Search

Background: Little is known about how health research systems (HRS) in low-income countries emerge and evolve over time, and how this process relates to their performance. Understanding how HRSs emerge is important for the development of well functioning National Health Research Systems (NHRS). The aim of this study was to assess how the HRS in Guinea Bissau has emerged and evolved over time and how the present system functions., Methods: We used a qualitative case-study methodology to explore the emergence and current performance of the HRS, using the NHRS framework. We reviewed documents and carried out 39 in-depth interviews, ranging from health research to policy and practice stakeholders. Using an iterative approach, we undertook a thematic analysis of the data., Results: The research practices in Guinea Bissau led to the emergence of a HRS with both local and international links and strong dependencies on international partners and donors. The post-colonial, volatile and resource-dependent context, changes in donor policies, training of local researchers and nature of the research findings influenced how the HRS evolved. Research priorities have mostly been set by 'expatriate' researchers and focused on understanding and reducing child mortality. Research funding is almost exclusively provided by foreign donors and international agencies. The training of Guinean researchers started in the mid-nineties and has since reinforced the links with the health system, broadened the research agenda and enhanced local use of research. While some studies have made an important contribution to global health, the use of research within Guinea Bissau has been constrained by the weak and donor dependent health system, volatile government, top-down policies of international agencies, and the controversial nature of some of the research findings., Conclusions: In Guinea Bissau a de facto 'system' of research has emerged through research practices and co-evolving national and international research and development dynamics. If the aim of research is to contribute to local decision making, it is essential to modulate the emerged system by setting national research priorities, aligning funding, building national research capacity and linking research to decision making processes. Donors and international agencies can contribute to this process by coordinating their efforts and aligning to national priorities.

We evaluated the ability of UNICEF-designed pot-chlorinators to achieve recommended free residual chlorine (FRC) levels in well water in Bissau, Guinea-Bissau, during a cholera outbreak. Thirty wells were randomly selected from six neighbourhoods. Pot-chlorinators--perforated plastic bottles filled with gravel, sand and calcium hypochlorite granules--were placed in each well. FRC was measured before and 24, 48 and 72 h after placement and compared with World Health Organization (WHO)-recommended levels of 21 mg L(-1) for well water during cholera outbreaks and 0.2-5 mg L 1 in non-outbreak settings. Presence of well covers, distance from wells to latrines, and rainfall were noted. Complete post-chlorination data were collected from 26 wells. At baseline, no wells had FRC>0.09 mg L(-1). At 24, 48 and 72 h post-chlorination, 4 (15%), 1 (4%) and 0 wells had FRC>or=1 mg L(-1) and 16 (62%), 4 (15%) and 1 (4%) wells had FRC between 0.2 and 5 mg L(-1), respectively. Several families reported discontinuing household water chlorination after wells were treated with pot-chlorinators. Pot-chlorinators failed to achieve WHO-recommended FRC levels in well water during a cholera outbreak, and conveyed a false sense of security to local residents. Pot-chlorination should be discouraged and alternative approaches to well-water disinfection promoted.

In Guinea Bissau, the majority of university level professionals are still being trained abroad and most of them do not return to their country. This was a major incentive for creating Guinea Bissau's Medical School. An observational, cross-sectional, analytic study was conducted on the second trimester of 2007 to characterize the socio-demographic, familial and educational profile of medical students, their satisfaction levels, difficulties and expectations concerning the medicine course. A questionnaire was used and a response rate of 63% achieved (81 students). Data was analyzed using SPSS v.17 for descriptive statistics. Students are very committed to their education. They tend to decide to take the medicine course early in their lives and are influenced by their relatives. They choose to be medical doctors because they like it but also for altruistic reasons and the desire to save lives. Although many face financial and material difficulties, they tend to have success in their academic live. They live with their parents, do not have children and some have side jobs to provide for extra income to help with their education. They expect their education to make them good doctors in any part of the world and want to work simultaneously in the public (to serve their country and pay their debt to the State) and in the private sector (to enhance their income). The large majority wants to work in a hospital, in Bissau, and to be a pediatrician or obstetrician. They have unreasonably high expectations concerning their future income as medical doctors.

Objective: To investigate the clinical and immunologic effects, and pattern of mortality associated with HIV-2 infection., Setting: A rural community in Guinea-Bissau., Methods: Serologic screening of 2774 subjects aged > 14 years followed by studies of the prevalence of clinical and immunologic abnormalities among 133 subjects with HIV-2 infection and 160 seronegative controls, and surveillance of mortality among all subjects who were screened during a mean of 2 years of follow-up., Results: Generalized lymphadenopathy was the only clinical abnormality significantly associated with HIV-2 infection. Infection was associated with lower CD4 counts and higher beta 2-microglobulin and neopterin levels. During follow-up, 5.5% of infected subjects died compared with 1.8% of the seronegatives (rate ratio adjusted for age and sex, 3.5; 95% confidence interval ((CI), 1.8-6.7). Proportional hazard regression analysis showed that the rate ratio varied with age (P = 0.003) and there was some evidence that the excess of mortality in infected subjects was, in absolute terms, least in the oldest subjects (trend test; P = 0.08)., Conclusions: The findings support previous suggestions that HIV-2 is less pathogenic than HIV-1; the data also suggest that mortality associated with infection may be lower in older subjects.

Objective: To analyse the impact of breast feeding on diarrhoeal disease and survival in children above 1 year of age in Guinea-Bissau, west Africa., Design: A community study of an open cohort followed up weekly by interviews over 15 months. Data on feeding practices, anthropometry, and survival were recorded for three years., Setting: 301 randomly selected houses in a semiurban area in the capital, Bissau., Subjects: 849 children aged less than 3 years., Main Outcome Measures: Incidence and duration of diarrhoea, weight for age, and death of a child., Results: The incidence of diarrhoea was higher in weaned children than in partially breast fed children, both in 1 year olds (relative risk 1.41; 95% confidence interval 1.23 to 1.62) and in 2 year olds (1.67; 1.29 to 2.15). The mean duration of an episode of diarrhoea was 5.3 days in breast fed children compared with 6.3 days in weaned children (P = 0.001). Independent of the age of weaning, a similar increase was found in an analysis comparing, for each child, the rate and duration of diarrhoea one month before and one month after weaning. Children with low weight for age were breast fed longer than the better nourished children (P = 0.02). Children aged 12-35 months who were not breast fed had a 3.5 times higher mortality (1.4 to 8.3) than breast fed children., Conclusions: The beneficial effects of breast feeding are not restricted to infancy. Though children who are partially breast fed after infancy may have a lower state of nutrition than the weaned ones, the benefit in terms of lower morbidity may be more important for child survival in places with a high morbidity from diarrhoea and with high mortality.

Cryptosporidium is increasingly recognized as an important agent of diarrhea in normal and immunocompromised humans. In young children in developing countries the parasite is a cause of persistent diarrhea with an associated excess mortality. To elucidate possible determinants of cryptosporidiosis, an open cohort of young children from a semiurban area of the capital of Guinea-Bissau was followed for 2 years. Data about possible risk factors were recorded each month, and a nested case-control study of 125 children with Cryptosporidium diarrhea and an equal number of matched controls was conducted. The following risk factors were identified by conditional multiple logistic regression: keeping of pigs (odds ratio (OR) = 2.5, 95% confidence interval (CI) 1.4-4.7) and dogs (OR = 2.1, 95% CI 1.0-4.2) in the household, storage of cooked food for later consumption (OR = 1.8, 95% CI 1.0-3.3), and child's sex (OR for boys = 1.9, 95% CI 1.0-3.4). Breast feeding was protective (OR = 0.3, 95% CI 0.1-1.1). The findings provide clues for interventions against this major cause of childhood diarrhea and give suggestions for further studies.

A potential enteropathogen was found in 50% of 1219 diarrheal episodes and 48% of 511 asymptomatic controls in a 1-year community study of childhood diarrhea. Rotavirus (3% of episodes), Cryptosporidium species (6%), and enteropathogenic Escherichia coli (EPEC) with EPEC adherence factor (4%) were more prevalent in cases than controls. Giardia lamblia (19%) was the most prevalent organism but was not associated with diarrhea. Enterotoxigenic E. coli (12%), Strongyloides stercoralis (5%), Shigella species (2%), Entamoeba histolytica trophozoites (2%), and Vibrio cholerae (1%) were found at nonsignificantly higher rates. Salmonella and Campylobacter species were more prevalent among control infants. Cryptosporidium species and sequential infections from other pathogens caused persistent diarrhea.

The influence of conventional live attenuated measles vaccine on cellular immune responsiveness was investigated in Sweden and Guinea-Bissau. Sixteen children in a residential area in Bissau and 16 living in southern Stockholm were examined before and 8-10 days after vaccination. Lymphoproliferation was measured to concanavalin A (con-A), PPD and tetanus toxoid (TT) using a whole-blood 3H-thymidine incorporation assay. Stimulation indices were significantly lower after vaccination than before, in the case of con-A (p = 0.03) and TT (p = 0.01) in the Guinean children and in the case of PPD (p = 0.009) and TT (p = 0.03) in the Swedish children. Stimulation of lymphocytes from measles-immune children with measles antigens resulted in weak lymphoproliferative responses. These observations may be relevant to the increased mortality found in children immunized with high-titre measles vaccines, as compared to controls, in recent studies. The study confirms the applicability and usefulness under field conditions of the whole blood version of the thymidine incorporation assay.

Objective: To investigate the epidemiology of and mortality from cryptosporidiosis in young children in Guinea Bissau, West Africa., Design: Three year community study of an open cohort followed up weekly., Setting: 301 randomly selected houses in a semi-urban area in the capital, Bissau., Subjects: 1315 children aged less than 4 years., Main Outcome Measures: Cryptosporidium infection detected by examination of stools during episode of diarrhoea and death of a child., Results: Cryptosporidium spp were found in 239 (7.4%) out of 3215 episodes of diarrhoea. The parasite was most common in younger children (median age 12 months) and at the beginning of the rainy seasons. The prevalence of cryptosporidiosis was 15% (77/513) in cases of persistent diarrhoea compared with 6.1% (148/2428) in diarrhoea lasting less than two weeks (p < 0.0001). Cryptosporidiosis was associated with excess mortality in children who had the infection in infancy, and this excess mortality persisted into the second year of life (relative mortality 2.9 (95% confidence interval 1.7 to 4.9)). The excess mortality could not be explained by malnutrition, or by socioeconomic factors, hygienic conditions, or breast feeding., Conclusions: Cryptosporidiosis is an important cause of death in otherwise healthy children in developing countries.

Patients enrolled in a hospital-based case control study (n = 1009) and a follow-up study (n = 130) of HIV-2 infection in Bissau were investigated with regard to sexual behaviour and sexually transmitted diseases (STD). A history of genital ulcer was more frequent in HIV-2 infected male patients (46.4%, 13 out of 28) than in seronegative male patients (17.9%, 7 out of 39) (P = 0.05). Serological evidence of a previous syphilitic infection was significantly related to HIV-2 infection (23%, 12 out of 52, of HIV-2 seropositive patients had a positive Treponema pallidum haemagglutination test compared with 7.1%, 5 out of 70, of seronegative patients, P = 0.025) and was equally frequent in men and women. There was no significant difference in number of non-marital sexual partners and frequency of intercourse between HIV-2 seropositive and seronegative individuals. The seroprevalence of HIV-2 infection was significantly higher among patients with a monogamous marriage, 23.1% (59 out of 255) among males and 31.3% (64 out of 204) among females, than among patients with an officially polygamous marriage, 10.3% (8 out of 77) among males and 11.8% (7 out of 59) among females (P = 0.025 for males and 0.005 for females). Infection-control measures directed at patients with STD should be promoted in Guinea-Bissau. Further research on sexual behaviour and attitudes is needed.

During 11 months in 1989-1990, 1009 consecutive hospitalized adult patients admitted to the medical wards of the National Hospital in Bissau were interviewed, examined clinically, and tested for antibodies to HIV-1 and HIV-2. The prevalence of HIV-2 infection was 20.4% (206 out of 1009) and of HIV-2-associated AIDS 4.4% (44 out of 1009). HIV-2 infection was more frequent in women (25%, 110 out of 440) than in men (16.9%, 96 out of 569). HIV-1 infection was diagnosed in one patient only, and one patient (with AIDS) had reactivity to both HIV-1 and HIV-2. Among HIV-2-seropositive patients, AIDS was demonstrated in 21.3% and AIDS-related symptoms (not fulfilling the AIDS criteria) in 19.4%. The frequency of AIDS-associated symptoms was significantly higher in HIV-2-seropositive patients than in seronegative patients. The clinical profile of the HIV-2-associated AIDS cases was very similar to that described in HIV-1-associated AIDS cases in Africa. Seven out of 51 patients fulfilling the clinical criteria for AIDS were HIV-seronegative. The World Health Organization (WHO) clinical case definition for AIDS in Africa had a specificity of 99% and a positive predictive value of 86%. Tuberculosis was more common in HIV-2-seropositive patients (6.3%) than in HIV-2-seronegative patients (2.2%). A history of blood transfusion was a significant risk factor for HIV-2 infection. HIV-2 infection and AIDS are public health problems in Guinea-Bissau.

A survey was performed of endemic goitre in the Oio, Gabu, and Cacheu regions of Guinea-Bissau. Among adult women, the following prevalences of goitre were observed: 53% (Oio), 48% (Gabu), and 27% (Cacheu). For goitres of grades 2 and 3 only, the prevalences were 20% (Oio), 13% (Gabu), and 2% (Cacheu). No cretinism or cases of thyroid dysfunction were found. The mean urinary iodine excretions in Oio, Gabu, and Cacheu were 17 micrograms/g, 24 micrograms/g and 33 micrograms/g creatinine, respectively.

In the first year of a prospective community study of childhood diarrhea conducted in a semiurban area in the capital of Guinea Bissau, Cryptosporidium sp. was found in 73 (6.0%) of 1216 episodes of diarrhea. The parasite was the second most prevalent intestinal parasite, and the only one significantly associated with diarrhea (OR = 2.79, P = 0.0006). The seasonal distribution was striking, with a peak prevalence in the beginning of the rainy season (May 17.6%) when an epidemic outbreak of diarrhea started. The prevalence was highest in children younger than 18 months, an age at which prevalences of other intestinal parasites were low. This reverse age pattern may possibly be explained by the small infective dose needed to create severe infections, by air-borne transmission and by the development of protective immunity.