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BACKGROUND: In a population-based epidemiological study in Ngaoundere, Cameroon, we studied cross-sectional child morbidity and the cost of necessary investigation and treatment. METHODS: Three teams of two to three health workers visited haphazardly selected households in all major housing quarters. We asked permission to enter for a health survey. Children with cough, fever or weight loss as well as sick adults were offered free-of-charge local hospital examination and treatment. RESULTS: From 177 households with 1777 persons, 51 (2.9%) persons were referred. Thirty-five of them had an undiagnosed disease threatening individual health and in many cases also public health. Seven were hospitalised, including three adults with tuberculosis. Malnutrition was diagnosed in nine small children. Four patients had AIDS, seven had malaria. Average total cost for ambulant patients was 15 USD, for hospitalised patients 110 USD.In the households, almost half of the women 16-50 years of age had no schooling. Two per cent of women and nine per cent of men were daily smokers. Coughing children were more likely than non-coughing children to live in a household with at least one smoker (OR = 3.58, 95% CI 1.72 to 7.46), and they generally lived in more poor households (P = 0.018). Twelve of 16 children with weight loss were referred from households with a high poverty score. CONCLUSIONS: Adult smoking and poverty affect children's health. The cost of hospitalisation or long-lasting therapy is beyond the means of most ordinary families. Diseases with severe consequences for public health, like tuberculosis, AIDS and malaria should have national programs with free, decentralised examination and treatment. Access to generic drugs is important. A major educational effort is needed to improve public health.
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PMID:Cross-sectional study of morbidity, morbidity-associated factors and cost of treatment in Ngaoundere, Cameroon, with implications for health policy in developing countries and development assistance policy. 1195 91

Forty-nine patients, aged 3 months to 13 years, were studied to determine the clinical presentation, bacteriology, treatment and outcome of empyema complicating pneumonia in children. There were 28 (57.2%) males and 21 (42.8%) females in the study, with a male/female ratio of 1.3/1. We found malnutrition in 15 (30.6%) patients. The most common symptoms at presentation were fever (93.8%) and cough (85.7%). Radiography demonstrated minimal effusions (6 patients, 12.2%), moderate effusions (23 patients, 46.9%), and massive effusions (20 patients, 40.9%). The pleural fluid was on the right side in 26 (53.1%) cases, the left side in 17 (34.6%) cases, and bilateral in 6 (12.3%) cases. Staphylococcus aureus was the most frequently isolated microorganism in pleural fluid. No organism was recovered in 33 (67.3%) patients. Most cases were treated with a combination of intravenous antibiotics and chest tube drainage. Decortication was carried out in only two patients. The hospitalization period was 28.02 +/- 10.18 days (11 to 57 days). There was one death due to widespread Staphylococcus aureus septicemia. All patients who were followed-up showed complete or near complete resolution of the chest radiography at six months, regardless of severity of disease or treatment modality. Children with pleural empyema can be successfully treated with appropriate antimicrobial therapy and adequate closed chest tube drainage. Further surgical intervention is rarely required.
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PMID:Parapneumonic empyema in children: conservative approach. 1202 1

We presented a case of pulmonary Rhizops microsporus var. rhizopodiformis infection which developed abruptly during treatment of bronchial asthma by systemic corticosteroids. The patient, an 85 year-old-woman, was given systemic steroid therapy for 15 days. She suddenly became febrile two days after the therapy and was coughing up yellow sputum. Chest X-ray film showed multiple nodules with cavities which became worsened rapidly. A specimen of sputum culture gave a growth of Mucoraceae, which was identified to be Rhizopus microsporus var. rhizopodiformis. She was given amphotericin B and miconazole was added on the basis of MIC value of the strain. Although she improved initially, her clinical course showed neutropenia, pseudomembranous enterocolitis, malnutrition, and then died after about six months. Because the diagnosis of pulmonary mucormycosis is difficult and prognosis is poor, further studies for investigating clinical features would be necessary.
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PMID:[A case of abrupt pulmonary infection by Rhizopus microsporus var. rhizopodiformis during treatment for bronchial asthma]. 1207 77

PLAN in Bolivia and the Dominican Republic has directed interventions to increase child survival. In Bolivia in August 1991, an 18 month infant with rapid breathing and cough was brought to a health center because the mother had remembered the warning symptoms provided by a community health worker. This child's life was saved by the contact with the health worker, the mother's action to bring the child to the health center, and the timely, appropriate use of antibiotics. Follow-up by a community worker revealed a return to health for the child; a child death was averted. The case of a measles epidemic in Santo Domingo, Dominican Republic in February 1992 was described, where health workers had targeted a slum area for house to house immunization and thus child deaths were averted when the measles epidemic struck. PLAN's child survival programs, funded by USAID and PLAN, have been innovative and successful in tailoring approaches to local needs and priorities. The Santo Domingo Field Office prioritized efforts in immunization, oral rehydration therapy, and child nutrition. Findings in 1992 showed that Child Survival participants had 50% less malnutrition than other neighboring community children aged 12-23 months. Bolivia's Field Office in Sucre stressed acute respiratory infections, immunizations, and oral rehydration therapy. Findings have shown that Child Survival families were four times more likely to use health facilities for respiratory infections. Success has been attributed to a focus on high risk populations, use of technical interventions, emphasis on selected key behavioral change objectives, a community based approach, cooperative relationships with other local health providers, and "community ownership" of interventions. Individual health taking behavior was changed.
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PMID:What is child survival? Child-focused strategy forms key element of PLAN's health policy. 1217 62

Child survival in Cameroon is measured in the 1991 Demographic and Health Survey and found to be substantially improved. The survey includes a sample of 3871 women aged 15-49 years and a sample of 814 husbands. Community services data is also collected. Child mortality is reported as declining from 198 to 126 deaths per 1000 births during 1976-91. Infant mortality is shown to decline to 65/1000. Mortality of children aged 1-4 years is 66/1000. 79% receive prenatal care from some source, and 70% receive a dose of tetanus toxoid vaccine during pregnancy. A health professional is present at delivery for 64% of pregnant women. 52% of children aged 12-23 months have a health card, and 41% have tuberculosis, polio, diphtheria, pertussis, tetanus, and measles immunization. One in five still does not have any immunization. 62% of children with mothers who have at least a secondary school education are immunized. Diarrhea morbidity in the two weeks preceding the survey is 18% for children aged under 5 years. 9% have a cough and rapid breathing, and 23% have a fever. Child mortality among children aged 1-5 years is due to diarrhea (27%), malaria (23%), measles (27%), and respiratory infections (16%). Only 3% of children aged under 5 years has acute malnutrition. One in four are stunted, which reflects prolonged or chronic undernutrition. The total fertility rate is 5.8 children per woman, which is a 10% decrease from 1978. The lowest fertility is among women in the main cities of Yaounde and Douala (4.4 children) and among women with a secondary or higher education (4.5). Over 50% of women have sexual intercourse before the age of 16 years, and 50% are married before the age of 17 years. 50% of married women have their first child at the age of 19 years. Contraceptive usage is 16% among women in any union, of which 25% is use of a modern method. Only 1 in 25 women use an effective method, but this rate is double the rate in 1978. Total fertility would be 10% if unwanted fertility were avoided. Most men and women want large families.
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PMID:Improved child survival in Cameroon. 1228 22

The US Centers for Disease Control in 1982 listed conditions and infections then associated with AIDS. That case definition, used as a model for many countries, was designed primarily for epidemiologic surveillance and now includes more than 20 conditions. The definition, however, requires diagnostic and laboratory technologies which are not always available in developing countries. The World Health Organization (WHO) therefore published the Bangui definition in 1985 which uses clinical criteria alone. Many developing countries have adapted this definition to the types of pathogens they encounter domestically. According to the AIDS clinical definition, the presence of generalized Kaposi sarcoma or cryptococcal meningitis is sufficient for the diagnosis of AIDS. AIDS is also diagnosed if at least two major signs and one minor sign are present in the absence of known causes of immunosuppression such as malnutrition. Major signs are fever for more than one month, loss of more than 10% of body weight, and diarrhea for more than one month. Minor signs include cough for more than one month, generalized pruritic dermatitis, recurrent herpes zoster or shingles, oropharyngeal candidiasis or thrush, chronic or aggressive ulcerative herpes simplex, and persistent generalized lymphadenopathy. WHO has also developed criteria for diagnosing symptomatic HIV infection as an aid to individual case management. These criteria, however, are not intended to replace the Bangui AIDS case definitions developed for epidemiological purposes. The diagnosis of symptomatic HIV infection is made through physical examination and the taking of a very detailed case history. In so doing, there may be cardinal, characteristic, and/or associated findings. Cardinal findings of HIV infection are Kaposi sarcoma, oesophageal candidiasis, cytomegalovirus retinitis, Pneumocystis carinii pneumonia, and Toxoplasma encephalitis. Characteristic findings include oral thrush in a patient not taking antibiotics; hairy leukoplakia; cryptococcal meningitis; miliary, extrapulmonary,, or non-cavity pulmonary tuberculosis; current or past herpes zoster or shingles; severe prurigo; Kaposi sarcoma of a less than generalized or rapidly progressive nature; and high-grade B-cell extranodal lymphoma. Finally, associated findings in the absence of any other obvious cause of immunosuppression are recent and/or explained weight loss of more than 10% of body weight; fever for more than one month; diarrhea for more than one month; ulcers for more than one month; cough for more than one month; neurological complaints or findings, peripheral neuropathy, dementia, and progressively worsening headache; generalized lymphadenopathy; previously unseen drug reactions; and severe or recurrent skin infections. A person has symptomatic HIV infection if there are one or more cardinal findings, two or more characteristics findings, one characteristic finding and two or more associated findings, three or more associated findings together with any risk factors, or two associated findings together with a positive HIV test result. Malawi, Zambia, Thailand, and the English-speaking Caribbean are adapting these criteria for national use.
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PMID:Diagnosing symptomatic HIV infection and AIDS in adults. 1228 34

Each year, at least 4 million African children die before they reach their fifth birthday, and 70% of the deaths are caused by pneumonia, diarrhea, malaria, measles, malnutrition, or, more commonly, a combination of these. Despite the fact that sick children often have more than one condition, busy clinics tend to treat only the one that is most obvious. With much of the effort of the past two decades directed to diarrhea, health workers have been taught their clinical skills in a piecemeal, rather than an integrated, fashion. In response to this problem, the World Health Organization and the UN Children's Fund developed a training course for the integrated management of childhood illnesses (IMCI) in 1993. IMCI is now being used in Uganda, Tanzania, and Zambia, and other African countries are preparing to institute it. IMCI relies on a straightforward clinical assessment and classification of illness that does not require the use of a laboratory. IMCI identifies general danger signs that may call for hospitalization of the child and then bases its assessment on the presence of 1) cough and difficulty breathing, 2) diarrhea, 3) fever, 4) measles, 5) ear infection, and 6) malnutrition. All sick children are screened for all of these conditions because IMCI capitalizes on the presence of the child in the clinic (vaccinations are also given if necessary). Training for IMCI involves 11 days, half of which are spent in clinical practice and demonstration and half in the classroom. Each country must adapt the IMCI guidelines and training course to meet its specific needs. Such adaptation provides an opportunity for collaboration among disease-specific programs; it stimulates a review of technical and clinical guidelines; and it provides an opportunity for the health system to focus on its essential drug needs, referral care, and supervisory system.
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PMID:The integrated management of childhood illness. 1229 34

Community health workers (CHWs) can help prevent the spread of tuberculosis (TB) in various ways. They can educate community members about TB symptoms and how TB is transmitted. They can encourage people with active TB to seek and complete treatment. They can check household contacts of infectious patients to identify and manage young children at special risk. Many people believe that TB cannot be cured, that God, magic, or witchcraft causes TB, or that only cursed or bad people acquire TB. These beliefs explain why many people seek treatment from traditional healers rather from medical personnel. CHWs need to be aware of these beliefs and to consider them when developing appropriate advice and relevant community health education. Some important public health advice to prevent the spread of TB includes covering the mouth and nose when coughing or sneezing, disposing of sputum carefully, and prohibiting children from sleeping in the same room as an infectious adult. CHWs should screen the whole family for TB, especially the young children, and evaluate the nutritional status of the children, if someone in the household has TB. Malnourished children are especially at risk of TB. CHWs need to ask the parents about and examine the child for the presence or absence of TB symptoms in their child. They need to perform a tuberculin test. They should immediately refer children with symptoms (vomiting, fever, persistent cough, weight loss) to a physician.
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PMID:Helping communities control tuberculosis. 1229 61

Health workers have four main tools at their disposal for detecting tuberculosis (TB) in patients: clinical symptoms, tuberculin testing, x-ray of the chest, and sputum smear microscopy. The two main detection tools for children are tuberculin skin test and chest x-ray. Signs and symptoms of TB to look for in adults are persistent cough (3 weeks), blood in the sputum, persistent chest pain (1 month), increasing weakness and weight loss, and past history of TB or treatment for cough. TB treatment should not begin until a positive sputum smear is confirmed in cases of pulmonary TB. Health workers should suspect TB if children younger than 5 are in close contact with someone who has confirmed TB, have a strongly positive tuberculin test, and have clinical signs and symptoms. Further tests are usually needed to confirm the diagnosis. In many areas, tests are impossible so health workers need to diagnose TB based on history, physical examination, and clinical symptoms. TB is difficult to diagnose in children because TB is either limited inside the lung or located outside the lungs. Malnourished children with TB usually have a negative tuberculin test. Malnourished children displaying signs of TB or whose X-ray suggests TB should be treated. A recent BCG vaccination can yield a weak positive tuberculin test result. TB signs and symptoms in children are nonspecific. General signs to look for are: unexplained weight loss, anorexia, failure to thrive and gain weight, at least 2 episodes of unexplained fever, swollen lymph nodes (especially in children with HIV), and persistent cough or wheeze (2 weeks). Specific signs depend on the site of infection: whole body, brain or spine, lungs, bones and joints, skin or mucous membranes. This article contains instructions on how to do the tuberculin skin test and sputum smear microscopy.
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PMID:How to detect and diagnose TB. 1229 65

The main causes of death in rural areas of the Faritany of Toamasina during 1986 are identified and classified by order of importance for the entire population as well as for vulnerable groups such as preschool children and reproductive-aged women. The 10 leading causes of death of infants and children under age 5 years are coughs and fevers, as well as thoracic pains; vomiting and diarrhea; age factors; high, intermittent fevers and chills; protein-calorie malnutrition; convulsions; other high fevers; cough of long duration; sudden death; and measles. Leading causes of death for women aged 15-49 years include coughs and fevers, as well as thoracic pains; high, intermittent fevers and chills; vomiting and diarrhea; other high fevers; delivery complications; cough of long duration; malnutrition; abortion or miscarriage; sudden death; and postpartum illnesses. Over 60% of deaths reported for children aged 0-5 years could have been prevented through a broader vaccination program, oral rehydration therapy, nutrition education and growth monitoring, and the preventive treatment of malaria. Priority focus should be given to respiratory infections.
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PMID:[Causes of mortality in a rural area in the Faritany of Toamasina in 1986]. 1229 43


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