Comment
in the local area further reduces costs. Although there is a pressing need for implementing faster, cheaper, and more effective ways of dealing with problems of cataract blindness, these should not be at the cost of a compromise in sterility.9 Extracapsular cataract extraction with implantation of the intraocular lens in the bag remains an indispensable option for cataract management. Relevant cost-effective adaptions in environments with few resources should improve the quality of surgery, resulting in good outcomes.
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*Abhay R Vasavada, Shetal M Raj Iladevi Cataract & IOL Research Centre, Raghudeep Eye Clinic, Memnager, Ahmedabad 380052, India
[email protected] We declare that we have no conflict of interest.
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Singh AJ, Garner P, Floyd K. Cost-effectiveness of public-funded options for cataract surgery in Mysore, India. Lancet 2000; 355: 180–84. Ruit S, Tabin GC, Nissman SA, Paudyal G, Gurung R. Low-cost high-volume extracapsular cataract extraction with posterior chamber intraocular lens implantation in Nepal. Ophthalmology 1999; 106: 1887–92. Gillies M, Brian G, La Nauze J, et al. Modern surgery for global cataract blindness: preliminary considerations. Arch Ophthalmol 1998; 116: 90–92. Civerchia L, Ravindran RD, Apoorvananda SW, et al. High-volume intraocular lens surgery in a rural eye camp in India. Ophthalmic Surg Lasers 1996; 27: 200–08. Yook RH. Low-cost high-volume ECCE with PC IOL. Ophthalmology 2000; 107: 1797–98. Ruit S, Paudyal G, Gurung R, Tabin G, Moran D, Brian G. An innovation in developing world cataract surgery: sutureless extracapsular cataract extraction with intraocular lens implantation. Clin Exp Ophthalmol 2000; 28: 274–79. Balent LC, Narendrum K, Patel S, Kar S, Patterson DA. High volume sutureless intraocular lens surgery in a rural eye camp in India. Ophthalmic Surg Lasers 2001; 32: 446–55. Foster A. Cataract and “Vision 2020-the right to sight” initiative. Br J Ophthalmol 2001; 85: 635–37. Khouri AS. Low-cost high-volume ECCE with PC IOL. Ophthalmology 2000; 107: 1797.
A new strategy for dengue control In this issue of The Lancet, Brian Kay and Vu Sinh Nam describe a low-technology—but highly effective—strategy for control of disease-carrying mosquitoes in Vietnam. The main target of the strategy is the Aedes aegypti mosquito that transmits dengue fever. Dengue is a classic emerging disease that illustrates the spectacular failure of top-down disease-control methods1 and one of the negative impacts of globalisation on poor communities.2 The reasons for the emergence of dengue and dengue haemorrhagic fever are not fully understood, but widely recognised social factors include: deterioration of public-health infrastructure, expansion of international travel and trade, and rapid increases in economically marginalised urban populations lacking basic services. Densely populated shanty towns provide perfect conditions for the transmission of vector-borne disease. Mosquitoes need standing water to breed. Lack of reliable piped-water supplies mean that water must be stored in or near the home; inadequate disposal of non-biodegradable containers provide further breeding sites for mosquitoes. The types of container used by the mosquito to breed vary by location. An important element of the strategy described by Kay and Nam involves an assessment of which containers produce the most mosquito larvae, and therefore are the important ones to target. In Vietnam, with its predominantly rural population and saline ground-water near river deltas, large water-storage tanks are an important mosquito-breeding site. The solution to this problem is a novel one, involving a form of biological control. Large water-tanks are inoculated with local species of Mesocyclops copepods, which live on various organisms, including mosquito larvae. However, other potential breeding sites, such as discarded containers, www.thelancet.com Vol 365 February 12, 2005
are too small to be treated successfully with Mesocyclops and need to be removed. Fortunately, the structure of Vietnamese society is well suited to community participation. The dengue-control programmes described by Kay and Nam are done by communal health workers, paid health-collaborators, and school teachers and pupils who inspect houses and collect discarded containers. Kay and Nam report eradication of A aegypti in most communes in the programme, and no subsequent cases of dengue in any of these communes. Compared with the rest of the country, the northern provinces are less suitable climatically for A aegypti3 and for dengue transmission.4 Relatively few cases of dengue were reported in the northern provinces even before the programme began (figure). Therefore the challenge is even greater for phase two of the programme in the central provinces. It is not clear how successful this strategy might be in cities or in other countries. Use of Mesocyclops is most effective in medium to large water-containers, which are less frequent breeding sites in most cities. Initial study areas were specifically chosen for their suitability in this respect.5 Extrapolation of the strategy to western cultures seems even less certain, because community participation will be more difficult to establish and maintain in societies with a strong culture of individualism and dislike of visible organisms in the drinking water. WHO’s strategy for dengue control advocates “integrated mosquito control with community and intersectoral participation”, but does not specify which methods are most appropriate.6 The Scientific Working Group on Insect Vectors and Human Health advocates genetic engineering to develop novel mosquito-control methods, and the improvement of existing biological insecticides.7 Even if sci-
See Public Health page 613
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Kay and Nam show that low-technology approaches to vector control can be effective if well planned and supported, with a strong emphasis on community participation. Their strategy is not a universal answer to the problem of dengue, but has the potential to make an important difference in rural communities. On a global scale, most of the population increase expected during the next quarter century will occur in the urban areas of poor countries,8 whose population is projected to double from 2 billion in the year 2000 to about 4 billion in 2030. Providing basic services to this rapidly expanding urban population must be a top priority if further dramatic increases in dengue, as well as other infectious diseases, are to be prevented.
*Simon Hales, Wilbert van Panhuis Wellington School of Medicine and Health Sciences, Wellington, New Zealand 8000 (SH); and WHO Collaborating Centre for Research on the Epidemiology of Disasters (CRED), Catholic University of Louvain, Brussels, Belgium (WvP)
[email protected] 0–50 51–100
We declare that we have no conflict of interest.
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Figure: Dengue cases by province, Vietnam, 1998 Nam Dinh province is enlarged. 18 communes in this province where interventions were done are in black.
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entifically achievable, these high-technology approaches to the control of dengue will only be a part solution, especially for low-resource areas that carry the largest disease burden.
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Lloyd LS. Best practices for dengue prevention and control in the Americas. Washington, DC: US Agency for International Development, February, 2003: http://www.ehproject.org/ PDF/Strategic_papers/SR7-BestPractice.pdf (accessed Jan 20, 2005). Saker L, Lee K, Cannito B, Gilmore A, Campbell-Lendrum D. Globalization and infectious diseases: a review of the linkages. Geneva: WHO, 2004: http://www.who.int/tdr/publications/ publications/ seb _topic3.htm (accessed Jan 20, 2005). Hopp M, Foley J. Global scale relationships between climate and the dengue fever vector, Aedes aegypti. Clim Change 2001; 48: 441–63. Hales S, de Wet N, Maindonald J, Woodward A. Potential effect of population and climate changes on global distribution of dengue fever: an empirical model. Lancet 2002; 60: 830–34. Kay B, Nam V, Tien T, et al. Control of Aedes vectors of dengue in three provinces of Vietnam by use of Mesocyclops (copepoda) and community-based methods validated by entomologic, clinical, and serological surveillance. Am J Trop Med Hyg 2002; 66: 40–48. Renganathan E, Parks W, Lloyd L, et al. Towards sustaining behavioural impact in dengue prevention and control. Dengue Bull 2003; 27: 6–12. WHO. Insect vectors and human health: report of the scientific working group meeting. Geneva: World Health Organisation, 2003: http://www.who.int/tdr/publications/publications/ insect_vectors.htm (accessed Jan 20, 2005). United Nations. World urbanization prospects: the 2001 revision. New York: United Nations Population Division, March 20, 2002: http:// www.un.org/esa/population/publications/wup2001/ wup2001dh.pdf (accessed Jan 20, 2005).
Of rats and men: superwarfarin toxicity See Case Report page 628
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He lay in a heap with face contorted, yet his friends delayed seeking medical help; one would later boast, “I did him in”. The autopsy showed haemorrhage in the left cerebral hemisphere and stomach, although a final report strangely omitted the gastric haemorrhage—possibly to conceal the fact
that one of the biggest mass murderers of all time, Joseph Stalin, had been poisoned with warfarin.1 20 years earlier, in 1933, Karl Link, a chemist at the Wisconsin Alumni Research Foundation, began work on identifying the active ingredient in mouldy sweet clover that had led to a haemorrhagic www.thelancet.com Vol 365 February 12, 2005
