Rapid monitoring in vaccination campaigns during emergencies: the post-earthquake campaign in Haiti

Problem

The earthquake that struck Haiti in January 2010 caused 1.5 million people to be displaced to temporary camps. The Haitian Ministry of Public Health and Population and global immunization partners developed a plan to deliver vaccines to those residing in these camps. A strategy was needed to determine whether the immunization targets set for the campaign were achieved.

Approach

Following the vaccination campaign, staff from the Ministry of Public Health and Population interviewed convenience samples of households – in specific predetermined locations in each of the camps – regarding receipt of the emergency vaccinations. A camp was targeted for “mop-up vaccination” – i.e. repeat mass vaccination – if more than 25% of the children aged 9 months to 7 years in the sample were found not to have received the emergency vaccinations.

Local setting

Rapid monitoring was implemented in camps located in the Port-au-Prince metropolitan area. Camps that housed more than 5000 people were monitored first.

Relevant changes

By the end of March 2010, 72 (23%) of the 310 vaccinated camps had been monitored. Although 32 (44%) of the monitored camps were targeted for mop-up vaccination, only six of them had received such repeat mass vaccination when checked several weeks after monitoring.

Lessons learnt

Rapid monitoring was only marginally beneficial in achieving immunization targets in the temporary camps in Port-au-Prince. More research is needed to evaluate the utility of conventional rapid monitoring, as well as other strategies, during post-disaster vaccination campaigns that involve mobile populations, particularly when there is little capacity to conduct repeat mass vaccination.     

Trends in mortality from respiratory disease in Latin America since 1998 and the impact of the 2009 influenza pandemic

Objective

To determine trends in mortality from respiratory disease in several areas of Latin America between 1998 and 2009.

Methods

The numbers of deaths attributed to respiratory disease between 1998 and 2009 were extracted from mortality data from Argentina, southern Brazil, Chile, Costa Rica, Ecuador, Mexico and Paraguay. Robust linear models were then fitted to the rates of mortality from respiratory disease recorded between 2003 and 2009.

Findings

Between 1998 and 2008, rates of mortality from respiratory disease gradually decreased in all age groups in most of the study areas. Among children younger than 5 years, for example, the annual rates of such mortality – across all seven study areas – fell from 56.9 deaths per 100 000 in 1998 to 26.6 deaths per 100 000 in 2008. Over this period, rates of mortality from respiratory disease were generally highest among adults older than 65 years and lowest among individuals aged 5 to 49 years. In 2009, mortality from respiratory disease was either similar to that recorded in 2008 or showed an increase – significant increases were seen among children younger than 5 years in Paraguay, among those aged 5 to 49 years in southern Brazil, Mexico and Paraguay and among adults aged 50 to 64 years in Mexico and Paraguay.

Conclusion

In much of Latin America, mortality from respiratory disease gradually fell between 1998 and 2008. However, this downward trend came to a halt in 2009, probably as a result of the (H1N1) 2009 pandemic.     

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.     

Trends in caesarean delivery by country and wealth quintile: cross-sectional surveys in southern Asia and sub-Saharan Africa

Objective

To examine temporal trends in caesarean delivery rates in southern Asia and sub-Saharan Africa, by country and wealth quintile.

Methods

Cross-sectional data were extracted from the results of 80 Demographic and Health Surveys conducted in 26 countries in southern Asia or sub-Saharan Africa. Caesarean delivery rates were evaluated – as percentages of the deliveries that ended in live births – for each wealth quintile in each survey. The annual rates recorded for each country were then compared to see if they had increased over time.

Findings

Caesarean delivery rates had risen over time in all but 6 study countries but were consistently found to be lower than 5% in 18 of the countries and 10% or less in the other eight countries. Among the poorest 20% of the population, caesarean sections accounted for less than 1% and less than 2% of deliveries in 12 and 21 of the study countries, respectively. In each of 11 countries, the caesarean delivery rate in the poorest 40% of the population remained under 1%. In Chad, Ethiopia, Guinea, Madagascar, Mali, Mozambique, Niger and Nigeria, the rate remained under 1% in the poorest 80%. Compared with the 22 African study countries, the four study countries in southern Asia experienced a much greater rise in their caesarean delivery rates over time. However, the rates recorded among the poorest quintile in each of these countries consistently fell below 2%.

Conclusion

Caesarean delivery rates among large sections of the population in sub-Saharan Africa are very low, probably because of poor access to such surgery.     

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.     

Smoking-attributable mortality in Bangladesh: proportional mortality study

Objective

To directly estimate how much smoking contributes to cause-specific mortality in Bangladesh.

Methods

A case–control study was conducted with surveillance data from Matlab, a rural subdistrict. Cases (n = 2213) and controls (n = 261) were men aged 25 to 69 years who had died between 2003 and 2010 from smoking-related and non-smoking-related causes, respectively. Cause-specific odds ratios (ORs) were calculated for “ever-smokers” versus “never-smokers”, with adjustment for education, tobacco chewing status and age. Smoking-attributable deaths among cases, national attributable fractions and cumulative probability of surviving from 25 to 69 years of age among ever-smokers and never-smokers were also calculated.

Findings

The fraction of ever-smokers was about 84% among cases and 73% among controls (OR: 1.7; 99% confidence interval, CI: 1.1–2.5). ORs were highest for cancers and lower for respiratory, vascular and other diseases. A dose–response relationship was noted between age at smoking initiation and daily number of cigarettes or bidis smoked and the risk of death. Among 25-year-old Bangladeshi men, 32% of ever-smokers will die before reaching 70 years of age, compared with 19% of never-smokers. In 2010, about 25% of all deaths observed in Bangladeshi men aged 25 to 69 years (i.e. 42 000 deaths) were attributable to smoking.

Conclusion

Smoking causes about 25% of all deaths in Bangladeshi men aged 25 to 69 years and an average loss of seven years of life per smoker. Without a substantial increase in smoking cessation rates, which are low among Bangladeshi men, smoking-attributable deaths in Bangladesh are likely to increase.     

Trends in all-cause mortality during the scale-up of an antiretroviral therapy programme: a cross-sectional study in Lusaka,Zambia

Objective

To follow the trends in all-cause mortality in Lusaka, Zambia, during the scale-up of a national programme of antiretroviral therapy (ART).

Methods

Between November 2004 and September 2011, we conducted 12 survey rounds as part of a cross-sectional study in Lusaka, with independent sampling in each round. In each survey, we asked the heads of 3600 households to state the number of deaths in their households in the previous 12 months and the number of orphans aged less than 16 years in their households and investigated the heads’ knowledge, attitudes and practices related to human immunodeficiency virus (HIV).

Findings

The number of deaths we recorded – per 100 person–years – in each survey ranged from 0.92 (95% confidence interval, CI: 0.78–1.09) in September 2011, to 1.94 (95% CI: 1.60–2.35) in March 2007. We found that mortality decreased only modestly each year (mortality rate ratio: 0.98; 95% CI: 0.95–1.00; P = 0.093). The proportion of households with orphans under the age of 16 years decreased from 17% in 2004 to 7% in 2011. The proportions of respondents who had ever been tested for HIV, had a comprehensive knowledge of HIV, knew where to obtain free ART and reported that a non-pregnant household member was receiving ART gradually increased.

Conclusion

The expansion of ART services in Lusaka was not associated with a reduction in all-cause mortality. Coverage, patient adherence and retention may all have to be increased if ART is to have a robust and lasting impact at population level in Lusaka.     

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.     

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.     

Variations in catastrophic health expenditure estimates from household surveys in India

Objective

To assess the comparability of out-of-pocket (OOP) payment and catastrophic health expenditure (CHE) estimates from different household surveys in India.

Methods

Data on CHE, outpatient and inpatient OOP payments and other expenditure from all major national or multi-state surveys since 2000 were compared. These included two consumer expenditure surveys (the National Sample Survey for 2004–05 [NSS 2004–05] and 2009–10 [NSS 2009–10]) and three health-focused surveys (the World Health Survey 2003 [WHS 2003]; the National Sample Survey on Morbidity, Health Care and the Condition of the Aged 2004 [NSS 2004]; and the Study on Global Ageing and Adult Health 2007–08 [SAGE 2007–08]). All but the NSS 2004–05 and the NSS 2009–10 used different questionnaires.

Findings

CHE estimates from WHS 2003 and SAGE 2007–08 were twice as high as those from NSS 2004–05, NSS 2009–10 and NSS 2004. Inpatient OOP payment estimates were twice as high in WHS 2003 and SAGE 2007–08 because in these surveys a much higher proportion of households reported such payments. However, estimates of expenditures on other items were half as high in WHS 2003 as in the other surveys because a very small number of items was used to capture these expenditures.

Conclusion

The wide variations observed in CHE and OOP payment estimates resulted from methodological differences. Survey methods used to assess CHE in India need to be standardized and validated to accurately track CHE and assess the impact of recent policies to reduce it.     

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.     

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.     

Asbestos: use,bans and disease burden in Europe

Objective

To analyse national data on asbestos use and related diseases in the European Region of the World Health Organization (WHO).

Methods

For each of the 53 countries, per capita asbestos use (kg/capita/year) and age-adjusted mortality rates (deaths/million persons/year) due to mesothelioma and asbestosis were calculated using the databases of the United States Geological Survey and WHO, respectively. Countries were further categorized by ban status: early-ban (ban adopted by 2000, n = 17), late-ban (ban adopted 2001–2013, n = 17), and no-ban (n = 19).

Findings

Between 1920–2012, the highest per capita asbestos use was found in the no-ban group. After 2000, early-ban and late-ban groups reduced their asbestos use levels to less than or equal to 0.1 kg/capita/year, respectively, while the no-ban group maintained a very high use at 2.2 kg/capita/year. Between 1994 and 2010, the European Region registered 106 180 deaths from mesothelioma and asbestosis, accounting for 60% of such deaths worldwide. In the early-ban and late-ban groups, 16/17 and 15/17 countries, respectively, reported mesothelioma data to WHO, while only 6/19 countries in the no-ban group reported such data. The age-adjusted mortality rates for mesothelioma for the early-ban, late-ban and no-ban groups were 9.4, 3.7 and 3.2 deaths/million persons/year, respectively. Asbestosis rates for the groups were 0.8, 0.9 and 1.5 deaths/million persons/year, respectively.

Conclusion

Within the European Region, the early-ban countries reported most of the current asbestos-related deaths. However, this might shift to the no-ban countries, since the disease burden will likely increase in these countries due the heavy use of asbestos.     

Health system strengthening and hypertension awareness,treatment and control: data from the China Health and Retirement Longitudinal Study

Objective

To monitor hypertension prevalence, awareness, treatment and control in China two to three years after major reform of the health system.

Methods

Data from a national survey conducted in 2011–2012 among Chinese people aged 45 years or older – which included detailed anthropometric measurements – were used to estimate the prevalence of hypertension and the percentages of hypertensive individuals who were unaware of, receiving no treatment for, and/or not controlling their hypertension well. Modified Poisson regressions were used to estimate relative risks (RRs).

Findings

At the time of the survey, nearly 40% of Chinese people aged 45 years or older had a hypertensive disorder. Of the individuals with hypertension, more than 40% were unaware of their condition, about 50% were receiving no medication for it and about 80% were not controlling it well. Compared with the other hypertensive individuals, those who were members of insurance schemes that covered the costs of outpatient care were more likely to be aware of their hypertension (adjusted RR, aRR: 0.737; 95% confidence interval, CI: 0.619–0.878) to be receiving treatment for it (aRR: 0.795; 95% CI: 0.680–0.929) and to be controlling it effectively (aRR: 0.903; 95% CI: 0.817–0.996).

Conclusion

In China many cases of hypertension are going undetected and untreated, even though the health system appears to deliver effective care to individuals who are aware of their hypertension. A reduction in the costs of outpatient care to patients would probably improve the management of hypertension in China.     

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.     

Adverse events attributed to traditional Korean medical practices: 1999–2010

Objective

To investigate adverse events attributed to traditional medical treatments in the Republic of Korea.

Methods

Adverse events recorded in the Republic of Korea between 1999 and 2010 – by the Food and Drug Administration, the Consumer Agency or the Association of Traditional Korean Medicine – were reviewed. Records of adverse events attributed to the use of traditional medical practices, including reports of medicinal accidents and consumers’ complaints, were investigated.

Findings

Overall, 9624 records of adverse events attributed to traditional medical practices – including 522 linked to herbal treatments – were identified. Liver problems were the most frequently reported adverse events. Only eight of the adverse events were recorded by the pharmacovigilance system run by the Food and Drug Administration. Of the 9624 events, 1389 – mostly infections, cases of pneumothorax and burns – were linked to physical therapy (n = 285) or acupuncture/moxibustion (n = 1104).

Conclusion

In the Republic of Korea, traditional medical practices often appear to have adverse effects, yet almost all of the adverse events attributed to such practices between 1999 and 2010 were missed by the national pharmacovigilance system. The Consumer Agency and the Association of Traditional Korean Medicine should be included in the national pharmacovigilance system.     

NHS Scotland reduces the postcode lottery for hip arthroplasty: an ecological study of the impact of waiting time initiatives

Objectives

Following the election of the Labour government in 1997, policies were developed in England to reduce waiting times for NHS treatment with commitments to reduce health inequalities. Similar policies were adopted in Scotland but with less emphasis on the use of the private sector to deliver NHS treatments than in England. This study uses routinely collected NHS Scotland data to analyse geographical and socioeconomic inequalities in elective hip arthroplasty treatment before and after the introduction of the waiting time initiatives in Scotland in 2003.

Design

Ecological study design.

Setting

Scotland.

Participants

NHS-funded patients receiving elective hip arthroplasty delivered by the NHS and private hospitals between 1 April 1998 and 31 March 2008.

Main outcome measures

Directly standardised treatment rates and incidence rate ratios calculated using Poisson regression.

Results

There was a 42% increase in NHS-funded hip arthroplasties carried out in Scotland from 4095 in 2002–2003 (1 April 2002–31 March 2003) to 5829 in 2007–2008. There is evidence of a statistically significant reduction in geographical inequality (likelihood ratio test p < 0.001) but no evidence of any statistically significant change in socioeconomic inequality (p = 0.108), comparing the 5 years after 1 April 2003 with the 5 years before 1 April 2003. The number of NHS-funded hip arthroplasties undertaken privately rose from 1.1% in 2002–2003 to 2.9% in 2007–2008, whereas the NHS Golden Jubilee National Hospital increased its share from 3.3% to 10.6% over the same period.

Conclusions

The reduction in geographical inequality, or ‘postcode lottery’, in hip arthroplasty treatment in Scotland may be due to increased NHS capacity, in particular the development of the NHS Golden Jubilee National Hospital in Clydebank, Greater Glasgow as a dedicated centre to reduce surgery waiting times.     

Does the 65 cm height cut-off as age proxy exclude children eligible for nutritional assessment in Bangladesh?

Setting:

Kamrangirchar slum, Dhaka, Bangladesh.

Objective:

During nutritional surveys and in circumstances when it is difficult to ascertain children’s age, length/height cut-offs are used as proxy for age to sample children aged 6–59 months. In a context of prevalent stunting, using data from primary health care centres where age and height parameters were well-recorded, we assessed the proportion of children aged between 6 and 59 months who would be excluded from nutritional assessment using a height cut-off of 65 cm as a proxy for age ≥6 months.

Design:

This was a secondary data analysis of primary health centre data.

Results:

A total of 2060 children were included in the analysis, with a median age of 24 months and a median height of 78 cm (SD 12.1, range 50–109 cm). There were 240 (12%, 95%CI 10–13) children aged between 6 and 29 months, with a height <65 cm. The majority (59%) of these children were females; 97.5% were aged 6–17 months.

Conclusion:

In an urban slum setting in Bangladesh, the use of the current height cut-off as a proxy for age excludes vulnerable children from nutritional assessment and could also lead to underestimation of the prevalence of malnutrition in nutritional surveys.     

Risk of self-harm and suicide in people with specific psychiatric and physical disorders: comparisons between disorders using English national record linkage

Background

Psychiatric illnesses are known risk factors for self-harm but associations between self-harm and physical illnesses are less well established. We aimed to stratify selected chronic physical and psychiatric illnesses according to their relative risk of self-harm.

Design

Retrospective cohort studies using a linked dataset of Hospital Episode Statistics (HES) for 1999–2011.

Participants

Individuals with selected psychiatric or physical conditions were compared with a reference cohort constructed from patients admitted for a variety of other conditions and procedures.

Setting

All admissions and day cases in National Health Service (NHS) hospitals in England.

Main outcome measures

Hospital episodes of self-harm. Rate ratios (RRs) were derived by comparing admission for self-harm between cohorts.

Results

The psychiatric illnesses studied (depression, bipolar disorder, alcohol abuse, anxiety disorders, eating disorders, schizophrenia and substance abuse) all had very high RRs (> 5) for self-harm. Of the physical illnesses studied, an increased risk of self-harm was associated with epilepsy (RR = 2.9, 95% confidence interval [CI] 2.8–2.9), asthma (1.8, 1.8–1.9), migraine (1.8, 1.7–1.8), psoriasis (1.6, 1.5–1.7), diabetes mellitus (1.6, 1.5–1.6), eczema (1.4, 1.3–1.5) and inflammatory polyarthropathies (1.4, 1.3–1.4). RRs were significantly low for cancers (0.95, 0.93–0.97), congenital heart disease (0.9, 0.8–0.9), ulcerative colitis (0.8, 0.7–0.8), sickle cell anaemia (0.7, 0.6–0.8) and Down''s syndrome (0.1, 0.1–0.2).

Conclusions

Psychiatric illnesses carry a greatly increased risk of self-harm as well as of suicide. Many chronic physical illnesses are also associated with an increased risk of both self-harm and suicide. Identifying those at risk will allow provision of appropriate monitoring and support.     

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.