Equity in maternal and child health in Thailand

Objective

To assess equity in health outcomes and interventions for maternal and child health (MCH) services in Thailand.

Methods

Women of reproductive age in 40 000 nationally representative households responded to the Multiple Indicator Cluster Survey in 2005–2006. We used a concentration index (CI) to assess distribution of nine MCH indicator groups across the household wealth index. For each indicator we also compared the richest and poorest quintiles or deciles, urban and rural domiciles, and mothers or caregivers with or without secondary school education.

Findings

Child underweight (CI: −0.2192; P < 0.01) and stunting (CI: −0.1767; P < 0.01) were least equitably distributed, being disproportionately concentrated among the poor; these were followed by teenage pregnancy (CI: −0.1073; P < 0.01), and child pneumonia (CI: −0.0896; P < 0.05) and diarrhoea (CI: −0.0531; P < 0.1). Distribution of the MCH interventions was fairly equitable, but richer women were more likely to receive prenatal care and delivery by a skilled health worker or in a health facility. The most equitably distributed interventions were child immunization and family planning. All undesirable health outcomes were more prevalent among rural residents, although the urban–rural gap in MCH services was small. Where mothers or caregivers had no formal education, all outcome indicators were worse than in the group with the highest level of education.

Conclusion

Equity of coverage in key MCH services is high throughout Thailand. Inequitable health outcomes are largely due to socioeconomic factors, especially differences in the educational level of mothers or caregivers.     

Under-registration of deaths in Thailand in 2005-2006: results of cross-matching data from two sources

Objective

To estimate the magnitude of under-registration of deaths, by age and sex, in Thailand.

Methods

The data in this study were derived from two sources: the Thai Survey of Population Changes (SPC) 2005–2006, a consecutive multi-round household survey conducted over a 12-month period, and Thailand’s vital registration records. SPC death entries for people of all ages were matched to 2005–2006 death records from vital registration. The principles of a dual records system were applied to estimate the magnitude of under-registration of deaths, classified by age and sex, using the Chandrasekaran-Deming formula.

Findings

Overall under-registration of deaths during 2005–2006 was 9.00% (95% confidence interval, CI: 8.95–9.05) for males and 8.36% (95% CI: 8.31–8.41) for females. For both males and females, under-registration decreased as age increased. Under-registration was greatest among people of either sex aged 1–4 years, whereas it was < 10% among people 60 years of age and older, both males and females.

Conclusion

These findings provided correction factors that can be used for adjusting mortality data from the registration system.     

Supplementary polio immunization activities and prior use of routine immunization services in non-polio-endemic sub-Saharan Africa

Objective

To determine participation in polio supplementary immunization activities (SIAs) in sub-Saharan Africa among users and non-users of routine immunization services and among users who were compliant or non-compliant with the routine oral poliovirus vaccine (OPV) immunization schedule.

Methods

Data were obtained from household-based surveys in non-polio-endemic sub-Saharan African countries. Routine immunization service users were children (aged < 5 years) who had ever had a health card containing their vaccination history; non-users were children who had never had a health card. Users were considered compliant with the OPV routine immunization schedule if, by the SIA date, their health card reflected receipt of required OPV doses. Logistic regression measured associations between SIA participation and use of both routine immunization services and compliance with routine OPV among users.

Findings

Data from 21 SIAs conducted between 1999 and 2010 in 15 different countries met inclusion criteria. Overall SIA participation ranged from 70.2% to 96.1%. It was consistently lower among infants than among children aged 1–4 years. In adjusted analyses, participation among routine immunization services users was > 85% in 12 SIAs but non-user participation was > 85% in only 5 SIAs. In 18 SIAs, participation was greater among users (P < 0.01 in 16, 0.05 in 1 and < 0.10 in 1) than non-users. In 14 SIAs, adjusted analyses revealed lower participation among non-compliant users than among compliant users (P < 0.01 in 10, < 0.05 in 2 and < 0.10 in 2).

Conclusion

Large percentages of children participated in SIAs. Prior use of routine immunization services and compliance with the routine OPV schedule showed a strong positive association with SIA participation.     

Factors influencing rising caesarean section rates in China between 1988 and 2008

Objective

To identify factors driving the rapid increase in caesarean section in China between 1988 and 2008.

Methods

Data from four national cross-sectional surveys (1993, 1998, 2003 and 2008) and modified Poisson regression were used to determine whether changes in household income, access to health insurance or women’s education accounted for the rise in caesarean sections in urban and rural areas.

Findings

In 2008, 64.1% of urban women and 11.3% of women in the poorest rural region reported giving birth by caesarean section. A fast rise was occurring in all socioeconomic groups. Between 1993 and 2008, the risk of caesarean section had increased more than threefold in urban areas (relative risk, RR: 3.63; 95% confidence interval, CI: 2.61–5.04) and more than 15-fold in rural areas (RR: 15.46; 95% CI: 10.46–22.86). After adjustment for improvements in income, education and access to health insurance over the study period, the RR dropped minimally in urban areas (RR: 3.07; 95% CI: 2.32–4.07), which suggests that these factors do not explain the rise; in rural areas, the adjusted RR dropped to 7.18 (95% CI: 4.82–10.69), which shows that socioeconomic change is only partly responsible for the rise. Socioeconomic region of residence was a more important driver of the caesarean section rate than individual socioeconomic status.

Conclusion

The large variation in caesarean section rate by socioeconomic region – independent of individual income, health insurance or education – suggests that structural factors related to service supply have influenced the increasing rate more than a woman’s ability to pay.     

Timing of antiretroviral therapy in Cambodian hospital after diagnosis of tuberculosis: impact of revised WHO guidelines

Objective

To determine if implementation of 2010 World Health Organization (WHO) guidelines on antiretroviral therapy (ART) initiation reduced delay from tuberculosis diagnosis to initiation of ART in a Cambodian urban hospital.

Methods

A retrospective cohort study was conducted in a nongovernmental hospital in Phnom Penh that followed new WHO guidelines in patients with human immunodeficiency virus (HIV) and tuberculosis. All ART-naïve, HIV-positive patients initiated on antituberculosis treatment over the 18 months before and after guideline implementation were included. A competing risk regression model was used.

Findings

After implementation of the 2010 WHO guidelines, 190 HIV-positive patients with tuberculosis were identified: 53% males; median age, 38 years; median baseline CD4+ T-lymphocyte (CD4+ cell) count, 43 cells/µL. Before implementation, 262 patients were identified; 56% males; median age, 36 years; median baseline CD4+ cell count, 59 cells/µL. With baseline CD4+ cell counts ≤ 50 cells/µL, median delay to ART declined from 5.8 weeks (interquartile range, IQR: 3.7–9.0) before to 3.0 weeks (IQR: 2.1–4.4) after implementation (P < 0.001); with baseline CD4+ cell counts > 50 cells/µL, delay dropped from 7.0 (IQR: 5.3–11.3) to 3.6 (IQR: 2.9–5.3) weeks (P < 0.001). The probability of ART initiation within 4 and 8 weeks after tuberculosis diagnosis rose from 23% and 65%, respectively, before implementation, to 62% and 90% after implementation. A non-significant increase in 6-month retention and antiretroviral substitution was seen after implementation.

Conclusion

Implementation of 2010 WHO recommendations in a routine clinical setting shortens delay to ART. Larger studies with longer follow-up are needed to assess impact on patient outcomes.     

Excess child mortality after discharge from hospital in Kilifi, Kenya: a retrospective cohort analysis

Objective

To explore excess paediatric mortality after discharge from Kilifi District Hospital, Kenya, and its duration and risk factors.

Methods

Hospital and demographic data were used to describe post-discharge mortality and survival probability in children aged < 15 years, by age group and clinical syndrome. Cox regression models were developed to identify risk factors.

Findings

In 2004–2008, approximately 111 000 children were followed for 555 000 person–years. We analysed 14 971 discharges and 535 deaths occurring within 365 days of discharge. Mortality was higher in the post-discharge cohort than in the community cohort (age-adjusted rate ratio, RR: 7.7; 95% confidence interval, CI: 6.6–8.9) and declined little over time. An increased post-discharge mortality hazard was found in children aged < 5 years with the following: weight-for-age Z score < −4 (hazard ratio, HR: 6.5); weight-for-age Z score > −4 but < −3 (HR: 3.4); hypoxia (HR: 2.3); bacteraemia (HR: 1.8); hepatomegaly (HR: 2.3); jaundice (HR: 1.8); hospital stay > 13 days (HR: 1.8). Older age was protective (reference < 1 month): 6–23 months, HR: 0.8; 2–4 years, HR: 0.6. Children with at least one risk factor accounted for 545 (33%) of the 1655 annual discharges and for 39 (47%) of the 83 discharge-associated deaths.

Conclusion

Hospital admission selects vulnerable children with a sustained increased risk of dying. The risk factors identified provide an empiric basis for effective outpatient follow-up.     

Home visits by community health workers to prevent neonatal deaths in developing countries: a systematic review

Objective

To determine whether home visits for neonatal care by community health workers can reduce infant and neonatal deaths and stillbirths in resource-limited settings.

Methods

We conducted a systematic review up to 2008 of controlled trials comparing various intervention packages, one of them being home visits for neonatal care by community health workers. We performed meta-analysis to calculate the pooled risk of outcomes.

Findings

Five trials, all from south Asia, satisfied the inclusion criteria. The intervention packages included in them comprised antenatal home visits (all trials), home visits during the neonatal period (all trials), home-based treatment for illness (3 trials) and community mobilization efforts (4 trials). Meta-analysis showed a reduced risk of neonatal death (relative risk, RR: 0.62; 95% confidence interval, CI: 0.44–0.87) and stillbirth (RR: 0.76; 95% CI: 0.65–0.89), and a significant improvement in antenatal and neonatal practice indicators (> 1 antenatal check-up, 2 doses of maternal tetanus toxoid, clean umbilical cord care, early breastfeeding and delayed bathing). Only one trial recorded infant deaths (RR: 0.41; 0.30–0.57). Subgroup analyses suggested a greater survival benefit when home visit coverage was ≥ 50% (P < 0.001) and when both preventive and curative interventions (injectable antibiotics) were conducted (P = 0.088).

Conclusion

Home visits for antenatal and neonatal care, together with community mobilization activities, are associated with reduced neonatal mortality and stillbirths in southern Asian settings with high neonatal mortality and poor access to facility-based health care.     

Maternal body mass index and gestational weight gain and their association with perinatal outcomes in Viet Nam

Objective

To examine the association between gestational weight gain and maternal body mass index (BMI) among Vietnamese women and the risk of delivering an infant too small or too large for gestational age.

Methods

A prospective health-facility-based study of 2989 pregnant Vietnamese women was conducted in the city of Nha Trang in 2007–2008. Cubic logistic regression was used to investigate the association of interest. Infants were classified into weight-for-gestational-age categories according to weight centiles for the Asian population. Gestational age was based on the date of last menstrual period and adjusted by the results of first-trimester ultrasound.

Findings

BMI was low (< 18.5), normal (18.5–22.9) and high (≥ 23.0) in 26.1%, 65.4% and 8.5% of the women, respectively. In each of these BMI categories, the percentage of women who delivered infants too small for gestational age was 18.1, 10.0 and 9.4, respectively, and the mean gestational weight gain was 12.5 kg (standard deviation, SD: ± 3.6), 12.2 kg (SD: ± 3.8) and 11.5 kg (SD: ± 4.7), respectively. Among women with low BMI, the risk of delivering an infant too small for gestational age ranged from approximately 40% if the gestational weight gain was < 5 kg to 20% if it was 5–10 kg.

Conclusion

Having a low BMI, commonly found in Viet Nam, puts women at risk of delivering an infant too small for gestational age, especially when total maternal gestational weight gain is < 10 kg.     

Scaling up antiretroviral therapy for HIV-infected children in C?te d’Ivoire: determinants of survival and loss to programme

Objective

To investigate deaths and losses to follow-up in a programme designed to scale up antiretroviral therapy (ART) for HIV-infected children in Côte d’Ivoire.

Methods

Between 2004 and 2007, HIV-exposed children at 19 centres were offered free HIV serum tests (polymerase chain reaction tests in those aged < 18 months) and ART. Computerized monitoring was used to determine: (i) the number of confirmed HIV infections, (ii) losses to the programme (i.e. death or loss to follow-up) before ART, (iii) mortality and loss-to-programme rates during 12 months of ART, and (iv) determinants of mortality and losses to the programme.

Findings

The analysis included 3876 ART-naïve children. Of the 1766 with HIV-1 infections (17% aged < 18 months), 124 (7.0%) died, 52 (2.9%) left the programme, 354 (20%) were lost to follow-up before ART, 259 (15%) remained in care without ART, and 977 (55%) started ART (median age: 63 months). The overall mortality rate during ART was significantly higher in the first 3 months than in months 4–12: 32.8 and 6.9 per 100 child-years of follow-up, respectively. Loss-to-programme rates were roughly double mortality rates and followed the same trend with duration of ART. Independent predictors of 12-month mortality on ART were pre-ART weight-for-age z-score < –2, percentage of CD4+ T lymphocytes < 10, World Health Organization HIV/AIDS clinical stage 3 or 4, and blood haemoglobin < 8 g/dl.

Conclusion

The large-scale programme to scale up paediatric ART in Côte d’Ivoire was effective. However, ART was often given too late, and early mortality and losses to programme before and just after ART initiation were major problems.     

Childhood and adult mortality from unintentional falls in India

Objective

To estimate fall-related mortality by type of fall in India.

Methods

The authors analysed unintentional injury data from the ongoing Million Death Study from 2001–2003 using verbal autopsy and coding of all deaths in accordance with the International statistical classification of diseases and related health problems, tenth revision, in a nationally representative sample of 1.1 million homes throughout the country.

Findings

Falls accounted for 25% (2003/8023) of all deaths from unintentional injury and were the second leading cause of such deaths. An estimated 160 000 fall-related deaths occurred in India in 2005; of these, nearly 20 000 were in children aged 0–14 years. The unintentional-fall-related mortality rate (MR) per 100 000 population was 14.5 (99% confidence interval, CI: 13.7–15.4). Rates were similar for males and females at 14.9 (99% CI: 13.7–16.0) and 14.2 (99% CI: 13.1–15.4) per 100 000 population, respectively. People aged 70 years or older had the highest mortality rate from unintentional falls (MR: 271.2; 99% CI: 249.0–293.5), and the rate was higher among women (MR: 281; 99% CI: 249.7–311.3). Falls on the same level were the most common among older adults, whereas falls from heights were more common in younger age groups.

Conclusion

In India, unintentional falls are a major public health problem that disproportionately affects older women and children. The contexts in which these falls occur and the resulting morbidity and disability need to be better understood. In India there is an urgent need to develop, test and implement interventions aimed at preventing falls.     

Estimated incidence of influenza-virus-associated severe pneumonia in children in El Salvador, 2008�C2010

Objective

To estimate the incidence of influenza-virus-associated severe pneumonia among Salvadorian children aged < 5 years.

Methods

Data on children aged < 5 years admitted with severe pneumonia to a sentinel hospital in the western region were collected weekly. Nasal and oropharyngeal swab specimens were collected from a convenience sample of case patients for respiratory virus testing. A health-care utilization survey was conducted in the hospital catchment area to determine the proportion of residents who sought care at the hospital. The incidence of influenza-virus-associated severe pneumonia among all Salvadorian children aged < 5 years was estimated from surveillance and census data, with adjustment for health-care utilization. Influenza virus strains were characterized by the United States Centers for Disease Control and Prevention to determine their correspondence with northern and southern hemisphere influenza vaccine formulations.

Findings

Physicians identified 2554 cases of severe pneumonia. Samples from 608 cases were tested for respiratory viruses and 37 (6%) were positive for influenza virus. The estimated incidence of influenza-virus-associated severe pneumonia was 3.2 cases per 1000 person–years (95% confidence interval, CI: 2.8–3.7) overall, 1.5 cases per 1000 person–years (95% CI: 1.0–2.0) during 2008, 7.6 cases per 1000 person–years (95% CI: 6.5–8.9) during 2009 and 0.6 cases per 1000 person–years (95% CI: 0.3–1.0) during 2010. Northern and southern hemisphere vaccine formulations matched influenza virus strains isolated during 2008 and 2010.

Conclusion

Influenza-virus-associated severe pneumonia occurred frequently among young Salvadorian children during 2008–2010. Antigens in northern and southern hemisphere influenza vaccine formulations corresponded to circulating strains.     

Maternal multiple micronutrient supplementation and pregnancy outcomes in developing countries: meta-analysis and meta-regression

Objective

To systematically review randomized controlled trials comparing the effect of supplementation with multiple micronutrients versus iron and folic acid on pregnancy outcomes in developing countries.

Methods

MEDLINE and EMBASE were searched. Outcomes of interest were birth weight, low birth weight, small size for gestational age, perinatal mortality and neonatal mortality. Pooled relative risks (RRs) were estimated by random effects models. Sources of heterogeneity were explored through subgroup meta-analyses and meta-regression.

Findings

Multiple micronutrient supplementation was more effective than iron and folic acid supplementation at reducing the risk of low birth weight (RR: 0.86, 95% confidence interval, CI: 0.79–0.93) and of small size for gestational age (RR: 0.85; 95% CI: 0.78–0.93). Micronutrient supplementation had no overall effect on perinatal mortality (RR: 1.05; 95% CI: 0.90–1.22), although substantial heterogeneity was evident (I² = 58%; P for heterogeneity = 0.008). Subgroup and meta-regression analyses suggested that micronutrient supplementation was associated with a lower risk of perinatal mortality in trials in which > 50% of mothers had formal education (RR: 0.93; 95% CI: 0.82–1.06) or in which supplementation was initiated after a mean of 20 weeks of gestation (RR: 0.88; 95% CI: 0.80–0.97).

Conclusion

Maternal education or gestational age at initiation of supplementation may have contributed to the observed heterogeneous effects on perinatal mortality. The safety, efficacy and effective delivery of maternal micronutrient supplementation require further research.     

Syphilis test availability and uptake at medical facilities in southern China

Objective

To examine syphilis testing capacity, screening coverage rates and types of syphilis tests used in medical facilities in southern China.

Methods

Eleven of the 14 municipalities in Guangdong province participated. Data on syphilis testing capacity, screening coverage and types of syphilis tests used were collected from all types of public medical facilities offering prenatal care (n = 109). A total of 494 680 women who delivered during 2004–2008 were studied.

Findings

In 2008, 54 196 pregnant women (43.1%) were not screened for syphilis. Among such women, 32 863 (60.6%) attended clinics without any syphilis testing capacity and 21 333 (39.4%) attended clinics that performed testing but were not screened. The likelihood of not having syphilis test capacity was much higher for hygiene stations (odds ratio, OR: 10; 95% confidence interval, CI: 4–25), services at the township level (OR: 33; 95% CI: 10–100) and services with ≤ 1000 deliveries per year (OR: 1.002; 95% CI: 1.001–1.003). These same service characteristics correlated with lower screening coverage rates (P < 0.01). Only one antenatal clinic had the capacity to conduct both treponemal and non-treponemal tests for diagnosing syphilis.

Conclusion

Syphilis screening is available in very few of the basic medical facilities offering prenatal care where most neonates in southern China are delivered. In light of this and of the increasing incidence of syphilis in the area, expanding point-of-care rapid syphilis testing is a priority.     

Mid-upper arm circumference at age of routine infant vaccination to identify infants at elevated risk of death: a retrospective cohort study in the Gambia

Objective

To determine the predictive value for death before 12 months of age of mid-upper arm circumference (MUAC) and weight-for-length Z score (WFLz).

Methods

A retrospective cohort analysis of infants living in Keneba, in rural Gambia, was conducted. Anthropometric measures were obtained from demographic surveillance system records for infants registered between February 1974 and July 2008 who had had MUAC and WFLz recorded at 6–14 weeks of age and vital status recorded at least once more. Hazard ratios (HRs), population attributable fractions and areas under receiver operating characteristic (ROC) curves were estimated to assess the predictive value for death in infancy of MUAC and WFLz.

Findings

Of 2876 infants included in the analysis, 40 died before the age of 12 months. The HR for death in this group versus in well-nourished infants was 5.8 (95% confidence interval, CI: 1.6–21) for a WFLz < −3. HRs for MUACs below the thresholds of 115 mm, 110 mm and 105 mm were 4.5 (95% CI: 1.4–15), 9.5 (95% CI: 2.6–35) and 23 (95% CI: 4.2–122), respectively. The attributable fractions for a MUAC < 130 mm and a WFLz < 0 were 51% and 13%, respectively. The areas under the ROC curve for death in infancy were 0.55 (95% CI: 0.46 to 0.64) for WFLz and 0.64 (95% CI: 0.55 to 0.73) for MUAC.

Conclusion

Among infants aged 6 to 14 weeks, unadjusted MUAC showed good performance in identifying infants at increased risk of death.     

Mortality and health among internally displaced persons in western Kenya following post-election violence, 2008: novel use of demographic surveillance

Objective

To evaluate mortality and morbidity among internally displaced persons (IDPs) who relocated in a demographic surveillance system (DSS) area in western Kenya following post-election violence.

Methods

In 2007, 204 000 individuals lived in the DSS area, where field workers visit households every 4 months to record migrations, births and deaths. We collected data on admissions among children < 5 years of age in the district hospital and developed special questionnaires to record information on IDPs. Mortality, migration and hospitalization rates among IDPs and regular DSS residents were compared, and verbal autopsies were performed for deaths.

Findings

Between December 2007 and May 2008, 16 428 IDPs migrated into the DSS, and over half of them stayed 6 months or longer. In 2008, IDPs aged 15–49 years died at higher rates than regular residents of the DSS (relative risk, RR: 1.34; 95% confidence interval, CI: 1.004–1.80). A greater percentage of deaths from human immunodeficiency virus (HIV) infection occurred among IDPs aged ≥ 5 years (53%) than among regular DSS residents (25–29%) (P < 0.001). Internally displaced children < 5 years of age did not die at higher rates than resident children but were hospitalized at higher rates (RR: 2.95; 95% CI: 2.44–3.58).

Conclusion

HIV-infected internally displaced adults in conflict-ridden parts of Africa are at increased risk of HIV-related death. Relief efforts should extend to IDPs who have relocated outside IDP camps, particularly if afflicted with HIV infection or other chronic conditions.     

Dicing with chance,life and death in systematic reviews and meta-analyses: D.I.C.E. 3, a simulation study

Objectives

To show the effects of chance on meta-analyses, and the potential dangers of being prompted to do a meta-analysis by one favourable trial.

Design

In total, 100,000 trials were simulated and combined into 10,000 meta-analyses, using data from the control group of a cancer trial. Each participant record was randomly coded to simulate allocation to ‘treatment’ or ‘control’.

Setting

Simulated study.

Participants

De-identified records for 578 patients from the control group of a cancer trial, of whom 147 had died.

Main outcome measure

Time to death from any cause.

Results

Of the 100,000 trials, 4897 (4.9%) were statistically significant at 2p < 0.05 and 123 (1.2%) of the 10,000 meta-analyses were significant at 2p < 0.01. The most extreme result was a 20% reduction (99% CI: 0.70–0.91; 2p = 0.00002) in the annual odds of dying in the ‘treatment’ group. If a meta-analysis contained at least one trial with a statistically significant result (at 2p < 0.05), the likelihood of the meta-analysis being significant (at 2p < 0.01) increased strikingly. For example, among the 473 meta-analyses in which the first trial in a batch of 10 was statistically significant (at 2p < 0.05), 18 (3.8%) favoured treatment at 2p < 0.01.

Conclusions

Chance can influence the results of meta-analyses regardless of how well they are conducted. Researchers should not ignore this when they plan a meta-analysis and when they report their results. People reading their reports should also be wary. Caution is particularly important when the results of one or more included studies influenced the decision to do the meta-analysis.     

Adult mortality and antiretroviral treatment roll-out in rural KwaZulu-Natal, South Africa

Objective

To investigate trends in adult mortality in a population serviced by a public-sector antiretroviral therapy (ART) programme in rural South Africa using a demographic surveillance system.

Methods

Verbal autopsies were conducted for all 7930 deaths observed between January 2000 and December 2006 in a demographic surveillance population of 74 500 in the Umkhanyakude district of northern KwaZulu-Natal province, South Africa. Age-standardized mortality rate ratios (SMRRs) were calculated for adults aged 25 to 49 years, the group most affected by HIV, for the 2 years before 2004 and the 3 subsequent years, during which ART had been available.

Findings

Between 2002–2003 (the period before ART) and 2004–2006 (the period after ART), HIV-related age-standardized mortality declined significantly, from 22.52 to 17.58 per 1000 person-years in women 25–49 years of age (P < 0.001; SMRR: 0.780; 95% confidence interval, CI: 0.691–0.881), and from 26.46 to 18.68 per 1000 person-years in men 25–49 years of age (P < 0.001; SMRR: 0.706; 95% CI: 0.615–0.811). On sensitivity analysis the results were robust to the possible effect of misclassification of HIV-related deaths.

Conclusion

Overall population mortality and HIV-related adult mortality declined significantly following ART roll-out in a community with a high prevalence of HIV infection. A clear public health message of the benefits of treatment, as revealed by these findings, should be part of a multi-faceted strategy to encourage people to find out their HIV serostatus and seek care.     

The impact of rural health system reform on hospitalization rates in the Islamic Republic of Iran: an interrupted time series

Objective

To assess the effects on hospital utilization rates of a major health system reform – a family physician programme and a social protection scheme – undertaken in rural areas of the Islamic Republic of Iran in 2005.

Methods

A “tracer” province that was not a patient referral hub was selected for the collection of monthly hospitalization data over a period of about 10 years, beginning two years before the rural health system reform (the “intervention”) began. An interrupted time series analysis was conducted and segmented regression analysis was used to assess the immediate and gradual effects of the intervention on hospitalization rates in an intervention group composed of rural residents and a comparison group composed of urban residents primarily.

Findings

Before the intervention, the hospitalization rate in the rural population was significantly lower than in the comparison group. Although there was no significant increase or decline in hospitalization rates in the intervention or comparison group before the intervention, after the intervention a significant increase in the hospitalization rate – of 4.6 hospitalizations per 100 000 insured persons per month on average – was noted in the intervention group (P < 0.001). The monthly increase in the hospitalization rate continued for over a year and stabilized thereafter. No increase in the hospitalization rate was observed in the comparison group.

Conclusion

The primary health-care programme instituted as part of the health system reform process has increased access to hospital care in a population that formerly underutilized hospital services. It has not reduced hospitalizations or hospitalization-related expenditure.     

Rotavirus mortality in India: estimates based on a nationally representative survey of diarrhoeal deaths

Objective

To estimate the number of rotavirus-associated deaths among Indian children younger than five years.

Methods

We surveyed more than 23 000 child deaths from a nationally representative survey of 1.1 million Indian households during 2001–2003. Diarrhoeal deaths were characterized by region, age and sex and were combined with the proportion of deaths attributable to rotavirus, as determined by hospital microbiologic data collected by the Indian Rotavirus Strain Surveillance Network from December 2005 to November 2007. Rotavirus vaccine efficacy data from clinical trials in developing countries were used to estimate the number of deaths preventable by a national vaccination programme. Data were analysed using Stata SE version 10.

Findings

Rotavirus caused an estimated 113 000 deaths (99% confidence interval, CI: 86 000–155 000); 50% (54 700) and 75% (85 400) occurred before one and two years of age, respectively. One child in 242 died from rotavirus infection before five years of age. Rotavirus-associated mortality rates overall, among girls and among boys were 4.14 (99% CI: 3.14–5.68), 4.89 (99% CI: 3.75–6.79) and 3.45 (99% CI: 2.58–4.66) deaths per 1000 live births, respectively. Rates were highest in Bihar, Uttar Pradesh and Madhya Pradesh, which together accounted for > 50% of deaths (64 400) nationally. Rotavirus vaccine could prevent 41 000–48 000 deaths among children aged 3–59 months.

Conclusion

The burden of rotavirus-associated mortality is high among Indian children, highlighting the potential benefits of rotavirus vaccination.