High-risk Districts Research Articles

Spatial analysis and data mining techniques for identifying risk factors of Out-of-Hospital Cardiac Arrest

Out-of-Hospital Cardiac Arrest (OHCA) is a critical issue of emergency medical service (EMS). In addition to the first aids given to OHCA patients by witnesses or bystanders, time factors such as arrival of ambulance and transportation from site to EMS are also important. Comprehensive coverage of EMS, especially enhanced by ubiquitous computing technologies, could significantly improve the survival rate of OHCA patients. However, it heavily challenges the resource allocation and management policy in the public health system of a metropolis. ObjectivesIn this study, we first used spatial analysis techniques with a finer granularity to identify high risk areas of OHCA in a metropolis. We then used data mining techniques to elucidate the effects of patients’ characteristics, pre-hospital resuscitation treatments, and spatial factors on post-OHCA survivability. With this information, public health institutions can enhance the EMS by allocating properly first-aid resources at the right places to improve the survival rate of OHCA patients. MethodsWe used New Taipei City, Taiwan as the scope of this study. Data of all registered OHCA cases in New Taipei City in 2011 were reviewed retrospectively. The dataset was combined with the National Doorplate Database to enhance the granularity of spatial analyses. Global and local spatial analyses based on Global Moran’s Index, Local Moran’s Index, and Getis-Ord Gi* statistic were performed to cluster high risk districts for OHCA in New Taipei City. Statistical methods such as Chi-square test, logistic regression, and decision tree were then adopted to analyze factors influencing 2-h survivability after OHCA. ResultsSignificant spatial clustering of OHCA events was found (p<0.05) in the western side of New Taipei City. We found that the 2-h survival rate after OHCA was significantly correlated (p<0.05) with type of OHCA, EMT-P (Emergency Medical Technicians-Paramedic) dispatch, intubation, drug administration, onsite ROSC (Return of Spontaneous Circulation), AED (Automated External Defibrillator) usage, bystander witnessing, AED initial cardiac rhythm, cardiac rhythm recovery before admission, and past histories of diabetes and renal disease. ConclusionsBased on the finding of this study, several important factors of OHCA can be improved to enhance the quality of the EMS service. With the spatial analysis of OHCA hotspots, public health institutions can manage the first-aid resources more efficiently and make EMS policies more effectively. As a result, the survival rate of OHCA patients can be improved.

Daily zero-reporting for suspect Ebola using short message service (SMS) in Guinea-Bissau

ObjectiveIntensified surveillance will be vital in the elimination phase to verify Ebola-free status and mitigate potential reemergence of the disease in West Africa. Zero-reporting from high-risk districts is a key strategy for surveillance. Our objective was to implement a pilot investigation to assess the feasibility of using short message service (SMS) texting for daily reporting of Ebola cases under investigation (CUI) in Guinea-Bissau in the context of an ongoing emergency-response training program known as Surveillance Training for Ebola Preparedness (STEP). Study designProspective cohort (pilot investigation) MethodsThe reporting period for the SMS pilot was January 24–March 24, 2015. STEP was conducted for two sequential groups during January 19–March 27, 2015 in Bissau, Guinea-Bissau. Training on SMS daily reporting occurred over one hour during the first week of didactic training of each group. Fourteen participants (nine from the first group and five from the second), including one surveillance officer from each of the 13 regions in Guinea-Bissau and one from the national laboratory, were selected as reporters, receiving a simple cell phone for sending SMS indicating the number of CUI for Ebola. The WHO suspect Ebola case definition was used initially and then modified on day 32 of the pilot. The text message was sent to the WiFi-connected smartphone at the Instituto Nacional Saúde Pública (INASA). The smartphone utilised an SMS-gateway application (Ushahidi SMSsync Android App) to upload the data to the Magpi cloud application. ResultsThe average daily reporting from the first group was 7.7 of 9 (86%) and for the second group was 4.1 of 5 (82%). For the two groups combined, the reporting rate was 85%. Among the 14 reporters the median reporting rate was 85% (range 36%–100%). No cases meeting the definition for an Ebola CUI were reported during the 60 days. ConclusionsReal-time, SMS-based, daily zero-reporting can be implemented in a rapid, simple way in a low resource country. We believe that the high compliance rates were due to the simplicity and familiarity of SMS and heightened sensitivity that resulted from STEP to the importance of zero-reporting in the midst of an Ebola epidemic in neighbouring countries. This model could be useful for rapid scale-up and implementation of alert systems in other outbreaks and public health emergencies.

Reducing vulnerability to the threat of Japanese encephalitis transmission in high risk districts in Nepal

Reducing vulnerability to the threat of Japanese encephalitis transmission in high risk districts in Nepal

A systems approach to natural disaster resilience

The frequency, social, and economic impacts of natural disasters show exponential increases in recent decades. Cities and countries around the world have begun to realize that these events are no longer “hundred year” storms, but repeat within a few years. As urbanisation continues throughout this century, more and more people and more economic activity will be concentrated in at-risk areas; especially as new arrivals in cities throughout Asia and Africa are likely to be concentrated in the highest risk districts, much as they often are in North America and Europe today. This article reviews recent growth of natural disasters and considers how a systems approach can improve approaches to mitigation and adaptation of these risks and to recovery from such events.

Crippling Violence: Conflict and Incident Polio in Afghanistan.

BackgroundDesigning effective public health campaigns in areas of armed conflict requires a nuanced understanding of how violence impacts the epidemiology of the disease in question.MethodsWe examine the geographical relationship between violence (represented by the location of detonated Improvised Explosive Devices) and polio incidence by generating maps of IEDs and polio incidence during 2010, and by comparing the mean number of IED detonations in polio high-risk districts with non polio high-risk districts during 2004–2009.ResultsWe demonstrate a geographic relationship between IED violence and incident polio. Districts that have high-risk for polio have highly statistically significantly greater mean numbers of IEDs than non polio high-risk districts (p-values 0.0010–0.0404).ConclusionsThe geographic relationship between armed conflict and polio incidence provides valuable insights as to how to plan a vaccination campaign in violent contexts, and allows us to anticipate incident polio in the regions of armed conflict. Such information permits vaccination planners to engage interested armed combatants to co-develop strategies to mitigate the effects of violence on polio.

Development of the World Health Organization Measles Programmatic Risk Assessment Tool Using Experience from the 2009 Measles Outbreak in Namibia

In the World Health Organization (WHO) African region, reported measles cases decreased by 80% and measles mortality declined by 88% during 2000-2012. Based on current performance trends, however, focused efforts will be needed to achieve the regional measles elimination goal. To prioritize efforts to strengthen implementation of elimination strategies, the Centers for Disease Control and Prevention and WHO developed a measles programmatic risk assessment tool to identify high-risk districts and guide and strengthen program activities at the subnational level. This article provides a description of pilot testing of the tool in Namibia using comparisons of high-risk districts identified using 2006-2008 data with reported measles cases and incidence during the 2009 outbreak. Of the 34 health districts in Namibia, 11 (32%) were classified as high risk or very high risk, including the district of Engela where the outbreak began in 2009. The district of Windhoek, including the capital city of Windhoek, had the highest overall risk score-driven primarily by poor population immunity and immunization program performance-and one of the highest incidences during the outbreak. Other high-risk districts were either around the capital district or in the northern part of the country near the border with Angola. Districts categorized as high or very high risk based on the 2006-2008 data generally experienced high measles incidence during the large outbreak in 2009, as did several medium- or low-risk districts. The tool can be used to guide measles elimination strategies and to identify programmatic areas that require strengthening.

The Spatial and Temporal Distribution of Coal Resource and its Utilization in China — Based on Space Exploration Analysis Technique ESDA

By using exploratory spatial data analysis technology, this paper studies the coal resource and its utilization in China's 31 provinces between 2001 and 2011. The research concluded that the distribution structure of China has a serious imbalance between coal production and coal consumption. The coal resource curse values for most provinces are decreasing apparently. It was also found out the coal-dominated economic development pattern of regions as “Sanxi” (Shanxi, Shaanxi and Mengxi) has become weakened. From the spatial autocorrelation test on coal resource curse, it is revealed that the observed spatial agglomeration of resource curse show significant positive global autocorrelation, i.e. the high curse value region tends to be cluster, with the low value region following the same trend. Moreover, the outcome of local spatial autocorrelation test indicates that several provinces have significant positive values, and the high-risk curse value district has shrunk to the coal endowment region.

Re-assess Vector Indices Threshold as an Early Warning Tool for Predicting Dengue Epidemic in a Dengue Non-endemic Country.

BackgroundDespite dengue dynamics being driven by complex interactions between human hosts, mosquito vectors and viruses that are influenced by climate factors, an operational model that will enable health authorities to anticipate the outbreak risk in a dengue non-endemic area has not been developed. The objectives of this study were to evaluate the temporal relationship between meteorological variables, entomological surveillance indices and confirmed dengue cases; and to establish the threshold for entomological surveillance indices including three mosquito larval indices [Breteau (BI), Container (CI) and House indices (HI)] and one adult index (AI) as an early warning tool for dengue epidemic.Methodology/Principal FindingsEpidemiological, entomological and meteorological data were analyzed from 2005 to 2012 in Kaohsiung City, Taiwan. The successive waves of dengue outbreaks with different magnitudes were recorded in Kaohsiung City, and involved a dominant serotype during each epidemic. The annual indigenous dengue cases usually started from May to June and reached a peak in October to November. Vector data from 2005–2012 showed that the peak of the adult mosquito population was followed by a peak in the corresponding dengue activity with a lag period of 1–2 months. Therefore, we focused the analysis on the data from May to December and the high risk district, where the inspection of the immature and mature mosquitoes was carried out on a weekly basis and about 97.9% dengue cases occurred. The two-stage model was utilized here to estimate the risk and time-lag effect of annual dengue outbreaks in Taiwan. First, Poisson regression was used to select the optimal subset of variables and time-lags for predicting the number of dengue cases, and the final results of the multivariate analysis were selected based on the smallest AIC value. Next, each vector index models with selected variables were subjected to multiple logistic regression models to examine the accuracy of predicting the occurrence of dengue cases. The results suggested that Model-AI, BI, CI and HI predicted the occurrence of dengue cases with 83.8, 87.8, 88.3 and 88.4% accuracy, respectively. The predicting threshold based on individual Model-AI, BI, CI and HI was 0.97, 1.16, 1.79 and 0.997, respectively.Conclusion/SignificanceThere was little evidence of quantifiable association among vector indices, meteorological factors and dengue transmission that could reliably be used for outbreak prediction. Our study here provided the proof-of-concept of how to search for the optimal model and determine the threshold for dengue epidemics. Since those factors used for prediction varied, depending on the ecology and herd immunity level under different geological areas, different thresholds may be developed for different countries using a similar structure of the two-stage model.

Cluster-randomized trial demonstrating impact on academic achievement of elementary social-emotional learning.

This study evaluated the results of a social and emotional learning (SEL) program on academic achievement among students attending a large, urban, high-risk school district. Using a cluster-randomized design, 24 elementary schools were assigned to receive either the intervention curriculum (Promoting Alternative Thinking Strategies, or PATHS) or a curriculum that delivered few if any SEL topics (i.e., the control group). In addition to state mastery test scores, demographic data, school attendance, and dosage information were obtained from 705 students who remained in the same group from the 3rd to the 6th grade. Analyses of odds ratios revealed that students enrolled in the intervention schools demonstrated higher levels of basic proficiency in reading, writing, and math at some grade levels. Although these between-groups differences held for race/ethnicity, gender, and socioeconomic status, significant within-group differences also were noted across these variables. Collectively, these findings indicated that social development instruction may be a promising approach to promote acquisition of academic proficiency, especially among youth attending high-risk school settings. Implications of these findings with respect to SEL programs conclude the article.

Application of the World Health Organization Programmatic Assessment Tool for Risk of Measles Virus Transmission-Lessons Learned from a Measles Outbreak in Senegal.

The World Health Organization (WHO) African Region set a goal for regional measles elimination by 2020; however, regional measles incidence was 125/1,000,000 in 2012. To support elimination efforts, the WHO and U.S. Centers for Disease Control and Prevention developed a tool to assess performance of measles control activities and identify high-risk areas at the subnational level. The tool uses routinely collected data to generate district-level risk scores across four categories: population immunity, surveillance quality, program performance, and threat assessment. To pilot test this tool, we used retrospective data from 2006 to 2008 to identify high-risk districts in Senegal; results were compared with measles case-based surveillance data from 2009 when Senegal experienced a large measles outbreak. Seventeen (25%) of 69 districts in Senegal were classified as high or very high risk. The tool highlighted how each of the four categories contributed to the total risk scores for high or very high risk districts. Measles case-based surveillance reported 986 cases during 2009, including 368 laboratory-confirmed, 540 epidemiologically linked, and 78 clinically compatible cases. The seven districts with the highest numbers of laboratory-confirmed or epidemiologically linked cases were within the capital region of Dakar. All except one of these seven districts were estimated to be high or very high risk, suggesting that districts identified as high risk by the tool have the potential for measles outbreaks. Prospective use of this tool is recommended to help immunization and surveillance program managers identify high-risk areas in which to strengthen specific programmatic weaknesses and mitigate risk for potential measles outbreaks.

Demographic Determinants of Disaster Preparedness Behaviors Amongst Tehran Inhabitants, Iran.

Background: Tehran is vulnerable to natural hazards, especially earthquakes. Disaster preparedness behaviors (DPB) are measures that can mitigate the adverse consequences of disasters. Demographic factors affect DPB, however, the role of some of these factors is not still clear. By understanding these effects, disaster specialists could design interventions toward specific demographics. In the present study, we aimed to investigate demographic determinants of DPB.Methods: This cross-sectional survey was conducted in August 2014. The target population included inhabitants of Tehran who were 18 years or older. A total of 1250 participants were selected randomly and interviewed using a standardized questionnaire.Results: Results of our study showed that monthly income level, previous disaster experience, residential district and occupation are demographic factors that influence DPB significantly. However, disaster preparedness was not affected by gender, educational level, number of household members, home type, home ownership and being the head of household.Conclusion: To promote DPB in Tehran, disaster specialists should focus on improving DPB in low-income and unemployed people, and individuals who live in high risk districts, especially in those who have not experienced disasters.Key words: Disaster, Preparedness behavior, Demographic determinants.

Malaria transmission in Tripura: Disease distribution & determinants.

Background & objectives:Malaria is a major public health problem in Tripura and focal disease outbreaks are of frequent occurrence. The State is co-endemic for both Plasmodium falciparum and P. vivax and transmission is perennial and persistent. The present study was aimed to review data on disease distribution to prioritize high-risk districts, and to study seasonal prevalence of disease vectors and their bionomical characteristics to help formulate vector species-specific interventions for malaria control.Methods:Data on malaria morbidity in the State were reviewed retrospectively (2008-2012) for understanding disease distribution and transmission dynamics. Cross-sectional mass blood surveys were conducted in malaria endemic villages of South Tripura district to ascertain the prevalence of malaria and proportions of parasite species. Mosquito collections were made in human dwellings of malaria endemic villages aiming at vector incrimination and to study relative abundance, resting and feeding preferences, and their present susceptibility status to DDT.Results:The study showed that malaria was widely prevalent and P. falciparum was the predominant infection (>90%), the remaining were P. vivax cases. The disease distribution, however, was uneven with large concentration of cases in districts of South Tripura and Dhalai coinciding with vast forest cover and tribal populations. Both Anopheles minimus s.s. and An. baimaii were recorded to be prevalent and observed to be highly anthropophagic and susceptible to DDT. Of these, An. minimus was incriminated (sporozoite infection rate 4.92%), and its bionomical characteristics revealed this species to be largely indoor resting and endophagic.Interpretation & conclusions:For effective control of malaria in the State, it is recommended that diseases surveillance should be robust, and vector control interventions including DDT spray coverage, mass distribution of insecticide-treated nets/long-lasting insecticidal nets should be intensified prioritizing population groups most at risk to avert impending disease outbreaks and spread of drug-resistant malaria.

Spatio-temporal distribution of malaria and its association with climatic factors and vector-control interventions in two high-risk districts of Nepal.

BackgroundOver the last decade, the incidence of confirmed malaria has declined significantly in Nepal. The aim of this paper is to assess the spatio-temporal distribution of malaria and its association with climatic factors and vector control interventions in two high-risk districts of Nepal.MethodsHotspot analysis was used to visualize the spatio-temporal variation of malaria incidence over the years at village level and generalized additive mixed models were fitted to assess the association of malaria incidence with climatic variables and vector control interventions.ResultsOpposing trends of malaria incidence were observed in two high-risk malaria districts of eastern and far-western Nepal after the introduction of long-lasting insecticidal nets (LLINs). The confirmed malaria incidence was reduced from 2.24 per 10,000 in 2007 to 0.31 per 10,000 population in 2011 in Morang district but increased from 3.38 to 8.29 per 10,000 population in Kailali district. Malaria hotspots persisted mostly in the same villages of Kailali district, whereas in Morang district malaria hotspots shifted to new villages after the introduction of LLINs. A 1° C increase in minimum and mean temperatures increased malaria incidence by 27% (RR =1.27, 95% CI =1.12-1.45) and 25% (RR =1.25, 95% CI =1.11-1.43), respectively. The reduction in malaria incidence was 25% per one unit increase of LLINs (RR =0.75, 95% CI =0.62-0.92). The incidence of malaria was 82% lower in Morang than in Kailali district (RR =0.18, 95% CI =0.11-0.33).ConclusionsThe study findings suggest that LLIN coverage should be scaled up to entire districts rather than high-incidence foci only. Climatic factors should be considered for malaria micro-stratification, mosquito repellents should be prescribed for those living in forests, forest fringe and foothills and have regular visits to forests, and imported cases should be controlled by establishing fever check posts at border crossings.Electronic supplementary materialThe online version of this article (doi:10.1186/1475-2875-13-457) contains supplementary material, which is available to authorized users.

Children's Parasympathetic Reactivity to Specific Emotions Moderates Response to Intervention for Early-Onset Aggression

Following theories that individual differences in respiratory sinus arrhythmia (RSA) denote differential sensitivity to environmental influences, this study examines whether differences in RSA reactivity to specific emotional challenges predict differential response to intervention. We present data from a randomized clinical trial of a targeted intervention for early onset aggression. In collaboration with a high-risk urban school district, 207 kindergarten children (73% African American, 66% male), identified by their teachers as having high levels of aggressive and disruptive behavior, were recruited. All children received a universal social-emotional curriculum. One hundred children were randomly assigned to an additional intervention consisting of weekly peer-based social skills training. Complete RSA data were available for 139 of the children. Teacher-reported externalizing symptoms and emotion regulation in 1st grade (post intervention) were examined controlling for baseline levels. First-grade peer nominations of aggressive behavior, controlling for baseline nominations, were also examined as outcomes. No effect of resting RSA was found. However, greater reactivity to anger was associated with higher externalizing symptoms and lower emotion regulation skills in 1st grade relative to low reactive children. Lower reactivity to fear was associated with greater improvement over time, an effect that was enhanced in the targeted intervention condition. Results suggest that measures of affective reactivity may provide insight into children's capacity to benefit from different types of interventions.

The burden of cholera in Uganda.

IntroductionIn 2010, the World Health Organization released a new cholera vaccine position paper, which recommended the use of cholera vaccines in high-risk endemic areas. However, there is a paucity of data on the burden of cholera in endemic countries. This article reviewed available cholera surveillance data from Uganda and assessed the sufficiency of these data to inform country-specific strategies for cholera vaccination.MethodsThe Uganda Ministry of Health conducts cholera surveillance to guide cholera outbreak control activities. This includes reporting the number of cases based on a standardized clinical definition plus systematic laboratory testing of stool samples from suspected cases at the outset and conclusion of outbreaks. This retrospective study analyzes available data by district and by age to estimate incidence rates. Since surveillance activities focus on more severe hospitalized cases and deaths, a sensitivity analysis was conducted to estimate the number of non-severe cases and unrecognized deaths that may not have been captured.ResultsCholera affected all ages, but the geographic distribution of the disease was very heterogeneous in Uganda. We estimated that an average of about 11,000 cholera cases occurred in Uganda each year, which led to approximately 61–182 deaths. The majority of these cases (81%) occurred in a relatively small number of districts comprising just 24% of Uganda's total population. These districts included rural areas bordering the Democratic Republic of Congo, South Sudan, and Kenya as well as the slums of Kampala city. When outbreaks occurred, the average duration was about 15 weeks with a range of 4–44 weeks.DiscussionThere is a clear subdivision between high-risk and low-risk districts in Uganda. Vaccination efforts should be focused on the high-risk population. However, enhanced or sentinel surveillance activities should be undertaken to better quantify the endemic disease burden and high-risk populations prior to introducing the vaccine.

Monitoring polio supplementary immunization activities using an automated short text messaging system in Karachi, Pakistan

Polio remains endemic in many areas of Pakistan, including large urban centres such as Karachi. During each of seven supplementary immunization activities against polio in Karachi, mobile phone numbers of the caregivers of a random sample of eligible children were obtained. A computer-based system was developed to send two questions--as short message service (SMS) texts--automatically to each number after the immunization activity: "Did the vaccinator visit your house?" and "Did the enrolled child in your household receive oral polio vaccine?" Persistent non-responders were phoned directly by an investigator. A cluster sampling technique was used to select representative samples of the caregivers of young children in Karachi in general and of such caregivers in three of the six "high-risk" districts of the city where polio cases were detected in 2011. In most of the supplementary immunization activities investigated, vaccine coverages estimated using the SMS system were very similar to those estimated by interviewing by phone those caregivers who never responded to the SMS messages. In the high-risk districts investigated, coverages estimated using the SMS system were also similar to those recorded--using lot quality assurance sampling--by the World Health Organization. For the monitoring of coverage in supplementary immunization activities, automated SMS-based systems appear to be an attractive and relatively inexpensive option. Further research is needed to determine if coverage data collected by SMS-based systems provide estimates that are sufficiently accurate. Such systems may be useful in other large-scale immunization campaigns.

Challenges of Asthma Management for School Nurses in Districts With High Asthma Hospitalization Rates

School nurses play a central role in assisting elementary school children in managing their asthma, especially those in higher-risk school districts that are at increased risk of uncontrolled asthma. Study purposes are to (1) identify barriers to asthma management by school nurses in higher-risk school districts; and (2) assess the extent to which National Asthma Education and Prevention Program (NAEPP) recommendations are followed in these districts. School districts containing at least one zipcode with high asthma hospitalization rates among children (0-14 years) in a New York State county were identified. Nurses in 44 elementary schools were surveyed about asthma management during 2008. Both quantitative and qualitative data were collected. Study nurses learned of children with asthma mainly through school records and when students presented with symptoms rather than through parents. The major obstacles to asthma management were communication with parents and parental support. Reluctance of some physicians to diagnose asthma in these children presented a barrier and contributed to the nurses' ability to gain parental cooperation. Adherence to the NAEPP school recommendations was inconsistent. Improvement in the communication among parents, school nurses, and providers is critical to the improvement of asthma management for children in high-risk school districts.

A 60-year review on the changing epidemiology of measles in capital Beijing, China, 1951-2011

BackgroundChina pledged to join the global effort to eliminate measles by 2012. To improve measles control strategy, the epidemic trend and population immunity of measles were investigated in 1951–2011 in Beijing.MethodsThe changing trend of measles since 1951 was described based on measles surveillance data from Beijing Centre of Disease Control and Prevention (CDC). The measles vaccination coverage and antibody level were assessed by routinely reported measles vaccination data and twenty-one sero-epidemiological surveys.ResultsThe incidence of measles has decreased significantly from 593.5/100,000 in 1951 (peaked at 2721.0/100,000 in 1955), to 0.5/100,000 in 2011 due to increasing vaccination coverage of 95%-99%. Incidence rebounded from 6.6/100,000 to 24.5/100,000 since 2005 and decreased after measles vaccine (MV) supplementary immunization activities (SIAs) in 2010. Measles antibody positive rate was 85%-95% in most of years since 1981. High-risk districts were spotted in Chaoyang, Fengtai and Changping districts in recent 15 years. Age-specific incidence and proportion of measles varied over time. The most affected population were younger children of 1–4 years before 1978, older children of 5–14 years in 1978–1996, infant of <1 years and adults of ≥15 years in period of aim to measles elimination.ConclusionStrategies at different stages had a prevailing effect on the epidemic dynamics of measles in recent 60 years in Beijing. It will be essential to validate reported vaccination coverage, improve vaccination coverage in adults and strengthen measles surveillance in the anticipated elimination campaign for measles.

Spatial Differentials in Childhood Mortality in South Africa: Evidence from the 2001 Census

This study examines spatial differentials in childhood mortality in South Africa using data from the 2001 population census. Of the complex routes of geographical area hierarchy maintained by South Africa, one route links provinces to Magisterial Districts (MDs). There are in all 354 MDs and nine provinces. Our analyses are conducted mainly at the level of MDs. The results show that provincial level indicators mask huge disparities in child health experienced by certain segments of the population. Children born in MDs such as Tabankulu, Lusikisiki, Bizana, Flagstaff, Libode and in the Eastern Cape Province in general are the most threatened early in life. Under prevailing mortality conditions, more than 10% of the children born in these districts are unlikely to celebrate their fifth anniversary. Most of the high mortality MDs form clusters that sometimes cut across provincial boundary. As it is to be expected, most of these high risk districts are among the poorest in the country as measured by average monthly expenditure. However, the worse-off districts, health-wise, are not necessarily the poorest and similarly, the best child health achievers are not necessarily the most economically well-off. On the basis of these findings, implementing policies targeting such high risk districts would seem a more rational way to help close the within country disparities in child mortality and thereby speed up progress toward the MDGs target

Conflict of interest: use of pyrethroids and amidines against tsetse and ticks in zoonotic sleeping sickness endemic areas of Uganda.

BackgroundCaused by trypanosomes and transmitted by tsetse flies, Human African Trypanosomiasis and bovine trypanosomiasis remain endemic across much of rural Uganda where the major reservoir of acute human infection is cattle. Following elimination of trypanosomes by mass trypanocidal treatment, it is crucial that farmers regularly apply pyrethroid-based insecticides to cattle to sustain parasite reductions, which also protect against tick-borne diseases. The private veterinary market is divided between products only effective against ticks (amidines) and those effective against both ticks and tsetse (pyrethroids). This study explored insecticide sales, demand and use in four districts of Uganda where mass cattle treatments have been undertaken by the ‘Stamp Out Sleeping Sickness’ programme.MethodsA mixed-methods study was undertaken in Dokolo, Kaberamaido, Serere and Soroti districts of Uganda between September 2011 and February 2012. This included: focus groups in 40 villages, a livestock keeper survey (n = 495), a veterinary drug shop questionnaire (n = 74), participatory methods in six villages and numerous semi-structured interviews.ResultsAlthough 70.5% of livestock keepers reportedly used insecticide each month during the rainy season, due to a variety of perceptions and practices nearly half used products only effective against ticks and not tsetse. Between 640 and 740 litres of insecticide were being sold monthly, covering an average of 53.7 cattle/km2. Sales were roughly divided between seven pyrethroid-based products and five products only effective against ticks. In the high-risk HAT district of Kaberamaido, almost double the volume of non-tsetse effective insecticide was being sold. Factors influencing insecticide choice included: disease knowledge, brand recognition, product price, half-life and mode of product action, product availability, and dissemination of information. Stakeholders considered market restriction of non-tsetse effective products the most effective way to increase pyrethroid use.ConclusionsConflicts of interest between veterinary business and vector control were found to constrain sleeping sickness control. While a variety of strategies could increase pyrethroid use, regulation of the insecticide market could effectively double the number of treated cattle with little cost to government, donors or farmers. Such regulation is entirely consistent with the role of the state in a privatised veterinary system and should include a mitigation strategy against the potential development of tick resistance.