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Public Health Laboratory - Ivo de Carneri
International Centre for Integrated Control, Operational Research
and Training on Communicable Diseases and Public Health Issues
In collaboration with the Ministry of Health and Social Welfare (Zanzibar)
and the Ivo de Carneri Foundation (Milan, Italy)
THE PUBLIC HEALTH LABORATORY "IVO DE CARNERI"
Disease surveillance and control Operational research ORGANIZATION AND MANAGEMENT
In Charge (at December 2006) STRUCTURE and EQUIPMENT
ACTIVITIES PERFORMED IN 2005 -2006
Diseases surveillance and control
Monitoring and evaluation of the Zanzibar Malaria Control Programme Diarrhoeal diseases surveillance Schistosomiasis Control Initiative HIV/AIDS and TB Diagnosis and Control Effect of zinc or iron supplementation Effects of intestinal helmints infection (Watoto Bora) Anaemia in Pregnancy (Mama na Afya) Safe Water in Chake Chake District Training Course on "Public Health Priorities in Sub-saharan Africa" Training and internship for research at the PHL-IdC Training of PHL-IdC staff SUMMARY OF THE ACTIVITIES PERFORMED BETWEEN 2000 AND 2006
Diseases surveillance and control VISION: THE WAY FORWARD
THE PUBLIC HEALTH LABORATORY "IVO DE CARNERI"
In 1988, late Professor Ivo de Carneri, on an official mission for the Italian Ministry of Foreign Affairs, visited Zanzibar, to assess the progress of the schistosomiasis control programme. In his mission report Prof. de Carneri stressed "the need of a Public Health Laboratory as a centre for quality control of the peripheral laboratories and to promote training and applied research to develop effective control strategies…".
In 1994, the Ivo de Carneri Foundation was created in his memory. In 1997 an agreement was signed between the Ivo de Carneri Foundation and the Government of Zanzibar for the construction and use of the Public Health Laboratory Ivo de Carneri (PHL-IdC) that was officially opened and became operational on 12th June 2000.
The agreement has been updated on 21st June 2004.
THE MISSION OF THE CENTRE IS: "To improve the health status and knowledge of the people of Zanzibar in accordance with their culture and traditions, through the development, assessment and implementation of strategies for the prevention, control, surveillance, research and training on endemic diseases". The PHL-IdC has been created and is run through a partnership between the Ministry of Health and Social Welfare (MoHSW-Zanzibar) and the Ivo de Carneri Foundation (Milan, Italy).
It is embedded in the organigram of the MoHSW, within the Directorate of Planning, Policy and Finance.
It collaborates with national scientific institutions and organizations such as the Zanzibar Health Research Council, the College of Health Sciences, the Research Centre in Ifakara, the National Institute of Medical Research (NIMR) and the Muhimbili University in Tanzania mainland.
The PHL-IdC also collaborates with international scientific institutions and organizations to assess and evaluate global strategies of disease surveillance and control. In 2005 the PHL-IdC became "WHO Collaborating Centre for control of schistosomiasis and intestinal parasitic infections".
Pemba, with the other major island of Unguja, is part of Zanzibar, laying few degrees south of the Equator, 50 km off the coast of mainland Tanzania. The "spice island" - with cloves as its main crop - has a population of about 400.000 on a surface of about 1.000 km2. Communicable endemic diseases such as malaria, tuberculosis, HIV/AIDS, acute respiratory infections, diarrhea, intestinal helminthiasis, schistosomiasis, lymphatic filariasis, leprosy, as well as non-communicable diseases such as Protein-Energy Malnutrition and micro-nutrient deficiencies, are the main public health problems and are responsible for the high morbidity and mortality, especially among women and children.
Zanzibar and Pemba are well known by tropical disease researchers and public health specialists for the pioneering works that have been carried out in schistosomiasis, malaria and soil-transmitted nematodes. In the late 70s and early 80s, collaboration between the Ministry of Health of Zanzibar, Italy and the World Health Organization was undertaken with major initiatives in the control of schistosomiasis and the implementation of the Expanded Programme of Immunization. In the early 1980s Zanzibar collaborated with WHO in a series of schistosomiasis field trials. This collaboration culminated, in 1986, with the implementation of the Pemba Schistosomiasis Control Programme. This initiative was funded directly by the WHO Director General and the Direzione Generale per la Cooperazione allo Sviluppo of the Italian Ministry of Foreign Affairs. The programme aimed at assess- ing the impact of large-scale regular chemotherapy on morbidity due to schis- tosomiasis. In the early 90s this control initiative was progressively integrated with other major disease control strate- PEMBA ISLAND
gies such as soil-transmitted helminthiasis and later (2006) with lymphatic filariasis.
The great strength of the Zanzibar experience has always been its continu- ous link between control and operational research. This has culminated in a series of major studies undertaken in collaboration with the Department of International Health of Johns Hopkins University, to assess the nutri- tional impact of regular antihelminthic chemotherapy in children and women. This activity has generated consider- able information on communicable diseases control that ranges from the impact of de- worming on growth and iron status of school- children in Zanzibar to the assessment of new tools to detect anaemia at the Primary Health The main lines of activity of the PHL-IdC were defined in a workshop held in August 2001 and opened by the Honorable Minister of Health and Social Welfare in presence of the local authorities and Programme Managers. The resolutions of the workshop were aimed at defining the role of PHL-IdC as a recognised Institution within the MoHSW for implementing research studies oriented to health priorities of Zanzibar, assisting surveillance of outbreaks, monitoring diseases control programmes, facilitating training of health staff both within the country and abroad. The exchange of information and continuous communication was considered essential for good collaboration and coordination with MoHSW programmes. A Technical Advisory Group of the PHL-IdC was envisaged to be created including experts from the MoHSW of Zanzibar in order to meet the technical challenges of performing research, surveillance and training activities of high scientific standard. The main fields of activity of the PHL-IdC are: disease surveillance and control, operational research and training.
3.1 DISEASE SURVEILLANCE AND CONTROL
PHL-IdC, in close collaboration with the MoH and the managers of Control Programs, provides technical support for the monitoring and evaluation of endemic diseases control activities.
Additionally, PHL-IdC advises and provides technical support in the surveillance, early detection and control of outbreaks, with particular reference to bacterial (diarrhea) and viral Technical support and co-ordination is envisaged for the laboratories of Hospitals and Health Centers. Finally, PHL-IdC facilitates and supports training activities for health staff in curative as well as preventive services and data collection/analysis from the hospitals and the peripheral health services. 3.2 OPERATIONAL RESEARCH
PHL-IdC's research is oriented according to the priorities defined by the Ministry of Health and Social Welfare of Zanzibar, in close relation with the surveillance and control of endemic and epidemic diseases: malaria, schistoso- miasis, intestinal parasitic infections, lymphatic filariasis, tuberculosis, leprosy, diarrhoeal diseases, HIV/AIDS and sexually-transmitted diseases, hepatitis, as well as malnutrition and related diseases. Research proposals are reviewed by the PHL- IdC Management Committee and approved by the PHL-IdC Commission. Ethical clearance is sought from the Zanzibar Health Research Council.
Application forms for the use of PHL-IdC for research activity are available on the Ivo de Carneri Foundation web-site (www. fondazionedecarneri.it).
3.3 TRAINING
Training activities of PHL-IdC include: · Workshops on public health priorities with national and international participants.
· Working/studying periods for students and researchers, to improve their knowledge on the methodology of public health research an on the challenge of controlling tropical diseases.
· Training abroad through scholarships for PHL-IdC staff, to improve its knowledge on interna- tional public health.
· Technical assistance provided to foreign countries or other institutions by PHL-IdC senior · Residential training courses for international health staff. Scientific collaborations are in progress with several international universities and institutions including: AMREF (Kenya), Cornell University (Ithaca, New York, USA), Department of Public Health, Microbiology and Virology, University of Milan (Italy), Engineers without Borders, University of Trento (Italy), Imperial College (London, UK), Institute of Infectious and Tropical Diseases, Ospedale "Luigi Sacco" (University of Milan, Italy), Institute of Infectious Diseases, INMI L. Spallanzani (Rome, Italy), Institute of Infectious and Tropical Diseases, University of Brescia (Italy), Johns Hopkins Bloomberg School of Public Health (Baltimore, USA), Karolinska Institute (Sweden), KEMRI/Hashimoto Initiative for the Control of Parasitic Diseases in East Africa (ESACIPAC), Kenya Medical Research Institute (KEMRI, Kenya), London School of Hygiene and Tropical Medicine (London, UK), Natural History Museum (London, UK), University of Kwa-Zulu Natal (Durban, South Africa), University of Ancona (Italy), University of Pavia (Italy), University of Siena (Italy), World Health Organization (Geneva). Collaboration with local institutions is ongoing and links are established with Centers in Tanzania such as Amani Research Institute, Ifakara Research Institute, Muhimbili University Dar es Salaam, NIMR and in other neighboring Institutes.
ORGANIZATION AND MANAGEMENT
The governing body of the PHL-IdC is the Commission, with five members: two from the Ministry of Health and Social Welfare of Zanzibar, two from the Ivo de Carneri Foundation of Italy, one from the World Health Organization Headquarters, Geneva, as observer and technical adviser. The Commission has at least two meetings a year.
The head of PHL–IdC is the Director, nominated by the Commission and assisted by a Deputy Director.
In charge for the activities and the organization are: the Chief of Laboratory Services, the Chief of Administration and the Chief of Finance.
A Management Committee, composed by the PHL-IdC core staff, advises on administrative/ A Technical Advisory Group (TAG), composed by professional experts, advises on research and technical issues.
MINISTRY OF HEALTH
IVO DE CARNERI
AND SOCIAL WELFARE
PHL –IdC
MANAGEMENT COMMITTEE
5.2 IN CHARGE (at December 2006)
Mohamed Saleh Jiddawi (PS MoHSW)
Malick A. Juma (GD MoHSW)
Sandra Carozzi de Carneri (President IdCF)
Marco Albonico (Scientific Secretary IdCF)
Lorenzo Savioli (WHO)
Hamad Juma Haji, MSc
Paolo Chiodini, MD
Chief of Laboratory
Shaali M. Ame, MSc
C. of Administration
Omar Issa
Chief of Finance
Abeid Said Muharram
N. 1 Laboratory Scientist
N. 2 Laboratory Technologists
N. 7 Laboratory Technicians
N. 1 Nutritionist
N. 1 Data manager
N. 3 Data entry clerks
N. 1 Assistant Administrator
N. 1 Assistant Accountant
N. 1 Secretary
N. 1 Store keeper
N. 1 Assistant Store keeper
N. 5 Cleaners and attendants
N. 3 Drivers
N. 3 Gardeners
N. 5 Watchman
STRUCTURE AND EQUIPMENT
PHL-IdC is located in Wawi, Chake-Chake, Pemba. The main building, of 800 m2, is divided into several sections: Laboratory (Parasitology, Bacteriology, Virology), Finance and A large conference room can accommodate up to 50 people and is equipped with training facilities (slides and overhead projector, computer link, library).
A second block of 400 m2 has been inaugurated in early 2005 and includes: offices for administration and data management, store, canteen. The block is dedicated to the memory of late Dr Carlo Urbani.
The PHL-IdC is equipped with telephone line, fax and Internet connection.
The laboratories are provided with the standard equipment and supplies and in addition with: two Freezers –80°C, three Freezers –20°C, two ELISA readers, two sterile hoods (class Biohazard II), one class I hood, one Co2 incubator, water distillers and autoclaves.
During 2007 the PCR technology and a CD4 Counter will be made available.
Electricity and Water supply
Electricity is provided by the main line. A Back-up generator of KVA 66 guarantees its Water supply is provided by the main pipe as well as by a water pressure system consist- ing of a reservoir of six tanks of 5000 litres each and 5 pumps, which draw water from a connected well on emergency.
For the implementation of some Projects, office centers and facilities for the fieldwork have been set up in the Districts, in collaboration with the local health authorities.
ACTIVITIES PERFORMED IN 2005 - 2006
7.1 DISEASE SURVEILLANCE AND CONTROL
7.1.1 Monitoring and evaluation of the Zanzibar Malaria Control Programme
The activities carried out concern two main areas: A) Quality Assurance and Quality Control (QA/QC) for malaria microscopy.
B) Health Care facilities data collection and analysis, to assess the adequacy of provision of
Intermittent Preventive Treatment in pregnant women a) Surveys were carried out to assess the standard of laboratory performance. In addition, QA/QC provided reports on activities and advised on further needs of training and supplies. In the future QA/QC activities will include other diagnostic investigations of public health importance.
b) Data collection in health care facilities was concentrated on Intermittent Preventive Treatment in pregnant women, which is part of the overall strategy for malaria control. The prevalence of malaria was found to be lower as compared to a survey carried out in 2003, when IPT was not yet introduced. Occasionally, lack of Sulphadoxine-Pirimethamine (SP) was registered in some peripheral health units.
Both activities have been successfully completed and generated ideas for further collaboration.
7.1.2 Diarrhoeal diseases surveillance
PHL-IdC has a long-standing collaboration with the MoHSW of Zanzibar on detection and follow-up of diarrhoeal diseases outbreaks. PHL staff members are ready to be mobilized in case of emergency.
Laboratory support is always provided during cholera outbreaks, which occur in Pemba almost every year at the end of the rainy season. During the 2006 cholera outbreak the PHL- IdC staff was fully involved in the laboratory diagnosis of suspected cases as well as in the investigation of the water sources in selected areas.
7.1.3 Schistosomiasis Control Initiative
PHL-IdC is the MoH reference unit for Pemba of a five years plan through SCI (Schistosomiasis Control Initiative) for the control of schistosomiasis and soil-transmitted helminthiasis. SCI launched in 2004 a yearly community-based Mass Drug Administration (MDA) against Schistosoma haematobium (Praziquantel 40 mg/kg) and STH (Albendazole 400 mg). The community-based campaigns, implemented through Primary Health Care Units, include also health education activities and imply the collaboration of social services at all levels.
A baseline survey was conducted in April 2004, revealing a prevalence of 62,9% for Schistosoma haematobium infection. Results from the monitoring protocol indicated a dramatic impact of the SCI after two annual treatments with excellent reductions in the intensity and prevalence of schistosomiasis infection. The impact on STH has not been as dramatic, with prevalence still around 70% (Teresa Sebastiani 2006, LSHTM MSc thesis). According to WHO guidelines on treating helminth infections (Montresor 2002), the drug distribution strategy in Pemba was changed in 2006 and targets the population with the highest rates of infection, namely school-aged children.
7.1.4 HIV/AIDS and TB Diagnosis and Control
The Project is funded by the Italian Cooperation and has the technical support of the INMI L. Spallanzani in Rome. It has been focused on TB and has enhanced the collaboration of PHL-IdC with the TB and Leprosy National Control Programme. From January 2007 the PHL-IdC provides a referral service, starting with culture of Mycobacteria. The PCR technology will be set up within the frame of this Project and will be available for other priority areas.
7.2.1 Effect of zinc or iron supplementation on mortality and morbidity during the
first three years of life
This large-scale trial has been conducted by the Johns Hokpins Bloomberg School of Public Health in the years 2000-2005. The study has been completed and some of the results published (Lancet 2006, 367: 133–43). The trial was done in parallel with similar studies in India and Nepal and aimed at assessing the efficacy of iron, folic acid and zinc supplementation on the health of children less than three years of age. It has been among the largest studies of this kind, with a total sample of about 32,000 children.
The main conclusion was that routine supplementation with iron and folic acid in pre- school children in a population with high rates of malaria may result in an increased risk of severe illness and death. In the presence of an active programme to detect and treat malaria and other infections, iron deficient and anaemic children can benefit from supplementation. However supplementation of those who are not iron deficient might be harmful. Results from this study have created an international debate on the guidelines for iron and folic acid supplementation.
The study gave also an insight on the benefits of daily zinc supplementation. These data are under analysis and not yet published. 7.2.2 Effects of intestinal helmints infection on inflammation, anaemia and malnutri-
tion in early childhood (Watoto Bora)
The study aimed to test whether periodic treatment with mebendazole can decrease the rates of severe anaemia and Protein Energy Malnutrition (PEM), to measure intestinal blood loss before and after treatment, to explain the link between pro-inflammatory cytokines response and The study revealed that a proportion of children infected with gastrointestinal nematodes had antigen-specific Th2 responses in the Whole Blood Assay (WBA). In addition there were no children with Th1 biased responses. A significantly higher number of infected children had cytokines responses, compared with those not infected. This study also has been completed in 2005. Results are being analyses and submitted for publication. 7.2.3 Anaemia in Pregnancy (Mama na Afya)
The study has evaluated the problem of anaemia in 2500 pregnant women, in a setting where intestinal worms and malaria are endemic. The main purpose of the study was to compare the efficacy of the standard regimen of care (SP for IPT twice during pregnancy, deworming with mebendazole 500 mg once, iron-folic acid daily) with the enhanced one (IPT and deworming with albendazole 400 mg twice, iron-folic acid-multivitamins daily). The collected data are not yet fully analysed. The prevalence of severe anaemia (Hb < 7 g/dl) was 4%, mild anaemia (Hb 7-11 g/dl) was 23% whereas 73% of the enrolled women had no anaemia (Hb > 11 g/dl). The most important factor linked with anaemia seems to be poverty.
Three sub-studies were also performed, dealing with assessment of blood loss at delivery, prevalence of Helicobacter Pylori and morbidity/mortality in low birth weight. Results are avail- able for the first two studies.
The study on blood losses used sophisticated techniques for measuring the amount of blood. The estimate made clinically by nurses was found almost as accurate. The amount of blood loss was clearly related with the subsequent level of anaemia.
The prevalence of Helicobacter Pylori was low compared to Tanzania mainland.
The women infected were more anaemic than the non-infected ones. Results are submitted for publication.
7.2.4 Safe Water in Chake Chake District
The project focused on the systematic verification of the water distribution network with appraisal of the state of the piping system and of the water pumping stations. Mapping with GPS of all the network, qualitative water analysis, standardization of the laboratory methods and training of the technical staff were also performed. The project showed a very critical situation with 11 out of 15 primary water sources analyzed turning out to be dangerously contaminated (= faecal contamination > 30%).
The water project team has also been involved in the 2006 Cholera outbreak activities.
The team has provided technical assistance in carrying out analysis on water sources and on stool samples. The timely intervention has contributed in limiting the spread of the epidemics.
The water quality monitoring activities are going on in collaboration with the Department for Water Development. A new project addressing the rehabilitation of the water network is envisaged for the near future. 7.2.5 Baby food
This study was a controlled trial of the acceptability and nutritional efficacy of "InstaLife" baby porridge, a complementary food to be used during weaning with the aim of avoiding nutritional deficiencies and the related health problems. The food provides adequate protein and calories intake together with micronutrients and vitamins. During the first phase of the study, the acceptability of the product was tested and confronted with different feeding choices.
Preliminary data show that the food was much appreciated by mothers and babies, but unsafe water was often used for re-constitution. Health messages have been developed to encourage mothers to boil the water in order to reduce infection's risks. Before the starting of the second phase (assessment of efficacy) an evaluation of the microbiological content of local food used for small children is scheduled for January 2007.
7.3 Training
7.3.1 Utaalam Project
The project's aim was to intervene within the National Health Education and Training Plan through the organisation of refresher/training courses addressed to health workers and primary school teachers, with regard to control of tropical diseases. Indirect beneficiaries were the College of Health Science (CH S) students, the pupils of the primary schools, their families and the local community using the healthcare services in which the trained staff will operate.
In 2004-2006 the following courses have been organized: · training course for 20 teachers of the CHS on tropical medicine and public health (advanced · training course for 20 laboratory technicians on microscopic diagnosis · training course for 70 primary-school teachers on water-related diseases, public health and · training course for 40 rural health workers on tropical medicine and public health (basic level)· training course for 40 nurses on artemisinin combination therapy and malaria patient man The Project has also contributed, with materials and equipment, to the rehabilitation of PHL-IdC and CHS.
7.3.2 Training Course on "Tropical Medicine and Public Health Priorities in Sub-saha-
ran Africa"
The initiative started in 2004 as a residential course and has now reached the third edition. In 2006 the course has been jointly developed by the University of Brescia (Infectious and Tropical Diseases Institute), the Ivo de Carneri Foundation and PHL-IdC. In the same year it has been accredited by the TropEd Circuite as advanced module.
TropEd is a network of European institutions for higher education leading to the Master's Degree in International Health. The Master programme consists of an introductory core course, specialised optional modules and a research project (www.troped.org). The two weeks training course is held once a year and is addressed to 20 participants, 10 European and 10 African, supported by scholarships assigned by the Ivo de Carneri Foundation.
It offers a unique opportunity for first hand site visits in resource-limited settings. The relevance of the initiative relies on the strategy of exchanging resources between North and South. Training of international level carried out in an African Institution reduces costs and gives more opportunities to the local health personnel. Furthermore, the possibility for health cadres from Europe of having an experience "in the field" is extremely important for a better understanding of the reality, the epidemiological scenario and the health challenges of a developing country. 7.3.3 Training and internship for research at the PHL-IdC
On an ongoing basis, students and researchers from selected Universities spend some peri- ods at PHL-IdC to carry out the fieldwork foreseen by their research proposal or thesis. PHL-IdC is happy to offer this unique opportunity of a well-equipped and functional infrastructure in Sub- Saharan Africa, which, together with its staff, can assist the visiting researchers in implementing their activities. Financial covering of expenses should be ensured. Official request should be sent to the PHL-IdC Director and more information about laboratory fee and accommodation are available upon request or can be downloaded from the following website: www.fondazionedecarneri.it.
7.3.4 Training of PHL-IdC staff
Selected PHL-IdC staff members are sent to attend short or long-term training courses in distinguished Universities. The candidates are covered with scholarships or study grants. This strategy is in line with PHL-IdC mission of investing in human resources and of addressing their upgrading needs.
In 2005-2006 the following staff members have been sent abroad for training: · Shaali M. Ame (Lab. Scientist): MSc Medical Parasitology (London School of Hygiene and Tropical Medicine) · Sabra Said Khalfan (Nutritionist): MSc International Development /Nutrition (Cornell · Saleh Juma Mohamed (Lab. Technician): Diploma Community Health (Amref, Nairobi).
· Lulua Ali Salum: Certificate in Secretary and Administration (Zanzibar) · Amour Khamis Amour (Lab. Technician): Diploma in Health Education (Tanzania)· Haji Said Haji (Lab. Technologist), Makame M. Kombo (Lab. Technologist): stages and refreshing courses in Italy and Tanzania.
SUMMARY OF THE ACTIVITIES PERFORMED BETWEEN 2000 AND 2006
Second phase study to develop tests London School Hyg.& to monitor anthelmintic drug efficacy/resistance Trop. Medicine, WHO in human intestinal nematodes Comparison of Pyrantel/Oxantel London School Hyg.& single dose for treatment of soil Trop. Medicine, WHO transmitted nematode infections Evaluation of safety and efficacy of co-administration of albendazole and ivermectin in a lymphatic filariasis endemic area Prevalence of Urinary Schistosomiasis London School Hyg.& and its morbidity Trop. Medicine, WHO after ten years of periodic treatment Prevalence and intensity London School Hyg.& of intestinal nematodes and evaluation of Trop. Medicine, WHO mebendazole and levamisole efficacy Evaluation of angina due to Streptococcus B Haemoliticus in children and its relation with University of Siena Rheumatic Heart Disease Genetic diversity within S. haematobium and use of Bulinus Nasutus for biological control (pilot study) Development and validation of a "tablet pole" for the administration of Praziquantel in Sub-Saharan Africa Antimalarial drug combination Karolinska Institute, therapy to improve treatment efficacy and delay drug resistance Effects of intestinal helminth infections in Johns Hopkins Univ.
early childhood on immune response, inflammation, London School Hyg.& anaemia and malnutrition (Watoto Bora) Physical, mental and social development of young children in rural East Africa: randomised trial of iron Johns Hopkins Univ.
and zinc supplementation and anthelmintic treatment Efficacy of Zinc or iron supplementation during the first three years of life in preventing mortality Johns Hopkins Univ.
and severe morbidy (ZINC) Institute of Infectious Collaboration study on viral diseases and Tropical Diseases with special focus on HIV infection Follow-up of an outbreak of neurospastic paralysis Strengthening of diagnostic and surveillance capacities on bacterial diarrhoeal diseases.
Support to Cholera control activities.
Anaemia in pregnancy, including Low Birth Weight Cornell University, study (Mama na Afya/LBW) Cornell University Schistosomiasis Control Initiative (SCI) Imperial College, London Health Training Project (Utaalam) for health workers and primary school teachers IdCF, Universities of Training Course "Challenges of Tropical Medicine Ancona and Brescia in the third millennium" Monitoring and evaluation Italian Cooperation of the Zanzibar Malaria Control Programme IdCF, University of Milan, Safe Water in Chake Chake District: Private and Public Engineers Without systematic monitoring of water supply "Baby food": research on acceptability Cornell University and efficacy of a fortified infant food HIV and TB Diagnosis and Treatment. Setting of Italian Cooperation, Mycobacteria culture and PCR technology INMI L.Spallanzani 9.1 DISEASES SURVEILLANCE AND CONTROL
Schistosoma Control Initiative
Imperial College, Mass Drugs Administration (MDA: praziquantel and albendazole) is planned for March and June 2007. After the MDA the initiative will end and a final report will be made available. In October 2006 the Control Program of schistosomiasis has been integrated with those for filariasis and soil transmitted helmints. The strategy has to be fully revised, considering the results achieved in the last few years (filarial transmission interrupted, prevalence of schistosoma infection reduced significantly, intestinal helmints only slightly diminished).
The PHL-IdC will take care of monitoring and research activities, leaving to the Health Services the provision of drugs.
Referral service for TB control
Italian Cooperation, MoHSW, Following the Project on HIV and TB diagnosis and treatment carried out in 2006 with the technical support of the Spallanzani Institute (INMI, Rome), the PHL-IdC will act as referral laboratory for the Zanzibar Control Programme for TB and Leprosy (both Pemba and Unguja), providing the culture of Mycobacteria.
After May 2007, the technology for PCR will be also available and it will be useful for different research purposes, beyond the area of TB diagnosis. Referral service for Malaria Diagnosis
Italian Cooperation, MoHSW This is another Project transformed into a routine service for the National Health System.
In collaboration with the Malaria Control Programme, the PHL-IdC will provide Quality Control of malaria diagnosis for the clinical laboratories in Pemba.
Referral service for Malaria I.P.T.
Italian Cooperation, MoHSW The Intermittent Presumptive Treatment of malaria in pregnancy is among the strategies for controlling the disease adopted in Zanzibar and has been monitored in 2006.
During 2007 PHL-IdC will continue collecting information on the availability of drugs, the compliance of the mothers, the use of impregnated bed-nets, the efficacy of the ongoing measures on the health of women and babies.
Referral service for HIV diagnosis
IITD Sacco Hospital Milan, Rotary, Private donors (Italy) The initiative follows the research on viral diseases performed in 2002-2004 with the technical support of the Sacco Hospital, Milan. If funded, PHL-IdC will be provided with new equipment, including a CD4 Counter. In addition to specific investigations, an updating on the prevalence of HIV infection will be carried out as well as a referral service will be made available for the clinicians and the Control Programme.
Water safety monitoring
Various Italian donors, Water Department Zanzibar The "Safe water" Project ended in December 2006. In the first half of 2007 the monitoring of the water sources will continue in Chake Chake District. Hopefully from August 2007 new funds will be available with the purpose of extending controls to the other Districts in Pemba and to perform at least some of the interventions necessary to improve the quality of the water people use for drinking (faecal contamination resulted worrisome).
Quality Assurance in Laboratories
PHL-IdC collaborates in a large initiative involving Tanzania, Kenya, Uganda and Zambia, with the responsibility and coordination of Amref. The final result will be a system of Quality Assurance for laboratory services. The initial step is the provision of adequate tools (specimen) for control and training. The exercise is done within the frame suggested by the WHO for standard procedures and Quality Assurance. 9.2 RESEARCH
School of Public Health This initiative is planned as a final activity of the "Zinc" project and as a bridge toward a five- year plan, which will follow (Gates Challenge 13). Its objectives are: - to provide data to evaluate the impact of zinc project in the last 5 years and to help develop field-tested, practically applicable instruments to measure mortality trends and census information in resource-poor settings; - to evaluate sibling history as a method for ascertaining mortality information and some variations in the questionnaires used.
Urine dipstick for Malaria
School of Public Health The hypothesis is that urine diagnosis of malaria can be sensitive and specific. At present 80% of people are treated for malaria on clinical basis only. Numerous studies have also documented that the accuracy of diagnosis is less than 50%. A new version of the malaria urine dipstick will be tested for specificity and sensitivity.
Verbal autopsy and Protein Signatures
School of Public Health Critical information on population health is needed to inform planning, resource allocation and monitoring. In the GC13 Population Health Metric Research Consortium Project a team is woring to improve the technology and methods for health measurement.
Verbal autopsy: comparison and validation of verbal autopsy instruments with gold standard.
Protein signature: standard and uniform procedure for analysing plasma sample and identify "signatures" of specific diseases.
Baby food efficacy trial
Cornell University This is the second phase of the study completed in 2006. It is a randomised controlled trial to compare the nutritional efficacy of different weaning solutions. The hypothesis to be tested are related both to the level of acceptance and consumption of the different products and to their effects on growth, micronutrient status, immunocompetence (malaria specific antibodies) and morbidity.
The Mass Drug Administration (albendazole, praziquantel, ivermectin) has been carried out in December 2006 after a pilot study, with active surveillance performed by PHL-IdC. The Laboratory will then take part in data analysis, monitoring, data collection and strategies' review, in collaboration with the new integrated National Control Programme.
Testing a Cholera Rapid Test
Testing a Cholera Vaccine
The two projects are planned as a follow up of the experience of the previous years in controlling the cholera epidemics, recurring almost yearly in several areas of Pemba. The very specific setting is considered important and useful for testing the accuracy of and validating diagnostic tool and the appropriateness of the immunization strategy in an endemic and highly polluted environment. A surveillance and monitoring system of diarrhoeal diseases will also be set up at PHL-IdC if funds will be confirmed.
9.3 Training
Course on Public Health Priorities
in Sub-saharan Africa
University of Brescia The course is held yearly and is now an advanced module of the Master in International Health of TropEd Europe (as described before among 2005-06 activities). The next course will be organised in November 2007 and detailed information will be available soon. Training of Trainers for integrated control
This innovative Course, promoted for the first time in anglofone Africa by WHO, will be addressed to programme managers of the Ministries of Health from selected African Countries and will focus on the implementation of preventive chemotherapy for the integrated control of lymphatic filariasis, onchocerciasis, schistosomiasis and intestinal helminths. 10. FINANCIAL REPORT
PHL-IdC is a "semiautonomous" institution, based on a partnership between the Ministry of Health and Social Welfare Zanzibar and the Ivo de Carneri Foundation. Most of its staff is regularly employed by the Ministry and posted at the Laboratory.
Until 2006 the activities were all structured as "projects" and supported by external A summary of the financial report for 2006 is presented here.
For sake of clarity, it is worth stressing that the expenses include: · The costs incurred by the projects and paid by their budget, either as a lump sum (fixed costs) or as actual expenses.
· The costs of activities or routine services provided by the PHL-IdC to the Health System.
· The fixed costs of the PHL-IdC as Institution (allowances, maintenance, operating costs, The incomes the PHL-IdC can rely on are: · The percentage overhead on the "grant projects" budget (F&A).
· The possible savings from the "fixed cost projects".
· Contributions from the Zanzibar Government and from the Italian Cooperation (public funds), private Italian and International donors.
Overall funding for 2006
13% Public Funds
18% Italian Private
69% International Private
International Private Expenditures for 2006
27% Running Costs
52% Staff
12% Operating Costs
July 2006 exchange rate 1 USD = 1.250 Tsh (Tanzanian Shillings) Activity by Sector
18% Training
52% Research
30% Control
ACTIVITY BY SECTOR
Helminth Infections Helminth Infections July 2006 exchange rate 1 USD = 1.250 Tsh (Tanzanian Shillings) 11. VISION: THE WAY FORWARD
PHL-IdC is a relatively new institution, yet it is becoming a reference infrastructure in Sub-Saharan Africa for the control of endemic diseases. PHL-IdC, being part of the Ministry of Health of Zanzibar, will keep and strengthen its role of monitoring center for the implementation of national control programs which benefit the local community. PHL-IdC is well equipped, has competent staff and can carry out efficiently operational research trials that could support decision making and priority setting in the local health policy strategy, and provide innovative and evidence-based information to the international scientific community. PHL-IdC is willing to expand its research activities through new international collaborations and to offer its infrastructure and personnel to assist visiting researchers. Finally, PHL-IdC strongly believes in the potential of training and in giving to health staff the opportunity to be constantly exposed to upgrading opportunities. PHL-IdC thus welcomes collaborations from Institutions willing to implement training courses in its premises. PHL- IdC can offer the logistical facilities, the organizational support and competent lecturers.
1. Albonico M., Ramsan M., Wright V., Haji H.J., Khatib J., Taylor M., Savioli L. and Bickle Q.
Soil-transmitted nematode infections and mebendazole treatment in Mafia Island
schoolchildren. Annals of Tropical Medicine and Parasitology 2002, 96(7): 717-726.
2. Albonico M., Bickle Q., Haji H.J., Ramsan M., Khatib J.K., Savioli L. and Taylor M.
Evaluation of the efficacy of pyrantel-oxantel for the treatment of soil-transmitted
nematode infections. Transactions of the Royal Society of Tropical Medicine and Hygiene
2002, 96: 685-690.
3. Albonico M., Bickle Q., Ramsan M., Montresor A., Savioli L. and Taylor M. Efficacy of
mebendazole and levamisole alone or in combination for the treatment of soil-
transmitted nematode infections following repeated targeted mebendazole treatment
in Zanzibar. Bulletin of the World Health Organization 2003, 81(5): 343-352.
4. Albonico M., Wright V. and Bickle Q. Molecular analysis of the b-tubulin gene of human
hookworms as a basis for possible benzimidazole resistance on Pemba Island.
Molecular and Biochemical Parasitology 2004, 134 (2): 281-284.
5. Albonico M., Mathema P., Montresor A., Khakurel B., Reggi V., Pandey S. and Savioli L.
Comparative study of quality and efficacy of originator and generic albendazole for
the mass treatment of soil-transmitted nematode infections in Nepal. Transactions of
the Royal Society of Tropical Medicine and Hygiene (in press).
6. Albonico M., Wright V., Ramsan M., Haji H.J., Taylor M., Savioli L. and Bickle Q.
Development of the Egg Hatch Assay for detection of anthelminthic resistance by
human hookworms. International Journal for Parasitology 2005 Jun, 35(7): 803-811.
7. Croce F., Fedeli P., Dahoma M.J.U., Dehò L., Ramsan M., Albonico M., Asha A., Shauri O.M.,
Adorni F. and Galli M. Prevalence and correlates of risk of Human Immunodeficiency
Virus infection in Zanzibar. Bulletin of WHO (submitted)
8. Gabrielli A.F., Ramsan M., Naumann C., Tsogzolmaa D., Bojang B., Khoshal M.H., Connolly Jr
M., Stothard R., Montresor A. and Savioli L. Soil-transmitted helminths and haemoglobin
status among Afghan children in World Food Programme assisted schools. Journal of
Helminthology 2005, 79: 381-384. 9. Gyorkos T.W., Ramsan M., Foum A. and Khamis I.S. Efficacy of New Low-Cost Filtration
Device for Recovering Schistosoma haematobium eggs from urine. Journal of Clinical
Microbiology, July 2001: pp 2681-82.
10. Goodman D., Haj, H.J., Bickle Q., Stoltzfus R.J., Tielsch J.M., Ramsan M., Savioli L. and
Albonico M. A comparison of methods for detecting the eggs of Ascaris, Trichuris and
hookworm in infant stool, and the epidemiology of infection in Zanzibari infants.
American Journal of Tropical Medicine and Hygiene (in press).
11. Mebrahtu T., Stoltzfus R.J., Chwaya H.M., Jape K.J., Savioli L., Montresor A., Albonico M. and
Tielsch J.M. Low-dose daily iron supplementation for 12 months does not increase
prevalence of malarial infection or density of parasites in young Zanzibari children.
The Journal of Nutrition 2004, 134: 3037-3041.
12. Montresor A., Ramsan M., Chwaya H.M., Ameir H., Foum A., Albonico M., Gyorkos T.
and Savioli L. School enrolment in Zanzibar linked to children's age and helminth
infections. Tropical Medicine & International Health 2001, 6(2): 1-5.
13. Montresor A., Ramsan M., Chwaya H.M., Ameir H., Foum A., Albonico M., Gyorkos T. and
Savioli L. Extending anthelminthic coverage to non-enrolled school-age children using
a simple and low-cost method. Tropical Medicine & International Health 2001, 6(7): 535-537.
14. Montresor A., Albonico M., Khalfan N., Stoltzfus R.J., Tielsch J.M. and Savioli L.
Performances of the Haemoglobin Colour Scale in the diagnosis of severe anaemia
and very severe anaemia. Tropical Medicine and International Health 2003, 8: 619-624.
15. Montresor A., Albonico M., Nassor K., Stoltzfus R.J., Tielsch J.M., Chwaya H.M. and Savioli L.
Field trial of a haemoglobin colour scale: an effective tool to detect anaemia in
preschool-children. Tropical Medicine and International Health 2000, 2(5): 129-133.
16. Montresor A., Engels D., Ramsan M., Foum A. and Savioli L. Field test of the "dose pole"
for Praziquantel in Zanzibar. Transaction of the Royal Society of Tropical medicine and
Hygiene 2002, 96: 323-324 17. Montresor A., Stoltzfus R.J., Albonico M., Tielsch J.M., Rice A.L., Chwaya H.M. and Savioli L.
Is the exclusion of children under 24 months from anthelminthic treatment justifiable?
Transactions of The Royal Society of Tropical Medicine and Hygiene 2002 96(2): 197-9.
18. Sazawal S., Black R., Chwaya H., Stoltzfus R.J., Dutta A., Dhingra U., Kabole I., Deb S., Othman
M. and Kabole F.M. Effects of routine prophylactic supplementation with iron and folic
acid on admission to hospital and mortality in preschool children in a high malaria
transmission setting: community-based, randomised, placebo-controlled trial. Lancet
2006, 367: 133-143 19. Stoltzfus R.J., Chwaya H.M., Montresor A., Albonico M., Savioli L. and Tielsch J.M. Malaria,
hookworms, and recent fever are related to anemia and iron status indicators in 0- to
5-y old Zanzibari children and these relationships change with age. Journal of Nutrition
2000, 130: 1724-1733.
20. Stoltzfus R.J., Chwaya H.M., Montresor A., Tielsch J.M., Jape Khatib.J., Albonico M. and
Savioli L. Low dose daily iron supplementation improves iron status and appetite but
not anemia, whereas quarterly anthelminthic treatment improves growth, appetite
and anemia in Zanzibari preschool children. Journal of Nutrition 2004, 134: 348-356.
21. Stoltzfus R.J., Kvalsvig J.D., Chwaya H.M., Montresor A., Albonico M., Tielsch J.M., Savioli L.
and Pollit E. Effects of iron supplementation and anthelminthic treatment on motor
and language development of preschool children in Zanzibar: double blind placebo
controlled study. British Medical Journal 2001, 323: 1-8.
22. Stothard J.R., Mgeni A.F., Khamis S., Seto E., Ramsan M. and Rollinson D. Urinary
Schistosomiasis in schoolchildren on Zanzibar Island Tanzania, a Parasitological
Survey supplemented with questionnaires. Transaction of the Royal Society of Tropical
Medicine and Hygiene 2002, 96: 507-514.
23. Stothard J.R., Mgeni A.F., Khamis S., Seto E., Ramsan M., Hubbard S.J., Kristensen T.K. and
Rollinson D. New insight into the transmission biology of urinary schistosomiasis in
Zanzibar. Transaction of the Royal Society of Tropical Medicine and Hygiene 2002 96: 470-475.
24. Stothard J.R., Loxton N., Rollinson D., Mgeni A.F., Khamis S., Ameri H., Ramsan M. and
Savioli L. The transmission status of Bulinus on Zanzibar Island (Unguja), with
implications for control of urinary schistosomiasis. Annals of Tropical Medicine and
Parasitology 2000, 94 (1): 87-94.
25. Yacoub S., Mohammed J.M., Ramsan M. and Albonico M. Clinical predictors of malaria
and other febrile illnesses in children under five on Pemba Island. Tropical Doctor 2005,
Public Health Laboratory Ivo de Carneri
P.O.Box 122 Chake-Chake United Republic of Tanzania Tel/Fax: +255 24 2452003 We acknowledge Publicis for the valuable collaboration in the graphic design of the Report.
P.O. BOX 122, Chake-Chake - Pemba Island, Zanzibar - TANZANIA Tel/fax: +255.24.2452003 e-mail: info@phlidc.net

Source: http://www.helianto.it/attach/BKUP/PDF/lab_sanita/info_download/PHL_Report_2005-2006.pdf

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