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Head-shaving practices of barbers and pilgrims to Makkah
INFECTIOUS DISEASE COST-EFFECTIVENESS OF METHOD FOR DETECTING
A RAPID DIPSTICK M A L A R I A . M. A. Lansang, V. Belizario, M. L. Amarillo, A. J. Saul. CEU, University of the Philippines, College of Public Health, Manila, Philippines; T h e Research Institute for Tropical Medicine, Philippines; Queensland Institute for Medical Research, Australia. Objective: Malaria patients in remote areas generally experience major delays in obtaining results of malaria blood films from the rural health centers. We determined the cost-effectiveness of a rapid dipstick method for detecting malaria (Parasight-F, PSF) as compared to malarial blood films. Design: Descriptive study, criterion standard. Setting: Community-based malaria control program in Agusan del Sur, Philippines. Participants: 253 patients presenting with fever in the past 3 days, associated with any of the following: chills, sweating or headache. Interventions: Malaria dipstick using HRP-ll ahtigens (PSF), and blood films for the diagnosis of malaria. Main O u t c o m e Measure(s): Sensitivity and specificity rates of PSF. Costs, from the perspective of the government and patient, were estimated for the following: blood films, travel to health center and village health station, delay in treatment (days of work lost), anti-malarial treatment, and the dipstick. Results: The sensitivity and specificity of PSF in detecting P. falciparum (PF) were: 94.6% (95% CI: 86.1%, 98.2%) and 84.4% (78.0%, 89.2%), respectively. The cost of blood fihn detection was PHP:~21+ + for every Pf case detected and treated, while the cost for PSF detection was PHP95 + +. Conclusions: The dipstick method is more cost-effective than the blood film for detecting malaria, especially in areas where there are significant delays in relaying results.
BEHAVIORAL RISK FACTORS (BRF) FOR DISEASES DURING PILGRIMAGE TO MAKKAH (HAJJ): T H E S E C O N D S U R V E Y . A. M. Al-Rabeah, H. E. El Bushra,
M. 0 . AI-Sayed, A. M. AI-Saigul, A. A. AI-Rasheedi, A. A. AlMazam, A. A. Abu Dahish, N. A. Al-Hamdan, M. H. Al-Jeff~. Field Epidemiology Training Program, Riyadh, Saudi Arabia. Objective: To assess BRF for important diseases and conditions among pilgrims to Makkah (Hajjees). Design: Cross-sectional survey. Setting: Mina, a holy place where more than two million Hajjees camp for at least three days. Participants: 1613 Hajjees (53 nationalities) interviewed using a selfadministered standard questionnaire translated into 15 languages (twostage cluster sampling). Interventions: None. M a i n Outcome Measure(s): Behaviors predisposing to the major Hajj-related illnesses. Results: Out of 1613 respondents, 71% were performing Hajj for the first time, 15% were residents of Saudi Arabia, and 61% wore identifying wristbands. Eighty-eight percent (95% C1 87-90) had the required vaccination against meningococcal meningitis. Risky behavior fi~r fi~od poisoning included bringing fi~ods from their home countries (:~7%), and eating fi~od from street vendors (32%). Heat stroke prevention included using umbrellas (59%). However, of all Hajjees, 3-5% moved between holy places on fi~ot, and 19% lost their way in Mina fi~ra median of 2 hours; drank a median (interquartile range) of 2500 (1500-3750) ml of fluids, and slept for a median of 6 hours per day. After completing Hajj rites, 56% (95% CI 5459) shaved their heads with razor blades and 25% (95% CI 21-29) put themselves at risk of bloodborne disease by reusing razor blades used by other Hajjees. Hajjees put themselves at risk of injury by hanging on the back of buses ( 12%, 95% CI 10-13). Conclusions: Data were consistent with a previous report and indicate the need for simple, innovative cross-cultural educational programs aimed at reducing BRF among religious visitors.
RCT ON THE COST.EFFECTIVENESS
OF AN INNOVATIVE PATIENT MOTIVATION STRATEGY IN IMPROVING COMPLIANCE TO PULMONARY TUBERCULOSIS CHEMOTHERAPY. C. S. Ghosh, P. Ravin&an, S. M. Devi, M. R. Joshi. CEU, Medical College, Trivandrum, India. Objective: To evaluate the cost-effectiveness of an innovative patient motivation strategy in impruving compliance to chemotherapy in pulmonary tuberculosis. Design: Randomized control trial. Setting: Tertiary care setting. Participants: 530 newly diagnosed sputum smear and X-ray positive pulmonary tuberculosis cases attending the Chest clinic of Medical College. Interventions: Study patients randomized to intervention (267) and control groups (263). Intervention patients received daily chemotherapy and innovative motivation strategy. Motivation included strategies to improve disease awareness, regular therapy, consequences of default, reinforcement, token payment and contracting. Control patients received routine daily chemotherapy for 6 months. Main Outcome Measure(s): Proportion of patients who completed more than 85% of prescribed medication and death. Cost: Out of pocket expenditure, cost of diagnosis and treatment for tuberculosis, cost of intervention and total expenditure for management. Cost imputed from market price. Direct cost used for calculation. Viewpoint: patient and societal. Results: Follow up data available for 504 cases, 253 controls (C) and 251 intervention (I) group. Male-female ratio was 8:2. Base-line characteristics were similar in both groups. Treatment completion rate was 70% (177) for (C) and 88% (221) for (I) groups (p = 0.001). Mortality rate was 7% (18) for (C) and 2% (7) for (I) group (p = 0.023). Average out of pocket per patient expenditure was Rs.837 -+ 537 for (C) and Rs.786 -+ 583 for (I) groups (p = 0.119). Average per patient treatment cost was Rs.2637 -+ 537 for (C) and Rs.2736 -+ 583 for (I) groups (p = 0.040). Intervention group incurred incremental cost of Rs.2.00. 3.8 million TB patients in India incur Rs.3180 million ($ 80 million) for palliation which is 50% of the actual curative treatment cost. Conclusions: With an additional expense of Rs.2.00 intervention patients showed better completion rate and mortality rate compared to control patients. Resource for curative treatment can be significantly improved if palliative expenditure can be minimized by early detection.
HEAD-SHAVING PRACTICES OF BARBERS AND PILGRIMS TO MAKKAH. A. A. Al-Salama, H. E. El
Bushra, A. Al-Saigul, A. Al-Rabeah, A. Al-Mazam, A. Al-Ra.shidi, M. Al-Sayed, N. Al-Hamdan. Field Epidemiology Training Program, Riyadh, Saudi Arabia. Objective: To identify unsafe head-shaving practices of barbers and pilgrims to Makkah (Hajjees) that could lead to transmission of bloodborne diseases among Hajjees. Design: Cross-sectional survey. Setting: Mina, where hundreds of thousands of Hajjees shave their heads within hours. Participants: 196 barbers who were asked, according to a standard checklist, about diseases transmitted by head-shaving and whose hands were inspected for cut wounds; 298 Hajjees from 23 nationalities whose heads were shaved with razor blades and whose scalps were visually checked for cut wounds (two-stage cluster sampling). Interventions: None. Main O u t c o m e Measure(s): Detection of unsafe head-shaving practices. Results: About 61% (95% CI 55-66) of Hajjees had cuts to the scalp (mean 2.6 per Hajjee, maximum 18). Of all Hajjees, 1.3% reported a history of hepatitis. Of 196 barbers, 23% (95% CI 17-30) had uncovered hand wounds, 21% (95% CI 16-28) used the same blade for more than one shave, and 82% (95% C1 76-87) threw at least one used blade on the floor. Hajjees (74%; 95% CI 66-77) and barbers (20%; 95% CI 6-15) were not aware of any health problems caused by shaving with used blades. Headshaving practices did not vary with educational level. Younger Hajjees (<50 years) from Western countries and sub-Saharan Africa were relatively more aware of potential transmission of H1V/A|DS by barbers, compared with Hajjees from other nationalities, and older Hajjees were more concerned about transmission of skin diseases. Conclusions: There is potential risk for bloodborne diseases during Hajj. Appropriate intervention should be fourfold: availability of safe shaving blades, health education, presence of affordable head-shaving services, and close supervision of barbers.
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A RAPID DIPSTICK M A L A R I A . M. A. Lansang, V. Belizario, M. L. Amarillo, A. J. Saul. CEU, University of the Philippines, College of Public Health, Manila, Philippines; T h e Research Institute for Tropical Medicine, Philippines; Queensland Institute for Medical Research, Australia. Objective: Malaria patients in remote areas generally experience major delays in obtaining results of malaria blood films from the rural health centers. We determined the cost-effectiveness of a rapid dipstick method for detecting malaria (Parasight-F, PSF) as compared to malarial blood films. Design: Descriptive study, criterion standard. Setting: Community-based malaria control program in Agusan del Sur, Philippines. Participants: 253 patients presenting with fever in the past 3 days, associated with any of the following: chills, sweating or headache. Interventions: Malaria dipstick using HRP-ll ahtigens (PSF), and blood films for the diagnosis of malaria. Main O u t c o m e Measure(s): Sensitivity and specificity rates of PSF. Costs, from the perspective of the government and patient, were estimated for the following: blood films, travel to health center and village health station, delay in treatment (days of work lost), anti-malarial treatment, and the dipstick. Results: The sensitivity and specificity of PSF in detecting P. falciparum (PF) were: 94.6% (95% CI: 86.1%, 98.2%) and 84.4% (78.0%, 89.2%), respectively. The cost of blood fihn detection was PHP:~21+ + for every Pf case detected and treated, while the cost for PSF detection was PHP95 + +. Conclusions: The dipstick method is more cost-effective than the blood film for detecting malaria, especially in areas where there are significant delays in relaying results.
BEHAVIORAL RISK FACTORS (BRF) FOR DISEASES DURING PILGRIMAGE TO MAKKAH (HAJJ): T H E S E C O N D S U R V E Y . A. M. Al-Rabeah, H. E. El Bushra,
M. 0 . AI-Sayed, A. M. AI-Saigul, A. A. AI-Rasheedi, A. A. AlMazam, A. A. Abu Dahish, N. A. Al-Hamdan, M. H. Al-Jeff~. Field Epidemiology Training Program, Riyadh, Saudi Arabia. Objective: To assess BRF for important diseases and conditions among pilgrims to Makkah (Hajjees). Design: Cross-sectional survey. Setting: Mina, a holy place where more than two million Hajjees camp for at least three days. Participants: 1613 Hajjees (53 nationalities) interviewed using a selfadministered standard questionnaire translated into 15 languages (twostage cluster sampling). Interventions: None. M a i n Outcome Measure(s): Behaviors predisposing to the major Hajj-related illnesses. Results: Out of 1613 respondents, 71% were performing Hajj for the first time, 15% were residents of Saudi Arabia, and 61% wore identifying wristbands. Eighty-eight percent (95% C1 87-90) had the required vaccination against meningococcal meningitis. Risky behavior fi~r fi~od poisoning included bringing fi~ods from their home countries (:~7%), and eating fi~od from street vendors (32%). Heat stroke prevention included using umbrellas (59%). However, of all Hajjees, 3-5% moved between holy places on fi~ot, and 19% lost their way in Mina fi~ra median of 2 hours; drank a median (interquartile range) of 2500 (1500-3750) ml of fluids, and slept for a median of 6 hours per day. After completing Hajj rites, 56% (95% CI 5459) shaved their heads with razor blades and 25% (95% CI 21-29) put themselves at risk of bloodborne disease by reusing razor blades used by other Hajjees. Hajjees put themselves at risk of injury by hanging on the back of buses ( 12%, 95% CI 10-13). Conclusions: Data were consistent with a previous report and indicate the need for simple, innovative cross-cultural educational programs aimed at reducing BRF among religious visitors.
RCT ON THE COST.EFFECTIVENESS
OF AN INNOVATIVE PATIENT MOTIVATION STRATEGY IN IMPROVING COMPLIANCE TO PULMONARY TUBERCULOSIS CHEMOTHERAPY. C. S. Ghosh, P. Ravin&an, S. M. Devi, M. R. Joshi. CEU, Medical College, Trivandrum, India. Objective: To evaluate the cost-effectiveness of an innovative patient motivation strategy in impruving compliance to chemotherapy in pulmonary tuberculosis. Design: Randomized control trial. Setting: Tertiary care setting. Participants: 530 newly diagnosed sputum smear and X-ray positive pulmonary tuberculosis cases attending the Chest clinic of Medical College. Interventions: Study patients randomized to intervention (267) and control groups (263). Intervention patients received daily chemotherapy and innovative motivation strategy. Motivation included strategies to improve disease awareness, regular therapy, consequences of default, reinforcement, token payment and contracting. Control patients received routine daily chemotherapy for 6 months. Main Outcome Measure(s): Proportion of patients who completed more than 85% of prescribed medication and death. Cost: Out of pocket expenditure, cost of diagnosis and treatment for tuberculosis, cost of intervention and total expenditure for management. Cost imputed from market price. Direct cost used for calculation. Viewpoint: patient and societal. Results: Follow up data available for 504 cases, 253 controls (C) and 251 intervention (I) group. Male-female ratio was 8:2. Base-line characteristics were similar in both groups. Treatment completion rate was 70% (177) for (C) and 88% (221) for (I) groups (p = 0.001). Mortality rate was 7% (18) for (C) and 2% (7) for (I) group (p = 0.023). Average out of pocket per patient expenditure was Rs.837 -+ 537 for (C) and Rs.786 -+ 583 for (I) groups (p = 0.119). Average per patient treatment cost was Rs.2637 -+ 537 for (C) and Rs.2736 -+ 583 for (I) groups (p = 0.040). Intervention group incurred incremental cost of Rs.2.00. 3.8 million TB patients in India incur Rs.3180 million ($ 80 million) for palliation which is 50% of the actual curative treatment cost. Conclusions: With an additional expense of Rs.2.00 intervention patients showed better completion rate and mortality rate compared to control patients. Resource for curative treatment can be significantly improved if palliative expenditure can be minimized by early detection.
HEAD-SHAVING PRACTICES OF BARBERS AND PILGRIMS TO MAKKAH. A. A. Al-Salama, H. E. El
Bushra, A. Al-Saigul, A. Al-Rabeah, A. Al-Mazam, A. Al-Ra.shidi, M. Al-Sayed, N. Al-Hamdan. Field Epidemiology Training Program, Riyadh, Saudi Arabia. Objective: To identify unsafe head-shaving practices of barbers and pilgrims to Makkah (Hajjees) that could lead to transmission of bloodborne diseases among Hajjees. Design: Cross-sectional survey. Setting: Mina, where hundreds of thousands of Hajjees shave their heads within hours. Participants: 196 barbers who were asked, according to a standard checklist, about diseases transmitted by head-shaving and whose hands were inspected for cut wounds; 298 Hajjees from 23 nationalities whose heads were shaved with razor blades and whose scalps were visually checked for cut wounds (two-stage cluster sampling). Interventions: None. Main O u t c o m e Measure(s): Detection of unsafe head-shaving practices. Results: About 61% (95% CI 55-66) of Hajjees had cuts to the scalp (mean 2.6 per Hajjee, maximum 18). Of all Hajjees, 1.3% reported a history of hepatitis. Of 196 barbers, 23% (95% CI 17-30) had uncovered hand wounds, 21% (95% CI 16-28) used the same blade for more than one shave, and 82% (95% C1 76-87) threw at least one used blade on the floor. Hajjees (74%; 95% CI 66-77) and barbers (20%; 95% CI 6-15) were not aware of any health problems caused by shaving with used blades. Headshaving practices did not vary with educational level. Younger Hajjees (<50 years) from Western countries and sub-Saharan Africa were relatively more aware of potential transmission of H1V/A|DS by barbers, compared with Hajjees from other nationalities, and older Hajjees were more concerned about transmission of skin diseases. Conclusions: There is potential risk for bloodborne diseases during Hajj. Appropriate intervention should be fourfold: availability of safe shaving blades, health education, presence of affordable head-shaving services, and close supervision of barbers.
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