Carsten Mantel

Summary: Objectives  Concerns about unsafe injection practices and possible infections with blood‐borne pathogens in the Syrian Arab Republic motivated an assessment of the injection safety situation in the country in July 2001. In light of the recommendations from this assessment, the Ministry of Health of Syria, with the assistance of WHO, implemented a set of activities under the ‘Focus Project’, which aims to ensure immunization safety. The first phase of the project ran from May 2002 to February 2004, and consisted of the improved provision of injection safety equipment and supplies, the elaboration and wide distribution of national guidelines on injection safety and safe waste management, a behaviour change and communication campaign targeting the general public, and comprehensive training of healthcare workers. A follow‐up survey was carried out in February 2004, 2 years after initiation of the project.Methods  Two representative surveys were conducted using a standardized assessment tool. A cluster sampling strategy, with probability proportionate to the population size, led to the inclusion of 80 health facilities in eight districts in 2001 and of 120 health facilities in 12 districts in 2004.Results  Injection practices had significantly improved 2 years after the start of the project. The 2001 study had pointed to a low, but non‐negligible risk to patients (2% unsafe injections), coupled with a high risk to healthcare workers (61% reported needle‐stick injuries in the last 12 months) and to the communities owing to unsafe waste disposal (sharps waste found outside 37% of health facilities, waste disposal considered unsafe in 48% of them). The 2004 survey showed that 90% of Syrian healthcare workers had received training in injection safety. All injections observed were given safely (difference to 2001 not significant), although some problems in preparation and reconstitution prevailed. The risk to healthcare workers was significantly reduced as only 14% of the staff reported needle‐stick injuries (p < 0.001). The risk to the communities was notably decreased following improvements in sharps waste management (sharps were found in the surroundings of only 13% of health facilities, p < 0.001).Conclusions  The example of Syria shows that rapid improvement in injection safety is possible and that the necessary tools and methods to monitor and evaluate progress are at our disposal. Challenges remain in transferring this successful programme from the well‐structured immunization programme to the more diverse curative health services.

Summary: Background  Modelling malaria parasitaemia as function of fever has been proposed as best alternative to estimate the attributable fraction of malaria fever and the sensitivity and specificity of different case definitions of malaria disease.Objectives  To determine the prevalence of fever and its relation to malaria parasitaemia and to establish a pyrogenic threshold for malaria disease in the area.Methods  We conducted two cross‐sectional surveys in children of 6 months to 9 years of age (2434 during the rainy season of 1993 and 2353 during the dry season of 1994) randomly selected from 21 areas of Bandiagara district, Mali.Results  The relationship between fever and Plasmodium falciparum parasitaemia depends strongly on the season, thus affecting the malaria‐attributable fraction of fever cases and the sensitivity and specificity of malaria case definitions. The overall proportion of fever attributable to malaria parasitaemia was 33.6% during the rainy season and 23.3% during the dry season, with the highest proportion occurring among the youngest children. The cut‐off value, where the sensitivity curve crosses the specificity curve, was around 3200 pf/μl for all age categories during the rainy season and 200 pf/μl during the dry season.Conclusions  Malaria remains a main cause of fever in this area of Mali. The pyrogenic threshold of parasitaemia depends strongly on the season, and different cut‐off levels of parasitaemia should be used during the two seasons to define malaria cases in this area.