Cow's milk protein allergy: An entity for recognition in developing countries

Aim:  The aim of this prospective study was to determine cow's milk protein allergy (CMPA) cases in a tertiary care hospital in India and to study its clinical presentations and outcome following treatment.
Methods:  Consecutive children with chronic diarrhea from June 2004 to December 2007 were evaluated with hemogram, anti-endomysial antibody, upper gastrointestinal endoscopy, sigmoidoscopy and intestinal biopsies. Initial diagnosis of CMPA was based on characteristic intestinal biopsy (> 6 eosinophils/HPF) and diagnosis was confirmed by positive milk challenge.
Results:  Forty CMPA cases (25 boys, with a mean age of 17.2 ± 7.8 months and symptom duration of 8.3 ± 6.2 months) presented with diarrhea (bloody in 16, watery in 16, combined in three, recurrent hematemesis in two, rectal bleeding in one and one case each with pain in the abdomen with vomiting and anemia with occult bleeding). Sigmoidoscopy revealed aphthous ulcers in 82% of cases and rectal biopsy was positive in 97% of cases. All children improved on a milk-free diet. Milk challenge was positive in 100% of cases when it was done early (within 6 months). On follow up of 15 ± 9 months, milk was successfully restarted in 25 cases after a median milk-free period of 15 months, 10 were still on a milk-free diet and five were lost to follow up while on a milk-free diet.
Conclusions:  CMPA is not uncommon in a developing country such as India. Presence of aphthous ulcers and abnormal rectal biopsy are clues to initial diagnosis. Milk challenge confirms the diagnosis in all if it is done on time.     

Assessing the water challenge of a new green revolution in developing countries

This article analyzes the water implications in 92 developing countries of first attaining the 2015 hunger target of the United Nations Millennium Development Goals and then feeding a growing population on an acceptable standard diet. The water requirements in terms of vapor flows are quantified, potential water sources are identified, and impacts on agricultural land expansion and water tradeoffs with ecosystems are analyzed. This article quantifies the relative contribution from infiltrated rainwater/green water in rain-fed agriculture, and liquid water/blue water from irrigation, and how far water productivity (WP) gains can go in reducing the pressure on freshwater resources. Under current WP levels, another 2,200 km(3).yr(-1) of vapor flow is deemed necessary to halve hunger by 2015 and 5,200 km(3).yr(-1) in 2050 to alleviate hunger. A nonlinear relationship between vapor flow and yield growth, particularly in low-yielding savanna agro-ecosystems, indicates a high potential for WP increase. Such WP gains may reduce additional water needs in agriculture, with 16% in 2015 and 45% by 2050. Despite an optimistic outlook on irrigation development, most of the additional water will originate from rain-fed production. Yield growth, increasing consumptive use on existing rain-fed cropland, and fodder from grazing lands may reduce the additional rain-fed water use further by 43-47% until 2030. To meet remaining water needs, a cropland expansion of approximately 0.8% yr(-1), i.e., a similar rate as over the past 50 years (approximately 0.65% yr(-1)), seems unavoidable if food production is to occur in proximity to local markets.     

Overweight and obesity in preschool children from developing countries

OBJECTIVES: To estimate levels and trends in overweight and obesity in preschool children from developing countries; to study how overweight varies by the educational level of the mother, by urban or rural residence, and by gender; to investigate how these relationships are related to the gross national product (GNP). DESIGN: 71 national nutrition surveys since 1986 from 50 countries were used. SUBJECTS: 150,482 children 12 to 60 months from the most recent survey from each country were the primary sample. MEASUREMENTS: Overweight and obesity were defined as weight-for-height (>1 or >2 s.d., respectively) of the WHO/NCHS reference curves. Stunting was <-2 s.d. of the same reference. Urban was as defined in each of the surveys and higher education was defined as at least one year of secondary schooling or higher. RESULTS: 32 of 50 countries had a prevalence of obesity below 2.3%, the value in the reference population. The prevalences of overweight and obesity were lowest in Asia and in Sub-Saharan Africa. In 17 countries with serial data, no consistent regional trends could be detected. Overweight was more common in urban areas, in children of mothers with higher education, and in girls; these relationships did not differ by GNP but GNP was related negatively to stunting and positively to overweight. CONCLUSIONS: Obesity does not appear to be a public health problem among preschool children in Asia and Sub-Saharan Africa. In a number of countries in Latin America and the Caribbean, the Middle East and North Africa, and the region of Central Eastern Europe/Commonwealth of Independent States, levels are as high as in the United States.     

Gastroenterology in developing countries： Issues and advances

Developing countries shoulder a considerable burden of gastroenterological disease. Infectious diseases in particular cause enormous morbidity and mortality. Diseases which afflict both western and developing countries are often seen in more florid forms in poorer countries. Innovative techniques continuously improve and update gastroenterological practice. However, advances in diagnosis and treatment which are commonplace in the West, have yet to reach many developing countries. Clinical guidelines, based on these advances and collated in resource-rich environments, lose their relevance outside these settings. In this two-part review, we first highlight the global burden of gastroenterological disease in three major areas： diarrhoeal diseases, hepatitis B, and Helicobacter pylori. Recent progress in their management is explored, with consideration of future solutions. The second part of the review focuses on the delivery of clinical services in developing countries. Inadequate numbers of healthcare workers hamper efforts to combat gastroenterological disease. Reasons for this shortage are examined, along with possibilities for increased specialist training. Endoscopy services, the mainstay of gastroenterology in the West, are in their infancy in many developing countries. The challenges faced by those se~ing up a service are illustrated by the example of a Nigerian endoscopy unit. Finally, we highlight the limited scope of many clinical guidelines produced in western countries. Guidelines which take account of resource limitations in the form of ＂cascades＂ are advocated in order to make these guidelines truly global. Recognition of the different working conditions facing practitioners worldwide is an important step towards narrowing the gap between gastroenterology in rich and poor countries.     

Prevention in developing countries

Developing countries have implemented primary health care programs directed primarily at prevention and management of important infectious and nutritional problems of children. Successful programs have emphasized the need for individual and community involvement and have been characterized by responsible government policies for equitable implementation of efficacious and cost-effective health interventions. Unfortunately, developing countries must also face increases in the chronic disease and social problems commonly associated with industrialized countries. Prevention efforts, for example, to reduce tobacco smoking, to modify the diet, to reduce injuries, or to avert environmental contamination, are needed to contain future morbidity and rapidly increasing medical care costs. Developing countries can build on their successful approaches to program implementation and add other measures directed at preservation of health and prevention of disease in adult as well as child populations. Received from the Department of International Health, The Johns Hopkins University School of Hygiene and Public Health, 615 North Wolfe Street, Baltimore, Maryland 21205.     

Sarcoidosis in developing countries

Sarcoidosis is seen in different parts of India and other developing countries with almost similar frequency as in the West. It was largely due to lack of awareness and non-availability of investigations for diagnosis that the disease was reported to be rare in the past. A combination of clinical, radiologic, and histologic criteria are used to diagnose sarcoidosis. A confident exclusion of other causes of granuloma formation, especially tuberculosis, is required. Absence of mycobacteria and of caseation in the histologic specimens and presence of skin anergy to tuberculin help make a diagnosis. Transbronchial lung biopsy obtained with the help of fiberoptic bronchoscopy is positive in about 80% of patients. Corticosteroids are used to treat patients with symptoms and those showing active organ involvement. Aggressive treatment is required for patients with acute and severe pulmonary, cardiac, ocular, or neurologic involvements.     

Aging in developing countries

After presenting informations about the general life conditions in the less developed regions, the author concentrates on the term "syndrome of poverty", which have a great impact on the life conditions and the status of the elderly. Demographic data concerning the world population of all ages and the aged population in the more developed and the less developed regions follow.     

Pneumoconioses: the situation in developing countries

In developing countries, the incidence and prevalence of pneumoconioses are high and appear to be increasing. The rapid expansion of mining, mineral extraction, construction, and other industries places many new workers at risk each year. The hygienically poor working conditions often expose workers to high concentrations of respirable dust, so that pneumoconioses can develop with rapid progression after a short latency period. The health risk is increased by the high prevalence of tuberculosis in most of those countries. Accurate statistical data on occupational diseases in developing countries are rare. Although some prevalence data are available from cross-sectional studies, incidence figures and risk estimates are usually lacking because of the absence of reliable information about the size of the population at risk and exposure measurements. Some figures on pneumoconioses from countries in Africa, Asia, and South America are presented. To prevent pneumoconioses, hygienic conditions at the workplaces should be controlled and improved and appropriate dust standards developed. Medical surveillance of exposed workers should be organized. Finally, research in the field of pneumoconioses in developing countries should be promoted.     

Hepatitis B: Epidemiology and prevention in developing countries

Hepatitis B virus(HBV)infection is a serious global public health problem.The infection may be transmitted through sexual intercourse,parenteral contact or from an infected mother to the baby at birth and,if contracted early in life,may lead to chronic liver disease,including cirrhosis and hepatocellular carcinoma.On the basis of the HBV carrier rate,the world can be divided in 3 regions of high,medium and low endemicity.The major concern is about high endemicity countries,where the most common route of infection remains vertical transmission from mother to child.Screening of all pregnant women and passive immunization with human hepatitis B immunoglobulin are not affordable for many developing countries.The infection rate can be reduced by modifying behavior,improving individual education,testing all blood donations,assuring asepsis in clinical practice and screening all pregnant women.However,availability of a safe and efficacious vaccine and adoption of appropriate immunization strategies are the most effective means to prevent HBV infection and its consequences.The unsolved problem for poorest countries,where the number of people currently infected is high,is the cost of the vaccine.A future challenge is to overcome the social and economic hurdles of maintaining and improving a prevention policy worldwide to reduce the global burden of the disease.     

Hepatitis A: Epidemiology and prevention in developing countries

Hepatitis A is the most common form of acute viral hepatitis in the world.Major geographical differences in endemicity of hepatitis A are closely related to hygienic and sanitary conditions and other indicators of the level of socioeconomic development.The anti-hepatitis A virus(HAV)seroprevalence rate is presently decreasing in many parts of the world,but in less developed regions and in several developing countries,HAV infection is still very common in the first years of life and seroprev-alence rates approach 100%.In areas of intermediate endemicity,the delay in the exposure to the virus has generated a huge number of susceptible adolescents and adults and significantly increased the average age at infection.As the severity of disease increases with age,this has led to outbreaks of hepatitis A.Several factors contribute to the decline of the infection rate,including rising socioeconomic levels,increased access to clean water and the availability of a hepatitis A vaccine that was developed in the 1990s.For populations with a high proportion of susceptible adults,implementing vaccination programs may be considered.In this report,we review available epidemiological data and implementation of vaccination strategies,particularly focusing on developing countries.