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  • Equally important to the scientific


    Equally important to the scientific findings of Soka and colleagues\' report is the context of the activities—established not as a research study but as a national programme oriented toward health service provision and risk reduction. The programme packaged semen testing with counselling for survivors to promote safer sex practices, including condom provision and instruction, and enabled referral for other health problems that survivors might encounter. A mobile team was established to expand programme access and to provide counselling for sexual partners. Although interpretation of the self-reported results and the potential for social desirability bias should be done with caution, the public health effects of the programme seemed to be substantial; participants reported increases in abstinence (p<0·0001) and condom use (p<0·0001), with 75% feeling “very confident” in correct condom use at programme graduation. These behavioural changes might have not only prevented sexual transmission of Ebola virus and potential re-ignition of the outbreak, but also other sexually transmitted diseases and unwanted pregnancies. 290 (97%) of 299 programme graduates reported that they would refer others to participate and 257 (86%) shared or planned to share their test results with their sexual partners. Soka and colleagues have graciously provided programmatic details in an online AP20187 to facilitate rapid establishment of similar programmes elsewhere.
    Globally, diarrhoea is the second most common cause of death in children younger than 5 years. About 1·2 billion episodes of diarrhoea occur annually worldwide, resulting in roughly 760 000 deaths in children. WHO defines diarrhoea as more than three loose or liquid stools per day. Diarrhoea could be acute watery (lasting for several hours or days as occurs in cholera cases), acute bloody (also known as dysentery), or persistent (lasting for 14 or more days). Acute watery diarrhoea results in dehydration, which can cause death. However, death is preventable in most cases by the use of oral rehydration solutions or intravenous fluids, depending on its severity. To prevent a fatal outcome, diarrhoea should be recognised, dehydration should be categorised, and appropriate therapy should be initiated according to the WHO Integrated Management of Childhood Illness (ICMI) guidelines. In , Adam Levine and colleagues developed a new clinical score for assessing diarrhoea in the Dehydration: Assessing Kids Accurately (DHAKA) study done in Dhaka, Bangladesh. This new clinical score was developed and internally validated and recommended for use for assessing dehydration in children with acute diarrhoea in a low-income country. The DHAKA score assesses general appearance, tears, skin turgor, and respirations (deep or not). The maximum score was 12 and a score of 4 or more was deemed as severe dehydration and 1 or less was deemed as no dehydration. Levine and colleagues have externally validated the score prospectively in a random sample of 496 children in Bangladesh. They validated the DHAKA score and dehydration grading with the IMCI approach against a gold standard, which was weight gained after rehydration in a child with acute watery diarrhoea, with children with severe dehydration gaining more than 9% of their bodyweight, those with some dehydration gaining 3–9% of their bodyweight, and those with no dehydration gaining less than 3% of their bodyweight. The IMCI assessment relies on general appearance, ability to drink, skin pinch, and sunken eyes but does not include numerical scoring. Adam Levine and colleagues have stated that because physicians and nurses see several cases of diarrhoea, categorising dehydration with numerical values, as done with the DHAKA score but not with the IMCI algorithm, might increase inter-rater reliability and perhaps result in better management. However, some questions remain unanswered with the DHAKA score. An increase in DHAKA score was found to result in an increase in specificity increases at the cost of sensitivity. The IMCI score does well across all ages in terms of sensitivity and specificity and is easy to remember with the help of flow charts. By contrast, the DHAKA score uses a numerical system, which might be difficult to remember. The DHAKA score does not have a clear cutoff to indicate severe, some, or no dehydration. The DHAKA score has not been validated in under-nourished children or those with hyponatraemia or hypernatraemia dehydration. In the study by Levine and colleagues, the same individual applied both the DHAKA score and IMCI algorithm on a child, hence systematic bias might exist.