Impact of control measures on malaria transmission and general mortality.

This paper is an attempt to relate modifications observed in general and infant mortality rates with the dynamic changes in transmission induced by malaria control measures. The observations indicated relationships between the efficacy of control and a decrease in mortality. The daily parasitological inoculation rate was reduced from 0.00958 infective bites per individual before treatment to 0.00037 after treatment (a decrease of 96%). In two years, general mortality decreased from 23.9 to 13.5 deaths per 1000 population and infant mortality decreased from 157 to 93 per 1000 live births. This indirect benefit of malaria control deserves attention in a wider assessment of measures directed against vector-borne diseases.     

中国儿童死亡状况的国际比较

目的:从全球视角研究中国在实现MDG4进程中的现状和趋势,分析与中国国情类似国家之间的差距。方法:利用WHO和UNICEF年度报告公布的数据,一是描述世界婴儿以及5岁以下儿童死亡的现状、发展趋势;二是比较中国的婴儿以及5岁以下儿童死亡负担及其变化趋势在世界各国中所处的位置;三是分别选出人均GDP(ppp)、总和生育率、成人识字率以及城市化率4项指标与中国类似的10个国家进行比较。结果:16年间虽然各国儿童健康总体状况持续改善,但是离MDG4所要求的4.3%的下降速率尚存在不小差距。中国在儿童死亡率的相对水平上表现尚可,但是绝对死亡负担居世界前列。从下降速率来看,中国在世界上排位居中,但近年的世界排名有所退步。同时婴儿死亡率的平均年下降速率为3.29%,5岁以下儿童死亡率平均年下降速率为3.35%,略低于实现MDG4所要求的4.3%。结论:中国的婴儿以及5岁以下儿童死亡率均低于世界平均水平,在死亡率的绝对水平上表现尚可。但是因为人口基数较大,婴儿以及5岁以下儿童死亡人数的负担居世界前列。与中国国情类似的国家中,秘鲁、南斯拉夫、伯利兹、斯里兰卡、越南、印尼和埃及的表现都要优于中国,其成功经验值得借鉴。     

Cost-effectiveness of malaria control interventions when malaria mortality is low: insecticide-treated nets versus in-house residual spraying in India

Malaria is one of the leading causes of morbidity and mortality in the developing world and a major public health problem in India. Disillusioned by in-house residual spraying (IRS), and increasingly aware that insecticide-treated nets (ITNs) have proved to be effective in reducing malaria mortality and morbidity in various epidemiological settings, policy-makers in India are keen to identify which is the more cost-effective malaria control intervention. A community randomised controlled trial was set up in Surat to compare the effectiveness and efficiency of IRS and ITNs. Both control strategies were shown to be effective in preventing malaria over the base-case scenario of early diagnosis and prompt treatment. The mean costs per case averted for ITNs was statistically significantly lower (Rs. 1848, 1567-2209; US$ 52) than IRS (Rs. 3121, 2386-4177, US$ 87). The incremental cost-effectiveness ratio for ITNs over IRS was Rs. 799 (US$ 22). The conclusions were robust to changes in assumptions. This study expands the scope of recent comparative economic evaluations of ITNs and IRS, since it was carried out in a low mortality malaria endemic area.     

Evaluation of lambdacyhalothrin-impregnated bednets in a malaria endemic area of India. Part 2. Impact on malaria vectors

In malaria endemic villages of the Indian State of Orissa, the impact of bednets treated with lambdacyhalothrin at 25 mg/m2 on malaria vectors was assessed during a 3-year intervention trial beginning in May 1990. The main malaria vector was Anopheles culicifacies with a small contribution from Anopheles fluviatilis. The impregnated bednets caused a significant reduction in vector density as assessed by morning indoor resting catches, man-biting rate, light trapping, the proportion of females engorged with human blood, and the parity rate as compared with villages with untreated or no nets. No statistically significant difference was observed in these parameters between the villages with untreated nets or no nets. The trial demonstrated that the lambdacyhalothrin-treated nets were highly effective against the malaria vectors.     

Equitable child health interventions: the impact of improved water and sanitation on inequalities in child mortality in Stockholm, 1878 to 1925

Today, many of the 10 million childhood deaths each year are caused by diseases of poverty--diarrhea and pneumonia, for example, which were previously major causes of childhood death in many European countries. Specific analyses of the historical decline of child mortality may shed light on the potential equity impact of interventions to reduce child mortality. In our study of the impact of improved water and sanitation in Stockholm from 1878 to 1925, we examined the decline in overall and diarrhea mortality among children, both in general and by socioeconomic group. We report a decline in overall mortality and of diarrhea mortality and a leveling out of socioeconomic differences in child mortality due to diarrheal diseases, but not of overall mortality. The contribution of general and targeted policies is discussed.     

The burden of malaria mortality among African children in the year 2000

BACKGROUND: Although malaria is a leading cause of child deaths, few well-documented estimates of its direct and indirect burden exist. Our objective was to estimate the number of deaths directly attributable to malaria among children <5 years old in sub-Saharan Africa for the year 2000. METHODS: We divided the population into six sub-populations and, using results of studies identified in a literature review, estimated a malaria mortality rate for each sub-population. Malaria deaths were estimated by multiplying each sub-population by its corresponding rate. Sensitivity analyses were performed to assess the impact of varying key assumptions. RESULTS: The literature review identified 31 studies from 14 countries in middle Africa and 17 studies and reports from four countries in southern Africa. In 2000, we estimated that approximately 100 million children lived in areas where malaria transmission occurs and that 803 620 (precision estimate: 705 821-901 418) children died from the direct effects of malaria. For all of sub-Saharan Africa, including populations not exposed to malaria, malaria accounted for 18.0% (precision estimate: 15.8-20.2%) of child deaths. These estimates were sensitive to extreme assumptions about the causes of deaths with no known cause. CONCLUSIONS: These estimates, based on the best available data and methods, clearly demonstrate malaria's enormous mortality burden. We emphasize that these estimates are an approximation with many limitations and that the estimates do not account for malaria's large indirect burden. We describe information needs that, if filled, might improve the validity of future estimates.     

Spillover of cause-specific longevity interventions: an independent mortality risk model

As an alternative to the "competing mortality risk model", this paper presents an "independent mortality risk model" in which the complementarity among various longevity investments is less obvious. In studying spillover effects of cause-specific longevity interventions, it distinguishes between two types of such interventions: cause-specific price reductions and cause-specific direct provisions. It finds that a cause-specific direct provision always has a positive spillover effect on longevity investments for other causes, but a cause-specific price reduction may have a negative spillover effect due to a substitution effect.     

Impact of age on associations between weight and mortality

The effect of age on the weight associated with the lowest mortality and the effect of age on the mortality risk associated with obesity are issues fraught with methodologic complexities. Current evidence supports the notion that the body mass index associated with the lowest mortality falls within the range of 18.5 to 24.9 in men and women between the ages of 30 and 74. The impact of age on the mortality risk associated with obesity changes with age, however, and the direction of the trend depends upon the measure used.     

Impact of rural family physician program on child mortality rates in Iran: a time-series study

Background

The rural family physician program and social protection scheme were started in Iran about 10 years ago, and no comprehensive study has been carried out to investigate the effects of this program on mortality-related health indicators yet. The present study aims to examine the impacts of implementation of the family physician program and rural insurance program, which was launched in June 2005, on neonatal (NMR), infant (IMR), and under-5-year (U5MR) mortality rates in rural areas of Iran between 1995 and 2011, using a time-series analysis.

Methods

Three segmented regression models were built to evaluate the effects of the program on NMR, IMR, and U5MR, and several independent variables were entered into the models, including annual incremental effect of the program (variable of interest), time effect, behvarz density, effect of the family physician and rural insurance programs, as well as socioeconomic variables including years of schooling, wealth index, sex ratio, and logarithmic scales of rural population size in each area. Data were gathered from secondary sources and other studies. Data pertaining to the year 2007 were excluded from the final analysis due to their inaccuracy.

Results

Our results show that the incremental effect of implementing the rural family physician program is associated with significant reductions in NMR (β?=???0.341. p???value?=?0.003) and IMR (β?=???0.016. p???value?=?0.009). Although the association between this effect and reductions in U5MR were evident, they were not statistically significant (β?=???0.003. p???value?=?0.542). Moreover, wealth status of inhabitants was associated with reductions in NMR (β?=???0.889. p???value?=?0.001), IMR (β?=???0.052. p???value?<?0.001), and U5MR (β?=???0.055. p???value?<?0.001) in the time period of the study.

Conclusions

In this nationally representative study, we showed that implementation of the second health system reform in Iran, known as the family physician program and social protection scheme for rural inhabitants, is associated with significant reductions in NMR and IMR. However, reported reductions in U5MR were not found to be statistically associated with the launch of the program.The advantage of this study was the ability to depict a more precise picture of the outcomes of a national-level intervention.

     

Impact of a community-based comprehensive primary healthcare programme on infant and child mortality in Bolivia

Community-based comprehensive primary healthcare programmes are a widely-promoted strategy for improving child survival in less-developed countries, but limited documentation exists concerning their effectiveness in actually reducing child mortality. This study examined the impact of a community-based comprehensive primary healthcare programme on child survival in Bolivia. Mortality rates from two intervention areas where Andean Rural Health Care (ARHC) had been conducting child-survival activities for 5-9 years were compared with those from two geographically-adjacent comparison areas that lacked such activities and that were virtually identical to the intervention areas in socioeconomic characteristics. Vital events were registered at the time of regular visit to all homes. In the comparison areas, limited services were available which reached only a small percentage of the population, while in the intervention areas, prenatal care, immunizations, growth monitoring, nutrition rehabilitation, and acute curative services were readily available to the entire population. In 1992-1993, the annual rates of mortality of children, aged less than five years, were 205.5 per 1,000 and 98.5 per 1,000 in the comparison and intervention areas respectively. The absolute difference in mortality of 107.0 deaths per 1,000 (95% confidence interval [CI], 72.7-141.3 per 1,000) represented 52.1% (95% CI, 35.2-68.8%) lower mortality of children aged less than five years in the intervention areas compared to the control communities. These results suggest that the provision of community-based, integrated health services can significantly improve child survival in poor countries. Better-designed and larger field trials of community-based comprehensive primary healthcare programmes in multiple regions of the world are needed to provide a stronger scientific basis for developing this approach further in developing countries.