Tropical medicine for the 21st century.

The specialty of tropical medicine originated from the needs of the colonial era and is removed from many of the health care requirements of tropical countries today. Tropical medicine concentrates on parasitic diseases of warm climates, although other infections and diseases related to poverty rather than climate dominate medicine in developing countries challenged by population pressure, civil strife, and migration. In the new century, tropical medicine would best be absorbed into the specialty of infectious diseases, which should incorporate parasitic diseases, travel medicine, and sexually transmitted diseases. Pressing questions for health care and research in developing countries concern the provision of appropriate services for problems such as HIV/AIDS, tuberculosis, sexually transmitted diseases, and injuries. The question of how to provide appropriate clinical care in resource poor settings for the major causes of morbidity and premature mortality has been neglected by donors, academic institutions, and traditional tropical medicine.     

Measures to improve dairy cow foot health: consequences for farmer income and dairy cow welfare

Dairy farming in western countries with cubicle housing is an efficient way of dairy farming. Though, a disadvantage is the high prevalence and incidence of foot disorders (clinical and subclinical), which cause high economic losses and also seriously impair the welfare of dairy cattle. To point out the importance of reducing the amount and severity of foot disorders, advice to farmers should include information about the scale of the problem and the consequences in terms of economics and animal welfare. To provide support in making decisions on implementing intervention measures, insight into costs and benefits of different measures should be available. The objective of this study, therefore, is to provide more insight into the costs and benefits, for farmer and cow, of different intervention measures to improve dairy cow foot health. Intervention measures were modeled when they were applicable on a dairy farm with cubicle housing and when sufficient information was available in literature. Net costs were calculated as the difference between the costs of the measure and the economic benefits resulting from the measure. Welfare benefits were calculated as well. Cost-effective measures are: improving lying surface (mattress and bedding, €7 and €1/cow per year, respectively), reducing stocking density (break even) and performing additional foot trimming (€1/cow per year). Simultaneously, these measures have a relative high welfare benefit. Labor costs play an important role in the cost-effectiveness of labor-intensive measures. More insight into cost-effectiveness and welfare benefits of intervention measures can help to prioritize when choosing between intervention measures.     

Verbal Intercourse and Sexual Communication: Impediments to STD Prevention

This article explores the problems of risky sexual behavior by examining the ways people verbally negotiate sexual interaction regarding sexually transmitted diseases. Based on in-depth interviews with 124 adults (ages 21–63) who are infected with genital herpes, the article shows that knowledge about sexually transmitted diseases is not necessarily related to the action needed for their prevention. People are more afraid of being rejected by a partner than they are of contracting an STD (except, of course, AIDS). By examining difficulties people have with sexual health discourse and showing how these difficulties are related to both the problem of communicating politeness and the problem of representing the self and the sexual other, this article demonstrates that STD prevention programs overlook a very important emotional and communicative issue: the lack of a culturally sanctioned language with which to discuss sexual health with partners, [genital herpes, STD prevention, STD communication, sexually transmitted diseases, STD risk]     

The course of the realization of the Harm Reduction program in the city of Nikolayev

The growth of drug addiction has been noted in Nikolaev. This growth has not been stopped by methods based on the use of force. The results of work in accordance with the program "Harm Reduction" are presented. The program functions on the basis of the Charity Fund "Blahodiinist" and is intended for the prevention of the spread of HIV infection in groups of risk among injecting drug users and in other groups. The realization of the program includes provision of information material, reduction of harm in connection with the use of drugs by injection and the risk of getting HIV and sexually transmitted diseases. The analysis of the results has shown the effectiveness of the program (the frequency of using condoms has increased, the number of sex partners and the number of casual liaisons have dropped, the custom of using sterile syringes has been formed). Considering that during epidemics the coverage of not less than 70% of the representative of risk groups is necessary, the program should be realized on a greater scale to increase its effectiveness.     

Women's Beliefs about Male Circumcision,HIV Prevention,and Sexual Behaviors in Kisumu,Kenya

It is important to understand how women''s sexual practices may be influenced by male circumcision (MC) as an HIV prevention effort. Women''s beliefs about MC and sexual behaviour will likely influence the scale-up and uptake of medical MC. We conducted qualitative interviews with 30 sexually active women in Kisumu, Kenya. Women discussed MC related to perceived health benefits, condom use, sexual behaviour, knowledge of susceptibility to HIV and sexually transmitted infections (STIs), circumcision preference, and influence on circumcision uptake. Respondents had a good understanding of the partial protection of MC for acquisition of HIV for men. Women perceived circumcised men as cleaner, carrying fewer diseases, and taking more time to reach ejaculation. Male''s circumcision status is a salient factor for women''s sexual decision making, including partner choice, and condom use. It will be important that educational information affirms that MC provides only partial protection against female to male transmission of HIV and some STIs; that other HIV and STI prevention methods such as condoms need to be used in conjunction with MC; that MC does not preclude a man from having HIV; and that couples should develop plans for not having sex while the man is healing.     

Information centers as an instrument for behavioral change in order to prevent HIV infection

The importance of information and behavioral changes in preventing HIV infection in three different groups of people is shown. The content of one of such strategies, the Prochaska-DiClemente model of behavior changing, which proved to be good in popular programs realized in many countries, including Russia, is demonstrated. In this model the change of behavior is presented as a process consisting of 5 stages of making definite decisions. The realization of the program has started by such organizations as "Médecins sans Frontières" (Holland) and "SPID-infosvyaz" (Russia) in the prevention of HIV infection, sexually transmitted diseases (including hepatitides) and drug dependence in 6 regions of Russia. The prospect lying before these activities is the creation in Russia of a network of organizations working in the above-mentioned field.     

A mathematical model for the investigation of the Th1 immune response to Chlamydia trachomatis

Chlamydia are bacterial pathogens of humans and animals causing the important human diseases trachoma, sexually transmitted chlamydial disease and pneumonia. Of the human chlamydial diseases, sexually transmitted disease caused by Chlamydia trachomatis is a major public health concern. Chlamydia trachomatis replicates intracellularly and is characterised by a complex developmental cycle. Chlamydia is susceptible to humoral and cell-mediated immunity. Here we investigate the Th1 cell-mediated immune response against Chlamydia-infected cells as the response changes over the chlamydial developmental cycle. We suggest a form for the immune response over one developmental cycle by modelling the change in the number of intracellular chlamydial particles and assume peptides are presented in proportion to the number of replicating forms of chlamydial particles. We predict, perhaps non-intuitively, that persistent Chlamydia should be induced and forced not to return to the lytic cycle. We also suggest that extending the length of the time of the lytic cycle will effectively decrease the required efficacy of the Th1 response to eliminate the pathogen. We produce plots of active disease progression, control and clearance for varying levels of Th1 effectiveness.     

Cost Evaluation of Reproductive and Primary Health Care Mobile Service Delivery for Women in Two Rural Districts in South Africa

Background

Cervical cancer screening is a critical health service that is often unavailable to women in under-resourced settings. In order to expand access to this and other reproductive and primary health care services, a South African non-governmental organization established a van-based mobile clinic in two rural districts in South Africa. To inform policy and budgeting, we conducted a cost evaluation of this service delivery model.

Methods

The evaluation was retrospective (October 2012–September 2013 for one district and April–September 2013 for the second district) and conducted from a provider cost perspective. Services evaluated included cervical cancer screening, HIV counselling and testing, syndromic management of sexually transmitted infections (STIs), breast exams, provision of condoms, contraceptives, and general health education. Fixed costs, including vehicle purchase and conversion, equipment, operating costs and mobile clinic staffing, were collected from program records and public sector pricing information. The number of women accessing different services was multiplied by ingredients-based variable costs, reflecting the consumables required. All costs are reported in 2013 USD.

Results

Fixed costs accounted for most of the total annual costs of the mobile clinics (85% and 94% for the two districts); the largest contributor to annual fixed costs was staff salaries. Average costs per patient were driven by the total number of patients seen, at $46.09 and $76.03 for the two districts. Variable costs for Pap smears were higher than for other services provided, and some services, such as breast exams and STI and tuberculosis symptoms screening, had no marginal cost.

Conclusions

Staffing costs are the largest component of providing mobile health services to rural communities. Yet, in remote areas where patient volumes do not exceed nursing staff capacity, incorporating multiple services within a cervical cancer screening program is an approach to potentially expand access to health care without added costs.     

The effect of combat exposure on sexually transmitted diseases

Traumatic exposures can affect beliefs and behaviors related to the spread of sexually transmitted diseases (STDs), a persistent public health problem. I leverage a natural experiment created by variation in US military deployment location assignments to estimate how combat exposure changes a surviving deployed male veteran’s probability of acquiring a sexually transmitted disease. I analyze longitudinal data from 1994 to 2008 on 485 deployed veterans with information theoretic methods to reduce the sensitivity of estimates to small samples, an infrequently observed outcome, and highly correlated covariates. For veterans assigned to a combat zone, I estimate combat exposure results in a 5.4 percentage point increase in the probability of acquiring an STD. Additional estimations provide evidence suggesting risky behaviors involving substance use or multiple sexual partners may serve as pathways from combat exposure to STDs. My results are relevant to discussions regarding STD screening and care needs for trauma exposed individuals.     

Economic returns to investment in AIDS treatment in low and middle income countries

Since the early 2000s, aid organizations and developing country governments have invested heavily in AIDS treatment. By 2010, more than five million people began receiving antiretroviral therapy (ART)--yet each year, 2.7 million people are becoming newly infected and another two million are dying without ever having received treatment. As the need for treatment grows without commensurate increase in the amount of available resources, it is critical to assess the health and economic gains being realized from increasingly large investments in ART. This study estimates total program costs and compares them with selected economic benefits of ART, for the current cohort of patients whose treatment is cofinanced by the Global Fund to Fight AIDS, Tuberculosis and Malaria. At end 2011, 3.5 million patients in low and middle income countries will be receiving ART through treatment programs cofinanced by the Global Fund. Using 2009 ART prices and program costs, we estimate that the discounted resource needs required for maintaining this cohort are $14.2 billion for the period 2011-2020. This investment is expected to save 18.5 million life-years and return $12 to $34 billion through increased labor productivity, averted orphan care, and deferred medical treatment for opportunistic infections and end-of-life care. Under alternative assumptions regarding the labor productivity effects of HIV infection, AIDS disease, and ART, the monetary benefits range from 81 percent to 287 percent of program costs over the same period. These results suggest that, in addition to the large health gains generated, the economic benefits of treatment will substantially offset, and likely exceed, program costs within 10 years of investment.     

Women's health. The childbearing years and after.

Health and development planners have tended to see women primarily in context of their reproductive role. As a result, solutions to women''s health needs have been restricted to expanding and improving maternal and child health systems. There has recently been a major shift in direction, largely because of the influence of the world conference on population and development held in Cairo in 1994. Dr Guiseppe Benagiano, director of the special programme of research, development and research training in human reproduction based at the WHO, says, "We need to remind ourselves constantly that reproductive health is not simply a biomedical issue but one with serious implications for our general health and by extension, for all our efforts in human social and economic development." The 1993 world development report on health identified the lack of a clear strategy for engaging women in health care and suggested that child health services, prenatal care, treatment of sexually transmitted diseases, and family planning services should be provided jointly at convenient times. In an example of this, the Chilean Institute of Reproductive Medicine now offers integrated family planning services at the same time as child health services, and Thailand is experimenting with mobile health clinics to reach women in their homes. As the proportion of elderly women increases, old age is increasingly being seen as a female issue. With the impact of urbanisation and industrialisation, more of these women are living isolated lives, often suffering from chronic debilitating diseases. In his opening statement to the global commission on women''s health in April 1995 which focused on health conditions of women in old age, Dr Hiroshi Nakajima, the WHO''s director general, said: "Our goal should not be solely to extend lives in the physical sense, but to ensure that the added years are worth living."     

Genetic Counseling—A Health Department Service to Physicians

Questions about inheritance in all kinds of diseases and defects are commonly asked of nearly all physicians. In attempting to answer these questions, however, the physician is often hampered by lack of formal instruction in clinical genetics.Since the health department, if it is to carry out its epidemiologic function, must be as concerned over the increasing identification of genetic agents in disease as it is and has been over environmental disease agents, it should come to represent a source of assistance not now generally available to the physician. In short, as it carries out those activities by which its store of general genetic information is increased, and until other sources of genetic consultation become reasonably available, the health department can be of real service to physicians as a resource to which they may turn for help when dealing with families wanting genetic information.Such a service has been provided experimentally for the last two years by the Contra Costa County Health Department.This program calls for the taking of family pedigrees by public health nurses on families with questions of a genetic nature who are health department clients and on families who are referred by their private physicians for this service. An interpretation of each pedigree is made by the department''s physician in charge of the program and submitted to the family''s physician for his use in counseling the family. Evidence to date suggests the process can be a highly useful service to the practitioner and his patient.     

How often is genital yeast infection sexually transmitted?

We analysed data from a computer-based bank of clinical records of patients seen in a clinic for sexually transmitted diseases over a three-year period to investigate the association between genital yeast infections and sexually transmitted diseases (STDs). We classified STDs as primary and secondary syphilis; gonorrhoea; lymphogranuloma venereum; trichomoniasis; scabies; pediculosis; genital herpes; warts; and molluscum contagiosum. Of a total of 2984 disease episodes among women, 1054 (35-3%) included yeast infections, whereas only 382 (6-9%) of 5501 episodes in heterosexual men were associated with yeast infections, We found a significant association between yeast infection and STD and non-specific genital infection (non-specific urethritis (NSU) and procitis in men, and female contacts of men with NSU), which suggested that yeast infection was sexually acquired in 414 out of 1054 disease episodes in women (39%) and 110 out of 382 episodes in heterosexual men (29%). We conclude that sexually active patients with genital yeast infections should be screened for other STDs particularly non-specific genital infection.     

Modeling AIDS as a function of other sexually transmitted disease.

The spread of AIDS, as with any sexually transmitted disease, will depend on the pattern of sexual activity. Both the proportion of the population who have high partner exchange rates and the extent to which that proportion interacts with the remainder of the population are likely to be important determinants of the AIDS epidemic. However, it does not seem likely that surveys could obtain sufficiently reliable information of this nature for use in an accurate model of the AIDS epidemic. On the other hand, such information is implicitly contained in the epidemiology of other sexually transmitted diseases (STDs). Therefore a method is suggested of calculating the parameters of a model of the AIDS epidemic by comparing it with the epidemiology of another STD. The result is a model that predicts the likelihood of infection by the AIDS virus as a function of time and an individual's history of STD. It is suggested that further work along these lines may lead to a quantitative approach to assessing the importance of various STDs as cofactors in the spread of AIDS.     

Vaccination strategies against Tritrichomonas foetus

Immunoprophyloxis for bovine trichomoniosis has been a priority because of the high prevalence o f the disease, the considerable economic loss due to the infection and the lack of approved chemotherapeutic agents. The commercial availability of first-generation vaccines provides hope not only for even more effective immunization regimens far this disease, but also for other protozoal infections and for sexually transmitted diseases (STDs) caused by a wide variety of infectious agents. At present, efficacious vaccines for protozoal diseases and for STDs are rare. Since information gained on immunization against Tritrichomonas foetus may have broad significance for control of these two classes of infection,it is important to explore the biological basis of protection against this protozoal infection of the reproductive tract In this paper, Lynette Corbeil reviews data on host-parasite relationships in bovine trichomoniasis as a basis for developing vaccine strategies.     

The prostitution situation in a number of cities of Russia, Ukraine and Byelarus

The analytical study indicating that 25% of prostitutes use drugs by intravenous injection is presented. As determined in this study, prostitutes face the double danger of being infected with HIV (they undergo treatment for drug addiction and sexually transmitted diseases). The conclusion has been made that no educational work on HIV/AIDS is carried out among this group of women, though they run a high risk of infection. According to this study, the requirements which ensure the health of prostitutes may be realized by itinerary educational programs, the publication of information materials, specially intended for distribution among such women. The necessity to supplement information on AIDS with information on STD is noted, alerting the public on the fact that these infections are closely connected. The necessity of educating transport and industrial workers, as well as people working in the system of the Ministry of Defense, with a view to prevent the spread of HIV infection is also considered to be an important factor (on the example of Belarus).     

Costs of mass drug administration for scabies in Fiji

In 2019, the Murdoch Children’s Research Institute in partnership with the Fiji Ministry of Health and Medical Services carried out an integrated mass drug administration (MDA) for the treatment of scabies and lymphatic filariasis in the Northern Division of Fiji (population estimate 131,914). We conducted a retrospective micro-costing exercise focused on the cost of scabies control in order to inform budgeting and policy decision making in an endemic setting. We collected detailed information on financial and economic costs incurred by both parties during the course of the MDA campaign (April 2018 to July 2019). We also conducted interviews with personnel involved in the financial administration of the MDA campaign. The economic cost of delivering two doses of ivermectin was US$4.88 per person. The cost of donated drugs accounted for 36.3% of total MDA costs. In this first large-scale MDA for the public health control of scabies, the estimated cost of delivering MDA per person for scabies was considerably more expensive than the costs reported for other neglected tropical diseases. The important cost drivers included the remuneration of health care workers who were extensively involved in the campaign, coverage of hard-to-reach, mainly rural populations and the two-dose regimen of ivermectin. These results highlight the importance of these cost determinants and can be used to plan current and future MDA programs.     

Health and the city: physical health and mental health

In France, city size has very little bearing on the mortality rate as a function of age and life expectancy and it is in large cities that these indicators are the most favorable. No increase in maternal or infant mortality rates or deaths due to cancers has been observed in large cities. The lower mortality rate linked to respiratory and cardiovascular diseases in large urban areas contradicts the fears concerning the impact of air pollution. Deaths linked to lifestyle are less frequent in big cities, which could be due to social structures (socio-professional level: the proportion of white-collar workers and professionals is higher in bigger cities than in the suburbs or small cities). However, although the overall mortality rate is lower, it should be emphasized that there is in large cities a greater incidence of sexually transmitted diseases, AIDS and certain infectious diseases (because of social diversity and the fact that certain individuals seeking anonymity and marginality are drawn to large cities). In terms of mental health, the breakdown of family structures, instability, unemployment, the lack of parental authority and failing schools render adolescents vulnerable and hinder their social integration. When the proportion of adolescents at risk is high in a neighborhood, individual problems are amplified and social problems result. In order to restore mental and social health to these neighborhoods, ambitious strategies are necessary which take into account family and social factors as well as environmental ones. At the present time, when physical health is constantly improving, the most pressing problems are those related to lifestyle and mental health which depend for a large part on social factors.