Climate change and its negative impacts on health are now globally recognized. A wide variety of diseases and health conditions – ranging from heat and radiation-related illnesses to water and vector-borne diseases, under-nutrition, respiratory and cardiac problems, drowning, injuries and mental stress arising from extreme and sudden weather events and their resultant population displacements – all have been associated with various components of changing climate. However, the exact nature and extent of such impacts are yet to be firmly established since many other non-climate factors also produce or affect similar outcomes. This calls for more research specially from the underdeveloped countries, where such impacts are disproportionately more but reliable data are remarkably less. Recognizing the importance of human influences on global warming, almost all countries in the world have undertaken some kind of policies and measures to mitigate adverse climatic changes. Unfortunately, even without further addition of greenhouse gases (GHGs) in our climate, the amount of GHGs already released has the potential to continue the damages for many more decades to come. Thus, all countries should also place priorities in assessing their own vulnerabilities from climate change and take adaptive measures accordingly. As climate change exerts its impact simultaneously in many non-health sectors as well, this would require strong intersectoral cooperation at various levels.

Background: Contamination of baby’s complementary food may occur with Escherichia coli from several sources including unclean utensils. We examined the relationship between socio-economic conditions, environmental factors, characteristics of food handlers and contamination of babies food-serving utensils with E. coli. Methods: The study was conducted in 21 villages of the Community Health Centre (CHC) Selayo in Indonesia. A cross-sectional design was used. A sample of 142 households, which had a 6-12 month-old baby on complementary food, was chosen randomly using midwives’ registration books. Respondents were interviewed using a semi-structured questionnaire. Check-lists were used for observations. Standard laboratory methods were used for collection of specimen and confirmation of contamination with E. coli. Results: More than half of the respondents (59.2%) used water that had high risk of contamination and 61.3% of the latrines did not meet the criteria of a healthy latrine. Waste management practices of nearly all respondents (97.9%) were below the standards set by the Ministry of Health. More than half of the respondents (68.3%) did not wash their hands with soap for 20 seconds and 52.1% did not use flowing water for washing hands. Majority of the respondents’ hands (57%, 81/142) and 72.2% (104/142) of the eating utensils were found to be contaminated by E. coli. Contaminated hands of food handlers were more likely to contaminate the babies food-serving utensils (OR: 3.7; 95%CI: 1.62-8.46, p 0.002). Conclusion: Contamination of the hands of food handler was associated with contamination of babies food-serving utensils by E. coli. Hence, food handlers should be trained on proper hand washing methods.

Background: Self-medication is widely practised in many developing countries. The determinants of self-medication need to be understood to design adequate medicine information policies and patient-dispenser education strategies. Hence, the prevalence of medicine use and predictors of self-medication were determined in Sri Lanka. Methods: In a community-based cross- sectional study, data were collected from 1800 adults selected from Gampaha and Polonnaruwa districts respectively. Study participants were sampled using a multistage cluster sampling technique. Trained public health midwives administered the questionnaire. Two Likert scales provided information on access to medical care and satisfaction with available pharmacy services. About 95% of the sampled population participated in the study. Results: Overall, prevalence of medication use (allopathic, traditional, home remedies) in urban and rural population was 33.9% and 35.3%, respectively. Self-medication prevalence of allopathic drugs in the urban sector (12.2%) was significantly higher than in the rural (7.9%) sector(p<0.05). In the urban sector, small household size and preference to have medicines from outside the pharmacies predisposed to self-medication. The higher acceptability of medical services and regularity of medical care decreased the likelihood of self-medication. In the rural sector, lower satisfaction about the healthcare providers’ concern for clients, lower satisfaction about affordability of medical care and higher satisfaction with technical competence of the pharmacy staff increased the likelihood of self-medication. In both urban and rural sectors, when symptom count increased, tendency to self-medicate decreased. Conclusions: Self-medication prevalence was higher in urban compared to rural areas in Sri Lanka. Some aspects of access to medical care, satisfaction with pharmacy services and perceived severity of the disease were found to be important determinants of self-medication.

Background: Denial of having a chronic condition, poor knowledge of the disease process and lack of adherence to standard treatment are often considered to be important factors that increase morbidity in asthma. We evaluated the effect of standard treatment guidelines and asthma education programme on asthma control among patients enrolled from a referral health facility of Delhi in India. Methods: Fifty patients who visited the health facility first time for treatment of asthma were enrolled after confirming the diagnosis of asthma by symptoms and reversible spirometry. Patients were interviewed at baseline using three researcher-administered questionnaires - quality of asthma management questionnaire, asthma control questionnaire (ACQ) and asthma knowledge questionnaire (AKQ). All patients were given pharmacotherapy according to standard treatment guidelines. In addition, every alternate patient was also given a face-to-face educational intervention. Patients were followed up at 2, 4, 8 and 12 weeks. The ACQ was used at each visit, and AKQ was reassessed at the twelfth week. The paired t test was used to detect significant changes in various domains of asthma control. Results: The knowledge of asthma among patients and the care provided by previous health-care providers were found to be poor at baseline assessment. The application of standard treatment guidelines improved asthma control by the second week and the changes became significant by the fourth week, which persisted till the twelfth week (p <0.0001). Educational intervention led to improvements in knowledge in several domains. Improvements in asthma symptoms began earlier among those who had additional educational intervention. Conclusions: Standard treatment guidelines and asthma education improved asthma control.

Background: Mental illnesses are becoming a public health issue in all countries. However, data in most of the developing countries including Bhutan are scarce. This study aimed to explore the trends of admissions in the psychiatric ward of a referral hospital in Thimphu city of Bhutan. Method: The study employed a retrospective analysis method. The data were obtained from the patient admission register of the psychiatric ward to capture distribution by age, gender, occupation, nationality, clinical diagnosis, and length of stay in the ward. International Classification of Diseases (ICD) 10^th Revision was used for classification of the diseases. Descriptive statistics were used to describe the pattern of patient admissions. Demographic characteristics of the sample were cross-tabulated with clinical diagnosis and chi-square test was used to test statistical significance. Results: In the psychiatric ward 1336 patients were admitted over a seven-year period. In 2004-05, 127 patients were admitted, which increased to 376 in 2010-11. Higher numbers of males (64.1%, 856) were admitted than females (35.9%, 480). Mental and behavioural disorders due to psychoactive substance use were the most common (45.5%) reason for admission. Among the admitted patients, 18.8% had no job or were dependents. A large number of patients were from Thimphu District (10.8%) and 42% of the patients stayed for one to two weeks in the hospital. Conclusions: Psychiatric admissions were found to be increasing every year. Alcohol and drug use disorders were the most frequent diagnosis leading to hospitalization. Attention must be paid to increasing the in-patient services for psychiatric patients.

Background: Developing a quantitative understanding of pandemic influenza dynamics in South-East Asia is important for informing future pandemic planning. Hence, transmission dynamics of influenza A/H1N1 were determined across space and time in Thailand. Methods: Dates of symptom onset were obtained for all daily laboratory-confirmed cases of influenza A/H1N1pdm in Thailand from 3 May 2009 to 26 December 2010 for four different geographic regions (Central, North, North-East, and South). These data were analysed using a probabilistic epidemic reconstruction, and estimates of the effective reproduction number, R(t), were derived by region and over time. Results: Estimated R(t) values for the first wave peaked at 1.54 (95% CI: 1.42-1.71) in the Central region and 1.64 (95% CI: 1.38-1.92) in the North, whilst the corresponding values in the North-East and the South were 1.30 (95% CI: 1.17-1.46) and 1.39 (95% CI: 1.32-1.45) respectively. As the R(t) in the Central region fell below one, the value of R(t) in the rest of Thailand increased above one. R(t) was above one for 30 days continuously through the first wave in all regions of Thailand. During the second wave R(t) was only marginally above one in all regions except the South. Conclusions: In Thailand, the value of R(t) varied by region in the two pandemic waves. Higher R(t) estimates were found in Central and Northern regions in the first wave. Knowledge of regional variation in transmission potential is needed for predicting the course of future pandemics and for analysing the potential impact of control measures.

Background: Unprotected sex is a major risk factor for transmission of sexually transmitted infections (STIs). We explored the behavioural risk factors for STIs among men who presented with STI-related symptoms. Methods: A systematic sample of 112 males presenting with STI symptoms at district sexually transmitted disease (STD) clinic located in Kandy, Sri Lanka were enrolled during 2009. They were interviewed using a semi-structured questionnaire. Selected sexual behaviours were discussed with them in greater detail. The chi-square and difference-in-two-proportion tests were used for testing the statistical significance for quantitative data, and qualitative methods were used for the analysis of responses to open-ended questions and in-depth discussion. Results: The median age of the respondents was 28 years. The majority of them (56%) had never been married. The median age at the first sexual intercourse was 22 years. The majority (87%) of respondents had their first intercourse before marriage; mostly with older females. Most (103, 92%) men reported having sexual intercourse during the past six months; of them, 40.8% had sex with multiple partners. Only 18.5% used condoms at the first premarital intercourse. The consistent use of condoms with non-marital partners during the past six months was only 13.7%. Common reasons for non-use of condoms were: belief that partner was faithful; poor knowledge about risk of unprotected sex; view that condoms reduce pleasure and negatively affect intimacy; and inhibition in accessing condoms in public. Conclusions: Sexual behaviours were found to be risky among men attending STD clinics in Sri Lanka. Strategies of sexual health promotion among vulnarable groups should be evaluated for planning proper interventions.

Background: Childhood tuberculosis (TB) is one of the major causes of childhood morbidity and mortality; however, it is relatively a neglected disease. Hence, we explored the risk factors for childhood TB. Methods: Ninty-five cases and 94 controls were selected during January to May 2011 from DOTS centres located in four sub-districts of Bangladesh. The exposure status of recently diagnosed childhood TB patients (<18-year-olds), who were sputum-positive, were compared with children who were sent to the laboratory with suspected tuberculosis but were found to be sputum-negative. Data were collected by a structured questionnaire. Crude odds ratios (OR), adjusted odds ratio (AOR) and 95% confidence intervals (CI) were estimated. Stepwise logistic regression model was used to identify independent predictors. Results: Children under 14 years of age (AOR: 0.25; 95% CI: 0.10-0.66), having completed primary education (AOR: 0.28; 95% CI: 0.10-0.74), whose fathers’ were in business or service (AOR: 0.24; 95% CI: 0.08-0.72), and who slept in a less crowded room (AOR: 0.32; 95% CI: 0.14-0.76), lived in a house with a separate kitchen (AOR: 0.39; 95% CI: 0.16-0.96) had less chance of having TB. Those who had contact with cases of TB among relatives or neighbours were less likely to have TB (AOR: 0.28; 95% CI: 0.16-0.70) compared to those who had contact with a TB case in the family. Conclusion: Age, education, father’s occupation, crowding, kitchen location and intimate contact with a TB case were significantly associated with smear-positive childhood TB.

Background: An outbreak of measles was reported in Timor-Leste during 2011. A concerted response at national level utilized this opportunity to improve measles immunization coverage rates. Methods: Health Management Information System and Surveillance System data were utilized to describe the outbreak. Attack rates and case fatality rates (CFR) were calculated using standard methods. Evaluation surveys were used to access immunization coverage. Proceedings of weekly meetings of the National Committee for Control of Disease Outbreaks were reviewed. Results: A total of 739 cases and 8 deaths were reported to the Surveillance Unit. Most (>82%) of the measles cases were reported from Dili and Ermera districts. The attack rate was 1.3 per 1000 population and CFR was 1.1%. The response was coordinated by the National Committee for Control of Disease Outbreaks, which included case management, active and passive surveillance, communication and measles immunization among six-month to 14-year old children. Immunization activity targeted 495 000 children, i.e. almost one-half of the Timor-Leste population and achieved high coverage (85%). Conclusions: The outbreak highlighted gaps in the immunity against measles. The National Committee for Control of Disease Outbreaks ensured a coordinated response which led to prevention of deaths from measles due to early case management with vitamin A supplementation, and high measles immunization coverage.

Background: In India, the process of decentralization of health services started taking shape in the mid-1990s. Systemic reforms envisaged delegation of administrative and financial responsibilities at district level for management of health-care institutions in 23 states of India in 1999. Subsequently, some of these reforms became part of the National Rural Health Mission (NRHM) launched in 2005. This study aims to document the process of decentralization in health services with special reference to the barriers and facilitating factors encountered during formulation and implementation of reform policies. Methods: Secondary data were reviewed, health facilities were observed, and semi-structured interviews of the key actors involved in decentralization were carried out in Haryana (India). Results: Political and bureaucratic commitment to reforms was found to be the most important facilitating factor. Orientation training on decentralized administrative structures and performance-based resource distribution were the other important facilitators. Structural changes in administrative procedures led to improvement in the financial management system. Significant improvement in the public health infrastructure was observed. From 2004 to 2008, the state government increased the budget of health sector by nearly 60%. Frequent changes in the top administration at the state level hampered the decentralization process. Districts having a dynamic administrative leadership implemented decentralization more effectively than the rest. Conclusions: Decentralization of financial resources has improved the functioning of health services to some extent. Major policy decisions on decentralization of human resource management, increase in financial allocation, and greater involvement of community in decision-making are required.