Malnutrition and mortality in Kohistan District, Afghanistan, April 2001.

CONTEXT: The humanitarian situation in Afghanistan has been deteriorating for more than 3 years because of civil war and severe drought. Because of recent events, the international community is predicting a severe worsening of the country's current situation. OBJECTIVE: To assess the magnitude and causes of mortality and prevalence of malnutrition in Kohistan district, Faryab province, Afghanistan. DESIGN: Two-stage, 30-cluster household survey conducted April 4 through 10, 2001, which included anthropometric measurements, assessment of food coping mechanisms, and retrospective mortality data collection for November 26, 2000, through April 4, 2001. SETTING AND PARTICIPANTS: A total of 378 households comprising 3165 people living in Kohistan district, Faryab province, Afghanistan. MAIN OUTCOME MEASURES: Crude mortality rate, mortality rate among children younger than 5 years, causes of death, prevalence of wasting and stunting among children aged 6 to 59 months (weight-for-height and height-for-age z scores <-2, respectively), and food coping mechanisms. RESULTS: The crude mortality rate among the 3165 persons surveyed during the period of interest was 2.6 (95% confidence interval [CI], 1.7-3.5) per 10 000 per day and the mortality rate among 763 children younger than 5 years was 5.9 (95% CI, 2.0-8.8) per 10 000 per day. Diarrhea (25.0%), respiratory tract infections (19.4%), measles (15.7%), and scurvy (6.5%) caused most of the 108 deaths. The prevalences of wasting and stunting among 708 children aged 6 to 59 months were 7.0% (95% CI, 5.9%-9.0%) and 63.7% (95% CI, 58.6%-68.8%), respectively. Evidence of late-stage food coping mechanisms and prefamine indicators existed among the population. CONCLUSIONS: These data indicate that, by April 2001, a humanitarian crisis already existed in Kohistan. Essential humanitarian services, including food aid and public health programs, are urgently required in such regions of Afghanistan and will be crucial if a worsening humanitarian crisis is to be avoided. For these services and programs to be implemented, the international community needs to create adequate humanitarian space (ie, a secure and accessible location where humanitarian organizations can provide services to emergency-affected populations) to ensure that humanitarian organizations have access to populations within Afghanistan as well as to refugees who flee to surrounding countries.     

Malnutrition in childhood lymphoblastic leukemia: a predictor of early mortality during the induction-to-remission phase of the treatment.

BACKGROUND: Previous reports have shown that undernourished children with acute lymphoblastic leukemia (ALL) have a poorer long-term survival as compared with children with normal nourishment status. It has been shown that both the relapse and mortality rates of undernourished children with ALL are higher during the continuation phase of the chemotherapy and are apparently related to a poor tolerance of ablative chemotherapy. No previous articles have analyzed the early mortality rate of these patients. METHODS: We carried out a case-control study, and have studied the effect of severe malnutrition on the mortality of 17 children with ALL during the initial induction-to-remission phase of the treatment. These 17 cases were compared with 76 controls who had survived at least the phases of induction and consolidation. RESULTS: It was found that the chance of dying during the initial phase of the treatment was 2.6 times higher (confidence interval 95%: 0.55-11.89) in undernourished children with ALL than in those children with normal nourishment status. The risk of death increased with the severity of undernourishment (p = 0.04). CONCLUSIONS: These data confirm the prognostic value of malnutrition in children with ALL and suggest that undernourishment may also influence early mortality during the induction-to-remission phase of the treatment.     

Occasional essay : Rape in war: the humanitarian response

Women and children are vulnerable to sexual violence in times of conflict, and the risk persists even after they have escaped the conflict area. The impact of rape goes far beyond the immediate effects of the physical attack and has long-lasting consequences. We describe the humanitarian community's response to sexual violence and rape in times of war and civil unrest by drawing on the experiences of Médecins Sans Frontières/Doctors Without Borders and other humanitarian agencies. Health care workers must have a keen awareness of the problem and be prepared to respond appropriately. This requires a comprehensive intervention protocol, including antibiotic prophylaxis, emergency contraception, referral for psychological support, and proper documentation and reporting procedures. Preventing widespread sexual violence requires increasing the security in refugee camps. It also requires speaking out and holding states accountable when violations of international law occur. The challenge is to remain alert to these often hidden, but extremely destructive, crimes in the midst of a chaotic emergency relief setting.     

Decline in measles mortality: nutrition, age at infection, or exposure?

The mortality from measles was studied in an urban area of Guinea-Bissau one year before and five years after the introduction of a vaccination programme. The years after the introduction of immunisation saw a decline in mortality among unvaccinated children with measles. This decline occurred despite a lower age at infection and an increasing prevalence of malnourished children. State of nutrition (weight for age) did not affect the outcome of measles infection. The incidence of isolated cases, however, increased in the period after the introduction of measles vaccination. As mortality was lower among these cases, diminished clustering explained some of the reduction in mortality. Comparison between the urban district and a rural area inhabited by the same ethnic group showed a lower age at infection, less clustering of cases, and lower case fatality ratios in the urban area. Endemic transmission of measles in urban districts leads to less clustering of cases, which may help explain the usually lower case fatality ratios in these areas. As measles vaccination increases herd immunity and diminishes clustering of cases, it may reduce mortality even among unvaccinated children who contract the disease.     

Vitamin A supplements and mortality related to measles: a randomised clinical trial

One hundred and eighty children admitted with measles were randomly allocated to receive routine treatment alone or with additional large doses of vitamin A (200,000 IU orally immediately and again the next day). Baseline characteristics of the two groups were virtually identical for age, severity of measles, and vitamin A and general nutritional states. In 91% of the children serum vitamin A concentrations were less than 0.56 mumol/l. Of the 88 subjects given vitamin A supplements, six (7%) died; of the 92 controls, 12 (13%) died (p = 0.13). This difference in mortality was most obvious for children aged under 2 years (one death out of 46 children receiving supplements versus seven deaths out of 42 controls; p less than 0.05) and for cases complicated by croup or laryngotracheobronchitis. Mortality was several times higher in marasmic than in better nourished children, regardless of study allocation (p less than 0.01).     

Quality of malnutrition assessment surveys conducted during famine in Ethiopia

Context  During 1999 and 2000, approximately 10 million people were affected by famine in Ethiopia. Results of nutrition assessments and surveys conducted by humanitarian organizations were used by donors and government agencies to determine needs for food aid and to make other decisions on geographic allocation of limited resources; however, accurate results might have been hampered by methodological errors. Objectives  To identify common methodological errors in nutrition assessments and surveys and to provide practical recommendations for improvement. Design and Setting  Nutrition assessments and surveys (n = 125) conducted by 14 nongovernmental organizations (NGOs) in 54 woredas (districts) in Ethiopia from May 1, 1999, through July 31, 2000. Surveys were ranked as valid and precise according to 5 criteria: use of population proportional to size sampling, sample size, number of clusters, number of children per cluster, and use of weight-for-height index. Main Outcome Measures  Number and proportion of surveys that used standard, internationally accepted methods and reported valid and precise results. Results  Fifty-eight of the 125 surveys (46%) were not intended to be standard 30 x 30 cluster surveys. Of the remaining 67 surveys, 6 (9%) met predetermined criteria for validity and precision. All 67 used the anthropometric index of weight-for-height, with 58 (87%) reporting z scores. Fifty-four (81%) used nonrandom sampling without consideration of population size and 6 (9%) had sample sizes of fewer than 500 persons. Conclusions  Major methodological errors were identified among 30 x 30 cluster surveys designed to measure acute malnutrition prevalence in Ethiopia during the famine of 1999-2000. Donor agencies and NGOs should be educated about the need for improved quality of nutrition assessments and their essential role in directing allocation of scarce food resources.      

宫内蛋白营养不良对大鼠胰岛素抵抗的影响

目的探讨宫内营养不良造成的宫内发育迟缓（IUGR）大鼠发育过程中胰岛素敏感性和糖代谢的变化。方法采用孕鼠低蛋白饮食法建立IUGR模型，测定雄性子鼠生后每周体重增长和3周、8周和12周的肾周脂肪重量．观察8周子鼠胰岛素耐量实验变化。结果UGR组子鼠平均出生体重明显低于对照组，4周时达到对照组平均水平。8周到12周IUGR组体重明显超过对照组。且8周和12周时，IUGR组的肾周脂肪重量明显高于对照组。IUGR子鼠3周时空腹血糖、胰岛素和游离脂肪酸水平与对照组差异无显著性，8周后IUGR子鼠出现高胰岛素血症，胰岛素抵抗指数（IRI）增高。12周时IUGR组出现高血糖。8周和12周时，IUGR组千鼠血清游离脂肪酸水平明显高于对照组。胰岛素耐量实验显示IUGR子鼠对外源性胰岛素反应迟钝。结论宫内蛋白质营养不良诱导IUGR大鼠葡萄糖稳态发生永久改变，成年后出现2型糖尿病表现。     

Mild measles and secondary vaccine failure during a sustained outbreak in a highly vaccinated population

A prolonged school-based outbreak of measles provided an opportunity to study "vaccine-modified" mild measles and secondary vaccine failure. Thirty-six (97%) of 37 unvaccinated patients had rash illnesses that met the Centers for Disease Control clinical case definition of measles, but 29 (15%) of 198 vaccinated patients did not, primarily because of low-grade or absent fever. Of 122 patients with seroconfirmed measles, 10 patients (all previously vaccinated) had no detectable measles-specific IgM and significantly milder illness than either vaccinated or unvaccinated patients with IgM-positive serum. Of 108 vaccinated patients with seroconfirmed measles, 17 patients (16%) had IgM-negative serology or rash illnesses that failed to meet the clinical case definition; their mean age (13 years), age at the time of vaccination, and time since vaccination did not differ from those of other vaccinated patients. The occurrence of secondary vaccine failure and vaccine-modified measles does not appear to be a major impediment to measles control in the United States but may lead to underreporting of measles cases and result in overestimation of vaccine efficacy in highly vaccinated populations.     

Tuberculosis mortality during a civil war in Guinea-Bissau

CONTEXT: Tuberculosis (TB) is an increasing global problem, despite effective drug therapies. Access to TB therapy during conflict situations has not been studied. OBJECTIVE: To determine the effect of irregular TB treatment due to an armed conflict in Guinea-Bissau, West Africa. DESIGN, SETTING, AND PATIENTS: Ongoing retrospective cohort study conducted in the capital city of Bissau among 101 patients with TB who received irregular or no treatment during the civil war (war cohort; June 7-December 6, 1998) and 108 patients with TB who received treatment 12 months earlier (peace cohort; June 7-December 6, 1997) and comparison of an additional 42 patients who had completed treatment before June 6, 1998, and 69 patients who had completed treatment before June 6, 1997. MAIN OUTCOME MEASURE: Mortality rates, compared by irregular (war cohort) vs regular (peace cohort) access to treatment, by intensive vs continuation phase of treatment, and by those who had previously completed treatment for TB. RESULTS: Irregular treatment was associated with an increased mortality rate among patients with TB. The mortality rate ratio (MR) was 3.12 (95% confidence interval [CI], 1.20-8.12) in the war cohort, adjusting for age, sex, human immunodeficiency virus (HIV) infection, residence, and length of treatment. Each additional week of treatment before the war started increased probability of survival by 5% (95% CI, 0%-10%). In the intensive phase of treatment, the adjusted MR was 3.30 (95% CI, 1.04-10.50) and in the continuation phase it was 2.26 (95% CI, 0.33-15.34). Increased mortality among the war cohort was most marked in HIV-positive patients, who had an adjusted MR of 8.19 (95% CI, 1.62-41.25). Mortality was not increased in HIV-positive or HIV-negative patients who had completed TB treatment when the war started. CONCLUSIONS: Interruption of treatment had a profound impact on mortality among patients with TB during the war in Guinea-Bissau. Regular treatment for TB was associated with significantly improved survival for HIV-infected individuals. In emergencies, it is crucial to ensure availability of TB drugs.     

Malnutrition, fertility and family planning.

Data derived primarily from published reports is used to assess the relationship between malnutrition and reproductive capacity in India. Findings of numerous studies support the conclusion that improvements in nutritional status are associated with increased fertility in the absence of contraception. Nutritional programs should therefore be provided in conjunction with family planning services in order to avoid an increase in population growth. Improvements in the nutritional status of members of a community may help motivate the community toward family planning. A recent Indian study demonstrates that higher caloric intake is associated with smaller family size, and other studies reveal a relationship between malnutrition and pregnancy failure, stillbirth, and infant mortality. The high infant mortality rate in India at the present time may serve to increase family size since couples tend to over produce in order to insure that some of their children will survive. The hypothesis that an inadequate diet is compensated for by an increase in sexual appetite, and hence, in fertility is not substantiated by recent investigations. For example, Indian states with higher protein intake/person have higher birth rates than those states with lower protein intake/person. Tables provide data on 1) birth rates, death rates, infant mortality rates, % of population increase, and sex ratios for each decade from 1921-1970 for India; 2) the relationship between diet and birth rates in several countries; 3) the relationship between various dietary factors and birth, death, and infant mortality rates forIndia; 4) fertility rates observed in several populations where contraception was not practiced; and 5) the relationship between family size and diet in India.     

Malnutrition and the heart.

Earlier concepts that the heart is spared in malnutrition have been shown to be incorrect. Inadequate intake of protein and energy results in proportional loss of skeletal and myocardial muscle. As myocardial mass decreases, so does the ability to generate cardiac output; however, various compensatory factors come into play. Nutritional supplementation for malnourished patients reverses the compensatory factors and may increase the short-term potential for heart failure. Severe cardiac debility results in poor nutrition, which may in turn produce unsuspected but clinically significant myocardial atrophy. Nutritional support may play a role in improving cardiac function in selected patients with cardiac cachexia who are being prepared for cardiac surgery and in patients with rapid weight loss who are at risk for sudden death due to arrhythmias. Malnutrition is common in hospitalized patients, and many patients in hospital now receive nutritional supplementation; both facts have important cardiac implications.     

Antibody response and clinical reactions in children given measles vaccine with immunoglobulin

Antibody responses and clinical reactions to three measles vaccines (Attenuvax, Mevilin, and Rimevax) injected into the opposite arm to immunoglobulin were assessed in 45 children with brain disorders making them susceptible to fits if given measles vaccine alone. In this small study no unacceptable reactions occurred and in only three cases was the antibody response minimal or absent. More children in this special category should be considered for vaccination against measles in this way.