An evaluation of the national measles vaccination campaign in the new shanty areas of Khayelitsha

A local component of the national measles vaccination campaign was evaluated in an area undergoing rapid urbanisation near Cape Town. Four serial cross-sectional cluster samples were used. Proven vaccination coverage before the campaign was 55.8% (95% confidence interval (CI) 46-66%), immediately afterwards it was 71.1% (95% CI 65-77%), and 6 months later 73.6% (95% CI 67-80%). The increase was not sustained among Transkei-born children. Significant determinants of vaccination coverage were: place of birth (chi 2 = 9.7; 2 df; P = 0.008); less than or equal to 6 months stay in Cape Town (odds ratio (OR) 2.22; 95% CI 1.2-4.0%); and home birth (OR 3.21; 95% CI 1.2-8.4%). The value of campaigns in controlling measles, as well as the role of a comprehensive health care service are discussed.     

Health status of hostel dwellers. Part IV. Immunisation of children

The immunisation status of children (0-5 years) living in the Zones, an urban migrant council-built hostel in Langa, was investigated to examine the effect of migrant labour and related to this, the effect of circular or oscillating migration between Cape Town and the eastern Cape (Transkei/Ciskei) on access to this preventive health care measure. 'Road-to-Health' cards were available for 69.4% of subjects--78.8% for those born in Cape Town and 50.8% for those born in Transkei. Immunisation of 'Road-to-Health' card holders ranged from 71.8% to 95%. The range dropped to 41-79.1% if it was assumed that children without 'Road-to-Health' cards (i.e. without positive proof of immunisation) had not been immunised. Children born in Cape Town have a significantly higher immunisation coverage than children born elsewhere (Transkei accounted for 82.7% of these children). Immunisations administered in Cape Town numbered 80.6%, while 62.6% of subjects were born in Cape Town. In Transkei, payment is required for immunisation, in Cape Town it is free. By implication, cost appeared to be an important reason for low coverage in Transkei. The findings of this study suggested that hostel migrant children who had access to the Cape Town health services through working parents had better immunisation coverage than children at the home-base who seldom or never reached the city.     

Survey of the health and nutrition status of a squatter community in Khayelitsha

The findings of a nutrition and health survey in Site B, a squatter area in Khayelitsha close to Cape Town, are reported. Of the children under 6 years, 16.8% were found to be under weight for age, 23.5% were stunted and 2.5% wasted, indicating a serious nutritional crisis in this community. Children with a low-birth-weight had a 3 times greater risk of being under weight for age and a 2 times greater risk of being stunted than children with birth-weights greater than 2,500 g. Of the children born outside Cape Town, 21.9% were under weight for age compared with 13.5% of children born in Cape Town. Of the pre-school children, 4.2% had completed or were on antituberculosis treatment compared with 2% of the children in the age group 6-18 years and 3.2% of adults. Sixty per cent of the pre-school children with tuberculosis were under weight for age. Half the adult population was fully employed, and 22% of households had no wage earners. Assuming literacy after 4 years of schooling, 76% of the adults were literate, but only 2.5% had completed Standard 10. Women were generally better qualified than men.     

Renal transplantation outcome and social deprivation in the French healthcare system: a cohort study using the European Deprivation Index

The study objective was to estimate the effect of social deprivation estimated by the European Deprivation Index (EDI) on the risk of death and graft failure on renal transplantation in France. EDI was calculated for 8701 of 9205 patients receiving a first renal transplantation between 2010 and 2014. Patients were separated in EDI quintiles of the general population. A Cox model (cs‐HR: cause‐specific hazard ratio of death or graft failure) and a Fine and Gray model (sd‐HR: subdistribution hazard ratio of death and graft failure) were used for the analysis. The 5th quintile group (most deprived) accounted for 32% of patients [2818 of 8701]. In the multivariate analysis, compared with quintile 1, the risk of death was higher for the 5^th quintile group in the complete cohort [cs‐HR: 1.31, 95% CI: (1.01–1.70), sd‐HR: 1.29, 95% CI: (1.00–1.68)], in the deceased donor group [cs‐HR: 1.31, 95% CI: (1.00–1.71), sd‐HR: 1.30, 95% CI: (1.00–1.70)] but not in living donor transplant patients. There was no association between the EDI groups and the risk of transplant failure. Social deprivation estimated by the EDI is associated with an increased risk of death in transplantation in France but not with the chance of allograft loss.     

Revascularization strategy in patients with multivessel disease and a major vessel chronically occluded; data from the CABRI trial.

OBJECTIVE: In patients with multivessel coronary artery disease and total occlusion of major epicardial vessel, completeness of revascularization has not been investigated in specific trials comparing the surgical and the percutaneous revascularization strategy. Analyzing the database of the CABRI study, which randomized a substantial number of these patients, we investigated the long-term effects of a successful or unsuccessful revascularization of the occluded vessel and completeness of the revascularization. METHODS AND RESULTS: The CABRI study randomized 1054 patients with multivessel coronary disease to coronary bypass or to coronary angioplasty. From the database of this trial, we selected patients with a major vessel chronically occluded (103 in the bypass group and 120 in the angioplasty group). At a median follow-up of 30 months, the incidence of death or Q-wave myocardial infarction (combined end point) was significantly lower in the bypass group than in the angioplasty group (6.8% vs 17.5%, respectively; hazard ratio [HR], 0.42 [95% CI 0.17-0.98]; p=0.047). On univariate analysis, age, proximal occlusion, complete revascularization, revascularization of the occluded vessel and revascularization procedure were identified as significant predictors of combined end points. On multivariate analysis, independent predictors of combined end points resulted in completeness of revascularization (HR 0.26; 95% CI 0.09-0.76; p=0.01) and age (HR 1.07; 95% CI 1.02-1.12; p<0.01). CONCLUSION: In patients with multivessel coronary disease and chronic occlusion of a major epicardial vessel, achieving of a complete revascularization by reopening or bypassing the occluded vessel is associated with a significantly better long-term prognosis.     

Prognostic factors for long-term survival in patients with thoracic metastatic disease: a 10-year experience.

OBJECTIVE: To compare survival results after resection in patients with thoracic parenchymal metastatic disease versus non-parenchymal metastatic disease and to identify prognostic factors for survival. METHODS: From 1990 to 2002, we retrospectively studied 134 procedures performed on 93 patients (3-84 years old). There were 73 patients with parenchymal resection and 20 patients with non-parenchymal resection. Tumor histology was epithelial in 62 patients, sarcoma in 21 patients, and teratomas and melanoma in 6 and 4 patients, respectively. Sixty-five patients underwent a metastasectomy once, whereas 28 had their metastatic disease repeatedly resected. RESULTS: Follow-up was 100% complete with a mean time of 43 months (range 1-169). In-hospital mortality was 2.2% (3/134 procedures) and major morbidity 5.5%. Median survival was 39 months (95% CI: 21-56 months). Overall, the actuarial survival at 1, 3, and 5 years were 84%, 55%, and 44%, respectively. For the entire group, by univariate analysis, among the 13 predictor variables selected, only the number of metastases (Hazard Ratio (HR)=3.4 [95% CI: 1.9-6.1]) and completeness of resection (HR=2.3 [95% CI: 1.3-4.2]) were found to be significant for death whereas repeated metastasectomy was found to be a significant predictor for survival (HR=0.25 [95% CI: 0.12-0.55]). In the group of parenchymal metastatic disease, a size greater than 3cm was a predictor for death (HR=2 [95% CI: 1.1-3.7]). In the subgroup of patients with colorectal metastasis, bilateral disease was also found to be a significant predictor for death (HR=3.6, [95% CI: 1.2-11.1]). CONCLUSION: This study supports our current aggressive approach to metastatic thoracic disease. Indeed, patient's survival is improved while a low mortality and morbidity is achieved. The most beneficial impact on long-term survival is correlated to the completeness of the surgery whereas the increasing number and size of the metastasis inversely correlate with survival.     

HIV prevalence in three predominantly Muslim residential areas in the Cape Town metropole.

OBJECTIVE: To report on the results of a random and representative household survey of HIV prevalence in 3 predominantly Muslim areas in the Cape Town metropole. METHOD: A cross-sectional representative community household survey was conducted in 3 residential areas. Aerial photographs were used in the selection of a random sample of 548 households, with the objective of obtaining an oral fluid sample and behavioural data from 2 inhabitants per household. Phase 1 of the study involved preparing the communities and notifying the household residents of the study. In phase 2, trained nurses collected oral fluid specimens for HIV testing and administered a confidential and anonymous behavioural questionnaire to household inhabitants aged 15 years and older. RESULTS: A total of 717 people completed a behavioural interview and 512 were tested for HIV, yielding response rates of 65% and 47% respectively. The specimens of 503 respondents were correctly matched with behavioural data; 352 of these respondents indicated that they were Muslim. Of these oral fluid specimens 9 were reactive and 341 were non-reactive. We therefore calculated HIV prevalence among Muslims living in the three areas at 2.56% (95% confidence interval (CI): 1.18 - 4.80%). None of the individuals who tested HIV-positive had been previously tested for HIV. There were no HIV infections in the remainder of the sample. CONCLUSION: The results indicate that HIV prevalence among Muslims living in the 3 targeted residential areas of the Cape Town metropole, while not trivial, is significantly lower than the national prevalence for South Africa. These results imply the need for ongoing prevention and education programmes specifically targeting Muslim youth and adults and support and assistance for Muslims infected with and affected by HIV.     

Cystic fibrosis in Cape Town

A retrospective study of all patients with cystic fibrosis (CF) seen at the Red Cross War Memorial Children's Hospital was undertaken. A total of 106 patients were identified and of these 64 still attend the CF clinic regularly. By 1 year of age 95% had symptoms but only 63% had been correctly diagnosed. In 27% the diagnosis was only made after 5 years of age. Chronic lung disease, failure to thrive, and diarrhoea or steatorrhoea were the most common presenting symptoms. Clinical scores of those still attending the clinic show that 79% are in the mild or better categories. The overall mortality rate was 21% and death was due to severe chest disease in the vast majority of cases. On the basis of the number of new patients with CF born during a 4-year period and the total number of live births recorded in this time, the calculated incidence of CF in Cape Town was 1/2,000 for whites and 1/12,000 for coloureds. Calculated prevalence rates for both whites and coloureds were much higher in urban Cape Town than in the rural areas of the western Cape. This suggests that many cases remain undiagnosed in the rural areas.     

Kidney allograft offers: Predictors of turndown and the impact of late organ acceptance on allograft survival

There is growing interest in understanding patterns of organ acceptance and reducing discard. Little is known about how donor factors, timing of procurement, and geographic location affect organ offer decisions. We performed a retrospective cohort study of 47 563 deceased donor kidney match‐runs from 2007 to 2013. Several characteristics unrelated to allograft quality were independently associated with later acceptance in the match‐run: Public Health Service increased‐risk donor status (adjusted odds ratio [aOR] 2.49, 95% confidence interval [CI] 2.29‐2.69), holiday or weekend procurement (aOR 1.11, 95% CI 1.07‐1.16), shorter donor stature (aOR 1.53 for <150 cm vs reference >180 cm, 95% CI 1.28‐1.94), and procurement in an area with higher intensity of market competition (aOR 1.71, 95% CI 1.62‐1.78) and with the longest waiting times (aOR 1.41, 95% CI 1.34‐1.49). Later acceptance in the match‐run was associated with delayed graft function but not all‐cause allograft failure (adjusted hazard ratio 1.01, 95% CI 0.96‐1.07). Study limitations include a lack of match‐run data for discarded organs and the possibility of sequence inaccuracies for some nonlocal matches. Interventions are needed to reduce turndowns of viable organs, especially when decisions are driven by infectious risk, weekend or holiday procurement, geography, or other donor characteristics unrelated to allograft quality.     

Postoperative mortality a university Department of General Surgery: incidence of cardiac-related deaths

OBJECTIVES: To evaluate the incidence of cardiac deaths following noncardiac nonvascular surgery. STUDY DESIGN: Retrospective survey. PATIENTS: All patients undergoing mainly endocrinous and digestive surgery in a University department of general surgery between 1991 and 1996. METHODS: Analysis of all deaths occurring intra- and postoperatively, until discharge of the patients. Demographic and medical data, including patent myocardial ischaemia and risk factors for coronary artery disease, were recorded and compared with a control group including all patients undergoing surgery from January to September 1996. RESULTS: In the 8,700 patients who underwent mainly endocrine neck surgery (66%), or intra-abdominal surgery (31%), the mortality rate (n = 96) was 1.1% (95% confidence interval [95% CI] = 0.9-1.3%). Patent myocardial ischaemia or high risk factors for coronary artery disease were existing in 24% of patients with neck surgery, 31% of those with intra-abdominal surgery, and in 60% of the deceased patients (P < 0.01 vs control group). Those who died were older, were in a higher ASA physical class, and had undergone an emergency procedure more often than patients of the control group (P < 0.002 for each parameter). Two cardiac deaths, in patients with a patent cardiopathy, were recorded (cardiac mortality: 0.02%; 95% CI = 0.003-0.08%). The main cause of death was infection (n = 46), followed by haemorrhage (n = 12). Seven deaths remained unexplained. CONCLUSION: This study suggests that cardiac morbidity is a rare cause of death after noncardiac nonvascular surgery.     

Alcohol consumption among South African blacks and its relationship to iron overload

The drinking habits of 123 black men (28 from Cape Town and 95 from Pietermaritzburg) were recorded, and their weekly alcoholic iron intakes calculated. Serum ferritin levels and liver function were measured in 57 subjects (Cape Town 12, Pietermaritzburg 45). Sorghum beer, with its high iron content, was considerably more popular in Pietermaritzburg than Cape Town, and the weekly iron consumption in Pietermaritzburg was significantly higher (P less than 0.05) than in Cape Town. The serum ferritin level was significantly higher in Cape Town than in Pietermaritzburg (P less than 0.05), no significant correlation being found between iron intake and serum ferritin. Age was positively correlated with serum ferritin (P less than 0.01). Of the subjects studied, 74% had abnormal lactate dehydrogenase levels. These results are considered in the light of the numerous problems associated with this type of project. The need for prospective studies in order to demonstrate a causal relationship between alcoholic iron intake and iron overload is emphasized.     

Deaths from asthma in Cape Town, 1980-1982

During the 3-year period 1980 - 1982, 351 patients were certified as having died from asthma in the Cape Town City Council area. An additional cause of death was listed in 120 of these. Of the 231 patients certified as having died from asthma only, 179 (77.5%) were over 40 years of age. The circumstances surrounding death in 28 of the remaining 52 patients under the age of 40 years are described. Inadequate assessment and therapy were major contributing factors. The incidence of death from asthma in Cape Town is three times greater than in the UK. It is probable that this also applies in other parts of the RSA. There is a need for improved education of health care professionals and patients about this common disease and for better community facilities for its treatment.     

External validation of the Glasgow Aneurysm Score to predict outcome in elective open abdominal aortic aneurysm repair

OBJECTIVES: Selecting patients based on their risk profiles could improve the outcome after elective surgery of an abdominal aortic aneurysm (AAA). The Glasgow Aneurysm Score (GAS) is a scoring system developed to determine such risk profiles. In other settings, the GAS has proved to have a predictive value for the postoperative outcome. The aim of this study was to investigate whether the GAS was also valid for the patients in our hospital and to examine risk factors with a possible predictive value for postoperative mortality and morbidity. METHODS: We performed a retrospective cohort study in a university hospital. The medical records of 229 patients who underwent open elective repair for an AAA in the period 1994 to 2003 were retrospectively analyzed to assess the GAS and to determine which of the examined risk factors had a predictive value for the prognosis. RESULTS: Five patients (2.2%) died after surgery and 30 (13.1%) had a major complication. The GAS was predictive for postoperative death (P = .021; sensitivity, 1.00; 95% confidence interval [CI], 0.52 to 1.00; specificity, 0.67; 95% CI, 0.61 to 0.73) and also for major morbidity (P = .029; sensitivity, 0.63; 95% CI, 0.46 to 0.78; specificity, 0.70; 95% CI, 0.64 to 0.76). The positive predictive value (mortality, 0.06; morbidity, 0.24) and the positive likelihood ratio (mortality, 3.07; morbidity, 2.14) were low, however. The best cutoff value for the GAS was determined at 77. All the deceased patients (100%) and 63.3% of those who had a major complication had a risk score of >or=77. Of all examined risk factors, suprarenal clamping during surgery was predictive of in-hospital mortality (8.3%, P = .017). For major morbidity, three risk factors, all of which are components of the GAS, were predictive: age (P = .046), cardiac disease (P = .032), and renal disease (P = .041). CONCLUSIONS: The Glasgow Aneurysm Score has a predictive value for outcome after open elective AAA repair. Because of its relatively low positive predictive value for death and major morbidity, the GAS is of limited value in clinical decision-making for the individual high-risk patient. In some particular cases, however, the GAS can be a useful tool, especially for low-risk patients because it has good negative predictive value for this group. Suprarenal clamping was found to be a risk factor for postoperative death.     

Injury-related behaviour among South African high-school students at six sites.

OBJECTIVES: To document and compare prevalence rates of adolescent injury-related risk behaviours at six sites in South Africa. DESIGN: The identical self-administered instrument was used at all sites. Prevalence rates (with 95% confidence intervals) were calculated taking the multistage cluster sampling strategy into account. SETTING AND SUBJECTS: In Cape Town, Durban, Port Elizabeth and Mankweng participants were drawn from either grades 8 or 9, and grade 11, while in Queenstown and Umtata they were drawn from grade 11 only. We selected 39 schools in Cape Town and Durban, 33 in Port Elizabeth and 20 in each of the rural areas. OUTCOME MEASURES: Road-related risk behaviour, violence, and suicide attempts. RESULTS: Across the sites there were high rates of risk behaviour in all domains. For example, in the 12 months preceding the survey an estimated 52.8% of grade 11 males in Cape Town had travelled in the front seat of a motor vehicle without a seatbelt, 33.0% of grade 8 males in Mankweng had bullied others, while 44.5% of the same group had been bullied, and 18.6% of females in Port Elizabeth had attempted suicide. Rates were lower in rural areas for behaviour involving motor vehicles, but there were no consistent urban-rural findings for violence-related behaviour. Females were at higher risk of suicidal behaviour and males were at higher risk of other injury-related behaviour. CONCLUSIONS: There is a need for effective interventions to reduce the extent of injury-related risk behaviour in adolescents in urban and rural settings.     

Acute respiratory infections as an important cause of childhood deaths in South Africa

Compared with other major preventable childhood diseases, such as diarrhoea, acute respiratory infections (ARI) have received comparatively little attention as an important cause of death in children. In this study of mortality from ARI in South Africa, national data was examined for the period 1968-1985, and data for Greater Cape Town for 1987. Almost 90% of ARI deaths were attributable to pneumonia and large inter-group differences were found that favoured whites and Asians over blacks and coloureds. For example, during 1980-1985 the mortality rate for pneumonia in coloured infants under 1 year of age was 11 times that observed in whites (88 v. 981/100,000). Pneumonia accounted for 14.5% of coloured and 12.7% of black deaths under 1 year of age during this period, compared with 6.7% of white and Asian deaths. The mortality rates from pneumonia declined substantially (50%) over the 18-year period in whites, coloureds and Asians. Sequential data for blacks is not available. There was a marked seasonality of deaths among coloured and Asian infants, with rates peaking in winter months. In Cape Town, pneumonia is now a more important cause of death among white and coloured children than diarrhoea, while it ranks with diarrhoea as a cause of death in black children. In all population groups, death rates from ARI are from 7 times to 270 times greater than those recorded in Western European countries. Studies are urgently required to discover why South African children suffer such a high mortality from ARI and how these deaths can be prevented.     

Fatal head injuries in Cape Town

Between 1 July 1983 and 30 June 1985 there were 563 cases of fatal head injuries in people over the age of 15 years recorded at the Salt River Police Mortuary, Cape Town. The demographic character of these cases was reviewed according to: (i) age, race and sex; (ii) date, day and time of injury; (iii) cause of death; and (iv) positive blood alcohol test. Assaults and transport-related accidents in association with a positive blood alcohol test in coloured males aged 40-60 years were a major characteristic.     

Temporal trends in TB notification rates during ART scale-up in Cape Town: an ecological analysis

Introduction

Although antiretroviral therapy (ART) reduces individual tuberculosis (TB) risk by two-thirds, the population-level impact remains uncertain. Cape Town reports high TB notification rates associated with endemic HIV. We examined population trends in TB notification rates during a 10-year period of expanding ART.

Methods

Annual Cape Town TB notifications were used as numerators and mid-year Cape Town populations as denominators. HIV-stratified population was calculated using overall HIV prevalence estimates from the Actuarial Society of South Africa AIDS and Demographic model. ART provision numbers from Western Cape government reports were used to calculate overall ART coverage. We calculated rates per 100,000 population over time, overall and stratified by HIV status. Rates per 100,000 total population were also calculated by ART use at treatment initiation. Absolute numbers of notifications were compared by age and sub-district. Changes over time were described related to ART provision in the city as a whole (ART coverage) and by sub-district (numbers on ART).

Results

From 2003 to 2013, Cape Town''s population grew from 3.1 to 3.7 million inhabitants, and estimated HIV prevalence increased from 3.6 to 5.2%. ART coverage increased from 0 to 63% in 2013. TB notification rates declined by 16% (95% confidence interval (CI), 14–17%) from a 2008 peak (851/100,000) to a 2013 nadir (713/100,000). Decreases were higher among the HIV-positive (21% (95% CI, 19–23%)) than the HIV-negative (9% (95% CI, 7–11%)) population. The number of HIV-positive TB notifications decreased mainly among 0- to 4- and 20- to 34-year-olds. Total population rates on ART at TB treatment initiation increased over time but levelled off in 2013. Overall median CD4 counts increased from 146 cells/µl (interquartile range (IQR), 66, 264) to 178 cells/µl (IQR 75, 330; p<0.001). Sub-district antenatal HIV seroprevalence differed (10–33%) as did numbers on ART (9–29 thousand). Across sub-districts, infant HIV-positive TB decreased consistently whereas adult decreases varied.

Conclusions

HIV-positive TB notification rates declined during a period of rapid scale-up of ART. Nevertheless, both HIV-positive and HIV-negative TB notification rates remained very high. Decreases among HIV positives were likely blunted by TB remaining a major entry to the ART programme and occurring after delayed ART initiation.     

Socio-economic inequalities as a predictor of health in South Africa--the Yenza cross-sectional study.

OBJECTIVES: To describe the demographic, environmental and health characteristics of the rural Eastern Cape and to explore demographic and environmental predictors of health. DESIGN: Cross-sectional study. SETTING: Engcobo and Umtata in the Eastern Cape, South Africa. SUBJECTS: 12,049 people from 4608 households. OUTCOME MEASURES: (i) Children: immunisation history and being breastfed; (ii) women aged 15-45 years: use of contraception; (iii) women aged 20-25 years: total numbers of dead children; and (iv) all adults: smoking status, body mass index and blood pressure. RESULTS: 2741 houses (59.5%) were structurally adequate, 1795 (39.0%) had access to clean water, and 1174 (25.6%) had access to gas or electric energy. Of children up to 5 years of age 1436 (44.2%) were fully immunised and 2472 (76.1%) were breastfed in their first year of life. Among women aged 15-45 years, 903 (37.8%) used contraceptives, and among women aged 20-25 years, 56 (11.8%) had lost at least 1 child. Self-report of chronic illness and disability was low. Current smokers include 264 men (12.7%) and 325 women (6.0%), and 315 men (15.2%) and 1439 women (26.7%) had a body mass index > 30. Adequate housing (odds ratio (OR) 1.31, 95% confidence interval (CI): 1.12-1.53) and access to refuse disposal (OR 1.65, 95% CI: 1.36-2.00) were predictive of complete immunisation in children. Children living in houses with access to clean water (OR 0.8, 95% CI: 0.64-0.99) and a fitted toilet (OR 0.56, 95% CI: 0.38-0.83) were less likely to be breastfed in the first year of their life. Women aged 15-45 years were likely to use contraception if they were well educated (OR 2.75, 95% CI: 1.76-4.28) and lived in houses with access to refuse disposal (OR 1.46, 95% CI: 1.20-1.78). Better education was associated with a reduced likelihood of loss of a child (OR 0.11, 95% CI: 0.02-0.51) and being a smoker (OR 0.52, 95% CI: 0.38-0.73). Obesity was associated with being female (OR 1.88, 95% CI: 1.62-2.18) and living in a house with electricity (OR 1.46, 95% CI: 1.26-1.68). High blood pressure was associated with living in a house with electricity (OR 1.36, 95% CI: 1.10-1.70) and with monthly household income exceeding R2 000 (OR 1.38, 95% CI: 1.07-1.78). CONCLUSIONS: High socio-economic deprivation in the Eastern Cape is associated with health status comparable to that of poorer regions in sub-Saharan Africa. The educational level of the population, access to electricity, clean water and refuse disposal facilities are important predictors of child, maternal and adult health.