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Biomedical subjects

R Brugha

Publications and source records attributed to R Brugha.

31 records · Page 2Linked to original sources
PubMed1999

Shifting the paradigm in tuberculosis control: illustrations from India.

Drawing on literature from India and key contributions from social science, this paper asks and attempts to answer the question 'who is to blame for treatment failures in TB'? Some key lessons emerge: effective tuberculosis control cannot be achieved so long as the disease is considered in isolation from the social processes that maintain it, create the conditions facilitating its spread and act as barriers to care. Insights into the economic and social burdens incurred with a diagnosis of TB are essential to understand why many patients, especially the most disadvantaged, are unable to comply with treatment regimens. TB and health care interventions need to be appropriate to the health service contexts in which they are applied, and sensitive to the competing demands, needs and priorities of people's lives. The paper argues for the need to reorient TB control programmes towards enabling patients to obtain care. The problem of access emerges as central to people's ability to obtain and maintain appropriate therapy. Examples and characteristics of successful non-governmental projects, from which policy makers, programmers and practitioners could learn, are outlined and contrasted with more rigid directly observed treatment approaches. We conclude that treatment failures are not patient failures, and that TB control programmes need to address the social dimensions of TB, and adhere to the principles of good TB care, with the same commitment that is devoted to ensuring patients follow treatment guidelines. We suggest a paradigm shift away from a focus on diseased patients towards enabling health in the community.

Antitubercular Agents↗
PubMed1998

Salivary diagnosis of rubella: a study of notified cases in the United Kingdom, 1991-4.

Rubella infections, notified by general practitioners on the basis of a clinical diagnosis, were investigated by testing blood and saliva samples for specific IgM. Overall 52 (29%) of 178 cases with appropriately timed blood specimens were confirmed as recent rubella by IgM serology. Only 2 (3%) of 74 cases in children under 5 years were confirmed compared to 50 (48%) of 104 cases in older children and adults. The confirmation rate was lower (6%) in those with documented vaccination history than in those without (42%). The specificity of saliva rubella IgM testing compared to testing corresponding blood samples was 99%. The overall sensitivity of saliva rubella IgM testing was 81%. This rose to 90% if results from inappropriately timed specimens and specimens taking more than 1 week to reach the laboratory were excluded. A corresponding saliva rubella IgG test was 98% sensitive and 100% specific. Of 126 rubella IgM negative cases, 25 (20%) were positive for parvovirus B19 IgM. This study confirmed that rubella surveillance based on clinical reports is not specific. It also demonstrated that saliva samples, if taken 7-42 days after onset of illness and transported rapidly to the laboratory, are a feasible alternative to blood samples for rubella surveillance.

Adolescent↗
PubMed1998

Improving the quality of private sector delivery of public health services: challenges and strategies.

Despite significant successes in controlling a number of communicable diseases in low and middle income countries, important challenges remain, one being that a large proportion of patients with conditions of public health significance, such as tuberculosis, malaria, or sexually transmitted diseases, seek care in the largely unregulated 'for profit' private sector. Private providers (PPs) often offer services which are perceived by users to be more attractive. However, the available evidence suggests that serious deficiencies in technical quality are often present. Evaluations of interventions to promote evidence-based care in high income countries have shown that multi-faceted strategies which increase provider knowledge have had some success in improving service quality. A wider range of factors needs to be considered in low and middle income countries (LMICs), especially factors which contribute to discrepancies between provider knowledge and practice. Studies have shown that PPs, especially, perceive or experience patient and community pressures to provide inappropriate treatments. LMIC governments also lack the capacity to enforce regulatory controls. Context-specific multi-faceted strategies are needed, including the local adaptation and dissemination to providers of relevant evidence, the education of patients and communities to adopt effective treatment-seeking and treatment-taking behaviour, and feasible mechanisms for ensuring and monitoring service quality, which may include a role for self-regulation by provider organizations or provider accreditation. Developing, implementing and evaluating strategies to improve the quality of service provision will depend on the involvement of the key stakeholders, including policy makers and PPs. Focusing on studies from Asia, Africa and Latin America, this paper develops a model for identifying the influences on PPs, mainly private medical practitioners, in their management of conditions of public health significance. Based on this, multi-faceted strategies for improving the quality of treatment provision are suggested. Interventions need to be inexpensive, practical, efficient, effective and sustainable over the medium to long term. Achieving this is a significant challenge.

Developing Countries↗
PubMed1998

Risk of hepatitis A infection in sewage workers.

OBJECTIVE: To evaluate the risk of hepatitis A virus (HAV) infection among sewage workers from occupational exposure to raw sewage. METHODS: An analytical cross sectional study of 241 company employees with possible occupational exposure to sewage in a large water and sewerage company was carried out. Previous exposure to hepatitis A virus infection was assessed, as were its associations with possible risk factors. RESULTS: Frequent occupational exposure to raw sewage was a significant risk factor for HAV infection, independently of other known risk factors (odds ratio 3.73, 95% confidence interval 1.48 to 9.37). Of 50 employees who reported occupational exposure to raw sewage most of the time, 30 (60%) had had HAV infection. CONCLUSION: Employees who are likely to be at risk of frequent exposure should have their immunity ensured. The salivary assay for IgG anti-HAV used in the study was highly specific and would be suitable for prevaccination testing of older employees, who are more likely to be immune.

Adult↗
PubMed1997

Genital herpes infection: a review.

Genital herpes infection is life-long and may result in painful and recurrent genital lesions, systemic complications, serious psychosocial morbidity, and rare but serious outcomes in neonates born to infected women, including permanent neurological handicap and death. Herpes simplex virus (HSV)-2 is the principal cause, with an increasing proportion of first-episode disease caused by HSV-1. Genital HSV transmission is usually due to asymptomatic viral shedding by people who are unaware that they are infected and clinical screening fails to detect most infections. Type-specific serological assays can distinguish the two viral subtypes, but these are expensive and currently restricted to a few research settings. Most infections are asymptomatic, or cause a mild illness which does not lead to health service attendance; but the limited evidence suggests a rise in disease incidence, perhaps related to a fall in HSV-1 age-specific prevalences. The prevalences of HSV genital infections increase with age and numbers of sexual partners, with higher rates in specific ethnic and low socioeconomic groups. However, infection is not restricted to high-risk populations. Antiviral agents, such as acyclovir, can reduce disease severity, prevent recurrences and shorten periods of viral shedding, but currently there are no effective population control measures. This may change with the advent of HSV vaccines, if their safety and long-term efficacy are confirmed. Possible applications for vaccines may include the suppression of disease and recurrences in patients with genital infections (immunotherapy), the prevention of viral transmission to their seronegative partners, and immunoprevention through vaccinating the latter. Economic evaluations of existing and potential control strategies, age-specific population HSV-1 and 2 seroprevalence studies for targeting future interventions, and cohort studies to elucidate the natural history of HSV-2 infections are needed.

Antiviral Agents↗
PubMed1997

Epidemiology of genital Chlamydia trachomatis in England and Wales.

OBJECTIVE: To describe the recent epidemiology of genital Chlamydia trachomatis infection in England and Wales. DESIGN: Retrospective study of routinely available surveillance datasets and ad hoc prevalence studies. METHODS: Numbers of new cases of genital C trachomatis infection, obtained from the Department of Health and Welsh Office, were combined with the estimated mid-year resident population of England and Wales. Rates were analysed for trend over time using a log linear age period model in GLIM4. Ad hoc prevalence and case finding studies carried out over the past 20 years were critically assessed in terms of study design and testing methodologies. RESULTS: Attendance rates at genitourinary medicine (GUM) clinics were higher for women than men over the period 1989 to 1994 as were the number of laboratory reports. The highest rate of attendance (GUM clinic data) was for women aged 16 to 19 years. There was an overall significant linear decrease in the attendance rates over time for both men (p = 0.0172) and women (p = 0.0000) between 1989 and 1994. There was considerable variation in the prevalence of genital C trachomatis infection detected within different clinical settings, together with a substantial level of asymptomatic infection. CONCLUSIONS: Genital C trachomatis infection is broadly distributed throughout the sexually active population, with a substantial reservoir of asymptomatic infection among those generally perceived to be at low risk of a sexually transmitted infection. Young people, particularly women aged 16 to 19 years, are at highest risk of genital C trachomatis infection. This is of concern since younger women are more susceptible than older women to developing complications of chlamydial infection, such as pelvic inflammatory disease. The broad distribution of infection across all sexually active health service attenders and the high level of asymptomatic infection suggest that a new, screening based, approach to the control of genital C trachomatis infection is required. Recommendations are made as to the epidemiological research required to guide such work.

Adolescent↗
PubMed1997

Surveillance of measles in England and Wales: implications of a national saliva testing programme.

The impact of a mass vaccination campaign against measles-rubella in England and Wales was assessed using the results of a saliva test for measles-specific IgM, which was offered to all notified cases of measles. By means of clinical data supplied by the reporting doctors, we estimated the sensitivity and specificity of various clinical case definitions in predicting a confirmed case. A saliva sample was obtained within the appropriate time period for 3442/7574 (45.4%) of notified cases; the proportion confirmed by saliva testing was low and fell from 67/681 (9.8%) at the start of the campaign to 1/373 (0.3%) after 35 weeks. The specificity of all clinical case definitions was low, but was highest at 41.1% (95% confidence interval, 39.2-43.0%) for the definition similar to that recommended in the USA. Extrapolating from cases observed during ongoing surveillance permits estimation of an annual notification rate for nonmeasles rash and fever illness. For countries with good measles control, a clinical case definition is too nonspecific for accurate surveillance. Laboratory confirmation of suspected measles cases is required and saliva testing is an acceptable method. The continued sensitivity of measles surveillance in England and Wales requires that the incidence of notified rash and fever illness and the proportion of cases in which measles infection was excluded by laboratory testing be monitored.

Adolescent↗
PubMed1996

A study of maternally derived measles antibody in infants born to naturally infected and vaccinated women.

Maternal, cord and infant measles antibody levels were measured and compared in a group of 411 vaccinated mothers and 240 unvaccinated mothers, and their babies, between 1983 and 1991. Maternal and cord sera were tested by haemagglutination inhibition and/or enzyme-linked immunosorbent assay, and plaque reduction neutralization tests were also used to test infant sera. Geometric mean titres were significantly higher in the unvaccinated than in the vaccinated mothers (P < 0.001). Infants born to mothers with a history of measles had higher antibody levels at birth than infants of vaccinated mothers and, although the difference narrowed over time, continued to have higher levels up to 30 weeks of age. Between 5 and 7 months of age significantly more of the children of vaccinated mothers had plaque reduction neutralization antibody levels below that which would interfere with vaccination. As the boosting effect of circulating natural measles disappears, earlier measles vaccination may need to be considered, perhaps as part of a two-dose policy.

Adult↗
PubMed1995

Immunization determinants in the eastern region of Ghana.

A study of the immunization determinants of children aged 12 to 18 months was conducted in 1991 in the Eastern Region of Ghana, using structured interviews of mothers and fathers. The completion of immunization schedules by one year, among the 294 children, was positively associated (P < 0.005) with the town of residence of the child and mother, the ability of the mother to speak English, the target child having been treated for illness at the local hospital, the child's mother having given birth to less than 5 children, the possession of a sewing machine by the mother, and the birth of the child in the current town of residence. Significantly higher immunization coverage levels were achieved where the Under Fives' Clinic was an affordable and acceptable service, integrating preventive and curative care, and where measures were implemented by the community to increase attendance levels at the Clinic. This was achieved among a target group who were otherwise at a relatively high risk of failing to complete immunization schedules on-time.

Fathers↗
PubMed1994

HIV counselling and care programmes at the district level in Ghana.

The district hospital is the focus for the presentation of HIV-related disease in rural sub-Saharan Africa. Patients require not only medical care, but often economic support and counselling for themselves and their families. Psychosocial support should be provided at the hospital and in the home, the latter often being the preferred option. A team approach to HIV disease care and counselling, with careful selection and support of staff, and appropriate training in counselling skills is essential. A primary health care approach at the district level, mobilizing community participation and intersectoral support is necessary. Community Health Outreach Departments, as integral parts of the district hospital, are recommended and could pilot low-cost HIV hospital and home-care programmes.

Community Health Services↗
PubMed1994

Determinants of nutrition status among children in the eastern region of Ghana.

A cross-sectional survey of children's weights was included in a population study which was designed to identify and measure the determinants of immunization status of 12-18-month-old children of 294 mothers in the Eastern Region of Ghana. Birth weight, among a subgroup of 91 children where this information was available from the mothers' Road To Health cards, was the variable with which current weight-for-age Z scores was most strongly associated (r = 0.38). Associations of current weight-for-age with certain socio-economic variables, at or close to statistically significant levels, corresponded with similar or stronger associations of birth weight with these same socio-economic variables. Cross-sectional studies of young children, to identify associations and possible determinants of nutrition status, are more informative where there is a high Road To Health card coverage and where birth weights have been recorded on these cards.

Birth Weight↗