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African Health Sciences
Volume 2 Number 2 August 2002
EDITORIAL
In this issue
Happy birthday African Health Sciences! Today we
celebrate the first birthday of our journal with humility but
also with a sense of satisfaction. In our continent where the
infant mortality rate for both humans and journals is very high,
survival ushers in a sense of satisfaction and increased
responsibility for the future.
We are particularly grateful to Nelson Sewankambo the dean of
Makerere University Faculty of Medicine, Drs Walker and Samba of
the WHO for seeing us through this first year. Many thanks also
to all our editorial colleagues and referees both in Uganda and
abroad for giving us the confidence to publish only vigorously
reviewed work. And of course to you our reader who gives us the
reason for existing: we thank you very much!
Talking of the future: we have in plan to make African
Health Science available to our readers on the Internet. That
will be a subject of future discussion.
Back to this birth-day issue of our journal. We have a
selection of very interesting articles both general and specific.
Dr. Dan Kaye's article on gestational trophoblastic disease
following complete hydatidiform mole1, gives a glimpse of the
clinical epidemiology, prevention and treatment of that
condition. Although it occurs in just over 3 per 1000 deliveries,
hydatidiform mole occurs in women with high fertility and is
associated with mortality and protean complications of treatment.
This is interesting information since there seems to be strong
evidence from the 2001 Uganda Demographic Health Survey results
linking high fertility rates and poverty.
Underlying our commitment to promoting evidence based
practice, we publish Dr. Wabinga's article in which he compares
the reliability of Giemsa stain with immunohistochemistry in the
demonstration of H.pylori: the germ linked to duodenal
ulcer and gastric carcinoma2. Despite the relatively small
numbers of patients studied, indications from this study are that
Giemsa stain had high positive and negative predictive values
with good agreement between the two tests. Given that Giemsa
stain is cheap and easily available in most laboratories in the
developed countries, recommending its use, as Webbing does, is
not altogether out of place.
To our old friend: cotrimoxazole! Now ubiquitously used in
primary care settings for treatment of acute respiratory
infections and for the prevention of Pneumocystis carinii
pneumonia in HIV infected children and adults, cotrimoxazole
seems destined to stay. Of major concern however is quality
control of our products in an environment where sophisticated and
time-consuming procedures may not always be possible.
Balyejjussa, Adome and Musoke3 have used a rapid method
(derivative spectrophotometry) for getting assays of the two
components of cotrimoxazole with success.
In their article on monitoring the severity of iodine
deficiency disorders in Uganda, Bimenya, Olio-Okui and
colleagues4 found that the prevalence of goitre has declined with
the introduction of iodised salt in the country in in the early
1990s. Despite this significant fall, the rates are much higher
than those recommended by the WHO and therefore iodine deficiency
disorders are still of public health significance. The over
consumption of iodine and its possible association with
hyperthyroidism in some districts of Uganda needs urgent
investigation.
It is probably appropriate to end this review with two papers:
one on eye disorders amongst school children and the other on the
role of community health workers in DOTs in South Africa. Drs.
Kawuma and Mayeku5 have found a high prevalence of astigmatism
and, surprisingly, not short sight! The implications of these
refractive disorders are discussed. Kironde and Bajunirwe6 leave
us with an interesting debate of a re-emerging health problem
with an old solution: using community health workers in DOTs.
When you follow the history of primary health care and Alma Ata,
you cannot but help beat off the sense of dejavu. Nobody will
blame you!
ORIGINAL ARTICLES
Gestational trophoblastic disease following complete
hydatidiform mole in Mulago Hospital, Kampala, Uganda
Dan K. Kaye
Department of Obstetrics and Gynaecology, Makerere University
Medical School,
P. O. Box 7072, Kampala, Uganda.
ABSTRACT
Objectives
To determine epidemiological characteristics and clinical
presentation of complete hydatidiform mole (CHM) and
complications associated with prophylactic chemotherapy with oral
methotrexate.
Setting
Mulago hospital, Kampala.
Design
Prospective study
Methods
Ninety-four patients with clinically and histologically
confirmed complete hydatidiform mole admitted between 1/9/1995
and 30/1/1998 were followed for periods ranging from 12 months to
30 months. Seventy-eight (83.0%) received a total of 187 courses
of oral methotrexate (0.4 mg/kg daily in 3 divided doses) as
prophylactic chemotherapy. The main outcome measures were pre-
and post-evacuation serum hCG levels and complications associated
with oral methotrexate use.
Results
The prevalence of CHM was 3.42 per 1,000 deliveries. The mean
age of subjects was 29.6 + 8.5 years. Eighteen women
(19.1%) were nulliparous and mean gravidity was 8.3. Many women
presented with high-risk disease. Risk factors for persistent
trophoblastic disease were prior molar pregnancy, age<19 or
>35 years and features of high-risk molar pregnancy.
Twenty-four of the seventy-eight patients (30.7%) developed
complications, mainly mucositis and haematological toxicity
(leucopenia, anaemia and thrombocytopenia), commonly after 3 or
more courses.
Conclusion
CHM was common and many patients presented with high-risk
disease. Oral methotrexate for prophylactic chemotherapy was
tolerable and safe for the first 2 courses, but serious
complications occur as the duration of treatment increases.
Prophylaxis did not prevent development of (or death from)
metastatic trophoblastic disease.
Recommendations
Patients with CHM should be monitored for the development of
post-evacuation trophoblastic disease. Those on prophylactic
chemotherapy require close monitoring for the toxic effects of
the drugs.
African Health Sciences 2002;2(2):47-51
Comparison of immunohistochemical and modified Giemsa
stains for demonstration of Helicobacter pylori infection in an African
population
H. R. Wabinga
Department of Pathology, Faculty of Medicine
Makerere University, P. O. Box 7072 Kampala, Uganda.
ABSTRACT
BackgroundModified Giemsa staining has been favoured by many
researchers because it is easy to perform but, like many other
stains, demonstration of the bacteria depends on its morphology.
It has been arged in some research circles that some of the
organisms in the gastric mucosa may not be true H.pylori.
Immunohistochemical techniques have been developed and make use
of anti H.pylori antibody, which reacts, with somatic antigens of
the whole bacteria and have been found to correlate well with the
presence of the bacteria.
Objective
To ascertain the efficacy of modified Giemsa stain in an
African setting where H.Pylori seems quite prevalent.
Study Design
A laboratory-based study of two diagnostic tests in which
modified Giema stain was compared with immunohistochemistry.
MethodsA total of 48 consecutive autopsy cases with no upper
gastro intestinal diseases had their gastric mucosa stained for
demonstration of H.pylori using both modified Giemsa and
immunohisto chemical staining techniques.
Results
Twenty-seven cases of H.pylori were demonstrated by both techniques and 14
cases were not identified by the two staining methods. In 2 cases immunostain
could not demonstrate the bacteria but they were identified with modified Giemsa
stain while in 5 cases the bacteria were identified by immunostain but not with
modified Giemsa stain. The sensitivity of modified Giemsa stain was 85%
(CI 66.5-98.8) while the specificity was 89% (CI 60.4 – 97.8). The positive
predictive value of modified Giemsa stain was 93% CI 75 - 98.8%) while the
negative predictive value was 74% (CI 48.6 - 89.9). The kappa statistic
comparing the 2 stains was 0.69 (p value 0.00001) giving a good agreement
between the two tests.
Conclusion
With the above results the modified Giemsa stain, which is
readily available in most African laboratories, is recommenced
for diagnosis of H.pylori, a prevalent infection in Africa.
Key words
H.pylori, modified Giemsa, immunohistochemical stains.
CI – Confidence Interval
African Health Sciences 2002;2(2):52-55
Spectrophotometric determination of sulphamethoxazole and
trimethoprim (co-trimoxazole) in binary mixtures and in tablets
S. Balyejjusaa, R.O. Adomeb and D. Musokec
Department of Pharmacy, Makerere University, Faculty of
Medicine,
P.O. Box 7072, Kampala, Uganda.
ABSTRACT
Background
The formulation of sulphamethoxazole (S) and trimethoprin (T)
(CO-TRIMOXAZOLE) in a combination mixture is very good
pharmacologically since it enhances the efficacy of the
individual drugs. However in this combination, difficulties in
analysis on ordinary UV spectrophotometry are introduced because
the two components give overlapping spectral bands on zero-order.
The United States Pharmacopoea (USP)-recommended HPLC analytical
method is quite expensive.
Objective
The objective of the present work was to assess whether
derivative spectrophotometry could be used to circumvent the
overlapping spectral bands of the components and hence use it for
routine analysis of the drug.
Study design
Experimental
MethodsThe aqueous solution of the individual drugs and their
binary mixutres were scanned on zero order and on first
derivative at the wave length between 200- 300nm and at the pH of
4.5. ResultsThe zero-order spectra of the compounds were
completely overlapping. However the first-derivative scan offered
better separation and hence T was determined from the absorbance
at 237.6nm with negligible contribution from S (since at this
point it was reading zero). Likewise S was determined at a
wavelength of 259nm when T was reading zero. The linear
calibration graphs were obtained for 4-25gml-1 of S and for
4-20gml-1 of T.
Conclusion
The method is rapid, simple and can be applied successfully to
assay a mixture of the two drugs in pharmaceutical preparations.
Key words
sulphamethoxazole, trimethoprim, derivative spectroscopy,
simultaneous determination.
African Health Sciences 2002;2(2):56-62
Monitoring the severity of iodine deficiency disorders in
Uganda
Gabriel S Bimenya, Olico-Okui, Dentos Kaviri , Nazarius Mbona
and Wilson Byarugaba
College of Health Sciences, Makerere University.
P. O. BOX 7072 Kampala, Uganda.
ABSTRACT
Background
Iodine deficiency disorders (IDD) cover a variety of
pathological conditions including goitre, mental retardation and
perinatal mortality in millions of individuals globally. IDD was
initially identified as a problem in 1970 and was confirmed in
1991. In 1993, the Uganda government introduced a policy of
Universal Salt Iodization (USI) requiring all household salt to
be iodized. After 5 years this study evaluates the USI programme.
Objectives
To determine goitre prevalence rate, establish the proportion
of household consuming iodized salt and determine the levels of
iodine intake in the sample districts.
Methods
A sample of 2880 school children aged 6-12 years from 72
Primary schools in 6 districts of Uganda was studied in October
1999. Goitre was established by palpation, salt iodine was
analysed by thiosulphate titration, while urinary iodine was
analyzed using ICCIDD recommended method F in which iodine is
detected colorimetrically at 410nm.
Results
The over all total goitre rate was 60.2% down from 74.3 in
1991 and visible goitre was 30% down from 39.2% in 1991. The
propotion of households taking adequately iodized salt was 63.8%
and the median urinary iodine was 310µg/L. Whereas 36% of 95
urine samples analysed in 1991 had urinary iodine below 50µg/L,
only 5% of the 293 urine samples studied in 1999 had the same
urine levels. This represents a considerable improvement in
iodine intake, which is confirmed by the fact that 63.8% of the
study households consume adequately iodized salt. If maintained
and evenly spread, this will enable Uganda to control IDD.
Conclusion
USI has improved iodine intake in Uganda. However, iodine
malnutrition is still a severe public health problem because some
communities in this study such as in Kisoro still have low iodine
consumption, while others such as Luwero now have iodine excess.
The latter is likely to predispose to hyperthyroidism.
Recommendation
The national set standard of household salt iodine of 100ppm
be revised. Locally produced salt be iodized, and a national
iodine monitoring programme be instituted to ensure evenly spread
consumption of adequately iodized salt by all communities in the
country.
African Health Sciences 2002;2(2):63-68
A survey of the prevalence of refractive errors among
children in lower primary schools in Kampala district
Medi Kawuma and Robert Mayeku
Department of Ophthalmology
Makerere University.
ABSTRACT
Background
Refractive errors are a known cause of visual impairment and
may cause blindness worldwide. In children, refractive errors may
prevent those afflicted from progressing with their studies. In
Uganda, like in many developing countries, there is no
established vision-screening programme for children on
commencement of school, such that those with early onset of such
errors will have many years of poor vision. Over all, there is
limited information on refractive errors among children in
Africa.
ObjectiveTo determine the prevalence of refractive errors
among school children attending lower primary in Kampala
district; the frequency of the various types of refractive
errors, and their relationship to sexuality and ethnicity.
Design
A cross-sectional descriptive study.
Setting
Kampala district, Uganda
Patients
A total of 623 children aged between 6 and 9 years had a
visual acuity testing done at school using the same protocol; of
these 301 (48.3%) were boys and 322 (51.7%) girls.
Results
Seventy-three children had a significant refractive error of
±0.50 or worse in one or both eyes, giving a prevalence of 11.6%
and the commonest single refractive error was astigmatism, which
accounted for 52% of all errors. This was followed by
hypermetropia, and myopia was the least common.
Conclusion
Significant refractive errors occur among primary school
children aged 6 to 9 years at a prevalence of approximately 12%.
Therefore, there is a need to have regular and simple vision
testing in primary school children at least at the commencement
of school so as to defect those who may suffer from these
disabilities.
African Health Sciences 2002;2(2):69-72
PRACTICE POINTS
Lay workers in directly observed treatment (DOT) programmes
for tuberculosis in high burden settings: Should they be paid?
A review of behavioural perspectives
a Samson Kironde and b Francis Bajunirwe
a Oxford University, Institute of Health Sciences, Dept of
Public Health and Primary Care, Oxford OX3 7LF, UK
b Mbarara University of Science and Technology, Dept of
Community Health,
P. O. Box 1410, Mbarara, Uganda
Key words: Lay workers, motivation, incentives,
tuberculosis
ABSTRACT
The current global tuberculosis (TB) epidemic has pressured
health care managers, particularly in developing countries, to
seek for alternative, innovative ways of delivering effective
treatment to the large number of TB patients diagnosed annually.
One strategy employed is direct observation of treatment (DOT)
for all patients. In high-burden settings innovation with this
strategy has resulted into the use of lay community members to
supervise TB patients during the duration of anti-TB treatment.
However, community involvement in health programmes is not a
simple matter. There is often a need for continued motivation of
community members in order to ensure sustainability of such
projects. Lay workers may demand payment for work done
particularly if this takes up a reasonable proportion of their
time. TB treatment, by its very nature, lasts for a considerable
period and this paper seeks to examine behavioural perspectives
that attempt to address the issue of whether lay workers in such
programmes should be paid for their services. The theories
explored suggest intrinsic and extrinsic motivation as factors
that lead people to volunteer for health programmes. Intrinsic
motivation encompasses such feelings as empathy and altruism as
well as other factors such as religious and cultural conviction.
The authors argue however that in high-burden TB settings, these
factors alone may be inadequate to provide continued motivation
for lay worker involvement in health programmes. Extrinsic
motivators, of which money is the strongest example, then also
serve to keep sustained interest particularly in resource-limited
settings where people expect payment for work done.
The debate on whether lay workers in health programmes should
be paid is thus compounded by issues such as what factors one
believes are responsible for motivation in particular contextual
settings; how long lay persons are expected to perform tasks at
hand; the capacity that exists to pay them and the sustainability
of the motivating option chosen. We recommend more qualitative
research to be done on this issue in high TB burden settings.
African Health Sciences 2002;2(2): 73-78
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