Mortality of HIV‐infected and uninfected children in a longitudinal cohort in rural south‐west Uganda during 8 years of follow‐up

Objectives To determine the impact of HIV on child mortality and explore potential risk factors for mortality among HIV‐infected and HIV‐exposed uninfected children in a longitudinal cohort in rural Uganda. Methods From July 2002 to March 2010, HIV‐infected and HIV‐exposed uninfected children aged 6 weeks–13 years were enrolled in an open population‐based clinical cohort. Antiretroviral therapy (ART) was introduced in 2005. Clinical and laboratory data were collected every 3 months. Person‐years at risk were calculated from time of enrolment until earliest date of ART initiation, death or last visit. Cox regression was used to estimate hazard ratios (HR) for mortality. Results Eighty‐nine (30.2%) HIV‐infected and 206 (69.8%) HIV‐exposed but uninfected children were enrolled. Twenty‐one children died. The mortality rate was six times higher in ART‐naive HIV‐infected children than in HIV‐exposed but uninfected children (HR = 6.4, 95% CI = 2.4–16.6). Among HIV‐infected children, mortality was highest in those aged <2 years. Decreasing weight‐for‐age Z (WAZ) score was the strongest risk factor for mortality among HIV‐infected children (HR for unit decrease in WAZ = 2.6, 95% CI = 1.6–4.1). Thirty‐five children (aged 7 months–15.6 years; median, 5.4 years) started ART. Conclusions Mortality among HIV‐infected children was highest among those aged <2 years. Intensified efforts to prevent mother‐to‐child transmission of HIV and ensure early HIV diagnosis and treatment are required to decrease child mortality caused by HIV in rural Africa.     

The economic burden of smoking and secondhand smoke exposure in rural South-West China

Objective: To estimate the direct and indirect costs of chronic diseases attributed to smoking and exposure to secondhand smoke (SHS) in a given year (2011) in rural southwest China. Methods: A prevalence-based, disease-specific attributable-risk approach was used to estimate the economic burden of chronic diseases attributable to both smoking and exposure to secondhand smoke (SHS). A cross-sectional questionnaire survey of 17?158 consenting adults aged ≥18 years was used to derive prevalence of smoking and exposure to SHS, as well as direct and indirect costs of chronic diseases. Results: In the study population, the prevalence rates of smoking and exposure to SHS are 73.1 and 38.2% for males and 1.4 and 43.4% for females, respectively. The total costs of illness are $25.85 million for COPD, $18.80 million for asthma, $37.25 million for CHD, $17.91 million for stroke, $264.35 million for hypertension and $17.11 million for peptic ulcer. The estimated costs attributable to smoking and exposure to SHS are $95.51 million and $79.35 million, accounting for 7.15 and 5.94% of local healthcare costs, respectively. Of the total costs of tobacco, direct costs and indirect costs are $94.66 million and Objective: To estimate the direct and indirect costs of chronic diseases attributed to smoking and exposure to secondhand smoke (SHS) in a given year (2011) in rural southwest China. Methods: A prevalence-based, disease-specific attributable-risk approach was used to estimate the economic burden of chronic diseases attributable to both smoking and exposure to secondhand smoke (SHS). A cross-sectional questionnaire survey of 17?158 consenting adults aged ≥18 years was used to derive prevalence of smoking and exposure to SHS, as well as direct and indirect costs of chronic diseases. Results: In the study population, the prevalence rates of smoking and exposure to SHS are 73.1 and 38.2% for males and 1.4 and 43.4% for females, respectively. The total costs of illness are $25.85 million for COPD, $18.80 million for asthma, $37.25 million for CHD, $17.91 million for stroke, $264.35 million for hypertension and $17.11 million for peptic ulcer. The estimated costs attributable to smoking and exposure to SHS are $95.51 million and $79.35 million, accounting for 7.15 and 5.94% of local healthcare costs, respectively. Of the total costs of tobacco, direct costs and indirect costs are $94.66 million and $0.85 million for smoking, and $78.22 million and $1.36 million for exposure to SHS. Smoking contributes more cost of illness than exposure to SHS in men, whereas exposure to SHS contributes more cost of illness than smoking in women. Conclusions: Smoking and exposure to SHS produce substantial economic burden as well as have a considerable public health impact in rural southwest China.     

How effectively can the New Cooperative Medical Scheme reduce catastrophic health expenditure for the poor and non‐poor in rural China?

Objectives China has implemented the New Cooperative Medical Scheme (NCMS) in rural areas since 2003 to provide financial protection to its rural population. This article explores the effect of NCMS on relieving catastrophic health expenditure (CHE) among the poor and non‐poor groups. Methods A questionnaire survey was conducted in three counties, with a random sample of 358 poor and 523 non‐poor NCMS enrollees who used inpatient services and obtained NCMS reimbursement in 2005. Results Majority of NCMS enrollees suffered CHE because of using inpatient services; the occurrence and intensity of CHE was greater among poor inpatients. NCMS reimbursement helped relieve CHE to a certain degree. Poor inpatients benefited more from NCMS than non‐poor, but the effects varied among counties. Cost control measures and other medical financial assistance (MFA) helped reduce inpatients’ economic burden. Conclusions The objective of NCMS is only partly achieved. However, NCMS has promoted equity in health financing as poor inpatients can acquire more protection than the non‐poor. Our analysis suggests that efforts should be made to improve NCMS design, strengthen cost containment and extend other MFA to further relieve economic burden of disease.     

Economic burden of acute pesticide poisoning in South Korea

Objectives To investigate the magnitude and characteristics of the economic burden resulting from acute pesticide poisoning (APP) in South Korea. Methods The total costs of APP from a societal perspective were estimated by summing the direct medical and non‐medical costs together with the indirect costs. Direct medical costs for patients assigned a disease code of pesticide poisoning were extracted from the Korean National Health Insurance Reimbursement Data. Direct non‐medical costs were estimated using the average transportation and caregiving costs from the Korea Health Panel Survey. Indirect costs, incurred by pre‐mature deaths and work loss, were obtained using 2009 Life Tables for Korea and other relevant literature. Results In 2009, a total of 11 453 patients were treated for APP and 1311 died, corresponding to an incidence of 23.1 per 100 000 population and a mortality rate of 2.6 per 100 000 population in South Korea. The total costs of APP were estimated at approximately US$ 150 million, 0.3% of the costs of total diseases. Costs due to pre‐mature mortality accounted for 90.6% of the total costs, whereas the contribution of direct medical costs was relatively small. Conclusion Costs from APP demonstrate a unique characteristic of a large proportion of the indirect costs originating from pre‐mature mortality. This finding suggests policy implications for restrictions on lethal pesticides and safe storage to reduce fatality and cost due to APP.     

Nutritional status of children living in a community with high HIV prevalence in rural Uganda: a cross‐sectional population‐based survey

Objectives To assess the nutritional status of children in a rural community with high HIV prevalence in rural Uganda and to examine the impact of HIV infection at the individual and population level. Methods Cross‐sectional population‐based survey of children aged 0–12 in a cohort comprising the residents of 25 neighbouring villages in rural southwest Uganda. Anthropometric indicators of nutritional status (height for age, weight for age and weight for height) were assessed in relation to children’s HIV serostatus, maternal HIV serostatus and maternal vital status. Children with a Z score of Z score vs. 30%), as was the prevalence of stunting (68%vs. 42%), but there was no significant difference in the prevalence of wasting (4%vs. 9%). There were no significant differences in the prevalences of indicators of undernutrition in children classified by maternal HIV and vital status. Conclusions Chronic childhood undernutrition is common in this rural community. HIV infection had a direct effect in worsening children’s nutritional status, but no indirect effect in terms of maternal HIV infection or maternal death. The population‐level impact of childhood HIV infection on nutritional status is limited on account of the low HIV prevalence in children. The response to undernutrition in children in Africa requires action on many fronts: not only delivering community‐wide HIV and nutritional interventions but also addressing the many interacting factors that contributed to childhood undernutrition before the HIV era and still do so now.     

Utilisation of maternal health care in western rural China under a new rural health insurance system (New Co‐operative Medical System)

Objective To investigate factors influencing maternal health care utilisation in western rural China and its relation to income before (2002) and after (2007) introducing a new rural health insurance system (NCMS). Methods Data from cross‐sectional household‐based health surveys carried out in ten western rural provinces of China in 2003 and 2008 were used in the study. The study population comprised women giving birth in 2002 or 2007, with 917 and 809 births, respectively. Correlations between outcomes and explanatory variables were studied by logistic regression models and a log‐linear model. Results Between 2002 and 2007, having no any pre‐natal visit decreased from 25% to 12% (difference 13%, 95% CI 10–17%); facility‐based delivery increased from 45% to 80% (difference 35%, 95% CI 29–37%); and differences in using pre‐natal and delivery care between the income groups narrowed. In a logistic regression analysis, women with lower education, from minority groups, or high parity were less likely to use pre‐natal and delivery care in 2007. The expenditure for facility‐based delivery increased over the period, but the out‐of‐pocket expenditure for delivery as a percentage of the annual household income decreased. In 2007, it was 14% in the low‐income group. NCMS participation was found positively correlated with lower out‐of‐pocket expenditure for facility‐based delivery (coefficient ?1.14 P < 0.05) in 2007. Conclusions Facility‐based delivery greatly increased between 2002 and 2007, coinciding with the introduction of the NCMS. The rural poor were still facing substantial payment for facility‐based delivery, although NCMS participation reduced the out‐of‐pocket expenditure on average.     

Green banana‐supplemented diet in the home management of acute and prolonged diarrhoea in children: a community‐based trial in rural Bangladesh

Objective To determine the effectiveness of green banana in the home management of acute (<7 days) or prolonged (≥7 days) diarrhoea at the community level. Methods A cluster randomized field trial was conducted among 2968 Bangladeshi rural children 6–36 months old. Wards (villages) were randomly assigned to either a standard care group or a standard care plus green banana group where mothers were instructed to add cooked green banana to the diets of diarrhoeal children. Through a village‐based surveillance system, diarrhoeal morbidity data (severity, duration, compliance) were collected for 14 days. Treatment effects were determined by analysing cumulative probability of cure by testing Cox proportional hazards models and relative risk (RR). Results The cumulative probability of cure was significantly (P < 0.001) different in children receiving GB for both acute [hazard ratio (HR) = 0.63 (95% CI: 0.56–0.67)] and prolonged diarrhoea [HR = 0.38 (95% CI: 0.26–0.59)]. The recovery rates of children with acute diarrhoea receiving GB (vs. control) were significantly more by day 3: 79.9%vs. 53.3% [(RR) = 0.47, 95% CI: 0.41–0.55], (P < 0.001) and day 7: 96.6%vs. 89.1% (RR = 0.32; 0.22–0.46), (P < 0.001). Children with prolonged diarrhoea receiving green banana had significantly higher recovery rates by day 10: 79.8%vs. 51.9% (RR = 0.42; 0.23–0.73), (P < 0.001) and day 14: 93.6%vs. 67.2% (RR = 0.22; 0.08–0.54), (P < 0.001). Conclusion A green banana‐supplemented diet hastened recovery of acute and prolonged childhood diarrhoea managed at home in rural Bangladesh.