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Healthcare in developing countries less funded than developed nations (0.8 to 4% vs. 10 to 15%, respectively), and must contend against approximately 1/3 of the population living below the poverty line ($1US/day), poor literacy (58% males/29% females), and less access to potable water and basic sanitation. Cultural and societal constraints combine with these economic obstacles to translate into poor transplantation activity. Donor shortage is a universal problem. Paid donation comprises 50% of all transplants in Pakistan. Post-transplant infections are a major problem in developing countries, with 15% developing tuberculosis, 30% cytomegalovirus, and nearly 50% bacterial infections. The solutions to these problems may seem simplistic: alleviate poverty, educate the general population, and expand the transplant programs in public sector hospitals where commerce is less likely to play a major role. The SIUT model of funding in a community-government partnership has increased the number of transplantations and patient and organ survival substantially. Over the last 15 years, it has operated by complete financial transparency, public audit and accountability. The scheme has proven effective and currently 110 transplants/year are performed, with free after care and immunosuppressive drugs. Confidence has been built in the community, with strong donations of money, equipment and medicines. We believe this model could be sustained in other developing nations.
In developing countries, many human immunodeficiency virus (HIV)-infected children require intensive care unit (ICU) resources for pneumonia, but there is little information on the etiology of pneumonia or the impact of ICU intervention. OBJECTIVE: To compare the etiology and outcome of pneumonia in HIV-positive and seronegative children admitted to ICU. DESIGN: Prospective study. SETTING: Two pediatric ICUs linked to the University of Cape Town, South Africa. PATIENTS: Consecutive children admitted for pneumonia during 1998. MEASUREMENTS AND MAIN RESULTS: Clinical, demographic, ventilatory, and laboratory data were collected. Blood for testing was obtained. Induced sputum or nondirected bronchoalveolar lavage was performed for culture and Pneumocystis carinii identification; gastric lavage (GL) provided specimens for mycobacterial culture. Seventy-six children (21 [27.6%, 95% confidence interval {CI} = 18-39.1] HIV-positive) were enrolled. At admission, HIV infection was diagnosed in 15 of the 21 (71.4% [47.8-88.7]) HIV-positive patients. P. carinii pneumonia occurred in eight HIV-positive children (38% of HIV-infected patients) and one HIV-negative child. It was the acquired immunodeficiency syndrome (AIDS)-defining illness in seven children (47%). The incidence of bacteremia (15.3%) was similar in HIV-positive (15.8%) and HIV-negative children (15.1%), p =.94; Streptococcus pneumoniae and Staphylococcus aureus were the predominant isolates. Bacterial and viral isolates from sputum or bronchoalveolar lavage, including Mycobacterium tuberculosis in six (8%) children, did not differ by HIV status. Intermittent positive pressure ventilation was used in 8 of 21 (38%) HIV-positive children and 28 of 55 (51%) HIV-negative children, p =.32. Median days of intermittent positive pressure ventilation (3 [2-6]), ICU (5 [3-9.5]), and hospital (11 [7.5-19]) did not vary by HIV status. The in-hospital mortality rate for HIV-positive children (6 of 21 [28.6%]) was double that for seronegative patients (8 of 55[14.5%], relative risk [RR] 1.96 [0.77-4.99], p =.16). CONCLUSION: More than a quarter of children admitted to ICU for pneumonia in this geographic area are HIV-positive; most are diagnosed with HIV at admission. P. carinii pneumonia is a common AIDS indicator disease. HIV-infected children admitted with pneumonia had a worse outcome than seronegative children, a difference that is rendered statistically insignificant by the small sample size.
In developed countries where tuberculosis is increasing in association with HIV infection, nosocomial transmission among patients and from patients to health care workers is being increasingly reported. Nosocomial tuberculosis among HIV-infected patients is difficult to prevent by conventional control measures because the clinical presentation of the disease may be atypical and confused with other respiratory infections, because the tuberculin skin test is less reliable, because cough generating procedures may increase the probability of transmission, because HIV-infected patients may progress rapidly from infection to disease, and because the organisms are increasingly drug resistant, making preventive therapy difficult. Substandard ventilation and the recirculation of air in many contemporary buildings has also been implicated in widespread nosocomial transmission. Source control through isolation and effective treatment of known or suspected cases remains the most effective strategy for preventing transmission. Dilution of infectious droplet nuclei through ventilation with outside air is important, but incompletely protective. Like ventilation with outside air, filtration of recirculated air may reduce the chance of infection by dilution, but it is expensive. Traditional surgical masks offer the wearer little or no protection. Finally, ultraviolet air disinfection may augment ventilation by inactivating organisms in the upper room air, or in ventilation ducts.
In developed countries, the excess consumption of some nutritive factors and foodstuffs becomes a major problem. The consumption of fat is included here due to its contribution to the high energy intake and its potential health risks. The consumption of fat as a nutrient is characterized by a steady increase. The physiological requirements of fat intake are not included in many dietary allowances and requirements of other indicators, such as linoleic acid, fatty acids, and cholesterol, are formulated in scientific papers only. The confrontation of existing fat allowances with the effective consumption indicates a tremendous excess. The same is true of some other indicators. The findings about the consumption of fat commodities complete these considerations. The indicated problems of fat consumption reveal the important position of this nutrient and of fat commodities in the food and nutrition situation. But opinions about these important factors are not sufficiently formulated what causes difficulties in food and nutrition planning and therefore in elaborating of the food and nutrition policy. For this reason, the international unification of opinions is urgently needed.
Microbiological risk assessment (MRA) has been evolving at the national and international levels as a systematic and objective approach for evaluating information pertaining to microbiological hazards in foods and the risks they pose. This process has been catalyzed by international food trade requirements to base sanitary measures on sound scientific evidence and appropriate risk assessments. All countries, including developing countries, need to understand and use MRA. MRA is resource intensive, as has been demonstrated by some of the the assessments undertaken in industrialized countries. However, when used in the appropriate circumstances MRA offers many benefits. The process of undertaking MRA improves the understanding of key issues, enables an objective evaluation of risk management options, and provides a scientific justification for actions. Although the gap between developing countries and some industrialized countries is quite extensive with regard to MRA, many developing countries recognize the need to at least understand and move toward using MRA. This process requires development of infrastructure and enhancement of scientific and technical expertise while making optimal use of limited resources. International organizations, such as the Food and Agriculture Organization of the United Nations, are in a position to provide countries with guidance, training, information resources, and technical assistance to develop and/or strengthen food safety infrastructure. Enhanced cooperation and collaboration at all levels are needed for such efforts to be successful and to ensure that MRA, as a food safety tool, is available to all countries.
Information can be an important tool in promoting a prevention strategy to address the emerging epidemic of cardiovascular disease in developing countries. Advances in information and communication technology offer new promises for global access to information and for global mobilization to prevent and control cardiovascular disease. This is especially true for health professionals, whose needs in areas such as networking, exchange of expertise and access to relevant advances remain unfulfilled. Information technology can also sensitize the lay public to the magnitude of cardiovascular diseases, creating awareness about risk states, and highlighting preventive strategies. Effective application mandates that the technology be relevant to local needs. Cost, feasibility, and relevance of information need to be considered before wide adoption is advocated. Several initiatives, such as ProCOR, Global Cardiovascular Infobase, Heartfile, and the Virtual Congress of Cardiology, have successfully utilized information technology to promote cardiovascular prevention. The experience of these initiatives suggests that, while information technology holds great potential, there are many potential perils, such as the widening global information gap, inequitable access, and irrelevant information. For now, information technology must be viewed as part of a broader strategy, which includes conventional communication media, to address the unmet information needs for cardiovascular prevention globally. Enlightened policies can exploit the energies of the recent information boom for promoting cardiovascular prevention, taking into account the considered limitations.
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