World Health Organization Goal Research Articles

The gas cylinder, the motorcycle and the village health team member: a proof-of-concept study for the use of the Microsystems Quality Improvement Approach to strengthen the routine immunization system in Uganda.

BackgroundAlthough global efforts to support routine immunization (RI) system strengthening have resulted in higher immunization rates, the World Health Organization (WHO) estimates that the proportion of children receiving recommended DPT3 vaccines has stagnated at 80% for the past 3 years (WHO Fact sheet—Immunization coverage 2014, WHO, 2014). Meeting the WHO goal of 90% national DPT3 coverage may require locally based strategies to support conventional approaches. The Africa Routine Immunization Systems Essentials-System Innovation (ARISE-SI) initiative is a proof-of-concept study to assess the application of the Microsystems Quality Improvement Approach for generating local solutions to strengthen RI systems and reach those unreached by current efforts in Masaka District, Uganda.MethodsThe ARISE-SI intervention had three components: health unit (HU) advance preparations, an action learning collaborative, and coaching of improvement teams. The intervention was informed and assessed using qualitative and quantitative methods. Data collection focused on changes and outcomes of improvement efforts among five HUs and one district-level team during the intervention (June 2011–February 2012) and five follow-up months.ResultsWorkshops and team meetings had a 95% attendance rate. All teams gained RI system knowledge and implemented changes to address locally identified problems. Specific changes included: RI register implementation and expanded use, Child Health Card provision and monitoring, staff cross-training, staffing pattern changes, predictable outreach schedules, and health system leader—community leader meetings. Several RI system barriers prevalent across Masaka District (e.g., lack of backup HU gas cylinders, inadequate outreach transportation, and village health team underutilization) were successfully addressed. Three of five HUs significantly increased the vaccines administered. All improvements were sustained 5 months post-intervention. External evaluation validated the findings of high levels of participant engagement, empowerment to make change, and willingness to sustain improvements.ConclusionsThe Microsystems Quality Improvement Approach is a comprehensive approach, grounded in systems thinking, and coupled with intensive coaching. It provides a robust framework for engaging teams in the development of unique local solutions that strengthen RI systems in resource poor settings. The sustained improvements in local RI systems from this study provide evidence that this approach may be an effective framework for enhancing the WHO’s Reaching Every District (RED) immunization strategy.

IMPORTANCE OF MULTIPLE CRITERIA FOR PRIORITY SETTING OF HIV/AIDS INTERVENTIONS.

This study describes the views of various stakeholders on the importance of different criteria for priority setting of HIV/AIDS interventions in Indonesia. Based on a general list of criteria and a focus group discussion with stakeholders (n = 6), a list was developed of thirty-two criteria that play a role in priority setting in HIV/AIDS control in West-Java province. Criteria were categorized according to the World Health Organization's health system goals and building block frameworks. People living with HIV/AIDS (n = 49), healthcare workers (HCW) (n = 41), the general population (n = 43), and policy makers (n = 22) rated the importance of thirty-two criteria on a 5-point Likert-scale. Thereafter, respondents ranked the highest rated criteria to express more detailed preferences. Stakeholders valued the following criteria as most important for the priority setting of HIV/AIDS interventions: an intervention's impact on the HIV/AIDS epidemic, reduction of stigma, quality of care, effectiveness on individual level, and feasibility in terms of current capacity of the health system (i.e., HCW, product, information, and service requirements), financial sustainability, and acceptance by donors. Overall, stakeholders' preferences for the importance of criteria are similar. Our study design outlines an approach for other settings to identify which criteria are important for priority setting of health interventions. For Indonesia, these study results may be used in priority setting processes for HIV/AIDS control and may contribute to more transparent and systematic allocation of resources.

Adult physical inactivity prevalence in the Muslim world: Analysis of 38 countries

ObjectivePhysical inactivity surveillance informs policy and treatment options toward meeting the World Health Organization's (WHO) goal of a 10% reduction in its prevalence by 2025. We currently do not know the aggregate prevalence for Muslim-majority countries, many of which have extremely high rates of comorbidities associated with physical inactivity. MethodBased on data for 163,556 persons in 38 Muslim countries that were collected by the Global Physical Activity Questionnaire and the International Physical Activity Questionnaire, unweighted and weighted physical inactivity prevalence estimates were calculated. I used two-proportion Z tests to determine gender and ethnic differences within the sample and between the sample and 94 non-Muslim countries and odds ratios to determine the magnitude of significant differences. ResultsTotal physical inactivity prevalence was 32.3% (95% CI: 31.9, 32.7). Prevalence among males and females was 28.8% and 35.5%, respectively. Prevalence among non-Arabs and Arabs was 28.6% and 43.7%, respectively. Females and Arabs were more likely physically inactive than their respective counterparts [OR=1.36 (1.33, 1.39) and OR=1.94 (1.90, 1.98)]. Muslim countries were more likely physically inactive [OR=1.23 (1.22, 1.25)] than non-Muslim ones, which was primarily due to the influence of Arabs [OR=2.01 (1.97, 2.04)], and in particular female Arabs [OR=2.22 (2.17, 2.27)]. ConclusionPhysical inactivity prevalence in the Muslim world is higher than non-Muslim countries and the difference is primarily due to higher rates among Arabs.

A systematic review of the effects of artemether-lumefantrine on gametocyte carriage and disease transmission

Background Despite significant advances made in the prevention and treatment of malaria in recent years, these successes continue to fall short of the World Health Organization (WHO) goals for malaria control and elimination. For elimination strategies to be effective, limited disease transmission, achieved through rapid reduction in infectious parasite reservoir and decreased gametocyte carriage, will be critical. Artemisinin-based combination therapy (ACT) forms the cornerstone of WHO-recommended treatment for uncomplicated Plasmodium falciparum malaria, and in combination with other effective interventions will undoubtedly play a vital role in elimination programmes. The gametocytocidal properties of ACTs are a bonus attribute; there is epidemiological evidence of reductions in malaria incidence and transmission in African regions since the introduction of these agents. Many studies and analyses have specifically investigated the effects of artemether-lumefantrine (AL) on gametocyte carriage.

A review of the effects of artemether-lumefantrine on gametocyte carriage and disease transmission.

While significant advances have been made in the prevention and treatment of malaria in recent years, these successes continue to fall short of the World Health Organization (WHO) goals for malaria control and elimination. For elimination strategies to be effective, limited disease transmission, achieved through rapid reduction in the infectious parasite reservoir and decreased gametocyte carriage, will be critical. Artemisinin-based combination therapy (ACT) forms the cornerstone of WHO-recommended treatment for uncomplicated Plasmodium falciparum malaria, and in combination with other effective interventions will undoubtedly play a vital role in elimination programmes. The gametocytocidal properties of artemisinins are a bonus attribute; there is epidemiological evidence of reductions in malaria incidence and transmission in African regions since the introduction of these agents. Many studies and analyses have specifically investigated the effects of the ACT, artemether-lumefantrine (AL) on gametocyte carriage. In this systematic review of 62 articles published between 1998 and January 2014, the effects of AL on gametocyte carriage and malaria transmission are compared with other artemisinin-based anti-malarials and non-ACT. The impact of AL treatment of asymptomatic carriers on population gametocyte carriage, and the potential future role of AL in malaria elimination initiatives are also considered. Despite the inherent difficulties in comparing data from a range of different studies that also utilized different diagnostic approaches to assess baseline gametocyte counts, the gametocytocidal effect of AL was proportionately consistent across the studies reviewed, suggesting that AL will continue to play a vital role in the treatment of malaria and contribute to clearing the path towards malaria elimination. However, the specific place of AL is the subject of much ongoing research and will undoubtedly be dependent on different demographic and geographical scenarios. Utilizing ACT, such as AL, within malaria elimination strategies is also associated with a number of other challenges, such as balancing potential increased use of ACT (e g, treatment of asymptomatic carriers and home-based treatment) with rational use and avoidance of drug resistance development.

Prime–Boost with Mycobacterium smegmatis Recombinant Vaccine Improves Protection in Mice Infected with Mycobacterium tuberculosis

The development of a new vaccine as a substitute for Bacillus Calmette–Guerin or to improve its efficacy is one of the many World Health Organization goals to control tuberculosis. Mycobacterial vectors have been used successfully in the development of vaccines against tuberculosis. To enhance the potential utility of Mycobacterium smegmatis as a vaccine, it was transformed with a recombinant plasmid containing the partial sequences of the genes Ag85c, MPT51, and HspX (CMX) from M. tuberculosis. The newly generated recombinant strain mc2-CMX was tested in a murine model of infection. The recombinant vaccine induced specific IgG1 or IgG2a responses to CMX. CD4+ and CD8+ T cells from the lungs and spleen responded ex vivo to CMX, producing IFN-γ, IL17, TNF-α, and IL2. The vaccine thus induced a significant immune response in mice. Mice vaccinated with mc2-CMX and challenged with M. tuberculosis showed better protection than mice immunized with wild-type M. smegmatis or BCG. To increase the safety and immunogenicity of the CMX antigens, we used a recombinant strain of M. smegmatis, IKE (immune killing evasion), to express CMX. The recombinant vaccine IKE-CMX induced a better protective response than mc2-CMX. The data presented here suggest that the expression of CMX antigens improves the immune response and the protection induced in mice when M. smegmatis is used as vaccine against tuberculosis.

Clinical variables associated with leprosy reactions and persistence of physical impairment

Leprosy is a chronic disease that affects skin and peripheral nerves. Disease complications include reactional episodes and physical impairment. One World Health Organization (WHO) goal of leprosy programs is to decrease the number of grade 2 impairment diagnoses by 2015. This study aims to evaluate clinical factors associated with the occurrence of leprosy reactions and physical impairment in leprosy patients. We conducted a retrospective study of data from medical records of patients followed in two important centers for the treatment of leprosy in Aracaju, Sergipe, Brazil, from 2005 to 2011. We used the chi-square test to analyze associations between the following categorical variables: gender, age, operational classification, clinical forms, leprosy reactions, corticosteroid treatment, and physical impairment at the diagnosis and after cure. Clinical variables associated with multibacillary leprosy and/or reactional episodes and the presence of any grade of physical impairment after cure were evaluated using the logistic regression model. We found that men were more affected by multibacillary forms, reactional episodes, and grade 2 physical impairment at diagnosis. Leprosy reactions were detected in a total of 40% of patients and all were treated with corticosteroids. However, physical impairment was observed in 29.8% of the patients analyzed at the end of the treatment and our multivariate analysis associated a low dose and short period of corticosteroid treatment with persistence of physical impairments. Physical impairment should receive an increased attention before and after treatment, and adequate treatment should be emphasized.

Patterns of migration and risks associated with leprosy among migrants in Maranhão, Brazil.

Leprosy remains a public health problem in Brazil with new case incidence exceeding World Health Organization (WHO) goals in endemic clusters throughout the country. Migration can facilitate movement of disease between endemic and non-endemic areas, and has been considered a possible factor in continued leprosy incidence in Brazil. A study was conducted to investigate migration as a risk factor for leprosy. The study had three aims: (1) examine past five year migration as a risk factor for leprosy, (2) describe and compare geographic and temporal patterns of migration among past 5-year migrants with leprosy and a control group, and (3) examine social determinants of health associated with leprosy among past 5-year migrants. The study implemented a matched case-control design and analysis comparing individuals newly diagnosed with leprosy (n = 340) and a clinically unapparent control group (n = 340) without clinical signs of leprosy, matched for age, sex and location in four endemic municipalities in the state of Maranhão, northeastern Brazil. Fishers exact test was used to conduct bivariate analyses. A multivariate logistic regression analysis was employed to control for possible confounding variables. Eighty cases (23.5%) migrated 5-years prior to diagnosis, and 55 controls (16.2%) migrated 5-years prior to the corresponding case diagnosis. Past 5 year migration was found to be associated with leprosy (OR: 1.59; 95% CI 1.07–2.38; p = 0.02), and remained significantly associated with leprosy after controlling for leprosy contact in the family, household, and family/household contact. Poverty, as well as leprosy contact in the family, household and other leprosy contact, was associated with leprosy among past 5-year migrants in the bivariate analysis. Alcohol consumption was also associated with leprosy, a relevant risk factor in susceptibility to infection that should be explored in future research. Our findings provide insight into patterns of migration to localize focused control efforts in endemic areas with high population mobility.

What will it take to eliminate pediatric HIV? Reaching WHO target rates of mother-to-child HIV transmission in Zimbabwe: a model-based analysis.

The World Health Organization (WHO) has called for the "virtual elimination" of pediatric HIV: a mother-to-child HIV transmission (MTCT) risk of less than 5%. We investigated uptake of prevention of MTCT (PMTCT) services, infant feeding recommendations, and specific drug regimens necessary to achieve this goal in Zimbabwe. We used a computer model to simulate a cohort of HIV-infected, pregnant/breastfeeding women (mean age, 24 y; mean CD4, 451/µl; breastfeeding duration, 12 mo). Three PMTCT regimens were evaluated: (1) single-dose nevirapine (sdNVP), (2) WHO 2010 guidelines' "Option A" (zidovudine in pregnancy, infant nevirapine throughout breastfeeding for women without advanced disease, lifelong combination antiretroviral therapy for women with advanced disease), and (3) WHO "Option B" (pregnancy/breastfeeding-limited combination antiretroviral drug regimens without advanced disease; lifelong antiretroviral therapy with advanced disease). We examined four levels of PMTCT uptake (proportion of pregnant women accessing and adhering to PMTCT services): reported rates in 2008 and 2009 (36% and 56%, respectively) and target goals in 2008 and 2009 (80% and 95%, respectively). The primary model outcome was MTCT risk at weaning. The 2008 sdNVP-based National PMTCT Program led to a projected 12-mo MTCT risk of 20.3%. Improved uptake in 2009 reduced projected risk to 18.0%. If sdNVP were replaced by more effective regimens, with 2009 (56%) uptake, estimated MTCT risk would be 14.4% (Option A) or 13.4% (Option B). Even with 95% uptake of Option A or B, projected transmission risks (6.1%-7.7%) would exceed the WHO goal of less than 5%. Only if the lowest published transmission risks were used for each drug regimen, or breastfeeding duration were shortened, would MTCT risks at 95% uptake fall below 5%. Implementation of the WHO PMTCT guidelines must be accompanied by efforts to improve access to PMTCT services, retain women in care, and support medication adherence throughout pregnancy and breastfeeding, to approach the "virtual elimination" of pediatric HIV in Zimbabwe. Please see later in the article for the Editors' Summary.

Related factors to choose normal vaginal delivery by mothers based on Health Belief Model

Background:Normal vaginal delivery (NVD) is the best method of delivery, but its rate is decreasing. Results of many studies have shown that the risk of cesarean section (CS) for both mother and child is more than that of NVD. The World Health Organization's (WHO) goal was to achieve a CS rate of 15% in 2010, but this rate in most of the developing countries is over than 50%. In this study, we try to determine the related factors influencing the method of delivery selection by mothers in Yazd city, Iran, based on Health Belief Model (HBM).Materials and Methods:This was a cross-sectional study done on 130 pregnant women who presented in four clinics of Yazd. The mothers were in 32–37 weeks of gestational age. Samples were selected by simple randomized method. Data were collected by questionnaire by interviewing and then analyzed by analysis of variance (ANOVA) and t-test.Results:Mean age of samples was 42.23 ± 4.52 years. Eighty-four (64%) women were primigravids and 49 (37.7%) mothers were multigravids. Of them, the method of delivery in previous pregnancy was NVD in 29 (22.3%) and CS in 20 (14.3%). In their present pregnancy, the method of delivery was NVD in 88 (67.7%) and CS in 42 (32.3%). The Pearson test showed a significant correlation between perceived barriers and behavior (P=0.012). Also, there was significant relationship between perceived susceptibility and behavior (P=0.03). There was no significant relation between other variables (perceived benefits and perceived severity).Conclusion:Based on the results of this study, perceived susceptibility and perceived barriers were related to behavior significantly, so we must educate mothers using HBM to influence their behavior toward selecting NVD as their delivery method.

HIV diagnostics in infants vertically exposed and receiving anti-retroviral treatment

In this multicenter, prospective, cohort study of neonates born to mothers infected with HIV, the value of performance of testing for both HIV-1 DNA and HIV-1 RNA was compared in infant aged ≤ 6 months. The novelty of this investigation is that the 1567 studied infants exposed to HIV received postnatal prophylaxis (and were not breastfed). The DNA and RNA tests performed similarly as diagnostic tests. Although both HIV-1 RNA and HIV-1 DNA polymerase chain reaction (PCR) tests had specificity of 100% for infants infected with HIV (except in first few postnatal days), sensitivity of tests rose to 100% only at 3 months of age (after discontinuation of 4-6 week course of anti-retroviral prophylaxis). At 1 month of age, 11% of children infected with HIV had negative DNA and RNA PCR test results. Our expert reviewers suggested that these data make the current World Health Organization's goal of diagnosing HIV-1 infections using tests with at least 95% sensitivity for all infants exposed to HIV by 4-6 weeks of age nonfeasible given the current standard of peri- and postnatal management and current limitations of viral detection methodology. Article page 60▶ Performance of HIV-1 DNA or HIV-1 RNA Tests for Early Diagnosis of Perinatal HIV-1 Infection during Anti-Retroviral ProphylaxisThe Journal of PediatricsVol. 160Issue 1PreviewTo compare performance of testing for human immunodeficiency virus (HIV)-1 DNA and HIV-1 RNA for diagnosis of HIV-1 infection in infants receiving preventive antiretroviral therapy. Full-Text PDF

Drug-resistant tuberculosis: emerging treatment options

Multidrug-resistant tuberculosis has emerged worldwide, with an increasing incidence due to failure of implementation of apparently effective first-line antituberculous therapy as well as primary infection with drug-resistant strains. Failure of current therapy is attributed to a long duration of treatment leading to nonadherence and irregular therapy, lack of patient education about the disease, poverty, irregular supply by care providers, drug–drug interactions in patients coinfected with human immunodeficiency virus (HIV), inadequate regulations causing market overlap and irresponsible drug usage in the private sector, and lack of research, with no addition of new drugs in the last four decades. Present standards of care for the treatment of drugsusceptible tuberculosis, multidrug-resistant tuberculosis, tuberculosis-HIV coinfection, and latent tuberculosis infection are all unsatisfactory. Since 2000, the World Health Organization (WHO) has focused on drug development for tuberculosis, as well as research in all relevant aspects to discover new regimens by 2015 and to eliminate tuberculosis as a public health concern by 2050. As a result, some 20 promising compounds from 14 groups of drugs have been discovered. Twelve candidates from eight classes are currently being evaluated in clinical trials. Ongoing research should prioritize identification of novel targets and newer application of existing drugs, discovery of multitargeted drugs from natural compounds, strengthening host factors by immunopotentiation with herbal immunomodulators, as well as protective vaccines before and after exposure, consideration of surgical measures when indicated, development of tools for rapid diagnosis, early identification of resistant strains, and markers for adequacy of treatment and an integrative approach to fulfill WHO goals. However, regulatory control over the drug market, as well as public-private partnership to use health program facilities to track patients and ensure completion of adequate therapy will be necessary to exploit fully the potential of the newer regimens to eliminate tuberculosis.

Edentulism and shortened dental arch in Brazilian elderly from the National Survey of Oral Health 2003

OBJECTIVE: To describe the distribution of edentulism and estimate the prevalence of functional dentition and shortened dental arch among elderly population. METHODS: A population-based epidemiological study was carried out with a sample of 5,349 respondents aged 65 to 74 years obtained from the 2002 and 2003 Brazilian Ministry of Health/Division of Oral Health survey database. The following variables were studied: gender; macroregion of residence; missing teeth; percentage that met the World Health Organization goal for oral health in the age group 65 to 74 years (50% having at least 20 natural teeth); presence of shortened dental arch; number of posterior occluding pairs of teeth. The Chi-square test assessed the association between categorical variables. The Kruskal-Wallis and Mann-Whitney tests were used to assess differences of mean between number of posterior occluding pairs teeth, macro-region and gender. RESULTS: The elderly population had an average of 5.49 teeth (SD: 7.93) with a median of 0. The proportion of completely edentulous respondents was 54.7%. Complete edentulism was 18.2% in the upper arch and 1.9% in the lower arch. The World Health Organization goal was achieved in 10% of all respondents studied. However, only 2.7% had acceptable masticatory function and aesthetics (having at least shortened dental arch) and a mean number of posterior occluding pairs of 6.94 (SD=2.97). There were significant differences of the percentage of respondents that met the World Health Organization goal and presence of shortened dental arch between men and women. There were differences in shortened dental arch between macroregions. CONCLUSIONS: The Brazilian epidemiological oral health survey showed high rate of edentulism and low rate of shortened dental arch in the elderly population studied, thus suggesting significant functional and aesthetic impairment in all Brazilian macroregions especially among women.

TBNet: The Impact of an Innovative Public–Private Intervention on Tuberculosis Control Among an Internationally Mobile Population

This study was undertaken to evaluate tuberculosis treatment success among an internationally mobile population. A record review was conducted of all detainees referred to TBNet by US Immigration and Customs Enforcement from May 1, 2005 through February 28, 2008. Detainees were referred prior to deportation and followed until diagnosis was finalized and/or treatment complete. A comparative analysis of cases by TB diagnosis, demographics, and co-morbidities was performed. Of the 929 individuals referred, 474 had been diagnosed with clinically active M. tuberculosis or started on medication for presumed active TB. Twenty-two cases were removed from consideration. Of the remaining 452 individuals, 383 were reported to have successfully completed treatment yielding an 84.7% treatment success rate. Detainees with active M. tuberculosis who are referred prior to deportation to TBNet by U.S. Immigration and Customs Enforcement demonstrate a high treatment success rate consistent with the World Health Organization's goal of 85% treatment completion.

The Swiss National Vaccination Coverage Survey, 2005–2007

We described the results from the Swiss National Vaccination Coverage Survey (SNVCS) 2005-2007, a survey designed to monitor immunization coverage of children and adolescents residing in Switzerland in each canton within a three-year period. The SNVCS is a cross-sectional survey using a two-stage sampling design targeting children aged 2, 8, and 16 years. Families of selected children were contacted by mail and telephone. Coverage was determined via vaccination cards or vaccination summary forms. A total of 25 out of 26 cantons participated in the survey, with 8,286 respondents for children aged 24-35 months, 10,314 respondents for children aged 8 years, and 9,301 respondents for teenagers aged 16 years. Compared with data from 1999-2003, coverage estimates for toddlers remained unchanged for diphtheria, tetanus, pertussis, poliomyelitis, and Haemophilus influenzae type b vaccines at three doses, but increased five percentage points to 86%-87% for measles-mumps-rubella at one dose and was 71% at two doses. Coverage for measles, mumps, and rubella were 89%-90% at one dose and 75% at two doses for 8-year-olds, and 94% and 76% for the two dosages, respectively, for 16-year-olds. Linguistic region and nationality were highly correlated with being vaccinated against measles for the two younger age groups. Despite the increase in vaccine coverage, measles vaccination is still low, and the World Health Organization goal to eliminate measles by 2010 was not achieved in Switzerland. More efforts are needed by the cantons and the central government to increase vaccination coverage.

Analyses of cataract surgery performed by the Unified Health System in Brazil, 2006-2007

Estimate cataract surgical rates (CSR) for Brazil and each federal unit in 2006 and 2007 based on the number of surgeries performed by the Unified Health System to help plan a comprehensive ophthalmology network in order to eliminate cataract blindness in compliance with the target set by the World Health Organization (WHO) of 3,000 cataract surgeries per million inhabitants per year. This descriptive study calculates CSR by using the number of cataract surgeries carried out by the Brazilian Unified Health System for each federal unit and estimates the need for cataract surgery in Brazil for 2006-2007, with official population data provided by the Brazilian Institute of Geography and Statistics. The number of cataract surgeries was compared with the WHO target. To reach the WHO goal for eliminating age-related cataract blindness in Brazil, 560,312 cataract surgeries in 2006 and 568,006 surgeries in 2007 needed to be done. In 2006, 179,121 cataract surgeries were done by the Unified Health System, corresponding to a CSR of 959 per million population; in 2007, 223,317 were performed, with a CSR of 1,179. With the Brazilian Council of Ophthalmology estimation of 165,000 surgeries each year by the non-public services, the CSR for Brazil would be 1,842 for 2006 and 2,051 for 2007. The proportions needed to achieve the proposed target were 38.6% in 2006 and 31.6% in 2007. Human resources, technical expertise, and equipment are crucial to reach the WHO goal. Brazil has enough ophthalmologists but needs improved planning and infrastructure in order to eliminate the problem, aspects that require greater financial investment and stronger political commitment.

Does Dietary Intake by Tehranian Adults Align with the 2005 Dietary Guidelines for Americans? Observations from the Tehran Lipid and Glucose Study

The aim of this study was to compare dietary intakes by Tehranian adults with recent dietary guidelines for the Americans. The study made a cross-sectional assessment of the dietary patterns of Tehranian adults using a validated food-frequency questionnaire. It included 2,510 subjects (1,121 men and 1,389 women) aged 19-70 years. They were the participants of the third follow-up survey of the Tehran Lipid and Glucose Study (2005-2008). The dietary patterns were assessed using the latest World Health Organization (WHO)'s nutritional goals and Dietary Guidelines for the Americans Adherence Index (DGAI) 2005. The mean [standard deviation (SD)] DGAI score for this population was 8.31 (1.9). Participants in the highest quartile category of DGAI were more likely to be female, older, non-smoking, and physically active than those in the lowest quartile category (p < 0.001). Percentage of participants meeting the DGA recommendations was low, especially for starchyvegetables (2.3%), orange vegetables (16.2%), lean meat (9.2%), grains (12.0%), and legumes (6.4%). Over-consumption of grains was observed in almost half of the participants while approximately 20% of the subjects over-consumed milk and meat groups. Intakes of most nutrients examined were significantly associated with the DGAI 2005 score (p < 0.001), except for vitamin E, vitamin B12, and vitamin D. The least adherence with the WHO goals was observed with n-3 PUFAs, sodium, fruit, and vegetable intakes. The results revealed that the dietary patterns of most Tehranian adults did not comply with the 2005 DGA and nutritional goals of WHO/Food and Agriculture Organization.

The epidemiological dynamics of infectious trachoma may facilitate elimination

IntroductionTrachoma programs use mass distributions of oral azithromycin to treat the ocular strains of Chlamydia trachomatis that cause the disease. There is debate whether infection can be eradicated or only controlled. Mass antibiotic administrations clearly reduce the prevalence of chlamydia in endemic communities. However, perfect coverage is unattainable, and the World Health Organization's goal is to control infection to a level where resulting blindness is not a public health concern. Here, we use mathematical models to assess whether more ambitious goals such as local elimination or even global eradication are possible. MethodsWe fit a class of non-linear, stochastic, susceptible–infectious–susceptible (SIS) models which allow positive or negative feedback, to data from a recent community-randomized trial in Ethiopia, and make predictions using model averaging. ResultsThe models predict that reintroduced infection may not repopulate the community, or may do so sufficiently slowly that surveillance might be effective. The preferred model exhibits positive feedback, allowing a form of stochastic hysteresis in which infection returns slowly after mass treatment, if it returns at all. Results for regions of different endemicity suggest that elimination may be more feasible than earlier models had predicted. DiscussionIf trachoma can be eradicated with repeated mass antibiotic distributions, it would encourage similar strategies against other bacterial diseases whose only host is humans and for which effective vaccines are not available.

Re-emergence of Measles in Young Infants

To the Editors: The World Health Organization goal of eliminating measles in Europe will not be met by the targeted year 2010.1 In Italy measles incidence declined since vaccine introduction in 1998. Childhood vaccination coverage at 24 months has increased from 56% in 1998 to 90% in 2008.2 Although public health authorities have made extraordinary efforts, measles is still spreading throughout Europe.3 After sporadic cases or clusters nationwide during the previous years, we recently observed a local resurgence of measles.3 At Bambino Gesù Hospital, in Rome, we had no hospitalizations associated with measles from January 2009 to February 2010, whereas we admitted into hospital 26 laboratory confirmed cases from March to September 2010. The median age was of 6 years (range from 1 month to 17 years). The observed complications were dehydration in 13 cases, pneumonia in 11 cases, and otitis in 2 cases. None of them died or had disabling sequelae after discharge. Measles circulation is likely a result of suboptimal vaccination coverage, even if vaccine is offered free-of-charge in a 2-dose routine immunization program, at 12 to 15 months and at 5 to 6 years of age.4 Vaccine coverage depends strongly on the acceptance of vaccination by parents, as well as on recommendations by pediatricians. Parents are free to decide on their child's vaccinations and measles immunization is not mandatory for school admission. Parents may consider the potential profit for the community—due to herd immunity effects and a reduced economical burden—as less important than the individual risk from potential vaccination side-effects. Among our hospitalized children, 7 were too young to be vaccinated. Four children were 3 months or younger and 3 were less than 12 months of age. Only one of the mothers of these children was immunized. Four mothers developed the disease 1 week before their children and they were the likely source of infection. In 1 case, the older sister experienced measles 10 days before and probably transmitted the disease to the infant. As for the other infants, parents were not able to identify the source of infection. Immunization was delayed or not consented by the parents of the older 19 children, who then likely had been infected in the household or at school. Among the reasons for not getting vaccinated were: (a) fear of injections or of side effects; (b) perception of measles as a benign disease; (c) no need of vaccination as the child seemed to be healthy; (d) perception of measles as an eliminated disease from Europe and consequently vaccination as unnecessary. Finally, we should consider the important role of the not yet vaccinated infants who may not be protected by passive immunity or who can experience waning immunity. In fact, measles immunity transmitted by mothers may wane shortly after birth.5 In conclusion, to prevent perspective outbreaks and interrupt measles circulation, strong efforts should be made to achieve and maintain routine coverage over 95%, to adhere to the immunization schedule, to immunize susceptible adults, and to consider offering the vaccine at 9 months of age. Elena Bozzola, MD Anna Quondamcarlo, MD Andrzej Krzysztofiak, MD Laura Lancella, MD Infection Unit Ospedale Pediatrico Bambino Gesù Mariateresa Romano Epidemiology Unit Ospedale Pediatrico Bambino Gesù Alberto Tozzi, MD Epidemiology Unit Ospedale Pediatrico Bambino Gesù Rome, Italy

Scaling Up Malaria Control in Zambia: Progress and Impact 2005–2008

Dear Sir: Your publication of the assessment of Zambia's National Malaria Control Program by Elizabeth Chizema-Kaweshia and others1 documents successful outcomes using evidence-based Integrated Vector Management in Zambia. World Health Organization (WHO) recommendations and goals of the Global Roll Back Malaria Partnership contributed a proven framework for implementing Zambia's national malaria control strategies. There is agreement regarding Integrated Vector Management as an important strategy for the national prevention and control of malaria in Zambia and other African Countries with endemic malaria.2 An integrated approach to vector management is critical to maintaining and improving Zambia's extensive collaborative efforts with multilateral and bilateral agencies and stakeholders globally and nationally. Between 2005 and 2008, Zambia applied Integrated Vector Management to malaria prevention and control. The results showed measurable improvements in the successful prevention and advancement of malaria control in Zambia. However, the authors did not acknowledge achievements and compare lessons learned from other African countries recording similar success with malaria control programs. There is a lack of data regarding capacity building for health communication among indigenous people in Zambia.3 Health communication tools and strategies in Zambia's Strategic Plan would support advocacy for wider rural community participation, coverage, and leadership.