CLINICAL SOCIAL WORK (CSW)
IMPRESSUM
CLINICAL SOCIAL WORK, 2012
EDITOR – IN – CHIEF:
Michal OlГЎh
Bratislava, Slovak Republic
[email protected]
Peter G. Fedor – Freybergh
Stockholm, Sweden
[email protected]
EDITORIAL BOARD:
Thomas Szekeres (Vienna)
Zlata OndruЕЎovГЎ (Bratislava)
Marian Bartkovjak (MГґle - St. Nicolas)
Fedor Apsa (Uzgorod)
Hristo Kyuchukov (Provadia)
Gabi Lezcano (San Francisco)
Susan Njambi (Nairobi)
Andrea Shahum (Yale)
Beldjebel Irad (Beirut)
Lenka FabianovГЎ (Trnava)
AlЕѕbeta MrГЎzovГЎ (Bratislava)
Eva Grey (Vienna)
Claus Muss (Augsburg)
Thomas Endler (Vienna)
Michael Maes (Antwerp)
COMMISSIONING EDITOR:
NataЕЎa BujdovГЎ
[email protected]
QUEST EDITOR:
Michal OlГЎh
[email protected]
PROOFREADER:
Andrej Fukas
[email protected]
CLINICAL SOCIAL WORK (CSW)
CONTENTS No. 4, VOL 3, 2012
NEW WORDS FROM THE EDITORS-IN-CHIEF…………………………………….
3
K. Sedlarova
CURRENT PALLIATIVE AND HOSPICE CARE IN SLOVAKIA………………….....
4
L. Hajduk
THE PRINCIPLE OF JUSTICE TO THE PROCEEDINGS……………………………..
9
R. Michel
YOUTH UNEMPLOYMENT AS A SOCIAL PROBLEM……………………………...
15
Е . TomovГЎ, ДЅ. Е tД›pГЎnek, A. ГЃrpovГЎ
VIDEO TRAINIG USE IN TEACHING COMMUNICATION SKILLS………………..
20
N. BujdovГЎ, S. Bujda, V. NovГЎk
THE STATE FAMILY POLICY OF THE SLOVAK REPUBLIC..................................
27
I. Gulášová, L. Görnerova, J. Breza, J. Breza, Jr.
THE AIMS OF PUBLIC HEALTHCARE SYSTEM IN „HEALTH IN 21.TH
CENTURY“ PROGRAM – HOW TU CRATE A HEALTHY LIFESTYLE……………
33
I. GulaЕЎovГЎ, V. DvorakovГЎ, J. HruЕЎka,
ANOMYMOUS AND SECRET CHILDBIRTHS………………………………………..
40
A. Akimjak
ROLE OF THE CONTEMPORARY FATHER………………………………………….
46
J. ДЊenteЕЎ
PROTECTION AGAINST LEGALIZATION AND TERRORIST FINANCING……..
54
Maros Satny
AMENDMENTS TO THE ACT ON SOCIAL SERVICES…………………………….
62
N. Kulkova, J. Sokolova, V. Krcmery, J. Benca, I. Beldjebel, T. Benson Alumbasi
15 TH INTERNATIONAL CONGRESS ON INFECTIOUS DISEASES – CONGRESS
REPORT FROM BANGKOK…………………………………………………………….
65
M. Kiwou, E. Nandolaya, Hoy Leunghoin, T. Oelnick, V. Chom, Or Tou, S. Sethaun,
S. Sorat, N. Kulkova, J. Sokolova, D. Pechacova, J. Ravasz, E. Vrankova, M. Hettes,
G. Kralik, F.Hanobik, G. Mikolasova, J. Benca, I. Kmit, E. Nicodeums, D. Kisundi,
G. Mikolasova, J. M. Muli, R. Michel, P. Blaskovic, S. Zabarova, Z. Gazova,
K. Molnarova, M. Chabadova, K. Feckova, B. Hatasova, A. Mrazova, E. Halasova,
G. Herdics, V. Korcek, M. Mutalova
EMERGENCIES IN TROPICAL SOCIAL WORK AND NURSING AND PUBLIC
HEALTH………………………………………………………………………………….
77
CLINICAL SOCIAL WORK (CSW)
Sol Sorath, Hoy Leaughoin, Rajoo Magaswari, C. Petersmann, F. Schumann,
H. Takthalie, H. Sondermann, T. Hahn, P. Solwerk, G. Mikolasova,G.Kralik, J. Benca,
J. Ravasz, E. Vrankova, M. Hettes, F. Hanobik, Or Tou, Vicet Chom, L. Seng Hong
SOCIAL AND HEALTHCARE IMPACT OF AIDS TO DEVELOPING
COUNTRIES……………………………………………………………………………... 99
J. Suvada, I. Kmit, A. Korba, E. Kovac, J. Stastna, L. Lukacova, J. Polachova,
N. Sebova, G. Kothaj, L. Macejkova, J. Stastna, A. Kostanjevec, R. Kucera, S.
Slezakova, M. Paulovicova, I. Mrazkova, B. Kozuch
GLOBAL DISEASE BURDEN AND SURVILLANCE STUDIES ON
HYPERTENSION, DIABETES, OBESITY, COMMUNICABLE DISEASES AND
OTHER SOCIAL STATUS RELATED DISEASES……………………………………. 106
Kmit I., M. Cierna, J. Facuna, A. Gabrielova, A. Galbava, S. Gilanova, V. Graus,
M. Gymerska, D. Horvathova, A. Hraskova, M. Hrasnova, A. Imrichova, A. Jancekova,
S. Judinyova, P. Kadlecik, J. Kollarcikova
SOCIAL WORK IN TROPICAL AREAS OF SUBSAHARAN AFRICA AND
SOUTHEAST ASIA……………………………………………………………………..
135
M. Mutalova, P. Vermes, G. Hendics. S. Zak, J. Doktorovova, J. Jexova, Z. Nagyova, T.
Oelnick, M. Vravcova
SOCIAL, LEGAL, ECONOMIC AND PUBLIC HEALTH ASPECTS IN AN
INFECTIOUS DISEASES 2012 ICAAC UPDATE……………………………………. 163
I. Gulášová, L. Görnerova, J. Breza, J. Breza, Jr.
HEALTHY AGING AS ONE OF OBJECTIVES OF THE "HEALTH IN THE 21ST
CENTURY" PROGRAMME……………………………………………………………
168
I. Kmit, M. Spisiak, V. Stanislav, J. Srenkel, Z. Takacova, J. Zavodna, L. Andrejiova,
A. Arpova, K. Borsodiova, T. Democko, L. Elkova, A. Farkasova, S. Florekova,
V. Graus, T. Haluska, K. Hartmannova
SOCIAL WORK WITH HOMELESS PEOPLE WITH TUBERCULOSIS AND
AIDS……………………………………………………………………………………... 175
J. Bordacova, I. Kmit, J. Benca, M. Heverova, A. Karasova, J. Kmec, A. Kurnat, P.
Matysak, J. Mulik, V. Novak, A. Ondrejkova, P. Orendac, T. Potomova, K. Rakova,
K. Raslova, K. Valachova, M. Bardiovsky, K. Bugalova
SOCIAL WORK WITH TUBERCULOSIS AND LEPROSY PATIENTS: NEW
TREATMENT AND NEW HOPES……………………………………………………
185
I. Kmit, M. Mutalova, P. Vermes, G. Herdics. S. Zak, J. Doktorovova, A. Imrichova,
M. Satny, J. Jexova, Z. Nagyova, T. Oelnick, M. Vravcova, S. Nemcik, J. Markova,
M. Sklenka, A. Ngudo
SOCIAL, LEGAL, ECONOMIC AND PUBLIC HEALTH ASPECTS IN HOSPITAL
ACQUIRED INFECTIOUS DISEASES IN 2012 – AN ICAAC UPDATE……………
194
CLINICAL SOCIAL WORK (CSW)
Kmit I., M. Schavel. J. Miklosko, J. Bordacova, A. Ngendo, K. Feketeova,
B. Acova, J. Benus, M. Beresova, S. Blahovska, V. Cehlar, M. Cerny,
A. Daniskova, A. Davidova, M. Dolezal, L. Horna, S. Hubinova, R. Hunes,
E. Madarova, O. Matko, M. Sedlacek
SOCIAL, LEGAL, NURSING AND INTERNATIONAL PUBLIC HEALTH
ASPECTS OF MALARIA IN LAST YEARS…………………………………………
199
Silharova B., Ladesova N., Kmit I., Sokolova J., Kulkova N., A. Zakutna, M.
Ceresnikova, Mikolasova G., Mikolasova P., G. Kralik, Pastekova T., Kalavska Z.,
Horvathova D., Bartosova M.
MISSIONARY PROJECTS IN UGANDA AND UPDATE ON VIRAL
HEAMORRHAGIC FEVERS……………………………………………………………. 205
R. Kagoya., P. Tumbu, R. Iriso., A. Zanaib., K. Otundo., Y. Karamagy., E. Namagala.
SOCIAL SUPPORT AND QUALITY OF LIFE AMONG PEOPLE LIVING WITH
HIV/AIDS IN CENTRAL UGANDA……………………………………………………. 211
N. Kulkova, J. Sokolova, I. Beldjebel, L. Alumbasi Timona
3rd SOUTHEAST EUROPEAN CONFERENCE ON CHEMOTHERAPY AND
INFECTION. NOVEMBER November 8th – 11th 2012………………………………… 224
A Ngendo, I. KmiЕҐ, J. Sokolova, G. Mikolasova, E. Nandolaya, D. Hes, C. Petersman,
D. Salwerk, G. Kralik, K. Hahn, H. Sondermann, Ch. Bonnack, J. Gerygk,
M. Chabadova, K. Feckova, B. Hatasova, E. Ceploova, Z. Gazova, C. Monte,
F. Schumann, K. Badanicova, T. Oelnick, M. Jancovic, J. Kafkova, N. Kulkova,
J. Ravasz , E. Vrankova, I. Feketova, J. Kajaba, A. Mrazova, E. Haluskova,
G. Herdics, A. Zakutna, P. Gogolakova, J. Kuffova, M. Hettes, F. Hanobik,
V. Namulanda, V. Okoth
NEWS IN MALARIA AND RELATED TROPICAL DISEASES IN SOCIAL WORK
AND HEALTH…………………………………………………………………………... 229
J. Suvada , V. Krcmery, J. Benca
REPORT FROM THE13TH ASIA-PACIFIC CONGRESS OF CLINICAL
ICROBIOLOGY AND INFECTION…………………………………………………….. 239
G. Lezcano, A. Stanova, V. Krcmery, I. Beldjebel
NEW ISSUE FOR ID FELLOWS IN SOCIAL WORK AND TROPICAL HEALTH
CARE – NEWS FROM ICAAC…………………………………………………………. 251
INSTRUCTIONS FOR AUTHORS……………………………………………………..
259
CLINICAL SOCIAL WORK (CSW)
Few words from the Editors-in-Chief
This journal brings authentic experiences of our social workers, doctors and teachers working
for the International Scientific Group of Applied Preventive Medicine I-GAP Vienna in
Austria, where we have been preparing students for the social practise over a number of years.
Our goal is to create an appropriate studying programme for social workers, a programme
which would help them to fully develop their knowledge, skills and qualification. The quality
level in social work studying programme is increasing along with the growing demand for
social workers.
Students want to grasp both: theoretical knowledge and also the practical models used in
social work. And it is our obligation to present and help students understand the theory of
social work as well as showing them how to use these theoretical findings in evaluating the
current social situation, setting the right goals and planning their projects. This is a
multidimensional process including integration on many levels. Students must respect client’s
individuality, value the social work and ethics. They must be attentive to their client’s
problems and do their best in applying their theoretical knowledge into practice.
It is a challenge to deliver all this to our students. That is also why we have decided to start
publishing our journal. We prefer to use the term �clinical social work’ rather than social work
even though the second term mentioned is more common. There is some tension in the
profession of a social worker coming from the incongruity about the aim of the actual social
work practice. The question is whether its mission is a global change of society or an
individual change within families. What we can agree on, is that our commitment is to help
people reducing and solving the problems which result from their unfortunate social
conditions. We believe that it is not only our professional but also ethical responsibility to
provide therapeutic help to individual and families whose lives have been marked with serious
social difficulties.
Finding answers and solutions to these problems should be a part of a free and independent
discussion forum within this journal. We would like to encourage you – social workers,
students, teachers and all who are interested, to express your opinions and ideas by publishing
in our journal. Also, there is an individual category for students’ projects. In the past few
years there have been a lot of talks about the language suitable for use in the field of the social
work. According to Freud, a client may be understood as a patient and a therapist is to be seen
as a doctor. Terminology used to describe the relationship between the two also depends on
theoretical approach. Different theories use different vocabulary as you can see also on the
pages of our journal.
Specialization of clinical social work programmes provides a wide range of education. We are
determined to pass our knowledge to the students and train their skills so they can one day
become professionals in the field of social work. Lately, we have been witnessing some crisis
in the development of theories and methods used in clinical social work. All the contributions
in this journal are expressing efforts to improve the current state. This issue of CWS Journal
brings articles about social work, psychology and other social sciences.
Michal OlГЎh
Peter G. Fedor-Freybergh
3
CLINICAL SOCIAL WORK (CSW)
CURRENT PALLIATIVE AND HOSPICE CARE IN SLOVAKIA
KatarГ­na SedlГЎrovГЎ
Constantine the Philosopher University in Nitra
Department of Social Work and Social Sciences, Slovak Republic
ABSTRACT
Care for terminally ill and dying people in Slovakia still does not reach satisfactory standards
in certain fundamental aspects. Palliative and hospice care is generally not affordable and ill
people cannot afford the place, where they would like to end their lives. We still do not get
necessary and true information about the diagnosis and the prognosis, palliative home care is
not supported, and professional support for those, who would like to assist a dying person at
home, is missing. In this context, we focus our attention in this contribution on the current
situation of this issue in Slovakia and on the complex of palliative and hospice care as an
aspect of the health and social system.
Key words:
Dying. Palliative care. Hospice care. Hospice.
Introduction
The process of ageing should be studied within European conditions in accordance with the
economic globalisation and the uneven economic development with crisis caused fluctuations.
The acknowledgement of the whole lifecycle also turns attention to the quality of social care
and social services for the dying. In this area of care for the terminally ill and the dying,
formal and informal, social and health care meet. Each person has the right to die with
dignity, which is enshrined in the European Council’s international treaties and in the Charter
of fundamental rights of the European Union and it includes the provision of each person�s
individual needs, starting from the basic biological, through experience needs, ending with
the spiritual needs.
The meaning of life and death belongs to the basic existential questions and people have been
asking them since the very beginning. We understand life and especially death as something
naturally present; however, how can we, as human beings, consider both of them as our most
natural definitions? The contribution focuses on the topic of human mortality and the situation
which almost each person is exposed to – the situation of dying.
The majority of authors from western civilisation, who are currently concerned with dying
and death agree that death, dying and the associated suffering and pain are still being
excluded from the public space of our society (Glaser&Strauss 1965, Littlewood 1993 etc.)
To speak about death and dying is still considered a taboo topic, especially in „the western
civilisation“. Death is being excluded, considered a taboo and hold behind „ hospital doors“.
In the past, people perceived death as a natural and common part of life. The ill person was
dying at home among the other family members. The situation nowadays is different, but the
topic of dying and death is starting to get attention, people are looking for answers to
questions: How to be dying? How not to suffer, so that the human dignity stays preserved, so
that I will not be left alone, abandoned? We live in a world where questions like these scare
all of us. But the way people perceive death has never been as poor as it is now.
4
CLINICAL SOCIAL WORK (CSW)
Dying and death at present
In the past, dying was considered a “social act”, which is almost not true anymore. Dying and
death are being institutionalized. Less people die at home, more in various institutions.
Although there are many institutions that help people in many emergency situations, the
training of doctors and other participating people, to teach them how to help people in their
most serious crisis just before death during terminal illnesses, has still not been revised.
People nowadays try to escape death, illness, suffering, disability, they do not want to hear
about it, speak about it, and they close their eyes before reality until a terminal illness
incompatible with life catches them. We watch the Dutch and Belgian model of euthanasia
and for many of us, when suffering a serious illness, the solution “not to live” seems to be an
objective way out. In medical terminology, the term dying is synonymous with the terminal
condition. HaЕЎkovcovГЎ (2000) speaks about a broader context of dying, which can last longer
than the terminal condition. Its beginning can be noticed in the moment when the illness
enters the consciousness of a specific person and is most likely incompatible with life. The
personВґs quality of life will be determined by the course of the illness.
Modern man resists fear and pain caused by dying more than the idea of death. The
philanthropic organization based in Singapore issued the first international “Quality of Death
Index”, which included 40 countries. In the part – public awareness of end of life care –
Slovakia is not even among the first half of the countries (Economist Intelligence Unit, 2010).
Currently, there are two types of dying – the institutionalized type and the home type. The
effort to enrich the analgesic therapy and to optimize the nursing care for dying people led to
the establishment of modern hospitals, where the ill get professional help. This redeployment
of the dying to hospitals creates a new type of care, the so called institutionalized type.
Through the emergence of the institutionalized type, dying and death have become a bigger
taboo, something, which “belongs behind hospital doors”. This type of dying misses the
necessary human contact, dying is not considered a social act anymore. The family comes for
a visit and does not know how to act, what to say and thinks that it is the professionalВґs task to
take care for the dying patient. Efforts exist to find a solution so that dying would be again
considered a social act. (BГЎrtlovГЎ, Matulay, 2009).
To be able to die at home. This, almost forgotten wish comes back to life. The wish of many
long-term ill people to spend the last section of their lives in home environment can be
accommodated by means of many offers.
Home care presupposes a certain level of family background that is often missing. This form
of nursing is often too challenging for the family members. Nursing requires a lot of time, so
that the nursing actions can be performed accordingly and without any rush. Then the ill
person feels that their relative has enough time and wants to care only for them (Barden,
Vogel, Wodraschka, 2002).
Currently it shows that respite care and respite services, which allow the caregiver to interrupt
the care and offer them the opportunity to take part on different activities and interests, are
very important for the relatives who care for a dying person (Е erfelovГЎ, 2011). Respite care
forms a part of institutionalized palliative care. It is a stimulating change of environment
which allows mutual support and cooperation of the people involved in the care for the
patient. The aim is to eliminate the consequences of the psychosocial burden resulting from
the care for the dying (2007 HansonovГЎ, In PayneovГЎ, SeymourovГЎ, IngletonovГЎ, 2008).
Approaches to care at the end of life
Currently, importance is placed on norms and standards that are necessary for health workers,
social workers and also for all those who work in the environment of hospice and palliative
care and can, through their decisions in the field of health care, influence the availability of
palliative care for patients.
In relation to the dying or seriously ill person, we are based on the holistic model which
understands the person as a bio-psycho-social-spiritual being. The holistic model is based on
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CLINICAL SOCIAL WORK (CSW)
the personВґs ability to adapt herself/himself to changing conditions. It is based on the
assumption that the human being is an open system that constantly has to respond to changes.
The more so when the person is confronted with a serious illness incompatible in life. Hence
the holistic approach is a philosophy which is applied in care for dying people. This care
focuses on the patientВґs family, their mutual relationships, needs and problems (KutnohorskГЎ,
2009).
Palliative medicine has its roots in the hospice movement, which originated as a reaction to
serious problems of the terminally ill and dying in the second half of 20th century. Thanks to
substantial medical discoveries the course of many illnesses has changed and many patientsВґ
hopes for complete recovery have increased. On the other hand, terminally ill and dying
patients have, from the economic point of view, become a burden for hospitals and a trauma
for doctors who wanted to be successful in the treatment.
In another sense, palliative care presents the most fundamental concept of care – care focused
to meet the patientВґs needs regardless his position, whether she/he is at home or in a an
institution. Palliative care honours and protects life. Dying and death are regarded as a normal
process; however, death is neither hastened nor delayed. It tries to preserve the maximum
possible quality of life until death (European Association for Palliative Care, 1998).
Hospice care performed in a hospice is one of the forms of palliative care. It means to
accompany the person in her/his terminal stage of life. No matter whether the hospice care is
provided in a special inpatient facility, in home environment or elsewhere, in effect it is still
a benefit to the whole society. To ensure this, the care has to be complex and all patientВґs
needs have to be met, application of the holistic approach.
Currently the provision of holistic services to the terminally ill in hospices in Slovakia is
neither diagnostically nor legislatively determined. The main indication is the patientВґs
adverse health that requires symptom control of the progressive terminal illness in the endstage. Hospices provide also respite forms of care.
We distinguish various forms of hospice care which can be divided into – hospice care in
home environment (mobile hospice), ambulances for hospice care, stationary hospice care
(hospice stationary) and inpatient hospice care.
Current state of palliative and hospice care in Slovakia
There are more than 5 million inhabitants in Slovakia. Life expectancy at birth in 2009 has
reached in men 71,27 years and in women 78,74 years. In recent years there have not been
any changes in the structure of mortality by cause of death in Slovakia (Report on the State of
Health in Slovakia, 2011). The most common cause of death is diseases of the circulatory
system. More than three quarters of deaths were caused by cardiovascular disorders (54, 8%)
and malignant tumours (22,5%).
The number of newly reported malignant tumours in the Slovak population rises each year by
more than 25 000. Almost 70% of all malignant tumours affect men and women aged over 60
years. Hence tumours present the second biggest cause of death not only in the Slovak
population, but also in all EU countries and throughout the whole European region (Report on
the State of Health in Slovakia, 2011).
The first department of palliative care was founded in the National Cancer Institute
Bratislava, led by MUDr. KriЕѕanovГЎ in 1995. Until 2002, Slovakia was the only Central
European country with no inpatient hospice facilities and only one palliative department. The
first Slovak inpatient hospice – Hospic Matky Terezy in Bardejovská Nová Ves was opened
in 2002.
Approval of the palliative medicine department concept including hospice care has
significantly moved forward the topic of care for the seriously ill and the dying. A step in the
positive direction came when; according to the decision of the Ministry of Health of the
Slovak Republic in 2006, it became a part of the national health policy priorities (SmoleЕ€ovГЎ,
2008).
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CLINICAL SOCIAL WORK (CSW)
Hospice care is organized mostly in home environment (in 2010 to the extent of 82%), the rest
is formed by hospice care in social welfare institutions and medical facilities for the long-term
ill.
Chart Nr.1: Overview of inpatient hospices in Slovakia
Founded in
Name of the hospice
Hospic Milosrdných sestier – Trenčín
Hospic Matky Terezy – Bardejov
Hospic pod VysokoЕЎpecializovanГЅm odbornГЅm Гєstavom
geriatrickým sv. Lukáša – Košice
Hospic Trstice a sluЕѕby sociГЎlnej starostlivosti
Hospic Hestia – Lučenec
Hospic svätej Alžbety v Ľubici
Hospic sv. Františka z Asisi – Palárikovo
Hospic - Dom BoЕѕieho Milosrdenstva - BanskГЎ Bystrica
Hospic – Dom pokoja a zmieru u Bernadetky - Nitra
Hospic HarmГіnia - SlovenskГ© novГ© mesto
2005
2002
2006
2003
2005
2005
2007
2008
2007
2004
Number of
beds
14
20
6
20
15
24
25
16
15
10
The provided services in hospices are funded from multiple sources – through the payment
from health insurances, the patient´s or the family members� payment on average 15 €/day,
through sponsorship from individuals and legal entities. Average costs for one day of nursing
in a hospice range from 50€ to 60€, while payments from health insurances range from 40 to
55% of this amount of money. Losses arising in hospices are covered mainly by founders and
sponsors and partially by clients, while the economic power of clients to pay extra for health
and social care in hospices is different within different regions of Slovakia. Costs for care for
the client of a hospice are voluntarily sacrificed sources for quality provision of this care
(VeselovskГЎ, 2011).
Conclusion
The current state of palliative and hospice care in Slovakia is not sufficient and it does not
respond to the patients’ needs. To be able to meet the recommendations of the Charter of the
Rights of the Dying, the recommendation of the Committee of Ministers for member
countries about the organisation of palliative care and the EAPC recommendation (European
Association for Palliative Care), it is necessary, through system and legislative changes, to
reach changes of the current situation. This is an issue within which we are trying to answer
questions concerning funding of palliative and hospice care, legislative questions, provision of
required education etc.
The basis of quality palliative and hospice care is offering of various forms of palliative care
that are connected and secure continuity of care and the patientВґs opportunities to choose the
place where they want to end their life. In Slovakia, the provision of health and social care for
the dying are not connected, insufficient education of social workers in the issue of dying etc.
To be truly included among developed countries, Slovakia has to provide care for the
weakest, the most defenceless – the dying.
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CLINICAL SOCIAL WORK (CSW)
REFERENCES
BARDEN I. - VOGEL A. - WODRASCHKA G. 2002. StarostlivosЕҐ o chorГЅch v domГЎcnosti.
Bratislava: VEDA SAV, 2002. 319 s. ISBN 80-88932-08-4.
BГЃRTLOVГЃ, S. - MATULAY, S. 2009. Sociologie zdravГ­, nemoci a rodiny. Martin: Osveta,
2009. 141 s. ISBN 978-80-8063-306-6.
European Association for Palliative Care [online].1998, [cit. 2012-20-8]. DostupnГ© na
internete: < http://www.eapcnet.org/about/definition.html>.
GLASER, B.-STRAUSS, A. L. 1965. Awarenes of Dieing. Chicago: Aldine Publishing, 1965.
305 p. ISBN 0-202-30763-8.
HAЕ KOVCOVГЃ, H. 2000. ThanatolГіgie. NГЎuka umГ­ranГ­ a smrti. Praha : GalГ©n, 2000. 191 s.
ISBN 80-7262-034-7.
KUTNOHORSKГЃ, J. 2009. VГЅzkum v oЕЎetЕ™ovatelstvГ­. Praha: Grada, 2009. 176 s. ISBN 97880-247-2713-4.
LITTLEWOOD, J. The denial of death and rites of passage in contemporary societies. In D.
Clark (Ed.).In The Sociology of Death. Oxford: Blackwell Publisher, 1993
PAYNEOVÁ, S. – SEYMOUROVÁ, J. – INGLETONOVÁ, CH. 2008. Principy a praxe
paliativnГ­ pГ©ДЌe. Brno: SpoloДЌnost pro odbornou literatГєru, 2008. 808 s. ISBN 80-87029-25-9.
SMOLEŇOVÁ, L. a kol. 2008. Vybrané kapitoly z paliatívnej starostlivosti. Trnava: Typi
Universitatis Tyrnaviensis, 2008. 98 s. ISBN 978-80-8082-197-5.
SprГЎva o stave zdravotnГ­ctva na Slovensku. Bratislava: Ministerstvo zdravotnГ­ctva SR, 2011.
240 s. ISBN 978-80-969507-9-9.
Е ERFELOVГЃ, R. 2011. Hodnotenie zГЎЕҐaЕѕe a kvality Еѕivota rodГ­n v paliatГ­vnej starostlivosti.
Profese online, 2011, roДЌ. IV/1, aprГ­l 2011. ISSN 1803-4330.
The quality of death. Ranking end-of-life care across the world. A report from the Economist
Intelligence Unit. [online]. 2012, [cit. 2012-20-8]. DostupnГ© na internete: <
http://graphics.eiu.com/upload/QOD_main_final_edition_Jul12_toprint.pdf>.
VESELSKГЃ, M. 2011. Paradoxy (nielen) hospicov. Bratislava: SlovenskГЎ katolГ­cka charita,
2011. 8-10 s.
Contact address:
Mgr. KatarГ­na SedlГЎrovГЎ
Katedra sociГЎlnej prГЎce a sociГЎlnych vied
FSVaZ UKF v Nitre
Kraskova 1, 949 01 Nitra
e-mail: [email protected]
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CLINICAL SOCIAL WORK (CSW)
THE PRINCIPLE OF JUSTICE TO THE PROCEEDINGS
Ludovit Hajduk
St. Elizabeth University of Health and Social Work, Bl. Sarah Institute Banska Bystrica
ABSTRACT
The theory of justice requires not only the formal considerations alone, but must also calculate
the ideals of substantive justice. Thus, the formal principles of justice (formal equality,
universality, reciprocity), as well as the ideals of justice (eg. solidarity, balance games tasks)
act primarily as a critical arguments themselves are not to guide our actions, or be constituted
legal-political programs. With this finding is in line before my claim that we are more able to
know what is unjust, than to justify equitable solution. Analysis of justice is inherently critical
analysis.
Key words:
A justice. Social justice. Proceeding. Universality.
Postulates of justice are always directed towards the entity capable of action. True, exit a
formulation of which is not directly obvious that the requirements are directed to the holder of
the procedure. We require, for example, fair wages and fair punishment. Obviously this is not
meant as a requirement that, in fact, directed towards an object unable to act. The requirement
of fair wages hopes that the company could also institutionalized forms of management and
distribution, which would be allocated for the work carried out as fairly rewards. The
requirement of fair punishment is reduced and the formulation means that the court has
determined punishment fit the criteria of justice and a powerful state apparatus to implement
it. Postulates of justice are fundamentally related to interpersonal relationships, t. j. principles
of justice; they want to determine the behaviour of one person against others. Again, although
we often use such formulations do not speak specifically about interpersonal behaviour, it is
difficult to know the structure of its own principles of justice and prove that they relate to
interpersonal relationships. He says, for example, often a person just or unjust, the just or
unjust institutions. A righteous man is obviously one that, in relation to other people act fairly,
equitable social institution is precisely when a fair relationship between the parties.
With the above - some indisputable - characters postulates of justice, that is directed
against persons qualified to act and relate to interpersonal relations, are correlated in the two
functions of the human being: (1) It is acting being, that their decisions can freely determine
their behaviour and life form and (2) is a social creature.
Ethical-anthropological way of approaching the problem of justice, as it considers
appropriate, is that we understand the postulates of justice in their role as determinants of the
proceedings and the content of the principles of justice, explain their function in society.
Conducts controlled understand information behaviour, attributed to the object, which
according to their purposes may intervene in the process. The process of processing
information in the decision to act and guidelines proceedings based on information about
facts: on the situation, causal lines, know - how and practical - we can also say attitudinal information. The core system consists of practical information purposes associated institution
of the proceedings. Acting is in addition to evaluate the relative ability of alternative
procedures. Analysis, aiming at providing a decision, respectively. programs of action that is
governed by the purposes and subject preferences, called "reflection on the utility."
For human action is typical that in addition to consideration of the utility to interfere with
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CLINICAL SOCIAL WORK (CSW)
even more determination moments: fixed intentions, autonomous standards heterogeneous
ideas and ideals of justice.
The bulk of these determinants, which approach the consideration of utility, the shape
function of human conduct with regard to community interests. In my opinion - and the
biology and ethology the concept confirmed - that these moments of social determination of
human action are already reflected in the slopes us as social creatures, not only products of
culture and education, but on the contrary: culture and acquired forms of life are based on
primary hereditary talents - for man, as with other organisms living in the communities.
The conditio humana is characterized by the fact that while man is never without a wellresearched biological tendencies - and therefore never value-free stance - but that the world
(living) creatures, as we know, has a unique array of free space for creating forms of life of
individuals and groups.
Not only is a single man living in the vacant spaces, but also institutions and
communities can be created by different, t. j. their character is determined by hereditary
program individuals who constitute the them, but they are only partially determined. This
view is a significant difference between swarm bees anthill or herd of wild animals and
human society.
Regulative and normative social ideals are always focused on social relationships.
Autonomous moral norms determine individual human behaviour with regard to the role an
individual plays against neighbour. Heterogeneous regulations of coordinating human
coexistence.
What is the general ethical-anthropological reflection on the concept of the
proceedings and the social nature of human existence theory of justice? Particularly this:
(A) The principles and ideals of justice are partly biological and partly cultural components
profound determination procedure. (B) The idea of justice, respectively. ideals of justice,
although some profound way, and biologically, are widely formable. Where exactly is the line
between irreversible and modifiable, it cannot easily find. The inheritance can be modified by
cultural influences. (C) With regard to value systems, one is never a tabula rasa. The same
applies to our fair spontaneous reactions and evaluations of human behaviour or institutions as
fair or unfair. It is empirically provable psychosocial well that every human individual has a
consciousness and develops ideas about justice. Social groups are a social justice values and
ideas. (D) theory of justice can count on the existence of the so-called sense of justice, but has
a clear role for him conceptually identify and cultivate their analyzes. Must ask for feelings of
justice, rationalize and adapt their current conditio humana. Therefore deals with the problem
of rational argumentation in matters of justice. (E) Justice is a moral issue and rights issue.
The interplay of morality and law from an ethical and legal-philosophical point of view is
essential because it is on one side of it, fairly autonomous action to create an entity with
regard to the neighbor on the other forms of institutionalization of fair society. Both
considerations of justice are complementary: they are not substantively equal. In addition, the
analysis of moral justice to the questioning of a different perspective than the legal-political
reasoning: moral - theoretical reflection is dominated by the question "How do I do?" A
behavioral assessment of neighbors, there is only a secondary place, in terms of legal policy
against the currently the primary institution for fair and equitable assessment of individual
relationships in individual cases should be seen by the general social aspects.
If the postulates of justice interpreted as determinants of the proceedings, it is easy to
understand this proposition: Issues of justice always act in addition to considerations of
utility, the ideals of justice work together with analyzes of the utility regulatory and
normative. Ideals of justice to exclude certain means and methods of procedure. Normative
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CLINICAL SOCIAL WORK (CSW)
regulations of form in the spirit of certain notions of justice are critically tested in terms of the
ideals of justice. Response of the individual or company to determine the results of
consideration of utility and justice. If I see correctly, as most theories of justice establishes the
principles of justice as absolute requirements that are divorced from all other moments and
conditioning procedures are strictly sentinel before all other determinants of action. Visibly
separates himself from the issue of fairness and motivation of action institutions (Rawls,
1995). I, however, consider that an adequate conception of the ethical and legal philosophical argumentation can be reached only if we take into account the dialectic
interplay analysis ideals of justice and utility. Justice itself is not viewed by me regardless of
the question of motivation.
If we use this analytical approach, the question arises, what is actually postulates of
justice differ from the time of setting goals that emerge in considering the utility. Then the
system does not coincide with the social purpose of the principles of justice? This question, in
my opinion can not be easily answered. The boundary between the utility and legalphilosophical postulates on the one hand and the ideals of justice on the other hand is not
about to set out very clearly. This relationship can be roughly explained as follows: The ideals
of justice are concepts that are understood as benchmarks and limits utilitarian considerations,
experience teaches that such an individual as well as the most diverse social groups actually
have ideals of justice, which does not coincide with the utilitarian goals, and on the one hand,
imply a limitation of available funds to achieve these objectives and on the other hand, as a
considerations, which in addition to dedicated analysis evaluates designed solutions. The
social setting of targets, economic and other practical objectives are the primary framework
and institution-building activities. Creating community facilities and sets out policies to
achieve the purposes of utility - not primarily because of righteousness, no way to achieve
these objectives are also limited by the ideals of justice.
The theory of justice requires not only the formal considerations alone, but must also
calculate the ideals of substantive justice. Thus, the formal principles of justice (formal
equality, universality, reciprocity), as well as the ideals of justice (eg, solidarity, balance
games tasks) act primarily as a critical arguments themselves are not to guide our actions, or
be constituted legal-political programs. With this finding is in line before my claim that we
are more able to know what is unjust, than to justify equitable solution. Analysis of justice is
inherently critical analysis.
General terms of analysis of justice on the one hand, certain formal criteria, on the
other hand, also postulate to ensure fair use of a normative order.
The formal principle of justice should be the same relevant conditions set the same legal
consequences. Perelman defines justice as the principle of formal proceedings, under which
the natures of the same category of being to be treated equally (Perelman, 1967). As can
easily show that this principle is equivalent to the postulate that the juristic assessed according
to general rules. In my above-mentioned formulation is contained in the relevant binding
conditions some fashion the decisive moment, which means that the principle is substantively
empty and bear with each ethical concept. Logic is not surprising, because he knows that the
formal principle of principle can not provide any content gauges. It forces us is relevant
conditions and the associated legal implications make explicit. This simplifies the assessment
base and exposed to criticism. Neither PerelmanВґs formulation, this principle does not give
any explanation of what content is fair, because the categories of substance, as well as legal
consequences remain uncertain. The term category of substance, as used Perelman, there is no
ontic givenness, but remains with the producer standards to determine the class. Again - that
is to say the postulate of formal justice - it seems critical reflection on the nature of justice and
their dependence on the assessment of attitudes.
The principle of reciprocity is a postulate of justice, which comes in various formulations.
Prima facie, it seems to be explained as an inverse relationship equality: equality (or equal
value) and return requires performance, equity mutual rights and obligations of stakeholders.
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CLINICAL SOCIAL WORK (CSW)
In this form it appears as a formal principle of justice. However, I have good reasons to doubt.
As a formal principle would have to have universal validity. Not for any relationship between
people, however, apply the reciprocity requirement. I think it only applies to those relations,
which we refer to as "partner". The principle of reciprocity is therefore not a formal policy.
Content-postulate of reciprocity is applied by the material the values of the decision or for the
need, require the reciprocity, further, that the kind of equality must be specified: exactly the
same work, same power output and return requires, equal willingness to help and so on.
Equivalence of mutual performance is not strict equality, but - according to circumstances the same highly differentiated values.
It seems appropriate not to consider the issue of reciprocity as a type of formal principles of
justice, but as one of the problems of relations tasks. The partnership, however, apply the
postulate of reciprocity in terms of equivalence to the tendency of mutual attitudes and
performance partners. A big role in the theory of justice, ethical universality plays,
respectively. Universality. If only requires universality of normative rules is equivalent to
postulate the principle of formal justice. To understand the versatility and admit only the
formal subsumption of any differentiation, then this postulate does not imply any restriction
on the admissibility of the contents of normative rules: not therefore any assessment criterion
of justice. Universality is often understood that the postulate of universality is understood as a
requirement "makes no difference," or at least as a presumption of equality - perhaps sharing
the same parts - when there is no reason for differentiation. Consider, however, that
evaluation is necessary decisions, in which groups of people have relationships as equal pay,
and which differentiated. Then actually growing from unrestricted universality of
differentiation. A principle of universality is not absolute, but relative to differentiated
conditions laid down by every normative order.
Hare at all considering how Universalisation of a constructive character a rule. In my opinion
this is a rather difficult concept. It is inappropriate to bind the basic semantic setting - here a
rule definition - the conditions that characterize the right to - be. In HareВґs concept is
problematic, as is to be understood universalization of individual standards. For example.
"You have to pay to Mr. N. 100 Euros. " How has this individual a rule universalism?
"Anyone who is identical with you, to Mr. N. to pay 100 Euros, pseudo-universality. If,
however, universalism other characterizing features of the recipient, so it may be entitled to
time and sometimes undue universalization. "Anyone from Mr. N. borrowed € 100, is ... "-"
Anyone who lives in this apartment has ... "assuming that both terms refer to one and the
same person. Marker functions can be broadly the same fact, but strongly different. Not every
feature indicating the results substantiated universalisation. Universality can pay as a criterion
of justice only if we use the term in a manner that corresponds to Kantian formulation, ie if
we ask, or may want to (want to, it is considered a good and fair), as applied to a universal
rule. Assessment in terms of general considerations only a physical justification, when
acceding to the substantive position of Kant expressed through want - can. The mere formal
criterion is not universal, however, sufficient basis for judgments about justice.
The analysis draws on the source material justice, their arguments? Some authors are involved
in some way natural law. I think it can only lead to an apparent argument, because the
principles of natural law would have to be objectified, that is, of course, can not succeed. But
we actually believe in justice and the ideals of justice, which is available to every community
and every person. (Talking about the existence of the same "feeling for justice.") Must
recognize this fact and value relativist. As arguments about justice beliefs play analogous role
as the so-called principles of natural law, but with the difference that act only as opinions that
can and should be criticized.
Positivist in my opinion a very good chance to make a rational analysis and evaluation of
justice, may be based on beliefs about fairness and their content may be the case. as well.
support the anthropological research. In addition, it highlights the importance of political
postulates of fair use rights, which in the context of the theory of justice is no minor point
12
CLINICAL SOCIAL WORK (CSW)
value. The most important postulates of justice in terms of ethics and law:
(A) must be based on the true findings of fact. Postulate is correct findings of fact, banal and
obvious requirement. But who has abused the sight of their legal systems pseudo-process and
who knows the problems of proving the fact of ethical and legal practice, he will accept this
postulate as the basis of justice and will not underestimate its importance.
(B) Implementation of the postulate. Ethical rules are not only legal basis for value
judgments, they are also statements of the case: rational relationships for ethical and legal
implications need to enforce in practice. (C) Postulates of procedural justice. Although the
theory system-relative justice is very important to set postulates a process of justice. Their
reasoning is based on our belief that an adequate organization's ethical and legal proceedings
to maximize the probability to reach a fair decision. The principles of procedural justice,
respectively. Our beliefs about the appropriate ethical and legal organizations, processes and
impact of organizations on the likelihood of substantive justice decisions should be subjected
to empirical verification, although it is not so easy, so it is rarely implemented.
Communities do not rely solely on factual coexistence, but also to the fact that in some way
come into structured forms that depend on the assessment and the expectations. Each
individual or group in the community have a role, as determined by normative regulatory. The
role is a complex of ideas and expectations arising from the roles and responsibilities, the
demands and expectations of action and adaptation.
Roles are social realities in which we enter automatically or volitional acts. We have
automatically nationals, members of the association or the spouse by a specific volitional act.
Man creates his play roles in part to the relatively free choice, or may modify the types of
institutionalized role in the development of their specific relationships.
The existence of communities and the roles are always linked to issues of justice. Each role is
bound up with specific responsibilities, expectations and ideals of justice.
Plays a role as a social institution is subject to the assessment of justice. The role and its
corresponding evaluation are determined by social function; cf. ethos doctor, judge, teacher,
social worker, and labourer. Issues of justice are concentrated on the balance of power and
return requires partner roles. When there is this balance? I think there is no single answer. In
some cases the kind of equality, for example. if you two promise each other farmers to help
each other at harvest. Sometimes there is no real equality of performance, but the same
willingness to meet, for example. Willingness of siblings to help in an emergency. Often a
kind of equivalence of inequalities in material performance and return requires such. The
exchange or buying and selling. Assessment of equivalence is a relative value judgment is
therefore dependent on the subjective attitudes, but with significant substantive restrictions.
They can also give a good, reasonable argument for the evaluation and value judgment will
depend on institutionalized practices, particularly in those cases where there is a relationship
which may be institutionalized roles (eg, marriage, games, and different forms of economic
cooperation).
Roles which constitute the agreement of the partners are governed by more or less firmly
institutionalized types (cf. marriage, business or association). The criterion of justice in the
individual case there is essentially institutionalized ethos or a match, which specifies a
framework of institutions. The institutionalized forms can - according to the agreement or the
situation - and make other than normal balance performance. It belongs to the conditio
humana, the question of the balance task is always open to discussion as a problem of justice.
The various communities are linked collective action, consisting either of that act together, or
that the officer acting as a community, t. j. set acts on behalf of the community. You are
required to act solely as an authority by the Community interest. Since his own interests are
usually partly coincide with the interests of the Community and in part to deviate from them,
there is a command official, track interests, not their personal interests. It's about the plight of
the proceedings creating standards.
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CLINICAL SOCIAL WORK (CSW)
REFERENCES
Blaha, ДЅ. 2001. Rawls and socialism: the search for alternatives to capitalism, the task today.
(Rawls a socializmus: hДѕadanie alternatГ­vy kapitalizmu Гєlohou dneЕЎka.) In: Slovo, 2001, ДЌ.
22, s. 16.
HABERMAS, J. 1999. Catching up revolution. (DobiehajГєca revolГєcia.) Bratislava, 1999.
HARE, R. M. 1973. Freedom and Reason. (Freiheit und Vernunft.) DГјsseldorf, 1973.
HARE, R. M. 1981. Moral thinking. Its Levels, Method and Point. Oxford, 1981.
PERELMAN, Ch. 1967. Justice. New York, 1967.
RAWLS, J. 1995. A Theory of justice. (Teorie spravedlnosti.) Praha, 1995.
VERDROSS, A. 1971. Statistical and dynamic nature of law. (Statistisches und dynamisches
Naturrecht.) Freiburg,1971.
Contact address:
Doc. Dr. ДЅudovГ­t Hajduk, Ph.D.
St. Elizabeth university of health and social work
NГЎm. 1. mГЎja 1
810 00 Bratislava (Slovakia)
e-mail: [email protected]
14
CLINICAL SOCIAL WORK (CSW)
YOUTH UNEMPLOYMENT AS A SOCIAL PROBLEM
Radoslav Michel
SP. Elizabeth University, Branch of the Queen of Peace of Medjugorje in Bardejov,
Slovakia
ABSTRACT
Young people after leaving school often in my life experienced by pocity social
uncertainty (concern) of the future that require the immediate involvement of young
people into work, which is for their personal identity ,,gateway“ to the world of
adulthood (responsibility). Reducing the labor of young people is a huge loss to the social
system of each country.
Key words:
Unemployment. Youth. Social work. Start clubs. Social assistance.
Introduction
Employment is one of life's irreplaceable position. It is an important condition for the
existence of decent, he brings not only material benefits, but it also gives him a sense of
fulfillment.
High unemployment has particularly adverse effect on the inclusion of young people
into work, such a group is the young generation, therefore graduates. Loss of job or inability
to find a job, a person can be reached at different stages of life. For the unemployed, it is
crucial to keep him in work habits and create the need for work.
It is important to know in what conditions and options coming graduates. These conditions
and options are often different, but generally can record similarities, which may, for example.
that is currently the burden on the necessary measure of enforcement. It is expected that he
will gradually be able to work with your application deal mostly alone.
Occupation (job) is for young people and a wide range of social relations through which they
create a space for self-expression and self-confidence. The company operates through the
creation
of
certain
important
values
that
are
the
result
of
work.
Graduates in the labor market are unemployed vulnerable group because of their lack of
preparedness and lack of practical work habits. It is very necessary to increase the number of
young people who are given the opportunity to apply their skills in first job. One has to
constantly adapt to change, which brings life and times in which it exists. In the past we had
with each person on the right job. On the one hand it was feeling kind of ,,social security”, on
the other hand, this meant suppressing competition in human society.
The importance of work for each person's life is undeniable, as is its integral part.
Work by nature stimulates the development of the individual. The work has a strong social
character, is carried out in a specific socio-cultural environment, causing social consequences.
For this reason, unemployment in our society adverse problem which inherently affects also
some families. This relates to the central role of work and employment in our society in which
we live. Job loss means the deprivation of basic needs that job and work directly or meet their
satisfaction is closely linked to them. In many cases, the wrapping, ,,snow ball” with one
problem causing another, for example. economic problem in humans can cause adverse health
problems.
15
CLINICAL SOCIAL WORK (CSW)
Young people faced with unemployment
Unemployment is a socio-economic phenomenon, coupled with the existence of the
market, in particular the labor market. It represents the result of a parallel speech imbalances
in the labor market, and the supply and demand for labor (Rievajova, Stanek, Krausova,
1997).
Juva (1994) states that youth is a stage of life in which there is significant biological,
psychological and social changes. It is usually specific, like childhood. We can therefore say
that youth is historically embodied social phenomenon of human society. Youth under the
general social ideas is a special single phase life who needs a social space free. Youth and
young generation can thus be defined as ,,a term referring to more or less vaguely defined age
group or social category defined by specific biological, psychological and social
characteristics”, which fall into the secondary school and university.
MicheДѕ (2010, p. 90) draws that ,,occupation (job) is for young people is very important part
of their personal identity and socialization. Everyone has the need to be a full member of
society and create some goods and services. Occupation (job) is for young people and a wide
range of social relations through which they create a space for self-expression and selfconfidence. The company operates through the creation of certain important values that are
the result of work.”
Jandourek (2001) draws the younger generation is attributed to ,,significant role of social
organization characterized as a progressive development entity.” And this generation as a
social group in a few years will determine our future. But now the real part and can actively
influence events in society.
High unemployment has a negative impact on the inclusion of young people into work
(school leavers). Loss of job or inability to find employment, the man reached in various
stages life. For unemployed young people is very important to keep him in work habits and
create the need for work. The process of assigning young people into work and related
problems are, among other things, a reflection of how the school was ready to enter the
workforce.
For most barriers in the labor market that prevent graduates find jobs, are considered:
- inadequate education;
- lack of experience;
- lack of knowledge and experience working with PC;
- ignorance of foreign languages (http://www.prohuman.sk/social work/unemploymentyoung-people-graduates-ascurrent-socia-problom-society).
Young people are one of the most vulnerable groups in society who may be most affected by
changes in modern society. Social discrimination and marginalization are not in Western
European countries is nothing new and is increasingly becoming a part of their symptoms and
life our company. Economic and social uncertainty leaves a growing number of young people
whose lives are marked by the uncertainty of the future. The young people's social ties are of
paramount importance bonds of friendship. Youth more emphasis on fashion apparel, which
is indeed a natural and appropriate to their age, but it should not take precedence over the
values of the inner qualities of the young man's personality. If thus demonstrating quite strong
effort for the average youth material support to realizing the importance of values education
and employment should be seen and those attitudes which are indicative of the unwillingness
to engage the public affairs.
We can not underestimate the impact of information that can significantly affect the life of a
young person, particularly his success in the labor market. Great importance is the role youth
information centers, where the system of providing information and advisory services,
account criteria anonymity to accepting a personal integrity of a young man. They place a
young person's direct contact with the information in this age is for him the price of gold.
When will mesh with appropriate counseling assistance can be a very effective tool for direct
assistance (Rimoczyova, 1994).
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CLINICAL SOCIAL WORK (CSW)
Rievajova, Stanek, Krausova (1997) states that unemployment and length of unemployment is,
inter alia, with work experience. At the end of each school year, the Council extended the
unemployed graduates, because lack of experience quickly reduces their chances for
employment in a competitive older more experienced workers.
Important advice for young people to find work
The important advice that can be given to young people to find work include:
- nobody owes you a job. If you want, you have to give it a look and - without compromise
success in finding a job depends on the effort;
- second you have to be mentally and financially prepared for the job search takes longer
than you think. Shortest periods ranges 2-18 weeks depending on various factors. Decide
the type of work on what you like, where you live, your age and the state of the economy
in the region;
- efforts until you find work. Perseverance is the key to success is to send your
resume to the employer by e-mail, then a letter and a copy of his last, week by phone;
- if you know what type of work you are interested in, tell everyone you know what it is.
You will also get another pair of eyes and ears that can find a job for you;
- forget what offers are in newspapers, on the web, etc. Find your kind of job, what you
want most;
- if you want to speed up the process of job search, focus on a number of different
organizations. Restrict ourselves to only two or three institutions will almost certainly
mean failure;
- think of the possibility of adopting a different kind of work than that for which you have
qualified (Bolles, 2004)
Principles of Social Work with unemployed
Social work builds on the knowledge of several social sciences (psychology, sociology,
pedagogy) and applying scientific knowledge to practical work. It deals with the optimal
functioning of social institutions designed to care, security and assistance to individuals,
groups or communities. The term social work is used to describe methods of preventive,
corrective, curative helping people. From the initial economic aid, realized in the 19th century,
social work extends particular social component.
(http://www.socionet.sk/index.php?kat=009&opn=opn&tit=00029).
,,The existence and development of human society is associated with various forms of social
relations. Every form of community from the earliest times until today, creates a space for
action to move relations in the community and also affect the functioning of the various forms
of mutual assistance. Activities, actions that lead to the development of man, his way of life, to
improve living conditions (unemployed young people), ... called social policy” (Hanobik,
2011).
Social assistance must take into account the specific situation of the unemployed. There must
be a support resource. These are the resources offered by government organizations in the socalled. active employment policies: the employment offices, job clubs, counseling centers.
Other resources offered by non-profit sector where to find opportunities for leisure time
unemployed, etc.
Social work services in fulfilling this target group (the unemployed) two basic functions: they
are vital for coping with the immediate consequences of unemployment: physical,
psychological and social deprivation. Unemployment has a negative impact on the psyche,
self-esteem, relationship with partner, and so on. Social work services are important to help
the unemployed back into the labor market.
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CLINICAL SOCIAL WORK (CSW)
Complex social services should have at least the following elements:
- social work in areas - motivation socially excluded socially oriented in various projects and
activities;
- basic counseling and follow-up in the public employment services: group (job clubs).
Furthermore, information centers to eject from office work, for example. in community
centers;
- preparation for employment - that focus on the labor market, training in social skills, etc.
Are very important information and counseling centers that have club character. Their mission
is to help those looking for employment longer. A common feature of these people is
unemployment and actively attempt to solve this problem. Programs such as job clubs aimed
at obtaining and maintaining these skills, using effective job search techniques, resume and
the ability to prepare a letter of motivation to learn how to act convincingly in admission
interviews, a realistic view of their own position in the labor market, maintaining social ties,
etc.
Starts clubs operate on the same principles, but are aimed at graduates unemployed and
without experience. These clubs are currently also founded the nonprofit sektoru (Kodymova,
Kolackova, 2005).
Conclusion
Graduates in the labor market are unemployed vulnerable group because of their lack
of preparedness and lack of practical work habits. It is very necessary to increase the number
of young people who are given the opportunity to apply their skills in first job.
The importance of work for each person's life is undeniable, as is its integral part.
Work by nature stimulates the development of the individual. The work has a strong social
character, is carried out in a specific socio-cultural environment, causing social consequences.
For this reason, unemployment in our society adverse problem which inherently affects also
some families. This relates to the central role of work and employment in our society in which
we live. Job loss means the deprivation of basic needs that job and work directly or meet their
satisfaction is closely linked to them.
In many cases, the recruitment of ,,snow ball” with one problem causing another, for
example. economic problem in humans can cause adverse health problems.
Unemployment is now a very serious problem. It has negative effects on the complex biopsycho-social aspects of personality. This is often the interconnection of various health and
economic problems that lead unemployed individuals to different feeling of resignation and
despair. It is essential that young unemployed people give up and tried to deal with their
situation immediately without undue prolongation of their unfavorable social situation. Young
unemployed people must try to make sense of life through vigorous life Е„tГЅlu, which in itself
will contain an active and meaningful use of leisure time and full-scale implementation of
activities that will contribute to the effective development of personality (self-esteem,
self-fulfillment, a sense of dignity and recognition).
REFERENCES
BOLLES, N. R. 2004. Ako si nГЎjsЕҐ dobrГЅ dЕѕob. 1. vyd. Bratislava : MotГЅДѕ, 2004. 144 s.
ISBN 80-88978-99-8.
HANOBIK, F. 2011. Гљvod do sociГЎlnej politiky. Bratislava : VysokГЎ ЕЎkola zdravotnictva a
sociГЎlnej prГЎce sv. AlЕѕbety, 2011. 164 s. ISBN 978-80-8132-019-4.
JANDOUREK, J. 2001. SociologickГЅ slovnГ­k. Praha: PortГЎl, 2001, 285 s. ISBN 80-7178-5380.
JЕ®VA, V. 1994. Гљvod do pedagogiky. Brno: Paido, 1994, 130 s. ISBN 80-901737-6-4.
KODYMOVГЃ, P. - KOLГЃДЊKOVГЃ, J. 2005. SociГЎlnГ­ prГЎce s nezamД›stnanГЅmi. In: SociГЎlnГ­
18
CLINICAL SOCIAL WORK (CSW)
prГЎce v praxi, 2005. s. 306. ISBN 978-80-7367-331-4.
MICHEДЅ, R. 2010. NezamestnanosЕҐ mladГЅch ДѕudГ­ ako sociГЎlny problГ©m : rigorГіzna prГЎca.
Bratislava : VЕ ZaSP sv. AlЕѕbety, 2010. 101 s.
RIEVAJOVГЃ, E. - STANEK, V. - KRAUSOVГЃ, A. 1997. TransformГЎcia sociГЎlnej
sféry v Slovenskej republike. 1. vyd. Bratislava – SPRINT, 1997. 206 s. ISBN 80-88848-164.
HANOBIK F., Introduction in to the social Policy. 2nd. Ed., SEUC. Bratislava, 2012,
pp.166
RIMГ“CZYOVГЃ, K. 1994. MlГЎdeЕѕ v konfrontГЎcii s realitou dneЕЎka. In: Slovensko v 90.
rokoch: Trendy a problГ©my, 1994. s. 262- 264. ISBN 80-85447-05-3.
NEZAMESTNANOSŤ MLADÝCH ĽUDÍ ,,ABSOLVENTOV“ AKO SÚČASNÝ SOCIÁLNY
PROBLÉM SPOLOČNOSTI. [online]. [cit. 05. 11. 2011]. Dostupné na
internete:ttp://www.prohuman.sk/socialna-praca/nezamestnanost-mladych-ludi-absolventovakosucasny-socialny-problem-spolocnosti.
SociГЎlna prГЎca. [online]. [cit. 04. 10. 2012] DostupnГ© na internete: http://socialnevedy.studentske.eu/2008/10/socializcia.html.
Contact adress:
PhDr. Radoslav Michel
e-mail adress: [email protected]
19
CLINICAL SOCIAL WORK (CSW)
VIDEO TRAINIG USE IN TEACHING COMMUNICATION SKILLS
Е ГЎrka TomovГЎ, ДЅubomir Е tД›pГЎnek, Anna ГЃrpova
1
2
Department of Nursing, Charles University, 2nd Faculty of Medicine, Prague
Institute of Scientific Information, Charles University, 2nd Faculty of Medicine, Prague
3
ST. Elizabeth University College of Health and Social Work Bratislava, Slovakia
ABSTRACT
This report is focused on the meaning of the communication training and communication
skills in present medical care. The request of professionally managed communication with a
patient is a part of rating the quality of the medical care. The preparation of imbibing the
communication skills among the upcoming doctors may be very important element at the
beginning of their professional career. Suitable and effective methods of teaching have a
massive effect on imbibing and deepening the trust among the doctor and the patient. Practical
training by a role-playing method and the analysis of the videotaped situations i some of the
most effective method of all communication teaching methods. It comes from the student’s
Leeds during the effective teaching process.
Keywords:
Communication. Communication skills. Soft-skills. Social interaction. Video-training.
Introduction
The social interaction is essential pillar and starting point in interpersonal contact.
According to the dictionary of foreign words is given interaction as interaction between two
or more agents. Social interaction is seen as a basic way of social behavior, perception,
cognition and self-awareness, communication and interaction between at least two people. So
it is always about people and their relationships to other people.
Communication is indispensable part of the mutual contact between people. It is an essential
component of mutual communication. ItВґs complicated and multi-layered process. It is
influenced by many factors among others for example by person´s individualism – his
upbringing, education, experience, skills, etc. The ground of this is biopsychosocial trim man,
indeed it is different by development, perception, hereditary predisposition, progress of
communication skills, education in family and by the way in which is it realized. Currently,
the concept of communication overused. Today, the word communication hides many
concepts that are disappearing and suppress, there are much lower frequency of words chat,
talk, debat, yarn, tell, share information, experiences and so on. Today two people simply
communicate. (LinhartovГЎ, 2007)
Proper text
Communication in health care is a topic which is still in the foreground of the lay and
professional public. The level of communication is a part of quality investigation in health
service. Not for nothing there are some questions in research of patientsВґ satisfaction with
nursing care in a facility dedicated to just the patient view on communication between other
members of the nursing team, to inform the patient about the course of treatment,
intelligibility of given information, adequately chosen language, etc. This interest in recent
decades relates not line with the concept of the patient as a partner in the nursing and medical
care and then for a change with accessibility to patient.
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CLINICAL SOCIAL WORK (CSW)
Between the basic concepts of communication, which significantly in nursing care come
into the foreground, pertain understanding and understanding. These terms of communication
and communication skills we rank among so-called soft skills. Soft skills relate how to work
together, not what to do. WHAT to do concern professional level, HOW to co-operate
concern a personal, human level. This level is influenced by many factor, such as how to get
along, how we fell, how we think, what is our value system, our motives, rituals, needs, etc.
Hard skills which include linguistic, logical-mathematical, usual spatial forms can be
measured by test of intelligence quotient (IQ). In contrast, soft skills are skills involved in
interpersonal relationships, but also how we are willing and able to work on ourselves and
that we are looking for opportunities for personal growth. (MГјhleisen, Oberhuber, 2008)
Our attitude towards soft skills can be divided into imaginary three areas
-
The area of personal skills
The area of social skills
The area of methodological skills
In the area of personal competences include for example the following components: selfconfidence, self-assurance, self-control, self-reflection, orientation to the goal and the result,
willingness to change, to learn, to self-motivation. In the area of social skills include the
following components: the ability to build relationships, contacts, the ability of integration
and teamwork, empathy, ability to motivate, lead, resolves conflicts, tact and style. In the area
of methodological competences there is for example ability to present and creatively solve
tasks, rhetorical skills, the ability to persuade and discuss terms, ability to process
information, visualize or ability to properly handle the time and realize that the day has only
24 hours.
The above areas and the emerging effort students up to personal development and growth
led us to the idea of elaborating a subject communication training medical students. For
communicative competence is as a dictionary of foreign words considered understanding
verbal and nonverbal interaction, different types of verbal expressions and written and printed
texts and records, images, usual used gestures, facial expressions, pantomime, sounds and
other media, thinking about them, adequate response on them and their suitable and
reasonable use for their own truthful and cultured expression and participation in social life
and events. The skills we consider for those whom the doctor should rule in nursing care.
Except the above mentioned communicative competencies is an integral part of medical
professionalism as well as social and work competences. These build on previous and applied
mainly in skills effectively, efficiently and politely cooperate in a group, adapt adequately to
his position and role in the group, positively affect the quality of collaborative work, exercise
effective work activity and creative efforts in their own business activities.
Communication in medicine is an area that, among many other aspects has a larger dimension
than communication generally conceived. An important role is played by a change in health
status of individuals with which communication takes place. Communication is the art of pass
words so that the other person understood what we had to say to understand our purpose. It is
necessary to state briefly and concisely communication scheme, according to which
communication takes place. At the beginning of the intention, the intention of which speaker
has. It pools the most appropriate communication channel, which would have made its
intention to pass the information to be processed. After then the recipient receives the
message. Differences in income information mentioned above. Recipient information
according to their capabilities and gives the speaker receives feedback. This process is
repeated several times during the communication. In short, described the transmission of
information is a very simplified description of the process of challenging the perception and
acceptance of the other individual. Of course, it's not just a form of verbal transmission of
information, but is equally represented a form of nonverbal communication and paralinguistic
21
CLINICAL SOCIAL WORK (CSW)
expressions of mutual communication. Given the breadth and importance of communication
is very wide, we look for our purposes only verbal communication, specifically on drilling
two most important communication skills, occurring mainly between doctor and patient.
The relationship between doctor and patient is in health, hence the nursing care, the basic
relations. Medical profession is the only one with which he meets every man in your life,
everyone becomes a patient. When our health is compromised and the current state of the
deviation from normal, begins each of us to realize its importance and value. Perhaps for these
reasons, we expect powerful and flawless healing, infallible and helpfulness filled with
medical approach, which in moments of tension and uncertainty examine under a microscope.
We expect the doctor's listening to our concerns, the ability to choose the correct and effective
words, his verbal resonance next to the most effective methods of therapy. Just good
communication skill of doctors consider for granted. Only a misunderstanding of all kinds
makes us reflect on this "non-obviousness". Nothing is self-evident, it is necessary to cope
with doctrinal part pertaining to the professional communication. (HaЕЎkovcovГЎ in PtГЎДЌek,
2011). At present, the doctor prepared during his studies mainly on the ability to heal, to know
and to choose the right method of treatment, asses and analyze the test results and think
logically about connectivity and related symptoms. At the expense of clinical skills is often
suppressed perception of humans as individuals, which the doctor learns to join the practice.
We ask ourselves whether this perception and acceptance of diversity of individuals should
already be part of the professional preparation of individuals to track the medical profession.
Due to the momentary representation of communication and teaching communication skills to
medical school, we believe that this issue deserves more attention.
When teaching communication skills we start from the needs of the student in the teaching
process, which is necessary for the successful acquisition of skills or qualifications. The basic
needs of the learner include humans as Petty explanation. Why the above procedure is used to
explain the student's understanding of the basis for further. If using procedures that do not
understand, do you often feel insecure. The explanation we should be familiar with all
relevant contexts topic. As stated Petty, "Learning without understanding is superficial."
(Petty, 2008). As further stated, among other needs resulting from the student teaching
process include the following example, activity, active, and repeat testing. In the
demonstration, a student feels the need to know exactly what is expected of him, as it is best
to do, how to use their skills or capacities correctly and on what occasion they can utilize.
Most students considered practicing law and practical skills for the use of the most effective
method of learning. Practicing skills in the educational process takes disproportionately more
time than any other activity. This aspect of the didactic point of view in teaching
communication skills to medical schools generally neglected. The need for "testing" is
another need for a student who completes the efficiency of the acquired skills. Demonstrate
ability or skill in a situation where it is close to a teacher, mentor, etc., is easier to manage
than skill alone / and, under normal conditions. This last step to mastering the skills or
competence in our case in a clinical setting is the most important. This step alone can assess
the student in the practical part of their training. Can assess in communication with the
patient, how is ready to handle unpredictable communication barriers and apply their acquired
communication skills.
For the above reasons, we have focused in teaching elective course called "Communication,
communication skills" on the effectiveness of using video methods in practice "active
listening" and "transfer of information" for students in master's degree program of General
Medicine at Charles University, 2nd LF. We chose elective course in the absence of a separate
subject, dealing with communications and basic communication skills in the program above.
The optional course we had the opportunity to examine and monitor the progress in the
development of the above mentioned two communication skills of medical students. The most
appropriate method of assessing progress in the development of communication skills, we
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CLINICAL SOCIAL WORK (CSW)
appeared to video situation, which detail captured each chapter of the observed situation. At
the beginning of the course, students had the chance to review and understand the importance
of these communication skills - active listening and communicating information on the
example of a prepared interview "a doctor with the patient" in the model classroom. Role of
the doctor and the patient were depicted by experienced students from higher years of medical
school, who have demonstrated experience in managing the monitored communication skills.
This interview was conducted in accordance with the predetermined scenario that both actors
got ready in advance and who was consulted with the teacher.
Respondents who participated in teaching, following the example of seeing a sample prepared
dialogue characteristic of them unknown diagnosis. The choice diagnosis was completely
random, so assumed to provide sufficient time period to prepare the topic. Entering the
student was quite clear - search and process all the information on the prevalence, incidence,
symptoms, diagnosis, treatment and prognosis of the disease so that the student is able to
transmit and explain to the patient, eventually family member. This element of unknown
diagnosis has become very effective in the preparation of training because not only supported
a separate preparation, but also the search context with already acquired knowledge and skills
of the student. It encourages the student to increase their motivation to study. The patient's
role was cast colleague from higher grades or completely unknown to the participating
students who were previously familiar with the scenario of their role. During the course was
created about 10 minutes of video communication situation of each individual. This video was
repeatedly made at the end of the course, ie the end of the semester of the academic year, as
the number of hours of teaching a one-semester elective course. Differences between the
video recordings of communication skills at the beginning and at the end of the course each
student were recorded in the pre-prepared forms. Evaluation was students themselves, who
observed the performance of each individual - and fellow recording performed during or
immediately after the output. Performance evaluation was carried out in two categories. The
first category consisted communication skill "Active listening", which was divided into verbal
labeled I / A subchapter encouragement, clarification, mirroring the content plane, mirroring
feelings, summarizing and feedback and non-verbal part, labeled I / B, presented subheads
maintain perspective , posture, gestures, facial expressions, touch & movement, distance. The
second communication skill, "Communication" was also divided into two sections. Marked
subchapter II / A included monitoring of brevity, conciseness, clarity, transparency, continuity
of speech, choice of technical terms, working with voice and feedback. Marked subchapter II /
B is concentrated on the page nonverbal communication skills. Contained the same circuit as
the monitor I / B, but these symptoms are completely different in listening and speaking, so
we dealt with them separately mentioned skills. Each subchapter student was rated on a scale
from 1 - totally unsatisfactory to 5 - totally satisfactory. Gave rise to a clear table of partial
results of each student before teaching communication skills and at the end of instruction,
labeled Pre and Post.
A total of sixteen students participated in the study, each parameter of each sub-subchapters
communication skills Pre and Post is always described sixteen values, once gained selfesteem and other fifteen students from other students. For the needs of all of the following
hypothesis tests, we have always enjoyed a student sixteen sum of these values for each
parameter communication, each student was then characterized in subchapter I / A, I / B II / B
always six values in II / A eight values . (Select sum, average, or irrelevant, the average is
always less than the sum of sixteen.) Collected data are quantitative in nature (it is always a
range of 1-5). Despite their small variability (only values 1-5) was necessary to think about
the possible presence of outliers (for example, if one student evaluated differently than the
rest of colleagues). Selling the Dixon test here but it was just for a small range of values files
practically applicable for low variability selections were also excluded outliers, but only the
extreme (ie values away from the odd quartiles by more than three times the width Quartile).
23
CLINICAL SOCIAL WORK (CSW)
All statistical calculations were held in StatSoft Statistica software environment, all
hypothesis tests were performed at a significance level О± = 0.05.
Through the implementation of Shapir-WilkovВґs test the assumption of normality in the data
for some parameters and subchapters communication skills untenable (even after excluding
extreme values), so further consideration in the inductive statistics were derived
predominantly by non-parametric tests. For non-Gaussian nature of some data also testified
previously made selections descriptive statistics of each communication quality (sample
mean, median, modus, standard deviation and variance, 1st and 3rd quartiles).
In the so-called inductive statistics here is primarily testing the hypotheses, it was first
performed using the median test than anticipated, the "optimal" evaluation of communication
quality students and their actual grades. Data were collected during a sample dialogue
between experienced and instructed students of higher classes (see above) both from the
evaluation of students, both from supervising qualified teachers. All students had been
properly instructed and interview for the assessment of the model were a few randomly
selected. If the median test rejected the null hypothesis of insignificance of the difference
between the assessment of students and supervising teachers, it would be necessary to educate
students on how to properly evaluate the quality of communication, and then the median test
repeated.
Then there was a statistical analysis of the working hypothesis that there was a statistically
significant change in the value of communication skills of students after graduation onesemester course, a significant difference between the card data Post and Pre. Given that our
data have a hierarchical structure (the category of "active listening" and "transfer of
information" composed of subchapters "verbal" and "nonverbal" and then those of the
individual parameters), it was necessary to focus on a comparison of only one of their
"Benches", as it is not suitable one and the same data repeatedly undergo modifications one
statistical test (the statistical fishing, excessive effort to find significance at the expense of the
rise alpha error). Suppose that it is appropriate to compare data in the greatest possible depth,
which is still well interpretable - that at subchapters (there are four, always "verbal" and
"nonverbal" in both categories). Data were within each subchapter add up. Overall, the data
was compared to all students in all four tests of hypotheses, just because of abnormal
distribution of the data and their pairing (each student evaluated Pre and Post), we always
chose WilcoxonВґs paired test, which built two-alternative hypothesis of a significant change in
the mean value of the data subchapter communication skills Post and Pre against the null
hypothesis of insignificance of the change between moments Post and Pre. Provided that the
time available data of the same character from the video situation, where students attend
dialogues with real patients in a real hospital environment, using the Friedman test the
hypotheses can remark that the Pre and Post data has already been processed once, to compare
three sets of communication skills of students, before taking this course (Pre), after its
completion (Post), and after graduating dialogs from the hospital environment.
Furthermore, we are under statistical scrutiny asked whether it is possible to divide the
communication skills of students, capturing the values of the parameters of all four
subchapters, respectively. changing these values between the Post and Pre moments to several
groups (clusters of clusters), which are character communication skills with each other to
some extent different, but to the contrary, students of each group were close to the values of
communication skills. The purpose of such division is primarily a "profile" group of students
according to their communication skills when representatives of each of the group will
establish a focus group with which the components of the qualitative research conducted
controlled dialogue. To create groups was performed multivariate method - cluster analysis.
Since it was appropriate to provide several clusters (groups of students) that would be
equivalent, we chose the cluster analysis and non-hierarchical clustering for quantitative
nature of the data namely K-means method according to MacQueen. The number of clusters
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CLINICAL SOCIAL WORK (CSW)
has previously been estimated using tenfold cross validation. As a measure of distance
between the values we choose the traditional Euclidean distance. Verification of
meaningfulness created clusters, thus groups of students according to their communication
skills, can be done by comparing the mean values of each parameter of all subchapters, when
the value of the cluster will be similar to his students averages between clusters on the
contrary, their values will vary somewhat. Each cluster is thus becoming a profile group that
is possible through the mean values cluster communication parameters "accurately" describe
as "talkative extroverts", "thoughtful introverts," etc., but it requires the researcher great
imagination and understanding of the principle of cluster analysis. According to the total
number of clusters - this should always be less than the number entering the elements that
must be divided, here students - can be selected from each cluster to one or more students, the
communication parameters are the averages of the closest cluster, and included in focus
groups.
The qualitative part of the research is dominated by organized dialogue with the focus group
on the topic. Although we have to build profile groups and thus to the formation of focus
groups used a quantitative method, namely cluster analysis, it is our opinion that the
qualitative character of subsequent research focus group not disturbed, students will only be
elected to focus groups targeted, not random. On the contrary, in this approach, we see little
innovation and efforts to establish a link between quantitative and qualitative phases of
research.
Conclusion
Teaching communication skills to medical school can be very important source of
communication reveal weaknesses of the individual, which may adversely affect the conduct
and behavior in clinical practice. Uncertainty in communication with the patient may divert
attention from the fundamental knowledge and inexperience in conducting interviews with
patients may seem stressful not only for the patient but also for the student to clinical practice.
Acquisition of communication skills through role-play and analysis of their video can be one
of the ways to get rid of student uncertainty, anxiety and fear of direct contact with the
patient. The selected method confirms its effectiveness and excellence especially in selfconcept and self-learner. It helps students see themselves, their reactions, the quality of their
vocabulary, but also read their nonverbal speech in a situation in which focus on the patient
and his current condition. It is not easy to handle all the skills immediately, it requires a
complete workout feedback that shows progress and eventual vice versa area that needs to be
addressed. Acquiring knowledge and communication skills, good training, these skills allow
any doctor constantly emphasizing individualized approach to patients, the medical profession
elevate the art of its kind.
REEFERENCES
PTACEK, Radek, BARTUNEK, Petr a kol. Etika a komunikace v medicГ­nД›. 1. vyd. Praha:
Grada. 2011. 528s. ISBN 978-80-247-3976-2
LINHARTOVГЃ, Vera. PraktickГЎ komunikace v medicГ­nД›. 1. vyd. Praha: Grada. 2007. 152 s.
ISBN 978-80-247-1784-5
MГњHLEISEN, Stefan, OBERHUBER, Nadine. KomunikaДЌnГ­ a jinГ© mД›kkГ© dovednosti. 1. vyd.
Praha: Grada. 2007. 192 s. ISBN 978-80-247-2662-5
PETTY, Geoffrey. ModernГ­ vyuДЌovГЎnГ­. 5. vyd. Praha: PortГЎl. 2008. 380 s. ISBN 978-807367-427-4
25
CLINICAL SOCIAL WORK (CSW)
Contact address:
PhDr. Е ГЎrka TomovГЎ
Department of Nursing of the 2nd Faculty of Medicine and University Hospital Motol
V Гљvalu 84
15006 Praha 5
Email: sarka.tomovafmotol.cuni.cz
Tel: 77561524
LubomГ­r Е tД›pГЎnek
Гљstav veЕ™ejnГЅch informacГ­
2. lГ©kaЕ™skГЎ fakulta UK
V Гљvalu 84
Praha 5 Motol
15006
PhDr. Anna ГЃrpovГЎ
ST. Elizabeth University College
of Healt and social work Bratislava
Department of Social Work
PalackГ©ho 1
811 01 Bratislava
Slovak republic
mail: [email protected]
Tel.: +421 917 468391
26
CLINICAL SOCIAL WORK (CSW)
THE STATE FAMILY POLICY OF THE SLOVAK REPUBLIC
NataЕЎa BujdovГЎ, Stanislav Bujda, VladimГ­r NovГЎk
St. Elizabeth University of Health and Social work Bratislava
Greek Catholic Theological Faculty of PreЕЎov
St. Elizabeth University of Health and Social work Bratislava
ABCTRACT
Through social policy takes state approach to define social situations. It is therefore
necessary to focus on the seriousness of the problems determined, their impact and influence
on individuals and families. Compliance of work life and family life among the priorities of
family , which creates favorable conditions for the combination of family and success in the
labor market.
Keywords: Child. Family. Family policy.
Family in Slovakia means for people a very important and stable value. In the life of every
family is especially important change a birth and care of a dependent child of the family and
increased spending on food, clothing and housing. As mentioned RusnГЎkovГЎ (2007), family
to perform its functions it needs have created a framework legislative, economic, social and
cultural conditions, and only then will be able to exercise its responsibility for themselves
and for the future of its members. Provide the framework for families living conditions and
give them the space to freely choose their own way of life and their own responsibility for the
application of the role of the state family policy.
In June 1996, the Slovak government adopted the Concept of the state family policy of the
Slovak Republik and the ongoing process of transformation of social security population
policy , the policy of gradually replacing the family , pointing to the “social welfare“of the
family as a whole. Since the Slovak Republic ranks among countries with “explicit family
policy“, which is the object of the family as a whole. (Macková, Barinková, In: Moderné
trendy socialnГ©ho zabezpeДЌenia)
Updating the state family policy Concept of 2004 opted for the promotion of universal
law, and also to highlight the merit principle in relation to no childcare but to participate in
the labor market. The main objective is to support rather then “responsible“ families become
“working“ families (tax bonus, parental benefits for the unemployed).Also in this area is
reflected access to the notion of citizen activism. (RusnГЎkovГЎ, 2007)
State family policy updated in 2004 states that the basic social policy in general, the
principles of personal responsibility, justice and solidarity. The effectiveness of family policy
as well as other close family policy is subject to the rigorous application of its principles in
formulating a practical application of the measures taken to implement it. Principles on the
basis of which a family policy in the future to implement fundamentally different from those
defined in the state family policy adopted by the government in 1996 and more then change
the principles of their parcitular application.
A key principle of family policy is a shared responsibility of the family satisfying the
needs its members. The rate of economic independence of the family is directly proportional
to the degree of independence of civil family. State of variant tools offer solutions to life
situations supports the freedom to choose its decision.
More progressive decentralization of state competencies , particularly in the area of
services for municipal authorities reinforces the practical application of the principle of
subsidiarity in family policy and responsibility of the entities at lower levels can be targeted
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CLINICAL SOCIAL WORK (CSW)
to meet the specific needs of families. In accordance with the Constitution at the central level
for the implementation of state family policy remains the responsibility of the state.
Strengthening the principle of targeting, personalized support individuals tends to
increase the efficiency and effectiveness of family policy tools and to prevent the same
approach.
Respects the principle of solidarity guarantee the necessary level of participation in
addressing adverse social situation of the individual. While the principles of the state family
policy also interested in supporting the principle of merit which is based on direct
contribution of the individual in society.
Identified family policy priorities for the next period, in particular to promote the
harmonization of work and family life expect-sensitive application of the principle of gender
equality.
The principle of equal access to parents, regardless of the legal form is based on
avoidance of certain forms of family favoritism at the expense of other forms.
Family policy increaes demand close coordination and harmonization of family policy.
The absence of a common approach for all those responsible for the creation of family policy
and its implementation, expecially at a time of transformation processes can greatly weaken
and impede efforts to support the family. Ensuring the protection of families with dependent
children and other groups in the reform of social protection systems is one of the most
pressing challenges related to the alleviation of poverty, which together identify the Slovak
Republic and the European Union.
Achieving a balance between the family support at each stage of family life cycle means
including the change of the traditional family policy orientation for young families and
families at the time the care of dependent children. Any help family should offer an
alternative choice of direct or indirect forms to support the family in its own how to deal with
life situations.
The principle of flexibility at the same time implies the harmonization of aid instruments
in order to use the tool from one system to another threatened sanction system.
Final intentions and plans for public action to require the family to monitor systematically
and comprehensively analyze the socio-economic living conditions of families, demographic
and behavioral aspects of value. Based on this knowledge, organizations may be responsible
for the design and implementation of family policy measures designed to correct, amend or
change the public support the family. The principle of openness and accessibility changes
requires a systematic collection of data relevant to the assessment of the living conditions of
families, especially in the field of legal protection of the family, socio-economic conditions
of life in the education and health of its members.
Key strategic objectives of the state family policy under the State family concept are:
• achieving relative economic independence of families as the basic of their independence
and the exercise of civil responsibilities and their own future choices,
• success of families in the implementation of their functions,
• social stability and quality of marital and parental relationship within the meaning of
equality and common division of family roles,
• creation of optimal conditions for the self-reproduction of society
• adoption of such measures, which will enable consistent application of the principleof
choice (compatibility) when choosing a parent for parental (work) role.
The above long-term strategic objectives should be implemented especially in five areas
of substantive competence of the state, namely :
• legal protection of the family and its members,
• education of children an youth, preparing for marriage and parenthood,
• health of family members,
• domography and population policy,
• socio-economic and family security. (Rusnáková, 2007)
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CLINICAL SOCIAL WORK (CSW)
FAMILY ORIENTED SOCIAL SERVICES
The level of security for families with children determines a number of factors, sucha
s historical traditions, economic and cultural sophistication of the country, the age structure
of the population, religion, and other natural environment. Application of family policy as
a set of measures to support families with dependent children is carried out combining
various instruments, legal, economic, through targeted social programs and social services.
(Mack, BaЕ™inkova, In: ModernГ© trendy sociГЎlneho zabezpeДЌenia, 2008)
Historically, it is the oldest part of social work. The organized form of social services,
we can no longer meet in the establishment of the first institution for handicapped individuals
whose greatest development occured in the late 18th and early 19th century. In the United
States began in the 80s of the 19the century formed “settlements – social services centres,
Neighbourhood Houses – houses for social assistance in the neighborhood, whose task was to
assist individuals and families in the immediate areas. Demand for social services and
development in the early 20th century undoubtedly influenced first social encyclical
Rerum Novarum, which the author was Pope Leo XIII. The growing concern for social
services shows the layout of the International congress of social services , which took place
in July 1928 in Paris, which was the first in the world focused on the social and health care,
which includes four separate conferences were linked together organizationally and
programmatically. Congress worked in the following sections: Organization and social
services , Education for social services, Individual and family care, Social care and industry ,
Social care and public health, Self-help social service, first World War I, the economic
crisis, extension tuberculosis and similar phenomena were for social work very prolific
period. From their solutions depend not only the late of individuals and their families , but its
extent influenced by the the situation in a particular country. In the period after the second
World War II, continue this line of development of social services and also began to pay to
new problems, sucha s hunger, disease in third world countries , the growth of crime, drug
addiction, AIDSm and so on . (ДЊechovГЎ et al.,In: TokarovГЎ et al., 2005).
As reported by Schavel and Zeman (In: Schavel et al., 2010), social service is
a professional activity, service activity or other action or set of such activities for the
prevention of unfavorable social situation, maintaining or restoring the conditions necessary
to meet basic living needs of individual, crisis management of an individual and the family,
and the prevention of social exclusion, physical persons and families.
During the historical development gradually from most natural forms of social services
for which we may term care service, has developed a range of social services, which can be
divided into classical and modern services. To traditional forms of social services include:
inpatient care of patients, elderly and physically disabled people, homeless shelters,
penitentiary and post – penitentiary care, nursing care, social counseling. The modern forms
of social services include social as pension plans , home care (including nursing) services,
intermedial, semi-constitutional forms of care, street worker – social survival. (Defended et
al.In: TokГЎrovГЎ et. Al 2005).
Social services according to the type of rules are:
• social services to provide the necessary conditions to satisfy the basic living needs of the
facilities , which are dormitory, shelter, halfway houses to low-threshold day center,
emergency housing,
• social services to support families with children who are assistance with personal care for
the child and support for reconciling work and family life, providing social services facilities
in the temporary care of children, providing services to low-threshold day center for children
and families,
• social services to deal with adverse social situations because of a severe disability, ill health
or due to reaching retirement age, which is the provision of social services in facilities for
individuals who need the assistance of another person and to individuals who reached the
29
CLINICAL SOCIAL WORK (CSW)
retirement age care services, transportation service, guide service, interpretation service
mediation, mediation of personal assistance, rental tools,
• social services using telecommunications Technologies, which are monitoring and alerting
needs assistance, crisis assistance through telecommunications Technologies,
• support services, namely facilitating service, assistance with guardianship rights and
responsibilities in the provision of social services of day center, in the integration center, in
the dining room, in the laundry and personal care center.(Olah, RohГЎc, 2010).
Into social services are also issues of economic rationality and efficiency. Social
services are important in terms of client activity, it helps him cope with extreme social
situation in which he found himself and from the perspective of the state economically costly
activity. When deciding on the number and the extent are applicable only in the state of
humanistic-social criteria, as well as partial economic interest. Economic criteria often decide
on the establishment or not establishment of some form of social services. The economic
demands of service is a major issue so that the forms and types of social services that a state
is obliged provide at its own expense, they are expressed normally in a particular state
legislative norms. (TokГЎrovГЎ et al. 2000).
The aim of the organization is to ensure social services and social welfare protection,
a certain level of quality of life for all citizens, which is reflected in the official social policy
of the state. Exeeding this level represents an increase of clients dependent on social welfare
state, social unrest, crime, increased morbidity, which ultimately leads to paralysis of the
state as a political body , and hence to the threat of its citizens who need social services.
When considering the establishment and providing any social services, is expected form the
state that as a guarantor of the quality of life of all its citizens, it will just state who manages
the services and will incur the cost of its operation. (Olah, RohГЎДЌ, 2010).
MEASURES FOR YOUNG FAMILIES
Measures to protect the family in the Slovak Republic in its legislative form dominated
mainly by the standards of family law, social security law, labour and tax law.
Preparation and implementation of specific measures to support families as the
specialist is a complex problem which is multi –disciplinary in nature. There are many
concepts that may interact also differ substantially. As mentioned above, measures to support
families should have the character of isolated, one-off measures, but should create
a comprehensive system connected internally and externally with other policies. It starts even
discover that family support is not sufficient at present has no system of measures, but should
be seen as a generating general living conditions. Measures in favor of families should be
linked to the social situation. It is necessary to develop a concept that would promote family
activity. Nowadays still is hoped that family support is the provision of “something“.
However, families must first create the conditions for the realization of area and its
intentions. Measures to support families are diverse, mostly those measures: legislative-legal,
socio-ecnomic, educational, health.
Legislative and legal measures designed to protect the family and its members, it is the
whole system of family law and legislative changes related to the family and is solely the
domain of the state. State legally protects and promote the stability of marriage and
relatioships. The position of the state to the other forms of a relationship is determined by the
needs of children and other dependents. State by legislative and institutionally guarantees the
rights and needs of children, primaly children’s right to parental care and family
environment. When parental care is failing , various forms of alternative education provided
by law and the law provides the obligation of adult children to their parents.
Socio-economic measures aimed at ensuring families from a substantive and achieve
a standard of living and in addition to the state have the opportunity to work in this area . The
basic responsibility of the state to families is to create conditions for the growth performance
of the economy, providing jobs and promoting macroeconomic balance. The state guarantees
30
CLINICAL SOCIAL WORK (CSW)
for the labor and socially weaker families direct social support to carry out tasks in various
stages of the family cycle. It also helps to manage some of life’s events, which impair the
financial situation of families – a child coming into the family, the presence of only one
breadwinner in the family, the presence of a disabled family member, and so on. State in
these cases provides single or multiple contributions. The state in cooperation with other
entities (especially municipalities) provides for the acquisition and maintenance of the
apartment. In the case of social dependent families come to consideration other supportive
measures. The state in cooperation with other entities providing assistance and support to
families in crisis.
To supporting measures that contribute to the harmonization of employee work life with
different needs and interests of its family life, can the employer considered acceptance rate of
barries to employment for various family reason for some time affect the emploee to work.
The legal framework of these barries at work represents only a minimum to prevent
employers and be more accommodating and allow an employee time off to draw on a wider
scale. (ThurzovГЎ, BundovГЎ, 2009).
Educational measures are intended to raise the moral values, provide education, preparation
for marriage and parenthood. The state along with other social entities create conditions for
families improve their educational activity. In terms if effective education is working in
partnership with families and other necessary institutions. In addition to basic education, the
state is works with family and other subjects in the area of sex education, education of
marriage and parenthood, the development of cultural , artistic, sporting and work activities.
Health measures concentrate on the protection of health. The state guarantees to
everyone the right for health and life in all stages of life to the level of current scientific
knowledge and economic opportunities. Resources and conditions for the provision of public
health care is provided by state legislative, economic and administrative measures and
international cooperation. The state supports the increase public awareness of health and
prevention of possible types of addictions.
All kinds of measures are in the form of various direct and indirect impacts on the
family. It is all about preparation and adoption of laws and standards, the ratification of
international conventions, design programs, project coordination , fiscal measures, providing
various benefits, contributions and support.
A substantial part of the system of social assistance to families with dependent children,
which the state covers mainlythe cost of bringing up small and dependent children shall be
done through the provision of state social benefits or by system of state social policy. This is
one of the fundamental rights of social security systems, which is designed in accordance
with the Constitution of the Slovak Republic.
Article 41 of the Slovak Constitution guarantees a woman during pregnancy special care
to protect the employment and appropriate working conditions, then provides the rights of
parents to care of children and their education and child’s right to parental upbringing and
care. This article also ensures the state help for parents taking care of the children.
The most important aim as stated in the Government Manifesto of the Slovak Republic
(2010), today the Government considered creating conditions for improving the quality of
life and standard living. The family policy will pay attention to and support the family during
critical phases of its existence, especially after childbirth or line of work and family life,
either direct subsidies or services for parents and promoting flexible form of work including
support for nursing services. Since the attention of the Government to encourage the creation
of new jobs through active labor market measures fail to meet about a quarter of existing
grants and contributions is not used (other are abused) and fails to meet the goal of reducing
their unemployed, so in the future proposed legislative changes that support motivate the
unemployed to accept jobs by introducing a combination of work and benefits for the longterm unemployed (intermediate labor market). One of the objectives is already filled by the
Government and to extend maternity leave and also extended maternity leave and increased
maternity. Then removed legislative barriers to the implementation of employment while
31
CLINICAL SOCIAL WORK (CSW)
receiving parental contribution. One of the objectives of the Government is to support the
development of services for parents with children such as by promoting or supporting microplayschools or support minders of intermediate labor market.
Conclusion
In the last years child care is one of the frequent topics of European and Slovak debate.
The focus is mainly of the reconciliation of work and family responsibilities and to seek
measures, but also to seek measure and tools how to improve the performance to parents in
these two areas of life. There is more and more talk about the division of responsibility for
care and upbringing of children between various organizations on security assistance not only
from the state but also by employers and municipalities or not profit organizations.
REFERENCES
BUJDOVГЃ, N., DANCГЃK, F. 2011.SluЕѕba v lГЎske. VЕ ZaSP sv. AlЕѕbety, Bratislava, 2011, 69 s. ISBN
97-80-8132-003-3
BUJDOVГЃ, N. 2011a. Vplyv spoloДЌensko-ekonomickГ©ho vГЅvoja na sГєДЌasnГЅ stav inЕЎtitГєcie rodiny. In:
Revue 1 – Medicíny v praxi. .ISSN 1336-202X , 2011, roč. 9, č. 1,. s. 33-34, 42.
HALUЕ KOVГЃ Eva, : Alcoholism and its impact on the functionality and quality of family.
In: Spoloczenstwo i Edukacja. Miedzynarodowe Studia humanistyczne. Nr.2/2009, s. 229-235. 249 s.
ISSN: 1898-0171. Legnica 2009.
HALUЕ KOVГЃ Eva - MIHOKOVГЃ Lucia: MoЕѕnГ© rieЕЎenia nezamestnanosti ako pretrvГЎvajГєceho
problГ©mu spoloДЌnosti. In: Spoloczenstwo i Edukacja. Miedzynarodowe
Studia humanistyczne. Nr.1/2010, s. 235-242. 270 s. ISSN: 1898-0171. Legnica 2010.
HALUЕ KOVГЃ, E., CHOMOVГЃ, M., : NezamestnanosЕҐ mladГЅch ДѕudГ­. In: ДЊlowiek SpocЖљeczeЗ№stwo
Cywilizacja : WyЕјsza SykoЖљa MiИ©dzynarodowych i Komunikacji w CheЖљmie, 2011, s. 249-255. s. 285.
ISBN 978-83-61787-64-8.
HUNYADIOVГЃ,S. 2012. KrГ­zovГЎ intervencia v pomГЎhajГєcich profesiГЎch. Гљstav sociГЎlnych vied
a zdravotnГ­ctva bl,P.P.GojdiДЌa PreЕЎov. ISBN 978-80-8132-060-6 EAN 9788081320606
MACKOVÁ, Z. – BARINKOVÁ, M. 2008. Postavenie a úloha rodiny pri zabezpečovaní starostlivosti
o rodinných príslušníkov. In: Moderné trendy sociálneho zabezpečenia. Bratislava: SAP – Slovak
Academic Press, 2008. 140 s. ISBN 978-80-8095-040-8
OLГЃH, M. - ROHГЃД†, J. 2010. AtribГєty sociГЎlnych sluЕѕieb. Bratislava : VysokГЎ ЕЎkola zdravotnГ­ctva
a sociГЎlnej prГЎce sv. AlЕѕbety, 2010. 132 s. ISBN 978-80-89271-88-7
RUSNГЃKOVГЃ, M. 2007. Rodina v slovenskej spoloДЌnosti v kontexte sociГЎlnej prГЎce. RuЕѕomberok:
PedagogickГЎ fakulta KatolГ­ckej univerzity v RuЕѕomberku, 2008. 167 s. ISBN 978-80-8084-248-2
THURZOVÁ, M. – BUJDOVÁ, N. 2009. Súlad pracovného a rodinného života. In: Právo pre ropo
a obce v praxi. ISSN 1337-7523, 2009, roДЌ. II., ДЌ. 9, s. 13-17
TOKAROVГЃ, A. et al. 2005. SociГЎlna prГЎca: Kapitoly z dejГ­n, teГіrie a metodiky sociГЎlnej prГЎce. II.
Vydanie. PreЕЎov: FF PreЕЎovskej univerzity Akcent Print, 2005. 573 s. ISBN 80-968367-5-7
Contact address:
PhDr. NataЕЎa BujdovГЎ, PhD.
[email protected]
Mgr. Stanislav Bujda
[email protected]
PaedDr. ThLic. Mgr. VladimГ­r NovГЎk
[email protected]
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THE AIMS OF PUBLIC HEALTHCARE SYSTEM IN „HEALTH IN
21. TH CENTURY“ PROGRAM – HOW TO CREATE A HEALTHY
LIFESTYLE
Ivica Gulašova,1 Lenka Görnerová,2 Jan Breza, jr.,3 Jan Breza4
1
St. Elizabeth University of Health & Social Sciences, Bratislava, Slovakia
College of Polytechnics, Jihlava, Czech Republic
3
Department of Urology and Centre for kidney transplantations, KramГЎre University
Hospital, Bratislava, Slovakia
4
Department of Urology and Centre for kidney transplantations, KramГЎre University
Hospital, Bratislava, Slovakia
2
ABSTRACT
Objective factors of the environment and also our subjective factors interact in shaping the
lifestyle. Lifestyle is the behavior of an individual, which is based on the interaction of living
conditions, personal characteristics, social factors and economic factors. It is necessary to
monitor and raise health awareness. It is necessary to raise awareness about healthy and
unhealthy lifestyle elements in all areas like eating habits, exercise habits, sports, sleep and
hardening. Lifestyle is actually a model of behavior. Its positive elements should be
automated.
Keywords
Lifestyle. Health awareness. Automation of positive elements of lifestyle.
Introduction
Environment in which we live, the water we drink and the air we breathe has a great impact
on the quality of our life. Our own attitude and perspective on life have the decisive impact on
it. Whether we consider our habits as correct, or at least we try to think a little about it, we can
change anything. Every day we are burdened by work problems and constant stress that
negatively affects our nervous system, which may lead to physical or mental pathological
changes in our bodies. Our eating habits often do not adapt to the needs of our bodies, but to
needs of our work or of other obligations. We avoid stairs and nature with apology of duties,
knowing that we just do not want to. Many of us cannot or even do not want to voluntarily
give up their tobacco, alcohol or even drug addiction. All of these bad habits shape our own
lifestyle. When we were kids, we were taught by our parents what is right. We did however
make our own decisions about what is best for us when our parents finished raising us. In
order to learn what is healthy and what is not, what harms us or help us, there are various
programs of organs of Public Health care of the Slovak Republic. And one of the tasks and
goals of public health is to inform citizens of the Slovak Republic on how to prevent diseases
by establishing of good habits. One of such programs is the National Health Promotion
Programme, which deals with the issue of healthy lifestyle. "National Health Promotion
Programme” as well as the concept of public health policy are governed by a policy based on
the" Health for All" and "Health 21" - documents which were adopted by WHO at the 51th
World Health Assembly in 1998." /HolДЌГ­k, 2009/
In our article we will give priority to the first goal of the National Health Promotion
Programme - a healthy lifestyle.
"HEALTH 21" - health for all in the 21st century
Health Policy 21 for the WHO European Region has the following main elements:
1. Long-term plan:
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CLINICAL SOCIAL WORK (CSW)
в—Џ to achieve the full potential of health for all.
2. Main directions:
в—Џ to promote and protect human health livelong.
в—Џ to reduce the incidence of new cases of serious illnesses and injuries and to avoid suffering
they cause.
3. Core values that form the ethical basis of HEALTH 21:
в—Џ health as a fundamental human right.
в—Џ equity in health and solidarity between and within all countries (among their people)
in the implementation of measures to improve health.
в—Џ participation and responsibility of individuals, groups, institutions and communities for
constitutional development of health.
Four main strategies to scientific, economic, social and political tools to ensure the
sustainability of the implementation of Health 21were chosen:
в—Џ interagency collaboration to improve the determinants of health (physical and social
environment, economy, culture, social situation, including the status of women in society)
and evaluating of the impact of those actions to health /Health 21 - health for all in the 21st
century. World Health Organization - European office. Bratislava. National Center for Health
Promotion 1999th 155 pp../
в—Џ programs and investing in the development of health and health care controlled by achieved
results in physiological functions of the body,
в—Џ integrated primary health care focused on family and community supported by sensitively
responsive and flexible system of hospitals,
в—Џ health development process associated with the involvement of all relevant partners (family,
school, workplaces, local communities and country) that supports common
decision-making, implementation and evaluation of performance.
WHO Regional Office for Europe will assist in carrying out five main tasks:
1. act as "health conscience", defending the principle of "health as a fundamental human
right" identifying and pointing to ongoing or emerging health problems
2. act as an information center on health and health development
3. promote and give visibility to health policy for everybody in the region and provide its
periodic update
4. provide member states with the latest tools to ensure effective implementation of health
policies, respectively its transformation into concrete measures and activities
5. work as a catalyst for activities by:
в—Џ providing of technical cooperation with Member States, WHO will strengthen the effect in
each country
в—Џ taking the lead in initiatives to eradicate, eliminate and control diseases that are the greatest
threat to human health, such as epidemics of transmittable diseases or pandemic diseases
associated with smoking
в—Џ promoting and supporting of policy based on a JCC with many partners through networks
of organizations or offices in the entire European region
в—Џ facilitating the coordination state of readiness to deal with health emergencies of a large
number of people type such as disasters or catastrophes.
“Health 21 is a challenge for all 51 member states of the WHO to use the new health
policy for the whole European region as inspiration for updating of their own health
policies, respectively their objectives.” /Health 21 - health for all in the 21st century. WHO European office. Bratislava. National Center for Health Promotion 1999/
The objectives of global strategy for health for all
From objectives of the program "Health 21" implies the role of public health authorities of the
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CLINICAL SOCIAL WORK (CSW)
Slovak Republic and of public Health as an element of prevention, protection and information
channel.
"In ensuring tasks under each objective of the program is necessary to coordinate the various
strategies of the World Health Organization and the decisions of the European Parliament and
the Council. Equally important is coordination with the State health policy strategy."
/Programs and Projects of Office of Public Health of the Slovak Republic for 2008 and
thereafter. Bratislava, the PHA SR 2007/
"Updated NPPZ in 2005 was focused on selected determinants of health, and consists of 11
targets:
1. healthy lifestyle,
2. health care,
3. healthy nutrition,
4. alcohol, tobacco, drugs,
5. prevention of accidents,
6. healthy family,
7. healthy working conditions,
8. healthy living conditions
9. reduction of the incidence of infectious diseases,
10. reduction of the incidence of non-transferable diseases
11. physical activity. " /Programs and Projects Office of Public Health of the Slovak Republic
for 2008 and beyond. Bratislava, the PHA SR 2007, 121 p./
The main objective of the National Health Promotion Programme is to support and develop
public health for the purpose of continuous improvement of the health status of the
population.
Part of the National Health Promotion Programme is ongoing communication with the
public. That allows free access to understandable information that broad the range of
knowledge and attitudes and behavior of citizens to their health. As communication channels
to communicate with the citizens of the Slovak Republic are used all available means of mass
media communication.
The objective of the "Health 21" - a healthy lifestyle
The role of public health is to achieve the first objective of the "Health 21", which talks about
a healthy lifestyle and to create conditions for improving the quality of life of citizens.
Definition of target: Lifestyle is the behavior of an individual, which is based on the
interaction of living conditions, personal characteristics, social factors and economic factors
/Jarvis, 2008/.
Current state of the problem: A healthy lifestyle is one of the priorities of the program,
which aims to educate people to health. The combination of health education and effective
health promotion strategies can achieve the improvement of public health.
Health awareness of the population
Recent survey of health awareness and behavior of the population of the Slovak Republic
confirmed that 78% of men and 72% of women rated their health as good, while with longterm illnesses suffer more women. The most frequent disease in elderly men and women is
heart disease, followed by cancer; in the younger age group dominate allergies. 60% of
respondents believe the possibility of effect on life by a way how they live and how they care
about their health and 90% of respondents of all ages stated their convenience as the main
cause of their unhealthy lifestyle /HolДЌГ­k, 2009/.
Activities to meet this target
1. Increase the level of awareness of the population on selected determinants of health
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CLINICAL SOCIAL WORK (CSW)
2. Reduce inequalities in health
3. Promote lifelong learning of certain groups (risk groups) focused on a healthy lifestyle
Indicators for monitoring of issues:
- Monitoring the health awareness of the population
- Monitoring of selected determinants of health:
- Eating habits
- Exercise
- Mental health
- Addiction on substances / Programs and Projects Office of Public Health of the Slovak
Republic for 2007 and beyond. Bratislava, PHA SR 2006 /.
Preventive examination
Our health affects number of factors such as genetics, social environment, health,
environment and especially our behavior. To keep ourselves healthy is not enough to eat, play
sports, relax and correctly satisfy to all our needs. 30% share of health is determined by
genetics and thus we should attend annual preventive check-ups with GP and Specialists.
Neglected preventive inspections can escalate into various diseases that could be detected at
an early stage and their effects can be reduced by treatment. If neglected they may be more
complicated and severe with impact to physical and mental health, and may even lead to
death.
Immunity – hardening
We us have some level of natural immunity and its real strength shows in critical or stressful
situations or in bad weather. The immune system is very important for the proper
functionality of our body and the interaction between organs and therefore we must take care
of it and strengthen it. Good immunity protects us against disease-causing organisms, tumors
and cancer. Prevention of these threats is the increased intake of vitamins, minerals and fiber,
and also regular exercise, regular sleep, stress reduction and ultimately the hardening.
Hardening
Hardening can increase our body resistance and thus adjust body to adverse external
influences. Therefore we should not sit back in overheated rooms but rather to move more in
the fresh air. A great workout is alternating showers or regular sauna, which removes mental
and physical fatigue and also helps to increase immunity.
Physical activity – sport
Other enhancer of immune system and of our overall health is physical activity. Sport can
prevent various chronic diseases and cardiovascular diseases /HolДЌГ­k, 2009/. Conversely its
lack can contribute to obesity and to the development of diabetes. Physical activity also
reduces the risk of cancer of lung, breast, colon or rectum. By jogging, dancing or skating in
adolescent age we can provide higher bone density in adulthood thus we can slow the loss of
bone mass and prevent osteoporosis. Movement is also an excellent "de-stressor" for either
mentally or physically working, mothers or students. With regular exercise we improve
quality of our sleep and eliminate feelings of anxiety or depression and we can cope with
stress and gain peace of mind much easily /Jarvis, 2008/.
We should move every day for at least twenty to thirty minutes. It does not matter how long,
but how often we sport. The best sports include brisk walking, swimming and cycling because
they do not burden the joints.
Sleep
Another indispensable element of our daily activities and biorhythm is sleeping thus
regeneration of the body. To allow our body to gain new strength and to clean up all the daily
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CLINICAL SOCIAL WORK (CSW)
experiences and ideas is essential to comply with the principles of proper sleep. Although we
sleep much time of our life, we know little about how important it is, how it affects our body
functions and what is actually happening in your sleep. The first principle is to get enough
sleep, which is somewhere between six and nine hours a day /KomГЎrek, ProvaznГ­k, 2011/. Of
course it also depends on the age, physical and mental fatigue and other factors, but the
golden average is seven hours. A very important principle is the quality of sleep - when we go
to bed, if we go to bed at all, if the light is on, if we are after a heavy meal or after a mentally
challenging movie etc. Proper sleep should be regular, that is to fall asleep and wake up at the
same hour of the day in order to create the habit to our body. Best sleep to regenerate is before
midnight, around 22 and 23 clocks. Just before going to bed, we should not eat at all,
especially food that burden organism. At least two hours before bedtime we should consume a
lighter meal and 3 to 4 hours before heavy one. In order to allow our body to turn off we need
dark, quiet and comfortable surface. Certainly we should avoid the consumption of alcohol,
sugar, fatty foods, nervousness, also evening doses of drugs and contraceptives. Sleep is of
course affected by the composition of diet, exercise or stress and reversely good sleep affects
our performance and stress management.
Food and drinks
From one manufacturer we are told that "it" is healthy, the other says “that” is healthy, then
we read an article where they write that it is harmful, and so we do not know what and how to
eat. But there is still the rule that everything eaten moderately is healthy. Nowadays, food has
become so publicized issue that we are often under stress and remorse that we ate something
bad and it leads to further mistakes. People are becoming so dependent on "Healthy diet" so
much that it becomes unhealthy. Whenever possible we have to choose the middle path. But
which is the one when we are surrounded by so many views? When we are healthy and we do
not need a special diet, we should eat to what we like, but moderately. Of course, we should
restrict ourselves if we only like sweet, heavy and oily foods. We should eat in small portions
at a designated time and in peace. Our meals should always include fresh vegetables, fruits,
nuts and grains. Our nutrition should be balanced - it means approximately 60% of
carbohydrates, 30% of fat and 10% of proteins. Very important is also the actual food
preparation - food is the most valuable when the least exposed to heat treatment, preferably
prepared only in steam. By hardening, movement, sleep, healthy nutrition and balanced diet
we can affect our immune system, which deals with “intruders” and prevent diseases that
shorten and degrade our life /Kaplan, 1996/.
Drinking regime
One of principles of a healthy lifestyle that is very often neglected is drinking. Also, as for
other needs, consumption of fluid has its own meaning and guidance on how to do it correctly
is to be followed. The need for fluids is of course individual and depends on various factors
such as age, sex, weight, physical and psychological stress, a variety of diseases, climate,
weather, etc. The average daily amount of liquid is somewhere from 1,5 liters to 2,5 liters.
The most appropriate fluid is filtered water, various teas and natural moderately mineralized
water. What we should avoid but are gaudy sodas, juices with added sugar and carbonated
drinks /Keller, Meier,Bertoli, 1993/.
Conclusion
Lifestyle is a pattern of behavior that we build during our life. This is how we behave in given
situations and circumstances. We alone can automate behavior that is beneficial to our health
and for our lives. It is not impossible after all, we just should to seek opportunities to learn our
own needs, listen to what our body is telling us and act in our own benefit. Public Health of
the Slovak Republic makes sure that we were well informed about the principles of a healthy
lifestyle and vice versa on the threats and risks that adversely affect our health. From a variety
of sources of information on the web or in other media we learn everything necessary how to
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CLINICAL SOCIAL WORK (CSW)
protect our health and how to take care of it /JurkoviДЌovГЎ, 2005/. According to my own poll
most of us are not satisfied with our own health and lifestyle and none of interviewed did not
really know what the healthy lifestyle mean. The most common reason why people do not live
in healthy way is prioritizing of our duties before our health. They get into a vicious circle
that initiate stress that interferes with sleep and eating habits, people are frustrated, irritated,
without zest for life and relaxing is replaced frequently by relax with a glass and cigarette /
SvaДЌina, 2008/. This is the most common model of respondent in my poll.
People are well informed, they realize their mistakes and they want to be healthier and less
threatened and want to do something for it. So then what's the problem? Do we lack
commitment or motivation? The question is whether we are willing to sacrifice something for
our goal, to give up something, to work for something, or will we lie to ourselves till the end
of our days that we do not have the time and opportunity. Once you find a way out of "vicious
circle" you find that you do not have to sacrifice anything and you only get the extra time,
because we work in a smaller stress, with a taste and do so even more efficiently. Instead of
spending time with gastroenterologist you will relax in a sauna and swimming with friends
while you build up the immune system to protect you from another PN-ing
/Kleinleinwächterová, Brázdová, 2001/. You will look at the world with different eyes when
you sleep like a wake, you find that you are more confident when you look good and you are
loved when you do not snap at your loved ones. You just have to find a way which brought
you into so called "vicious circle" and get out of it.
Bibliography
HOLДЊГЌK, J. 2009. Civilizace, hodnoty, zdravГ­ a zdravotnГ­ problГ©my. In. : Civilizace a nemoci.
2009. Praha: FUTURA
JARVIS, C. 2008. Physical examination and health assessment. 5 vyd. St. Louis, Saunders
Elsevier 2008
JURKOVIДЊOVГЃ, J. 2005. Vieme zdravo ЕѕiЕҐ? Bratislava UK 2005, 165 s.
KAPLAN, R.M. et al. 1996. Zdravie a sprГЎvanie ДЌloveka. 1. Vyd.. Bratislava, SPN 1996,
450s.
KELLER, U., MEIER, R., BERTOLI, S. 1993. KlinickГЎ vГЅЕѕiva. Praha: Scientia Medica 1993,
236 s.
KLEINWACHTEROVГЃ, H., BRГЃZDOVГЃ, Z. 2001. VГЅЕѕivovГЅ stav ДЌlovД›ka a zpusoby jeho
zjiЕЎЕҐovГЎnГ­. Brno. 2001. Brno: IDV PZ, 102 s.
KOMГЃREK, L., PROVAZNГЌK, K.et.al. 2011. Ochrana a podpora zdravГ­. Praha: CINDI 3.
lГ©kaЕ™skГЎ fakulta UK. 2011. 99 s. ISBN 978-80-260-1159-0
Programy a projekty Гљradov verejnГ©ho zdravotnГ­ctva v Slovenskej republike na rok 2007 a na
ДЏalЕЎie roky. Bratislava, ГљVZ SR 2006, 134 s.
Programy a projekty Гљradov verejnГ©ho zdravotnГ­ctva v Slovenskej republike na rok 2008 a na
ДЏalЕЎie roky. Bratislava, ГљVZ SR 2007, 121 s.
SVAДЊINA, Е . et al. 2008. KlinickГЎ dietologie. Praha: Grada. 2008
Zdravie 21 – zdravie pre všetkých v 21. storočí. Svetová zdravotnícka organizácia – Európska
ГєradovЕ€a. Bratislava. NГЎrodnГ© centrum podpory zdravia 1999. 155 s.
Bibliography
HOLДЊГЌK, J. 2009th Civilization, values, health and medical problems. In. : Civilizyce and
disease. 2009th London: FUTURA
JARVIS, C. 2008th Physical examination and health assessment. 5 ed. St. Louis, Saunders
Elsevier 2008
JURKOVIДЊOVГЃ, J. 2005th We live healthy? UK Bratislava 2005, 165 p.
KAPLAN, R.M. et al. 1996th Health and human behavior. First Ed .. Bratislava, SPN 1996,
450s.
KELLER, U., MEIER, R., Bertoli, S. 1993rd Clinical Nutrition. Prague: Scientia Medica
1993, 236 p.
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CLINICAL SOCIAL WORK (CSW)
KLEINWACHTEROVГЃ, H., BRГЃZDOVГЃ, Z. 2,001th Nutritional status of humans and its
detection methods. Brno. 2,001th Brno: IDV CA, 102 p.
KomГЎrek, L., PROVAZNГЌK, K.et.al. 2011th Protecting and promoting health. London: 3rd
CINDI Faculty of Medicine, UK. 2011th 99 s. ISBN 978-80-260-1159-0
Programs and Projects Office of Public Health of the Slovak Republic for 2007 and beyond.
Bratislava, the PHA SR 2006, 134 p.
Programs and Projects Office of Public Health of the Slovak Republic for 2008 and beyond.
Bratislava, the PHA SR 2007, 121 p.
SVAДЊINA, Е . et al. 2008th Clinical dietetics. London: Grad. 2,008
Health 21 - health for all in the 21st century. World Health Organization - European office.
Bratislava. National Center for Health Promotion 1999th 155 pp..
CONTACTS:
Prof. MUDr. JГЎn Breza, DrSc.
UrologickГЎ klinika s Centrom pre transplantГЎcie obliДЌky, FNsP KramГЎre, Limova ul. 5.,
Bratislava, SZU Bratislava, LFUK Bratislava, Slovensko
MUDr. JГЎn Breza ml., PHD.
UrologickГЎ klinika s Centrom pre transplantГЎcie obliДЌky, FNsP KramГЎre, Limova ul. 5.,
Bratislava, LFUK Bratislava, Slovensko
Mgr. Lenka GornerovГЎ
VysokГЎ ЕЎkola PolytechnickГЎ, Katedra zdravotnickГЅch studii
TolstГ©ho 16, 586 01 Jihlava, ДЊesko
prof. PhDr. Ivica GulГЎЕЎovГЎ, PhD.
Katedra oЕЎetrovateДѕstva, VЕ ZaSP sv. AlЕѕbety, n.o.,
Bratislava, Slovakia
39
CLINICAL SOCIAL WORK (CSW)
ANONYMOUS AND SECRET CHILDBIRTHS
Ivica GulГЎЕЎovГЎ,Vlasta DvoЕ™ГЎkovГЎ, JГЎn HruЕЎka
St. Elizabeth University of Health & Social Sciences, Bratislava, Slovak Republic
College of Polytechnics, Jihlava, Czech Republic
Zdravstav, RuЕѕomberok, Slovak Republic
Summary
The issue of anonymous and secret childbirths has been analysed many times in history.
Unfortunately, contemporary women got into situation of unwanted or complicated deliveries
too. One of the solutions is anonymous or secret delivery. According to the current legislation,
women can carry out anonymous delivery or they can put newborn into Baby box. Such
situations are frequently very complex ant they can easily escalate into criminal offense.
Every approval process of such new Law should be preceded by wide discussion of
professionals from areas of gynaecology, medicine ethics and bioethics, psychology,
theology, law and social services.
Key words
Secret delivery, anonymous delivery, Baby box, female psychical state, legislative.
Introduction
The woman who becomes unwanted pregnant will desperately keep her secret – not be be
seen she can be pregnant – until the time of secret childbirth. Since that time she knows, that
the child will reveal her. She refuses them, have not been seeing any other chance. Beeing in
this situation she can resort to worst and for example kill the newborn child. But if she has got
a chance to cover her shame, beeing undiscovered, keeping inpunity and hereby stay her child
alive,she sure would choose this solution.
Why?
There are various reasons why the newborn child is left. Sometimes there are psychotic
diseases or defect of personality. But sometimes there cen be only effects of personal or social
circumstances. If mother has not possibility to care about her child and decides to indemnify
them keeping this way, it is admirable. It is very difficult to decide for everyone from theese
women.
We are no able to imagine we have to stay before such decision. Many young people have no
knowledges about effects of their performance. They have no clear guidelines for situation at
unwanted pregnancy and about the future of their child and themselves. If they have no
qualified information about various possibilities how to solve the situation, or are not
interested in, they can worsen their health as well as threaten just starting new life. o rieЕЎenie.
The only chance of solution is often an arteficial abortion. That is the reason why is good to
know various up to date alternative ways. What does mean „The Mandate for maternity“? It
means: women rather choose retreating from maternity, choose not to join the matherhood..
/Woollett, 1987 in: Nicolson, 1998/
But the best wishing of most people remains : never anymore find a dead newborn body.
Childbirth
The spontaneous delivery goes in three periods. Each of them takes its time and has their
charakreristics. The first – opening - period takes 6-7 hours on average,if it is a primipara,
multipara needs 3 – 4 hours. The uterine muscles contract regularly, the intensity and
40
CLINICAL SOCIAL WORK (CSW)
frekvention of contractions increases. The second - callen expelling period - takes 5 – 10
minutes in case of multipara and more – about 15 – 20 minutes in primipara. During this time
the newborn goes through the birthways , in this time are the contractions very strong and the
abdominal muscles provide the abdominal press. The third period means delivery of
placenta. /KamenГ­kovГЎ, KyasovГЎ, 2003/.
The fourth period takes 2 hours after the delivery, mother remains in the delivery room and
in the care of nurse. In the case the delivery was normal, watching the status of newborn and
also of mother can the child stay in mother s hands (RoztoДЌil, 2008).
It is very difficult to bear alone without help of another person. Pregnant women in most cases
make that decision if they have no information about the complications during the delivery.
Some of them risk their life, when the reason is not to appear they were pregnant and had an
unwanted child.
Secret childbirth
Definition of secret childbirth is: Pregnant woman can ask the health-care obstetricdepartment to make secret her personal data. According the law No 576/2004 ZZ if the
pregnancy was unwanted she can come to any hospital in the area of Slovak Republic and
order to bear in anonymous and secret childbirths regimen. This kind of ending the unwanted
pregnancy is safe either for the mother or for her child. The child will be de jure free. There
is the possibilty to adopt them. The data are sealed and safe-kept in the hospital. The mother
remains in secret after the delivery, the data about the delivery are not ment in her
documentation. The Name, Given names and Data are not written into the documents.
Definition of anonymous childbirth : Woman need not give her personal data concerning the
delivering process in the hospital. That s the reason why these data can not to be registered
and archivated anywhere.
Anonymous postponement of the child - we understand as the possibility to postpone the
child who was born out from the hospital ( resque nest ). There is no need to know mothers
personal data. This acitivity is considered not to be criminal.
History – secret childbirths have been registered in ancient times already. The first known
case was Moses, who had been found in 14-th century before Crist sailing in the basket along
Nile and naked by PharaoВ°s daughter. He was formed and mannered in the kings residence.
He became respectable as the pharaoВ°s adviser.
Even in ancient Rome was the postponement of newborn child not criminalised.
We have confirmation that there have been dishes of marble at the entrance of the temples and
cathedrales in French in the th century already. The dishes were there to postpone the
unwanted children. Xenodochium , based in 787 in Milan, was the first institution for
children who had been foundlings .
Children have important place in many religions, the care for their well-beeing is based like
instruction to be followed. Children in islamic countries have important place as family
integral members. In the Koran is placed: Child killing is the serious sin.
The secret department with a secret entrance was established in Prague during 19 th century in
ZemskГЎ porodnice Hospital. Women born there incognito. A sealed cover with their name
was opened only in case of their death. Similarly big secret was given to rich women in
Olomouc during their chiltbirth time. The could walk blanked out or in the masque. They
were allowed to postpone newborn into the hospital, giviong them salary about 80 golden
(DoleЕѕal,2001).
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CLINICAL SOCIAL WORK (CSW)
Project „Rescue nest“
The first Rescue Nest in Slovak republic was opened in Bratislava in Derer Hospital during
December 2004. The organiser is civil coalition „The chance for unwanted“ .
Women in critical situation must know: These places exist and they can postpone unwanted
baby into them, staing anonymous.
Nowadays are the rescue-nests in this towns:
Bratislava, Žilina, Prešov, Bratislava – Petržalka, Nové Zámky, Nitra, Trnava, Ružomberok,
Banská Bystrica, Košice, Dolný Kubín. Nonstop Helpline „Linka Hniezda záchrany – 0905
888 234 - is based to help for mothers in critical situations. Once happened – an obstetrician
instructed mother by phone what to do during her childbirth. He assured her to put the
newborn into the rescue nest in Nitra.
Psychology of the woman abandoning her baby.
This is very specific group of women living through pregnancy and childbirth, but
abandoning her baby after the delivery. There is a lead meaning in the society that only poor
woman can do this way ( these are most common cases), but there are appearing married
women from rich families, with good social background, too. The lower social status appears
as unsatisfying circumstances, poor lifestyle ( no good foods, smoking, ethyl, drugs, sexual
transmitting diseases), and last but not least the stress. The poor social situation we can point
also in case the woman is abused psychically or physically. The poor emotional and social
support, isolation, singleness leads to frustration of basal needs. The depression may occur,
Children born into these conditions are often born preterminally, with lower weight. The
trauma initiating the placental abruption occurs in the case of abused pregnant woman. Theses
mothers are often malevolent ad negative to child, often fail health care services
(RastislavovГЎ, 2008).
Pregnant women decided to abandon her baby often get ideas, if they really would be able to
do it. They are afraid if their doubt have not be been harming the child during pregnancy
already. They are afraid that their decision will persecute them until the end of their life or
about needs to get the child back or even search them. They are afraid of discrimination from
the society. I tis much easier covering-up pregnancy terminated by abortion than pregnancy
with childbirth. The way of life agenda, if is not compatible with matherhood, can also
influence the decisions. These woman often say they are absolutely no able to care the child in
future. Some of them dyslike having illegitimate child or having bad experience with
praevious abortion. If pregnant woman confesses she would abandon her stil unborn child,
there is very important giving her all the information offering her all alternatives she could
do, because she must very hard consider all the alternatives and decide what to do. This
woman must not get the silence and become depression. The specialistic help should be
offered her, we are to try to comprehend her. (MatД›jДЌek, 1999).
The effort to give the alterative for pregnant women or women very soon after the delivery ist
often ment to be the reason for acceptance - like aim to make possible one of the wais for
childbirth as well as anonymous child postponing . These women often choose worse
solutions, for instance abortion or they leave their newborn child in bad and dangerous
condition for life ( dust bin, empty space etc.) event thein murder /Martis, Breckwoldt,
Pfleiderer, 1997/.
The most iuportant reasons to child-postponing.
Low education, drugs abuse, bad financial condition; expected shame; fear from parents;
illegál stay in the state; religious moment – for example the muslims mustr not have coitus
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CLINICAL SOCIAL WORK (CSW)
before wedding; mothers who became pregnat after violation. We thing the nuber of reasons
is equal to number of children who were abandoned or postponed.
The possibility to secret or bear them anonymous is here for the first like the motivation for
unwanted pregnant women to choose better solution and bear in the hospital, where they
become all unavoidable helhealtcare. If is the child postponed elsewhere, although in the
place when somebody can find them ( police station, public space), such mother would be
punished and go to prison for 2 – 6 years /Random 1996/.
Reasons for and against
According to prepared project any woman could leave her child in the obstetric department
where the child had been born, without the risk she had been punished.
But the legislative change project nowadays prepared in the Slovak Republic, which makes
secret and anonymosu chilbirths possible, as well as anonynomous postpone of newborn,
brings dangerous message that leaving of newborn child can be morally accepted..
The legislative change shoud lead to lowering the number of arteficial abortion, abandoned
newborns in dangerous conditon and murder of newborn. We wish that these change will
make the situation better. But we have doubts based on foreign experiences if only the
legislative change is able to fulfill this purpose, especially according to dangerous moral
message hidden in them..
The acceptance of this legislative suggestion should be accompanied by wide discussion of
experts in gynecology, obstetrics , medical ethics, bioethics, psychology, psychiatrics,
teology, social work and lawyer.
What we must notice?
There is still no research supporting by evidence, that the possibility to bear anonymous or in
secret regimen really has decreased thenumber of arteficial abortion.
Respecting the law woman in Slovak Republic can ask for arteficial abortion until her
pregnancy is ot older than 12 weeks without the reason statement. The medical reason, mostly
genetic, is also accepted even till the week 24. The abortion must be provided legally,
however. But the legislative change suggestion does not fit any term until the pregnant
woman must decide /PonЕҐuch a kol, 1994/.
Experts who joined the study in the U.S.A and in Germany say: Hand to hand with the
possibility of anonymous childbirths and secret childbirth regimen and postponig the newborn
goes the start of creation a new group of clients. These woman start to enjoy new possibilities.
But these mothers in the case if they shoud not have this alternative would not abandon their
children or event kill them. They would probably give the children to legally adoption and
give all personal data legally. Since legalisation the regimen of secret childbirth and
anonymous postponing in Germany (since beginning 2000) can we see from the study realised
at The Hannover University, that he rescue-nests („Babyklappen“) and anomymous
childbirths caused until autumn of 2002 increasing the number of abandoned children really
up to 100 - 120. ( minimally up to 90). If these possibilities would not exist, these children
would be given to adoption /FriДЌovГЎ, 2004/.
The similar conclusion was given by Gouvernor of state Hawai, Mrs. Linda Lingle (in June
2003). Following Lingle: The society rather is to endeavour another way than legalisation of
abandoning children , for example education of young people not to become unwanted
pregnant. And when they have been pregnant already, give them support and consultations.
But reccomendation to an Adoption Agency is much better way then point them the
possibility to abandon the child.
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CLINICAL SOCIAL WORK (CSW)
The situation in Czech Republic.
Nowadays there are five various legal ways for child - postponnig. Woman can give the
newborn to Baby-box, take chance for secret childbirth, or discret childbirth, she can leave
herr child and give them for adoption or can give the child to Child endangered Foundation.
1. Baby-box
LudvГ­k Hess. Is the founder of Baby-box in the Czech Republic. The baby box is safe box
with constant temperature 37 В° C. The door can be only once opened. After its closing and
automatical system starts and calles the persnal of obstetric department. Newborn comes to
nursing hands in a few minutes, beeing ensured by healthcare and social care. The person who
had postponed the baby left without attention. The first baby-box was installed in Prague in
2005. Now there are 50 baby boxes in the Czech Republic and they have rescued up to 70
babies already. According the law we consider the baby as foundling. Woman who abandoned
newborn by this way can not be punished,
2. Secret childbirth
According to law 422/2004 Z. z. since 1. 9. 2004 in Slovak Republic the new possibility for
legal postpone the newborn was offered to women: she can ask for concealing her person
concerning delivery. She has to fulfill some conditions: She must declare her stay in Czech
Republic, she is unmarried or divorced and her former partrner can not be the farher of
the cocepted child. The personal data are not written into documents. The ftaher is in this
case unknownn, he can not be writtened into papers ,too. The secret childbirth can be
provided in all obsterician departmenst (HrabГЎk, 2004).
3. Discret childbirth
The idea i sused for childbirth in obstetrical department, which is located far from the usual
mother s stay. The newborn is left in this department and given to replacement care. The
operinatal and early postnatal care is provided identically like by any else childbirth, the
documentation is also identical. In case od dicret childbirth is the anonymity secured by
obligatory silention only. The child is written into the register in the born-place, but with
obligatory personal data of their parents.
4. The postpone of newborn at the neonatal department
If pregnant woman consideres to give newborn to adoption, she must that declare in the
moment of acceptance into obstetrics department. This application is written into
documentation. If the woman does not ask for secret childbirth, her initialles will be written
into documentation and register, as well the father s initialls. Before the departure from the
obstetrical deprtment is the woman visited by social nurse to make the consultation about the
reasons leading to postpone the child. If the situation is unchangeable, woman must sign the
agreement with adoption up to six weeks after the childbirth.
5. Anonymous giving the child to Child endangered Foundation
Since 2001 the Child endangered Foundation offers anonymous acceptance of newborn.
This is reachable 24 hours 365 days in the year nonstop. The acceptance is possible to arrange
until l hour, The child is considered to be foundling( JankЕЇ, 2007).
Conclusion
At the end there is one more dangerous aspect of secret and anonymous childbirths. The
Constitution of Slovak Republic in the Part 41 paragraph 4 declares: The child care is defined
as law of tehir parernts but also their duty. All given suggestions make possible to abandon
44
CLINICAL SOCIAL WORK (CSW)
this duty very easy. In general there is well known that law can influence the morals of the
society.. If is something possible by law, people begin succesively that accept like moral. So
this is the reason why this legislative change can be accepted strictly in the case, that would
be clearly and exactly shown the number of unwanted and unborn babies will decrease. If are
there existing doubts , our meaning is the society could not accept such suggestions because
of moral worths protection, but search other, better solutions – for example the improvement
of the system for mothers in trouble, improvement the possibility for giving the child for
adoption.
Do not forget about dangerous message: Abandoning of the child could become morally
accpeted.
Bibliography
DOLEЕЅAL, A. 2001. Od babictvГ­ k porodnictvГ­. 1. vyd. Univerzita Karlova Praha:
Karolinum, 2001. ISBN 80-246-0277-6.
FRIДЊOVГЃ, M.: 2004. AnonymnГ© a utajenГ© pГґrody a anonymnГ© odloЕѕenie dieЕҐaЕҐa. FГ“RUM
ЕЅIVOTA. ДЊ. 4/2004
HRABГЃK, J. 2004. UtajenГЅ porod jako novГЅ institut zdravotnickГ©ho prГЎva. ZdravotnictvГ­
a prГЎvo 10, str. 12-13
KAMENГЌKOVГЃ, M, KYASOVГЃ, M. 2003. OЕЎetЕ™ovatelskГ© diagnГіzy na porodnГ­m sГЎle.
Grada.
KÜMMEL, J., JANKŮ, P. 2007. Legální anonymní odložení novorozence – současné
možnosti v ČR. Praktická gynekologie 4, str. 174 – 176
MARTIS, G. BRECKWOLDT, M. PFLEIDERER, A. 1997. : Gynekologie a porodnictvГ­.
Martin, Osveta
MATEJДЊEK, Z. a kol. 1999. NГЎhradnГ­ rodinnГЎ pГ©ДЌe: prЕЇvodce pro odbornГ­ky, osvojitele
a pД›stouny. 1. vyd. Praha: PortГЎl, 1999. ISBN 80-7778-304-8.
PONŤUCH, A. a kol.: 1994. Gynekológia a pôrodníctvo. Martin, Osveta
RANDOM House, Inc. 1996. Zdravoveda pre Еѕeny. Media klub
RASTISLAVOVÁ, K. 2008. Aplikovaná psychologie – porodnictví. 1. vyd. Praha: Reklamní
atelier Area s.r.o. 2008. ISBN 978-80-254-2186-4.
ROZTOДЊIL, A. 2008. ModernГ­ porodnictvГ­. 1. vydГЎnГ­. Praha: Grada Publishing, 2008. ISBN
978-80-247-1941-2.
CONTACTS:
Prof. PhDr. Ivica GulГЎЕЎovГЎ, PhD.
Katedra oЕЎetrovateДѕstva, VЕ ZaSP sv. AlЕѕbety, n.o.,
Bratislava, Slovakia
PhDr. Vlasta DvoЕ™ГЎkovГЎ
VysokГЎ ЕЎkola PolytechnickГЎ, Katedra zdravotnickГЅch studii
TolstГ©ho 16, 586 01 Jihlava, ДЊesko
MUDr. JГЎn HruЕЎka
Zdravstav
MaroЕЎa MadaДЌova 1943/5
03401 RuЕѕomberok, Slovakia
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CLINICAL SOCIAL WORK (CSW)
ROLE OF THE CONTEMPORARY FATHER
Amantius Akimjak
Catholic University in RuЕѕomberok
ABSTRACT
Real fatherhood requires personal engagement, a will to overcome oneself, a just male
creative potential, as well as return to the real values, such as responsibility, courage,
sacrifice, humbleness, tolerance, etc. However, a lot of men prefer career and the responsible
fatherhood is thus shifted to the “unknown” times, yet to come. This study attempts to explain
the role of the father in the contemporary society and also to point out perception of this role
by the Church.
Key words
Father. Heavenly Father. Fatherhood. Spiritual Fatherhood.
Introduction
When analysing fatherhood in the 21st century we find out that the real contemporary
fatherhood is in a deep crisis. This crisis is caused not only by the nature and behaviour of
men themselves, but also by the crisis of marriage and family, which are the basis of each and
every successful fatherhood. Although a number of men have gone astray when carrying out
their fatherly roles, they have not lost a deep desire to have and bring up children. If we want
to think about the contemporary fatherhood, and if we want to look for the solutions of this
crisis, we should think back on what we were given from our parents, in order to be successful
parents ourselves.
Being a father does no longer mean to have the ruling say in the family, with an
unquestionable authority. Present-day fatherhood is more of a service to children. Let us talk
about fatherhood not as a role or function, passed on from generation to generation, but rather
as a vocation and profession.1 Some are asking the following questions: “Is it not too much
for one man? Responsibility at work, fulfilling of difficult work-related tasks, tough work
discipline … plus fatherhood?“ If we want to answer these questions, we have to clarify the
term of fatherhood, and also to take a look at the interpretation of fatherhood by the Church.
1. The term of fatherhood
Fatherhood refers to the biological relationship of the father and his children, strictly
speaking. However, its social and legal aspects are also relevant.2 Along with the process of
separation of private and public spheres during the process of industrialisation, men began to
leave home for work and their family role began to be defined as purely of bread winners.3
Since the end of the 19th century, the state began to intervene with the role of the father in the
family, whose role was reduced to purely an economic one.4
1
Augustyn, J.: Otcovstvo. Bratislava : VydavateДѕstvo DobrГЎ kniha, 2002, p. 328. (ISBN: 80-7141-382-8).
Badinter, E.: XY. Identita muЕѕa. Bratislava : Aspekt, 1999.
3
Bosý, D. – Brndiarová, A.: Rozdielne očakávanie mužov a žien od úlohy otca v rodine. Bratislava : man., 2001.
4
BunДЌГЎk, M.: JednokariГ©rovГ© alebo dvojkariГ©rovГ© manЕѕelstvo?: Postoje k deДѕbe rГґl v rodine. In: Mozaika
rodiny. Bratislava 2001.
46
2
CLINICAL SOCIAL WORK (CSW)
Traditional model of fatherhood is defined as the opposite of the idealised idea of
motherhood, with the fathers being defined as usually not present, distant, without a strong
sensual engagement in the relationship to children, etc. Newer approaches to fatherhood stem
from the belief that the presence of the father in the process of upbringing means an
improvement the quality of life of children, but also of men/fathers.5 An important factor of
the relationship between parents takes place when they have divided the chores of formation
of children evenly (with the emphasis of a common experiencing of everyday life). An
important input in the creation of conditions for a “new fatherhood” could be in such an
approach of the state, which would support and motivate men in their attitude to fatherhood.
2. Myths and reality of fatherhood
The future or new father has certain ideas of what constitutes being a father. These thoughts
stem from his own experience with his own father, and from the thoughts and expectations of
fathers. More and more fathers want to be a loving companion for their child, they want to
spend more time with their child, create a stable relationship with the child and keep it that
way. There are a number of definitions of “a good father”. These are more myths than reality,
each of them expressing part of the truth that they are hiding. Jana HГЅroЕЎovГЎ states the
following five myths.6
Myth no. 1 – Only the feelings of future mothers are important
Remarkable physical changes of the wife – mother and the preparation for the birth could lead
individuals to believing that the feelings of the mother are the only ones affecting the family.
Caring for the physical and mental health of the wife, of course before and after the birth, is
very important, but this is also the case with one’s own feelings.
It is simple to talk about the exciting aspects of fatherhood for the future father. It is far more
difficult – but evenly important – to talk about one’s fear and worries: Will I not faint during
the birth? Will there be complications? Will my relationship with my partner change after the
birth? How to align fatherhood with career?
The wife should know these feelings of her husband. A lot of men conceal their worries
concerning pregnancy and fatherhood, for they do not want to make it difficult for their wives.
However, majority of women desire such conversations and they know that the changes
brought about by pregnancy also relate to men – husbands. The way men manage to share
their worries with their wives can bring the partners closer together. They can exchange their
experience with other would-be fathers or they can read a good book about it. They should
allow feelings of vulnerability and worries. If they believe to be strong men, they are to lose
their contact with oneself. If they talk about their worries caused by pregnancy of their
partners, they will deconstruct the myth that men only accompany women during their
pregnancies.
Myth no. 2 – Infants do not need fathers
A strong bond between the wife – mother and the infant – which is created through
breastfeeding – can lead to the question, whether the baby needs the father at all. Fathers
should rest assured that they are needed. Fathers are an important in the life of their child and
children feel comfortable in their company. In order for the father to create such bond with
his child, he has to carry the child, swing him/her and talk to him/her. One has to wait until
5
Phares, V.: Conducting nonsexist research, prevention, and treatment with fathers and mothers: A Call for
change. In: Psychology of Women Quarterly 20, 1996, pp. 55–77.
6
Hýroššová, J.: Päť mýtov o otcovstve. In: Časopis mladej rodiny : mama a ja. Bratislava : vydavateľstvo Orbis
in, 2010, pp. 2-3.
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CLINICAL SOCIAL WORK (CSW)
the feeding is over and then capture the full attention of the child. When the father grabs the
child after feeding, he will enable the mother to rest a little.
Mothers can be helped also with feeding, if they do not breastfeed. Fathers can care for their
children also indirectly, by taking up the housework. If the mother does not have to spend
time doing the housework, she can spend more time with her child. They should think that it
will bring something to all members of the family.
Myth no. 3 – Fathers cannot handle young children
This is a massive lie, which discourages men from forming beautiful relationship with their
children. Besides this, it creates a sense of fear in the mothers that men are unable to care for
and protect their own children. Nowadays we know that fathers can become an important
person for their children. Parenthood is a job that can be learnt by anyone, both mothers and
fathers. If they spend time with their children, they tend to learn his/her needs very fast.
Myth no. 4 – Men who concentrate on their children fail at work
Men used to be often taught in the past that their self-esteem and respect come from their
work. This means that men who prefer their families to their jobs are not successful
professionally. However, presently we are experiencing major changes in the cultural norms.
A majority of men believe it important to have children, which elevates the status of fathers.
Some men sacrifice their careers for their time spent with the family, for here they see their
fulfilment, and not because they are unable to be successful on the job market. More and more
men believe that being a good father enriches their own life.
Myth no. 5 – Men want to behave the way their own father behaved in the past
The father will require a new experience when the son becomes father himself. At this stage,
it is absolutely natural to think about one’s own past, and whether one wants to be like one’s
father was. However, his father does not have to be his only role model. He should think of
everyone, who has cared for him, including teachers, priests, colleagues, uncles, brother etc.
He should create from all of these his own identity of the father. The American author, Dr
Bruce Linton found during his research no evidence of the matching model of the father.
Various cultures deal with this in various ways. In some African culture, “father” stands for a
whole array of men, not a particular one. Fatherhood is a social construct, which adapts to the
needs of each and every society. This is the way our fathers perceived fatherhood. For them
“being a good father” meant having a roof over one’s head, provide the family with food,
shelter and upbringing. Our fathers did not spend as much time with their children as we want
to spend with ours. However, they were performing duties they deemed best for satisfying its
needs in the same way. Now we have to decide what is best for the contemporary family. Let
us perceive fatherhood as a task, which we want to penetrate and the possibilities of which we
want to research. Doing this, we can apply and incorporate the positive aspects of our own
past.
On the basis of the aforementioned, Jana HГЅroЕЎЕЎovГЎ7 recommends future fathers the
following:
•
Find the time for thinking about the way that “becoming a good father” relates to you.
Share these feeling with your partner and other fathers.
Hýroššová, J.: Päť mýtov o otcovsve. In: Časopis mladej rodiny : mama a ja. Bratislava : vydavateľstvo Orbis
in, 2010, pp. 2-3.
48
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CLINICAL SOCIAL WORK (CSW)
•
•
•
•
Carry, swing and talk to the newly-born baby from his/her birth.
Learn to change the nappies, bath and feed the child. Be a part of everyday life of your
baby.
Think about the compromises in your career you are willing to make, in order to spend
time with your child.
Observe the things you like most about your own father, teachers, colleagues, friends
and relatives, in order to create your own identity of the father. Everyone caring for
you can become a good example.8
3. Fatherhood as perceived in the teaching of the Catholic Church
According to an old Piarist tradition, God is recognised in our turning to Him, in a
loving relationship, and it is possible to experience Him in a personal encounter. In the
contemporary society, which is losing the personal touch, which would provide this
experience in the personal relations, beginning with the family, a number of people will ask
the following question: Is it possible today to know God, who is revealed in His relationship
to people? Some would object that God can be recognised in nature, in the creation. But also
from the aspect of this ending period of history, which experienced the rule of the culture of
technologically deviated creation, industrialised, information and urban culture, there is a
number of generations, who have never experienced their authentic experience. It happens
often today that people found the infinite goodness and tenderness of God, who is the first to
come to them, only at the end of their dramatic and tragic journey, full of fraud and
disappointments.
It is thanks to the fact that God is far from knowledge, or it is the nature of living as if
God did not exist, an experience of a schizophrenic personality takes place. We are forced to
constantly change our behaviour according to various circumstances, our life is controlled by
a number of desires, everything becomes an illusive moment, and through sticking to one’s
own ego and concentrating on a given moment, which must be followed by another one, in
order to overcome the most frequent enemy – boredom, stereotype and oblivion. Our memory
is distant from God, who is Love, the Charitable God; our memory becomes a memory of a
computer, which keeps to be erased, in order to be able to free itself. That is why it becomes
our demon, it haunts us and we have to put in all our strengths and effort to silence it. In the
era of mass media we must state that we live the era of information inflation about evil. In the
ever narrower tunnel, in the culture characterized by closing up of oneself, in this chaos of
subjectivism, in which the world becomes relative and not even the human life presents the
highest value, we become the witnesses of nostalgia for old times, which seemed to have been
buried for good a few years ago.9
Spiritual father and his inevitable traits
In this context, the Church wants to become a new force in the consciousness to
preach Christ. The aim of this is to initiate new evangelisation, stemming from a powerful
message. Without it, the new gospel will be unable to pursue its own mission in the deChristianised Europe. The tradition perceives the spiritual fatherhood as a gift of the Holy
Spirit, as an exceptional charisma (the East – the Elders, the West – Spiritual Leaders). In the
Hýroššová, J.: Päť mýtov o otcovsve. In: Časopis mladej rodiny : mama a ja. Bratislava : vydavateľstvo Orbis
in, 2010, pp. 2-3.
9
Porov.: Rupnik, M. I.: O duchovnom otcovstve. Olomouc : C. Aletti, 2001.
49
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CLINICAL SOCIAL WORK (CSW)
light of Vatican II, it is the vocation of each and every Christian to become a spiritual father.10
It is however not easy to find a good spiritual father. Marko Ivan Rupnik in his work on
fatherhood claims that no Christian, undertaking spiritual accompanying, a father or a
spiritual father, should lack the following characteristics11:
Spiritual father is a person full of the Holy Spirit: spiritual father is someone who,
through the great force of the Holy Spirit gives birth to people for God. The aim of a real
fatherhood is to give life.
Spiritual father is a person knowing the hearth: The Holy Spirit, who explores the
depth of God and gives the life to the Holy Spirit, is someone who opens the human heart for
the spiritual father.12 There is nothing magical or strange about it. This heart diagnosis is
nothing but an intuition of love for the person. Thanks to love we know other people in the
right way and real way, not in the abstract way. The more we love the more we know the
others.
Spiritual father is a person who differentiates: he is the teacher in the creation of
encounters between human beings and God by doing good deeds, and by knowing both of
them in their mutual getting nearer to one another. The accompanying force in this is the
differentiation, affective and rational moderation.
Spiritual father is someone who teaches and applies tradition: he does not act for his
own benefit, the less he boasts about his own charisma and he relies only on his own intuition.
It is usually linked to a deep humbleness, study, reflection and a certain gift of being able to
teach. When the spiritual father preaches, a number of friends of the distanced past are present
in his words, who are made present as if they were his counterparts. The whole Church is
embodied in the spiritual father. This is the major difference between the spiritual father and a
guru.
Spiritual father is someone who serves God and the persons close to God. Spiritual
father is not oriented to oneself, to his teaching or wit, but he is in the position of submission
to God. He is someone who acts according to the will of God and is turned to those whom
God wants to touch Himself.13
Spiritual father prays with others and for others. He accompanies people who have
entrusted themselves to him through a permanent prayer, he is joined with them at heart; he
prays with them, he invokes his blessings and the love of God onto them.
He can be called the spiritual father only by others. No one proclaims himself a
spiritual father and no one promotes himself to be one. This person can be recognised by the
worn off of his house’s threshold and by the life of his spiritual sons.14
No one, who is called upon to be a spiritual father, should be afraid on the basis of
perfectionism, and he should not become a moralist. It is important that although a spiritual
father does not posses many of the above stated qualities, he should poses at least some of
them, and that his future development takes place within the above notions
10
Porov.: DOKUMENTY DRUHÉHO VATIKÁNSKEHO KONCILU. Citta del Vaticano : Acta Apostolicae
Sedis et LВґOsservatore Romano, 1963-1965. Slovak translation: KBS. Trnava : SSV, 2008.
11
Cf.: Rupnik, M. I.: O duchovnom otcovstve. Olomouc : C. Aletti, 2001.
12
KATECHIZMUS KATOLГЌCKEJ CIRKVI. Citta del Vaticano : Libreria Editrice Vaticana, 1997. Slovak
translation: KBS. Trnava : SSV, 1999, art. 239.
13
KATECHIZMUS KATOLГЌCKEJ CIRKVI. Citta del Vaticano : Libreria Editrice Vaticana, 1997. Slovak
translation: KBS. Trnava : SSV, 1999, art. 270.
14
KATECHIZMUS KATOLГЌCKEJ CIRKVI. Citta del Vaticano : Libreria Editrice Vaticana, 1997. Slovak
translation: KBS. Trnava : SSV, 1999, art. 2214.
50
CLINICAL SOCIAL WORK (CSW)
The work of the spiritual father
A witness of charity. It is an evidence of the aspect of Jesus Christ. This point of view
accompanies Peter the Apostle during the three years of their common wandering up to the
court of the prince, where it struck him in all its depth. Spiritual father rules on sins, not the
sinner, his face reflects the spirit of acceptance without tiredness or limits.
The middleman. It is impossible to capture all and collect everything that they have
lost. He is turned to his Father himself, he attempts to give further to the upcoming person that
he has contemplated. We shall become spiritual fathers to that effect to which we learn to
perceive the world through the eyes of the Father.
Faithfulness as a relationship trial. Faithfulness is the fundament of interpersonal
relations. The more mature and purer the love is, the more true it is. Once faithfulness has
been lost, people cannot talk about love anymore. For the spiritual father has experienced the
mercy of the Father, therefore he himself offers a true and merciful relationship to the person,
he has been entrusted with.15
Entrust the life of others to God. Thanks to a permanent internal contemplation, and a
permanent openness to the Holy Spirit, the spiritual father entrusts and gives to the Father
everything that He can see, hear or learn. He points out to the internal connection between
various pieces of experience, which fill one to another, provided that the stuff they are
experiencing is open to God. And through the art of distinguishing, it helps the individual to
decipher the speech, through which God talks to him, which is being uncovered in the life
events for the word of God that has been dedicated to him. In this way, human beings through
the spiritual father will be able to perceive their life as one accepted and embraced in an
extremely warm welcome in the heart of God. Last but not least, it is not the spiritual father,
whom he experiences in love that is not a judgmental one, but the Heavenly Father Himself,
who is the only way of change and growth – realisation of a man, which will not be neither
forced nor authoritarian and violent.16
Recovery of the mind. Contemporary human beings need to meet someone, who will
accept them without asking them where they have been, what they have been up to, why they
are so dirty, but quite on the contrary, he will give the human being courage through
preparing of a similar feast that the father had prepared for the prodigal son, not mentioning
his sins. The deepest knowledge of God is the knowledge through forgiveness. Spiritual father
is the image of this mercy. In the same way, father of the family should be such image.17
Help the encounter of human beings and God. In the same way as the Son of God
helped the people to know and love God, in the same way every father of the family, but
especially the spiritual father in the parish family is obliged to help his children, his spiritual
children to meet God.
Obstacles, which should be omitted by fathers and spiritual fathers
Spiritual father can never replace Jesus Christ. He cannot assume the role of the Holy
Spirit, and lead the thinking of the man step by step. He cannot become the light, which
would illuminate the one that has been entrusted to him. In the same way as the pathological
dependence on him – this is a real block in the faith.
15
KATECHIZMUS KATOLГЌCKEJ CIRKVI. Citta del Vaticano : Libreria Editrice Vaticana, 1997. Slovak
translation: KBS. Trnava : SSV, 1999, art. 2367.
16
KATECHIZMUS KATOLГЌCKEJ CIRKVI. Citta del Vaticano : Libreria Editrice Vaticana, 1997. Slovak
translation: KBS. Trnava : SSV, 1999, art. 2368.
17
DOKUMENTY DRUHÉHO VATIKÁNSKEHO KONCILU. Citta del Vaticano : Acta Apostolicae Sedis et
LВґOsservatore Romano, 1963-1965. Slovak translation: KBS. Trnava : SSV, 2008, Lumen gentium 35.
51
CLINICAL SOCIAL WORK (CSW)
A partial mistake is to be impressed by the person, who suffers and the will to deal with the
person at the human and spiritual level.
Another mistake is when one is concentrated on something that the spiritual father is saying,
not on God and His word.
The biggest mistake is to remain in the past through investigating the person and dealing with
various cases.
“New evangelisation that Popes John Paul II and Benedict XVI are constantly imploring us to
undertake, mainly rests upon accompanying of a human being struck by the experience of
love.“
Marko Ivan Rupnik also talks about some impulses and particular encounters: during
listening to prayer and especially not judging. He highlights the spiritual fatherhood, which
educates toward the Church, it orients us toward the community and it shapes us for the
community. It helps us to accept the Church and live in it, which is the true rebirth of man.
4. Optimistic examples
The following life experience talks about a father – businessman, about whom a
woman, colleague, businesswoman, speaks in the following way: “In the telephone call, the
colleague of the father, a businessman, heard the following: … OK my dear, I shall come to
pick you up. Do you have that badminton, right? … And what about school, etc. My heart was
embraced by love, states further the colleague. These words expressed a colleague of mine,
when he was talking on the phone to his school-age daughter. He is a father of four now. The
youngest is 2 months old and the remaining three are of school-age. He is very busy, because
of his business activities, for he is an entrepreneur and skipping work because of the family.
These words, which he uttered, might seem normal and meaningless… but they were full of
love and care. I felt very thankful for them and I was thanking him in spirit for his fatherhood.
I thought of my own children, who were brought up without such expressions, and I
am not talking only about my own children. There is a number of children, who are not given
love by one of the parents, usually the father. Also mothers are sometimes irresponsible and
without feelings. A number of children grow up as orphans, although their natural parents
exist. You are not going to find the expression of a happy child in their look. You will
encounter fear; their eyes have a great depth, for they express a deep sadness. And so, when
we perceive fatherly love, thankful eyes of children, who can turn their eyes anywhere, for
they will meet the loving eyes of their father, I cannot but thank you my dear fathers.
You, who dedicate yourself to your children with love, you, who have not impoverished your
children, who are not looking into the bottom of the glass in a cold environment of the pub,
where all kinds of love are slaughtered by addiction, you who entrust your children to God,
you who are an authority to your children, and authority built on love. You, fathers governed
by the Holy Spirit, give us all a remarkable gift in your children. We thank you” – as much
the colleague of the father – a businessman.
Renewing of fatherhood requires a great deal of personal engagement, a will to
overcome oneself, a real manly creative approach, as well as coming back to spirituality and
religion. A very famous monograph of father Augustine on fatherhood is aimed at a broad
range of readership: men preparing for a married life, men who are bringing up children,
priests and family counsellors.18
Conclusion
Situation in contemporary Europe is characterised by a postmodern human being
finding him/herself in a state of detachment of objectivity – being detached from life, being
18
Augustyn, J.: Otcovstvo. Bratislava : VydavateДѕstvo DobrГЎ kniha, 2002, pp. 328. (ISBN: 80-7141-382-8).
52
CLINICAL SOCIAL WORK (CSW)
imprisoned by a number of systems and numerous intellectual, sociological, scientific,
political and cultural structures, which are not giving him/her a chance to breathe in – people
become limited and without a chance to develop. We find ourselves in the time of looking for
a remedy. The modern age promised individual happiness based on an economic welfare, and
now we experience sadness of this false expectation. We live in a society filled by things, but
we are disappointed for we are not happy. By the fact that the rationalistic and overtechnological society gave rise to a life of a material culture, the realm of relationships, the
dimension of love was left limited, deprived of the possibility to be materialised. If the
contemporary society wants to improve this situation, it has to start from the word go, i.e.
from the father in the family. As an example we should consider the Heavenly Father, who
gave us His only Son for the love of mankind, who constantly pointed out His Heavenly
Father. I and my Father are one. Therefore, contemporary family should be healed by a great
help of the father, who wants to be not only a physical, but also a spiritual father to his family
and he receives his strength from the Heavenly Father.
REFERENCES
Sources:
KATECHIZMUS KATOLГЌCKEJ CIRKVI. Citta del Vaticano : Libreria Editrice Vaticana,
1997. Slov. preklad: KBS. Trnava : SSV, 1999.
DOKUMENTY DRUHÉHO VATIKÁNSKEHO KONCILU. Citta del Vaticano : Acta
Apostolicae Sedis et LВґOsservatore Romano, 1963-1965. Slov. preklad: KBS. Trnava : SSV,
2008.
Literature:
AKIMJAK, A.: Vybrané kapitoly z pastorálno-liturgickej teológie. Spišská Kapitula –
SpiЕЎskГ© Podhradie, 1997.
AUGUSTYN, J.: Otcovstvo. Bratislava : VydavateДѕstvo DobrГЎ kniha, 2002
BADINTER, E.: XY. Identita muЕѕa. Bratislava : Aspekt, 1999
BOSÝ, D. – BRNDIAROVÁ, A.: Rozdielne očakávanie mužov a žien od úlohy otca v rodine.
Bratislava : man., 2001.
BUNДЊГЃK, M.: JednokariГ©rovГ© alebo dvojkariГ©rovГ© manЕѕelstvo?: Postoje k deДѕbe rГґl v
rodine. In: Mozaika rodiny. Bratislava 2001.
PHARES, V.: Conducting nonsexist research, prevention, and treatment with fathers and
mothers: A Call for change. In: Psychology of Women Quarterly 20, 1996, s. 55–77.
HÝROŠŠOVÁ, J.: Päť mýtov o otcovsve. In: Časopis mladej rodiny : mama a ja. Bratislava :
vydavateДѕstvo Orbis in, 2010
RUPNIK, M. I.: O duchovnom otcovstve. Olomouc : C. Aletti, 2001.
Contact:
Prof. PhDr. ThDr. Amantius Akimjak, PhD.
Catholic University in RuЕѕomberok
Faculty of Education
HrabovskГЎ cesta 1
034 01 RuЕѕomberok
[email protected]
53
CLINICAL SOCIAL WORK (CSW)
PROTECTION AGAINST LEGALIZATION AND TERRORIST
FINANCING
Jozef ДЊenteЕЎ
Office of the General Prosecutor, Bratislava, Slovak Republic
Department of Criminal Law, Criminology and Criminalistics
ABSTRACT
Money laundering issue is one of the key questions in the Slovak Republic. Protection against
this phenomenon requires adoption of several efficient legal regulations and creation of
institutional measures. In the article, the attention is paid to Slovak legal regulation aimed to
protection against money laundering. Also, the article underlines how important is that
obligated persons fulfill their obligations imposed in order to counter money laundering.
Key words
legalization, terrorism financing, money laundering, protection, law, obligated persons,
unusual commercial operation, reporting, notification
One of the present issues, on which much attention is concentrated in the Slovak
Republic, is the problem of protection against legalization of revenues from criminal activity
(hereinafter referred to as legalization) and the financing of terrorism. The so called money
laundering and financing of terrorism represent a menace which must be eliminated through
palpable institutional measures on the national and on the international level. The
international community intensifies the steps to adopt effective measures which shall secure a
better protection1) and will enable a coordinated action of the whole community against
legalization and terrorism financing.
Because of these reasons an important role is played by international documents, where
the philosophy of the community tendency to encounter these negative effects is regulated.
We count to the most important international documents which are a „way out“ for the Slovak
legal order: United Nations Convention against Illicit Traffic in Narcotic Drugs and
Psychotropic Substances, United Nations Convention against Transnational Organized Crime,
Council of Europe Convention on Laundering, Search, Seizure and Confiscation of the
Proceeds from Crime and on the Financing of Terrorism and 40 Financial Action Task Force
(hereinafter referred to as ,,FATF“). From the point of view of the European Union the most
important documents are Directive of the European Parliament and the Council 2005/60/EC
adopted on 26 October 2005 on the Prevention of Money Laundering and Terrorist Financing
(hereinafter referred to as Directive 2005/60/EC“), Directive of the Commission 2006/70/EC
adopted on 1 August 2006, by which the executive measures of the Directive 2005/60/EC are
adopted, while there is the definition of the ,,politically exposed person“ and technical criteria
of the process of the facilitated obligatory care in the relation to the client and exceptions on
the basis of financial activities executed from time to time or in a very limited way
(hereinafter referred to as „Directive 2006/70/EC“) and the Framework Decision of the
Council 2002/475/SVV adopted on 13 June 2002 on Fight against Terrorism (hereinafter
referred to as Framework Decision of the Council 2002/475/SVV). 2)
From legal instruments eliminating the mentioned problem the article concentrates on
the Law no. 297/2008 Coll. on Protection against the Legalization of the Income from
Criminal Activity and on Protection from Financing of Terrorism and on amending other laws
(hereinafter referred to as “Law on Protection against the Legalization of the Income from
Criminal Activity and on Protection against Financing of Terrorism“).
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CLINICAL SOCIAL WORK (CSW)
I. Law on Protection against the Legalization of the Income from Criminal Activity and
on Protection against Financing of Terrorism
Law on Protection against the Legalization of the Income from Criminal Activity and on
Protection against Financing of Terrorism that entered into force on 1 September 2008 is the
basis for the non-criminal regulation in the Slovak Republic.
I.1 Chosen provisions of the Law on Protection against the Legalization of the Income
from Criminal Activity and on Protection against Financing of Terrorism
I.1.1 Legalization
Notion of ,,Legalization“ is the pillar of the Law on Protection against the Legalization
of the Income from Criminal Activity and on Protection against Financing of Terrorism. The
provision of section 2 paragraph 1 regulates the intentional behaviour which is one form of
active behaviour as stated in section 2 paragraph 1 letters a) to c) as being accomplice in this
kind of action and this in form of grouping, aiding, abetting and inciting as well as in the case
of attempt (section 2 paragraph 1 letter d/). Definition of legalization comes from the notion of
money laundering in the article 1 paragraph 2 of the Directive 2005/60/EC. Notion of
legalization and money laundering are almost identical thereinafter synonyms. Money
laundering is however too expressive and familiar. Standards of the Slovak legal terminology
are met with the notion of legalization, which is used in this article.
Legalization is an activity, of which the goal is to cover the existence of property
coming from illegal activities or cover up operation for the purposes of hiding the illegality of
its origin, determination or its clearing from the illegality which comes because of its illegal
origin, determination or use and its use in a way as a legitimate origin.3) From the
abovementioned one can infer that legalization is an activity by which the activities of
criminals are covered. Activities through which the criminals illegally acquired an income,
property or other rights.4) After receiving the income, property or other rights, the essence of
legalization is realised, which is the cover up of illegal activities, creating the cloth of legality
and investment of illegal finances through legal economics. Legalization is preceded by other
means of criminal activity that is generating income, which are subsequently legalized.
Sometimes the act of legalization helps to uncover former crimes, which could be
complicated through the work done by the criminal. The suspicion of legalization is usually
made by unusual commercial operations.
When dealing with legalization, it is not decisive, whether the illegal activity generating
property was done on the territory of the Slovak Republic or on the territory of another
country. Legalization does not recognize borders and limits between countries. Legalization is
an international (or transnational) act, that misuses the existence of state borders, geographic
distances between states and the existing differences (different legal orders, economic
systems, organization and functioning of state organs, institutions etc.5)
I.1.2 Financing of Terrorism
Law on Protection against the Legalization of the Income from Criminal Activity and on
Protection against Financing of Terrorism reacts also to the danger that is caused by terrorism.
One of the decisive aspects of the fight against terrorism is limiting its financing. The
preventing and uncovering of financing of terrorism has its specifics, that were attached to the
legislation created in consent with the legal order of the European Union.6) Under section 3 of
the Law no. 297/2008 Coll. the notion of „Financing of Terrorism” means providing or
accumulating finances with the intent to use them or with the knowledge that they shall be
used fully or in part to commit one of the enumerated crimes (section 3 paragraph 1 letter a/)
or b/ or inciting , aiding and abetting the person to commit ( to attempt to commit) one of the
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CLINICAL SOCIAL WORK (CSW)
stated crimes (section 3 paragraph 1 letter a/) or b/ with the goal to commit the crime of
establishing, organizing and supporting a terroristic group or crime of terrorism.
The legal regulation that defines financing of terrorism does not take into account the
origin of the finances and the fact whether the finances come from illegal activities as it is
foreseen in the case of legalization. In the case of financing of terrorism the willingness of
owners to sacrifice 30 – 40 per cent of the finances is not present. The need to legalize
increases with the amount of money and for the financing of a terrorist act a relatively small
amount of money suffices. For example during the terrorist attack on the traffic in London in
2006 only an amount of several thousands pounds was needed.7)
I.1.3 Unusual commercial operation
Another key term of Law on Protection against the Legalization of the Income from
Criminal Activity and on Protection against Financing of Terrorism is the notion of unusual
commercial operation (hereinafter referred to as „UCO”), which is a legal act or other act, that
implies that through its commitment the legalization or financing of terrorism might have
been committed (section 4 paragraph 1). The definition of UCO states the amount of the
legislative understanding of this term. At the same time one can positively say that the Law
enumerates particular cases which may be understood as UCO (section 4 paragraph 2).
Taking into regard the broad circle of persons and their profession the list of activities
can be regarded as demonstrative. This regulation is logical as it is a highly sophisticated and
dynamic issue, which does not enable to come with an exhaustive list; becasue of these
reasons it was not possible to react to all the forms and methods of legalization and financing
of terrorism that could occur in practice.
I.1.4 Obliged persons
The fulfilling of duties stated in the Law on Protection against the Legalization of the
Income from Criminal Activity and on Protection against Financing of Terrorism foresees an
early uncovering and announcing of UCO. The responsibility lies with the obliged persons
(section 5), that because of their experience relating to legal and natural persons, with which
they do business (section 9 letter h/) will determine if it was a usual or unusual transaction.
The term of business combines the terms of commerce, commercial operation and property
that are used in the Law8). In this way the ambiguity is cleared whether commerce is also
a commercial operation, or buying and selling property that is done by the client on his/her
own behalf.
The decisive criterion to classify the subjects between obliged persons is that when
executing ones’ profession and ones’ activities, they encounter realities that evidence that
there is a case of legalization or financing of terrorism. From this list of obliged persons
(which is demonstrative because under section 5 paragraph 1 letter o/ obliged person is also
a person if it is stipulated by another law) one can infer that the legislator wanted to regulate
all of the possible cases, fields and activities in which there is a real possibility of establishing
of these undesirable acts. In section 5 of the Law 297/2008 Coll. the obliged persons are
mentioned which are in the preventive way the most important, i.e. credit and financial
institutions and other legal and natural person which are regulated by the Law.
I.1.5 Politically exposed person
Law on Protection against the Legalization of the Income from Criminal Activity and on
Protection against Financing of Terrorism regulates in the Slovak legal order the notion of the
politically exposed person (section 6). The mentioned term is the incorporation of the
Directives 2005/60/EC and 2006/70/EC. This term can be applied to politically exposed
persons that do not have domicile on the territory of the Slovak Republic. The persons are
56
CLINICAL SOCIAL WORK (CSW)
concerned that hold important public positions with nationwide or worldwide importance.
To decide whether a person is or is not politically exposed (this person can be also a foreign
national) one needs to find out information whereas it is important to use publicly available
sources of information or the information from other obliged persons. For this purpose we can
use also commercial lists. The obliged person needs however to have the risk process
evaluation whether a person is politically exposed. When identifying close collaborators on
which political functions were bestowed, it is foreseen that the relation with the collaborator is
publicly known, or the obliged persons have reason to suppose that such a relation does exist.
I.1.6 Due care of the obliged person in the relation to a client
In the second part of the Law on Protection against the Legalization of the Income from
Criminal Activity and on Protection against Financing of Terrorism a basic, facilitated and
qualified care is defined.
Law on Protection against the Legalization of the Income from Criminal Activity and on
Protection against Financing of Terrorism regulates the particular cases when the obligation
arises in the relation to a client as a basic care (customer due diligence) and defines the range,
that is applied by the obliged person on the basis of its qualified consideration concerning the
risk of legalization or the financing of terrorism..
Not taking into account cases when the obliged person must apply the basic care, there
are cases when the client must be identified and verified whether the data were acquired
without the duty to apply the respective case. The provision of section 10 differentiates the
cases when the duty to identify the client (section 7) and verify (section 8) the acquired data
without the duty of basic care arises. The fulfilling of the basic duty is realized through the
handover of the data and documentation that the client is obliged to provide to the obliged
person when executing the basic care.
Facilitated care is taken into regard in cases when the obliged person is not obliged to
execute the basic care. It is the case of clients that are obliged persons and products that are
not likely to be misused for legalization or financing of terrorism (section 11). The exceptions
from the basic care do not mean that the obliged person has no duties. The person is obliged
to examine whether the requirements are met to apply the facilitated care (for example in the
situation when the client is present, he/she must be identified and it must verify the acquired
data and should examine whether the planned business transaction is a usual one or unusual
one.
Law on Protection against the Legalization of the Income from Criminal Activity and on
Protection against Financing of Terrorism regulates the duty to pay special attention to all
complicated, unusually big transactions and also to the risk of legalization or financing of
terrorism that can arise from products, business transactions or technological innovations.
When higher risk of legalization or financing of terrorism is in question the obliged
person applies qualified care. In this case the obliged person decides the range of the qualified
care according to the qualification of risk (section 12). There are cases however when the
qualified care must be executed at all time (for instance if the client is a politically exposed
person or if the client is not present for the purposes of identification or verification).
As far as the mentioned facts are stated one needs to suppose that the actual execution of
one of the types of the care enables to uncover the UCO. Because of these reasons the person
focuses all of his/her attention on each risk of legalization or financing of terrorism that can
be identified while exercising its duties.
I.1.7 Other duties of the obliged person
Law on Protection against the Legalization of the Income from Criminal Activity and on
Protection against Financing of Terrorism imposes other duties on the obliged person:
a) Examining the UCO (section 14)
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CLINICAL SOCIAL WORK (CSW)
b) Refusal of concluding business transaction, breaking the business relation or refusal to
execute a transaction (section 15)
c) Withholding UCO (section 16)
d) Announcing UCO (section 17)
e) Remain silent about the UCO (section 18)
f) Programme of ones activity (section 20)
g) Other obligations of the obliged person (section 21).
Ad a) Examining the UCO (section 14)
Examination of the UCO is regulated in section 14. The examination of transactions
enables to search for UCO. The obliged person will focus on the unusual big transactions,
transactions of unusual nature as well as on the risk of legalization and financing of terrorism,
which can be identified while exercising his/her profession.
Ad b) Refusal of concluding business transaction, breaking the business relation or
refusal to execute a transaction (section 15)
The legal possibilities of the required refusal are not regulated in the business sector in a
clear way and because of this reason the prevention is regulated in a specified way. The list of
reasons to refuse is defined by the Directive 2005/60/EC. In particular we can state that the
Law on Protection against the Legalization of the Income from Criminal Activity and on
Protection against Financing of Terrorism impose this obligation only when and because of
reasons that are on the side of the client and it is not possible to deliver or execute the basic
care (section 10 particularly letters a/ - c/). This applies also in case when the client refuses in
front of the obliged person to declare on behalf of whom he acts.
Ad c) Withholding UCO (section 16)
The obligation to withhold the prepared or the executed UCO is of great importance in
the relation to the early reaction and efficiency of measures that can be executed by the
financial service within a day after announcement. Law on Protection against the Legalization
of the Income from Criminal Activity and on Protection against Financing of Terrorism
regulates the process in case when there is real danger that by executing the UCO a seizure of
funds from criminal activity or funds to finance terrorism will be impossible. Then the obliged
person withholds the UCO until the written announcement is acquired. The longest period
however is 48 hours since the acquirement of the announcement of the UCO by the financial
service. If the financial service demands the withholding of the UCO in writing, the 48 hours
period starts to run since the moment stated in the written demand (usually it is the moment
when the client submits the notion for transfer of a business transaction (for example cash
withdraval). The maximum period of withholding can be 72 hours (48 hours + 24 hours).
In case of withholding a UCO, one takes into account the technical and running details
of the obliged person. If these do not enable to withhold the UCO, then they will not be
withheld. The Law regulates the act of non-withholding of the UCO in the case, when after a
warning by the financial service the act of withholding would disable its manipulation.
Ad d) Announcing UCO (section 17)
The obligation to withhold the UCO is narrowly connected with the obligation of
announcing and the attempt to execute it. Law on Protection against the Legalization of the
Income from Criminal Activity and on Protection against Financing of Terrorism does not
regulate a period for announcing a UCO; under section 17 paragraph 1 UCO must be
announced without undue delay, i.e. as soon as possible.
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The way and the content of the announcement require an analysis of the transaction by
the obliged persons. It is up to the obliged persons when there is a case of a usual or an
unusual transaction. The obliged person applies the principle “know your own client” which
enables the obliged person to recognize when a transaction is unusual, i.e. through the usual
contact with the client, overview of his/her usual transactions or his/her financial
development.
At the same time the Law lays down in section 17 paragraph 2 and 3 the fulfilment of
the obligation to announce and the formal requirements of the announcing of the UCO. The
range of identification data is defined with the purposes to document the activity of specified
natural and legal persons in a way that they will not be doubts, who executed the particular act
and for the purposes to secure evidence in writing that can be used in criminal investigation
and trial. The Law distinguishes between the identification of the client and verification of the
acquired data. The identification and verification of the client will be realized in one single
step. The obliged person when fulfilling the announcing obligation is examining anomalies
that by their nature, contents or its exceptionality do not match the usual profile or
characteristics of transaction of a specified client. A demonstrative list of UCO mentioned in
the Law enables the obliged persons to focus their attention on the most important aspects
when examining the transaction.
For the sake of protecting the employees as it is foreseen by the Directive 2005/60/EC,
the announcement does not content the data on the employee, by which the UCO was
determined. The financial service accepts, evidences, checks and uses the UCO
announcements for fulfilling its duties laid down in the Law of the National Council of the
Slovak Republic no. 171/1993 Coll. on Police as amended. In this context it is important to
highlight that the act of announcing the UCO to the financial services of the police is not
protected by the legal obligation to remain silent according to section 17 paragraph 6 of the
Law no. 297/2008. The Law stipulates a certain difference in the case of attorneys and
defence counsels.
Ad e) Obligation to be taciturn about the UCO (section 18)
The purpose of the Law on Protection against the Legalization of the Income from
Criminal Activity and on Protection against Financing of Terrorism would have remained
unfulfilled if it had not regulated the obligation to remain silent about the announced UCO.
This obligation applies to a third person including the person which is directly affected by the
UCO. This obligation does not apply to the obliged person, if the employee acts under the
rules of the obliged person, which regulate the process of prevention of legalization and
financing of terrorism. The employee must know to whom he may pass the information about
the UCO within the structures of the obliged person. If he/she discloses the information to
a person, which was not designed by the obliged person, the obligation to remain silent would
be violated. The obliged person by regulating the protection of data that can refer to the UCO,
defining the flow of information and by other measures, increases the protection of employees
who participate in uncovering the UCO. The obligation to remain silent applies also to
employees of control organs.
The legal regulation in the Law determines when the financial unit deprives the obliged
person of the obligation to remain silent. When depriving someone of the obligation to remain
silent, one decides for a process that cannot endanger the measures that were already adopted
to fight legalization or financing of terrorism.
For the sake of a more effective process in the prevention of legalization and financing
of terrorism, one limits the ban on exchange of information about the UCO between
institutions that are business and credit interconnected and also between obliged persons that
are taking part in a business operation of the same client. This exchange of information
enables the obliged person to examine the businesses of the client in a more effective way and
also to warn other obliged persons about the risk identified. At the same time the Law
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regulates that the obliged persons can deliver information without the consent of the involved
persons (section 18 paragraph 9).
Taking into regard that the state organs that fulfil the tasks in the field of the
constitutional organs, domestic order and state security acquire information as stated by Law,
the particular obligation to remain silent about the information and documentation from the
Financial Unit is regulated.
With the obligation to remain silent the analysis and storing of data is connected (section
19). The obliged person can acquire personal and other data that are necessary to execute the
relevant care, only according to the Law no. 428/2002 Coll. on Protection of Personal Data as
amended. Because of this the Law on Protection against the Legalization of the Income from
Criminal Activity and on Protection against Financing of Terrorism stipulates the range of
data, the purpose of its analysis and the list of the persons connected.
The great amount of acquired and stored data enables to document and go back to
business transactions and acquire written evidence for the purposes of criminal investigation
and trial.
In some well reasoned cases the financial unit can impose the obligation to store data
and documentation over the obliged person for a period longer than five years. The reason for
this regulation is to prevent the destruction of written evidence. The obligation to store the
data and written documentation in the stipulated period does not finish for a businessman
when he stops being a businessman.
Ad f) The programme of the obliged person’s activity (section 20)
For the purposes to secure the application of the Law on Protection against the
Legalization of the Income from Criminal Activity and on Protection against Financing of
Terrorism the obliged person is bound to come with a programme of its own activity.
According to the requirements of the Directive 2005/60/EC and on the basis of real
experience, obligatory parts and duties are defined as far as the relation to the employees is
concerned. From the legal regulation in the Law one can infer the obligation to elaborate the
mentioned programme in writing, whereas it must be accessible to the employees of the
obliged person.
The obliged person updates the programme of its own activity according to the object
of its business and according to the valid and effective legislation. One can state that it is up to
the financial unit and the obliged person that come into contact with the UCO to identify and
to define the forms and methods of the UCO and to prepare its employees for the obligations
stipulated in the Law on Protection against the Legalization of the Income from Criminal
Activity and on Protection against Financing of Terrorism (section 20 paragraph 3). We deem
this provision very important when we take into account the activity of banks that are
governed by the section 23 paragraph 1 letter h (...) the competence and liability for the
protection against legalization and financing of terrorism.“.
Ad g) Other duties of the obliged person (section 21)
Taking into regard the fact that the financial unit has to fulfil tasks that are imposed by
the Law when protecting against legalization and financing of terrorism, the new regulation
comes with new duties for the obliged person (section 21), which enables the financial unit to
access the necessary data and written documentation.
II. Conclusion
To conclude we want to highlight that the Slovak legal regulation that is analysed in
this article regulates the system of prevention, several institutes and methods of protection
against legalization and financing of terrorism. Only when strictly coping with the mentioned
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CLINICAL SOCIAL WORK (CSW)
rules we can effectively fight against legalization and financing of terrorism. At the same time
we must observe that this fight is not only a fight against legalization but a fight against
organized crime. The act of blocking and making the access to finances more difficult, can
help to infringe the access to an important source of finances and by that it can help to
infringe the development of the organized crime.
REFERENCES
1)
Sidak, M. V. - ДЊunderlГ­k, ДЅ.: Legal Aspects of Organization and Operation of the Banking
Systems in the Countries of Europe [electronic optical disc], In: International Relations 2011 :
Pressing Questions of the World Economy and Politics (CD-ROM). - Bratislava : EkonГіm,
2011. - S. 957-967. - ISBN 978-80-225-3357-7 [International Relations 2011: Pressing
Questions of the World Economy and Politics 12. International Scientific Conference.
Smolenice, 1.-2.12.2011]
2)
Look up the article 31 paragraph 1 letter e/ of the Treaties of the EU and other relevant
documents, Е anta, J.: On the Reasons of Low Efficiency of Punishment of the Crime of
Legalization of Income from Criminal Activity, In: Justičná revue, 60, 2008, no. 5, p. 796 –
797.
3)
Liščák, L. – Segeš, I.: On the Law of the National Council of the Slovak Republic on Fight
against Legalization of Income from Criminal Activity, In: JustiДЌnГЎ revue, 46, 1994, no. 1112, p. 20.
4)
Look up ДЊentГ©ЕЎ, J.: Legal Regulation of Punishment of the Legalization of the Income from
Criminal Activity in the Slovak Republic, In: Booklet to the Conference at the Faculty of Law
Masaryk University in Brno ,,New Developments in Economic Criminality“, February 2005,
Spisy Právnické fakulty Masarykovy univerzity v Brně, s. 17 – 26, ISBN 80-210-3831-4.
5)
PГєry, F.: Remarks to the Legal Regulation against Legalization of the Income from
Criminal Activity: In: TrestnД›prГЎvnГ­ revue, 4, 2004, no. 3, p. 74.
6)
Article1 paragraph 4 of the Directive 2005/60/EC and articles 1 to 4 of the Framework
Decision of the Council 2002/475/SVV.
7)
The reasoning report on the Law on Protection against the Legalization of the Income from
Criminal Activity and Law on Protection against Financing of Terrorism
8)
Section 9 letter a/ and h/ of the Law on Protection against the Legalization of the Income
from Criminal Activity and Law on Protection against Financing of Terrorism
The article was published as part of the grant VEGA Legal-economic aspects of long-term
unemployment in the Slovak Republic, grant no. 1/0935/12.
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CLINICAL SOCIAL WORK (CSW)
AMENDMENTS TO THE ACT ON SOCIAL SERVICES
Maros Satny
The director DSS and DD St. Dominic
SATNY, Maros: He has worked since 1991 in the field of social services. He is director of
the Greek Catholic diocesan charity for 15 years and later he worked in regional government.
Currently he works as director of a social service facilities that provide services to seniors.
In the article the author addresses the issue of the legislative changes to the act on social
services. He examines the causes and provides the financial implications of these changes in
practice.
Key words: Social services, the act, financial contribution, ministry, community, recipient,
provider.
Social Services Act in its relatively short history, came into force on 1st January 2009,
has undergone several significant legislative changes. The first legislative change was an
effort to eliminate legal discrimination against beneficiaries and private providers of social
services necessitated by the finding of the Constitutional Court of the Slovak Republic in
2010. Another important legislative change in 2012 was a change of financing public
providers established or incorporated by municipality, and also private providers in selected
types of social services.
On 18 May 2010 The Constitutional Court of the Slovak Republic ruled that the
provisions of В§ 8. 2 and 3 points. d) of the Act no. 448/2008 on social services are not in
accordance with the Constitution of the Slovak Republic. Subsequent amendment to the Act
no. 551/2010, which amended the Act no. 448/2008 on social services, this discrepancy was
removed. It is discriminatory provisions which determine how to ensure municipalities and
higher territorial unit availability and the right to choose social services for individual, social
services to the recipient. In practice, this meant that the municipality or higher territorial unit
within its scope for natural person who is dependent on social services:
• provides social services
• ensure the provision of social services through a legal entity set up or established for
that purpose
• ensure the provision of social services with other public social service provider
Only if the municipality or higher territorial unit can not provide or ensure the
provision of social services in this way, by the public provider, then can ensure the provision
of social services by non-public providers. This meant that overt discrimination by private
providers of social services, providing its services in the public interest, which was clearly in
conflict with the Constitution of the Slovak Republic.
The second amendment to the Act on Social Services, Act no. 50/2012, which entered
into force 03.01.2012, provides a new way of funding public providers established or
incorporated by municipality, as well as private providers in selected types of social services.
Legislative conditions for the financial contribution provided by the Ministry of
Labour, social affairs and family (the ministry) to finance social service for providers in
public facilities established or incorporated by municipality, as provided for in В§ 71 section 6
and В§ 78b Act on Social Services. The Ministry provides financial contributing from his
dedicated community grants to fund social services in the following facilities:
• dormitory
• shelter
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CLINICAL SOCIAL WORK (CSW)
•
•
•
•
•
•
•
•
•
•
home half way
the emergency housing
centre for temporery care of children
assisted living facility
facility for seniors
nursing care facilities
rehabilitation centre
social service home
specialized facility
day care center
The financial contribution is provided by the type of social services and by the number of
facilities in the amount under this Act (see table).
Legislative conditions for the provision of a financial contribution to ensure the
provision of private providers of social services in selected types of social services are
regulated in В§ 78a and В§ 78b of the Act on social services. The Ministry doesn't provide a
financial contribution directly from their dedicated funding to ensure the provision of social
services to private providers, but through the municipality, where private social service
provider provides the following facilities:
• dormitory
• facility for seniors
• nursing care facilities
• day care center
An open question remains why the Ministry provides to the municipality from its
special purpose grants financial contribution to fund 12 kinds of social services and private
providers to fund only four kinds of social services?
The community submit application about finance resources to ministry for public
provider, established or founded by themselves and as well as for not public provider, i fit
provides social services in already said 4 selected species of social services. The community
delivers application about finance resource to ministry for particular financial year to 31st of
August of previous year at the latest. I tis not possible to accept the applications, which are
delivered to ministry after this date. In practice it means, that if community does not deliver
its application on time, the provider of social services remains a year and a half without
finance resources.
Also it is not possible to provide finance resource during a year, for example if there is
a possibility of increasing a capacity of equipment. Not to mention the amount of already
provided finance resources, which ministry of the amendment to the law set lower than the
minimum amount of finance resource used to be provided to provider, who provided social
help by the law no. 195/1998 about social help, the law from the year of 1998, the law from
last century. For better comparison of the amount of finance resources for provision of
providing social service, please see the next table.
Table : Comparison of financial contributions in accordance with the amendment to the Social
Services Act of 2012 and the Social Assistence Act of 1998.
Height provided financial
contributions
Kind of social services
Amendment to the
Act on Social
Services of 2012
63
Social
Assistence
Act of 1998
Comparison
between the
amount of
the current
post
growth (+) /
decrease (-)
CLINICAL SOCIAL WORK (CSW)
EUR
Dormitory
Shelter
Home half way
The emergency housing
Centre for temporery care of
children
Assisted living facility
Facility for seniors
Nursing care facilities
Rehabilitation centre
Social service home
Specialized facility
Day care centre
SKK
SKK
SKK
1 440
1 440
1 800
1 800
43 381
43 381
54 227
54 227
30 000
60 000
33 000
+ 13 381
- 16 619
2 160
2 400
3 840
3 840
2 208
3 960
3 960
2 208
65 072
72 302
115 684
115 684
66 518
119 299
119 299
66 518
85 000
95 000
110 000
125 000
117 000
155 000
85 000
- 19 928
- 22 698
+ 5 684
- 9 316
- 50 482
- 35 701
+ 21 227
- 18 482
ItВґs disappointing to say that the general and local government accepted a draft legislative
standards that funding social services back more than 10 years ago, in exchange for access to
the financial resources of the state. Because the average amount of financial contribution to
the ministry for one client, which is designed to ensure the provision of social services now, is
compared with the minimum amount of financial contributions to the Social Assistance Act of
1998, lower by 441,-EUR.
This means that a provider of social services has now the statutory financial
contribution less than its predecessor dating back more than ten years.
Ing. Maros Satny,
The director DSS and DD St. Dominic
In Presov 12.12.2012
REFERENCES
The Act no. 195/1998 on social services, SR.
The Act no. 448/2008 on social services, SR.
HALUЕ KOVГЃ, E., JURAЕ EK, M.,: Vplyv sociГЎlno-ekonomickГЅch podmienok
marginalizovanej rГіmskej kominuty ЕѕijГєcej v KoЕЎickom kraji na kvalitu Еѕivota. In:
Spocƚeczeǹstwo – ekonomicze problemy gospodarowania wwarunkach transformacji
Warszawa 2011 :Uczelnia Warszawska im. Marii SkЖљodowskiej-Curie. Warszawa 2011, s.
321-330. 351 s. ISBN 83-89884-42-9.
OLAH, M., ROHAC, J. 2010. Atributes of social services. 1. edition. Bratislava: St. Elizabeth
University of Health and Social Services, Department of Social work, 2010. ISBN 978-8089271-88-7.
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15 TH INTERNATIONAL CONGRESS ON INFECTIOUS DISEASES –
CONGRESS REPORT FROM BANGKOK
N. Kulkova, J. Sokolova, V. Krcmery, J. Benca, I. Beldjebel, T. Benson Alumbasi
SEUC Phnom Penh, Cambodia
Plenary Lecture II: Killed oral cholera vaccines: from concept to public health reality
Worldwide, cholera causes ≈ 100 000 deaths annually, with Vibrio cholerae serogroup O1,
biotype El Toro being the most prevalent and serogroup O139 less prevalent. In 1960Вґs
vaccine trials began, but first vaccines provided patients with only transient immunity and
were highly reactogenic. Natural cholera infection is immunising as it leads to mucosal
secretory antibodies production. These Ab act synergistically with antitoxins and cell
mediated immunity. Cholera vaccines are mostly killed with formalin or heat-killed
containing serougroup O1, Okinawa subtype.
First trial was introduced in Bangladesh in 1985, which later led to Dukoral license in
Sweden. Also in Vietnam was trial started, in wchich also serogroup O131 was included, but
this vaccine was used exclusively in Vietnamese population. Later, attenuated serotype Inaba
was add (strain CVD 103-HgR) at University of Maryland, but unfortunately, vaccine was
shown to be ineffective.
As Ducoral is just too expensive for patients in developing countries research on more
affordable vaccines was initiated. In 2000 there was an effort started to internationalise
Vietnamese vaccine, but that had a several limitations as Vietnamese national regulations did
not meet the WHO requirements. Therefore the vaccine development was transferred to India
(which has suitable regulations for worldwide distribution) and clinical development program
started. In phase I – III trials no weighty and important adverse effects were found and
protective efficacy at 66% was proved. Also, immunity was found to be not declining and
reaching highest level at vulnerable age group of 5 – 15. In 2009 the vaccine was licensed in
India as ShanChal (produced by Shantha Biotech – part of Sanofi).
Even when ShanChal price was set at 1,85 USD/dose (2 doses must be administered) it was
surprisingly not placed on WHO priority list until Haiti earthquake followed by cholera
epidemic.
Importance of vaccination consists in “vaccine herd protection”, when considering that
protection of population is even better when person to person transmission is avoided. Risk
of infection is much lower in unvaccinated people when there is at least 50% vaccination
coverage in overall population. For example, in populaation with no vaccination there is
incidence of 11,2 cholera cases/1000 persons, but in population with 58% vaccine coverage,
there is only incidence of 0,6 cases/1000 persons.
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Fungal Infection, Near and Far
Pythium insidiosum infections: Clinical presentations and treatment. B.
Sathapatayavongs
Pythium insidiosum is a fungus-like organism, which is endemic in Thailand. There are only
few pathogens in Pythium genus. Cutaneous pythiosis was firstly reported in 1985 in 46 years
old women with alpha-thalassemia. She was suffering from unknown leg infection. Biopsy
revealed hyphae but no growth in culture medium occurred. Patient developed massive
occlusion of femoral artery which required limb amputation. After 1 month, gangrene and
aneurysm of abdominal aorta was developed, followed by below knee amputation.
Amphotericin B therapy was administered, but there was rupture of aortic stamp and patient
died after 17 months of illness.
Alpha-thalassemia or other hemoglobinopathy was found to be predisposing factor for
acquiring pythiosis. In therapy, surgical removement of aneurysm of clotted vessel remains to
be first choice. Also, Pythium vaccince was developed in US and can be sometimes
successfully used in treatment, but in some patients there si only moderate response. Therapy
with antifungal agents can be carry out by combinational therapy with terbinaffne plus
itraconazole, which was successful in some cases, and also with amphotericine B and
fluconazole. In vitro Pythium was found to be susceptible to tygecycline, tertacyclines and
macrolides, and synergy of terbinaffine with echinocandines and azoles was also showed.
Other cases of pythiasis were also described, such as cerebral pythiasis, GIT pythiasis and
ocular infection after trauma.
Few methods are available for diagnosing pythium infection including smear, cultivation on
SA, histopathology (difficult to differ from Mucorales), serodiagnostics (ELISA) and
molecular biology (PCR).
Penicillium marneffei infections. K. Supparatpinyo
P. marneffei is the 4th most frequent fungal infection among HIV positive patients in
Thailand. It is a dimorphic fungus (at 37В°C it is a yeast, but at 25В°C is a mould), which was
firstly isolated in Vietnam in 1956. First case of infection caused by P. marneffei was
described in patient with Hodgkin lymphoma. First case of infection in HIV positive patient
was described in Bangkok in 1989. Since 1991 there has been documented increased
prevalence of this infection worldwide, not only in Asia, even though South-east Asia is
endemic area. Number of infected patients is increasing during rainy season.
There are two main risk factors for P. marneffei infections - (i) younger age (16 – 30 years,
OR = 2,22) and (ii) exposure to soil, especially in rainy season (OR=1,91). It was remarked
that penicilliosis sometimes occur shortly after ART start. The only reservoirs of P. marneffei
are bamboo rats and humans, but also other mice could act as reservoir. To this day mode of
transmission in unknown (may be inhalation of conidia or through injured skin).
Clinical manifestation includes fever, weight loss, diarrhoea, cough, skin lesion etc. However,
infection may have subclinical course in some patients living in endemic areas. Diagnosis is
based on positive cultivation from blood, skin biopsy or bone biopsy, which is followed by
histopathology (typical septae). Also other methods can be performed, such as serology
(immunodiffusion test, fluorescent antibody test, ELISA, latex agglutination test) and
molecular biology.
P. marneffei was showed to be very good susceptible to itraconazole, ketoconazole,
miconazole, 5-fluorocytosine and other antifungal drugs. Severe cases of marneffei
penicilliosis should be treated with amphotericin B and mild cases with itraconazole or
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voriconazole. Itraconazole can be used as prophylaxis as well. According to guidelines,
prophylaxis is recommended in endemic areas in patients with CD4 less than 100 cells /ml.
Changing epidemiology and treatment options in invasive candida infections, T. Gottlieb
Treatment options for invasive candidosis are mainly threatened by two most important
resistance patterns – fluconazole resistance and echinocandin resistance, even though
echinocandin resistance occurs only in ~ 3% of patients, which is offered by mutations in fks
gene. Oftenly, there are troubles with diagnosing and proving candidosis. Fungal blood
cultures are proved to be susceptible to antifungals in 25 - 82% of isolates and only 50% of
deaths are autopsy-proved cases of candidosis. This is mainly due to long cultivation required
by yeast to grow from clinical samples (24 – 48 hours for C. albicans, > 48 hours for C.
tropicalis and C. parapsilosis, > 120 hours for C. glabrata). In treatment, following should be
included: (i) line removal, (ii) pre-emptive therapy (if possible), (iii) susceptibility check and
(iv) antifungal therapy. Antifungal therapy can be performed with (i) azoles which are
cheaper, less toxic and avialable per orally, (ii) echinocandines which have broader spectrum
of activity, are fungicidal and provide improved outcomes; and by (iii) polyenes.
Cryptococcus infection in immunocompetent individuals, G. Reid
Cryptococcal infections account for approximately one third of HIV-associated deaths.
Moratlity on cryptococcal infections is 9 – 70%. C. neoformans varieta grubii is the most
prevalent in HIV-posotive patients. Diagnostics in immunocompromised host is not easy and
is based on serology. However, serology is not very strong method as almost 77% are falsenegative results. India ink method is also often negative and problems with differentiation of
gatti vs grubii varieta occur. In case of cryptococcal vasculitis, nodulus and cyst forming,
MRI can be performed. Treatment of Cryptococcus infection is based on immune status of the
patient and patient should be checked for IRIS during the treatment. IDSA guidelines for
therapy of cryptococcal infection in HIV-patients advise therapy based on immune status,
which has 3 phases: (i) induction therapy, (ii) consolidation and (iii) maintenance (see Table
1).
Table 1: IDSA Updated Guideline for Management of Cryptococcal Disease 1
Phase
1
2
3
Therapy
Amphotericin B (AmB) deoxycholate (AmBd; 0.7–1.0 mg/kg per day
intravenously [IV]) plus flucytosine (100 mg/ kg per day orally in 4
divided doses; IV formulations may be used in severe cases and in those
Consolidation without oral intake where the preparation is available) for at least 2
weeks, followed by fluconazole (400 mg [6 mg/kg] per day orally) for a
minimum of 8 weeks (A-I).
Lipid formulations of AmB (LFAmB), including liposomal AmB (3–4
mg/kg per day IV) and AmB lipid complex (ABLC; 5 mg/kg per day
IV) for at least 2 weeks, could be substituted for AmBd among patients
with or predisposed to renal dysfunction (B-II).
Fluconazole (200 mg per day orally) (A-I). 8. Itraconazole (200 mg
Maintance
twice per day orally; drug-level monitoring strongly advised) (C-I). 9.
AmBd (1 mg/kg per week IV); this is less effective than azoles and is
associated with IV catheter–related infections; use for azole-intolerant
individuals (C-I). 10. Initiate HAART 2–10 weeks after commencement
of initial antifungal treatment (B-III). 11. Consider discontinuing
Induction
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suppressive therapy during HAART in patients with a CD4 cell count
1100 cells/mL and an undetectable or very low HIV RNA level
sustained for _3 months (minimum of 12 months of antifungal therapy)
(BII); consider reinstitution of maintenance therapy if the CD4 cell
count decreases to !100 cells/mL (B-III). 12. For asymptomatic
antigenemia, perform lumbar puncture and blood culture; if results are
positive, treat as symptomatic meningoencephalitis and/or disseminated
disease.
Without evidence of meningoencephalitis, treat with fluconazole (400
mg per day orally) until immune reconstitution (see above for
maintenance therapy) (B-III).
Carbapenem Resistance
Overview of Carbapenemase mediated resistance, G. Cornaglia
Chromosomal metallo-beta-lactamases (MBL) can be found in some Gram-negative bacterial
species such as Stenontrophomonas spp., Myroides spp., Aeromonas hydrophilla etc. Most of
the carbapenemases alone confer only to lower susceptibility no to overall and absolute
resistance.
There are some beta-lactamases (BL) which we consider to be the most important, those
including IMP, VIM, NDM, KPC and OXA. These were circulating in Europe during 2011.
IMP, VIM and DIM can be found in most clinically important gram –negative species. IMP
was detected in 1990Вґs in Serratia marcescens in Japan and then was found all over the world.
In Europe there is a high prevalence of VIM which is in contrast to the rest of the world.
OXA-48 found in Klebsiella sp. causes many nosocomial outbreaks.
Detection of Carbapenemase-mediated resistance, P. Nordmann
Carbapenemase production is often suspected when multidrug resistance is obvious in
antibiogram, but this is particularly hard in case of OXA-48, which confers to only low
resistance level. But even cases of low-level resistance may be caused (and often really are)
by carbapenemase producers. Therefore, MIC testing should be followed by typing of (i)
strain variability, (ii) BL variability, (iii) chromosomal vs plasmid encoding and (iv) level of
expression, to assess the heterogeneity of the pathogen.
Detection of imipenem/ertapenem resistance (in Enterobacter spp., E. coli and Klebsiella
spp.) not provided by carbapenemases is performed by adding oxacillin to disk diffusion test.
KPC detection is done by adding boronic acid disk test and this takes 24 – 48 hours (see Fig
1).
Detection of MBL is performed by EDTA inhibition with combination of E-test (Fig 2).
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Figure 1: Different phenotypes of imipenem resistance as revealed by Etest MBL strips in
two P. aeruginosa isolates carrying the VIM-1 (A) and VIM-2 (B) determinants. 2
Class D of carbapenemases (e.g. OXA) do not hydrolyse ceftazidime and can be detected by
temocillin.
Figure 2: Representative results of the CLSI ESBL confirmatory test (A and C) and its
modification using antibiotic disks containing BA (B and D) for ESBL PCR-positive (A and
B) and ESBL PCR-negative (C and D) KPC-possessing isolates. 3
Value of Hodge test for carbapenemase detection is not always very high, it has low
sensitivity and specificity and should be replaced by more valuable test – by newly developed
carba NP test. Carba NP test is very sensitive and specific (100% both) and do not require
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very experienced stuff neither equipped lab. Detection of carbapenemase activity may be done
by spectrophotometry, mass spectrometry, or by PCR.
The role of antimicrobial stewardship in curbing Carbapenem resistance, D. Lye
Author presents experience with antimicrobial stewardship program (ASP) containing MDR
A. baumannii and KPC Enterobacteriaceae. The results of 3 years of a comprehensive multifaceted multi-disciplinary ASP at Tan Tock Seng Hospital in Singapore are shared, where
reduction in carbapenem use was associated with sustained reduction in carbapenem-resistant
P. aeruginosa but not MDR A. baumannii. Rebound in carbapenem overuse has been
associated with emergence of carbapenem-resistant Enterobacteriaceae including locally
acquired NDM-1. It was found that ertapenem use selects P. aeruginosa with cross resistance
to other carbapenems, so fewer carbapenems in usage led to fewer P. aeruginosa with
resistance. Aminopenicillines, fluoroquinolones and vancomycin in therapy were found to be
predictors of KPC-producing K. pneumoniae colonization. Risk factors for A. baumanii
acquisition were imipenem in therapy, 3G cephalosporins therapy and other non-antibiotic
factors (bad infection control of beds, sinks, and taps). Author concludes that limiting
antibiotic usage alone may fail as the only one ASP intervention and therefore should be
combined with careful infection control and judicious ATB usage.
Facing the Challenges of Malaria
Artemisinin resistance in falciparum malaria, A. Dondorp
Artemisinin acts very quickly and kills also ring forms of parasites, what is the biggest
difference from other antimalarials. Nowadays artemisinin based therapy (ACT) is
considered being the best treatment choice for uncomplicated malaria. In case of several
malaria Sequamat, which reduced mortality on malaria at 23% in sub-Saharan Africa, is good
treatment choice. Artemisinin starts to work very quickly and kills ~ 10.000 parasites every
48 hours.
It is interesting that parasite clearance was found to be much slower in western Cambodia.
This was ascribed partially to bad drug use (monotherapy), fake drugs and parasite population
which are somehow more adapted to resistance evolvement. With increasing failure rate of
ACT in Cambodia, as well as in other near countries such as Thailand and Myanmar,
percentage of parasites with very low susceptibility increased to 25% (Lancet, 2012). Then it
was found that there are also other reasons responsible for delayed clearance, these including
(i) immunity status of host, (ii) drug quality, which can be variable and (iii) genetic factor of
the parasite. Genetic factor of plasmodium confers to 60% of decreased clearance and it is a
heritable sign. It was found that in western Cambodia almost all patients are so called “slow
clearers”. When looking for molecular markers, 3 genes (PfMDR1, PFCRT and PfUBQ)
were looked for changes, but no mutation was found in them. With transcriptome studies
genome region of artemisinin resistance (ASR) was revealed on chromsome 13. This area was
found to be down-regulated in ring forms and up-regulated in schizont stages. Strategy to
prevent ASR spreading must involve primaquine, which act as a transmission blocking agent
because it reduces gametocytaemia. Also new compounds in artemisinin group –
spiroindolone (NITD609) arterolane were presented in the lecture.
Progress towards effective malaria vaccination, C. Ockenhouse
Malaria vaccine development is one of the millennium developmental goals. There are only
limited funds for malaria control but these are disproportioned. Development objectives
consist of preventing strategy, lessen the diseases and block transmission.
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Malaria vaccine may be prepared as (a) radiologically attenuated whole cell vaccine, or (b) Tcell based DNA/ viral-vectored or (c) combined protein vaccine (description in Table 2).
Table 2: Types of malaria vaccines with typical characteristics
Type of vaccine Typical signs
ATTENUATED WHOLE CELL
VACCINE high level protection
targets liver stage
provides no protection if only DNA vectored
T-CELL BASED DNA/VIRAL uses Ad5 vectors if viral vectored
VECTORED VACCINE stimulates CD8+-T-cell immunity
high neutralizing Ab
targets pre-erythrocyte and blood stage
PROTEIN VACCINE has limited CD8+ activity
The first effective malaria vaccine is RTS,S. RTS,S showed 56% reduction of malaria cases
and 48% reduction of complicated cases. The RTS,S vaccine was prepared from genes of the
outer protein of Plasmodium falciparum and a portion of a hepatitis B virus, plus a chemical
adjuvant was added to boost the immune system response. It is developed by
GlaxoSmithKline (GSK) with support from the Bill and Melinda Gates Foundation. Now the
research group is trying to improve the efficacy of this vaccine to 80%, as well as to develop
new one (second generation vaccine PfCel TOS - Plasmodium protein Cell-traversal protein
for ookinetes and sporozoites).
Plenary lecture III: Infection control: worldwide perspectives; D. Pittet
More than 1,4 million patients get infected every day nosocomially. First challenge in fight
against nosocomial infections was to assess what actually is health care associated infection
(HCAI). HCAI is defined as an infection occurring in a patient during the process of care in a
hospital or other health-care facility that was not manifest or incubating at the time of
admission. This includes infections acquired in the hospital and any other setting where
patients receive health care and may appear even after discharge.
Risk of HCAI acquisition is 2 – 18 times higher in developing countries (where less than 5%
of the gross national product is spent on health care) 4, which in a bit contrast to what was
anticipated – that nosocomial infections are major problem in industrialized rich countries.
Compliance to hand washing interventions is/was less than 40% even it is the best
intervention for preventing HCAI. It was even found that the more opportunities the stuff has
to clean their hands the less frequently they were doing it. The major reason for poor hand
hygiene compliance was the fact that it was very time consuming, as one hand cleaning with
soap took 1 min and 5 sec. Therefore, alcohol-based hand rub (ABHR) was introduced which
is lot more efficient than other hand hygiene methods (such as soap cleaning, iodophore
cleaning) and is much quicker.
Thus, system change was required in particular hospital (Geneva) which is now known as
“The Geneva Hand Hygiene Model”. Interventions were proved to be very cost-effective,
while moneys are saved by preventing nosocomial infections. For example, in Geneva
hospital workplace alerts were placed to educate the stuff everywhere and nowadays Geneva
University Hospital has 78% compliance to hand hygiene interventions. After significant
success of Geneva model, WHO started to take interest in applying these interventions as
WHO General Model. With 1st WHO Global Patient Safety Meeting international
implementation started. Now, the campaign covers 90,2% of world population and 5th May
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was declared as Day of clean hands. Also presently there are new approaches implemented
into the programme, such as (i) local production of alcohol for ABHR to provide low-cost
solution in resource limited settings (e.g. Mali, South Africa); or (ii) hand hygiene selfassessment framework, which is a scoring system to classify the level of hand hygiene
control. According to this scoring system, hand hygiene control can be assessed as (i)
inadequate, (ii) basic, (iii) intermediate and (iv) advanced.
Plenary lecture VI: Confronting tuberculosis in the era of HIV; S. Lawn
Highest prevalence of tuberculosis is in South Africa and south-east Asian countries such as
Cambodia and Myanmar. Tuberculosis (TB) starts to develop mostly in HIV-positive patients
with CD4 cells count less than 200 per millilitre (See Table 3). Patients with antiretroviral
therapy have smaller risk of TB acquisition, which is due to CD4-associatred benefit. Most of
these patients do have symptoms, like cough lasting more than 2 weeks, dry cough and they
met WHO criteria. There are few new diagnostic methods available for detection of TB,
which are presented below.
Xpert MTB/RIF was originally invented for diagnosing other microorganisms primarily for
military purposes (anthrax). This tool requires at least 131 colony forming units (CFU) in
sputum to be able to detect TB. It was even found that those patients, who were proved to be
TB negative with Xpert, were less sick, had better CD4 status and less viral load, what
suggest that Xpert can diagnose those ones who are most important.
There was lipo-arabino-mannan (LAM) antigenouria observed in patients with TB so rapid
tests for LAM detection were developed. It was found that half of LAM-positive urine
samples were also positive with Xpert. New point-of-care test named “Determine TB LAM”
was developed by ALere (USA) and is based on ELISA detection of LAM. It can be
performed in less than half hour, cost only 3,50 USD per test and is simple to read out. LAM
based diagnostic seem to be most effective in the sickest patients with CD4 cells < 50/ml, but
it should not be stand-alone.
When comparing abovementioned systems, it was found, that of all culture positive patients
5% will die, of all Xpert positive 10% will die and of all LAM positive 20% will die.
Table 3: CD4 status and its association with decreased protection against tuberculosis
CD4 status
Level
of
decrease
protection
< 200/ml
84%
200 – 350/ml
66%
> 350/ml
57%
Acute Febrile Illness in the Tropics
Acute febrile illness in Africa; O. Mediannikov
Main causes of tropical fever in Africa are undiagnosed fever, malaria and rickettsiosis (in
travellers). Also many other several diseases can be manifested as febrile disease, including
typhoid/paratyphoid fevers, pneumococcal bacteraemia, viral infections like influenza, yellow
fever, dengue, Chikungunya virus and Rift Valley fever. In Africa, facilities have been
established in several areas focused to diagnose primary malaria for starting immediate
treatment, but as malaria regresses, more cases of fever remain unexplained. Diagnostic
methods to detect non-malaria causes of febrile illnesses are limited in such settings. Thus
team around dr. Mediannikov started their project in Dielmo village in Senegal aimed on
rapid PCR diagnostic of febrile diseases. Blood samples were taken from all febrile patients,
DNA was extracted and samples were tested to evaluate bacterial infection. DNA extraction
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was performed without centrifugation and point-of-care laboratory was constructed. POC
laboratory was able to perform testing in field, was equipped with immunochromatography
for antigen detection and with PCR cycler, thereupon able to provide result within 2 hours.
Principle of preserving reagents against climatic influences and to restore them capable of
POC molecular testing lean on using freeze-dried PCR mixes which are then reconstituted by
adding water and extracted DNA. testing panel contains probes to detect Borrelia, Rickettsia,
Influenza, Bartonella, Coxiella, Dengue, Leptospira and Mycobacterium spp.
With this system was found that the most prevalent causes of fever in Senegal are as follows
1. Rickettsia felis, 2. Borrelia crocidurae, 3. Malaria and 4. Q fever; and abovementioned
method enabled to detect up to 30% fevers of previously unknown origin.
Acute febrile illness: Epidemiology versus clinical judgement; R. Premaratna
Diagnosis of tropical fever is mainly based on clinical picture, while confirmatory tests are
not always available or affordable. In treatment we often meet with so called epidemiologybased tunnel vision or epidemiology-based blindness, when 2/3 of patients who are treated for
malaria (even with antibiotics) do not have it.
Laboratory diagnosis of acute febrile illness: Where are we now? C.C. Chao
Acute febrile illness has been recognized as an important group of illness that is difficult to
differentiate due to their similarity in symptoms. Rickettsia-related diseases, such as scrub
typhus, murine typhus, spotted fever group rickettsia, Q fever and leptospirosis, have emerged
or re-emerged in different area around the world. IFA (immunofluorescence assay) was the
most used test for detection of complicated rickettsial infections, but was followed by
development of nucleic acid based test (NA tests) and serological (antigenic) tests (Ag tests).
List of available assays is summarized in Table 4.
Table 4: List of test used for diagnostic of febrile illnesses
Type of
test
Ag tests
Infection
Principle of test
Pros/cons
Scrub typhus
SDS-page and western blot of
Orientia call lystae
Q-fever
detection of Com-1 or Ada A or
OmpH protein
detection of 3 important antigens
rapid test
can be perforemd in 10
min
specificity/sensitivity ≈
90%
rapid tests are in
development
80%
specificity/sensitivity
strip test
Amplification and
detection of gene can be
completed in a single
step, by incubating the
mixture of samples,
primers, DNA
polymerase with strand
displacement activity
and substrates at a
constant temperature
Leptospirosis
NA test
LAMP
(other than
PCR)
Use of different primers
specifically designed to
recognize distinct regions on the
target gene and the reaction
process proceeds at a constant
temperature using strand
displacement reaction
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(about 65В°C). It
provides high
amplification efficiency,
with DNA being
amplified 109-1010
times in 15-60 minutes.
Because of its high
specificity, the presence
of amplified product can
indicate the presence of
target gene. The total
cost can be reduced, as
LAMP does not require
special reagents or
sophisticated
equipments.
comparable
susceptibility to qPCR
lasts ≈ 20 min
RPA
bacterial RecA binds with
primers to specicfic site and
amplifies this region without
thermal cycling
LAMP – Loop mediated isothermal amplification; RPA – recombinase-polymerase reaction
Plenary lecture: Finding a cure for HIV: the need for science, collaboration and
advocacy; S. Lewin
With increasing numbers of HIV-infected people, emerging new toxicities secondary to
HAART and the need for life-long treatment, there is now a real urgency to find a cure for
HIV. When considering treatment of HIV we have to differ between sterilising cure
(elimination of all HIV particles, thus havin less than 1 copy per ml) and functional cure –
remission (with less than 50 copies per ml).
Sterilising cure can be achieved by transplantation of ∆32/∆32 mutated cells, which are
naturally resistant to HIV infection. Otherwise to achieve remission requires strong T-cell
response while there is an on-going replication. Post-ART controllers – patients who started
their ART very early after infection – are those who can be introduced in such position. T-cell
response is associated also with different HLA-types, e.g. B27 and B57 are associated with
very good response to ART.
There are few candidate strategies to cure HIV including (i) elimination of latently infected
cells, (ii) elimination of HIV replication (ERAMUNE) and (iii) make cells resistant to HIV.
When trying eliminate latently infected cells, transcription must be induced in those patients
on ART. Newly produced HIV particles are then eliminated by ART. HIV can be activated in
cells in vitro with HDAC (histone deacetylases) inhibitors, antiPD1 agents, disulfuram etc.
These agents act via uncoiling chromosomal DNA therefore inducing transcription of
incorporated HIV-DNA. Vorinostat administered in daily dose of 400 mg showed ability of
turning HIV genes on. Similarly with disulfuram adminstered for 14 days at 500 mg/daily was
observed increased transcription of HIV genes.
To force cell to become resistant against HIV requires blocking new infections and allowing
infected cells to die. Experiments started in 6 patients. These are focused on expression of
CCR5, wchihc is a ZN-finger nuclease recognizing HIV DNA sequences. In those 6 patients
was viral load decreased do undetectable level.
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MRSA: Keeping up with the Evolving Pathogen
Developing resistance to drugs against MRSA; I. Gould
Treatment of serious MRSA infection is still mostly carry out by vancomycin (VAN). Its
increased usage soon led to evolvement of VRSA, GISA and hVISA species (vancomycinresistant S. aureus, GISA – glycopeptide-intermediate susceptible S. aureus and vancomycinheteroresistant S. aureus respectively). Studies proved that there is a significantly higher
mortality with infections caused by hVISA. Treatment outcome is influenced by clinical and
pathogen factors. When evaluating data from long-term stored isolates we have to keep in
mind their possibility of increase their VAN minimal inhibitory concentration (MIC), and
before starting work with such isolates we have to regenerate the strain. Also with different
methods (broth microdilution testing, Vitek, Etest, Microscan) we can reach different MIC
value, but Etest is considered as the most relevant in good clinical response. VAN MIC value
breakpoints according to CLSI are as following: VSSA ≤ 2 mg/L, VISA > 8 mg/L and VRSA
≥ 16 mg/L, while in EUCAST there is no intermediate category.
The most important molecular features which are responsible for VAN resistance are
regulatory genes such as agr and gra loci, and cell wall associated such as mprf (mpfr is a cfr
methyltransferase which is a transferable gen responsible also for linezolid resistance) or cce6
and of course VanA gene acquired from enterococci.
Resistance to agents for MRSA decolonization and its clinical implications; A.
Apisarnthanarak
Most of the neonates are colonized with MRSA in less than 1 month abter birth. Of adults,
20% remain to be persistant carriers and 60% intermittent carriers, with males being more
likely to be colonised. Strategies for decolonization include daily bathing and use of topical or
oral antibiotics. Bathing may be performed with chlorhexidine (CHG), unfortunately can lead
to skin irritation or rash, especially in Asia. Decreased MIC to CHG is caused by MDR-efflux
pumps encoded by qacAB gene, which can be plasmid-mediated.
Decolonization with topical and oral antibiotics and topical antiseptics should be profrmed
before surgery procedures. Agents used for this purpose are mupirocin, polysporin,
vancomycin or bacitracin, and these should be alwys used in combination to be efficient.
However, we met mupirocin resistance which now can lead to failure of decontamination, but
mupirocin resistance is not normally tested. The most important mechanism of mupirocin
resistance is encoded by the gene mupA, which is plasmid mediated and leads to mutation in
tRNA synthetase.
Newly studied topical agents for MRSA-decontamination include retapamulin
(GlaxoSmithKline), and fusidic acid with trimetoprime/sulphametoxazole. Retapamuline
belongs to novel class of pleuromutilin antibiotics. Nowadays it is in Phase II of clinical trials
and was approved by FDA for treatment of impetigo.
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REFERENCES
1. Perfect JR, Dismukes WE, Dromer F, et al. Clinical practice guidelines for the management
of cryptococcal disease: 2010 update by the infectious diseases society of america. Clinical
infectious diseases : an official publication of the Infectious Diseases Society of America.
2010;50(3):291-322.
Available
at:
http://www.ncbi.nlm.nih.gov/pubmed/20047480.
Accessed June 26, 2012.
2. Luzzaro F, Endimiani A, Docquier J-D, et al. Prevalence and characterization of metallobeta-lactamases in clinical isolates of pseudomonas aeruginosa. Diagnostic microbiology and
infectious
disease.
2004;48(2):131-5.
Available
at:
http://www.ncbi.nlm.nih.gov/pubmed/14972383.
3. Tsakris A, Poulou A, Themeli-Digalaki K, et al. Use of boronic acid disk tests to detect
extended- spectrum beta-lactamases in clinical isolates of KPC carbapenemase-possessing
enterobacteriaceae. Journal of clinical microbiology. 2009;47(11):3420-6. Available at:
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2772593&tool=pmcentrez&rende
rtype=abstract. Accessed July 6, 2012.
4. Allegranzi B, Bagheri Nejad S, Combescure C, et al. Burden of endemic health-careassociated infection in developing countries: systematic review and meta-analysis. Lancet.
2011;377(9761):228-41. Available at: http://www.ncbi.nlm.nih.gov/pubmed/21146207.
Accessed March 19, 2012.
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EMERGENCIES IN TROPICAL SOCIAL WORK, NURSING AND
PUBLIC HEALTH
M. Kiwou, E. Nandolaya, Hoy Leunghoin, T. Oelnick, Or Tou, V. Chom Or Tou, S.
Sethaun, S. Sorat, N. Kulkova, J. Sokolova, D. Pechacova, J. Ravasz, E. Vrankova,
M. Hettes, F. Hanobik, A. Mrazova, E. Haluskova, G. Mikolasova, J. Benca, I. KmiЕҐ, E.
Nicodeums, D. Kisundi, G. Mikolasova, R. Michel, P. Blaskovic, S. Zabavova, Z. Gazova, K.
Molnarova, M. Chabadova, K. Feckova, B. Hatasova, V. Korcek, M. Mutalova, J. M. Muli
Tropicteam SEUC Bratislava, PreЕЎov, Michalovce, Bardejov, Dunajska Streda,
PieЕЎЕҐany, Skalica, ЕЅilina, Pribram, Slovakia
St. Charles Lwanga, Nairobi SEUC, Antimalnutrition Centre Nairobi, Kenya
St. Maxmillian Kolbe Clinic Phnom Penh, Cambodia
ABSTRACT
News in Emergenciesin and their impact or social work and public health in Subsaharan africa, Central
Europe (imported) and SE Asia is reviewed by our social work and health tropicteam
Introduction:
Typhoid Fever Outbreak Associated With Frozen Mamey Pulp Imported From Guatemala to the
Western United States, 2010
Anagha Loharikar et al. Clinical Infectious Diseases 2012, 55(1):61-6
Fifty-four outbreaks of domestically acquired typhoid fever were reported between 1960 and
1999. In 2010, the Southern Nevada Health District detected an outbreak of typhoid fever
among persons who had not recently travelled abroad. In this case-control study autors
examine the relationship between illness and exposures. A case was defined as illness with the
outbreak strain of Salmonella serotype Typhi, as determined by pulsed-field gel
electrophoresis (PFGE), with onset during 2010. Controls were matched by neighborhood,
age, and sex. Bivariate and multivariate statistical analyses were completed using logistic
regression. Traceback investigation was completed. We identified 12 cases in 3 states with
onset from 15 April 2010 to 4 September 2010. The median age of case patients was 18 years
(range, 4-48 years), 8 (67%) were female, and 11 (92%) were Hispanic. Nine (82%) were
hospitalized; none died. Consumption of frozen mamey pulp in a fruit shake was reported by
6 of 8 case patients (75%) and none of the 33 controls (matched odds ratio, 33.9; 95%
confidence interval, 4.9). Traceback investigations implicated 2 brands of frozen mamey pulp
from a single manufacturer in Guatemala, which was also implicated in a 1998-1999 outbreak
of typhoid fever in Florida.Reporting of individual cases of typhoid fever and subtyping of
isolates by PFGE resulted in rapid detection of an outbreak associated with a ready-to-eat
frozen food imported from a typhoid-endemic region. Improvements in food manufacturing
practices and monitoring will prevent additional outbreaks. (1-13)
Variation in Reported neonatal Group B Streptococcal Disease Incidence in Developing
Countries.
Alemnew F. Dagnew et al. Clinical Infectious Diseases 2012, 55(1):91-102
Group B Streptococcus (GBS) is a leading cause of neonatal sepsis in developed countries. Its
burden in the developing world is less clear. Studies reporting neonatal GBS disease
incidence from developing countries were identified from 5 literature databases. Studies were
assessed with respect to case finding and culture methods. Only 20 studies were identified.
The GBS incidence ranged 0–3.06 per 1000 live births with variation within and between
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geographic regions. All but 1 study identified GBS cases within a hospital setting, despite the
potential for births in the community. Possible case under-ascertainment was only discussed
in 2 studies. A higher GBS incidence was reported when using automated culture methods.
Prospective, population-based surveillance is urgently needed in developing countries to
provide an accurate assessment of the neonatal GBS disease burden. This will be crucial for
the design of interventions, including novel vaccines, and the understanding of their potential
to impact mortality from neonatal sepsis.
Rapid Implementation of New TB Diagnostic Tests. Is It Too Soon for a Global Roll-Out
of Xpert MTB/RF?
Daniela E. Kirwan, Am. J. Trop. Med. Hyg., 87(2), 2012, pp. 197-201
In 2011 the World Health Organization approved Xpert MTB/RIF for tuberculosis diagnosis
and recommended its rapid implementation. Xpert MTB/RIF is accurate: sensitivity is 72.5 98.2% (smear-negative and -positive cases, respectively) and specificity 99.2%. Benefits
include same-day diagnosis and simultaneous detection of rifampicin resistance. However, the
test has some shortcomings and has not had time for thorough evaluation. Cost-effectiveness
studies are difficult to perform and few have been completed. Existing data suggest costeffectiveness in some, but not all, settings. The urgent need for better diagnostics is evident.
Yet, serial implementation of new technologies causes ineffective spending and fragmentation
of services. How new tests are incorporated into existing diagnostic algorithms affects both
outcomes and costs. More detailed data on performance, effect on patient-important
outcomes, and costs when used with adjunct tests are needed for each setting before
implementation. While awaiting further clarification it seems prudent to slow its
implementation among resource-constrained tuberculosis control programs.
Drug Coverage Surveys for Neglected Tropical Diseases: 10 Years of Field Experience
Caitlin Worrell et al. Am. J. Trop. Med. Hyg., 87(2), 2012, pp. 216-222
Mass drug administration is one of the public health strategies recommended by the World
Health Organization for the control and elimination of seven neglected tropical diseases
(NTDs). Because adequate coverage is vital to achieve program goals, periodically
conducting surveys to validate reported coverage to guide NTD programs is recommended.
Over the past decade, the Centers for Disease Control and Prevention (CDC) and
collaborators conducted more than 30 two-stage cluster household surveys across three
continents. The questionnaires gathered coverage data and information relevant to improving
NTD programs including NTD-related attitudes and practices. From the 37 coverage survey
estimates obtained in those surveys, 73.3% indicated an over reporting of coverage, including
all three that assessed school-based distributions. It took an average of 1 week to conduct a
survey. Our experiences led us to conclude that coverage surveys are useful and feasible tools
to ensure NTD elimination and control goals are reached.
Artemisinin-resistant Malaria: research Challenges, Opportunities and Public Health
Implications
Rick M. Fairhurst et al. Am. J. Trop. Med. Hyg., 87(2), 2012, pp. 231-241
Artemisinin-based combination therapies are the most effective drugs to treat Plasmodium
falciparum malaria. Reduced sensitivity to artemisinin monotherapy, coupled with the
emergence of parasite resistance to all partner drugs, threaten to place millions of patients at
risk of inadequate treatment of malaria. Recognizing the significance and immediacy of this
possibility, the Fogarty International Center and the National Institute of Allergy and
Infectious Diseases of the U.S. National Institutes of Health convened a conference in
November 2010 to bring together the diverse array of stakeholders responding to the growing
threat of artemisinin resistance, including scientists from malarious countries in peril. This
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conference encouraged and enabled experts to share their recent unpublished data from
studies that may improve our understanding of artemisinin resistance. Conference sessions
addressed research priorities to forestall artemisinin resistance and fostered collaborations
between field- and laboratory-based researchers and international programs, with the aim of
translating new scientific evidence into public health solutions. Inspired by this conference,
this review summarizes novel findings and perspectives on artemisinin resistance, approaches
for translating research data into relevant public health information, and opportunities for
interdisciplinary collaboration to combat artemisinin resistance.
Health research in Africa: getting priorities right
Ole F. Olesen et al. Tropical Medicine and International Health, Vol. 17, No. 9, pp.
1048
Scaling up Xpert MTB/RIF technology: the costs of laboratory vs. clinic-based roll-out
in South Africa
Kathryn Schnippel et al. Tropical Medicine and International Health, Vol. 17, No. 9, pp. 1142
The World Health Organization recommends using Xpert MTB/RIF for diagnosis of
pulmonary tuberculosis (PTB), but there is little evidence on the optimal placement of Xpert
instruments in public health systems. In this study used recent South African data to compare
the cost of placing Xpert at points of TB treatment (all primary clinics and hospitals) with the
cost of placement at sub-district laboratories. Autors estimated Xpert's cost/test in a primary
clinic pilot and in the pilot phase of the national Xpert roll-out to smear microscopy
laboratories; the expected future volumes for each of 223 laboratories or 3799 points of
treatment; the number and cost of Xpert instruments required and the national cost of using
Xpert for PTB diagnosis for each placement scenario in 2014. In 2014, South Africa will test
2.6 million TB suspects. Laboratory placement requires 274 Xpert instruments, while pointof-treatment placement requires 4020 instruments. With an Xpert cartridge price of $14.00,
the cost/test is $26.54 for laboratory placement and $38.91 for point-of-treatment placement.
Low test volumes and a high number of sites are the major contributors to higher point-oftreatment costs. National placement of Xpert at laboratories would cost $71 million/year;
point-of-treatment placement would cost $107 million/year, 51% more.
Placing Xpert
technology at points of treatment is substantially more expensive than placing the instruments
in smear microscopy laboratories. The incremental benefits of point-of-treatment placement,
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in terms of better patient outcomes, will have to be equally substantial to justify the additional
cost to the national health budget.
Cohort monitoring of persons with hypertension: an illustrated example from a primary
healthcare clinic for Palestine refugees in Jordan
Ali Khader et al. Tropical Medicine and International Health, Vol. 17, No. 9, pp. 1163-1170
There were 97 newly registered patients with hypertension in quarter 1, 2012, and a total of
4130 patients with hypertension ever registered since E-Health started in October 2009. By 31
March 2012, 3119 (76%) of 4130 patients were retained in care, 878 (21%) had failed to
present to a healthcare worker in the last 3 months and the remainder had died, transferred
out or were lost to follow-up. Cumulative and 12-month cohort outcome analysis indicated
deficiencies in several components of clinical performance related to blood pressure
measurements and fasting blood glucose tests to screen simultaneously for diabetes. Between
8% and 15% of patients with HT had serious complications such as cardiovascular disease
and stroke. Cohort analysis is a valuable tool for the monitoring and management of noncommunicable chronic diseases such as HT.
Zinc as adjunct treatment in infants aged between 7 and 120 days with probable serious
bacterial infection: a randomised, double-blind, placebo-controlled trial
Shinjini Bhatnagar et al. Lancet 2012, 379: 2072-78
Serious bacterial infections are a major cause of death in early infancy in developing
countries. Inexpensive and accessible interventions that can add to the effect of standard
antibiotic treatment could reduce infant mortality. We measured the effect of zinc as an
adjunct to antibiotics in infants with probable serious bacterial infection. In this randomised,
double-blind, placebo-controlled trial, we enrolled infants aged 7—120 days with probable
serious bacterial infection at three hospitals in New Delhi, India, between July 6, 2005, and
Dec 3, 2008. With computer-generated sequences, we randomly assigned infants in permuted
blocks of six, stratified by whether patients were underweight or had diarrhoea at enrolment,
to receive either 10 mg of zinc or placebo orally every day in addition to standard antibiotic
treatment. The primary outcome was treatment failure, which was defined as a need to change
antibiotics within 7 days of randomisation, or a need for intensive care, or death at any time
within 21 days. Participants and investigators were masked to treatment allocation. All
analyses were done by intention-to-treat. 352 infants were randomly assigned to receive zinc
and 348 to placebo. 332 given zinc and 323 given placebo could be assessed for treatment
failure. Significantly fewer treatment failures occurred in the zinc group (34 [10%]) than in
the placebo group (55 [17%]; relative risk reduction 40%, 95% CI 10—60, p=0·0113;
absolute risk reduction 6·8%, 1·5—12·0, p=0·0111). Treatment of 15 (95% CI eight to 67)
infants with zinc would prevent one treatment failure. Ten infants receiving zinc died
compared with 17 given placebo (relative risk 0·57, 0·27—1·23, p=0·15).
Zinc could be given as adjunct treatment to reduce the risk of treatment failure in infants aged
7—120 days with probable serious bacterial infection.
Department of Biotechnology, Government of India; the European Commission; the Meltzer
Foundation; and the Research Council of Norway.
The initial health-system response to the earthquake in Christchurch, New Zealand, in
February, 2011
Michael W. Ardagh et al. Lancet 2012, 379: 2109-15
Feb 22, 2011, an earthquake struck Christchurch, New Zealand, causing widespread
destruction. The only regional acute hospital was compromised but was able to continue to
provide care, supported by other hospitals and primary care facilities in the city. 6659 people
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were injured and 182 died in the initial 24 h. The massive peak ground accelerations, the time
of the day, and the collapse of major buildings contributed to injuries, but the proximity of the
hospital to the central business district, which was the most affected, and the provision of
good medical care based on careful preparation helped reduce mortality and the burden of
injury. Lessons learned from the health response to this earthquake include the need for
emergency departments to prepare for: patients arriving by unusual means without prehospital
care, manual registration and tracking of patients, patient reluctance to come into hospital
buildings, complete loss of electrical power, management of the many willing helpers,
alternative communication methods, control of the media, and teamwork with clear
leadership. Additionally, atypical providers of acute injury care need to be integrated into
response plans.
Efficacy of Miltefosine in the Treatment of Visceral Leishmaniasis in India After
a Decade of Use
Shyam Sundar et al. Tropical Infectious Diseases 2012, 55(4): 543-50
Miltefosine is the only oral drug available for treatment of Indian visceral leishmaniasis (VL),
which was shown to have an efficacy of 94% in a phase III trial in the Indian subcontinent. Its
unrestricted use has raised concern about its continued effectiveness. This study evaluates the
efficacy and safety of miltefosine for the treatment of VL after a decade of use in India.
An open-label, noncomparative study was performed in which 567 patients received oral
miltefosine (50 mg for patients weighing <25 kg, 100 mg in divided doses for those weighing
≥25 kg, and 2.5 mg per kg for those aged <12 years, daily for 28 days) in a directly observed
manner. Patients were followed up for 6 months to see the response to therapy.
At the end of treatment the initial cure rate was 97.5% (intention to treat), and 6 months after
the end of treatment the final cure rate was 90.3%. The overall death rate was 0.9% (5 of
567), and 2 deaths were related to drug toxicity. Gastrointestinal intolerance was frequent
(64.5%). The drug was interrupted in 9 patients (1.5%) because of drug-associated adverse
events. As compared to the phase III trial that led to registration of the drug a decade ago,
there is a substantial increase in the failure rate of oral miltefosine for treatment of VL in
India.
In Vitro Susceptibilities and Molecular Analysis of Vancomycin-Intermediate and
Vancomycin- Resistant Staphylococcus aureus Isolates
Louis D. Saravolatz Tropical Infectious Diseases 2012, 55(4): 582-6
There is increasing frequency of vancomycin-intermediate and -resistant Staphylococcus
aureus (VISA and VRSA) isolates identified in clinical practice. There are limited reports
evaluating susceptibility patterns and molecular characteristics of these strains. Laboratory
analysis was performed on 13 VRSA and 33 VISA isolates, including susceptibility testing by
broth microdilution, detection of Panton-Valentine leukocidin (PVL) genes, arginine catabolic
mobile element (ACME), and staphylococcal cassette chromosome mec typing using
polymerase chain reaction. Strain typing using pulsed-field gel electrophoresis (PFGE) was
performed on VRSA isolates. Telavancin, linezolid, tigecycline, and minocycline were active
against >90% of VISA isolates, while >90% of VRSA isolates were susceptible to ceftaroline,
daptomycin, linezolid, minocyline, tigecycline, rifampin, and trimethoprim/sulfamethoxazole.
There were no VISA or VRSA isolates that carried PVL genes or ACME, and most strains
(69.8%) were staphylococcal cassette chromosome mec type II. VRSA isolates were
predominantly related to USA100 (53.8%) and none were related to USA300 or USA400.
A large number of available antimicrobial agents retain very good in vitro activity against
VRSA and VISA isolates. The present isolates appear to be derived from healthcareassociated strains based on the absence of features associated with community-associated
strains, and VRSA isolates are polyclonal by PFGE.
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Rapid Diagnostic Tests for a Coordinated Approach to fever Syndromes in Lowresource Settings
Yansouni CP et al. Clin Infect Dis. 2012 Aug;55(4):610-1
This large unrecognized outbreak of severe disease from a clonal strain of Salmonella
illustrates the pitfals of focusing on a single pathogen, sucha s malaria, in patients presenting
with febrile illnesses in low-resource settings. Futher, widespread adoption of malaria rapid
diagnostic tests (RDT) has resulted in dramatic increases in empiric antibacterial use among
the three-quarters of febrile patients in whom no malaria is found. This dichotomous
diagnostic approach can only fuel emerging antimicrobial resistance in the settings that can
least afford it.
Current rabies vaccines and prophylaxis schedules: Preventing rabies before and after
exposure
Warell M. J. et al. Tropical Medicine and Infectious Disease 2012, 10, 1-15
Travellers are probably the largest group in the general population to receive rabies preexposure prophylaxis. The dangerous consequences of the unavailability of rabies immune
globulin in many countries could be ameliorated if pre-exposure rabies vaccination were
practised more widely, especially in children, living in dog rabies enzootic countries. The
WHO has recommended several different regimens for post-exposure prophylaxis, while
individual countries decide on protocols for local use. Intramuscular regimens are expensive
and waste vaccine. Although failure to receive vaccine is usually the due to the cost, the
economical potential of intradermal vaccination has still not been realised 19 years after its
introduction. The currently recommended 2-site intradermal post-exposure regimen is not
economical for use in rural areas where 80% of Indian rabies deaths occur. Most countries
using it demand higher potency vaccine, indicating that they do not have complete confidence
in the method. This intradermal regimen has only been used where immunoglobulin is likely
to be available for severely bitten patients. Increased intradermal doses are sometimes used
for selected patients. Provision of economical rabies prophylaxis can be improved. Decisions
to change recommendations should take account of the immunological, financial, practical
and logistical aspects of dog bite treatment in remote areas.
Adherence to artemether/lumefantrine treatment in children under real-life situations in
rural Tanzania
Daudi O. Simba et al. Transaction of the Royal Society of Tropical Medicine and Hygiene
106(2012)3-9
A follow-up study was conducted to determine the magnitude of and factors related to
adherence to artemether/lumefantrine (ALu) treatment in rural settings in Tanzania. Children
in five villages of Kilosa District treated at health facilities were followed-up at their homes
on Day 7 after the first dose of ALu. For those found to be positive using a rapid diagnostic
test for malaria and treated with ALu, their caretakers were interviewed on drug
administration habits. In addition, capillary blood samples were collected on Day 7 to
determine lumefantrine concentrations. The majority of children (392/444; 88.3%) were
reported to have received all doses, in time. Non-adherence was due to untimeliness rather
than missing doses and was highest for the last two doses. No significant difference was
found between blood lumefantrine concentrations among adherent (median 286 nmol/l) and
non-adherent [median 261 nmol/l; range 25 nmol/l (limit of quantification) to 9318 nmol/l].
Children from less poor households were more likely to adhere to therapy than the poor [odds
ratio (OR)=2.45, 95% CI 1.35-4.45; adjusted OR=2.23, 95% CI 1.20-4.13]. The high reported
rate of adherence to ALu in rural areas is encouraging and needs to be preserved to reduce the
risk of emergence of resistant strains. The age-based dosage schedule and lack of adherence to
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ALu treatment guidelines by health facility staff may explain both the huge variability in
observed lumefantrine concentrations and the lack of difference in concentrations between the
two groups.
Morbidity and mortality of severe malnutrition among Sudanese children in New Halfa
Hospital, Eastern Sudan
Hyder M. Mahgoub et al. Transaction of the Royal Society of Tropical Medicine and Hygiene
106(2012) 66-68
Medical files of children with severe malnutrition admitted at New Halfa hospital, Sudan
during 2007-2009 were reviewed. A total of 1097 children (54.9%, 602 male) with severe
malnutrition were admitted during the three year period. Oedematous severe malnutrition was
found in 179 (16.3%) children. Of these 1097, 796 (72.6%) patients with severe malnutrition
were children <2 years old. Out of these 1097 children, 780 (71.1%) and 112 (10.2%) had
diarrhoea and malaria, respectively. Sixty-one (5.5%) of these children died, 237 (21.6%)
discharged against medical advice and 799 (72.8%) were discharged. Of the 61 children who
died 11 (18.0%) had septicaemia following diarrhoea and respiratory tract infections. The
case fatality rate was not different with sex or with presence/absence of oedema.
Nerve damage in leprosy: a continuing challenge to scientists, clinicians and service
providers
Diana N. Lockwood et al. International health 4 (2012) 77-85
This review focuses on nerve damage in leprosy. We present evidence to support the
argument that leprosy is best seen as a chronic neurological condition rather than a simple
skin disease. Nerve damage affects small dermal nerves and peripheral nerve trunks.
Perineural inflammation is a characteristic and hallmark of early leprosy. T cell-mediated
inflammation is the main pathological process in leprosy nerve damage. The level of nerve
damage in leprosy is high with up to 60% of multibacillary patients having clinically apparent
nerve damage at the time of diagnosis; 30% of patents may develop further nerve damage
during treatment and 10% may develop new nerve damage after drug treatment. Since the
nerve damage is immune mediated, the antibiotics used to treat Mycobacterium leprae
infection have little effect on the accompanying nerve damage. This requires treatment with
immunosuppressants to stop the inflammation. Treatment of nerve damage with steroids can
be effective but about 50% of patients relapse and require a further course of steroids.
Research is needed to refine steroid regimens to be used and define appropriate alternatives.
Neuropathic pain is now being recognised as another late complication for leprosy patients.
There are also service challenges relating to how best to identify patients who need steroid
treatment and how to manage patients with established neuropathy who may require health
services for many years.
Mortality after surgery in Europe: a 7 day cohort study
Rupert M. Pearse et al. Lancet 2012, 380: 1059-65
Clinical outcomes after major surgery are poorly described at the national level. Evidence of
heterogeneity between hospitals and health-care systems suggests potential to improve care for
patients but this potential remains unconfirmed. The European Surgical Outcomes Study was an
international study designed to assess outcomes after non-cardiac surgery in Europe. We did this 7 day
cohort study between April 4 and April 11, 2011. We collected data describing consecutive patients
aged 16 years and older undergoing inpatient non-cardiac surgery in 498 hospitals across 28 European
nations. Patients were followed up for a maximum of 60 days. The primary endpoint was in-hospital
mortality. Secondary outcome measures were duration of hospital stay and admission to critical care.
We used П‡2 and Fisher's exact tests to compare categorical variables and the t test or the MannWhitney U test to compare continuous variables. Significance was set at p<0В·05. We constructed
multilevel logistic regression models to adjust for the differences in mortality rates between countries.
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We included 46 539 patients, of whom 1855 (4%) died before hospital discharge. 3599 (8%) patients
were admitted to critical care after surgery with a median length of stay of 1·2 days (IQR 0·9—3·6).
1358 (73%) patients who died were not admitted to critical care at any stage after surgery. Crude
mortality rates varied widely between countries (from 1·2% [95% CI 0·0—3·0] for Iceland to 21·5%
[16·9—26·2] for Latvia). After adjustment for confounding variables, important differences remained
between countries when compared with the UK, the country with the largest dataset (OR range from
0·44 [95% CI 0·19—1·05; p=0·06] for Finland to 6·92 [2·37—20·27; p=0·0004] for Poland).
The mortality rate for patients undergoing inpatient non-cardiac surgery was higher than anticipated.
Variations in mortality between countries suggest the need for national and international strategies to
improve care for this group of patients.
Perioperative and anaesthetic-related mortality in developed and developing countries:
a systematic review and meta-analysis
Daniel Bainbridge et al. Lancet 2012, 380: 1075-81
The magnitude of risk of death related to surgery and anaesthesia is not well understood. We aimed to
assess whether the risk of perioperative and anaesthetic-related mortality has decreased over the past
five decades and whether rates of decline have been comparable in developed and developing
countries. We did a systematic review to identify all studies published up to February, 2011, in any
language, with a sample size of over 3000 that reported perioperative mortality across a mixed surgical
population who had undergone general anaesthesia. Using standard forms, two authors independently
identified studies for inclusion and extracted information on rates of anaesthetic-related mortality,
perioperative mortality, cardiac arrest, American Society of Anesthesiologists (ASA) physical status,
geographic location, human development index (HDI), and year. The primary outcome was
anaesthetic sole mortality. Secondary outcomes were anaesthetic contributory mortality, total
perioperative mortality, and cardiac arrest. Meta-regression was done to ascertain weighted event rates
for the outcomes. 87 studies met the inclusion criteria, within which there were more than 21В·4 million
anaesthetic administrations given to patients undergoing general anaesthesia for surgery. Mortality
solely attributable to anaesthesia declined over time, from 357 per million (95% CI 324-394) before
the 1970s to 52 per million (42-64) in the 1970s-80s, and 34 per million (29-39) in the 1990s-2000s
(p<0В·00001). Total perioperative mortality decreased over time, from 10,603 per million (95% CI
10,423-10,784) before the 1970s, to 4533 per million (4405-4664) in the 1970s-80s, and 1176 per
million (1148-1205) in the 1990s-2000s (p<0В·0001). Meta-regression showed a significant relation
between risk of perioperative and anaesthetic-related mortality and HDI (all p<0В·00001). Baseline risk
status of patients who presented for surgery as shown by the ASA score increased over the decades
(p<0В·0001). Despite increasing patient baseline risk, perioperative mortality has declined significantly
over the past 50 years, with the greatest decline in developed countries. Global priority should be
given to reducing total perioperative and anaesthetic-related mortality by evidence-based best practice
in developing countries.
Untreated surgical conditions in Sierra Leone: a cluster randomised, cross-sectional,
countrywide survey
Reinou S. et al. Groen Lancet 2012, 380: 1082-87
Surgical care is increasingly recognised as an important part of global health yet data for the
burden of surgical disease are scarce. The Surgeons OverSeas Assessment of Surgical Need
(SOSAS) was developed to measure the prevalence of surgical conditions and surgically
treatable deaths in low-income and middle-income countries. We administered this survey
countrywide in Sierra Leone, which ranks 180 of the 187 nations on the UN Development
Index. The study was done between Jan 9 and Feb 3, 2012. 75 of 9671 enumeration areas, the
smallest administrative units in Sierra Leone, were randomly selected for the study clusters,
with a probability proportional to the population size. In each cluster 25 households were
randomly selected to take part in the survey. Data were collected via handheld tablets by
trained local medical and nursing students. A household representative was interviewed to
establish the number of household members (defined as those who ate from the same pot and
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slept in the same structure the night before the interview), identify deaths in the household
during the previous year, and establish whether any of the deceased household members had a
condition needing surgery in the week before death. Two randomly selected household
members underwent a head-to-toe verbal examination and need for surgical care was recorded
on the basis of the response to whether they had a condition that they believed needed surgical
assessment or care. Of the 1875 targeted households, data were analysed for 1843 (98%). 896
of 3645 (25%; 95% CI 22·9—26·2) respondents reported a surgical condition needing
attention and 179 of 709 (25%; 95% CI 22·5—27·9) deaths of household members in the
previous year might have been averted by timely surgical care. Our results show a large
unmet need for surgical consultations in Sierra Leone and provide a baseline against which
future surgical programmes can be measured. Additional surveys in other low-income and
middle-income countries are needed to document and confirm what seems to be a neglected
component of global health.
Clusters of leprosy transmission and of late diagnosis in a highly endemic area in Brazil:
focus on different spatial analysis
Carlos H. Alencar et al. Tropical Medicine and International Health, Vol. 17, No. 4, pp: 518
A total of 254 (68.0%) municipalities were classified as hyperendemic (mean annual detection
rates >40 cases/100 000 inhabitants). There was a concentration of municipalities with
higher detection rates in ParГЎ and in the center of MaranhГЈo. Spatial scan statistic identified
23 likely clusters of new leprosy case detection rates, most of them localized in these two
states. These clusters included only 32% of the total population, but 55.4% of new leprosy
cases. We also identified 16 significant clusters for the detection rate <15 years and 11
likely clusters of new cases with grade-2. Several clusters of new cases with grade2/population overlap with those of new cases detection and detection of children <15 years
of age. The proportion of new cases with grade-2 did not reveal any significant clusters.
Rural electrification in Brazil and implications for schistosomiasis transmission:
a preliminary study in a rural community in Minas Gerais State, Brazil
Helmut Kloos et al. Tropical Medicine and International Health, Vol. 17, No. 4, pp: 526-530
Our results indicate that further studies are needed to determine the infectivity of well water
and its impact on schistosomiasis transmission.
Virological Failure and Drug Resistance in Patients on Antiretroviral Therapy After
Treatment Interruption in Lilongwe, Malawi
Julia Luebbert et al. CID 2012, 55(3):441-8
Since 2004, Malawi has rapidly scaled up access to antiretroviral therapy (ART) in the national
program following a public health approach with limited laboratory monitoring. We examined
virological outcomes in patients with treatment interruption at 2 clinics of the Lighthouse Trust,
Lilongwe, Malawi. We evaluated patients who resumed first-line ART after having at least 1 treatment
interruption documented in the electronic data system in 2008-2009. Viral load (VL) was analyzed at
least 2 months after resumption of ART. For VL ≥1000 copies/mL, drug-resistance genotype was
characterized using the Stanford database. Between June and November 2009, we enrolled 133
patients (58.7% female) with a mean age of 38.4 years. Mean duration of ART prior to treatment
interruption was 14.3 months. After a minimum of 2 months following ART resumption, VL was
undetectable in 81 (60.9%) patients, was 400-1000 copies/mL in 12 (9.0%) patients, and was ≥1000
copies/mL in 40 (30.1%) patients. Genotyping and drug-resistance testing were successfully
performed for 36 of 40 patients, all carrying human immunodeficiency virus type 1 subtype C.
Relevant mutations affecting nonnucleoside reverse transcriptase inhibitors were found in 32 of 133
(24.1%) patients and combined with relevant nucleoside reverse transcriptase mutations in 27 of 133
(20.3%) patients. Virological failure combined with drug resistance after resumption of first-line ART
occurred in 24.1% of the patients with treatment interruption, requiring a switch to protease inhibitorbased second-line therapy. Patients with treatment interruption should receive VL assessment after
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resumption of ART to detect treatment failure and to reduce development and spread of drug
resistance.
Procalcitonin to Guide Initiation and Duration of Antibiotic Treatment in Acute Respiratory
Infections: An Individual Patient Data Meta- Analysis
Philipp Schuetz et al. CID 2012, 55(5): 651-62
Procalcitonin algorithms may reduce antibiotic use for acute respiratory tract infections (ARIs). We
undertook an individual patient data meta-analysis to assess safety of this approach in different ARI
diagnoses and different clinical settings. We identified clinical trials in which patients with ARI were
assigned to receive antibiotics based on a procalcitonin algorithm or usual care by searching the
Cochrane Register, MEDLINE, and EMBASE. Individual patient data from 4221 adults with ARIs in
14 trials were verified and reanalyzed to assess risk of mortality and treatment failure-overall and
within different clinical settings and types of ARIs. Overall, there were 118 deaths in 2085 patients
(5.7%) assigned to procalcitonin groups compared with 134 deaths in 2126 control patients (6.3%;
adjusted odds ratio, 0.94; 95% confidence interval CI, .71-1.23)]. Treatment failure occurred in 398
procalcitonin group patients (19.1%) and in 466 control patients (21.9%; adjusted odds ratio, 0.82;
95% CI, .71-.97). Procalcitonin guidance was not associated with increased mortality or treatment
failure in any clinical setting or ARI diagnosis. Total antibiotic exposure per patient was significantly
reduced overall (median [interquartile range], from 8 [5-12] to 4 [0-8] days; adjusted difference in
days, -3.47 [95% CI, -3.78 to -3.17]) and across all clinical settings and ARI diagnoses. Use of
procalcitonin to guide initiation and duration of antibiotic treatment in patients with ARIs was
effective in reducing antibiotic exposure across settings without an increase in the risk of mortality or
treatment failure. Further high-quality trials are needed in critical-care patients.
An Outbreak of Shiga Toxin-Producing Escherichia coli O104:H4 Hemolytic Uremic
Syndrome in Germany: Presentation and Shortterm Outcome in Children
Sebastian Loos et al. CID 2012, 55(6): 753-9
In May and June 2011 the largest known outbreak of hemolytic uremic syndrome (HUS)
occurred in northern Germany. Because, quite unusually, a large number of adults was
affected and the causative Escherichia coli strain, serotype O104:H4, showed an atypical
virulence factor pattern, it was speculated that this outbreak was associated with an aggressive
course and an unfavorable prognosis also in children. Retrospective analysis of medical
records of 90 children and comparison to previous outbreak and sporadic case series. Median
age was unusually high (11.5 years) compared with that in historical series. Only 1 patient
(1.1%) died in the acute phase. Most patients (67/90 [74%]) received supportive care only.
Renal replacement therapy was required in 64 of 90 (71%) of the children. Neurological
complications, mainly seizures and altered mental stage, were present in 23 of 90 (26%)
patients. Ten patients received plasmapheresis, 6 eculizumab, and 7 a combination of both.
After a median follow-up of 4 months, renal function normalized in 85 of 90 (94%) patients,
whereas 3 patients had chronic kidney disease stage 3 or 4, and 1 patient (1.1%) still requires
dialysis. Complete neurological recovery occurred in 18 of 23 patients. Mild to moderate and
major residual neurological changes were present in 3 patients and 1 patient, respectively,
although all patients were still improving.
E. coli O104:H4 caused the largest HUS outbreak in children reported in detail to date and
most patients received supportive treatment only. Initial morbidity, as well as short-term
outcome, due to this pathogen, is comparable to previous pediatric series of Shiga toxinproducing E. coli HUS.
The Role of Asymptomatic Bacteriuria in Young Women With Recurrent Urinary Tract
Infections: To Treat or Not to Treat?
Tommaso Cai et al. CID 2012, 55(6): 771-7
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Little is known about the role of asymptomatic bacteriuria (AB) treatment in young women
affected by recurrent urinary tract infection (UTI). We aimed to evaluate the impact of AB
treatment on the recurrence rate among young women affected by recurrent UTI. A total of
673 consecutive asymptomatic young women with demonstrated bacteriuria from January
2005 to December 2009 were prospectively enrolled. Patients were split into 2 groups: not
treated (group A, n = 312) and treated (group B, n = 361). Microbiological and clinical
evaluations were performed at 3, 6, and 12 months. Quality of life was also measured.
Recurrence-free rate at the end of the entire study period was the main outcome measure. At
baseline, the 2 most commonly isolated pathogens were Escherichia coli (group A, 38.4%;
group B, 39.3%) and Enterococcus faecalis (group A, 32.7%; group B, 33.2%). At the first
follow-up visit, there was no difference between the 2 groups (relative risk [RR], 1.05; 95%
confidence interval [CI], 1.01-1.10), whereas after 6 months, 23 (7.6%) in group A and 98
(29.7%) in group B showed recurrence with a statistically significant difference (RR, 1.31;
95% CI, 1.21-1.42; P < .0001). At the last follow-up, 41 (13.1%) in group A and 169 (46.8%)
in group B showed recurrence (RR, 3.17; 95% CI, 2.55-3.90; P < .0001). One patient in group
A and 2 patients in group B were found to have pyelonephritis. This study shows that AB
should not be treated in young women affected by UTI, suggesting it may play a protective
role in preventing symptomatic recurrence.
Costs of Healthcare- and Community-Associated Infections With Antimicrobial–
Resistant Versus Antimicrobial-Susceptible Organisms
Matthew J. Neidell et al. CID 2012, 55(6): 807-15
We compared differences in the hospital charges, length of hospital stay, and mortality
between patients with healthcare- and community-associated bloodstream infections, urinary
tract infections, and pneumonia due to antimicrobial-resistant versus -susceptible bacterial
strains. . A retrospective analysis of an electronic database compiled from laboratory,
pharmacy, surgery, financial, and patient location and device utilization sources was
undertaken on 5699 inpatients who developed healthcare- or community-associated infections
between 2006 and 2008 from 4 hospitals (1 community, 1 pediatric, 2 tertiary/quaternary
care) in Manhattan. The main outcome measures were hospital charges, length of stay, and
mortality among patients with antimicrobial-resistant and -susceptible infections caused by
Staphylococcus aureus, Enterococcus faecium, Enterococcus faecalis, Klebsiella pneumoniae,
Pseudomonas aeruginosa, and Acinetobacter baumannii. . Controlling for multiple
confounders using linear regression and nearest neighbor matching based on propensity score
estimates, resistant healthcare- and community-associated infections, when compared with
susceptible strains of the same organism, were associated with significantly higher charges
($15 626; confidence interval [CI], $4339–$26 913 and $25 573; CI, $9331–$41 816,
respectively) and longer hospital stays for community-associated infections (3.3; CI, 1.5–5.4).
Patients with resistant healthcare-associated infections also had a significantly higher death
rate (0.04; CI, 0.01–0.08). . With careful matching of patients infected with the same
organism, antimicrobial resistance was associated with higher charges, length of stay, and
death rates. The difference in estimates after accounting for censoring for death highlight
divergent social and hospital incentives in reducing patient risk for antimicrobial resistant
infections.
Efficacy and safety of tigecycline for the treatment of infectious diseases: a meta-analysis
Efthimia Tasina et al. Lancet 2011, 11: 834-44
Multidrug resistance among bacteria increases the need for new antimicrobial drugs with high
potency and stability. Tigecycline is one candidate drug, and a previous meta-analysis of only
published randomised controlled trials suggested that it might as effective as comparator
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treatments; we did a meta-analysis to include new and unpublished trials to assess its efficacy
for the treatment of adult patients with serious bacterial infection. We searched PubMed,
Cochrane Central Register, and Embase up to March 30, 2011, to identify published studies,
and we searched clinical trial registries to identify completed unpublished studies, the results
of which were obtained through the manufacturer. Eligible studies were randomised trials
assessing the clinical efficacy, safety, and eradication efficiency of tigecycline versus other
antimicrobial agents for any bacterial infection. The primary outcome was treatment success
in patients who received at least one dose of the study drug, had clinical evidence of disease,
and had complete follow-up (the clinically assessable population). Meta-analysis was done
with random-effects models because of heterogeneity across the trials. 14 randomised trials,
comprising about 7400 patients, were included. Treatment success was lower with tigecycline
than with control antibiotic agents, but the difference was not significant (odds ratio 0В·87,
95% CI 0·74—1·02). Adverse events were more frequent in the tigecycline group than in the
control groups (1·45, 1·11—1·88), with significantly more vomiting and nausea. All-cause
mortality was higher in the tigecycline group than in the comparator groups, but the difference
was not significant (1·28, 0·97—1·69). Eradication efficiency did not differ between
tigecycline and control regimens, but the sample size for these comparisons was small.
Tigecycline is not better than standard antimicrobial agents for the treatment of serious
infections. Our findings show that assessment with unpublished studies is needed to make
appropriate decisions about new agents.
Efficacy and effectiveness of influenza vaccines: a systematic review and meta-analysis
Michael T. Osterholm et al. Lancet 2012, 12: 36-44
No published meta-analyses have assessed efficacy and effectiveness of licensed influenza
vaccines in the USA with sensitive and highly specific diagnostic tests to confirm influenza.
We searched Medline for randomised controlled trials assessing a relative reduction in
influenza risk of all circulating influenza viruses during individual seasons after vaccination
(efficacy) and observational studies meeting inclusion criteria (effectiveness). Eligible articles
were published between Jan 1, 1967, and Feb 15, 2011, and used RT-PCR or culture for
confirmation of influenza. We excluded some studies on the basis of study design and vaccine
characteristics. We estimated random-effects pooled efficacy for trivalent inactivated vaccine
(TIV) and live attenuated influenza vaccine (LAIV) when data were available for statistical
analysis (eg, at least three studies that assessed comparable age groups).
We screened 5707 articles and identified 31 eligible studies (17 randomised controlled trials
and 14 observational studies). Efficacy of TIV was shown in eight (67%) of the 12 seasons
analysed in ten randomised controlled trials (pooled efficacy 59% [95% CI 51—67] in adults
aged 18—65 years). No such trials met inclusion criteria for children aged 2—17 years or
adults aged 65 years or older. Efficacy of LAIV was shown in nine (75%) of the 12 seasons
analysed in ten randomised controlled trials (pooled efficacy 83% [69—91]) in children aged
6 months to 7 years. No such trials met inclusion criteria for children aged 8—17 years.
Vaccine effectiveness was variable for seasonal influenza: six (35%) of 17 analyses in nine
studies showed significant protection against medically attended influenza in the outpatient or
inpatient setting. Median monovalent pandemic H1N1 vaccine effectiveness in five
observational studies was 69% (range 60—93). Influenza vaccines can provide moderate
protection against virologically confirmed influenza, but such protection is greatly reduced or
absent in some seasons. Evidence for protection in adults aged 65 years or older is lacking.
LAIVs consistently show highest efficacy in young children (aged 6 months to 7 years). New
vaccines with improved clinical efficacy and effectiveness are needed to further reduce
influenza-related morbidity and mortality.
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Fidaxomicin versus vancomycin for infection with Clostridium difficile in Europe,
Canada and the USA: a double-blind, non-inferiority, randomised controlled trial
Oliver A. Cornely et al. Lancet 2012, 12: 281-89
Infection with Clostridium difficile is the primary infective cause of antibiotic-associated diarrhoea.
We aimed to compare efficacy and safety of fidaxomicin and vancomycin to treat patients with C
difficile infection in Europe, Canada, and the USA. In this multicentre, double-blind, randomised,
non-inferiority trial, we enrolled patients from 45 sites in Europe and 41 sites in the USA and
Canada between April 19, 2007, and Dec 11, 2009. Eligible patients were aged 16 years or
older with acute, toxin-positive C difficile infection. Patients were randomly allocated (1:1) to
receive oral fidaxomicin (200 mg every 12 h) or oral vancomycin (125 mg every 6 h) for 10
days. The primary endpoint was clinical cure, defined as resolution of diarrhoea and no
further need for treatment. An interactive voice-response system and computer-generated
randomisation schedule gave a randomisation number and medication kit number for each
patient. Participants and investigators were masked to treatment allocation. Non-inferiority
was prespecified with a margin of 10%. Modified intention-to-treat and per-protocol
populations were analysed. This study is registered with ClinicalTrials.gov, number
NCT00468728. Of 535 patients enrolled, 270 were assigned fidaxomicin and 265
vancomycin. After 26 patients were excluded, 509 were included in the modified intention-totreat (mITT) population. 198 (91В·7%) of 216 patients in the per-protocol population given
fidaxomicin achieved clinical cure, compared with 213 (90В·6%) of 235 given vancomycin,
meeting the criterion for non-inferiority (one-sided 97В·5% CI в€’4В·3%). Non-inferiority was
also shown for clinical cure in the mITT population, with 221 (87В·7%) of 252 patients given
fidaxomicin and 223 (86В·8%) of 257 given vancomycin cured (one-sided 97В·5% CI в€’4В·9%).
In most subgroup analyses of the primary endpoint in the mITT population, outcomes in the
two treatment groups did not differ significantly; although patients receiving concomitant
antibiotics for other infections had a higher cure rate with fidaxomicin (46 [90В·2%] of 51)
than with vancomycin (33 [73В·3%] of 45; p=0В·031). Occurrence of treatment-emergent
adverse events did not differ between groups. 20 (7В·6%) of 264 patients given at least one
dose of fidaxomicin and 17 (6В·5%) of 260 given vancomycin died. Fidaxomicin could be an
alternative treatment for infection with C difficile, with similar efficacy and safety to
vancomycin.
Daclatasvir for previosly untreated chronic hepatitis C genotype-1 infection:
a randomised, paralel-group, double-blind, placebo-controlled, dose-finding, phase 2a
trial
Stanislas Pol et al. Lancet 2012, 12: 617-77
Daclatasvir seems to be a potent NS5A replication complex inhibitor that increases the antiviral
potency of peginterferon and ribavirin. Our findings support the further development of regimens
containing 60 mg daclatasvir for the treatment of chronic genotype-1 HCV infection.
Effectiveness and safety of drotrecogin alfa (activated) for severe sepsis: a meta-analysis
and metaregression
Andre C. Kalil et al. Lancet 2012, 12: 678-86
Real-life use of drotrecrogin alfa (activated) was associated with significant reduction in
hospital mortality and increased rates of bleeding in patients with severe sepsis. Our
effectiveness findings were in line with the PROWESS trial but not with the PROWESSSHOCK trial.
How changes in coverage affect equity in maternal and child health interventions in 35
Countdown to 2015 countries: an analysis of national surveys
Cesar G. Victora et al. Lancet 2012, 380: 1149-56
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Achievement of global health goals will require assessment of progress not only nationally
but also for population subgroups. We aimed to assess how the magnitude of socioeconomic
inequalities in health changes in relation to different rates of national progress in coverage of
interventions for the health of mothers and children. We assessed coverage in low-income and
middle-income countries for which two Demographic Health Surveys or Multiple Indicator
Cluster Surveys were available. We calculated changes in overall coverage of skilled birth
attendants, measles vaccination, and a composite coverage index, and examined coverage of a
newly introduced intervention, use of insecticide-treated bednets by children. We stratified
coverage data according to asset-based wealth quintiles, and calculated relative and absolute
indices of inequality. We adjusted correlation analyses for time between surveys and baseline
coverage levels. We included 35 countries with surveys done an average of 9В·1 years apart.
Pro-rich inequalities were very prevalent. We noted increased coverage of skilled birth
attendants, measles vaccination, and the composite index in most countries from the first to
the second survey, while inequalities were reduced. Rapid changes in overall coverage were
associated with improved equity. These findings were not due to a capping effect associated
with limited scope for improvement in rich households. For use of insecticide-treated bednets,
coverage was high for the richest households, but countries making rapid progress did almost
as well in reaching the poorest groups. National increases in coverage were primarily driven
by how rapidly coverage increased in the poorest quintiles.
Countdown to 2015: changes in official development assistance to maternal, newborn
and child health in 2009-10 and assessment of progress since 2003
Justine Hsu et al. Lancet 2012, 380: 1157-68
Tracking of financial resources to maternal, newborn, and child health provides crucial
information to assess accountability of donors. We analysed official development assistance
(ODA) flows to maternal, newborn, and child health for 2009 and 2010, and assessed progress
since our monitoring began in 2003. We coded and analysed all 2009 and 2010 aid activities
from the database of the Organisation for Economic Co-operation and Development,
according to a functional classification of activities and whether all or a proportion of the
value of the disbursement contributed towards maternal, newborn, and child health. We
analysed trends since 2003, and reported two indicators for monitoring donor disbursements:
ODA to child health per child and ODA to maternal and newborn health per livebirth. We
analysed the degree to which donors allocated ODA to 74 countries with the highest maternal
and child mortality rates (Countdown priority countries) with time and by type of donor.
Donor disbursements to maternal, newborn, and child health activities in all countries
continued to increase, to $6511 million in 2009, but slightly decreased for the first time since
our monitoring started, to $6480 million in 2010. ODA for such activities to the 74
Countdown priority countries continued to increase in real terms, but its rate of increase has
been slowing since 2008. We identified strong evidence that targeting of ODA to countries
with high rates of maternal mortality improved from 2005 to 2010. Targeting of ODA to child
health also improved but to a lesser degree. The share of multilateral funding continued to
decrease but, relative to bilaterals and global health initiatives, was better targeted. The recent
slowdown in the rate of funding increases is worrying and likely to partly result from the
present financial crisis. Tracking of donor aid should continue, to encourage donor
accountability and to monitor performance in targeting aid flows to those in most need.
Bill & Melinda Gates Foundation; World Bank; Governments of Australia, Canada, Norway,
Sweden, and the UK.
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Reduction in child mortality in Niger: a Countdown to 2015 country case study
Agbessi Amouzou et al. Lancet 2012, 380: 1169-78
The Millennium Development Goal 4 (MDG 4) is to reduce by two-thirds the mortality rate of
children younger than 5 years, between 1990 and 2015. The 2012 Countdown profile shows
that Niger has achieved far greater reductions in child mortality and gains in coverage for
interventions in child survival than neighbouring countries in west Africa. Countdown
therefore invited Niger to do an in-depth analysis of their child survival programme between
1998 and 2009. We developed new estimates of child and neonatal mortality for 1998—2009
using a 2010 household survey. We recalculated coverage indicators using eight nationallyrepresentative surveys for that period, and documented maternal, newborn, and child health
programmes and policies since 1995. We used the Lives Saved Tool (LiST) to estimate the
child lives saved in 2009. The mortality rate in children younger than 5 years declined
significantly from 226 deaths per 1000 livebirths (95% CI 207—246) in 1998 to 128 deaths
(117—140) in 2009, an annual rate of decline of 5·1%. Stunting prevalence decreased slightly
in children aged 24—35 months, and wasting declined by about 50% with the largest
decreases in children younger than 2 years. Coverage increased greatly for most child survival
interventions in this period. Results from LiST show that about 59 000 lives were saved in
children younger than 5 years in 2009, attributable to the introduction of insecticide-treated
bednets (25%); improvements in nutritional status (19%); vitamin A supplementation (9%);
treatment of diarrhoea with oral rehydration salts and zinc, and careseeking for fever, malaria,
or childhood pneumonia (22%); and vaccinations (11%). Government policies supporting
universal access, provision of free health care for pregnant women and children, and
decentralised nutrition programmes permitted Niger to decrease child mortality at a pace that
exceeds that needed to meet the MDG 4.
Bill & Melinda Gates Foundation; World Bank; Governments of Australia, Canada, Norway,
Sweden, and the UK; and UNICEF.
Mumps Outbreak in Orthodox Jewish Communities in the United States
Albert E. Barskey et al. N Engl J Med, 367, 18, 2012
By 2005, vaccination had reduced the annual incidence of mumps in the United States by more than
99%, with few outbreaks reported. However, in 2006, a large outbreak occurred among highly
vaccinated populations in the United States, and similar outbreaks have been reported worldwide. The
outbreak described in this report occurred among U.S. Orthodox Jewish communities during 2009 and
2010. Cases of salivary-gland swelling and other symptoms clinically compatible with mumps were
investigated, and demographic, clinical, laboratory, and vaccination data were evaluated. From June
28, 2009, through June 27, 2010, a total of 3502 outbreak-related cases of mumps were reported in
New York City, two upstate New York counties, and one New Jersey county. Of the 1648 cases for
which clinical specimens were available, 50% were laboratory-confirmed. Orthodox Jewish persons
accounted for 97% of case patients. Adolescents 13 to 17 years of age (27% of all patients) and males
(78% of patients in that age group) were disproportionately affected. Among case patients 13 to 17
years of age with documented vaccination status, 89% had previously received two doses of a mumpscontaining vaccine, and 8% had received one dose. Transmission was focused within Jewish schools
for boys, where students spend many hours daily in intense, face-to-face interaction. Orchitis was the
most common complication (120 cases, 7% of male patients ≥12 years of age), with rates significantly
higher among unvaccinated persons than among persons who had received two doses of vaccine. The
epidemiologic features of this outbreak suggest that intense exposures, particularly among boys in
schools, facilitated transmission and overcame vaccine-induced protection in these patients. High rates
of two-dose coverage reduced the severity of the disease and the transmission to persons in settings of
less intense exposure.
Evaluation of Immigrant Tuberculosis Screening in Industrialized Countries
Manish Pareek et al. Emerging Infectious Diseases, 2012, Vol. 18, No. 9 x
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CLINICAL SOCIAL WORK (CSW)
In industrialized countries, tuberculosis (TB) cases are concentrated among immigrants and
driven by reactivation of imported latent TB infection (LTBI). We examined mechanisms
used to screen immigrants for TB and LTBI by sending an anonymous, 18-point questionnaire
to 31 member countries of the Organisation for Economic Co-operation and Development.
Twenty-nine (93.5%) of 31 responded; 25 (86.2%) screened immigrants for active TB. Fewer
countries (16/29, 55.2%) screened for LTBI. Marked variations were observed in targeted
populations for age (range <5 years of age to all age groups) and TB incidence in countries of
origin of immigrants (>20 cases/100,000 population to >500 cases/100,000). LTBI screening
was conducted in 11/16 countries by using the tuberculin skin test. Six countries used
interferon-Оі release assays, primarily to confirm positive tuberculin skin test results.
Industrialized countries performed LTBI screening infrequently and policies varied widely.
There is an urgent need to define the cost-effectiveness of LTBI screening strategies for
immigrants.
Old Drugs, New Purpose: Retooling Existing Drugs for Optimized Treatment of
Resistant Tuberculosis
Kelly E. Dooley et al. Tropical Infectious Diseases 2012, 55(4): 572-81
Treatment of drug-resistant tuberculosis is hindered by the high toxicity and poor efficacy of
second-line drugs. New compounds must be used together with existing drugs, yet clinical
trials to optimize combinations of drugs for drug-resistant tuberculosis are lacking. We
conducted an extensive review of existing in vitro, animal, and clinical studies involving
World Health Organization-defined group 1, 2, and 4 drugs used in drug-resistant tuberculosis
regimens to inform clinical trials and identify critical research questions. Results suggest that
optimizing the dosing of pyrazinamide, the injectables, and isoniazid for drug-resistant
tuberculosis is a high priority. Additional pharmacokinetic, pharmacodynamic, and
toxicodynamic studies are needed for pyrazinamide and ethionamide. Clinical trials of the
comparative efficacy and appropriate treatment duration of injectables are recommended. For
isoniazid, rapid genotypic tests for Mycobacterium tuberculosis mutations should be nested in
clinical trials. Further research focusing on optimization of dose and duration of drugs with
activity against drug-resistant tuberculosis is paramount.
Screening of patients with tuberculosis for diabetes mellitus in China
Liang Li Tropical Medicine and International Health, Vol. 17, No. 10, pp. 1294-1301
There is a high burden of both diabetes (DM) and tuberculosis (TB) in China, and this study
aimed to assess feasibility and results of screening patients with TB for DM within the routine
healthcare setting of six health facilities. Agreement on how to screen, monitor and record
was reached in May 2011 at a stakeholders’ meeting, and training was carried out for staff in
the six facilities in July 2011. Implementation started in September 2011, and we report on
7 months of activities up to 31 March 2012. There were 8886 registered patients with TB.
They were first asked whether they had DM. If the answer was no, they were screened with a
random blood glucose (RBG) followed by fasting blood glucose (FBG) in those with
RBG ≥ 6.1 mm (one facility) or with an initial FBG (five facilities). Those with
FBG ≥ 7.0 mm were referred to DM clinics for diagnostic confirmation with a second FBG.
Altogether, 1090 (12.4%) patients with DM were identified, of whom 863 (9.7%) had a
known diagnosis of DM. Of 8023 patients who needed screening for DM, 7947 (99%) were
screened. This resulted in a new diagnosis of DM in 227 patients (2.9% of screened patients),
and of these, 226 were enrolled to DM care. In addition, 575 (7.8%) persons had impaired
fasting glucose (FBG 6.1 to <7.0 mm). Prevalence of DM was significantly higher in patients
in health facilities serving urban populations (14.0%) than rural populations (10.6%) and
higher in hospital patients (13.5%) than those attending TB clinics (8.5%). This pilot project
shows that it is feasible to screen patients with TB for DM in the routine setting, resulting in a
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high yield of patients with known and newly diagnosed disease. Free blood tests for glucose
measurement and integration of TB and DM services may improve the diagnosis and
management of dually affected patients.
Screening patients with Diabetes Mellitus for Tuberculosis in China
Yan Lin et al. Tropical Medicine and International Health, Vol. 17, No. 10, pp. 1302-1308
Objective There is a high burden of both diabetes (DM) and tuberculosis (TB) in China, and
as DM increases the risk of TB and adversely affects TB treatment outcomes, there is a need
for bidirectional screening of the two diseases. How this is best performed is not well
determined. In this pilot project in China, we aimed to assess the feasibility and results of
screening DM patients for TB within the routine healthcare setting of five DM clinics.
Method Agreement on how to screen, monitor and record was reached in May 2011 at a
national stakeholders meeting, and training was carried out for staff in the five clinics in July
2011. Implementation started in September 2011, and we report on 7 months of activities up
to 31 March 2012. DM patients were screened for TB at each clinic attendance using a
symptom-based enquiry, and those positive to any symptom were referred for TB
investigations. Results In the three quarters, 72% of 3174 patients, 79% of 7196 patients and
68% of 4972 patients were recorded as having been screened for TB, resulting in 7 patients
found who were already known to have TB, 92 with a positive TB symptom screen and 48 of
these newly diagnosed with TB as a result of referral and investigation. All patients except
one were started on anti-TB treatment. TB case notification rates in screened DM patients
were several times higher than those of the general population, were highest for the five sites
combined in the final quarter (774/100 000) and were highest in one of the five clinics in the
final quarter (804/100 000) where there was intensive in-house training, special assignment
of staff for screening and colocation of services. Conclusion This pilot project shows that it
is feasible to carry out screening of DM patients for TB resulting in high detection rates of
TB. This has major public health and patient-related implications.
Fetal outcome of antepartum and intrapartum eclampsia in Aba, southeastern Nigeria
Chukwuemeka N. Onyearugha et al. Tropical Doctor 2012, 42: 129-132
The objective of this study was to evaluate the fetal outcome of antepartum and intrapartum
eclampsia. All cases of antepartum and intrapartum eclampsia managed at the Abia State
University Teaching Hospital, Aba, Nigeria, between 1 January 2002 and 31 December 2007
were retrospectively analysed. Of the women who were delivered in our hospital over the
period studied, 0.80% had ante- or intrapartum eclampsia which started mostly outside the
hospital: 85.4% were unbooked; 62.5% nulliparous; and 62.5% aged less than 30 years. Fortyeight babies were delivered by the eclamptic mothers. All of the fetuses were delivered in the
last trimester: 68.8% of the fetuses were preterm; and 58.7% had a low birthweight. Stillbirths
occurred in 60.4%; 8.3% suffered severe birth asphyxia; and 70.9% were delivered vaginally.
Sustained education of pregnant women on the need for early booking and regular antenatal
visits is recommended.
Tetanus – still a scourge in the 21st century: a paediatric hospital-based study in India
Kirtisudha Mishra et al. Tropical Doctor July 2012, 42
Tetanus remains endemic in India. A retrospective hospital-based study was conducted to
review the profile of all children admitted with diagnosis of tetanus between January 2009
and December 2010. A total of 140 cases of tetanus were admitted; 45 cases of neonatal
tetanus (NT) and 77 cases of post-neonatal tetanus (PNT) were studied. Age of presentation of
NT was 9.4 В± 1.2 days. Home-delivered children accounted for 86.7% of cases, with 77.8%
being attended by untrained birth attendants. Unimmunized mothers accounted for 93.4%. In
PNT, otogenic route of infection and trauma were present in 58.4% and 23.3% of cases,
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respectively. The rate of hospital admission of tetanus remains high. Unlike previously
published reports, otogenic route is the most common mode of PNT infection in this study.
Improving immunization, increasing deliveries by skilled birth attendants and prompt
treatment of suppurative otitis media are the main areas in which public health initiatives need
to be focused.
Plasmodium vivax remains responsive to chloroquine with primaquine treatment
regimen: a prospective cohort study from tertiary care teaching hospital in southern
India
Kavitha Saravu et al. Tropical Doctor 2012, 42: 163-164
We conducted this prospective study among 110 symptomatic Plasmodium vivax patients
attending the Kasturba Hospital, Manipal, India, in order to evaluate their clinico-laboratory
profile during July 2007-July 2009. Complications observed among patients were: anaemia
(46.4%; 95% confidence interval [CI], 37.08-55.72%); thrombocytopenia (68.2%; 95% CI,
59.5-76.9%); leucopenia (29.1%; 95% CI, 20.61-37.59%); hyperbilirubinaemia (20%; 95%
CI, 12.53-27.47%); non-oliguric renal failure (10.9%; 95% CI, 5.08-16.72%); elevated serum
transaminases (33.6%; 95% CI, 24.77-42.43%); hypotension (8.2%; 95% CI, 3.07-13.33%);
hepatomegaly (27.3%; 95% CI, 18.97-35.63%); and splenomegaly and jaundice in 12.7%
(95% CI, 6.48-18.92%). The 99% chloroquine response and zero mortality observed in this
study of vivax malaria are encouraging points for practicing physicians.
Rapid evolution and spread of carbapenemases among Enterobacteriaceae in Europe
CantГіn R. et al. Clin Microbiol Infect 2012, 18: 413-431
Plasmid-acquired carbapenemases in Enterobacteriaceae, which were first discovered in
Europe in the 1990s, are now increasingly being identified at an alarming rate. Although their
hydrolysis spectrum may vary, they hydrolyse most ОІ-lactams, including carbapenems. They
are mostly of the KPC, VIM, NDM and OXA-48 types. Their prevalence in Europe as
reported in 2011 varies significantly from high (Greece and Italy) to low (Nordic countries).
The types of carbapenemase vary among countries, partially depending on the
cultural/population exchange relationship between the European countries and the possible
reservoirs of each carbapenemase. Carbapenemase producers are mainly identified among
Klebsiella pneumoniae and Escherichia coli, and still mostly in hospital settings and rarely in
the community. Although important nosocomial outbreaks with carbapenemase-producing
Enterobacteriaceae have been extensively reported, many new cases are still related to
importation from a foreign country. Rapid identification of colonized or infected patients and
screening of carriers is possible, and will probably be effective for prevention of a scenario of
endemicity, as now reported for extended-spectrum ОІ-lactamase (mainly CTX-M) producers
in all European countries.
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FIG. 1. European situation regarding carbapenemase-producing Enterobacteriaceae, using an
epidemiological scale of nationwide expansion (data have been updated from reference 17)
and carbapenemase types in different countries or geographical areas known until January
2012.
FIG. 2. Rates of non-susceptibility (intermediate plus resistant) of Klebsiella pneumoniae to
carbapenems in European countries. Data were obtained from the EARS-Net database (2010).
(http://ecdc.euro pa.eu/en/activities/surveillance/EARS-Net/database/Pages/database.as px).
Only those countries with non-susceptible isolates are included.
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FIG. 3. Evolution of the carbapenemase-producing Enterobacteriaceae
Travel-related imported infections in Europe, euro TravNet 2009
Odolini S. et al. Clin Microbiol Infect 2012, 18: 468-474
The aim of this study was to investigate travel-associated morbidity in European travellers in
2009 in comparison with 2008, with a par-ticular emphasis on emerging infectious diseases
with the potential for introduction into Europe. Diagnoses with demographic, clinical and
travel-related predictors of disease from ill returning travelers presenting to 12 core
uroTravNet sites from January to December 2009 were analysed. A total of 6392 patients
were seen at EuroTravNet core sites in 2009, as compared with 6957 in 2008. As compared
with 2008, there was a marked increase in the number of travellers exposed in North America
and western Europe. Respiratory illnesses, in particular pandemic A(H1N1) influenza,
influenza-like syndromes, and tuberculosis, were also observed more frequently. A significant
increase in reported dengue cases in 2009 as compared with 2008 was observed (n = 172,
2.7% vs. n = 131, 1.90%) (p 0.002). The numbers of malaria and chikungunya cases were also
increasing, although not significantly. Two deaths were recorded: visceral leishmaniasis and sepsis in a Sudanese migrant, and Acinetobacter sp. pneumonia in a patient who
had visited Spain. This is the most compre-hensive study of travel-related illness in Europe in
2009 as compared with 2008. A significant increase in travel-related respiratory and vectorborne infections was observed, highlighting the potential risk for introduction of these
diseases into Europe, where competent vectors are present. The number of traveller deaths is
probably underestimated. The possible role of the travellers in the emergence of infectious
diseases of public health concern is highlighted.
The impact of multidrug resistance in healthcare-associated and nosocomial Gramnegative bacteraemia on mortality and lenght of stay: cohort study
Lye D. C. et al. Clin Microbiol Infect 2012, 18: 502-508
Multidrug-resistant Gram-negative bacteria (MDR-GNB) are an emerging public health
threat. Accurate estimates of their clinical impact are vital for justifying interventions directed
towards preventing or managing infections caused by these pathogens. A retrospective
observational cohort study was conducted between 1 January 2007 and 31 July 2009,
involving subjects with healthcare-associated and nosocomial Gram-negative bacteraemia at
two large Singaporean hospitals. Outcomes studied were mortality and length of stay postonset of bacteraemia in survivors (LOS). There were 675 subjects (301 with MDR-GNB)
matching study inclusion criteria. On multivariate analysis, multidrug resistance was not
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associated with 30-day mortality, but it was independently associated with longer LOS in
survivors (coefficient, 0.34; 95% CI, 0.21–0.48; p < 0.001). The excess LOS attributable to
multidrug resistance after adjustment for confounders was 6.1 days. Other independent risk
factors for higher mortality included male gender, higher APACHE II score, higher Charlson
comorbidity index, intensive care unit stay and presence of concomitant pneumonia.
Concomitant urinary tract infection and admission to a surgical discipline were associated
with lower risk of mortality. Appropriate empirical antibiotic therapy was neither associated
with 30-day mortality nor LOS, although the study was not powered to assess this covariate
adequately. Our study adds to existing evidence that multidrug resistance per se is not
associated with higher mortality when effective antibiotics are used for definitive therapy.
However, its association with longer hospitalization justifies the use of control efforts.
REFERENCE
1. Artemisinin-resistant Malaria: research Challenges, Opportunities and Public Health
Implications, Rick M. Fairhurst, Am. J. Trop. Med. Hyg., 87(2), 2012, pp. 231-241
2. Scaling up Xpert MTB/RIF technology: the costs of laboratory vs. clinic-based rollout in South Africa, Kathryn Schnippel, Tropical Medicine and International Health,
Vol. 17, No. 9, pp. 1142-1151, Sept. 2012
3. Suvada J. Viral hemorrhagic fevers and health care in central region of Africa. HealthNet
News Readers, 2012 Nov 4, WHO, electronic version [http://healthnet.org/hnn-chat]
4. Suvada J. Marburg virus outbreak. HealthNet News Readers, 2012 Aug 1, WHO,
electronic version [http://healthnet.org/hnn-chat]
5. Suvada J. Ebola outbreak in Uganda. HealthNet News Readers, 2012 Nov 4, WHO,
electronic version [http://healthnet.org/hnn-chat]
6. Typhoid Fever Outbreak Associated With Frozen Mamey Pulp Imported From Guatemala to
the Western United States, 2010, Anagha Loharikar, Clinical Infectious Diseases 2012,
55(1):61-6
7. Current rabies vaccines and prophylaxis schedules: Preventing rabies before and after
exposure, Warell M. J., Tropical Medicine and Infectious Disease 2012, 10, 1-15
8. Suvada J et al. Spectrum of patient´s diagnosis in rural hospital in Buikwe – Uganda. J.
Tropical Health Social work Vol 7,2010. 36-38
9. Suvada, J. (2010). ChildrenВґs Palliative Care in low-resource settings. Agatres (U),
LTD Press, Kampala, Uganda, 2010
10. Suvada, J., (2010). Pastekova T., Nkonwa I., Ianetti R, Kaiserova E., Merks J.H.M.,
Krcmery V, 2010. Neoplastic Diseases in Children with HIV infection in our register.
The 4th Annual Paediatric HIV and AIDS Conference, 28th – 30th September, 2010,
Kampala. Oral lecture No. 20. In the international abstract book p. 11
11. In Vitro Susceptibilities and Molecular Analysis of Vancomycin-Intermediate and
Vancomycin- Resistant Staphylococcus aureus Isolates, Louis D. Saravolatz, Tropical
Infectious Diseases 2012, 55(4): 582-6
12. Costs of Healthcare- and Community-Associated Infections With Antimicrobial–
Resistant Versus Antimicrobial-Susceptible Organisms, Matthew J. Neidell, CID
2012, 55(6): 807-15
13. Mumps Outbreak in Orthodox Jewish Communities in the United States, Albert E.
Barskey, N Engl J Med, 367, 18, Nov 1 , 2012
14. Selected Topics in Public Health: Krcmery V., Hettes M., Rovny I., Bielik I., Hamade
J., Starzyk M., et all.: Bratislava : St. Elizabeth Univesity College, 2011., pp: 70
15. Selected Topics in Public Health: Krcmery, V., Hettes M., Rovny I., Truskova I.,
Bielik I., Hamade J., Kimakova T., et all: Bratislava : St. Elizabeth Univesity College
2011, pp: 70
97
CLINICAL SOCIAL WORK (CSW)
16. Suvada, J. et all. (2010). Issues in Social Work and Health. Health/Social Work,
4/2010-1,2/2011, Volume 7-8, ISSN 1333-0023, p.145
17. Suvada, J. (2011). Improving Quality & Safety through Infection Control. UPMPA
CPD Workshop 3rd – 4th September 2011. Kampala, Uganda.
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SOCIAL AND HEALTHCARE IMPACT OF AIDS TO
DEVELOPING COUNTRIES
Sol Sorath, Hoy Leaughoin, Rajoo Magaswari, C. Petersmann, F. Schumann, H. Takthalie,
H. Sondermann, T. Hahn, P. Solwerk, G. Mikolasova,G.Kralik, J. Benca, J. Ravasz,
E. Vrankova, M. Hettes, F. Hanobik, Or Tou, Vicet Chom, L. Seng Hong
St. Maximilian Kolbe and St. Elizabeth University College Tropical Programme,
Phnom Penh, Cambodia
ABSTRACT
News in AIDS and their impact or social work and public health in Subsaharan Africa, Central
Europe (imported) and SE Asia is reviewed by our social work and health tropicteam.
Introduction:
Early HIV viral load determination after initiating first-line antiretroviral therapy for
identifying patients with high risk of developing virological failure: data from a cohort study
in a resource-limited setting Gerardo Alvarez-Uria Tropical Medicine and International
Health, Vol. 17, No. 9, pp. 1152-1155, Sept. 2012.
To evaluate the performance of a single determination of HIV viral load (VL) 6-12 months
after starting antiretroviral therapy (ART) for identifying patients who will subsequently
develop virological failure.
We selected HIV-infected patients with at least two VL determinations after 6 months of
ART from an HIV cohort study in India. Patients were divided in two groups depending on
whether the first VL was below (Group 1) or above (Group 2) 1000 copies/ml. Cut-off for
virological failure was defined according to World Health Organization recommendation
(>5000 copies/ml).
The study included 584 patients and 560.1 person-years of follow-up. Of all virological
failures, 83% were diagnosed at the first VL determination. The cumulative incidence of
virological failure after 1 and 2 years since the first VL was 0.9% [95% confidence interval
(CI), 0.3-2.7] and 1.7% (95% CI, 0.6-5), respectively, for Group 1, and 58.2% (95% CI, 4769.7) and 63.1% (95% CI, 49.8-76.4), respectively, for Group 2. Compared with Group 1,
patients from Group 2 had a hazard ratio for virological failure of 78.3 (95% CI, 27.8-220.2).
A single VL determination after 6
risk of virological failure.
months of ART was able to identify patients with high
The decline of typhoid and the rise of non-typhoid salmonellae and fungal infections in
a changing HIV landscape: bloodstream infection trends over 15 years in southern
Vietnam
Tran Vu Thieu Nga, Transaction of the Royal Society of Tropical Medicine and Hygiene
106(2012) 26-34
The etiological spectrum of bloodstream infections is variable between industrialized and
developing countries and even within a defined location over time. We investigated trends in
bloodstream infections at an infectious disease hospital in Ho Chi Minh City, Vietnam, from
1994-2008. Amongst 66,111 blood cultures performed, a clinically relevant pathogen was
isolated in 7645 episodes (positivity rate; 116/1000 cultures). Salmonella Typhi was the
predominant pathogen until 2002; however, a considerable annual decline in the proportion of
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S. Typhi was observed (OR 0.6993, 95% CI [0.6885, 0.7103], p<0.0001). Conversely, there
was a significant increase in the proportions of non-typhoidal Salmonella (NTS),
Cryptococcus neoformans and Penicillium marneffei, concurrent with increasing HIV
prevalence. These data document a substantial longitudinal shift in bloodstream infection
etiology in southern Vietnam. We propose such changes are related to increasing economic
prosperity and HIV prevalence, and this pattern marks a substantial change in the
epidemiology of invasive salmonellosis in Southeast Asia.
Adoptionof new HIV treatment guidelines and drug substitutions within first-line as
a measure of quality of care in rural Lesotho: health centers and hospitals compared
Niklaus D. Labhardt, Tropical Medicine and International Health, Vol. 17, No. 10, pp. 12451254, October 2012
Objective In 2007, Lesotho launched new national antiretroviral treatment (ART) guidelines,
prioritising tenofovir and zidovudine over stavudine as a backbone together with lamivudine.
We compared the rate of adoption of these new guidelines and substitution of first-line drugs
by health centers (HC) and hospitals in two catchment areas in rural Lesotho.
Retrospective cohort analysis. Patients aged ≥16 years were stratified into a HC- and a
hospital-group. Main outcome variables: Type of backbone at ART-initiation (i), substitutions
within first line (ii) and type of backbone among patients retained by December 2010 (iii). A
multiple logistic regression model including HC vs. hospital, patient characteristics (sex, age,
WHO-stage, baseline CD4-count, concurrent pregnancy, concurrent tuberculosis treatment)
and year of ART-start, was used.
Of 3936 adult patients initiated on ART between 2007 and 2010, 1971 started at hospitals and
1965 at HCs. Hospitals were more likely to follow the new guidelines as measured by
prescription of backbones without stavudine (Odds-ratio 1.55; 95%CI: 1.32-1.81) and had a
higher rate of drug substitutions while on first-line ART (2.39; 1.83-3.13). By December
2010, patients followed at health centres were more likely to still receive stavudine (2.28;
1.83-2.84).
Health centers took longer to adopt the new guidelines and substituted drugs less frequently.
Decentralised ART-programmes need close support, supervision and mentoring to absorb new
guidelines and to adhere to them.
Low martality risk but high loss follow-up among patients in the Tanzanian national
HIV care and treatment programme
Somi G. Tropical Medicine and International Health, Vol. 17, No. 4, pp. 497-506, April 2012
To analyse survival and retention rates of the Tanzanian care and treatment programme.
Routine patient-level data were available from 101 of 909 clinics. Kaplan-Meier probabilities
of mortality and attrition after ART initiation were calculated. Mortality risks were corrected
for biases from loss to follow-up using Egger's nomogram. Smoothed hazard rates showed
mortality and attrition peaks. Cox regression identified factors associated with death and
attrition. Median CD4 counts were calculated at 6 month intervals.
In 88,875 adults, 18% were lost to follow up 12 months after treatment initiation, and 36%
after 36 months. Cumulative mortality reached 10% by 12 months (15% after correcting
for loss to follow-up) and 14% by 36 months. Mortality and attrition rates both peaked
within the first six months, and were higher among males, those under 45 kg and those with
CD4 counts below 50 cells/Вµl at ART initiation. In the first year on ART, median CD4
count increased by 126 cells/Вµl, with similar changes in both sexes.
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Earlier diagnoses through expanded HIV testing may reduce high mortality and attrition rates
if combined with better patient tracing systems. Further research is needed to explore reasons
for attrition.
Switching children previously exposed to nevirapine to nevirapinne-based treatment
after initial suppression with a protease-inhibitor-based regimen: long-term follow-up of
a randomised, open-label trial
Louise Kuhn,
Lancet 2012, 12, 521-30
We followed up the children for a median of 156 weeks and there were three deaths in each
group. Children in the switch group (Kaplan-Meier probability 0В·595) were less likely to
experience non-suppression greater than 50 copies per mL than in the control group (0В·687;
p=0В·01) and had better CD4 and growth responses initially after switching (52 children in the
switch group vs 66 control group met this endpoint). By 156 weeks after randomisation, more
children had virological failure--which we defined as confirmed viraemia of more than 1000
copies per mL--in the switch group (22 children) than in the control group (ten children;
p=0В·009). We detected all 22 failures in the switch group by 52 weeks compared with five in
the control group. Virological failure was related to non-adherence and pretreatment drug
resistance. In children without pretreatment drug resistance, we did not identify a significant
difference in virological failure between the switch (Kaplan-Meier probability 0В·140) and
control (0В·095) groups (p=0В·34; seven failures in the switch group vs five in the control
group). Children in the switch group were significantly more likely to develop grade 1-3
alanine aminotransferase abnormalities over the duration of follow-up.
Optimising the manufacture, formulation and dose of antiretroviral drugs for more
cost-efficient delivery in resource-limited settings: a consensus statement
Keith W. Crawford
Lancet 2012, 12, 550-60
It is expected that funding limitations for worldwide HIV treatment and prevention in
resource-limited settings will continue, and, because the need for treatment scale-up is urgent,
the emphasis on value for money has become an increasing priority. The Conference on
Antiretroviral Drug Optimization--a collaborative project between the Clinton Health Access
Initiative, the Johns Hopkins University School of Medicine, and the Bill & Melinda Gates
Foundation--brought together process chemists, clinical pharmacologists, pharmaceutical
scientists, physicians, pharmacists, and regulatory specialists to explore strategies for the
reduction of antiretroviral drug costs. The antiretroviral drugs discussed were prioritised for
consideration on the basis of their market impact, and the objectives of the conference were
framed as discussion questions generated to guide scientific assessment of potential strategies.
These strategies included modifications to the synthesis of the active pharmaceutical
ingredient (API) and use of cheaper sources of raw materials in synthesis of these ingredients.
Innovations in product formulation could improve bioavailability thus needing less API. For
several antiretroviral drugs, studies show efficacy is maintained at doses below the approved
dose (eg, efavirenz, lopinavir plus ritonavir, atazanavir, and darunavir). Optimising
pharmacoenhancement and extending shelf life are additional strategies. The conference
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highlighted a range of interventions; optimum cost savings could be achieved through
combining approaches.
Prediction of Treatment Failure Using 2010 World Health Organization Guidelines Is
Associated With High Misclassification Rates and Drug Resistance Among HIV-Infected
Cambodian Children
Benjamin P. Westley
CID 2012, 55(3)432-40
Antiretroviral therapy (ART) in resource-limited settings (RLS) is monitored clinically and
immunologically, according to World Health Organization (WHO) or national guidelines.
Revised WHO pediatric guidelines were published in 2010, but their ability to accurately
identify virological failure is unclear.
We evaluated performance of WHO-2010 guidelines and compared them to WHO-2006 and
Cambodia-2011 guidelines among children on ≥6 months of 1st line ART at Angkor Hospital
for Children between 1/2005 and 9/2010. We determined sensitivity, specificity, positive and
negative predictive value, and accuracy using bootstrap resampling to account for multiple
tests per child. HIV resistance was compared between those correctly and incorrectly
identified by each guideline.
Among 457 children with 1079 viral loads (VLs), 20% had >400 copies/mL. For children
with WHO stage 1/2, misclassification as failure (met CD4 failure criteria, but VL
undetectable) was 64% for WHO-2006, 33% for WHO-2010 and 81% for Cambodia-2011;
misclassification as success (did not meet CD4 failure, but VL detectable) was 11%, 12% and
12%. For children with WHO stage 3/4, misclassification as failure was 35%, 40% and 43%;
misclassification as success was 13%, 24% and 21%. Compared to WHO-2006, WHO-2010
significantly increased the risk of misclassification as success in stage 3/4 (p<0.05). The
WHO-2010 guidelines failed to identify 98% of children with extensive reverse transcriptase
resistance.
In our cohort, lack of virological monitoring would result in unacceptable treatment failure
misclassification, leading to premature ART switch and resistance accumulation. Affordable
virological monitoring suitable for use in RLS is desperately needed.
Maternal HIV-1 Disease Progression 18-24 Months Postdelivery According to
Antiretroviral Prophylaxis Regimen (Triple-Antiretroviral Prophylaxis During
Pregnancy and Breastfeeding vs Zidovudine/Single-Dose Nevirapine Prophylaxis): The
Kesho Bora Randomized Controlled Trial
CID 2012, 55(3)449-60
Antiretroviral (ARV) prophylaxis effectively reduces mother-to-child transmission of human
immunodeficiency virus type 1 (HIV). However, it is unclear whether stopping ARVs after
breastfeeding cessation affects maternal HIV disease progression. We assessed 18-24-month
postpartum disease progression risk among women in a randomized trial assessing efficacy
and safety of prophylactic maternal ARVs.
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From 2005 to 2008, HIV-infected pregnant women with CD4(+) counts of 200-500/mm(3)
were randomized to receive either triple ARV (zidovudine, lamivudine, and
lopinavir/ritonavir during pregnancy and breastfeeding) or AZT/sdNVP (zidovudine until
delivery with single-dose nevirapine without postpartum prophylaxis). Maternal disease
progression was defined as the combined endpoint of death, World Health Organization
clinical stage 4 disease, or CD4(+) counts of <200/mm(3).
Among 824 randomized women, 789 had at least 1 study visit after cessation of ARV
prophylaxis. Following delivery, progression risk up to 24 months postpartum in the triple
ARV arm was significantly lower than in the AZT/sdNVP arm (15.7% vs 28.3%; P = .001),
but the risks of progression after cessation of ARV prophylaxis (rather than after delivery)
were not different (15.0% vs 13.8% 18 months after ARV cessation). Among women with
CD4(+) counts of 200-349/mm(3) at enrollment, 24.0% (95% confidence interval [CI], 15.735.5) progressed with triple ARV, and 23.0% (95% CI, 17.8-29.5) progressed with
AZT/sdNVP, whereas few women in either arm (<5%) with initial CD4(+) counts of
≥350/mm(3) progressed.
Interrupting prolonged triple ARV prophylaxis had no effect on HIV progression following
cessation (compared with AZT/sdNVP). However, women on triple ARV prophylaxis had
lower progression risk during the time on triple ARV. Given the high rate of progression
among women with CD4(+) cells of <350/mm(3), ARVs should not be discontinued in this
group.
Co-formulated elvitegravir, cobicistat, emtricitabine and tenofovir versus co-formulated
efavirenz, emtricitabine and tenofovir for initial treatment of HIV-1 infection:
a randomised, double-blind, phase 3 trial, analysis of results after 48 weeks
Paul E. Sax
Lancet 2012, 379: 2439-48
If regulatory approval is given, EVG/COBI/FTC/TDF would be the only single-tablet, oncedaily, integrase-inhibitor-based regimen for initial treatment of HIV infection.
Global trends in antiretroviral resistance in treatment-naive individuals with HIV after
rollout of antiretroviral treatment in resource-limited settings: a global collaborative
study and meta-regression analysis
Ravindra K. Gupta
Lancet 2012, 380: 1250-58
The emergence and spread of high levels of HIV-1 drug resistance in resource-limited settings
where combination antiretroviral treatment has been scaled up could compromise the
effectiveness of national HIV treatment programmes. We aimed to estimate changes in the
prevalence of HIV-1 drug resistance in treatment-naive individuals with HIV since initiation
of rollout in resource-limited settings.
We did a systematic search for studies and conference abstracts published between January,
2001, and July, 2011, and included additional data from the WHO HIV drug resistance
surveillance programme. We assessed the prevalence of drug-resistance mutations in
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untreated individuals with respect to time since rollout in a series of random-effects metaregression models.
Study-level data were available for 26 102 patients from sub-Saharan Africa, Asia, and Latin
America. We recorded no difference between chronic and recent infection on the prevalence
of one or more drug-resistance mutations for any region. East Africa had the highest estimated
rate of increase at 29% per year (95% CI 15 to 45; p=0В·0001) since rollout, with an estimated
prevalence of HIV-1 drug resistance at 8 years after rollout of 7В·4% (4В·3 to 12В·7). We
recorded an annual increase of 14% (0% to 29%; p=0·054) in southern Africa and a nonsignificant increase of 3% (—0·9 to 16; p=0·618) in west and central Africa. There was no
change in resistance over time in Latin America, and because of much country-level
heterogeneity the meta-regression analysis was not appropriate for Asia. With respect to class
of antiretroviral, there were substantial increases in resistance to non-nucleoside reverse
transcriptase inhibitors (NNRTI) in east Africa (36% per year [21 to 52]; p<0В·0001) and
southern Africa (23% per year [7 to 42]; p=0В·0049). No increase was noted for the other drug
classes in any region.
Our findings suggest a significant increase in prevalence of drug resistance over time since
antiretroviral rollout in regions of sub-Saharan Africa; this rise is driven by NNRTI resistance
in studies from east and southern Africa. The findings are of concern and draw attention to the
need for enhanced surveillance and drug-resistance prevention efforts by national HIV
treatment programmes. Nevertheless, estimated levels, although increasing, are not
unexpected in view of the large expansion of antiretroviral treatment coverage seen in lowincome and middle-income countries—no changes in antiretroviral treatment guidelines are
warranted at the moment.
Bill & Melinda Gates Foundation and the European Community's Seventh Framework
Programme
REFERENCES
1. Prediction of Treatment Failure Using 2010 World Health Organization Guidelines Is
Associated With High Misclassification Rates and Drug Resistance Among HIVInfected Cambodian Children, Benjamin P. Westley,CID 2012, 55(3)432-40
2. Early HIV viral load determination after initiating first-line antiretroviral therapy for
identifying patients with high risk of developing virological failure: data from a cohort
study in a resource-limited setting, Gerardo Alvarez-Uria, Tropical Medicine and
International Health, Vol. 17, No. 9, pp. 1152-1155, Sept. 2012
3. Suvada J. Viral hemorrhagic fevers and health care in central region of Africa. HealthNet
News Readers, 2012 Nov 4, WHO, electronic version [http://healthnet.org/hnn-chat]
4. Suvada J. Marburg virus outbreak. HealthNet News Readers, 2012 Aug 1, WHO,
electronic version [http://healthnet.org/hnn-chat]
5. 10. Suvada J. Ebola outbreak in Uganda. HealthNet News Readers, 2012 Nov 4, WHO,
electronic version [http://healthnet.org/hnn-chat]
6. Suvada J et al. Spectrum of patient´s diagnosis in rural hospital in Buikwe – Uganda. J.
Tropical Health Social work Vol 7,2010. 36-38
7. Suvada, J. et all. (2010). Issues in Social Work and Health. Health/Social Work,
4/2010-1,2/2011, Volume 7-8, ISSN 1333-0023, p.145
8. Suvada, J. (2011). Improving Quality & Safety through Infection Control. UPMPA
CPD Workshop 3rd – 4th September 2011. Kampala, Uganda
104
CLINICAL SOCIAL WORK (CSW)
9. Optimising the manufacture, formulation and dose of antiretroviral drugs for more
cost-efficient delivery in resource-limited settings: a consensus statement, Keith W.
Crawford, Lancet 2012, 12, 550-60
10. Switching children previously exposed to nevirapine to nevirapinne-based treatment
after initial suppression with a protease-inhibitor-based regimen: long-term follow-up
of a randomised, open-label trial, Louise Kuhn, Lancet 2012, 12, 521-30
11. Selected Topics in Public Health : Krcmery V., Hettes M., Klement C., Rovny I.,
Bielik I., Hamade J., Halzlova L., Estokova M., Mihalska E., et all: Skalica : St.
Elizabeth University College, Bratislava, 2012, pp: 143
12. Selected Topics in Public Health: Krcmery, V., Hegyi, L., Hettes M., Rovny I., Olear
V., Klement C., Bielik I., Hamade J.: St. Elizabeth University College, Bratislava,
2011, pp: 586
13. Suvada, J. (2010). ChildrenВґs Palliative Care in low-resource settings. Agatres (U),
LTD Press, Kampala, Uganda, 2010
14. Suvada, J., (2010). Pastekova T., Nkonwa I., Ianetti R, Kaiserova E., Merks J.H.M.,
Krcmery V, 2010. Neoplastic Diseases in Children with HIV infection in our register.
The 4th Annual Paediatric HIV and AIDS Conference, 28th – 30th September, 2010,
Kampala. Oral lecture No. 20. In the international abstract book p. 11
105
CLINICAL SOCIAL WORK (CSW)
GLOBAL DISEASE BURDEN AND SURVILLANCE STUDIES ON
HYPERTENSION, DIABETES, OBESITY, COMMUNICABLE DISEASES AND
OTHER SOCIAL STATUS RELATED DISEASES
J. Suvada, I. Kmit, A. Korba, E. Kovac, J. Stastna, L. Lukacova, J. Polachova, N. Sebova,
G. Kothaj, L. Macejkova, J. Stastna, A. Kostanjevec, R. Kucera, S. Slezakova,
M. Paulovicova, I. Mrazkova, B. Kozuch
Graduate School St. Elisabeth University PhD. programe Bratislava, Slovakia
and MPC Nairobi, Kenya
ABSTRACT
Data on mortality and communicable or civilisation disorders are criticaly reviewed by
members of St. Ekisabeth University PhD programe (1-12) and presented an social and public
health tropicteam strategies
Age-specific and sex-specific mortality in 187 countries, 1970-2010: a systematic analysis
for the Global Burden of Disease Study 2010, Haidong Wang, Lancet 2012, 380: 2071-94
Estimation of the number and rate of deaths by age and sex is a key first stage for calculation
of the burden of disease in order to constrain estimates of cause-specific mortality and to
measure premature mortality in populations. We aimed to estimate life tables and annual
numbers of deaths for 187 countries from 1970 to 2010.
We estimated trends in under-5 mortality rate (children aged 0—4 years) and probability of
adult death (15—59 years) for each country with all available data. Death registration data
were available for more than 100 countries and we corrected for undercount with improved
death distribution methods. We applied refined methods to survey data on sibling survival that
correct for survivor, zero-sibling, and recall bias. We separately estimated mortality from
natural disasters and wars. We generated final estimates of under-5 mortality and adult
mortality from the data with Gaussian process regression. We used these results as input
parameters in a relational model life table system. We developed a model to extrapolate
mortality to 110 years of age. All death rates and numbers have been estimated with 95%
uncertainty intervals (95% UIs).
From 1970 to 2010, global male life expectancy at birth increased from 56В·4 years (95% UI
55·5—57·2) to 67·5 years (66·9—68·1) and global female life expectancy at birth increased
from 61·2 years (60·2—62·0) to 73·3 years (72·8—73·8). Life expectancy at birth rose by
3—4 years every decade from 1970, apart from during the 1990s (increase in male life
expectancy of 1В·4 years and in female life expectancy of 1В·6 years). Substantial reductions in
mortality occurred in eastern and southern sub-Saharan Africa since 2004, coinciding with
increased coverage of antiretroviral therapy and preventive measures against malaria. Sexspecific changes in life expectancy from 1970 to 2010 ranged from gains of 23—29 years in
the Maldives and Bhutan to declines of 1—7 years in Belarus, Lesotho, Ukraine, and
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CLINICAL SOCIAL WORK (CSW)
Zimbabwe. Globally, 52·8 million (95% UI 51·6—54·1 million) deaths occurred in 2010,
which is about 13·5% more than occurred in 1990 (46·5 million [45·7—47·4 million]), and
21·9% more than occurred in 1970 (43·3 million [42·2—44·6 million]). Proportionally more
deaths in 2010 occurred at age 70 years and older (42В·8% in 2010 vs 33В·1% in 1990), and
22В·9% occurred at 80 years or older. Deaths in children younger than 5 years declined by
almost 60% since 1970 (16·4 million [16·1—16·7 million] in 1970 vs 6·8 million [6·6—7·1
million] in 2010), especially at ages 1—59 months (10·8 million [10·4—11·1 million] in
1970 vs 4·0 million [3·8—4·2 million] in 2010). In all regions, including those most affected
by HIV/AIDS, we noted increases in mean ages at death.
Despite global and regional health crises, global life expectancy has increased continuously
and substantially in the past 40 years. Yet substantial heterogeneity exists across age groups,
among countries, and over different decades. 179 of 187 countries have had increases in life
expectancy after the slowdown in progress in the 1990s. Efforts should be directed to reduce
mortality in low-income and middle-income countries. Potential underestimation of
achievement of the Millennium Development Goal 4 might result from limitations of
demographic data on child mortality for the most recent time period. Improvement of civil
registration system worldwide is crucial for better tracking of global mortality.
Figure 2. Decline in global age-specific mortality rate, 1970–2010
107
CLINICAL SOCIAL WORK (CSW)
Figure 8. Mean age of death in Global Burden of Disease regions in 1970 compared with 2010
Global and regional mortality from 235 causes of death for 20 age groups in 1990 and
2010: a systematic analysis for the Global Burden of Disease Study 2010, Rafael Lozano,
Lancet 2012, 380: 2095-128
Reliable and timely information on the leading causes of death in populations, and how these
are changing, is a crucial input into health policy debates. In the Global Burden of Diseases,
Injuries, and Risk Factors Study 2010 (GBD 2010), we aimed to estimate annual deaths for
the world and 21 regions between 1980 and 2010 for 235 causes, with uncertainty intervals
(UIs), separately by age and sex.
We attempted to identify all available data on causes of death for 187 countries from 1980 to
2010 from vital registration, verbal autopsy, mortality surveillance, censuses, surveys,
hospitals, police records, and mortuaries. We assessed data quality for completeness,
diagnostic accuracy, missing data, stochastic variations, and probable causes of death. We
applied six different modelling strategies to estimate cause-specific mortality trends
depending on the strength of the data. For 133 causes and three special aggregates we used the
Cause of Death Ensemble model (CODEm) approach, which uses four families of statistical
models testing a large set of different models using different permutations of covariates.
Model ensembles were developed from these component models. We assessed model
performance with rigorous out-of-sample testing of prediction error and the validity of 95%
UIs. For 13 causes with low observed numbers of deaths, we developed negative binomial
models with plausible covariates. For 27 causes for which death is rare, we modelled the
higher level cause in the cause hierarchy of the GBD 2010 and then allocated deaths across
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CLINICAL SOCIAL WORK (CSW)
component causes proportionately, estimated from all available data in the database. For
selected causes (African trypanosomiasis, congenital syphilis, whooping cough, measles,
typhoid and parathyroid, leishmaniasis, acute hepatitis E, and HIV/AIDS), we used natural
history models based on information on incidence, prevalence, and case-fatality. We
separately estimated cause fractions by aetiology for diarrhoea, lower respiratory infections,
and meningitis, as well as disaggregations by subcause for chronic kidney disease, maternal
disorders, cirrhosis, and liver cancer. For deaths due to collective violence and natural
disasters, we used mortality shock regressions. For every cause, we estimated 95% UIs that
captured both parameter estimation uncertainty and uncertainty due to model specification
where CODEm was used. We constrained cause-specific fractions within every age-sex group
to sum to total mortality based on draws from the uncertainty distributions.
In 2010, there were 52В·8 million deaths globally. At the most aggregate level, communicable,
maternal, neonatal, and nutritional causes were 24В·9% of deaths worldwide in 2010, down
from 15В·9 million (34В·1%) of 46В·5 million in 1990. This decrease was largely due to
decreases in mortality from diarrhoeal disease (from 2В·5 to 1В·4 million), lower respiratory
infections (from 3В·4 to 2В·8 million), neonatal disorders (from 3В·1 to 2В·2 million), measles
(from 0В·63 to 0В·13 million), and tetanus (from 0В·27 to 0В·06 million). Deaths from HIV/AIDS
increased from 0В·30 million in 1990 to 1В·5 million in 2010, reaching a peak of 1В·7 million in
2006. Malaria mortality also rose by an estimated 19В·9% since 1990 to 1В·17 million deaths in
2010. Tuberculosis killed 1В·2 million people in 2010. Deaths from non-communicable
diseases rose by just under 8 million between 1990 and 2010, accounting for two of every
three deaths (34В·5 million) worldwide by 2010. 8 million people died from cancer in 2010,
38% more than two decades ago; of these, 1В·5 million (19%) were from trachea, bronchus,
and lung cancer. Ischaemic heart disease and stroke collectively killed 12В·9 million people in
2010, or one in four deaths worldwide, compared with one in five in 1990; 1В·3 million deaths
were due to diabetes, twice as many as in 1990. The fraction of global deaths due to injuries
(5В·1 million deaths) was marginally higher in 2010 (9В·6%) compared with two decades earlier
(8В·8%). This was driven by a 46% rise in deaths worldwide due to road traffic accidents (1В·3
million in 2010) and a rise in deaths from falls. Ischaemic heart disease, stroke, chronic
obstructive pulmonary disease (COPD), lower respiratory infections, lung cancer, and
HIV/AIDS were the leading causes of death in 2010. Ischaemic heart disease, lower
respiratory infections, stroke, diarrhoeal disease, malaria, and HIV/AIDS were the leading
causes of years of life lost due to premature mortality (YLLs) in 2010, similar to what was
estimated for 1990, except for HIV/AIDS and preterm birth complications. YLLs from lower
respiratory infections and diarrhoea decreased by 45—54% since 1990; ischaemic heart
disease and stroke YLLs increased by 17—28%. Regional variations in leading causes of
death were substantial. Communicable, maternal, neonatal, and nutritional causes still
accounted for 76% of premature mortality in sub-Saharan Africa in 2010. Age standardised
death rates from some key disorders rose (HIV/AIDS, Alzheimer's disease, diabetes mellitus,
and chronic kidney disease in particular), but for most diseases, death rates fell in the past two
decades; including major vascular diseases, COPD, most forms of cancer, liver cirrhosis, and
maternal disorders. For other conditions, notably malaria, prostate cancer, and injuries, little
change was noted.
Population growth, increased average age of the world's population, and largely decreasing
age-specific, sex-specific, and cause-specific death rates combine to drive a broad shift from
communicable, maternal, neonatal, and nutritional causes towards non-communicable
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CLINICAL SOCIAL WORK (CSW)
diseases. Nevertheless, communicable, maternal, neonatal, and nutritional causes remain the
dominant causes of YLLs in sub-Saharan Africa. Overlaid on this general pattern of the
epidemiological transition, marked regional variation exists in many causes, such as
interpersonal violence, suicide, liver cancer, diabetes, cirrhosis, Chagas disease, African
trypanosomiasis, melanoma, and others. Regional heterogeneity highlights the importance of
sound epidemiological assessments of the causes of death on a regular basis.
Table 1: Decomposition analysis of the change of global death numbers (thousands) by level 1 causes from 1990 to
2010 into total population growth, population ageing, and changes in age-specific, sex-specific, and cause-specific death
rates.
All ages deaths (thousands)
Age-standardised death rates (per
100  000)
1990
2010
%∆
1990
2010
%∆
All causes
46  511·2
(45  497·4–
47  726·2)
52  769·7
(50  877·7–
53  917·2)
13В·5%
999В·1
(979·2–
1022В·0)
784В·5
(756·3–
801В·6)
–21·5
Communicable, maternal, neonatal,
and nutritional disorders
15 859·2
(15 065·8–
16 842·5)
13 156·4
(12 377·2–
13 807·6)
в€’17В·0%
271В·1
(258·4–
287В·2)
189В·8
(178·6–
199В·2)
в€’30В·0
HIV/AIDS and tuberculosis
1770В·3
(1600·2–
2032В·7)
2661В·4
(2358·1–
2895В·7)
50В·3%
39В·3
(35·4–
45В·2)
39В·4
(34·8–
42В·9)
0В·2
Tuberculosis
1471В·5
(1318·5–
1716В·1)
1196В·0
(923·7–
1376В·8)
в€’18В·7%
33В·3
(29·8–
38В·7)
18В·0
(13·9–
20В·7)
в€’46В·0
HIV/AIDS
298В·8
(242·0–
378В·5)
1465В·4
(1334·2–
1606В·0)
390В·4%
6·0 (4·8–
7В·7)
21В·4
(19·4–
23В·5)
258В·4
HIV disease resulting in
mycobacterial infection
53·8 (42·4–
70В·0)
256В·9
(231·9–
284В·1)
377В·2%
1·1 (0·8–
1В·4)
3·7 (3·4–
4В·2)
254В·4
HIV disease resulting in other
specified or unspecified
diseases
245В·0
(197·7–
312В·6)
1208В·4
(1091·6–
1333В·9)
393В·3%
4·9 (3·9–
6В·3)
17В·6
(15·9–
19В·5)
259В·3
7772В·1
(7136·0–
8769В·2)
5276В·9
(4742·2–
5790В·4)
в€’32В·1%
131В·9
(122·4–
146В·5)
76В·4
(68·6–
83В·7)
в€’42В·1
2487В·4
(2306·8–
2661В·9)
1445В·8
(1278·9–
1607В·0)
в€’41В·9%
41В·0
(38·3–
43В·6)
20В·9
(18·5–
23В·3)
в€’49В·0
Cholera
120·9 (96·7–
149В·1)
58·1 (44·2–
74В·3)
в€’52В·0%
1·8 (1·4–
2В·2)
0·8 (0·6–
1В·0)
в€’54В·5
Other salmonella infections
134В·7
(107·5–
162В·4)
81·3 (61·8–
101В·7)
в€’39В·6%
2·3 (1·8–
2В·7)
1·2 (0·9–
1В·5)
в€’48В·2
Shigellosis
194В·0
122·8 (97·4–
в€’36В·7%
3·3 (2·8–
1·8 (1·4–
в€’46В·5
Diarrhoea, lower respiratory
infections, meningitis, and other
common infectious diseases
Diarrhoeal diseases
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CLINICAL SOCIAL WORK (CSW)
All ages deaths (thousands)
Age-standardised death rates (per
100  000)
1990
2010
(161·5–
227В·4)
149В·6)
Enteropathogenic E
coli infection
205В·5
(163·0–
250В·2)
88·7 (66·8–
112В·8)
Enterotoxigenic E coli infection
184В·0
(155·6–
218В·2)
Campylobacter enteritis
1990
2010
3В·9)
2В·2)
в€’56В·8%
3·0 (2·4–
3В·6)
1·2 (0·9–
1В·6)
в€’58В·2
120·8 (95·7–
147В·6)
в€’34В·4%
3·3 (2·7–
3В·9)
1·8 (1·4–
2В·2)
в€’45В·8
210В·8
(171·2–
253В·6)
109·7 (81·8–
137В·2)
в€’48В·0%
3·3 (2·7–
4В·0)
1·6 (1·2–
2В·0)
в€’52В·5
Amoebiasis
67·7 (53·2–
82В·8)
55·5 (40·6–
73В·8)
в€’18В·1%
1·4 (1·1–
1В·7)
0·8 (0·6–
1В·1)
в€’39В·0
Cryptosporidiosis
222В·6
(181·5–
264В·7)
99·8 (76·1–
125В·0)
в€’55В·2%
3·2 (2·6–
3В·8)
1·4 (1·1–
1В·8)
в€’56В·6
Rotaviral enteritis
523В·3
(433·5–
605В·7)
250В·9
(191·5–
308В·2)
в€’52В·1%
7·9 (6·5–
9В·2)
3·6 (2·7–
4В·4)
в€’54В·9
Other diarrhoeal diseases
623В·9
(466·5–
814В·3)
458В·3
(339·1–
603В·9)
в€’26В·5%
11В·6
(8·8–
14В·8)
6·8 (5·0–
8В·9)
в€’41В·6
Typhoid and paratyphoid fevers
136·5 (16·5–
254В·7)
190·2 (23·8–
359В·1)
39В·4%
2·4 (0·3–
4В·4)
2·7 (0·3–
5В·1)
15В·5
Lower respiratory infections
3415В·4
(3109·5–
3650В·9)
2814В·4
(2487·8–
3033В·0)
в€’17В·6%
62В·3
(57·0–
67В·2)
41В·0
(36·3–
44В·2)
в€’34В·1
Influenza
574В·6
(519·3–
625В·8)
507В·9
(444·2–
553В·8)
в€’11В·6%
10В·9
(10·0–
11В·8)
7·5 (6·5–
8В·1)
в€’31В·8
Pneumococcal pneumonia
858В·4
(778·5–
932В·3)
827В·3
(718·4–
899В·5)
в€’3В·6%
17В·0
(15·5–
18В·6)
12В·1
(10·5–
13В·2)
в€’28В·7
H influenzae type B pneumonia
606В·9
(541·5–
669В·6)
379В·9
(337·1–
420В·5)
в€’37В·4%
9·8 (8·9–
10В·8)
5·5 (4·8–
6В·0)
в€’44В·4
Respiratory syncytial virus
pneumonia
534В·8
(463·4–
608В·4)
253В·5
(215·0–
296В·6)
в€’52В·6%
7·6 (6·6–
8В·6)
3·5 (3·0–
4В·1)
в€’53В·3
Other lower respiratory
infections
840В·6
(747·9–
926В·9)
845В·8
(734·1–
927В·6)
0В·6%
16В·9
(15·1–
18В·6)
12В·4
(10·8–
13В·6)
в€’26В·5
Upper respiratory infections
4·0 (3·6–4·2)
3·0 (2·7–3·4)
в€’23В·6%
0·1 (0·1–
0В·1)
<0В·05
(0·0–
0В·05)
в€’36В·2
Otitis media
5·2 (0·0–
61В·0)
3·5 (0·0–
39В·8)
в€’33В·5%
0·1 (0·0–
1В·0)
<0В·05
(0·0–0·6)
в€’42В·3
Meningitis
492В·2
(444·1–
583В·3)
422В·9
(360·2–
471В·7)
в€’14В·1%
8·1 (7·4–
9В·4)
6·1 (5·1–
6В·7)
в€’25В·0
Pneumococcal meningitis
124В·9
(111·8–
149В·3)
118·4 (98·4–
132В·0)
в€’5В·2%
2·1 (1·9–
2В·5)
1·7 (1·4–
1В·9)
в€’19В·5
H influenzae type B meningitis
118В·9
(103·2–
148В·5)
83·0 (70·6–
97В·0)
в€’30В·2%
1·8 (1·5–
2В·2)
1·2 (1·0–
1В·4)
в€’33В·9
Meningococcal infection
77·1 (68·8–
92В·7)
75·0 (61·8–
85В·0)
в€’2В·6%
1·3 (1·2–
1В·5)
1·1 (0·9–
1В·2)
в€’16В·5
Other meningitis
171В·3
(153·2–
199В·2)
146В·4
(119·8–
164В·4)
в€’14В·6%
2·9 (2·6–
3В·3)
2·1 (1·7–
2В·4)
в€’27В·4
111
%∆
%∆
CLINICAL SOCIAL WORK (CSW)
All ages deaths (thousands)
Age-standardised death rates (per
100  000)
1990
2010
%∆
1990
2010
%∆
Encephalitis
143В·5
(126·7–
168В·1)
119·3 (98·0–
137В·1)
в€’16В·9%
2·4 (2·1–
2В·8)
1·7 (1·4–
2В·0)
в€’28В·3
Diphtheria
6·3 (0·0–
53В·0)
2·9 (0·0–
24В·9)
в€’53В·5%
0·1 (0·0–
0В·8)
<0В·05
(0·0–0·3)
в€’55В·2
Whooping cough
166·5 (0·6–
815В·7)
81·4 (0·3–
399В·0)
в€’51В·1%
2·3 (0·0–
11В·4)
1·1 (0·0–
5В·5)
в€’51В·6
Tetanus
272В·8
(163·4–
456В·1)
61·3 (31·0–
114В·0)
в€’77В·5%
4·1 (2·4–
7В·6)
0·9 (0·4–
1В·6)
в€’78В·8
Measles
631В·2
(188·2–
1492В·6)
125·4 (41·3–
295В·5)
в€’80В·1%
9·0 (2·7–
21В·3)
1·7 (0·6–
4В·1)
в€’80В·6
Varicella
11·2 (0·0–
75В·0)
6·8 (0·0–
46В·4)
в€’38В·9%
0·2 (0·0–
1В·3)
0·1 (0·0–
0В·7)
в€’50В·8
Neglected tropical diseases and
malaria
1210В·6
(1014·1–
1485В·4)
1321В·8
(1055·6–
1677В·6)
9В·2%
21В·0
(17·5–
25В·9)
18В·9
(15·1–
23В·9)
в€’10В·0
Malaria
975В·7
(781·2–
1239В·5)
1169В·5
(916·5–
1526В·9)
19В·9%
16В·6
(13·4–
21В·3)
16В·7
(13·0–
21В·7)
0В·5
Chagas disease
9·3 (4·6–
19В·9)
10·3 (5·1–
28В·6)
10В·8%
0·2 (0·1–
0В·5)
0·2 (0·1–
0В·4)
в€’30В·4
Leishmaniasis
87·2 (50·6–
138В·4)
51·6 (33·2–
76В·1)
в€’40В·9%
1·5 (0·9–
2В·4)
0·7 (0·5–
1В·1)
в€’51В·3
African trypanosomiasis
33·5 (9·9–
72В·7)
9·1 (1·1–
29В·0)
в€’72В·8%
0·6 (0·2–
1В·4)
0·1 (0·0–
0В·4)
в€’79В·2
Schistosomiasis
10·5 (0·0–
62В·9)
11·7 (0·0–
69В·8)
10В·9%
0·2 (0·0–
1В·5)
0·2 (0·0–
1В·1)
в€’28В·6
Cysticercosis
0·7 (0·0–2·8)
1·2 (0·0–4·3)
58В·5%
<0В·05
(0·0–0·1)
<0В·05
(0·0–0·1)
7В·3
Echinococcosis
2·0 (0·0–7·7)
1·2 (0·0–4·7)
в€’41В·2%
<0В·05
(0·0–0·2)
<0В·05
(0·0–0·1)
в€’62В·2
Dengue
11·4 (3·7–
23В·5)
14·7 (6·1–
24В·3)
28В·9%
0·2 (0·1–
0В·4)
0·2 (0·1–
0В·4)
3В·2
Rabies
54·1 (32·4–
103В·4)
26·4 (15·2–
45В·2)
в€’51В·2%
1·0 (0·6–
1В·9)
0·4 (0·2–
0В·7)
в€’61В·7
Intestinal nematode infections
3·4 (0·0–
16В·4)
2·7 (0·0–
13В·0)
в€’21В·7%
0·1 (0·0–
0В·2)
<0В·05
(0·0–0·2)
в€’27В·3
3·4 (0·0–
16В·4)
2·7 (0·0–
13В·0)
в€’21В·7%
0·1 (0·0–
0В·2)
<0В·05
(0·0–0·2)
в€’27В·3
Other neglected tropical diseases
22·9 (14·3–
29В·5)
23·7 (16·6–
30В·9)
3В·4%
0·5 (0·3–
0В·6)
0·3 (0·2–
0В·5)
в€’23В·6
Maternal disorders
358В·6
(297·7–
429В·4)
254В·7
(203·8–
303В·3)
в€’29В·0%
6·9 (5·7–
8В·3)
3·7 (2·9–
4В·4)
в€’47В·2
Maternal haemorrhage
84·8 (69·0–
101В·7)
58·3 (46·2–
68В·7)
в€’31В·2%
1·7 (1·4–
2В·0)
0·8 (0·7–
1В·0)
в€’49В·8
Maternal sepsis
33·8 (28·0–
41В·6)
21·9 (17·6–
26В·7)
в€’35В·3%
0·6 (0·5–
0В·8)
0·3 (0·2–
0В·4)
в€’50В·8
Hypertensive disorders of
pregnancy
69·8 (57·6–
85В·0)
47·1 (37·7–
57В·2)
в€’32В·5%
1·3 (1·1–
1В·6)
0·7 (0·5–
0В·8)
в€’48В·8
Obstructed labour
19·1 (15·6–
23В·8)
10·9 (8·6–
13В·5)
в€’43В·0%
0·4 (0·3–
0В·5)
0·2 (0·1–
0В·2)
в€’57В·3
Abortion
56·1 (46·4–
68В·7)
37·1 (29·8–
45В·1)
в€’33В·8%
1·1 (0·9–
1В·3)
0·5 (0·4–
0В·6)
в€’50В·3
Other maternal disorders
95·1 (78·4–
112В·8)
79·4 (63·0–
92В·4)
в€’16В·6%
1·9 (1·5–
2В·2)
1·1 (0·9–
1В·3)
в€’38В·7
Neonatal disorders
3081В·1
2236В·4
в€’27В·4%
42В·4
31В·0
в€’26В·8
Ascariasis
112
CLINICAL SOCIAL WORK (CSW)
All ages deaths (thousands)
Age-standardised death rates (per
100  000)
1990
2010
(2684·2–
3393В·8)
(2014·6–
2470В·1)
Preterm birth complications
1204В·1
(998·1–
1376В·8)
859В·7
(731·6–
990В·1)
Neonatal encephalopathy (birth
asphyxia/trauma)
638В·1
(516·7–
798В·1)
Sepsis and other infectious
disorders of the newborn baby
1990
2010
(36·9–
46В·7)
(27·9–
34В·3)
в€’28В·6%
16В·6
(13·7–
18В·9)
11В·9
(10·1–
13В·7)
в€’28В·0
511В·4
(402·2–
619В·4)
в€’19В·9%
8·8 (7·1–
11В·0)
7·1 (5·6–
8В·6)
в€’19В·2
534В·6
(292·0–
817В·1)
513В·7
(317·6–
841В·0)
в€’3В·9%
7·4 (4·0–
11В·2)
7·1 (4·4–
11В·7)
в€’3В·1
Other neonatal disorders
704В·3
(529·1–
860В·3)
351В·7
(293·5–
429В·8)
в€’50В·1%
9·7 (7·3–
11В·8)
4·9 (4·1–
6В·0)
в€’49В·7
Nutritional deficiencies
976В·9
(854·4–
1155В·7)
684В·1
(546·0–
790В·1)
в€’30В·0%
17В·3
(15·1–
20В·4)
9·9 (7·9–
11В·5)
в€’42В·8
Protein–energy malnutrition
883В·0
(726·7–
1052В·6)
599В·8
(459·4–
701В·9)
в€’32В·1%
15В·4
(12·6–
18В·3)
8·7 (6·6–
10В·1)
в€’43В·7
Iodine deficiency
2·0 (1·7–2·4)
3·4 (2·4–3·8)
67В·7%
<0В·05
(0·0–0·1)
<0В·05
(0·0–0·1)
17В·5
Iron-deficiency anaemia
80·8 (66·5–
97В·8)
69·4 (51·6–
78В·9)
в€’14В·1%
1·6 (1·3–
2В·0)
1·0 (0·8–
1В·2)
в€’37В·3
Other nutritional deficiencies
11·1 (9·6–
14В·0)
11·5 (8·0–
12В·8)
3В·4%
0·2 (0·2–
0В·3)
0·2 (0·1–
0В·2)
в€’31В·4
Other communicable, maternal,
neonatal, and nutritional
disorders
689В·5
(569·9–
815В·1)
721В·2
(626·8–
830В·4)
4В·6%
12В·3
(10·4–
14В·2)
10В·6
(9·2–
12В·1)
в€’14В·3
Sexually transmitted diseases
excluding HIV
209В·4
(130·0–
324В·3)
118·3 (71·6–
187В·7)
в€’43В·5%
3·0 (1·9–
4В·6)
1·6 (1·0–
2В·6)
в€’45В·6
Syphilis
202В·9
(121·9–
315В·8)
113·3 (66·9–
181В·7)
в€’44В·1%
2·9 (1·8–
4В·4)
1·6 (0·9–
2В·5)
в€’45В·4
Sexually transmitted
chlamydial diseases
1·5 (0·8–2·0)
1·2 (0·8–1·8)
в€’23В·7%
<0В·05
(0·0–
0В·05)
<0В·05
(0·0–
0В·05)
в€’49В·1
Gonococcal infection
1·1 (0·6–1·5)
0·9 (0·6–1·3)
в€’23В·6%
<0В·05
(0·0–
0В·05)
<0В·05
(0·0–
0В·05)
в€’49В·0
Other sexually transmitted
diseases
3·8 (2·0–5·0)
2·9 (2·0–4·5)
в€’23В·6%
0·1 (0·0–
0В·1)
<0В·05
(0·0–
0В·01)
в€’49В·0
210В·2
(200·3–
221В·1)
307В·7
(268·2–
356В·5)
46В·4%
4·4 (4·2–
4В·6)
4·6 (4·0–
5В·3)
4В·6
Acute hepatitis A
99·0 (56·5–
154В·2)
102·8 (51·2–
228В·1)
3В·9%
2·1 (1·1–
3В·3)
1·5 (0·8–
3В·4)
в€’25В·1
Acute hepatitis B
68·6 (46·7–
84В·4)
132·2 (91·1–
169В·7)
92В·7%
1·5 (1·1–
1В·9)
2·0 (1·4–
2В·6)
29В·2
Acute hepatitis C
8·1 (4·9–
11В·6)
16·0 (11·6–
21В·4)
97В·1%
0·2 (0·1–
0В·3)
0·2 (0·2–
0В·3)
25В·6
Acute hepatitis E
34·5 (19·6–
55В·0)
56·6 (23·3–
113В·3)
64В·2%
0·6 (0·3–
0В·9)
0·8 (0·3–
1В·6)
36В·1
269В·9
(192·2–
320В·5)
295В·2
(205·6–
362В·1)
9В·4%
4·9 (3·5–
5В·7)
4·3 (3·0–
5В·3)
в€’11В·8
26 560·3
(25 843·4–
34 539·9
(33 164·7–
30В·0%
645В·9
(629·9–
520В·4
(499·5–
в€’19В·4
Hepatitis
Other infectious diseases
Non-communicable diseases
113
%∆
%∆
CLINICAL SOCIAL WORK (CSW)
All ages deaths (thousands)
Age-standardised death rates (per
100  000)
1990
2010
27 249·3)
35 313·0)
Neoplasms
5779В·1
(5415·9–
6201В·9)
7977В·9
(7337·1–
8403В·8)
Oesophageal cancer
344В·7
(279·7–
428В·8)
Stomach cancer
Liver cancer
1990
2010
662В·9)
532В·0)
38В·0%
140В·8
(131·9–
151В·4)
121В·4
(111·6–
127В·9)
в€’13В·8
395В·2
(298·4–
482В·1)
14В·7%
8·5 (6·9–
10В·6)
6·1 (4·6–
7В·4)
в€’28В·7
774В·1
(602·8–
1014В·2)
754В·9
(571·9–
990В·4)
в€’2В·5%
19В·0
(14·8–
25В·0)
11В·5
(8·7–
15В·1)
в€’39В·5
463В·0
(386·5–
526В·8)
752В·1
(643·6–
880В·3)
62В·4%
11В·2
(9·4–
12В·8)
11В·5
(9·8–
13В·4)
2В·3
Liver cancer secondary to
hepatitis B
210В·2
(176·9–
239В·4)
341В·4
(290·1–
402В·6)
62В·4%
5·1 (4·3–
5В·8)
5·2 (4·4–
6В·1)
2В·6
Liver cancer secondary to
hepatitis C
113·0 (96·6–
129В·3)
195В·7
(165·2–
222В·0)
73В·3%
2·8 (2·4–
3В·2)
3·0 (2·5–
3В·4)
7В·6
Liver cancer secondary to
alcohol use
93·4 (78·6–
106В·4)
149В·0
(127·3–
172В·6)
59В·5%
2·3 (1·9–
2В·6)
2·3 (1·9–
2В·6)
в€’0В·1
Other liver cancer
46·5 (38·2–
52В·6)
66·0 (57·2–
77В·3)
42В·0%
1·1 (0·9–
1В·2)
1·0 (0·9–
1В·2)
в€’7В·7
Larynx cancer
81·9 (43·5–
133В·4)
98·3 (52·8–
159В·2)
20В·1%
2·0 (1·1–
3В·3)
1·5 (0·8–
2В·4)
в€’25В·1
Trachea, bronchus, and lung
cancers
1036В·3
(825·8–
1314В·3)
1527В·1
(1126·3–
1779В·4)
47В·4%
25В·5
(20·4–
32В·4)
23В·4
(17·3–
27В·3)
в€’8В·3
Breast cancer
319В·1
(310·1–
337В·0)
438В·7
(420·1–
461В·9)
37В·5%
7·8 (7·6–
8В·3)
6·6 (6·4–
7В·0)
в€’15В·3
Cervical cancer
192В·3
(120·5–
264В·4)
225В·4
(145·2–
311В·5)
17В·3%
4·7 (2·9–
6В·4)
3·4 (2·2–
4В·7)
в€’26В·9
Uterine cancer
45·2 (25·3–
79В·4)
58·6 (27·5–
87В·8)
29В·7%
1·1 (0·6–
2В·0)
0·9 (0·4–
1В·3)
в€’20В·2
Prostate cancer
155·6 (88·8–
239В·6)
256В·0
(141·1–
404В·4)
64В·5%
4·0 (2·3–
6В·1)
3·8 (2·1–
6В·1)
в€’3В·1
Colon and rectum cancers
490В·5
(417·2–
547В·3)
714В·6
(627·9–
822В·6)
45В·7%
12В·2
(10·4–
13В·6)
10В·8
(9·5–
12В·5)
в€’10В·9
Mouth cancer
81·9 (68·6–
88В·3)
123В·9
(104·2–
136В·3)
51В·2%
2·0 (1·7–
2В·2)
1·9 (1·6–
2В·1)
в€’5В·9
Nasopharynx cancer
45·2 (29·9–
59В·6)
64·9 (42·3–
83В·3)
43В·6%
1·1 (0·7–
1В·4)
1·0 (0·6–
1В·3)
в€’8В·2
Cancer of other part of pharynx and
oropharynx
74·0 (43·8–
90В·9)
102·4 (59·5–
128В·5)
38В·3%
1·8 (1·1–
2В·2)
1·6 (0·9–
2В·0)
в€’12В·9
Gallbladder and biliary tract cancer
97·4 (66·1–
136В·0)
151В·7
(100·4–
206В·8)
55В·7%
2·4 (1·6–
3В·4)
2·3 (1·5–
3В·1)
в€’4В·7
Pancreatic cancer
200В·0
(154·1–
261В·5)
310В·2
(231·7–
393В·1)
55В·1%
5·0 (3·8–
6В·5)
4·7 (3·5–
6В·0)
в€’4В·8
Malignant melanoma of skin
31·0 (20·3–
46В·6)
49·1 (29·9–
69В·5)
58В·4%
0·8 (0·5–
1В·1)
0·7 (0·5–
1В·1)
в€’1В·5
Non-melanoma skin cancer
20·5 (12·5–
32В·7)
30·6 (17·5–
46В·3)
49В·6%
0·5 (0·3–
0В·8)
0·5 (0·3–
0В·7)
в€’10В·7
114
%∆
%∆
CLINICAL SOCIAL WORK (CSW)
All ages deaths (thousands)
Age-standardised death rates (per
100  000)
1990
2010
%∆
1990
2010
%∆
Ovarian cancer
113·6 (82·9–
138В·8)
160В·5
(115·9–
200В·6)
41В·2%
2·8 (2·0–
3В·4)
2·4 (1·8–
3В·1)
в€’12В·1
Testicular cancer
6·5 (3·8–8·3)
7·7 (4·8–
10В·0)
18В·6%
0·1 (0·1–
0В·2)
0·1 (0·1–
0В·1)
в€’18В·9
Kidney and other urinary organ
cancers
85·1 (62·0–
112В·9)
162В·1
(125·5–
219В·8)
90В·6%
2·1 (1·5–
2В·7)
2·5 (1·9–
3В·3)
19В·4
Bladder cancer
123В·4
(100·2–
148В·5)
170В·7
(131·1–
201В·2)
38В·3%
3·1 (2·5–
3В·7)
2·6 (2·0–
3В·0)
в€’16В·3
Brain and nervous system cancers
131·5 (88·7–
188В·3)
195В·5
(115·1–
239В·3)
48В·7%
3·0 (2·1–
4В·4)
3·0 (1·7–
3В·6)
в€’2В·5
Thyroid cancer
24·0 (18·0–
29В·9)
36·0 (26·4–
43В·2)
50В·2%
0·6 (0·4–
0В·7)
0·5 (0·4–
0В·7)
в€’6В·7
Hodgkin's disease
18·9 (11·8–
26В·2)
17·7 (11·6–
25В·5)
в€’6В·0%
0·4 (0·3–
0В·6)
0·3 (0·2–
0В·4)
в€’36В·7
Non-Hodgkin lymphoma
143В·2
(119·4–
158В·9)
210В·0
(166·0–
228В·5)
46В·7%
3·3 (2·8–
3В·7)
3·2 (2·5–
3В·4)
в€’5В·0
Multiple myeloma
49·3 (34·5–
71В·2)
74·1 (48·9–
102В·2)
50В·4%
1·2 (0·9–
1В·8)
1·1 (0·7–
1В·6)
в€’7В·5
Leukaemia
218В·3
(175·7–
269В·2)
281В·3
(219·6–
328В·0)
28В·9%
4·7 (3·8–
5В·9)
4·2 (3·3–
4В·9)
в€’11В·5
Other neoplasms
412В·7
(319·5–
521В·9)
608В·4
(441·2–
737В·3)
47В·4%
9·8 (7·6–
12В·4)
9·2 (6·7–
11В·2)
в€’5В·7
Cardiovascular and circulatory
diseases
11 903·7
(11 329·4–
12 589·3)
15 616·1
(14 542·2–
16 315·1)
31В·2%
298В·1
(283·9–
314В·9)
234В·8
(218·7–
245В·2)
в€’21В·2
Rheumatic heart disease
462В·6
(431·5–
517В·7)
345В·1
(305·8–
374В·3)
в€’25В·4%
11В·1
(10·3–
12В·4)
5·2 (4·6–
5В·6)
в€’53В·1
Ischaemic heart disease
5211В·8
(5014·5–
5643В·9)
7029В·3
(6577·2–
7431В·1)
34В·9%
131В·3
(126·4–
142В·2)
105В·7
(98·8–
111В·9)
в€’19В·5
Cerebrovascular disease
4660В·4
(4436·1–
5154В·9)
5874В·2
(5304·7–
6280В·1)
26В·0%
105В·7
(98·8–
111В·9)
88В·4
(79·8–
94В·4)
в€’24В·6
Ischaemic stroke
2241В·1
(2088·0–
2494В·9)
2835В·4
(2657·0–
3262В·8)
26В·5%
57В·6
(53·7–
64В·0)
42В·3
(39·6–
48В·7)
в€’26В·6
Haemorrhagic and other nonischaemic stroke
2419В·4
(2050·9–
2827В·9)
3038В·8
(2643·4–
3496В·9)
25В·6%
59В·7
(50·6–
69В·7)
46В·1
(40·1–
53В·1)
в€’22В·7
Hypertensive heart disease
590В·7
(481·0–
740В·6)
873В·2
(715·5–
1074В·1)
47В·8%
14В·9
(12·1–
18В·6)
13В·1
(10·8–
16В·2)
в€’11В·5
Cardiomyopathy and myocarditis
286В·8
(250·5–
316В·8)
403В·9
(361·5–
450В·4)
40В·8%
6·7 (5·9–
7В·4)
6·1 (5·4–
6В·8)
в€’9В·8
Atrial fibrillation and flutter
34·4 (27·9–
43В·1)
114·7 (92·7–
144В·7)
233В·9%
0·9 (0·7–
1В·1)
1·7 (1·4–
2В·1)
89В·6
Aortic aneurysm
131·9 (94·6–
173В·3)
191В·7
(140·3–
249В·2)
45В·3%
3·3 (2·4–
4В·3)
2·9 (2·1–
3В·8)
в€’12В·7
Peripheral vascular disease
18·6 (12·2–
28В·7)
49·8 (32·9–
74В·8)
167В·0%
0·5 (0·3–
0В·7)
0·7 (0·5–
1В·1)
53В·3
115
CLINICAL SOCIAL WORK (CSW)
All ages deaths (thousands)
Age-standardised death rates (per
100  000)
1990
2010
%∆
1990
2010
%∆
Endocarditis
35·8 (30·0–
44В·4)
48·3 (39·3–
55В·4)
34В·8%
0·8 (0·7–
1В·0)
0·7 (0·6–
0В·8)
в€’8В·0
Other cardiovascular and
circulatory diseases
470В·6
(446·3–
489В·9)
685В·9
(664·0–
705В·3)
45В·7%
11В·5
(11·0–
11В·9)
10В·3
(9·9–
10В·5)
в€’10В·9
Chronic respiratory diseases
3986В·3
(3914·3–
4063В·8)
3776В·3
(3648·2–
3934В·1)
в€’5В·3%
98В·2
(96·4–
100В·1)
57В·0
(55·1–
59В·4)
в€’41В·9
Chronic obstructive pulmonary
disease
3099В·0
(2914·2–
3338В·6)
2899В·9
(2669·3–
3245В·8)
в€’6В·4%
77В·4
(72·8–
83В·3)
43В·8
(40·4–
49В·1)
в€’43В·3
Pneumoconiosis
167·0 (86·3–
295В·2)
124·7 (78·3–
196В·9)
в€’25В·3%
4·2 (2·2–
7В·3)
1·9 (1·2–
3В·0)
в€’54В·8
Asthma
380В·2
(273·8–
589В·6)
345В·7
(282·6–
529В·1)
в€’9В·1%
9·0 (6·6–
13В·9)
5·2 (4·3–
8В·0)
в€’42В·1
Interstitial lung disease and
pulmonary sarcoidosis
65·0 (44·5–
89В·8)
115·1 (76·7–
152В·0)
77В·2%
1·6 (1·1–
2В·2)
1·7 (1·2–
2В·3)
9В·1
Other chronic respiratory diseases
275В·2
(200·8–
375В·8)
290В·8
(226·8–
356В·5)
5В·7%
6·0 (4·4–
8В·1)
4·3 (3·4–
5В·3)
в€’28В·3
Cirrhosis of the liver
777В·8
(663·1–
867В·9)
1030В·8
(868·8–
1160В·5)
32В·5%
18В·6
(15·8–
20В·7)
15В·6
(13·2–
17В·6)
в€’15В·8
Cirrhosis of the liver secondary to
hepatitis B
241В·7
(198·5–
270В·5)
312В·4
(270·8–
378В·3)
29В·3%
5·8 (4·8–
6В·5)
4·8 (4·1–
5В·8)
в€’18В·5
Cirrhosis of the liver secondary to
hepatitis C
211В·9
(181·1–
240В·7)
287В·4
(245·4–
330В·5)
35В·6%
5·2 (4·4–
5В·9)
4·4 (3·7–
5В·0)
в€’15В·3
Cirrhosis of the liver secondary to
alcohol use
206В·1
(168·6–
245В·3)
282В·8
(225·6–
335В·0)
37В·2%
5·0 (4·1–
5В·9)
4·3 (3·4–
5В·1)
в€’13В·9
Other cirrhosis of the liver
118В·2
(101·4–
136В·7)
148В·2
(126·6–
173В·0)
25В·4%
2·6 (2·2–
3В·0)
2·2 (1·9–
2В·6)
в€’14В·4
Digestive diseases (except
cirrhosis)
973В·1
(877·1–
1063В·5)
1111В·7
(999·5–
1210В·0)
14В·2%
22В·9
(20·7–
25В·0)
16В·7
(15·0–
18В·1)
в€’27В·2
Peptic ulcer disease
319В·3
(265·9–
338В·8)
246В·3
(215·0–
282В·2)
в€’22В·9%
7·5 (6·3–
8В·0)
3·7 (3·2–
4В·2)
в€’50В·9
Gastritis and duodenitis
15·6 (11·3–
21В·1)
14·3 (11·0–
18В·2)
в€’8В·7%
0·4 (0·3–
0В·5)
0·2 (0·2–
0В·3)
в€’42В·1
Appendicitis
39·5 (27·2–
57В·0)
34·8 (22·0–
46В·9)
в€’12В·0%
0·8 (0·6–
1В·2)
0·5 (0·3–
0В·7)
в€’38В·1
Paralytic ileus and intestinal
obstruction without hernia
121·0 (78·7–
141В·1)
148В·1
(112·1–
192В·2)
22В·4%
2·8 (1·8–
3В·2)
2·2 (1·7–
2В·9)
в€’20В·9
Inguinal or femoral hernia
23·3 (22·8–
23В·7)
17·1 (16·7–
17В·3)
в€’26В·7%
0·5 (0·5–
0В·6)
0·3 (0·2–
0В·3)
в€’53В·4
Non-infective inflammatory bowel
disease
29·5 (16·8–
37В·7)
34·0 (23·6–
39В·7)
15В·1%
0·6 (0·4–
0В·8)
0·5 (0·3–
0В·6)
в€’20В·3
Vascular disorders of intestine
51·4 (28·9–
104В·6)
73·4 (41·2–
150В·0)
42В·9%
1·3 (0·7–
2В·6)
1·1 (0·6–
2В·3)
в€’15В·2
Gallbladder and bile duct disease
74·0 (63·6–
93В·6)
89·1 (72·1–
105В·0)
20В·4%
1·8 (1·5–
2В·2)
1·3 (1·1–
1В·6)
в€’25В·5
Pancreatitis
51·6 (37·7–
64В·6)
76·6 (57·4–
95В·5)
48В·5%
1·2 (0·9–
1В·5)
1·2 (0·9–
1В·4)
в€’6В·0
Other digestive diseases
247В·9
378В·1
52В·5%
5·9 (4·6–
5·7 (4·5–
в€’3В·1
116
CLINICAL SOCIAL WORK (CSW)
All ages deaths (thousands)
Age-standardised death rates (per
100  000)
1990
2010
(194·2–
296В·2)
(301·6–
500В·4)
Neurological disorders
594В·5
(468·3–
703В·0)
1273В·8
(980·9–
1466В·9)
Alzheimer's disease and other
dementias
141В·2
(110·8–
208В·5)
Parkinson's disease
1990
2010
7В·0)
7В·5)
114В·3%
13В·7
(10·8–
16В·1)
18В·8
(14·5–
21В·8)
37В·8
485В·7
(307·8–
590В·5)
244В·0%
3·6 (2·8–
5В·4)
7·1 (4·5–
8В·6)
95В·4
53·5 (42·4–
70В·1)
111·1 (81·2–
138В·6)
107В·7%
1·4 (1·1–
1В·8)
1·7 (1·2–
2В·1)
20В·8
Epilepsy
130·2 (86·4–
167В·7)
177В·6
(119·7–
222В·3)
36В·4%
2·6 (1·8–
3В·1)
2·6 (1·7–
3В·2)
1В·0
Multiple sclerosis
15·4 (11·4–
18В·8)
18·2 (14·1–
21В·8)
17В·8%
0·4 (0·3–
0В·4)
0·3 (0·2–
0В·3)
в€’25В·0
Other neurological disorders
254В·2
(154·1–
343В·1)
481В·1
(317·9–
690В·7)
89В·3%
5·7 (3·5–
7В·7)
7·2 (4·8–
10В·4)
25В·9
Mental and behavioural
disorders
138·1 (95·2–
188В·0)
231В·9
(176·3–
329В·1)
68В·0%
3·2 (2·2–
4В·3)
3·5 (2·6–
4В·9)
9В·3
Schizophrenia
20·0 (13·1–
24В·6)
19·8 (16·6–
25В·0)
в€’1В·3%
0·5 (0·3–
0В·6)
0·3 (0·2–
0В·4)
в€’36В·7
Alcohol use disorders
74·6 (40·1–
119В·2)
111·1 (64·0–
186В·3)
48В·9%
1·8 (1·0–
2В·8)
1·7 (1·0–
2В·8)
в€’5В·0
Drug use disorders
26·6 (15·5–
56В·4)
77·6 (48·8–
124В·4)
191В·7%
0·5 (0·3–
1В·2)
1·1 (0·7–
1В·8)
112В·5
Opioid use disorders
8·9 (5·0–
18В·7)
43·0 (26·9–
68В·4)
385В·8%
0·2 (0·1–
0В·4)
0·6 (0·4–
1В·0)
257В·5
Cocaine use disorders
1·2 (0·7–2·7)
0·5 (0·2–0·5)
в€’55В·1%
<0В·05
(0·0–0·1)
<0В·05
(0·0–
0В·05)
в€’67В·7
Amphetamine use disorders
0·3 (0·1–0·5)
0·5 (0·1–0·3)
40В·1%
<0В·05
(0·0–
0В·05)
<0В·05
(0·0–
0В·05)
1В·5
Other drug use disorders
16·2 (9·6–
34В·2)
33·6 (21·9–
55В·9)
107В·3%
0·3 (0·2–
0В·7)
0·5 (0·3–
0В·8)
50В·3
Eating disorders
5·4 (2·4–8·3)
7·3 (4·5–9·9)
35В·0%
0·1 (0·1–
0В·2)
0·1 (0·1–
0В·1)
в€’12В·8
Other mental and behavioural
disorders
11·4 (5·2–
17В·0)
16·1 (9·8–
22В·1)
41В·7%
0·3 (0·1–
0В·4)
0·2 (0·1–
0В·3)
в€’11В·4
Diabetes, urogenital, blood, and
endocrine diseases
1544В·3
(1420·0–
1804В·0)
2726В·2
(2447·1–
2999В·1)
76В·5%
36В·1
(33·4–
41В·6)
41В·0
(36·8–
45В·1)
13В·8
Diabetes mellitus
665В·0
(593·3–
757В·5)
1281В·3
(1065·2–
1347В·9)
92В·7%
16В·3
(14·5–
18В·6)
19В·5
(16·2–
20В·5)
19В·7
Acute glomerulonephritis
135·2 (57·4–
357В·3)
84·2 (41·4–
191В·8)
в€’37В·7%
2·7 (1·2–
7В·4)
1·2 (0·6–
2В·8)
в€’54В·5
Chronic kidney diseases
403В·5
(354·5–
468В·9)
735В·6
(612·1–
810В·4)
82В·3%
9·6 (8·4–
11В·2)
11В·1
(9·2–
12В·2)
15В·4
Chronic kidney disease due to
diabetes mellitus
91·9 (79·7–
109В·9)
178В·3
(147·7–
198В·4)
94В·1%
2·3 (2·0–
2В·7)
2·7 (2·3–
3В·0)
19В·2
Chronic kidney disease due to
hypertension
91·5 (80·1–
106В·9)
175В·3
(147·0–
193В·3)
91В·5%
2·2 (2·0–
2В·6)
2·6 (2·2–
2В·9)
18В·5
Chronic kidney disease
unspecified
220В·2
(191·9–
382В·0
(317·9–
73В·5%
5·1 (4·5–
5В·9)
5·7 (4·8–
6В·3)
12В·3
117
%∆
%∆
CLINICAL SOCIAL WORK (CSW)
All ages deaths (thousands)
Age-standardised death rates (per
100  000)
1990
2010
252В·9)
422В·3)
%∆
1990
2010
%∆
140В·1
(102·5–
172В·6)
267В·1
(204·5–
343В·4)
90В·7%
3·4 (2·5–
4В·2)
4·0 (3·0–
5В·1)
18В·0
Tubulointerstitial nephritis,
pyelonephritis, and urinary tract
infections
83·0 (61·4–
107В·2)
163В·3
(109·1–
199В·8)
96В·7%
2·0 (1·5–
2В·6)
2·4 (1·6–
3В·0)
20В·0
Urolithiasis
18·4 (12·4–
27В·8)
19·0 (11·0–
26В·0)
3В·1%
0·5 (0·3–
0В·7)
0·3 (0·2–
0В·4)
в€’36В·8
Other urinary diseases
38·6 (26·2–
49В·3)
84·9 (63·5–
114В·1)
119В·6%
0·9 (0·6–
1В·1)
1·3 (1·0–
1В·7)
40В·8
Gynaecological diseases
5·1 (3·7–6·4)
7·0 (5·9–8·0)
39В·0%
0·1 (0·1–
0В·1)
0·1 (0·1–
0В·1)
в€’9В·0
Uterine fibroids
0·4 (0·3–0·5)
0·8 (0·6–0·9)
85В·7%
<0В·05
(0·0–
0В·05)
<0В·05
(0·0–
0В·05)
16В·5
Endometriosis
<0·05 (0·0–
0В·05)
<0·05 (0·0–
0В·05)
91В·5%
<0В·05
(0·0–
0В·05)
<0В·05
(0·0–
0В·05)
28В·6
Genital prolapse
0·2 (0·1–0·2)
0·4 (0·3–0·4)
118В·5%
<0В·05
(0·0–
0В·05)
<0В·05
(0·0–
0В·05)
32В·5
Other gynaecological diseases
4·5 (3·2–5·7)
5·9 (4·9–6·7)
31В·5%
0·1 (0·1–
0В·1)
0·1 (0·1–
0В·1)
в€’13В·4
111·4 (72·8–
160В·4)
114·8 (86·2–
151В·1)
3В·1%
2·1 (1·4–
3В·0)
1·7 (1·3–
2В·2)
в€’22В·2
Thalassaemias
25·1 (17·0–
34В·4)
17·9 (15·1–
20В·4)
в€’28В·9%
0·4 (0·3–
0В·6)
0·3 (0·2–
0В·3)
в€’41В·3
Sickle-cell disorders
23·8 (15·1–
32В·7)
28·6 (16·8–
40В·9)
20В·5%
0·4 (0·3–
0В·5)
0·4 (0·2–
0В·6)
3В·6
G6PD deficiency
4·3 (3·4–5·3)
4·0 (3·5–4·6)
в€’5В·6%
0·1 (0·1–
0В·1)
0·1 (0·1–
0В·1)
в€’31В·8
Other haemoglobinopathies and
haemolytic anaemias
58·3 (36·2–
91В·2)
64·3 (40·9–
89В·2)
10В·3%
1·2 (0·8–
1В·8)
0·9 (0·6–
1В·3)
в€’23В·0
Other endocrine, nutritional, blood,
and immune disorders
84·0 (42·3–
115В·5)
236В·1
(148·8–
417В·9)
181В·2%
1·8 (0·9–
2В·5)
3·5 (2·2–
6В·2)
91В·8
Musculoskeletal disorders
69·5 (46·2–
89В·6)
153В·5
(110·7–
214В·8)
121В·0%
1·7 (1·1–
2В·2)
2·3 (1·7–
3В·2)
37В·8
Rheumatoid arthritis
33·5 (23·5–
43В·5)
48·9 (37·9–
68В·6)
45В·8%
0·8 (0·6–
1В·1)
0·7 (0·6–
1В·0)
в€’9В·9
Other musculoskeletal disorders
36·0 (25·0–
42В·8)
104·7 (83·8–
143В·7)
191В·0%
0·8 (0·6–
1В·0)
1·6 (1·2–
2В·1)
84В·0
Other non-communicable
diseases
793В·9
(670·6–
970В·4)
641В·7
(524·8–
721В·4)
в€’19В·2%
12В·7
(10·8–
15В·3)
9·2 (7·5–
10В·3)
в€’28В·0
Congenital anomalies
663В·2
(551·7–
843В·4)
510В·4
(404·7–
596В·3)
в€’23В·0%
10В·1
(8·4–
12В·7)
7·2 (5·7–
8В·4)
в€’28В·3
Neural tube defects
118·5 (70·5–
173В·3)
70·8 (39·8–
104В·6)
в€’40В·3%
1·7 (1·0–
2В·5)
1·0 (0·6–
1В·5)
в€’42В·2
Congenital heart anomalies
278В·9
(234·9–
355В·9)
223В·6
(199·5–
246В·7)
в€’19В·8%
4·3 (3·7–
5В·3)
3·2 (2·8–
3В·5)
в€’26В·4
Cleft lip and cleft palate
8·4 (3·3–
16В·6)
3·7 (2·1–5·5)
в€’56В·2%
0·1 (0·0–
0В·2)
0·1 (0·0–
0В·1)
в€’56В·2
Down's syndrome
22·0 (9·8–
37В·5)
17·4 (11·1–
25В·4)
в€’21В·0%
0·3 (0·2–
0В·6)
0·2 (0·2–
0В·4)
в€’28В·3
Urinary diseases and male
infertility
Haemoglobinopathies and
haemolytic anaemias
118
CLINICAL SOCIAL WORK (CSW)
All ages deaths (thousands)
Age-standardised death rates (per
100  000)
1990
2010
%∆
1990
2010
%∆
Other chromosomal
abnormalities
34·6 (11·9–
80В·3)
18·9 (9·7–
33В·8)
в€’45В·4%
0·5 (0·2–
1В·1)
0·3 (0·1–
0В·5)
в€’46В·8
Other congenital anomalies
200В·8
(115·8–
298В·9)
176В·0
(118·9–
218В·7)
в€’12В·3%
3·1 (1·9–
4В·5)
2·5 (1·7–
3В·1)
в€’19В·3
100·6 (77·5–
118В·3)
109·2 (84·9–
124В·0)
8В·5%
2·2 (1·7–
2В·6)
1·6 (1·3–
1В·8)
в€’26В·5
Cellulitis
26·1 (19·9–
30В·8)
26·6 (20·4–
30В·2)
2В·0%
0·6 (0·4–
0В·7)
0·4 (0·3–
0В·5)
в€’28В·9
Abscess, impetigo, and other
bacterial skin diseases
42·1 (31·2–
51В·0)
39·7 (31·1–
45В·1)
в€’5В·7%
0·8 (0·6–
1В·0)
0·6 (0·5–
0В·7)
в€’30В·6
Decubitus ulcer
32·1 (26·0–
38В·5)
42·6 (32·9–
48В·7)
32В·5%
0·8 (0·6–
1В·0)
0·6 (0·5–
0В·7)
в€’20В·6
Other skin and subcutaneous
diseases
0·3 (0·1–0·1)
0·4 (0·1–0·1)
4В·4%
<0В·05
(0·0–
0В·05)
<0В·05
(0·0–
0В·05)
в€’28В·7
30·0 (15·4–
56В·7)
22·0 (13·1–
36В·5)
в€’26В·7%
0·4 (0·2–
0В·8)
0·3 (0·2–
0В·5)
в€’26В·7
4091В·7
(3851·9–
4489В·7)
5073В·3
(4556·7–
5548В·1)
24В·0%
82В·0
(77·2–
90В·3)
74В·3
(66·8–
81В·3)
в€’9В·3
Transport injuries
958В·2
(770·4–
1175В·0)
1396В·8
(1101·4–
1850В·1)
45В·8%
19В·4
(15·4–
23В·6)
20В·5
(16·1–
27В·1)
5В·9
Road injury
907В·9
(764·1–
1123В·4)
1328В·5
(1050·9–
1747В·0)
46В·3%
18В·4
(15·4–
22В·7)
19В·5
(15·4–
25В·6)
6В·2
Pedestrian injury by road
vehicle
284В·1
(210·6–
333В·9)
461В·0
(337·1–
617В·3)
62В·3%
5·8 (4·2–
6В·7)
6·8 (5·0–
9В·1)
17В·6
Pedal cycle vehicle
54·9 (41·7–
66В·7)
83·3 (62·3–
101В·4)
51В·7%
1·1 (0·9–
1В·4)
1·2 (0·9–
1В·5)
7В·8
Motorised vehicle with two
wheels
131·7 (99·4–
163В·4)
206В·4
(159·7–
233В·8)
56В·7%
2·6 (2·0–
3В·3)
3·0 (2·3–
3В·4)
14В·4
Motorised vehicle with three or
more wheels
336В·9
(268·8–
420В·5)
474В·5
(379·3–
581В·4)
40В·9%
6·8 (5·5–
8В·4)
7·0 (5·6–
8В·5)
2В·4
Road injury other
100·3 (49·0–
182В·3)
103·3 (50·7–
202В·2)
3В·0%
2·0 (1·0–
3В·7)
1·5 (0·7–
3В·0)
в€’25В·2
Other transport injury
50·2 (41·7–
65В·1)
68·3 (58·0–
82В·7)
35В·9%
1·0 (0·8–
1В·3)
1·0 (0·8–
1В·2)
в€’0В·0
Unintentional injuries other than
transport injuries
2030В·1
(1896·0–
2266В·8)
2122В·8
(1867·5–
2283В·8)
4В·6%
39В·6
(37·1–
44В·3)
31В·0
(27·3–
33В·4)
в€’21В·6
Falls
348В·6
(311·2–
415В·3)
540В·5
(415·2–
611В·9)
55В·0%
7·8 (7·0–
9В·4)
8·0 (6·1–
9В·1)
2В·0
Drowning
432В·9
(353·3–
516В·1)
349В·1
(299·9–
437В·8)
в€’19В·4%
7·5 (6·3–
9В·0)
5·1 (4·3–
6В·3)
в€’33В·1
Fire, heat, and hot substances
280В·1
(233·6–
330В·1)
337В·6
(234·7–
433В·8)
20В·5%
5·3 (4·5–
6В·3)
4·9 (3·4–
6В·3)
в€’7В·3
Poisonings
202В·9
(157·3–
326В·8)
180В·4
(130·1–
239В·9)
в€’11В·1%
4·0 (3·2–
6В·5)
2·6 (1·9–
3В·5)
в€’34В·4
Exposure to mechanical forces
276В·0
(199·6–
417В·1)
215В·6
(154·6–
255В·3)
в€’21В·9%
5·5 (4·0–
8В·1)
3·2 (2·3–
3В·7)
в€’42В·2
Skin and subcutaneous diseases
Sudden infant death syndrome
Injuries
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All ages deaths (thousands)
Age-standardised death rates (per
100  000)
1990
2010
%∆
1990
2010
%∆
Mechanical forces (firearm)
127·5 (76·8–
206В·0)
79·8 (52·0–
127В·1)
в€’37В·4%
2·5 (1·5–
4В·1)
1·2 (0·8–
1В·8)
в€’53В·2
Mechanical forces (other)
148В·5
(103·0–
197В·4)
135·7 (83·5–
161В·0)
в€’8В·6%
3·0 (2·1–
3В·9)
2·0 (1·2–
2В·4)
в€’33В·1
Adverse effects of medical
treatment
42·0 (32·7–
49В·3)
83·7 (64·6–
96В·2)
99В·1%
0·9 (0·7–
1В·0)
1·2 (1·0–
1В·4)
41В·0
Animal contact
75·0 (50·7–
97В·5)
64·3 (41·0–
88В·4)
в€’14В·3%
1·4 (1·0–
1В·9)
0·9 (0·6–
1В·3)
в€’34В·4
Animal contact (venomous)
54·9 (30·1–
89В·3)
47·0 (25·6–
84В·7)
в€’14В·3%
1·0 (0·6–
1В·7)
0·7 (0·4–
1В·2)
в€’34В·4
Animal contact (nonvenomous)
20·1 (10·7–
30В·8)
17·3 (10·0–
24В·6)
в€’14В·2%
0·4 (0·2–
0В·6)
0·3 (0·1–
0В·4)
в€’34В·5
Unintentional injuries not classified
elsewhere
372В·5
(311·9–
403В·8)
351В·6
(301·4–
387В·8)
в€’5В·6%
7·1 (6·0–
7В·7)
5·1 (4·4–
5В·7)
в€’27В·9
Self-harm and interpersonal
violence
1008В·5
(838·8–
1201В·9)
1340В·0
(1108·2–
1616В·9)
32В·9%
21В·1
(17·5–
25В·4)
19В·7
(16·2–
23В·8)
в€’6В·9
Self-harm
669В·8
(519·5–
853В·4)
883В·7
(655·6–
1105В·2)
31В·9%
14В·5
(11·3–
18В·4)
13В·1
(9·7–
16В·3)
в€’9В·6
Interpersonal violence
338В·7
(245·8–
416В·6)
456В·3
(354·9–
610В·9)
34В·7%
6·7 (4·8–
8В·3)
6·6 (5·1–
8В·9)
в€’1В·0
Assault by firearm
141В·8
(107·4–
175В·7)
196В·2
(153·9–
233В·6)
38В·4%
2·8 (2·1–
3В·5)
2·8 (2·2–
3В·4)
1В·9
Assault by sharp object
83·1 (55·4–
119В·8)
126·7 (82·2–
188В·2)
52В·5%
1·7 (1·1–
2В·4)
1·8 (1·2–
2В·7)
10В·9
Assault by other means
113·8 (85·2–
129В·3)
133В·4
(107·3–
159В·0)
17В·2%
2·2 (1·7–
2В·5)
1·9 (1·6–
2В·3)
в€’13В·5
Forces of nature, war, and legal
intervention
94·9 (65·0–
162В·3)
213В·7
(119·2–
433В·5)
125В·2%
1·9 (1·3–
3В·4)
3·1 (1·7–
6В·3)
62В·0
Exposure to forces of nature
31·4 (18·2–
60В·0)
196В·0
(106·9–
401В·9)
523В·5%
0·7 (0·4–
1В·3)
2·9 (1·6–
5В·8)
336В·4
Collective violence and legal
intervention
63·5 (44·3–
101В·8)
17·7 (12·2–
29В·6)
в€’72В·2%
1·3 (0·9–
2В·1)
0·3 (0·2–
0В·4)
в€’79В·5
Data are deaths (95% uncertainty interval) or % change. %О”=percentage change. E coli=Escherichia coli. H
influenzae=Haemophilus influenzae. G6PD=glucose-6-phosphate dehydrogenase.*For these causes the mean
value is outside of the 95% uncertainty interval; this occurs because the full distribution of 1000 draws is
asymmetric with a long tail. A small number of high values in the uncertainty distribution raises the mean above
the 97В·5 percentile of the distribution.
Table 2. Global deaths for 235 causes in 1990 and 2010 for all ages and both sexes combined (thousands)
(thousands) and ageagestandardised rates (per 100 
100 000) with 95% UI and percentage change
Common values in assessing health outcomes from disease and injury: disability weights
measurement study for the Global Burden of Disease Study 2010, Joshua A. Salomon,
Lancet 2012, 380: 2129-43
Measurement of the global burden of disease with disability-adjusted life-years (DALYs)
requires disability weights that quantify health losses for all non-fatal consequences of disease
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and injury. There has been extensive debate about a range of conceptual and methodological
issues concerning the definition and measurement of these weights. Our primary objective
was a comprehensive re-estimation of disability weights for the Global Burden of Disease
Study 2010 through a large-scale empirical investigation in which judgments about health
losses associated with many causes of disease and injury were elicited from the general public
in diverse communities through a new, standardised approach.
We surveyed respondents in two ways: household surveys of adults aged 18 years or older
(face-to-face interviews in Bangladesh, Indonesia, Peru, and Tanzania; telephone interviews
in the USA) between Oct 28, 2009, and June 23, 2010; and an open-access web-based survey
between July 26, 2010, and May 16, 2011. The surveys used paired comparison questions, in
which respondents considered two hypothetical individuals with different, randomly selected
health states and indicated which person they regarded as healthier. The web survey added
questions about population health equivalence, which compared the overall health benefits of
different life-saving or disease-prevention programmes. We analysed paired comparison
responses with probit regression analysis on all 220 unique states in the study. We used
results from the population health equivalence responses to anchor the results from the paired
comparisons on the disability weight scale from 0 (implying no loss of health) to 1 (implying
a health loss equivalent to death). Additionally, we compared new disability weights with
those used in WHO's most recent update of the Global Burden of Disease Study for 2004.
13,902 individuals participated in household surveys and 16,328 in the web survey. Analysis
of paired comparison responses indicated a high degree of consistency across surveys:
correlations between individual survey results and results from analysis of the pooled dataset
were 0В·9 or higher in all surveys except in Bangladesh (r=0В·75). Most of the 220 disability
weights were located on the mild end of the severity scale, with 58 (26%) having weights
below 0В·05. Five (11%) states had weights below 0В·01, such as mild anaemia, mild hearing or
vision loss, and secondary infertility. The health states with the highest disability weights
were acute schizophrenia (0В·76) and severe multiple sclerosis (0В·71). We identified a broad
pattern of agreement between the old and new weights (r=0В·70), particularly in the moderateto-severe range. However, in the mild range below 0В·2, many states had significantly lower
weights in our study than previously.
This study represents the most extensive empirical effort as yet to measure disability weights.
By contrast with the popular hypothesis that disability assessments vary widely across
samples with different cultural environments, we have reported strong evidence of highly
consistent results.
A comparative risk assessment of burden of disease and injury attributable to 67 risk
factors and risk factor clusters in 21 regions, 1990-2010: a systematic analysis for the
Global burden of disease Study 2010, Stephen S. Lim, Lancet 2012, 380: 2224-60
Quantification of the disease burden caused by different risks informs prevention by
providing an account of health loss different to that provided by a disease-by-disease analysis.
No complete revision of global disease burden caused by risk factors has been done since a
comparative risk assessment in 2000, and no previous analysis has assessed changes in burden
attributable to risk factors over time.
We estimated deaths and disability-adjusted life years (DALYs; sum of years lived with
disability [YLD] and years of life lost [YLL]) attributable to the independent effects of 67 risk
factors and clusters of risk factors for 21 regions in 1990 and 2010. We estimated exposure
distributions for each year, region, sex, and age group, and relative risks per unit of exposure
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by systematically reviewing and synthesising published and unpublished data. We used these
estimates, together with estimates of cause-specific deaths and DALYs from the Global
Burden of Disease Study 2010, to calculate the burden attributable to each risk factor
exposure compared with the theoretical-minimum-risk exposure. We incorporated uncertainty
in disease burden, relative risks, and exposures into our estimates of attributable burden.
In 2010, the three leading risk factors for global disease burden were high blood pressure
(7·0% [95% uncertainty interval 6·2—7·7] of global DALYs), tobacco smoking including
second-hand smoke (6·3% [5·5—7·0]), and alcohol use (5·5% [5·0—5·9]). In 1990, the
leading risks were childhood underweight (7·9% [6·8—9·4]), household air pollution from
solid fuels (HAP; 7·0% [5·6—8·3]), and tobacco smoking including second-hand smoke
(6·1% [5·4—6·8]). Dietary risk factors and physical inactivity collectively accounted for
10·0% (95% UI 9·2—10·8) of global DALYs in 2010, with the most prominent dietary risks
being diets low in fruits and those high in sodium. Several risks that primarily affect
childhood communicable diseases, including unimproved water and sanitation and childhood
micronutrient deficiencies, fell in rank between 1990 and 2010, with unimproved water and
sanitation accounting for 0·9% (0·4—1·6) of global DALYs in 2010. However, in most of
sub-Saharan Africa childhood underweight, HAP, and non-exclusive and discontinued
breastfeeding were the leading risks in 2010, while HAP was the leading risk in south Asia.
The leading risk factor in Eastern Europe, most of Latin America, and southern sub-Saharan
Africa in 2010 was alcohol use; in most of Asia, North Africa and Middle East, and central
Europe it was high blood pressure. Despite declines, tobacco smoking including second-hand
smoke remained the leading risk in high-income north America and western Europe. High
body-mass index has increased globally and it is the leading risk in Australasia and southern
Latin America, and also ranks high in other high-income regions, North Africa and Middle
East, and Oceania.
Worldwide, the contribution of different risk factors to disease burden has changed
substantially, with a shift away from risks for communicable diseases in children towards
those for non-communicable diseases in adults. These changes are related to the ageing
population, decreased mortality among children younger than 5 years, changes in cause-ofdeath composition, and changes in risk factor exposures. New evidence has led to changes in
the magnitude of key risks including unimproved water and sanitation, vitamin A and zinc
deficiencies, and ambient particulate matter pollution. The extent to which the
epidemiological shift has occurred and what the leading risks currently are varies greatly
across regions. In much of sub-Saharan Africa, the leading risks are still those associated with
poverty and those that affect children.
Risk factors for and clinical implications of mixed Candida/bacterial bloodstream
infections, Kim S. H., Clin Microbiol Infect 2013, 19: 62-68
Mixed Candida/bacterial bloodstream infections (BSIs) have been reported to occur in more
than 23% of all episodes of candidaemia. However, the clinical implications of mixed
Candida/bacterial BSIs are not well known. We performed a retrospective case-control study
of all consecutive patients with candidaemia over a 5-year period to determine the risk factors
for and clinical outcomes of mixed Candida/bacterial BSIs (cases) compared with
monomicrobial candidaemia (controls). Thirty-seven (29%) out of 126 patients with
candidaemia met the criteria for cases. Coagulase-negative staphylococci were the
predominant bacteria (23%) in cases. In multivariate analysis, duration of previous hospital
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CLINICAL SOCIAL WORK (CSW)
stay ≥7 weeks (odds ratio (OR), 2.86; 95% confidence interval (CI), 1.09-7.53), prior
antibiotic therapy ≥7 days (OR, 0.33; 95% CI, 0.14-0.82) and septic shock at the time of
candidaemia (OR, 2.60; 95% CI, 1.14-5.93) were significantly associated with cases.
Documented clearance of candidaemia within 3 days after initiation of antifungal therapy
was less frequent in cases (63% vs. 84%; p = 0.035). The difference in the rate of
treatment failure at 2 weeks was not significant between cases (68%) and controls (62%; p
= 0.55). The crude mortality at 6 weeks and survival through 100 days did not differ
between the two patient groups (p = 0.56 and p = 0.80, respectively). Mixed
Candida/bacterial BSIs showed a lower clearance rate of candidaemia during the early period
of antifungal therapy, although the treatment response and survival rate were similar
regardless of concurrent bacteraemia. Further studies on the clinical relevance of speciesspecific Candida-bacterial interactions are needed.
High rate of colistin resistance among patients with carbapenem-resistant Klebsiella
pneumoniae infection accounts for an excess of mortality, Capone A., Clin Microbiol
Infect 2013, 19: E23-E30
Carbapenem-resistant Klebsiella pneumoniae (CR-KP) is becoming a common cause of
healthcare-associated infection in Italy, with high morbidity and mortality. Prevalent CR-KP
clones and resistance mechanisms vary between regions and over time. Therapeutic
approaches and their impact on mortality have to be investigated. We performed a prospective
study of patients with CR-KP isolation, hospitalized in nine hospitals of Rome, Italy, from
December 2010 to May 2011, to describe the molecular epidemiology, antibiotic treatment
and risk factors for mortality. Overall, 97 patients (60% male, median age 69 years) were
enrolled. Strains producing blaKPC-3 were identified in 89 patients, blaVIM in three patients
and blaCTX-M-15 plus porin defects in the remaining five patients. Inter-hospital spread of
two major clones, ST512 and ST258, was found. Overall, 36.1% and 20.4% of strains were
also resistant to colistin and tigecycline, respectively. Infection was diagnosed in 91 patients
who received appropriate antibiotic treatment, combination therapy and removal of the
infectious source in 73.6%, 59.3% and 28.5% of cases, respectively. Overall, 23 different
antibiotic regimens were prescribed. In-hospital mortality was 25.8%. Multivariate analysis
adjusted for appropriate treatment, combination therapy and infectious-source removal,
showed that Charlson comorbidity score, intensive-care unit onset of infection, bacteraemia
and infection due to a colistin-resistant CR-KP strain were independent risk factors for
mortality. The spread of clones producing K. pneumoniae carbapenemases, mainly ST258, is
currently the major cause of CR-KP infection in central Italy. We observed a high rate of
resistance to colistin that is independently associated with worse outcome.
Community Health Workers' Experiences and Perspectives on Mass Drug
Administration for Schistosomiasis Control in Western Kenya: The SCORE Project,
Martin O. Omedo, Am J. Trop med Hyg 2012, 87(6), 1065-1072
The Schistosomiasis Consortium for Operational Research and Evaluation (SCORE) includes
communitywide treatment in areas with ≥ 25% prevalence of schistosomiasis along the shores
of Lake Victoria using community health workers (CHWs). The CHWs are key drivers in
community-owned mass drug administration (MDA) intervention programs. We explored
their experiences and perceptions after initial MDA participation. Unstructured open-ended
group discussions were conducted after completion of MDA activities. Narratives were
obtained from CHWs using a digital audio recorder during the group discussion, transcribed
verbatim and translated into English where applicable. Thematic decomposition of data was
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CLINICAL SOCIAL WORK (CSW)
done using ATLAS.t.i. software. From the perspective of the CHWs, factors influencing
MDA compliance included drug side effects, food supply stability, and conspiracy theories
about the "real" purpose of treatment. The interest of CHWs to serve as community drug
distributors stemmed from both intrinsic and extrinsic factors. Feedback from CHWs can
promote more effective MDA in rural Kenyan communities.
Oral miltefosine for Indian post-kala-azar dermal leishmaniasis: a randomised trial,
Shyam Sundar, Tropical Medicine and International Health, Vol. 18., No. 1, 96-100, Jan 2013
Standard treatment of Indian post-kala-azar dermal leishmaniasis (PKDL) is unsatisfactory
because to achieve therapeutic effectiveness, heroic courses of parenteral and toxic agents
have to be administered. Our objective was to evaluate oral miltefosine for its potential to
provide effective as well as tolerable treatment for this disease.
Open-label, randomised, parallel-group multicentric trial. Miltefosine, 100 mg/day to all but
one patient, was administered for 12 weeks or 8 weeks, with a target of 18 patients in each
treatment group. Key endpoints were tolerance during treatment and efficacy at 12 months of
follow-up.
The ITT and per-protocol cure rates after 12 months of follow-up for patients receiving
12 weeks of therapy were 78% (14 of 18 patients: 95% CI = 61-88%) and 93% (14 of 15
patients: 95% CI = 71-95%), respectively, after 12 months of follow-up. The ITT and perprotocol cure rates for patients receiving 8 weeks of therapy were 76% (13 of 17 patients:
95% CI = 53-90%) and 81% (13 of 16 patients: 95% CI = 57-93%), respectively.
Gastrointestinal and other adverse events were rare.
This study suggests that oral miltefosine for 2-3 months can be considered a treatment of
choice for Indian PKDL.
Impact of vancomycin minimum inhibitory concentration on clinical outcomes of
patients with vancomycin-susceptible Staphylococcus aureus infections: a meta-anylysis
and meta-regression, Michael N. Mavros, International Journal of Antimicrobial Agents 40,
2012, 496-509
Although the vancomycin minimum inhibitory concentration (VMIC) susceptibility
breakpoint for Staphylococcus aureus was recently lowered to ≤2 mg/L, it is argued that
isolates in the higher levels of the susceptible range may bear adverse clinical outcomes.
Clinical outcomes (all-cause mortality and treatment failure) of patients with S. aureus
infections by 'high-VMIC' (conventionally defined as VMIC >1 mg/L but ≤2 mg/L) and 'lowVMIC' (VMIC≤1 mg/L) isolates were compared by performing a systematic review and metaanalysis. The effect of potential confounders was assessed by univariate meta-regression
analyses. In total, 33 studies (6210 patients) were included. Most studies were retrospective
(28/33), used the Etest (22/33) and referred to meticillin-resistant S. aureus (MRSA)
infections (26/33) and bacteraemia (23/33). Irrespective of VMIC testing method, meticillin
resistance and site of infection, the high-VMIC group had higher mortality [relative risk
(RR)=1.21 (95% confidence interval 1.03-1.43); 4612 patients] and more treatment failures
[RR=1.67 (1.26-2.21); 2049 patients] than the low-VMIC group. The results were not affected
by the potential confounders and were reproduced in the subset of patients with MRSA
infections [mortality, RR=1.19 (1.02-1.40), 2956 patients; treatment failure, RR=1.69 (1.262.25), 1793 patients]. In conclusion, infection by vancomycin-susceptible S. aureus with
VMIC>1mg/L appears to be associated with higher mortality than VMIC≤1mg/L. Further
research is warranted to verify these results and to assess the impact of VMIC on meticillin124
CLINICAL SOCIAL WORK (CSW)
susceptible S. aureus infections. Evaluation of alternative antimicrobial agents also appears
justified.
Outcomes of the Surviving Sepsis Campaign in intensive care units in the USA and
Europe: a prospective cohort study, Mitchell M. Levy, Lancet Infect Dis 2012, 12: 919-24
Mortality from severe sepsis and septic shock differs across continents, countries, and regions.
We aimed to use data from the Surviving Sepsis Campaign (SSC) to compare models of care
and outcomes for patients with severe sepsis and septic shock in the USA and Europe.
The SSC was introduced into more than 200 sites in Europe and the USA. All patients
identified with severe sepsis and septic shock in emergency departments or hospital wards and
admitted to intensive care units (ICUs), and those with sepsis in ICUs were entered into the
SSC database. Patients entered into the database from its launch in January, 2005, through
January, 2010, in units with at least 20 patients and 3 months of enrolment of patients were
included in this analysis. Patients included in the cohort were limited to those entered in the
first 4 years at every site. We used random-effects logistic regression to estimate the hospital
mortality odds ratio (OR) for Europe relative to the USA. We used random-effects linear
regression to find the relation between lengths of stay in hospital and ICU and geographic
region.
25 375 patients were included in the cohort. The USA included 107 sites with 18 766 (74%)
patients, and Europe included 79 hospital sites with 6609 (26%) patients. In the USA, 12 218
(65В·1%) were admitted to the ICU from the emergency department whereas in Europe, 3405
(51В·5%) were admitted from the wards. The median stay on the hospital wards before ICU
admission was longer in Europe than in the USA (1В·0 vs 0В·1 days, difference 0В·9, 95% CI
0В·8-0В·9). Raw hospital mortality was higher in Europe than in the USA (41В·1%vs 28В·3%,
difference 12В·8, 95% CI 11В·5-14В·7). The median length of stay in ICU (7В·8 vs 4В·2 days, 3В·6,
3В·3-3В·7) and hospital (22В·8 vs 10В·5 days, 12В·3, 11В·9-12В·8) was longer in Europe than in the
USA. Adjusted mortality in Europe was not significantly higher than that in the USA
(32В·3%vs 31В·3%, 1В·0, -1В·7 to 3В·7, p=0В·468). Complete compliance with all applicable
elements of the sepsis resuscitation bundle was higher in the USA than in Europe (21В·6%vs
18В·4%, 3В·2, 2В·2-4В·4).
The significant difference in unadjusted mortality and the fact that this difference disappears
with severity adjustment raise important questions about the effect of the approach to critical
care in Europe compared with that in the USA. The effect of ICU bed availability on
outcomes in patients with severe sepsis and septic shock requires further investigation.
Invasive Mold Infections Following Combat related Injuries, Tyler Warkentien, Clinical
Infectious Diseases 2012, 55(11): 1441-9
Major advances in combat casualty care have led to increased survival of patients with
complex extremity trauma. Invasive fungal wound infections (IFIs) are an uncommon, but
increasingly recognized, complication following trauma that require greater understanding of
risk factors and clinical findings to reduce morbidity.
The patient population includes US military personnel injured during combat from June 2009
through December 2010. Case definition required wound necrosis on successive debridements
with IFI evidence by histopathology and/or microbiology (Candida spp excluded). Case
finding and data collected through the Trauma Infectious Disease Outcomes Study utilized
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CLINICAL SOCIAL WORK (CSW)
trauma registry, hospital records or operative reports, and pathologist review of
histopathology specimens.
A total of 37 cases were identified: proven (angioinvasion, n=20), probable (nonvascular
tissue invasion, n=4), and possible (positive fungal culture without histopathological
evidence, n=13). In the last quarter surveyed, rates reached 3.5% of trauma admissions.
Common findings include blast injury (100%) during foot patrol (92%) occurring in southern
Afghanistan (94%) with lower extremity amputation (80%) and large volume blood
transfusion (97.2%). Mold isolates were recovered in 83% of cases (order Mucorales, n=16;
Aspergillus spp, n=16; Fusarium spp, n=9), commonly with multiple mold species among
infected wounds (28%). Clinical outcomes included 3 related deaths (8.1%), frequent
debridements (median, 11 cases), and amputation revisions (58%).
IFIs are an emerging trauma-related infection leading to significant morbidity. Early
identification, using common characteristics of patient injury profile and tissue-based
diagnosis, should be accompanied by aggressive surgical and antifungal therapy (liposomal
amphotericin B and a broad-spectrum triazole pending mycology results) among patients with
suspicious wounds.
Pertussis in Older Adults: Prospective Study of Risk Factors and Morbidity, Bette C.
Liu, Clinical Infectious Diseases 2012, 55(11): 1450-6
There is limited information on the incidence, morbidity and risk factors for pertussis in
adults, particularly those aged over 65 years.
Population-based prospective cohort study of 263094 adults aged over 45 years (mean 62.8
years) recruited in the Australian state of New South Wales (the 45 and Up Study) between
2006 and 2008, and followed by record-linkage to laboratory-confirmed pertussis
notifications, hospitalizations, and death records. The incidence of pertussis notifications and
hospitalizations and relative risk (RR) of pertussis according to various participant
characteristics was estimated using proportional hazards models.
Over a total follow-up of 217524 person-years, 205 adults had a pertussis notification and 12
were hospitalized; the incidence rate was 94 (95% confidence interval [CI], 82-108) and 5.5
(95% CI, 3.1-9.7) per 100000 person-years, respectively. The incidence of a pertussis
notification did not differ by age but hospitalization rates progressively increased (2.2, 8.5,
and 13.5 per 100000 person-years in age groups 45-64, 65-74, and 75+ years, respectively;
P(trend) = .01). After adjusting for age, sex, and other factors, adults with a high body mass
index (BMI; RR=1.52; 95% CI, 1.06-2.19 for BMI 30+kg/m(2) vs BMI <25 kg/m(2)) and
with preexisting asthma (RR=1.64; 95% CI, 1.06-2.55 compared to those without asthma)
were more likely to be notified.
Adults older than 65 years are more likely to be hospitalized for pertussis than those aged 4564 years. Obesity and preexisting asthma were associated with a higher likelihood of pertussis
notification. These findings suggest that pertussis vaccination would be particularly important
for adults with these characteristics.
Fluoroquinolones and the Risk of Serious Arrhytmia: A Population-Based Study,
Francesco Lapi, Clinical Infectious Diseases 2012, 55(11): 1457-65
Fluoroquinolones have been suspected to cause cardiac arrhythmia but data are lacking,
particularly for the individual fluoroquinolones. We assessed the risk of serious arrhythmia,
defined as ventricular arrhythmia or sudden/unattended death identified in hospital discharge
diagnoses, related to fluoroquinolones as a class as well as for each individual molecule.
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We used a cohort of patients treated for respiratory conditions from 1 January 1990 to 31
December 2005, identified using the healthcare databases from the province of Quebec
(Canada), with follow-up until 31 March 2007. A nested case-control analysis was performed
within this cohort, with all cases of serious arrhythmia occurring during follow-up identified
from hospitalization records. These cases were matched with up to 20 controls. Conditional
logistic regression was used to compute adjusted rate ratios (RRs) of serious arrhythmia
associated with fluoroquinolone use.
Within the cohort of 605127 subjects, 1838 cases were identified (incidence rate=4.7/10000
person-years). The rate of serious arrhythmia was elevated with current fluoroquinolone use
(RR=1.76; 95% confidence interval [CI], 1.19-2.59), in particular with new current use
(RR=2.23; 95% CI, 1.31-3.80). Gatifloxacin use was associated with the highest rate
(RR=7.38; 95% CI, 2.30-23.70); moxifloxacin and ciprofloxacin were also associated with
elevated rates of serious arrhythmia (RR=3.30; 95% CI, 1.47-7.37 and RR=2.15; 95% CI,
1.34-3.46, respectively).
The use fluoroquinolones is associated with an elevated risk of serious arrhythmia, with some
differences among molecules. Given that the individual fluoroquinolones share various
indications, the relative risks of serious arrhythmia could inform the choice of different
molecules in high-risk patients.
Population-Based Study of Statins, Angiotensin II Receptor Blockers and AngiotensinConverting Enzyme Inhibitors on Pneumonia- Related Outcomes, Eric M. Mortensen,
Clinical Infectious Diseases 2012, 55(11): 1466-73
Studies suggest that statins and angiotensin-converting enzyme (ACE) inhibitors might be
beneficial for the treatment of infections. Our purpose was to examine the association of
statin, ACE inhibitor, and angiotensin II receptor blocker (ARB) use with pneumonia-related
outcomes.
We conducted a retrospective cohort study using Department of Veterans Affairs data of
patients aged ≥ 65 years hospitalized with pneumonia. We performed propensity-score
matching for 3 medication classes simultaneously.
Of 50119 potentially eligible patients, we matched 11498 cases with 11498 controls.
Mortality at 30 days was 13%; 34% used statins, 30% ACE inhibitors, and 4% ARBs. In
adjusted models, prior statin use was associated with decreased mortality (odds ratio [OR],
0.74; 95% confidence interval [CI], .68-.82) and mechanical ventilation (OR, 0.81; 95% CI,
.70-.94), and inpatient use with decreased mortality (OR, 0.68; 95% CI, .59-.78) and
mechanical ventilation (OR, 0.68; 95% CI, .60-.90). Prior (OR, 0.88; 95% CI, .80-.97) and
inpatient (OR, 0.58; 95% CI, .48-.69) ACE inhibitor use was associated with decreased
mortality. Prior (OR, 0.73; 95% CI, .58-.92) and inpatient ARB use (OR, 0.47; 95% CI, .30.72) was only associated with decreased mortality. Use of all 3 medications was associated
with reduced length of stay.
Statins, and to a lesser extent ACE inhibitors and ARBs, are associated with improved
pneumonia-related outcomes. Prospective cohort and randomized controlled trials are needed
to examine potential mechanisms of action and whether acute initiation at the time of
presentation with these infections is beneficial.
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Choice and Doses of Antibacterial Agents for Cement Spacers in Treatment of
Prosthetic Joint Infections: Review of Published Studies, Larikov D., Clinical Infectious
Diseases 2012, 55(11): 1474-80
Addition of antibacterial drugs to interim antibacterial cement spacers (ACSs) is considered to
be standard of care for surgical revision in prosthetic joint infections (PJIs). We reviewed
published studies evaluating the choice and doses of antibacterials in spacers.
We conducted a PubMed search of all clinical study reports evaluating the use of ACSS in a
2-stage hip or knee arthroplasty for treatment of PJI (1988 through August 2011). The trial
design, antibacterials used, and end points studied were analyzed.
No randomized trials were found comparing either ACSs with different concentrations of
antibacterials or ACSs with or without antibacterials. Most of the studies were uncontrolled
and used various time points to evaluate the outcome. Twenty publications that reported doses
of antibacterials in spacers and had a follow-up of ≥ 24 months after the second stage were
selected for review. Most ACSs included vancomycin and aminoglycosides. The doses of
aminoglycosides and vancomycin ranged from 0.25 to 4.8 g and from 1 to 4 g, respectively,
per 4 g of cement. No association between reported eradication of the infection and
antibacterial load was found.
Published data do not allow evaluation of whether antibacterials in temporary cement spacers
provide additional benefits in the treatment of PJI, compared with systemic antibacterials, and
are not sufficient to support recommendations on dosages. Complications of ACSs have not
been consistently analyzed. Prospective randomized trials comparing spacers with and
without antibacterials or spacers with different loads of antibacterials are needed to evaluate
the safety and efficacy of ACSs.
Three-Month Antibiotic Therapy for Early- Onset Postoperative Spinal Implant
Infections, Vincent Dubee, Clinical Infectious Diseases 2012, 55(11): 1481-7
Optimal duration and modalities of antibiotic therapy for early-onset spinal implant infection
(EOSII) remain controversial.
Between November 2004 and November 2007, we conducted a prospective, monocentric
study to assess the efficacy of a 3-month course of antibiotics for patients diagnosed with
EOSII, as defined by a proven deep infection of the surgical site occurring within 30 days
after spinal instrumented surgery. All patients with EOSII underwent surgical debridement
with implant retention. Combination antibiotic therapy was administered intravenously for 2
weeks. Treatment was switched orally for the following 10 weeks.
50 patients matched the inclusion criteria and were included in this study. The median age
was 68 (interquartile range [IQR]: 51-75) years; the median ASA score was 2 (IQR: 2-2).
Emergency spinal surgery had been performed in 18 patients. Staphylococcus aureus was the
most frequently isolated pathogen (n=27), followed by Enterobacteriaceae (n=22) and
coagulase-negative staphylococci (n=6). Seventeen patients had polymicrobial infections, and
13 patients (26%) had bacteremia. The median time from the first symptoms of infection to
debridement surgery was 3 days (IQR: 2-5 days). Three patients underwent 2 debridement
surgeries. The median follow-up was 43 (IQR: 34-54) months. The 2-year survival rate for
those who did not experience treatment failure was 88% (95% confidence interval [CI]:
75.7%-95.5%). Three patients experienced treatment failure (6%, 95% CI: 1.3%-16.5%),
including 1 relapse due to methicillin-susceptible S. aureus and 2 reinfections with another
pathogen.
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In this homogenous cohort of 50 patients with EOSII, treatment consisting of debridement
surgery with implant retention followed by combination antibiotic therapy for 3 months
appeared safe and effective.
Addition of Vitamin D Status to Prognostic Scores Improves the Prediction of Outcome
in Community-Acquired Pneumonia, Hilde H. F. Remmelts, Clinical Infectious Diseases
2012, 55(11): 1488-94
Vitamin D deficiency is associated with adverse outcome in CAP. Vitamin D status is an
independent predictor of 30-day mortality and adds prognostic value to other biomarkers and
prognostic scores, in particular the PSI score.
Rate of Transmission of Extended-Spectrum Beta – Lactamase-Producing
Enterobacteriaceae Without Contact Isolation, Sarah Tschudin, Clinical Infectious
Diseases 2012, 55(11): 1505-11
Extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae are emerging
worldwide. Contact isolation is recommended; however, little is known about the rate of
transmission without contact isolation in the non-epidemic setting. Therefore, we aimed to
estimate the rate of spread (R(0)) of ESBL-producing Enterobacteriaceae in a tertiary care
center with 5 intensive care units.
In this observational cohort study performed from June 1999 through April 2011, all patients
at the University Hospital Basel, Switzerland, who were hospitalized in the same room as a
patient colonized or infected with an ESBL-producing Enterobacteriaceae for at least 24 hours
(index case) were screened for ESBL carriage by testing of rectal swab samples, swab
samples from open wounds or drainages, and urine samples from patients with foley catheters.
Strains with phenotypic evidence for ESBL were confirmed by polymerase chain reaction.
Nosocomial transmission was assumed when the result of screening for ESBL carriage in a
contact patient was positive and molecular typing by pulsed-field gel electrophoresis (PFGE)
revealed clonal relatedness with the strain from the index patient.
Active screening for ESBL carriage could be performed in 133 consecutive contact patients.
Transmission confirmed by PFGE occurred in 2 (1.5%) of 133 contact patients, after a mean
exposure to the index case of 4.3 days.
The estimated rate of spread of ESBL-producing Enterobacteriaceae-in particular, Escherichia
coli-was low in a tertiary care university-affiliated hospital with high levels of standard
hygiene precautions. The low level of nosocomial transmission and the rapid emergence of
community-acquired ESBL challenge the routine use of contact isolation in a non-epidemic
setting, saving resources and potentially improving patient care.
Magic bullets for the 21st century: the reemergence of immunotherapy for multi-and
pan-resistant microbes, Damien Roux, J Antimicrob Chemother 2012, 67: 2785-2787
In our current world, antibiotic resistance among pathogenic microbes keeps getting worse
with few new antibiotics being pursued by pharmaceutical companies. Modern-day
immunotherapies, reminiscent of the serotherapy approaches used in the early days of
antimicrobial treatments, are a potential counter-measure, but are usually limited by the
narrow spectrum against target antigens. Surprisingly, many multidrug-resistant (MDR)
bacteria share a common surface polysaccharide, poly-ОІ-1,6-N-acetylglucosamine (PNAG).
Natural antibodies to PNAG are present in normal human sera, but are not protective.
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However, human monoclonal antibodies (MAbs) or polyclonal antisera raised to a
deacetylated glycoform of PNAG mediate opsonic killing and protect mice against infections
due to all PNAG-positive MDR pathogens tested. An MAb is currently in Phase II clinical
trials. These discoveries could lead to utilization of antibodies to PNAG for either therapeutic
use in patients infected by PNAG-producing MDR bacteria or prophylactic use in patients at
risk of developing MDR infections.
Lack of upward creep of glycopeptide MICs for methicillin-resistant Staphylococcus
aureus (MRSA) isolated in the UK and Ireland 2001-07, Reynolds R., J Antimicrob
Chemother 2012, 67: 2912-2918
There have been several reports of upward creep in vancomycin MICs for Staphylococcus
aureus [predominantly methicillin-resistant S. aureus (MRSA)] over recent years, but only in
single centres or using contemporaneous results. We aimed to test the hypothesis of MIC
creep in a multicentre study, testing all the isolates concurrently.
Nineteen laboratories in the UK and Ireland contributed isolates from blood to the BSAC
Bacteraemia Resistance Surveillance Programme every year between 2001 and 2007. MICs
for 271 MRSA from these sites were re-measured at a single central laboratory during a single
week by the BSAC agar dilution method, but with в€љ2-fold instead of conventional 2-fold
dilutions. Re-test results were compared with the original results obtained each year at the
same central laboratory.
The re-test results were much less variable than the original results and avoided the
confounding of experimental variation with year of collection. They demonstrated statistically
significant but very slow downward trends in MICs of vancomycin and teicoplanin, at 0.027
and 0.055 doubling dilutions/year, respectively. The original results had suggested more rapid
trends in MICs, upward for vancomycin and downward for teicoplanin. The proportion of
EMRSA-16 fell from 21% to 9% over the study period, while EMRSA-15 rose from 76% to
85%.
Historical data can give a misleading impression of trends in MIC values because of
experimental variation between tests conducted at different times. There was no upward creep
in glycopeptide MICs for MRSA in the UK and Ireland between 2001 and 2007.
Nevirapine use, prolonged antiretroviral therapy and high CD4 nadir values are
strongly correlated with undetectable HIV-DNA and RNA levels and CD4 cell gain,
Loredana Sarmati, J Antimicrob Chemother 2012, 67: 2932-2938
To evaluate the correlations of the combination of undetectable HIV-DNA (<10 copies/10(6)
peripheral blood mononuclear cells) and HIV-RNA (<1 copy/mL of plasma) levels and a CD4
cell count of >500 cells/mm(3) (defined as the treatment goal) in a group of 420 antiretroviral
treatment (ART) responder patients.
A cross-sectional, open-label, multicentre trial was conducted in a cohort of 420 HIV-infected
ART-treated subjects with viral loads persistently <50 copies/mL for a median observation
time of 28.8 months. HIV-DNA and residual viraemia values and demographic, virological
and immunological data were collected for each subject.
Undetectable HIV-DNA was found in 16.6% (70/420) of patients and was significantly
correlated with undetectable (<1 copy/mL) plasma viraemia (P = 0.0001). Higher CD4 cell
count nadir (P < 0.001), a lower HIV-RNA viraemia at the start of treatment (P = 0.0016) and
nevirapine use (P < 0.001) were correlated with an undetectable value of HIV-RNA. Twenty-
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six out of 420 patients (6.2%) reached the treatment goal. In multivariate analysis, higher
nadir CD4 cell count (OR 3.86, 95% CI 1.47-10.16, P = 0.006), the duration of therapy (OR
1.07, 95% CI 1.02-1.12, P = 0.004) and the use of nevirapine (OR 2.59, 95% CI 1.07-6.28,
P = 0.034) were independently related to this condition.
Only 6.2% of ART-responder patients presented the combination of three laboratory markers
that identified them as full responders. These results indicate the high variability of the ARTresponding population and lead us to suggest caution in the selection of patients for possible
simplification regimens.
Sales of veterinary antibacterial agents in nine European countries during 2005-09:
trends and patterns, Kari Grave, J Antimicrob Chemother 2012, 67: 3001-3008
To identify trends and patterns of sales of veterinary antimicrobial agents in nine European
countries during 2005-09 in order to document the situation.
Existing sales data, in tonnes of active ingredients, of veterinary antimicrobial agents by class
were collected from nine European countries in a standardized manner for the years 2005-09
(one country for 2006-09). A population correction unit (PCU) is introduced as a proxy for
the animal population potentially treated with antimicrobial agents. The sales data are
expressed as mg of active substance/PCU.
Data coverage was reported to be 98%-100% for the nine countries. Overall, sales of
veterinary antimicrobials agents, in mg/PCU, declined during the reporting period in the nine
countries. Substantial differences in the sales patterns and in the magnitude of sales of
veterinary antimicrobial agents, expressed as mg/PCU, between the nine countries are
observed. The major classes sold were penicillins, sulphonamides and tetracyclines. The sales
accounted for by the various veterinary antimicrobial agents have changed substantially for
most countries. An increase in the sales of third- and fourth-generation cephalosporins and
fluoroquinolones were observed for the majority of the countries.
Through re-analysis of existing data by application of a harmonized approach, an overall
picture of the trends in the sales of veterinary antimicrobial agents in the nine countries was
obtained. Notable differences in trends in sales between the countries were observed. Further
studies, preferably including data by animal species, are needed to understand the factors that
explain these observations.
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Global patient safety and antiretroviral drug-drug interactions in the resource-limited
setting, Kay Seden, J Antimicrob Chemother 2013, 68: 1-3
Scale-up of HIV treatment services may have contributed to an increase in functional health
facilities available in resource-limited settings and an increase in patient use of facilities and
retention in care. As more patients are reached with medicines, monitoring patient safety is
increasingly important. Limited data from resource-limited settings suggest that medication
error and antiretroviral drug-drug interactions may pose a significant risk to patient safety.
Commonly cited causes of medication error in the developed world include the speed and
complexity of the medication use cycle combined with inadequate systems and processes. In
resource-limited settings, specific factors may contribute, such as inadequate human resources
and high disease burden. Management of drug-drug interactions may be complicated by
limited access to alternative medicines or laboratory monitoring. Improving patient safety by
addressing the issue of antiretroviral drug-drug interactions has the potential not just to
improve healthcare for individuals, but also to strengthen health systems and improve vital
communication among healthcare providers and with regulatory agencies.
The emerging problem of linezolid-resistant Staphylococcus, Bing Gu, J Antimicrob
Chemother 2013, 68: 4-11
The oxazolidinone antibiotic linezolid has demonstrated potent antimicrobial activity against
Gram-positive bacterial pathogens, including methicillin-resistant staphylococci. This article
systematically reviews the published literature for reports of linezolid-resistant
Staphylococcus (LRS) infections to identify epidemiological, microbiological and clinical
features for these infections. Linezolid remains active against >98% of Staphylococcus, with
resistance identified in 0.05% of Staphylococcus aureus and 1.4% of coagulase-negative
Staphylococcus (CoNS). In all reported cases, patients were treated with linezolid prior to
isolation of LRS, with mean times of 20.0 В± 47.0 months for S. aureus and 11.0 В± 8.0 days for
CoNS. The most common mechanisms for linezolid resistance were mutation (G2576T) to the
23S rRNA (63.5% of LRSA and 60.2% of LRCoNS) or the presence of a transmissible cfr
ribosomal methyltransferase (54.5% of LRSA and 15.9% of LRCoNS). The emergence of
linezolid resistance in Staphylococcus poses significant challenges to the clinical treatment of
infections caused by these organisms, and in particular CoNS.
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Impact on hospital mortality of catheter removal and adequate antifungal therapy in
Candida spp. Bloodstream infections, JosГ© Garnacho-Montero, J Antimicrob Chemother
2013, 68: 206-213
We set out to identify the prognostic factors in adult patients with Candida spp. bloodstream
infection, assessing the impact on in-hospital mortality of catheter removal and adequacy of
antifungal therapy.
Patients with positive blood culture for Candida spp. and a central venous catheter in place at
the time of candidaemia were included. Data collected included demographics, underlying
diseases, severity of illness, clinical presentation, catheter withdrawal and adequacy of
empirical therapy.
We included 188 patients (mortality 36.7%). The mortality rate was 34.9% (23/66) in patients
with early adequate antifungal treatment and 18.9% (7/37) in patients with early adequate
antifungal therapy and catheter withdrawal in the first 48 h. The APACHE (Acute Physiology
and Chronic Health Evaluation) II score on the day of candidaemia [adjusted hazard ratio
(aHR) 1.12; 95% CI 1.06-1.17; P < 0.001] was associated with death whereas early adequate
therapy (aHR 0.4; 95% CI 0.23-0.83; P = 0.012) and catheter withdrawal (aHR 0.34; 95% CI
0.16-0.70; P = 0.03) were protective factors. In primary candidaemia, mortality was 28%
(14/50) in patients with adequate therapy and decreased to 17.7% (6/34) in patients with both
interventions in the first 48 h. Catheter removal was a protective factor and adequacy of
antifungal therapy in the first 48 h showed a strong tendency to protection against death (aHR
0.46; 95% CI 0.19-1.08; P = 0.07). In secondary non-catheter-related candidaemia, only early
adequate therapy was a protective factor for mortality.
Delay in catheter withdrawal and in administration of adequate antifungal therapy was
associated with increased mortality in candidaemic patients. Catheter management did not
influence the prognosis of secondary non-catheter-related candidaemia.
Reference:
1) Haidong Wang, Age-specific and sex-specific mortality in 187 countries, 1970-2010:
a systematic analysis for the Global Burden of Disease Study 2010, Lancet 2012, 380:
2071-94
2) Rafael Lozano, Global and regional mortality from 235 causes of death for 20 age
groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease
Study 2010, Lancet 2012, 380: 2095-128
3) Joshua A. Salomon, Common values in assessing health outcomes from disease and
injury: disability weights measurement study for the Global Burden of Disease Study
2010, Lancet 2012, 380: 2129-43
4) Haluskova, E., Miedz. Stud. Human, 2009, 2, 229 - 235
5) Kiwou, M., Haluskova, E. Korcek, V., Mutalova, M.: Clin Soc Work. 4,2012, 127
6) Haluskova, E., Miedz. Stud. Human, 2009, 1, 229 - 236
7) Haluskova, E., Miedz. Stud. Human 2010, 2, 217 - 224
8) Sirotiakova J., Minarik P., Kopernicka Z., Magulova L., Piesecka L., Zak V.,
133
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Liskova A.: Linezolid in the treatment of complicated gram positive infections by
critically ill patients, Clinical & Experimental Pharmacology and physiology, 2004,
31, Suppl. A114
9) Sirotiakova J., Minarik P., Hoppman M.: Screening of risk factors in the population of
40 years' men and women in Nitra region, importance of primary prevention.
Coronary Artery Disease, 2007, 1(7), s. 137
10) Dukat A., Lietava J., Krahulec B., Caprnda M., Vacula I., Kosmalova V., Minarik P.:
The prevalence of abdominal obesity in Slovakia. The IDEA Slovakia study, Vnitr.
Lek. 2007, 53(4), s. 326-30
11) Hoppman M., Minarik P., Sirotiakova J.: New possibilities in the treatment of
hypertension in pregnancy – looking for the effective and safe drug of future. Interna
medicina, 7 (1), 2007, s. 58
12) Minarik P., Hoppman M., Sirotiakova J.: Screening of risk factors in the population of
40 years men and women in Nitra region, regarding to the importance of primary
prevention, Interna mediciny, 7 (1), 2007, s. 58
13) Kay Seden, Global patient safety and antiretroviral drug-drug interactions in the
resource-limited setting, J Antimicrob Chemother 2013, 68: 1-3
14) Bing Gu, The emerging problem of linezolid-resistant Staphylococcus, J Antimicrob
Chemother 2013, 68: 4-11
15) JosГ© Garnacho-Montero, Impact on hospital mortality of catheter removal and
adequate antifungal therapy in Candida spp. Bloodstream infections, J Antimicrob
Chemother 2013, 68: 206-213
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SOCIAL WORK IN TROPICAL AREAS OF SUBSAHARAN AFRICA AND
SOUTHEAST ASIA
Kmit I., M. Cierna, J. Facuna, A. Gabrielova, A. Galbava, S. Gilanova, V. Graus,
M. Gymerska, D. Horvathova, A. Hraskova, M. Hrasnova, A. Imrichova, A. Jancekova,
S. Judinyova, P. Kadlecik, J. Kollarcikova
Graduate School St. Elisabeth University PhD. programe Bratislava, Slovakia
and MPC Nairobi, Kenya
Abstract:
Review of Social work issues in Subsaharan Africa, critically selected by SEU PhD team
(1-12) is presented and analyzed.
The Association of Beliefs About Heredity with Preventive and Interpersonal Behaviors
in Communities Affected by Podoconiosis in Rural Ethiopia, Desta Ayode, Am. J. Trop.
Med. Hyg., 87(4), 2012, pp. 623-630
Little is known about how beliefs about heredity as a cause of health conditions might
influence preventive and interpersonal behaviors among those individuals with low genetic
and health literacy. We explored causal beliefs about podoconiosis, a neglected tropical
disease (NTD) endemic in Ethiopia. Podoconiosis clusters in families but can be prevented if
individuals at genetically high risk wear shoes consistently. Adults (N = 242) from four rural
Ethiopian communities participated in qualitative assessments of beliefs about the causes of
podoconiosis. Heredity was commonly mentioned, with heredity being perceived as (1) the
sole cause of podoconiosis, (2) not a causal factor, or (3) one of multiple causes. These beliefs
influenced the perceived controllability of podoconiosis and in turn, whether individuals
endorsed preventive and interpersonal stigmatizing behaviors. Culturally informed education
programs that increase the perceived controllability of stigmatized hereditary health
conditions like podoconiosis have promise for increasing preventive behaviors and reducing
interpersonal stigma.
Cystic echinococcosis in sub-Saharan Africa, Kerstin Wahlers, Lancet Infect Dis 2012, 12:
871-80
Cystic echinococcosis is regarded as endemic in sub-Saharan Africa; however, for most
countries only scarce data, if any, exist. For most of the continent, information about burden
of disease is not available; neither are data for the animal hosts involved in the lifecycle of the
parasite, thus making introduction of preventive measures difficult. Available evidence
suggests that several species or strains within the Echinococcus granulosus complex are
prevalent in sub-Saharan Africa and that these strains might be associated with varying
virulence and host preference. Treatment strategies (chemotherapy, percutaneous radiological
techniques, but mainly surgery) predominantly target active disease. Prevention strategies
encompass anthelmintic treatment of dogs, slaughter hygiene, surveillance, and healtheducational measures. Existing data are suggestive of unusual clinical presentations of cystic
echinococcosis in some parts of the continent, for which the causes are speculative.
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WHO European review of social determinants of health and the health divide, Michael
Marmot, Lancet 2012, 380: 1011-29
The European region has seen remarkable heath gains in those populations that have
experienced progressive improvements in the conditions in which people are born, grow, live,
and work. However, inequities, both between and within countries, persist. The review
reported here, of inequities in health between and within countries across the 53 Member
States of the WHO European region, was commissioned to support the development of the
new health policy framework for Europe: Health 2020. Much more is understood now about
the extent, and social causes, of these inequities, particularly since the publication in 2008 of
the report of the Commission on Social Determinants of Health. The European review builds
on the global evidence and recommends policies to ensure that progress can be made in
reducing health inequities and the health divide across all countries, including those with low
incomes. Action is needed—on the social determinants of health, across the life course, and in
wider social and economic spheres—to achieve greater health equity and protect future
generations.
Global burden of cancer in 2008: a systematic analysis of disability-adjusted life-years in
12 world regions, Isabelle Soerjomataram, Lancet 2012, 380: 1840-50
Country comparisons that consider the effect of fatal and non-fatal disease outcomes are
needed for health-care planning. We calculated disability-adjusted life-years (DALYs) to
estimate the global burden of cancer in 2008.
We used population-based data, mostly from cancer registries, for incidence, mortality, life
expectancy, disease duration, and age at onset and death, alongside proportions of patients
who were treated and living with sequelae or regarded as cured, to calculate years of life lost
(YLLs) and years lived with disability (YLDs). We used YLLs and YLDs to derive DALYs
for 27 sites of cancers in 184 countries in 12 world regions. Estimates were grouped into four
categories based on a country's human development index (HDI). We applied zero
discounting and uniform age weighting, and age-standardised rates to enable cross-country
and regional comparisons.
Worldwide, an estimated 169В·3 million years of healthy life were lost because of cancer in
2008. Colorectal, lung, breast, and prostate cancers were the main contributors to total
DALYs in most world regions and caused 18—50% of the total cancer burden. We estimated
an additional burden of 25% from infection-related cancers (liver, stomach, and cervical) in
sub-Saharan Africa, and 27% in eastern Asia. We noted substantial global differences in the
cancer profile of DALYs by country and region; however, YLLs were the most important
component of DALYs in all countries and for all cancers, and contributed to more than 90%
of the total burden. Nonetheless, low-resource settings had consistently higher YLLs (as a
proportion of total DALYs) than did high-resource settings.
Age-adjusted DALYs lost from cancer are substantial, irrespective of world region. The
consistently larger proportions of YLLs in low HDI than in high HDI countries indicate
substantial inequalities in prognosis after diagnosis, related to degree of human development.
Therefore, radical improvement in cancer care is needed in low-resource countries.
Dutch Scientific Society, Erasmus University Rotterdam, and International Agency for
research on Cancer.
Patients' Expectations about Effects of Chemotherapy for Advanced Cancer, Jane C.
Weeks, N. Engl. J. Med. 367, 17, October 25, 2012
Chemotherapy for metastatic lung or colorectal cancer can prolong life by weeks or months
and may provide palliation, but it is not curative.
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We studied 1193 patients participating in the Cancer Care Outcomes Research and
Surveillance (CanCORS) study (a national, prospective, observational cohort study) who were
alive 4 months after diagnosis and received chemotherapy for newly diagnosed metastatic
(stage IV) lung or colorectal cancer. We sought to characterize the prevalence of the
expectation that chemotherapy might be curative and to identify the clinical,
sociodemographic, and health-system factors associated with this expectation. Data were
obtained from a patient survey by professional interviewers in addition to a comprehensive
review of medical records.
Overall, 69% of patients with lung cancer and 81% of those with colorectal cancer did not
report understanding that chemotherapy was not at all likely to cure their cancer. In
multivariable logistic regression, the risk of reporting inaccurate beliefs about chemotherapy
was higher among patients with colorectal cancer, as compared with those with lung cancer
(odds ratio, 1.75; 95% confidence interval [CI], 1.29 to 2.37); among nonwhite and Hispanic
patients, as compared with non-Hispanic white patients (odds ratio for Hispanic patients, 2.82;
95% CI, 1.51 to 5.27; odds ratio for black patients, 2.93; 95% CI, 1.80 to 4.78); and among
patients who rated their communication with their physician very favorably, as compared with
less favorably (odds ratio for highest third vs. lowest third, 1.90; 95% CI, 1.33 to 2.72).
Educational level, functional status, and the patient's role in decision making were not
associated with such inaccurate beliefs about chemotherapy.
Many patients receiving chemotherapy for incurable cancers may not understand that
chemotherapy is unlikely to be curative, which could compromise their ability to make
informed treatment decisions that are consonant with their preferences. Physicians may be
able to improve patients' understanding, but this may come at the cost of patients' satisfaction
with them.
Effect of Three Decades of Screening Mammography on Breast-Cancer Incidence,
Archie Bleyer, N. Engl. J. Med. 367, 21, November 22, 2012
To reduce mortality, screening must detect life-threatening disease at an earlier, more curable
stage. Effective cancer-screening programs therefore both increase the incidence of cancer
detected at an early stage and decrease the incidence of cancer presenting at a late stage.
We used Surveillance, Epidemiology, and End Results data to examine trends from 1976
through 2008 in the incidence of early-stage breast cancer (ductal carcinoma in situ and
localized disease) and late-stage breast cancer (regional and distant disease) among women 40
years of age or older.
The introduction of screening mammography in the United States has been associated with a
doubling in the number of cases of early-stage breast cancer that are detected each year, from
112 to 234 cases per 100,000 women--an absolute increase of 122 cases per 100,000 women.
Concomitantly, the rate at which women present with late-stage cancer has decreased by 8%,
from 102 to 94 cases per 100,000 women--an absolute decrease of 8 cases per 100,000
women. With the assumption of a constant underlying disease burden, only 8 of the 122
additional early-stage cancers diagnosed were expected to progress to advanced disease. After
excluding the transient excess incidence associated with hormone-replacement therapy and
adjusting for trends in the incidence of breast cancer among women younger than 40 years of
age, we estimated that breast cancer was overdiagnosed (i.e., tumors were detected on
screening that would never have led to clinical symptoms) in 1.3 million U.S. women in the
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past 30 years. We estimated that in 2008, breast cancer was overdiagnosed in more than
70,000 women; this accounted for 31% of all breast cancers diagnosed.
Despite substantial increases in the number of cases of early-stage breast cancer detected,
screening mammography has only marginally reduced the rate at which women present with
advanced cancer. Although it is not certain which women have been affected, the imbalance
suggests that there is substantial overdiagnosis, accounting for nearly a third of all newly
diagnosed breast cancers, and that screening is having, at best, only a small effect on the rate
of death from breast cancer.
Outcomes of the Surviving Sepsis Campaign in intensive care units in the USA and
Europe: a prospective cohort study, Mitchell M. Levy, Lancet Infect Dis 2012, 12: 919-24
Mortality from severe sepsis and septic shock differs across continents, countries, and regions.
We aimed to use data from the Surviving Sepsis Campaign (SSC) to compare models of care
and outcomes for patients with severe sepsis and septic shock in the USA and Europe.
The SSC was introduced into more than 200 sites in Europe and the USA. All patients
identified with severe sepsis and septic shock in emergency departments or hospital wards and
admitted to intensive care units (ICUs), and those with sepsis in ICUs were entered into the
SSC database. Patients entered into the database from its launch in January, 2005, through
January, 2010, in units with at least 20 patients and 3 months of enrolment of patients were
included in this analysis. Patients included in the cohort were limited to those entered in the
first 4 years at every site. We used random-effects logistic regression to estimate the hospital
mortality odds ratio (OR) for Europe relative to the USA. We used random-effects linear
regression to find the relation between lengths of stay in hospital and ICU and geographic
region.
25 375 patients were included in the cohort. The USA included 107 sites with 18 766 (74%)
patients, and Europe included 79 hospital sites with 6609 (26%) patients. In the USA, 12 218
(65В·1%) were admitted to the ICU from the emergency department whereas in Europe, 3405
(51В·5%) were admitted from the wards. The median stay on the hospital wards before ICU
admission was longer in Europe than in the USA (1В·0 vs 0В·1 days, difference 0В·9, 95% CI
0·8—0·9). Raw hospital mortality was higher in Europe than in the USA (41·1% vs 28·3%,
difference 12·8, 95% CI 11·5—14·7). The median length of stay in ICU (7·8 vs 4·2 days, 3·6,
3·3—3·7) and hospital (22·8 vs 10·5 days, 12·3, 11·9—12·8) was longer in Europe than in
the USA. Adjusted mortality in Europe was not significantly higher than that in the USA
(32В·3% vs 31В·3%, 1В·0, в€’1В·7 to 3В·7, p=0В·468). Complete compliance with all applicable
elements of the sepsis resuscitation bundle was higher in the USA than in Europe (21В·6% vs
18·4%, 3·2, 2·2—4·4).
The significant difference in unadjusted mortality and the fact that this difference disappears
with severity adjustment raise important questions about the effect of the approach to critical
care in Europe compared with that in the USA. The effect of ICU bed availability on
outcomes in patients with severe sepsis and septic shock requires further investigation.
Eli Lilly Co, Baxter Lifesciences, Philips Medical Systems, the Society of Critical Care
Medicine, and the European Society of Intensive Care Medicine.
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Prevalence of tuberculosis, hepatitis C virus, and HIV in homeless people: a systematic
review and meta-analysis, Ulla Beijer, Lancet Infect Dis 2012, 12: 859-70
100 million people worldwide are homeless; rates of mortality and morbidity are high in this
population. The contribution of infectious diseases to these adverse outcomes is uncertain.
Accurate estimates of prevalence data are important for public policy and planning and
development of clinical services tailored to homeless people. We aimed to establish the
prevalence of tuberculosis, hepatitis C virus, and HIV in homeless people.
We searched PubMed, Embase, and Cumulative Index to Nursing and Allied Health
Literature for studies of the prevalence of tuberculosis, hepatitis C virus, and HIV in homeless
populations. We also searched bibliographic indices, scanned reference lists, and
corresponded with authors. We explored potential sources of heterogeneity in the estimates by
metaregression analysis and calculated prevalence ratios to compare prevalence estimates for
homeless people with those for the general population.
We identified 43 eligible surveys with a total population of 63 812 (59 736 homeless
individuals when duplication due to overlapping samples was accounted for). Prevalences
ranged from 0В·2% to 7В·7% for tuberculosis, 3В·9% to 36В·2% for hepatitis C virus infection,
and 0В·3% to 21В·1% for HIV infection. We noted substantial heterogeneity in prevalence
estimates for tuberculosis, hepatitis C virus infection, and HIV infection (all Cochran's П‡2
significant at p<0·0001; I2=83%, 95% CI 76—89; 95%, 94—96; and 94%, 93—95;
respectively). Prevalence ratios ranged from 34 to 452 for tuberculosis, 4 to 70 for hepatitis C
virus infection, and 1 to 77 for HIV infection. Tuberculosis prevalence was higher in studies
in which diagnosis was by chest radiography than in those which used other diagnostic
methods and in countries with a higher general population prevalence than in those with a
lower general prevalence. Prevalence of HIV infection was lower in newer studies than in
older ones and was higher in the USA than in the rest of the world.
Heterogeneity in prevalence estimates for tuberculosis, hepatitis C virus, and HIV suggests
the need for local surveys to inform development of health services for homeless people. The
role of targeted and population-based measures in the reduction of risks of infectious diseases,
premature mortality, and other adverse outcomes needs further examination. Guidelines for
screening and treatment of infectious diseases in homeless people might need to be reviewed.
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Assessment of Streptococcus pneuminiae pilus islet-I prevalence in carried and
transmitted isolates from mother-infant pairs on the Thailand-Burma border, Turner P.,
Clin Microbiol Infect 2012, 18: 970-975
Streptococcus pneumoniae pilus islet-1 (PI-1)-encoded pilus enhances in vitro adhesion to the
respiratory epithelium and may contribute to pneumococcal nasopharyngeal colonization and
transmission. The pilus subunits are regarded as potential protein vaccine candidates. In this
study, we sought to determine PI-1 prevalence in carried pneumococcal isolates and explore
its relationship with transmissibility or carriage duration. We studied 896 pneumococcal
isolates collected during a longitudinal carriage study that included monthly nasopharyngeal
swabbing of 234 infants and their mothers between the ages of 1 and 24 months. These were
cultured according to the WHO pneumococcal carriage detection protocol. PI-1 PCR and
genotyping by multilocus sequence typing were performed on isolates chosen according to
specific carriage and transmission definitions. Overall, 35.2% of the isolates were PI-1positive, but PI-1 presence was restricted to ten of the 34 serotypes studied and was most
frequently associated with serotypes 19F and 23F; 47.5% of transmitted and 43.3% of nontransmitted isolates were PI-1-positive (OR 1.2; 95% CI 0.8-1.7; p 0.4). The duration of firstever infant pneumococcal carriage was significantly longer with PI-1-positive organisms, but
this difference was not significant at the individual serotype level. In conclusion, PI-1 is
commonly found in pneumococcal carriage isolates, but does not appear to be associated with
pneumococcal transmissibility or carriage duration.
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A seroepidemiological study of pandemic A/H1N1 (2009) influenza in a rural population
of Mali, Koita O. A., Clin Microbiol Infect 2012, 18: 976-981
The swine-origin H1N1 influenza A virus (pH1N1(2009)) started to circulate worldwide in
2009, and cases were notified in a number of sub-Saharan African countries. However, no
epidemiological data allowing estimation of the epidemic burden were available in this
region, preventing comprehensive comparisons with other parts of the world. The CoPanFluMali programme studied a cohort of 202 individuals living in the rural commune of Dioro
(southern central Mali). Pre-pandemic and post-pandemic paired sera (sampled in 2006 and
April 2010, respectively) were tested by the haemagglutination inhibition (HI) method.
Different estimates of pH1N1(2009) infection during the 2009 first epidemic wave were used
(increased prevalence of HI titre of ≥1/40 or ≥1/80, seroconversions) and provided convergent
attack rate values (12.4-14.9%), the highest values being observed in the 0-19-year age group
(16.0-18.4%). In all age groups, pre-pandemic HI titres of ≥1/40 were associated with
complete absence of seroconversion; and geometric mean titres were <15 in individuals who
seroconverted and >20 in others. Important variations in seroconversion rate existed among
the different villages investigated. Despite limitations resulting from the size and composition
of the sample analysed, this study provides strong evidence that the impact of the
pH1N1(2009) first wave was more important than previously believed, and that the
determinants of the epidemic spread in sub-Saharan populations were quite different from
those observed in developed countries.
New category of probable invasive pulmonary aspergillosis in haematological patients,
Girmenia C., Clin Microbiol Infect 2012, 18: 990-996
The European Organization for Research and Treatment of Cancer and the Mycosis Study
Group (EORTC-MSG) radiological definitions of invasive pulmonary aspergillosis (IPA) may
lack diagnostic sensitivity. We evaluated applying less restrictive radiological criteria, when
supported by specific microbiological findings, to define IPA in acute myeloid leukaemia
(AML), lymphoproliferative diseases (LD) and allogeneic stem cell transplant (allo-SCT)
patients. Overall, 109 consecutive episodes of proven/probable IPA in 56 AML, 31 LD and 22
allo-SCT patients diagnosed from February 2006 through to January 2011 were considered.
IPA was diagnosed with EORTC-MSG criteria (control group, 76 patients) or without
prespecified radiological criteria (study group, 33 patients). The latter differed from the
former by the inclusion of patients with pulmonary infiltrates not fulfilling the three EORTCMSG IPA specific findings of dense, well-circumscribed lesions with or without halo sign, air
crescent sign or cavity. All the analysed clinical and mycological characteristics, 3-month
response to antifungal therapy and 1- and 3-month cumulative survival were comparable in
the control and study groups in AML, LD and allo-SCT patients. Seventeen of 33 (51.5%)
patients of the study group fulfilled EORTC-MSG radiological criteria at subsequent imaging
performed a median of 15 days (range, 6-40 days) after documentation of the pulmonary
infection. Our study seems to confirm the possibility of revising the EORTC-MSG criteria by
extending the radiological suspicion of IPA to less specific chest computerized tomography
scan findings when supported by microbiological evidence of Aspergillus infection in highrisk haematological patients.
Serogroup A meningococcal conjugate vaccination in Burkina Faso: analysis of national
surveillance data, Ryan Novak T., Lancet Infect Dis 2012, 12: 757-64
An affordable, highly immunogenic Neisseria meningitidis serogroup A meningococcal
conjugate vaccine (PsA-TT) was licensed for use in sub-Saharan Africa in 2009. In 2010,
Burkina Faso became the first country to implement a national prevention campaign,
vaccinating 11В·4 million people aged 1-29 years. We analysed national surveillance data
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around PsA-TT introduction to investigate the early effect of the vaccine on meningitis
incidence and epidemics.
We examined national population-based meningitis surveillance data from Burkina Faso
using two sources, one with cases and deaths aggregated at the district level from 1997 to
2011, and the other enhanced with results of cerebrospinal fluid examination and laboratory
testing from 2007 to 2011. We compared mortality rates and incidence of suspected
meningitis, probable meningococcal meningitis by age, and serogroup-specific
meningococcal disease before and during the first year after PsA-TT implementation. We
assessed the risk of meningitis disease and death between years.
During the 14 year period before PsA-TT introduction, Burkina Faso had 148 603 cases of
suspected meningitis with 17 965 deaths, and 174 district-level epidemics. After vaccine
introduction, there was a 71% decline in risk of meningitis (hazard ratio 0В·29, 95% CI 0В·280В·30, p<0В·0001) and a 64% decline in risk of fatal meningitis (0В·36, 0В·33-0В·40, p<0В·0001).
We identified a statistically significant decline in risk of probable meningococcal meningitis
across the age group targeted for vaccination (62%, cumulative incidence ratio [CIR] 0В·38,
95% CI 0В·31-0В·45, p<0В·0001), and among children aged less than 1 year (54%, 0В·46, 0В·240В·86, p=0В·02) and people aged 30 years and older (55%, 0В·45, 0В·22-0В·91, p=0В·003) who were
ineligible for vaccination. No cases of serogroup A meningococcal meningitis occurred
among vaccinated individuals, and epidemics were eliminated. The incidence of laboratoryconfirmed serogroup A N meningitidis dropped significantly to 0В·01 per 100 000 individuals
per year, representing a 99В·8% reduction in the risk of meningococcal A meningitis (CIR
0В·002, 95% CI 0В·0004-0В·02, p<0В·0001).
Early evidence suggests the conjugate vaccine has substantially reduced the rate of meningitis
in people in the target age group, and in the general population because of high coverage and
herd immunity. These data suggest that fully implementing the PsA-TT vaccine could end
epidemic meningitis of serogroup A in sub-Saharan Africa.
Aggressive versus conservative initiation of antimicrobial treatment in critically ill
surgical patients with suspected intensive-care-unit-acquired infection: a quasiexperimental, before and after observational cohort study, Tjasa Hranjec, Lancet Infect
Dis 2012, 12: 774-80
Antimicrobial treatment in critically ill patients can either be started as soon as infection is
suspected or after objective data confirm an infection. We postulated that delaying
antimicrobial treatment of patients with suspected infections in the surgical intensive care unit
(SICU) until objective evidence of infection had been obtained would not worsen patient
mortality.
We did a 2-year, quasi-experimental, before and after observational cohort study of patients
aged 18 years or older who were admitted to the SICU of the University of Virginia
(Charlottesville, VA, USA). From Sept 1, 2008, to Aug 31, 2009, aggressive treatment was
used: patients suspected of having an infection on the basis of clinical grounds had blood
cultures sent and antimicrobial treatment started. From Sept 1, 2009, to Aug 31, 2010, a
conservative strategy was used, with antimicrobial treatment started only after objective
findings confirmed an infection. Our primary outcome was in-hospital mortality. Analyses
were by intention to treat.
Admissions to the SICU for the first and second years were 762 and 721, respectively, with
101 patients with SICU-acquired infections during the aggressive year and 100 patients
during the conservative year. Compared with the aggressive approach, the conservative
approach was associated with lower all-cause mortality (13/100 [13%] vs 27/101 [27%];
p=0В·015), more initially appropriate therapy (158/214 [74%] vs 144/231 [62%]; p=0В·0095),
and a shorter mean duration of therapy (12В·5 days [SD 10В·7] vs 17В·7 [28В·1]; p=0В·0080). After
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adjusting for age, sex, trauma involvement, acute physiology and chronic health evaluation
(APACHE) II score, and site of infection, the odds ratio for the risk of mortality in the
aggressive therapy group compared with the conservative therapy group was 2В·5 (95% CI
1·5—4·0).
Waiting for objective data to diagnose infection before treatment with antimicrobial drugs for
suspected SICU-acquired infections does not worsen mortality and might be associated with
better outcomes and use of antimicrobial drugs.
Intestinal colonisation and blood stream infections due to vancomycin-resistant
enterococci (VRE) and extended – spectrum beta-lactamase-producing
Enterobacteriaceae (ESBLE) in patients with haematological and oncological
malignancies, Liss B. J., Infection 2012, 40: 613-619
In patients with haematological or oncological malignancies, we aimed to assess the rate of
intestinal colonisation and blood stream infections (BSI) with extended-spectrum betalactamase-producing Enterobacteriaceae (ESBLE) and vancomycin-resistant enterococci
(VRE), mortality and risk factors associated with ESBLE/VRE BSI, as well as the impact of
faecal screening for ESBLE and VRE in combination with adapted empiric treatment of
febrile neutropenia.
Within 72 h of admission to our department, an ESBLE and VRE screening stool sample was
collected. In the case of neutropenic fever, blood cultures were drawn. Data of all admitted
patients were prospectively documented. Explorative forward-stepwise logistic regression
analyses were used to identify risk factors for progression from intestinal colonisation to BSI.
During the study period, 1,805 stool samples were obtained from 513 patients during 1,012
inpatient stays, and 2,766 blood cultures were obtained from 578 patients during 1,091
inpatient stays. Ninety (17.5 %) of these patients were colonised with ESBLE and 51 (9.9 %)
with VRE. Proportions of 40 % (36/90) of ESBLE and 61 % (31/51) of VRE colonisations
were healthcare-associated. Six of 90 (6.6 %) ESBLE-colonised patients and 1/51 (2 %) VREcolonised patients developed BSI with the respective organism. None of these patients died
after receiving early appropriate empiric antibiotics based on colonisation status. Colonisation
with ESBLE or VRE was associated with increased risk ratios (RR) towards developing
ESBLE BSI [RR 4.5, 95 % confidence interval (CI): 2.89-7.04] and VRE BSI (RR 10.2, 95 %
CI: 7.87-13.32), respectively. Acute myelogenous leukaemia and prior treatment with
platinum analogues or quinolones were identified as independent risk factors for ESBLE BSI
in colonised patients.
Intestinal ESBLE/VRE colonisation predicts BSI. Faecal screening in haematology/oncology
patients in combination with directed empiric treatment may reduce ESBLE BSI-related
mortality.
Lack of benefit of preoperative antimicrobial prophylaxis in children with acute
appendicitis: a prospective cohort study, Bansal V., Infection 2012, 40: 635-641
Histology confirmed acute appendicitis in 92 patients of group A and 95 patients of group B.
In patients with histological simple appendicitis, postoperative infectious complications were
noted in 2 (3.0 %) of 69 patients from group A and in none of 70 patients from group B, and
in patients with histological perforated appendicitis in 5 (22 %) of 23 and 4 (16 %) of 25
patients from groups A and B, respectively. Postoperative infectious complications were more
frequent (p < 0.05) in perforated than in simple appendicitis. These infectious complications
included in simple appendicitis two wound infections in group A, and in perforated
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appendicitis four intraabdominal abscesses and one wound infection in group A and two
intraabdominal abscesses and two wound infections in group B.
Postoperative infectious complications were seen more often in patients with perforated
appendicitis than in those with simple appendicitis. Preoperative antimicrobial prophylaxis
with metronidazole did not reduce the rates of postoperative infectious complications
Pet animals and foreign travel are risk factors for colonisation with extended-spectrum
Гџ-lactamase-producing Escherichia coli, Meyer E., Infection 2012, 40: 685-687
This is the first report showing that contact with pets increases by almost seven-fold the
chance to be colonised with ESBL Escherichia coli. A colonisation rate of 3.5 % with ESBLproducing enterobacteriaceae among infection control personnel is of concern and reflects
probably less an occupational health risk but the reservoir of and the expansion into the
community, especially in persons with pet animals and travel history to high-endemicity
countries.
Prevalence of infections in long-term care facilities: how to read it? Marchi M., Infection
2012, 40: 493-500
Prevalence surveys are mostly used in European countries for infection surveillance in longterm care facilities (LTCFs). The purpose of this paper is to document the prevalence of
infections in LTCFs and to identify and discuss the potential sources of variation in the
overall prevalence of infections.
Six repeated prevalence surveys were carried out over a period of 3 years in 11 LTCFs in the
Emilia-Romagna region, involving a mean of 812 residents in each survey. In one facility,
continuous surveillance was also conducted. McGeer's infection criteria were used. Observers
undertook a 1-day training course and on-field training.
The average prevalence of infected residents was 11.5/100 residents: respiratory tract
infections were the most common (5.7/100 residents), followed by urinary tract infections
(2.6%), skin infections (1.9%), and ocular infections (1.4%). In a multivariate model, the
prevalence significantly varied by season (p < 0.001) and residents' case-mix index (CMI, p <
0.001). In individual homes, the case mix varied from 0.91 to 1.1 and the observed prevalence
varied from 6.6 to 40.4%. One facility set up and maintained continuous surveillance: three
clusters of lower respiratory tract infection were identified in 1.5 years by a temporal scan
test. Cases belonging to one outbreak only were captured by the prevalence surveys
conducted in the same periods.
Impact of a multidimensional infection control strategy on catheter-associated urinary
tract infection rates in the adult intensive care units of 15 developing countries: findings
of the International Nosocomial Infection Control Consortium (INICC), Rosenthal V. D.,
Infection 2012, 40: 517-526
We aimed to evaluate the impact of a multidimensional infection control strategy for the
reduction of the incidence of catheter-associated urinary tract infection (CAUTI) in patients
hospitalized in adult intensive care units (AICUs) of hospitals which are members of the
International Nosocomial Infection Control Consortium (INICC), from 40 cities of 15
developing countries: Argentina, Brazil, China, Colombia, Costa Rica, Cuba, India, Lebanon,
Macedonia, Mexico, Morocco, Panama, Peru, Philippines, and Turkey.
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We conducted a prospective before-after surveillance study of CAUTI rates on 56,429
patients hospitalized in 57 AICUs, during 360,667 bed-days. The study was divided into the
baseline period (Phase 1) and the intervention period (Phase 2). In Phase 1, active surveillance
was performed. In Phase 2, we implemented a multidimensional infection control approach
that included: (1) a bundle of preventive measures, (2) education, (3) outcome surveillance,
(4) process surveillance, (5) feedback of CAUTI rates, and (6) feedback of performance. The
rates of CAUTI obtained in Phase 1 were compared with the rates obtained in Phase 2, after
interventions were implemented.
We recorded 253,122 urinary catheter (UC)-days: 30,390 in Phase 1 and 222,732 in Phase 2.
In Phase 1, before the intervention, the CAUTI rate was 7.86 per 1,000 UC-days, and in Phase
2, after intervention, the rate of CAUTI decreased to 4.95 per 1,000 UC-days [relative risk
(RR) 0.63 (95% confidence interval [CI] 0.55-0.72)], showing a 37% rate reduction.
Our study showed that the implementation of a multidimensional infection control strategy is
associated with a significant reduction in the CAUTI rate in AICUs from developing
countries.
Epidemiology, characteristics, and outcome of infective endocarditis in Italy: the Italian
study on Endocarditis, Leone S., Infection 2012, 40: 527-535
A number of clinical variables were collected through an electronic case report form and
analyzed to comprehensively delineate the features of IE. We report the data on patients with
definite IE.
A total of 1,082 patients with definite IE were included. Of these, 753 (69.6%) patients had
infection on a native valve, 277 (25.6%) on a prosthetic valve, and 52 (4.8%) on an
implantable electronic device. Overall, community-acquired (69.2%) was more common than
nosocomial (6.2%) or non-nosocomial (24.6%) health care-associated IE. Staphylococcus
aureus was the most common pathogen (22.0%). In-hospital mortality was 15.1%. From the
multivariate analysis, congestive heart failure (CHF), stroke, prosthetic valve infection, S.
aureus, and health care-associated acquisition were independently associated with increased
in-hospital mortality, while surgery was associated with decreased mortality.
Dilemmas in the diagnosis of acute community-acquired bacterial meningitis, Matthijs C.
Brouwer, Lancet 2012, 380: 1684-92
Rapid diagnosis and treatment of acute community-acquired bacterial meningitis reduces
mortality and neurological sequelae, but can be delayed by atypical presentation, assessment
of lumbar puncture safety, and poor sensitivity of standard diagnostic microbiology. Thus,
diagnostic dilemmas are common in patients with suspected acute community-acquired
bacterial meningitis. History and physical examination alone are sometimes not sufficient to
confirm or exclude the diagnosis. Lumbar puncture is an essential investigation, but can be
delayed by brain imaging. Results of cerebrospinal fluid (CSF) examination should be
interpreted carefully, because CSF abnormalities vary according to the cause, patient's age
and immune status, and previous treatment. Diagnostic prediction models that use a
combination of clinical findings, with or without test results, can help to distinguish acute
bacterial meningitis from other causes, but these models are not infallible. We review the
dilemmas in the diagnosis of acute community-acquired bacterial meningitis, and focus on the
roles of clinical assessment and CSF examination.
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Advances in treatment of bacterial meningitis, Diederik Van de Beek, Lancet 2012, 380:
1693-702
Bacterial meningitis kills or maims about a fifth of people with the disease. Early antibiotic
treatment improves outcomes, but the effectiveness of widely available antibiotics is
threatened by global emergence of multidrug-resistant bacteria. New antibiotics, such as
fluoroquinolones, could have a role in these circumstances, but clinical data to support this
notion are scarce. Additionally, whether or not adjunctive anti-inflammatory therapies (eg,
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dexamethasone) improve outcomes in patients with bacterial meningitis remains
controversial; in resource-poor regions, where the disease burden is highest, dexamethasone is
ineffective. Other adjunctive therapeutic strategies, such as glycerol, paracetamol, and
induction of hypothermia, are being tested further. Therefore, bacterial meningitis is a
substantial and evolving therapeutic challenge. We review this challenge, with a focus on
strategies to optimise antibiotic efficacy in view of increasingly drug-resistant bacteria, and
discuss the role of current and future adjunctive therapies.
Effect of vaccines on bacterial meningitis worldwide, Peter B. McIntyre, Lancet 2012, 380:
1703-11
Three bacteria—Haemophilus influenzae, Streptococcus pneumoniae, and Neisseria
meningitidis—account for most acute bacterial meningitis. Measurement of the effect of
protein-polysaccharide conjugate vaccines is most reliable for H influenzae meningitis
because one serotype and one age group account for more than 90% of cases and the
incidence has been best measured in high-income countries where these vaccines have been
used longest. Pneumococcal and meningococcal meningitis are caused by diverse serotypes
and have a wide age distribution; measurement of their incidence is complicated by epidemics
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and scarcity of surveillance, especially in low-income countries. Near elimination of H
influenzae meningitis has been documented after vaccine introduction. Despite greater than
90% reductions in disease attributable to vaccine serotypes, all-age pneumococcal meningitis
has decreased by around 25%, with little data from low-income settings. Near elimination of
serogroup C meningococcal meningitis has been documented in several high-income
countries, boding well for the effect of a new serogroup A meningococcal conjugate vaccine
in the African meningitis belt.
Evaluating the Sustained Health Impact of Household Chlorination of Drinking Water
in Rural Haiti, Eric Harshfield, Am. J. Trop. Med. Hyg. 87(5), 2012, pp. 786-795
The Jolivert Safe Water for Families program has sold sodium hypochlorite solution
(chlorine) and conducted household visits in rural Haiti since 2002. To assess the impact of
the program on diarrheal disease, in 2010 we conducted a survey and water quality testing in
201 program participants and 425 control households selected at random. Fifty-six percent of
participants (versus 10% of controls) had free chlorine residuals between 0.2 and 2.0 mg/L,
indicating correct water treatment. Using intention-to-treat analysis, we found that
significantly fewer children < 5 in participant households had an episode of diarrhea in the
previous 48 hours (32% versus 52%; P < 0.001) with 59% reduced odds (odds ratio = 0.41,
95% confidence interval = 0.21-0.79). Treatment-on-treated estimates of the odds of diarrhea
indicated larger program effects for participants who met more stringent verifications of
participation. Diarrheal disease reduction in this long-term program was comparable with that
seen in short-term randomized, controlled interventions, suggesting that household
chlorination can be an effective long-term water treatment strategy.
Development of Clinical Immunity to Malaria in Highland Areas of Low and Unstable
Transmission, Melissa A. Rolfes, Am. J. Trop. Med. Hyg. 87(5), 2012, pp. 806-812
In highland areas of unstable, low malaria transmission, the extent to which immunity to
uncomplicated malaria develops with age and intermittent parasite exposure has not been well
characterized. We conducted active surveillance for clinical malaria during April 2003-March
2005 in two highland areas of western Kenya (Kapsisiywa and Kipsamoite). In both sites,
annual malaria incidence was significantly lower in persons ≥ 15 years of age than in persons
< 5 years of age (Kapsisiywa: incidence = 382.9 cases/1,000 persons among persons < 1-4
years of age versus 135.1 cases/1,000 persons among persons ≥ 15 years of age; Kipsamoite:
incidence = 233.0 cases/1,000 persons in persons < 1-4 years of age versus 43.3 cases/1,000
persons in persons ≥ 15 years of age). In Kapsisiywa, among persons with malaria, parasite
density and axillary body temperature were also significantly lower in persons ≥ 15 years of
age than in persons < 5 years of age. Even in highland areas of unstable and low malaria
transmission, age is associated with development of clinical immunity to malaria.
Mechanism of Anemia in Schistosoma mansoni-Infected School Children in Western
Kenya, Sara E. Butler, Am. J. Trop. Med. Hyg. 87(5), 2012, pp. 862-867
A better understanding of the mechanism of anemia associated with Schistosoma mansoni
infection might provide useful information on how treatment programs are implemented to
minimize schistosomiasis-associated morbidity and maximize treatment impact. We used a
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cross-sectional study with serum samples from 206 Kenyan school children to determine the
mechanisms in S. mansoni-associated anemia. Serum ferritin and soluble transferrin receptor
levels were measured by using an enzyme-linked immunosorbent assay. Results suggest that
S. mansoni-infected persons are more likely (odds ratio = 3.68, 95% confidence interval =
1.33-10.1) to have levels of serum ferritin (> 100 ng/mL) that are associated with anemia of
inflammation (AI) than S. mansoni-uninfected children. Our results suggest that AI is the
most common form of anemia in S. mansoni infections. In contrast, the mechanism of anemia
in S. mansoni-uninfected children was iron deficiency. Moreover, the prevalence of AI in the
study participants demonstrated a significant trend with S. mansoni infection intensity (P <
0.001). Our results are consistent with those observed in S. japonicum-associated anemia.
Schistosoma mansoni Morbidity among School-Aged Children: A SCORE Project in
Kenya, Aaron M. Samuels, Am. J. Trop. Med. Hyg. 87(5), 2012, pp. 874-882
Schistosomiasis control programs aim to reduce morbidity but are evaluated by infection
prevalence and intensity reduction. We present baseline cross-sectional data from a nested
cohort study comparing indicators of morbidity for measuring program impact. Eight hundred
twenty-two schoolchildren 7-8 years of age from Nyanza Province, Kenya, contributed stool
for diagnosis of Schistosoma mansoni and soil-transmitted helminths (STH) and blood smears
for malaria, and were evaluated for anemia, quality of life, exercise tolerance, anthropometry,
and ultrasound abnormalities. Schistosoma mansoni, STH, and malaria infection prevalence
were 69%, 25%, and 8%, respectively. Only anemia and S. mansoni infection (adjusted odds
ratio [aOR] = 1.70; confidence interval [CI] = 1.03-2.80), and hepatomegaly and heavy S.
mansoni infection (aOR = 2.21; CI = 1.19-4.11) were associated. Though anemia and
hepatomegaly appeared most useful at baseline, additional morbidity indicators may be
sensitive longitudinal measures to evaluate schistosomiasis program health impact.
Compliancewith anti-H1N1 vaccine among healthcare workers and general population,
Blasi F., Clin Microbiol Infect 2012, 18, (5) 37-41
Concern about vaccine safety and distrust of health authorities are the commonest reasons
given for low compliance with vaccination by healthcare workers. Better communication
strategies to improve vaccination acceptance by the general population and by healthcare
workers are required.
A number of studies have addressed the behavioural responses to the influenza pandemic in
HCWs (2-4, 16-26). Overall, uncertainty about vaccine side-effects, concern about vaccine
safety and distrust of the health authorities were the commonest reasons for non-vaccination.
These interventions changed the behaviour of the Dutch general practitioners from
a vaccination rate of 36% in the 2007-08 influenza season to a vaccination rate higher than
80% in 2009 (19, 23).
Preventing influenza in younger children, Esposito S., Clin Microbiol Infect 2012, 18, (5)
42-49
Influenza is common in infants and children: attack rates vary from 23% to 48% each year
during inter-pandemic periods, and are even higher during pandemics. Severe cases occur
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more frequently in children with underlying chronic diseases; however, epidemiological
studies have clearly shown that influenza also causes an excess of medical examinations, drug
prescriptions and hospitalizations in otherwise healthy children (particularly those aged
<5 years), as well as a considerable number of paediatric deaths. Childhood influenza also has
a number of social and economic consequences. However, many European health authorities
are still reluctant to include influenza vaccinations in their national vaccination programmes
for healthy children because, among other things, there are doubts concerning their real ability
to evoke a protective immune response, especially in children in the first years of life. New
hope for the solution of these problems has come from the introduction of vaccines containing
more antigens and the possibility of intradermal administration. However, further studies are
needed to establish whether universal influenza vaccination in the first years of life should be
recommended, and with which vaccine.
Influenza vaccination recommendation
WHO/Europe
Recommend that member states vaccinate all individuals ≥6 months
EU
Six member states currently recommend paediatric vaccination
Recommendations vary by country
6 months to <18 years of age: austria, Estonia and Slovakia
6-35 months: Finland
6-24 months: Slovenia, Latvia
USA, Canada and PAHO countries
USA: All individuals ≥6 months of age
Canada: Children 6-24 months of age and encourages all individuals
≥6 months of age to be vaccinated
Currently, 27 PAHO countries and territories recommend paediatric
Seasonal influenza vaccination
PAHO, Pan American Health Organization.
PAHO recommendations vary by country or territory
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Measles still spreads in Europe: who is responsible for the failure to vaccinate? CarrilloSantisteve P., Clin Microbiol Infect 2012, 18, (5) 50-56
All countries in the European Region of the World Health Organization (WHO) have renewed
their commitment to eliminate measles transmission by 2015. Measles elimination is a
feasible target but requires vaccination coverage above 95% with two doses of a measlesmumps-rubella vaccine (MMR) in all population groups and in all geographical areas.
Measles has re-emerged in the EU recently, due to suboptimal immunization levels that led to
accumulation of susceptible populations over the last years. In fact, while an overall
decreasing trend had been observed until 2009, the number of cases increased by a factor of
four between 2010 and 2011. According to vaccination coverage data reported to the WHO,
between 2000 and 2010, almost 5 million individuals in the EU in the age group 2-12 had not
had MMR vaccination. Catch-up vaccination activities for susceptible populations are
paramount in order to reach the elimination goal, but only feasible if a multi-component
approach is put in place quickly and efficiently. Advocacy and communication are key
strategic areas.
Rotavirus vaccination: a concise review, Vesikari T., Clin Microbiol Infect 2012, 18, (5)
57-63
Live attenuated oral rotavirus vaccines were tested for proof-of-concept in the early 1980s,
the first vaccine (RotaShield, Wyeth) was introduced in 1998 but was subsequently
withdrawn because of association with intussusception, and the two currently licensed vaccine
(Rotarix, GlaxoSmithKline, and RotaTeq, Merck) were introduced in 2006. Before licensure
both vaccines were extensively tested for safety (for intussusception) and efficacy in trials
comprising in over 60,000 infants each. Rotarix is a single-strain human rotavirus vaccine
(RV1) and RotaTeq is a combination of five bovine-human reassortant rotaviruses (RV5).
Although the composition of the two vaccines is different, their field effectiveness and,
largely, mechanism of action are similar. Both prevent effectively severe rotavirus
gastroenteritis (RVGE) but are less efficacious against mild RVGE or rotavirus infection.
Field effectiveness of these vaccines in Europe and the USA against severe RVGE has been
above 90% and in Latin America around 80%. Trials in Africa have yielded efficacy rates
between 50 and 80%. Rotavirus vaccination has been introduced into the national
immunization programmes of about 20 countries in Latin America, with Brazil and Mexico as
leading countries, as well as in the USA, Australia and South Africa. Introduction into other
African countries will start in 2012. In Europe, Belgium, Luxembourg, Austria and Finland
and five federal states of Germany have introduced universal rotavirus vaccination. The
reasons for the slow progress in Europe include low mortality from RVGE, unfavourable
cost-benefit calculations in some countries, and concerns that still exist over intussusception.
The spread of vaccine-preventable diseases by international travellers: a public-health
concern, Gautret P., Clin Microbiol Infect 2012, 18, (5) 77-84
Vaccine-preventable diseases (VPDs) are costly at both the individual and societal levels. The
most common VPDs recorded in travellers are enteric (typhoid or paratyphoid B) fever, acute
viral hepatitis, influenza, varicella, measles, pertussis and bacterial meningitis. Travellers
suffering from VPDs are frequently hospitalized, illustrating the point that VPDs are serious
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and expensive. Many travellers are not properly immunized before travel. In addition to
individual consequences, VPDs can have public-health consequences if they are introduced or
re-introduced by infected travellers returning to areas with susceptible populations. The
international spread of poliomyelitis, Neisseria meningitidis serogroup W135 meningococcal
infections, measles and influenza provides strong evidence of the role of international travel
in the globalization of VPDs. The surveillance of the emergence, re-emergence or spread of
VPDs is essential to adapt pre-travel advice and the responses to the VPD.
Poliomyelitis is close to eradication. The efforts of the Global Polio Eradication Initiative
have brought down the number of polio cases worlwide from 350 000 cases in more than 125
countries in 1988 to 2000 cases in nine countries in 2002. Only four countries (Afghanistan,
India, Nigeria and Pakistan) have never completely interrupted the transmission of wild
poliovirus. However a major obstacle to polio eradication appears to be international spread
via travellers, be it refugees, pilgrims, traders or tourists. Between 2003 and 2006, polio was
imported by travellers into 24 polio-free countries. The origin of these importations was
largely the four countries where polio transmission was never completely interrupted. The
importations resulted in approximately 1400 secondary cases of the disease.
Can infants be protected by means of maternal vaccination? Esposito S., Clin Microbiol
Infect 2012, 18, (5) 85-92
The administration of vaccines is not usually recommended in pregnant women because of a
fear of severe adverse events for the fetus. However, contraindication to vaccination applies
only to vaccines based on live attenuated viruses for the theoretical possibility that they might
infect the fetus. In contrast, the use of several inactivated vaccines is useful and
recommended. As a result of the transplacental passage of antibodies, maternal immunization
can reduce the risk of vaccine-preventable diseases that may occur in the first months of life
before the start or completion of the suggested vaccination schedule. One of the best examples
is vaccination against influenza that can protect pregnant women from a disease that can lead
to hospitalization and death in a significantly higher number of cases than in the general
population and can induce protective specific antibody levels as well as being effective in
infants in the first months of life. Other examples are vaccinations against tetanus, pertussis,
pneumococcal infections and Haemophilus influenzae type b infection. This review analyses
the advantages and limitations of maternal immunization as revealed by experience and the
main publications.
Vaccination of immunocompromised patients, Ljungman P., Clin Microbiol Infect 2012,
18, (5) 93-99
Vaccination of immunocompromised patients is challenging both regarding efficacy and
safety. True efficacy data are lacking so existing recommendations are based on immune
responses and safety data. Inactivated vaccines can generally be used without risk but the
patients who are most at risk for infectious morbidity and mortality as a result of their
severely immunosuppressed state are also those least likely to respond to vaccination.
However, vaccination against pneumococci, Haemophilus influenzae and influenza are
generally recommended. Live vaccines must be used with care because the risk for vaccineassociated disease exists.
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Vaccines for the elderly, Weinberger B., Clin Microbiol Infect 2012, 18, (5) 100-108
Vaccination is the most efficient strategy to prevent infectious disease. The increased
vulnerability to infection of the elderly makes them a particularly important target population
for vaccination. However, most vaccines are less immunogenic and efficient in the elderly
because of age-related changes in the immune system. Vaccination against influenza,
Streptococcus pneumoniae and varicella zoster virus is recommended for the elderly in many
countries. Various strategies such as the use of adjuvants and novel administration routes are
pursued to improve influenza vaccination for the elderly and recent developments in the field
of pneumococcal vaccination led to the licensure of protein-conjugated polysaccharide
vaccines containing up to 13 serotypes. As antibody titres are generally lower in the elderly
and-particularly for inactivated vaccines-decline fast in the elderly, regular booster
immunizations, for example against tetanus, diphtheria and, in endemic areas, tick-borne
encephalitis, are essential during adulthood to ensure protection of the elderly. With
increasing health and travel opportunities in old age the importance of travel vaccines for
persons over the age of 60 is growing. However, little is known about immunogenicity and
efficacy of travel vaccines in this age group. Despite major advances in the field of
vaccinology over the last decades, there are still possibilities for improvement concerning
vaccines for the elderly. Novel approaches, such as viral vectors for antigen delivery, DNAbased vaccines and innovative adjuvants, particularly toll-like receptor agonists, will help to
achieve optimal protection against infectious diseases in old age.
Impact of Community Management of Fever (Using Antimalarials With or Without
Antibiotics) on Childhood Mortality: A Cluster-Randomized Controlled Trial in Ghana,
Margaret A. Chinbuah, Am. J. Trop. Med. Hyg., 87(5), 2012, pp. 11-20
Malaria and pneumonia are leading causes of childhood mortality. Home Management of
fever as Malaria (HMM) enables presumptive treatment with antimalarial drugs but excludes
pneumonia. We aimed to evaluate the impact of adding an antibiotic, amoxicillin (AMX) to
an antimalarial, artesunate amodiaquine (AAQ + AMX) for treating fever among children 2–
59 months of age within the HMM strategy on all-cause mortality. In a stepped-wedge
cluster-randomized, open trial, children 2–59 months of age with fever treated with AAQ or
AAQ + AMX within HMM were compared with standard care. Mortality reduced
significantly by 30% (rate ratio [RR] = 0.70, 95% confidence interval [CI] = 0.53–0.92, P =
0.011) in AAQ clusters and by 44% (RR = 0.56, 95% CI = 0.41–0.76, P = 0.011) in AAQ +
AMX clusters compared with control clusters. The 21% mortality reduction between AAQ
and AAQ + AMX (RR = 0.79, 95% CI = 0.56–1.12, P = 0.195) was however not statistically
significant. Community fever management with antimalarials significantly reduces under-five
mortality. Given the lower mortality trend, adding an antibiotic is more beneficial.
Mortality in under-five children remains a major concern. I tis one of the key millennium
development goals. Although some countries have seen reductions in under-five mortality
rates, rates of decline have been slower and almost stagnant in Africa and Asia. In Ghana,
under-five mortality increased from 108 of 1,000 live births in 1999 to 111 of 1,000 live
births in 2003 and remained at that level in 2006.
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Malaria and pneumonia are responsible for 16% and 15% of under-five mortality, respectively
in sSA.
Integrated Community Case Management of Fever in Children under Five Using Rapid
Diagnostic Tests and Respiratory Rate Counting: A Multi-Country Cluster Randomized
Trial, David Mukanga, Am. J. Trop. Med. Hyg., 87(5), 2012, pp. 21-29
Evidence on the impact of using diagnostic tests in community case management of febrile
children is limited. This effectiveness trial conducted in Burkina Faso, Ghana, and Uganda,
compared a diagnostic and treatment package for malaria and pneumonia with presumptive
treatment with anti-malarial drugs; artemisinin combination therapy (ACT). We enrolled
4,216 febrile children between 4 and 59 months of age in 2009–2010. Compliance with the
malaria rapid diagnostic test (RDT) results was high in the intervention arm across the three
countries, with only 4.9% (17 of 344) of RDT-negative children prescribed an ACT.
Antibiotic overuse was more common: 0.9% (4 of 446) in Uganda, 38.5% (114 of 296) in
Burkina Faso, and 44.6% (197 of 442) in Ghana. Fever clearance was high in both
intervention and control arms at both Day 3 (97.8% versus 96.9%, P = 0.17) and Day 7
(99.2% versus 98.8%, P = 0.17). The use of diagnostic tests limits overuse of ACTs. Its
impact on antibiotic overuse and on fever clearance is uncertain.
Increased Use of Community Medicine Distributors and Rational Use of Drugs in
Children less than Five Years of Age in Uganda Caused by Integrated Community Case
Management of Fever, Joan N. Kalyango, Am. J. Trop. Med. Hyg., 87(5), 2012, pp. 36-45
We compared use of community medicine distributors (CMDs) and drug use under integrated
community case management and home-based management strategies in children 6-59
months of age in eastern Uganda. A cross-sectional study with 1,095 children was nested in a
cluster randomized trial with integrated community case management (CMDs treating malaria
and pneumonia) as the intervention and home-based management (CMDs treating only
malaria) as the control. Care-seeking from CMDs was higher in intervention areas (31%) than
in control areas (22%; P = 0.01). Prompt and appropriate treatment of malaria was higher in
intervention areas (18%) than in control areas (12%; P = 0.03) and among CMD users (37%)
than other health providers (9%). The mean number of drugs among CMD users compared
with other health providers was 1.6 versus 2.4 in intervention areas and 1.4 versus 2.3 in
control areas. Use of CMDs was low. However, integrated community case management of
childhood illnesses increased use of CMDs and rational drug use.
Private Sector Drug Shops in Integrated Community Case Management of Malaria,
Pneumonia, and Diarrhea in Children in Uganda, Phylis Awor, Am. J. Trop. Med. Hyg.,
87(5), 2012, pp. 92-96
We conducted a survey involving 1,604 households to determine community care-seeking
patterns and 163 exit interviews to determine appropriateness of treatment of common
childhood illnesses at private sector drug shops in two rural districts of Uganda. Of children
sick within the last 2 weeks, 496 (53.1%) children first sought treatment in the private sector
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versus 154 (16.5%) children first sought treatment in a government health facility. Only 15
(10.3%) febrile children treated at drug shops received appropriate treatment for malaria. Five
(15.6%) children with both cough and fast breathing received amoxicillin, although no
children received treatment for 5-7 days. Similarly, only 8 (14.3%) children with diarrhea
received oral rehydration salts, but none received zinc tablets. Management of common
childhood illness at private sector drug shops in rural Uganda is largely inappropriate. There
is urgent need to improve the standard of care at drug shops for common childhood illness
through public-private partnerships.
Household Costs for Treatment of Severe Pneimonia in Pakistan, Salim Sadruddin, Am.
J. Trop. Med. Hyg., 87(5), 2012, pp. 137-143
Current World Health Organization (WHO) guidelines for severe pneumonia treatment of
under-5 children recommend hospital referral. However, high treatment cost is a major barrier
for communities. We compared household costs for referred cases with management by lady
health workers (LHWs) using oral antibiotics. This study was nested within a cluster
randomized trial in Haripur, Pakistan. Data on direct and indirect costs were collected through
interviews and record reviews in the 14 intervention and 14 control clusters. The average
household cost/case for a LHW managed case was $1.46 compared with $7.60 for referred
cases. When the cost of antibiotics provided by the LHW program was excluded from the
estimates, the cost/case came to $0.25 and $7.51 for the community managed and referred
cases, respectively, a 30-fold difference. Expanding severe pneumonia treatment with oral
amoxicillin to community level could significantly reduce household costs and improve
access to the underprivileged population, preventing many child deaths.
Duodenal Infusion of Donor Feces for Recurrent Clostridium difficile, Els van Nood, N
Engl J Med 2013, 368: 407-15
Recurrent Clostridium difficile infection is difficult to treat, and failure rates for antibiotic
therapy are high. We studied the effect of duodenal infusion of donor feces in patients with
recurrent C. difficile infection.
We randomly assigned patients to receive one of three therapies: an initial vancomycin
regimen (500 mg orally four times per day for 4 days), followed by bowel lavage and
subsequent infusion of a solution of donor feces through a nasoduodenal tube; a standard
vancomycin regimen (500 mg orally four times per day for 14 days); or a standard
vancomycin regimen with bowel lavage. The primary end point was the resolution of diarrhea
associated with C. difficile infection without relapse after 10 weeks.
The study was stopped after an interim analysis. Of 16 patients in the infusion group, 13
(81%) had resolution of C. difficile–associated diarrhea after the first infusion. The 3
remaining patients received a second infusion with feces from a different donor, with
resolution in 2 patients. Resolution of C. difficile infection occurred in 4 of 13 patients (31%)
receiving vancomycin alone and in 3 of 13 patients (23%) receiving vancomycin with bowel
lavage (P<0.001 for both comparisons with the infusion group). No significant differences in
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adverse events among the three study groups were observed except for mild diarrhea and
abdominal cramping in the infusion group on the infusion day. After donor-feces infusion,
patients showed increased fecal bacterial diversity, similar to that in healthy donors, with an
increase in Bacteroidetes species and clostridium clusters IV and XIVa and a decrease in
Proteobacteria species.
The infusion of donor feces was significantly more effective for the treatment of recurrent C.
difficile infection than the use of vancomycin.
Antibiotics as Part of the Management of Severe Acute Malnutrition, Indi Trehan, N Engl
J Med 2013, 368: 425-35
Severe acute malnutrition contributes to 1 million deaths among children annually. Adding
routine antibiotic agents to nutritional therapy may increase recovery rates and decrease
mortality among children with severe acute malnutrition treated in the community.
In this randomized, double-blind, placebo-controlled trial, we randomly assigned Malawian
children, 6 to 59 months of age, with severe acute malnutrition to receive amoxicillin,
cefdinir, or placebo for 7 days in addition to ready-to-use therapeutic food for the outpatient
treatment of uncomplicated severe acute malnutrition. The primary outcomes were the rate of
nutritional recovery and the mortality rate.
A total of 2767 children with severe acute malnutrition were enrolled. In the amoxicillin,
cefdinir, and placebo groups, 88.7%, 90.9%, and 85.1% of the children recovered,
respectively (relative risk of treatment failure with placebo vs. amoxicillin, 1.32; 95%
confidence interval [CI], 1.04 to 1.68; relative risk with placebo vs. cefdinir, 1.64; 95% CI,
1.27 to 2.11). The mortality rates for the three groups were 4.8%, 4.1%, and 7.4%,
respectively (relative risk of death with placebo vs. amoxicillin, 1.55; 95% CI, 1.07 to 2.24;
relative risk with placebo vs. cefdinir, 1.80; 95% CI, 1.22 to 2.64). Among children who
recovered, the rate of weight gain was increased among those who received antibiotics. No
interaction between type of severe acute malnutrition and intervention group was observed for
either the rate of nutritional recovery or the mortality rate.
The addition of antibiotics to therapeutic regimens for uncomplicated severe acute
malnutrition was associated with a significant improvement in recovery and mortality rates.
Myths, Presumptions and Facts about Obesity, Krista Casazza, N Engl J Med 2013, 368:
446-54
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Many beliefs about obesity persist in the absence of supporting scientific evidence
(presumptions); some persist despite contradicting evidence (myths). The promulgation of
unsupported beliefs may yield poorly informed policy decisions, inaccurate clinical and
public health recommendations, and an unproductive allocation of research resources and may
divert attention away from useful, evidence-based information.
Using Internet searches of popular media and scientific literature, we identified, reviewed, and
classified obesity-related myths and presumptions. We also examined facts that are well
supported by evidence, with an emphasis on those that have practical implications for public
health, policy, or clinical recommendations.
We identified seven obesity-related myths concerning the effects of small sustained increases
in energy intake or expenditure, establishment of realistic goals for weight loss, rapid weight
loss, weight-loss readiness, physical-education classes, breast-feeding, and energy expended
during sexual activity. We also identified six presumptions about the purported effects of
regularly eating breakfast, early childhood experiences, eating fruits and vegetables, weight
cycling, snacking, and the built (i.e., human-made) environment. Finally, we identified nine
evidence-supported facts that are relevant for the formulation of sound public health, policy,
or clinical recommendations.
False and scientifically unsupported beliefs about obesity are pervasive in both scientific
literature and the popular press.
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Sequential versus triple therapy for the first-line treatment of Helicobacter pylori:
a multicentre, open-label, randomised trial, Jyh-Ming Liou, Lancet 2013, 381: 205-13
Whether sequential treatment can replace triple therapy as the standard treatment for
Helicobacter pylori infection is unknown. We compared the efficacy of sequential treatment
for 10 days and 14 days with triple therapy for 14 days in first-line treatment.
For this multicentre, open-label, randomised trial, we recruited patients (≥20 years of age)
with H pylori infection from six centres in Taiwan. Using a computer-generated
randomisation sequence, we randomly allocated patients (1:1:1; block sizes of six) to either
sequential treatment (lansoprazole 30 mg and amoxicillin 1 g for the first 7 days, followed by
lansoprazole 30 mg, clarithromycin 500 mg, and metronidazole 500 mg for another 7 days;
with all drugs given twice daily) for either 10 days (S-10) or 14 days (S-14), of 14 days of
triple therapy (T-14; lansoprazole 30 mg, amoxicillin 1 g, and clarithromycin 500 mg for 14
days; with all drugs given twice daily). Investigators were masked to treatment allocation. Our
primary outcome was the eradication rate in first-line treatment by intention-to-treat (ITT) and
per-protocol (PP) analyses. This trial is registered with ClinicalTrials.gov, number
NCT01042184.
Between Dec 28, 2009, and Sept 24, 2011, we enrolled 900 patients: 300 to each group. The
eradication rate was 90В·7% (95% CI 87В·4-94В·0; 272 of 300 patients) in the S-14 group, 87В·0%
(83В·2-90В·8; 261 of 300 patients) in the S-10 group, and 82В·3% (78В·0-86В·6; 247 of 300
patients) in the T-14 group. Treatment efficacy was better in the S-14 group than it was in the
T-14 group in both the ITT analysis (number needed to treat of 12В·0 [95% CI 7В·2-34В·5];
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p=0В·003) and PP analyses (13В·7 [8В·3-40], p=0В·003). We recorded no significant difference in
the occurrence of adverse effects or in compliance between the three groups.
Our findings lend support to the use of sequential treatment as the standard first-line treatment
for H pylori infection.
Preventing preterm births: analysis of trends and potential reductions with
interventions in 39 countries with very high human development index, Hannah H.
Chang, Lancet 2013, 381: 223-34
Every year, 1В·1 million babies die from prematurity, and many survivors are disabled.
Worldwide, 15 million babies are born preterm (<37 weeks' gestation), with two decades of
increasing rates in almost all countries with reliable data. The understanding of drivers and
potential benefit of preventive interventions for preterm births is poor. We examined trends
and estimate the potential reduction in preterm births for countries with very high human
development index (VHHDI) if present evidence-based interventions were widely
implemented. This analysis is to inform a rate reduction target for Born Too Soon.
Countries were assessed for inclusion based on availability and quality of preterm prevalence
data (2000-10), and trend analyses with projections undertaken. We analysed drivers of rate
increases in the USA, 1989-2004. For 39 countries with VHHDI with more than 10,000
births, we did country-by-country analyses based on target population, incremental coverage
increase, and intervention efficacy. We estimated cost savings on the basis of reported costs
for preterm care in the USA adjusted using World Bank purchasing power parity.
From 2010, even if all countries with VHHDI achieved annual preterm birth rate reductions of
the best performers for 1990-2010 (Estonia and Croatia), 2000-10 (Sweden and Netherlands),
or 2005-10 (Lithuania, Estonia), rates would experience a relative reduction of less than 5%
by 2015 on average across the 39 countries. Our analysis of preterm birth rise 1989-2004 in
USA suggests half the change is unexplained, but important drivers include non-medically
indicated labour induction and caesarean delivery and assisted reproductive technologies. For
all 39 countries with VHHDI, five interventions modelling at high coverage predicted a 5%
relative reduction of preterm birth rate from 9В·59% to 9В·07% of livebirths: smoking cessation
(0В·01 rate reduction), decreasing multiple embryo transfers during assisted reproductive
technologies (0В·06), cervical cerclage (0В·15), progesterone supplementation (0В·01), and
reduction of non-medically indicated labour induction or caesarean delivery (0В·29). These
findings translate to roughly 58,000 preterm births averted and total annual economic cost
savings of about US$3 billion.
We recommend a conservative target of a relative reduction in preterm birth rates of 5% by
2015. Our findings highlight the urgent need for research into underlying mechanisms of
preterm births, and development of innovative interventions. Furthermore, the highest preterm
birth rates occur in low-income settings where the causes of prematurity might differ and have
simpler solutions such as birth spacing and treatment of infections in pregnancy than in highincome countries. Urgent focus on these settings is also crucial to reduce preterm births
worldwide.
Antimicrobial catheters for reduction of symptomatic urinary tract infection in adults
requiring short-term catheterisation in hospital: a multicentre randomised controlled
trial, Robert Pickard, Lancet 2012, 380: 1927-35
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Catheter-associated urinary tract infection (CAUTI) is a major preventable cause of harm for
patients in hospital. We aimed to establish whether short-term routine use of antimicrobial
catheters reduced risk of CAUTI compared with standard polytetrafluoroethylene (PTFE)
catheterisation.
In our parallel, three group, multicentre, randomised controlled superiority trial, we enrolled
adults (aged ≥16 years) requiring short-term (≤14 days) catheterisation at 24 hospitals in the
UK. Participants were randomly allocated 1:1:1 with a remote computer allocation to receive
a silver alloy-coated catheter, a nitrofural-impregnated catheter, or a PTFE-coated catheter
(control group). Patients undergoing unplanned catheterisation were also included and consent
for participation was obtained retrospectively. Participants and trial staff were unmasked to
treatment assignment. Data were collected by trial staff and by patient-reported questionnaires
for 6 weeks after randomisation. The primary outcome was incidence of symptomatic urinary
tract infection for which an antibiotic was prescribed by 6 weeks. We postulated that a 3В·3%
absolute reduction in CAUTI would represent sufficient benefit to recommend routine use of
antimicrobial catheters. This study is registered, number ISRCTN75198618.
708 (10%) of 7102 randomly allocated participants were not catheterised, did not confirm
consent, or withdrew, and were not included in the primary analyses. Compared with 271
(12В·6%) of 2144 participants in the control group, 263 (12В·5%) of 2097 participants allocated
a silver alloy catheter had the primary outcome (difference -0В·1% [95% CI -2В·4 to 2В·2]), as
did 228 (10В·6%) of 2153 participants allocated a nitrofural catheter (-2В·1% [-4В·2 to 0В·1]).
Rates of catheter-related discomfort were higher in the nitrofural group than they were in the
other groups.
Silver alloy-coated catheters were not effective for reduction of incidence of symptomatic
CAUTI. The reduction we noted in CAUTI associated with nitrofural-impregnated catheters
was less than that regarded as clinically important. Routine use of antimicrobial-impregnated
catheters is not supported by this trial.
Ecology of zoonoses: natural and unnatural histories, William B. Karesh, Lancet 2012,
380: 1936-45
More than 60% of human infectious diseases are caused by pathogens shared with wild or
domestic animals. Zoonotic disease organisms include those that are endemic in human
populations or enzootic in animal populations with frequent cross-species transmission to
people. Some of these diseases have only emerged recently. Together, these organisms are
responsible for a substantial burden of disease, with endemic and enzootic zoonoses causing
about a billion cases of illness in people and millions of deaths every year. Emerging
zoonoses are a growing threat to global health and have caused hundreds of billions of US
dollars of economic damage in the past 20 years. We aimed to review how zoonotic diseases
result from natural pathogen ecology, and how other circumstances, such as animal
production, extraction of natural resources, and antimicrobial application change the
dynamics of disease exposure to human beings. In view of present anthropogenic trends, a
more effective approach to zoonotic disease prevention and control will require a broad view
of medicine that emphasises evidence-based decision making and integrates ecological and
evolutionary principles of animal, human, and environmental factors. This broad view is
essential for the successful development of policies and practices that reduce probability of
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CLINICAL SOCIAL WORK (CSW)
future zoonotic emergence, targeted surveillance and strategic prevention, and engagement of
partners outside the medical community to help improve health outcomes and reduce disease
threats.More than 60% of human infectious diseases are caused by pathogens shared with
wild or domestic animals. Zoonotic disease organisms include those that are endemic in
human populations or enzootic in animal populations with frequent cross-species transmission
to people. Some of these diseases have only emerged recently. Together, these organisms are
responsible for a substantial burden of disease, with endemic and enzootic zoonoses causing
about a billion cases of illness in people and millions of deaths every year. Emerging
zoonoses are a growing threat to global health and have caused hundreds of billions of US
dollars of economic damage in the past 20 years. We aimed to review how zoonotic diseases
result from natural pathogen ecology, and how other circumstances, such as animal
production, extraction of natural resources, and antimicrobial application change the
dynamics of disease exposure to human beings. In view of present anthropogenic trends, a
more effective approach to zoonotic disease prevention and control will require a broad view
of medicine that emphasises evidence-based decision making and integrates ecological and
evolutionary principles of animal, human, and environmental factors. This broad view is
essential for the successful development of policies and practices that reduce probability of
future zoonotic emergence, targeted surveillance and strategic prevention, and engagement of
partners outside the medical community to help improve health outcomes and reduce disease
threats. Key messages:
• Nearly two-thirds of human infectious diseases arise from pathogens shared with wild
or domestic animals
• Endemic and enzootic zoonoses cause about a billion cases of illness in people and
millions of deaths every year, and emerging zoonoses are a rising threat to global
health, having caused hundreds of billions of US dollars of economic damage in the
past 20 years
• Ecological and evolutionary perspectives can provide valuable insights into pathogen
ecology and can inform zoonotic disease-control programmes
• Anthropogenic practices, such as changes in land use and extractive industry actions,
animal production systems, and widespread antimicrobial applications affect zoonotic
disease transmission
REFERENCES
1) Desta Ayode, The Association of Beliefs About Heredity with Preventive and
Interpersonal Behaviors in Communities Affected by Podoconiosis in Rural Ethiopia,
Am. J. Trop. Med. Hyg., 87(4), 2012, pp. 623-630
2) Kerstin Wahlers, Cystic echinococcosis in sub-Saharan Africa, Lancet Infect Dis 2012,
12: 871-80
161
CLINICAL SOCIAL WORK (CSW)
3) Mitchell M. Levy, Outcomes of the Surviving Sepsis Campaign in intensive care units
in the USA and Europe: a prospective cohort study, Lancet Infect Dis 2012, 12: 91924
4) Haluskova, E., Miedz. Stud. Human, 2009, 2, 229 - 235
5) Kiwou, M., Haluskova, E. Korcek, V., Mutalova, M.: Clin Soc Work. 4,2012, 127
6) Haluskova, E., Miedz. Stud. Human, 2009, 1, 229 - 236
7) Haluskova, E., Miedz. Stud. Human 2010, 2, 217 - 224
8) Sirotiakova J., Minarik P., Kopernicka Z., Magulova L., Piesecka L., Zak V.,
Liskova A.: Linezolid in the treatment of complicated gram positive infections by
critically ill patients, Clinical & Experimental Pharmacology and physiology, 2004,
31, Suppl. A114
9) Sirotiakova J., Minarik P., Hoppman M.: Screening of risk factors in the population of
40 years' men and women in Nitra region, importance of primary prevention.
Coronary Artery Disease, 2007, 1(7), s. 137
10) Dukat A., Lietava J., Krahulec B., Caprnda M., Vacula I., Kosmalova V., Minarik P.:
The prevalence of abdominal obesity in Slovakia. The IDEA Slovakia study, Vnitr.
Lek. 2007, 53(4), s. 326-30
11) Hoppman M., Minarik P., Sirotiakova J.: New possibilities in the treatment of
hypertension in pregnancy – looking for the effective and safe drug of future. Interna
medicina, 7 (1), 2007, s. 58
12) Minarik P., Hoppman M., Sirotiakova J.: Screening of risk factors in the population of
40 years men and women in Nitra region, regarding to the importance of primary
prevention, Interna mediciny, 7 (1), 2007, s. 58
13) Phylis Awor, Private Sector Drug Shops in Integrated Community Case Management
of Malaria, Pneumonia, and Diarrhea in Children in Uganda, Am. J. Trop. Med. Hyg.,
87(5), 2012, pp. 92-96
14) William B. Karesh, Ecology of zoonoses: natural and unnatural histories, Lancet 2012,
380: 1936-45
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SOCIAL, LEGAL, ECONOMIC AND PUBLIC HEALTH ASPECTS IN AN
INFECTIOUS DISEASES 2012 ICAAC UPDATE
M. Mutalova, P. Vermes, G. Hendics. S. Zak, J. Doktorovova,
J. Jexova, Z. Nagyova, T. Oelnick, M. Vravcova
Department of Social Work, Department of Public Health, SEUC Tropic team and PhD
programme Bratislava, Slovakia and Mole St. Nicolas, Haiti
ABSTRACT
Social, Legal, Economic and Public Health Aspects in Infectious Diseases in 2012 – an
ICAAC update.
Critical review of updates in social work and infectious diseases areas, mainly hospital related
communicable diseases, social, legal, economic and public health aspects (1-8) is provided
here. HIV/AIDS and tropical diseases, both in US and non-US regions of WHO, is presented
the by the SEUC tropicteam after 3 years of deadly earthquake in Haiti. An ICAAC 2012
update presented in the conference in San Francisco 2012 is reviewed.
1) Staphylococcus, Vaccines, Nosocomial Infections
Rapid whole-genome sequencing for investigation of a neonatal MRSA outbreak
Koser C.
N Engl J Med 366, 2267-75
Whole-genome sequencing can provide clinically relevant data within a time frame that can
influence patient care.
USA300 was associated with early complications in PNEUMO patients.
An association between bacterial genotype combined with a high-vancomycin minimum
inhibitory concentration and risk of endocarditis in methicillin-resistant Staphylococcus
aureus bloodstream infection
Miller C.
Clin Infect Dis 54, 591-600
An interaction V-MIC can influence the risk of endocarditis associated with MRSA BSI,
implying involvement of both therapeutic and host-pathogen factors.
Prevalence of methicillin-resistant staphylococcus aureus as an etiology of communityacquired pneumonia
Moran G.
Clin Infect Dis 54, 1126-33
Uncommon cause of CAP. Detection of MRSA was associated with more severe clinical
presentation.
Concurrent Epidemics of Soft Tissue Infection and Bloodstream Infection Due to
Community-Associated Methicillin-Resistant Staphylococcus aureus
Tattevin P.
Clin Infect Dis 55, 781-8
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CLINICAL SOCIAL WORK (CSW)
Strategies to control the USA300 SSTI epidemic may lessen the severity of the concurrent
USA300 BSI epidemic.
High vancomycin MIC was associated with a higher mortality rate in MRSA BSI.
2) HIV - AIDS
Antiretroviral prophylaxis for HIV prevention in heterosexual men and women.
Baeten JM
N Engl J Med 2012, 367, 411-22
Oral TDF and TDF-FTC both protect against HIV-1 infection in heterosexual men and
women
Antiretroviral preexposure prophylaxis for heterosexual HIV transmission in Botswana
Thigpen MC
N Engl J Med 2012, 367, 423-34
Daily TDF-FTC prophylaxis prevented HIV infection in sexually active heterosexual adults.
The long-term safety of daily TDF-FTC prophylaxis.
What's love got to do with it? Explaining adherence to oral antiretroviral pre-exposure
prophylaxis for HIV-serodiscordant couples
Ware NC
Immune Defic Syndr. 2012, Apr., 15, 59(5): 463-8
PrEP use instable couples may be associated with improved adherence and thus, greater
affectiveness.
FTC-TP concetrations in all tissue types were detected for only 2 days after dose.
Determinants of per-coital act HIV-1 infectivity among african HIV-1 serodiscordant
couples
Hughes JP
Journal of Infectious Diseases, 2012, 205: 358-65
Modifiable risk factors for HIV-1 transmission were plasma HIV-1 RNA level and condom
use and in HIV-1 uninfected partners, herpes simplex virus 2 infection, genital ulcers,
Trichomonas vaginalis, vaginitis or cervicitis and male circumcision.
Symptomatic vaginal discharge is a poor predictor of sexually transmitted infections
and genital tract inflammation in high risk women in South Africa
Mlisana K
Journal of Infectious Diseases, 2012, 206: 6-14
The Cost-Effectiveness of Preexposure Prophylaxis for HIV Prevention in the United
States
Juusola JL
Ann Intern med. 2012, 156: 541-550
Use in high-risk MSM compares favorably with other interventions that are considered costeffective but could result in annual PrEP expenditures of more than $4 billion.
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CLINICAL SOCIAL WORK (CSW)
Nevirapine versus ritonavir-boosted lopinavir for HIV-infected children
Violari A.
N Engl J Med 2012 Jun 21, 366(25): 2380-9
Outcomes were superior with ritonavir-boosted lopinavir among young children with no prior
exposure to nevirapine. Factors that may have contributed to the suboptimal results with
nevirapine include elevated viral load at baseline, selection for nevirapine resistance,
background regimen of nucleoside reverse-transcriptase inhibitors and the standard ramp-up
dosing strategy.
Three postpartum antiretroviral regimens to prevent intrapartum HIV infection
Nielsen-Saines
N Engl J Med 2012 Jun 21, 366(25): 2368-79
Zidovudine for 6 weeks plus three doses of nevirapine during the first 8 days of life, or
zidovudine for 6 weeks plus nelfinavir and lamivudine for 2 weeks (three-drug group).
In neonates whose mothers did not receive ART during pregnancy, prophylaxis with a two- or
three-drug ART regimen is superior to zidovudine alone for the prevention of intrapartum
HIV transmission, the two-drug regimen has less toxicity than the three drug regimen.
Sexually transmitted diseases, urinary tract infections and antibiotic resistance
Ciprofloxacin for 7 days versus 14 days in woman with acute pyelonephritis
Sandberg T.
Lancet 2012, Aug., 4, 380(9840): 484-90
Can be treated successfully and safely with oral ciprofloxacin for 7 days.
The emerging threated of untreatable gonococcal infection
Bolan GA
N Engl J Med 2012, Feb., 9, 366(6):485-7
Reduced susceptibility to cephalosporins results from the combined effects of several
chromosomal gene mutations, including mutations in penA, the gene that encodes penicillinbinding protein 2 (PBP2), penB, which affects drug entry through an outer membrane protein
channel (PorB1b) and mtrR, a repressor of the MtrCDE-encoded pump.
Ceftriaxone-resistant neisseria gonorrhoeae, Japan
High-level cefixime- and ceftriaxone-resistant neisseria gonorrhoeae in France
Neisseria gonorrhoeae with high-level resistance to azithromycin
Massive increase, spread and Exchange of extended spectrum Гџ-lactamase-encoding
genes among intestinal Enterobacteriaceae in hospitalized children with severe acute
malnutrition in niger
Identification of New Delhi metalo-Гџ-lactamase 1 in Acinetobacter Iwofii of food animal
origin
Гџ-Lactam/Гџ-lactam inhibitor combinations for the treatment of bacteremia due to
extended-spectrum Гџ-lactamase-producing Escherichia coli: a post hoc analysis of
prospective cohorts
RodrГ­guez-Bano
Clin Infect Dis. 2012, Jan., 15, 54(2):167-74
Comment in Can we really use Гџ-lactam/Гџ-lactam inhibitor combinations for the treatment of
infections caused by extended-spectrum Гџ-lactamase-producing bacteria?
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CLINICAL SOCIAL WORK (CSW)
Excess deaths associated with tigecycline after approval based on noninferiority trials
Prasad P.
Clin Infect Dis. 2012, Jun., 54(12):1699-709
Pooling noninferiority studies to examine survival may help ensure the safety and efficacy of
new antibiotics. The association of tigecycline with excess deaths and noncure includes
indications for which i tis approved and marketed.
Tigecycline cannot be relied on in serious infections.
Editorial commentary: asking the right questions: morbidity, mortality and measuring what's
important in unbiased evaluations of antimicrobials.
Efficacy and safety of tigecycline for the treatment of infectious diseases: a meta-analysis
Tigecycline is not better than standard antimicrobial therapy.
High-dose, extended-interval colistin administration in critically ill patients: is this the
right dosing strategy? A preliminary study.
Dalfino L.
Clin Infect Dis. 2012, Jun., 54(12):1720-6
9 MU and a 9-MU twice-daily fractioned maintenance dose, titrated on renal function. Our
study shows that in severe infections due to COS gram-negative bacteria, the high-dose,
extended-interval CMS regimen has a high efficacy, without significant renal toxicity.
Zinc as adjunct treatment in infants aged between 7 and 120 days with probable serious
bacterial infection: a randomized, double-blind, placebo-controlled trial
Bhatnagar S.
Lancet 2012 June 2, 379(9831): 2027-8
To receive either 10 mg of zinc or placebo orally every day in addition to standard antibiotic
treatment. Significantly fewer treatment failures occurred in the zinc group (34/10%/) than in
the placebo group (55/17%/), relative risk reduction 40%, 95% CI 10-60, p=0.0113 absolute
risk reduction 6.8%, 1.5-12.0, p=0.0111).
3) Other viral and fungal infections
Risk of adverse fatal outcomes following administration of a pandemic influenza
A(H1N1)
JAMA 2012 Jul 11, 308(2): 165-74
Vaccine during pregnancy was not associated with a significantly increased risk of major birth
defects.
Risk of natalizumab-associated progressive multifocal leukoencephalopathy
N Engl J med 366(20): 1870-1880
Association between vaccination for herpes zoster and risk of herpes zoster infection
among alder patients with selected immune-mediated diseases
JAMA 308(1):43-49
Receipt of HZ vaccine was not associated with a short-term increase in HZ incidence.
The Effect of Therapeutic Drug Monitoring on Safety and Efficacy of Voriconazole in
Invasive Fungal Infections: A Randomized Controlled Trial
Routine TDM of voriconazole may reduce drug discontinuation due to adverse events and
improve the treatment response in invasive fungal infections.
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REFERENCES
1) Köser CU, Holden MT, Ellington MJ, Cartwright EJ, Brown NM, Ogilvy-Stuart AL,
Hsu LY, Chewapreecha C, Croucher NJ, Harris SR, Sanders M, Enright MC, Dougan
G, Bentley SD, Parkhill J, Fraser LJ, Betley JR, Schulz-Trieglaff OB, Smith GP,
Peacock SJ. Rapid whole-genome sequencing for investigation of a neonatal MRSA
outbreak. N Engl J Med. 2012 Jun 14;366(24):2267-75.
2) Sokolova, J. and Meningitis Research Team. Analysis of 104 cases of sepsis with
bacterial meningitis within 20 years of meningitis survery in Slovakia.
Neuroendocrinol Lett 2012; 33(Suppl.1):29–30
3) Haluskova, E., Miedz. Stud. Human, 2009, 2, 229 - 235
4) Kiwou, M., Haluskova, E. Korcek, V., Mutalova, M.: Clin Soc Work. 4,2012, 127
5) Haluskova, E., Miedz. Stud. Human, 2009, 1, 229 - 236
6) Kisac et al. Overview of 84 cases of meningococcal meningitis both from community
and hospital. Neuroendocrinol Lett 2012; 33(Suppl.1):21-22.
7) Haluskova, E., Miedz. Stud. Human 2010, 2, 217 - 224
8) Miller CE, Batra R, Cooper BS, Patel AK, Klein J, Otter JA, Kypraios T, French GL,
Tosas O, Edgeworth JD. An association between bacterial genotype combined with a
high-vancomycin minimum inhibitory concentration and risk of endocarditis in
methicillin-resistant Staphylococcus aureus bloodstream infection. Clin Infect Dis.
2012 Mar 1;54(5):591-600. doi: 10.1093/cid/cir858. Epub 2011 Dec 20.
167
CLINICAL SOCIAL WORK (CSW)
HEALTHY AGING AS ONE OF OBJECTIVES OF THE "HEALTH IN
THE 21ST CENTURY" PROGRAMME.
Ivica Gulašova,1 Lenka Görnerová,2 Jan Breza, jr.,3 Jan Breza4
1
St. Elizabeth University of Health & Social Sciences, Bratislava, Slovakia
College of Polytechnics, Jihlava, Czech Republic
3
Department of Urology and Centre for kidney transplantations, KramГЎre University
Hospital, Bratislava, Slovakia
4
Department of Urology and Centre for kidney transplantations, KramГЎre University
Hospital, Bratislava, Slovakia
2
ABSTRACT
This article deals with the issue of healthy aging. Attention is focused at the physical,
psychological, social and spiritual changes in aging humans. An important aspect affecting
the quality of life of seniors is their economic situation in old age, which is also analyzed.
Highlighted is the importance of developing of a suitable lifestyle which is related to their
interests and to performing of as much positive activities into old age as possible. The end of
article analyses the possibilities of professional activities for seniors and of preparations for
aging which include the elderly, their families and society as a whole complex.
Keywords
Psychological preparation for aging, lifestyle, changes in old age, friends
Introduction
There are different views on the old age. In ancient Greece and Rome, the ancient people
respected elderly and made them heads of government, teachers or counselors. In Egypt were
with elderly people fed crocodiles. Similar practices were using the ancient hunting and
nomad tribes who killed old people or forced them to commit suicide. Plato in his philosophy
praised old age because it deepens the wisdom of a man. Socrates feared old age, because old
people are often sick and have a number of diseases. For many years, mankind yearns for
longevity, seeking miraculous means to delay the arrival of old age. In particular, the women
in the higher circles wanted and longed to be eternally young and beautiful. Proof of this is
the legend of Countess BГЎtoriДЌka who has bathed in the blood of young virgins. Secrets of
long life were sought in live and dead water, life potions in a special tea of long life or in
immortality potion. None of them had the desired effect. They used the rejuvenating grass
roots of ginseng or human breast milk. Creating moral attitude to the elderly has always
depended and will depend on the overall atmosphere in the society.
To age worthily and wisely and to avoid early age onset of various limitations of old age is
largely in the hands of each of us. The course of aging affects number of factors, particularly
factors that show in middle age of everyone's life. The positive influences are good mental
state with which it is closely related to the socio - economic status. Negatively acts
particularly intense and long-term stress and serious physical or mental illnesses. Everyone's
life has periods of development: from birth through childhood, adolescence, maturity period
full of life, as well as old age. Aging is a natural process of physiological changes in the body,
which basically takes the entire human age, aging starts from birth and continue this process
even further, through the youth even if we do not even know it and it is natural and good. The
aging process of our body overcomes various changes, some visible, others less visible.
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CLINICAL SOCIAL WORK (CSW)
Healthy aging can be seen as a complex process consisting of several components. These
mainly include genetic factors, the effects of the external environment, lifestyle, ability to
adapt to changing conditions, good nutrition and physical activity and full life with loving
partner /Hegyi, KrajДЌГ­k, 2006/.
The last century has brought a huge change in lifestyle of inhabitants of industrialized
countries. It is now well known that the human age is prolonging and birth rate is declining,
and thus number of elderly people grows and working population decline. We say that the
population is aging.
While we are young and full of energy we do not see problems of old age. Modern society is
obsessed with youth, with personality cult of beautiful, slim, healthy, attractive and powerful
people, with a kind of fear of old age.
Active and fulfilling life in the senior age is best enjoyed when one is healthy. We distinguish
physiological – natural and premature aging. While the physiological aging is characterized
by a natural and gradual process that is characteristic to individuals of a given population,
premature aging is characterized by partial or total acceleration of the pace of aging, which
leads to the fact that the individual overcomes the natural physiological aging rate relating to
his inclusion in the population.
Premature aging is a declination from the natural course of this process related to the action of
various factors that can be recognized and overcome and to some extent removed. If
biological age overtakes chronological age, so it is obviously the premature aging, if the
biological age lags behind the chronological age, it is the promise of a longer active life.
Comparison of the biological age gives an objective idea of the pace of aging and of possible
longevity. Difference between chronological and biological age can be a of up to 10 years. It
means that two individuals of the same chronological age can be one to about 10 years
younger biologically. We should not only notice the negative things on the old age, but also
positive ones. Older people are more consistent in complying with laws, they engage in
community life, when going to work they have better attendance and have more responsible
approach to work. During the last 100 years the average life improved by about 20 years. For
the future it will be important how many people reach the age of 80 years. Scientific estimates
say that people could live for 120 years. This should be helped by latest medical knowledge.
Negative phenomenon of our time is the enlarging gap between generations, which indicate
the crisis of inter-human relationships.
Lifestyle of seniors
Among the most important factors that influence the aging process belongs undoubtedly the
lifestyle.
There are currently two models of lifestyle for seniors. Disengagement and idle theory and
passive acceptance of events were accepted by lovers of peaceful life without stress. Activity
Theory, which is associated with the effort to achieve a social necessity and usefulness by the
engaging in social, leisure, cultural, and political life and which by contrast features activities
and full participation in society.
Various studies have shown that the change of life at retirement leads to one or two preferred
activities, ie. basal activities. More than 17 percent of all seniors of both sexes would like to
continue in their professional activities, although at reduced scale. This effort is twice as
common in people with lower incomes, so it is likely that this is caused more by difficult
economic situation than by interest in the work. About 30 to 40 percent consider their
retirement apartment, house or garden as the ideal place to carry out their activities /Hegyi,
KrajДЌГ­k, 2006/. Craft activities are more common in men and usually are tied with their bluecollar past. About 50 percent of seniors are interested in picnics, walking and excursions.
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CLINICAL SOCIAL WORK (CSW)
During the 20th century disapeared multi-generational families and increased isolated
tendency of children and parents living separately with maintaining of their regular the
interaction. The trend of the past thirty years shows negative trends. About one fifth of the
current families is incomplete, fails at self-sufficiency and need help. Old people inhabit
mostly older and cheaper apartments and houses, often with low levels of amenities, with
many risks of accidents in the home. People who for various reasons cannot or do not want to
remain in their own home, but are still mobile and largely self-sufficient, can be placed in
nursing homes or in the pensions for elderly.
Professional activities of seniors
Depend on the labor market, health, objective needs and on life philosophy. It is proven that
active people live longer. Housewives after retirement actually remain on the job, they
perform home care and they often care about their life partner. Hard work persists in women
up to the age of 80 years and may be one of the positive reasons for their prolonged survival.
Too early retirement can negatively affect quality of life, health and life expectancy. On the
other hand, the transition to retirement should be a gradual process by shortening of working
hours or by to transferring to less exposed area adequate to education and health of the
worker. Very suitable for the active life of aging seniors are learning activities /Hegyi,
KrajДЌГ­k, 2006/. They are based on the fact that even in old age, one is able to acquire new
knowledge. The pace of teaching should be slower and individualized based on age, health
status, skills and knowledge. A very good way of learning are universities and academies of
the third age which in addition to new knowledge bring social contacts, meaning of life,
filling of free time and improvement of the quality of life. Academies offer candidates various
courses. Universities of the Third Age bring more challenging activities to seniors, for some it
requires not only participation, but also self-study, which is checked by trials. Groups,
political participation and other similar social activities demonstrate the integration of
individual and social groups. They help to increase the proportion of seniors in the activities
of society. Their activities are usually directed at improving the health and social situation of
the elderly, mutual assistance and participation in municipal management in matters relating
to seniors.
Sport activities of seniors
Maintaining physical fitness is a positive factor for longevity. During aging there is a decrease
in performance, in particular the strength and speed and the medium decrease of mobility and
balance. The condition of proper implementation of sporting activities is gradual loading of
the body, proper load and an appropriate choice of sport. Although the age limit in the sport
does not exist, the appropriateness relating current health condition should be taken into
account in sports activities. Priority is given to endurance exercise, inappropriate are isometric
and resistance exercises. As suitable sports for seniors are considered walking, swimming or
cycling. Doctors say that the exercise could be incorporated into our daily lives constantly,
even in old age. It is a drug that has a particularly positive effect not only on the body but
mind. This means that if we want to live to old age and be fit we should keep constantly in
physical activity. This activity is ideally real and regular sport, but an excellent alternative are
also regular walking and light stretching, which promotes brain activity, improves the ability
to concentrate and keep a good memory. Daily walking, swimming, or running help to
increase brain capacity, prevent many diseases, or help in their treatment /Stehen, George,
Ken, 2007/. Those who regularly move have more neurons, which mean better brain function.
Thanks to this, the seniors can effectively participate in many activities and remain selfsufficient for longer time. Moreover, the good news is that exercising people are happier and
they do not suffer from bad mood or depression.
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Preparing for aging
To remedy and support efficiencies of organism finds its expression in a lifetime preparing for
the aging that aims to prepare the individual to an active old age, preferably in good health,
well-being and the creative mood, in a dignified environment and social security. Long-term
preparations are made throughout all human life. It is part of education for marriage and
parenthood, health education, but also social and ethical education in schools and is shown in
appropriate attitudes towards aging and older generation.
Short-term training on aging begins around five years before reaching retirement age and the
emphasis is focused on health measures, psychological preparation for the change of social
role and for optimal solving of social issues associated with the smooth transition into
retirement. Preparation for aging can be divided to medical, psychological and social parts
/KЕ™ivohlavГЅ, 2004/.
Medical preparation for aging
Is based on prevention, early diagnosis of the disease, diagnosis and elimination of risk
factors, especially hypertension, obesity, smoking, hypercholesterolemia. It also includes
recommendations of physical activity appropriate to the maintenance of the principles of
personal and occupational hygiene.
Psychological preparation for aging
It is based on the principles of mental health and gerontopsychology. The positive influence to
mental functions, processes and states is made by constant stimulation with the appropriate
requirements in family and social life, at work, in sports and the meaningful use of leisure
time. Adversely affect the course of illness in the elderly. Mental health is also negatively
influenced by isolation, unilateralism, incorrect inappropriate attitudes towards aging and the
role of an aging man in society /LinhartovГЎ, 2007/. Social preparation to aging means to
ensure changes in the organization of work according to age, performance, education and
health condition of senior.
The transition from employment to retirement should be smooth and gradual, facilitated by
adjustment of working hours and change of job descriptions. Training is related also to social
and housing issues, food, length of holidays, leisure and so on. Preparing for the aging has
individual dimension, which consists of addressing of the medical, psychological and social
problems, particularly during the transition to retirement, but also the dimension of whole
society, creating conditions for greater understanding between generations. The main task of
preparations to the aging is view at aging and dealing with problems of own old age, such as
loss of physical and mental powers, retirement or coping with its own finali / KЕ™ivohlavГЅ,
2002/. With advancing age the social relations are narrowing and are less common, social
relations are getting worse also because in this period are highlighting such features as
egotism, selfishness, pedantness, suspiciousness, touchiness or handedness. But even old age
and aging can be lived through in health and happiness. Permanent physical and mental
activity, proper way of life or healthy diet are the most effective ways to fight premature
aging.
The role of family
The most important element that helps seniors to cope with the changes that brings age is the
family. Home environment and daily contact with loved ones has an irreplaceable role in the
emotional, social and psychological level of senior, when is his health weakening the social
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contacts are narrowing and dependence on aid increase. To fulfill this important role should
be created the external environment by developing a network of services which help families
to harmonize their work responsibilities with caring for elderly family members.
It is important to put these projects into practice through education and training in the field of
prevention and compliance with the principles of good lifestyle for seniors. Everyone should
take care for the slowing of their own aging to retain vitality into old age, but it also requires
some knowledge of the physiology of aging.
Factors affecting the health
Health is a state of complete physical, mental and social well-being. Health is influenced by
many different internal and external factors. Life and health are for the family and the senior
himself irreplaceable value. Human health is linked to culture. Positive health contributes to
welfare of people, to their job performance, the extension of active life and the joy of life.
Most diseases have their cause in the external environment. The bulk of diseases stems from
the overall environment of work, lifestyle, habits and behavior of people. To the factors
affecting the length and quality of life for senior citizens should be assigned also natural
factors and social factors. Natural factors are divided to physical, chemical and biological.
Physical factors include mechanical factors, thermic factors, lighting. This includes water,
soil, air and noise. Among biological agents belong also increased pressure, increased blood
sugar, low HDL cholesterol, overweight and obesity /HorЕ€ГЎk, 2000/. Social factors are
created by seniors themselves. The most important are the standard of living, life assurances,
interpersonal relations or working environment. Among the lifestyle factors belong smoking,
unhealthy diet, excessive alcohol intake or lack of physical activity. Alcohol has the effect on
increasing of the risk of injury, on occurrence of noncommunicable diseases and neurological,
mental or psychical diseases of the elderly people.
The factors that we cannot influence are age, sex and genetic dispositions. Modifiable factors
are education, welfare, financial income and working conditions. To the successful aging also
contributes the quality of air, which is very important factor for the health of whole
population. Other important components are living conditions of people. The quality of home
environment is reflected in health state. Very important is the presence of risk factors of
chemical, biological and physical nature but also influence of psychological and social
factors. Excessive stress is a risk factor which is in the last 20 years widely highlighted.
Almost everyone ever experienced effects of stress. The increased pace of life places greater
demands on people than it was before. This is caused by high work demands, by the economic
situation and also by the possibility of losing their jobs. Risks of effects of stress to our bodies
are impacts on mental health, development of psychosomatic diseases or effects on our
immune system. Depression and anxiety can affect all of us. They are a common source of
chronic diseases. Untreated depression can lead to suicide, job problems and marital problems
in the lives of seniors. Chronic depression can result into substance abuse or alcoholism
among seniors. Movement as a protective factor protects against the risk of diseases. Physical
activity, for example brisk walking, reduces the risk of serious chronic hypertension, heart
disease, diabetes or osteoporosis /Stehen, George, Ken, 2007/. Physical activity improves
quality of life in old age prevents signs of aging as for example decline in mental functions or
increase of subcutaneous fat of elderly. With regular physical activity at least once a day, we
can gain more energy during the day, reduce overweight and obesity, improve digestion and
digestive system function and better management of mental burdens. It is estimated that 70%
of the elderly has insufficient physical activity. Modern factor affecting the health of seniors
is poverty. Most often it is associated with low incomes, rising costs of living and with low
education. Seniors suffering from poverty have higher mortality, higher morbidity and have
limited access to services providing health care. Mental health in the elderly is one of the
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other factors affecting our mental health. It refers to a number of factors, life situations and
areas that may interact on disturbances of emotional balance and mental health of senior
citizens, but they also may, under certain conditions, have indispensable role in strengthening
or re-acquisition of their mental health. It covers all areas of life of elderly, with an emphasis
on their well-being and emotional balance. As a result of the application of the principles of
mental health is not strengthened only mental health but also physical health. These factors
include for example family, school, social relationships or self-education for seniors. One way
to effectively influence their health in a positive way is the knowledge and application of
principles of mental hygiene in their daily life. Subject of mental health are problems of
elderly, such as improper diet, fatigue, anxiety, emotional distress, poor social environment
and the possibilities of eliminating or at least mitigating of them, while taking into account the
whole person, which we perceive as a bio-psycho-social beГЎny /Stehen, George, Ken, 2007/.
Its overall objective is mental balance, mental health and healthy way of life of human in all
age periods. Another important component is prevention as part of health care. The goal is
prevention, protection, or restoration of health of the elderly people. The most common
diseases are cardiovascular diseases, cancer and allergies. Consideration should be given to
the regeneration process of our body. Regeneration is a natural part of life. Any activity leads
to more or less fatigue and each fatigue requires recovery.
We know the passive and the active form of regeneration. It is understood as the set of
measures to promote the recovery procedures, eliminating fatigue and restoration of physical
and mental performance of the elderly. There are used for example biological agents as proper
nutrition, physical stimulation in sauna, massages, spas, pharmacological agents are vitamins
and the psychological agents are music therapy or effective use of leisure time. With the
development of civilization was found that our bodies are badly affected by the negative
effects of noise. Acoustic load has increased many times /VacГ­novГЎ, LangovГЎ, 2011/. Noise
does not compromise the nervous system, but leads to disturbances in heart rhythm, blood
pressure, peptic ulcer disease, migraine and reduces resistance to infectious diseases. On other
hand sound waves can also heal. Sound and vibration are used by people since ancient ages.
Sound and music can affect blood sugar, peristalsis or the volume and speed of blood
circulation. Music that promotes balance of both hemispheres and the formation of alpha and
theta waves in the brain can be considered curative. Occupational diseases are diseases in
which injury has been caused in relation to the work and appear on the List of Occupational
Diseases. Records of occupational diseases are held in National Health Information Center in
cooperation with the Department of Occupational Medicine and Clinical Toxicology. They
are generally recorded in the list sorted according to diagnosed illnesses, not according to
professional groups. Seniors, however, know only a little about it.
Stress or illnesses caused by stress are not on the list of occupational diseases as diseases
caused by stress, because it is extremely difficult to prove the link to work. Stress, sedentary
job and working with people, however, may trigger chronic lifestyle diseases and health
disorders, such as cardiovascular disease, digestive disorders, disorders of mood and behavior
and even addictions. Climatic conditions also affect our health. They include extreme heat,
resulting in heat-related illnesses and heat stress, flooding that cause the rising incidence of
gastro - intestinal diseases through contamination of surface water, population migration
resulting in an increased risk of diseases as a result of the poor living conditions of migrants.
Important role in the aging process play biorhythms. From the birth is our body and mental
strength continuously affected by biorhythms. They affect what we do, what we feel and what
we think. For decades are the biorhythms disparaged and came up with the pace of life of
modern times. Biorhythm of each individual is based on date of birth.
We know of three types of biorhythms – physical, emotional and intellectual. They affect
alternately with many influences such as health status, age, environment or stress. Not
respecting of biorhythms results into mental disorders, neuroses, depressive moods and
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chronic fatigue.
It is assumed that the biorhythms lie in the beginning of all lifestyle diseases.
Nutrition and diet
Nutrition is an essential factor in the lifestyle to maintain health. Proper diet composition is an
essential component of prevention of cardio - vascular diseases. Biologically valuable food
covers the physiological needs of the elderly in proportion to their needs and to the conditions
of his environment in relation to age, sex or type of activities. It should include all substances
that the body needs. Its rationalization thus provides an opportunity to protect and save the
health. One way to prevent disease is lifestyle with a rational diet, maintaining proper body
weight, physical activity and the removal of harmful habits. The principles of good nutrition
should be followed from childhood to ensure the proper development of the organism.
Harmful is overfeeding with sweets, white flour products and foods and especially frequent
consumption of fast food and sugary drinks. Young people eating extremely unhealthy cooked
and baked dishes strongly stimulate the production of enzymes in the pancreas. Seniors do not
produce such a high number of those enzymes /VolekovГЎ, Е atnГ­k, 2008/. Their daily diet is
quite monotonous and does not provide them with the necessary amounts of vital nutrients.
What is the cause of pathological changes
One of the main factors is improper diet, a diet high in fat, excessively large amounts of
sugar, frequent and excessive salting that result in obesity, high blood pressure and
accelerated aging of vessels. In order to prevent the disease process of aging, our daily habits
should be changed. Ingestion of excessive amounts of alcohol and especially smoking
accelerates the formation of many diseases.
Conclusion
Active and meaningful life is best enjoyed when one is healthy. If someone tried to live for
his all life healthy lifestyle, he should be at an advantage in old age. This means eating
healthily, non-smoking, no alcohol consumption, moving appropriately to age and filling life
with positive mental and spiritual activities.
REFERENCES
HEGYI, L., KRAJДЊГЌK, Е . 2006. Geriatira pre praktickГ©ho lekГЎra. Bratislava: Herba, 2006,
394 s., ISBN 80- 89171-36-2
HORŇÁK, M. 2000. Urológia pre praktických lekárov. Bratislava: Herba, 2000, 264 s., ISBN
80-967994-2-8
K�IVOHLAVÝ, J. 2002. Konflikty mezi lidmi. Praha: Portál, 2002, 189 s., ISBN 80-7178642-X
K�IVOHLAVÝ, J. 2004. Pozitivní psychologie. Praha: Portál, 2004, 195 s., ISBN 80-7178835-X
LINHARTOVГЃ, V. 2007. PraktickГЎ komunikace v medicГ­nД›. Pro mediky, lГ©kaЕ™e a oЕЎetЕ™ujГ­cГ­
personГЎl. Praha: Grada Avicenum, 2007, 152 s., ISBN 978-80-247-1784-5
MUNZAROVГЃ, M. 2005. ZdravotnickГЎ etika od A do Z. Praha: Grada Avicenum. 2005, 153
s., ISBN 80-247-1024-2
STEPHEN, C. GEORGE., KEN WINSTON CAINE. 2007. Šest etap stárnutí – zdravý muž –
cesta dospД›lГ©ho muЕѕe k dokonalГ©mu zdravГ­. Praha: Colombus, 2007, 522 s., ISBN 978-807249-235-0
STEPHEN, C. GEORGE., KEN WINSTON CAINE. 2007. Psychické i fyzické mistrovství –
zdravГЅ muЕѕ. Praha: Colombus, 2007, 457 s., ISBN 978-80-7249-230-5
174
CLINICAL SOCIAL WORK (CSW)
VACГЌNOVГЃ, M., LANGOVГЃ, M. 2011. VybranГ© kapitoly z psychologie. Praha:
ДЊeskoslovenskГЅ spisovatel. 2011. 159 s., ISBN 978-80-7459-014-6
VOLEKOVГЃ, M., Е ATNГЌK, V. 2008. ManuГЎl klinickГ©m vГЅЕѕivy. Martin: Osveta, 2008, 95.s.,
ISBN 978-80-8063-274-8
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SOCIAL WORK WITH HOMELESS PEOPLE WITH TUBERCULOSIS
AND AIDS
I. Kmit, M. Spisiak, V. Stanislav, J. Srenkel, Z. Takacova, J. Zavodna, L. Andrejiova,
A. Arpova, K. Borsodiova, T. Democko, L. Elkova, A. Farkasova, S. Florekova, V. Graus,
T. Haluska, K. Hartmannova
Department of Social Work, Department of Public Health, SEUC Tropic team and PhD
programme Bratislava, Slovakia
Abstract:
Current issues on homelless problems with AIDS, Tuberculosis, Obesita, HIV and other
imported disordes (1-14) are critically argued by graduate schol PhD. social work fellows and
presented.
Prevalence of tuberculosis, hepatitis C virus, and HIV in homeless people: a systematic
review and meta-analysis, Ulla Beijer, Lancet Infect Dis 2012, 12: 859-70
100 million people worldwide are homeless; rates of mortality and morbidity are high in this
population. The contribution of infectious diseases to these adverse outcomes is uncertain.
Accurate estimates of prevalence data are important for public policy and planning and
development of clinical services tailored to homeless people. We aimed to establish the
prevalence of tuberculosis, hepatitis C virus, and HIV in homeless people.
We searched PubMed, Embase, and Cumulative Index to Nursing and Allied Health
Literature for studies of the prevalence of tuberculosis, hepatitis C virus, and HIV in homeless
populations. We also searched bibliographic indices, scanned reference lists, and
corresponded with authors. We explored potential sources of heterogeneity in the estimates by
metaregression analysis and calculated prevalence ratios to compare prevalence estimates for
homeless people with those for the general population.
We identified 43 eligible surveys with a total population of 63 812 (59 736 homeless
individuals when duplication due to overlapping samples was accounted for). Prevalences
ranged from 0В·2% to 7В·7% for tuberculosis, 3В·9% to 36В·2% for hepatitis C virus infection,
and 0В·3% to 21В·1% for HIV infection. We noted substantial heterogeneity in prevalence
estimates for tuberculosis, hepatitis C virus infection, and HIV infection (all Cochran's П‡2
significant at p<0·0001; I2=83%, 95% CI 76—89; 95%, 94—96; and 94%, 93—95;
respectively). Prevalence ratios ranged from 34 to 452 for tuberculosis, 4 to 70 for hepatitis C
virus infection, and 1 to 77 for HIV infection. Tuberculosis prevalence was higher in studies
in which diagnosis was by chest radiography than in those which used other diagnostic
methods and in countries with a higher general population prevalence than in those with a
lower general prevalence. Prevalence of HIV infection was lower in newer studies than in
older ones and was higher in the USA than in the rest of the world.
Heterogeneity in prevalence estimates for tuberculosis, hepatitis C virus, and HIV suggests
the need for local surveys to inform development of health services for homeless people. The
role of targeted and population-based measures in the reduction of risks of infectious diseases,
premature mortality, and other adverse outcomes needs further examination. Guidelines for
screening and treatment of infectious diseases in homeless people might need to be reviewed.
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Association of Schistosomiasis and HIV Infection in Tanzania, Jennifer A. Downs,
Am. J. Trop. Med. Hyg., 87(5), 2012, pp. 868-873
Animal and human studies suggest that Schistosoma mansoni infection may increase risk of
human immunodeficiency virus (HIV) acquisition. Therefore, we tested 345 reproductive age
women in rural Tanzanian villages near Lake Victoria, where S. mansoni is hyperendemic, for
sexually transmitted infections (STIs) and schistosomiasis by circulating anodic antigen
(CAA) serum assay. Over one-half (54%) had an active schistosome infection; 6% were HIVseropositive. By univariate analysis, only schistosome infection predicted HIV infection (odds
ratio [OR] = 3.9, 95% confidence interval = [1.3-12.0], P = 0.015) and remained significant
using multivariate analysis to control for age, STIs, and distance from the lake (OR = 6.2 [1.722.9], P = 0.006). HIV prevalence was higher among women with more intense schistosome
infections (P = 0.005), and the median schistosome intensity was higher in HIV-infected than
-uninfected women (400 versus 15 pg CAA/mL, P = 0.01). This finding suggests that S.
mansoni infection may be a modifiable HIV risk factor that places millions of people
worldwide at increased risk of HIV acquisition.
The Effect of HIV Infection on the Risk, Frequency and Intensity of Plasmodium
falciparum Parasitemia in Primigravid and Multigravid Women in Malawi,
Ella T. Nkhoma, Am. J. Trop. Med. Hyg., 87(6), 2012, pp. 1022-1027
Human immunodeficiency virus (HIV) is common in pregnant women in many malariaendemic regions and may increase risk of placental parasitemia. Placental malaria is more
common in primigravidae than multigravidae, but the relationship between HIV and malaria
across gravidities is not well characterized. We recruited pregnant Malawian women during
the second trimester and followed them until delivery. Parasitemia was assessed at
enrollment, follow-up visits, and delivery, when placental blood was sampled. There was no
difference in risk of parasitemia between HIV-positive and HIV-negative primigravidae.
Among multigravidae, HIV-infected women had greater than twice the risk of parasitemia as
HIV-uninfected women throughout follow-up. Human immunodeficiency virus was also
associated with more frequent peripheral parasitemia in multigravidae but not primigravidae.
Both HIV and primigravid status were independently associated with higher peripheral and
placental parasite densities. Although risk of parasitemia is lower in multigravidae than
primigravidae, the HIV effect on risk of malaria is more pronounced in multigravidae.
Nutritional supplementation: the additional costs of managing children infected with
HIV in resource-constrained settings, Cobb G., Tropical Medicine and International Health,
Vol. 18, No. 1, pp: 45-52, Jan 2013
To explore the financial implications of applying the WHO guidelines for the nutritional
management of HIV-infected children in a rural South African HIV programme.
WHO guidelines describe Nutritional Care Plans (NCPs) for three categories of HIV-infected
children: NCP-A: growing adequately; NCP-B: weight-for-age z-score (WAZ) ≤-2 but no
evidence of severe acute malnutrition (SAM), confirmed weight loss/growth curve flattening,
or condition with increased nutritional needs (e.g. tuberculosis); NCP-C: SAM. In resourceconstrained settings, children requiring NCP-B or NCP-C usually need supplementation to
achieve the additional energy recommendation. We estimated the proportion of children
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initiating antiretroviral treatment (ART) in the Hlabisa HIV Programme who would have been
eligible for supplementation in 2010. The cost of supplying 26-weeks supplementation as a
proportion of the cost of supplying ART to the same group was calculated.
A total of 251 children aged 6 months to 14 years initiated ART. Eighty-eight required 6month NCP-B, including 41 with a WAZ ≤-2 (no evidence of SAM) and 47 with a WAZ >-2
with co-existent morbidities including tuberculosis. Additionally, 25 children had SAM and
required 10-weeks NCP-C followed by 16-weeks NCP-B. Thus, 113 of 251 (45%) children
were eligible for nutritional supplementation at an estimated overall cost of $11 136, using
2010 exchange rates. These costs are an estimated additional 11.6% to that of supplying 26week ART to the 251 children initiated.
It is essential to address nutritional needs of HIV-infected children to optimise their health
outcomes. Nutritional supplementation should be integral to, and budgeted for, in HIV
programmes.
Biomarkers of Microbial Translocation and Macrophage Activation: Association With
Progression of Subclinical Atherosclerosis in HIV-1 Infection, Theodoros Kelesidis, The
Journal of Infectious Diseases 2012, 206: 1558-67
The relationships between soluble CD14 (sCD14), endotoxin (lipopolysaccharide [LPS]), and
progression of atherosclerosis have not been defined in human immunodeficiency virus (HIV)
infection.
We retrospectively assessed serum sCD14 and LPS levels of 91 subjects in a prospective 3year study of carotid artery intima-media thickness (CIMT) (AIDS Clinical Trials Group
[ACTG] 5078), where subjects were enrolled as risk factor-controlled triads of HIVuninfected (n = 36) and HIV-infected individuals with (n = 29) or without (n = 26) protease
inhibitor (PI)-based therapy for ≥2 years. The primary end point was the yearly rate of change
of CIMT (∆CIMT).
In multivariate analysis of the HIV-infected subjects, each 1 Вµg/mL above the mean of
baseline serum sCD14 corresponded to an additional 1.52 Вµm/y (95% confidence interval,
.07-2.98; P = .04) in the ∆CIMT. Every 100 pg/mL above the mean of baseline serum LPS
corresponded to an additional 0.49 Вµm/y (95% confidence interval, .18-.81; P = .003) in the
∆CIMT. However, in univariate analysis in the HIV-uninfected group sCD14 (P = .33) and
LPS (P = .27) levels were not associated with higher ∆CIMT. HIV infection and PI therapy
were not associated with baseline serum LPS and sCD14 levels (P > .1).
Our data are among the first to suggest that serum biomarkers of microbial translocation
(LPS) and macrophage activation (sCD14) predict subclinical atherosclerosis progression in
HIV-infected persons.
Empiric deworming to delay HIV disease progression in adults with HIV who are
ineligible for initiation of antiretroviral treatment (the HEAT study): a multi-site,
randomised trial, Judd Walson, Lancet Infect dis 2013, 12: 925-32
Co-infection with HIV and helminths is common in sub-Saharan Africa and findings from
previous studies have suggested that anthelmintic treatment might delay immunosuppression
in people with HIV. We aimed to assess the efficacy of empiric deworming of adults with
HIV in delaying HIV disease progression.
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In this non-blinded randomised trial, we enrolled adults (aged ≥18 years) with HIV who did
not meet criteria for the initiation of antiretroviral treatment from three sites in Kenya. Using
a computer-generated sequence, we randomly assigned (1:1) eligible participants to either
empiric albendazole every 3 months plus praziquantel annually (treatment group) or to
standard care (control group). Participants were followed up for 24 months. We measured
CD4 cell counts every 6 months and plasma HIV RNA annually. The primary endpoints were
a CD4 count of less than 350 cells per ВµL and a composite endpoint consisting of the first
occurrence of a CD4 count of less than 350 cells per ВµL, first reported use of antiretroviral
treatment, and non-traumatic deaths. We compared these measures by use of Cox proportional
hazards regression and Kaplan-Meier survival analyses. Primary analysis was done by
intention to treat. The trial was registered with ClinicalTrials.gov, number NCT0050722.
Between Feb 6, 2008, and June 21, 2011, we enrolled and followed-up 948 participants; 469
were allocated to the treatment group and 479 to the control group. All participants were
provided with co-trimoxazole prophylaxis. Median baseline CD4 cell counts and HIV RNA
concentrations did not differ between groups. We recorded no statistically significant
difference between the treatment and control groups in the number of people reaching a CD4
count of fewer than 350 cells per ВµL (41В·6 events per 100 person-years vs 46В·2 events per 100
person-years; hazard ratio 0В·89, 95% CI 0В·75-1В·06, p=0В·2) or the composite endpoint (44В·0
events per 100 person-years vs 49В·8 events per 100 person-years; 0В·88, 0В·74-1В·04, p=0В·1).
Serious adverse events, none of which thought to be treatment-related, occurred at a similar
frequency in both groups.
Our findings do not suggest an effect of empiric deworming in the delaying of HIV disease
progression in adults with HIV in an area where helminth infection is common. Alternative
approaches are needed to delay HIV disease progression in areas where co-infections are
common.
Early versus deferred antiretroviral therapy for children older than 1 year infected with
HIV (PREDICT): a multicentre, randomised, open-label trial, Thanyawee Puthanakit,
Lancet Infect dis 2013, 12: 933-41
The optimum time to start antiretroviral therapy for children diagnosed with HIV infection
after 1 year of age is unknown. We assessed whether antiretroviral therapy could be deferred
until CD4 percentages declined to less than 15% without affecting AIDS-free survival.
In our multicentre, randomised, open-label trial at nine research sites in Thailand and
Cambodia, we enrolled children aged 1-12 years who were infected with HIV and had CD4
percentages of 15-24%. Participants were randomly assigned (1:1) by a minimisation scheme
to start antiretroviral therapy at study entry (early treatment group) or antiretroviral therapy to
start when CD4 percentages declined to less than 15% (deferred treatment group). The
primary endpoint was AIDS-free survival (based on US Centers for Disease Control and
Prevention category C events) at week 144, assessed with the Kaplan-Meier analysis and the
log-rank approach. This study is registered with ClinicalTrials.gov, number NCT00234091.
Between March 28, 2006, and Sept 10, 2008, we enrolled 300 Thai and Cambodian children
infected with HIV, with a median age of 6В·4 years (IQR 3В·9-8В·4). 150 children were randomly
allocated early antiretroviral therapy (one participant was excluded from analyses after
withdrawing before week 0) and 150 children were randomly allocated deferred antiretroviral
therapy. Median baseline CD4 percentage was 19% (16-22%). 69 children (46%) in the
deferred treatment group started antiretroviral therapy during the study. AIDS-free survival at
week 144 in the deferred treatment group was 98В·7% (95% CI 94В·7-99В·7; 148 of 150 patients)
compared with 97В·9% (93В·7-99В·3; 146 of 149 patients) in the early treatment group (p=0В·6).
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AIDS-free survival in both treatment groups was high. This low event rate meant that our
study was underpowered to detect differences between treatment start times and thus
additional follow-up of study participants or future studies are needed to answer this clinical
question.
Highly Active Antiretroviral Therapy and Adverse Birth Outcomes Among HIVInfected Women in Botswana, Jennifer Y. Chen, JID 2012, 206, 1 Dec.
It is unknown whether adverse birth outcomes are associated with maternal highly active
antiretroviral therapy (HAART) in pregnancy, particularly in resource-limited settings.
We abstracted obstetrical records at 6 sites in Botswana for 24 months. Outcomes included
stillbirths (SBs), preterm delivery (PTD), small for gestational age (SGA), and neonatal death
(NND). Among human immunodeficiency virus (HIV)-infected women, comparisons were
limited to HAART exposure status at conception, and those with similar opportunities for
outcomes. Comparisons were adjusted for CD4(+) lymphocyte cell count.
Of 33,148 women, 32,113 (97%) were tested for HIV, of whom 9504 (30%) were HIV
infected. Maternal HIV was significantly associated with SB, PTD, SGA, and NND.
Compared with all other HIV-infected women, those continuing HAART from before
pregnancy had higher odds of PTD (adjusted odds ratio [AOR], 1.2; 95% confidence interval
[CI], 1.1, 1.4), SGA (AOR, 1.8; 95% CI, 1.6, 2.1) and SB (AOR, 1.5; 95% CI, 1.2, 1.8).
Among women initiating antiretroviral therapy in pregnancy, HAART use (vs zidovudine)
was associated with higher odds of PTD (AOR, 1.4; 95% CI, 1.2, 1.8), SGA (AOR, 1.5; 95%
CI, 1.2, 1.9), and SB (AOR, 2.5; 95% CI, 1.6, 3.9). Low CD4(+) was independently
associated with SB and SGA, and maternal hypertension during pregnancy with PTD, SGA,
and SB.
HAART receipt during pregnancy was associated with increased PTD, SGA, and SB.
Previously Transmitted HIV-1 Strains Are Preferentially Selected During Subsequent
Sexual Transmission, Andrew D. Redd, JID 2012, 206, 1 November
A genetic bottleneck is known to exist for human immunodeficiency virus (HIV) at the point
of sexual transmission. However, the nature of this bottleneck and its effect on viral diversity
over time is unclear.
Interhost and intrahost HIV diversity was analyzed in a stable population in Rakai, Uganda,
from 1994 to 2002. HIV-1 envelope sequences from both individuals in initially HIVdiscordant relationships in which transmission occurred later were examined using Sanger
sequencing of bulk polymerase chain reaction (PCR) products (for 22 couples), clonal
analysis (for 3), and next-generation deep sequencing (for 9).
Intrahost viral diversity was significantly higher than changes in interhost diversity (P < .01).
The majority of HIV-1-discordant couples examined via bulk PCR (16 of 22 couples), clonal
analysis (3 of 3), and next-generation deep sequencing (6 of 9) demonstrated that the viral
populations present in the newly infected recipient were more closely related to the donor
partner's HIV-1 variants found earlier during infection as compared to those circulating near
the estimated time of transmission (P = .03).
These findings suggest that sexual transmission constrains viral diversity at the population
level, partially because of the preferential transmission of ancestral as opposed to
contemporary strains circulating in the transmitting partner. Future successful vaccine
strategies may need to target these transmitted ancestral strains.
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CLINICAL SOCIAL WORK (CSW)
Modest Nonadherence to Antiretroviral Therapy promotes Residual HIV-1 Replication
in the Absence of Virological Rebound in Plasma, Alexander O. Pasternak, JID 2012, 206,
1 November
Modern antiretroviral therapy (ART) regimens are widely assumed to forgive modest
nonadherence, because virological suppression in plasma is common at adherence levels of
>70%. Yet, it is unknown whether human immunodeficiency virus type 1 (HIV-1) replication
is completely suppressed at these levels of adherence.
We longitudinally quantified levels of cell-associated HIV-1 RNA and DNA in 40 patients
(median duration of successful ART before study initiation, 46 months), whose 1-week
adherence to therapy prior to the sampling moments was measured electronically.
Patients were constantly 100% adherent (the optimal-adherence group), demonstrated
improving adherence over time (the improving-adherence group), or neither of the above (the
poor-adherence group). Adherence never decreased to <70% in any patient, and no rebound in
plasma virological levels was observed. Nevertheless, poor adherence but not optimal or
improving adherence caused a significant longitudinal increase in cell-associated HIV RNA
levels (P = .006). Time-weighted changes and regression slopes of viral RNA load for the
poor-adherence group were significantly higher than those for the optimal-adherence group (P
< .01).
Because ART only blocks infection of new cells but not viral RNA transcription in cells
infected before therapy initiation, the observed effects strongly suggest that modest
nonadherence can cause new cycles of HIV-1 replication that are undetectable by commercial
plasma viral load assays.
Diagnosis, Clinical Presentation and In-Hospital Mortality of Severe Malaria in HIVCoinfected Children and Adults in Mozambique, Iise C. Hendriksen, CID 2012, 55
/October/
Severe falciparum malaria with human immunodeficiency virus (HIV) coinfection is common
in settings with a high prevalence of both diseases, but there is little information on whether
HIV affects the clinical presentation and outcome of severe malaria.
HIV status was assessed prospectively in hospitalized parasitemic adults and children with
severe malaria in Beira, Mozambique, as part of a clinical trial comparing parenteral
artesunate versus quinine (ISRCTN50258054). Clinical signs, comorbidity, complications,
and disease outcome were compared according to HIV status.
HIV-1 seroprevalence was 11% (74/655) in children under 15 years and 72% (49/68) in adults
with severe malaria. Children with HIV coinfection presented with more severe acidosis,
anemia, and respiratory distress, and higher peripheral blood parasitemia and plasma
Plasmodium falciparum histidine-rich protein-2 (PfHRP2). During hospitalization,
deterioration in coma score, convulsions, respiratory distress, and pneumonia were more
common in HIV-coinfected children, and mortality was 26% (19/74) versus 9% (53/581) in
uninfected children (P < .001). In an age- and antimalarial treatment-adjusted logistic
regression model, significant, independent predictors for death were renal impairment,
acidosis, parasitemia, and plasma PfHRP2 concentration.
Severe malaria in HIV-coinfected patients presents with higher parasite burden, more
complications, and comorbidity, and carries a higher case fatality rate. Early identification of
HIV coinfection is important for the clinical management of severe malaria.
181
CLINICAL SOCIAL WORK (CSW)
An Updated Systematic Review and Meta-analysis on the Treatment of Active
Tuberculosis in Patients With HIV Infection, Faiz Ahmad Khan, CID 2012, 55 /October/
Human immunodeficiency virus (HIV) infection increases the risk of poor outcomes in active
tuberculosis. We updated a systematic review and meta-analysis assessing the effects of
duration of rifamycins, schedule of dosing, and antiretroviral therapy (ART) on failure,
relapse, death during treatment, and acquired drug resistance (ADR) in patients with HIV and
active tuberculosis.
We searched for randomized control trials (RCTs) and observational studies published
between January 2008 and November 2011. We pooled risk differences (RD) from RCTs
comparing rifampin for ≥9 months and 6 months. Within strata of the 3 treatment covariates,
we calculated pooled risks and adjusted odds ratios (aORs) using outcomes from RCTs and
observational studies.
After screening 2293 citations, 7 studies were added in the update. Risk of relapse was
lowered with rifampin treatment for ≥9 months compared with 6 months (pooled RD = -9.1%;
95% CI, -16.5, -1.8). Odds of relapse were higher with shorter durations of rifamycins (aOR 2
vs ≥8 months = 5.0 [1.9, 13.2]; 6 vs ≥8 months = 2.4 [1.2, 5.0]) and in the absence of ART
(aOR = 14.3, [2.1, 97.8]). Post hoc meta-regression restricted to arms with ART demonstrated
no associations between rifamycin duration, dosing schedule, and outcomes.
In patients with HIV and active tuberculosis, ART reduces the risk of TB relapse. Use of
rifamycins for ≥8 months and daily dosing in the intensive phase also improve TB treatment
outcomes; however, a paucity of evidence makes their importance less clear for patients on
ART. There is an urgent need to increase the number of coinfected patients receiving ART.
Underutilization of Aspirin for Primary Prevention of Cardiovascular Disease Among
HIV-Infected Patients, Greer A. Burkholder, Clinical Infectios Diseases 2012,55(11):1550-7
Individuals infected with human immunodeficiency virus (HIV) are at increased risk for
cardiovascular disease (CVD) events compared with uninfected persons. However, little is
known about HIV provider practices regarding aspirin (ASA) for primary prevention of CVD.
A cross-sectional study was conducted among patients attending the University of Alabama at
Birmingham 1917 HIV Clinic during 2010 to determine the proportion receiving ASA for
primary prevention of CVD and identify factors associated with ASA prescription. Ten-year
risk for CVD events was calculated for men aged 45-79 and women aged 55-79. The 2009 US
Preventive Services Task Force (USPSTF) guidelines were used to determine those qualifying
for primary CVD prevention.
Among 397 patients who qualified to receive ASA (mean age, 52.2 years, 94% male, 36%
African American), only 66 (17%) were prescribed ASA. In multivariable logistic regression
analysis, diabetes mellitus (odds ratio [OR], 2.60; 95% confidence interval [CI], 1.28-5.27),
hyperlipidemia (OR, 3.42; 95% CI, 1.55-7.56), and current smoking (OR, 1.87; 95% CI, 1.033.41) were significantly associated with ASA prescription. Odds of ASA prescription more
than doubled for each additional CVD-related comorbidity present among hypertension,
diabetes, hyperlipidemia, and smoking (OR, 2.13, 95% CI, 1.51-2.99).
In this HIV-infected cohort, fewer than 1 in 5 patients in need received ASA for primary CVD
prevention. Escalating likelihood of ASA prescription with increasing CVD-related
comorbidity count suggests that providers may be influenced more by co-occurrence of these
diagnoses than by USPSTF guidelines. In the absence of HIV-specific guidelines,
182
CLINICAL SOCIAL WORK (CSW)
interventions to improve HIV provider awareness of and adherence to existing general
population guidelines on CVD risk reduction are needed.
Characterization of HIV-1 antiretroviral drug resistance after second-line treatment
failure in Mali a limited-resources setting, Almoustapha Issiaka Maiga, J Antimicrob
Chemother 2012, 67: 2943-2948
We describe the outcomes of second-line drug resistance profiles and predict the efficacy of
drugs for third-line therapy in patients monitored without the benefit of plasma HIV-1 RNA
viral load (VL) or resistance testing.
We recruited 106 HIV-1-infected patients after second-line treatment failure in Mali. VL was
determined by the Abbott RealTime system and the resistance by the ViroSeq HIV-1
genotyping system. The resistance testing was interpreted using the latest version of the
Stanford algorithm.
Among the 106 patients, 93 had isolates successfully sequenced. The median age, VL and
CD4 cells were respectively 35 years, 72 000 copies/mL and 146 cells/mm(3). Patients were
exposed to a median of 4 years of treatment and to six antiretrovirals. We found 20% of wildtype viruses. Resistance to etravirine was noted in 38%, to lopinavir in 25% and to darunavir
in 12%. The duration of prior nucleos(t)ide reverse transcriptase inhibitor exposure was
associated with resistance to abacavir (P < 0.0001) and tenofovir (P = 0.0001), and duration of
prior protease inhibitor treatment with resistance to lopinavir (P < 0.0001) and darunavir
(P = 0.06).
Long duration of therapy prior to failure was associated with high levels of resistance and is
directly related to limited access to VL monitoring and delayed switches to second-line
treatment, precluding efficacy of drugs for third-line therapy. This study underlines the need
for governments and public health organizations to recommend the use of VL monitoring and
also the availability of darunavir and raltegravir for third-line therapies in the context of
limited-resource settings.
Feasibility and benefits of scaling up antiretroviral treatment provision with the 2010
WHO antiretroviral therapy guidelines in rural Lesotho, Helen Bygrave, International
Health 4, 2012, 170-175
The latest WHO guidelines (2010) for antiretroviral therapy (ART) in adults and adolescents
recommend that countries should progressively reduce the use of stavudine in favour of
tenofovir or zidovudine and that ART initiation commence at an earlier CD4 threshold of
<350 cell/mm3. In Lesotho, a high-burden, resource-limited setting, these two changes had
been recommended since late 2007. A number of practical steps were taken to support
implementation of Lesotho's national ART guidelines at the program level including:
development of guidelines tailored to nurses working in primary care settings; training and
clinical mentorship of different levels of health care workers; laboratory support; pharmacy
support; and monitoring and evaluation. Clinical and programmatic benefits included
decreased mortality, toxicity, and simplified patient management that was supportive of the
decentralized, nurse-led model of care. This experience demonstrates that, despite limited
resources, it was feasible to provide a standard of care similar to that of western guidelines
and that these changes were supportive of simplified patient management.
183
CLINICAL SOCIAL WORK (CSW)
REFERENCES:
1) Ulla Beijer, Prevalence of tuberculosis, hepatitis C virus, and HIV in homeless people:
a systematic review and meta-analysis, Lancet Infect Dis 2012, 12: 859-70
2) Jennifer A. Downs, Association of Schistosomiasis and HIV Infection in Tanzania,
Am. J. Trop. Med. Hyg., 87(5), 2012, pp. 868-873
3) Ella T. Nkhoma, The Effect of HIV Infection on the Risk, Frequency and Intensity of
Plasmodium falciparum Parasitemia in Primigravid and Multigravid Women in
Malawi, Am. J. Trop. Med. Hyg., 87(6), 2012, pp. 1022-1027
4) Haluskova, E., Miedz. Stud. Human, 2009, 2, 229 - 235
5) Kiwou, M., Haluskova, E. Korcek, V., Mutalova, M.: Clin Soc Work. 4,2012, 127
6) Haluskova, E., Miedz. Stud. Human, 2009, 1, 229 - 236
7) Haluskova, E., Miedz. Stud. Human 2010, 2, 217 - 224
8) Sirotiakova J., Minarik P., Kopernicka Z., Magulova L., Piesecka L., Zak V.,
Liskova A.: Linezolid in the treatment of complicated gram positive infections by
critically ill patients, Clinical & Experimental Pharmacology and physiology, 2004,
31, Suppl. A114
9) Sirotiakova J., Minarik P., Hoppman M.: Screening of risk factors in the population of
40 years' men and women in Nitra region, importance of primary prevention.
Coronary Artery Disease, 2007, 1(7), s. 137
10) Dukat A., Lietava J., Krahulec B., Caprnda M., Vacula I., Kosmalova V., Minarik P.:
The prevalence of abdominal obesity in Slovakia. The IDEA Slovakia study, Vnitr.
Lek. 2007, 53(4), s. 326-30
11) Hoppman M., Minarik P., Sirotiakova J.: New possibilities in the treatment of
hypertension in pregnancy – looking for the effective and safe drug of future. Interna
medicina, 7 (1), 2007, s. 58
12) Minarik P., Hoppman M., Sirotiakova J.: Screening of risk factors in the population of
40 years men and women in Nitra region, regarding to the importance of primary
prevention, Interna mediciny, 7 (1), 2007, s. 58
13) Greer A. Burkholder, Underutilization of Aspirin for Primary Prevention of
Cardiovascular Disease Among HIV-Infected Patients, Clinical Infectios Diseases
2012,55(11):1550-7
14) Almoustapha Issiaka Maiga, Characterization of HIV-1 antiretroviral drug resistance
after second-line treatment failure in Mali a limited-resources setting, J Antimicrob
Chemother 2012, 67: 2943-2948
184
CLINICAL SOCIAL WORK (CSW)
SOCIAL WORK WITH TUBERCULOSIS AND LEPROSY PATIENTS:
NEW TREATMENT AND NEW HOPES
J. Bordacova, I. Kmit, J. Benca, M. Heverova, A. Karasova, J. Kmec, A. Kurnat, P. Matysak,
J. Mulik, V. Novak, A. Ondrejkova, P. Orendac, T. Potomova, K. Rakova, K. Raslova,
K. Valachova, M. Bardiovsky, K. Bugalova
Department of Social Work, Department of Public Health, SEUC Tropic team and PhD
programme Bratislava, Slovakia
ABSTRACT
Newest data on Social work with tuberculosis, obesity, leprosy, diabetes and aids patients
who are homelles on have any social distress (1-12) are reviewed by St. Elisabeth tropical
programe and analyzed.
14-day bactericidal activity of PA-824, bedaquiline, pyrazinamide, and moxifloxacin
combinations: a randomised trial, Andreas H. Diacon, Lancet 2012, 380: 986-93
New drugs, but also shorter, better-tolerated regimens are needed to tackle the high global
burden of tuberculosis complicated by drug resistance and retroviral disease. We investigated
new multiple-agent combinations over the first 14 days of treatment to assess their suitability
for future development.
In this prospective, randomised, early bactericidal activity (EBA) study, treatment-naive,
drug-susceptible patients with uncomplicated pulmonary tuberculosis were admitted to
hospitals in Cape Town, South Africa, between Oct 7, 2010, and Aug 19, 2011. Patients were
randomised centrally by computer-generated randomisation sequence to receive bedaquiline,
bedaquiline-pyrazinamide, PA-824-pyrazinamide, bedaquiline-PA-824, PA-824moxifloxacin-pyrazinamide, or unmasked standard antituberculosis treatment as positive
control. The primary outcome was the 14-day EBA assessed in a central laboratory from the
daily fall in colony forming units (CFU) of M tuberculosis per mL of sputum in daily
overnight sputum collections. Bilinear regression curves were fitted for each group separately
and groups compared with ANOVA for ranks, followed by pair-wise comparisons adjusted
for multiplicity. Clinical staff were partially masked but laboratory personnel were fully
masked. This study is registered, NCT01215851.
The mean 14-day EBA of PA-824-moxifloxacin-pyrazinamide (n=13; 0В·233 [SD 0В·128]) was
significantly higher than that of bedaquiline (14; 0В·061 [0В·068]), bedaquiline-pyrazinamide
(15; 0В·131 [0В·102]), bedaquiline-PA-824 (14; 0В·114 [0В·050]), but not PA-824-pyrazinamide
(14; 0В·154 [0В·040]), and comparable with that of standard treatment (ten; 0В·140 [0В·094]).
Treatments were well tolerated and appeared safe. One patient on PA-824-moxifloxacinpyrazinamide was withdrawn because of corrected QT interval changes exceeding criteria
prespecified in the protocol.
PA-824-moxifloxacin-pyrazinamide is potentially suitable for treating drug-sensitive and
multidrug-resistant tuberculosis. Multiagent EBA studies can contribute to reducing the time
needed to develop new antituberculosis regimens.
185
CLINICAL SOCIAL WORK (CSW)
Prevalence of and risk factors for resistance to second-line drugs in people with
multidrug-resistant tuberculosis in eight countries: a prospective cohort study, Tracy
Dalton, Lancet 2012, 380: 1406-17
The prevalence of extensively drug-resistant (XDR) tuberculosis is increasing due to the
expanded use of second-line drugs in people with multidrug-resistant (MDR) disease. We
prospectively assessed resistance to second-line antituberculosis drugs in eight countries.
From Jan 1, 2005, to Dec 31, 2008, we enrolled consecutive adults with locally confirmed
pulmonary MDR tuberculosis at the start of second-line treatment in Estonia, Latvia, Peru,
Philippines, Russia, South Africa, South Korea, and Thailand. Drug-susceptibility testing for
study purposes was done centrally at the Centers for Disease Control and Prevention for 11
first-line and second-line drugs. We compared the results with clinical and epidemiological
data to identify risk factors for resistance to second-line drugs and XDR tuberculosis.
Among 1278 patients, 43В·7% showed resistance to at least one second-line drug, 20В·0% to at
least one second-line injectable drug, and 12В·9% to at least one fluoroquinolone. 6В·7% of
patients had XDR tuberculosis (range across study sites 0·8—15·2%). Previous treatment
with second-line drugs was consistently the strongest risk factor for resistance to these drugs,
which increased the risk of XDR tuberculosis by more than four times. Fluoroquinolone
resistance and XDR tuberculosis were more frequent in women than in men. Unemployment,
alcohol abuse, and smoking were associated with resistance to second-line injectable drugs
across countries. Other risk factors differed between drugs and countries.
Previous treatment with second-line drugs is a strong, consistent risk factor for resistance to
these drugs, including XDR tuberculosis. Representative drug-susceptibility results could
guide in-country policies for laboratory capacity and diagnostic strategies.
US Agency for International Development, Centers for Disease Control and Prevention,
National Institutes of Health/National Institute of Allergy and Infectious Diseases, and
Korean Ministry of Health and Welfare.
Systematic review and meta-analysis of the associations between indoor air pollution
and tuberculosis, Colin Sumpter, Tropical Medicine and International Health, Vol. 18, No: 1,
101-108, Jan 2013
Half the world's population uses biomass fuel for their daily needs but the resultant emissions
and indoor air pollution (IAP) are harmful to health. So far, evidence for a link between IAP
and tuberculosis (TB) was insufficient. We report an updated systematic review due to recent
increase in the evidence and growing interest in testing interventions.
Systematic search of PubMed (including Medline), CAB abstracts (through Ovid SP) and
Web of Knowledge using the following search terms: 'IAP or biomass or cooking smoke' and
'TB'. 452 abstracts were reviewed, and only 12 articles were deemed to be reporting the
effects of IAP on TB and were taken forward to full review, and one study was added through
hand search of references. Data on measures of effect of IAP on TB were extracted, and metaanalysis was carried out to estimate pooled measures of effect.
Thirteen studies have reported investigating association between IAP and TB since 1996. TB
cases are more likely to be exposed to IAP than healthy controls (pooled OR 1.30; 95% CI,
1.04-1.62; P = 0.02).
There is increasingly strong evidence for an association between IAP and TB. Further studies
are needed to understand the burden of TB attributable to IAP. Interventions such as clean
cook stoves to reduce the adverse effects of IAP merit rigorous evaluation, particularly in
Africa and India where the prevalence of IAP and TB is high.
186
CLINICAL SOCIAL WORK (CSW)
Costs of inpatient treatment for multi-drug-resistant tuberculosis in South Africa
Kathryn Schnippel, Tropical Medicine and International Health, Vol. 18, No: 1, 116-108, Jan
2013
In South Africa, patients with multi-drug-resistant tuberculosis (MDR-TB) are hospitalised
from MDR-TB treatment initiation until culture conversion. Although MDR-TB accounts for
<3% of incident TB in South Africa, 55% of the public sector TB budget is spent on MDRTB. To inform new strategies for MDR-TB management, we estimated the per-patient cost
(USD 2011) of inpatient MDR-TB treatment.
All resources used by patients admitted to the MDR-TB hospital with confirmed MDR-TB
from March 2009 to February 2010 were abstracted from patient records for up to 12 months
after initial admission or until the earliest of final discharge, abscondment or death. Costs of
hospital stay/day were estimated from hospital expenditure records and costs for drugs,
laboratory tests, radiography and surgery from public sector sources. 133 patients met study
inclusion criteria of whom 121 had complete cost records.
By 12 months, 86% were discharged with culture conversion, 8% died in hospital, 2% were
still admitted, and 3% had absconded. The mean hospital stay was 105 days. The mean total
cost per patient was $17 164, of which 95% were hospitalisation costs (buildings, staff, etc.)
and ≤ 2% each for MDR-TB drugs ($380); TB laboratory tests, including drug susceptibility
testing ($236); and other costs.
The inpatient cost per patient treated for MDR-TB is more than 40 times the cost of treating
drug-susceptible TB in South Africa. There is potential for substantial cost savings from
improved management of drug-susceptible TB and shifting to a model of decentralised,
outpatient MDR-treatment.
The burden of tuberculosis in crisis-affected populations: a systematic review, William
Kimbrough, Lancet Infect dis 2012, 12: 950-65
Crises caused by armed conflict, forced population displacement, or natural disasters result in
high rates of excess morbidity and mortality from infectious diseases. Many of these crises
occur in areas with a substantial tuberculosis burden. We did a systematic review to
summarise what is known about the burden of tuberculosis in crisis settings. We also analysed
surveillance data from camps included in UN High Commissioner for Refugees (UNHCR)
surveillance, and investigated the association between conflict intensity and tuberculosis
notification rates at the national level with WHO data. We identified 51 reports of
tuberculosis burden in populations experiencing displacement, armed conflict, or natural
disaster. Notification rates and prevalence were mostly elevated; where incidence or
prevalence ratios could be compared with reference populations, these ratios were 2 or higher
for 11 of 15 reports. Case-fatality ratios were mostly below 10% and, with exceptions, drugresistance levels were comparable to those of reference populations. A pattern of excess risk
was noted in UNHCR-managed camp data where the rate of smear testing seemed to be
consistent with functional tuberculosis programmes. National-level data suggested that
conflict was associated with decreases in the notification rate of tuberculosis. More studies
with strict case definitions are needed in crisis settings, especially in the acute phase, in
internally displaced populations and in urban settings. Findings suggest the need for early
establishment of tuberculosis services, especially in displaced populations from high-burden
areas and for continued innovation and prioritisation of tuberculosis control in crisis settings.
187
CLINICAL SOCIAL WORK (CSW)
Year(s) of
displacement,
war, or
disaster
Refugee camps
Cambodian
1979
refugees in
Thailand
(1981–84)30
Type of
study
Case
definition;
type of cases
Notification rate
reported
(cases/personyears*)
Rate ratio
for
comparison
with
notification
rate in
reference
populations
(reference
notification
rate)
Rate ratio
for
comparison
with
estimated
incidence
in
reference
populations
(reference
incidence)
Strength of
evidence
Clinicbased
surveillance
Smear/WHO;
aTB, pTB
500 (629/125 800)
aTB; 240
(302/125 800) ss+
pTB
Cambodia
(1982–
84):313В·4
(145) aTB;
2В·7 (89) ss+
pTB
NA
Medium
Nicaraguan
refugees in
Costa Rica
(1985)32
1983–85
Clinicbased
surveillance
Smear;
smearpositive; pTB
400 (5/1160)
Nicaragua:
8В·0 (50)33
Costa Rica:
25В·0 (16)34
NA
Lower
Ethiopian
refugees in
eastern
Sudan
(1986–90)35
1967–83
(about 30% of
refugees);
1984–85
(about 70%)
Clinicbased
surveillance
Smear; ss+
pTB
1986 (1510); 1987
(790); 1988 (630);
1990 (450)‡
Ethiopia: NA
Sudan: NA
NA
Lower
Somali and
Sudanese
refugees in
Kenya
(1992–93)36
1991–94
Clinicbased
surveillance
Smear/WHO;
aTB, ss+
pTB
1142
(3116/272 800)
aTB; 453
(1235/272 800) ss+
pTB
Kenya: 16В·7
(69) aTB,
12В·9 (35)
ss+pTB
Somalia: NA
Sudan: 11В·4
(101) aTB,
NA ss+pTB
Kenya: 7·1–
8·8 (130–
161) aTB
Somalia:
3·0–5·7
(202–383)
aTB
Sudan: 7·2–
13·5 (85–
160) aTB
Medium
Tibetan
refugees in
India
(1994, 96)37
1959
Clinicbased
surveillance
and camp
screening
Smear/WHO;
aTB
1994–96 (980
[1575/160 018]);
1994 (1090); 1995
(1100); 1996 (770)
China: 27В·2
(36)
India: 7В·8
(126)
China: 6·3–
9·3 (105–
155)
India: 4·0–
5·2 (189–
246)
Higher
Tibetan
refugees in
India
(1994–96)38
1959
Clinicbased
surveillance
and camp
screening
Smear/WHO;
aTB
835 (1197/143 373)
China: 23В·2
(36)
India: 6В·6
(126)
China: 5·4–
8·0 (105–
155)
India: 3·4–
4·4 (189–
246)
Higher
Bhutanese
refugees in
Nepal
(1999–
2004)39
1990–98
(peak in 1992)
National
programme
data
Smear/WHO;
aTB, ss+
pTB
242 (1214/501 653)
aTB; 126
(631/501 653) new
ss+ pTB
Bhutan: 1В·3
(181) aTB;
2В·1 (59) new
ss+ pTB
Nepal: 2В·0
(119) aTB;
2В·3 (55) new
ss+ pTB
Bhutan:
0·9–1·3
(189–278)
aTB
Nepal: 1·2–
1·8 (133–
197) aTB
Higher
Burmese
refugees in
Thailand
(1987–
2005)40
1984–2004
Clinicbased
surveillance
WHO; aTB
122 (978/NA); sharp
increase from 1987
(22) to 1991 (212),
then gradual
decrease to 2005
(43)
Burma
(1990–2005):
1В·5 (81)
Thailand
(1990–2005):
1В·7 (71)
Burma
(1990–
2005): 0·2–
0·4 (319–
501)
Thailand
(1990–
2005): 0·7–
1·2 (106–
172)
Medium
WHO; aTB,
1997–2000 (186
Republic of
NA
Lower
War-affected but non-displaced
Republic of
1997–99
National
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CLINICAL SOCIAL WORK (CSW)
Year(s) of
displacement,
war, or
disaster
Congo
(1994–
2000)41
Type of
study
Case
definition;
type of cases
Notification rate
reported
(cases/personyears*)
Rate ratio
for
comparison
with
notification
rate in
reference
populations
(reference
notification
rate)
programme
data†pTB
[21 886/11 758 000]
aTB; 133
[15 666/11 758 000]
pTB); 1997 (122,
96); 1998 (136,
103); 1999 (172,
126); 2000 (304,
202)
Congo
(1994–
96):411В·3
(142) aTB,
1В·2 (111)
pTB
Rate ratio
for
comparison
with
estimated
incidence
in
reference
populations
(reference
incidence)
Strength of
evidence
Kosovo
(2000–
01);42 much
of
population
lived in
refugee
camps in
1999
1998–99
National
programme
data
Smear/WHO;
aTB, ss+
pTB
82 (3450/4 208 125)
aTB; 21
(879/4 208 125) new
ss+ pTB
Serbia
excluding
Kosovo:43 2В·4
(34) aTB,
1В·0 (20) new
ss+ pTB
NA
Medium
Dang
district,
Nepal
(1998–
2003)44
1996–2003
National
programme
data
Smear/WHO;
aTB
1998–99 (90);
2000–01 (194);
2002–03 (208)‡
Nepal
(1998–99):
0В·8 (110)
Nepal
(2000–01):
1В·6 (120)
Nepal
(2002–03):
1В·7 (119)
Nepal
(1998–99):
0·5–0·7
(133–197)
Nepal
(2000–01):
1·0–1·5
(133–197)
Nepal
(2002–03):
1·1–1·6
(133–197)
Medium
Clinicbased
surveillance
WHO; aTB
145 (11/7577)
Iran: 8В·1 (18)
Iran: 4·7–
6·9 (21–31)
Lower
National
programme
data
Smear/WHO;
aTB ss+ pTB
2006–10 (111
[21 564/19 421 550])
aTB; 31
[6294/19 421 550]
ss+pTB); 2006 (102,
29); 2007 (112, 34);
2008 (104, 33);
2009 (125, 34);
2010 (112, 32)
AzadJammuKashmir
province
(2004–05):
0В·9 (127)
aTB, 1В·0
(33) ss+pTB
NA
None
(insufficient
information)
Natural disaster
Earthquake, December,
Bam city,
2003 (one
Iran
month before)
(2004)45
Earthquake,
Azad
Jammu and
Kashmir
province,
Pakistan
(2004–10)§
October, 2005
All rates are per 100 000 per year. aTB=all forms of tuberculosis. ss+=sputum-smear positive. pTB=pulmonary
tuberculosis. NA=not available.
*For some reports, we estimated person-years based on the rate, period of data collection, and number of tuberculosis cases reported.
†The report presents only numerators (cases). We calculated rates using US Census Bureau demographic projections for the Republic of
Congo.46
‡Cases and person-years not reported.
В§Abrar Ahmad Chughtai, Pakistan National Tuberculosis Control Programme, Islamabad, Pakistan, personal communication.
Table 1. Reports of tuberculosis incidence (notification rate) in crisis-affected populations, 1980–2011
189
CLINICAL SOCIAL WORK (CSW)
Year(s) of
displacement,
war or disaster
Type of
study
Case
definition; type
of cases
Reported
prevalence
(cases/persons
tested)
Lower-upper
range of ratio for
comparison with
estimated
prevalence in
reference
populations
(reference
prevalence, lowerupper range)
Strength
of
evidence
Ethiopian
refugees in
Somalia
(1981)47
1978–80
Household
survey
Smear; ss+ pTB
2350 (mean of two
camps; cases and
persons tested not
reported)
NA
Lower
Vietnamese
refugees in
Thailand
(1985–
1986)48
1985–86
Camp entry
screening
Smear, culture;
pTB, ss+ pTB
580 (115/19 726)
pTB
100 (20/19 726) ss+
pTB
NA
Higher
Vietnamese
refugees in
Hong Kong
(1992)49
1975–91
Clinic–
based
surveillance
WHO; aTB,
pTB
680 (102/15 000)
aTB
440 (66/15 000) pTB
Vietnam: 1·0–3·8
(178–678) aTB
Hong Kong: 2·4–
11·9 (57–280) aTB
Medium
Afghan
refugees in
Iran (1996,
2004)50
1985
Camp
screening
Smear/WHO;
aTB, pTB, ss+
pTB
1996 (630 [17/NA]
aTB; 593 [16/NA]
pTB; 297 [8/NA];
ss+ pTB); 2004 0
(0/1397) aTB, 0
(0/1397) pTB, 0
(0/1397) ss+pTB
Afghanistan (1996):
0·8–3·2 (198–760)
Afghanistan (2004):
0 (198–760)
Iran (1996): 6·6–
26·3 (24–95)
Iran (2004): 0 (24–
95)
Medium
Kosovar
refugees in
Switzerland
(1999)51
1998–99
Camp entry
screening
Smear,
culture/WHO;
pTB
256 (8/3119)
NA
Higher
Kosovar
refugees in
Norway
(1999)52
1998–99
Camp entry
screening
Smear,
culture/WHO;
pTB, sc+ pTB,
ss+ pTB
500 (4/800) pTB
125 (1/800) sc+ pTB
0 (0/800) ss+ pTB
NA
Higher
Laotian
refugees in
Thailand
(2004–05)53
1975–94
Camp exit
screening
Smear/WHO;
aTB, sc+ pTB,
ss+ pTB
1760 (272/15 455)
aTB
369 (57/15 455) sc+
TB
220 (34/15 455) ss+
pTB
Laos: 8·0–35·2 (50–
219) aTB
Thailand: 5·5–20·2
(87–321) aTB
Higher
Burmese
refugees in
Thailand
(2007)54
1984–2007
Camp exit
screening
Smear; sc+
pTB, ss+ pTB
598 (28/4686) sc+
pTB
150 (7/4686) ss+
pTB
NA
Higher
Bhutanese
refugees in
Nepal (2007–
09)55
1990–98
Camp exit
screening
Smear/culture;
pTB, ss+ pTB
644 (151/23 459)
pTB
230 (54/23 459) ss+
pTB
NA
Higher
1992–93
Camp
screening
Smear/WHO;
aTB
537 (5/931)
Georgia: 2·6–20·7
(26–209)
Lower
Refugee camps
IDP
IDP living in
hostels in
Georgia
(1999)56
All prevalences are per 100 000 people. ss+=sputum-smear positive. pTB=pulmonary tuberculosis. NA=not
available. aTB=all forms of tuberculosis. sc+=sputum-culture positive. IDPs=internally displaced persons.
Table 2. Reports of tuberculosis prevalence in crisis-affected populations, 1980–2011
190
CLINICAL SOCIAL WORK (CSW)
Type of study
Case definition;
type of cases
Case-fatality rate
(deaths/patients)
Type of
treatment
plan used
Strength of
evidence
Cambodian refugees in
Thailand (1981–83)59
Clinic-based
surveillance
Smear; pTB
6В·0% (36/615)
DOTS
Lower
Cambodian refugees in
Thailand (1981–84)30
Clinic-based
surveillance
Smear/WHO;
aTB, ss+ pTB
5В·0% aTB (28/558)
3В·9% ss+pTB (NA)
DOTS
Medium
Cambodian refugees in
Thailand (1981–90)60
Clinic-based
surveillance
Smear; ss+ pTB
5В·0% (46/929)
DOTS
Medium
Cambodian refugees in
Thailand (1984–85)61
Clinic-based
surveillance
WHO; aTB
3В·8% (47/1240)
DOTS
Medium
Somali and Sudanese
refugees in Kenya (1992–
93)36
Clinic-based
surveillance
Smear/WHO; ss+
pTB
2В·6% (32/1235)
Not
specified
Medium
Tibetan refugees in India
(1994–96)38
Clinic-based
surveillance and
camp screening
Smear/WHO;
aTB
3В·8% (45/1184)
Not
specified
Higher
Burundian and Rwandan
refugees in Tanzania
(1995–99)62
Clinic-based
surveillance
Smear; ss+ pTB
10В·9% (60/546)
DOTS
Medium
Burmese refugees in
Thailand (1987–2005)40
Clinic-based
surveillance
WHO; aTB
5В·8% (57/978)
DOTS
Medium
Somali refugees in Kenya
(2010)63
Clinic-based
surveillance
Smear/WHO;
aTB, pTB, ss+
pTB
2В·7% (11/411) aTB
2В·2% (7/325) pTB
2В·3% (4/174) ss+ pTB
Not
specified
None
(insufficient
information)
IDP from south Sudan in
camps, Khartoum, Sudan
(2000)64
Clinic-based
surveillance
WHO; ss+ pTB
4В·5% (11/245) for IDP;
3В·7% (5/136) for host
population
Not
specified
Medium
Northern Uganda (1992–
2002);65 all war-affected,
about 70% internally
displaced people in camps
Hospital-based
surveillance
WHO; aTB
10В·4% (81/777)
Not
specified
Medium
Refugee camps
IDP
War-affected but non-displaced
Addis Ababa city,
Ethiopia (1983–85)66
Hospital-based
surveillance
Smear/WHO;
aTB, pTB
7В·9% (19/240) aTB
8В·7% (10/115) pTB
Not
specified
Lower
Gedo region, Somalia
(1994–95)67
Hospital-based
surveillance
Smear/WHO;
aTB, pTB, ss+
pTB
7В·6% (16/211) aTB
7В·8% (15/192) pTB
3В·2% (4/125) ss+ pTB
DOTS
Medium
Churachandpur district,
India (1998);68 district
included 39% IDP
population
Clinic-based
surveillance
Smear/WHO;
aTB, ss+ pTB
2В·8% (5/178 aTB [22В·2%
(4/18) for HIV- positive
patients])
2В·4% (2/85) ss+ pTB
DOTS
Higher
Brazzaville city, Republic
of Congo (1999–2004)69
Hospital-based
surveillance
Smear/WHO;
pTB (children
aged 12–23
months)
0% (0/45) for HIVnegative patients; 20В·0%
(7/35) for HIV-positive
patients
Not
specified
Medium
Upper Nile, south Sudan
(2001)70
Clinic-based
surveillance
Smear/WHO;
aTB, ss+ pTB
4В·3% (7/163) aTB
9В·1% (3/33) ss+ pTB, all
HIV-negative
DOTS
(Manyatta
regimen)
Medium
Kosovo (2001–04)42
Clinic-based
surveillance
WHO; ss+ pTB
2001 (4В·3% [18/421]);
2002 (1В·5% [6/402]);
2003 (1В·4% [4/292]);
2004 (1В·8% [5/272])
DOTS
Medium
Jammu and Kashmir state,
India (2003–07)71
Hospital-based
surveillance
Smear; MDR ss+
pTB
21В·1% (11/52)
DOTS
Lower
pTB=pulmonary tuberculosis. DOTS=directly observed treatment, short course. aTB=all forms of tuberculosis.
ss+=sputum-smear positive. IDPs=internally displaced persons. MDR=multidrug resistant. NA=not available.
Table 3. Reports of tuberculosis case-fatality ratio in crisis-affected populations, 1980–2011
191
CLINICAL SOCIAL WORK (CSW)
Rapid Molecular Diagnosis of Pulmonary Tuberculosis in Children Using
Nasopharyngeal Specimens, Heather J. Zar, Clinical Infectious Diseases 2012, 55(8): 108895
A rapid diagnosis of pediatric pulmonary tuberculosis (PTB) using Xpert MTB/RIF
(Mycobacterium tuberculosis/rifampicin) automated testing on induced sputum (IS) is
possible, but the capacity for performing IS is limited. The diagnosis using a nasopharyngeal
aspirate (NPA), which can be non-invasively obtained, is desirable.
Paired specimens (NPA and IS) were tested using smear, liquid culture and Xpert. The
diagnostic accuracy of Xpert and smear was compared with culture for different specimens in
children with suspected PTB.
There were 535 children [median age 19 months, 117 (21В·9%) HIV-infected] who had one IS
and one NPA specimen; 396 had two paired specimens. A positive smear, Xpert test or
culture occurred in 30 (5.6%), 81 (15.1%) and 87 children (16.3%), respectively. The culture
yield was higher from IS (84/87, 96.6%) vs NPA (61/87, 70.1%, P < .001). Amongst children
with two paired specimens, 63 culture-confirmed cases occurred [60 (95.2%) IS vs 48
(76.2%) NPA, P = .002]. The sensitivity of two Xpert tests was similar for IS and NPAs
[(45/63) 71% vs (41/63) 65%, P = .444)]; the sensitivity of smear was lower for IS (21/63,
33%) and NPA (16/63, 25%). The incremental yield from a second IS was 9 cases (17.6%) by
culture and 9 (25%) by Xpert testing; a second NPA increased the culture yield by 10 (26.3%)
and Xpert by 11 (36.7%). Xpert specificity was 99.1% (98.1-100) for IS and 98.2% (96.899.6) for NPAs. Xpert testing provided faster results than culture (median 0 vs 15 days, P <
.001).
Xpert testing on 2 NPAs is useful in children with suspected PTB, particularly in settings
where IS and culture are not feasible.
REFERENCES
1) Andreas H. Diacon, 14-day bactericidal activity of PA-824, bedaquiline,
pyrazinamide, and moxifloxacin combinations: a randomised trial, Lancet 2012, 380:
986-93
2) Tracy Dalton, Prevalence of and risk factors for resistance to second-line drugs in
people with multidrug-resistant tuberculosis in eight countries: a prospective cohort
study, Lancet 2012, 380: 1406-17
3) Haluskova, E., Miedz. Stud. Human, 2009, 2, 229 - 235
4) Kiwou, M., Haluskova, E. Korcek, V., Mutalova, M.: Clin Soc Work. 4,2012, 127
5) Haluskova, E., Miedz. Stud. Human, 2009, 1, 229 - 236
6) Haluskova, E., Miedz. Stud. Human 2010, 2, 217 - 224
7) Sirotiakova J., Minarik P., Kopernicka Z., Magulova L., Piesecka L., Zak V.,
Liskova A.: Linezolid in the treatment of complicated gram positive infections by
critically ill patients, Clinical & Experimental Pharmacology and physiology, 2004,
31, Suppl. A114
8) Sirotiakova J., Minarik P., Hoppman M.: Screening of risk factors in the population of
40 years' men and women in Nitra region, importance of primary prevention.
Coronary Artery Disease, 2007, 1(7), s. 137
192
CLINICAL SOCIAL WORK (CSW)
9) Dukat A., Lietava J., Krahulec B., Caprnda M., Vacula I., Kosmalova V., Minarik P.:
The prevalence of abdominal obesity in Slovakia. The IDEA Slovakia study, Vnitr.
Lek. 2007, 53(4), s. 326-30
10) Hoppman M., Minarik P., Sirotiakova J.: New possibilities in the treatment of
hypertension in pregnancy – looking for the effective and safe drug of future. Interna
medicina, 7 (1), 2007, s. 58
11) Minarik P., Hoppman M., Sirotiakova J.: Screening of risk factors in the population of
40 years men and women in Nitra region, regarding to the importance of primary
prevention, Interna mediciny, 7 (1), 2007, s. 58
12) Heather J. Zar, Rapid Molecular Diagnosis of Pulmonary Tuberculosis in Children
Using Nasopharyngeal Specimens, Clinical Infectious Diseases 2012, 55(8): 1088-95
193
CLINICAL SOCIAL WORK (CSW)
SOCIAL, LEGAL, ECONOMIC AND PUBLIC HEALTH ASPECTS IN
HOSPITAL ACQUIRED INFECTIOUS DISEASES IN 2012 – AN ICAAC
UPDATE
I. Kmit, M. Mutalova, P. Vermes, G. Herdics. S. Zak, J. Doktorovova, A. Imrichova,
M. Satny, J. Jexova, Z. Nagyova, T. Oelnick, M. Vravcova, S. Nemcik, J. Markova,
M. Sklenka, A. Ngudo
Department of Social Work, Department of Public Health, SEUC Tropic team and PhD
programme Bratislava, Slovakia and Mole St. Nicolas, Haiti
ABSTRACT
Social, Legal, Economic and Public Health Aspects in Infectious Diseases in 2012 – an
ICAAC update.
Critical review of updates in social work and infectious diseases areas, mainly hospital related
communicable diseases, social, legal, economic and public health aspects (1-11) is provided
here. HIV/AIDS and tropical diseases, both in US and non-US regions of WHO, is presented
the by the SEUC tropicteam after 3 years of deadly earthquake in Haiti. An ICAAC 2012
update presented in the conference in San Francisco 2012 is reviewed.
4) Staphylococcus, Vaccines, Nosocomial Infections
Rapid whole-genome sequencing for investigation of a neonatal MRSA outbreak
Koser C., N Engl J Med 366, 2267-75
Whole-genome sequencing can provide clinically relevant data within a time frame that can
influence patient care.
USA300 was associated with early complications in PNEUMO patients.
An association between bacterial genotype combined with a high-vancomycin minimum
inhibitory concentration and risk of endocarditis in methicillin-resistant Staphylococcus
aureus bloodstream infection
Miller C., Clin Infect Dis 54, 591-600
An interaction V-MIC can influence the risk of endocarditis associated with MRSA BSI,
implying involvement of both therapeutic and host-pathogen factors.
Prevalence of methicillin-resistant staphylococcus aureus as an etiology of communityacquired pneumonia
Moran G., Clin Infect Dis 54, 1126-33
Uncommon cause of CAP. Detection of MRSA was associated with more severe clinical
presentation.
Concurrent Epidemics of Soft Tissue Infection and Bloodstream Infection Due to
Community-Associated Methicillin-Resistant Staphylococcus aureus
Tattevin P., Clin Infect Dis 55, 781-8
Strategies to control the USA300 SSTI epidemic may lessen the severity of the concurrent
USA300 BSI epidemic.
High vancomycin MIC was associated with a higher mortality rate in MRSA BSI.
194
CLINICAL SOCIAL WORK (CSW)
5) HIV - AIDS
Antiretroviral prophylaxis for HIV prevention in heterosexual men and women.
Baeten JM., N Engl J Med 2012, 367, 411-22
Oral TDF and TDF-FTC both protect against HIV-1 infection in heterosexual men and
women
Antiretroviral preexposure prophylaxis for heterosexual HIV transmission in Botswana
Thigpen MC., N Engl J Med 2012, 367, 423-34
Daily TDF-FTC prophylaxis prevented HIV infection in sexually active heterosexual adults.
The long-term safety of daily TDF-FTC prophylaxis.
What's love got to do with it? Explaining adherence to oral antiretroviral pre-exposure
prophylaxis for HIV-serodiscordant couples
Ware NC., Immune Defic Syndr. 2012, Apr., 15, 59(5): 463-8
PrEP use instable couples may be associated with improved adherence and thus, greater
affectiveness.
FTC-TP concetrations in all tissue types were detected for only 2 days after dose.
Determinants of per-coital act HIV-1 infectivity among african HIV-1 serodiscordant
couples
Hughes JP., Journal of Infectious Diseases, 2012, 205: 358-65
Modifiable risk factors for HIV-1 transmission were plasma HIV-1 RNA level and condom
use and in HIV-1 uninfected partners, herpes simplex virus 2 infection, genital ulcers,
Trichomonas vaginalis, vaginitis or cervicitis and male circumcision.
Symptomatic vaginal discharge is a poor predictor of sexually transmitted infections
and genital tract inflammation in high risk women in South Africa
Mlisana K., Journal of Infectious Diseases, 2012, 206: 6-14
The Cost-Effectiveness of Preexposure Prophylaxis for HIV Prevention in the United
States
Juusola JL., Ann Intern med. 2012, 156: 541-550
Use in high-risk MSM compares favorably with other interventions that are considered costeffective but could result in annual PrEP expenditures of more than $4 billion.
Nevirapine versus ritonavir-boosted lopinavir for HIV-infected children
Violari A., N Engl J Med 2012 Jun 21, 366(25): 2380-9
Outcomes were superior with ritonavir-boosted lopinavir among young children with no prior
exposure to nevirapine. Factors that may have contributed to the suboptimal results with
nevirapine include elevated viral load at baseline, selection for nevirapine resistance,
background regimen of nucleoside reverse-transcriptase inhibitors and the standard ramp-up
dosing strategy.
Three postpartum antiretroviral regimens to prevent intrapartum HIV infection
Nielsen-Saines, N Engl J Med 2012 Jun 21, 366(25): 2368-79
Zidovudine for 6 weeks plus three doses of nevirapine during the first 8 days of life, or
zidovudine for 6 weeks plus nelfinavir and lamivudine for 2 weeks (three-drug group).
195
CLINICAL SOCIAL WORK (CSW)
In neonates whose mothers did not receive ART during pregnancy, prophylaxis with a two- or
three-drug ART regimen is superior to zidovudine alone for the prevention of intrapartum
HIV transmission, the two-drug regimen has less toxicity than the three drug regimen.
Sexually transmitted diseases, urinary tract infections and antibiotic resistance
Ciprofloxacin for 7 days versus 14 days in woman with acute pyelonephritis
Sandberg T., Lancet 2012, Aug., 4, 380(9840): 484-90
Can be treated successfully and safely with oral ciprofloxacin for 7 days.
The emerging threated of untreatable gonococcal infection
Bolan GA., N Engl J Med 2012, Feb., 9, 366(6):485-7
Reduced susceptibility to cephalosporins results from the combined effects of several
chromosomal gene mutations, including mutations in penA, the gene that encodes penicillinbinding protein 2 (PBP2), penB, which affects drug entry through an outer membrane protein
channel (PorB1b) and mtrR, a repressor of the MtrCDE-encoded pump.
Гџ-Lactam/Гџ-lactam inhibitor combinations for the treatment of bacteremia due to
extended-spectrum Гџ-lactamase-producing Escherichia coli: a post hoc analysis of
prospective cohorts
RodrГ­guez-Bano, Clin Infect Dis. 2012, Jan., 15, 54(2):167-74
Comment in Can we really use Гџ-lactam/Гџ-lactam inhibitor combinations for the treatment of
infections caused by extended-spectrum Гџ-lactamase-producing bacteria?
Excess deaths associated with tigecycline after approval based on noninferiority trials
Prasad P., Clin Infect Dis. 2012, Jun., 54(12):1699-709
Pooling noninferiority studies to examine survival may help ensure the safety and efficacy of
new antibiotics. The association of tigecycline with excess deaths and noncure includes
indications for which i tis approved and marketed.
Tigecycline cannot be relied on in serious infections.
Editorial commentary: asking the right questions: morbidity, mortality and measuring what's
important in unbiased evaluations of antimicrobials.
Efficacy and safety of tigecycline for the treatment of infectious diseases: a meta-analysis
Tigecycline is not better than standard antimicrobial therapy.
High-dose, extended-interval colistin administration in critically ill patients: is this the
right dosing strategy? A preliminary study.
Dalfino L., Clin Infect Dis. 2012, Jun., 54(12):1720-6
9 MU and a 9-MU twice-daily fractioned maintenance dose, titrated on renal function. Our
study shows that in severe infections due to COS gram-negative bacteria, the high-dose,
extended-interval CMS regimen has a high efficacy, without significant renal toxicity.
Zinc as adjunct treatment in infants aged between 7 and 120 days with probable serious
bacterial infection: a randomized, double-blind, placebo-controlled trial
Bhatnagar S., Lancet 2012 June 2, 379(9831): 2027-8
To receive either 10 mg of zinc or placebo orally every day in addition to standard antibiotic
treatment. Significantly fewer treatment failures occurred in the zinc group (34/10%/) than in
196
CLINICAL SOCIAL WORK (CSW)
the placebo group (55/17%/), relative risk reduction 40%, 95% CI 10-60, p=0.0113 absolute
risk reduction 6.8%, 1.5-12.0, p=0.0111).
6) Other viral and fungal infections
Risk of adverse fatal outcomes following administration of a pandemic influenza
A(H1N1)
JAMA 2012 Jul 11, 308(2): 165-74
Vaccine during pregnancy was not associated with a significantly increased risk of major birth
defects.
Risk of natalizumab-associated progressive multifocal leukoencephalopathy
N Engl J med 366(20): 1870-1880
Association between vaccination for herpes zoster and risk of herpes zoster infection
among alder patients with selected immune-mediated diseases
JAMA 308(1):43-49
Receipt of HZ vaccine was not associated with a short-term increase in HZ incidence.
The Effect of Therapeutic Drug Monitoring on Safety and Efficacy of Voriconazole in
Invasive Fungal Infections: A Randomized Controlled Trial
Routine TDM of voriconazole may reduce drug discontinuation due to adverse events and
improve the treatment response in invasive fungal infections.
REFERENCES
9) Köser CU, Holden MT, Ellington MJ, Cartwright EJ, Brown NM, Ogilvy-Stuart AL,
Hsu LY, Chewapreecha C, Croucher NJ, Harris SR, Sanders M, Enright MC, Dougan
G, Bentley SD, Parkhill J, Fraser LJ, Betley JR, Schulz-Trieglaff OB, Smith GP,
Peacock SJ. Rapid whole-genome sequencing for investigation of a neonatal MRSA
outbreak. N Engl J Med. 2012 Jun 14;366(24):2267-75.
10) Sokolova, J. and Meningitis Research Team. Analysis of 104 cases of sepsis with
bacterial meningitis within 20 years of meningitis survery in Slovakia.
Neuroendocrinol Lett 2012; 33(Suppl.1):29–30
11) Haluskova, E., Miedz. Stud. Human, 2009, 2, 229 - 235
12) Kiwou, M., Haluskova, E. Korcek, V., Mutalova, M.: Clin Soc Work. 4,2012, 127
13) Haluskova, E., Miedz. Stud. Human, 2009, 1, 229 - 236
14) Kisac et al. Overview of 84 cases of meningococcal meningitis both from community
and hospital. Neuroendocrinol Lett 2012; 33(Suppl.1):21-22.
15) Haluskova, E., Miedz. Stud. Human 2010, 2, 217 - 224
16) Sirotiakova J., Minarik P., Kopernicka Z., Magulova L., Piesecka L., Zak V.,
Liskova A.: Linezolid in the treatment of complicated gram positive infections by
critically ill patients, Clinical & Experimental Pharmacology and physiology, 2004,
31, Suppl. A114
17) Sirotiakova J., Minarik P., Hoppman M.: Screening of risk factors in the population of
40 years' men and women in Nitra region, importance of primary prevention.
Coronary Artery Disease, 2007, 1(7), s. 137
197
CLINICAL SOCIAL WORK (CSW)
18) Dukat A., Lietava J., Krahulec B., Caprnda M., Vacula I., Kosmalova V., Minarik P.:
The prevalence of abdominal obesity in Slovakia. The IDEA Slovakia study, Vnitr.
Lek. 2007, 53(4), s. 326-30
19) Hoppman M., Minarik P., Sirotiakova J.: New possibilities in the treatment of
hypertension in pregnancy – looking for the effective and safe drug of future. Interna
medicina, 7 (1), 2007, s. 58
20) Minarik P., Hoppman M., Sirotiakova J.: Screening of risk factors in the population of
40 years men and women in Nitra region, regarding to the importance of primary
prevention, Interna mediciny, 7 (1), 2007, s. 58
21) Miller CE, Batra R, Cooper BS, Patel AK, Klein J, Otter JA, Kypraios T, French
GL, Tosas O, Edgeworth JD. An association between bacterial genotype combined
with a high-vancomycin minimum inhibitory concentration and risk of endocarditis in
methicillin-resistant Staphylococcus aureus bloodstream infection. Clin Infect Dis.
2012 Mar 1;54(5):591-600. doi: 10.1093/cid/cir858. Epub 2011 Dec 20.
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SOCIAL, LEGAL, NURSING AND INTERNATIONAL PUBLIC
HEALTH ASPECTS OF MALARIA IN LAST YEARS
Kmit I., M. Schavel. J. Miklosko, J. Bordacova, A. Ngendo, K. Feketeova,
B. Acova, J. Benus, M. Beresova, S. Blahovska, V. Cehlar, M. Cerny,
A. Daniskova, A. Davidova, M. Dolezal, L. Horna, S. Hubinova, R. Hunes,
E. Madarova, O. Matko, M. Sedlacek
Department of Social Work, Department of Public Health, SEUC Tropic team and PhD
programme Bratislava, Slovakia
ABSTRACT
Critical review of Social, Legal, Nursing and International Public Health aspects in last 2
years is presented by St. Elisabeth University PhD. programmes and reviewed by the
members of University PhD. team (1-12).
Effect of intermittent preventive treatment for malaria during infancy on serological
responses to measles and other vaccines used in the Expanded Programe on
Immunization: results from five randomised controlled trials (Jane Crawley, Lancet 2012,
380: 1001-10)
Intermittent preventive treatment for malaria during infancy (IPTi) is the administration of a
full therapeutic course of antimalarial drugs to infants living in settings where malaria is
endemic, at the time of routine vaccination in the first year of life. We investigated whether
IPTi with sulfadoxine-pyrimethamine or other antimalarial drug combinations adversely
affected serological responses to vaccines used in the Expanded Programme on Immunization
(EPI).
The study was done in a subset of children enrolled in five randomised controlled trials in
Navrongo, Ghana; Kilimanjaro, Tanzania; Manhica, Mozambique; Kisumu, Kenya; and
Bungoma, Kenya. All infants presenting for the second dose of the diphtheria-tetanuspertussis vaccination (given at 8-10 weeks of age) were eligible, and analyses included all
children who had received measles vaccination (at 9 months of age) and at least one dose of
IPTi or placebo. Blood samples were collected before and after vaccination, and antibody
titres were measured by plaque reduction neutralisation (measles, yellow fever),
microneutralisation (polio serotypes 1 and 3), and ELISA (all other EPI antigens). Laboratory
personnel were unaware of the randomisation groups. We compared the proportion of infants
in the IPTi and placebo groups who did not attain protective antibody titres after vaccination,
using a one-sided significance non-inferiority margin of 5% for measles (the primary
endpoint) and 10% for other EPI antigens.
Between September, 2000, and May, 2008, 8416 children were enrolled in the five studies.
Paired samples from 2368 children from sites where sulfadoxine-pyrimethamine was
compared with placebo were analysed for measles antibodies. 464 children with detectable
measles antibody in their sample before vaccination were excluded, leaving 1904 individuals
(934 placebo and 970 sulfadoxine-pyrimethamine) in the study. IPTi with sulfadoxinepyrimethamine did not have a clinically significant effect on immune responses to measles
vaccine; 61 of 970 (6В·3%) children who received IPTi did not develop a protective antibody
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response after measles vaccination compared with 60 of 934 (6В·4%) who received placebo, a
difference of -0В·14% (95% CI -2В·3 to 2В·1). When other antimalarial drugs were used for IPTi
the results were much the same. Among 2396 children from whom serological response data
for other EPI antigens were available, we identified no evidence of an adverse effect of IPTi
with sulfadoxine-pyrimethamine or other antimalarial drugs on the proportion achieving
protective antibody concentrations.
IPTi with sulfadoxine-pyrimethamine does not affect serological responses to EPI vaccines.
This analysis, therefore, supports the WHO recommendation for coadministration of IPTi
with sulfadoxine-pyrimethamine to infants at the time of the second and third doses of DTP
and measles vaccination, in areas of sub-Saharan Africa with moderate to high malaria
transmission and where malaria parasites are sensitive to these drugs. It also suggests that
treatment of clinical malaria at or around the time of vaccination does not compromise
vaccine responsiveness.
Prevalence of Raised Intracranial Pressure in Cerebral Malaria Detected by Optic
Nerve Sheat Ultrasound, Nicholas A., Am J Trop Med Hyg 2012, 87(6), 985-988
We aimed to use optic nerve sheath (ONS) ultrasound to determine the prevalence of raised
intracranial pressure (ICP) in African children with cerebral malaria (CM); and if increased
ONS diameter is associated with poor outcome. We measured ONS diameter in 101 children
with CM and 11 children with malaria and impaired consciousness in Malawi. The prevalence
of raised ICP detected by increased ONS diameter was 49%. Case fatality was similar in
children with increased ONS diameter on admission (9/55) and those children without
increased ONS diameter (11/57). Neurological sequelae were more common in those children
with increased ONS diameter (7/46 versus 2/46, P < 0.05). Lumbar puncture (LP) opening
pressure was elevated in 95% of 46 children who underwent LP. In Malawian children with
CM, raised ICP is less commonly detected by ONS ultrasound than LP. This study suggests
that raised ICP is not universal in CM and that other mechanisms may account for coma.
Use of Rapid Diagnostic Tests in Malaria School Surveys in Kenya: Does their Underperformance Matter for Planning Malaria Control? Caroline W., Am J Trop Med Hyg
2012, 87(6), 1004-1011
Malaria rapid diagnostic tests (RDTs) are known to yield false-positive results, and their use
in epidemiologic surveys will overestimate infection prevalence and potentially hinder
efficient targeting of interventions. To examine the consequences of using RDTs in school
surveys, we compared three RDT brands used during a nationwide school survey in Kenya
with expert microscopy and investigated the cost implications of using alternative diagnostic
approaches in identifying localities with differing levels of infection. Overall, RDT sensitivity
was 96.1% and specificity was 70.8%. In terms of classifying districts and schools according
to prevalence categories, RDTs were most reliable for the < 1% and > 40% categories and
least reliable in the 1-4.9% category. In low-prevalence settings, microscopy was the most
expensive approach, and RDT results corrected by either microscopy or polymerase chain
reaction were the cheapest. Use of polymerase chain reaction-corrected RDT results is
recommended in school malaria surveys, especially in settings with low-to-moderate malaria
transmission.
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Clinical Profile of Concurrent Dengue Fever and Plasmodium vivax Malaria in the
Brazilian Amazon: Case Series of 11 Hospitalized Patients, Belisa M. L. Magalhaes, Am J
Trop Med Hyg 2012, 87(6), 1119-1124
Malaria and dengue fever are the most prevalent vector-borne diseases worldwide. This study
aims to describe the clinical profile of patients with molecular diagnosis of concurrent malaria
and dengue fever in a tropical-endemic area. Eleven patients with concurrent dengue virus
(DENV) and Plasmodium vivax infection are reported. Similar frequencies of DENV-2,
DENV-3, and DENV-4 were found, including DENV-3/DENV-4 co-infection. In eight
patients, the World Health Organization (WHO) criteria for severe malaria could be fulfilled
(jaundice being the most common). Only one patient met severe dengue criteria, but warning
signs were present in 10. Syndromic surveillance systems must be ready to identify this
condition to avoid misinterpretation of severity attributed to a single disease.
New Insights into Acquisition, Boosting and Longevity of Immunity to Malaria in
Pregnant Women, Freya JI Fowkes, The Journal of Infectious Diseases 2012, 206: 1612-21
How antimalarial antibodies are acquired and maintained during pregnancy and boosted after
reinfection with Plasmodium falciparum and Plasmodium vivax is unknown.
A nested case-control study of 467 pregnant women (136 Plasmodium-infected cases and 331
uninfected control subjects) in northwestern Thailand was conducted. Antibody levels to P.
falciparum and P. vivax merozoite antigens and the pregnancy-specific PfVAR2CSA antigen
were determined at enrollment (median 10 weeks gestation) and throughout pregnancy until
delivery.
Antibodies to P. falciparum and P. vivax were highly variable over time, and maintenance of
high levels of antimalarial antibodies involved highly dynamic responses resulting from
intermittent exposure to infection. There was evidence of boosting with each successive
infection for P. falciparum responses, suggesting the presence of immunological memory.
However, the half-lives of Plasmodium antibody responses were relatively short, compared
with measles (457 years), and much shorter for merozoite responses (0.8-7.6 years), compared
with PfVAR2CSA responses (36-157 years). The longer half-life of antibodies to
PfVAR2CSA suggests that antibodies acquired in one pregnancy may be maintained to
protect subsequent pregnancies.
These findings may have important practical implications for predicting the duration of
vaccine-induced responses by candidate antigens and supports the development of malaria
vaccines to protect pregnant women.
Malaria prevention in pregnancy, birthweight and neonatal mortality: a meta-analysis
of 32 national cross-sectional datasets in Africa, Thomas P. Eisele, Lancet Infect dis 2012,
12: 942-49
Low birthweight is a significant risk factor for neonatal and infant death. A prominent cause
of low birthweight is infection with Plasmodium falciparum during pregnancy. Antimalarial
intermittent preventive therapy in pregnancy (IPTp) and insecticide-treated mosquito nets
(ITNs) significantly reduce the risk of low birthweight in regions of stable malaria
transmission. We aimed to assess the effectiveness of malaria prevention in pregnancy (IPTp
or ITNs) at preventing low birthweight and neonatal mortality under routine programme
conditions in malaria endemic countries of Africa.
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We used a retrospective birth cohort from national cross-sectional datasets in 25 African
countries from 2000-10. We used all available datasets from multiple indicator cluster
surveys, demographic and health surveys, malaria indicator surveys, and AIDS indicator
surveys that were publically available as of 2011. We tried to limit confounding bias through
exact matching on potential confounding factors associated with both exposure to malaria
prevention (ITNs or IPTp with sulfadoxine-pyrimethamine) in pregnancy and birth outcomes,
including local malaria transmission, neonatal tetanus vaccination, maternal age and
education, and household wealth. We used a logistic regression model to test for associations
between malaria prevention in pregnancy and low birthweight, and a Poisson model for the
outcome of neonatal mortality. Both models incorporated the matched strata as a random
effect, while accounting for additional potential confounding factors with fixed effect
covariates.
We analysed 32 national cross-sectional datasets. Exposure of women in their first or second
pregnancy to full malaria prevention with IPTp or ITNs was significantly associated with
decreased risk of neonatal mortality (protective efficacy [PE] 18%, 95% CI 4-30; incidence
rate ratio [IRR] 0В·820, 95% CI 0В·698-0В·962), compared with newborn babies of mothers with
no protection, after exact matching and controlling for potential confounding factors.
Compared with women with no protection, exposure of pregnant women during their first two
pregnancies to full malaria prevention in pregnancy through IPTp or ITNs was significantly
associated with reduced odds of low birthweight (PE 21%, 14-27; IRR 0В·792, 0В·732-0В·857),
as measured by a combination of weight and birth size perceived by the mother, after exact
matching and controlling for potential confounding factors.
Malaria prevention in pregnancy is associated with substantial reductions in neonatal
mortality and low birthweight under routine malaria control programme conditions. Malaria
control programmes should strive to achieve full protection in pregnant women by both IPTp
and ITNs to maximise their benefits. Despite an attempt to mitigate bias and potential
confounding by matching women on factors thought to be associated with access to malaria
prevention in pregnancy and birth outcomes, some level of confounding bias possibly
remains.
Artemisinin-resistant Plasmodium falciparum in Pursat province, western Cambodia:
a parasite clearance rate study, Chanaki Amaratunga, Lancet Infect Dis 2012, 12: 851-58
Artemisinin-resistant Plasmodium falciparum has been reported in Pailin, western Cambodia,
detected as a slow parasite clearance rate in vivo. Emergence of this phenotype in western
Thailand and possibly elsewhere threatens to compromise the effectiveness of all artemisininbased combination therapies. Parasite genetics is associated with parasite clearance rate but
does not account for all variation. We investigated contributions of both parasite genetics and
host factors to the artemisinin-resistance phenotype in Pursat, western Cambodia.
Between June 19 and Nov 28, 2009, and June 26 and Dec 6, 2010, we enrolled patients aged
10 years or older with uncomplicated falciparum malaria, a density of asexual parasites of at
least 10 000 per µL of whole blood, no symptoms or signs of severe malaria, no other cause of
febrile illness, and no chronic illness. We gave participants 4 mg/kg artesunate at 0, 24, and
48 h, 15 mg/kg mefloquine at 72 h, and 10 mg/kg mefloquine at 96 h. We assessed parasite
density on thick blood films every 6 h until undetectable. The parasite clearance half-life was
calculated from the parasite clearance curve. We genotyped parasites with 18 microsatellite
markers and patients for haemoglobin E, О±-thalassaemia, and a mutation of G6PD, which
encodes glucose-6-phosphate dehydrogenase. To account for the possible effects of acquired
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immunity on half-life, we used three surrogates for increased likelihood of exposure to P
falciparum: age, sex, and place of residence. This study is registered with ClinicalTrials.gov,
number NCT00341003.
We assessed 3504 individuals from all six districts of Pursat province seeking treatment for
malaria symptoms. We enrolled 168 patients with falciparum malaria who met inclusion
criteria. The geometric mean half-life was 5В·85 h (95% CI 5В·54-6В·18) in Pursat, similar to that
reported in Pailin (p=0В·109). We identified two genetically different parasite clone groups:
parasite group 1 (PG1) and parasite group 2 (PG2). Non-significant increases in parasite
clearance half-life were seen in patients with haemoglobin E (0В·55 h; p=0В·078), those of male
sex (0В·96 h; p=0В·064), and in 2010 (0В·68 h; p=0В·068); PG1 was associated with a significant
increase (0В·79 h; p=0В·033). The mean parasite heritability of half-life was 0В·40 (SD 0В·17).
Heritable artemisinin resistance is established in a second Cambodian province. To accurately
identify parasites that are intrinsically susceptible or resistant to artemisinins, future studies
should explore the effect of erythrocyte polymorphisms and specific immune responses on
half-life variation.
Effect of the Affordable Medicines Facility-malaria (AMFm) on the availability, price
and market share of quality-assured artemisinin-based combination therapies in seven
countries: a before-and-after analysis of outlet survey data, Sarah Tougher, Lancet 2012,
380: 1916-26
Malaria is one of the greatest causes of mortality worldwide. Use of the most effective
treatments for malaria remains inadequate for those in need, and there is concern over the
emergence of resistance to these treatments. In 2010, the Global Fund launched the
Affordable Medicines Facility—malaria (AMFm), a series of national-scale pilot programmes
designed to increase the access and use of quality-assured artemisinin based combination
therapies (QAACTs) and reduce that of artemisinin monotherapies for treatment of malaria.
AMFm involves manufacturer price negotiations, subsidies on the manufacturer price of each
treatment purchased, and supporting interventions such as communications campaigns. We
present findings on the effect of AMFm on QAACT price, availability, and market share, 6—
15 months after the delivery of subsidised ACTs in Ghana, Kenya, Madagascar, Niger,
Nigeria, Uganda, and Tanzania (including Zanzibar).
We did nationally representative baseline and endpoint surveys of public and private sector
outlets that stock antimalarial treatments. QAACTs were identified on the basis of the Global
Fund's quality assurance policy. Changes in availability, price, and market share were
assessed against specified success benchmarks for 1 year of AMFm implementation. Key
informant interviews and document reviews recorded contextual factors and the
implementation process.
In all pilots except Niger and Madagascar, there were large increases in QAACT availability
(25·8—51·9 percentage points), and market share (15·9—40·3 percentage points), driven
mainly by changes in the private for-profit sector. Large falls in median price for QAACTs
per adult equivalent dose were seen in the private for-profit sector in six pilots, ranging from
US$1В·28 to $4В·82. The market share of oral artemisinin monotherapies decreased in Nigeria
and Zanzibar, the two pilots where it was more than 5% at baseline.
Subsidies combined with supporting interventions can be effective in rapidly improving
availability, price, and market share of QAACTs, particularly in the private for-profit sector.
Decisions about the future of AMFm should also consider the effect on use in vulnerable
populations, access to malaria diagnostics, and cost-effectiveness.
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REFERENCES
1) Jane Crawley, Effect of intermittent preventive treatment for malaria during infancy
on serological responses to measles and other vaccines used in the Expanded
Programe on Immunization: results from five randomised controlled trials, Lancet
2012, 380: 1001-10)
2) Nicholas A., Prevalence of Raised Intracranial Pressure in Cerebral Malaria Detected
by Optic Nerve Sheat Ultrasound, Am J Trop Med Hyg 2012, 87(6), 985-988
3) Haluskova, E., Miedz. Stud. Human, 2009, 2, 229 - 235
4) Kiwou, M., Haluskova, E. Korcek, V., Mutalova, M.: Clin Soc Work. 4,2012, 127
5) Haluskova, E., Miedz. Stud. Human, 2009, 1, 229 - 236
6) Haluskova, E., Miedz. Stud. Human 2010, 2, 217 - 224
7) Sirotiakova J., Minarik P., Kopernicka Z., Magulova L., Piesecka L., Zak V.,
Liskova A.: Linezolid in the treatment of complicated gram positive infections by
critically ill patients, Clinical & Experimental Pharmacology and physiology, 2004,
31, Suppl. A114
8) Sirotiakova J., Minarik P., Hoppman M.: Screening of risk factors in the population of
40 years' men and women in Nitra region, importance of primary prevention.
Coronary Artery Disease, 2007, 1(7), s. 137
9) Dukat A., Lietava J., Krahulec B., Caprnda M., Vacula I., Kosmalova V., Minarik P.:
The prevalence of abdominal obesity in Slovakia. The IDEA Slovakia study, Vnitr.
Lek. 2007, 53(4), s. 326-30
10) Hoppman M., Minarik P., Sirotiakova J.: New possibilities in the treatment of
hypertension in pregnancy – looking for the effective and safe drug of future. Interna
medicina, 7 (1), 2007, s. 58
11) Minarik P., Hoppman M., Sirotiakova J.: Screening of risk factors in the population of
40 years men and women in Nitra region, regarding to the importance of primary
prevention, Interna mediciny, 7 (1), 2007, s. 58
12) Thomas P. Eisele, Malaria prevention in pregnancy, birthweight and neonatal
mortality: a meta-analysis of 32 national cross-sectional datasets in Africa, Lancet
Infect dis 2012, 12: 942-49
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MISSIONARY PROJECTS IN UGANDA AND UPDATE ON VIRAL
HEAMORRHAGIC FEVERS
Silharova B., Ladesova N., Kmit I., Sokolova J., Kulkova N., Mikolasova G., A. Zakutna,
M. Ceresnikova, Mikolasova P., Pastekova T., Kalavska Z., Horvathova D., Bartosova M.
St. Charles Lwanga, St. Elisabeth Tropical programe Ngogwe, Buikwe, Uganda
Hemorrhagic Fever Viruses - background
The term viral hemorrhagic fever (HF) refers to the illness associated with a number of
geographically restricted viruses. It is very important know to these agents and knowledge of
how to prevent them. In general, they present as a febrile disease that progress to manifest
some degree of hemorrhage, often in the form of increased capillary permeability, which may
lead to death. Although a number of other febrile viral infections may produce hemorrhage,
only the agents of Lassa, Marburg, Ebola, and Crimean-Congo hemorrhagic fevers are known
to have caused significant outbreaks of diseases with person-to-person transmission (3,9,10,
15, 16).
The viruses known to cause hemorrhagic fever (HF) in humans differ in their structure and
genetics but share the ability to cause a generalized illness that can be severe, marked by
involvement of visceral organs and by thrombocytopenia or other coagulation defects that
lead to disseminated intravascular coagulation or other bleeding diatheses. Humans likely are
not the primary hosts for any of these viruses, with the possible exception of dengue.
The two most important routes of exposure are insect bites (yellow fever, dengue, Rift Valley
fever, Crimean-Congo HF, Kyasanur Forest disease, and Omsk HF) and exposure to
infectious rodent urine either directly or, more often, via contaminated airborne dust (Lassa
fever, Argentine HF, Bolivian HF, and Hantaan and related HFs). Nosocomial transmission,
often under conditions where routine safe hospital practices are not being followed.
Person-to-person transmission may occur, but is usually not the dominant mode of
transmission (1, 3). The natural route of exposure is not known for Marburg and Ebola HFs
(11-13). Laboratory-acquired infections have been reported for Hantaan HF (1, 107) and
Kyasanur Forest disease, but person-to-person transmission is not known to occur with yellow
fever, dengue, Argentine HF, Bolivian HF, Rift Valley fever, Hantaan HF, Kyasanur Forest
disease, or Omsk HF, and these diseases are not discussed further here (108). Both Ebola and
Marburg virus can persist in tissues for several months following acute infection, emphasizing
the need for careful handling. As with Lassa and Marburg viruses, it is recommended to
supplement Standard with full Contact Precautions (3, 16).
Historically, some were also weaponized as biological warfare agents, and today there is
considerable concern that they could be used as terrorist weapons.
Current danger of VHFs at the missionary project in Central region of Africa
During the last 3 months there are 3 outbreaks of VHFs in Uganda which kills more than two
hundred people including health care workers.
Marburg Hemorrhagic Fever Outbreak in Uganda (2012)
As of November 13, 2012, the Ugandan Ministry of Health reported 17 cases (probable and
confirmed) of Marburg virus infection, including 9 deaths, in the Kabale District of southwest
Uganda. Testing of samples by CDC's Viral Special Pathogens Branch is ongoing at the
Uganda Virus Research Institute in Entebbe. Working with the Ministry's National Task
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Force, a CDC team is on site to assist in the diagnostic and ecological aspects of the outbreak.
Note that Kabale District, on the border with neighboring Rwanda, is distinct from Kibaale
District, the site of the recently-ended Ebola outbreak; both districts are in Uganda's Western
Region (8).
A recent history of Marburg cases and outbreaks in Uganda includes:
a fatal case in 2008 of a Dutch tourist who visited the Python Cave, a bat cave in Queen
Elizabeth National Park (QENP);
a non-fatal case in 2008 of an American tourist who visited the same cave in QENP; and,
a 2007 small outbreak of Marburg HF among miners working in the Kitaka lead and gold
mine in Kamwenge District (8,9).
Marburg virus/Marburg VHF is a highly infectious viral haemorrhagic fever, which kills in
a short time but can be prevented. Marburg virus infection is spread through direct contact
with body fluids like blood, saliva, vomit, stool, and urine of an infected person. A person
suffering from Marburg virus disease presents with sudden onset of high fever with any of the
following; headache, vomiting blood, joint and muscle pains, and bleeding through the body
openings, that is, eyes (red eyes), nose, gums, ears, anus, and the skin. Virus can be spread
also through use of unsterilised injection syringes, contaminated linen, beddings, and clothes;
by the use of skin piercing instruments that have been used by an infected person. And also by
direct physical handling of persons who have died of Marburg virus disease (3,9).
The following measures have to be taken to avert the spread of the disease:
- Report immediately any suspected patient to a nearby health unit
- Avoid direct contact with body fluids of a person suspected to be suffering from Marburg
virus disease by using protective materials like gloves and masks
- Persons who have died of Marburg virus disease must be handled with strong protective
wear and buried immediately
- Avoid eating dead animals [sic; presumably animals that died of disease]
- Avoid unnecessary public gatherings especially in the affected district
- Burial of suspicious community deaths should be done under close supervision of well
trained burial teams - Report all suspicious deaths to a nearby health facility (9).
Ebola Hemorrhagic Fever Outbreak in Democratic Republic of Congo (2012)
According to the DRC Ministry of Health report on October 27, 2012, a total of 35 confirmed
cases (12 of them fatal), all from the Isiro area in DRC's Province Orientale, were reported.
The case count also includes 17 probable and 25 suspect cases, with 24 deaths in these 2
categories. CDC is assisting the Ministry of Health in the epidemiologic and diagnostic
aspects of the investigation. Laboratory support was provided both through CDC's field
laboratory in Isiro, and through the CDC/UVRI lab in Uganda. The Public Health Agency of
Canada (PHAC) also provides diagnostic support through its field lab in Isiro. The outbreak in
DRC is not linked epidemiologically to the recently-ended Ebola outbreak in the Kibaale
district of Uganda (8).
Ebola Hemorrhagic Fever Outbreak in Uganda (2012)
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On July 28th, 2012, the Uganda Ministry of Health reported an outbreak of Ebola
Hemorrhagic fever in the Kibaale District of Uganda. A total of 24 human cases (probable
and confirmed only), 17 of which were fatal, have been reported since the beginning of July.
Laboratory tests of blood samples, conducted by the Uganda Virus Research Institute (UVRI)
and the U. S. Centers for Disease Control and Prevention (CDC), confirmed Ebola virus in 11
patients, four of whom have died (8).
Ebola virus/ Ebola VHF – Ebola virus belongs to the family _Filoviridae_ which is
comprised of 5 distinct species: Zaire, Sudan, Cote d'Ivoire, Bundibugyo and Reston. Zaire,
Sudan and Bundibugyo species have been associated with large Ebola haemorrhagic fever
(EHF) outbreaks in Africa with high case fatality ratio (25-90 percent) while Cote d'Ivoire and
Reston have not. Reston species can infect humans but no serious illness or death in humans
have been reported to date (3,8).
The natural reservoir of the Ebola virus is unknown despite extensive studies, but it seems to
reside in the rain forests on the African continent and in the Western Pacific. Although nonhuman primates have been a source of infection for humans, they are not thought to be the
reservoir. They, like humans, are believed to be infected directly from the natural reservoir or
through a chain of transmission from the natural reservoir. On the African continent, Ebola
infections of human cases have been linked to direct contact with gorillas, chimpanzees,
monkeys, forest antelope and porcupines found dead in the rain forest. So far, the Ebola virus
has been detected in the wild in carcasses of chimpanzees (in Cote-d'Ivoire and the Republic
of the Congo), gorillas (Gabon and the Republic of the Congo) and duikers (the Republic of
the Congo)(8).
Different hypotheses have been developed to explain the origin of Ebola outbreaks.
Laboratory observation has shown that bats experimentally infected with Ebola do not die,
and this has raised speculation that these mammals may play a role in maintaining the virus in
the tropical forest (3).
Health officials (Dr Joseph Amonye/MOH and Dr. Jozef Suvada/International Tropic Team)
told reporters in Kampala that the 14 dead were among 20 reported with the disease. Two of
the infected have been isolated for examination by researchers and health officials. A clinical
officer and, days later, her 4-month-old baby died from the disease caused by the Ebola virus,
officials said. Officials urged Ugandans to be calm, saying a national emergency taskforce
had been set up to stop the disease from spreading far and wide. There is no cure or vaccine
for Ebola, and in Uganda, where in 2000 the disease killed 224 people and left hundreds more
traumatized, it resurrects terrible memories (10).
Ebola, which manifests itself as a hemorrhagic fever, is highly infectious and kills quickly. It
was first reported in 1976 in Congo and is named for the river where it was recognised,
according to the Centers for Disease Control and Prevention. Scientists don't know the natural
reservoir of the virus, but they suspect the first victim in an Ebola outbreak gets infected
through contact with an infected animal, such as a monkey (8,10).
How is Ebola spread?
Infections with Ebola virus are acute. There is no carrier state. Because the natural reservoir
of the virus is unknown, the manner in which the virus first appears in a human at the start of
an outbreak has not been determined. However, researchers have hypothesized that the first
patient becomes infected through contact with an infected animal.
After the first case-patient in an outbreak setting is infected, the virus can be transmitted in
several ways. People can be exposed to Ebola virus from direct contact with the blood and/or
secretions of an infected person. Thus, the virus is often spread through families and friends
because they come in close contact with such secretions when caring for infected persons.
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People can also be exposed to Ebola virus through contact with objects, such as needles, that
have been contaminated with infected secretions (3, 16).
Nosocomial transmission refers to the spread of a disease within a health-care setting, such as
a clinic or hospital. It occurs frequently during Ebola HF outbreaks. It includes both types of
transmission described above. In African health-care facilities, patients are often cared for
without the use of a mask, gown, or gloves. Exposure to the virus has occurred when health
care workers treated individuals with Ebola HF without wearing these types of protective
clothing. In addition, when needles or syringes are used, they may not be of the disposable
type, or may not have been sterilized, but only rinsed before reinsertion into multi-use vials of
medicine. If needles or syringes become contaminated with virus and are then reused,
numerous people can become infected (10).
The virus can be transmitted in several ways, including through direct contact with the blood
of an infected person. During communal funerals, for example, when the bereaved come into
contact with an Ebola victim, the virus can be contracted, officials said, warning against
unnecessary contact with suspected cases of Ebola. In Kibaale, some villagers had started
abandoning their homes in recent weeks to escape what they thought was an illness that had
something to do with bad luck, because people were quickly falling ill and dying, and there
was no immediate explanation (8,10).
This is the 4th outbreak of [ebolavirus] in the country since 2000, when it killed 224 people.
About 40 people died of the disease in villages along the border with the Democratic Republic
of Congo in 2008, while another isolated death occurred last year [2011, in Uganda]. Ebola
[hemorrhagic fever], which has no known cure, is highly infectious and symptoms include
vomiting, diarrhea, and external and internal bleeding. It was first identified in 1976 in Congo
near the River Ebola. Regarding bleeding in Ebola hemorrhagic fever, during the Ebola
outbreak in Gulu, Uganda in 2000-2001, we collected detailed clinical information on over
100 patients with laboratory confirmed Ebola Sudan virus infection. Excluding
subconjunctival bleeding/injection, hemorrhage was noted in only approximately 20 percent
of the patients and virtually always occurred in the later stage of illness. Hematemesis and
bleeding from the gums were the most frequent hemorrhagic manifestations. Many patients
die without visible hemorrhage although, when present, hemorrhage does confer a poor
prognosis. Studies done in the isolation ward demonstrated that [ebolavirus] was shed in a
wide variety of bodily fluids during the acute period of illness but that the risk of transmission
from fomites or from convalescent patients was low (7).
Dr Joseph Amonye, the national coordinator of the Ebola task force disclosed through Dr.
Jozef Suvada that health experts were monitoring 398 cases believed to have come into
contact with people who died of Ebola [hemorrhagic fever]. Of these, 84 have passed the 21day period during which signs of infection would have shown, although they are still being
monitored (8,10).
The epicenter of the outbreak is in Sombwe Parish, Nyimbwa Sub County, Luwero district,
which is located about 40 km north of the capital Kampala. Joseph Okware, the Luwero
District Health Officer, was quoted on Wednesday [13 Nov 2012] as saying that 2 people
belonging to the same family had died of the disease over the weekend. The outbreak comes
at a time when the country is still experiencing the deadly Marburg fever in several parts of
western Uganda. In July this year [2012], the Ebola outbreak in the midwestern Ugandan
district of Kibaale left at least 20 people dead (10).
Ebola victims present with symptoms like fever, vomiting, diarrhea, abdominal pain,
headache, measles-like rash, red eyes, and sometimes with bleeding from body openings
(3,10, 16).
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Recommendation for postexposure prophylaxis: Little information is available regarding
PEP of viral hemorrhagic fevers. Ribavirin, administered orally, may be effective in
preventing Lassa fever. (14, 15)
Therapeutic Countermeasures for Viral Hemorrhagic Fever
The mainstay of treatment for VHF is supportive, intensive care as indicated by the
complications of the disease. Management of bleeding diatheses is controversial but generally
involves the administration of blood and clotting factor components as indicated by the
laboratory findings. Heparin or tissue factor antagonists may be useful therapeutic choices in
cases of DIC. Steroids have not been shown to be effective but should be considered with
evidence of adrenal involvement (3, 11, 13). Ribavirin has some in vitro activity against
members of the Arenaviridae and Bunyaviridae (7).
Postexposure Prophylaxis
There is no effective PEP for asymptomatic persons exposed to VHF virus.
The Working Group on Civilian Biodefense instead recommends that exposed populations be
placed under surveillance for signs of fever or other symptoms suggestive of VHF.
In the event of a documented fever higher than 38,5В°C, persons should be given intravenous
ribavirin unless the agent is a confirmed filovirus or flavivirus. This is an off-label use.
Surveillance should continue for 21 days following exposure and is recommended for HCWs
in the epidemic time by caregiving to ill people suspected of VHF (1,7).
Vaccine
The only effective licensed vaccine against VHF is yellow fever vaccine (2). In the event of a
epidemia attack, yellow fever vaccine would not be effective as a prophylactic treatment
following exposure, because the disease incubation period is significantly shorter than the
time required
for
developing immunity following vaccination
(3,
14).
Vaccines against Argentine HF and Rift Valley fever are known to be efficacious but are
available only as investigational drugs (13). Efforts to develop additional vaccines against
various HF viruses are ongoing (2, 11).
Implications for Healthcare Workers
Nosocomial transmission has usually occurred by contact with infected body fluids or blood
(3, 11). Needlesticks or the reuse of needles has also been associated with viral transmission
(1, 12, 13). Although these viruses form stable infectious aerosols, person-to-person airborne
transmission is distinctly uncommon, the potential for airborne transmission in a healthcare
setting cannot be ruled out (3, 11, 13). HCWs must exercise appropriate isolation procedures
for patients with suspected or confirmed VHF including a combination of Airborne and
Contact Precautions. The Working Group on Civilian Biodefense recommends the following
precautions for healthcare settings (7): All HCWs must have appropriate personal protective
equipment, including N95 masks or personal air-purifying respirators (PAPR). Patients must
be placed in a negative pressure room, with restriction of nonessential staff and visitors. All
healthcare workers who have had high-risk close contact with patients suspected of having
VHF should be placed under medical surveillance for 21 days following exposure. If multiple
patients suspected of having VHF are admitted to a healthcare facility, they should be
cohorted to minimize exposure to HCWs and other patients (2).
All cases of suspected VHF should be reported immediately to state or local public health
officials, according to disease reporting requirements.
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REFERENCES
1. R. B. Wallace, N. Kohatsu, J. M. Last. Public Health & Preventive Medicine. The McGrawHill Companies, 2008, pp.1404
2. E. Lautenbach, K. Woeltje Practical Handbook for Healthcare Epidemiologists. The Society
for Healthcare Epidemiology of America, SLACK Incorporated, NJ, 2005:401
3 Suvada J. Viral hemorrhagic fevers and health care in central region of Africa. HealthNet
News Readers, 2012 Nov 4, WHO, electronic version [http://healthnet.org/hnn-chat]
4. Committee on Infectious Diseases, American Academy of Pediatrics. 2000 Red Book: Report
of the Committee on Infectious Diseases. 25th ed. Ill:American Academy of Pediatrics; 2000
5. Chin J. Control of Communicable Diseases Manual. 17th ed. Washington, DC: American
Public Health Association; 2000
6. Mandell GL, Bennett JE, Dolin R, eds. Principles and Practice of Infectious Diseases. 5th ed.
New York, NY:Churchill Livingstone; 2000
7. Bausch et al, J Infect Dis. 2007 Nov 15; 196 Suppl 2:S142-7
8. Hettes M. http://www.cdc.gov /1st November, 2012/
9. Suvada J. Marburg virus outbreak. HealthNet News Readers, 2012 Aug 1, WHO, electronic
version [http://healthnet.org/hnn-chat]
10. Suvada J. Ebola outbreak in Uganda. HealthNet News Readers, 2012 Nov 4, WHO,
electronic version [http://healthnet.org/hnn-chat]
11. LeDuc JW. Epidemiology of hemorrhagic fever viruses. Rev Infect Dis 1989;11(suppl
4):S730-S735.
12 Frame JD, Baldwin JM, Gocke DJ, et al. Lassa fever, a new virus disease of man from West
Africa. I. Clinical description and pathological findings. Am J Trop Med Hyg 1970;19:670-676.
13 Peters CJ. Marburg and Ebola virus hemorrhagic fevers. In: Mandell GL, Douglas RG Jr,
Dolin R, eds. Principles and practice of infectious diseases, 5th ed. New York: Churchill
Livingstone, 2000:1821-1823.
14. White HA. Lassa fever. A study of 23 hospital cases. Trans R Soc Trop Med Hyg
1972;66:390-401.
15 The Medical Letter, Hettes M., Drugs and vaccines against biological weapons, Med Lett,
43(W1115A), 87–89, 2001
16 Suvada J et al. Spectrum of patient´s diagnosis in rural hospital in Buikwe – Uganda. J.
Tropical Health Social work Vol 7,2010. 36-38
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SOCIAL SUPPORT AND QUALITY OF LIFE AMONG PEOPLE
LIVING WITH HIV/AIDS IN CENTRAL UGANDA
Kagoya R., Tumbu P, Iriso R., Zanaib A., Otundo K., Karamagy Y., M. Franekova,
B. Silharova, Namagala E.
St. Charles Lwanga, St. Elisabeth University programe Ngogwe, Uganda
Introduction
The development of anti-HIV medicine has led to significant increases in life expectancy and
quality of life for people living with HIV/AIDS (PLWHA). The average number of years a
PLWHA lives after treatment started with combination antiretroviral therapy is estimated to
be 20–35 years [3]. This tends to transform HIV to a chronic disease [33]. Chronic traits of a
disease increase demand for care, treatment, and support for PLWHA. In order to fulfill
demand for care and treatment, family, friends, and the community can be major sources of
support [20]. A number of research studies have indicated that there is a significant relation
between social support and quality of life [4, 5, 12, 16, 28, 29, 32, 40, 51].
Hope is an under researched concept in the social aspects of HIV treatment [8]. The concept
has been explored minimally within the context of HIV/AIDS [36], previous research on
HIV/AIDS mainly focused on the dynamics of hope in the process of caring PLWHA [35],
maintaining hope while coping with the end-stage of AIDS and how nurses inspire and instill
hope in terminally ill AIDS patients [14]. Some authors [1] suggested that the goal of
fostering hope should focus on how to improve quality of life of the individual. However,
thorough research on factors that mediate the relationship between social support and healthrelated outcome or quality of life on PLWHA is unavailable.
The assumptions made in this paper are:
(1) There will be a significant positive correlation between perceived satisfaction from
social support and quality of life, perceived satisfaction from social support and
hope and perceived hope and quality of life among PLWHA;
(2) Perceived satisfaction from social support and hope considered together will explain
more of the variance of quality of life than either variable considered
independently.
Review
Defining social support
The roots of the concept of social support are found in nineteenth century sociologists such as
Durkheim [15], who established the link between diminishing social ties and an increase in
suicide [44, 52]. As a concept, it has evolved over time starting with the term ��social ties’’ as
used by Durkheim [52]. Caplan [10] describes a social system as others who (1) help people
to mobilize their psychological resources in order to deal with emotional problems (linking,
loving, and empathy); (2) information (about the environment), (3) instrumental aid (provide
an individual with money, material, skills, and advice in order to help them to deal with
particularly stressful situations that they are exposed to). Social support has come to possess
different dimensions and is expressed in different forms and different ways. The source of
social support can come in the form of emotional support from family, friends, and peers [20].
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It can also emanate from social interactions in the community including professionals [9] and
even from interaction with the environment [19, 54].
Social support and hope in HIV
Herth [26] examined hope-fostering strategies on PLWHA which were defined as those
sources that assist to install, support or restore hope in some way. Further strategies were
categorized into seven categories: (1) interpersonal connectedness; mainly focuses on love
from family and friends, i.e., meaningful relationships, being loved and giving love; (2)
spiritual base focusing on spiritual practice as a source of hope, belief in God and family,
belief helps to overcome the suffering; (3) attainable aim direct to setting goals and
maintaining independence, goals are further divided into attainable and unattainable; (4)
affirmation of worth; focusing on positive relationships within professional careers, helping
relationship regarding illness and being treated with courtesy and respect; (5) light
heartedness; focusing on friendship with others who are suffering from a same cause,
laughing with professionals and laughing as an inner resource; (6) personal attribute; focusing
on determination and being a fighter; (7) uplifting memories; focusing on recalling uplifting
moments acting as a hope-fostering strategy. Hindrances to hope were defined as those factors
that interfere or inhibit the possibility of attaining or maintaining hope, which constitute: (1)
abandonment and isolation, physical and emotional loss of significant others, such as spouse
that will not or cannot support patient psychologically, poor communication with
professionals; (2) uncontrollable pain and discomfort, continuance of overwhelming pain or
discomfort despite repeated attempts to control; and (3) devaluation of personhood, being
treated as a non-person having little value.
Another study on HIV suggested that hope is an important component of effectively dealing
with HIV and AIDS. The experience of hope is less just after diagnosis of HIV, and potential
sources for fostering hope are (1) receiving support; (2) engaging in meaningful life
experiences; (3) perceiving options; (4) receiving treatment; and maintaining quality of life
[23].
One of the studies on PLWHA identified four major ways that hope was maintained: by
miracles, religion, involvement in work or vocations, and support of family and friends [21,
52]. Specific ways of being in relationships with others include dealing with one’s family,
renegotiating the friendship group, helping others with HIV and developing a relationship
with a higher power, and in this case, social support act as the functional component of
relationships, such as emotional and tangible assistance [5].
A study on HIV infected terminally ill persons indicates that there were significant differences
in the level of hope according to diagnosis [26], and hope can help PLWHA to deal with the
HIV diagnosis and acts as an internal resource for helping individuals living with HIV to
experience increased well-being [25].
One of the studies on women with HIV showed a significant positive relationship between
hope and coping, hope and managing the illness, and between hope and spiritual activities. A
significant negative relationship was observed between hope, and inability to cope and stigma
was associated with less hope [42].
Promoting hope and acceptance of HIV-status enables PLWHA to develop a positive
therapeutic relationship with medication, which in turn promotes adherence to treatment.
Treatment adherence was related to active participation in social networks [39]. Facilitating
hope appears to be an important therapeutic goal in working with newly diagnosed HIVpositive individuals, and hope was connected to longer life for PLWHA [23].
There are two sources of social support that have been discussed in previous studies. The first
relates to family and friends, and the second to community-based support, government
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agencies, and the health care industry [48]. The non-family support mostly comes from nurses
or nursing practice, and it is connected with the concepts of nursing, caring, and helping [14],
peer counselors and health workers are important to provide referral information (as
informational support) for livelihood to receive counseling and medical treatment in the
process of fostering hope [1, 23].The support from friends and family is valuable to counter
stigma [2, 17].
Social support and quality of life in HIV Quality of life is defined as a ��fighting spirit’’
associated with longer life expectancies for individuals with HIV/ AIDS [37, 53]. Social
support of PLWHA was significantly correlated with health-related quality of life [41].
Research on PLWHA indicates that a supportive social environment, particularly friends and
family acceptance, was significantly associated with quality of life [16, 28]. Alienation,
rejection, and isolation can threaten hope and well-being of PLWHA [38].
Taking care of physical, psychological, and social relationship was important for maintaining
health-related quality of life and social support of PLWHA [49]. One of the studies suggested
that social support is significantly associated with health-related quality of life, with the
exception of physical functioning and bodily pain aspects [6]. A low level of social support
causes a worsening of physical functioning [45]. Another study suggested that psychological
functioning and physical symptoms were associated with a higher level of social support [54].
Furthermore, the type of social support influences the level of quality of life, as the level of
emotional support decreases physical distress, mental distress, activity limitation, depressive
symptoms, anxiety symptoms, insufficient sleep, and pain [50, 54], the tangible or functional
support seems to be more relevant to PLWHA [18]. Social support from peers was critical for
psychological functioning of PLWHA in many circumstances. However, in periods of crisis,
family support becomes a more important determinant of psychological functioning [13].
Also, quality of life relates both to adequacy of material circumstances and to personal
feelings about these circumstances, and it includes ��overall subjective feelings of well-being
that are closely related to morale, happiness and satisfaction’’ [37, 43].
In summary, in terms of research on HIV, the above review of literature showed that hope is
an inner resource to experience well-being for long-term survival. Most of the research
findings [4, 5, 12, 16, 28, 29, 32, 40, 51] suggested the existence of relationships among
aspects of social support and quality of life. Others [1, 14, 35] pointed out relationships
among aspects of hopelessness, depression, despair, coping, managing illness, and quality of
life. None of the studies explored the relationship among positive aspects of life, which is
being �hopeful about the future’, perceived satisfaction from social support, and uality of life.
Yet, even with some progress, hope has remained a complex and even elusive concept to
measure in community settings where PLWHA are receiving care, support, and treatment. A
lack of research in the area continues to exist in relation to the HIV/AIDS population.
In addition, most of the tools used in previous research in HIV were not specific HIV/AIDS.
This research intends to fill the gaps in the conceptual approach of hope as having positive
attributes from social support and tools to measure hope and perceived social support specific
to HIV.
Methodology
Study design and participants
The study was descriptive and cross-sectional in design, focusing on adults living with
HIV/AIDS in Uganda. The underlying criterion for sample selection was PLWHA receiving
support from a community-based NGO. Further, the study also relied on a convenient and
purposefully selected sample (N = 160). Selection of participants was based on the following
criteria: (1) PLWHA receiving care, support, and treatment, (2) PLWHA being at least 18
years old, and (3) PLWHA who were physically able to answer the questionnaire. The study
was conducted during 2010– 2011, and data collection was undertaken by the author with the
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CLINICAL SOCIAL WORK (CSW)
support of hired professional research assistants from the Busoga University, Uganda and St.
Elizabeth University, Slovakia. Oneto- one interviews were conducted during monthly
meetings in eight community-based organizations where PLWHA gather to share their
experiences and to receive other support. Prior to the interviews, the purpose of the study was
explained to the participants, and with their consent, information was collected agreeing that
their names and addresses would not be included in the questionnaire, as well as in research
paper.
Measurements
Demographic questionnaire
The first questionnaire was administered to gather information regarding age, gender, type of
religion, educational level, occupational status, mode of transmission, duration of living with
HIV, stigma, how they handle with stigma and self-reported CD4 count.
Hope scale
The hope scale was developed particularly for this study.
The construct of the scale was based on the meaning of hope defined by 25 PLWHA during
in-depth interviews and the hope concept suggested by Hays [24] and Herth [26], which was
specific to PLWHA. The ��Hope scale’’ consists of seven items and measures perceived hope.
The first item measures hope from engaging in meaningful life, the second item measures
hope from personnel willpower, the third item measures level of hopelessness due to
discrimination by others, the fourth item measures perceived hope from family love and care,
the fifth item measures perceived hope because of help from friends, counselors or health and
community workers, the sixth item measures perceived hope from others help with material,
such as caring spouse, and the seventh item measures perceived hope from belief in religion
or God. The scale was translated into Ugandan language and the Ugandan version of the scale
showed good internal reliability. The scale applied a five point value ranging from not at all to
extremely hopeful; a higher score indicated better hope [50, 54].
Social support questionnaire
The social support scale was adapted from the shorter Sarason’s Social Support questionnaire
(SSQ-S) developed by Sarason et al. [46]. The SSQ-S original is a 12-item instrument that
measures two aspects of perceived social support: six odd-numbered items count social
support network (the number of people in the individual’s social support system), the total
number of people in the individual’s social support system is further divided into family
network and non-family network support and six even-numbered items measures perceived
satisfaction from social support network. The overall satisfaction from specific support is
based on a six-point scale ranging from very satisfied to very dissatisfied. The original scale
was modified into a 14-item scale. The added and modified two odd items were to measure
��whom they could really count on when they needed help for’’ HIV/AIDS-related treatment
and help from spouse, for living arrangement, for food, for transportation and others, followed
by two even number for level of satisfaction from support. A factor analysis of the seven odd
number items outcome revealed three distinct factors and each corresponds to a different
support function; the first tangible, the second informational, and the third emotional support.
The modified version of HIV-specific social support questionnaire was translated from
English into Luganda language and translated back from Luganda into English by
independent translators. Each of the domains in the Luganda version of the scale showed good
internal reliability, yielding Cronbach’s alpha of .90 emotional, .87 informational, .82
tangible, and .88 for overall support.
Quality of life
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CLINICAL SOCIAL WORK (CSW)
The (WHO) QOL-26 tool consists of 26 items and was derived from the (WHO) QOL-100
items tool. It includes seven items in the physical domain (physical state), six items in the
psychological domain (cognitive and affective state), three items in the social domain
(interpersonal relationship and social role in life), eight items in the environmental domain
(relationship to salient feature of the environment), one item for general quality of life, and
one item for health-related quality of life combining together as global domain [34, 51]. The
PLWHA were required to rate their quality of life in the past 2 weeks. The item scores ranged
from 1 to 5, with a higher score indicating a better quality of life. Because the numbers of
items were different for each domain, the domain scores were calculated by multiplying the
average of the scores of all items in the domain by 4 to standardize all domain scores and
make it comparable with other domains [27, 31, 49, 53].
Statistical analysis
Statistical analysis was performed using the Statistical Package for Social Sciences (SPSS)
version 17.0. The respondents’ demographics status was presented as a mean and a
percentage. Scores of quality of life, social support, and hope scale were presented as a mean,
standard deviation and range. Pearson’s correlation analysis was performed to see the
correlation between perceived satisfactions from social support, hope, and quality of life.
Stepwise hierarchical multiple regression was also conducted to observe the contribution of
the independent variables, social support and hope, had on each quality of life domain.
Results
The demographic and clinical characteristics of the study sample are summarized in Table 1.
Of the 160 HIVinfected person included in study, 72.5% were female and 27.5% were male,
11.3% of them were between 18 and 25 years old, 25% were between 25 and 32, 51.2% were
between 33 and 40, and 12.5% were over 40 years old. In addition, 26.3% were unmarried,
41.9% were married, 13.8% were widow, and 18% were divorced. It was also found out that
60.6% of respondents were Protestant, 28.1% were Muslims, and 11.3% were Catholic.
In terms of education, 18.7% were uneducated, 58.7% had received primary education, 19.4%
had higher education, 3.1% of respondents had university. The data on occupation showed
that 28.1% were employed where as 60% were unemployed and 11.9% were involved in
social work in community-based NGOs. Time since diagnosis, 25.1% were in 2010–2011,
32.5% were 2–4 years ago, 6.9% were between 5 and 8 years, and 35.5% were more than 8
years.
The acknowledge risk factors showing 53.8% had infection cause of sex with other than a
partner and 43.1% were infected by their husbands, 3.1% were infected with another rout of
the HIV transmission (perinataly were infected 4 and by transfusion 1person) and 30.69% had
<200 cells/ВµL CD4 count blood level, and 69.4% had more than 200 cells/ВµL.
Table 1 Characteristics of study participants
Characteristics
Number
person
Age
18-25
18
25-32
40
33-40
82
Over 40
20
Gender
Male
44
Female
116
Marital status
215
of Percentage
11.3
25.0
51.2
12.5
27.5
72.5
CLINICAL SOCIAL WORK (CSW)
Unmarried
Married
Widow
Divorced
Religion
Protestant
Muslim
Catholic
Education
Uneducated
Primary school
High school
Graduate
Employment
Employed
Unemployed
Social work
Duration of living
with HIV
This year
2-4 years ago
5-8 years ago
More than 8 years
ago
Acknowledge risk
factors
Sex with other
From husband/wife
Others
(blood
transfusion - 1,
perinatal - 4)
Medical
outcome
(CD4 count)
>200
<200
42
67
22
29
26.3
41.9
13.8
18.0
97
45
18
60.6
28.1
11.3
30
94
31
5
18.7
58.8
19.4
3.1
45
96
19
28.1
60.0
11.9
40
52
11
57
25.1
32.5
6.9
35.5
86
69
5
53.8
43.1
3.1
111
49
69.4
30.6
The mean standard deviation and range of score for the social support, hope, and quality of
life scale are presented in Table 2. The mean score was 5.15 for overall satisfaction from
social support, 3.87 for hope, 14.01 for physical capacity, 14.36 for psychological
functioning, 12.48 for social relationship, 13.66 environmental functioning, and 6.73 for
global domains of quality of life.
As predicted, a significant positive correlation was found between the perceived overall
satisfaction from the social support and all domain of quality of life, physical capacity (r =
.296, p = .000), psychological functioning (r = .243, p = .001), social relationship (r = .152, p
= .029), environmental functioning (r = .398, p = .000), and global functioning (r = .286, p =
.000). Satisfaction with informational, tangible, and emotional support was a stronger
predictor of physical functioning, psychological functioning, environmental functioning, and
global domains of quality of life than social relationship. The correlations obtained between
perceived satisfaction from social support and the domains of quality of life are summarized
in Table 3.
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CLINICAL SOCIAL WORK (CSW)
As predicted, a significant positive correlation was found between hope and quality of life
domain, although hope is significantly correlated with all domains of quality of life, hope was
a stronger predictor for the environmental functioning (r = .445, p = .000) than the other four
domains of the quality of life. The result of the correlations is summarized in Table 4.
As predicted, perceived satisfaction with social support and hope considered together would
explain more variance in quality of life than either variables considered independently,
implying stepwise hierarchical multiple regression perceived satisfaction from social support
was entered into regression equation on the first step. The adjusted R2 shows that 7% of
variance in physical functioning (F = 14.095, p = .000), 5% of variance in psychological
functioning (F = 10.371, p = .002), 2% of variance in social relationship (F = 4.319, p = .039),
17% of variance in environmental functioning (F = 33.212, p = .000), and 8% of variance in
global functioning (F = 14.321, p = .000) domains of quality of life were explained by overall
satisfaction from perceived social support. Entering hope into equation at step two, the
adjusted R2 indicates that 15% of variance in physical functioning (F = 14.508, p = .000)
explaining an additional 7% of variance, 14% variance in psychological functioning (F =
13.594, p = .000) explaining an additional 8% variance, 9.8% variance in social relationship
(F = 9.331, p = .000) explaining an additional 8% variance, 27% variance in environmental
functioning (F = 30.364, p = .000) explaining an additional 10% variance, 12.% of variance in
global functioning (F = 11.762, p = .004) explaining an additional 4% variance of domains in
quality of life. The variance in environmental functioning explained by the satisfaction with
social support independently or considered together was greater than the other domain of
quality of life. Together perceived satisfaction with social support and hope was significantly
explained more by variance in quality of life.
Discussion
The aim of the study was first to assess the level of satisfaction from social support, the level
of hope and the quality of life of PLWHA, second to examine the relationship among social
support, hope, and quality of life. This study applied hope as a mediation factor between
social support and quality of life. It is plausible to argue that this study is reflective of the
general HIV population in the context of risk factor and age group distribution and other
characteristics in rural Uganda, therefore, the findings of the study may be generalized to
HIV-infected people being cared, supported, and treated in other community settings in
Uganda. Social support should not be conceptualized simply in terms of availability, but in its
perceived adequacy. Social support may not be considered useful unless the individual
perceives it as supportive. It has been proposed that the qualitative components of perceived
satisfaction from three major components of social support i.e., informational, tangible, and
emotional supports [24] are considered more important than the quantitative aspects of social
support [51, 54]. Perception is generally a better predictor of health outcome than the receipt
[53].
The result of the correlation analyses shows that satisfaction with social support was
significantly correlated with all domains in the quality of life. These findings support those
found in previous studies, which show that social support was significantly correlated with
quality of life [27, 41, 51]. The greatest impact of social support was on environmental
functioning, whereas the lowest impact was on social relationship (Table 3). This study’s
finding was different from previous studies by Bastardo and Kimberlin [6], Jia et al. [29], and
Remor [45], who suggested that that social support was not correlated with the physical
functioning, and only psychological functioning was correlated with social support [54].
Furthermore, satisfaction from the informational and tangible support was a better predictor of
quality of life except social relationship domain (Table 3).
The findings of this study show that mean score of family support network was less than the
non-family support network (Table 2), the family support is a major source of emotional
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CLINICAL SOCIAL WORK (CSW)
support [13, 48], limited emotional support can inhibit social relationship [50], and a study by
Friedland et al. [16] and Ichikawa [28]) suggested that family acceptance was significantly
related to the social relationship of quality of life. Harris and Larsen [22] suggested that nonfamily members such as health workers, counselors, volunteers, and friends have vital
contributions in providing information and tangible support for livelihood and treatment.
Therefore, the concept of providing information support should be based on the information
to acquire emotional support from family and other social relations, which would further
increase the social relationship of PLWHA.
Overall satisfaction from social support was significantly correlated with hope, and this
finding is similar to that which shows hope was positively associated with perceived social
support by PLWHA [55]. Again, satisfactionfrom emotional support was less of a predictor of
levels of hope than informational and tangible support. A similar finding has been reported by
[1, 5, 18, 24] indicating instrumental or informational support seems more relevant to people
living with HIV when patients experience AIDS-related symptoms.
Hope was significantly correlated with all domains of the quality of life. This finding is
collaborated by similar findings in which hope was found to be an important internal resource
for the increased functioning of PLWHA [11, 25]. The greatest impact of hope was on
environmental functioning and the lowest was on global functioning. The employment status,
Table 1, showed that 11.9% of the respondents were engaged as support provider and they
were working as counselors or assisting in the referral system. They called themselves a social
worker, which, in turn, puts them in the company of others who are also infected with HIV.
This is in line with the hope-fostering strategy suggested by Herth [26]. The argument states
that being around others who have HIV and who have been living long healthy lives helps
PLWHA to experience hope that they may also have a long healthy life, the findings in this
study showed that not only being around others, but also receiving various types of support
from PLWHA can foster hope which leads to better quality of life. This study’s findings
confirm that social support has impact on the all domains of quality of life and hope.
The result from the regression analysis showed that the effect of social support on the quality
of life was through the mediation variable hope, when controlling other demographic
characteristics. Although the independent variables, social support plus hope, together explain
significant amount of variance in quality of life, there still exists a large number of variance
unexplained.
This study found that HIV infected males experienced less perceived satisfaction from social
support, which, in turn, concurs the finding that HIV-infected men receive less social support
[31]. This may refer to Beine’s [7] proposed dominant cultural model of HIV/AIDS, in which
he suggested that widely shared understanding of HIV/AIDS as a fetal, infectious, and
sexually transmitted disease and further suggested that the common themes regarding
HIV/AIDS as a ��bad person’s’’ disease, HIV/AIDS as the result of bad spirit which are
against the moral and traditional customs. Cultural values such as accuses for transmitting
disease to their husband, fear of stigmatization, and discrimination prevent women from
disclosing their status, not to seek medical support or advices and men are to proud to do so
[30]. Furthermore, socio-cultural factors may influence the social support, hope, and quality
of life of women participants in this study.
Conclusion
Correlation analysis showed that social support was significantly associated with hope and
quality of life, and hope was also significantly associated with quality of life; however, social
relationship had less of a correlation than other domains. Emotional support was less of a
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predictor of quality of life and hope. Increasing social support and increasing hope together
may have influence a better quality of life in this sample. Although the independent variables
social support and hope account for a significant amount of variance of quality of life, there is
still a large number of variance remaining unexplained. Further research is suggested to
investigate other sources of variance in the domains of quality of life of person being cared,
treated, and supported in community setting in Uganda.
Community-based workers and health professionals should provide tangible support and
inform to HIV-infected persons about psycho-social support from friends and family,
particularly to males. The regression analysis also showed that the effect of social support on
quality of life was mainly through the mediation variable hope, suggesting that improving
social support will increase hope, which, in turn, would improve their quality of life.
Table 2 Mean score achieved by subjects on the study Instruments (N = 160)
Scale
Mean
SD
Range
Satisfaction with social 5.15
0.5
2-6
support
Overall network
4.20
1.5
1-9
Family network
2.53
1.2
1-6
Non-family network
4.82
0.93
4-8
Hope
3.87
0.5
2.33-5.33
QOL domain
Physical functioning
14.01
2.12
7-19
Psychological
14.38
1.78
7-21
functioning
Social relationship
12.12
1.96
4-15
Environmental
13.44
1.80
9-17
functioning
Global functioning
6.75
1.80
3-9
SD, standard deviation
Table 3 Correlation between overall social support, types of support, and quality of life (N =
160)
Quality of life
Physical
functioning
Psychological
functioning
Social
relationship
Environmental
functioning
Global
functioning
Overall
satisfaction
.296**
Informational
satisfaction
.295**
Tangible
satisfaction
.240**
Wmitional
satisfaction
.253**
.243**
.230**
.232**
.218**
.152*
.167*
.150*
.131*
.398**
.344**
.449**
.300**
.286**
.233**
.258**
.274**
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CLINICAL SOCIAL WORK (CSW)
Table 4 Correlation between hope and quality of life (N = 160)
Quality of life
Hope
Physical functioning
.375**
Psychological functioning
.357**
Social relationship
.352**
Environmental functioning
.445**
Global functioning
.313**
Numbers indicate Pearson r (** p<0.01)
REFERENCES
1. Sushil Yadav (2009). Perceived social support, hope, and quality of life of persons living
with HIV/AIDS: a case study from Nepal. Springer Science. Qual Life Res, DOI
10.1007/s11136-009-9574-z, pp.10
2. Andrews, S. (1995). Social support as a stress buffer among human immunodeficiency
virus-seropositive urban mothers [case reports]. Holistic Nursing Practice, 10(1), 36–43.
3. Antiretroviral Therapy Cohort, C. (2008). Life expectancy of individuals on combination
antiretroviral therapy in high-income countries: A collaborative analysis of 14 cohort studies
[research support, non-US Gov’t]. Lancet, 372(9635), 293–299.
4. Ashton, E., Vosvick, M., Chesney, M., Gore-Felton, C., Koopman, C., O’Shea, K., et al.
(2005). Social support and maladaptive coping as predictors of the change in physical health
symptoms among persons living with HIV/AIDS [article]. Aids Patient Care and STDs, 19(9),
587–598.
5. Barroso, J. (1997). Social support and long-term survivors of AIDS [article]. Western
Journal of Nursing Research, 19(5), 554–573.
6. Bastardo, Y. M., & Kimberlin, C. L. (2000). Relationship between quality of life, social
support and disease-related factors in HIV-infected persons in Venezuela. Aids CarePsychological and Socio-Medical Aspects of Aids/Hiv, 12(5), 673–684.
7. Beine, D. K. (2003). Ensnared by AIDS: Cultural contexts of HIV/AIDS in Nepal (p. 411).
Kantipath, Kathmandu, Nepal: Mandala Book Point.
8. Bernays, S., Rhodes, T., & Barnett, T. (2007). Hope: A new way to look at the HIV
epidemic [article]. Aids, 21, S5–S11.
9. Brashers, D. E. (2002). Belonging to AIDS activist group helps HIV ? to cope. Journal of
Social and Personal Relationships, 19, 113–130.
10. Caplan, G. (1974). Support systems and community mental health. New York: Behavioral
Publications.
11. Chammas, G. Y. (1999). Hope, functional status, and quality of life in hospitalized
patients with human immunodeficiency virus infection and acquired immunodeficiency
syndrome (doctoral dissertation, Columbia University Teachers College, 1999). Dissertation
Abstracts International, 60(03), 1027B (UMI No. 9921384).
12. Chesney, M. A., Chambers, D. B., Taylor, J. M., & Johnson, L. M. (2003). Social support,
distress, and well-being in older men living with HIV infection [article]. Jaids-Journal of
Acquired Immune Deficiency Syndromes, 33, S185–S193.
220
CLINICAL SOCIAL WORK (CSW)
13. Crystal, S., & Kersting, R. C. (1998). Stress, social support, and distress in a statewide
population of persons with AIDS in New Jersey [article]. Social Work in Health Care, 28(1),
41–60.
14. Cutcliffe, J. R. (1995). How do nurses inspire and instill hope in terminally ill HIV
patients [article]. Journal of Advanced Nursing, 22(5), 888–895.
15. Durkheim, E. (1984). The division of labor in society. New York: The Free Press.
16. Friedland, J., Renwick, R., & McColl, M. M. (1996). Coping and social support as
determinants of quality of life in HIV/AIDS [article]. Aids Care-Psychological and SocioMedical Aspects of Aids/Hiv, 8(1), 15–31.
17. Galvan, F. H., Davis, E. M., Banks, D., & Bing, E. G. (2008) HIV stigma and social
support among African Americans [research support, N.I.H., extramural; research support,
non-US gov’t]. AIDS Patient Care STDS, 22(5), 423–436.
18. Gant, L. M., & Ostrow, D. G. (1995). Perceptions of social support and psychological
adaptation to sexually acquired HIV among white and African-American men [article]. Social
Work, 40(2), 215–224.
19. Gottlieb, B. H. (1983). Social support strategies: Guidelines for mental health practice.
Beverly Hills, CA: Sage.
20. Greenberger, E., Chen, C. S., Tally, S. R., & Dong, Q. (2000). Family, peer, and
individual correlates of depressive symptomatology among US and Chinese adolescents.
Journal of Consulting and Clinical Psychology, 68(2), 209–219.
21. Hall, B. A. (1994). Ways of maintaining hope in HIV disease.
22. Harris, G. E., & Larsen, D. (2007). HIV peer counseling and the development of hope:
Perspectives from peer counselors and peer counseling recipients [article]. Aids Patient Care
and STDS, 21(11), 843–859.
23. Harris, G. E., & Larsen, D. (2008). Understanding hope in the face of an HIV diagnosis
and high-risk behaviors [article]. Journal of Health Psychology, 13(3), 401–415.
24. Hays, R. B., Turner, H., & Coates, T. J. (1992). Social support, aids-related symptoms,
and depression among gay men [article]. Journal of Consulting and Clinical Psychology,
60(3), 463–469.
25. Heinrich, C. R. (2003). Enhancing the perceived health of HIV seropositive men [article].
Western Journal of Nursing Research, 25(4), 367–382.
26. Herth, K. (1990). Fostering hope in terminally-ill people [review]. Journal of Advanced
Nursing, 15(11), 1250–1259.
27. Hirabayashi, N., Fukunishi, I., Kojima, K., Kiso, T., Yamashita, Y., Fukutake, K., et al.
(2002). Psychosocial factors associated with quality of life in Japanese patients with human
immunodeficiency virus infection. Psychosomatics, 43(1), 16–23.
28. Ichikawa, M., & Natpratan, C. (2006). Perceived social environment and quality of life
among people living with HIV/AIDS in northern Thailand [article]. Aids Care-Psychological
and Socio-Medical Aspects of Aids/Hiv, 18(2), 128–132.
29. Jia, H. G., Uphold, C. R., Wu, S., Reid, K., Findley, K., & Duncan, P. W. (2004). Healthrelated quality of life among men with HIV infection: Effects of social support, coping, and
depression [article]. Aids Patient Care and STDS, 18(10), 594–603.
30. Karki, S. (2008). HIV/Aids situation in Nepal: Transition to women (Master thesis),
Linkoping University, Sweden.
31. Klein, K., Armistead, L., Devine, D., Kotchick, B., Forehand, R., Morse, E., et al. (2000).
Socioemotional support in African American families coping with maternal HIV: An
examination of mothers’ and children’s psychosocial adjustment [article]. Behavior Therapy,
31(1), 1–26.
32. Koopman, C., Gore-Felton, C., Marouf, F., Butler, L. D., Field, N., Gill, M., et al. (2000).
Relationships of perceived stress to coping, attachment and social support among HIV-
221
CLINICAL SOCIAL WORK (CSW)
positive persons [article]. Aids Care-Psychological and Socio-Medical Aspects of Aids/Hiv,
12(5), 663–672.
33. Kucera, K. A. (1998). Case management of the HIV/AIDS client [review]. Journal of
Case Management, 7(2), 62–66.
34. Kuyken, W., Orley, J., Power, M., Herrman, H., Schofield, H., Murphy, B., et al. (1995).
The world health organization quality of life assessment (WHOQOL): Position paper from the
world health organization. Social Science and Medicine, 41(10), 1403–1409.
35. Kylma, J. (2005). Despair and hopelessness in the context of HIV: A meta-synthesis on
qualitative research findings [article]. Journal of Clinical Nursing, 14(7), 813–821.
36. Kylma, J., Vehvilainen-Julkunen, K., & Lahdevirta, J. (2003). Dynamics of hope in
HIV/AIDS affected people: An exploration of significant others’ experiences. Research and
Theory for Nursing Practice, 17(3), 191–205.
37. Leserman, J., Perkins, D. O., & Evans, D. L. (1992). Coping with the threat of AIDS: The
role of social support. American Journal of Psychiatry, 149(11), 1514–1520.
38. Miller, J. F. (1989). Hope-inspiring strategies of the critically ill. Applied Nursing
Research, 2(1), 23–29.
39. Nama, S. L., Fielding, K., Avalos, A., Dickinson, D., Gaolathe, T., & Geissler, P. W.
(2008). The relationship of acceptance or denial of HIV-status to antiretroviral adherence
among adult HIV patients in urban Botswana (vol 67, pg 301, 2008). Social Science and
Medicine, 67(11), 1934.
40. Ncama, B. P., McInerney, P. A., Bhengu, B. R., Corless, I. B., Wantland, D. J., Nicholas,
P. K., et al. (2008). Social support and medication adherence in HIV disease in KwaZuluNatal, South Africa [article]. International Journal of Nursing Studies, 45(12), 1757–1763.
41. Nunes, J. A., Raymond, S. J., Nicholas, P. K., Leuner, J. D., & Webster, A. (1995). Social
support, quality of life, immune function, and health in persons living with HIV. Journal of
Holistic Nursing, 13(2), 174–198.
42. Phillips, K. D., & Sowell, R. L. (2000). Hope and coping in HIVinfected AfricanAmerican women of reproductive age [research support, non-US gov’t]. Journal of National
Black Nurses Association, 11(2), 18–24.
43. Rabkin, J. G., Remien, R., Katoff, L., & Williams, J. B. W. (1993). Resilience in adversity
among long-term survivors of AIDS. Hospital & Community Psychiatry, 44(2), 162–167.
44. Rawls, A. W. (1997). Durkheim’s epistemology: The initial critique, 1915–1924.
Sociological Quarterly, 38(1), 111–145.
45. Remor, E. (2002). Social support and quality of life in the HIV infection [comparative
study; english abstract; research support, non-US gov’t]. Atencion Primaria, 30(3), 143–148.
46. Sarason, I. G., Levine, H. M., Basham, R. B., & Sarason, B. R. (1983). Assessing social
support: The social support questionnaire [article]. Journal of Personality and Social
Psychology, 44(1), 127–139.
47. Saxena, S., Chandiramani, K., & Bhargava, R. (1998). WHOQOL- Hindi: A questionnaire
for assessing quality of life in health care settings in India [article]. National Medical Journal
of India, 11(4), 160–165.
48. Shippy, R. A. (2007). Taking care of each other. GMHC Treat Issues, 21(2), 7–8.
49. Srisurapanont, M., Sambatmai, S., & Jarusuraisin, N. (2001). HIV-seropositive results,
health-related quality of life, and social support: A 24-week prospective study in Thailand
[article]. Aids Patient Care and STDS, 15(4), 211–215.
50. Strine, T. W., Chapman, D. P., Balluz, L., & Mokdad, A. H. (2008). Health-related quality
of life and health behaviors by social and emotional support. Their relevance to psychiatry
and medicine. Social Psychiatry and Psychiatric Epidemiology, 43(2), 151–159.
51. Suvada, J. (2010). ChildrenВґs Palliative Care in low-resource settings. Agatres (U), LTD
Press, Kampala, Uganda, 2010
222
CLINICAL SOCIAL WORK (CSW)
52. Suvada, J., (2010). Pastekova T., Nkonwa I., Ianetti R, Kaiserova E., Merks J.H.M.,
Krcmery V, 2010. Neoplastic Diseases in Children with HIV infection in our register. The
4th Annual Paediatric HIV and AIDS Conference, 28th – 30th September, 2010, Kampala.
Oral lecture No. 20. In the international abstract book p. 11
53. Suvada, J. et all. (2010). Issues in Social Work and Health. Health/Social Work, 4/20101,2/2011, Volume 7-8, ISSN 1333-0023, p.145
54. Suvada, J. (2011). Improving Quality & Safety through Infection Control. UPMPA CPD
Workshop 3rd – 4th September 2011. Kampala, Uganda.
55. Zich, J., & Temoshok, L. (1987). Perceptions of social support in men with AIDS and
ARC-relationship with distress and hardiness. Journal of Applied Social Psychology, 17(3),
193–215.
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3rd SOUTHEAST EUROPEAN CONFERENCE ON
CHEMOTHERAPY AND INFECTION. NOVEMBER November 8th –
11th 2012
N. Kulkova, J. Sokolova, I. Beldjebel, L. Alumbasi Timona
University Trnava, Slovakia
SEUC Eldoret, Kenya
Session: The impact of Antibiotic PK/PD Relations on Clinical outcome of Infection
Bruno Barsic: Continuous infusion of antibiotics in critically ill patients
Pharmacokinetic parameters are significantly changed in critically ill patients with
suffering of severe infections. Many factors are responsible for these changes but the most
important one is capillary leak syndrome. Because of those concentrations of many
antibiotics, particularly beta-lactams are greatly reduced and associated with treatment
failures. Satisfactory time-above MIC is the most important PK/PD parameter associated with
treatment outcome for beta-lactams, and it is significantly shortened in patients with severe
infections, particularly if caused by organisms of reduced susceptibility (higher MIC values).
This is the reason that continuous or prolonged administration of beta-lactam antibiotics is
used in ICU setting. Although randomized, controlled trials did not show the advantage of
such treatment, they did not include the most severe patients. Meropenem, ceftazidime,
cefepime, piperacillin-tazobactam and vancomycin are the most common antibiotics
administered in continuous infusion. Imipenem-cilastatin and oxacillin are given in prolonged
infusions (3 hours).
Presently, in the absence of expensive monitoring of antibiotic concentrations,
continuous use of antibiotics represents a safe and easy to perform modality of drug
administration, enhancing the possibility of obtaining the most appropriate PK/PD premises
for optimal treatment.
Anouk Muller: Appropriate PK/PD management of combinations
Combination therapy of antimicrobials to increase efficacy is still a controversial
issue, although studies published over the last three years clearly show a clinical benefit in
severely ill patients. In addition, in vitro studies and experimental evidence from animal
studies clearly indicate the benefit for some combinations. There is increasing evidence that,
similar to usage in tuberculosis and AIDS, emergence of resistance could be reduced or at
least slowed down by using combination therapy. Since the emergence of resistant mutants is
a direct result of selective pressure by antimicrobial therapy, the chance of resistant mutants
being present to two antimicrobials in the parent population is a product of the mutation
frequencies, provided that resistance mechanisms are independent. Comparative studies in in
vitro pharmacokinetic models and in vivo indicate that emergence of resistance is less
common when combination therapy is used. This is particularly true for micro-organisms
known to develop resistance relatively fast, such as Pseudomonas aeruginosa and resistance
mechanisms which occur at a relatively high frequency.
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Session: MDR Gram negative: An ongoing epidemic
Maria Souli: The epidemiology of Gram- negative infections
The term “multidrug resistance” (MDR) is defined as acquired resistance to at least
three classes of therapeutically relevant antimicrobial agents. Carbapenem-resistant Klebsiella
pneumoniae, Pseudomonas aeruginosa and Acinetobacter baumannii, have been recognized
as the most important nosocomial MDR Gram negatives worldwide. The production of a
carbapenemase is usually the mechanism which is responsible for this phenotype. VIM-type
enzymes are responsible for carbapenem resistance among P. aeruginosa and K. pneumoniae
whereas NDM-type enzymes have been already identified in a variety of Enterobacteriaceae
and non-fermenters. KPC is currently the most prevalent carbapenemase among K.
pneumoniae while OXA-type enzymes have been identified among A. baumannii with the
exception of OXA-48, which has emerged among K. pneumoniae first in Turkey and recently
in other European countries. There is a considerable variation of resistance rates across
Europe, with the Southern countries experiencing higher rates than the Northern ones.
Nevertheless, MDR organisms are easily carried across international borders through
the transfer of patients. For that reason multidrug resistance should definitely be considered a
global problem.
Stefania Stefani, Maria Lina Mezzatesta, Floriana Gona: Rapid diagnosis of MDR
organisms
Multidrug-resistant (MDR) gram-negative pathogens are one of major hazards for
patients requiring long-term hospitalisation or hospitalisation in ICU, leaving very few
treatment options. Their prevalence and diffusion in hospitals is rapidly increasing worldwide.
Many mechanisms, involving three or more different antimicrobial families, contributed to the
MDR phenotypes, including extended-spectrum ОІ-lactamases (ESBLs) that affect fourth-as
well as third-generation analogues, that were universally active against Enterobacteriaceae
and also active against P. aeruginosa and, often, A. baumannii. The confirmation tests for
ESBL detection were used in the laboratories until 2010; currently, following the most recent
guidelines that have lowered all breakpoints related to these drugs, testing is not anymore
requested by both agencies (CLSI and EUCAST). The suggestion to perform confirmation
tests is guided by epidemiological and infection control purposes only. During the last decade,
carbapenem resistance has emerged, and its epidemiology is compounded by the diversity of
carbapenems-hydrolysing enzymes such as KPC, metallo-beta-lactamases and oxacillinases.
Among these enzymes, the class A Klebsiella pneumoniae- carbapenemases (KPC) have a
rapid international spread and it is also of note that KPCs are mostly plasmid encoded so that
they can easily disseminate to other Enterobacterial strains.
Phenotypic and molecular tests are needed for their rapid and accurate detection
during diagnostic procedures, due to an often heterogeneous expression of resistance. A
number of simple phenotypic tests, most of them in the disk diffusion format, have been
described and evaluated as methodologies for the specific detection of carbapenemases. In
many cases, PCR-based confirmation is necessary. Furthermore, the identification of
epidemic MDR clones is also an important step for controlling the MDR spread in hospitals.
Diamantis Plachouras: MDR-GNB: An ongoing epidemic. Prevention and control.
Antimicrobial resistance (AMR) constitutes one of the most serious threats to public
health on a global scale. Current dissemination of carbapenem resistant Enterobacteriaceae
(CRE) presents the most worrisome trend. What are effective and practical measures to
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prevent and control the spread of this epidemic before it makes a number of modern medical
achievements obsolete?
First, there is a need for continuous and consistent quantification and assessment of
the extent and trends of AMR and the timely recognition of emerging hazards. This can be
accomplished through strengthened surveillance on regional, national and international levels.
In order to prevent the emergence of resistance, the optimization of the use of antibiotics
through antimicrobial stewardship cannot be overemphasized. Dissemination of resistance
demands the strict implementation of infection control practices. Education of healthcare
providers is extremely important. At a hospital level, identifying colonized patients is
indispensable. To this end, active screenings as well as screening of patient contacts and
point-prevalence surveys are often needed. Single-room placement or cohorting are effective
strategies to control the spread of MDR-GNB. Various measure bundles are applicable
depending on the prevalence of the problem in the specific setting. However measures at an
institutional level are not sufficient. Action at a regional level appears to be necessary, as
evidenced by one of the few successful stories of controlling the spread of CPE in Israel.
Even on a larger scale, international cooperation is required due to factors that lead to
the spread of resistant bacteria across borders, including transfer of patients and medical
tourism. In conclusion, it is only through multi-faceted, multi-level approaches that the
problem can be contained.
George Petrrikos, Mical Paul: Treatment options for Carbapenem-resistant Gram-Negative
bacteria.
Carbapenem-resistant Gram-negative bacteria remain variably susceptible to colistin,
aminoglycosides and tigecycline. No study has compared these treatment alternatives. Recent
observational studies examined colistin treatment in comparison with carbapenems or betalactams. Overall, a compilation of these studies demonstrates increased mortality with
colistin, [unadjusted odds ratio 1.70 (95% confidence interval 1.36-2.13); multivariableadjusted OR 1.63 (95% CI 1.22-2.17)]. Pharmacokinetic studies raise the possibility that
suboptimal dosing of colistin in these studies might have been responsible for its inferior
outcomes. The time to reach therapeutic concentrations of colistin in plasma (≥2 mg/L) was
36-48 hours without a loading dose and steady state levels were frequently sub-therapeutic. A
loading dose followed by a twice-daily schedule of at least 9 million IU per day might
improve microbiological efficacy. However, the effect of such a dosing strategy on
nephrotoxicity and overall patient outcomes has yet to be described. Even in trials using the
older dosing regimens the rate of renal failure with colistin was higher than with beta-lactams,
(OR 1.58; 95% CI 1.11-2.26). Eventually, therapeutic drug monitoring will probably be
necessary to guide optimal use of colistin in clinical practice. Observational studies show
promise for colistin inhalations in the treatment of pneumonia, but the effects of this
intervention should be assessed in a randomized controlled trial. The penetration of colistin to
CSF is very poor and although slightly increased during meningitis, reported levels were
usually below 0.1 mg/L. Intrathecal/intraventricular colistin has only been reported in case
reports that present a relatively high success rate. In-vitro studies currently examine the
interactions of colistin with several antibiotics. The most studied combination is colistin/
polymyxin-carbapenem combination therapy. A systematic review of these studies shows that
synergy is most commonly observed for Acinetobacter baumannii. Clinical trials are under
way to examine the effects of colistin combination therapy on clinical outcomes.
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CLINICAL SOCIAL WORK (CSW)
Plenary Session: New Antibiotics on the Horizon.
Ethan Rubinstein: New antibiotics 2012.
After many years of dryness in the antibiotic development pipeline the situation seems
to have changed and currently there are a number of compounds under development (Table
1).
The antibiotics in the most advanced stage of development are those aimed at
Staphylococcus aureus, particularly against MRSA, hVISA and penicillin-resistant S.
pneumoniae. Older drugs that are in Phase III clinical trials include the glycopeptides:
oritavancin (The Medicine Group), Dalbavancin (Durata), Telavancin (Theravance) for
ABSSI the later also for HAP/VAP. They are all active against vancomycin resistant S.
aureus (VRSA) , MRSA, MSSA and GAS. Other compounds active against MRSA include
the oral AFN 1252 (Affinium)- a-fatty acid synthesis inhibitor, JNJ 6Q-2 (Furiex)- a
fluoroquinolone,
PMX
30063
(Polymedix)
a
cell-wall
active
compound,
Delafloxacin/Radezolid (Rib-X Pharmaceuticals) an oxazolidinone, BC 3781 (Nabriva
Therapeutics) and Tedezolid (Trius) the later has finished a phase III ABSSI trial
successfully. New fluoroquinolones those are active against Gram-positive organisms
including MRSA and hVISA, include ozenoxacin and delafloxacin that finished phase II
study successfully in ABSSI. Of these compounds it seems that Tedezolid is the more
advanced and will likely be marketed in the not too distant future.
In the Gram negative arena, plazmomycin is a new aminoglycoside which seems to be
safer than gentamicin and tobramycin and achieved in a pharmacodynamics model target
attainment against Enterobacteriaceae that was superior to cefipime and gentamicin, but not
active against Ps. aeruginosa. A whole series of beta-lactam antibiotics combined with betalactamase inhibitors have been developed: ceftaroline/avibactam (=NXL 104),
ceftazidime/avibactam, cefepime/tazobactam, ceftolozane/tazobactam, and the carbapenem
RPX2003/RPX 7009. All of them demonstrate very good activity against beta-lactamase
producing Gram-negatives, including Acinetobacter, Ps. aeruginosa, ESBL’s producers,
NDM-1 producers, OXA 48 etc. Pyrollamines are non-fluoroquinolones with a site of activity
that is the bacterial topoisomerase. Other agents that target this enzyme are as following:
coumarins, simocyclinone and albicidin. New potentially effective anti-mycobacterial agents
include the nitroimidazole TBA-354 which is bactericidal for the Tuberculosis bacillus
including MDR and XDR TB at low concentrations and is inactive against other bacteria.
If only a few of these agents would become clinically available it will certainly change
the gloomy scene that we are facing today with increased bacterial resistance and dwindling
amount of effective agents.
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Table 1: New antimicrobials under development in 2012
AntiTB
Anti-Gram-negative
Anti-Gram positive
Name
Oritavancin
Dalbavancin
Telavancin
AFN 1252
JNJ 6Q-2
ozenoxacin
delafloxacin
PMX 30063
Delafloxacin/Radezolid
Tedezolid (formerly torezolid)
BC 3781
Plasomycin
Ceftaroline/avibactam
Ceftazidime/avibactam
Cefepime/tazobactam
Ceftolozane/tazobactam
RPX2003/RPX 7009
Coumarins,
Simocyclinone
Albicidin
Pyrollamines
TBA-354
Bedaquilin
Group
Glycopeptides
Fatty acid synthesis inhibitor
Fluoroquinollones
Cell-wall inhibitor
Oxazolidinone
Pleuromutillins
Aminoglycoside
Beta-lactams with inhibitors of beta-lactamases
Carbapenem
Non-fluoroquinollone inhibitors of topoisomerase
Nitroimidazole
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NEWS IN MALARIA AND RELATED TROPICAL DISEASES IN
SOCIAL WORK AND HEALTH
Ngendo, I. KmiЕҐ, J. Sokolova, G. Mikolasova, E. Nandolaya, D. Hes, C. Petersman,
D. Salwerk, K. Hahn, H. Sondermann, Ch. Bonnack, J. Gerig, M. Chabadova,
K. Feckova, B. Hatasova, E. Ceploova, Z. Gazova, C. Monte, F. Schumann,
K. Badanicova, T. Oelnick, M. Jancovic, J. Kafkova, N. Kulkova, J. Ravasz ,
E. Vrankova, I. Feketova, J. Kajaba, M. Mrazova, E. Haluskova, G. Herdics,
A. Zakutna, P. Gogolakova, J.Vermes, J. Kuffova, M. Hettes, F. Hanobik,
V. Namulanda, V. Okoth
St. Elizabeth University Tropicteam Bratislava, Slovakia
St. Bakhita Clinic, Mihango, Kenya
ABSTRACT
News in malaria and their impact or social work and public health in Subsaharan africa,
Central Europe (imported) and SE Asia is reviewed by our social work and health tropicteam
Introduction
Antenatal Receipt of Sulfadoxine-Pyrimethamine Does Not Exacerbate Pregnancy-Associated
Malaria Despite the Expansion of Drug-Resistant Plasmodium falciparum: Clinical Outcomes
From the QuEERPAM Study
Steve M. Taylor
Clinical Infectious Diseases 2012, 55(1):42-50
Antenatal intermittent preventive therapy with 2 doses of sulfadoxine-pyrimethamine (IPTpSP) is the mainstay of efforts in sub-Saharan Africa to prevent pregnancy-associated malaria
(PAM). Recent studies report that drug resistance may cause IPTp-SP to exacerbate PAM
morbidity, raising fears that current policies will cause harm as resistance spreads.
We conducted a serial, cross-sectional analysis of the relationships between IPTp-SP receipt,
SP-resistant Plasmodium falciparum, and PAM morbidity in delivering women during a
period of 9 years at a single site in Malawi. PAM morbidity was assessed by parasite
densities, placental histology, and birth outcomes.
The prevalence of parasites with highly SP-resistant haplotypes increased from 17% to 100%
(P < .001), and the proportion of women receiving full IPTp (≥2 doses) increased from 25%
to 82% (P < .001). Women who received full IPTp with SP had lower peripheral (P = .018)
and placental (P < .001) parasite densities than women who received suboptimal IPTp (<2
doses). This effect was not significantly modified by the presence of highly SP-resistant
haplotypes. After adjustment for covariates, the receipt of SP in the presence of SP-resistant
P. falciparum did not exacerbate any parasitologic, histologic, or clinical measures of PAM
morbidity.
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In this longitudinal study of malaria at delivery, the receipt of SP as IPTp did not potentiate
PAM morbidity despite the increasing prevalence and fixation of SP-resistant P. falciparum
haplotypes. Even when there is substantial resistance, SP may be used in modified IPTp
regimens as a component of comprehensive antenatal care. (1-11)
The impact intermittent preventive treatment with sulfadoxine-pyrimethamine on the
prevalence of malaria parasitaemia in pregnancy
Uchenna Anthony Umeh
Tropical Doctor July, 2012, 42
The levels of parasitaemia in the intervention group upon registration (4.9%) and at 34 weeks
(63.9%) were not significantly different (P > 0.05) from that of the control group (10%) and at
34 weeks gestation (68.3%). IPT with SP during pregnancy did not significantly reduce the
prevalence of the malaria parasitaemia among the pregnant women in our environment.
Tropical Medicine in the Fight against Plague, Death, Famine and War
Peter J. Hotez
Am. J. Trop Med. Hyg., 87(1), 2012, pp. 3-10
Table 1
Plague and pestilence: Number of global cases of tropical diseases*
Disease
Estimated no. cases
Ascariasis
807 million
Trichuriasis
604 million
Hookworm infection
576 million
Schistosomiasis
391–587 million
†Amebiasis
480 million
Malaria
216 million
Lymphatic filariasis
115 million
Dengue
70–500 million
Trachoma
40 million
Strongylodiasis
30–100 million
Onchocerciasis
26 million
‡
Liver fluke infection
24 million
Paragonimiasis
23 million
Typhoid fever
22 million
Leishmaniasis
12 million
Chagas disease
10 million
Intestinal fluke infection 7 million
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Disease
Paratyphoid fever
Cholera
Fascioliasis
Leprosy
Total
Estimated no. cases
5 million
3–5 million
3 million
< 0.5 million
3.5–4.2 billion
Table 2
Death: Annual number of global deaths from tropical diseases*
Disease
Estimate no. deaths
Malaria
655,000
Schistosomiasis
280,000†Typhoid fever
217,000
Cholera
120,000
Hookworm infection
65,000
Rabies
55,000
Leishmaniasis
51,000
Amebiasis
40,000
Dengue
21,000
Chagas disease
14,000
Trichuriasis
10,000
Food-borne trematodiases 7,000
Leprosy
6,000
Total
1.5 million
No Evidence of Delayed Parasite Clearance after Oral Artesunate Treatment of
Uncomplicated Falciparum Malaria in Mali
Amelia W. Maiga
Am. J. Trop Med. Hyg., 87(1), 2012, pp. 23-28
Plasmodium falciparum resistance to artemisinins by delayed parasite clearance is present in
Southeast Asia. Scant data on parasite clearance after artemisinins are available from Africa,
where transmission is high, burden is greatest, and artemisinin use is being scaled up.
Children 1-10 years of age with uncomplicated malaria were treated with 7 days of artesunate
and followed for 28 days. Blood smears were done every 8 hours until negative by light
microscopy. Results were compared with a similar study conducted in the same village in
2002-2004. The polymerase chain reaction-corrected cure rate was 100%, identical to 20022004. By 24 hours after treatment initiation, 37.0% of participants had cleared parasitemia,
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compared with 31.9% in 2002-2004 (P = 0.5). The median parasite clearance time was 32
hours. Only one participant still had parasites at 48 hours and no participant presented
parasitemia at 72 hours. Artesunate was highly efficacious, with no evidence of delayed
parasite clearance. We provide baseline surveillance data for the emergence or dissemination
of P. falciparum resistance in sub-Saharan Africa.
Effect of HIV Infection and Plasmodium falciparum Parasitemia on Pregnancy
Outcomes in Malawi
Ella T. Nkhoma
Am. J. Trop Med. Hyg., 87(1), 2012, pp. 29-34
Plasmodium falciparum and human immunodeficiency virus (HIV) are both risk factors for
low birth weight (LBW) and maternal anemia, and they may interact to increase risk of
adverse pregnancy outcomes. In 2005 and 2006, we followed 831 pregnant women attending
antenatal care clinics in southern Malawi through delivery. HIV was associated with increased
risk of LBW (adjusted prevalence ratio [PR(adj)] = 3.08, 95% confidence interval [CI] = 1.40,
6.79). Having greater than or equal to three episodes of peripheral parasitemia was also
associated with increased risk of LBW (PR(adj) = 2.68, 95% CI = 1.06, 6.79). Among
multigravidae, dual infection resulted in 9.59 (95% CI = 2.51, 36.6) times the risk of LBW
compared with uninfected multigravidae. HIV infection and placental parasitemia were each
associated with increased risk of anemia. Thus, HIV infection and parasitemia are important
independent risk factors for adverse pregnancy outcomes. Among multigravidae, HIV
infection and placental parasitemia may interact to produce an impact greater than the sum of
their independent effects.
Serious and Fatal Illness Associated with Falciparum and Vivax Malaria among
Patients Admitted to Hospital at West Sumba in Eastern Indonesia
Siti Nurleila
Am. J. Trop Med. Hyg., 87(1), 2012, pp. 41-49
Records of 3,449 patients admitted to Karitas Hospital at Waitabula in eastern Indonesia with
microscopy-confirmed malaria through 2008 and 2009 were systematically reviewed.
Falciparum, vivax, and mixed species malaria occurred among 1,541, 1,837, and 71
admissions, respectively. Among these, 400 (26%), 199 (11%), and 15 (21%) had serious
illness. Fatalities occurred in 46 (12%), 18 (9%), and 2 (13%) of these patients, respectively.
Although patients with a diagnosis of falciparum malaria were more likely to have serious
illness compared with those with vivax malaria (odds ratio [OR] = 2.9; 95% confidence
interval [CI]: 2.4–3.5), this diagnosis nonetheless was associated with 32% of serious illness
and 27% of fatalities. Among the seriously ill with a diagnosis of falciparum or vivax malaria,
no significant difference in risk of death occurred (OR = 1.3; 95% CI: 0.7–2.5). Serious and
fatal illness was predominantly anemia or altered mental state syndromes among patients with
either of the species diagnoses. Plasmodium vivax was associated with a substantial share of
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the burden of morbidity and mortality caused by malaria in this hypo- to meso-endemic
community.
Repeated Artemisinin-based Combination Therapies in a Malaria Hyperendemic Area
of Mali: Efficacy, safety and Public Health Impact
Issaka Sagara
Am. J. Trop Med. Hyg., 87(1), 2012, pp. 50-56
Artemisinin-based combination therapies (ACTs) are the first-line treatment of uncomplicated
malaria. The public health benefit and safety of repeated administration of a given ACT are
poorly studied. We conducted a randomized trial comparing artemether-lumefantrine,
artesunate plus amodiaquine (AS+AQ) and artesunate plus sulfadoxine-pyrimethamine
(AS+SP) in patients 6 months of age and older with uncomplicated malaria in Mali from July
2005 to July 2007. The patient received the same initial treatment of each subsequent
uncomplicated malaria episode except for treatment failures where quinine was used. Overall,
780 patients were included. Patients in the AS+AQ and AS+SP arms had significantly less
risk of having malaria episodes; risk ratio (RR) = 0.84 (P = 0.002) and RR = 0.80 (P = 0.001),
respectively. The treatment efficacy was similar and above 95% in all arms. Although all
drugs were highly efficacious and well tolerated, AS+AQ and AS+SP were associated with
less episodes of malaria.
Community Health Workers Use Malaria Rapid Diagnostic Tests (RDTs) Safely and
Accurately: Results of a Longitudinal Study in Zambia
Helen Counihan
Am. J. Trop Med. Hyg., 87(1), 2012, pp. 57-63
Malaria rapid diagnostic tests (RDTs) could radically improve febrile illness management in
remote and low-resource populations. However, reliance upon community health workers
(CHWs) remains controversial because of concerns about blood safety and appropriate use of
artemisinin combination therapy. This study assessed CHW ability to use RDTs safely and
accurately up to 12 months post-training. We trained 65 Zambian CHWs, and then provided
RDTs, job-aids, and other necessary supplies for village use. Observers assessed CHW
performance at 3, 6, and 12 months post-training. Critical steps performed correctly increased
from 87.5% at 3 months to 100% subsequently. However, a few CHWs incorrectly read faint
positive or invalid results as negative. Although most indicators improved or remained stable
over time, interpretation of faint positives fell to 76.7% correct at 12 months. We conclude
that appropriately trained and supervised CHWs can use RDTs safely and accurately in
community practice for up to 12 months post-training.
Review: Emerging Nucleic Acid-Based Tests for Point-of-Care Detection of Malaria
Michael S. Cordray
Am. J. trop. Med. Hyg., 87(2), 2012, pp.223-230
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CLINICAL SOCIAL WORK (CSW)
Malaria remains a serious disease in the developing world. There is a growing consensus that
new diagnostics are needed in low-resource settings. The ideal malaria diagnostic should be
able to speciate; measure parasitemia; low-cost, quick, and simple to use; and capable of
detecting low-level infections. A promising development are nucleic acid tests (NATs) for the
diagnosis of malaria, which are well suited for point-of-care use because of their ability to
detect low-level infections and speciate, and because they have high sensitivity and
specificity. The greatest barrier to NAT use in the past has been its relatively high cost, and
the amount of infrastructure required in the form of equipment, stable power, and reagent
storage. This review describes recent developments to decrease the cost and run time, and
increase the ease of use of NAT while maintaining their high sensitivity and specificity and
low limit of detection at the point-of-care.
Table 3
Comparison of diagnostic characteristics that are relevant to the ability of a test to be useful at
the point-of-care* *RDT = rapid diagnostic test; PCR = polymerase chain reaction; RT =
reverse transcription; LDA = lactate dehydrogenase assay; ELISA = enzyme-linked
immunosorbent assay; LAMP = loop-mediated isothermal amplification; NASBA = nucleic
acid sequence–based amplification; NALFIA = nucleic acid lateral flow immunoassay.
†Costs listed for more established techniques (microscopy PCR and RDTs) reflect a more
realistic cost to the end user including shipping, storage, and reagent costs. Costs listed for the
techniques under development (RT-PCR, PCR LDA, PCR ELISA, LAMP, NASBA, and
NALFIA) reflect only the cost of the materials required to perform the assay as given by the
authors of the cited studies and likely underestimate the ultimate end cost to the user.
Insecticide-treated Plastic Sheeting for Emergency Malaria Prevention and Shelter
among Displaced Populations: An Observational Cohort Study in a Refugee Setting in
Sierra Leone
Matthew Burns
Am. J. trop. Med. Hyg., 87(2), 2012, pp.242-250
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CLINICAL SOCIAL WORK (CSW)
A double-blind phase III malaria prevention trial was conducted in two refugee camps using
pre-manufactured insecticide-treated plastic sheeting (ITPS) or untreated polyethylene
sheeting (UPS) randomly deployed to defined sectors of each camp. In Largo camp the ITPS
or UPS was attached to inner walls and ceilings of shelters, whereas in Tobanda the ITPS or
UPS was used to line only the ceiling and roof. In Largo the Plasmodium falciparum
incidence rate in children up to 3 years of age who were cleared of parasites and monitored
for 8 months was 163/100 person-years under UPS and 63 under ITPS (adjusted odds ratio
[AOR] = 0.40, 95% confidence interval [CI] = 0.33-0.47). In Tobanda incidence was 157/100
person-years under UPS and 134 under ITPS (AOR = 0.85, 95% CI = 0.75-0.95). Protective
efficacy was 61% under fully lined ITPS and 15% under roof lined ITPS. Anemia rates
improved under ITPS in both camps. This novel tool proved to be a convenient, safe, and
long-lasting method of malaria control when used as a full shelter lining in an emergency
setting.
Lack of Evidence for Chloroquine-Resistant Plasmodium falciparum Malaria, Leogane,
Haiti
Ami Neuberger
Emerging Infectious Diseases, Vol. 18, No. 9, Sept. 2012
Plasmodium falciparum malaria in Haiti is considered chloroquine susceptible, although
resistance transporter alleles associated with chloroquine resistance were recently detected.
Among 49 patients with falciparum malaria, we found neither parasites carrying haplotypes
associated with chloroquine resistance nor instances of chloroquine treatment failure.
Continued vigilance to detect emergence of chloroquine resistance is needed.
Novel Vectors of Malaria Parasites in the Western Highlands of Kenya
These fi ndings highlight the value of the use of characteristics of local Anopheles spp.
populations, including their behavior, based on morphologic features and DNA analysis, to
accurately determine whether the species is contributing to malaria parasite transmission. This
knowledge is essential for implementation of appropriate, and therefore successful, malaria
control interventions.
The seroprevalence of Helicobacter pylori and its relationship to malaria in Ugandan
children
Vinay Gupta
Transaction of the Royal Society of Tropical Medicine and Hygiene 106(2012)35-42
Helicobacter pylori epidemiology in sub-Saharan Africa, particularly among children, has
been little investigated. A secondary endpoint of our study was to examine for associations
between the seroprevalence of H. pylori and the incidence of malaria. We explored H. pylori
prevalence by measuring serum IgG antibodies to H. pylori whole cell and cytotoxinassociated gene A (CagA) antigens by ELISA in a longitudinal cohort of 200 Ugandan
children, aged 1-10 years at enrollment, in whom malaria incidence was followed over 572
person-years. First-sample seroprevalence for H. pylori -specific IgG (63%) and for the H.
pylori protein CagA (78.5%) were both high, and they were positively associated with
advancing age (per each 1-year age increase, OR (95% CI): 1.60 (1.39-1.85), P<0.001). We
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CLINICAL SOCIAL WORK (CSW)
observed nearly universal prevalence of CagA+ H. pylori by the age of 10 years in Kampala
and found no evidence that H. pylori-positivity is protective against malaria.
Diagnosis and treatment of malaria by health care providers: findings from a post
conflict district in Sri Lanka
Lima J.
International Health 4 (2012) 148-150
This study determines whether 72 health care providers in a previously conflict-affected
district in Sri Lanka adhere to the recommendations of the Anti Malaria Campaign with
regard to diagnosis, prescribing antimalarials and reporting of a positive case. All patients
suspected of clinically having malaria are being referred for laboratory confirmation,
indicating that presumptive treatment is not practiced. The knowledge amongst health care
providers regarding accurate management and reporting of a malaria positive case needs to be
improved.
Optimal dose finding for novel antimalarial combination therapy
Duparc S.
Tropical Medicine and International Health, Vol. 17, No. 4, pp. 409-413, April 2012
A recent discussion meeting convened by the Medicines for Malaria Venture examined how
best to manage the discovery and preclinical pipeline to achieve novel combination therapies
which would address the key clinical needs in malaria. It became clear that dose optimisation
of components within combination therapy was a key issue in achieving antimalarial efficacy
and for preserving that efficacy against parasite resistance emergence. This paper outlines
some of the specific issues in malaria that cause dose-ranging and dose-optimisation studies to
be particularly challenging and discusses the potential of factorial study design to address
such challenges.
Treatment of acute P. falciparum infection is not the only clinical objective. There are other
targets that could potentially benefit from novel antimalarial combinations.
• Plasmodium vivax acute therapy: chloroquine resistance is an issue in some regions (Baird
2011).
• Treatment of P. vivax hypnozoites, the cause of clinical relapse (Galappaththy et al. 2007).
• Drugs that interrupt malaria transmission: a key component of malaria elimination efforts
(The malERA Consultative Group on Drugs 2011).
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CLINICAL SOCIAL WORK (CSW)
Lack of Evidence for Chloroquine-Resistant Plasmodium falciparum Malaria, Leogane,
Haiti
Ami Neuberger, Emerging Infectious Diseases, Vol. 18, No. 9, Sept. 2012
Artemisinin-based combination therapy is the first-line treatment for uncomplicated alciparum
malaria. This study assessed the antimalarial efficacy and safety of a combination of 150 mg
of arterolane maleate and 750 mg of piperaquine phosphate (AM-PQP) in comparison to
Coartem (artemether and lumefantrine) in patients with acute uncomplicated P. falciparum
malaria.
In this open-label, randomized, multicentric, parallel group clinical trial, 240 patients were
randomized to receive AM-PQP (160 patients) or Coartem (80 patients). Patients with P.
falciparum monoinfection and initial parasite densities ranging from 1000 to 100 000 asexual
parasites/ВµL of blood were followed for 28 days. Polymerase chain reaction-corrected
adequate clinical and parasitologic response on day 28, parasite clearance time, and fever
clearance time were evaluated.
A total of 151 (94.4%) of 160 patients in the AM-PQP group completed the trial, while 77
(96.3%) of 80 patients in the Coartem group completed the trial. No treatment failure was
noted in the AM-PQP group, while one patient receiving Coartem failed treatment on day 28.
There was no difference in the median parasite clearance time (30 hours in both groups) or
median fever clearance time (24 hours in both groups) after administration of the 2 study
treatments.
The available data support the evaluation of a drug combination in a larger population as a
fixed-dose combination.
Placental Malaria is Associated With Increased Risk of Nanmalaria Infection During
the First 18 Months of Life in a Beninese Population
Antoine Rachas
CID 2012, 55(5): 672-8
Several studies have shown that the risk of malaria infection increases for children born of a
mother with placental malaria infection. An immune tolerance phenomenon has been
hypothesized. We addressed whether Plasmodium falciparum placental infection could
additionally be associated with the risk of non-malaria fevers in infants.
From 2007 to 2009, 553 infants were followed up from birth to 18 months in Benin. The
occurrence of fever was actively screened by trained community workers. Malaria fevers
(temperature >37.5В°C with positive rapid diagnostic test or thick-blood smear) were excluded
from analysis. The association between placental malaria infection and the number of total,
gastrointestinal and respiratory febrile episodes was explored using binomial negative
regression, adjusting for maternal age, parity, parents' schooling, socioeconomic level, sex,
village of birth, season of birth, prematurity, Apgar score and nutritional status.
The prevalence of placental malaria infection was 11.2%. During a median follow-up of 17.8
months, 624 non-malaria fevers were registered. Placental malaria infection was associated
with a higher risk of non-malaria fever episodes (adjusted IRR=1.4; 95% CI 1.1-1.8) as well
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as gastrointestinal (1.6; 1.1-2.5) and respiratory (1.5; 1.1-2.1) febrile syndromes. The same
pattern was obtained when considering consultations after the age of 6 months.
These results suggest an association between placental malaria infection and non-malaria
infections in the first 18 months of life. Immune tolerance could lead to impaired immune
development not specific to malaria infections in infants born from placental malaria
infection, but further studies are needed.
REFERENCES
1. Lack of Evidence for Chloroquine-Resistant Plasmodium falciparum Malaria,
Leogane, Haiti, Ami Neuberger, Emerging Infectious Diseases, Vol. 18, No. 9, Sept.
2012
2. Diagnosis and treatment of malaria by health care providers: findings from a post
conflict district in Sri Lanka, Lima J., International Health 4 (2012) 148-150
3. No Evidence of Delayed Parasite Clearance after Oral Artesunate Treatment of
Uncomplicated Falciparum Malaria in Mali, Amelia W. Maiga, Am. J. Trop Med.
Hyg., 87(1), 2012, pp. 23-28
4. Suvada J. Viral hemorrhagic fevers and health care in central region of Africa. HealthNet
News Readers, 2012 Nov 4, WHO, electronic version [http://healthnet.org/hnn-chat]
5. Suvada J. Marburg virus outbreak. HealthNet News Readers, 2012 Aug 1, WHO,
electronic version [http://healthnet.org/hnn-chat]
6. 10. Suvada J. Ebola outbreak in Uganda. HealthNet News Readers, 2012 Nov 4, WHO,
electronic version [http://healthnet.org/hnn-chat]
7. Placental Malaria is Associated With Increased Risk of Nanmalaria Infection During
the First 18 Months of Life in a Beninese Population, Antoine Rachas, CID 2012,
55(5): 672-8
8. Suvada, J. (2010). ChildrenВґs Palliative Care in low-resource settings. Agatres (U),
LTD Press, Kampala, Uganda, 2010
9. Suvada, J., (2010). Pastekova T., Nkonwa I., Ianetti R, Kaiserova E., Merks J.H.M.,
Krcmery V, 2010. Neoplastic Diseases in Children with HIV infection in our register.
The 4th Annual Paediatric HIV and AIDS Conference, 28th – 30th September, 2010,
Kampala. Oral lecture No. 20. In the international abstract book p. 11
10. Suvada, J. et all. (2010). Issues in Social Work and Health. Health/Social Work,
4/2010-1,2/2011, Volume 7-8, ISSN 1333-0023, p.145
11. Suvada, J. (2011). Improving Quality & Safety through Infection Control. UPMPA
CPD Workshop 3rd – 4th September 2011. Kampala, Uganda.
12. The seroprevalence of Helicobacter pylori and its relationship to malaria in Ugandan
children, Vinay Gupta, Transaction of the Royal Society of Tropical Medicine and
Hygiene 106(2012)35-42
13. Selected Topics in Public Health: Krcmery V., Mrazova A., Rovny I., Truskova I.,
Bielik I., Kimakova T. et all.: Bratislava, St. Elizabeth College, 2011, pp: 70.
14. Selected Topics in Public Health: Rovny I., Bielik I, Hamade J.,: Bratislava, St.
Elizabeth College 2009,pp: 185
15. Suvada J et al. Spectrum of patient´s diagnosis in rural hospital in Buikwe – Uganda. J.
Tropical Health Social work Vol 7,2010. 36-38
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REPORT FROM THE13TH ASIA-PACIFIC CONGRESS OF
CLINICAL MICROBIOLOGY AND INFECTION
Suvada J, Krcmery V., Benca J.
Beijing, China, Oct. 25-28, 2012
Community-onset Methicillin-Resistant Staphylococcus aureus Infections: from
Epidemiology to Clinical Management
Staphylococcus aureus has been well-recognized as an important pathogen among patients
with community-onset infection. Even with rapid progress in modern medicine, patients with
S. aureus infection, especially for those with bloodstream, endovascular, deep-seated, or low
respiratory tract infections, still carry significant risk for disease-associated mortality and
morbidity. Treatment of S. aureus infections, however, is further challenged as the increasing
recognition of methicillin-resistant isolate recovered from patients with community-onset
infection.
Traditionally, S. aureus infections acquired in the community are generally expected to be
less resistant to antimicrobial agents than infections acquired in the hospital. Most community
patients with methicillin-resistant S. aureus (MRSA) infection have direct or indirect
epidemiological linkage to prior healthcare-associated (HA) exposure. It is therefore
reasonable to reserve empirical anti-MRSA therapy for community patients with previous HA
exposure in terms of the risk of antimicrobial resistance and the infection-associated mortality
rate. Recently, however, infection with novel community-associated MRSA (CA-MRSA) in
community patients without prior HA exposure has been increasingly identified and emerged
as a global public health issue.
As the wide spread of CA-MRSA in the communities, whether anti-MRSA agents should be
empirically implemented for all community patients suspecting S. aureus infection has
become an important and challenging therapeutic issue. It is, however, a clinical dilemma of
introducing selection pressure for high antimicrobial-resistant micro-organism from
antibiotics overuse or posing adverse patient outcomes from delay of effective anti-MRSA
antibiotics. To propose possible solution, we analyzed this important clinical issue in three
main dimensions: (1) the epidemiology and evolution of methicillin resistance among patients
with community-onset S. aureus infection; (2) risk stratification for MRSA infection among
community patients with S. aureus infection; (3) impact of methicillin-susceptible S. aureus,
CA-MRSA, and traditional hospital MRSA infections on clinical outcomes of patients with
community-onset infections. Though currently there is no direct answer, recent studies still
provide important evidence and help first-line physicians with their treatment decision.
The Artificial Liver Support System in the People’s Republic of China (Jianrong
Huang)
Artificial liver support system (ALSS) is a very effective and important method in treatment
of liver failure. The artificial liver support system (ALSS) is an extracorporeal device that
clears up harmful substances produced by liver failure with mechenical or biological
mechanism. Through offering the nessecery substances produced or metabolized by liver, or
balancing of the water and electrolites, the ALSS temporarily substitues the main fuction of
liver which provides a chance for hepatocytes regenerating and thus improves the survivial
rate of liver failure patients.
The ALSS in China has its own specialty due to its development history and the special
pathogenesis of liver failure. The ALSS evolves from the combination of blood dialysis and
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CLINICAL SOCIAL WORK (CSW)
plasma supplement in China, and thus plasma exchange is the cornerstone of ALSS. Around
90% patients of liver failure are induced by viruses in China. Besides, around 28%-67%
patients of liver failure are induced by medication in England, USA, France and Australia.
The history of ALSS in China could be divided into three periods. Between the late 1970s to
middle 1980s, the ALSS was in its initial period, during which hemoperfusion using activated
charcoal were attempted in treating severe hepatitis. The activated charcoal has its
disadvantage such as immunological reaction and poor biocompatibility. The second stage
was between the middle 1980s to late 1990s, ALSS research centers was found in the First
Affiliated Hospital of Zhejiang University. A set of ALSS was developed, which overcame
major difficulties such as bleeding and coagulation, hypotention and overburden of heart.
Ever since late 1990s, ALSS has been popularized and performed in approximately 200
hospitals in 31 provinces across China, the total number of patients receving ALSS is more
than 35,000. The main molds of ALSS include: plasma exchange (PE), plasma dialysis,
plasma filtration, and plasma absorption. In the clinical practice, they are used in
combinations to maximum the cure effect. The most common methods are selective plasma
exchange, plasma diafiltration(PDF), and continuous renal replacement therapy(CRRT).
While in the western world the most success ful ALSS are MARS and Prometheus which are
based on albumine dialysis.
The treatment effect of ALSS is evaluated by cure rate for short period or by 6 month or 1
year survival rate for long period.Statistical data from 650 acute- on-chornic liver failure
patients in Zhejiang University shows that the survival rate of ALSS group is 47.9%, which is
significantly higher than that of internal medicion group(34.6%). Up to now more than 1500
patients have received more than 4000 times of ALSS therapy in our center, and the clinical
cure rate of acute and sub-acute liver failure increased from 11.9% to 51.4%, the
improvement rate of acute-on-chronic and chronic liver failure increased from 15.4% to
42.5%.
The aim of The National Science&Technology Major Project for Infectious Disease Control
of China (2008ZX10002-05) is to decrease the morbidity and mortality of liver failure
induced by HBV. A research queue of 1800 HBV liver failure patients was collected, which
includs a ALSS subgroup composed by 630 HBV liver failure patients from multiple research
centers. The death rate of acute liver failure was decreased to 38.5%, subacute liver failure to
41.7% and chronic liver failure to 43.3%.
The exploring in bioartificial liver in China could be cast back to 1990s. In 2003, Professor
Li’s group published a research of hybrid artificial liver combining ALSS and biological
device containing chinese minitype porcine hepatocytes.
15 cases chronic severe hepatitis patients were treated with hybrid ALSS, 11 cases survived.
In receant years, more and more researchers focus on stem cells and their use in bioartificial
liver. Several cilinical trial and animal experiment has showed good foregroud in this field.
In all, the ALSS in China has its own specialty and is very effective and important in
treatment of liver failure. With the communication between China and other countries, the
application of ALSS will be international and exert more power.
Carbapenemases in Enterobacteriaceae: Enzymes and Answers (David M Livermore,
UK)
For 20 years after imipenem’s introduction in 1985, carbapenems retained near-universal
activity against Enterobacteriaceae. Occasional resistance, particularly to ertapenem, arose
contingent on porin loss in strains that produced ESBLs or AmpC enzymes but was generally
unstable meaning that strains with this mode of resistance achieve little spread. Latterly,
however, true carbapenemases have begun to proliferate amongst Enterobacteriaceae,
particularly Klebsiella. These enzymes are diverse, including Class A (KPC), B (IMP, VIM
and NDM) and D (OXA-48 and -181) types. Each is spreading globally from initial foci: KPC
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from the US; VIM for SE Europe; NDM from India and Pakistan and OXA-48 from Turkey.
The diversity of enzyme types complicates the design of stable agents and inhibitors.
Monobactams evade Class B (metallo) enzymes but not other types; many cephalosporins
escape OXA-48/181 but not other types; avibactam inhibits Class A and D carbapenemases
but not Class B types. One comprehensive answer is to protect a monobactam (stable to class
B enzymes) with an inhibitor of other carbapenemases and of the various ESBL and AmpC
enzymes that commonly accompany carbapenemases; another is to use multiple inhibitors.
KPC carbapenems are strongly associated with a high-risk clone, K. pneumoniae ST258,
which has spread globally. This has been brought under control in Israel (not elsewhere) by
nationally co-ordinated infection control, predicated on rigorous screening and cohorting of
patients.
Other carbapenemases are more associated with promiscuous plasmids, disseminating among
bacterial strains; blaNDM is especially adept at transferring among plasmids. This
epidemiology is less tractable to classical infection control than clonal dissemination, but
spread may be discouraged by good antibiotic stewardship and, in countries where
disseminating is occurring outside hospitals, notably India, by improved public sanitation.
Progression in the Molecular Epidemiology of Tuberculosis and Research on the Beijing
Genotype of Mycobacterium Tuberculosis (Dick van Soolingen, Netherlands)
Study on the spread of tuberculosis and underlying mechanisms DNA fingerprinting of
Mycobacterium tuberculosis has been used to trace transmission of tuberculosis since the
early 1990s. VNTR typing has in the last years gained recognition as the gold standard in
typing, and the first two proficiency studies in nearly 40 laboratories world wide have brought
important insights in the performance of this methodology.
Meanwhile, the new possibilities of Whole Genome Sequencing in molecular epidemiology
are being explored. In The Netherlands nearly 200 M. tuberculosis isolates of cases with
known epidemiological links were examined for their genetic turnover, but revealed no
consistent molecular clock over short time scales.
In Europe, within the framework of an ECDC project it has been shown that about half of the
MDR/XDR-TB cases, especially in the Eastern part of Europe, are due to transmission. One
major outbreak, involving nearly 450 cases and detected in 15 European countries, is caused
by one Beijing genotype strain. Interestingly, the mutations associated with first-line drugs are
identical (AA315 in the katG gene and AA531 in the rpoB gene), but the mutations associated
with resistance to second line drugs vary. In a recent publication it was shown that the same
Beijing strain is also the driving force behind part of the transmission of MDR/XDR-TB in
other Central Asian areas. The underlying mechanisms for successful spread are not well
understood. We recently found a much higher frequency of mutations encoding rifampicin
resistance for part of the Beijing strains in comparison to East African Indian strains. In
addition, a part of the Beijing strains revealed a lower in vitro susceptibility to rifampicin.
Gagneux et al disclosed mutations in the rpoA and rpoC gene that compensate for the loss of
fitness in MDR-TB strains associated with transmission. Not surprisingly, the European
outbreak strain revealed such a mutation in rpoC, namely F452S.
In Vietnam, where about 40% of the TB cases are caused by strains of the Beijing genotype,
nationwide as well as local, population-based studies showed a clear correlation between this
genotype and low age, suggesting active and ongoing spread. Furthermore, while the Beijing
genotype was not associated with treatment failure it was strongly associated with TB relapse
in a prospective cohort study, indicating a possible mechanism for its epidemiological
success.
In China, more and more molecular epidemiological studies are being conducted. In a recently
published study in
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multiple provinces, 73% of the cases were caused by Beijing strains, while in the Beijing
region 93% of the isolates represented this genotype. The indications that the Beijing
genotype is also in this region associated with resistance are increasing. In the Chinese
province Guangxi, hypothetical ancestors of the Beijing genotype were traced and this will
facilitate future research on the evolutionary development of this successful genotype.
A Decade of Outpatient Parenteral Antibiotic Therapy; Acceptance and Sustainability
(Dale Andrew Fisher, Singapore)
In 2004, Singapore’s Health Ministry permitted access to the National health funding scheme
for OPAT expenses. Prior to this, costs were borne personally by patients. In 2006, 243
episodes of care were delivered by OPAT centres in 2 of Singapore’s largest hospitals. This
number increased to 509 episodes in 2011.
Our study included 2487 episodes of OPAT care. Antibiotic provision at the hospital-based
infusion centres was preferred in 76% of cases but 17% and 7% respectively received home
based therapy either via a caregiver or by visiting nurses.
Male patients predominated (64.2%; p<0.001) and the treatment course median was 16 (range
1-205) days. The median age was 56 (range 7-94) years. Seven children (<13yrs) have been
enrolled.
The most common diagnoses were osteomyelitis (15.1%), primary bacteraemia (10.0%) and
liver abscess (9.8%).The most frequently prescribed antibiotics were ceftriaxone (21.6%) and
ertapenem (18.2%).
Four patients absconded (0.2%) and there was 1 unexpected death. All-cause readmission was
12.6% across the six-year period (2006-2011); 52.0% were due to worsened co-morbidity,
while 19.6% were due to worsened OPAT ID condition.
Clinical outcomes in OPAT services worldwide consistently compare well with inpatient care.
Healthcare costs have been shown in Singapore, European and North American OPATs to be
<20% of that observed in inpatient care. OPAT has been shown to be safe, cost effective and
preferred by many patients and their caregivers.
Cefazolin (John Turnidge, Australia)
The susceptibility testing breakpoints for cephalosporins and Enterobacteriaceae were
recently revised extensively by CLSI. As a consequence, cephalothin was recognised to be
ineffective against Enterobacteriaceae, and was relegated to surrogate testing to represent the
oral first-generation cephalosporins. Furthermore, after a false start with the revision for
cefazolin breakpoints, these were adjusted to ≤2 mg/L as susceptible, 4 mg/L as intermediate
and ≥ 8 mg/L as resistant. The adjustment was made to prevent the susceptible breakpoint
from bisecting the wild-type of the common Enterobacteriaceae, namely E. coli, Klebsiella
spp. and P. mirabilis, which in their wild type state are considered to be the natural targets of
the drug. Since these breakpoints have been implemented, a number of issues have emerged.
Many laboratories, especially those using automated instruments for susceptibility testing,
have been using cefazolin as a surrogate agent for the oral first-generation cephalosporins,
even though CLSI does not recommend this. They have chosen to do this because no
testing panels have incorporated both cefazolin and cephalothin up to now, and putting up
a cephalothin disk requires extra time and expense at the bench. CLSI have now commenced
a process that will attempt to resolve this problem, comparing disk and MIC testing of
cefazolin, cephalothin and a range of oral cephalosporins (cephalexin in particular), hoping to
identify a suitable surrogate test for the oral first-generation cephalosporins. The other
significant concern expressed by some laboratories has been the notable increase in resistance
percentages in the institutions that they serve. This undoubtedly reflects the prevalence of a
variety of ОІ-lactamases in their institutions. It should not be a reason to review breakpoints yet
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again. Nevertheless, the question has been raised about whether higher breakpoints might
apply to isolates from the urinary tract. Currently this is not done for any ОІ-lactams by CLSI.
On the other hand, EUCAST have not set breakpoints for cefazolin, but do provide
breakpoints for cephadroxil and cephalexin for uncomplicated urinary tract infection only.
Both of these latter agents must be tested directly. EUCAST has no provision currently for
surrogate testing of a single first-generation cephalosporin to represent all the oral agents. The
only difficulty this poses is that there are no parenteral first-generation cephalosporins that
can be tested against the Enterobacteriaceae using EUCAST standards. Laboratories wishing
to test cefazolin may choose to supplement EUCAST breakpoints with the CLSI breakpoints
for this agent because the testing conditions for this agent are identical in both standards.
Clinical Impact of Carbapenem Updated Breakpoints for Enterobacteriaceae: CLSI vs.
EUCAST (Wen-Chien Ko,Taiwan)
Antimicrobial resistance among Gram-negative bacilli has become an increasingly urgent and
troublesome problem worldwide. To avoid the labor-intensive and time-consuming detection
of bacterial isolates with specific resistance mechanisms, it is necessary to update the
interpretive criteria for antimicrobial agents so that false rates of susceptibility can be
minimized. With the concerns of carbapenemases, the Clinical and Laboratory Standards
Institute (CLSI) revised the interpretive criteria of carbapenems for Enterobacteriaceae in the
M100-S21 after their evaluation of pharmacokinetic-pharmacodynamic properties, MIC
distributions, and limited clinical data. However, the clinical impact of such a revision
remained undefined. A total of 251 patients with bacteremia caused by ESBL-producing
Escherichia coli and Klebsiella pneumoniae isolates treated by a carbapenem were identified
and susceptibility rates of ertapenem (MICs ≤0.25 µg/ml) were 83.8% and 76.4%, meropenem
100% and 99.3%, and imipenem 100% and 97.9%, respectively. Multivariate analysis of the
variables related to sepsis-related mortality found that the presence of severe sepsis, hospitalonset bacteremia, and ertapenem-nonsusceptible isolates were independent risk factors.
Infections due to the ertapenem-susceptible isolates (MICs ≤0.25 µg/ml) were associated with
a more favorable outcome than those due to ertapenem-nonsusceptible isolates (MICs >0.25
Вµg/ml), if treated by a carbapenem. However, the mortality of bacteremic episodes due to
isolates with MICs ≤0.5 µg/ml was similar to those with MICs >0.5 µg/ml (P=0.8). More
clinical data will be welcomed to better define the most useful susceptible breakpoints of
carbapenems for Enterobacteriaceae, irrespective of the presence of the beta-lactamase types
alone or in combination.
Peumococcal Resistance and Serotypes in Asia (Jae-Hoon Song)
Emergence of multidrug-resistant 19A serotypes
After the introduction of heptavalent pneumococcal conjugate vaccine (PCV7), epidemiology
of S. pneumoniae, including serotype distribution and prevalence of antimicrobial resistance,
has been changing in many countries. Incidence of invasive pneumococcal diseases caused by
vaccine serotypes (4, 6B, 9V, 14, 18C, 19F, and 23F) has substantially declined while nonvaccine serotypes such as 19A, 3, and 6A have remarkably increased worldwide. In particular,
serotype 19A has emerged as an important cause of invasive pneumococcal diseases . Data
from the Asian Network for Surveillance of Resistant Pathogens (ANSORP) study in 20082009 showed that 47.5% of isolates showed non-PCV7 serotypes with 19A (8.2%) as the
most prevalent non-vaccine serotype in the Asian region. Emergence of serotype 19A was due
to multiple factors including effect of PCV7 vaccination, clonal spread of serotype 19A
strains, and injudicious use of antimicrobial agents. Emergence of non-vaccine serotypes was
also associated with increasing prevalence of antimicrobial resistance. Particularly, macrolide
resistance has remarkably increased in many parts of the world, which was reported to be >
70% among clinical isolates from Asian countries.
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ANSORP data showed that resistance to erythromycin was extremely prevalent in the Asian
region (72.7%), including China (96.4%), Taiwan (84.9%), and Vietnam (80.7%). Serotype
19 A was also associated with the emergence of multidrug resistance in pneumococci . In
Asia, 80 % of serotype 19A isolates showed multidrug resistance. Antimicrobial resistance
and serotypes in S. pneumoniae have been evolving with the introduction of pneumococcal
conjugate vaccines. Given the clinical importance of pneumococcal infections, continuous
surveillance of resistance and serotypes is warranted, especially in the Asian region.
The Role of the Bacteria in Mortality from Influenza (Keith P. Klugman, South Africa)
Pneumonia is the leading vaccine preventable cause of death, yet little research is devoted to
its treatment and prevention. Influenza may progress to bacterial pneumonia, but the extent of
the contribution of bacteria to influenza associated pneumonia morbidity and mortality is
unknown. In a double blind randomized trial pneumococcal conjugate vaccine (PCV9)
prevented hospitalized clinical pneumonia associated influenza by 45%. More recently it has
been shown that States in the USA that quickly adopted PCV7 in infants, had less influenza
associated hospitalization, than States that were slower to introduce PCV7. This suggests that
a major fraction of influenza associated pneumonias in children may be due to pneumococcal
super-infection. Analysis of the 1918 influenza pandemic suggests that, in contrast to recent
prevailing wisdom, >90% of pneumonias occurred > 6 days after onset of symptoms; the time
to mortality of untreated pneumococcal pneumonia follows an identical time course to the
1918 influenza deaths; a recent recut of autopsy specimens from the 1918 epidemic found
bacterial infection in all of 58 specimens of lung tissue from influenza deaths during the
pandemic; bacteria were isolated from blood in 16% of patients with pneumonia following
influenza, compared to <1% bacteremia among uncomplicated influenza patients during the
pandemic; specimens cultured from pleural fluid or lung tissue, revealed bacteria during life
in 80%; the pneumococcus was predominant, in up to 50% of patients, with hemolytic
streptococci second, and staphylococci rarely isolated. Finally bacterial vaccine studies
performed during the 1918 pandemic were poorly designed by today’s standard, but a re –
analysis of these studies, using influenza cases as the denominator, suggest that pneumococcal
killed bacterial vaccines may have prevented both pneumonia and deaths. Autopsy data from
the 2009 H1N1 pandemic in the USA found bacteria in 29% of 77 confirmed deaths;
predominant pathogen was again the pneumococcus followed by group A streptococci and
staphylococci. A similar study of autopsies of 2009 H1N1 victims in New York found 55% to
have bacterial co – infection. A smaller autopsy study from Brazil among 21 patients found
38% with bacterial infection. In the UK 40% of fatal pediatric cases had presumed or
confirmed bacterial co –infection. Case control studies from Brazil and Japan found that
detection of the pneumococcus in the nasopharynx was associated with increased risk of
hospitalization or death due to H1N1. These studies suggest that a large fraction of
hospitalizations and deaths in otherwise healthy individuals during 2009 may have been due
to bacterial co – infection, and pneumococcal infection in particular. A model of a 1918 – like
pandemic in a contemporary setting suggests 10 fold less pneumococcal pneumonia due to
lower frequency of pneumococcal carriage and herd immunity from PCV7 vaccine.
Clinical Significance of Quantitative HBsAg in the Natural History of Chronic Hepatitis
B (Jia-Horng Kao, Taiwan)
In our clinical practice, hepatitis B surface antigen (HBsAg) is the hallmark of HBV infection
and it has been qualitatively used for the diagnosis of hepatitis B virus (HBV) infection over
the past decades. Virologically, HBsAg is produced by 2 pathways: from translation of
transcriptionally active cccDNA molecules that serve as a template for replication and from
translation of viral genes transcribed from integrated HBV DNA sequences in the host
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genome. Using recently developed commercial quantitative assays, qHBsAg has been shown
to be helpful in the understanding and management of patients with chronic HBV infection.
Studies consistently showed that HBsAg level is highest in immune tolerant phase (4.5-5.0
log10 IU/mL) and is lowest (1.5-3.0 log10 IU/mL) in low replication phase. Thus, the
reduction of HBsAg for >1 log IU/mL could reflect improved host immune control against
HBV infection. The combined single point quantification of HBsAg <1000 IU/mL and HBVDNA ≤ 2000 IU/mL can identify minimal risk HBV carriers in both genotype D and non-D
HBeAg-negative patients. In genotype B and C dominant HBeAg-negative carriers with
normal ALT, the lower the serum HBsAg level < 1000 IU/mL the higher the chance of
spontaneous HBsAg seroclearance, and an HBsAg level of ≤100 IU/mL is an appropriate cutoff for predicting HBsAg loss over time. Regarding the role of qHBsAg in predicting disease
progression in HBV carriers with a low viral load (< 2000 IU/mL), our recent studies
indicated that a higher HBsAg level (>1000 IU/mL) is associated with a higher HCC risk.
Taking these lines of evidence together, qHBsAg can complement HBV-DNA for the
monitoring of HBV patients in the clinical practice. In conclusion, qHBsAg can be integrated
into future clinical practice guidelines for the management of chronic HBV infection.
Host Heat-Stress Cognate 70 as a Potential Drug Target against Drug Resistance in
Hepatitis B Virus (Jian-Dong Jiang, China)
Heat-stress cognate 70 (Hsc70) is a host protein associated with hepatitis B viral (HBV)
replication. The goal of this study is to investigate whether Hsc70 could be an anti-HBV drug
target. Our results showed that introducing Hsc70 increased HBV replication in the HBV(+)
human hepatocytes (HepG2.2.15 cells). The coiled coil region on Hsc70 (nt 1533-1608, aa
511-536) was the key sequence for HBV replication. Knockdown of Hsc70 expression by
RNAi largely inhibited HBV replication with no cytotoxicity to the host.
Using Hsc70 mRNA screening assay, natural compound oxymatrine (OMTR) was found to be
a selective inhibitor for Hsc70 expression. Then, OMTR was used to investigate the potential
of Hsc70 as an anti-HBV drug target. OMTR inhibited Hsc70 mRNA expression by 80% and
HBV DNA replication by over 60% without causing cytotoxicity. The anti-HBV effect of
OMTR appeared to be mediated through destabilizing Hsc70 mRNA. The T1/2 of Hsc70
mRNA decreased by 50% in OMTR treated hepatocytes. The Hsc70 mRNA 3’UTR sequence
was the element responsible for OMTR’s destabilization activity. OMTR suppressed HBV de
novo synthesis at the reverse transcription stage from pgRNA to DNA, and was active against
either wild-type HBV or those resistant to lamivudine, adefovir and entecavir. Therefore, host
Hsc70 could be a novel drug target against HBV; and OMTR appears to inhibit HBV
replication through destabilizing Hsc70 mRNA. As the target is not a viral protein, OMTR is
active for either wild-type HBV or those resistant to reverse transcriptase (RT) inhibitors.
Clinical studies showed that OMTR monotherapy (oral, 12 months) reduced blood HBV DNA
by 96% and HBeAg by 70% in the chronic hepatitis B (CHB) patients resistant to lamivudine
(n=17), equal to its efficacy in the naГЇve CHB cohort (n=20). Liver biopsy study showed that
OMTR treatment caused a decrease of Hcs70 mRNA in liver cells, paralleled with which was
a reduction of intracellular HBV DNA. Combination of lamivudine with OMTR (n=15) (oral,
12 months) showed an enhanced anti-HBV effect as compared to lamivudine monotherapy
(n=25). The incidence of drug-resistance against lamivudine in the combination group was
significantly lower than that in lamivudine group (1/15 vs 7/25; p<0.01). The results were
further confirmed in vitro. Treatment of HBV(+) HepH2215 cells with sub-optimal dose of
OMTR for 8 months suppressed HBV replication without inducing drug-resistance, whereas
lamivudine monotherapy caused drug-resistant mutation in 3 months. Combination of OMTR
with lamivudine prevented HBV from developing drug-resistance. In conclusion, OMTR
appears to be effective in treating CHB patients with drug-resistant HBV and might reduce
the chance of drug-resistance to RT inhibitors in clinic.
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Impact and Overcoming Challenges of ART in Resource- Limited Settings (Kiat
Ruxrungtham, Thailand)
By 2101, according to the WHO, 6.6 million people (47%) of those in need (CD4+ cell count
<350 cells/mm3) were on antiretroviral therapy (ART). Most reports had shown the 1 year
survival rate was more than 80%. However there was up to 15% of patients died from OIs
and/or IRIS in the first 6 months of treatment due to the late presenting to care. When to start
in RLS: Most countries have been implementing the recent WHO treatment guidelines to start
at the CD4 350 cut-off. After the HPTN052 study has demonstrated that early commencing
HAART can reduce 96% of the HIV transmission rate from the HIV-infected individuals to
their uninfected partners, a number of countries have amended their guidelines to also
commencing HAART in individuals who have sero-discordant partners irrespective of their
CD4+ count. What to start in RLS: While in resource rich settings 4 preferred regimens are
available (2 NRTIs+ EFV, or ATV/r, or DRV/r or Ral), in RLS there is only the NNRTIbased regimen (EFV or NVP) is available. How to monitor in RLS: Adherence is the
cornerstone of the durability of treatment success.
However to early detect non-adherence, a proper laboratory monitoring particularly viral load
test is essential. Due to the high cost and lack of availability, most countries can provide only
CD4+ count to follow up the treatment response. There are only a few countries providing
viral load test at least once yearly in their national AIDS program. Although a randomized
study has shown that the VL monitor had only a modest impact on morbidity/mortality
reduction when compared to the CD4 monitoring, the report from the Chinese National
Program has found that by using CD4 alone, by 5 years 50% had immunological failure.
The delay in detecting virologic failure will eventually lead to an accumulation of HIV
resistant mutants and will consequently compromise future ART options (of which has
already been very limited). Aging issues in RLS: In countries where HAART have been
implementing for more than a decade, there are more patients (who can live longer) become
older than 60. The aging-related issues are thus concerning for example: the risk of TDF r
bPI-associated toxicities, and drug-drug interaction. In conclusions: Millions of patients in
various RLSs have now been treating with HAART and have a significant improvement in
survival and quality of life. While wider coverage are implementing, a number of challenges
and limitations have to be overcome. These include strategies to earlier identify new cases, an
effective system of linking to care and retention, expanding the trainings for HCWs to
increase their expertise, implementing low cost and cost-effective frequency of VL test to
early detect VF, increasing a number of low cost second and third-line ART options, and
encouraging treating discordant couple as early as possible for treatment-as-prevention.
Complications of Antiretroviral Therapy (Graeme J. Moyle, GB)
The demographics of the HIV-1 pandemic in Europe and North America have changed over
the past three decades. The HIV-1+ cohort is ageing, and individuals receiving diagnosis
when over the age of 50 have been identified as the fastest growing epidemiological risk
group in the USA. Increased transmission within the older demographic may be attributable to
under perception of risk, low uptake of condom use, and increased susceptibility at the
mucosal site of viral entry. In addition to increased transmission and diagnoses within this
older group of people, those individuals diagnosed at an earlier age are living longer, owing to
the irrefutable success of combination antiretroviral therapy (cART). Consequently the
average age of HIV-1+ patients in the USA is expected to exceed 50 by 2015 with similar
senescence of cohorts occurring in Europe, presenting a very relevant consideration for future
therapeutic strategies.
Individuals contracting HIV-1 at an older age have a poorer prognosis owing to a combination
of factors. Late diagnosis is more common, with 53% of over 50s diagnosed late compared to
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only 21% of patients diagnosed aged 30 and under, resulting in treatment at a later stage of
HIV-1 disease. Once cART is initiated, CD4 T-cell recovery is less rapid in older people,
discordance in treatment-mediated immune reconstitution and virologic suppression is more
common, and concomitant medication for the treatment of commonly occurring comorbidities of advancing age and higher than expected frequencies of age-inappropriate
diseases within the HIV-1+ cohort, complicate cART adherence and potentiate drug:drug
interactions.
Factors such as efficacy, short-term tolerability, lack of mitochondrial toxicity and the
administrative convenience of fixed-dose co-formulation has led to tenofovir
DF/emtricitabine (TDF/FTC) and abacavir/lamivudine (ABC/3TC) becoming the most widely
prescribed initial NRTI backbones in industrialised countries. Both NRTI pairs have long
term safety issues which remain incompletely elucidated. Concerns regarding the impact of
TDF on renal function and bone mineral density has been raised in preclinical studies, using
biomarkers and in cohort studies where excess relative risk of chronic kidney disease and
fracture risk has been associated with TDF use, especially with boosted protease inhibitors
(PI). While the short term risk of abacavir hypersensitivity can be eliminated by HLA-B5701
testing, concerns about abacavir use and an increase in myocardial infarction have been raised
based mostly on data from observational cohort studies. To date, there are no established
biological mechanisms to explain a potential increase in risk of myocardial infarction in ABC
recipients.
Following anecdotal reports or short case series of myocardial infarction in persons who had
recently started ART an association between combination antiretroviral therapy and the risk
of myocardial infarction was reported from cohort studies. Data from the “Data collection of
Adverse events of Anti-HIV Drugs Group” (DAD) study reported an association between
cumulative exposure to some PIs and an increased risk of myocardial infarction.
Subsequently, current or recent (within the last 6 months) use of the NRTIs abacavir (ABC)
and didanosine (ddI) was associated with an increased risk of cardiovascular disease within
the setting of the DAD cohort study and the viral suppression arm of the SMART. A modest
association was also found with the cumulative use of ABC and risk of myocardial infarction.
By contrast, the results of a case-control study nested within the French Hospital Database on
HIV showed that any association of short-term/recent exposure to ABC with risk of MI was
lost when subjects were case-matched to controls by cocaine or intravenous drug use. The
authors concluded that the association with ABC use could not be considered causal. Results
from a Veterans Administration’s (VA) Clinical Case registry, show that cumulative exposure
to ABC was not associated with significant increase in risk of MI but with a reduced risk of
stroke.
Moreover, any trend towards an association of ABC use with MI was weaker after adjustment
for traditional cardiovascular risk factors including renal function. However, a second VA
cohort study suggest ABC use was associated with MI risk and TDF use associated with an
increases relative risk of cardiac failure.
In the absence of data from randomised controlled trials (RCTs), clinicians rely on cohort data
for safety signals as part of post-approval pharmacovigilance. However, there is controversy
over the validity of non-randomised evidence, related to the existence and magnitude of
selection bias. The primary criticism of observational studies is that either known or unknown
confounding factors may influence any observed association between an exposure of interest
and a given outcome.
Overview of Antiretroviral Treatment in China: Advancement and Challenges
(Taisheng Li, China)
To respond the HIV/AIDS epidemic in China, the national AIDS control policy, "Four Frees
and One Care" was announced since 2003. There were a lot of difficulties in complementing
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the national free antiretroviral treatment (ART) program, including lack of qualified human
resources, inadequate access to laboratory monitoring and limited class of available
antiretroviral drugs. Overcoming these difficulties, China has made significant strides in the
fight against HIV/AIDS. Over 150 000 adult persons had received first-line HAART thus far
and mortality significantly decreased to 4 or 5 deaths per 100 person years. By 2011, at least
2000 children had received ART. However many challenges remain and well-coordinated
efforts will be needed for continued progress. Increased funding, development of the health
care system, and greater attention to side effects and comorbid conditions will help China
achieve its future HIV-treatment goal.
Severe Community-acquired Pneumonia 2012 (Michael S. Niederman, M.D., USA)
Approximately 10% of all hospitalized patients with community –acquired pneumonia (CAP)
require ICU admission, but it is important to identify patients who need ICU care as soon as
possible, since delayed transfer to a critical care unit is associated with increased mortality,
compared to early and direct admission.
No prognostic scoring system is ideal to define when to identify patients with severe CAP,
and in the absence of obvious criteria such as septic shock and need for mechanical
ventilation, a number of minor criteria are usually present to identify when intensive care is
needed. The Pneumonia Severity Index, the CURB-65, SMART-COP and REA-ICU scoring
systems have been used with varying success to define when severe pneumonia is present, in
the absence of obvious findings. The IDSA/ ATS gudielines defined 9 minor criteria for
severe CAP, and the presence of 3-4 of these criteria does identify patients who need ICU
care. Recently, biomarkers such as procalcitonin , have been added to prognostic scoring tools
to define the optimal site of care for CAP patients.
Once in the ICU, patients should receive prompt therapy , but never with a single agent.
Empiric therapy of CAP is directed at pneumococcus and atypical pathogens for all patients,
but those with risk factors (bronchiectasis, corticosteroid therapy, malnutrition and recent
antibiotic therapy) also need therapy directed at P. aeruginosa. Current therapy algorithms
recommend either a beta-lactam/macrolide combination or a beta-lactam/ quinolone
combination. If Pseudomonal risk factors are present then the patient needs an antiPseudomonal beta-lactam (imipenem, meropenem, piperacillin/tazobactam, cefepime) with an
aminoglycoside plus a macrolide or quinolone. Alternatively, this patient could also be treated
with an ant-Pseudomonal beta-lactam plus an anti-Pseudomonal quinolone (levofloxacin,
ciprofloxacin). Data show an advantage for a macrolide in most patients with severe CAP,
including those with pneumococcal bacteremia, but a quinolone may be preferred if legionella
is present. Recently, community-acquired MRSA has emerged in ICU-admitted CAP patients,
and requires therapy with an antibiotic and an agent to inhibit bacterial toxin production,
which means the use of either vancomycin with clindamycin, or linezolid alone. One
controversy in the therapy of severe CAP is whether routine corticosteroid therapy is
beneficial, but recent data do not show a clear benefit, and do suggest some risk for late onset
infection and delayed clinical failure.
Patients with severe CAP may have a substantial mortality at 6 months that far exceeds the
rate of death in the hospital. Current research suggests that this delayed mortality may be
related to cardiac disease, with the possibility that acute cardiac events are promoted by the
inflammatory response to the presence of pneumonia.
CAP, Tuberculosis, and Fluoroquinolones (Donald E Low, Canada)
Community-acquired pneumonia (CAP) is a common and important disease that occurs in all
age groups worldwide. The fluoroquinolones for treatment of respiratory diseases, including
moxifloxacin, and levofloxacin, have an excellent spectrum, providing coverage for the most
important respiratory pathogens, including drug-resistant S. pneumoniae and atypical
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pathogens. The rate of fluoroquinolone-resistant pneumococcal infection is <3% in most
countries. As a result, the fluoroquinolones for treatment of respiratory diseases have been
recommended and are increasingly being used as preferred or alternative therapy for the
treatment of CAP.
Fluoroquinolones have excellent in vitro activity against M. tuberculosis. They are one of the
most important drug classes for the treatment of multidrug-resistant TB and of patients who
experience severe adverse effects of first-line anti-TB therapy. Depending on the prevalence
of TB in a specific region, a percentage of patients with CAP who are empirically treated with
a fluoroquinolone will actually have pulmonary TB with or without infection due to a
copathogen. In a study of CAP in adult patients in Asian countries, Song et al. found that the
etiology was M. tuberculosis in 3.3% of cases. There therefore is concern that monotherapy
with a fluoroquinolone may temporarily improve the patient's symptoms and, therefore, delay
diagnosis and/or may select for fluoroquinolone-resistant M. tuberculosis strains. Long et al.
had access to 2 large provincial TB registries in Canada with linkages to corresponding
prescription drug plans, the authors found that, although outpatient fluoroquinolone use
(ostensibly for CAP) was not uncommon among patients with pulmonary TB,
fluoroquinolone-resistant M. tuberculosis was identified infrequently; only 3 of 74 patients
who had been treated with a fluoroquinolone prior to the diagnosis of pulmonary TB were
infected with a fluoroquinolone-resistant strain. The newer fluoroquinolones, including
moxifloxacin and levofloxacin, have better in vitro and bactericidal activity and more
favorable pharmacokinetic properties, compared with the older fluoroquinolones,
ciprofloxacin and ofloxacin. The duration of exposure of the M. tuberculosis infecting
organisms to the fluoroquinolone may also be a risk factor for the development of resistance.
Resistance is unlikely to emerge with a short duration of therapy for CAP, especially with an
active agent. At the end of the day, the most important strategy to reduce the risk of a
mistaken diagnosis of CAP in a patient with pulmonary TB is to always consider the “great
mimicker” as a possible cause and, when suspected, to perform the relevant diagnostic tests
before prescribing fluoroquinolones.
Antimicrobial Resistance and Serotype Distribution of
Streptococcus pneumoniae Isolated from Multi-centers across China
Qi Wang et all, Peking University People’s Hospital, China
Background: To investigate the trends of resistance of S. pneumonia and evaluate the
potential coverage of pneumococcal conjugate vaccine (PCV), we examined the antibiotic
susceptibility and serotype distribution of 471 pneumococcal strains isolated from invasive
(37 strains from blood and cerebrospainl fluid) and noninvasive (434 strains from sputum and
other specimen) diseases in multi-center across China from 2010 to 2011.
Methods: In vitro susceptibility to 17 antimicrobial agents was determined by agar dilution
method. Serotyping of S. pneumoniae was performed by using latex agglutination and
quelling reaction. Vaccines coverage by 7- and 13- valent conjugate vaccine were estimated
by calculating the percentage of isolates that belonged to the serotypes included in the
vaccines.
Results: Among all strains tested, 50.1% were resisant to penicillin (MIC≥2µg/mL, oral
breakpoint), and for invasive isolates, the resistance rate was 32.4%. Overall, 60.3%, 58.8%
and 18.5% of S. pneumoniae were resistant to cefaclor, cefuroxime and ceftriaxone,
respectively. The resistance rates to other antibiotic agents, such as erythromycin,
tetracycline, clindamycin, trimethoprim/sulfamethoxazole, and chloramphenicol, were 93.2%,
89.6%, 88.7%, 62.8% and 22.1%, respectively. Multidrug resistance rates to tetracycline,
erythromycin, and clindamycin were higher than 80%. The most prevalent serotype was 19F
(23.8%), followed by 19A (13.4%), 3 (7.4%), 14(7%), 23F (6.2%), 6A (4.9%) and 15 (3.8%).
Serotype 19F accounted for 39% of penicillin-resistant S. pneumoniae (PRSP), 19A for
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24.6%, and 23F for 8.1%. The potential coverage by 7- and 13-valent pneumococcal
conjugate vaccine was 43.1% and 66.9%, respectively.
Conclusions: The antibiotic resistance of S. pneumoniae was erious in China. Most of PRSP
belonged to serotype 19F and 19A (over 60%). PCV13 covered the most of the isolates
(66.9%), especially for PRSP (over 88%), which was higher than PCV7.
REFERENCES
1. Lack of Evidence for Chloroquine-Resistant Plasmodium falciparum Malaria,
Leogane, Haiti, Ami Neuberger, Emerging Infectious Diseases, Vol. 18, No. 9, Sept.
2012
2. Diagnosis and treatment of malaria by health care providers: findings from a post
conflict district in Sri Lanka, Lima J., International Health 4 (2012) 148-150
3. No Evidence of Delayed Parasite Clearance after Oral Artesunate Treatment of
Uncomplicated Falciparum Malaria in Mali, Amelia W. Maiga, Am. J. Trop Med.
Hyg., 87(1), 2012, pp. 23-28
4. Suvada J. Viral hemorrhagic fevers and health care in central region of Africa. HealthNet
News Readers, 2012 Nov 4, WHO, electronic version [http://healthnet.org/hnn-chat]
5. Suvada J. Marburg virus outbreak. HealthNet News Readers, 2012 Aug 1, WHO,
electronic version [http://healthnet.org/hnn-chat]
6. 10. Suvada J. Ebola outbreak in Uganda. HealthNet News Readers, 2012 Nov 4, WHO,
electronic version [http://healthnet.org/hnn-chat]
7. Placental Malaria is Associated With Increased Risk of Nanmalaria Infection During
the First 18 Months of Life in a Beninese Population, Antoine Rachas, CID 2012,
55(5): 672-8
8. Suvada, J. (2010). ChildrenВґs Palliative Care in low-resource settings. Agatres (U),
LTD Press, Kampala, Uganda, 2010
9. Suvada, J., (2010). Pastekova T., Nkonwa I., Ianetti R, Kaiserova E., Merks J.H.M.,
Krcmery V, 2010. Neoplastic Diseases in Children with HIV infection in our register.
The 4th Annual Paediatric HIV and AIDS Conference, 28th – 30th September, 2010,
Kampala. Oral lecture No. 20. In the international abstract book p. 11
10. Suvada, J. et all. (2010). Issues in Social Work and Health. Health/Social Work,
4/2010-1,2/2011, Volume 7-8, ISSN 1333-0023, p.145
11. Suvada, J. (2011). Improving Quality & Safety through Infection Control. UPMPA
CPD Workshop 3rd – 4th September 2011. Kampala, Uganda.
12. The seroprevalence of Helicobacter pylori and its relationship to malaria in Ugandan
children, Vinay Gupta, Transaction of the Royal Society of Tropical Medicine and
Hygiene 106(2012)35-42
13. Selected Topics in Public Health: Krcmery V., Hettes M., Rovny I., Truskova I.,
Bielik I., Kimakova T. et all.: Bratislava, St. Elizabeth College, 2011, pp: 70.
14. Selected Topics in Public Health: Rovny I., Bielik I, Hettes M.: Bratislava, St.
Elizabeth College 2009,pp: 185
15. Suvada J et al. Spectrum of patient´s diagnosis in rural hospital in Buikwe – Uganda. J.
Tropical Health Social work Vol 7,2010. 36-38
250
CLINICAL SOCIAL WORK (CSW)
NEW ISSUE FOR ID FELLOWS IN SOCIAL WORK AND TROPICAL
HEALTH CARE – NEWS FROM ICAAC
G. Lezcano, A. Stanova, V. Krcmery, I. Beldjebel
University of San Francisco, CA, St. Elizabeth University Bratislava,
St. Charles Clinic Beirut, Lebanon
ABSTRACT
News from ICAAC and and their impact or social work and public health in Subsaharan
africa, Central Europe (imported) and SE Asia is reviewed by our social work and health
tropicteam (1-13)
Treatment of MDR-R E.coli and other gramnegative MDR bacteria
1) COL+IMI is probably better for MDR A. baumni
2) FOSFOMYCIN is active option for ESBL E.coli
3)
3.1 III. phase. NXL 104 (Betalactamase inhibitor) CTAZ + AVIbactam
3.2 Plazomycin ACHN-490-Aminoglycoside active agent ESBL-E.coli plus
ESBS producing K.pneumoniae
B. News in Vaccines
1) Single dose of FLU vaccine is OK, for all ages also in pregnancy effects 4%.
2) Pneumococcal vaccine PCV 13 (single dos)
3) Live attenuated Vacinella – Zoster – plus do not give to pts with steroides, decrease zoster
and postherpetic neuralgia, HIV < CD4 or pregnancy should not receive the vaccine
4) Tetanus vaccine should be revaccinated after 5-10 years
5) Di-Te-Pu in US receive pregnant woman in 3rd trimester of pregnancy also the
grandparents who care for infants < 12 years
6) Zoster + hepatitis B + Influenza + Tdap should be given in people > 60 in nursing or
assisted living facility. It should be like Mother in law – never forgets
7) All female 11-12 should receive HPV vaccine, Catch up for 13-26 (Gardasil)
C. HIV Treatment options
CD4 < 350 All, CD4-CD500 AII?, CD4 > 500 B III. IAS – USA guidelines July 2012 (Risk
groups – pregnant, MSM -0, sexually active neonate).
Posibilites: TEN/ tab (FTC) efavivenz (gold standard) –single dose
1st line
TEN/FTC + nevirapin
TEN/FTC + lopinavir/cobistat
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CLINICAL SOCIAL WORK (CSW)
TEN/FTC + efavirenz
TEN/FTC + vitonavir/lopavir (once daily, pills)
2nd relapsed (or virology failure) similar requirements
3rd patients with co morbidity - Abacair + 3TC + (efavirenz – IVO) NRTI – sparing reginen
(PI)
D. Global health: Pandenias, Middle East war conflicts, Lakh of make food (Media –
Anthrax, Sars, Pandemic Bird, Swine FLU, ATB resistance, HIV, TB)
Resume – global meaning, foreign travel – Western Nile, SARS, NDM-1, N1N1 – all travel
Instruments – Pro Med Mail)
E. Hepatitis C – 130 mil. people infected
Very high – Libya, Congo, Mongolia, China) HCV-HC-LC-HCC (Cancer). Cirrhosis is on the
rise – from 5 up to 120 mil. cases, and per 1 to 10 mild. Cases of liver cancer (HCC)
We desperately need vaccine. Therapy is available (TELAPRAVIR, BOCEPREVIR)
Current Tx Ribavin + IFN (about 50% are on tx)
New Tx – direct targeting antivirals (N53 phrase, or N55 protease – inhibition = Telapravir or
Cocepravir
Investigational – dadatasovir t6SK 7977 (80% net pons)
Unfortunately – money investments to research in now one 10x higher than to malaria/TB.
Reason – HCV is STD in rich us and EU drug users and MSM – homosexual individuals.
Malaria/TB is decrease in 1,2 bill. poor people in the third world countries (Africa, SE Asia).
F. Laboratory and ID – Technology evolution
Nobelists: RIA (1977 Rosalyn Yallow Nobel Price)
DNA (1989 Sepecing – Sagen Gilvat – HIV resistance mechanism)
PCR 1993
Moss spectroscopy 1998 – Tanaka
First genome – Plagne 1977
Latest HIV Salina test
The future? Necessity is the mother irritation, prevention care – patient test for 3rd
world and developing countries.
G. New antibiotics:
Production/Research of antibiotics – price is 1 bill. USD.
1) Finally antibiotics in nature (atrhemisin, aminoglycosides)
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CLINICAL SOCIAL WORK (CSW)
2) Magic bullets new genets = 2nd gen of tetracycline – tigencylin, pentacycline scaffold 5/4
d.gn of cefatrolin fosamil + avibactam, 2nd gen - ceptalosporin
The most potent ATB 1956-1988 explain – Varecamycin, nalidix1960 – moxiplaxacin 1999
Phase 3 – amadacycline
- dalba vancin, tela vancin, oritavancin
- cefatreolin fosamil (avibactam) – only one for grangoline bacteria
- neomycin
Future – looking for new bacterial all targets and enzymes, new combination of new ATB:
ecq BLA + BLA/ INH ( transpylidare, transglycolitase) lipoid II. enzymes)
Example: (antimicrobial peptides) (LP+D-lypopoysactobecide)
Thiaorylquinolone – Bedaquillin is the ONLY – ATB-ATP synthetase inhibitor
Combination tx – historical examples, ampicellin + subacten, RIF+INH.
H. Top 10 papers in infect. Control:
Brown, Ann Surg 2011, Eveng and Eng team.
Hatim, Surg. Endless 2011 Duration of operative line highly correlated JAmColl Surg. 2010,
LD Proctor, and general Surgery Operative duration. AE Anderson, AJIC, Traffic flow
(>CFU/m3) is related per door opens in surgtheat, T. Anthy, Arch surg. 2011: Mechanical,
oral ATB+ Cefoxilin, versus PREVENTION (ATR but not mechanical bowelo...45% vs. 24%
infections (PLO 004) Buddle is ..ether.
UOSS, A: Of returning Agents for 2009: Veterinary use still high ESBI still high is Dutch
community patients, ESDI- lot in vegetables.
JAC – Farming fish with quinolones – resistance plasmids (Cows surg – eat more chicken)
JAC – Organic retail 44% of samples have ESRL.
I. News Indicators for quinolones – 50 years anniversary
1) Polyroma vines neplopathy in NSET ICIS 2005. Cipo recipients developed less BK viral
load viruria/less cystitis
2) Leprosy and FQ (1873 M. TBC Dr. Hansen)
Antilepton Bayer, 1921 Louisiana
1941 Promina (Sulfozaine), 1950 Dapsove pills (Dr. Chochane) 1970 Malta – MDR
1981 – WHO recommend – Armadillo in US, Mexico leprosy is the worst form. Current
therapy:
-
Dapson 100 mg + RIF 600 mg 12 m (USA) vs. RIF + OFL + Minocycline (WHO),
(+- clofazimin has 70 days half-life)
- Alternative OFL +RIF 6-12 month (or MOXI + RIF) single dose 1 week
3) TBC and quinolones – 4 month MOXI + RIF + INH is enough for tx and 2 months for tx of
latent TB, and option is XDR-R TBC
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CLINICAL SOCIAL WORK (CSW)
4) Use and abuse FQ: 1962 Nalidixic Acid/Sterling Wintog by product of choroquine
synthesis. Now floxacin 1977 Mlich 1980 developed in Japan but licensed in US in 1987.
1980 -1990 OFL, CIP, PEF, ENO, lenofoacin in Japan 1990 long PEF, lipophillic. In Greece
– no prescription for CIPro. India- also as OTC. Renewal due to toxicity – Terma Flox,
Spartloxacin, Tronafloxacin now in EU. After PEN and CEF are quinolone the third most
posited
groups.
- Problem – veterinary use, resistance in 6NB including PA, E.coli. Correlation between
MRSA and high quinolone use. In vitro surgery testing against gram-negative bacteria.
Combination treatment is usually not tested. Synergy is not tested; With E tests two longer
cross or with bactericidal test
J. Tropical medicine
J1 Cysticercosis – therapy
Albendazol + praziquantel + surgery + antiepileptic’s + steroids – solitary using or albendazol
has to be always giver with steroids – calcified old lesions
J2 – Infections in migrants
Schistosomiasis (Katayama fever) – treatment always praziquantel 40 – 60 mg/kg +
steroids/repeat after 2 months
Artemisins 2 days. Mefloquine – also active clinics of Katayama fever 2 weeks – 4 weeks
after exposure – fever, eosinophilia, cough, asthma, rash
J3 Tropical dermatology – commonest – eczema/dermatitis, infestation scabies,
pyodermia, fungal infection, acne vulgaris
•
Vietnam – eating raw snake cobra blood or cobra heart
•
sparganosis
1.
Vietnamese man early raw reptiles US soldier with beetle dermatitis,
2.
US Army medical Journal, 2009, July, 6 – 15, Outbreak of dermatitis linearis in Iraq,
3.
Ghana/Guinea equatorial amoeba abscess,
4.
14 years old girl with apoptosisis – loaosis (Calabar coast smelling),
5.
Flea infestation in a street from Guayna (Tungiasis) – by returning slaves from
America,
6.
12 year old boy returned from summer vacation from Nigera, dispigmentation in
gingival – cherring Betel areca palm nut, Discoloration gingival (minocyclin, amalgam, lead)
7.
Cady with tabood gingival
8.
Periorbital edema in Haiti lady – T. cruzi chagoma and Male with coetaneous
J4 Blood exposure during travel
•
STD is in Thailand . HIV
•
Lymphogranuloma venereum proctitis in MSM in London, Doxicyclin 21 days,
254
CLINICAL SOCIAL WORK (CSW)
•
MSM with proctitis and hepatitis Cm repeat HCV antibody not treat
•
Laboratory technology in San Salvador, 1 x weekly chloroquine for Plasmodium vivax
prophylaxis. Get Denque fever, or may are virus arthritis + fever. (Tarantola A, Rachline A,
Konto C, HouzГ© S, Sabah-Mondan C, Vrillon H, Bouvet E.: Occupational Plasmodium
falciparum malaria following accidental blood exposure: a case, published reports and
considerations for post-exposure prophylaxis. Scand J Infect Dis. 2005;37(2):131-40.)
K. New antibiotics
Approvals: FDA 2011 – 4, 2012 – 2, 2010 – 8, Number decreasing
Global ATM Share in USA – now only 25% ! of global market. Asia (outside of Japan 35%!!.
9 billions USD of total antibacterial sales, 12 billions USD – China + India!! US + EU stage
depression. Phase IV. trials.
Do we need in USA government FDA reform?
In 2000 – last 2 classes (Oxazolidines – linezolid, lipopeptides – daptomycin)
In 2011 – only 1! new anti G – ATB is available – Teflovi Cefalotin + NLX (Aribactazon).
One other old molecule Fidoxamycin and 1 aminoglycozide (Slazomycin). Even 2 new
compound collapsed 2012 – PROWES SHOCK – Xigvis and Tigecyl (Pfitzer) after 10 years
in the mark et.
1)
Resistance is a Public health Risk,
2)
ATB resistance is also Public health risk,
India and China are imposing quality good industry,
EU – Greece – 53% of Ciprofloxacin is OTC, Belgium, Spain.
Access to ATB – About 70% of neonatal infections cannot be treated with currently available
ATB. About 30 – 40% of children in sepsis in Darces Saloam die.
L. New antibiotics (Few and no new class, but some hope)
No new class, all – old classes
L1 Macrolides ATB – Fidaxomicin relatives to Rifampin, Erytromycin – natural ATB
close structure to glycopeptides
Clinical: Vankomycin vs. Fidaxomycin – similar result against Clostridium difficile colitis (p
= 0.048 – not very convincing)
Cetromycin
Solithromycin – fluoroketolide, active against gram-positibe plus atypical - Phase II.
Pneumonia versus levofloxacin.
Cyclopeptid – Cubist CB183.315
Dalbaraicin – DUR 001 – 1 x week - Phase III in SSTI in surgery.
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CLINICAL SOCIAL WORK (CSW)
L2 Oxazolidines – Teclizolid
Apart of linezolides are investigate (Ribex – Rib X company). Active against mycobacteria
and vankomycГ­n resistant Enterococci and MRSA.
Linezolid resistance: VRE, MRSA emerging.
Sutezolid . vest against TB – Phase II
Rudezolid – Rib X company – Phase I
Tudizolid – Torezolid – Phase II
L3 Cepharolin: not active against Pseudomonas aeruginosa or ESBL + 6 NB (Astra
Zeneca /SKB) active against MRSA and PEN-R Str. pneumoniae also some VRE.
Cepharolin – fosamil 600 mg intravenous or intramuscular, every 13 hours.
Despite 28 – EMEA, CA pneumonia and CA – SSTI. Not for bloodstream and not for
nosocomial pneumonia. Cepharolin is against anti 6 + ATB (useless ATB in the time of need
of anti MR 5NB Pseudomonas aeruginosa, AB.
L4 Aribactam (BAL30072) against + AU BLA except of SHV, AmC.
Bazilen: MER + BAL, Ceftazidin – aribacten (AZ/Forrest), Cefholozan + AVI or cefdolozan
+ doxipenem but in Pseudomonas aeruginosa has Cefttozolan + tazobactam, active also
against PA (only phase I – II) only exception are OXA in Acinetobacter (Atibactam)
Future – UTI but not VAP.
L5 Plazomycin – neoglycodise (aminoglycoside)
ACHN – 490, derivate of srisomycin, first presented ICAAC 2009, Achaogen however, they
is no better activity against Pseudomonas aeruginosa and AB – similar to TOB. Once a day 4
– 7 mg/kg for 10 days. Currently in phase II in comparison to Levofloxacin other
aminoglicosides – SXP2523, select X Neomycin B Lipid conjugates.
M. Infections in ivdu (intravenous drug users)
- botulism. Wounds infectious multiple. Protein – toxin – Anthrax in Marihuana Smokers 47
cases, 13 deaths. Coutaneus anthrax, rare but OK.
N. ID in children
TB or not TB in children (latent TB) isoniasid is better in children than in adults, 9 month 2 x
week, or NHH 6 months (RIF for 4 month, or NHH + IRF 3 months Rifampin + Isoniasid, for
12 week.
New treatment – none (TMC – 208 – is only adults, Bedaquillin) pKard pD for children
In children, bronchoscopy not too much used. Only resist TB – major problem (FQ, high
isoniasid, CLAR).
HUS . Shiga toxin related Hemolytic uremic syndrome.
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CLINICAL SOCIAL WORK (CSW)
Reservoir – is Enterohaemorhagic Escherichia coli. (Buchholz U, Bernard H, Werber D,
Böhmer MM, Remschmidt C, Wilking H, Deleré Y, an der Heiden M, Adlhoch C, Dreesman
J, Ehlers J, Ethelberg S, Faber M, Frank C, Fricke G, Greiner M, Höhle M, Ivarsson S, Jark
U, Kirchner M, Koch J, Krause G, Luber P, Rosner B, Stark K, KГјhne M. German outbreak
of Escherichia coli O104:H4 associated with sprouts. N Engl J Med. 2011 Nov
10;365(19):1763-70.) Adjuctive treatment: Entizumab German adults study used
plasmaferesis and carbapenems (E. coli was ESBL positive).
HBV and HCV clinic in children
Usually asymptomatic, only 5%, 2% HCC, sometimes HBV vaccination (during immune).
Lamivudin or tenofovir plus Interferon for treatment (25% response only) cannot change the
face of the Infection (confirmed treatment better)
Duration of therapy is unknown.
Cirhosis – less than 2% for HCV. HCV – ribavirin + pegiled interferon.
Boceprevir/ talapravir data in children are cause. MTCT is less of 5% Pneumococcal
vaccines.
Meningitis/bacteremia decreased, pneumonia increased – in Utah, al in Alaska – 70%
reduction.
Cab effectiveles – 10 years prevent 0.5 millions cases of invasive pneumococcal disease
shifting, therefore we need a universal pneumococcal vaccine.
REFERENCES
1. Lack of Evidence for Chloroquine-Resistant Plasmodium falciparum Malaria,
Leogane, Haiti, Ami Neuberger, Emerging Infectious Diseases, Vol. 18, No. 9, Sept.
2012
2. Diagnosis and treatment of malaria by health care providers: findings from a post
conflict district in Sri Lanka, Lima J., International Health 4 (2012) 148-150
3. No Evidence of Delayed Parasite Clearance after Oral Artesunate Treatment of
Uncomplicated Falciparum Malaria in Mali, Amelia W. Maiga, Am. J. Trop Med.
Hyg., 87(1), 2012, pp. 23-28
4. Suvada J. Viral hemorrhagic fevers and health care in central region of Africa. HealthNet
News Readers, 2012 Nov 4, WHO, electronic version [http://healthnet.org/hnn-chat]
5. Suvada J. Marburg virus outbreak. HealthNet News Readers, 2012 Aug 1, WHO,
electronic version [http://healthnet.org/hnn-chat]
6. Suvada J. Ebola outbreak in Uganda. HealthNet News Readers, 2012 Nov 4, WHO,
electronic version [http://healthnet.org/hnn-chat]
7. Placental Malaria is Associated With Increased Risk of Nanmalaria Infection During the
First Months of Life in a Beninese Population, Antoine Rachas, CID 2012, 55(5): 672-8
8. Suvada, J. (2010). ChildrenВґs Palliative Care in low-resource settings. Agatres (U), LTD
Press, Kampala, Uganda, 2010
9. Suvada, J., (2010). Pastekova T., Nkonwa I., Ianetti R, Kaiserova E., Merks J.H.M.,
Krcmery V, 2010. Neoplastic Diseases in Children with HIV infection in our register.
257
CLINICAL SOCIAL WORK (CSW)
The 4th Annual Paediatric HIV and AIDS Conference, 28th – 30th September, 2010,
Kampala. Oral lecture No. 20. In the international abstract book p. 11
10. Suvada, J. et all. (2010). Issues in Social Work and Health. Health/Social Work,
4/2010-1,2/2011, Volume 7-8, ISSN 1333-0023, p.145
11. Suvada, J. (2011). Improving Quality & Safety through Infection Control. UPMPA
CPD Workshop 3rd – 4th September 2011. Kampala, Uganda.
The seroprevalence of Helicobacter pylori and its relationship to malaria in Ugandan
children, Vinay Gupta, Transaction of the Royal Society of Tropical Medicine and
Hygiene 106(2012)35-42
12. Selected Topics in Public Health: Rovny I., Truskova I., Bielik I., 11. Hettes M.,
Kimakova T. et all.: Bratislava, St. Elizabeth College, 2011, pp: 70.
Selected Topics in Public Health: Rovny I., Bielik I, Hamade J.: Bratislava, St.
Elizabeth College 2009,pp: 185
13. Suvada J et al. Spectrum of patient´s diagnosis in rural hospital in Buikwe – Uganda. J.
Tropical Health Social work Vol 7,2010. 36-38
14. ICAAC Book of Abstracts 2012, XX ICAAC, ASM, San Francisco 2012
258
CLINICAL SOCIAL WORK (CSW)
INSTRUCTIONS FOR AUTHORS
Allow me to introduce a new expert journal – Clinical Social Work. We would like to
offer you an opportunity to contribute to its content as we would like to aspire to create a
collection of real experiences of social workers, doctors, missionaries, teachers, etc. CWS
Journal is published by the International Scientific Group of Applied Preventive Medicine IGAP in Vienna, Austria.
The journal is to be published quarterly and only in English language as it will be
distributed in various foreign countries.
We prefer to use the term �clinical social work’ rather than social work even though it
is less common. In the profession of clinical social work, there clearly is some tension coming
from unclear definitions of competence of social workers and their role in the lives of the
clients; the position of social work in the structures of scientific disciplines especially in cases
where people declare themselves to be professionals even though they have no professional
educational background. These are only few of the topics we would like to discuss in the
CWS Journal.
Your contribution should fit into the following structure:
1. Editorial
2. Interview, Case Reports
3. Review
4. Original article
5. Letters
Instructions for contributors:
All articles must be in accordance with the current language standards in English, current ISO
and the law on copyrights and rights related to copyrights.
Your contributions are to be sent via e-mail (addressed to: [email protected]) as an
attachment or on a CD via regular postal service. In both cases written and saved in MS Word
(no older version than year 2000).
Style Sheet Requirements:
Maximum length: 3500 words
Letter type: Times New Roman
Letter size: 12
Lining: 1
All articles must include:
Name of the article and author’s address in English
Article abstract of 150 words in English
Brief professional CV of the author (100 words)
Publishing languages: English, German
Each article contains:
1. Name of the article and author’s address in English
2. Abstract in English, which consists of at most 150 words
3. Short CV of the author in English, which consists of at most 100 words
4. Text of the article consisting of at most 3500 words
259
CLINICAL SOCIAL WORK (CSW)
Each article must be an original never published before. When using references, parts of other
articles or publications it is inevitable to quote them and provide information about the source.
We reserve the right to formally edit and reduce the text if needed. Academic articles undergo
an anonymous critique. Each author will receive a prior statement of publishing his/her
article.
When writing a review it is necessary to attach a copy of the cover of the book.
Thank you for your cooperation
Yours sincerely
Michal OlГЎh, Ph.D.
Edition of journal
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CLINICAL SOCIAL WORK (CSW)
Copyright В© 2012 CLINICAL SOCIAL WORK
All rights reserved. No party may be reproduced, stored in a retrieval system, or transmitted in
any form or by any means, electronic, mechaical, photocopyng, recording, or ortherwise,
without prior written permission from the Editor-in-Chief: [email protected].

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