Final Report Summaries 2003–2004 Implementedimplemented Duringduring 2004–20062004–2006
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WHO-EM/TDR/110/E Final Report Summaries 2003–2004 ImplementedImplemented duringduring 2004–20062004–2006 RESULTS PORTFOLIO 3 Small Grants Scheme CONTENTS Foreword 2 Preface 3 Final report summaries by disease 1. Brucellosis • Molecular epidemiology 4 2. HIV/AIDS • Condom use 6 • Knowledge, attitudes, practice and behaviour 8 3. HIV/AIDS/Hepatitis • Risk reduction 12 • Risky behaviour 14 • Surveillance 16 4. Human African Trypanosomiasis • Diagnostics 18 5. Infectious diseases • Surveillance 20 6. Leishmaniasis Cutaneous leishmaniasis • Drug studies 22 • Vector control 28 Visceral leishmaniasis • Diagnostics 32 7. Lymphatic Filariasis • Control 36 • Epidemiology 38 8. Malaria • Control 40 • Community participation 42 • Drug studies 44 • Epidemiology 50 • Health-seeking behaviour 52 • Vector control 54 9. Sexually transmitted diseases • Diagnosis 60 • Epidemiology 62 10. Tuberculosis • Case detection 64 • Community participation 72 • Control 76 • Defaulter tracing 78 • Monitoring and evaluation 80 • Quality of care 82 • Treatment success 84 • Public-Private Mix 88 11. Vaccine preventable diseases • Disease burden 100 • Immunization coverage 102 • Molecular epidemiology 106 12. Vector control • Insecticide resistance 108 List of publications 110 FOREWORD In the name of God, the Compassionate, the Merciful It is with great pleasure that the WHO Regional Office for the Eastern Mediterranean presents the third issue of the final research report summaries of the UNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases (TDR) supported Small Grants Scheme (SGS). The aim of the series is to disseminate the results of the operational research projects supported by the scheme with the ultimate goal that they are translated into the policies and practices of national control programmes. Operational research is crucial for identifying ways to increase access to timely diagnosis and effective treatment. It involves the evaluation of programme implementation, leading to improved policy-making, better design and operation of health systems, and more efficient methods of service delivery. The scheme stimulates collaboration between national control programmes and academia. National control programmes are encouraged to identify key issues regarding programme operation and performance in order to initiate operational research in collaboration with researchers. The challenge extends beyond programme operations to the need to introduce new tools such as drugs, vaccines and diagnostics. The evaluation of these new tools through the scheme is crucial to making a significant impact on disease burden. Operational research has therefore become an integral component of strategies to reduce the burden of communicable diseases in endemic countries. Hussein A. Gezairy MD, FRCS Regional Director for the Eastern Mediterranean PREFACE The WHO Regional Office for the Eastern Mediterranean supports operational research in tropical and other diseases through the TDR Small Grants Scheme. The scheme encourages collaboration between national control programmes and researchers from academia. A two-page summary has been developed from each of the final reports of the research projects. They include the key research results and their implications for disease control. However, this is not a peer reviewed publication and the investigators are encouraged to submit their manuscripts to indexed journals. This would provide evidence for the reliability of reported results with regard to the international scientific community. This issue includes an updated list of around 90 articles resulting from Small Grant Scheme-supported research published in indexed journals. It is hoped that the research-driven and evidence-based recommendations reported in this issue will be used to improve programme performance, increase the access of the community to timely diagnosis and effective treatment, and assist national control programmes in achieving the UN Millennium Development Goals. Dr Zuhair Hallaj Director, Communicable Disease Control Brucellosis Molecular Epidemiology Lebanon Molecular characterization Abstract made. Dairy food production in Lebanon occurs mostly in the Bekaa valley. and antibiotic A study was done to characterize and evaluate the antibiotic susceptibility of Brucella species Few studies have been conducted to resistance of isolated from dairy products in Lebanon. For assess the microbiological quality and level Brucella spp. the study, 238 samples were collected from the of contamination of dairy food with isolated from Bekaa valley, north east Lebanon, and Brucella pathogens or the resistance of food-borne various dairy colonies were isolated using Brucella agar and pathogens to commonly used identified using standard biochemical tests. Real products in antimicrobials. Given the marked Lebanon time polymerase chain reaction (PCR) was used for species identification. Antibiotic susceptibility importance of Brucella organisms as food- testing was also carried out. borne pathogens, a study was done to Lebanon isolate and characterize, at the molecular Results The study reported a prevalence of level, different strains of Brucella present Bekaa valley, north east Brucella abortus infection of 2.94%, 4.16% and Lebanon 1.64% in baladi, shanklish and kishk cheese, in dairy products that are consumed raw respectively. Bacteria were resistant to at least in Lebanon. It also aimed to evaluate the Study period: one or more of the tested antibiotics, with the antibiotic susceptibility profile of the isolated highest resistance observed against organisms. October 2004–August streptomycin and ciprofloxacin and the highest 2005 susceptibility for ceftriaxone and doxycycline. Materials and methods These findings are alarming and Conclusion Kishk (dried fermented cereal mixture), Small Grants call for better control of brucellosis in animals. shanklish (cheese balls) and baladi cheese Scheme Proper sanitation and quality control measures should be strictly followed during food samples were randomly collected from the (SGS) 2004 No. 189 preparation to minimize contamination with Bekaa valley in Lebanon. They were pathogenic organisms. The high levels of collected from supermarkets and mini- Principal Investigator antibiotic resistance to commonly-used antibiotics could be attributed to irrational drug markets, as well as small farms. The area Dr Steve Harakeh was divided into different communes based American University of Beirut use and should be taken into consideration on the number of inhabitants residing in Beirut, Lebanon when managing brucellosis cases. e-mail: [email protected] those communes. A total of 238 samples Background were aseptically collected in the same way Dairy products are consumed by a large as delivered to the consumers. Samples proportion of the population in Lebanon on were then packaged in sterile bags and a daily basis. While some of these products brought to the laboratory on ice in a cooler. are prepared in dairy plants, many are still All samples were refrigerated, enumerated produced in old factories or are home- and analysed within a maximum of 24 hours after their arrival at the laboratory. Plate count agar media were used for Conclusions and implications of the detection of aerobic bacteria present the study using the aerobic plate count method. The detection of total coliform was carried out Dairy food production in Lebanon occurs mostly in the Bekaa using McConkey agar or violet red bile valley, where the study found prevalence rates of Brucella abortus agar. Brucella agar was used for the of up to 4.16% in dairy products. These findings are alarming and detection of Brucella species. Colonies call for better control of brucellosis in animals. Proper sanitation were identified based on morphological, and quality control measures should be strictly followed during food cultural and biochemical criteria. Suspected preparation to minimize contamination with pathogenic organisms. Brucella colonies were selected and were The study reported high levels of antibiotic resistance to the primarily identified on the basis of gram commonly-used antibiotics. This could be attributed to irrational staining oxidase and urea hydrolysis. Plates drug use and should be taken into consideration when managing with bacterial counts ranging from 30–300 brucellosis cases. colonies were considered for the determination of the colony forming units (CFU) per gram. Total DNA was extracted and standard polymerase Brucellosis chain reaction (PCR) was used for genus identification and real-time PCR for species identification. Characterized strains were tested for their susceptibility to eight antimicrobials, using the disk diffusion method. The tested antibiotics were: rifampicin, doxycycline, ciprofloxacin, streptomycin, tetracycline, trimethoprim- sulfamethoxazole, ceftriaxone and gentamicin. Main study findings A total of 238 cheese samples were collected from different communes in Bekaa valley: 122 were kishk, 68 baladi and 48 shanklish. The calculated CFU counts showed high contamination levels. Of 110 suspected isolates, 6 were confirmed as being Brucella. The prevalence of contamination was 2.94%, 4.16% and 1.64% in baladi, shanklish and kishk cheese samples, respectively. Real-time PCR showed that all isolates were Brucella abortus strain. High antibiotic resistance (66.67%) was reported against streptomycin and ciprofloxacin, while 50% resistance was reported against gentamicin. A lower resistance of 33.33% was reported