in areas with a high risk for typhoid fever had lower literacy rates and economic status, bigger household size, and resided closer to waterbodies and study treatment centers than residents in low risk areas. Conclusion: There was a close correlation between the characteristics detected based on individual cases and characteristics associated with high incidence areas. Because the comparison of risk factors of populations living in high versus low risk areas is statistically very powerful this methodology holds promise to detect risk factors associated with diseases using geographic information systems.
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Affiliation(s)
- Dipika Sur
- 1National Institute of Cholera and Enteric Diseases, Kolkata, India.
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Agtini MD, Soeharno R, Lesmana M, Punjabi NH, Simanjuntak C, Wangsasaputra F, Nurdin D, Pulungsih SP, Rofiq A, Santoso H, Pujarwoto H, Sjahrurachman A, Sudarmono P, von Seidlein L, Deen JL, Ali M, Lee H, Kim DR, Han O, Park JK, Suwandono A, Ingerani, Oyofo BA, Campbell JR, Beecham HJ, Corwin AL, Clemens JD. Erratum To: The burden of diarrhoea, shigellosis, and cholera in North Jakarta, Indonesia: findings from 24 months surveillance. BMC Infect Dis 2007. [PMCID: PMC1797178 DOI: 10.1186/1471-2334-7-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
This is a correction of an earlier published article.
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Dutta S, Sur D, Manna B, Sen B, Deb AK, Deen JL, Wain J, Von Seidlein L, Ochiai L, Clemens JD, Kumar Bhattacharya S. Evaluation of new-generation serologic tests for the diagnosis of typhoid fever: data from a community-based surveillance in Calcutta, India. Diagn Microbiol Infect Dis 2006; 56:359-65. [PMID: 16938421 DOI: 10.1016/j.diagmicrobio.2006.06.024] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2006] [Revised: 06/28/2006] [Accepted: 06/29/2006] [Indexed: 11/30/2022]
Abstract
Although typhoid fever is confirmed by culture of Salmonella enterica serotype Typhi, rapid and simple diagnostic serologic tests would be useful in developing countries. We examined the performance of Widal test in a community field site and compared it with Typhidot and Tubex tests for diagnosis of typhoid fever. Blood samples were collected from 6697 patients with fever for > or =3 days for microscopy, culture, and serologic testing and from randomly selected 172 consenting healthy individuals to assess the baseline Widal anti-Typhi O lipopolysaccharide antibody (anti-TO) and anti-Typhi H flagellar antibody (anti-TH) titers. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the 3 serologic tests were calculated using culture-confirmed typhoid fever cases as "true positives" and paratyphoid fever and malaria cases as "true negatives". Comparing cutoff values for the Widal test, an anti-TO titer of 1/80 was optimal with 58% sensitivity, 85% specificity, 69% PPV, and 77% NPV. Sensitivity was increased to 67% when the Widal test was done on the 5th day of illness and thereafter. The sensitivity, specificity, PPV, and NPV of Typhidot and Tubex were not better than Widal test. There is a need for more efficient rapid diagnostic test for typhoid fever especially during the acute stage of the disease. Until then, culture remains the method of choice.
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Affiliation(s)
- Shanta Dutta
- National Institute of Cholera and Enteric Diseases, P-33 CIT Road, Scheme XM, Beliaghata, P.O. Box 177, Calcutta 700010, India
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Abstract
There is a growing need for vaccine trials in developing countries. This need arises from the fact that some vaccines do not perform as well in developing as in industrialized country populations and because some newly developed candidates target diseases found only in less-developed countries. Here we discuss several key issues in the design and implementation of vaccine trials in less-developed countries. These include the phasing of vaccine trials on safety, immunogenicity and efficacy to achieve licensure; the recent use of trials to obtain other information crucial to the ultimate deployment of vaccines (such as immunological correlates of protection, indirect vaccine effects, and practical information on the feasibility, costs and acceptability of vaccine introduction); and several ethical issues that have arisen in connection with trials done in developing countries.
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von Seidlein L, Kim DR, Ali M, Lee H, Wang X, Thiem VD, Canh DG, Chaicumpa W, Agtini MD, Hossain A, Bhutta ZA, Mason C, Sethabutr O, Talukder K, Nair GB, Deen JL, Kotloff K, Clemens J. A multicentre study of Shigella diarrhoea in six Asian countries: disease burden, clinical manifestations, and microbiology. PLoS Med 2006; 3:e353. [PMID: 16968124 PMCID: PMC1564174 DOI: 10.1371/journal.pmed.0030353] [Citation(s) in RCA: 332] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2006] [Accepted: 06/21/2006] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The burden of shigellosis is greatest in resource-poor countries. Although this diarrheal disease has been thought to cause considerable morbidity and mortality in excess of 1,000,000 deaths globally per year, little recent data are available to guide intervention strategies in Asia. We conducted a prospective, population-based study in six Asian countries to gain a better understanding of the current disease burden, clinical manifestations, and microbiology of shigellosis in Asia. METHODS AND FINDINGS Over 600,000 persons of all ages residing in Bangladesh, China, Pakistan, Indonesia, Vietnam, and Thailand were included in the surveillance. Shigella was isolated from 2,927 (5%) of 56,958 diarrhoea episodes detected between 2000 and 2004. The overall incidence of treated shigellosis was 2.1 episodes per 1,000 residents per year in all ages and 13.2/1,000/y in children under 60 months old. Shigellosis incidence increased after age 40 years. S. flexneri was the most frequently isolated Shigella species (1,976/2,927 [68%]) in all sites except in Thailand, where S. sonnei was most frequently detected (124/146 [85%]). S. flexneri serotypes were highly heterogeneous in their distribution from site to site, and even from year to year. PCR detected ipaH, the gene encoding invasion plasmid antigen H in 33% of a sample of culture-negative stool specimens. The majority of S. flexneri isolates in each site were resistant to amoxicillin and cotrimoxazole. Ciprofloxacin-resistant S. flexneri isolates were identified in China (18/305 [6%]), Pakistan (8/242 [3%]), and Vietnam (5/282 [2%]). CONCLUSIONS Shigella appears to be more ubiquitous in Asian impoverished populations than previously thought, and antibiotic-resistant strains of different species and serotypes have emerged. Focusing on prevention of shigellosis could exert an immediate benefit first by substantially reducing the overall diarrhoea burden in the region and second by preventing the spread of panresistant Shigella strains. The heterogeneous distribution of Shigella species and serotypes suggest that multivalent or cross-protective Shigella vaccines will be needed to prevent shigellosis in Asia.
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Deen JL, Harris E, Wills B, Balmaseda A, Hammond SN, Rocha C, Dung NM, Hung NT, Hien TT, Farrar JJ. The WHO dengue classification and case definitions: time for a reassessment. Lancet 2006; 368:170-3. [PMID: 16829301 DOI: 10.1016/s0140-6736(06)69006-5] [Citation(s) in RCA: 245] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Jacqueline L Deen
- International Vaccine Institute, Kwanak PO Box 14, Seoul, Republic of Korea.
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Siddiqui FJ, Bhutto NS, von Seidlein L, Khurram I, Rasool S, Ali M, Zafar A, Deen JL, Clemens JD, Nizami Q, Bhutta ZA. Consecutive outbreaks of Vibrio cholerae O139 and V. cholerae O1 cholera in a fishing village near Karachi, Pakistan. Trans R Soc Trop Med Hyg 2006; 100:476-82. [PMID: 16443247 DOI: 10.1016/j.trstmh.2005.07.019] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2004] [Revised: 07/22/2005] [Accepted: 07/26/2005] [Indexed: 11/23/2022] Open
Abstract
In July 2002 and June 2003, cholera outbreaks were detected by a diarrhoea surveillance system in a village outside Karachi, Pakistan. Specimens were culture confirmed. The first outbreak was caused by Vibrio cholerae O139 (n = 30) and the second outbreak by V. cholerae O1 (n = 39). Demographic and clinical features of patients were recorded and case-control studies were conducted following each outbreak. Clinical information was obtained for 29 of the 30 patients in the first outbreak, and 2 of the patients in the second outbreak were either out of the area or lost to follow-up, leaving 29 and 37 cases in the analysis for the first and second outbreak, respectively. Eighteen (49%) of the 37 V. cholerae O1 patients were under 2 years of age compared with 6 (21%) of the 29 V. cholerae O139 patients (P = 0.02). Vibrio cholerae O139-infected patients were more likely to be febrile (16/29) than those infected with V. cholerae O1 (2/37; P<0.001). A household contact with cholera was a risk factor in both outbreaks; water source was a risk factor in the first outbreak only. Geographically, cases were clustered during the first outbreak but not during the second. Person-to-person contact and water reservoirs appear to be the main transmission routes for cholera in this setting.
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Affiliation(s)
- Fahad J Siddiqui
- Department of Paediatrics, Aga Khan University, P.O. Box 3500, Stadium Road, Karachi 74800, Pakistan
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Ali M, Park JK, von Seidlein L, Acosta CJ, Deen JL, Clemens JD. Organizational aspects and implementation of data systems in large-scale epidemiological studies in less developed countries. BMC Public Health 2006; 6:86. [PMID: 16584571 PMCID: PMC1450272 DOI: 10.1186/1471-2458-6-86] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2005] [Accepted: 04/04/2006] [Indexed: 11/29/2022] Open
Abstract
Background In the conduct of epidemiological studies in less developed countries, while great emphasis is placed on study design, data collection, and analysis, often little attention is paid to data management. As a consequence, investigators working in these countries frequently face challenges in cleaning, analyzing and interpreting data. In most research settings, the data management team is formed with temporary and unskilled persons. A proper working environment and training or guidance in constructing a reliable database is rarely available. There is little information available that describes data management problems and solutions to those problems. Usually a line or two can be obtained in the methods section of research papers stating that the data are doubly-entered and that outliers and inconsistencies were removed from the data. Such information provides little assurance that the data are reliable. There are several issues in data management that if not properly practiced may create an unreliable database, and outcomes of this database will be spurious. Results We have outlined the data management practices for epidemiological studies that we have modeled for our research sites in seven Asian countries and one African country. Conclusion Information from this model data management structure may help others construct reliable databases for large-scale epidemiological studies in less developed countries.
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Affiliation(s)
- Mohammad Ali
- International Vaccine Institute, SNU Research Park, San 4-8 Bongcheon-7 dong, Kwanak-gu, Seoul, Korea
| | - Jin-Kyung Park
- International Vaccine Institute, SNU Research Park, San 4-8 Bongcheon-7 dong, Kwanak-gu, Seoul, Korea
| | - Lorenz von Seidlein
- International Vaccine Institute, SNU Research Park, San 4-8 Bongcheon-7 dong, Kwanak-gu, Seoul, Korea
| | - Camilo J Acosta
- International Vaccine Institute, SNU Research Park, San 4-8 Bongcheon-7 dong, Kwanak-gu, Seoul, Korea
| | - Jacqueline L Deen
- International Vaccine Institute, SNU Research Park, San 4-8 Bongcheon-7 dong, Kwanak-gu, Seoul, Korea
| | - John D Clemens
- International Vaccine Institute, SNU Research Park, San 4-8 Bongcheon-7 dong, Kwanak-gu, Seoul, Korea
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Thiem VD, Deen JL, von Seidlein L, Canh DG, Anh DD, Park JK, Ali M, Danovaro-Holliday MC, Son ND, Hoa NT, Holmgren J, Clemens JD. Long-term effectiveness against cholera of oral killed whole-cell vaccine produced in Vietnam. Vaccine 2006; 24:4297-303. [PMID: 16580760 DOI: 10.1016/j.vaccine.2006.03.008] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2005] [Revised: 02/19/2006] [Accepted: 03/02/2006] [Indexed: 10/24/2022]
Abstract
We assessed the long-term protection afforded by a killed whole-cell oral cholera vaccine produced in Vietnam. A mass immunization of children and adults with the killed whole-cell oral cholera vaccine was undertaken in half of the communes of Hue, Vietnam, in 1998; the remaining communes were immunized in 2000. No cholera was observed in Hue until 2003, when an outbreak of El Tor cholera made it possible to conduct a case-control study. The overall vaccine effectiveness 3-5 years after vaccination was 50% (9-63%). This low-cost, easily administered vaccine should be considered as a tool for the control of cholera.
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Affiliation(s)
- Vu Dinh Thiem
- National Institute of Hygiene and Epidemiology, Hanoi, Vietnam
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Ochiai RL, Wang X, von Seidlein L, Yang J, Bhutta ZA, Bhattacharya SK, Agtini M, Deen JL, Wain J, Kim DR, Ali M, Acosta CJ, Jodar L, Clemens JD. Salmonella paratyphi A rates, Asia. Emerg Infect Dis 2006; 11:1764-6. [PMID: 16318734 PMCID: PMC3367370 DOI: 10.3201/eid1111.050168] [Citation(s) in RCA: 139] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Little is known about the causes of enteric fever in Asia. Most cases are believed to be caused by Salmonella enterica serovar Typhi and the remainder by S. Paratyphi A. We compared their incidences by using standardized methods from population-based studies in China, Indonesia, India, and Pakistan.
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Affiliation(s)
- R Leon Ochiai
- International Vaccine Institute, Kwanak PO Box 14, Seoul, South Korea 151-600.
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Wang XY, Ansaruzzaman M, Vaz R, Mondlane C, Lucas MES, von Seidlein L, Deen JL, Ampuero S, Puri M, Park T, Nair GB, Clemens JD, Chaignat CL, Rajerison M, Nato F, Fournier JM. Field evaluation of a rapid immunochromatographic dipstick test for the diagnosis of cholera in a high-risk population. BMC Infect Dis 2006; 6:17. [PMID: 16451731 PMCID: PMC1402302 DOI: 10.1186/1471-2334-6-17] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2005] [Accepted: 02/01/2006] [Indexed: 11/23/2022] Open
Abstract
Background Early detection of cholera outbreaks is crucial for the implementation of the most appropriate control strategies. Methods The performance of an immunochromatographic dipstick test (Institute Pasteur, Paris, France) specific for Vibrio cholerae O1 was evaluated in a prospective study in Beira, Mozambique, during the 2004 cholera season (January-May). Fecal specimens were collected from 391 patients with acute watery nonbloody diarrhea and tested by dipstick and conventional culture. Results The overall sensitivity and specificity of the rapid test compared to culture were 95% (95% confidence interval [CI]: 91%–99%) and 89% (95% CI: 86%–93%), respectively. After stratification by type of sample (rectal swab/bulk stool) and severity of diarrhea, the sensitivity ranged between 85% and 98% and specificity between 77% and 97%. Conclusion This one-step dipstick test performed well in the diagnosis of V. cholerae O1 in a setting with seasonal outbreaks where rapid tests are most urgently needed.
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Affiliation(s)
- Xuan-Yi Wang
- The International Vaccine Institute, Seoul, Korea
| | - M Ansaruzzaman
- ICDDR,B: Centre for Health and Population Research, Dhaka, Bangladesh
| | | | | | | | | | | | | | - Mahesh Puri
- The International Vaccine Institute, Seoul, Korea
| | - Taesung Park
- The International Vaccine Institute, Seoul, Korea
- Department of Statistics, Seoul National University, Seoul
| | - GB Nair
- ICDDR,B: Centre for Health and Population Research, Dhaka, Bangladesh
| | - John D Clemens
- The International Vaccine Institute, Seoul, Korea
- National Institute of Child Health and Human Development, Bethesda, Maryland, USA
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Sur D, von Seidlein L, Manna B, Dutta S, Deb AK, Sarkar BL, Kanungo S, Deen JL, Ali M, Kim DR, Gupta VK, Ochiai RL, Tsuzuki A, Acosta CJ, Clemens JD, Bhattacharya SK. The malaria and typhoid fever burden in the slums of Kolkata, India: data from a prospective community-based study. Trans R Soc Trop Med Hyg 2006; 100:725-33. [PMID: 16455118 DOI: 10.1016/j.trstmh.2005.10.019] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2005] [Revised: 10/20/2005] [Accepted: 10/20/2005] [Indexed: 11/17/2022] Open
Abstract
Recent research has indicated that the malaria burden in Asia may have been vastly underestimated. We conducted a prospective community-based study in an impoverished urban site in Kolkata, India, to estimate the burden of malaria and typhoid fever and to identify risk factors for these diseases. In a population of 60452 people, 3605 fever episodes were detected over a 12-month period. The blood films of 93 febrile patients contained Plasmodium (90 P. vivax, 2 P. falciparum and 1 P. malariae). Blood cultures from 95 patients grew Salmonella enterica serotype Typhi. Malaria patients were found to be significantly older (mean age 29 years) compared with patients with typhoid fever (15 years; P<0.001) but had similar clinical features on presentation. Having a household member with malaria, illiteracy, low household income and living in a structure not built of bricks were associated with an increased risk for malaria. Having a household member with typhoid fever and poor hygiene were associated with typhoid fever. A geographic analysis of the spatial distribution of malaria and typhoid fever cases detected high-risk neighbourhoods for each disease. Focal interventions to minimise human-vector contact and improved personal hygiene and targeted vaccination campaigns could help to prevent malaria and typhoid fever in this site.
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Affiliation(s)
- Dipika Sur
- National Institute of Cholera and Enteric Diseases, P-33 CIT Rd. Scheme - XM, Beliaghata, Kolkata 700010, India
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Sur D, Deen JL, Manna B, Niyogi SK, Deb AK, Kanungo S, Sarkar BL, Kim DR, Danovaro-Holliday MC, Holliday K, Gupta VK, Ali M, von Seidlein L, Clemens JD, Bhattacharya SK. The burden of cholera in the slums of Kolkata, India: data from a prospective, community based study. Arch Dis Child 2005; 90:1175-81. [PMID: 15964861 PMCID: PMC1720149 DOI: 10.1136/adc.2004.071316] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
AIMS To conduct a prospective, community based study in an impoverished urban site in Kolkata (formerly Calcutta) in order to measure the burden of cholera, describe its epidemiology, and search for potential risk factors that could be addressed by public health strategies. METHODS The study population was enumerated at the beginning and end of the study period. Surveillance through five field outposts and two referral hospitals for acute, watery, non-bloody diarrhoea was conducted from 1 May 2003 to 30 April 2004. Data and a stool sample for culture of Vibrio cholerae were collected from each patient. Treatment was provided in accordance with national guidelines. RESULTS From 62 329 individuals under surveillance, 3284 diarrhoea episodes were detected, of which 3276 (99%) had a stool sample collected and 126 (4%) were culture confirmed cholera. Nineteen (15%) were children less than 2 years of age, 29 (23%) had severe dehydration, and 48 (38%) were hospitalised. Risk factors for cholera included a household member with cholera during the period of surveillance, young age, and lower educational level. CONCLUSIONS There was a substantial burden of cholera in Kolkata with risk factors not easily amenable to intervention. Young children bear the brunt not only of diarrhoeal diseases in general, but of cholera as well. Mass vaccination could be a potentially useful tool to prevent and control seasonal cholera in this community.
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Affiliation(s)
- D Sur
- National Institute of Cholera and Enteric Diseases, Kolkata, India
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Cavailler P, Lucas M, Perroud V, McChesney M, Ampuero S, Guérin PJ, Legros D, Nierle T, Mahoudeau C, Lab B, Kahozi P, Deen JL, von Seidlein L, Wang XY, Puri M, Ali M, Clemens JD, Songane F, Baptista A, Ismael F, Barreto A, Chaignat CL. Feasibility of a mass vaccination campaign using a two-dose oral cholera vaccine in an urban cholera-endemic setting in Mozambique. Vaccine 2005; 24:4890-5. [PMID: 16298025 DOI: 10.1016/j.vaccine.2005.10.006] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2005] [Revised: 09/26/2005] [Accepted: 10/07/2005] [Indexed: 11/19/2022]
Abstract
We conducted a study to assess the feasibility and the potential vaccine coverage of a mass vaccination campaign using a two-dose oral cholera vaccine in an urban endemic neighbourhood of Beira, Mozambique. The campaign was conducted from December 2003 to January 2004. Overall 98,152 doses were administered, and vaccine coverage of the target population was 58.6% and 53.6% for the first and second rounds, respectively. The direct cost of the campaign, which excludes the price of the vaccine, amounted to slightly over 90,000 dollars, resulting in the cost per fully vaccinated person of 2.09 dollars, which is relatively high. However, in endemic settings where outbreaks are likely to occur, integrating cholera vaccination into the routine activities of the public health system could reduce such costs.
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Agtini MD, Soeharno R, Lesmana M, Punjabi NH, Simanjuntak C, Wangsasaputra F, Nurdin D, Pulungsih SP, Rofiq A, Santoso H, Pujarwoto H, Sjahrurachman A, Sudarmono P, von Seidlein L, Deen JL, Ali M, Lee H, Kim DR, Han O, Park JK, Suwandono A, Oyofo BA, Campbell JR, Beecham HJ, Corwin AL, Clemens JD. The burden of diarrhoea, shigellosis, and cholera in North Jakarta, Indonesia: findings from 24 months surveillance. BMC Infect Dis 2005; 5:89. [PMID: 16242013 PMCID: PMC1276796 DOI: 10.1186/1471-2334-5-89] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2005] [Accepted: 10/20/2005] [Indexed: 11/10/2022] Open
Abstract
Background In preparation of vaccines trials to estimate protection against shigellosis and cholera we conducted a two-year community-based surveillance study in an impoverished area of North Jakarta which provided updated information on the disease burden in the area. Methods We conducted a two-year community-based surveillance study from August 2001 to July 2003 in an impoverished area of North Jakarta to assess the burden of diarrhoea, shigellosis, and cholera. At participating health care providers, a case report form was completed and stool sample collected from cases presenting with diarrhoea. Results Infants had the highest incidences of diarrhoea (759/1 000/year) and cholera (4/1 000/year). Diarrhea incidence was significantly higher in boys under 5 years (387/1 000/year) than girls under 5 years (309/1 000/year; p < 0.001). Children aged 1 to 2 years had the highest incidence of shigellosis (32/1 000/year). Shigella flexneri was the most common Shigella species isolated and 73% to 95% of these isolates were resistant to ampicillin, trimethoprim-sulfamethoxazole, chloramphenicol and tetracycline but remain susceptible to nalidixic acid, ciprofloxacin, and ceftriaxone. We found an overall incidence of cholera of 0.5/1 000/year. Cholera was most common in children, with the highest incidence at 4/1 000/year in those less than 1 year of age. Of the 154 V. cholerae O1 isolates, 89 (58%) were of the El Tor Ogawa serotype and 65 (42%) were El Tor Inaba. Thirty-four percent of patients with cholera were intravenously rehydrated and 22% required hospitalization. V. parahaemolyticus infections were detected sporadically but increased from July 2002 onwards. Conclusion Diarrhoea causes a heavy public health burden in Jakarta particularly in young children. The impact of shigellosis is exacerbated by the threat of antimicrobial resistance, whereas that of cholera is aggravated by its severe manifestations.
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Affiliation(s)
- Magdarina D Agtini
- National Institute of Health Research and Development, Jakarta Indonesia, Ministry of Health, Jakarta, Indonesia
| | - Rooswanti Soeharno
- National Institute of Health Research and Development, Jakarta Indonesia, Ministry of Health, Jakarta, Indonesia
| | - Murad Lesmana
- United States Navy Medical Research Unit 2, Jakarta, Indonesia
| | | | | | - Ferry Wangsasaputra
- National Institute of Health Research and Development, Jakarta Indonesia, Ministry of Health, Jakarta, Indonesia
- United States Navy Medical Research Unit 2, Jakarta, Indonesia
| | - Dazwir Nurdin
- United States Navy Medical Research Unit 2, Jakarta, Indonesia
| | - Sri Pandam Pulungsih
- Infectious Disease Hospital Sulianti Saroso, Ministry of Health, Jakarta, Indonesia
| | - Ainur Rofiq
- National Institute of Health Research and Development, Jakarta Indonesia, Ministry of Health, Jakarta, Indonesia
| | - Hari Santoso
- Communicable Disease Control and Environmental Health, Ministry of Health, Jakarta, Indonesia
| | - H Pujarwoto
- National Institute of Health Research and Development, Jakarta Indonesia, Ministry of Health, Jakarta, Indonesia
| | | | - Pratiwi Sudarmono
- Department of Microbiology, University of Indonesia, Jakarta, Indonesia
| | | | | | | | - Hyejon Lee
- International Vaccine Institute, Seoul, Korea
| | | | - Oakpil Han
- International Vaccine Institute, Seoul, Korea
| | | | - Agus Suwandono
- National Institute of Health Research and Development, Jakarta Indonesia, Ministry of Health, Jakarta, Indonesia
| | - Buhari A Oyofo
- United States Navy Medical Research Unit 2, Jakarta, Indonesia
| | | | - H James Beecham
- United States Navy Medical Research Unit 2, Jakarta, Indonesia
| | - Andrew L Corwin
- United States Navy Medical Research Unit 2, Jakarta, Indonesia
| | - John D Clemens
- International Vaccine Institute, Seoul, Korea
- National Institute of Child Health and Human Development, Bethesda, Maryland, USA
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Ansaruzzaman M, Lucas M, Deen JL, Bhuiyan NA, Wang XY, Safa A, Sultana M, Chowdhury A, Nair GB, Sack DA, von Seidlein L, Puri MK, Ali M, Chaignat CL, Clemens JD, Barreto A. Pandemic serovars (O3:K6 and O4:K68) of Vibrio parahaemolyticus associated with diarrhea in Mozambique: spread of the pandemic into the African continent. J Clin Microbiol 2005; 43:2559-62. [PMID: 15956363 PMCID: PMC1151933 DOI: 10.1128/jcm.43.6.2559-2562.2005] [Citation(s) in RCA: 85] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Forty-two episodes of Vibrio parahaemolyticus infections were detected in Beira, Mozambique, from January to May 2004. The majority of the isolates (81%) belonged to the pandemic serovars (O3:K6 and O4:K68) of V. parahaemolyticus. The pandemic serovars were positive by group-specific PCR (GS-PCR) and a PCR specific for open reading frame ORF8 (ORF8-PCR), which are molecular markers of the pandemic clone, and were positive for tdh but negative for trh. The remaining 19% of the strains also possessed the tdh gene but were GS-PCR and ORF8-PCR negative and did not belong to the pandemic serovars. Patients with V. parahaemolyticus infection were older (mean age, 27 years) than patients infected by other diarrheal agents (mean age, 21 years). Ten percent of diarrhea patients from whom no V. parahaemolyticus was cultured were severely dehydrated, but none of the V. parahaemolyticus cases were severely dehydrated. This is the first report of the isolation of pandemic strains of V. parahaemolyticus in sub-Saharan Africa and clearly indicates that the pandemic of V. parahaemolyticus has spread into the African continent.
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Affiliation(s)
- M Ansaruzzaman
- Laboratory Sciences Division, ICDDR,B: Centre for Health and Population Research, GPO Box-128, Dhaka-1000, Bangladesh.
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Lee H, Kotloff K, Chukaserm P, Samosornsuk S, Chompook P, Deen JL, Von Seidlein L, Clemens JD, Wanpen C. Shigellosis remains an important problem in children less than 5 years of age in Thailand. Epidemiol Infect 2005; 133:469-74. [PMID: 15962553 PMCID: PMC2870270 DOI: 10.1017/s0950268804003590] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
This is a review of existing data on the burden of shigellosis in Thailand to determine trends, vulnerable groups, predominant species and serotypes, and antimicrobial resistance patterns. Diarrhoea and dysentery morbidity and mortality data from 1991 to 1999 was collected from the routine surveillance system and demographic data from the government census. International and local literature published between 1988 and 2000 was systematically reviewed. Based on the routine surveillance system, the annual incidence of bacillary dysentery decreased from 1.3 to 0.2/10,000 persons per year. The remaining burden is highest in children <5 years of age at 2.7/10,000 persons per year. In comparison, a prospective study utilizing active surveillance found an incidence in children <5 years of age that was more than 100-fold higher at 640/10,000 persons per year. Despite the decrease in morbidity and mortality based on routinely collected data, shigellosis remains an important problem in children <5 years of age in Thailand.
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Affiliation(s)
- H Lee
- International Vaccine Institute, Research Park, San 4-8 Bongcheon-7-Dong, Kwanak-gu, Seoul, South Korea.
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Dutta S, Sur D, Manna B, Bhattacharya SK, Deen JL, Clemens JD. Rollback of Salmonella enterica serotype Typhi resistance to chloramphenicol and other antimicrobials in Kolkata, India. Antimicrob Agents Chemother 2005; 49:1662-3. [PMID: 15793167 PMCID: PMC1068649 DOI: 10.1128/aac.49.4.1662-1663.2005] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Lucas MES, Deen JL, von Seidlein L, Wang XY, Ampuero J, Puri M, Ali M, Ansaruzzaman M, Amos J, Macuamule A, Cavailler P, Guerin PJ, Mahoudeau C, Kahozi-Sangwa P, Chaignat CL, Barreto A, Songane FF, Clemens JD. Effectiveness of mass oral cholera vaccination in Beira, Mozambique. N Engl J Med 2005; 352:757-67. [PMID: 15728808 DOI: 10.1056/nejmoa043323] [Citation(s) in RCA: 181] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND New-generation, orally administered cholera vaccines offer the promise of improved control of cholera in sub-Saharan Africa. However, the high prevalence of human immunodeficiency virus (HIV) infection in many cholera-affected African populations has raised doubts about the level of protection possible with vaccination. We evaluated a mass immunization program with recombinant cholera-toxin B subunit, killed whole-cell (rBS-WC) oral cholera vaccine in Beira, Mozambique, a city where the seroprevalence of HIV is 20 to 30 percent. METHODS From December 2003 to January 2004, we undertook mass immunization of nonpregnant persons at least two years of age, using a two-dose regimen of rBS-WC vaccine in Esturro, Beira (population 21,818). We then assessed vaccine protection in a case-control study during an outbreak of El Tor Ogawa cholera in Beira between January and May 2004. To estimate the level of vaccine protection, antecedent rates of vaccination were compared between persons with culture-confirmed cholera severe enough to have prompted them to seek treatment and age- and sex-matched neighborhood controls without treated diarrhea. RESULTS We assessed the effectiveness of the vaccine in 43 persons with cholera and 172 controls. Receipt of one or more doses of rBS-WC vaccine was associated with 78 percent protection (95 percent confidence interval, 39 to 92 percent; P=0.004). The vaccine was equally effective in children younger than five years of age and in older persons. A concurrently conducted case-control study designed to detect bias compared persons with treated, noncholeraic diarrhea and controls without diarrhea in the same population and found no protection associated with receipt of the rBS-WC vaccine. CONCLUSIONS The rBS-WC vaccine was highly effective against clinically significant cholera in an urban sub-Saharan African population with a high prevalence of HIV infection.
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Deen JL, von Seidlein L, Clemens JD. Multidisciplinary studies of disease burden in the Diseases of the Most Impoverished Programme. J Health Popul Nutr 2004; 22:232-239. [PMID: 15609775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
With limited healthcare resources, rational prioritization of healthcare interventions requires knowledge and analysis of disease burden. In the absence of actual disease-burden data from less-developed countries, various types of morbidity and mortality estimates have been made. Besides having questionable reliability, these estimates do not capture the full burden of a disease since they provide only the number of cases and deaths. The modelling methods that include disability are more comprehensive but are difficult to understand, and their reliability is affected by baseline approximations. To provide policy-makers with information needed for rational decision-making, the Diseases of the Most Impoverished (DOMI) Programme of the International Vaccine Institute has used a multidisciplinary approach to describe the burden of disease due to typhoid fever, shigellosis, and cholera. Recognizing the relative advantages and disadvantages of various methodologies, the programme employs passive clinic-based surveillance in defined communities to provide prospective data. The prospective data are complemented with retrospectively-collected information from existing sources, frequently less accurate and complete but readily available for the whole population over extended periods. To create a more complete picture, economic and qualitative studies specific to each disease are incorporated in these prospective studies. The goal is to achieve a more complete and realistic picture by combining the results of these various methodologies, acknowledging the strengths and limitations of each. These projects also build in-country capacity in terms of treatment, diagnosis, epidemiology, and data management.
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Sur D, Manna B, Deb AK, Deen JL, Danovaro-Holliday MC, von Seidlein L, Clemens JD, Bhattacharya SK. Factors associated with reported diarrhoea episodes and treatment-seeking in an urban slum of Kolkata, India. J Health Popul Nutr 2004; 22:130-138. [PMID: 15473516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
In an urban slum in eastern Kolkata, India, reported diarrhoea rates, healthcare-use patterns, and factors associated with reported diarrhoea episodes were studied as a part of a diarrhoea-surveillance project. Data were collected through a structured interview during a census and healthcare-use survey of an urban slum population in Kolkata. Several variables were analyzed, including (a) individual demographics, such as age and educational level, (b) household characteristics, such as number of household members, religious affiliation of the household head, building material, expenditure, water supply and sanitation, and (c) behaviour, such as hand-washing after defecation and healthcare use. Of 57,099 study subjects, 428 (0.7%) reported a diarrhoea episode sometime during the four weeks preceding the interview. The strongest independent factors for reporting a history of diarrhoea were having another household member with diarrhoea (adjusted odds ratio [OR]=3.8; 95% confidence interval [CI] 3.3-4.4) and age less than 60 months (adjusted OR=3.7; 95% CI 3.0-4.7). The first choice of treatment by the 428 subjects was as follows: 151 (35%) had self- or parent-treatment, 150 (35%) consulted a private allopathic practitioner, 70 (16%) went directly to a pharmacy, 29 (7%) visited a hospital, 14 (3%) a homoeopathic practitioner, 2 (0.5%) an ayurvedic practitioner, and 12 (3%) other traditional healers. The choices varied significantly with the age of patients and their religion. The findings increase the understanding of the factors and healthcare-use patterns associated with diarrhoea episodes and may assist in developing public-health messages and infrastructure in Kolkata.
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Affiliation(s)
- Dipika Sur
- National Institute of Cholera and Enteric Diseases, P-33 CIT Road Scheme XM, Beliaghata, Kolkata 700 010, India.
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Simanjuntak CH, Punjabi NH, Wangsasaputra F, Nurdin D, Pulungsih SP, Rofiq A, Santoso H, Pujarwoto H, Sjahrurachman A, Sudarmono P, von Seidlein L, Acosta C, Robertson SE, Ali M, Lee H, Park J, Deen JL, Agtini MD, Clemens JD. Diarrhoea episodes and treatment-seeking behaviour in a slum area of North Jakarta, Indonesia. J Health Popul Nutr 2004; 22:119-129. [PMID: 15473515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
Visits to household during a census in an impoverished area of north Jakarta were used for exploring the four-week prevalence of diarrhoea, factors associated with episodes of diarrhoea, and the patterns of healthcare use. For 160,261 urban slum-dwellers, information was collected on the socioeconomic status of the household and on diarrhoea episodes of individual household residents in the preceding four weeks. In households with a reported case of diarrhoea, the household head was asked which form of healthcare was used first. In total, 8,074 individuals (5%)--13% of children aged less than five years and 4% of adults--had a diarrhoea episode in the preceding four weeks. The two strongest factors associated with a history of diarrhoea were a diarrhoea episode in another household member in the four weeks preceding the interview (adjusted odds ratio [OR] 11.1; 95% confidence interval [CI] 10.4-11.8) and age less than five years (adjusted OR 3.4; 95% CI 3.2-3.5). Of the 8,074 diarrhoea cases, 1,969 (25%) treated themselves, 1,822 (23%) visited a public-health centre (PHC), 1,462 (18%) visited a private practitioner or a private clinic, 1,318 (16%) presented at a hospital, 753 (9%) bought drugs from a drug vendor, and 750 (9%) used other healthcare providers, such as belian (traditional healers). Children with diarrhoea were most often brought to a PHC, a private clinic, or a hospital for treatment. Compared to children, adults with diarrhoea were more likely to treat themselves. Individuals from households in the lowest-income group were significantly more likely to attend a PHC for treatment of diarrhoea compared to individuals from households in the middle- and higher-income groups.
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Affiliation(s)
- Cyrus H Simanjuntak
- National Institute of Health Research and Development, Ministry of Health, Jakarta, Indonesia
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Vu DT, Hossain MM, Nguyen DS, Nguyen TH, Rao MR, Do GC, Naficy A, Nguyen TK, Acosta CJ, Deen JL, Clemens JD, Dang DT. Coverage and costs of mass immunization of an oral cholera vaccine in Vietnam. J Health Popul Nutr 2003; 21:304-308. [PMID: 15043004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
The objective of this study was to describe a mass-immunization campaign of a locally-produced oral, killed whole-cell cholera vaccine in Hue city, Vietnam. Mass immunization with a 2-dose regimen of the vaccine was conducted in 13 communes in early 1998. The total, age- and sex-specific vaccine coverage was calculated using data from the vaccination records and the government census. The number of vaccine doses procured, administered, wasted, and left over, and the human and other resources required to prepare and conduct the vaccination campaign were systematically recorded. Government expenditure for planning, procurement, and delivery of the vaccine were documented. In total, 118,555 (79%) of the 49,557 targeted population were fully vaccinated during the mass-vaccination campaign. The total expenditure for the project was US dollar 105,447, resulting in a cost per fully-vaccinated person of US dollar 0.89. Mass immunization with this locally-produced oral, killed cholera vaccine was found to be feasible and affordable with attainment of high vaccination coverage.
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Affiliation(s)
- Dinh Thiem Vu
- National Institute of Hygiene and Epidemiology, Hanoi, Vietnam
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