Mortality from neglected tropical diseases in Brazil, 2000–2011

Objective

To describe mortality from neglected tropical diseases (NTDs) in Brazil, 2000–2011.

Methods

We extracted information on cause of death, age, sex, ethnicity and place of residence from the nationwide mortality information system at the Brazilian Ministry of Health. We selected deaths in which the underlying cause of death was a neglected tropical disease (NTD), as defined by the World Health Organization (WHO) and based on its International statistical classification of diseases and related health problems, 10th revision (ICD-10) codes. For specific NTDs, we estimated crude and age-adjusted mortality rates and 95% confidence intervals (CI). We calculated crude and age-adjusted mortality rates and mortality rate ratios by age, sex, ethnicity and geographic area.

Findings

Over the 12-year study period, 12 491 280 deaths were recorded; 76 847 deaths (0.62%) were caused by NTDs. Chagas disease was the most common cause of death (58 928 deaths; 76.7%), followed by schistosomiasis (6319 deaths; 8.2%) and leishmaniasis (3466 deaths; 4.5%). The average annual age-adjusted mortality from all NTDs combined was 4.30 deaths per 100 000 population (95% CI: 4.21–4.40). Rates were higher in males: 4.98 deaths per 100 000; people older than 69 years: 33.12 deaths per 100 000; Afro-Brazilians: 5.25 deaths per 100 000; and residents in the central-west region: 14.71 deaths per 100 000.

Conclusion

NTDs are important causes of death and are a significant public health problem in Brazil. There is a need for intensive integrated control measures in areas of high morbidity and mortality.     

The epidemiology of child homicides in South Africa

Objective

To describe age- and sex-specific rates of child homicide in South Africa.

Methods

A cross-sectional mortuary-based study was conducted in a national sample of 38 medicolegal laboratories operating in 2009. These were sampled in inverse proportion to the number that were operational in each of three strata defined by autopsy volume: < 500, 500–1499 or > 1499 annual autopsies. Child homicide data were collected from mortuary files, autopsy reports and police interviews. Cause of death, evidence of abuse and neglect or of sexual assault, perpetrator characteristics and circumstances surrounding the death were investigated.

Findings

An estimated 1018 (95% confidence interval, CI: 843–1187) child homicides occurred in 2009, for a rate of 5.5 (95% CI: 4.6–6.4) homicides per 100 000 children younger than 18 years. The homicide rate was much higher in boys (6.9 per 100 000; 95% CI: 5.6–8.3) than in girls (3.9 per 100 000; 95% CI: 3.2–4.7). Child abuse and neglect had preceded nearly half (44.5%) of all homicides, but three times more often among girls than among boys. In children aged 15 to 17 years, the homicide rate among boys (21.7 per 100 000; 95% CI: 14.2–29.2) was nearly five times higher than the homicide rate among girls (4.6 per 100 000; 95% CI: 2.4–6.8).

Conclusion

South Africa’s child homicide rate is more than twice the global estimate. Since a background of child abuse and neglect is common, improvement of parenting skills should be part of primary prevention efforts.     

Diarrhoea-related hospitalizations in children before and after implementation of monovalent rotavirus vaccination in Mexico

Objective

To assess, by socioeconomic setting, the effect of nationwide vaccination against species A rotavirus (RVA) on childhood diarrhoea-related hospitalizations in Mexico.

Methods

Data on children younger than 5 years who were hospitalized for diarrhoea in health ministry hospitals between 1 January 2003 and 31 December 2011 were collected from monthly discharge reports. Human development indexes were used to categorize the states where hospitals were located as having generally high, intermediate or low socioeconomic status. Annual rates of hospitalization for diarrhoea – per 10 000 hospitalizations for any cause – were calculated. Administrative data were used to estimate vaccine coverage.

Findings

In the states with high, intermediate and low socioeconomic status, coverage with a two-dose monovalent RVA vaccine – among children younger than 5 years – had reached 93%, 86% and 71%, respectively, by 2010. The corresponding median annual rates of hospitalization for diarrhoea – per 10 000 admissions – fell from 1001, 834 and 1033 in the “prevaccine” period of 2003–2006, to 597, 497 and 705 in the “postvaccine” period from 2008 to 2011, respectively. These decreases correspond to rate reductions of 40% (95% confidence interval, CI: 38–43), 41% (95% CI: 38–43) and 32% (95% CI: 29–34), respectively. Nationwide, RVA vaccination appeared to have averted approximately 16 500 hospitalizations for childhood diarrhoea in each year of the postvaccine period.

Conclusion

Monovalent RVA vaccination has substantially reduced childhood diarrhoea-related hospitalizations for four continuous years in discretely different socioeconomic populations across Mexico.     

Effect of breastfeeding on immunogenicity of oral live-attenuated human rotavirus vaccine: a randomized trial in HIV-uninfected infants in Soweto,South Africa

Objective

To investigate the effect of abstention from breastfeeding, for an hour before and after each vaccination, on the immune responses of infants to two doses of rotavirus vaccine.

Methods

In Soweto, South Africa, mother–infant pairs who were uninfected with human immunodeficiency virus (HIV) were enrolled as they presented for the “6-week” immunizations of the infants. Each infant was randomly assigned to Group 1 – in which breastfeeding was deferred for at least 1 h before and after each dose of rotavirus vaccine – or Group 2 – in which unrestricted breastfeeding was encouraged. Enzyme-linked immunosorbent assays were used to evaluate the titres of rotavirus-specific IgA in samples of serum collected from each infant immediately before each vaccine dose and 1 month after the second dose. Among the infants, a fourfold or greater increase in titres of rotavirus-specific IgA following vaccination was considered indicative of seroconversion.

Findings

The evaluable infants in Group 1 (n = 98) were similar to those in Group 2 (n = 106) in their baseline demographic characteristics and their pre-vaccination titres of anti-rotavirus IgA. After the second vaccine doses, geometric mean titres of anti-rotavirus IgA in the sera of Group-1 infants were similar to those in the sera of Group-2 infants (P = 0.685) and the frequency of seroconversion in the Group-1 infants was similar to that in the Group-2 infants (P = 0.485).

Conclusion

Among HIV-uninfected South African infants, abstention from breastfeeding for at least 1 h before and after each vaccination dose had no significant effect on the infants’ immune response to a rotavirus vaccine.     

A prospective study of maternal,fetal and neonatal deaths in low- and middle-income countries

Objective

To quantify maternal, fetal and neonatal mortality in low- and middle-income countries, to identify when deaths occur and to identify relationships between maternal deaths and stillbirths and neonatal deaths.

Methods

A prospective study of pregnancy outcomes was performed in 106 communities at seven sites in Argentina, Guatemala, India, Kenya, Pakistan and Zambia. Pregnant women were enrolled and followed until six weeks postpartum.

Findings

Between 2010 and 2012, 214 070 of 220 235 enrolled women (97.2%) completed follow-up. The maternal mortality ratio was 168 per 100 000 live births, ranging from 69 per 100 000 in Argentina to 316 per 100 000 in Pakistan. Overall, 29% (98/336) of maternal deaths occurred around the time of delivery: most were attributed to haemorrhage (86/336), pre-eclampsia or eclampsia (55/336) or sepsis (39/336). Around 70% (4349/6213) of stillbirths were probably intrapartum; 34% (1804/5230) of neonates died on the day of delivery and 14% (755/5230) died the day after. Stillbirths were more common in women who died than in those alive six weeks postpartum (risk ratio, RR: 9.48; 95% confidence interval, CI: 7.97–11.27), as were perinatal deaths (RR: 4.30; 95% CI: 3.26–5.67) and 7-day (RR: 3.94; 95% CI: 2.74–5.65) and 28-day neonatal deaths (RR: 7.36; 95% CI: 5.54–9.77).

Conclusion

Most maternal, fetal and neonatal deaths occurred at or around delivery and were attributed to preventable causes. Maternal death increased the risk of perinatal and neonatal death. Improving obstetric and neonatal care around the time of birth offers the greatest chance of reducing mortality.     

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.     

Introducing rapid diagnostic tests for malaria to drug shops in Uganda: a cluster-randomized controlled trial

Objective

To evaluate the impact – on diagnosis and treatment of malaria – of introducing rapid diagnostic tests to drug shops in eastern Uganda.

Methods

Overall, 2193 households in 79 study villages with at least one licensed drug shop were enrolled and monitored for 12 months. After 3 months of monitoring, drug shop vendors in 67 villages randomly selected for the intervention were offered training in the use of malaria rapid diagnostic tests and – if trained – offered access to such tests at a subsidized price. The remaining 12 study villages served as controls. A difference-in-differences regression model was used to estimate the impact of the intervention.

Findings

Vendors from 92 drug shops successfully completed training and 50 actively stocked and performed the rapid tests. Over 9 months, trained vendors did an average of 146 tests per shop. Households reported 22 697 episodes of febrile illness. The availability of rapid tests at local drug shops significantly increased the probability of any febrile illness being tested for malaria by 23.15% (P = 0.015) and being treated with an antimalarial drug by 8.84% (P = 0.056). The probability that artemisinin combination therapy was bought increased by a statistically insignificant 5.48% (P = 0.574).

Conclusion

In our study area, testing for malaria was increased by training drug shop vendors in the use of rapid tests and providing them access to such tests at a subsidized price. Additional interventions may be needed to achieve a higher coverage of testing and a higher rate of appropriate responses to test results.     

Ritual circumcision and risk of autism spectrum disorder in 0- to 9-year-old boys: national cohort study in Denmark

Objective

Based on converging observations in animal, clinical and ecological studies, we hypothesised a possible impact of ritual circumcision on the subsequent risk of autism spectrum disorder (ASD) in young boys.

Design

National, register-based cohort study.

Setting

Denmark.

Participants

A total of 342,877 boys born between 1994 and 2003 and followed in the age span 0–9 years between 1994 and 2013.

Main outcome measures

Information about cohort members’ ritual circumcisions, confounders and ASD outcomes, as well as two supplementary outcomes, hyperkinetic disorder and asthma, was obtained from national registers. Hazard ratios (HRs) with 95% confidence intervals (CIs) associated with foreskin status were obtained using Cox proportional hazards regression analyses.

Results

With a total of 4986 ASD cases, our study showed that regardless of cultural background circumcised boys were more likely than intact boys to develop ASD before age 10 years (HR = 1.46; 95% CI: 1.11–1.93). Risk was particularly high for infantile autism before age five years (HR = 2.06; 95% CI: 1.36–3.13). Circumcised boys in non-Muslim families were also more likely to develop hyperkinetic disorder (HR = 1.81; 95% CI: 1.11–2.96). Associations with asthma were consistently inconspicuous (HR = 0.96; 95% CI: 0.84–1.10).

Conclusions

We confirmed our hypothesis that boys who undergo ritual circumcision may run a greater risk of developing ASD. This finding, and the unexpected observation of an increased risk of hyperactivity disorder among circumcised boys in non-Muslim families, need attention, particularly because data limitations most likely rendered our HR estimates conservative. Considering the widespread practice of non-therapeutic circumcision in infancy and childhood around the world, confirmatory studies should be given priority.     

Effect of Chiranjeevi Yojana on institutional deliveries and neonatal and maternal outcomes in Gujarat,India: a difference-in-differences analysis

Objective

To evaluate the effect of the Chiranjeevi Yojana programme, a public–private partnership to improve maternal and neonatal health in Gujarat, India.

Methods

A household survey (n = 5597 households) was conducted in Gujarat to collect retrospective data on births within the preceding 5 years. In an observational study using a difference-in-differences design, the relationship between the Chiranjeevi Yojana programme and the probability of delivery in health-care institutions, the probability of obstetric complications and mean household expenditure for deliveries was subsequently examined. In multivariate regressions, individual and household characteristics as well as district and year fixed effects were controlled for. Data from the most recent District Level Household and Facility Survey (DLHS-3) wave conducted in Gujarat (n = 6484 households) were used in parallel analyses.

Findings

Between 2005 and 2010, the Chiranjeevi Yojana programme was not associated with a statistically significant change in the probability of institutional delivery (2.42 percentage points; 95% confidence interval, CI: −5.90 to 10.74) or of birth-related complications (6.16 percentage points; 95% CI: −2.63 to 14.95). Estimates using DLHS-3 data were similar. Analyses of household expenditures indicated that mean household expenditure for private-sector deliveries had either not fallen or had fallen very little under the Chiranjeevi Yojana programme.

Conclusion

The Chiranjeevi Yojana programme appears to have had no significant impact on institutional delivery rates or maternal health outcomes. The absence of estimated reductions in household spending for private-sector deliveries deserves further study.     

Nutritional quality of diet and academic performance in Chilean students

Objective

To explore associations between the nutritional quality of diet at age 16 years and academic performance in students from Santiago, Chile.

Methods

We assessed the nutritional quality of diet, using a validated food frequency questionnaire, in 395 students aged 16.8 ± 0.5 years. Depending on the amount of saturated fat, fibre, sugar and salt in the foods, diet was categorized as unhealthy, fair or healthy. Academic performance was assessed using high school grade-point average (GPA) and tests for college admission in language and mathematics. Academic results on or above the 75th percentile in our sample were considered good academic performance. We tested associations between nutritional quality of diet and good academic performance using logistic regression models. We considered sociodemographic, educational and body-mass index (BMI) factors as potential confounders.

Findings

After controlling for potential confounding factors, an unhealthy diet at age 16 years was associated with reduced academic performance. Compared to participants with healthy diets, those with unhealthy diets were significantly less likely to perform well based on language tests (odds ratio, OR: 0.42; 95% confidence interval, CI: 0.18–0.98) mathematics tests (OR: 0.35; 95% CI: 0.15–0.82) or GPA (OR: 0.22; 95% CI: 0.09–0.56).

Conclusion

In our sample, excessive consumption of energy-dense, low-fibre, high-fat foods at age 16 years was associated with reduced academic performance.     

Associations between estrogen receptor genetic polymorphisms,smoking status,and prostate cancer risk: a case–control study in Japanese men

Objective

Prostate cancer (PCa) is one of the major causes of death among men. Our study investigated the association of ESR1 and ESR2 genotypes with susceptibility to PCa in relation to smoking status in Japanese.

Method

A case–control study was performed with 750 Japanese prostate cancer patients and 870 healthy controls. After age-matching in case–controls, 352 controls and 352 cases were enrolled in this study. By using logistic regression analysis, the different genotypes from ESR1 and ESR2 were analyzed according to case/control status.

Result

ESR2 rs4986938 AG and AG + AA genotypes were associated with significantly decreased risk of PCa (AG: OR = 0.68, 95 % CI 0.47–0.97, P < 0.05 and AG + AA: OR = 0.67, 95 % CI 0.47–0.94, P < 0.05). However, there was no significant association between ESR1 rs2234693 and PCa risk. When patients were grouped according to smoking status, the ESR2 rs1256049 AA genotype (OR = 0.48, 95 % CI 0.25–0.95, P < 0.05) and ESR2 rs4986938 AG + AA genotype (OR = 0.64, 95 % CI 0.41–1.00, P < 0.05) showed significantly decreased PCa risk in the ever-smoker group.

Conclusion

Our results suggest that the estrogen receptor ESR2 has a very important function to predict PCa and that different SNPs have different predictive values. Smoking may influence estrogenic activity and may influence PCa together with the estrogen receptor.     

Exposure to Dichlorodiphenyltrichloroethane and the Risk of Breast Cancer: A Systematic Review and Meta-analysis

Objectives

This study extended and updated a meta-analysis of the association between exposure to dichlorodiphenyltrichloroethane (DDT) and the risk of breast cancer.

Methods

We reviewed the published literature on exposure to DDE and breast cancer risk to update a meta-analysis from 2004. The total of 35 studies included 16 hospital-based case–control studies, 11 population-based case–control studies, and 10 nested case–control studies identified through keyword searches in the PubMed and EMBASE databases.

Results

The summary odds ratio (OR) for the identified studies was 1.03 (95% confidence interval 0.95–1.12) and the overall heterogeneity in the OR was observed (I² = 40.9; p = 0.006). Subgroup meta-analyses indicated no significant association between exposure to DDE and breast cancer risk by the type of design, study years, biological specimen, and geographical region of the study, except from population-based case–control studies with estimated DDE levels in serum published in 1990s.

Conclusion

Existing studies do not support the view that DDE increases the risk of breast cancer in humans. However, further studies incorporating more detailed information on DDT exposure and other potential risk factors for breast cancer are needed.     

Age-specific prevalence of hepatitis?B virus infection in young pregnant women,Hong Kong Special Administrative Region of China

Objective

To investigate the age-specific prevalence of hepatitis B virus (HBV) infection in young pregnant women in Hong Kong Special Administrative Region (SAR), China, and to determine whether an increase in prevalence occurs during adolescence.

Methods

HBV prevalence was quantified using data from routine antenatal screening for hepatitis B surface antigen (HBsAg) in 10 808 women aged 25 years or younger born in Hong Kong SAR and managed at a single hospital between 1998 and 2011. The effect on prevalence of maternal age, parity and birth before or after HBV vaccine availability in 1984 was assessed, using Spearman’s correlation and multiple logistic regression analysis.

Findings

Overall, 7.5% of women were HBsAg-positive. The prevalence ranged from 2.3% to 8.4% in those aged ≤ 16 and 23 years, respectively. Women born in or after 1984 and those younger than 18 years of age were less likely to be HBsAg-positive (odds ratio, OR: 0.679; 95% confidence interval, CI: 0.578–0.797) and (OR: 0.311; 95% CI: 0.160–0.604), respectively. For women born before 1984, there was no association between HBsAg carriage and being younger than 18 years of age (OR: 0.60; 95% CI: 0.262–1.370) Logistic regression analysis showed that the prevalence of HBsAg carriage was influenced more by the woman being 18 years old or older (adjusted OR, aOR: 2.80; 95% CI: 1.46–5.47) than being born before 1984 (aOR: 1.42; 95% CI: 1.21–1.67).

Conclusion

Immunity to HBV in young pregnant women who had been vaccinated as neonates decreased in late adolescence.     

Economic evaluation of neonatal care packages in a cluster-randomized controlled trial in Sylhet,Bangladesh

Objective

To evaluate and compare the cost-effectiveness of two strategies for neonatal care in Sylhet division, Bangladesh.

Methods

In a cluster-randomized controlled trial, two strategies for neonatal care – known as home care and community care – were compared with existing services. For each study arm, economic costs were estimated from a societal perspective, inclusive of programme costs, provider costs and household out-of-pocket payments on care-seeking. Neonatal mortality in each study arm was determined through household surveys. The incremental cost-effectiveness of each strategy – compared with that of the pre-existing levels of maternal and neonatal care – was then estimated. The levels of uncertainty in our estimates were quantified through probabilistic sensitivity analysis.

Findings

The incremental programme costs of implementing the home-care package were 2939 (95% confidence interval, CI: 1833–7616) United States dollars (US$) per neonatal death averted and US$ 103.49 (95% CI: 64.72–265.93) per disability-adjusted life year (DALY) averted. The corresponding total societal costs were US$ 2971 (95% CI: 1844–7628) and US$ 104.62 (95% CI: 65.15–266.60), respectively. The home-care package was cost-effective – with 95% certainty – if healthy life years were valued above US$ 214 per DALY averted. In contrast, implementation of the community-care strategy led to no reduction in neonatal mortality and did not appear to be cost-effective.

Conclusion

The home-care package represents a highly cost-effective intervention strategy that should be considered for replication and scale-up in Bangladesh and similar settings elsewhere.     

The accumulation of healthy lifestyle behaviors prevents the incidence of chronic kidney disease (CKD) in middle-aged and older males

Aim

This study was retrospectively designed to evaluate the influence of healthy lifestyle behaviors on the incidence of chronic kidney disease (CKD) during a 5-year follow-up period in middle-aged and older males.

Methods

The subjects included 252 males without a history of cardiovascular disease, stroke, renal dysfunction and/or dialysis treatment who were not taking any medications. Their lifestyle behaviors were evaluated using a standardized self-administered questionnaire and defined as follows: (1) habitual moderate exercise, (2) daily physical activity, (3) fast walking speed, (4) slow eating speed, (5) no late-night dinner, (6) no bedtime snacking and (7) no skipping breakfast. The participants were divided into four categories, which were classified into quartile distributions according to the number of healthy lifestyle behaviors (7–6, 5, 4 and ≤3 groups).

Results

After 5 years, the incidence of CKD [estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m² and/or proteinuria] was observed in 23 subjects (9.1 %). The Kaplan–Meier survival curves showed that the cumulative incidence of CKD significantly decreased according to an increase in the number of healthy lifestyle behaviors (log-rank test: p = 0.003). According to a multivariate analysis, habitual moderate exercise [hazard ratio (HR) 0.20, 95 % confidence of interval (CI) 0.06–0.69, p = 0.011] and no bedtime snacking (HR 0.19, 95 % CI 0.08–0.48, p = 0.004) were significantly associated with the incidence of CKD.

Conclusions

These results suggest that the accumulation of healthy lifestyle behaviors, especially those related to habitual moderate exercise and no bedtime snacking, is considered to be important to reduce the risk of CKD.

Electronic supplementary material

The online version of this article (doi:10.1007/s12199-016-0506-6) contains supplementary material, which is available to authorized users.     

The influence of market deregulation on fast food consumption and body mass index: a cross-national time series analysis

Objective

To investigate the effect of fast food consumption on mean population body mass index (BMI) and explore the possible influence of market deregulation on fast food consumption and BMI.

Methods

The within-country association between fast food consumption and BMI in 25 high-income member countries of the Organisation for Economic Co-operation and Development between 1999 and 2008 was explored through multivariate panel regression models, after adjustment for per capita gross domestic product, urbanization, trade openness, lifestyle indicators and other covariates. The possible mediating effect of annual per capita intake of soft drinks, animal fats and total calories on the association between fast food consumption and BMI was also analysed. Two-stage least squares regression models were conducted, using economic freedom as an instrumental variable, to study the causal effect of fast food consumption on BMI.

Findings

After adjustment for covariates, each 1-unit increase in annual fast food transactions per capita was associated with an increase of 0.033 kg/m² in age-standardized BMI (95% confidence interval, CI: 0.013–0.052). Only the intake of soft drinks – not animal fat or total calories – mediated the observed association (β: 0.030; 95% CI: 0.010–0.050). Economic freedom was an independent predictor of fast food consumption (β: 0.27; 95% CI: 0.16–0.37). When economic freedom was used as an instrumental variable, the association between fast food and BMI weakened but remained significant (β: 0.023; 95% CI: 0.001–0.045).

Conclusion

Fast food consumption is an independent predictor of mean BMI in high-income countries. Market deregulation policies may contribute to the obesity epidemic by facilitating the spread of fast food.     

Public sector services for the prevention of mother-to-child transmission of HIV infection: a micro-costing survey in Namibia and Rwanda

Objective

To assess the costs associated with the provision of services for the prevention of mother-to-child transmission (PMTCT) of human immunodeficiency virus in two African countries.

Methods

In 2009, the costs to health-care providers of providing comprehensive PMTCT services were assessed in 20 public health facilities in Namibia and Rwanda. Information on prices and on the total amount of each service provided was collected at the national level. The costs of maternal testing and counselling, male partner testing, CD4+ T-lymphocyte (CD4+ cell) counts, antiretroviral prophylaxis and treatment, community-based activities, contraception for 2 years postpartum and early infant diagnosis were estimated in United States dollars (US$).

Findings

The estimated costs to the providers of PMTCT, for each mother–infant pair, were US$ 202.75–1029.55 in Namibia and US$ 94.14–342.35 in Rwanda. These costs varied with the drug regimen employed. At 2009 coverage levels, the maximal estimates of the national costs of PMTCT were US$ 3.15 million in Namibia and US$ 7.04 million in Rwanda (or < US$ 0.75 per capita in both countries). Adult testing and counselling accounted for the highest proportions of the national costs (37% and 74% in Namibia and Rwanda, respectively), followed by management and supervision. Treatment and prophylaxis accounted for less than 20% of the costs of PMTCT in both study countries.

Conclusion

The costs involved in the PMTCT of HIV varied widely between study countries and in accordance with the protocols used. However, since per-capita costs were relatively low, the scaling up of PMTCT services in Namibia and Rwanda should be possible.     

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.     

Tobacco smoking and tuberculosis treatment outcomes: a prospective cohort study in Georgia

Objective

To assess the effect of tobacco smoking on the outcome of tuberculosis treatment in Tbilisi, Georgia.

Methods

We conducted a prospective cohort study of adults with laboratory-confirmed tuberculosis from May 2011 to November 2013. History of tobacco smoking was collected using a standardized questionnaire adapted from the global adult tobacco survey. We considered tuberculosis therapy to have a poor outcome if participants defaulted, failed treatment or died. We used multivariable regressions to estimate the risk of a poor treatment outcome.

Findings

Of the 591 tuberculosis patients enrolled, 188 (31.8%) were past smokers and 271 (45.9%) were current smokers. Ninety (33.2%) of the current smokers and 24 (18.2%) of the participants who had never smoked had previously been treated for tuberculosis (P < 0.01). Treatment outcome data were available for 524 of the participants, of whom 128 (24.4%) – including 80 (32.9%) of the 243 current smokers and 21 (17.2%) of the 122 individuals who had never smoked – had a poor treatment outcome. Compared with those who had never smoked, current smokers had an increased risk of poor treatment outcome (adjusted relative risk, aRR: 1.70; 95% confidence interval, CI: 1.00–2.90). Those who had ceased smoking more than two months before enrolment did not have such an increased risk (aRR: 1.01; 95% CI: 0.51–1.99).

Conclusion

There is a high prevalence of smoking among patients with tuberculosis in Georgia and smoking increases the risk of a poor treatment outcome.     

Cross-sectional studies of tuberculosis prevalence in Cambodia between 2002 and 2011

Objective

To measure trends in the pulmonary tuberculosis burden between 2002 and 2011 and to assess the impact of the DOTS (directly observed treatment, short-course) strategy in Cambodia.

Methods

Cambodia’s first population-based nationwide tuberculosis survey, based on multistage cluster sampling, was conducted in 2002. The second tuberculosis survey, encompassing 62 clusters, followed in 2011. Participants aged 15 years or older were screened for active pulmonary tuberculosis with chest radiography and/or for tuberculosis symptoms. For diagnostic confirmation, sputum smear and culture were conducted on those whose screening results were positive.

Findings

Of the 40 423 eligible subjects, 37 417 (92.6%) participated in the survey; 103 smear-positive cases and 211 smear-negative, culture-positive cases were identified. The weighted prevalences of smear-positive tuberculosis and bacteriologically-positive tuberculosis were 271 (95% confidence interval, CI: 212–348) and 831 (95% CI: 707–977) per 100 000 population, respectively. Tuberculosis prevalence was higher in men than women and increased with age. A 38% decline in smear-positive tuberculosis (P = 0.0085) was observed with respect to the 2002 survey, after participants were matched by demographic and geographical characteristics. The prevalence of symptomatic, smear-positive tuberculosis decreased by 56% (P = 0.001), whereas the prevalence of asymptomatic, smear-positive tuberculosis decreased by only 7% (P = 0.7249).

Conclusion

The tuberculosis burden in Cambodia has declined significantly, most probably because of the decentralization of DOTS to health centres. To further reduce the tuberculosis burden in Cambodia, tuberculosis control should be strengthened and should focus on identifying cases without symptoms and in the middle-aged and elderly population.