Providing tenofovir and emtricitabine with nevirapine during labor greatly reduces the extent of resistance to non-nucleoside reverse transcriptate inhibitors (NNRTIs), such as nevirapine, which HIV-positive women take to lower the risk of mother-to-child transmission during childbirth.

Benjamin Chi, M.D., assistant professor of obstetrics and gynecology at UAB, and colleagues, reported their findings online in this week’s edition of The Lancet. Chi said the drug combination reduced resistance to NNRTIs by more than half at six weeks after delivery. This finding is important because between 20 and 69 percent of women given nevirapine develop resistance to the NNRTIs after taking a single dose. Although resistance becomes undetectable one to two years after ingestion, there are concerns that it could still compromise a woman’s future treatment options.

In this study, 399 participants were randomly assigned to receive or not receive single dose tenofovir and emtricitabine along with routine care. Routine care meant starting the anti-HIV drug zidovudine (or AZT) at 32 weeks gestation, and then ingesting a single dose of nevirapine at the start of labor. Participants were healthy and did not yet require treatment with potent antiretroviral therapy. The main goal of the study was to see if there was a difference in the presence of NNRTI resistance mutations six weeks after giving birth. The study was conducted in Lusaka, Zambia between 2005 and 2007.

Overall, 12 percent of women given the tenofovir and emtricitabine dose developed NNRTI resistance, compared to 25 percent among those who did not receive the additional drugs. Tenofovir and emtricitabine appeared to be safe, with no attributable side effects. Although these additional drugs did prevent NNRTI resistance, their use did not lead to substantial reductions in mother-to-child HIV transmission.

These results are encouraging for places like Zambia, which must rely on nevirapine for both HIV prevention and treatment. “The simplicity and effectiveness of this regimen is an important aspect of this intervention,” Chi said.

“HIV-infected pregnant women who take nevirapine in labor now have an easy way to reduce some of the negative consequences associated with the drug.”

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Source: Jennifer Lollar

University of Alabama at Birmingham

“Reprinted with permission from kaisernetwork. You can view the entire Kaiser Daily Health Policy Report, search the archives, or sign up for email delivery at kaisernetwork/dailyreports/healthpolicy. The Kaiser Daily Health Policy Report is published for kaisernetwork, a free service of The Henry J. Kaiser Family Foundation . © 2005 Advisory Board Company and Kaiser Family Foundation. All rights reserved.

“Reprinted with permission from kaisernetwork. You can view the entire Kaiser Daily Health Policy Report, search the archives, or sign up for email delivery at kaisernetwork/dailyreports/healthpolicy. The Kaiser Daily Health Policy Report is published for kaisernetwork, a free service of The Henry J. Kaiser Family Foundation . © 2005 Advisory Board Company and Kaiser Family Foundation. All rights reserved.

Before 2003, measles was one of the five major causes of childhood illness in Zambia. A campaign that year cut measles cases to zero.

This year’s nationwide follow-up immunization campaign was organized by the Ministry of Health, with support and funding from UNICEF, WHO and a coalition of other partners in what is known as the ‘Life saving partnership’ against Measles.

The campaign was a response to the rising number of sporadic cases of measles in the last two years, with over 100 cases recorded in 2006.

Local volunteers supported the campaign. Nationwide, more than 8,997 vaccinators and volunteers participated in the campaign at 1,351 fixed and mobile immunization posts. This followed several weeks of preparations to pre-position immunization supplies across the country using several modes of transport, including by lorries and airlifting supplies to remote regions of the country.

Announcing the results in Lusaka , Zambia’s Minister of Health, Dr. Brian Chituwo said, “Measles can be deadly to children, killing more worldwide each year than any other vaccine-preventable disease, but is easily prevented by immunization”. Dr. Chituwo was happy that this would not be the case for Zambia’s children following the successful campaign.

Globally measles is still one of the major causes of childhood illness and a leading cause of child death in many developing countries, despite the fact that a safe vaccine has been available for many decades which costs less than a dollar per child.

In addition to a shot of the measles vaccine, participating children were given a dose of Vitamin A which was also supplied by UNICEF and is essential for immune system function and the survival, growth and development of children. Children aged one year to five years were also given de-worming tablets, mebendazole, and close to half a million of caretakers had their mosquito nets re-treated for malaria control. Almost all the doses of vaccines and syringes were procured through UNICEF’s Supply Division in Copenhagen, and reached Lusaka weeks before the campaign.

“This was a remarkable example of good cooperation between different organizations,” said Lota Sywander, the UNICEF Country Representative. “UNICEF mobilized its staff and participated in the whole campaign from planning stages to its fruition”. “Our Staff were involved in all committees and played a key advisory role, be it in social mobilization, logistics, service delivery, transport, monitoring and evaluation of the campaign, they were there.” The UNICEF Communication team mobilized of media, traditional leaders, church organizations, schools, and businesses to reach every family and explain the importance and benefits of the vaccination campaign.

The massive campaign cost US$ 3 million with the international agencies contributing the bulk of the money. UNICEF was the largest contributor releasing more than US$1,700,000 with WHO also contributing UD$590,000. UNICEF funds also partly covered operating costs including internal transportation, training, social mobilization, and staff costs. The government of Zambia contributed over US$185 cash and in kind infrastructure and personnel, all estimated to have cost an additional US$ 500,000.

About the Measles Initiative

The Measles Initiative is a partnership committed to reducing measles deaths globally. Launched in 2001, the Measles Initiative-led by the American Red Cross, the United Nations Foundation, the U.S. Centers for Disease Control and Prevention, UNICEF and the World Health Organization-provides technical and financial support to governments and communities on vaccination campaigns in all regions of the world. To date, the Initiative has supported the vaccination of more than 372 million children helping to reduce measles deaths by more than 60 percent globally (compared to 1999). To learn more or make a donation, visit measlesinitiative.

About UNICEF

UNICEF is on the ground in over 150 countries and territories to help children survive and thrive, from early childhood through adolescence. The world’s largest provider of vaccines for developing countries, UNICEF supports child health and nutrition, good water and sanitation, quality basic education for all boys and girls, and the protection of children from violence, exploitation, and AIDS. UNICEF is funded entirely by the voluntary contributions of individuals, businesses, foundations and governments.

unicef

“Reprinted with permission from kaisernetwork. You can view the entire Kaiser Daily Health Policy Report, search the archives, or sign up for email delivery at kaisernetwork/dailyreports/healthpolicy. The Kaiser Daily Health Policy Report is published for kaisernetwork, a free service of The Henry J. Kaiser Family Foundation . © 2005 Advisory Board Company and Kaiser Family Foundation. All rights reserved.

Keeping track of all those test results can be very time-consuming, especially in developing countries where health workers rely on paper copies. That’s why MIT graduate student Joaquin Blaya decided to try out a new tracking method: personal digital assistants.

In a project launched in Lima, Peru, the researchers found that equipping health care workers with PDAs to record data dropped the average time for patients’ test results to reach their doctors from 23 days to eight days.

“You can monitor patients in a more timely way. It also prevents results from getting lost,” says Blaya, a PhD student in the Harvard-MIT Division of Health Sciences and Technology (HST).

Their work was reported in the online edition of the International Journal of Infectious Diseases.

Blaya started the project after taking a year off during his graduate studies to return to Chile, where he was born.

“I went back to Chile and realized ??¦ the key was to focus on the population I wanted to help,” he says. “Instead of saying, ‘I’m a mechanical engineer, what kind of device can I build,’ I should be saying ‘Who are the people working in the settings I want to work in?’”

When Blaya returned to MIT, he took lecturer Amy Smith’s D-Lab course and got connected with Partners in Health, a nonprofit whose mission is to promote health care in resource-poor areas.

Working with faculty members from HST and the Brigham and Women’s Hospital, Blaya launched the PDA project in Lima. He also worked closely with the Peruvian sister organization of Partners in Health, Socios en Salud. “The way to solve healthcare problems is by involving the community,” he says.

Under the old patient tracking system, a team of four healthcare workers would visit more than 100 health care centers and labs twice a week to record patient test results on paper sheets. A couple of times a week, they returned to their main office to transcribe those results onto two sets of forms per patient – one for the doctors and one for the health care administrators.

From start to finish, that process took an average of more than three weeks per patient. In some extreme cases, results were temporarily misplaced and could take up to three months to be recorded. There was also greater potential for error because information was copied by hand so many times.

With the new system, health care workers enter all of the lab data into their handheld devices, using medical software designed for this purpose. When the workers return to their office, they sync up the PDAs with their computers.

“The doctors get what they want, the administrators get what they want, and the team only has to enter the data once,” says Blaya.

The new system dramatically dropped the average time to record results to eight days, and eliminated the few cases where results went missing for several weeks or months. “You can really prevent patients from falling through the cracks,” says Blaya.

Getting timely and accurate lab results “is essential to determine if a patient is responding to treatment and, if not, to alert physicians to the possible need for medication changes,” the researchers wrote.

Peruvian health care workers enthusiastically embraced the program, which started in two of Lima’s districts and has now been expanded to all five. In addition to saving time, the handheld devices are also more cost-effective than the paper-based system, the researchers reported recently in the International Journal of Tuberculosis and Lung Disease.

Other authors of the International Journal of Infectious Diseases paper are Ted Cohen, assistant professor at Harvard Medical School; Pablo Rodriguez, engineer at Socios en Salud; Jihoon Kim, statistician at the Brigham and Women’s Hospital; and Hamish Fraser, assistant professor at Harvard Medical School.

Anne Trafton, MIT News Office

MIT

Now scientists have found that the vitamin D receptor is a key player amid the gut bacteria – what scientists refer to matter-of-factly as the “gut flora” – helping to govern their activity, responding to their cues, and sometimes countering their presence. The work was published online recently in the American Journal of Pathology.

The findings deliver a new lead to scientists investigating how bacteria might play a role in the development of inflammatory bowel diseases such as Crohn’s disease or ulceractive colitis. The work complements studies suggesting that Salmonella infection can increase the risk of inflammatory bowel disease.

“Vitamin D deficiency is a known factor in the pathology of inflammatory bowel disease and colon cancer,” said microbiologist Jun Sun, Ph.D., of the University of Rochester Medical Center, “but there have been very few reports about how bacteria might play a role by targeting the vitamin D receptor. Our work suggests one possible mechanism, by working through the vitamin D receptor, a sensor and regulator for the majority of functions of vitamin D.”

Sun specializes in the actions of bacteria in the body and how their interactions within the body contribute to disease. She has shown that bacteria often found in the human intestine affect molecular signals known to contribute to inflammatory response and cell growth.

Her work with the vitamin D receptor takes place at a time when the molecule is coming under increasing scrutiny. Scientists have associated vitamin D and the receptor with many types of cancer, as well as osteoporosis, heart disease, diabetes, inflammatory bowel disease, and infection.

Sun’s team took a close look at the vitamin D receptor in mice and its interactions with bacteria in the colon. The team studied normal mice; mice in which the vitamin D receptor had been knocked out; and mice that were completely free of any germs. Scientists observed how the mice responded to infection with either a harmless strain of E. coli or a pathogenic strain of Salmonella Typhimurium.

The team found that Salmonella is able to regulate the vitamin D receptor, increasing its activity and determining where in the colon the receptor is active. In the presence of Salmonella, the receptor was more prevalent than usual deep within folded intestinal structures known as crypts.

Sun’s team also discovered that the vitamin D receptor plays a key role in defending the body from assault by Salmonella and squelching inflammation. The receptor stops a molecule known as NF-Kappa B, a well-known master player in the world of inflammation, by binding to it and preventing it from activating other inflammatory molecules. While scientists have known that the receptor interacts with NF-Kappa B, details of the interaction modulated by bacteria in the colon are new.

The scientists found that Salmonella was much more virulent and aggressive in mice in which the vitamin D receptor had been turned off. These mice showed higher levels of activity of inflammatory molecules, and they lost weight more quickly and were much more likely to die in response to infection.

“We live together in a mutually beneficial state with most of the bacteria in our gut,” said Sun, assistant professor in the Gastroenterology and Hepatology Division of the Department of Medicine. “They help us digest foods like fruits and vegetables, and we provide them a place to live and thrive. We co-exist peacefully – most of the time.

“But we aren’t able to culture most of these bacteria in the laboratory, and we don’t know what most of them are doing. We need to understand our gut flora much more than we do. This is particularly important for understanding how we might manipulate the natural gut flora to stop an invader like Salmonella,” added Sun, who also has appointments in the James P. Wilmot Cancer Center and the Department of Microbiology and Immunology.

Notes:

In addition to Sun, authors of the study from Rochester include the first author, post-doctoral associate Shaoping Wu, Ph.D., of the Gastroenterology and Hepatology Division; Jian-Dong Li, M.D., Ph.D., of the Department of Microbiology and Immunology; former technician Anne P. Liao; and former research assistant Yinglin Xia, Ph.D.

Other authors include Yan Chun Li, Ph.D., of the University of Chicago, who supplied the vitamin D receptor “knockout” mice, and R. Balfour Sartor, M.D., of the University of North Carolina at Chapel Hill, who supplied the specialized germ-free mice through the Center for Gastrointestinal Biology and Diseases Gnotobiotic Core Facility and the National Gnotobiotic Rodent Resource Center.

This work was funded by the National Institute of Diabetes and Digestive and Kidney Diseases.

Source:
University of Rochester Medical Center

Starting from the principle that tuberculosis control must involve the identification of the obstacles to full comprehensive access to treatment, IRD researchers and their partners (1) studied, in Senegal, the different geographical, behavioural and socio-cultural factors that enter into the perception of the treatment and adherence to it.

In these countries, where over 9000 new cases of tuberculosis are diagnosed every year, access to free treatment is provided by the National Tuberculosis Control Programme through government health districts (2). However, nearly 30 % of patients do not follow this treatment correctly and scarcely 60% of people ill from the disease receiving a prescription manage to be cured. What are the reasons for this? Long distances from the health centres are among the first difficulties encountered. However, insufficient emphasis on listening to patients, counselling and information provision by health district personnel, associated with shortfalls in following up the DOT strategy also combine to discourage patients from taking the treatment right to the end of the prescribed course. In this context, the researchers looked simultaneously into the relations between health-care staff and the tuberculosis patients, the perception of the disease and its treatment in the community in which they live. They thus proposed action consisting of four major strands: training of health-care personnel, aiming to improve communication and support to patients, the decentralization of access to treatment to offer availability at local medical posts by involving health personnel who are attached to these, reinforcement of the DOT strategy by allowing patients to choose their supporter from among the staff or from within their community (imam, family relation, teacher??¦) and improved coordination of the activity of medical posts from the district centres.

To test the effectiveness of this action, a randomized controlled clinical trial was run between June 2003 and January 2005 on 16 district health centres and 1522 patients, who were separated at random into two groups. The first group was treated according to the action procedure proposed by the researchers, the second according to the usual strategy of the National Tuberculosis Control Programme (control group). After one year, a distinct improvement in adherence to treatment was observed in the first case: the rate of cure from tuberculosis rose by 20% and the proportion of patients defaulting fell by two-thirds (from 16.8 to 5.5 %).

The training of health-care personnel, communication to inform patients and make them aware of their responsibilities, just as the taking into account of the local, social and cultural context of communities, clearly appear to be essential factors for the sound running of the therapy and the long-term efficacy of actions geared to tuberculosis control. This action strategy, by improving adherence to treatment and the rate of successful patient outcomes, should thus help restrict the spread of the disease and prevent the arrival on the scene of new resistant strains of bacteria. Research work is continuing, in the form of a trial conducted by the IRD in conjunction with WHO, aiming to make available a shorter, 4-month treatment which could lead to still a further improvement of adherence and outcome results.

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Marie Guillaume-Signoret – IRD Translation : Nicholas Flay

(1) This research involved IRD research unit UR 145 (Programme Tuberculose), the London School of Hygiene and Tropical Medicine, the Programme National de Lutte anti-tuberculeuse of Senegal, and the International Union against Tuberculosis and Lung Diseases, based in Paris.

(2) The standard treatment recommended here lasts 8 months: a 2-month phase to attack the disease by combining rifampicin, isoniazid, pyrazinamid and ethambutol followed by stabilizing phase of 6 months involving combined treatment with isoniazid and ethambutol.

Key-words: tuberculosis, adherence to treatment, Senegal.

For further information

Contact :

Christian Lienhardt – IRD and International Union Against Tuberculosis and Lung Diseases, 6 bd. Saint Michel Paris Vie, France.

References :

Sylla Thiam, Andrea M. LeFevre, Fatoumata Hane, Alimatou Ndiaye, Fatoumata Ba, Katherine L. Fielding, Moustapha Ndir, Christian Lienhardt – Effectiveness of a Strategy to Improve Adherence to Tuberculosis Treatment in a Resource-Poor Setting. A Cluster Randomized Controlled Trial, Journal of American Medical Association (JAMA), January 24/31, 2007, vol. 297, n°4.

Fatoumata Hane, Sylla Thiam, Abdou Salam Fall, Laurent Vidal, Awa-H?©l??ne Diop, Moustapha Ndir, Christian Lienhardt – Identifying barriers to effective tuberculosis control in Senegal: year anthropological approach. International Journal of Tuberculosis and Lung Diseases. In press, 2007, vol 11.

Contact: Marie Guillaume
Institut de Recherche Pour le D?©veloppement

Reprinted with kind permission from kaisernetwork. You can view the entire Kaiser Daily Health Policy Report, search the archives, or sign up for email delivery at kaisernetwork/dailyreports/healthpolicy. The Kaiser Daily Health Policy Report is published for kaisernetwork, a free service of The Henry J. Kaiser Family Foundation© 2005 Advisory Board Company and Kaiser Family Foundation. All rights reserved.

“Reprinted with permission from kaisernetwork. You can view the entire Kaiser Daily Health Policy Report, search the archives, or sign up for email delivery at kaisernetwork/dailyreports/healthpolicy. The Kaiser Daily Health Policy Report is published for kaisernetwork, a free service of The Henry J. Kaiser Family Foundation . © 2005 Advisory Board Company and Kaiser Family Foundation. All rights reserved.