Giornale Italiano di Medicina Tropicale Italian Journal of

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Giornale Italiano
di
Medicina Tropicale
Italian Journal of Tropical Medicine
rivista uffiCiale Della soCietà italiana Di meDiCina tropiCale
offiCial Journal of the italian soCiety of tropiCal meDiCine
Direttore/eDitor
Giancarlo Majori
Comitato Di reDazione/eDitorial BoarD
Marco Albonico; Anna Beltrame; Zeno Bisoffi; Guido Calleri; Giuppa
Cassarà; Francesco Castelli; Umberto D’Alessandro; Giovanni Gaiera;
Federico Gobbi; Alberto Matteelli; Eduardo Missoni; Giovanni Rezza;
Rosario Russo; Giorgio Tamburlini; Luciano Venturi
Comitato Di Consulenza/aDvisory BoarD
Jorge Alvar; Giampiero Carosi; Giuseppe Cascio; Antonio Cassone;
Manuel Corachan; Robert N. Davidson; Anatole Kondrachine; Vittorio
Laghi; Dominique Le Ray; Adriano Mantovani; Hans O. Lobel; Giancarlo
Majori; Piero Olliaro; Sergio Pauluzzi; Antonio Sebastiani; Sergio Spinaci;
Jef Van den Ende
reDazione/eDitorial offiCe
Giornale Italiano di Medicina Tropicale
c/o Istituto Superiore di Sanità,
Dipartimento di Malattie Infettive, Parassitarie e Immunomediate, Reparto
di Malattie trasmesse da Vettori e Sanità Internazionale
Viale Regina Elena, 299 - 00161 Roma
Tel. 06-49906102; Fax 06-49903561
E-mail: [email protected]
Periodico trimestrale registrato al n. 499/87 del 22 settembre 1987 del Registro del Tribunale di Roma.
Proprietà: Società Italiana di Medicina Tropicale
Direttore Responsabile: Giancarlo Majori
Composizione e impaginazione: Maria Grazia Bedetti
Stampa: Centrostampa De Vittoria S.r.l., Via degli Aurunci, 19 - 00185 Roma
Finito di stampare nel mese di novembre 2010
Giornale Italiano di Medicina Tropicale
Italian Journal of Tropical Medicine
VOLUME 14 NUMERO 1-4, GENNAIO - DICEMBRE 2009
VOLUME 14 NO 1-4, JANUARY - DECEMBER 2009
1
Malaria prevalence in HIV patients under cotrimoxazole. Case of Kindu, Maniema, D.R. Congo.
Preliminary results
A. M. Bulabula, Mayanga, Mafwila, Ngandu, Amsini, AMISI, Unganda
3
Overdiagnosis of malaria among the health services providers in Hodeida-Yemen
K. Al-Selwi
7
The effect of washing on insecticide impregnated cotton fabrics against vector species of
mosquitoes under laboratory conditions
N. Kapoor
13
Outcome of severely malnourished children treated according to UNICEF 2004 guidelines in a
rural hospital in Ethiopia
J. M. Ramos, F. Reyes, A. Tesfamariam, N. Gil-Fournier
17
Microbiological quality of street food in Puebla City, Mexico
R. J. Ortiz-Bautista, J. M. Freyre Santiago, G. Zamora-Ortiz, J. L. Sanchez-Salas
21
Solar photocatalytic disinfection of water contaminated with Escherichia coli using nitrogen-doped
titanium dioxide
J. L. Sanchez-Salas, J. Castillo, E. R. Bandala
29
Fattori di rischio di disagio psicologico in migranti ospiti nel Centro Accoglienza Richiedenti Asilo
(C.A.R.A.) di Bari-Palese correlati allo stress da acculturazione
M. De Nicolò, C. Fiume, M. Cavallo
33
The relationship between serum level of iron, zinc and copper with giardiasis in children
M. Fallah, R. Assar Dalooi, A.H. Maghsood, M. Rezaei
37
Gender and HIV: Reasons for increasing number of HIV infected women in Eastern Europe
L. Burruano, E. Bently
43
The prevalence of trichomoniasis in high-risk behavior group women attending penitentiaries clinic
of Tehran province
Z. Valadkhani, M. Assmar, N. Hassan, Z. Aghighi, A. Amirkhani, F. Kazemi, I. Esmaili, M.
Samandar, M. Moradynasab, Sabzali, Dastpak
47
Focolai di tubercolosi in Emilia Romagna
M. Morandi, D. Resi, S. Giordani, L. Droghini, M. Marchi, M. L. Moro
53
Mariano’s Journey: Real Life Health Challenges for Timor-Leste 2009
M. Gibbons, C. Davies
57
Continuing on the road for a proposal of criteria useful for the purpose to prepare a list of essential
veterinary drugs for primary animal health care in developing countries
L. Venturi
61
ISTRUZIONI PER GLI AUTORI
62
INSTRUCTIONS TO AUTHORS
GIORNALE ITALIANO DI MEDICINA TROPICALE
VOL. 14, N. 1-4, 2009
malaria prevalence in hiv patients under cotrimoxazole.
Case of Kindu, maniema, D.r. Congo.
preliminary results
1
1
1
1
2
3
3
a. m. BulaBula , mayanga , mafwila , nganDu , amsini , amisi , unganDa
Programme National Multisectoriel de Lutte contre VIH/SIDA (PNMLS), République Démocratique du Congo
Faculté de Médecine, Université de Kindu (UNIKI), Maniema, République Démocratique du Congo
3
Hopital general de Kindu, Maniema, République Démocratique du Congo
1
2
summary - Objective: To study the prevalence of malaria in HIV patients under cotrimoxazole. Methods: The parasitemia
was determined in a prospective case-control study, in 115 HIV patients under cotrimoxazole (cases) and in 230 controls.
These subjects were followed from February to May 2009. Both the thick and thin smears of blood stained with GIEMSA
were used in this study. The Plasmodium falciparum was the parasite found. Our study settings were: age, sex, malaria
prevalence (positive smear for plasmodia), the benefit of cotrimoxazole in HIV patients. For the statistical analysis, we
computed: the mean age and standard deviation, within a 95% confidence interval and the P, the etiological risk fraction
(benefit of using cotrimoxazole), the prevalence within groups. Results: Females predominate in HIV patients 59% (68/115)
vs 48% (110/230) in controls. The cases mean age was of 37±10.38 years old (95% CI 35.03 - 38.97, P<0.05) versus
24±12.45 years old (95% CI 22.14 - 25.86, P<0.05) years old. Malaria prevalence was 6.9% (8/115) in cases versus 4.8%
(11/230) in controls. The benefit of cotrimoxazole in HIV patients was determined by the etiological risk fraction, 30.4%.
Conclusion: The HIV patients under cotrimoxazole seem to be protected against malaria, the real importance of this protection needs to be determined at the end of this study.
Key words: malaria, HIV patients, cotrimoxazole prophylaxis
introDuCtion
Malaria and HIV/AIDS are frequent in Sub-Saharan
Africa, their association worsens mutually the issue,
and it is responsible for 4 millions of deaths each
year (WHO, 2004).
Malaria and HIV/AIDS are poverty related diseases
with a serious burden on health systems; we are in
an endemic zone for malaria and post-conflict area
where socio-economic situation is worse than ever
and then ensure favorite conditions to the diseases
development.
The prevalence of malaria and HIV/AIDS is highly
variable from a region to another and even in areas
of a given region (WHO, 2004), that way it is
important to study the prevalence in our province.
The incidence of malaria during HIV infection as
well as its morbidity in adults and pregnant women,
have been well-established (Rukyalekere et al.,
2007); the cotrimoxazole prophylaxis has been
widely used but still the variability of the results
concerning the reduction of malaria risk in HIV-
infected patients trigger further investigations. It has
been noticed that the cotrimoxazole is associated
with a reduced risk of malaria in HIV infected
patients (Rukyalekere et al., 2007; Badri et al.,
2001; Castetbon et al., 2001; Mermin et al., 2004;
Witkor et al., 1999). In our country there are a few
works on the evaluation of the real benefit in using
the cotrimoxazole prophylaxis.
materials & methoDs
The Maniema province is located at 900 to 1500 m
of altitude; the annual mean temperature is in the
range of 23 to 25°C (centigrades) and the precipitation 1200 to 2000 mm.
We did a prospective case-control study from
February to May 2009, a randomized sample of 115
HIV-infected patients receiving co-trimoxazole
determined the study group or cases, and 230
randomly selected HIV negative patients not receiving cotrimoxazole made the controls group.
At enrollment, we realized in the two groups both
e-mail address for correspondence: [email protected]
th
Communication presented at the 6 European Congress on Tropical
Medicine and International Health. Verona, Italy 6-10 September, 2009.
1
A.M. BULABULA ET AL.
the thick and thin smears of blood stained with
GIEMSA, in order to check for plasmodia (parasitemia) and determine the specie.
As for study settings, we analyzed: age, sex, malaria
prevalence (positive smear for plasmodia), the benefit of cotrimoxazole in HIV patients.
For the statistical analysis, we computed: the mean
age and standard deviation, within a 95% confidence
interval and the P, the etiological risk fraction (benefit
of using cotrimoxazole), the prevalence within groups.
results
Females predominate in HIV patients 59% (68/115)
versus 48% (110/230) in controls. The cases mean
age was of 37±10.38 years old (95% CI 35.03 38.97, P<0.05) versus 24±12.45 years old (95% CI
22.14 - 25.86, P<0.05). The Plasmodium falciparum
was diagnosed.
The relationship between the administration of cotrimoxazole to HIV infected patients and its protection
effect against malaria was determined by the Odds
Ratio: OR = 1.5 (95% CI 0.58 - 3.81).
Malaria prevalence was 6.9% (8/115) in cases
versus 4.8% (11/230) in controls; the overall prevalence of malaria was 5.5 % (95 % CI 3.1 - 7.9).
The benefit of cotrimoxazole in HIV patients was
determined by the etiological risk fraction, 30.4%.
DisCussion
In our study, seemingly females predominate with
59%, this has been the case in many studies
(Rukyalekere et al., 2007; Mermin et al., 2006).
The P. falciparum was the most frequent parasite
found, this is widely related to the fact that we are
located in the tropical region; it has been noticed in
large scale studies (Malamba et al., 2006).
The prevalence of malaria in cases was 6.9% versus
4.8% in controls, this slight difference (not statistically significant) may be related to the sample size
and the duration of the study, but it has been established that the malaria incidence is reduced in the
group receiving co-trimoxazole as well as the
morbidity (Mermin et al., 2006).
The benefit (etiological risk fraction) of using cotrimoxazole prophylaxis for malaria in HIV infected
patients was as higher as 30.4% in our study, this
contributes to the reduction of morbidity and mortality in HIV infection as shown in other studies on cotrimoxazole prophylaxis for HIV related diseases
(Mermin et al., 2004; Herrero et al., 2007).
referenCes
BADRI M., EHRLICH R., WOOD R., MAARTENS G.
(2001). Initiating co-trimoxazole prophylaxis in HIVinfected patients in Africa: an evaluation of the
provisional WHO/UNAIDS recommendations. AIDS,
15(9): 1143-8.
2
CASTETBON K., ANGLARET X., ATTIA A., TOURE
S., DAKOURY-DOGBO N., MESSOU E., N'DRIYOMAN T., DABIS F., SALAMON R. (2001).
Effect of early chemoprophlylaxis with cotrimoxazole on nutritional status evolution in HIV-1infected adults in Abidjan, Côte d’Ivoire. AIDS,
15(7): 869-876.
HERRERO M.D., RIVAS P., RALLÓN N.I. (2007). HIV
and malaria. AIDS, 9(2): 88-98.
MALAMBA S.S., MERMIN J., REINGOLD A. (2006).
Effect of co-trimoxazole prophylaxis taken by human
immunodeficiency virus (HIV)-infected persons on
the selection of sulfadoxine-pyrimethamine-resistant
malaria parasites among HIV-uninfected household
members. The American Journal of Tropical
Medicine and Hygiene, 75(3): 375-80.
MERMIN J., EKWARU J.P., LIECHTY C.A. (2006).
Effect of co-trimoxazole prophylaxis, antiretroviral
therapy, and insecticide-treated bednets on the
frequency of malaria in HIV-1-infected adults in
Uganda: a prospective cohort study. The Lancet,
367(9518): 1256-61.
MERMIN J., LULE J., EKWARU J.P., MALAMBA S.,
DOWNING R., RANSOM R., KAHARUZA F.,
CULVER D., KIZITO F., BUNNELL R., KIGOZI
A., NAKANJAKO D., WAFULA W., QUICK R.
(2004). Effect of co-trimoxazole prophylaxis on
morbidity, mortality, CD4-cell count, and viral load
in HIV infection in rural Uganda. The Lancet, 364:
1428-1434.
RUKYALEKERE A.K., DORSEY G., GASASIRA A.F. ,
ACHAN J., MEBRAHTU T., NAMALE A.,
HAVLIR D., KAMYA M.R. (2007). Incidence of
malaria in HIV-infected children receiving
cotrimoxazole prophylaxis and insecticide treated bed
nets in Uganda. Oral abstract n. 1031 presented at:
“2007 HIV/AIDS Implementers’ Meeting”. Kigali,
Rwanda, June 16-19, 2007.
WITKOR S.Z., SASSAN-MOROKRO M., GRANT A.D.,
ABOUYA L., KARON J.M., MAURICE C.,
DJOMAND G., ACKAH A., DOMOUA K., KADIO
A., YAPI A., COMBE P., TOSSOU O., ROELS
T.H., LACKRITZ E.M., COULIBALY D., DE
COCK K.M., COULIBALY I.M., GREENBERG
A.E. (1999). Efficacy of trimethroprimsulphamethoxazole prophylaxis to decrease morbidity
and mortality in HIV-1-infected patients with
tuberculosis in Abidjan, Côte D’Ivoire: a randomized
controlled trial. The Lancet, 353: 1469-1475.
WORLD HEALTH ORGANIZATION (2004). Paludisme
et VIH: Interactions et répercussions sur les
politiques de santé publique. Rapport d’une
consultation technique, Genève, Suisse, 23-25 juin
2004. 48 pp.
VOL. 14, N. 1-4, 2009
overdiagnosis of malaria among the health services
providers in hodeida-yemen
K. al-selwi
Tropical Medicine Center, Hodiedah, Republic of Yemen
summary - Overdiagnosis or misdiagnosis of malaria has many negative consequences on society’s health. This qualitative
study about health service providers and malaria overdiagnosis performed in Hodeida, the most affected town in Yemen,
aimed to determine if health service providers are aware of the problem. Health service providers included doctors working
in hospitals, centers, or private clinics; medical assistants working in clinics, laboratories involved in diagnosing and treating
malaria; and pharmacists prescribing and selling malaria treatment drugs, all of whom are officially registered in the health
office. The study sample was obtained from the 2006 registration records by choosing every other person from the list. Half
of the registered health service providers were from agencies in rural area and the other half was from urban areas. The stratified sample received an in depth interview by investigators and the data were analyzed using Epi Info software, version 6.3.
The results indicated that 59% of physicians, 59% of laboratory technicians, 75% of pharmacists, and 50% of nurses think
that malaria is misdiagnosed. Nurses were least concerned about misdiagnosis, followed by physicians and laboratory technicians, and pharmacists were the most concerned. On the other hand, 56% of physicians, 43% of nurses, 41% of laboratory
technicians, and 58% of pharmacists think that malaria is overdiagnosed. All providers agreed that both laboratory technicians and physicians overdiagnosis malaria. A large proportion of laboratory technicians (39%) acknowledge primary
responsibility for the problem, whereas only a small proportion of physicians (24%) acknowledge secondary responsibility.
Key words: Health providers, physicians, medical assistants, laboratory technicians, malaria overdiagnosis.
introDuCtion
One of the main factors of international policy of
malaria control is an early diagnosis and prompt
treatment (World Health Organization, 2005). This
is confronted by over diagnosis or misdiagnosis of
the disease Worldwide (Bell et al., 2006), health
providers are working according to job description
as flowing, high qualified doctors in hospitals and
main centers in urban and rural areas. Medical assistants can provide only basic medical services but not
the diagnosis of diseases (World Health
Organization, 2006); laboratory technicians only
diagnose certain diseases through their tools; and
pharmacists are responsible for selling the drug
safety (Talisuna and Njama Meya, 2007) they only
sell the drugs according to medical prescriptions. In
Hodiedah, for example, regarding the malaria diagnosis, all those who provide their services to the
public when K that a prescription is not needed to
get malaria treatment. Illiteracy and absence of job
descriptions make many pharmacists and laboratory
technicians work as doctors. This leads to a more
hazardous situation especially in malarial diagnosis.
Overdiagnosis is known in many other countries
also and is a subject of studies (Whitty et al., 2005).
hodiedah situation
According to the feedback report of quality control
laboratory, about 40% of the results are false-positive. Overdiagnosis of the disease and losing time in
incorrect diagnosis and management of cases make
their situation even worse. Economical and psychological seculars are high in poverty and psychology
problems.
Doctors and health workers should be awarded of
this where treatment is an urgent need.
methoDs
As has been said before, health service providers
represented many groups, like doctors, practitioners
who work either in hospitals, centers or private clinics, medical assistants who worked in their clinics,
laboratories who diagnose and treat malaria, and
pharmacists who sell and prescribe malaria treatment. All these people are officially registered in
health office, and taken from the registration of
th
3
K. AL-SELWI
2006. There are 116 doctors, 132 medical assistants,
100 laboratory technicians and 136 pharmacists,
who represent the population of study.
the sampling
From the population of the study registries in health
office, half of them were tested by us who figured in
the study sample. Rural and urban areas were
included and every stratum was also, a sample of 58
clinician’s (doctors), 66 medical assistants, 50 laboratory technicians, 68 pharmacists. The sampling
fraction was 50% for every stratum. Questionnaires
and depth interviews were conducted to answer the
study questioners, we obtain verbal consent before
each interview. The scientific Team from Tropical
Medicine Center in Hodiedah University, revised
ethical step, data was analyzed by Epi-info version
6,3, with confident interval 95%, and P value, 03.
results
59% of physicians think malaria is not diagnosed
properly, 50% of nurses think malaria is diagnosed
properly, and 59% of laboratory technicians think
malaria diagnosis is not properly, while 75% of
pharmacists think malaria diagnosis not suitable
(Tab. 1).
table 1 - Do you think malaria is diagnosed properly?
Physicians
Nurses
Lab. technicians
Pharmacists
Yes
No
41%
50%
41%
25%
59%
50%
59%
75%
Inferential statistic was done in order to see the
different between the groups, using Epi-info version
6,3, chi square=4,48, crud OR=1,61,
1,03<1,60,<2,47.
Confident interval 95%, P value, 03. Where nurses
group is the less awarded about the problem, flowed
by laboratory technicians and physicians, while the
pharmacist group is the most awarded.
Majority of physicians 56% think there is overdiagnosis, 43% of nurses, 41% of laboratory technicians
and 58% of pharmacists (Tab. 2).
table 2 - how do you think the diagnosis of malaria in
hodeida is?
Physicians
Nurses
Lab. technicians
Pharmacists
Suitabile
Over
Under
33%
38%
40%
23%
56%
43%
41%
58%
11%
19%
19%
19%
Regarding the responsibility of this problem, all
providers think this problem is related to laboratory
4
technicians first and physicians second, then others
providers, 39% of laboratory technicians recognize
that they are mainly responsible of the problem,
while only 24% of physicians recognize they are
secondly responsible of the problem (Tab. 3).
table 3 - who is responsible for this problem?
Physicians
Nurses
Lab. technic.
Pharmacists
Patients
Physicians Nurses
Lab. tec.
13%
20%
20%
16%
34%
34%
25%
26%
52%
38%
39%
45%
11%
8%
19%
13%
DisCussion
Referring back to studies carried out in other countries (Reyburn et al., 2004), this study tries to
discover how health service providers are aware
about malaria overdiagnosis, while in other countries this problem is already confirmed by all health
service providers (Jonkman et al., 1995; Hamer et
al., 2007, Reyburn et al., 2007) and they are dealing
with solving this problem, as the study which was
carried out in Tanzania, and had the following
conclusion: malaria is commonly overdiagnosed in
people presenting with severe febrile illness, especially in those who live in areas with low to moderate transmission and among adults. This is associated with a failure to treat alternative causes of
severe infection. Diagnosis needs to be improved
and syndromes treatment considered (Moody, 2002;
Murray et al., 2003) whereas this study propose to
suspect syndromes treatment in all cases to cover the
defect of overdiagnosis problem. Another study in
Zambia (Barat et al., 1999), despite efforts to
expand the provision of malaria diagnostics in
Zambia, they continue to be underused and patients
with negative test results frequently receive anti
malarias. Improving the accuracy of malaria diagnosis with rapid antigen-detection diagnostic tests
(RDTs) has been proposed as an approach for reducing overtreatment of malaria in the current era of
widespread implementation of artemisinin-based
combination therapy in sub-Saharan Africa (Hume
et al., 2008). The group of pharmacists is the most
awarded about malaria overdiagnosis may be due to
their direct contact with the patients who compliance failure of malaria treatment.
reCommenDations
• Workshops regarding diagnosis of malaria symptoms and key important factor of laboratory.
• Special programs which help in more awareness
about of overdiagnosis problem should be carried
out by the concerned authority.
• A program of upgrading the under graduate staff
(nurses-laboratory technicians) should be carried
out now.
OVER DIAGNOSIS OF MALARIA AMONG THE HEALTH SERVICES PROVIDERS IN HODEIDA-YEMEN
• Refreshment course for the new and old physicians should be started.
• Motivations to all groups should be provided.
• Applying the low and the job description to
restrict those who work as doctors while they are
undergraduate nurses, or pharmacists.
• Marketing the anti-malarial drugs by a specific
unit and supervision of malaria control drugs and
restricting pharmacist in involving in diagnosis of
the diseases.
referenCes
BARAT L., CHIPIPA J., KOLCZAK M., SUKWA T.
(1999). Does the availability of blood slide
microscopy for malaria at health centers improve the
management of persons with fever in Zambia?
American Journal of Tropical Medicine and Hygiene,
60(6): 1024-1030.
BELL D., WONGSRICHANALAI C., BARNWELL J.W.
(2006). Ensuring quality and access for malaria
diagnosis: how can it be achieved? Nature Reviews
Microbiology, 4: 682-695.
HAMER D.H., NDHLOVU M., ZUROVAC D., FOX M.,
YEBOAH-ANTWI
K.,
CHANDA
P.,
SIPILINYAMBE N., SIMON J.L., SNOW R.W.
(2007). Improved diagnostic testing and malaria
treatment practices in Zambia. The Journal of the
American Medical Association, 297(20): 2227-2231.
HUME J.C.C., BARNISH G., MANGAL T., ARMAZIO
L., STREAT E., BATES I. (2008). Household cost of
malaria overdiagnosis in rural Mozambique. Malaria
Journal, 7: 33.
JONKMAN A., CHIBWE R.A., KHOROMANA C.O.,
LIABUNYA U.L., CHAPONDA M.E., KANDIERO
G.E., MOLYNEUX M.E., TAYLOR T.E. (1995).
Cost-saving through microscopy-based versus
presumptive diagnosis of malaria in adult outpatients
in Malawi. Bulletin of the World Health
Organization, 73(2): 223-227.
MOODY A. (2002). Rapid diagnostic tests for malaria
parasites. Clinical Microbiology Reviews, 15(1): 6678.
MURRAY C.K., BELL D., GASSER R.B.,
WONGSRICHANALAI C. (2003). Rapid diagnostic
testing for malaria. Tropical Medicine &
International Health, 8(10): 876-883.
REYBURN H., MBAKILWA H., MWANGI R.,
MWERINDE O., OLOMI R., DRAKELEY C.,
WHITTY C.J.M. (2007). Rapid diagnostic tests
compared with malaria microscopy for guiding
outpatient treatment of febrile illness in Tanzania:
randomized trial. British Medical Journal, 334: 403.
REYBURN H., MBATIA R., DRAKELY C.,
CARNEIRO I., MWAKASUNGULA E.,
MWERINDE O., SAGANDA K., SHAO J., KITUA
A., OLOMI R., GREENWOOD B.M., WHITTY
C.J.M. (2004). Overdiagnosis of malaria in patients
with severe febrile illness in Tanzania: a prospective
study. British Medical Journal, 329: 1212.
TALISUNA A.O. AND NJAMA MEYA D. (2007).
Diagnosis and treatment of malaria. British Medical
Journal, 334: 375-376.
WHITTY C. J.M., ANSAH E., REYBURN H. (2005).
Treating severe malaria. British Medical Journal,
330: 317-318.
WORLD HEALTH ORGANIZATION (2005). Global
Strategic Plan: Roll Back Malaria 2005-2015. Roll
Back Malaria (RBM) Partnership. Geneva,
Switzerland. 52 pp.
WORLD HEALTH ORGANIZATION (2006).
Guidelines for the Treatment of Malaria. Geneva,
Switzerland. WHO/HTM/MAL/2006.1108. 240 pp.
5
VOL. 14, N. 1-4, 2009
the effect of washing on insecticide impregnated cotton
fabrics against vector species of mosquitoes under
laboratory conditions
n. Kapoor
Indira Gandhi Open University, Maidan Garhi, New Delhi, India
summary - The effect of different factors i.e. rinsing with cold water, washing with cold water and detergent, hot water and
detergent on efficacy of synthetic pyrethroid i.e. deltamethrin, lambda-cyhalothrin, cyfluthrin and etofenprox impregnated
curtains was evaluated under laboratory conditions. Results revealed that there is a gradual loss of insecticide when curtains
are rinsed in cold water or washed with cold water and detergent but there is a drastic reduction in insecticidal activity when
curtains are washed with hot water and detergent. On washing with cold water, cold water + detergent, hot water + detergent,
deltamethrin persistence on impregnated curtains was observed for 40,24, 8 weeks respectively, lambda-cyhalothrin activity
was observed for 32, 20, 6 respectively, cyfluthrin was persistant for 28,16, and 6 weeks respectively. Etofenprox showed its
activity for 28,20, 6 weeks respectively against Anopheles stephensi. Significant difference was not observed between the
persistence of insecticides for An. stephensi and Aedes aegypti (P>0.05), however there was a significant difference (P<0.05)
between the persistence of insecticides for An. stephensi and Culex quinquefasciatus.
Key words: An. stephensi, Ae. aegypti, Cx. quinquefasciatus, synthetic pyrethroid
introDuCtion
Recently, much emphasis has been placed on
personal protection measures against mosquitoes.
Synthetic pyrethroids due to their quick knock down
effect have been in vogue for quite some time
specially for impregnation of nets and curtains. In
view of this insecticide treated nets (ITN) and insecticide treated curtains (ITC) have been advocated to
roll back malaria in endemic countries (Rozendaal
and Curtis, 1989; Curtis, 1993). Effective control
has already been demonstrated in India and elsewhere (Snow et al., 1988; Jana-Kara et al., 1995).
Mosquitoes normally rest on hanging objects such
as curtains which are used by the majority of inhabitants in urban areas, therefore the use of ITCs would
be appropriate. ITCs play an important role in
controlling vector-borne diseases in certain areas.
However, curtains get dirty with time and need
washing. Thus the present study was undertaken to
study the effects of washing of curtains in the cold
water, hot water and after the addition of detergents
in water.
materials anD methoDs
• mosquito species: Anopheles stephensi Liston, a
principal vector of urban malaria, Aedes aegypti
Linnaeus, a principal vector of dengue and dengue
hemorrhagic fever, and Culex quinquefasciatus, a
principal vector of bancroftian filariasis and a
nuisance mosquito were selected for laboratory
evaluation.
• Cotton fabric: With 0.5x0.18mm hole size with
560 horizontal and 180 vertical threads per m2
weighing 432g/m2.
• insecticides: Emulsifiable concentrate formulations of synthetic pyrethroids i.e. deltamethrin
(2.8%) (Hoechst India Ltd., Maharashtra, India),
lambda-cyhalothrin (5%) (ICI India Ltd., New
Delhi, India), cyfluthrin (5%) (Bayer India Ltd.,
Bombay, India) and etofenprox (10%) (Mitsui
Toatsu Chemicals Ltd., Japan) were used for the
study.
Curtains were impregnated as described by Ansari et
al. (1998). Cotton fabric was impregnated at
100mg/m2. Mosquito colonies were maintained in
the insectary at 28+1°C and 70-80% relative humidity as described earlier by Ansari et al. (1978).
• washing with cold water: After impregnating
cotton curtains with 100mg/m 2 of above said
insecticides, the fabrics were rinsed in cold water
th
7
N. KAPOOR
significant difference (P<0.05) was observed
between the activity of deltamethrin with rest of
insecticides (Tab. 1).
Washing the insecticide-impregnated curtains with
detergent and then rinsing in cold water shows
greater reduction in mortality. Persistence of insecticides was observed for 16-24 weeks for different
mosquito species with different insecticides. It was
observed that there was not much difference
(P>0.05) in the activity of insecticides (Tab. 2).
When impregnated curtains were washed with detergent and then rinsed in hot water a drastic reduction
in mortality of different mosquito species was
observed. Persistence of different insecticides was
observed only for 6-8 weeks (P>0.05) (Tab. 3).
Among all the factors influencing the efficiency of
insecticides it was found that hot water + detergent
caused severe reduction in mortality of all mosquito
species followed by the effect of cold water + detergent and cold water (Tab. 4).
These results reveal that high temperature has
adverse effect on the efficacy of insecticides as hot
water and sunlight reduced the mortality of mosquitoes drastically. Detergent also causes the impairment of insecticidal effect (Tab. 5).
• When deltamethrin impregnated curtains are
washed with cold water it is observed that 50%
insecticide is lost in 28 rinses and entire is lost in
40 rinses. When lambda-cyhalothrin, cyfluthrin
and etofenprox impregnated curtains are washed
with cold water, 50% insecticide is lost in 12-14
rinses and insecticide is lost completely in 24-28
rinses.
• Cotton curtains imbued with deltamethrin and
lambda-cyhalothrin exhibit 50% loss in 10
washes. In same token cyfluthrin and etofenprox
exhibit 50% loss in 8-10 washes, cold water with
at 20°C for about half an hour once a week. These
fabrics were then dried till the insecticide stopped
washing off. These fabrics were then subjected to
laboratory bioassay tests as specified by WHO.
Each experiment was replicated ten times and
percentage knock down and corrected mortality
was calculated by using Abbott’s formula (Abbott,
1925).
% Observed mortality-% Control mortality
% Corrected mortality= --------------------------------------------- X 100
100-%Control mortality
• washing with cold water and detergent: Effect
of washing with detergent was studied by thorough rinsing of each treated fabric in cold water
containing detergent (surf) for about half an hour.
After rinsing in cold water, fabric was dried. Each
fabric was put through assay which was replicated
ten times and the corrected mortality was calculated.
• washing with hot water and detergent: Effect
of washing with detergent was studied by squeezing the fabric in hot water and detergent (surf)
mixture for about half an hour. Then the fabric
was rinsed in cold water and dried in shade. Ten
replicates were carried out with each fabric and
insecticide.
• Factorial analysis of Variance (ANOVA) and-test
were carried on the corrected mortality using the
professional computer software package.
results anD DisCussion
When cotton curtains impregnated with synthetic
pyrethroids i.e. deltamethrin, lambda-cyhalothrin,
cyfluthrin, and etofenprox @ 100mg/m2 are rinsed
in cold water weekly, persistence was observed for
28-40 weeks for different mosquito species. A
table 1 - % Corrected mortality of test mosquitoes with various insecticides (100 mg/sq.m) on cotton fabrics
subsequent to washing with cold water.
no. of weeks
insecticide
mosquito species
Delthamethrin
(2.5% E.C.)
An. stephensi
Ae. aegypti
Cx. quinquefasciatus
Lambda-cyhalothrin
(5% E.C)
An. stephensi
Ae. aegypti
Cyfluthrin
(5% E.W.)
Etofenprox
(10% E.C.)
8
0
4
8
12
16
20
24
28
32
36
40
100
100
100
98
95
88
92
82
76
85
75
65
80
62
42
70
48
25
62.8 50
32 10
10
0
38
0
15
0
94
93.3
95.3
82
75
78
72
50
48
52
32
30
34
10
15
15
0
8
5
0
0
-
An. stephensi
Ae. aegypti
98
88.6
89.6
85
72
70
73
48
52
52
30
38
30
12
14
18
0
8
2
0
2
0
An. stephensi
Ae. aegypti
95
92
90
80
75
78
70
42
50
53
28
35
32
15
22
20
5
13
8
0
5
8
0
5
THE EFFECT OF WASHING ON INSECTICIDE IMPREGNATED COTTON FABRICS
subsequent to washing with cold water + detergent.
no. of weeks
insecticide
mosquito species
0
4
8
12
16
20
24
Delthamethrin
(2.5% E.C.)
An. stephensi
Ae. aegypti
100
100
100
75
70
72
58
52
55
45
35
38
25
15
20
10
0
8
0
0
Lambda-cyhalothrin
(5% E.C)
An. stephensi
Ae. aegypti
94
93.3
95.3
68
65
68
52
40
52
30
20
35
10
0
10
0
0
Cyfluthrin
(5% E.W.)
An. stephensi
Ae. aegypti
98
88.6
89.6
72
65
68
48
30
32
18
0
15
0
0
Etofenprox
(10% E.C.)
An. stephensi
Ae. aegypti
95
92
90
70
72
68
50
40
52
25
22
30
15
0
15
0
0
subsequent to washing with hot water + detergent.
no. of washes
insecticide
mosquito species
0
2
4
6
8
Delthamethrin (2.5% E.C.)
An. stephensi
Ae. aegypti
100
100
100
60
58
55
32
30
35
15
12
10
0
0
0
Lambda-cyhalothrin (5% E.C)
An. stephensi
Ae. aegypti
94
93.3
95.3
52
50
48
25
22
20
0
0
0
Cyfluthrin (5% E.W.)
An. stephensi
Ae. aegypti
98
88.6
89.6
56
46
50
20
25
18
0
0
0
Etofenprox (10% E.C.)
An. stephensi
Ae. aegypti
95
92
90
55
50
47
22
18
15
0
0
0
table 4 - no. of weeks for which insecticides persist on insecticide impregnated fabrics.
mosquito species
An. stephensi
Ae. aegypti
Cold water
Cold water + detergent
hot water + detergent
D
l
C
e
D
l
C
e
D
l
C
e
40
32
28
32
20
24
28
20
24
28
20
8
24
20
24
20
16
20
16
12
16
20
16
20
8
8
8
6
6
6
6
6
6
6
6
6
detergent shows parallel result with all the insecticides.
• Hot water and detergent caused drastic reduction
of 50% insecticide within 2 washes and 100% loss
was observed in 6-8 washes.
Observation made by several investigators both in
the laboratory and in the field have reported washing
of fabrics, either with or without soap had a detrimental effect on the pyrethroid deposit and hence on
mosquito mortality. Hand washing of synthetic
netting approximately halved the permethrin content
as measured by gas liquid chromatography as
reported by Snow et al. (1988).
Several studies (Schreck et al., 1978; Snow et al.,
9
N. KAPOOR
table 5 - Comparison of corrected mortalities of mosquito species when exposed to impregnated curtains washed
with cold water and washed with cold water + detergent.
DM & LC
DM & CY
DM & ET
LC & CY
LC & ET
CY & ET
An. stephensi
Ae. aegypti
2.52*
3.40*
2.31*
0.78
0.3
1.12
2.11*
2.52*
2.42*
0.47
1.22
0.98
3.11*
2.66*
3.40*
2.31*
0.51
0.43
*P<0.05
1988a; Rozendaal and Curtis, 1989) show that
washing of fabric can cause a severe decline in
insecticidal activity depending on the method of
washing.
Miller et al. (1991) evaluated the persistence of a
wash-resistant formulation of permethrin in the
Gambia and experimental hut trials with their washresistant formulation showed that this formulation
was more resistant to washing under simulated
village conditions than the ordinary EC formulation.
Lindsay et al. (1991) compared twelve synthetic
pyrethroid preparations and found that washing
resulted in a serious loss of insecticide and consequently reduced the insecticidal activity of the
impregnated material.
Rozendaal and Curtis (1989) studied the effects of
washing cotton cloth nets with soap and cold water,
a weekly habit among the local study population in
Surinam, and after one wash observed nearly 70%
reduction in insecticidal activity as determined by
the percentage knockdown after exposure in a
susceptibility test-kit.
It is therefore inferred that washing the netting
samples resulted in a serious loss of insecticide and
even if no detergent was used, the rubbing of the
material in running water caused a sharp loss in the
mean percentage mortality in the bioassay results.
In contrast, some other workers like Schreck et al.
(1982 and 1982a) reported that the permethrinimpregnated military uniforms could stand 3 to 4
machine washes with detergent and gave good
protection against mosquitoes and ticks.
Hand washing the curtain fabrics one month postimpregnation had a detrimental effect on the insecticidal effectiveness of each of the insecticides. Hot
water reduced the efficacy of all the insecticides
drastically. Higher is the dose the more it is wash
resistant. Deltamethrin on cotton shows the greatest
wash resistance.
ConClusion
It is not reasonable to expect people to keep their
curtains unwashed for many months as dirt and dust
gets accumulated in tropical climate of India. It can
be safely concluded that impregnated curtains
10
should be washed with cold water and detergent at
the intervals for 3-4 months. These results infer that
curtains should be rinsed in cold water and washed
with detergent and dried in shade under normal
conditions.
referenCes
ABBOTT W.S. (1925). A method for computing
effectiveness of an insecticide. Journal of Economic
Entomology, 18: 265-7.
ANSARI M.A., KAPOOR N. AND SHARMA V.P.
(1998). Relative efficacy of synthetic pyrethroids
impregnated fabrics against mosquitoes under
laboratory conditions. Journal of the American
Mosquito Control Association, 14(4): 406-409.
ANSARI M.A., SING V.P., RAZDAN R.K. (1978). Mass
rearing procedures for Anopheles stephensi Liston.
Journal of Communicable Diseases, 10(2): 131-135.
CURTIS C.F. (1993). Workshop on impregnated bednets
at the International Congress of Tropical Medicine.
Japanese Journal of Sanitary Zoology, 44: 65-8.
JANA-KARA B.R., JIHULLAH W.A., SHAHI B., DEV
V., CURTIS C.F., SHARMA V.P. (1995).
Deltametihrin impregnated bednets against An.
minimus transmitted malaria in Assam, India. Journal
of Tropical Medicine and Hygiene, 98: 73-83.
LINDSAY S.W, HOSSAIN I.M., BENNETT S., CURTIS
C.F. (1991). Preliminary studies on the insecticidal
activity and wash resistance of 12 pyrethroids
impregnated in to bed netting assayed against
mosquitoes. Pesticide Science, 32: 397-411.
MILLER JE, LINDSAY SW, ARMSTRONG JRM
(1991). Experimental hut trials of bed nets
impregnated with synthetic pyrethroids or
organophosphates insecticides for mosquito control
in the Gambia. Medical and Veterinary Entomology,
5: 465-467.
ROZENDAAL, J.A. AND CURTIS, C.F. (1989). Recent
research on impregnated mosquito nets. Journal of
the American Mosquito Control Association, 5: 500507.
THE EFFECT OF WASHING ON INSECTICIDE IMPREGNATED COTTON FABRICS
SCHRECK C.E, MOUNT G.A., CARLSON D.A. (1982).
Pressurized sprays of Permethrin on clothing for
personal protection against the lone star tick (Acari:
Ixododae). Journal of Economic Entomology, 75:
1059-1061.
SNOW R.W., LINDSAY S.W., HAYES R.J.,
GREENWOOD B.M. (1988). Permethrin-treated bed
nets (mosquito nets) prevent malaria in Gambian
children. Transactions of the Royal Society of
Tropical Medicine and Hygiene, 82: 838-42.
SCHRECK C.E, MOUNT G.A., CARLSON D.A (1982a).
Wear and wash resistance of permethrin used as a
clothing treatment for personal protection against the
lone star tick (Acari: Ixodidae). Journal of Medical
Entomology, 19: 143-146.
SNOW R.W., ROWAN K.M., LINDSAY, S.W.,
GREENWOOD B.M. (1988a). A trial of bednets
(mosquito nets) as a malaria control strategy in a
rural area of the Gambia, West Africa. Transactions
of the Royal Society of Tropical Medicine and
Hygiene, 82: 212-215.
SCHRECK C.E., POSEY K.H., SMITH N. (1978).
Durability of permethrin as a potential clothing
treatment to protect against blood feeding arthropods.
Journal of Economic Entomology, 71: 397-400.
11
VOL. 14, N. 1-4, 2009
outcome of severely malnourished children treated
according to uniCef 2004 guidelines in a rural hospital
in ethiopia
1, 2
2
2
3
J. m. ramos , f. reyes , a. tesfamariam , n. gil-fournier
Gambo General Rural Hospital, POB 121, Shashemane, Ethiopia.
Infectious Diseases Unit, Hospital General Universitario de Elche, Alicante, Spain.
3
Endocrinology Unit, Hospital Principe de Asturias, Alcalá de Henares, Madrid, Spain
1
2
summary - To evaluate the UNICEF 2004 Guidelines for the Management of Severe Malnutrition in during 29 months to
Paediatric Ward of Gambo General Hospital, Ethiopia. It is a 135-bed rural general hospital located in West-Arsi zone, 250
Km south of Addis Ababa. We reviewed the medical chart of malnourish children admitted from October 2005 to February
2008. During period of study were admitted to paediatrics ward due to severe malnutrition a 693 children, 53% were male.
Median of age was 2 years (interquartile range [IQR]: 0.91-3.5). Marasmus was diagnosed in 298 (43%) cases and kwashiorkor in 395 (57%). The age of children with marasmus was lower than children with kwashiorkor (median [IQR]: 0.9 [0.62] vs. 3 [1.8-4]) (p=<0.001). The median of hospital stay was 20 days (IQR: 13-28); it was higher in marasmus than kwashiorkor child (median [IQR]: 10 [14-30] vs. 18 [13-26]) (p=0.008). The mortality rate was 11.5%. Five hundred sixteen
(74.5%) children were discharged improved, 8.8% self-discharges and 5.2% medical transferred were recorded before their
improvement could be determined. Our results show that correct implementation of UNICEF guidelines for the inpatients
treatment of severe malnourished children can lead to a relatively low mortality rate.
Key words: Malnourished children, Malnutrition, Marasmus, Kwashiorkor, Ethiopia.
introDuCtion
Severe acute malnutrition (SAM) is defined as a
weight-for-height measurement of 70% or less
below the median, or three SD or more below the
mean National Centre for Health Statistics reference
values, the presence of bilateral pitting oedema of
nutritional origin, or a mid-upper-arm circumference
of less than 110 mm in children age 1-5 years
(Collins et al., 2006). Thirteen million children
under age 5 years have SAM, about 2% of children
in developing countries have SAM and the disorder
is associated with 1 million to 2 million preventable
child deaths each year (UNICEF, 2005). Many
advanced cases of SAM are complicated by concurrent infective illness, particularly acute respiratory
infection, diarrhoea, and gram-negative septicaemia.
The SAM is an extremely common disorder, associated with high rates of mortality and morbidity and
requiring specialised treatment and prevention interventions (UNICEF, 2005).
Until 2007, an exclusive inpatient approach to the
clinical care of SAM was recommended. The core
of accepted WHO management protocols is ten
steps in two phases (stabilisation and rehabilitation)
(World Health Organization, 2000; Ministry of
Health, 2004). The approach requires many trained
staff and substantial inpatient bed capacity. The
objective the present study was to evaluate the
UNICEF 2004 Guidelines for the Management of
SAM (Ministry of Health, 2004) in during 29
months to Paediatric Ward of Gambo General
Hospital (GGH), Ethiopia.
methoDs anD methoDs
The GGH is a 135-bed rural general hospital located
in West-Arsi zone, 250 Km south of Addis Ababa.
The catchment area of the GGH is restricted to
approximately 90,000 inhabitants. The GGH is situated about 2,200 meters above sea level. The mean
temperature range is 7-22 ºC. Most of the population
live in a rural setting. The admission criteria, treatment, surveillance, monitoring and discharged were
performed according UNICEF 2004 guidelines
(Ministry of Health, 2004).
th
13
J. M. RAMOS ET AL.
We retrospectively reviewed the medical chart of
admitted in Paediatric Ward and the registration
book for therapeutic feeding from October 2005 to
February 2008. Medical records were retrospectively reviewed and the following information
analysed: (1) gender, (2) age, (3) place of residence,
(4) diagnosis of admission, (5) weight of admission,
(6) height of admission (7) oedema, (8) Mid-Upper
Arm Circumference (MUAC), (9) weight of
discharge and (10) outcome.
The epidemiological, and clinical data from the
records were transferred into a computer database
(Excel 2000; Microsoft) and then analysed using
version 12.0 of the SPSS package of statistical software (SPSS Inc; Chicago, IL). Medians and
interquartile range [IQR]: were calculated for the
continuous variables. Fisher’s exact test, Chi-square
test, or Kruskal-Wallis test were used for the
comparisons, as appropriate.
results
During 29 months period of study were admitted to
paediatrics ward due to severe malnutrition a 693
children, 53% were male and 47% were female.
Median of age was 2 years (IQR: 0.91-3.5).
Children below the age of 12 and 24 months constituted for 34.1% and 58.66% of all the admissions,
respectively. The score of oedema in children were:
0 (no oedema) in 298 (43.0%), 1+ in 88 (12.7%), +2
in 177 (25.5%) and +3 (diffuse bilateral oedema) in
130 (18.7%).
Marasmus was diagnosed in 298 (43%) cases and
kwashiorkor in 395 (57%). The characteristics of the
population according to type of malnutrition are
shown in table 1. The age of children with marasmus was lower than children with kwashiorkor
(median [IQR]: 0.92 [0.58-2.0] vs. 3 [1.75-4.0])
(p=<0.001). The median of weight of children with
marasmus was significantly lower than infant with
kwashiorkor (median [IQR] 4.63 [3.52-6.43] vs.
8.54 [7.05-8.54]) (p=0.03). The median of weight
decrease during the admission was 0.29 [0.0-1]. The
median of hospital stay was 20 days (IQR: 13-28); it
was higher in marasmus than kwashiorkor children
(median [IQR]: 10 [14-30] vs. 18 [13-26])
(p=0.008).
Five hundred sixteen (74.5%) children were
discharged improved, 61 (8.8%) self-discharges and
36 (5.2%) medical transferred were recorded before
their improvement could be determined. There are
not significantly differences between marasmus and
kwashiorkor malnourish (Tab. 1). The mortality rate
was 11.5% (80 children), 12.4% in marasmus and
10.9% in kwashiorkor child. Fifty percents of
patients died in less than 6 day after admission, 70%
in less than 11 days, and 82.5% in less than 15 days.
The possible factors related with de mortality are
shown in table 2. The children with +2 score of
table 1- Differences between marasmus and Kwashiorkor.
Variables
epidemiology characteristics
Gender, male
Median of age (IQR) (years)
Median weight (IQR) (Kg.)
Median decrease of weight (IQR) (Kg.)
Median of hospital stay (IQR) (days)
outcome
Cured
Died
Defaulter
Medial transfer
Marasmus
(n=298)
Kwashiorkor
(n=395)
P
165 (55.4%)
0.92 (0.58-2.00)
4.63 (3.52-6.43)
0.05 (0.0-0.26)
21 (14-30)
201 (50.9%)
3.0 (1.75-4.0)
8.54 (7.05-8.54)
0.65 (0.20-1.3)
18 (13-26)
0.2
<0.001
0.04
0.5
0.008
212 (71.1%)
37 (12.4%)
32 (10.7%)
17 (5.7%)
304 (77.0%)
43 (10.9%)
29 (7.3%)
19 (4.8%)
0.6
0.4
0.4
0.6
Died
(n=80)
No-died
(n=613)
P
42 (52.5%)
0.88 (1.58-3.25)
324 (52.9%)
2.0 (0.92-3.5)
0.5
0.5
37 (46.3%)
11 (13.8%)
11 (13.8%)
21 (26.8%)
261 (42.6%)
77 (12.6%)
166 (27.1%)
109 (17.8%)
0.6
0.5
0.03
0.1
IQR: interquartile range
table 2- factors relates with the mortality among of malnourish children.
Variables
epidemiology characteristics
Gender, male
Median of age (IQR) (years):
oedema score
0
+1
+2
+3
IQR: interquartile range
14
OUTCOME OF SEVERELY MALNOURISHED CHILDREN IN A RURAL HOSPITAL IN ETHIOPIA
oedema were associated with less mortality (6.2%).
The age, type of malnourish, and gender were not
related with the mortality.
DisCussion
Since WHO guidelines for the inpatients treatment
of malnourished children have been introduced in
African countries, several studies have shown that
case-fatality rates have been fallen (Ashworth et al.,
2004; Karaolis et al., 2007). In Ethiopia, from 1997
to 2000 study carried out in Gondar University
Hospital the mortality rate of SAM malnutrition
despite hospitalization was 18.4% with a dropout
rate of 9.1% (Amsalu and Asnakew, 2006). In other
study of SAM treated according to UNICEF 2004
guidelines carried out in St. Luke Catholic Hospital
in South East Shewa, Ethiopia, the mortality rate
was 7.1-9 (Berti et al., 2008). In this study was
slight high (11.5%). These results might be related
to population or hospital factors. In this retrospective study, the prevalence of co-morbidities was not
analyzed. And probably the malnutrition was related
with other co-morbidity as measles, tuberculosis or
HIV infection.
HIV is increasing the workload of nutritional rehabilitation units treating SAM through both the direct
effects of infection and the indirect negative effects
on livelihoods and food security (Sadler et al.,
2007). A high proportion of SAM children admitted
to hospital nutritional units are now also HIV positive, especially those with marasmus (UNICEF,
2005; Sadler et al., 2007). Nevertheless, in this
study, the HIV test was not done systematically;
only it has been performed in special cases. The
prevalence HIV infection was not available.
In our study the rate of self-discharges was 8.8%,
near double that in the carried out in St. Lukes
Hospital (Berti et al., 2008). The reasons for the
high self-discharged rate might be a low parental
compliance, family problems, and harvesting time.
Our results show that correct implementation of
UNICEF guidelines for the inpatients treatment of
SAM can lead to a relatively low mortality rate. The
clinical skills of nursing and medical staff were
considered an important factor in improving the
outcome of malnourished patients. We found that
proper implementation of WHO guidelines for the
hospital treatment of severely malnourished children
can lead to a relatively low mortality rate, especially
when good clinical monitoring is assured.
The outpatient therapeutic programme for severe
acute malnutrition with ready-to-use therapeutic
food, (Plumpynut®) has been shown very effective
in treating case of SAM and is highly acceptable by
planners, health care providers and beneficiaries
(Belachew and Nekatibeb, 2007). In those
programmes the malnourished children not need to
be admitted to treat. Moreover, a new strategy in the
arsenal of techniques to manage complex nutritional
emergencies in rural communities is communitybased therapeutic care (CTC). The CTC approach
uses a newly developed to rehabilitate severely
malnourished children in their home communities.
The CTC strategy yielded results that were superior
to those of programs limited to therapeutic feeding
centers, as show in this study. The CTC is an important tool to effectively address nutritional emergencies and may be a valuable entry point for long-term
development, since it fosters capacity building and
improvement in local communities (Chaiken et al.,
2006).
referenCes
AMSALU S., ASNAKEW G. (2006). The outcome of
severe malnutrition in northwest Ethiopia:
retrospective analysis of admissions. Ethiopian
Medical Journal, 44: 151-177.
ASHWORTH A., CHOPRA M., MCCOY D., SANDERS
D., JACKSON D., KARAOLIS N., SOGAULA N.,
SCHOFIELD C. (2004). WHO guidelines for
management of severe malnutrition in rural South
African hospitals: effect on case fatality and the
influence of operational factors. The Lancet, 363:
1110-1115.
BELACHEW T., NEKATIBEB H. (2007). Assessment of
outpatient therapeutic programme for severe acute
malnutrition in three regions of Ethiopia. East
African Medical Journal, 84: 577-588.
BERTI A., BREGANI E.R., MANENTI F., PIZZI C.
(2008). Outcome of severely malnourished children
treated according to UNICEF 2004 guidelines: a oneyear experience in a zone hospital in rural Ethiopia.
Transactions of the Royal Society of Tropical
Medicine and Hygiene, 102: 939-944.
CHAIKEN M.S., DECONINCK H., DEGEFIE T. (2006).
The promise of a community-based approach to
managing severe malnutrition: A case study from
Ethiopia. Food and Nutrition Bulletin, 27: 95-104.
COLLINS S., DENT N., BINNS P., BAHWERE P.,
SADLER K., HALLAM A. (2006) Management of
severe acute malnutrition in children. The Lancet,
368: 1992-2000.
KARAOLIS N., JACKSON D., ASHWORTH A.,
SANDERS D., SOGAULA N., MCCOY D.,
CHOPRA M., SCHOFIELD C. (2007). WHO
guidelines for severe malnutrition: are they feasible
in rural African hospitals? Archives of Diseases in
Childhood, 92: 198-204.
MINISTRY OF HEALTH (2004). Guidelines for the
management of severe malnutrition. The Federal
Ministry of Health, Ethiopia.
15
J. M. RAMOS ET AL.
SADLER K., KERAC M., COLLINS S., KHENGERE
H., NESBITT A. (2007). Improving the management
of severe acute malnutrition in an area of high HIV
prevalence. Journal of Tropical Pediatrics, 54: 364369.
UNICEF (2005). Global database on child malnutrition.
http://www.childinfo.org/areas/malnutrition/wasting.
php. Accessed Dec 20, 2005.
16
WORLD HEALTH ORGANIZATION (2000).
Management of the child with a serious infection or
severe malnutrition: guidelines for care at the firstreferral level in developing countries. Geneva,
Switzerland. 175 pp.
VOL. 14, N. 1-4, 2009
microbiological quality of street food in puebla City,
mexico
1
1
1
2
r. J. ortiz-Bautista , J. m. freyre santiago , g. zamora-ortiz , J. l. sanChez-salas
Department of Health Sciences, Universidad de Las Américas, Sta. Catarina Martir, Cholula, Puebla, Mexico
Department of Chemistry and Biological Sciences, Universidad de Las Américas, Sta. Catarina Martir, Cholula,
Puebla, Mexico.
1
2
summary - Objective: The aim of this work was to analyze the microbiological quality including parasites (cyst and eggs of
helminthes). Methods: 102 special tortillas with beans, fresh mexican salsa and fresh cheese (street food called “gordita”)
were collected. Ten grams of each sample were processed using different concentration methods by differential density
“Willis” or “Faust” or “Faust modified” in which this last was added one step of rinse with 1% of sodium dodecyl sulfate
(SDS) to eliminate oil material which is used to prepare the special tortilla. Some samples (12.7%) were analyzed for fecal
coliforms. Results: Using the three methods Giardia lamblia and Entamoeba histolytica were identified. Only in two
samples using Willis’s and Faust modified we detected eggs of Enterobious vermicularis. Using Willis’s method G. lamblia
was detected in 42% of the samples; in Faust method 21% and Faust modified 14%. E. histolytica was detected in 7% in
Willis method; 4% in Faust and 4% in Faust modified. We found 55 % of correlation between Willis’s and Faust method,
14% between Willis and Faust modified and 40% between Faust and Faust modified. Conclusion: The special tortilla sold on
streets shows high percent of contamination with G. lamblia, cysts (21 to 42%). Although this parasite can produce diarrhea
not all the people acquire the disease perhaps existing some immunological response but not for foreign people. Faust still is
one of the most used methods in clinical laboratories on developing countries but the main problem to detect the parasites is
the skill of the analyst and is needed to verify each observation with confirmatory tests.
Key words: parasitosis, foodborne diseases, floatation method
introDuCtion
The gastrointestinal parasitosis includes a variety of
agents, protozoa and helminthes, which affect different parts of the digestive tube and its relation with
the intestinal wall, is variable. They can constitute a
considerable clinical problem or just pass unobserved for a long time. Their damage mechanisms
are not consistent and the balance environment, host
and infectious agent are essential (Soong, 2008).
Intestinal parasitic infections represent worldwide,
one of the most frequent health problems in children
and adults (UNAM, 2007). WHO estimates more
than two million people infected (Cortes et al.,
2008).
Underdeveloped countries have a prevalence of 4070% as a consequence of a phenomena variation:
population urbanization with a deficient environmental cleaning, food customs, human migrations,
low socio-economic conditions, little medical
culture and health quality services.
The Epidemiology General Directorate of the
th
Mexican Ministry of Health reports four different
types of intestinal parasites (protozoa, helminthes,
nematodes and trematodes) as one of the 20 main
causes of general morbidity. In Mexico, the parasitosis has been the 5th cause of external consult in
the Instituto Mexicano of Seguro Social (UNAM,
2007; Cedillo-Rivera et al., 2009).
In Mexico, lack of safe drinking water affects an
important fraction of population. According to the
Mexican National System of Epidemiological
Surveillance, diseases caused by waterborne infectious microorganisms affected in 2000 about 6.4%
of the total population of the country (SNVE, 2002).
The most affected sector was rural population representing around 25.3% of the Mexican population, of
which only about 65% have access to piped water
supply systems (CNA, 2000).
Consumption of poor microbiological quality drinking water involves important negative consequences
for human health. Besides, lack of safe drinking
water may lead to economic burdens to the local,
Corresponding author: José Luis Sanchez-Salas
Department of Chemistry and Biological Sciences. Universidad de
Las Américas, Sta. Catarina Martir, Cholula 72820 Puebla, Mexico.
Tel. +522222292604. E-mail: [email protected]
17
R.J. ORTIZ-BAUTISTA ET AL.
state or federal government to deal with the health
effects of poor water quality, reduced number of
working people, and difficulties in everyday life that
prevent proper socio-economic growth. For example, it has been estimated that the cost of dealing
with waterborne diarrheic illnesses in Mexico is in
the range of US$ 37 to 470 depending if governmental or private service is used (Arredondo, 1997).
Additionally, rural zones frequently lack of social
health services and to reach the closest rural medical
center implies several hours of walking from the
community. Consequently, the lack of access to safe
drinking water deteriorates not only human health
but also diminishes economic growth and significantly inhibits the sustainable development in a
large fraction of population in Mexico and other
developing countries (Diaz et al., 2003).
Our goal was to recover cysts or helminth eggs from
food sealed on streets using different common laboratory methods and calculate the frequency of each
parasite found.
methoDology
sample collection
The places selected to collect samples were the
places close to government offices, church, hospitals
and malls of Puebla City.
In each place three samples of special tortilla called
“gordita” were collected. “Gordita” consists in a
tortilla to which, before cooking, a mix of beans and
special flavor is added and finally pork oil, salsa
(green or red), cheese powder and onion are addded.
sample processing for cyst and eggs detection
The gorditas were taken to the laboratory to process
immediately (no more 2 hrs after collected) using
different flotation methods used regularly in clinical
laboratories or in field conditions as Faust or Willis
method.
Briefly, for Faust method (Becerril, 2008) the
sample was processed as follows: 10 g of the sample
was blended 5 minutes with 10 mL of distillated
water. The sample was passed twice throw chiffon
(folded 4 times) to separate the big material. Then
the material was collected in a tube and centrifuged
at 500 rpm for 5 minutes and supernatant discarded.
The sample was rinsed with distillated water until
the supernatant was clear (4 times). The pellet was
well suspended in 10 mL of ZnSO4 (1.180) with a
vortex and centrifuged at 2500 rpm/2 minutes.
Without taking out the tube, with a pasteur pipet 0.5
ml was collected from the top of the supernatant and
transferred to an eppendorff tube. One mL of distillated water was added to the sample, mixed by
vortex and centrifuged for 1 minute at 10,000 rpm in
a microcentrifuge. The supernatant was discarded
18
and a drop was deposited on a microscope’s slide
plus a drop of lugol solution, covered with the cover
slide and observed using 40 X objective. The hole
process was carried out at room temperature.
Since the sample is rich in oil, a surfactant (1% of
dodecyl sodium sulphate or SDS 1%) was added
during the first step of blending to include organic
material to hydrophilic phase. This treatment was
called Faust modified method and this change was
taken from the variation introduced by AndreaCamargo (Andrea-Camargo and Campuzano, 2006)
in vegetables.
willis method (Becerril, 2008)
Briefly for Willis method the sample was processed
as follows: 10 g of the sample was blended 5
minutes with 10 mL of distillated water. The sample
was passed twice throw chiffon (folded 4 times) and
collected in a 15 mL centrifuge. The material
collected was centrifuged at 2500 rpm for 2 minutes
and supernatant discarded. The pellet was suspended
using first 5 mL of a supersaturated solution of NaCl
(SSNaCL) using vortex. Then extra SSNaCL was
added until the top of the tube and left on the table
for one hour. After that 0.5 mL of the supernatant
was collected and transferred to a eppendorff tube
and processed as above mentioned.
results
The sampling was carried out during May and June
visiting 102 small street places. 306 “gorditas” were
collected and processed as reported in material and
methods. The Willis method showed the best sensibility, allowing the detection of Giardia lamblia, in
42% of the samples while Faust or Faust modified,
allowed the detection in 25% of the samples. The
same was observed with Entamoeba histolytica/E.
dispar. Eggs of Enterobius vermicularis were
detected in 1.9 % of the samples. These results are
described in table 1. We found 55% of correlation
between Willis’s and Faust method, 14% between
Willis and Faust modified and 40% between Faust
and Faust modified.
table 1 - percent of detection of cysts and eggs from
“gorditas” using different floatation methods.
parasites
Giardia lamblia
Entamoeba
histolytca/dispar
Enterobius
vermicularis
willis
faust
faust modified
42%
7%
21%
4%
14%
4%
1.9%
0
1.9%
DisCussion
The sampling method was done according the main
places were more people regularly eat food on
street, certainly are not the all places distributed on
MICROBIOLOGICAL QUALITY OF STREET FOOD
the city because in some places, one of this small
business are almost in each corner, however, the
sampling cover the whole city. It is important to
note that food establishments do not have any official register in our cities because is informal business. On the other hand, there is not enough information on the reviewed literature concerning parasites in prepared food. For this reason, further
research is necessary to compare results, to evaluate
sensitivity and specificity of the methods used as
well as the parasitosis prevalence in daily-popular
consumed food in the modern Mexican culture.
In previous experiences Willis method was used in
field research and good results for stool samples
were obtained. One of the problems with Willis is
that the high NaCl concentration can damage the
cyst and eggs (Becerril, 2008; Kumate, 2001;
Romero, 2007). That was the reason of reducing the
salt concentration diluting it at the last step with
distillated water. Furthermore, the results of our
study do agree with the seroprevalence of
immunoglobulin G against Giardia spp. in the
Mexican population of 55.3%. The results found
lead to an hypothesis that the exposure to Giardia
spp. as well as the clinical phase does not complete
in a 100% in the Mexican population as it is
commonly thought. At the present time, we are still
analyzing the samples to identify the quality of
foods using the coliform bacteria as indicator.
The best correlation was found between Willis and
Faust method and less between Willis and Faust
modified. Beside, less of 50% correlation was found
between Faust and Faust modified. We do not have
a clear idea of this correlation. One constrain of each
method is the skills of the watcher in comparing the
morphology with positive samples. It is therefore
recommended to use another kind of method that
can confirm the findings as fluorescent antibodies or
molecular methods.
It is encouraged to develop different methods, which
can be easily used in all laboratories, with the minimum equipment and expenses.
ConClusion
The gordita sold on streets shows a high percentage
of contamination with G. lamblia cysts (21 to 42%).
Although this parasite can produce diarrhea not all
the people acquire the disease. Faust’s method is
still one of the most used methods in clinical laboratories in developing countries. Nevertheless, the
main problem to detect the parasites is the skills the
analysts possess as well as the application of confirmatory tests to verify each observation. Regarding
the E. histolytica/dispar findings, the used method
did not allow us to identify the species.
referenCes
ANDREA-CAMARGO N., CAMPUZANO S. (2006).
Estudio piloto de detección de parásitos en frutas y
hortalizas expendidas en los mercados públicos y
privados de la ciudad de Bogotá DC. Nova, 4: 1-116.
ARREDONDO A.D. (1997). Costos económicos en la
producción de servicios de salud: del costo de los
insumos al costo de manejo de caso. Salud Pública de
México, 39: 117-124.
BECERRIL M.A. (2008). Parasitologia Medica. 2 da
Edición. Mc Graw Hill-Interamericana. Mexico D.F.,
250 pp.
CEDILLO-RIVERA R, LEAL A.Y., YEPEZ-MULIA L.,
GOMEZ-DELGADO A., ORTEGA-PIERRES G,
TAPIA-CONYER R., MUÑOZ O. (2009).
Seroepidemiology of Giardiasis in Mexico. American
Journal of Tropical Medicine and Hygiene, 80(1): 610.
CNA (2000). Comisión Nacional del Agua, México.
Presente y Futuro del Agua en México. 4th Edition,
México, 500 pp.
CORTES D.M., ESTRADA M.R., ARENAS K.Y.,
TELLEZ A. (2008). Frecuencia de parásitos
intestinales en expendedores de alimentos ubicados
en los recintos de la UNAN-León. Universitas; 2: 2528.
DIAZ E., MONDRAGON J., RAMIREZ E., BERNAL R.
(2003). Epidemiology and control of intestinal
parasites with nitazoxanide in children in Mexico.
American Journal of Tropical Medicine and Hygiene,
68: 384-38.
KUMATE J. (2001). Manual de Infectología Clínica. 16a
Edicion. Méndez (Ed.) México D.F. 890 pp.
ROMERO R. (2007). Microbiologia y Parasitologia. 3a
Edición. Editorial Medica Panamericana, Mexico
D.F. 1802 pp.
SNVE (2002). Sistema Nacional de Vigilancia
Epidemiologica. Secretaria de Salud Publica, Mexico.
http://www.ssa.gob.mx/epide.
SOONG L. (2008). Modulation of Dendritic Cell Function
by Leishmania Parasites. Journal of Immunology,
180: 4355-4360.
UNAM (2007). Universidad Nacional Autónoma de
México. Epidemiología y Salud Pública de las
Parasitosis Intestinales. http://www.facmed.unam.mx
/deptos/salud/periodico/parasitosis/index.html.
19
VOL. 14, N. 1-4, 2009
solar photocatalytic disinfection of water contaminated
with Escherichia coli using nitrogen-doped titanium
dioxide
1
1
2
J. l. sanChez-salas , J. Castillo , e. r. BanDala
Department of Chemistry and Biological Sciences. Universidad de Las Américas, Puebla. Sta. Catarina Martir,
Cholula, Puebla, Mexico.
2
Department of Civil and Environmental Engineering. Universidad de Las Américas, Puebla. Sta. Catarina
Martir, Cholula, Puebla, Mexico.
1
summary - Bacterial inactivation using N-doped TiO2 was carried out using complete (UV+Visible) and visible solar radiation under different pH conditions. For control experiments, non doped titanium dioxide particles were obtained by the same
procedure without adding nitrogen source. Four different N-doped and non-doped TiO2 concentrations (0.0, 0.10, 0.25 and
0.5 mg/mL) were tested under three different solar radiation conditions: dark, complete and visible radiation at six (6.0, 6.5,
7.0, 7.5, 8.0, and 8.5) pH values. It was found that, by the use of nitrogen doped titanium dioxide, bacteria inactivation was
achieved with higher rate than those experiments carried out with regular TiO2 or solar radiation alone. The value of pH of
the suspensions was observed to have an important role in the inactivation mechanisms which seems to be related with the
cell wall permeability in some cases and with particle’s surface charge in others. It may be concluded that the use of Ndoped TiO2 to enhance solar water disinfection could be a very powerful tool for water treatment in isolated region or emerging economies to prevent vulnerable population sector to be affected by waterborne diseases.
Key words: Photocatalysis, solar water disinfection, Escherichia coli, N-doped TiO2
introDuCtion
Safe drinking water supply in developing countries
is a necessity and a duty if welfare of the mankind,
as part of the global sustainable development, wants
to be achieved. Lack of access to safe drinking water
is commonly related to waterborne diseases and
other serious human health effects, poor economy
and limitations for sustainable development (Gleik,
2000). All around the world, unsafe drinking water
affects more than 1.2 billion people and contributes
to the death of 1.5 million children every year. It has
been estimated that about 1.3 billion people lack
access to clean water (WHO/UNICEF, 2000). In
Mexico, lack of safe drinking water affects an
important fraction of population. According to the
Mexican National System of Epidemiological
Surveillance, diseases caused by waterborne infectious microorganisms affected in 2000 about 6.4%
of the total population of the country (SNVE, 2002).
The most affected sector was rural population representing around 25.3% of the Mexican population, of
which only about 65% have access to piped water
supply systems (CNA, 2000).
th
Consumption of poor microbiological quality drinking water involves important negative consequences
for human health. Besides, lack of safe drinking
water may lead to economic burdens to the local,
state or federal government to deal with the health
effects of poor water quality, reduced number of
working people, and difficulties in everyday life that
prevent proper socioeconomic growth. For example,
it has been estimated that the cost of dealing with
waterborne diarrheic illnesses in Mexico is in the
range of US$ 37 to 470 depending if governmental
or private service is used (Arredondo, 1997).
Additionally, rural zones frequently lack of social
health services and the closest rural medical center
is several hours away from the community.
Consequently, the lack of access to safe drinking
water deteriorates not only human health but also
diminishes economic growth and significantly
inhibits the sustainable development in a large fraction of population in Mexico and other developing
countries.
Recently, efforts devoted to develop emerging technologies capable to provide safe drinking water in
Corresponding author: José Luis Sanchez-Salas
Department of Chemistry and Biological Sciences. Universidad de
Las Américas, Sta. Catarina Martir, Cholula 72820 Puebla, Mexico.
Tel. +522222292604. E-mail: [email protected]
21
J. L. SANCHEZ-SALAS ET AL.
remote, poor rural areas of developing countries
have show solar water disinfection (SODIS) as a
very interesting alternative. SODIS is a simple,
environmentally friendly and low cost point-of-use
treatment technology for drinking water purification
which uses solar radiation and the presence of
dissolved oxygen in killing the pathogens. These
reactive oxygen species contribute to the inactivation and killing of pathogenic microorganisms.
Several informal reports have been published claiming numerous advantages of water treatment using
SODIS (Lonen et al., 2005; Reed et al., 2000), only
few studies have been published (Clansen and
Smith, 2005; Mintz et al., 2001) dealing with the
scientific evaluation of this methodology and its
sustainable application for water supply to small
isolated rural populations.
Some studies (McGuigan et al., 1998) have shown
that thermal inactivation of Escherichia coli is
important only after water reaches temperatures over
45°C, when a strong synergy with the effect of radiation is observed. These studies concluded that in
places with high heatstroke, disinfection using solar
energy is a low cost and effective method to
improve the microbiological quality of water.
However, bacterial re-growth after short storage
(24h) of SODIS treated water has been recently
observed (Gelover et al., 2006). In more recent
reports, seeking for improvements of SODIS performance, reduction of irradiation time and avoidance
of bacteria re-growth, Advanced Oxidation
Technologies (AOTs) have also been tested. AOTs
are technologies based on the generation of
hydroxyl radicals (•OH) and include titanium dioxide (TiO2) photocatalysis, Fenton reagent (ferrous
iron and hydrogen peroxide), UV/hydrogen peroxide, UV/Ozone, electron beams, sonolysis, and
gamma irradiation. AOTs are very attractive for the
mineralization (conversion to carbon dioxide, water,
and other mineral species) of aqueous pollutants and
inactivation of pathogenic microorganisms. Several
studies (Sichel et al., 2007; Yu et al., 2002; Sunada
et al., 2003; Huang et al., 2000) have reported that
solar photocatalysis using titanium dioxide can
promote cellular destruction in more than one way,
leading to cell death under UV radiation. Titanium
dioxide is well known for its photo-activity and ability to produce hydroxyl radicals under excitation by
near UV light which can mineralize aqueous organic
pollutants such as chlorinated phenols, pesticides,
and reactive dyes (Gelover et al., 1999; Bandala et
al., 2002; Bandala et al., 2004; Villafan et al., 2007)
as well as bacteria (Gelover et al., 2006; Alrousan et
al., 2009), fungi, protozoa (Dunlop et al., 2008),
viruses and even tumor cells (Sunada et al., 2003a).
According to these results, the use of TiO2 photocatalysis offers an attractive complement to SODIS,
22
accelerating bacteria death and destroying toxic
organic compounds at the same time. One of the
main problems with the use of titanium dioxide for
solar applications is related to its limited capability
to absorb only the radiation in the UV range. In our
experience the UV-A component of incoming solar
radiation available at ground level is about 5-8% of
the total solar radiation. This restriction, in addition
to other issues such as the relatively low quantum
yield (3-10%) of TiO2 photocatalysis, provides the
motivation to develop TiO2-based materials that can
also absorb in the visible light in order to better
exploit solar light as a source of energy for disinfection.
Many different attempts to extend the absorption
band-edge of TiO2 from UV to visible region have
been pursued in the past. These approaches include
doping with transition metals (Ghosh and Maruska,
1977; Anpo, 1997; Subramanian et al., 2001) or
forming reduced TiOx photocatalyst (Li et al., 2007).
In recent years, several reports on the use of anionic
non-metallic dopants such nitrogen (Asahi et al.,
2001; Lindgren et al., 2003; Irie et al., 2003; Yang
and Gao, 2004) among some others (Li et al., 2007)
have been published demonstrating the extent of the
photocatalytic activity of TiO2 into visible region.
Recently, the effectiveness of N-TiO2 to degrade
cyanobacterial toxins in water by using visible radiation have been demonstrated (Choi et al., 2007;
Pelaez et al., 2009). However, relatively few reports
on the use of N-TiO2 for the inactivation of bacteria
are available and even fewer those related with the
use of direct solar radiation despite the potential to
use visible-light to active photocatalyst which,
would allow the use of the main part of the solar
radiation, increasing the photocatalytic efficiency
and reducing procedure costs by avoiding the need
of UV energy (Di Valentin et al., 2007; Liu et al.,
2007; Li et al., 2007; Yu et al., 2002).
The aim of this work is to study the role of solar
radiation in the photocatalytic to enhance disinfection of water using E. coli as model microorganism
and N-TiO2 as visible light absorption photocatalyst.
experimental section
reagents. All the materials and reagents used in this
work were purchased as A.C.S. reagents and used as
received without any further purification.
n-tio2 preparation. To prepare the modified solgel solution, anhydrous ethylenediamine (EDA,
Fisher) was dissolved in isopropanol (i-PrOH) as
nitrogen source. Acetic acid (Fisher) was added to
maintain low pH (6.4). Then, titanium (IV)
isopropoxide (TTIP, 97%, Aldrich) was added drop
wise under vigorous stirring and more acetic acid
was added for peptidization. The final sol obtained
was transparent, homogeneous and stable after
PHOTOCATALYTIC DISINFECTION OF WATER
min. Each sample was diluted in water and each
dilution was spread on Trypticase Soy Agar (TSA)
to measure the amount of survivals colony forming
units (CFU). All the experimental runs were carried
out under mixing using a magnetic bar and a 500
mL pyrex Erlen-Meyer flask as photoreactor.
Additional to the experimental runs performed using
the N-doped TiO2, experiments using non-N-doped
titanium dioxide, synthesized under similar conditions to those described earlier but without addition
of nitrogen, were carried out. All the experiments
were carried out by triplicate and the maximum
deviation for the replicates was 10%.
results
Bacteria inactivation under non radiation and
complete (uv+vis) solar radiation. Figure 1 show
the effect of complete (UV+Vis) solar radiation on
bacteria inactivation at different pH values. As
shown, when no radiation was used (dark experiments) no decrease in the bacteria count was
observed but an increase in the CFU/mL values
determined within time. The maximum bacteria
resistance is about pH 7-7.5 where almost no bacteria inactivation (less than 1-log) was observed after
more than 90 min of irradiation (average solar radiation was 900 W/m2) as shown on the figure 1.
1.00E+08
1.00E+07
1.00E+06
1.00E+05
CFU/mL
stirred overnight at room temperature. Afterwards,
the sol was dried at room temperature for 24 h and
then calcined in a multi-segment programmable
furnace (Paragon HT-22-D, Thermcraft) where the
temperature was increased at a ramp rate of 60°C/h
to 100°C and maintained for 1 h. Then it was
increased up to 400°C under the same ramp rate,
maintained for 2 h and cooled down naturally to
finally obtain a yellowish powder. The iPrOH:acetic acid:EDA:TTIP molar ratio employed
in the sol-gel for the preparation of the TiO2 photocatalyst was 0.65:1.0:0.1:0.05. The synthesized
nanoparticles were compared with Kronos vlp 7000,
a commercially available visible light activated TiO2
photocatalyst (Kronos International Inc., D-51373).
Bacteria propagation and viability assessments.
The enhanced TiO2 disinfection tests were carried
out using E. coli (ATCC 25922) as bacteria model.
E. coli was kept frozen at -20°C on LB broth plus
10% glycerol. Before each experiment, the phenotype of the culture was analyzed streaking on Mc
Conkey agar for colony morphology and biochemical features using the 32 GN miniAPI® galleries,
and the semiautomatic miniAPI® reader. However,
for the disinfection process, the bacterial cells were
cultured on 10 to 20 mL of Trypticase Soy Broth
(TSB) overnight at 37°C to have enough cells and in
beginning the stationary phase. The cells suspension
was later adjusted with 0.5 McFarland standards to6
obtain a final concentration corresponding to 1x10
cells/mL in the photocatalytic test system.
photocatalytic enhanced solar disinfection
processes. Different pH values, 6.0, 6.5, 7.0, 7.5,
8.0 and 8.5 were tested using four different N-TiO2
photocatalyst concentrations (0.0, 0.10, 0.25 and
0.50 mg/mL) and three different radiation conditions: without solar radiation (dark experiments),
UV+Visible solar radiation (complete solar spectrum) and visible solar radiation. In order to use only
the visible part of the solar radiation, experiments
were carried out using an Arco® acrylic filter (cutoff, 400 nm).
For the experiments under dark conditions, bacteria
were transferred to 300 mL of distilled-deionizedsterilized water from the cultures described earlier.
In order to quantify the effect of pH on the disinfection process, different experiments were carried out
adjusting the pH using H 2SO 4 or NaOH 0.1 M
depending on the desired pH.
For the experiments performed using solar radiation,
the photocatalyst concentration was calculated and
added according the volume of the photo-reactor
containing the bacteria suspension and, after that,
the photoreactor cap was windrowed and the
suspension mixtures were submitted to solar radiation. Samples of 1 mL were taken in duplicated in
the following 5, 10, 15, 30, 45, 60, 90, 120 and 180
1.00E+04
1.00E+03
UV+Vis, pH 6
1.00E+02
UV+Vis, pH 6.5
UV+Vis, pH 7.0
UV+Vis, pH 7.5
1.00E+01
UV+Vis, pH 8.0
UV+Vis, pH 8.5
1.00E+00
Dark
1.00E-01
0
10
20
30
40
50
60
70
80
90
100
Time, min
figure 1 - effect of non radiation and complete
(uv+vis) solar radiation on bacteria inactivation at
different ph values without photocatalyst.
An increase in the inactivation rate was observed by
using the photocatalyst as depicted in figure 2. In
this figure, the comparison between different conditions of inactivation is shown.
From figure 2 it is noticeable that only slight bacteria inactivation (about 2-log) was reached using
non-doped TiO2 as photocatalyst under complete
(UV+Visible) solar radiation. The best results were
obtained using 0.5 mg/mL of N-TiO2, under these
conditions 5-log inactivation was reached after 60
2
minutes of solar irradiation (average 950 W/m ).
The same inactivation was achieved under similar
23
solar radiation conditions for 0.1 and 0.25 mg/mL of
doped titania but after 90 minutes of irradiation.
1.0E+07
1.0E+06
1.0E+07
1.0E+05
1.0E+06
CFU/mL
1.0E+04
1.0E+05
CFU/mL
1.0E+04
1.0E+03
UV+Vis, pH 7
1.0E+02
Vis
Dark
1.0E+03
1.0E+01
Vis, [N-TiO2]=0.1mg/mL
UV+Vis, pH 7
1.0E+02
Vis
1.0E+00
Vis, [TiO2]=0.25mg/mL
Dark
1.0E+01
UV+Vis,[N-TiO2]=0.1mg/mL
1.0E-01
UV+Vis, [N-TiO2]=0.25mg/mL
0
20
30
UV+Vis,[TiO2]=0.25mg/mL
0
10
20
30
40
50
60
70
80
90
100
Time, min
figure 4 - Bacteria inactivation using different
concentrations of n-tio2 under visible solar radiation
at ph 7.0.
1.0E-01
40
50
60
70
80
90
100
Time, min
figure 2 - Bacteria inactivation for complete
(uv+visible) solar radiation using n-doped and
undoped tio2 at ph 7.0.
Results changed considerably by using N-TiO2. As
shown, over 5-log inactivation is reached in any of
the cases when using doped titanium dioxide for the
different suspension concentrations tested (0.1, 0.25
and 0.5 mg/mL) being the irradiation time necessary
to reaching bacteria inactivation the only difference
among them. The best result was observed using NTiO2 at 0.5 mg/mL where 5-log E. coli inactivation
was achieved in 60 min of
solar irradiation (average
2
solar radiation 900 W/m ). When the photocatalyst
load was 0.25 mg/mL, the same bacteria inactivation
was achieved after 80 min solar irradiation and
further decrease in the N-TiO 2 concentration
produced that irradiation time required increases up
to 90 min.
As showed for the use of UV+Visible solar radiation, pH also plays an important role in the case of
visible light driven disinfection as shown in figure 5.
The results obtained when comparing the effect of
pH on the efficiency of the inactivation for the same
photocatalyst concentration are show in figure 3. As
observed, the general trend is similar to those
showed in figure 1 except because all the experiments showed 5-log inactivation after 90 minutes of
solar irradiation. The other interesting thing is, as
seen in figure 1, extreme pH values (pH 6.5 and 8.5)
showed the lowest inactivation time. Nevertheless,
in this case, assessments at pH 6.0 showed inactivation kinetics similar to those showed by experiments
carried out at pH values close to neutral.
1.00E+06
1.00E+05
1.00E+04
1.00E+06
1.00E+03
1.00E+05
1.00E+02
1.00E+01
pH 6.0
pH 6.5
pH 7.0
pH 7.5
pH 8.0
1.00E+00
pH 8.5
1.00E+04
CFU/mL
CFU/mL
10
UV+Vis, [N-TiO2]=0.5mg/mL
1.0E+00
1.00E+03
1.00E+02
pH 6.0
pH 6.5
1.00E+01
1.00E-01
0
10
20
30
40
50
60
70
80
90
Time, min
figure 3 - Bacteria inactivation using n-doped tio2
(0.25 mg/ml) under complete (uv+vis) solar
radiation at different ph values.
Bacteria inactivation under visible solar radiation. The effect of visible solar radiation on E. coli
inactivation using different concentrations of N-TiO2
at pH 7.0 is depicted on figure 4. Visible solar radiation was not able to inactivate bacteria in water as
shown in this figure, however, an increase on bacteria counts since the first minutes of the experiment
was observed. Also, the use of non-doped titanium
dioxide did not shown any decrease in bacteria
counts even after several minutes of irradiation.
24
pH 7.0
100
pH 7.5
pH 8.0
1.00E+00
pH 8.5
1.00E-01
0
20
40
60
80
100
120
140
Time, min
figure 5 - Bacteria inactivation using n-doped tio2
(0.25 mg/ml) using visible solar radiation under
different ph values.
As it can be observed from figure 5, 5-log bacteria
inactivation was achieved for all the assessments at
the different pH values. When the photocatalyst load
was 0.25 mg/mL, the same bacteria inactivation was
achieved after 80 min solar irradiation and further
decrease in the N-TiO2 concentration produced that
irradiation time required increases up to 90 min.
DisCussion
The bacterial inactivation was reached using the
complete (UV + Vis) solar radiation as reported
previously. It is possible to see that in all the assessments, except the dark condition, small decrease of
the number of cells during the first 20 to 30 minutes
and then a sudden decrease on the viable cell counts
was observed. This effect have been also observed
and explained (Sunada et al., 2003) to be generated
by the effect of the oxidants on the outer cell
membrane, which is present in all gram negative
bacteria and acts like a shield. Nevertheless, after
time, the oxygen radicals reach the cytoplasm
membrane denaturalization the proteins (channels,
enzymes) and phospholipids and destroying the
cells. This latest effect, also agreed with previous
studies (Griffith and Setlow, 2009) dealing with
mutants of Bacillus subtilis that lacked the major
cardiolipin (CL) and other enzymes for synthesis of
phospholipids. In this study, authors found that the
rate of spore germination with nutrients was
decreased c.a. 50%. However, spores lacking the
minor CL synthase or an enzyme essential for
glycolipid synthesis exhibited 50-150% increases in
rates of dodecylamine germination, while spores
lacking enzymes for phosphatidylethanolamine
(PE), phosphatidylserine (PS) and lysylphosphatidyl-glycerol (l-PG) synthesis exhibited a 3050% decrease. Another interesting discover was that
the spore sensitivity to H2O2 and tert-butylhydroperoxide was increased 30-60% in the absence of the
major CL synthase, meaning the importance of the
main phospholipid to keep the resistance to H2O2
and tert-butylhydroperoxide in direct or indirect
way.
However, in dark conditions, we found no cell inactivation as commented before but a slightly increase
of the cell counts. This effect can be due to the small
amount of media added together with the cells at the
beginning of the experiment and can be avoided if
the cells are rinsed before but only confirm that
independently of this media, the complete solar radiation is enough to inactivate the bacterial cells.
It is noticeable that maximum bacteria resistance is
about pH 7-7.5 where almost no bacteria inactivation (less than 1-log) was observed, without addition
of photocatalyst, after more than 90 min of irradia2
tion (average solar radiation was 900 W/m ) as
shown on the figure 1. It is possible to think that all
structures at this pH value are with a special conformation which avoid the oxygen radicals reach easily
the vulnerable points of oxidations. However,
completely different results were found for pH at
acid or alkaline values. In order to explain the
observed behavior, each condition should be
analyzed separately.+ First, under acidic condition
due to changes in H ions permeability at lower pH
cells should adjust the influx or
(6 or 6.5), bacterial
+
efflux of H when changed from pH 7 to 6.5 or 6.0
to keep the homeostasis of the cell. It is known that,
when suddenly changed from neutral to acidic environment, E. coli induce synthesis+ of cyclopropane
fatty acids (CFAs) which reduce H ion permeability
influx and increase its efflux (Shabala and Ross,
2008). This synthesis takes around 7 minutes to
induce and start to form this compound. Considering
this assumption, it is possible that the rate of synthesis of the new compounds that can protect the cells
is not fast enough according the amount of oxygen
radicals produced. In the other side, it has been
reported that permeability of the outer membrane,
which is the main shelter to the oxidant species for
the cell, increases at alkaline pH (Irving et al.,
1981). It was expected that at pH 6 the cells turns
more sensitive than at pH 6.5. This behavior was not
clear from the experiments and was rationalized by
the ionization grade of sugars on the bacteria’s
lipopolysaccharide (LPS). LPS is considered the
main component in the outer membrane of E. coli
and it is known that this molecule has a net charge
of -1.5 at neutral pH, when pH decreases, this net
charge lead to 0 changing the cell membrane into a
less hydrophilic conformation and fewer permeable
to polar species including the oxidant species at pH
6.0 (Nikaido, 2003).
It is worthy to note that no bacteria inactivation was
observed under dark or visible solar light conditions,
these results confirm that solar UV radiation is a
necessary condition for bacteria inactivation as it
has been reported previously in different works
(EAWAG/SANDEC, 2002; Gelover et al., 2006;
Rincon and Pulgarin, 2003).
In the other hand, the use of N-TiO2 showed interesting improvements in the inactivation kinetics as
also shown in figure 2. In general, the inactivation
trend for the experiments performed using N-TiO2 is
quite different from the one carried out using nondoped TiO2. In the former case, low inactivation rate
during the initial 50-55 minutes of irradiation is
observed followed by deep slope decrease leading to
the main inactivation in few minutes. For the latest,
constant inactivation is observed with time, more
like first order kinetics commonly reported for this
type of experiments (Gelover et al., 2006; Rincon
and Pulgarin, 2003).
It is also interesting that changing the pH values, the
efficiency of cell inactivation change too and
showed the lowest inactivation time at extreme pH
values (pH 6.5 and 8.5). Nevertheless, in this case,
assessments at pH 6.0 showed inactivation kinetics
similar to those showed by experiments carried out
at pH values close to neutral. This behavior could be
due to the fact that, despite low pH, the cells seems
to be more sensitive to oxidants attack (already
25
discussed above). Besides, at pH 6.0, N-TiO2 and
the interaction between N-doped titania and bacteria
decrease under this conditions and may produce
lower inactivation rates.
When using only visible solar radiation it was
observed that this radiation by itself is not able to
inactivate bacteria in water, but an important
increase on bacteria count was observed since the
first minutes of the experiment. In the same way, the
use of non-doped titanium dioxide did not shown
any decrease in bacteria counts even after several
minutes of irradiation. This last result is reasonable
considering that non-doped TiO 2 is not able to
absorbing radiation above 400 nm. In this case,
almost all visible radiation impinging the photoreactor will be reflected or scattered out of the bacteria
suspension and no charge carriers will be produced
able to produce inactivation. However, 5-log bacteria inactivation was achieved for all the assessments
when N-doped TiO2 (0.25 mg/mL) was tested at
different pH values using visible solar radiation. The
difference among the results showed them is the
irradiation time and the general trend showed in
figure 5. Probably, the difference observed in the
inactivation time is related with the irradiative flux
available to activate the photocatalyst. Whereas in
the case of complete solar radiation UV and visible
radiation are available for catalyst activation, when
the acrylic filter was used the UV radiation (among
5 to 8% of the total incoming radiation) is unable to
impinge the photocatalyst nanoparticles. This
decrease in the radiation field available for the activation of the photocatalyst may cause the differences in inactivation time showed on the plots.
Nevertheless, even in the worst experimental conditions, N-TiO2 improved considerably bacteria inactivation compared with solar disinfection using
complete or visible solar radiation.
ConClusions
The search for different media to reduce or eliminate
different water borne diseases that can be easy to
use, cheap and applicable almost anywhere result
very value. The possibility to reduce the incidence
of waterborne diseases, (i.e. cholera, tourist’s diarrhea, cryptosporidiosis, typhoid fever, to mention
some) in poor areas or in places where the health
assistance is few or null, will lead us to improve the
quality of life on that places including the reduction
of mortality in children.
In this work we have demonstrated that the N-doped
TiO 2 photocatalyst is an interesting material for
application in systems capable to operate on poor
regions to improve the water quality by inactivating
fecal microorganism including pathogens like
E.coli, Salmonella species or even for Vibrio
cholerae.
26
These results encouraged us to continue in the
search of novel photocatalyst or operational conditions to improve the currently available systems to
generate novel technological approaches capable to
eliminate other kind of microorganisms considered
as more resistant pathogens like cyst of protozoa or
helminthes eggs.
aCKnowleDments
This work was funded by Consejo Nacional de Ciencia y
Tecnología, Mexico (Grant SNI-2008/091319).
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28
VOL. 14, N. 1-4, 2009
fattori di rischio di disagio psicologico in migranti ospiti
nel Centro accoglienza richiedenti asilo (C.a.r.a.) di
Bari-palese correlati allo stress da acculturazione
1
1
2
m. De niColò , C. fiume , m. Cavallo
Università degli Studi di Bari, Psicologia, Bari, Italia
Università degli Studi di Milano, Psicologia, Milano, Italia
1
2
Individual risk factors correlated to stress of acculturation in immigrants of Center of Refugees and Asylum seeking in Bari.
summary - The paper reports the results of an interview carried out at the Medical center of Refugees and Asylum seeking
in Bari-Palese (C.A.R.A.), to investigate the story of the trip of immigrants toward Italy, the subective experiences of coabitation with other guests, the future project and the health’s state worries. The trip is described as an hard experience that 84%
have faced alone. More than 60% of the listened people has been imprisoned in Lybia and has been victim of physical and/or
sexual violence. 47% haven’t some project for own future in Italy. Many requests of medical cares from the guests are not
justified. As reported in literature, loneliness, physical and psychological traumas and absence of a future project are
confirmed highly correlated factors to the condition of stress of acculturation and psychological disease that brings the guest
of C.A.R.A. to develop hypocondriac symptoms and generally situations of psychological illness.
Key words: Immigration, Refugees, Asylum seeking, acculturation risk factors
introDuzione
Migrare significa confrontarsi con un nuovo stile di
vita che coinvolge tutti gli aspetti dell’essere umano.
Cambiano il clima e le abitudini alimentari, e questo
pone il fisico di fronte alla sfida di adattarsi a nuove
condizioni fisiologiche. Si deve comprendere, dare
nuovi significati e interagire quotidianamente con
nuovi codici culturali, linguistici e comportamentali.
La relazione interculturale può provocare paura e
tensione in quanto mette in discussione molte delle
proprie credenze. Si tratta di un complesso processo
di adattamento di tipo biologico, psicologico, sociale e culturale, che può produrre significative modificazioni sia nel tema di vita individuale sia nella concezione di benessere soggettivo. La rappresentazione sociale del corpo e delle sue patologie deriva in
gran parte da consuetudini comportamentali, valori,
credenze religiose, attribuzioni sociali radicate nella
cultura (Ingstad, 1999; Saraswathi, 1992); pertanto è
ormai riconosciuta l’influenza dei fattori culturali
sulle condizioni di salute degli individui e sulle loro
conseguenze, con particolare riferimento all’insorgenza di patologie acute e croniche.
In Psicologia Transculturale con il termine acculturazione si intende un processo in cui gruppi di per-
sone appartenenti a culture differenti entrano in contatto e stabiliscono una relazione fra loro che attua
dei cambiamenti. L’orientamento verso l’acculturazione include una valutazione della posizione soggettiva che l’individuo ha rispetto alla cultura ospitante. I migranti portano con sé un bagaglio di istruzioni culturali apprese nel paese di origine, le quali
vengono applicate e confrontate con quelle della
cultura ospitante non trovando sempre uno spazio di
condivisione ed è qui che ha inizio il processo di
acculturazione. Gli esiti di questo processo sono
determinati da una relazione transculturale che si
basa su diverse capacità: da parte dei migranti nell’acquisire istruzioni dalla cultura di accoglienza e,
da parte della cultura ospitante nel favorire e rendere
più fluide le possibilità di contatto. Viceversa nei
casi in cui l’applicazione di queste competenze non
produce risultati positivi, l’interazione tra due sistemi culturali sfocia in conflitti, errori di attribuzione
o semplicemente vuoti di comunicazione. Le difficoltà connesse al mantenimento di un doppio registro di comportamento possono determinare conseguenze negative, tra cui identità ambivalente e
stress. Quando compare, il disagio del migrante si
basa essenzialmente sulla difficoltà di far condivide-
th
Comunicazione presentata al 6 European Congress on Tropical Medicine
and International Health. Verona, Italy 6-10 September, 2009.
29
M. DE NICOLò ET AL.
re ed integrare il mondo delle origini con il nuovo
contesto di vita. Si definisce stress da acculturazione un fallimento nel processo di adattamento psicologico, influenzato dalla personalità, dall’entità dei
cambiamenti di vita e dalla mancanza di supporto
sociale e si manifesta con disturbi dell’umore e sintomi depressivi (Stone Feinsten e Ward 1990; Ward
e Kennedy, 1993; Ward e Searle, 1991).
L’andamento dell’esperienza di acculturazione nelle
persone immigrate attraversa varie fasi: honey moon
(fase euforica molto breve dovuta all’eccitazione per
la nuova vita); culture shock e acculturazione (fase
che include un’esperienza di oscillazione fra la scelta di rimanere fedele alle proprie radici culturali e la
scelta di diventare altro, avvicinandosi ai modelli
culturali della società di accoglienza) (Hofstede,
1991). Nella nostra indagine ci soffermeremo particolarmente nella fase di culture shock relativa alla
difficoltà esperita nell’assolvimento dei compiti
quotidiani, legata alla capacità di adattarsi o di negoziare gli aspetti interattivi della nuova cultura
(apprendimento sociale). Questa capacità sembra
essere influenzata dalla durata del soggiorno, dalle
competenze linguistiche, dalla distanza culturale e
dall’entità del contatto con la maggioranza (Searle e
Ward, 1990; Ward e Kennedy, 1993).
oBiettivo
Scopo del presente lavoro di ricerca è stato quello di
approfondire il legame fra esperienze individuali,
obiettivi futuri, salute ed il rischio di sviluppare
disagio psicologico, quale stress da acculturazione e
sintomi ipocondriaci, in un campione di immigrati
ospiti del Centro Accoglienza Richiedenti Asilo
(C.A.R.A.) di Bari-Palese. I soggetti coinvolti in
questa ricerca venivano segnalati dal Presidio
Sanitario del Campo; medici e infermieri, infatti,
trasmettevano agli psicologi i nominativi degli
immigrati che si presentavano frequentemente in
infermeria e con preoccupazioni riguardanti lo stato
di salute non giustificate dalle condizioni cliniche
riscontrate.
metoDologia
Sono state ascoltate 52 persone, 11 donne e 41
uomini, con età media di 26 anni (DS ± 6,6) in un
range che variava tra i 19 e i 46 anni. All’interno del
campione vi è la seguente distribuzione per nazionalità: 57% dei soggetti è di nazionalità Nigeriana,
l’11% sono Somali, il 10% provengono dal Gambia,
il 5% sono Tunisini, il 5% Marocchini, il 5% del
Ghana, il 2% dell’Eritrea e il 2% della Guinea. Tale
distribuzioni riproduce a grandi linee la distribuzione complessiva per nazionalità dell’intero Centro di
Accoglienza. Più della metà (55%) dei soggetti è di
religione cristiana, il 31% è mussulmano e il 14%
non risponde alla domanda. Il 56% è celibe, il 7% è
30
separato, il 21% è coniugato e il 15% ha una relazione sentimentale stabile. I dati relativi al livello di
istruzione mostrano un 40% di soggetti non scolarizzati, il 18% con licenza elementare, il 26% con
licenza media, solo il 16% in possesso di diploma e
nessun soggetto con un titolo di studi universitario.
Il colloquio attraverso lo strumento dell’intervista
strutturata ci ha consentito di apprendere, almeno in
parte, le caratteristiche dell’esperienza quotidiana
soggettivamente percepita dagli ospiti del Centro di
Accoglienza dei Richiedenti Asilo di Bari-Palese,
consentendoci di far luce sui processi psicologici,
sociali e culturali coinvolti nel contatto interculturale.
L’intervista semi-strutturata era divisa in due parti:
la prima parte prevedeva la raccolta di una serie di
informazioni di carattere anagrafico: nome, cognome, luogo e data di nascita, sesso, nazionalità, città
di provenienza, etnia, religione, stato civile, titolo di
studi, attività lavorativa svolta nel paese d’origine,
data di compilazione del questionario, numero identificativo dell’ospite, numero di collocazione nel
modulo abitativo. La seconda parte dell’intervista
andava ad esplorare tre aree fondamentali: quella del
passato, del presente e del futuro. Attraverso la prima area si sono volute indagare le condizioni di vita
nel paese di origine, le motivazioni che hanno spinto
alla migrazione, le esperienze traumatiche vissute
con un’attenzione particolare all’esperienza del
viaggio dal Paese d’origine all’Italia.
Per indagare questa area venivano rivolte le seguenti
domande: Come è composta la tua famiglia d’origine? Con chi vivevi nel tuo paese? Come sono/erano
i rapporti con i tuoi genitori? Cosa hai imparato da
loro? Hai fratelli o sorelle? Com’è il tuo rapporto
con loro? Qualcuno della tua famiglia ha mai avuto
problemi di carattere medico? Quanto sono durati?
Come mai sei andato via dal tuo paese? Ci sono
eventi che hanno modificato significativamente la
tua vita? Come è stato per te? Sei mai stato in carcere? Per quanto tempo? Hai subito violenze o torture?
Come è nata l’idea di migrare? Di chi è stato il progetto? Come è stato il viaggio?
L’area del presente indagava come gli ospiti valutavano la vita del campo e quali fossero le loro maggiori preoccupazioni, prestando particolare attenzione a quelle riguardanti la salute. Queste area veniva
indagata attraverso le seguenti domande: Sei già
andato in commissione? Da quanto tempo sei in
questo centro? Sei venuto in Italia con la tua famiglia o con amici? Come ti stai trovando qui? Come è
il tuo rapporto con gli altri ospiti del centro? Com’è
il tuo rapporto con gli operatori? C’è qualcosa in
questo periodo che ti preoccupa? Quando ti senti triste o hai un problema, con chi ne parli? Hai attualmente preoccupazioni per la tua salute? Di che tipo?
Da quanto tempo durano i tuoi problemi? Prima di
FATTORI DI RISCHIO DI DISAGIO PSICOLOGICO IN MIGRANTI OSPITI NEL CENTRO DI BARI-PALESE
partire soffrivi di particolari problemi di salute?
Temi che il tuo stato di salute ti impedisca di fare
qualcosa? Cosa in particolare?
L’area del futuro valutava la presenza di progettualità per il futuro intesa come risorsa e protezione
rispetto alla assoluta mancanza di prospettive per il
futuro ed era valutata attraverso le seguenti domande: Cosa farai e dove andrai una volta ottenuti i
documenti? Conosci tuoi connazionali che vivono
nelle vicinanze? Che progetti hai per il futuro?
La durata dell’intervista era variabile e dipendeva
dalla disponibilità del soggetto a parlare in maniera
più o meno approfondita delle sue esperienze di vita.
Essa avveniva previo appuntamento con l’ospite e
con l’ausilio di un interprete.
risultati
Dall’analisi dei dati raccolti in riferimento all’area
del “Passato” è emerso che nonostante il 62,5% dei
soggetti vivesse un clima familiare positivo si sono
verificati eventi di vita che li hanno costretti ad
abbandonare il paese d’origine. Nel 12,5% a causa
dell’estrema povertà; nel 10,42% per scontri religiosi; nel 18,75% a causa di violenti scontri tra partiti
politici; nel 8,3% per un sentimento di insoddisfazione per la condizione di vita; 8,3% a causa della
guerra; nel 25% poiché minacciati di morte; nel
14,58% per difficoltà familiari di carattere economico; nel 2% per problemi con la giustizia.
E’ doveroso sottolineare l’estrema drammaticità dell’esperienza del viaggio dal Paese d’origine fino in
Italia. Esso è descritto come un’esperienza estremamente dura (molti hanno visto morire i compagni
durante la traversata del deserto o in mare) che
l’84% degli ospiti ha vissuto da solo. Il 60% è stato
incarcerato in Libia e sottoposto a violenze fisiche
e/o sessuali, dato sottostimato a causa della non
omogeneità nel campione tra uomini e donne. Se si
prende in considerazione il campione costituito da
sole donne, infatti, questo dato sale ad 80% circa.
In riferimento all’area del “Presente”, il 90% del
campione ascoltato dichiara di condurre una vita
serena all’interno del campo e di avere relazioni
distese con gli altri ospiti e gli operatori. Il 70% non
ha condiviso con nessuno all’interno del campo le
esperienze vissute e vive in solitudine i momenti
emotivamente difficile, quando riaffiorano i ricordi
relativi alle esperienze vissute ed ai cari rimasti in
patria. Tra le maggiori preoccupazioni riportate vi
sono la famiglia, le incertezze per il futuro.
Particolarmente significativo è il dato riguardante la
preoccupazione per il proprio stato di salute riscontrata nel 70% del campione. Nel 50% dei casi tali
disturbi non erano presenti quando vivevano nel loro
paese d’origine.
Circa il 50% degli ospiti ascoltati dichiara di non
avere chiaro in mente un progetto per il futuro e,
qualora dovessero ottenere il permesso di soggiorno,
di non sapere come muoversi per costruirsi una nuova vita in Italia.
ConClusioni
Dai risultati della ricerca emerge che gli ospiti che
richiedono più spesso visite mediche non giustificate da motivi di salute oggettivi, sono persone che
vivono in profonda solitudine sia il viaggio sia la
permanenza nel Centri di Accoglienza. Spesso hanno vissuto esperienze traumatiche (a volte anche torture e violenze) durante la migrazione. Alcune di
loro sono prive di un progetto per il futuro, essendo
il loro principale scopo la fuga da concreti rischi per
la vita. Solitudine, traumi psicofisici ed assenza di
una progettualità futura si confermano fattori altamente correlati alla condizione di stress da acculturazione e disagio psicologico che porta l’ospite di un
C.A.R.A. a sviluppare sintomi ipocondriaci e, in
generale, situazioni di disagio psicologico. Un dato
interessante, e che meriterebbe ulteriori approfondimenti, riguarda la condivisione sociale della storia di
vita e degli stati emotivi.
Il veicolo primario attraverso cui immigrato e nativo
possono incontrarsi e trasmettersi istruzioni normative e culturali è il linguaggio verbale e non verbale
adottato nell’interazione interpersonale (Benhabib,
2002). La carenza di informazione associata alle difficoltà relazionali e alle barriere comunicative ostacolano il processo di integrazione e di valorizzazione delle risorse individuali.
Poiché numerose ricerche evidenziano come la condivisine sociale degli stati emozionali negativi favorisca una più veloce elaborazione degli eventi traumatici (Pennebacker, 1989; 1995; Schachter, 1964),
è possibile ipotizzare che la mancata condivisione
possa essere un fattore di rischio di disagio psicologico degli ospiti del centro.
BiBliografia
BENHABIB S. (2002). The Claims of Culture: Equality
and Diversity in the Global Era. Princeton University
Press. 280 pp.
HOFSTEDE (1991). Culture influences of quality
expectations. Journal of Service Research, 1: 178186.
INGSTAD B. (1999). Measurement issues in healthrelated quality of life: challenges for health
psychology. Psychology and Health, 15: 99-108.
PENNEBAKER J. W. (1989). Confession, Inhibition, and
Disease. In: Advances in experimental social
psychology vol. 22. L. Berkowitz (Ed.). New York:
Academic Press. pp. 211-244.
31
M. DE NICOLò ET AL.
PENNEBAKER J. W. (1995). Emotion, Disclosure, and
Health. Washington, D.C.: American Psychological
Association. pp. 124-154.
SARASWATHI T. S. (1992). Child survival and health
and their linkages with psycho-social factors in home
and community. Psychology and Developing
Societies, 4: 73-87.
SCHACHTER S. (1964). The interaction of cognitive and
physiological determinants of emotional state. In:
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L. Berkowitz (Ed.). New York: Academic Press. pp.
48-81.
SEARLE W., WARD C. (1990). The prediction of
psychological and sociocultural adjustment during
cross-cultural transitions. International Journal of
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STONE FEINSTEN B.E., WARD C. (1990). Loneliness
and psychological adjustment of sojourners: New
perspectives on culture shock. In: Heterogeneity in
cross-cultural psychology. D.M. Keats, D. Munro, &
L. Mann (Eds.). Swets & Zeitlinger, Lisse,
Netherlands. pp. 537-547.
WARD C., KENNEDY A. (1993). Where’s the culture in
cross-cultural transition? Comparative studies of
sojourner adjustment. Journal of Cross-Cultural
Psychology, 24: 221-249.
WARD C., SEARLE W. (1991). The impact of value
discrepancies and cultural identity on psychological
and sociocultural adjustment of sojourners.
International Journal of Intercultural Relations, 15:
209-225.
VOL. 14, N. 1-4, 2009
the relationship between serum level of iron, zinc and
copper with giardiasis in children
1
1
1
2
m. fallah , r. assar Dalooi , a.h. maghsooD , m. rezaei
Dept Parasitology, School of Medicine, Hamadan University of Medical Sciences, Hamadan, Iran
Dept Biochemistry, School of Medicine, Hamadan University of Medical Sciences, Hamadan, Iran
1
2
summary - Introduction: Giardia lamblia is a protozoan parasite of the small intestine that causes extensive morbidity
worldwide, including Iran especially among children aged 2-14 years. Giardiasis is a cosmopolitan infection that chronic
diarrhea, malabsorption, and impairment of growth of children may occur. In this case-control study, effects of giardiasis on
serum level of iron, zinc and copper elements were assessed in Hamadan, west of Iran, in the year 2007. Materials and methods: Thirty children, 2-14 years old with giardiasis as case group (confirmed by stool examination) and 45 healthy children,
negative for G. lamblia (without any clinical symptom) confirmed by 3 consecutive stool examination as the control group
enrolled in the study. Demographic data collected by a questionnaire, regarding to all research ethics rules. Blood samples
was taken from both case and control groups an serums were separated and kept in the freezer -20˚C. The level of iron,
copper and zinc in the serums were measured by atomic absorption spectrophotometry. Average amounts of iron, copper and
zinc in case and control groups were compared with t-student test and p<0.05 considered statistically significant. Data
analyzed by SPSS software, version 10. Results: The mean of level of copper in serums was 117.06 26.54 and 126.1718.46
in case and control groups respectively. Difference between two groups was not significant statistically. The mean of level of
iron was 72.3316.98 and 93.4920.23 in case and control groups and, the mean of zinc in serums was 88.7422.97 and
105.3416.06 in case and control groups respectively. Differences between means of iron and zinc in two groups were significant statistically (P0<0.00). Conclusion: These results reveal that giardiasis decreases the level of iron and zinc in the serum
of the infected children but does not change the level of copper in the serum.
Key words: Giardiasis, children, iron, zinc, copper
introDuCtion
Intestinal parasitic infections are still a remarkable
public health problem in the developing countries
that found mainly in specific geographical areas
among groups with specific socioeconomic status
(Thompson et al., 1993). Giardia lamblia, the
causative agent of giardiasis, is a flagellate intestinal
protozoan, found worldwide in temperate and tropical climates. It can produce serious diarrhoeal
disease with intestinal malabsorption and marked
weight loss (Katz and Taylor, 2001). In infants and
young children, impairment of growth and development is one of the symptoms. Clinical symptoms
manifest more seriously in children aged between 2and 14-years-old (Garcia, 2005). This protozoan
parasite is one of the most common intestinal parasites that is endemic in most parts of Iran
(Mohammad et al., 1995), including Hamadan
Province (Fallah et al., 2004; Fallah, 2003). The
prevalence rate among Iranian children has been
th
reported from 4.5% to 45.5% (with a mean of
14.5%).
Infections due to the intestinal parasites are common
throughout the tropics, posing serious public health
problems in developing countries. In these parts of
the world, the high prevalence rate of intestinal
parasite is attributed to largely poor sanitation, inadequate medical care, and particularly absence of safe
drinking water supplies (Katz and Taylor, 2001).
Under-nutrition and intestinal parasitic infections
affect childhood development and morbidity in
many developing countries. Under nutrition may
increase susceptibility to parasitic infections which
in turn impair the nutritional status of the host.
Intestinal parasitic infections in children lead especially to iron-deficiency anemia, micronutrient deficiencies, protein-energy malnutrition, and growth
retardation, associated with diarrhea and malabsorption syndrome (Garcia, 2005). The most important
vital elements in the human body are zinc, copper,
Corresponding author: Prof. M. Fallah, Dept of Parasitology,
School of Medicine, Hamadan University of Medical Sciences,
Hamadan, Iran. E-mail: [email protected]
33
M. FALLAH ET AL.
and iron. Zinc is especially vital for the immune
system, and its depletion is associated with decline
in lymphocyte and thymus functions. Because of its
role in immune system functions, zinc deficiencies
make infants suffer from acute diarrhea (Taneli,
1996).
Copper is essential for the production of red blood
cells, hemoglobin formation, absorption of iron, and
for the activity of various enzymes (Kongsbak et al.,
2006). Iron is needed to make hemoglobin, the red
part of the blood that carries oxygen to all parts of
the body. It is also important for the nervous system,
for healthy growth, and to fight infections. Iron
plays an essential role in carrying oxygen through
the body, but zinc also helps drive many aspects of
immunity, including the production of antibodies
and T-cells and other blood cell activity.
Being a chronic infection producing malabsorption,
effects of giardiasis on serological levels of three
vital elements of the body - zinc, copper and iron were assessed in this study.
Stool samples of 30 children aged between 2- and
14-years-old, who were admitted to the private pediatrics clinics Pediatrics and clinical laboratories in
the city of Hamadan with various gastrointestinal
complaints were examined. Patients who were found
to be positive for G. lamblia cysts and/or trophozoites by at least one method of direct saline wet
mount or formalin ether concentration technique,
were enrolled in the study group (SG). In the control
group (CG), 45 healthy, age-matched children without any health complaints were enrolled. All the
children in the SG underwent thorough physical and
laboratory examinations to exclude infections or
diseases, except giardiasis. Children in the control
group went through the same procedures and their
three consecutive stool samples were examined by
formalin- ether concentration technique. Blood
samples and serums were obtained from both groups
during stool collection and kept in freezer (-20°C).
After melting, all serum samples were diluted by 1%
nitric acid. Zinc, copper and iron levels were
measured by atomic absorption spectrophotometer
(Thermo Jarrell Ash, Smith-Hieftye-22, USA)
through preparing suitable calibration graphics of
wavelengths for each parameter.
Data were analyzed by SPSS for Windows 13
(SPSS, Chicago, IL, USA), compatible with
Windows 2003 software environment. Differences
between the quantitative variables were evaluated by
Student’s t-test and differences of P<0.05 were
accepted as statistically significant.
results
The range of children age was 8.9±3.46 and
34
9.26±3.22 years in cases and controls group respectively (P>0.05). The common symptoms in patients
were abdominal pain, anorexia and diarrhea. In our
study, the serum zinc and iron levels were shown
lower significantly in children with giardiasis in
comparison to healthy control group. However,
there was no significant difference in serum copper
levels between the two groups. The main results of
this study are summarized in Table 1. As in the table
shown, mean concentration of iron, zinc and copper
in the patients are 93.49±2033; 105.34±16.06 and
126.17±18.48 respectively.
table 1 - the mean level of trace elements in the
infected and non-infected to Giardia lamblia in
hamadan, west of iran.
trace elements
iron
zinc
Copper
Infected
(µg/dl)
Non-infected
(µg/dl)
P value
72.33±16.98
88.74±22.97
117.06±26.54
93.49±20.23
105.34±16.06
126.17±18.46
P<0.000
P<0.001
P<0.1
DisCussion
This study indicated that the serum zinc and iron
levels decreased significantly (P<0.001) in children
with giardiasis. These findings are in agreement
with the findings of Demirci et al. 2003. Alterations
in concentrations of serum zinc, iron, magnesium
and copper are commonly found in patients with
gastrointestinal infections as well as in chronic rhino
sinusitis (Thakur et al., 2004; Unal et al., 2004).
Depending on the severity of Giardia infection, the
absorptive, secretary and reabsorptive capacities for
water and electrolytes, carbohydrates, fats and
proteins and vitamins and trace elements diminish,
resulting in a generalized malabsoptive state, leading to malnutrition and failure to thrive (Taneli,
1996). Also, availability, transport and utilization of
principal nutrients are impaired in chronic giardiasis. Zinc loss in chronic giardiasis through diarrhoeal wash-out, results in reduced pancreatic
exocrine secretions, desquamation of mucosal cells
rich in zinc, competition between host and parasite,
and diminished absorption due to colonization of the
trophozoites at its absorptive site, the duodenum.
Nutrient zinc, besides being a growth promoter for
the trophozoites, is also important for their survival
and colonization. In addition, as a metal cofactor,
zinc plays a major role in the function of gustin in
human beings in promoting the trophic effect on
growth and development of taste buds. Therefore, in
zinc-deficient states loss of the sense of taste ensues
which leads to anorexia and inability to gain weight
and is soon followed by overt malnutrition. Giardia
has an absolute requirement for a low
oxidation/reduction potential which is provided by
SERUM LEVEL OF IRON, ZINC, COPPER IN GIARDIASIS
cysteine. Cysteine has an additional role on trophozoites as a growth promoter due to cysteine-dependant zinc binding to its protein membrane (Zhang et
al., 1993).
Infections with Giardia are abundant in many developing countries where malnutrition is widespread,
and particularly among children, so it seems reasonable that Giardia could contribute to the malnutrition observed in many communities. Importance of
Giardia as cause of malnutrition is not clear cut.
Iron deficiency anemia is said to be a constant
feature of Giardia infection. Actually, in one of
study series, serum iron was found to be significantly reduced. However, it was amazing to see that
the chronic giardiasis-induced iron deficiency
anemia was quickly abolished shortly after the institution of the specific therapy for giardiasis (Taneli et
al., 1992). In a study on the 45 children, aged
between 2 and 14 years old in Turkey, diagnosed,
serum zinc levels were detected as 67.43 (± 17.72)
mg/L and 145.20 (± 9.13) mg/L; copper levels were
198.45 (± 39.14) mg/L and 150 (± 21.14) mg/L; and
iron levels were 87.98 (± 18.31) mg/L and 160.45 (±
45.40) mg/L in the study and in the control group.
They found that giardiasis increased the serological
levels of copper, like other infectious disease (Ertan
et al., 2002).
In Iran (IR), there is only one documented study on
the giardiasis and zinc concentration in the serum
(Nazari, 1994). In this study a total of 113 serum
samples of Giardia infected school children aged 612 years and 43 samples from non-infected as
control group were examined by atomic absorption
method. The mean zinc amount in first group was
0.75 µg/ml and in second group it was 0.98 µg/ml
(P<0.05).
In a study in India, Zn levels of 2.56+- 0.15 ug/ml as
compared to 3.92+-0.35 ug/ml in the control group
(P=0.003) and Cu levels of 0.74+-0.05 ug/ml in the
malnutrition group as compared to 1.19+-0.08 ug/ml
in the control group were observed. These workers
concluded serum trace element deficiency my be a
contributing factor to the pathophysiology of protein
malnutrition and replacement of these elements in
the management of this condition might be important (Thakur et al., 2004). Iron deficiency in children with chronic giardiasis may be protective
because iron plays a role in the formation of
hydroxyl radicals. For this reason, giardiasis therapy
should be initiated before treatment of iron deficiency in children with chronic giardiasis (Demirci
et al., 2003). This mater is also correct for zinc deficiency because of its role as being a growth
promoter for the trophozoites (Taneli et al., 1992).
In other study, the workers shown variant-specific
surface proteins of G. lamblia are zinc-binding
proteins and this suggest unusual ways that the para-
site may interact with its host and even competes for
zinc intake (Nash and Mowatt, 1993). In conclusion,
the chronic giardiasis may results to zinc and iron
deficiency but no effect on cooper levels in children.
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DEMIRCI M., DELIBAS N., ALTUNTAS I., OKTEM
F., YONDEN Z. (2003). Serum iron, zinc and copper
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M. FALLAH ET AL.
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36
UNAL M., TAMER L., PATA Y.S., KILIC S.,
DEGIRMANCI U., AKBAS Y., GORUR K., &
ATIK U. (2004). Serum level of antioxidant vitamins,
copper, zinc and magnesium in children with chronic
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VOL. 14, N. 1-4, 2009
gender and hiv: reasons for increasing number of hiv
infected women in eastern europe
1
2
l. Burruano , e. Bently
Clinic for Dermatology and Allergy Medicine, Ruhr University Bochum, St. Josef Hospital, Bochum, Germany
Oxford University, England
1
2
summary - The scale of the HIV epidemic in the Russian Federation and the Ukraine is still growing. Over the years from
1999 to 2008 inclusive, with al little growth of the number of examinations, the number of newly registered HIV cases
increases every year. According to the data from UNAIDS, nearly 90% of newly reported HIV diagnoses in Eastern Europe
in 2006 were from the Russian Federation (66%) and the Ukraine (21%). Recent trends suggest an increasing proportion of
women affected by HIV. The aim of the study was to understand important factors influencing recent developments in, and
the prevalence of, the HIV/AIDS epidemic among women in both countries demonstrating the importance of integrating
gender into HIV programmes that increase women’s access to information. This study also gives an overview of HIV/AIDS
surveillance in the Russian Federation and the Ukraine, and then looks at the AIDS illness itself and the most significant
ways of transmission among women in both countries. Methods: We reviewed the recent reported HIV/AIDS cases from the
official epidemiological register of the Ukrainian Centre for AIDS Prevention alongside data from the Russian Federal AIDS
Centre. Results: In 2008, 18,963 new HIV cases were registered in the Ukraine and 54,046 new HIV cases in the Russian
Federation. In the newly registered cases of HIV, the proportion of women rose from 24.0% in 2001 to 42.0% in 2008 in the
Russian Federation and from 37.2% in 1995 to 44.5% in 2008 in the Ukraine. There has also been a considerable increase in
mother-to-child-transmission of HIV. Between 1987 and 1994 the proportion of children among the people newly infected
with HIV in the Ukraine was 2.2%. In 2008 it was 19.1%. Conclusions: The growing number of HIV infected women in the
Russian Federation and the Ukraine suggest a feminization of the HIV/AIDS epidemic in Eastern Europe. Considering the
findings with a view to recommending future policies to enhance and strengthen anti-HIV interventions, and to understanding better the impact of gender on the HIV/AIDS situation in both countries, the following should be highlighted: not only
unawareness of HIV and AIDS and insufficient knowledge about the different determinants of women‘s vulnerability to HIV
infection, but also urbanisation, mobility, crime, income and the growth of new sexually transmitted HIV infections are
important factors influencing recent developments in, and the prevalence of, the HIV/AIDS epidemic in both countries.
Key words: HIV, women’s health, Russian Federation, Ukraine
introDuCtion
The Russian Federation and the Ukraine are among
the European countries with the most rapidly
increasing number of newly diagnosed HIV cases,
mainly transmitted by intravenous drug users, but
also increasingly by sexual contact in the general
population and by mother-to-child-transmission.
The Russian Federation continues to have the most
severe epidemic, accounting for 66% of all new
infections in Eastern Europe in 2006, a reported
39.652 new infections (UNAIDS, 2007). By the end
of 2008, over 438,400 (cumulative total) HIV infections were registered in the Russian Federation
(initial registration), including more than 280,000
men and more than 149,000 women (Ministry of
Health and Social Development, 2009). According
th
Communicationpresented at the 6 European Congress on Tropical
to the Ukrainian Ministry of Health, the cumulative
number of reported HIV infections by the end of
2008 more than 100.000 with 18,963 new cases
(10,508 men and 8,455 women) in 2008. Some
health officials believe that by 2010 there may be as
many as 1.5 million HIV infected individuals in the
Ukraine (Barnett et al., 2000).
The important factors influencing recent developments of the HIV/AIDS epidemic in the Russian
Federation and the Ukraine in, and the prevalence
of, the HIV/AIDS epidemic in both countries will be
analysed, demonstrating the importance of integrating gender into HIV programmes that increase
women’s access to information. This study also
gives an overview of HIV/AIDS surveillance in the
Russian Federation and the Ukraine, and then looks
Corresponding author: Dr. Larissa Burruano, MPH
Clinic for Dermatology and Allergy Medicine, Ruhr
University Bochum, St. Josef Hospital. Gudrunstr.
56 - 44791 Bochum. E-mail: [email protected]
37
L. BURRUANO, E. BENTLY
at the AIDS illness itself and the most significant
ways of transmission in both countries between
1995 and 2008.
methoDs
Reported HIV/AIDS cases from the official
epidemiological register of the Ukrainian Centre for
AIDS Prevention alongside data from the Russian
Federal AIDS Centre were analyzed.
Since 1987, HIV infections and AIDS cases in the
Ukraine have been recorded by the Ukrainian Centre
for AIDS Prevention in Kiev, Ukraine. The
Ukrainian Centre for AIDS Prevention is the central
institution in the field of: recognising, preventing
and combating infectious diseases, particularly the
HIV/AIDS epidemic, and is responsible for coordinating 27 local Ukrainian centres for AIDS prevention. The core functions of the centres include scientific investigation, epidemiological monitoring and
medical analysis and assessment of HIV/AIDS
figures.
The Federal Applied Research Centre of the
Ministry of Health and Social Development for the
Prevention of and Fight against AIDS (hereafter the
Federal AIDS Centre) is responsible for federal
guidelines, normative direction and the epidemiology of the HIV/AIDS epidemic in the Russian
Federation. The Russian Federation has a well
developed government HIV/AIDS health service
infrastructure including the Federal AIDS Centre, 7
okrug (interre gional) AIDS centres, 89 regional
AIDS centres and 20 municipal AIDS centres
(WHO, 2008).
The 1995 Federal Law on HIV/AIDS in the Russian
Federation called for obligatory blood screening for
blood donors, health professionals who are particularly exposed to infection in their work, and for
people who care for patients with illnesses that share
the same forms of transmission as HIV (hepatitis,
STIs, etc.) (Fischer, 2006). Under this law, the state
guaranteed anonymous and confidential HIV testing,
pre- and post-test counselling and free access to
healthcare and social welfare services for people
living with HIV. Voluntary counselling and testing,
although available on a large scale, are often
compromised by their poor quality, lack of informed
consent and lack of confidentiality (World Health
Organization, 2008).
The law “AIDS prophylaxes and the social effect on
the population” specified the following population
groups in the Ukraine as being obliged to have an
HIV test: drug addicts, prostitutes, prisoners, blood
donors and foreigners or foreign students who want
to enter the Ukraine for more than 3 months
(Kobyshsha, 1999). In addition, pregnant women
and Ukrainian citizens who want to travel abroad
have to have an HIV test. People can also take an
38
HIV test voluntarily at state hospitals (Kobyshsha,
1999).
In both countries reporting a new HIV case traditionally involves two stages: registering the screening test results and referral to a health institution for
official registration, to record the patient’s medical
history, and for advice. The visit to a clinic is also
important because on the basis of the interviews
there, patients are re-classified according to their
transmission category. HIV tests are offered free of
charge. Positive test results are first confirmed by a
further ELISA test and in special cases, e.g. inconsistent results, an additional Western Blot test is
carried out. The results are sent with the patient’s
name and date of birth to the appropriate regional
centre for AIDS prevention and afterwards to the
central registration office - the Ukrainian Centre for
AIDS Prevention in Kiev and to the Federal AIDS
Centre in Moscow.
The HIV-positive patient registered in the Ukraine
must be clinically examined by a doctor as well. At
this stage other medical treatment is discussed
alongside a repeated diagnosis, and social-psychological assistance is also offered. However, only
about half of all those entitled to this additional
examination after testing positive to HIV take up the
opportunity (Burruano and Seydel, 2006). Since not
all the positively tested patients take up this additional offer, there is a considerable underestimation
of those diagnosed with HIV in the official statistics.
By the end of 2005, over 162,000 new infections in
total were registered within the framework of initial
registration. In comparison, the official statistics of
the Health Ministry of the Ukraine indicated that
only about 89,000 people were diagnosed with HIV,
among them about 33,000 women (Burruano and
Seydel, 2006).
results
hiv infection
The first HIV infections in the Russian Federation
were registered in 1987. In 2004 33,740 HIV infections were registered (Fig. 1) (Federal AIDS Centre,
2008). In 2008, 54,046 new HIV diagnoses were
officially reported, bringing the total number of
infections documented since the epidemic began to
438,400 (Federal AIDS Centre, 2009). However, the
official count only reflects those people who have
had direct contact with the HIV registering system.
The actual number of people estimated to be living
with HIV is much higher: 940,000 at the end of
2005 (UNAIDS, 2006).
The annual number of newly registered HIV cases
declined between 2001 and 2003, but has subsequently started to increase again. A partial explanation for the decline in HIV diagnoses after 2001 is
GENDER AND HIV: REASONS FOR INCREASING NUMBER OF HIV INFECTED WOMEN IN EASTERN EUROPE
that fewer HIV tests were carried out in some of the
population groups at high risk of HIV infection,
such as intravenous drug users and prisoners.
The first HIV infections in the Ukraine were also
registered in 1987. By the end of 1987, 6 Ukrainian
citizens (including 5 women) were registered as
HIV positive. Up to 1994 the number of newly
infected Ukrainian citizens fluctuated yearly
between 6 and 40 people. In 1995 there was an
explosive increase in the number of new HIV infections, with a total of 1,490 registered cases. Since
then, the number of people tested as HIV positive
has risen rapidly. In 2005 13,770 new HIV infections were registered in the Ukraine and in 2008
18,963 (Fig. 1) (Ukrainian Centre for AIDS
Prevention, 2009).
ways of transmission among women
The number of HIV positive women is increasing
both in the Russian Federation and in the Ukraine.
In the newly registered cases of HIV, the proportion
of women in the Russian Federation rose from
13.0% in 1995 to 44.0% in 2006 and in the Ukraine
from 37.2% in 1995 to 44.5% % in 2008 (Federal
AIDS Centre, 2009; Ukrainian Centre for AIDS
Prevention, 2009) (Figs. 3 and 4).
figure 3 - newly diagnosed hiv infections by gender
(%) - ukraine, 1995 - 2006.
figure 1 - hiv infections newly diagnosed - russian
federation and ukraine, 1999-2008.
aiDs cases
A considerable increase in the number of newly
registered AIDS cases in the Russian Federation can
be seen since 1996. This figure rose from 50 in 1996
to 588 in 2006. The number of newly registered
AIDS cases in the Ukraine rose from 45 in 1995 to
4,380 in 2008 (Fig. 2) (Ukrainian Centre for AIDS
Prevention, 2009). There was a comparable increase
in the number of registered AIDS deaths in both
countries, too.
figure 2 - registered aiDs cases and aiDs deaths in
total population of the ukraine, 1987-2008.
figure 4 - newly diagnosed hiv infections by gender
(%) - russian federation, 1995 - 2006.
From 1995 onwards, the most significant way of
HIV transmission among women of child-bearing
age in the Ukraine was intravenous drug use,
followed by heterosexual contact. After 2001,
however, this ratio changed and transmission by
heterosexual contact exceeded the level of transmission by intravenous drug use. In 2005 the most
common way of HIV transmission among women
was also by heterosexual contact.
The number of pregnant women infected with HIV
in Ukraine rose from 495 in 2000 to 2,822 in 2006.
The number of pregnant women infected with HIV
in the Russian Federation rose from 770 in 2000 to
13,110 in 2007 and to 14,364 in 2008 (Ministry of
Health and Social Development, 2009). The number
of children infected with the human immunodeficiency virus depends crucially on whether pregnant
women observe the legally prescribed precautionary
check-ups and whether, in the case of an HIV infection, therapeutic measures are begun on time. There
39
has also been a considerable increase in mother-tochild-transmission of HIV. While only a total of 9
children whose mothers were HIV positive were
registered with HIV in 1995 in the Ukraine, there
were 3,635 cases in 2008. Between 1987 and 1994
the proportion of children among the people newly
infected with HIV in the Ukraine was 2.2%. In 2008
it was 19.1%.
limitations
There are several limitations that should be considered when drawing conclusions from this study.
Official surveillance data only provides information
about people who have been tested and diagnosed
with HIV or AIDS, and not those who remain
untested and thus undiagnosed. The HIV prevalence
data in both countries should be treated with caution
because it does not refer to HIV incidence and
depends heavily on patterns of HIV testing, which
may vary across space and time.
The low number of AIDS cases in the Russian
Federation in comparison with the Ukraine can be
explained in particular by the later development of
the epidemic. The Russian Federation placed
emphasis on reporting HIV infections in its surveillance. The Russian AIDS records are likely to be
very incomplete - probably because some cases have
not been diagnosed and also because not all cases
that are diagnosed are reported.
DisCussion
The Russian Federation and the Ukraine are among
the European countries with the most rapidly
increasing number of newly diagnosed HIV cases,
mainly transmitted by intravenous drug users, but
also increasingly by sexual contact in the general
population and by mother-to-child-transmission.
The presence of STIs can also increase the risk of
HIV transmission by 10-fold In Ukraine still has the
forth highest rate of syphilis amongst children and
young people aged 15 to 19 years. Syphilis rates
among children increased steadily between 1990 and
2003. The rate for boys aged 0 to 14 was 0.14 per
100,000 in 1990 and 2.72 per 100,000 in 2003,
while the rate for girls of the same group increase
from 0.25 per 100,000 in 1990 to 3.60 per 100,000
in 2003 (Teltschik, 2008).
The majority of new sexually transmitted HIV infections can be attributed to a lack of awareness of
one’s HIV status. According to recent results from a
quantitative survey, the level of awareness of HIV
for example in the Ukraine is not particularly high
(Teltschik, 2008). This survey was carried out
among children and young people aged 10 to 19
living or working on the streets of Kiev and Odessa.
In total 650 children and young people were
recruited for interview. In Kiev and Odessa, the
40
majority were aware that HIV is a disease (79% in
Kiev and 56% in Odessa). However, 21% in Kiev
and 44% in Odessa did not know that HIV is a
disease (Teltschik, 2008).
The rapid increase in HIV/AIDS not only in the
general population but also among women in the
Russian Federation and the Ukraine following the
collapse of the Soviet Union was remarkable, but
perhaps not surprising (Burruano and Kruglov,
2009). The deterioration of the economic and social
fabric of the countries which followed created a
vacuum in which illicit drug use and prostitution
flourished. An increase in prostitution in Russia has
coincided with an increase in intravenous drug use
among female sex workers. This is alarming, especially considering the fact that Moscow alone has up
to 70,000 sex workers and the Open Society
Institute (2001) estimated that in some cities in
Russia 40 to 80 per cent of sex workers are HIV
positive (Stillwaggon, 2005).
Social and economic factors (including high youth
unemployment, a boom in drug trafficking and
growth in informal economies) associated with the
disintegration of the former Soviet Union fuelled
rampant intravenous drug use in both countries.
Until the beginning of the 1990s, an increase in drug
consumption was registered in all of the former
republics of the USSR (Malinowska-Sempruch et
al., 2003; Poznyak et al., 2002). In 1990 there were
22,466 registered drug addicts (4.3 people per
10,000 of the population) in the Ukraine. In 1999
this figure reached 74,554 (14.9 people per 10,000)
(Steschenko et al., 2000). The actual number of drug
addicts is between five and ten times higher according to estimates of the Health Ministry of the
Ukraine (UNDP, 2004).
HIV is at an extremely high level in the Russian
Federation and the Ukraine, due in no small part to
the large number of HIV infected women. Women
are often afraid of being tested for HIV in both
countries in case their diagnosis is disclosed. HIV
infected people continue to be stigmatized by relatives and friends, by co-workers and even by the
staff of the healthcare facilities they visit. The fear
of encountering prejudice from healthcare workers
sometimes discourages women from seeking
medical care from the women’s health service; and,
in the event of an HIV infection being confirmed,
from registering with an AIDS centre or continuing
to be examined at the women’s health service. In
large regions of the Russian Federation it is not
always possible for HIV infected women living in
outlying districts to attend the regional AIDS
centers, sometimes due to the cost of the journey
(Voronin et al., 2005).
In addition, the overall gender disparity in the both
countries is personal as well as political. Forced
GENDER AND HIV: REASONS FOR INCREASING NUMBER OF HIV INFECTED WOMEN IN EASTERN EUROPE
equality under Soviet rule certainly did not make
women equal in every aspect of life, but it did have
an effect in the official realms of education and
work at least (Alexandrova, 2004). The equality of
women, however, was far from established in the
mindset and mentality of the region. Nothing has
changed in the gender disparity, at its widest where
machismo in men and passivity in women is encouraged, leading to a disparity in power that makes it
unacceptable for a woman to refuse unwanted or
unprotected sex. Many Russian women don’t
demand that their partner uses a condom because
they are afraid of hurting his feelings or not being
able to completely satisfy him sexually (Osadcheva
et al., 2003). According to statistics, about 50% of
HIV positive women in Russia were infected by
their permanent partner or husband.
Considering the findings with a view to recommending future policies to enhance and strengthen antiHIV interventions, and to understanding better the
impact of gender on the HIV/AIDS situation in the
Russian Federation and the Ukraine, the following
should be highlighted: not only unawareness of HIV
and AIDS and insufficient knowledge about the
different determinants of women‘s vulnerability to
HIV infection, in particular biological, social and
cultural determinants and education about HIV, but
also urbanisation, mobility, crime, income and the
growth of new sexually transmitted HIV infections
are important factors influencing recent developments in, and the prevalence of, the HIV/AIDS
epidemic in both countries.
Without a considerably more efficient package of
countermeasures, together with effective prevention
and intervention, the HIV/AIDS epidemic in the
Russian Federation and the Ukraine may soon
become a burden too difficult for them to handle by
themselves, with repercussions for neighbouring
European countries. Interdisciplinary cooperation
between medical experts, experts in base health
work, medical research scientists and epidemiologists needs to be developed further to allow people
with HIV/AIDS, regardless of their sex, background
and social position, to share in the results of the
research and the advances in the prevention and
treatment of HIV/AIDS.
Evidence-based responses in HIV prevention, treatment, and care, are most effective when based on
accurate assessment of the stage, scale, and characterization of populations affected by HIV/AIDS.
HIV/AIDS epidemic in Eastern Europe has been
changing from nascent to concentrated spread
among at risk population including IDU, their sex
partners, an MSM. The available data suggests a
continued emphasis is needed on prevention among
women. Investigation of the factors responsible for
the resurgence among women is needed to better
inform prevention measures. Data integration exercises using the available data from different sources
may be useful for improving the understanding of
the epidemic in highly affected localities throughout
the region.
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KRUGLOV Y. (2000). The HIV/AIDS epidemic in
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FISCHER H. (2006). AIDS and Russia: a health
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VOL. 14, N. 1-4, 2009
the prevalence of trichomoniasis in high-risk behavior
group women attending penitentiaries clinic of tehran
province
1
1
1
1
1
1
2
z. valaDKhani , m. assmar , n. hassan , z. aghighi , a. amirKhani , f. Kazemi , i. esmaili , m.
3
3
3
3
samanDar , m. moraDynasaB , saBzali , DastpaK
Pasteur Institute of Iran, Tehran
Tehran Prison HQ, Research Council of Tehran
3
Gynecology clinics of Prisons in Tehran Province
1
2
summary - Trichomoniasis is a common worldwide sexually transmitted infection (STIs) and associated with important
public health problems, including amplification of HIV transmission. The prevalence of trichomoniasis depends on host
factors like age, sexual activity, number of sexual partners and sexual behavior. The aim of this study was to evaluate the
prevalence of this infection in high-risk behavior groups (drug addicted and multiple sexual partners’) of women attending
gynecology clinics in penitentiaries of Tehran province. The discharge of posterior vaginal fornix and urine samples of the
women with different symptoms have been checked by direct smear and cultured in TYI-S-33 culture media. Results showed
that 10.2% of subjects were positive for trichomoniasis, however 82.7% of infected patients were belonged to symptomatic
individuals who complained of vaginal discharge, itching and/or burning sensation. Per speculum examination was shown
that 50% of Trichomoniasis vaginalis positive subjects had normal appearance of vagina and cervix. T. vaginalis infection is
commonly associated with other STIs and a marker of high-risk sexual behavior.
Key words: Trichomoniasis, prisoners, STI, diagnosis
introDuCtion
Trichomoniasis is a common sexually transmitted
infection (STIs) that affects both women and men,
although symptoms are more common in women.
This infection presents a broad spectrum of clinical
patterns, however asymptomatic disease is common
in both men and women, thus screening for disease
is important. Infected individual with Trichomonas
vaginalis manifest a wide range of symptoms,
including low birth weight infants, preterm labour,
and predisposition to cervical cancer, atypical pelvic
inflammatory disease, infertility and premature
rupture of membrane in pregnant women. But
importance of this infection is the association
between T. vaginalis and an increase risk of transmission and acquisition of other sexually transmitted diseases including human immunodeficiency
virus. The genital inflammation caused by trichomoniasis can increase a woman’s susceptibility to HIV
infection if she is exposed to the virus. Having
trichomoniasis may increase the chance that an
HIV-infected woman passes the virus to her sex
partner(s) (Cotch et al., 1991). The present study
was undertaken to evaluate the prevalence of
trichomoniasis in high risk behavior group including
drug users and multi sexual partners’ women serving time in penitentiaries of Tehran province. Multi
sexual partners’ women are an important group for
transmission of most sexually transmitted diseases
(STD) all over the world (Swygard et al., 2004).
Most of the studies are based on microscopic examination and culture in different culture media.
Although culture media is not economy way for
epidemiological study but it is a gold standard
method. In females, T. vaginalis primarily inhabits
the vagina but may also invade the urethra. In
women, it is associated with a classically green,
frothy liquid discharge with a malodor. Dysuria and
dyspareunia are also common (Sobel, 1996). The
study was conducted among females’ inmates in
three prisons (Evin, Rajaee shahr and Varamin) of
Tehran province, in order to establish possible asso-
th
43
Z. VALADKHANI ET AL.
ciations between T. vaginalis infection and high risk
behavior group.
methoDs
We surveyed 450 female who attended in gynecology clinics of three prisons (Evin, Rajaee shahr and
Varamin) in Tehran province over 12 month period.
All patients were interviewed according to a questionnaire based on the following: personal data
name, age, occupation, and educational level, reason
to arrest, contraceptive method used, clinical signs
and symptoms.
To isolate T. vaginalis from female prisoners in this
study, two sterile cotton swabs were used for collection of vaginal discharge from posterior vaginal
fornix of each patient, and sterile tubes for urine
samples. One swab was cultured immediately in
Diamond’s TYIS-33 medium, and incubated at 37ºC
and the other swab used for direct smear examination. Urine samples were centrifuged at 1500xg for
10 min and pellet was checked for any motile protozoa, and one drop was also added in the culture
medium. The cultured samples were examined
under inverted microscope daily for seven days to
check for growth of T. vaginalis as described by
(Valadkhani et al., 2004).
Those patients complaining of vaginal discharge
and/or pruritis, dysuria, and dyspareunia were
considered as symptomatic patients (Sp). Isolates
obtained from patients with no complain of above
mentioned symptoms were considered as asymptomatic patients isolates (Asp).
statistical analysis: Data were analyzed for statistical significance using Epi-info software.
results
Out of 450 individuals examined, 358 samples
belonged to those which arranged in high risk
behavior group that consist of drug users and those
who have multi sexual partners. Twenty five positive samples (54.3%) out of total were belonged to
this group. The differences in prevalence were
statistically significant by using Epi-info analysis
software (p<0.05). Age is one of the social and
demographic markers for STD, the peak prevalence
of 33.3% occurred in the age group 32-36 in this
study. According to the duration of living in prison,
results showed that most number of infected women
was living less than one month in the jail i.e. nine
samples (19.6%). The most number of infected
women in high risk behavior group belonged to drug
users (54.3%) that differences with other groups
were statistically significant (p<0.05), it shows that
drug addiction is one of the most important determinant of risk. Among infected women, 43.5% had
history of abortion. The least infectivity were among
those who used IUD as contraceptive, however
44
15.2% of infected ones used condom alone for
contraception and 17.4% relied on oral contraceptives. The marital statuses of infected women were
also recorded. According to questionair 21.7% of
the patients were divorced and 15.2% were widows.
Based on husband occupation of infected women,
results showed that 7 of them were driver.
table 1 - prevalence of trichomoniasis in samples
obtained from prisoners
prison
no. examined no. infected
% of infected
Evin
187
Rajaee Shahr 190
Varamin
73
23
18
6
12.3
9.5
8.2
Total
46
10.2
450
table 2 - Comparison of diagnostic test for T. vaginalis
in females
Diagnostic methods
Vaginal direct
vaginal culture
urine direct
urine culture
no. of positive
sensitivity
41
46
14
34
92%
98%
60%
80%
DisCussion
With respect to importance of trichomoniasis as
sexually transmitted infection worldwide and its
association with AIDS, led to study about this parasite. T. vaginalis is site specific for the genitourinary
tract and has been isolated from all genitourinary
structures. This infection presents a broad spectrum
of clinical patterns, however asymptomatic disease
is common in both men and women, thus screening
for disease is important. Various sociodemographic
factors have been correlated with presence of T.
vaginalis, and may be used to predict infection.
Diagnosis is usually made from wet mount
microscopy and direct visualization, which are
insensitive. In areas where diagnostic methods are
limited, management of trichomoniasis is usually as
part of a clinical syndrome, vaginal discharge for
women and urethral discharge for men. Reports on
prevalence of trichomoniasis in high risk behavior
group in Iran are rare. The prevalence of trichomoniasis in central penitentiary of Tehran in year 1992
were reported 33.8 % (Dibaji, 1991). In order to
know the actual state of trichomoniasis as one of the
sexually transmitted diseases in prison, the prevalence and diagnostic procedures of this infection
have been studied. The latest study in Evin house of
detention population reported 26% positivity for
trichomoniasis in women attended in gyneacology
clinic in year 2003 (Mousaviani et al., 2005),
however our findings indicate that the prevalence of
THE PREVALENCE OF TRICHOMONIASIS IN HIGH-RISK BEHAVIOR GROUP WOMEN
T. vaginalis is 12.3% in this year. This decline may
due to increase the level of health services, teaching
prevention of sexual infections guideline by using
photographs and videotapes to help participants
better visualizing and understanding, and increase
the educational level from different ways of public
relation in prisoners in recent years.
Factors such as low socioeconomic level, poor
education, increase of promiscuity, family instability
may affect on sexual behavior and therefore on the
risk of STIs in a community. Without any doubt
STIs are very serious problem for public health and
affects more in women and their children than for
men. Infected women suffer more from complications such as infertility, cervical cancer and complications for the fetus and newborn.
As it has been mentioned in result section, the duration days of 19.6% of infected women living in
prison was less than one month. It shows that due to
free and enough medical facilities in prisons in Iran,
most of those who have genital problems try to use
these facilities. Wet smear and culture are routine
diagnostic methods for T. vaginalis with varying
sensitivity in different studies. Sharbatdaran et al.
(2005) mentioned the highest sensitivity in wet
smear compared to the culture. In a study by Hazrati
Tappeh et al. (2004) also reported that wet smear
has more sensitive than culture. The mentioned
reports are not in the same way of this study; our
results show that culture is gold standard method for
diagnosis of this infection with 98% sensitivity. The
test of cure for trichomoniasis is necessary because
asymptomatic patients are good carriers of this
infection. Due to temporary keeping of prisoners in
the jail in order to be finding guiltyor transferring to
other prison, we only could follow-up the treatment
of a number of patients. Among 28 infected women
when treated with metronidazole, after one month,
twenty two of recollected samples were negative for
T. vaginalis. Four of six treatment failure was
successfully treated with further courses of metronidazole. Only two women after several treatments
still were complaining of vaginal discharge, itching
and/or burning sensation and their collected samples
were positive for T. vaginalis, however they were
not meeting their husbands.
The infection to trichomoniasis by using clinical
parameters reported 14.2% between women referred
to gynecology clinics of Zahedan medical university
by Sakhavar et al. (2008), however by using culture
media it showed 8.5%. This study showed that clinical diagnosis by gynecologist has low level of specificity and manuscript wrong drugs cause side effects
and drug resistance in these groups.
In one study by Garcia et al. (2004), 31.2% T. vaginalis was found among female inmate in Lisbon,
that only 65.1% of them presented symptoms.
As 10-50% of women and 15-50% of men (Krieger
et al., 1993) are asymptomatic at diagnosis this
potentially excludes a large proportion of patients
from follow-up. We feel that guidelines for treating
T. vaginalis should clarify the importance of not
relying on the presence or absence of symptoms in
patients who were asymptomatic to start with.
However, concomitant treatment of sexual partners
is recommended.
There is one report from legal prostitutes in Ankara,
Turkey, that found 64 (28 %) out of 225 vaginal wet
smears were positive for T. vaginalis (Tanyuksel et
al., 1996).
The incidence of trichomoniasis is highest in women
with multiple sexual partners and in group with a
high prevalence of other STDs (Cotch, 1990).
Garcia et al. (2004) also studied the association
between the existences of T. vaginalis, multiple
sexual partners, drug addiction and no condom use.
They reported that there is no statistically significant
relation between the existences of T. vaginalis,
multiple sexual partners, drug addiction and no
condom use. However using condom is not much
important in prevalence of trichomoniasis as in our
study also showed, but other two factors have significant relation for distributing STIs. Because the
prescription of physicians in our community is
based on signs/symptoms of the patients, due to
drug resistance, drug fee and drug side effects, it is
suggested that treatment be performed after a definite diagnostic method.
Prevention guidelines should be informed through
public advertisements about the importance of
having a stable sexual relationship, encourage them
to visit gynecologist regularly, to prevent the sharing of intravenous needles and beware of STIs and
AIDS which helps in reduction of transmission.
Diagnosis of other STIs also is commended.
aCKnowleDgment
With special thanks to all colleagues in the obstetrics and
gynecology clinic of state prisons and security and corrective measures organization and those who help us to do
this research. This study was funded by Pasteur Institute
of Iran, Tehran.
referenCes
COTCH M.F. (1990). Carriage of Trichomonas vaginalis
is associated with adverse pregnancy
outcome. In:
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Program and Abstracts of the 30 Interscience
Conference on Antimicrobial Agents and
Chemotherapy. Atlanta, Georgia. Abstr. 681, p. 199.
COTCH M.F., PASTOREK J.G., NUGENT R.P., YERG
D.E., MARTIN D.H., ESCHENBACH D.A. (1991).
Demographic and behavioral predictors of
Trichomonas vaginalis infection among pregnant
women. Obstetrics & Gynecology, 78(6):1087-92.
45
Z. VALADKHANI ET AL.
DIBAJI S. (1991). Study of diagnostic methods and
prevalence of trichomoniasis in Tehran penitentiary
center. M.Sc. thesis. College of Medical Health,
Tehran Medical University. 98 pp.
GARCIA A., EXPOSTO F., PRIETO E., LOPES M.,
DUARTE A., CORREIA DA SILVA R. (2004).
Association of Trichomonas vaginalis with
sociodemographic factore and other STDs among
female inmate in Lisbon. International Journal of
STD & AIDS, 15(9): 615-8.
HAZRATI TAPPEH K.H., MOHAMMAD ZADEH H.,
MOSTAGHIM M., FEREIDONI J., MEHRI E.
(2004). A comparative study on the sensitivity of two
different diagnostic ways of Diamond culture andwet
mount in Trichomonas vaginalis diagnosis and
correlationbetween infectionand clinical finding.
Journal of Uromieh University of Medical Sciences,
15: 9-15.
KRIEGER J., JENNY C., VERDON M., SIEGEL N.,
SPRINGWATER R., CRITCHLOW C., HOLMES
K. (1993). Clinical manifestations of trichomoniasis
in men. Annals of Internal Medicine, 118(11): 844-9.
MOUSAVIANI Z., BEHBAHANI S., ESMAILI I.
(2005). Diagnosing contamination and determining
effective factores on contraction of Trichomonas
vaginalis and gonorrhea in female prisoners at Evin
jail Tehran. Pajouhandeh, 41: 301-303.
SAKHAVAR N., TAIMOURI B., MIRTAIMOURI M.
(2008). Diagnostic evaluation of clinical
46
trichomoniasis by paraclinical methods in women
attending in obstetrics and gynecology clinics ofth
Zahedan Medical University. In: Abstracts Book, 17
Iranian Congress on Infectious Disease and Tropical
Medicine. p. 307.
SHARBATDARANM, SHEFAEI SH, SAMIEI H,
HAJIAHMADI M, RAMEZANPOUR R, MERSADI
N,BEHRAD A. (2005). Comparison of clinical
presentation, wet smear, Papanicolaou smear with
Dorswt’s culture for diagnosis of Trichomonas
vaginalis in doubtful women to trichomoniasis.
Journal of Babol University of Medical Sciences,
27(7): 46-9.
SOBEL J.D. (1996). Vaginitis. The New England Journal
of Medicine, 337: 1896-1903.
SWYGARD H., SENA A., HOBBS M., COHEN M.
(2004). Trichomoniasis: clinical manifestations,
diagnosis and management. Sexually Transmitted
Infections, 80: 91- 95.
TANYüKSEL M., GüN H., DOGANCI L. (1996).
Prevalence of Trichomonas vaginalis in prostitutes in
Turkey. Central European Journal of Public Health,
4(2): 96-7.
VALADKHANI Z., SHARMA S., HARJAI K., GUPTA
I. AND MALLA N. (2004). Evaluation of
Trichomonas vaginalis isolates from symptomatic
and asymptomatic patients in mouse model. Iranian
Journal of Public Health, 33: 60-66.
VOL. 14, N. 1-4, 2009
focolai di tubercolosi in emilia romagna
m. moranDi, D. resi, s. giorDani, l. Droghini, m. marChi, m. l. moro
Agenzia Sanitaria e Sociale della Regione Emilia Romagna, Area Rischio Infettivo, Bologna, Italy
Tuberculosis clusters in Emilia Romagna Region
summary - The aim of this study is to describe the epidemiological characteristics of TB clusters in Emilia Romagna
Region and to analyse social-demographic characteristics of involved cases by linkage of current surveillance systems. From
2004 to 2008, 78 TB clusters have been identified (18 of whom were outbreaks), involving 183 cases. In sixty-five clusters
(83%) the index cases were indicated as foreign-born (with 43% from Africa and 31% from Europe), most of whom were
males (68%) with a median age of 29 yrs (1°-3°IQ: 23-39). TB clusters were frequent particularly among family members
(86%), 5% occurred in public structures (hospitals, schools and prisons), 9% in other communities. The number of clusters
that involved children under 15 yrs has risen from around 20% in 2004 to around 50% in 2008. The annual average of children under 15 yrs involved in clusters was 5,3 cases over the period 2004-2006 compared to 10,0 over the period 2006-2008.
Globally 88% of involved children were from foreign-born family. In 2008, of the 14 cases of TB belonging to clusters and
younger than 15 yrs, 78% were children under 5 yrs. This study underlined the public health relevance of TB clusters and of
their monitoring: for doing so, existing surveillance systems need to be improved.
riassunto - L’obiettivo di questo studio è descrivere le caratteristiche epidemiologiche dei focolai di TB in Emilia Romagna
ed analizzare le caratteristiche socio-demografiche dei casi coinvolti correlando i flussi correnti di notifica. Dal 2004 al 2008
in Emilia Romagna sono stati identificati 78 focolai di TB (18 dei quali microepidemie) che hanno coinvolto 183 casi. In 65
focolai (83%) i casi indice erano nati in un Paese estero (il 43% in Africa e il 31% in Europa), la maggior parte erano maschi
(68%), con un’età mediana di 29 anni (1°-3°IQ: 23-39). I focolai si sono manifestati nell’86% in ambito familiare ed il
numero di focolai con coinvolgimento di bambini sotto i 15 anni è passato da circa il 20% nel 2004 a circa il 50% nel 2008.
La media annuale di bambini sotto i 15 anni coinvolti in focolai è passata da 5,3 casi nel periodo 2004-2006 a 10,0 casi nel
periodo 2006-2008. Complessivamente i bambini coinvolti erano nell’88% di famiglia di origine straniera. Nel 2008, dei 14
casi di TB appartenenti ad un focolaio e sotto i 15 anni, il 78% aveva meno di 5 anni. Questo studio conferma l’utilità di sorvegliare i focolai di TB: è però necessario migliorare i sistemi di sorveglianza esistenti.
Key words: tuberculosis, epidemiology, risk factor, transmission, control.
introDuzione
Il rapporto 2009 dell’Organizzazione Mondiale della
Sanità mette in evidenza ancora numerosi ostacoli al
raggiungimento degli obiettivi per il controllo della
tubercolosi a livello globale (WHO, 2006; 2009).
La tubercolosi ha differenti modalità di insorgenza e
di trasmissione in base al tasso di incidenza e di prevalenza nella popolazione.
Per i Paesi ad elevata endemia la trasmissione della
malattia avviene in particolare nelle fasce giovani
della popolazione con una prevalenza diffusa dell’infezione, mentre nei Paesi a bassa endemia il
manifestarsi della tubercolosi avviene a seguito di
riattivazione di infezioni latenti nella popolazione
anziana oppure per insorgenza e diffusione a partire
da particolari gruppi a rischio.
In Italia, dal dopoguerra agli anni Ottanta si è assi-
stito ad una progressiva riduzione della frequenza
della TB nella popolazione (Istituto Superiore di
Sanità, 1998), mentre negli ultimi dieci anni il trend
è stato sostanzialmente stabile e al di sotto dei 10
casi per 100,000 residenti, valore che pone l’Italia al
di sotto del valore soglia per essere considerato
Paese a bassa endemia tubercolare (Ministero della
Salute, 2009).
L’incidenza dei nuovi casi si concentra in alcuni
gruppi a rischio ed in alcune classi di età. In particolare le fasce di popolazione a maggior rischio sono
gli anziani e in generale la popolazione straniera, la
quale conta quasi il 50% dei casi di TB in Italia e
mostra tassi di incidenza di un ordine superiore
rispetto alla popolazione italiana (per alcune nazionalità i tassi sono perfino superiori a 100 casi per
100,000 residenti). Negli ultimi anni si è assistito ad
e-mail per la corrispondenza: [email protected]
th
Comunicazione presentata al 6 European Congress on Tropical Medicine
and International Health. Verona, Italy 6-10 September, 2009.
47
M. MORANDI ET AL.
un incremento dell’incidenza nella fasce di età dei
giovani adulti.
Pertanto per la situazione italiana risulta di fondamentale importanza monitorare eventuali focolai
epidemici e studiare i determinanti sociali di insorgenza e trasmissione della tubercolosi per identificare interventi preventivi che riducano l’incidenza, in
supporto alla diagnosi precoce e all’accessibilità ad
una terapia efficace (Lonroth, 2009).
In questo articolo presentiamo una descrizione dei
focolai e delle microepidemie nella Regione Emilia
Romagna nel periodo dal 2004 al 2008 ed un’analisi
delle caratteristiche socio-demografiche dei casi
indice e dei casi secondari in riferimento alla modalità di trasmissione della malattia tubercolare.
materiali e metoDi
I focolai e le microepidemie di TB sono state identificate utilizzando come fonte informativa il sistema
di nazionale di notifica delle malattie infettive
(Ministero della Salute, 1990; 1998). La tubercolosi
rientra fra le patologie di classe III; quando durante
l’inchiesta epidemiologica si riscontra una relazione
fra due o più casi di TB configurando le caratteristiche di focolaio epidemico questo viene segnalato
con le modalità della classe IV. Il sistema di notifica
segue il flusso Aziende Sanitarie, Regioni e
Ministero della Salute.
In Emilia-Romagna, dal 1996 le informazioni relative ai casi di TB notificati in classe III sono disponibili in formato elettronico ed includono i dati socio
demografici, clinici e epidemiologici. Le schede di
classe IV in formato cartaceo contengono per ogni
focolaio la data di inizio dei sintomi del primo caso
e dell’ultimo, il numero dei casi coinvolti, la comunità in cui è avvenuta la trasmissione (ad esempio
intra-familiare o in altre strutture pubbliche o private).
Al momento delle segnalazione di un focolaio di TB
vengono abitualmente raccolti mediante la scheda di
classe IV anche i principali dati anagrafici e il grado
di parentela tra caso indice e casi secondari. Tali dati
hanno permesso il collegamento tra schede di classe
IV e schede di classe III al fine di attribuire ad ogni
caso coinvolto in un focolaio le variabili presenti in
queste ultime.
Nell’analisi, il paese d’origine è stato attribuito in
base al paese di nascita; i bambini (0-14 anni), indipendentemente dal paese di nascita, sono stati considerati stranieri quando nella famiglia di origine
almeno un genitore era nato all’estero.
È definito “focolaio” la trasmissione dell’infezione/malattia dal caso indice ad almeno un contatto ed
“epidemia” la trasmissione ad almeno 2 persone.
L’associazione fra i casi coinvolti nei focolai non è
stata valutata attraverso la tipizzazione dei ceppi di
Mycobacterium tuberculosis.
Per la classificazione temporale i focolai sono stati
raggruppati in base all’anno di esordio dell’ultimo
caso (ad es. i focolai del 2008 comprendono tutti i
focolai in cui l’ultimo caso ha avuto sintomi di esordio nel periodo dal 1/1/2008 al 31/12/2008).
Sono stati utilizzati il test non parametrico di
Kruskal-Wallis per confrontare la mediana delle età
tra gruppi ed il test della differenza meno significativa (LSD) per il confronto delle medie; è stato considerato significativo un P<0,05.
Per l’elaborazione statistica e grafica si sono utilizzati i programmi SPSS 9.0 e Microsoft Office Excel
per Windows.
risultati
Nel periodo dal 2004 al 2008 nella Regione Emilia
Romagna sono stati notificati 78 focolai epidemici
(di cui 18 epidemie). Il numero annuale dei focolai
notificati è stato di 11 nel 2004, 9 nel 2005, 18 nel
2006, 17 nel 2007 e 23 nel 2008 (Tab. 1). Nella
maggior parte dei focolai la trasmissione è avvenuta
in ambito familiare ed amicale (86%), il 5% dei
focolai si è verificato in strutture pubbliche (ospedali, scuole e prigioni), il 9 % in altre comunità.
Nell’intero periodo le province maggiormente coinvolte sono state Bologna (38,8% del totale dei focolai), Modena (17,5%) e Reggio Emilia (11,3%). Il
numero medio di casi per focolaio è stato 2,34 (l’epidemia più grande è stata segnalata nel 2006 ed ha
coinvolto 6 persone). La media annuale del numero
di epidemie è stato di circa 4 senza variazioni temporali. Complessivamente sono state coinvolte 183
persone.
tabella 1 - numero di focolai tB per anno e numero di casi coinvolti per sesso e origine.
anno
focolai nr
italiani nr
M (ci)
F (ci)
M (ci)
stranieri nr
F (ci)
totale nr
NN (ci)
2004
2005
2006
2007
2008
11
9
18
17
23
5 (2)
3 (1)
5 (2)
4 (1)
2 (2)
1 (1)
3 (1)
2 (0)
6 (3)
2 (0)
13 (5)
11 (5)
23 (10)
14 (8)
29 (14)
6 (3)
7 (2)
17 (6)
10 (5)
16 (5)
0
0
0
0
4 (2)
25
24
47
34
53
Totale
78
19 (8)
14 (5)
90 (42)
56 (21)
4 (2)
183
*ci = casi indice
48
FOCOLAI DI TUBERCOLOSI IN EMILIA ROMAGNA
illustrato in figura 1 dal box-plot della distribuzione
delle età per anno in cui si nota una maggior riduzione dell’età mediana per il 2008.
100
80
Età media casi coinvolti in focolai TB
Circa il 60% dei casi coinvolti era di sesso maschile
e la stessa percentuale era pressoché costante disaggregando per italiani e stranieri. Due terzi dei casi
indice era di sesso maschile (67%, escludendo 2 casi
nel 2008 in cui non era noto il sesso) e non si evidenziavano differenze significative tra cittadini italiani (8/13) e stranieri (42/64). Nei casi secondari la
predominanza maschile risultava lievemente inferiore rispetto ai casi indice (56% vs 65%) (Tab. 1).
L’età mediana dei casi coinvolti era di 29,5 anni (1°3°IQ: 18-39 anni), 30 anni nei maschi (1°-3°IQ:
22,5-40 anni) e 29 anni nelle femmine (1°-3°IQ:
12,5-37,5 anni). Nei casi indice l’età mediana era 31
anni (1°-3°IQ: 24,5-41,5 anni) mentre per i casi
secondari era di 27 anni (1°-3°IQ: 11,5-37,5 anni).
Era presente una notevole differenza tra l’età mediana dei casi italiani (44; 1°-3°IQ: 33-75 anni) e stranieri (17; 1°-3°IQ: 28-37 anni).
I casi indice erano per oltre il 50% maschi e di
nazionalità straniera con un’età mediana di 29 anni
(1°-3°IQ: 23-39). Mentre i casi indice di nazionalità
italiana e di sesso femminile presentavano l’età
mediana maggiore (46; 1°-3°IQ: 33-76,5 anni), i
casi secondari di origine straniera e di sesso femminile presentavano l’età mediana minore (25; 1°3°IQ: 10-34 anni).
Il numero annuale medio di bambini al di sotto dei
15 anni coinvolti in focolai nel periodo dal 2004 al
2006 è stato di 5,3 casi rispetto ai 10,0 casi nel
periodo dal 2006 al 2008. Nel periodo in esame il
numero di focolai che ha coinvolto bambini al di
sotto dei 15 anni è passato da circa il 20% nel 2004
a circa il 50% nel 2008. Complessivamente dal 2004
al 2008 nel 27% dei focolai è stato coinvolto almeno
un bambino minore di 5 anni e l’88% dei bambini
coinvolti apparteneva ad una famiglia straniera
(Tab. 2).
L’età media dei casi insorti come parte di un focolaio era significativamente più bassa nel 2008 rispetto agli anni precedenti ad eccezione del 2006
(P=0,21).
Il confronto dell’età mediana tra gruppi evidenziava
una differenza statisticamente significativa per casi
indice o secondari (P=0,02), per nazionalità
(P<0,001) e per anno (P=0,03); quest’ultimo dato è
60
40
20
0
N=
25
23
47
34
53
2004
2005
2006
2007
2008
ANNO
figura 1 - Box-plot delle età dei casi coinvolti in focolai
tB nel periodo 2004-2008 in regione emilia
romagna.
Negli anni, mentre il numero di focolai con esclusivo coinvolgimento di cittadini italiani è rimasto
pressoché costante, il numero di focolai con interessamento di cittadini stranieri è aumentato progressivamente rappresentando nel 2008 il 90% dei focolai
di TB (Fig. 2). Il caso indice era di origine straniera
25
Focolai TB con stranieri
Focolai TB con solo italiani
Totale focolai TB
20
15
Nr
10
5
0
2004
2005
2006
2007
2008
figura 2 - numero di focolai tB con coinvolgimento di
stranieri o di soli italiani nel periodo 2004-2008 in
regione emilia romagna.
tabella 2 - numero di focolai tB per anno e numero di casi coinvolti totali, minori di 15 anni e minori di 5 anni.
anno
tot. focolai
focolai tB
con minori
di 15 anni
focolai tB
con minori
di 5 anni
totale
Casi
(stranieri)
Casi minori
di 15 anni
(stranieri)
Casi minori
di 5 anni
(stranieri)
2004
2005
2006
2007
2008
11
9
18
17
23
2
2
9
3
11
2
1
8
1
9
25 (19)
24 (18)
47 (40)
34 (24)
53 (49)
2 (2)
3 (2)
12 (11)
4 (3)
14 (13)
2 (2)
1 (1)
9 (9)
2 (1)
11 (11)
Totale
78
27
21
183 (150)
35 (31)
25 (24)
49
M. MORANDI ET AL.
in 65 focolai (83%); il 43% proveniva dall’Africa
(in particolare Marocco, 17 focolai nell’intero periodo) ed il 31% dall’Europa (in particolare Romania,
15 focolai nell’intero periodo). Negli ultimi 2 anni è
stato osservato un proporzionale decremento di casi
indice provenienti da Africa (media sull’intero
periodo 43%, nel 2008 era il 24%), mentre si è assistito ad un aumento della proporzione di notifiche
per persone provenienti da Europa dell’Est (media
sull’intero periodo 31%, nel 2008 era il 43%), Asia
(media sull’intero periodo 17%, nel 2008 era il
24%).
Nel 2008 la totalità dei focolai ha presentato una
modalità di trasmissione in ambito familiare. I casi
indice erano delle seguenti nazionalità: 8 Romania
(di cui 7 maschi), 3 Marocco, 2 Italia, 2 Cina, 1
Bangladesh, 1 Ecuador, 1 Moldavia, 1 Nigeria, 1
Pakistan, 1 Perù, 1 Sri Lanka, 1 Tunisia. Nel 2008
sono stati segnalati 11 focolai con coinvolgimento di
minori di 15 anni (in totale 14 bambini, di cui il
78% avevano meno di 5 anni). Nello stesso anno
l’origine delle famiglie in cui è avvenuta la trasmissione da adulto a bambino era rumena (in 4 casi),
bengalese, cinese, ecuadoregna, italiana, marocchina, nigeriana e tunisina.
DisCussione
Nel periodo 2004-2008 in Regione Emilia Romagna
attraverso il sistema di notifica delle malattie di classe IV sono stati individuati 78 focolai di tubercolosi,
con evidenza di trasmissione prevalentemente intrafamiliare, in particolare in famiglie straniere.
L’aumento progressivo della popolazione straniera
presente sul territorio (spesso proveniente da aree ad
elevata endemia tubercolare) (Istituto Nazionale di
Statistica, 2009), la maggior parità delle donne straniere rispetto alle donne italiane (Regione Emilia
Romagna, 2008), le condizioni di maggior fragilità
sociale legate a condizioni abitative e lavorative difficili e che predispongono ad una maggior suscettibilità di sviluppare la malattia e diffonderla, ed i
numerosi ostacoli (legali, logistici, socio-economici,
culturali) ad una reale fruibilità dei servizi di diagnosi e cura (Caritas/Migrantes, 2008) sono tutti fattori che spiegano un aumento del rischio di trasmissione intra-familiare da adulto a bambino, in particolare in famiglie immigrate.
Tale rischio sostanziale potrebbe essere acuito a
seguito delle politiche di esclusione sociale e di criminalizzazione della popolazione immigrata irregolare (Ministero della Salute, 2009a), le quali potrebbero essere un grave deterrente per l’accesso ai servizi di prima assistenza e per una corretta assunzione della terapia antitubercolare.
Il grado variabile di sottonotifica dei focolai legato
alla diversa sensibilità degli operatori e della pro-
50
pensione dei servizi a segnalare i focolai di tubercolosi è un limite all’analisi.
Nonostante questo limite, sembra evidenziarsi un
tendenziale aumento della notifica dei focolai con
presenza di minori ed in particolare, nell’ultimo
anno analizzato, di minori di 5 anni.
Questo dato potrebbe essere influenzato da una
maggiore tracciabilità da parte dei servizi in caso di
focolai con presenza di minori.
Si sottolinea però che nonostante per la classe di età
inferiore a 15 anni i tassi specifici a livello nazionale
non sembrino destare particolare preoccupazione,
l’evidenza di una maggiore frequenza di focolai
all’interno di famiglie straniere con coinvolgimento
di bambini ed in particolare di bambini minori di 5
anni pone un importante problema rispetto al sistema di notifica e di sorveglianza.
Infatti, per i casi della fascia d’età 0-14 di origine
straniera coinvolti in focolai TB non è possibile fare
un confronto con i dati di notifica individuale ed
individuare la proporzione di casi clusterizzati poiché nell’attuale sistema i bambini di famiglia immigrata nati in Italia vengono considerati tra i casi italiani. Ciò determina una dispersione del rischio
all’interno della popolazione italiana, quando invece
il rischio sarebbe molto maggiore per i bambini delle famiglie straniere.
Si considera pertanto necessario un monitoraggio
continuo del fenomeno e si propone quindi di
migliorare, potenziare e promuovere i sistemi di sorveglianza già in uso quali il sistema di notifica e la
segnalazione dei focolai epidemici; in tal senso si
ritiene importante introdurre una chiave di linkage
tra scheda di notifica di classe IV e notifiche di classe III per relazionare i casi primari e secondari e
poter accedere ai dati sulle caratteristiche socio
demografiche dei casi individuali. Tale linkage dei
dati permetterebbe di studiare la modalità di trasmissione a livello territoriale e di individuare eventuali
aree e gruppi a rischio mediante modelli di georeferenziazione e di analisi dei determinanti sociali.
Per monitorare il rischio di trasmissione alle seconde e terze generazioni di bambini di famiglie immigrate si propone di rilevare nelle schede di notifica
oltre al Paese di nascita, anche la cittadinanza.
Infine, per ridurre il rischio di esacerbazione della
malattia a livello generale sarà necessario monitorare e migliorare l’accesso e la fruibilità dei servizi di
diagnosi e garantire a tutti (inclusi gli immigrati irregolari) le cure per il tempo indispensabile per un
corretto follow up e per la guarigione secondo le
linee guida internazionali.
BiBliografia
CARITAS/MIGRANTES (2008). Immigrazione 2008.
Dossier statistico, XVIII Rapporto. 232-233 pp.
FOCOLAI DI TUBERCOLOSI IN EMILIA ROMAGNA
ISTITUTO NAZIONALE DI STATISTICA (2009). Dati
sulla popolazione residente, bilancio demografico e
cittadini stranieri. http://demo.istat.it
ISTITUTO SUPERIORE DI SANITA’ (1998). La
tubercolosi in Italia/Italian tuberculosis index: 19551995. A cura di/Edited by Malfait P., Salamina G.,
Declich S., Squarcione S., D’Amato S., e Moro M.L.
Strumenti di Riferimento, Istituto Superiore di
Sanità, Roma. 172 pp.
LöNNROTH K., JARAMILLO E., WILLIAMS B.G.,
DYE C., RAVIGLIONE M. (2009). Drivers of
tuberculosis epidemics: the role of risk factors and
social determinants. Social Science & Medicine,
68(12): 2240-6.
Ministero della Salute - DG della Prevenzione
Sanitaria – Ufficio V – Malattie Infettive e Profilassi
Internazionale. http://www.ministerosalute.it/imgs/
C_17_pubblicazioni_613_allegato.pdf.
MINISTERO DELLA SALUTE (2009a). Legge n° 94 del
15 luglio 2009. Disposizioni in materia di sicurezza
pubblica.
REGIONE EMILIA ROMAGNA (2008). La nascita in
Emilia Romagna. 5° Rapporto sui dati del Certificato
di Assistenza al Parto (CedAP). Regione Emilia
Romagna, Giunta regionale, Direzione Generale
Sanità e Politiche Sociali.
MINISTERO DELLA SALUTE (1990). Decreto
Ministeriale 15 dicembre 1990. Sistema informativo
delle malattie infettive e diffusive.
WORLD HEALTH ORGANIZATION (2006). The Stop
TB Strategy: building on and enhancing DOTS to
meet the TB-related Millennium Development Goals.
World Health Organization and Stop TB Partnership,
Geneva. 24 pp.
MINISTERO DELLA SALUTE (1998). Decreto
Ministeriale 29 luglio 1998. Modifica alla scheda di
notifica di caso di tubercolosi e micobatteriosi non
tubercolare.
tuberculosis control: epidemiology, strategy,
financing: WHO report 2009. World Health
Organization, Geneva. 314 pp.
MINISTERO DELLA SALUTE (2009). Epidemiologia
della tubercolosi in Italia (anni 1995-2005). Fonte:
51
VOL. 14, N. 1-4, 2009
mariano’s Journey: real life health Challenges for
timor-leste 2009
1
2
m. giBBons , C. Davies
105 Green Point Drive, Forster NSW 2428, Australia
School of Nursing, Midwifery & Indigenous Health, Charles Sturt University, Locked Bag 588, Wagga Wagga
NSW 2678, Australia
1
2
summary - A recent clinical example of a young man’s journey through illness to death illustrates the heavy burden of
disease in Timor-Leste and the challenges faced by the government in developing accessible, appropriate and efficient
services. The Timor-Leste Ministry of Health has made significant advances in rebuilding the health services from near total
destruction since independence in 1999. Traditional or religious beliefs delay seeking or continuing with modern care.
Although care is free, accessing care and not working is a large financial burden. Human resources, diagnostic and technical
resources, drug supply and quality of care are often inadequate so that patients lose faith in the service. What is not acceptable in a developed country is often seen as acceptable in a developing country. With respect to the National TB Program,
active casefinding, culturally appropriate health education and promotion, follow-up of defaulters, financial and psychological support for patients may all help avoid the continuing death of young people such as this patient.
Keywords: Tuberculosis, health services, access to care, Timor-Leste
historiCal BaCKgrounD
Timor-Leste fought a guerrilla war against Indonesia
from the time of the declaration of independence
from colonial Portugal in 1975 until 1999. An estimated 200,000 people, a quarter of the population,
died from atrocities, injuries, illness or starvation
during this time (Fox and Soares, 2003). Following
the 1999 United Nations-sponsored (UN) popular
referendum in favour of independence, a three week
rampage by Indonesian military (TNI), police and
TNI-sponsored local militia caused destruction of
nearly all infrastructure, both public and private, and
most people were displaced either internally or to
West Timor. This stopped only with the arrival of
foreign peacekeeping forces (INTERFET) on 20
September 2000 (Fox and Soares, 2003). The UN
provided a transitional administration until 20 May
2002, when Timor-Leste finally became independent.
An internal security crisis erupted in 2006, involving police, army and gang violence: the Prime
Minister, Mari Alkatiri, resigned; Australian/NZ
troops were deployed as peacekeepers; and UN
police returned. Up to 115,000 people fled to
Internally Displaced Persons (IDP) camps, mainly in
the capital, Dili (World Food Programme, 2007).
However, peaceful elections have since been held,
and by August 2009 the IDP camps have been
closed.
Case report
In late 2007, a 17-year-old boy, Mariano, made a
four and a half hour journey from a small rural
village, lying in the back of a truck. Three days
earlier he had developed severe pain in his back and
had become paraplegic. When he did not recover,
his parents paid for the truck to take him to a
national hospital where he was diagnosed with
Pott’s Disease. Mariano, with his parents, spent two
months in hospital on ‘DOTS’ (Directly Observed
Treatment, Short-course) but in this time he developed large sacral bedsores. His parents, dissatisfied
with his deterioration, took him home for treatment
by a traditional healer and to tend their gardens and
animals. His catheter blocked, his ulcers worsened
and after a week he made the journey again to the
city in the back of a truck. This time he went to a
non-government organization (NGO) clinic, because
his parents were desperately seeking a cure for him,
and no longer trusted the larger hospital.
He was in urinary retention, wasted (estimated
weight 30 kgs), anemic (HB 50) and febrile due to a
th
53
M. GIBBONS, C. DAVIES
UTI. He initially seemed to respond to treatment
with IM ceftriaxone for three days but, when
changed to oral cephalexin because of a shortage of
antibiotics, he relapsed with septicemia and
pyogenic arthritis. No bacteriology testing was
available. He was given IM gentamycin but again,
only for three days. Blood from the National Blood
Bank must be replaced by donations from family or
friends, but there are cultural difficulties around
blood donation for many people. It took Mariano
more than two weeks to find a donor. Differences
between treating health workers, without laboratory
services and without essential drugs, led to
disjointed care.
He was nursed on the floor by his parents, who
cleaned him and tried to turn him; they learnt to
catheterise him, but the catheter was often found
lying in his faeces. Limited nursing care, malnutrition and ongoing poor protein and calorie intake in
the clinic also contributed to his death three weeks
after admission. The death of young people from TB
and its complications is commonly seen in TimorLeste.
Challenges illustrated by the Case study
Community
The people of Timor-Leste were amongst the poorest and sickest in Indonesia and had suffered health
atrocities such as forced contraception and sterilisation during the Indonesian occupation. During the
September 1999 rampage, health system infrastructure was destroyed and Indonesian doctors fled (Zwi
et al., 2007). Despite significant good will and aid
from the international community, the Ministry of
Health has faced many challenges developing a
primary health care service, from the Timorese
community and from within the health system itself.
Fifty per cent of Timorese live below the Basic
Needs Poverty Line. They are poorly nourished,
with micronutrient deficiencies (UNDP, 2009) and
poorly housed. Seventy-five per cent of Timorese
are rural agricultural workers widely spread across
hilly terrain which is difficult to access due to poor
roads and bridges which are often washed out by
tropical monsoons. Health posts may be a two hour
walk away, and specialised services are limited to
district capitals or the two cities. Health care is free
but illness is expensive in terms of transport costs,
time off work and time away from other family.
There is a low level of modern understanding of
health issues. Traditional and religious beliefs can
delay seeking or continuing with modern care; treatable disease is often attributed to social transgression or regarded with fatalism (Zwi et al., 2009).
Family and community often make decisions about
seeking health care. Fifty per cent of adults are illiterate so health education cannot be delivered by
54
written word alone (UNDP, 2009). Most rural
people do not have access to radio or television.
Loss of faith in modern services occurs because the
actual delivery is often inadequate (Zwi et al.,
2009).
Health Workforce and Technology
Low numbers in the health workforce have varying
and often low skills. They are lowly paid. Varying
conceptions of the health worker’s role exist with
varying commitment from workers. Many foreign
workers and volunteers within the system may not
know local epidemiology or disease protocols and
may have their own mandate (Boscolo et al., 2007).
Frequent poor health worker-patient interaction
occurs; there are social, ethnic and language barriers, yet kindness, respect and good communication
from health workers encourage presentation and
return. Within different health service organizations,
conflict and lack of trust between workers occur. In
the face of severe disease, workers have overwhelming feelings of helplessness and frustration. There
are inadequate modern technologies, for example,
limited radiology and laboratory services, inadequate supplies of essential drugs, and equipment
breakdown (Zwi et al., 2007).
Tuberculosis Control
Timor-Leste has the highest notification rate for TB
in South-East Asia and the Western Pacific (The
Global Fund, 2009). The fighting and displacements
of 1999 and 2006 led to disruptions in the National
Tuberculosis Program (NTP) and the fleeing of
many people to live in crowded camps. The NTP,
based on DOTS, commenced in the mid-1990s and
has reduced the prevalence of TB from
1,208/100,000 in 1990 to 789/100,000 in 2007
(Martins et al., 2008). Case finding relies on selfpresentation to a clinic and correct diagnosis by the
health worker. Sputum microscopy is well established but there are only three hospitals with x-ray
facilities. Many patients are treated on suspicion for
pulmonary and extra-pulmonary disease. There is
little contact tracing or active case finding, so much
undiagnosed TB contributes to new infections and
re-infections. Health services have little capacity to
cope with the complications of TB (Martins et al.,
2009).
Many health workers believe that TB deaths are
under-reported, as they occur at home in undiagnosed patients. Treatment has been clinic-based,
with little support for patients or their individual
needs. The Health Minister, Martins (2008),
acknowledged the need to decentralise treatment
services, reimburse transport costs, offer food
supplements and develop a volunteer helper
network. There is limited community knowledge of
the cause and treatment of TB and strong beliefs in
MARIANO’S JOURNEY: REAL LIFE HEALTH CHALLENGES FOR TIMOR-LESTE 2009
the value of traditional treatment (Martins, 2008).
Table 1 shows statistics for Timor-Leste in 2007.
table 1 - statistics - timor leste
Total Population (in 1000s)
Population age 0-4 (in 1000s)
Population age 15-49 (in 1000s)
Population below the Basic Needs
Poverty Line ($US 0.88/day)
Infant Mortality Rate (per 1000 live births)
Child Mortality Rate (per 1000 live births)
Prevalence of underweight children <5years
One-year-olds immunised against measles 2008
Births attended by skilled attendant
Maternal Mortality Rate (per 100,000 live births)
Number of people tested positive for HIV
Number of reported cases of malaria
Net enrolment primary school/completion rate
Rural Literacy Rate
Access to Safe Drinking Water/Sanitation
TB prevalence, all forms
TB incidence, all forms
TB incidence, smear-positive
TB mortality, all forms
no./%
1067
182
482
49.9%
77
97
48.6%
74%
41.3%
660
92
215,402
63/73%
52%
62/47%
8789
6187
2784
1093
(The Global Fund, 2009; UNDP, 2009; UNICEF, 2008)
DisCussion
Good health is a fundamental human right and has
been a priority for the government of Timor-Leste.
In the 10 years since independence, many challenges
have evolved in achieving this goal, as illustrated by
the case study. Health services have been developed
on the framework of primary health care but this
framework is not yet solid and health status remains
poor (Tab. 2). Evidence-based, cost effective solutions are known that can improve the health of the
poor, but these solutions need to be informed by,
and adapted to, local beliefs, customs and community priorities to achieve sustainable improvements
(International Federation of Red Cross, 2009).
Monitoring and ongoing research are necessary to
maintain and develop program efficiency.
Intersectoral cooperation leading to better roads and
communications will aid health service access and
improve food security, housing, water and sanitation.
For TB, DOTS provides a framework but community and individual factors must be considered for
effective implementation. Consultation with TB
patients in regards to their beliefs about their illness
and their needs (transport, food) can lead to specific
health education and support to increase the proba-
table 2 - overview of health services Development
20 september 1999-february 2000 ‘emergency period’
• UN/WHO coordination with clinical care by NGOs, INTERFET military teams
• WHO providing disease surveillance, immunization, vitamin A
• NGO Caritas continues DOTS (Directly Observed Treatment, Short-course)
february 2000
• Interim Health Authority (IHA) established – 16 Timorese health professionals, eight international advisors, with emphasis on Timorese leadership
• IHA became Ministry of Health (MoH)
september 2001
• MoH took over all public services and employed 25 expatriate doctors to work in the districts or as specialists
• NGOs continued to provide vertical services under MoH umbrella
• Health Sector Rehabilitation Project developed the National Referral Hospital in Dili, as well as five district hospitals,
seven community health centres (with beds in far districts), subdistrict clinics, health posts and mobile clinics. Every
person was to be within a two-hour walk of a health facility
• A National Laboratory was established in Dili with limited services elsewhere, as was the National Blood Bank. An
Autonomous Medical Supply Service (SAMES) provided essential drugs and medical supplies
• Primary health care principles were emphasised. Clinical services concentrated on the management of common diseases
and injuries and a Basic Package of Services included maternal and child health, immunization and nutrition; and health
promotion was developed. Vertical programs such as vitamin A supplementation, permethrin-impregnated bednets, mass
polio vaccination, de-worming, school-feeding, DOTS and Leprosy Case Finding continued or commenced.
2005
• Cuba offered a Medical Brigade of 200 health workers, including 150 doctors; every subdistrict now has doctors, and
specialist services have increased. There are 800 Timorese medical students in Cuba and the Dili Medical School has been
established.
2007
• Health status remained unchanged and the MoH made a commitment to improve services to rural people, with decentralization of services and increased community involvement in planning and delivery (SISCa - Community Health Integrated
Service).
55
M. GIBBONS, C. DAVIES
bility of treatment completion (Martins et al., 2009).
Taking services from the town clinics to the rural
villages combined with wide community education
about TB causation, early treatment success, and
emphasising the importance of prevention will
increase the numbers of people in treatment. The
rapid increase in multi-drug resistant TB and the
static or increased incidence of TB in many parts of
the world that have achieved ‘good’ results by
DOTS criteria (WHO, 2007) emphasize the need for
ongoing research to determine the most effective
approaches to control and develop technological
advances to improve efficiency.
ConClusion
Mariano’s story of multiple barriers to basic health
care is a common one in the world’s least developed
countries. His death challenges his community, his
government, his health care providers and the international community to strive to improve all the
conditions which impact on health, that is, social,
cultural, political, economic, environmental, and
medical, so that there is truly health for all.
referenCes
BOSCOLO M., MAROCCO S., ANGHEBEN A.,
MONTEIRO G., ANSELMI M., ROSSANESE A.,
BISOFFI Z. (2007). The risk of a missed or delayed
diagnosis in a changing epidemiological context.
European Journal Tropical Medicine and
International Health, 12(s1): 199.
FOX J.J., SOARES D.B. (2003). Out of the Ashes: The
nd
Destruction and Reconstruction of East Timor. 2
Edition. Published by ANU E Press, Canberra ACT
0200, Australia. 276 pp.
INTERNATIONAL FEDERATION OF RED CROSS
(2009). Timor Leste: Plan 2009-2010. Retrieved
from: http://www.ifrc.org/docs/appeals/annual09/
MAATP00109p.pdf.
MARTINS N. (2008). Qualitative study of barriers to and
enabling actors for tuberculosis adherence in TimorLeste. Public Lecture, University of Sydney: Sydney, 5
August. Retrieved from: http://www.usyd.edu.au/globalhealth/images/content/news/TB_Presentantion.pdf.
MARTINS N., GRACE J., KELLY P.M. (2008). An
ethnographic study of barriers to and enabling factors
for tuberculosis treatment adherence in Timor Leste.
56
International Journal of Tuberculosis and Lung
Disease, 12: 532-7.
MARTINS N., MORRIS P., KELLY P. (2009). Food
incentives to improve completion of tuberculosis
treatment: Randomised controlled trial in Dili,
Timor-Leste. British Medical Journal, 339:b4248.
Retrieved from: http://www.bmj.com/cgi/content/
full/339/oct26_1/b4248.
THE GLOBAL FUND (2009). Timor-Leste and the Global
Fund. Retrieved from: http://www.theglobalfund.org/
programs/grant/?compid=630&grantid=306&lang=
en&CountryId=TMP.
UNDP (2009). United Nations Development Programme.
The Millennium Development Goals, Timor-Leste 2009.
UNDP, Dili. Retrieved from: http://www.tl.undp.org/
undp/Publications/Other%20publications/MDG%20T
imor-Leste_2009.pdf.
UNICEF (2008). The state of the world’s children 2009.
UNICEF, New York. Retrieved from:
http://www.unicef.org/publications/index.html.
WORLD FOOD PROGRAMME (2007). Update on WFP
operations for refugees and internally displaced
persons. Retrieved from: http://documents.wfp.org/
stellent/groups/public/documents/op_reports/wfp122
447.pdf.
tuberculosis control: Surveillance, planning and
financing. WHO, Geneva. Report No
WHO/HTM/TB/2007.376. Retrieved from:
http://www.who.int/tb/publications/global_report/200
8/chapter_3/en/index1.html.
ZWI A., BLIGNAULT I., GLAZEBROOK D.,
CORREIA V., BATEMAN STEEL C., FERREIRA
E. & PINTO B. (2009). Timor-Leste health care
seeking behaviour study. The University of New
South Wales, Sydney. Retrieved from:
http://www.sphcm.med.unsw.edu.au/SPHCMWeb.ns
f/page/Timor-Leste.
ZWI A., MARTINS J., GROVE N., WAYTE K.,
MARTINS N., KELLY P., GUTERRES A.,
TRAVNOR D., GLEESON P., TARANTOLA D.,
WHELAN A., & SILOVE D. (2007). Timor-Leste:
Health sector resilience and performance in a time of
instability. The University of New South Wales,
Sydney. Retrieved from: www.sphcm.med.unsw.edu.au/
SPHCMWeb.nsf/page/Timor-Leste.
VOL. 14, N. 1-4, 2009
Continuing on the road for a proposal of criteria useful for
the purpose to prepare a list of essential veterinary drugs
for primary animal health care in developing countries
l. venturi
Department of Veterinary Public Health and Animal Pathology, University of Bologna, Italy
summary - The concept of essential veterinary medicines is well known as a fundamental component of promotion of
human rights in the world. From long time in Veterinary Public Health there is a lack of searches on the theme. The author,
following to a precedent communication, tries to fill the void by identifying and defining the key criteria useful to produce a
list of essential veterinary medicines for an appropriate approach to primary animal health care in developing countries.
Key words: essential veterinary medicines, primary animal health care, developing countries.
introDuCtion
Since 1977 the World Health Organization established the concept of essential drugs in human medicine defining the first “Model list of essential medicines”, one year in advance of the fundamental 1978
Alma Ata Declaration of Health For All:
“…..Essential medicines are those that satisfy the
priority health care needs of the population. They
are selected with due regard to public health relevance, evidence on efficacy and safety, and comparative cost-effectiveness. Essential medicines are
intended to be available within the context of functioning health systems at all times in adequate
amounts, in the appropriate dosage forms, with
assured quality and adequate information, and at a
price the individual and the community can afford.
The implementation of the concept of essential medicines is intended to be flexible and adaptable to
many different situations; exactly which medicines
are regarded as essential remains a national
responsibility. Experience has shown that careful
selection of a limited range of essential medicines
results in a higher quality of care, better management of medicines (including improved quality of
prescribed medicines), and a more cost-effective use
of available health resources………”
An “ad hoc” WHO Expert Committee produced in
2005 the 14 th list (World Health Organization,
2005); moreover, few years before (2002), an
International Non-Governmental Organization
(INGO) attempted to define this list in an operational way publishing a wide used 330 pages handbook (Medecins sans Frontieres, 2002) with 146
references, organized in two parts and 14 sections.
In less developed countries, exception is made for
the works of A. Daborn (1994), R.B Griffiths and
M. Ghirotti (1996) which have proposed the following definition “… veterinary essential medicines
have been defined that products that are noticed to
be more effective, in a balance with their cost, and
sure in the prevention and control, in the animal
populations, of diseases of social and economic
importance.” There are no similar lists available to
support cooperation projects in animal health and
zoonoses control and/or widely in other fields of
Veterinary Public Health (VPH).
Carrying out a foregoing debate and contacts with
some projects-managers and technicians involved in
development aid programs and following to a
preliminary note (Venturi et al., 2009) this work
tries to fill the void by identifying and defining the
key criteria useful to produce a list of essential drugs
in order to establish an initial budget for founding
field positions for primary animal health care
(PAHC) in developing countries, with particular
focus on sub-Saharan Africa.
The work has been developed through several steps
during which some pillars have been selected:
th
57
L. VENTURI
friendly, based on budget allocations and availability “in loco” of products:
a) chemotherapeutics,
b) antiphlogistics,
c) insecticides,
d) sedatives.
Establishment of some animal species: the work has
previously tried to select a target on which to focus
the following steps by identifying, in a traditional
farming way, of cattle, sheep and goats.
Identifying of the geographical area and its environmental, socio-economic and epidemiological
features: areas as tropical and subtropical savanna
and pre-desert, with high temperatures, low rainfall
and significant presence of communicable diseasesvectors (Ticks and Glossina), are the types to which
it was decided to dedicate first arguments.
DisCussion
Primary animal health care in developing countries characterized by limited human and economic
resources, low professional level of technicians,
adverse field conditions, traditional models of livestock management - needs support to enable veterinarian services in providing appropriate interventions aimed to the control of various animal diseases
of social and economic importance (Venturi, 1993;
Venturi et al., 1998).
This proposal of criteria for the purpose to prepare a
list of essential drugs is the output of a project held
in the Postgraduate School of the Faculty of
Veterinary Medicine of the University of Bologna
and they are selected with due regard to public
health relevance, evidence on efficacy and safety,
and comparative cost-effectiveness.
The implementation of a concept of essential veterinary drugs - to be understood as a contribution of
Veterinary Public Health to a more and more
approved movement, so-called “One Medicine for
One Health” and to the achievement of human rights
(Hogerzeil, 2006) - is intended to be flexible and
adaptable to different situations, therefore the
proposed tools are in the field being a useful support
for technical assistance in developing countries but a
discussion paper too.
Construction of a check list which takes into
account the reduced effect of induction of drug
resistance, limited suspension time, good resistance
to adverse weather conditions, wide spectrum, costeffectiveness balance: some characteristics consistent with the “basic criteria” established for essential drugs were selected to build a system based on
sheets and weighted scores.
Production of a sheet for each selected category and
validation of its appropriateness: four drug classes
have been built, tested and proposed by the working
group with the attempt to produce a support in
cooperation project formulation and its implementation.
results
The four tables reported allow - as a hypothesis
submitted to the experience test - the selection of
drugs categories, the organization of references in
the form of a limited range compendium of usertable 1 - pharmacological class: Chemotherapeutics
SELECTION
CRITERIA
SPECTRUM STABILITY (resistance to
PERIOD OF
DRUG
EASY TO USE (administration EXPENSE
OF ACTIVITY adverse weather conditions) SUSPENSION RESISTANCE
way and dosage)
1-6 pt
1-6 pts
1-4 pts
1-3 pts
1-4 pts
1-6 pts
SCORE
6-29 pts
MEDICAMENT 1
table 2 - pharmacological class: antiphlogistics
SELECTION
CRITERIA
ADVERSE
EFFECTS
PERIOD OF
SUSPENSION
DRUG
RESISTANCE
EASY TO USE (administration
way and dosage)
EXPENSE
SCORE
1-4 pt
1-4 pts
1-3 pts
1-4 pts
1-6 pts
5-21 pts
MEDICAMENT 1
table 3 - pharmacological class: insecticides (external and/or internal use)
SELECTION
CRITERIA
SPECTRUM
OF ACTIVITY
PERIOD OF
SUSPENSION
EASY TO USE (administration
way and dosage)
ADVERSE EFFECTS
EXPENSE
SCORE
1-6 pt
1-4 pts
1-4 pts
1-4 pt
1-6 pts
5-24 pts
MEDICAMENT 1
table 4 - pharmacological class: sedatives
SELECTION
CRITERIA
MEDICAMENT 1
58
STABILITY (resistance to adverse weather
conditions)
EASY TO USE (administration way
and dosage)
EXPENSE
SCORE
1-5 pt
1-4 pts
1-6 pts
3-15 pts
CONTINUING ON THE ROAD FOR A PROPOSAL OF CRITERIA USEFUL FOR THE PURPOSE TO PREPARE A LIST OF ESSENTIAL
referenCes
DABORN C. (1994). Round Table on the “Management
of essential drugs and vaccines for development
projects in Africa”. Istituto Superiore di Sanità,
Rome, 5 - 7 July, 1994.
GHIROTTI M. (1996). A proposal for the adoption of an
essential veterinary drugs policy for development and
emergency projects in Africa. Giornale Italiano di
Medicina Tropicale, 1(1-2): 157-165
HOGERZEIL H.V. (2006). Essential medicines and
human rights: what can they learn from each other?
Bulletin of the World Health Organization, 84: 371375.
MEDECINS SANS FRONTIERES (2002). Médicaments
essentiels - Guide pratique d’utilisation. Troisieme
Edition Revisée, 1998.
VENTURI L. (1993). Monitoraggio e valutazione dei
progetti di cooperazione per l’allevamento nei PVS.
La Medicina Tropicale nella Cooperazione allo
Sviluppo, 9(2-3): 105-107.
VENTURI L., BERNABEO A., CAPPUCCIO P.,
CIARAVINO G., COSSIO A., DARDI M.,
D’ANTONIO M., DIAFERIA M., DELL’ANNA S.,
FAGIOLI P., FALASCA P., GNUDI M., LIGABUE
M., PALAZZO S., RAGONA G., RAVAGLIA C.,
SAVORELLI E. (2009). A proposal of criteria useful
for listing essential veterinary drugs for primary
animal health care in developing countries. Tropical
Medicine and International Health, 14(2): 110-111.
VENTURI L., LOLLI A., DINIS J., KIASSEKOKA M.
(1998). Relatorio do primeiro seminario nacional
“Impacto da Medicina Veterinaria na Saude Publica
em Angola”. Lubango, Angola, 15-16 Sep 1998.
WORLD HEALTH ORGANIZATION (2005). The
selection and use of essential medicines. Report of
the Expert Committee. Technical Report Series, 933.
World Health Organization, Geneva.
59
istruzioni per gli autori
La Rivista “Giornale Italiano di Medicina Tropicale”
(Italian Journal of Tropical Medicine) pubblica:
- articoli originali, rassegne, note brevi, monografie, atti di
congressi, brevi note tecniche nei diversi campi attinenti
alla medicina tropicale umana e veterinaria e attività di
cooperazione sanitaria, lettere al Direttore.
presentazione Dei manosCritti
I lavori devono essere inviati al Direttore della Rivista
“Giornale Italiano di Medicina Tropicale”, c/o Istituto
Superiore di Sanità, Dipartimento di Malattie Infettive,
Parassitarie e Immunomediate, Reparto di Malattie trasmesse da Vettori e Sanità Internazionale, Viale Regina
Elena, 299 - 00161 Roma. Possono essere presentati solo
lavori originali, ovvero che non siano stati pubblicati né
presentati per la pubblicazione altrove, in lingua italiana,
inglese o francese.
I lavori saranno sottoposti a valutazione da parte di
Esperti nei diversi settori.
I dattiloscritti devono essere presentati in duplice copia
con doppia spaziatura.
I lavori originali devono essere suddivisi in sezioni:
Introduzione, Materiali e Metodi, Risultati, Discussione e
Bibliografia.
Ogni articolo deve essere necessariamente accompagnato
da:
- un riassunto in italiano e in inglese (contenente il titolo),
di circa 200 parole, presentati su pagine separate;
- parole chiave in inglese, fino a un numero massimo di
cinque.
Nel testo potranno essere usati termini abbreviati purché
citati per esteso la prima volta che compaiono, seguiti dall’abbreviazione inserita tra parentesi.
Le note tecniche non necessariamente devono contenere
un riassunto e non devono essere suddivisi nelle diverse
sezioni.
Le lettere al Direttore non dovrebbero eccedere le 500
parole; tabelle e figure sono raramente accettate. I riferimenti bibliografici, solo se essenziali, devono essere citati
nel testo.
prima pagina
La prima pagina del manoscritto deve includere il titolo
seguito dai nomi degli Autori e dall’indicazione degli
Istituti di appartenenza, città e stato, e un titolo corrente di
massimo 40 caratteri (inclusi lettere e spazi).
Deve inoltre essere chiaramente indicato il nome dell’autore al quale dovrà essere indirizzata la corrispondenza, il
suo indirizzo, numero di telefono e fax.
presentazione Del testo su CD
E’ gradita la presentazione del testo anche su CD, indicando il programma di videoscrittura utilizzato e la versione
(preferibilmente una versione di Microsoft Word).
taBelle e figure
Le tabelle devono essere presentate su pagine separate;
ciascuna tabella deve essere fornita di didascalia sufficiente a renderlo comprensibile anche senza riferimenti al
testo.
Le figure (disegni, grafici e fotografie) devono essere presentate su pagine separate in forma adatta per la riprodu-
VOL. 14, N. 1-4, 2009
zione su singola colonna (75 mm), su pagina intera (160
mm).
Le didascalie delle figure devono essere riportate in pagine separate e devono fornire una sufficiente spiegazione
dell’oggetto.
Tabelle e figure devono avere numerazione progressiva
(in numeri arabi) ed essere citate all’interno del testo.
riferimenti BiBliografiCi
Tutti i riferimenti bibliografici devono essere citati nel
testo fra parentesi indicando l’Autore o gli Autori e l’anno
di pubblicazione. Se gli Autori sono più di due, deve essere citato solo il primo, seguito da “et al.”
Tutti i riferimenti bibliografici citati nel testo devono essere riportati alla fine dell’articolo in ordine alfabetico,
secondo il seguente modello:
a) Lavori pubblicati su riviste: cognome dell’Autore con
l’iniziale del nome, anno di pubblicazione in parentesi,
titolo del lavoro, nome della rivista per intero, numero del
volume, prima e ultima pagina, es.:
PASTICCI M.B., MORETTI A., PAULUZZI S. (1991).
Antibiotic resistance in methicillin-resistant staphylococchi: a cause for concern. Farmaci & Terapia, 8: 203-204.
ROUGEMONT A., BRESLOW N., BRENNER E.,
MORET A.L., DOUMBO O., DOLO A. SOULA G. &
PERRIN L. (1991). Epidemiological basis for clinical diagnosis of childhood malaria in an endemic zone in West
Africa. The Lancet, 338: 1292-5.
b) Libri: cognome dell’Autore con l’iniziale del nome,
anno di pubblicazione in parentesi, titolo per intero, edizione, nome e città della casa editrice, prima e ultima
pagina, es.:
BRUCE-CHWATT L.J. (1985). Essential Malariology
(2nd edition). W. Heinemann Medical Books, London.
452 pp.
CASSONE A., TOROSANTUCCI A. (1991).
Immunological moieties of the cell wall. In: The molecular biology of Candida albicans. R. Prasad (Ed.). Springer
Verlag, Berlin-Heidelberg, pp. 89-107.
control of Schistosomiasis. Technical Report Series n.
728. World Health Organization, Geneva. 113 pp.
c) Atti di Congresso: cognome dell’Autore con l’iniziale
del nome, anno di pubblicazione in parentesi, titolo del
lavoro, titolo degli Atti, luogo e data del Congresso, nome
e città della casa editrice, numero delle pagine, es.
SOULE’ C., FABIEN J. F., MAILLOT E. (1994) Animal
Hydatidosis in France. In: Abstracts of 8th International
Congress of Parasitology. Izmir, Turkey, 10-14 October
1994. Turkish Society for Parasitology. Izmir, Turkey, p.
348.
Bozze
Le bozze dell’articolo saranno inviate agli autori per la
correzione e dovranno essere restituite con il visto “si
stampi” corredato da firma, entro 3 giorni dalla ricezione.
61
VOL. 14, N. 1-4, 2009
instruCtions to authors
Giornale Italiano di Medicina Tropicale (Italian Journal of
Tropical Medicine) publishes:
- original articles, review articles, monographic issues,
short notes, technical notes on health cooperation programmes in the different field of tropical medicine, proceedings of meetings, letters.
presentation of the manusCripts
Manuscripts submitted for publication should be sent to:
The Editor, “Giornale Italiano di Medicina Tropicale”, c/o
Istituto Superiore di Sanità, Dipartimento di Malattie
Infettive, Parassitarie e Immunomediate, Reparto di
Malattie trasmesse da Vettori e Sanità Internazionale,
Viale Regina Elena, 299 - 00161 Roma, Italy.
All works submitted for publication must be original.
They are submitted for review to qualified Referees.
English and Italian languages are accepted.
The Authors are kindly requested to present their manuscripts in two copies printed and on CD with the exact
name and version of the word processing program used.
Original articles should be divided into the following sections: Introduction, Materials and Methods, Results,
Discussion, and References.
Each paper must be accompained by:
- a summary (with the title translated) in English of up to
200 words. Papers in Italian must have also a summary in
Italian;
- key words in English, up to 5 words.
All abbreviations and acronyms must be put in extenso the
first time they are used.
Short notes and technical notes should not have an
abstract and need not to be divided into sections.
Letters to the editor should not exceed 500 words; tables
and figures are rarely accepted. References, if essential,
should be given in the text.
first page
The first page of each manuscript should contain the title,
the name(s) of author(s), the institution of the author(s),
and e-mail address for the correspondence.
A running title of no more than 40 characters (including
letters and spaces) should also be provided.
taBles anD figures
Each table should be typed on a separate sheet. The heading should be sufficiently clear so that the meaning of the
data will be understandable without reference to the text.
Figures (drawings, graphs, photographs) should be of a
size suitable for reduction to single column (75mm) or full
page (160mm) width. Figures should be in .jpg or .tif format.
Figure legends should be sufficiently clear so that the
figure is understandable without reference to the text.
Tables and figures should be numbered with Arabic numbers in a consecutive and independent way and must be
referred to in the text.
62
referenCes
The list of references should include only those publications which are cited in the text and should be in alphabetical order at the end of the paper.
In the text, references should be cited thus: “.......it has
been shown (BRUCE-CHWATT, 1986).
If there are two authors, both should be named; if more
than two, only the first need to be named, followed by “et
al.”, in the text.
Each reference should include the following:
a) Paper published in periodicals: Author’s surname with
the initials of first name, year of publication in brackets,
full title of paper, full journal title, volume number, first
and last page numbers, e.g.:
PASTICCI M.B., MORETTI A., PAULUZZI S. (1991).
Antibiotic resistance in methicillin-resistant staphylococchi: a cause for concern. Farmaci & Terapia, 8: 203-204;
ROUGEMONT A., BRESLOW N., BRENNER E.,
MORET A.L., DOUMBO O., DOLO A. SOULA G. &
PERRIN L. (1991). Epidemiological basis for clinical diagnosis of childhood malaria in an endemic zone in West
Africa. The Lancet, 338: 1292-5.
b) Books: Author’s surname with the initials of first name,
year of publication in brackets, full title, edition, name and
city of publisher, first and last page numbers e.g.
BRUCE-CHWATT L.J. (1985). Essential Malariology
(2nd edition). W. Heinemann Medical Books, London.
452 pp.
CASSONE A., TOROSANTUCCI A. (1991).
Immunological moieties of the cell wall. In: The molecular biology of Candida albicans. R. Prasad (Ed.). BerlinHeidelberg, Springer Verlag, pp. 89-107
control of Schistosomiasis. Technical Report Series n.
728. World Health Organization, Geneva. 113 pp.
c) Abstracts in Proceedings of Congress: Author’s surname with the initials of first names, year of publication in
brackets, full title, name and city of publisher, page numbers, e.g.:
SOULE’ C., FABIEN J. F., MAILLOT E. (1994). Animal
Hydatidosis in France. In: Abstracts of 8th International
Congress of Parasitology. Izmir, Turkey, 10-14 October
1994. Turkish Society for Parasitology. Izmir, Turkey, p.
348.
proofs
Proofs will be sent to Authors for correction and should be
returned to the Editorial Office.

Giornale Italiano di Medicina Tropicale Italian Journal of

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