SARS-CoV-2 infection by trimester of pregnancy and adverse perinatal outcomes: a Mexican retrospective cohort study

OBJECTIVE

Conflicting evidence for the association between COVID-19 and adverse perinatal outcomes exists. This study examined the associations between maternal COVID-19 during pregnancy and adverse perinatal outcomes including preterm birth (PTB), low birth weight (LBW), small-for-gestational age (SGA), large-for-gestational age (LGA) and fetal death; as well as whether the associations differ by trimester of infection.

DESIGN AND SETTING

The study used a retrospective Mexican birth cohort from the Instituto Mexicano del Seguro Social (IMSS), Mexico, between January 2020 and November 2021.

PARTICIPANTS

We used the social security administrative dataset from IMSS that had COVID-19 information and linked it with the IMSS routine hospitalisation dataset, to identify deliveries in the study period with a test for SARS-CoV-2 during pregnancy.

OUTCOME MEASURES

PTB, LBW, SGA, LGA and fetal death. We used targeted maximum likelihood estimators, to quantify associations (risk ratio, RR) and CIs. We fit models for the overall COVID-19 sample, and separately for those with mild or severe disease, and by trimester of infection. Additionally, we investigated potential bias induced by missing non-tested pregnancies.

RESULTS

The overall sample comprised 17 340 singleton pregnancies, of which 30% tested positive. We found that those with mild COVID-19 had an RR of 0.89 (95% CI 0.80 to 0.99) for PTB and those with severe COVID-19 had an RR of 1.53 (95% CI 1.07 to 2.19) for LGA. COVID-19 in the first trimester was associated with fetal death, RR=2.36 (95% CI 1.04, 5.36). Results also demonstrate that missing non-tested pregnancies might induce bias in the associations.

CONCLUSIONS

In the overall sample, there was no evidence of an association between COVID-19 and adverse perinatal outcomes. However, the findings suggest that severe COVID-19 may increase the risk of some perinatal outcomes, with the first trimester potentially being a high-risk period.

How predictive of SARS-CoV-2 infection are clinical characteristics at presentation among individuals with COVID-like symptoms treated at the Mexican Institute of Social Security

BACKGROUND

The COVID-19 pandemic has progressed rapidly, with the emergence of new virus variants that pose challenges in treating infected individuals. In Mexico, four epidemic waves have been recorded with varying disease severity. To understand the heterogeneity in clinical presentation over time and the sensitivity and specificity of signs and symptoms in identifying COVID-19 cases, an analysis of the changes in the clinical presentation of the disease was conducted.

AIM

To analyze the changes in the clinical presentation of COVID-19 among 3.38 million individuals tested for SARS-CoV-2 at the Mexican Social Security Institute (IMSS) from March 2020 to October 2021 and evaluate the predictivity of signs and symptoms in identifying COVID-19 cases.

METHODS

A retrospective analysis of clinical presentation patterns of COVID-19 among individuals treated at IMSS was performed, contrasting the signs and symptoms among SARS-CoV-2-positive individuals with those who tested negative for the virus but had respiratory infection symptoms. The sensitivity and specificity of each sign and symptom in identifying SARS-CoV-2 infection were estimated.

RESULTS

The set of signs and symptoms reported for COVID-19-suspected patients treated at IMSS were not highly specific for SARS-CoV-2 positivity. The signs and symptoms exhibited variability based on age and epidemic wave. The area under the receiver operating characteristic (ROC) curve was 0.62 when grouping the five main symptoms (headache, dyspnea, fever, arthralgia, and cough). Most of the individual symptoms had ROC values close to 0.5 (16 out of 22 between 0.48 and 0.52), indicating non-specificity.

CONCLUSIONS

The results highlight the difficulty in making a clinical diagnosis of COVID-19 due to the lack of specificity of signs and symptoms. The variability of clinical presentation over time and among age groups highlights the need for further research to differentiate whether the changes are due to changes in the virus, who is becoming infected, or the population, particularly with respect to prior infection and vaccination status.

Associations of diabetes, hypertension and obesity with COVID-19 mortality: a systematic review and meta-analysis

INTRODUCTION

Despite a growing body of scholarly research on the risks of severe COVID-19 associated with diabetes, hypertension and obesity, there is a need for estimating pooled risk estimates with adjustment for confounding effects. We conducted a systematic review and meta-analysis to estimate the pooled adjusted risk ratios of diabetes, hypertension and obesity on COVID-19 mortality.

METHODS

We searched 16 literature databases for original studies published between 1 December 2019 and 31 December 2020. We used the adapted Newcastle-Ottawa Scale to assess the risk of bias. Pooled risk ratios were estimated based on the adjusted effect sizes. We applied random-effects meta-analysis to account for the uncertainty in residual heterogeneity. We used contour-funnel plots and Egger's test to assess possible publication bias.

RESULTS

We reviewed 34 830 records identified in literature search, of which 145 original studies were included in the meta-analysis. Pooled adjusted risk ratios were 1.43 (95% CI 1.32 to 1.54), 1.19 (95% CI 1.09 to 1.30) and 1.39 (95% CI 1.27 to 1.52) for diabetes, hypertension and obesity (body mass index ≥30 kg/m2) on COVID-19 mortality, respectively. The pooled adjusted risk ratios appeared to be stronger in studies conducted before April 2020, Western Pacific Region, low- and middle-income countries, and countries with low Global Health Security Index scores, when compared with their counterparts.

CONCLUSIONS

Diabetes, hypertension and obesity were associated with an increased risk of COVID-19 mortality independent of other known risk factors, particularly in low-resource settings. Addressing these chronic diseases could be important for global pandemic preparedness and mortality prevention.

PROSPERO REGISTRATION NUMBER

CRD42021204371.

Readiness for Integrated Care of Older People: A Cross-Sectional Study in Mexico

AIM

To evaluate the readiness of the Mexican healthcare system to implement the integrated care for older people (ICOPE) approach into an existing healthcare model.

METHODS

We conducted a cross-sectional study with data from 2473 healthcare workers analyzed using the model for understanding success in quality (MUSIQ) framework to gather data from healthcare professionals. Their perceptions regarding the readiness for ICOPE were assessed across five dimensions: team, microsystem, infrastructure, organization, and external environment.

RESULTS

Only 717 (29%) of the participants believed ICOPE could be successfully implemented in Mexico without any modifications. A total of 1261 (51%) participants rated the readiness of ICOPE with some barriers. The main barriers were reallocating resources and the external environment.

OBSERVATION

Mexico's healthcare system faces barriers to innovation that could hinder the successful integration of the ICOPE approach. A systematic identification of these barriers provides an opportunity to suggest adaptations and refinements to increase the probability of success. Using the contextual factors identified as facilitators and the proposal of interventions such as the ICOPE app could improve the chances of success.

CONCLUSION

The participants of this study evaluated ICOPE as ready to implement, with some contextual barriers. The readiness evaluation supports the stakeholders' and policymakers' decisions in implementing and monitoring the program in a natural setting. Evaluating the readiness of the intervention increases the possibility of aligning the innovation with contextual factors, increasing the chances of its successful adoption and implementation.

Who is most at risk of dying if infected with SARS-CoV-2? A mortality risk factor analysis using machine learning of patients with COVID-19 over time: a large population-based cohort study in Mexico

OBJECTIVE

COVID-19 would kill fewer people if health programmes can predict who is at higher risk of mortality because resources can be targeted to protect those people from infection. We predict mortality in a very large population in Mexico with machine learning using demographic variables and pre-existing conditions.

DESIGN

Cohort study.

SETTING

March 2020 to November 2021 in Mexico, nationally represented.

PARTICIPANTS

1.4 million laboratory-confirmed patients with COVID-19 in Mexico at or over 20 years of age.

PRIMARY AND SECONDARY OUTCOME MEASURES

Analysis is performed on data from March 2020 to November 2021 and over three phases: (1) from March to October in 2020, (2) from November 2020 to March 2021 and (3) from April to November 2021. We predict mortality using an ensemble machine learning method, super learner, and independently estimate the adjusted mortality relative risk of each pre-existing condition using targeted maximum likelihood estimation.

RESULTS

Super learner fit has a high predictive performance (C-statistic: 0.907), where age is the most predictive factor for mortality. After adjusting for demographic factors, renal disease, hypertension, diabetes and obesity are the most impactful pre-existing conditions. Phase analysis shows that the adjusted mortality risk decreased over time while relative risk increased for each pre-existing condition.

CONCLUSIONS

While age is the most important predictor of mortality, younger individuals with hypertension, diabetes and obesity are at comparable mortality risk as individuals who are 20 years older without any of the three conditions. Our model can be continuously updated to identify individuals who should most be protected against infection as the pandemic evolves.

Evaluating the design of the Integrated Care for Older People: a theory of change approach

Introduction

Given the progressive aging of the population, there is an urgent need at the health system level to implement effective models to care for older people (OP). Healthy aging is imperative to reach the Sustainable Development Goals. The World Health Organization (WHO) developed the Integrated Care for Older People (ICOPE) strategy to address this challenge. Implementing ICOPE requires its adaption to a specific context. We propose a pathway for such adaptation through an evaluation of the design of ICOPE; thus, we aim to describe the Theory of Change (ToC) of ICOPE and evaluate it for its implementation in Mexico City.

Methods

Based on the WHO and published literature documentation, we drafted an initial ToC for ICOPE. Then, we validated the ToC with experts in ICOPE, after which we evaluated and refined it by discussing the causal pathway, intervention required to activate it, rationale, and assumptions in consecutive workshops with 91 stakeholders and healthcare workers, using the nominal group technique to reach a consensus.

Results

The resulting ToC has the potential to contribute to healthy aging by three expected impacts: (1) prevention, reversal, or delaying of the decline of intrinsic capacity (IC) in OP; (2) improvement of the quality of life of OP; and (3) increase of disability-free life expectancy. The ICOPE causal pathway had ten preconditions, including the availability of resources, identifying at-risk individuals, available treatments, and evaluating results.

Discussion

We adapted ICOPE to a specific implementation context by evaluating its ToC in a participatory process that allows us to identify challenges and address them, at least in terms of the guidelines to operate the strategy. As ICOPE is an approach for a primary healthcare system, its adoption in a community healthcare program is promising and feasible. Evaluation as a tool could contribute to the design of effective interventions. The evaluation of the design of ICOPE for its implementation contributes to the strength of its potential to improve care for OP. This design for implementing ICOPE has the potential to be applied to similar contexts, for example, in other lower-middle-income countries.

Changes in the epidemiological profile of SARS-CoV-2-positive individuals in Mexico across pandemic waves as an explanation of fatality reduction: a retrospective observational study

OBJECTIVES

We aim to quantify shifts in hospitalisation and mortality and how those were related to the first three phases of the epidemic and individuals' demographics and health profile among those with a positive test for SARS-CoV-2 treated at the Mexican Social Security Institute's facilities from March 2020 to October 2021.

DESIGN

Retrospective observational study using interrupted time series analysis to identify changes in hospitalisation rate and case fatality rate (CFR) by epidemic wave.

SETTING

Data from the Mexican Institute of Social Security's (IMSS) Online Influenza Epidemiological Surveillance System (SINOLAVE) that include all individuals that sought care at IMSS facilities all over Mexico.

PARTICIPANTS

All individuals included in the SINOLAVE with a positive PCR or rapid test for SARS-CoV-2.

PRIMARY AND SECONDARY OUTCOME MEASURES

Monthly test positivity rates, hospitalisation rates, CFRs and prevalence of relevant comorbidities by age group.

RESULTS

From March 2020 to October 2021, the CFR declined between 1% and 3.5%; the declines were significant for those 0-9, 20-29, 30-39, 40-49 and 70 and older. The decline was steep during the first wave and was less steep or was temporarily reversed at the beginning of the second and third waves (changes in the trend of about 0.3% and 3.8%, and between 0.7% and 3.8%, respectively, for some age groups), but then continued to the end of the analytical period. Prevalence of diabetes, hypertension and obesity among patients testing positive also declined-two for most age groups (reductions of up to 10 percentage points for diabetes, 12 percentage points for hypertension and 19 percentage points for obesity).

CONCLUSION

Data suggest that the decrease in COVID-19 fatality rate is at least partially explained by a change in the profile of those contracting the disease, that is, a falling proportion of individuals with comorbidities across all age groups.

Socioeconomic and geographic inequities in vaccination among children 12 to 59 months in Mexico, 2012 to 2021

Objective

To document the evolution of socioeconomic and geographical inequalities in childhood vaccination in Mexico from 2012 to 2021.

Methods

Repeated cross-sectional analysis using three rounds of National Health and Nutrition Surveys (2012, 2018, and 2021). Dichotomous variables were created to identify the proportion of children who received no dose of each vaccine included in the national immunization schedule (BCG; diphtheria, pertussis, and tetanus-containing; rotavirus; pneumococcal conjugate; and measles, mumps, and rubella [MMR]), and the proportion completely unvaccinated. The distribution of unvaccinated children was analyzed by state, and by socioeconomic status using the concentration index.

Results

The prevalence of completely unvaccinated children in Mexico was low, with 0.3% children in 2012 and 0.8% children in 2021 receiving no vaccines (p = 0.070). Notwithstanding, for each vaccine, an important proportion of children missed receiving any dose. Notably, the prevalence of MMR unvaccinated children was 10.2% (95% CI 9.2-11.1) in 2012, 22.3% (95% CI 20.9-23.8) in 2018, and 29.1% (95% CI 26.3-31.8) in 2021 (p < 0.001 for the difference between 2012 and 2021). The concentration index indicated pro-rich inequalities in non-vaccination for 2 of 5 vaccines in 2012, 3 of 5 vaccines in 2018, and 4 of 5 vaccines in 2021. There were marked subnational variations. The percentage of MMR unvaccinated children ranged from 3.3% to 17.9% in 2012, 5.5% to 36.5% in 2018, and 13.1% to 72.5% in 2021 across the 32 states of Mexico.

Conclusions

Equitable access to basic childhood vaccines in Mexico has deteriorated over the past decade. Vigilant equity monitoring coupled with tailored strategies to reach those left out is urgently required.

Diabetes, obesity, hypertension and risk of severe COVID-19: a protocol for systematic review and meta-analysis

INTRODUCTION

Previous evidence from several countries, including China, Italy, Mexico, UK and the USA, indicates that among patients with confirmed COVID-19 who were hospitalised, diabetes, obesity and hypertension might be important risk factors for severe clinical outcomes. Several preliminary systematic reviews and meta-analyses have been conducted on one or more of these non-communicable diseases, but the findings have not been definitive, and recent evidence has become available from many more populations. Thus, we aim to conduct a systematic review and meta-analysis of observational studies to assess the relationship of diabetes, obesity and hypertension with severe clinical outcomes in patients with COVID-19.

METHOD AND ANALYSIS

We will search 16 major databases (MEDLINE, Embase, Global Health, CAB Abstracts, PsycINFO, CINAHL, Academic Research Complete, Africa Wide Information, Scopus, PubMed Central, ProQuest Central, WHO Virtual Health Library, Homeland Security COVID-19 collection, SciFinder, Clinical Trials and Cochrane Library) for articles published between December 2019 and December 2020. We will follow the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols 2016 guidelines for the design and reporting the results. We will include observational studies that assess the associations of pre-existing diabetes, obesity and hypertension in patients with COVID-19 with risk of severe clinical outcomes such as intensive care unit admission, receiving mechanical ventilation or death. Stata V.16.1 and R-Studio V.1.4.1103 statistical software will be used for statistical analysis. Meta-analysis will be used to estimate the pooled risks and to assess potential heterogeneities in risks.

ETHICS AND DISSEMINATION

The study was reviewed for human subjects concerns by the US CDC Center for Global Health and determined to not represent human subjects research because it uses data from published studies. We plan to publish results in a peer-reviewed journal and present at national and international conferences.

PROSPERO REGISTRATION NUMBER

CRD42021204371.

Advances and challenges on the path toward the SDGs: subnational inequalities in Mexico, 1990-2017

BACKGROUND

The sustainable development goals (SDGs) have generated momentum for global health, aligning efforts from governments and international organisations toward a set of goals that are expected to reflect improvements in life conditions across the globe. Mexico has huge social inequalities that can affect access to quality care and health outcomes. The objective of this study is to analyse inequalities among Mexico's 32 states on the health-related SDG indicators (HRSDGIs) from 1990 to 2017.

METHODS

These analyses rely on the estimation of HRSDGIs as part of the Global Burden of Disease study 2017. We estimated the concentration index for 40+3 HRSDGI stratified by Socio-demographic Index and marginalisation index, and then for indicators where inequalities were identified, we ran decomposition analyses using structural variables such as gross domestic product per capita, poverty and health expenditure.

FINDINGS

Mexico has made progress on most HRSDGIs, but current trends in improvement do not appear to fast enough to meet 2030 targets. Out of 43 HRSDGIs, we identified evidence of inequality between Mexico's states for 30 indicators; of those, 23 HRSDGIs were unequal distributed affecting states with lower development and seven affecting states with higher development. The decomposition analysis indicates that social determinants of health are major drivers of HRSDGI inequalities in Mexico.

INTERPRETATION

Modifying current trends for HRSDGIs will require subnational-level and national-level policy action, of which should be informed by the latest available data and monitoring on the health-related SDGs. The SDGs' overarching objective of leaving no-one behind should be prioritised not only for individuals but also for communities and other subnational levels.

Rape, transactional sex and related factors among migrants in transit through Mexico to the USA

Migrants in transit through Mexico to the USA are at risk of violence, including sexual violence, during the immigration process. This study sought to identify the socio-demographic factors, migration experiences and health conditions associated with the likelihood of sexual violence. A mixed methods study was conducted between 2012 and 2015. The quantitative phase of the work involved a non-random sample (n = 3539) of migrants who were the users of migrant shelters in Mexico. A probit regression model was used to identify the variables associated with the experience of sexual violence by participants. A total of 58 semi-structured interviews took place with migrants who had either experienced sexual violence or who were acquainted with the sexual violence experienced by other migrants. Of those who experienced any kind of violence, 5.7% reported having experienced sexual violence, with statistically significant differences by gender. According to male migrants, women in transit had the advantage of having an 'entry ticket [to the USA] between their legs'. The dynamics of undocumented transit migration provide multiple opportunities for gender-based inequality and sexual violence. We consider the major underreporting of sexual violence due to the stigma and normalisation of violence, in a social context marked by impunity.

Non-communicable diseases and inequalities increase risk of death among COVID-19 patients in Mexico

BACKGROUND

The SARS-CoV-2 pandemic compounds Mexico's pre-existing challenges: very high levels of both non-communicable diseases (NCD) and social inequity.

METHODS AND FINDINGS

Using data from national reporting of SARS-CoV-2 tested individuals, we estimated odds of hospitalization, intubation, and death based on pre-existing non-communicable diseases and socioeconomic indicators. We found that obesity, diabetes, and hypertension are positively associated with the three outcomes in a synergistic manner. The municipal poverty level is also positively associated with hospitalization and death.

CONCLUSIONS

Mexico's response to COVID-19 is complicated by a synergistic double challenge: raging NCDs and extreme social inequity. The response to the current pandemic must take both into account both to be effective and to ensure that the burden of COVID-19 not falls disproportionately on those who are already disadvantaged.

Migrants in transit through Mexico to the US: Experiences with violence and related factors, 2009-2015

Objectives

The objectives of the study are to 1) estimate the burden of physical, sexual, and psychological violence among migrants in transit through Mexico to the US; and 2) examine the associations between experiencing violence and sociodemographic characteristics, migratory background, and health status in this vulnerable population.

Method

A cross-sectional study combining qualitative and quantitative methods was carried out from 2009 to 2015 with a sample of 12,023 migrants in transit through Mexico to the US. Information on gender (male, female, and transsexual, transgender and transvestite -TTTs-); nationality; health status; migratory background; and experiences with violence was obtained. Fifty-eight migrants participated in in-depth interviews to explore any experiences of violence during their journey. A descriptive analysis was performed and a probit regression model was applied to analyze the factors associated with violence. Qualitative information was analyzed to understand experiences, meanings and responses to violence.

Results

The overall prevalence of suffering from any form of violence was 29.4%. Nearly 24% reported physical violence, 19.5% experienced psychological violence, and approximately 2% reported sexual violence. TTTs experienced a significantly greater burden of violence compared to men and women. Violence occurred more frequently among migrants from Central American (30.6%) and other countries (40.0%) than it did among Mexican migrants (20.5%). Experiences involving sexual, physical and psychological violence as well as theft and even kidnapping were described by interviewees. Migrants mistrust the police, migration authorities, and armed forces, and therefore commonly refrain from revealing their experiences.

Conclusion

Migrants are subjected to a high level of violence while in transit to the US. Those traveling under irregular migratory conditions are targets of even greater violence, a condition exacerbated by gender inequality. Migrants transiting through Mexico from Central American and other countries undergo violence more frequently than do Mexican migrants. Protective measures are urgently needed to ensure the human rights of these populations.

Genetic and phenotypic aspects of early reproductive performance in Raeini Cashmere goats

This study used pedigree information and data collected from 1979 to 2012 at the Raeini Cashmere goat breeding station, located in Baft City in Kerman Province in southeastern Iran. Genetic and phenotypic parameters for early reproductive traits of breeding does, including total numbers of kids born at first kidding (LSB1), total numbers of kids weaned at first kidding (LSW1), total birth weight of all kids born at first kidding (LWB1), total weaning weight of all kids weaned at first kidding (LWW1), and age at first kidding (AFK), were estimated using a Bayesian approach via Gibbs sampling. Posterior means for heritability estimates of LSB1, LSW1, LWB1, LWW1, and AFK were statistically significant, with values of 0.12, 0.23, 0.17, 0.15, and 0.46, respectively. Low-to-moderate additive genetic variation was present for the studied reproductive traits. Estimated genetic correlations among LSB1, LSW1, LWB1, and LWW1 were statistically significant and ranged from 0.12 between LWB1 and LWW1 to 0.72 between LSB1 and LSW1. Corresponding phenotypic correlation estimates were also statistically significant and ranged from 0.04 between LWB1 and LWW1 to 0.55 between LSB1 and LSW1. Posterior means of genetic and phenotypic correlations between AFK and other studied traits were statistically significant only for LSB1 and LWB1. For LSB1, LSW1, LWB1, and LWW1, we conclude that genetic and phenotypic improvement in any of these traits in Raeini Cashmere does would favorably influence all of the other traits. However, does that first kidded at younger ages have smaller litters at birth and lower litter birth weights at their first parity.

Household wellbeing and health risks in Mexican households with and without migrants: a cross-sectional analysis

BACKGROUND

Migration between Mexico and the USA constitutes the world's largest migration corridor with more than 13 million movements of people in 2016. Furthermore, Mexico has a complex migration profile, being a country of origin, transit, destination, and return. While there has been discussion on the relationship between migration and development of origin communities, evidence on social and health issues faced by origin households is limited. This case study is a first attempt at documenting, through analyzing a national representative health survey of Mexican households (n = 9474), the relationship between international migration from Mexico and origin household health characteristics.

CASE PRESENTATION

Mexican international migration moves largely (90% of migrants) toward the USA. Migration has passed from being mostly circular (from the early to late 1990s) to a permanent pattern of residence in the destination country due to changes in migration policies that have progressively restricted the irregular entrance of immigrants making re-entry more difficult.The present case study compares the socioeconomic, demographic, and health characteristics of households in Mexico with and without emigrants using data from a national representative health survey. Accordingly, in 2016, 5.8% (n = 1,802,980) of all Mexican households reported having a member living abroad.Households with members living abroad were found to more likely be headed by a female (45.8%), have Seguro Popular health insurance, and not to be among the poorest household population. In terms of health profile, a higher frequency of adults with a reported diagnosis of diabetes and/or hypertension (33.9 vs 21.7% for households with vs without emigrants, respectively; p = 0.067), and a higher severity of diabetes reflected a higher probability of hospitalization.

CONCLUSIONS

Results showed that socioeconomic, demographic, and health conditions differed between households with and without emigrants. These differences were determined as not being attributable to migration and cannot be considered as predisposing factors of migration.

Mexico's household health expenditure on diabetes and hypertension: What is the additional financial burden?

OBJECTIVE

This study aimed to estimate the magnitude of the association between overall household health expenditures & the presence of members with a chronic disease in the household.

RESEARCH DESIGN & METHODS

This was a cross-sectional analysis of a probabilistic household survey, which gathered data on previously diagnosed type 2 diabetes mellitus and hypertension as well as health expenditure in Mexico. From an analytic sample of 44,000 households, we identified those having at least one member with diabetes or hypertension and determined their health expenditure. Using matching procedures, we compared these data with those of households lacking such individuals.

RESULTS

We found that 24% of the households had at least one member who had been diagnosed with diabetes, hypertension, or both. Households with such members reported health expenditures that were 25%-34% (P <0.01) higher than households without such individuals. Such differences were more pronounced among households at lower socioeconomic levels and among those with no or limited health insurance.

CONCLUSIONS

In addition to their impact on individual health, chronic ailments exert financial pressure on households. The additional health-care expenditure for households owing to such diseases leaves them financially exposed-especially households with lower income levels.

Over-the-scope clip-assisted method for resection of full-thickness submucosal lesions of the gastrointestinal tract

BACKGROUND AND STUDY AIMS

The over-the-scope clip (OTSC; Ovesco Endoscopy, Tübingen, Germany) is deployed after suctioning tissue into the cap. The tissue may then be resected endoscopically. The aim of this study was to evaluate the efficacy and safety of the OTSC for the endoscopic resection of gastrointestinal tumors.

PATIENTS AND METHODS

This was a retrospective, observational cohort study of patients undergoing endoscopic resection of submucosal lesions.

RESULTS

Eight patients underwent endoscopic resection of neuroendocrine tumors (NETs) of the duodenum (n = 4), rectum (n = 1), or stomach (n = 2), or granular cell tumor (GCT) of the esophagus (n = 1). The mean size of the lesions was 13.4 mm (range 9 - 20 mm). Application of the clip was successful in all patients. A successful endoscopic resection was accomplished in all. A complete resection (R0) was accomplished in 7/8 patients (87.5 %). A full-thickness resection was achieved in 2/8 (25.0 %), one in a patient with a gastric NET and the other in a patient with GCT of the esophagus. There were no complications.

CONCLUSIONS

This case series suggests that the OTSC system may be a valuable tool for the resection of submucosal lesions, but further prospective and randomized studies are necessary to assess the indications and outcome.

Small Bowel Neoplasias: Current Options for Diagnosis, Staging and Therapeutic Management

Although small bowel polyps and tumors are rare, their incidence has increased significantly over the past 30 years. Small bowel malignancies can be classified depending upon their cellular origin into four principal histologic types: adenocarcinomas, lymphomas, neuroendocrine tumors or carcinoids and lymphomas, which also include gastrointestinal stromal tumors. The relative ‘rarity' of these tumors has led to stagnation in the development of effective curative or adjuvant therapies. Thus, the prognosis of most of these tumors is still dismal. Nevertheless, hope is now on the horizon as new methods such as capsule endoscopy and balloon-assisted enteroscopy have contributed to a rise in the diagnosis of these lesions and a diagnosis at earlier stages. Using balloon-assisted enteroscopy methods it is possible to resect most small bowel polyps such as adenomas and hamartomas. Improved imaging methods have led to a better understanding of these pathologies and hopefully will bring new hopes in therapy. In addition, multi-center studies are being performed to determine the best therapeutic options for small bowel tumors. <b>Key Message</b> New imaging techniques such as capsule endoscopy and balloon-assisted endoscopy have facilitated the early diagnosis of small bowel malignancies, leading to a better understanding of the biology of these tumors and to improved clinical outcomes for the patient. <b>Practical Implications</b> Although relatively rare, the incidence of tumors and polyps in the small intestine has increased over the past 20 years. The use of endoscopic or radiologic techniques is crucial for the detection and resection of polyps. It is highly recommended to perform a submucosal injection of epinephrine-saline solution prior to endoscopic resection. Due to their non-specific symptoms, neuroendocrine tumors are often diagnosed in advanced stages; surgical excision of the primary tumor is key to a better prognosis. The main therapies for neuroendocrine tumors are surgery, chemoembolization, chemotherapy and the use of somatostatin analogues. Small bowel adenocarcinomas are extremely rare but can be highly fatal. Surgical resection is still the core treatment, though fluoropyrimidine and oxaliplatin-based chemotherapy have shown beneficial effects for the treatment of metastatic disease. Amongst the gastrointestinal stromal tumors, 30% are located in the small intestine. The management of gastrointestinal stromal tumors requires a combination of surgery, pathology techniques and pharmacological interventions, including the use of tyrosine kinase inhibitors.

Linking mass media campaigns to pictorial warning labels on cigarette packages: a cross-sectional study to evaluate effects among Mexican smokers

OBJECTIVE

This study assessed the effects of pictorial health warning labels (HWLs) and a linked media campaign in Mexico.

METHODS

Cross-sectional data were collected from a population-based sample of 1756 adult smokers, aged 18-55 years, during the initial implementation of pictorial HWLs, which some smokers had seen on cigarette packages while others had seen only the text-based HWLs. Exposure to the campaign and pictorial HWLs was assessed with aided recall methods, and other questions addressed attention and cognitive impact of HWLs, knowledge related to HWL and campaign content, and quit-related thoughts and behaviours. Logistic and linear regression models were estimated to determine associations between key outcomes and intervention exposure.

RESULTS

In bivariate and multivariate adjusted models, recall of pictorial HWLs and of the campaign were positively associated with greater attention to and cognitive impact of HWLs, whereas only pictorial HWL exposure was associated with having refrained from smoking due to HWLs. Both recall of pictorial HWLs and of the campaign were independently associated with greater knowledge of secondhand smoke harms and toxic tobacco constituents. Smokers who recalled only the pictorial HWLs were more likely to try to quit than smokers who recalled neither the pictorial HWLs nor the campaign (17% vs 6%, p<0.001).

CONCLUSIONS

Consistent with other studies, adult smokers' exposure to new pictorial HWLs in Mexico was associated with psychosocial and behavioural responses related to quit behaviour. Exposure to the complementary media campaign was associated with independent additive effects on campaign-related knowledge, and it enhanced psychosocial responses to pictorial HWLs.

Herpes simplex virus type 2 among Mexican high school adolescents: prevalence and association with community characteristics

BACKGROUND

We undertook this study to estimate the prevalence and correlates of herpes simplex virus type 2 (HSV-2) among Mexican adolescents in high school.

METHODS

This was a cross-sectional analysis using data that had been collected to evaluate a school-based HIV prevention intervention. As part of the final round of evaluation, capillary blood samples were taken from volunteers to test for antibodies to HSV-2. The effect of each school's seroprevalence on the probability of an individual being seropositive was estimated, and the results were grouped by town to evaluate the association between characteristics of the locality and student HSV-2 seroprevalence.

RESULTS

Dried blood spots were collected for 80% of the 1607 participants in the survey who reported that they were sexually active. Of these samples, 21% tested positive for HSV-2 antibodies, with no significant difference in prevalence between men and women. Seroprevalence among schools ranged from 0 to 57%. The number of sex workers registered in the locality was the most important covariate of seroprevalence, with each additional female sex worker (FSW) per 1000 women between 18 and 45 years of age in the town associated with an increase of 1% in the seroprevalence of HSV-2.

CONCLUSIONS

Characteristics of adolescents' micro-environments that influence their pool of potential sexual partners and the likelihood that these partners are HSV-2 positive may be more important predictors of the risk of STI infection than self-reported condom use.

Access to condoms for female sex workers in Andhra Pradesh

BACKGROUND

Condoms are an essential part of comprehensive HIV prevention and care programmes. We report the accessibility of male condoms for female sex workers (FSWs) and the associated characteristics that may play a major role in determining access to condoms for FSWs.

METHODS

Confidential interviews of 6509 street- and home-based FSWs in 13 districts of the Indian state of Andhra Pradesh provided data on the number of paying clients and various aspects of access to free condoms and purchase of condoms. Access to condoms was defined as having ever obtained condoms either through free distribution or through purchase. Multivariate analyses were done separately for street- and home-based FSWs to describe correlates of their access to condoms. The requirement of condoms was assessed based on the number of paying clients during the past 15 days.

RESULTS

Data on condom access were available for 6465 (99.3%) FSWs. A total of 2850 (44.1%; 95% CI: 36.2%-52.0%) reported accessing free condoms ever and 2336 (36.1%; 95% CI: 30.6%-41.6%) had purchased condoms ever (not mutually exclusive). The primary sources for condoms were non-governmental organization facilities (73.8%) and pharmacies (79.7%) for free and purchased condoms, respectively. A total of 3510 (54.3%; 95% CI: 48.5%-60.1%) FSWs reported no access to free or purchased condoms during the past 15 days, and this no access was significantly higher for those > 30 years of age, with no schooling, street-based FSWs, and with no participation in a FSW support group (p < 0.001 for each in univariate analysis). Participation in a FSW support group was the main predictor of access to free condoms for both types of FSWs during the past 15 days with multivariate analysis. Condom requirements during the past 15 days were met for 67.5% of FSWs who had accessed only free condoms and for 33.8% of those who had accessed only purchased condoms.

CONCLUSIONS

One-fourth of FSWs had never accessed condoms, and a little over half of those who had ever accessed reported no access during the past 15 days. Condom requirements were not met for three-fifths of the FSWs. HIV prevention programmes need to Increase access to free condoms for FSWs in Andhra Pradesh as access to condoms is a necessary prerequisite for condom use.

HIV prevention in Mexican schools: prospective randomised evaluation of intervention

OBJECTIVE

To assess effects on condom use and other sexual behaviour of an HIV prevention programme at school that promotes the use of condoms with and without emergency contraception.

DESIGN

Cluster randomised controlled trial.

SETTING

40 public high schools in the state of Morelos, Mexico.

PARTICIPANTS

10 954 first year high school students.

INTERVENTION

Schools were randomised to one of three arms: an HIV prevention course that promoted condom use, the same course with emergency contraception as back-up, or the existing sex education course. Self administered anonymous questionnaires were completed at baseline, four months, and 16 months. Students at intervention schools received a 30 hour course (over 15 weeks) on HIV prevention and life skills, designed in accordance with guidelines of the joint United Nations programme on HIV/AIDS. Two extra hours of education on emergency contraception were given to students in the condom promotion with contraception arm.

MAIN OUTCOME MEASURES

Primary outcome measure was reported condom use. Other outcomes were reported sexual activity; knowledge and attitudes about HIV and emergency contraception; and attitudes and confidence about condom use.

RESULTS

Intervention did not affect reported condom use. Knowledge of HIV improved in both intervention arms and knowledge of emergency contraception improved in the condom promotion with contraception arm. Reported sexual behaviour was similar in the intervention arms and the control group.

CONCLUSION

A rigorously designed, implemented, and evaluated HIV education course based in public high schools did not reduce risk behaviour, so such courses need to be redesigned and evaluated. Addition of emergency contraception did not decrease reported condom use or increase risky sexual behaviour but did increase reported use of emergency contraception.

Demography and sex work characteristics of female sex workers in India

BACKGROUND

The majority of sex work in India is clandestine due to unfavorable legal environment and discrimination against female sex workers (FSWs). We report data on who these women are and when they get involved with sex work that could assist in increasing the reach of HIV prevention activities for them.

METHODS

Detailed documentation of demography and various aspects of sex work was done through confidential interviews of 6648 FSWs in 13 districts in the Indian state of Andhra Pradesh. The demography of FSWs was compared with that of women in the general population.

RESULTS

A total of 5010 (75.4%), 1499 (22.5%), and 139 (2.1%) street-, home-, and brothel-based FSWs, respectively, participated. Comparison with women of Andhra Pradesh revealed that the proportion of those aged 20-34 years (75.6%), belonging to scheduled caste (35.3%) and scheduled tribe (10.5%), illiterate (74.7%), and of those separated/divorced (30.7%) was higher among FSWs (p < 0.001). The FSWs engaged in sex work for >5 years were more likely to be non-street-based FSWs, illiterate, living in small urban towns, and to have started sex work between 12-15 years of age. The mean age at starting sex work (21.7 years) and gap between the first vaginal intercourse and the first sexual intercourse in exchange for money (6.6 years) was lower for FSWs in the rural areas as compared with those in large urban areas (23.9 years and 8.8 years, respectively).

CONCLUSION

These data highlight that women struggling with illiteracy, lower social status, and less economic opportunities are especially vulnerable to being infected by HIV, as sex work may be one of the few options available to them to earn money. Recommendations for actions are made for long-term impact on reducing the numbers of women being infected by HIV in addition to the current HIV prevention efforts in India.

How much attention is needed towards men who sell sex to men for HIV prevention in India?

Background

HIV prevention in India has mostly focussed on heterosexual transmission. Data on homosexual transmission are not readily available from India. We therefore assessed the probability of acquiring and transmitting HIV for men who sell sex to men and compared this with women who sell sex in India.

Methods

Sexual behaviour characteristics of 6661 men who have sex with men and 6648 women who sell sex were obtained in the Indian state of Andhra Pradesh through confidential interviews. These, along with estimates of HIV rates among them and risk of HIV transmission per unprotected sex act from other sources, were used to calculate their annual probability of acquiring and transmitting HIV.

Results

Of 6661 men who have sex with men in this sample, 1776 (26.7%) had sold sex to men. For every 1000 men who sell sex to men, annually 146 (95% confidence interval [CI] 116–179) would acquire HIV and HIV would be transmitted to 55 (95% CI 42–71) men who do not sell sex or women. These estimates were higher by 6.7 (95% CI 4.9–9.2) times for acquiring HIV and 2.5 (95% CI 2.0–3.2) times for transmitting HIV to sex partners outside their group, as compared with similar estimates for women who sell sex. In this sample, the average annual probability of acquiring HIV was higher among men who have sex with men but do not sell sex as compared with women who sell sex.

Conclusion

These data indicate that men who sell sex to men are at much higher risk of acquiring and transmitting HIV than women who sell sex. Therefore, men who sell sex to men and their clients warrant substantial attention for comprehensive HIV prevention in India.

HIV testing among female sex workers in Andhra Pradesh, India

Of 6648 female sex workers (FSW) in 13 districts of Andhra Pradesh state in India, only 7.9% reported having undergone HIV testing, and three-quarters of the rest were unwilling to undergo HIV testing in the future. The risk of HIV infection as a result of the non-use of condoms was higher among FSW who reported not having been tested and were also unwilling to get tested, and they also held significantly more negative beliefs about HIV/AIDS.

High risk of HIV in non-brothel based female sex workers in India

BACKGROUND

Heterosexual contact is the most common mode of HIV transmission in India that is largely linked to sex work. We assessed the non-use of condoms in sex work and with regular sex partners by female sex workers (FSWs), and identified its associations that could assist in planning HIV prevention programmes.

METHODS

Detailed documentation of various aspects of sex work, and sexual behaviour with regular sex partners, was done through confidential interviews for 6,648 FSWs in 13 districts in the Indian state of Andhra Pradesh. Multivariate analysis was done to understand condom non-use with clients.

RESULTS

5,010 (75.4%), 1,499 (22.5%), and 139 (2.1%) FSWs were street-, home-, and brothel-based, respectively. Of the total 6,648 FSWs, 6,165 (92.7%) had penetrative vaginal/anal sex with at least one client in the last 15 days, and of these 2,907 (47.2%; 95% CI 41.2-53.2%) reported non-use of condom with at least one of her last three clients. Lack of knowledge that HIV could be prevented (odds ratio 5.01; 95% CI 4.38-5.73), no access to free condoms (odds ratio 3.45; 95% CI 2.99-3.98), being street-based as compared with brothel-based (odds ratio 3.36; 95% CI 1.87-6.04), and no participation in FSW support groups (odds ratio 2.02; 95% CI 1.50-2.70) were the most significant predictors of condom non-use with clients. Other associations included lower social support, lower income, age >24 years, illiteracy, and living in medium-size urban or rural areas. Of the 2582 who had penetrative sex with regular sex partner within the last 7 days, 2428 (94%; 95% CI 92.1-95.9%) had not used condom at last sex, and 1032 (41.8%) had neither used condom consistently with clients nor with regular sex partner.

CONCLUSION

About half the FSWs do not use condom consistently with their clients in this Indian state putting them at high risk of HIV infection. Non-brothel-based FSWs, who form the majority of sex workers in India, were at a significantly higher risk of HIV infection as compared with brothel-based FSWs. With their high vulnerability, the success of expansion of HIV prevention efforts will depend on achieving and sustaining an environment that enables HIV prevention with the non-brothel based FSWs.

Sex behaviour of men who have sex with men and risk of HIV in Andhra Pradesh, India

OBJECTIVE

To obtain information on sex behaviour of a large sample of men who have sex with men (MSM) in India that would assist in planning HIV prevention.

METHODS

Homosexual/bisexual behaviour of 6661 MSM at 62 urban-rural locations of various sizes in the Indian state of Andhra Pradesh was assessed through detailed interview. Multivariate analyses were performed to understand the associations with unprotected penetrative sex and barriers to condom use assessed.

RESULTS

The average number of different male sex partners in past 4 weeks was six. In last three sex encounters with men, totalling 19 640, anal sex occurred in 16 769, at least once by 6121 (91.9%) MSM of which 3423 [55.9%; 95% confidence interval (CI), 51.7-60.1%] did not use condom at least once. A total of 2785 (41.8%) were currently married to women and 3354 (50.4%) had had vaginal/anal sex with women in the past 3 months, of which 2818 (84%; 95% CI, 81.1-86.9%) did not use a condom. Furthermore, 1585 (25.9%; 95% CI, 22.7-29.1%) had anal sex without a condom with men and also vaginal/anal sex without a condom with women. This was prevalent across urban-rural locations and its strongest association was with currently married MSM (odds ratio 15.1; 95% CI, 12.5-18.2). The predominant reason for not using a condom with women was 'do not use with regular partner' (68.4%).

CONCLUSION

This high rate of unprotected penetrative sex by MSM with both men and women suggests that HIV prevention efforts in India should include a focus on MSM as well as their wives across many urban-rural locations and not only in large cities.

Emergency contraception use is correlated with increased condom use among adolescents: results from Mexico

PURPOSE

To evaluate the association between knowledge about, or experience with, emergency contraception (EC), and condom use among school-attending adolescents in the state of Morelos, Mexico.

METHODS

We analyzed data from anonymously self-administered questionnaires (n = 10,918), from a cluster-randomized controlled trial among first year students from 40 (75%) public high schools in Morelos, Mexico. The survey included specific questions about EC knowledge and experience as well as questions about perceived ability to negotiate and condition sexual relations on condom use; and condom use at first and last sexual intercourse.

RESULTS

Overall, 61% (6384) of students had heard of EC, and 36% (1964) of girls and 39% (1997) of boys had correct knowledge about EC. Correct knowledge was based upon knowing that EC is pills taken up to 3 days after unprotected sex to prevent pregnancy. Of 1695 (15.6%) reporting lifetime sexual activity, 16.4 % (275) reported they had tried to obtain EC and almost of all them (263) reported having used EC. The probability of a student reporting he/she is capable of interrupting sexual intercourse to use a condom was significantly higher for those who had correct EC knowledge, and a history of EC use was strongly correlated with condom use at last sexual intercourse.

CONCLUSIONS

Experience with emergency contraception has no adverse effects on condom use, but rather is associated with an increased probability of condom use and an increased perceived capacity to negotiate condom use. Despite concern that information about, and access to EC may encourage sexual risk taking, our results suggest the reverse is true. These data support the position that there is no justification to withhold EC information or access from adolescents.

Achieving the WHO/UNAIDS antiretroviral treatment 3 by 5 goal: what will it cost?

The "3 by 5" goal to have 3 million people in low and middle income countries on antiretroviral therapy (ART) by the end of 2005 is ambitious. Estimates of the necessary resources are needed to facilitate resource mobilisation and rapid channelling of funds to where they are required. We estimated the financial costs needed to implement treatment protocols, by use of country-specific estimates for 34 countries that account for 90% of the need for ART in resource-poor settings. We first estimated the number of people needing ART and supporting programmes for each country. We then estimated the cost per patient for each programme by country to derive total costs. We estimate that between US5.1 billion dollars and US5.9 billion dollars will be needed by the end of 2005 to provide ART, support programmes, and cover country-level administrative and logistic costs for 3 by 5.

Interlobar differences in bronchoalveolar lavage fluid from children with cystic fibrosis

Bronchoalveolar lavage (BAL) performed in specialist centres has improved the understanding of infant cystic fibrosis (CF) lung disease. As most researchers sample from a single lobe, it was determined whether BAL results could be generalized to other lung segments. Thirty-three CF children, aged 1.5-57 months, underwent in random order sequential BAL of their right middle and lingula lobes. Specimens from each lobe had separate quantitative bacteriology, cytology and cytokine analysis. Bacterial counts > or = 1 x 10(5) colony forming units (cfu) x mL(-1) were observed in nine (27%) subjects, including six involving only the right middle lobe. These six children had similar inflammatory indices in their right middle and lingula lobes, and interleukin (IL)-8 concentrations in the latter were significantly higher than that observed within the lingula lobes of the 24 CF children with bacterial counts < 1 x 10(5) cfu x mL(-1). Lingula neutrophil and IL-8 levels correlated best with right middle lobe bacteria numbers. This observational study in cystic fibrosis children suggests that while inflammation is detected in both lungs, bacterial distribution may be more inhomogeneous. Bronchoalveolar lavage microbiological findings from a single lobe may therefore, not be generalized to other lung segments. When performing bronchoalveolar lavage in cystic fibrosis children, it is important to sample from multiple sites.