- Email: [email protected]
Rising dengue death toll in Indonesia
CORRESPONDENCE
Since all HIV-1-positive patients in this study were prevalent cases, use of injections in the previous year could not be the cause of their infection, and the higher rates of receipt of injections in these people is largely due to higher rates of illness, presumably as a consequence of HIV-1 infection. In other analyses, we found that receipt of injections among HIV-1-negative individuals was not associated with HIV-1 acquisition.2 This finding suggests that estimates of the proportion of prevalent HIV-1 associated with receipt of injections, as reported by Gisselquist and colleagues,3 are likely to be biased by differential morbidity due to HIV-1, and do not necessarily reflect a causal association. *Marie Thoma, Ronald H Gray, Noah Kiwanuka, David Serwadda, Maria Wawer Department of Population and Family Health Sciences, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA (MT, RG); Rakai Project, Uganda Virus Research Institute, Entebbe, Uganda (NK); Institute of Public Health, Makerere University, Kampala, Uganda (DS); and Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York, NY, USA (MW) (e-mail: [email protected]) 1
2
3
Schmid GP, Buve A, Mugyenyi P, et al. Transmission of HIV-1 infection in subSaharan Africa and effect of elimination of unsafe injections. Lancet 2004; 363: 482–88. Kiwanuka N, Gray RH, Serwadda D, et al. The incidence of HIV-1 associated with injections and transfusions in a prospective cohort, Rakai, Uganda. AIDS 2004; 18: 342–44. Gisselquist D, Potterat JJ. Heterosexual transmission of HIV in Africa: an empiric estimate. Int J STD AIDS 2003;14: 162–73.
tainers, and larvae die at temperatures below 10°C. The mosquitoes fly only a few hundred yards from their breeding sites.2 The immediate response to the Indonesian epidemic—ie, mass fogging of metropolitan cities with insecticides— was nothing but a show-piece. It may have a political advantage, but in reality it merely yields a false sense of security. Moreover, even if Indonesians constantly use mosquito repellents and nets during the night, they could still be bitten by A aegypti during the day. And if individuals were to spend a considerable portion of their time in night clubs or similarly brightly lit places, they could be bitten by A aegypti in the night too. Indonesians should be asked to avoid shorts and skirts, and instead wear breeches or trousers. Fashion designers should be stimulated to offer attractive mosquito-proof clothing. Such innovative dress designs from Indonesian fashion designers would be valuable even for travellers on short visits to popular resorts in dengue-endemic areas. Only a judicious strategy against the vector would ensure that prospective funding of 50 billion rupiahs (US$5·9 million)1 was well spent, and resulted in a halt in the progression of dengue virus. *Subhash C Arya, Anjali Varma Centre for Logistical Research and Innovation, M-122 Greater Kailash Part 2, New Delhi 110048, India (e-mail: [email protected]) 1 2
Ahmad K. Dengue toll rises in Indonesia. Lancet 2004; 363: 956. Womack M. The yellow fever mosquito, Aedes aegypti. Wing Beats 1993; 5: 4.
Rising dengue death toll in Indonesia
Patients’ charges in Slovakia
Sir—Your Medicine and Health Policy coverage (Mar 20, p 363)1 points to the excessive death toll from dengue in different parts of Indonesia in 2004. Recently instituted health camps in otherwise overcrowded hospital premises would indeed be effective in case management of very large number of cases. However, community efforts to control the vector, Aedes aegypti, have so far ignored some of its fundamental properties. A aegypti is an early morning or late afternoon feeder, but will also bite at night under artificial illumination. Human blood is preferred over that of animals, and ankles are the favourite bite area. A aegypti eggs can resist desiccation for up to a year, and will hatch when flooded with deoxygenated water. Larval habitats are artificial con-
Sir—The introduction of charges to see a doctor in Germany has started an interesting discussion (Feb 21, p 630).1 Participants in this discussion are patients, doctors, and the insurers, and no party seems to be truly satisfied with this health-system reform. In Slovakia, a similar system was introduced a year ago. Patients must pay a nominal charge of 20 Slovak koruna (SKK; about US$0·50) for a visit and SKK 50 (about $1·25) for a day in hospital. Even adjusted for gross domestic product per capita, this is a much lower rate than in Germany (€10 [$12] per visit). The charges have substantially lowered the number of unnecessary visits,2 and especially the frequency of socially caused hospital admissions (eg, admission of elderly patients during their relatives’ holidays). These findings
show that sometimes developed countries can learn from the developing. Peter Celec Institute of Pathophysiology and Department of Molecular Biology, Comenius University, Galbaveho 3, 841 01 Bratislava, Slovak Republic (e-mail: [email protected]) 1
2
Orellana C. German patients angered by new charges for consultations. Lancet 2004; 363: 630. Website of the Ministry of Health of the Slovak Republic. http://health.gov.sk (accessed Mar 30, 2004).
European Clinical Trials Directive: the Italian position Sir—European Directive 2001/20/EC on human experimentation has been criticised on the grounds that it might be a threat to independent, not-forprofit clinical research.1,2 Compliance with the rules of good clinical practice and the bureaucratic burden of the external monitoring are seen as too heavy for studies without commercial sponsors. We propose principles and suggestions for a compromise between the requirements of the European Directive and the need to promote non-for-profit clinical trials. Clinical studies that address relevant questions about public health should be given priority by public authorities and agencies. The rules of good clinical practice enforced now by the European Directive represent a guide to the standards of quality and transparency for all products to be registered. The substantial and documented compliance with the quality requirements and principles of good clinical practice does not necessarily coincide with the rigid application of all the bureaucratic procedures. Non-for-profit controlled trials, when relevant and methodologically reliable, must be regarded as a priority investment by health authorities and not only an economic and operational burden. According to the above principle, the following measures could be adopted for not-for-profit trials: fees for examination by ethics committees could be withheld; insurance could be assumed by the general insurance policy of the participating hospitals because the trial would be recognised a as part of health care itself; the participation of clinicians in such trials could count towards continuing medical education; fasttrack authorisation could be recommended to ethics committees; and agreements with industries interested in
THE LANCET • Vol 363 • May 15, 2004 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet.
1651
Since all HIV-1-positive patients in this study were prevalent cases, use of injections in the previous year could not be the cause of their infection, and the higher rates of receipt of injections in these people is largely due to higher rates of illness, presumably as a consequence of HIV-1 infection. In other analyses, we found that receipt of injections among HIV-1-negative individuals was not associated with HIV-1 acquisition.2 This finding suggests that estimates of the proportion of prevalent HIV-1 associated with receipt of injections, as reported by Gisselquist and colleagues,3 are likely to be biased by differential morbidity due to HIV-1, and do not necessarily reflect a causal association. *Marie Thoma, Ronald H Gray, Noah Kiwanuka, David Serwadda, Maria Wawer Department of Population and Family Health Sciences, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA (MT, RG); Rakai Project, Uganda Virus Research Institute, Entebbe, Uganda (NK); Institute of Public Health, Makerere University, Kampala, Uganda (DS); and Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York, NY, USA (MW) (e-mail: [email protected]) 1
2
3
Schmid GP, Buve A, Mugyenyi P, et al. Transmission of HIV-1 infection in subSaharan Africa and effect of elimination of unsafe injections. Lancet 2004; 363: 482–88. Kiwanuka N, Gray RH, Serwadda D, et al. The incidence of HIV-1 associated with injections and transfusions in a prospective cohort, Rakai, Uganda. AIDS 2004; 18: 342–44. Gisselquist D, Potterat JJ. Heterosexual transmission of HIV in Africa: an empiric estimate. Int J STD AIDS 2003;14: 162–73.
tainers, and larvae die at temperatures below 10°C. The mosquitoes fly only a few hundred yards from their breeding sites.2 The immediate response to the Indonesian epidemic—ie, mass fogging of metropolitan cities with insecticides— was nothing but a show-piece. It may have a political advantage, but in reality it merely yields a false sense of security. Moreover, even if Indonesians constantly use mosquito repellents and nets during the night, they could still be bitten by A aegypti during the day. And if individuals were to spend a considerable portion of their time in night clubs or similarly brightly lit places, they could be bitten by A aegypti in the night too. Indonesians should be asked to avoid shorts and skirts, and instead wear breeches or trousers. Fashion designers should be stimulated to offer attractive mosquito-proof clothing. Such innovative dress designs from Indonesian fashion designers would be valuable even for travellers on short visits to popular resorts in dengue-endemic areas. Only a judicious strategy against the vector would ensure that prospective funding of 50 billion rupiahs (US$5·9 million)1 was well spent, and resulted in a halt in the progression of dengue virus. *Subhash C Arya, Anjali Varma Centre for Logistical Research and Innovation, M-122 Greater Kailash Part 2, New Delhi 110048, India (e-mail: [email protected]) 1 2
Ahmad K. Dengue toll rises in Indonesia. Lancet 2004; 363: 956. Womack M. The yellow fever mosquito, Aedes aegypti. Wing Beats 1993; 5: 4.
Rising dengue death toll in Indonesia
Patients’ charges in Slovakia
Sir—Your Medicine and Health Policy coverage (Mar 20, p 363)1 points to the excessive death toll from dengue in different parts of Indonesia in 2004. Recently instituted health camps in otherwise overcrowded hospital premises would indeed be effective in case management of very large number of cases. However, community efforts to control the vector, Aedes aegypti, have so far ignored some of its fundamental properties. A aegypti is an early morning or late afternoon feeder, but will also bite at night under artificial illumination. Human blood is preferred over that of animals, and ankles are the favourite bite area. A aegypti eggs can resist desiccation for up to a year, and will hatch when flooded with deoxygenated water. Larval habitats are artificial con-
Sir—The introduction of charges to see a doctor in Germany has started an interesting discussion (Feb 21, p 630).1 Participants in this discussion are patients, doctors, and the insurers, and no party seems to be truly satisfied with this health-system reform. In Slovakia, a similar system was introduced a year ago. Patients must pay a nominal charge of 20 Slovak koruna (SKK; about US$0·50) for a visit and SKK 50 (about $1·25) for a day in hospital. Even adjusted for gross domestic product per capita, this is a much lower rate than in Germany (€10 [$12] per visit). The charges have substantially lowered the number of unnecessary visits,2 and especially the frequency of socially caused hospital admissions (eg, admission of elderly patients during their relatives’ holidays). These findings
show that sometimes developed countries can learn from the developing. Peter Celec Institute of Pathophysiology and Department of Molecular Biology, Comenius University, Galbaveho 3, 841 01 Bratislava, Slovak Republic (e-mail: [email protected]) 1
2
Orellana C. German patients angered by new charges for consultations. Lancet 2004; 363: 630. Website of the Ministry of Health of the Slovak Republic. http://health.gov.sk (accessed Mar 30, 2004).
European Clinical Trials Directive: the Italian position Sir—European Directive 2001/20/EC on human experimentation has been criticised on the grounds that it might be a threat to independent, not-forprofit clinical research.1,2 Compliance with the rules of good clinical practice and the bureaucratic burden of the external monitoring are seen as too heavy for studies without commercial sponsors. We propose principles and suggestions for a compromise between the requirements of the European Directive and the need to promote non-for-profit clinical trials. Clinical studies that address relevant questions about public health should be given priority by public authorities and agencies. The rules of good clinical practice enforced now by the European Directive represent a guide to the standards of quality and transparency for all products to be registered. The substantial and documented compliance with the quality requirements and principles of good clinical practice does not necessarily coincide with the rigid application of all the bureaucratic procedures. Non-for-profit controlled trials, when relevant and methodologically reliable, must be regarded as a priority investment by health authorities and not only an economic and operational burden. According to the above principle, the following measures could be adopted for not-for-profit trials: fees for examination by ethics committees could be withheld; insurance could be assumed by the general insurance policy of the participating hospitals because the trial would be recognised a as part of health care itself; the participation of clinicians in such trials could count towards continuing medical education; fasttrack authorisation could be recommended to ethics committees; and agreements with industries interested in
THE LANCET • Vol 363 • May 15, 2004 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet.
1651