Engineering in the time of cholera: overcoming institutional and political challenges to rebuild Zimbabwe's water and sanitation infrastructure in the aftermath of the 2008 cholera epidemic
A devastating cholera epidemic swept Zimbabwe in 2008, causing over 90,000 cases, and leaving more than 4,000 dead. The epidemic raged predominantly in urban areas, and the cause could be traced to the slow deterioration of Zimbabwe's water and sewerage utilities during the economic and political crisis that had gripped the country since the late 1990s. Rapid improvement was needed if the country was to avoid another cholera outbreak. In this context, donors, development agencies and government departments joined forces to work in a unique partnership, and to implement a programme of swift improvements that went beyond emergency humanitarian aid but did not require the time or massive investment associated with full-scale urban rehabilitation. The interventions ranged from supply of water treatment chemicals and sewer rods to advocacy and policy advice. The authors analyse the factors that made the programme effective and the challenges that partners faced. The case of Zimbabwe offers valuable lessons for other countries transitioning from emergency to development, and particularly those that need to take rapid action to upgrade failing urban systems. It illustrates that there is a ‘middle path’ between short-term humanitarian aid delivered in urban areas and large-scale urban rehabilitation, which can provide timely and highly effective results.
Water services and public health: the 2000-01 cholera outbreak in KwaZulu-Natal, South Africa
Paper presented at the 8th World Congress on Environmental Health, Durban, South Africa, 22-27 February
Sources of Information on Lymphoma Associated with Anti-Tumour Necrosis Factor Agents
AbstractBackground: Anti-tumour necrosis factor (TNF) agents, through their intense immunoregulatory effect, have been suspected to increase the risk of malignant lymphoma. However, the classical epidemiological approaches conducted over about the last 10 years have not totally succeeded in addressing the question of a causal or artifactual association. Therefore, the analysis of a substantial set of case reports, although usually considered as poorly generalizable to the general population, could be particularly informative. Two main sources of case reports in postmarketing settings are available; publications in medical journals and reports to pharmacovigilance systems.
 Objective: The aim of the study was to compare the characteristics of case reports from both these sources in order to understand whether they provided the same information for the investigation of the causal link between lymphoma and anti-TNF agents.
 Methods: All case reports of malignant lymphoma in patients treated with an anti-TNF agent published in MEDLINE and all reports to the French pharmacovigilance system up to 1 February 2010 were identified. Cases of malignant lymphoma identified in postmarketing surveillance from both sources were compared regarding the following variables: age, sex, anti-TNF agent involved, indication for use, type of lymphoma, prior or concomitant immunosuppressive drugs and time to onset of lymphoma.
 Results: A total of 81 published case reports and 61 cases reported to the French pharmacovigilance system were compared. In published reports, patients were younger (p = 0.03) and more frequently receiving a first anti-TNF treatment (p = 0.03), particularly infliximab (p = 0.03). Conversely, in the pharmacovigilance system reports, a succession of different anti-TNFs (p = 0.03) and adalimumab (p< 0.0001) were more frequently reported. Lymphomas in patients treated with anti-TNF agents for Crohn’s disease were more prevalent in published cases than in pharmacovigilance reports (p< 0.0001), and in particular involved hepatosplenic T-cell lymphoma. Conversely, rheumatoid arthritis was the main indication for anti-TNF agents in pharmacovigilance reports (p = 0.01). Time to onset was markedly shorter in published cases (median 12 months) than in pharmacovigilance reports (median 30 months; p = 0.0001).
 Conclusions: Characteristics of published cases and those reported to the French pharmacovigilance system differed markedly for all characteristics tested, except sex and the use of prior or concomitant immunosuppressive drugs. Published case reports favoured convincing arguments for drug causation whereas cases reported to the pharmacovigilance system were more disparate but could describe more accurately the reality of lymphoma occurrence in this particular population. These results argue for the use of the pharmacovigilance reports when case reports are used to investigate the causal link between lymphoma and anti-TNF agents at the population level. Data from cases notified to the French pharmacovigilance system did not indicate an increased risk of lymphoma during the early phase of anti-TNF treatment. To confirm this hypothesis, a study combining pharmacovigilance reports from several countries, or, if feasible, a cohort study both with a large sample size and a long duration of follow-up would be required.