Iron and folic acid supplements and reduced early neonatal deaths in Indonesia

Objective

To examine the relationship between antenatal care, iron and folic acid supplementation and tetanus toxoid vaccination during pregnancy in Indonesia and the risk of early neonatal death (death in days 0–6 of life).

Methods

We analysed pooled data on neonatal survival in singleton infants born in the 5 years before each of the Indonesian demographic and health surveys of 1994, 1997 and 2002–2003. Only the most recently born infant of each mother was included. Multivariate Cox proportional hazards models were used to identify factors linked to early neonatal death.

Findings

Of the 40 576 infants included, 442 experienced early neonatal death. After adjustment, the risk of early neonatal death was significantly reduced for infants of mothers who received either any form of antenatal care (hazard ratio, HR: 0.48; 95% confidence interval, CI: 0.31–0.73), any quantity of iron and folic acid (HR: 0.53; 95% CI: 0.36–0.77) or ≥ 2 tetanus toxoid injections (HR: 0.66; 95% CI: 0.48–0.92). When we analysed different combinations of these measures, iron and folic acid supplementation provided the main protective effect: early neonatal deaths were still significantly reduced among infants whose mothers received iron and folic acid supplements but no other form of antenatal care (HR: 0.10; 95% CI: 0.01–0.67), or the supplements but < 2 tetanus toxoid injections (HR: 0.46; 95% CI: 0.29–0.73). Subsequent analysis showed that 20% of early neonatal deaths in Indonesia could be attributed to a lack of iron and folic acid supplementation during pregnancy.

Conclusion

Iron and folic acid supplementation during pregnancy in Indonesia significantly reduced the risk of early neonatal death and could also do so in other low- and middle-income countries.     

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

Objective

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

Methods

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

Findings

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

Conclusion

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

Effect on road traffic injuries of criminalizing road traffic offences: a time-series study

Objective

To determine the effect of criminalizing some traffic behaviours, after the reform of the Spanish penal code in 2007, on the number of drivers involved in injury collisions and of people injured in traffic collisions in Spain.

Methods

This study followed an interrupted times–series design in which the number of drivers involved in injury collisions and of people injured in traffic collisions in Spain before and after the criminalization of offences were compared. The data on road traffic injuries in 2000–2009 were obtained from the road traffic collision database of the General Traffic Directorate. The dependent variables were stratified by sex, age, injury severity, type of road user, road type and time of collision. Quasi-Poisson regression models were fitted with adjustments for time trend, seasonality, previous interventions and national fuel consumption.

Findings

The overall number of male drivers involved in injury collisions dropped (relative risk, RR: 0.93; 95% confidence interval, CI: 0.89–0.97) after the reform of the penal code, but among women no change was observed (RR: 0.99; 95% CI: 0.95–1.03). In addition, 13 891 men (P < 0.01) were prevented from being injured. Larger reductions were observed among young male drivers and among male motorcycle or moped riders than among the drivers of other vehicles.

Conclusion

The findings suggest that criminalizing certain traffic behaviours can improve road safety by reducing both the number of drivers involved in injury collisions and the number of people injured in such collisions.     

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.     

Chronic hepatitis C treatment outcomes in low- and middle-income countries: a systematic review and meta-analysis

Objective

To assess the effectiveness of treatment for hepatitis C virus (HCV) infection in low- and middle-income countries and identify factors associated with successful outcomes.

Methods

We performed a systematic review and meta-analysis of studies of HCV treatment programmes in low- and middle-income countries. The primary outcome was a sustained virological response (SVR). Factors associated with treatment outcomes were identified by random-effects meta-regression analysis.

Findings

The analysis involved data on 12 213 patients included in 93 studies from 17 countries. The overall SVR rate was 52% (95% confidence interval, CI: 48–56). For studies in which patients were predominantly infected with genotype 1 or 4 HCV, the pooled SVR rate was 49% (95% CI: 43–55). This was significantly lower than the rate of 59% (95% CI: 54–64) found in studies in which patients were predominantly infected with other genotypes (P = 0.012). Factors associated with successful outcomes included treatment with pegylated interferon and ribavirin, infection with an HCV genotype other than genotype 1 or 4 and the absence of liver damage or human immunodeficiency virus infection at baseline. No significant difference in the SVR rate was observed between weight-adjusted and fixed-dose ribavirin treatment. Overall, 17% (95% CI: 13–23) of adverse events resulted in treatment interruption or dose modification, but only 4% (95% CI: 3–5) resulted in treatment discontinuation.

Conclusion

The outcomes of treatment for HCV infection in low- and middle-income countries were similar to those reported in high-income countries.     

Time trends and regional differences in maternal mortality in China from 2000 to 2005

Objective

To examine trends and variations in maternal mortality in China between 2000 and 2005.

Methods

We used Poisson regression analysis of data from the Chinese National Maternal and Child Health Routine Reporting System between 2000 and 2005 to identify time trends in the maternal mortality ratio (MMR) by province and region.

Findings

The MMR declined by an average of 5% per year (crude relative risk, RR: 0.95; 95% confidence interval, CI: 0.94–0.97). There was no interaction between region and year (P = 0.2311). Mortality declined by 5% per year in the eastern region (crude RR: 0.95; 95% CI: 0.92–0.97), by 5% per year in the central region (crude RR; 0.95; 95% CI: 0.94–0.96), and by 4% per year in the western region (crude RR: 0.96; 95% CI: 0.94–0.98). The absolute difference in MMR between the western and eastern regions declined from 65.4 deaths per 100 000 live births in 2000 to 49.4 per 100 000 live births in 2005.

Conclusion

China is making good progress towards achieving the fifth Millennium Development Goal, and there is no evidence of a widening gap between better-off and economically more deprived provinces.     

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

Objective

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

Methods

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

Findings

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

Conclusion

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

Effectiveness of zinc supplementation plus oral rehydration salts for diarrhoea in infants aged less than 6 months in Haryana state, India

Objective

To determine if educating caregivers in providing zinc supplements to infants < 6 months old with acute diarrhoea is effective in treating diarrhoea and preventing acute lower respiratory infections (ALRIs), and whether it leads to a decrease in the use of oral rehydration salts (ORS).

Methods

In this retrospective subgroup analysis of infants aged < 6 months, six clusters were randomly assigned to intervention or control sites. Care providers were trained to give zinc and ORS to children with acute diarrhoea at intervention sites, and only ORS at control sites. Surveys were conducted at 3 and 6 months to assess outcomes. Differences between intervention and control sites in episodes of diarrhoea and ALRI in the preceding 24 hours or 14 days and of hospitalizations in the preceding 3 months were analysed by logistic regression.

Findings

Compared with control sites, intervention sites had lower rates of acute diarrhoea in the preceding 14 days at 3 months (odds ratio, OR: 0.60; 95% confidence interval, CI: 0.43–0.84) and 6 months (OR: 0.72; 95% CI: 0.54–0.94); lower rates of acute diarrhoea in the preceding 24 hours at 3 months (0.66; 95% CI: 0.50–0.87) and of ALRI in the preceding 24 hours at 6 months (OR: 0.59; 95% CI: 0.37–0.93); and lower rates of hospitalization at 6 months for all causes (OR: 0.40; 95% CI: 0.34–0.49), diarrhoea (OR: 0.34; 0.18–0.63) and pasli chalna or pneumonia (OR: 0.36; 95% CI: 0.24–0.55).

Conclusion

Educating caregivers in zinc supplementation and providing zinc to infants < 6 months old can reduce diarrhoea and ALRI. More studies are needed to confirm these findings as these data are from a subgroup analysis.     

Common perinatal mental disorders in northern Viet Nam: community prevalence and health care use

Objective

To establish the prevalence of common perinatal mental disorders their determinants, and their association with preventive health care use among women in one rural and one urban province in northern Viet Nam.

Methods

We conducted a cross-sectional survey of cohorts of pregnant women and mothers of infants recruited systematically in 10 randomly-selected communes. The women participated in psychiatrist-administered structured clinical interviews and separate structured interviews to assess sociodemographic factors, reproductive health, the intimate partner relationship, family violence and the use of preventive and psychiatric health care. Associations between these variables and perinatal mental disorders were explored through univariate analyses and multivariable logistic regression.

Findings

Among women eligible for the study (392), 364 (93%) were recruited. Of these, 29.9% (95% confidence interval, CI: 25.20–34.70) were diagnosed with a common perinatal mental disorder (CPMD). The frequency of such disorders during pregnancy and in the postpartum period was the same. Their prevalence was higher among women in rural provinces (odds ratio, OR: 2.17; 95% CI: 1.19–3.93); exposed to intimate partner violence (OR: 2.11; 95% CI: 1.12–3.96); fearful of other family members (OR: 3.36; 95% CI: 1.05–10.71) or exposed to coincidental life adversity (OR: 4.40; 95% CI: 2.44–7.93). Fewer women with a CPMD used iron supplements than women without a CPMD, but the results were not statistically significant (P = 0.05). None of the women studied had ever received mental health care.

Conclusion

Perinatal depression and anxiety are prevalent in women in northern Viet Nam. These conditions are predominantly determined by social factors, including rural residence, poverty and exposure to family violence. At present the needs of women with common perinatal mental disorders are unrecognized and not attended to and their participation in essential antenatal preventive care appears to be compromised.     

The effectiveness of chronic care management for heart failure: meta-regression analyses to explain the heterogeneity in outcomes

Objective

To support decision making on how to best redesign chronic care by studying the heterogeneity in effectiveness across chronic care management evaluations for heart failure.

Data Sources

Reviews and primary studies that evaluated chronic care management interventions.

Study Design

A systematic review including meta-regression analyses to investigate three potential sources of heterogeneity in effectiveness: study quality, length of follow-up, and number of chronic care model components.

Principal Findings

Our meta-analysis showed that chronic care management reduces mortality by a mean of 18 percent (95 percent CI: 0.72–0.94) and hospitalization by a mean of 18 percent (95 percent CI: 0.76–0.93) and improves quality of life by 7.14 points (95 percent CI: −9.55 to −4.72) on the Minnesota Living with Heart Failure questionnaire. We could not explain the considerable differences in hospitalization and quality of life across the studies.

Conclusion

Chronic care management significantly reduces mortality. Positive effects on hospitalization and quality of life were shown, however, with substantial heterogeneity in effectiveness. This heterogeneity is not explained by study quality, length of follow-up, or the number of chronic care model components. More attention to the development and implementation of chronic care management is needed to support informed decision making on how to best redesign chronic care.     

Iodine status in late pregnancy and psychosocial determinants of iodized salt use in rural northern Viet Nam

Objective

To establish iodine status among pregnant women in rural northern Viet Nam and explore psychosocial predictors of the use of iodized salt in their households.

Methods

This prospective study included pregnant women registered in health stations in randomly-selected communes in Ha Nam province. At recruitment (< 20 weeks of gestation), sociodemographic factors, reproductive health, intimate partner relationship, family violence, symptoms of common mental disorders and use of micronutrient supplements were assessed. During a second assessment (> 28 weeks of gestation) a urine specimen was collected to measure urinary iodine concentration (UIC) and iodized salt use was assessed. Predictors were explored through univariable analyses and multivariable linear and logistic regression.

Findings

The 413 pregnant women who provided data for this study had a median UIC of 70 µg/l; nearly 83% had a UIC lower than the 150 µg/l recommended by the World Health Organization; only 73.6% reported using iodized salt in any form in their households. Iodized salt use was lower among nulliparous women (odds ratio, OR: 0.56; 95% confidence interval, CI: 0.32–0.96); less educated women (OR: 0.34; 95% CI: 0.16–0.71); factory workers or small-scale traders (OR: 0.52; 95% CI: 0.31–0.86), government workers (OR: 0.35; 95% CI: 0.13–0.89) and women with common mental disorders at recruitment (OR: 0.61; 95% CI: 0.38–0.98).

Conclusion

The decline in the use of iodized salt in Viet Nam since the National Iodine Deficiency Disorders Control Programme was suspended in 2005 has placed pregnant women and their infants in rural areas at risk of iodine deficiency disorders.     

Heterogeneity in host risk factors for incident melanoma and non-melanoma skin cancer in a cohort of US women

Background

Melanoma, squamous cell carcinoma (SCC), and basal cell carcinoma (BCC) are 3 types of skin cancer that have distinct biologic characteristics and prognoses. We evaluated phenotypic differences in the risk of these cancers in US women.

Methods

We conducted a prospective study of 113 139 female nurses from 1984 to 2002. Over the 18 years of follow-up, there were 375 cases of melanoma, 495 cases of SCC, and 9423 cases of BCC.

Results

Women with melanoma were more likely to have a family history of melanoma (melanoma: RR 1.94, 95% confidence interval [CI] 1.36–2.76; SCC: RR 0.82, 95% CI 0.58–1.37; BCC: RR 1.49, 95% CI 1.38–1.62) and 6 or more moles on the left arm (melanoma: RR 3.66, 95% CI 2.15–6.24; SCC: RR 1.53, 95% CI 0.83–2.79; BCC: RR 1.48, 95% CI 1.28–1.72). Polytomous logistic regression analysis showed that age at diagnosis (P < 0.0001), family history of melanoma (P = 0.016), and number of moles on the left arm (P = 0.007) were significantly different across the 3 cancers.

Conclusions

This prospective observational study demonstrated that known phenotypic factors for skin cancer have a differential impact on the risk of melanoma, SCC, and BCC.Key words: melanoma, squamous cell carcinoma, basal cell carcinoma, phenotype     

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

Objective

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

Methods

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

Findings

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

Conclusion

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

Prevalence and determinants of common perinatal mental disorders in women in low- and lower-middle-income countries: a systematic review

Objective

To review the evidence about the prevalence and determinants of non-psychotic common perinatal mental disorders (CPMDs) in World Bank categorized low- and lower-middle-income countries.

Methods

Major databases were searched systematically for English-language publications on the prevalence of non-psychotic CPMDs and on their risk factors and determinants. All study designs were included.

Findings

Thirteen papers covering 17 low- and lower-middle-income countries provided findings for pregnant women, and 34, for women who had just given birth. Data on disorders in the antenatal period were available for 9 (8%) countries, and on disorders in the postnatal period, for 17 (15%). Weighted mean prevalence was 15.6% (95% confidence interval, CI: 15.4–15.9) antenatally and 19.8% (19.5–20.0) postnatally. Risk factors were: socioeconomic disadvantage (odds ratio [OR] range: 2.1–13.2); unintended pregnancy (1.6–8.8); being younger (2.1–5.4); being unmarried (3.4–5.8); lacking intimate partner empathy and support (2.0–9.4); having hostile in-laws (2.1–4.4); experiencing intimate partner violence (2.11–6.75); having insufficient emotional and practical support (2.8–6.1); in some settings, giving birth to a female (1.8–2.6), and having a history of mental health problems (5.1–5.6). Protective factors were: having more education (relative risk: 0.5; P = 0.03); having a permanent job (OR: 0.64; 95% CI: 0.4–1.0); being of the ethnic majority (OR: 0.2; 95% CI: 0.1–0.8) and having a kind, trustworthy intimate partner (OR: 0.52; 95% CI: 0.3–0.9).

Conclusion

CPMDs are more prevalent in low- and lower-middle-income countries, particularly among poorer women with gender-based risks or a psychiatric history.     

Quality-of-care audits and perinatal mortality in South Africa

Problem

Suboptimal care contributes to perinatal mortality rates. Quality-of-care audits can be used to identify and change suboptimal care, but it is not known if such audits have reduced perinatal mortality in South Africa.

Approach

We investigated perinatal mortality trends in health facilities that had completed at least five years of quality-of-care audits. In a subset of facilities that began audits from 2006, we analysed modifiable factors that may have contributed to perinatal deaths.

Local setting

Since the 1990s, the perinatal problem identification programme has performed quality-of-care audits in South Africa to record perinatal deaths, identify modifiable factors and motivate change.

Relevant changes

Five years of continuous audits were available for 163 facilities. Perinatal mortality rates decreased in 48 facilities (29%) and increased in 52 (32%). Among the subset of facilities that began audits in 2006, there was a decrease in perinatal mortality of 30% (16/54) but an increase in 35% (19/54). Facilities with increasing perinatal mortality were more likely to identify the following contributing factors: patient delay in seeking help when a baby was ill (odds ratio, OR: 4.67; 95% confidence interval, CI: 1.99–10.97); lack of use of antenatal steroids (OR: 9.57; 95% CI: 2.97–30.81); lack of nursing personnel (OR: 2.67; 95% CI: 1.34–5.33); fetal distress not detected antepartum when the fetus is monitored (OR: 2.92; 95% CI: 1.47–5.8) and poor progress in labour with incorrect interpretation of the partogram (OR: 2.77; 95% CI: 1.43–5.34).

Lessons learnt

Quality-of-care audits were not shown to improve perinatal mortality in this study.     

Integrating antiretroviral therapy into antenatal care and maternal and child health settings: a systematic review and meta-analysis

Objective

To determine whether integrating antiretroviral therapy (ART) into antenatal care (ANC) and maternal and child health (MCH) clinics could improve programmatic and patient outcomes.

Methods

The authors systematically searched PubMed, Embase, African Index Medicus and LiLACS for randomized controlled trials, prospective cohort studies, or retrospective cohort studies comparing outcomes in ANC or MCH clinics that had and had not integrated ART. The outcomes of interest were ART coverage, ART enrolment, ART retention, mortality and transmission of human immunodeficiency virus (HIV).

Findings

Four studies met the inclusion criteria. All were conducted in ANC clinics. Increased enrolment of pregnant women in ART was observed in ANC clinics that had integrated ART (relative risk, RR: 2.09; 95% confidence interval, CI; 1.78–2.46; I²: 15%). Increased ART coverage was also noted in such clinics (RR: 1.37; 95% CI: 1.05–1.79; I²: 83%). Sensitivity analyses revealed a trend for the national prevalence of HIV infection to explain the heterogeneity in the size of the effect of ART integration on ART coverage (P = 0.13). Retention in ART was similar in ANC clinics with and without ART integration.

Conclusion

Although few data were available, ART integration in ANC clinics appears to lead to higher rates of ART enrolment and ART coverage. Rates of retention in ART remain similar to those observed in referral-based models.     

High total serum cholesterol, medication coverage and therapeutic control: an analysis of national health examination survey data from eight countries

Objective

To determine the fraction of individuals with high total serum cholesterol who get diagnosed and effectively treated in eight high- and middle-income countries.

Methods

Using data from nationally representative health examination surveys conducted in 1998–2007, we studied a probability sample of 79 039 adults aged 40–79 years from England, Germany, Japan, Jordan, Mexico, Scotland, Thailand and the United States of America. For each country we calculated the prevalence of high total serum cholesterol (total serum cholesterol ≥ 6.2 mmol/l or ≥ 240 mg/dl) and the mean total serum cholesterol level. We also determined the fractions of individuals being diagnosed, treated with cholesterol-lowering medication and effectively controlled (total serum cholesterol < 6.2 mmol/l or < 240 mg/dl).

Findings

The proportion of undiagnosed individuals was highest in Thailand (78%; 95% confidence interval, CI: 74–82) and lowest in the United States (16%; 95% CI: 13–19). The fraction diagnosed but untreated ranged from 9% in Thailand (95% CI: 8–11) to 53% in Japan (95% CI: 50–57). The proportion being treated who had attained evidence of control ranged from 4% in Germany (95% CI: 3–5) to 58% in Mexico (95% CI: 54–63). Time series estimates showed improved control of high total serum cholesterol over the past two decades in England and the United States.

Conclusion

The percentage of people with high total serum cholesterol who are effectively treated remains small in selected high- and middle-income countries. Many of those affected are unaware of their condition. Untreated high blood cholesterol represents a missed opportunity in the face of a global epidemic of chronic diseases.     

Childhood and adult mortality from unintentional falls in India

Objective

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

Methods

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

Findings

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

Conclusion

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

Arsenic exposure in pregnancy increases the risk of lower respiratory tract infection and diarrhea during infancy in Bangladesh

Background

Previous studies have reported associations between prenatal arsenic exposure and increased risk of infant mortality. An increase in infectious diseases has been proposed as the underlying cause of these associations, but there is no epidemiologic research to support the hypothesis.

Objective

We evaluated the association between arsenic exposure in pregnancy and morbidity during infancy.

Methods

This prospective population-based cohort study included 1,552 live-born infants of women enrolled during 2002–2004 in Matlab, Bangladesh. Arsenic exposure was assessed by the concentrations of metabolites of inorganic arsenic in maternal urine samples collected at gestational weeks 8 and 30. Information on symptoms of lower respiratory tract infection (LRTI) and diarrhea in infants was collected by 7-day recalls at monthly home visits.

Results

In total, 115,850 person-days of observation were contributed by the infants during a 12-month follow-up period. The estimated risk of LRTI and severe LRTI increased by 69% [adjusted relative risk (RR) = 1.69; 95% confidence interval (CI), 1.36–2.09)] and 54% (RR = 1.54; 95% CI, 1.21–1.97), respectively, for infants of mothers with urinary arsenic concentrations in the highest quintile (average of arsenic concentrations measured in early and late gestation, 262–977 μg/L) relative to those with exposure in the lowest quintile (< 39 μg/L). The corresponding figure for diarrhea was 20% (RR = 1.20; 95% CI, 1.01–1.43).

Conclusions

Arsenic exposure during pregnancy was associated with increased morbidity in infectious diseases during infancy. Taken together with the previous evidence of adverse effects on health, the findings strongly emphasize the need to reduce arsenic exposure via drinking water.     

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

Objective

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

Methods

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

Findings

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

Conclusion

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