Influenza-associated mortality in temperate and subtropical Chinese cities, 2003-2008

Objective

To estimate influenza-associated mortality in urban China.

Methods

Influenza-associated excess mortality for the period 2003–2008 was estimated in three cities in temperate northern China and five cities in the subtropical south of the country. The estimates were derived from models based on negative binomial regressions, vital statistics and the results of weekly influenza virus surveillance.

Findings

Annual influenza-associated excess mortality, for all causes, was 18.0 (range: 10.9–32.7) deaths per 100 000 population in the northern cities and 11.3 (range: 7.3–17.8) deaths per 100 000 in the southern cities. Excess mortality for respiratory and circulatory disease was 12.4 (range: 7.4–22.2) and 8.8 (range: 5.5–13.6) deaths per 100 000 people in the northern and southern cities, respectively. Most (86%) deaths occurred among people aged ≥ 65 years. Influenza-associated excess mortality was higher in B-virus-dominant seasons than in seasons when A(H3N2) or A(H1N1) predominated, and more than half of all influenza-associated mortality was associated with influenza B virus.

Conclusion

Between 2003 and 2008, seasonal influenza, particularly that caused by the influenza B virus, was associated with substantial mortality in three cities in the temperate north of China and five cities in the subtropical south of the country.     

Influenza-associated mortality in 2009 in four sentinel sites in Bangladesh

Objective

To estimate influenza-associated mortality in Bangladesh in 2009.

Methods

In four hospitals in Bangladesh, respiratory samples were collected twice a month throughout 2009 from inpatients aged < 5 years with severe pneumonia and from older inpatients with severe acute respiratory infection. The samples were tested for influenza virus ribonucleic acid (RNA) using polymerase chain reaction. The deaths in 2009 in five randomly selected unions (the smallest administrative units in Bangladesh) in each hospital’s catchment area were then investigated using formal records and informal group discussions. The deaths of those who had reportedly died within 14 days of suddenly developing fever with cough and/or a sore throat were assumed to be influenza-associated. The rate of such deaths in 2009 in each of the catchment areas was then estimated from the number of apparently influenza-associated deaths in the sampled unions, the proportion of the sampled inpatients in the local hospital who tested positive for influenza virus RNA, and the estimated number of residents of the sampled unions.

Findings

Of the 2500 people known to have died in 2009 in all 20 study unions, 346 (14%) reportedly had fever with cough and/or sore throat within 14 days of their deaths. The estimated mean annual influenza-associated mortality in these unions was 11 per 100 000 population: 1.5, 4.0 and 125 deaths per 100 000 among those aged < 5, 5–59 and > 59 years, respectively.

Conclusion

The highest burden of influenza-associated mortality in Bangladesh in 2009 was among the elderly.     

Estimated incidence of influenza-virus-associated severe pneumonia in children in El Salvador, 2008�C2010

Objective

To estimate the incidence of influenza-virus-associated severe pneumonia among Salvadorian children aged < 5 years.

Methods

Data on children aged < 5 years admitted with severe pneumonia to a sentinel hospital in the western region were collected weekly. Nasal and oropharyngeal swab specimens were collected from a convenience sample of case patients for respiratory virus testing. A health-care utilization survey was conducted in the hospital catchment area to determine the proportion of residents who sought care at the hospital. The incidence of influenza-virus-associated severe pneumonia among all Salvadorian children aged < 5 years was estimated from surveillance and census data, with adjustment for health-care utilization. Influenza virus strains were characterized by the United States Centers for Disease Control and Prevention to determine their correspondence with northern and southern hemisphere influenza vaccine formulations.

Findings

Physicians identified 2554 cases of severe pneumonia. Samples from 608 cases were tested for respiratory viruses and 37 (6%) were positive for influenza virus. The estimated incidence of influenza-virus-associated severe pneumonia was 3.2 cases per 1000 person–years (95% confidence interval, CI: 2.8–3.7) overall, 1.5 cases per 1000 person–years (95% CI: 1.0–2.0) during 2008, 7.6 cases per 1000 person–years (95% CI: 6.5–8.9) during 2009 and 0.6 cases per 1000 person–years (95% CI: 0.3–1.0) during 2010. Northern and southern hemisphere vaccine formulations matched influenza virus strains isolated during 2008 and 2010.

Conclusion

Influenza-virus-associated severe pneumonia occurred frequently among young Salvadorian children during 2008–2010. Antigens in northern and southern hemisphere influenza vaccine formulations corresponded to circulating strains.     

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.     

Pneumonia and influenza,and respiratory and circulatory hospital admissions in Belgium: a retrospective database study

Background

Influenza infections can lead to viral pneumonia, upper respiratory tract infection or facilitate co-infection by other pathogens. Influenza is associated with the exacerbation of chronic conditions like diabetes and cardiovascular disease and consequently, these result in acute hospitalizations. This study estimated the number, proportions and costs from a payer perspective of hospital admissions related to severe acute respiratory infections.

Methods

We analyzed retrospectively, a database of all acute inpatient stays from a non-random sample of eleven hospitals using the Belgian Minimal Hospital Summary Data. Codes from the International Classification of Diseases, Ninth Revision, Clinical Modification was used to identify and diagnose cases of pneumonia and influenza (PI), respiratory and circulatory (RC), and the related complications.

Results

During 2002–2007, we estimated relative hospital admission rates of 1.69% (20960/1237517) and 21.79% (269634/1237517) due to primary PI and RC, respectively. The highest numbers of hospital admissions with primary diagnosis as PI were reported for the elderly patient group (n = 10184) followed by for children below five years of age (n = 3451).Of the total primary PI and RC hospital admissions, 56.14% (11768/20960) and 63.48% (171172/269634) of cases had at least one possible influenza-related complication with the highest incidence of complications reported for the elderly patient group. Overall mortality rate in patients with PI and RC were 9.25% (1938/20960) and 5.51% (14859/269634), respectively. Average lengths of hospital stay for PI was 11.6 ± 12.3 days whereas for RC it was 9.1 ± 12.7 days. Annual average costs were 20.2 and 274.6 million Euros for PI and RC hospitalizations. Average cost per hospitalization for PI and RC were 5779 and 6111 Euros (2007), respectively. These costs increased with the presence of complications (PI: 7159, RC: 7549 Euros).

Conclusion

The clinical and economic burden of primary influenza hospitalizations in Belgium is substantial. The elderly patient group together with children aged <18 years were attributed with the majority of all primary PI and RC hospitalizations.

Trial registration

Not applicable.     

Survey of children accessing HIV services in a high prevalence setting: time for adolescents to count?

Objective

To establish the proportion of adolescents among children infected with human immunodeficiency virus (HIV) in Zimbabwe who receive HIV care and support, and what clinic staff perceives to be the main problems faced by HIV-infected children and adolescents.

Methods

In July 2008, we sent a questionnaire to all 131 facilities providing HIV care in Zimbabwe. In it we requested an age breakdown of the children (aged 0–19 years) registered for care and asked what were the two major problems faced by younger children (0–5 years) and adolescents (10–19 years).

Findings

Nationally, 115 (88%) facilities responded. In 98 (75%) that provided complete data, 196 032 patients were registered and 24 958 (13%) of them were children. Of children under HIV care, 33% were aged 0–4 years; 25%, 5–9 years; 25%, 10–14 years; and 17%, 15–19 years. Staff highlighted differences in the problems most commonly faced by younger children and adolescents. For younger children, such problems were malnutrition and lack of appropriate drugs (cited by 46% and 40% of clinics, respectively); for adolescents they concerned psychosocial issues and poor drug adherence (cited by 56% and 36%, respectively).

Conclusion

Interventions for the large cohort of adolescents who are receiving HIV care in Zimbabwe need to target the psychosocial concerns and poor drug adherence reported by staff as being the main concerns in this age group.     

HIV infection in older adults in sub-Saharan Africa: extrapolating prevalence from existing data

Objective

To quantify the number of cases and prevalence of human immunodeficiency virus (HIV) infection among older adults in sub-Saharan Africa.

Methods

We reviewed data from Demographic and Health Surveys (DHS). Although in these surveys all female respondents are < 50 years of age, 18 of the surveys contained data on HIV infection among men aged ≥ 50 years. To estimate the percentage of older adults (i.e. people ≥ 50 years of age) who were positive for HIV (HIV+), we extrapolated from data from the Joint United Nations Programme on HIV/AIDS on the estimated number of people living with HIV and on HIV infection prevalence among adults aged 15–49 years.

Findings

In 2007, approximately 3 million people aged ≥ 50 years were living with HIV in sub-Saharan Africa. The prevalence of HIV infection in this group was 4.0%, compared with 5.0% among those aged 15–49 years. Of the approximately 21 million people in sub-Saharan Africa aged ≥ 15 years that were HIV+, 14.3% were ≥ 50 years old.

Conclusion

To better reflect the longer survival of people living with HIV and the ageing of the HIV+ population, indicators of the prevalence of HIV infection should be expanded to include people > 49 years of age. Little is known about comorbidity and sexual behaviour among HIV+ older adults or about the biological and cultural factors that increase the risk of transmission. HIV services need to be better targeted to respond to the growing needs of older adults living with HIV.     

Increased paediatric hospitalizations for empyema in Australia after introduction of the 7-valent pneumococcal conjugate vaccine

Objective

To examine rates of paediatric hospitalization for empyema and pneumonia in Australia before and after the introduction of the seven-valent pneumococcal conjugate vaccine (PCV7).

Methods

Rates of paediatric hospitalization for empyema and pneumonia (bacterial, viral and all types) were calculated following the codes of the International Classification of Diseases, tenth revision (ICD-10) as a principal diagnosis. The expected number of hospitalizations after the PCV7 was introduced was estimated on the basis of the observed number of hospitalizations before the introduction of the PCV7. Incidence rate differences (IRDs) and incidence rate ratios (IRRs) were calculated. Hospitalization incidence in each study period was expressed as the number of hospitalizations per million (10⁶) person–years. The population of children aged 0–19 years in Australia from 1998 to 2004 and from 2005 to 2010, as reported by the Australian Bureau of Statistics, was used to calculate the number of person–years in each period.

Findings

In the 5 years following the introduction of the PCV7, hospitalizations for pneumonia were fewer than expected (15 304 fewer; 95% confidence interval, CI: 14 646–15 960; IRD: −552 per 10⁶ person–years; 95% CI: −576 to −529 per 10⁶ person–years; IRR: 0.78; 95% CI: 0.77–0.78). Hospitalizations for empyema, on the other hand, were more than expected (83 more; 95% CI: 37–128; IRD: 3 per 10⁶ person–years; 95% CI: 1–5 per 10⁶ person–years; IRR: 1.35; 95% CI: 1.14–1.59). Reductions in hospitalizations were observed for all ICD-10 pneumonia codes across all age groups. The increase in empyema hospitalizations was only significant among children aged 1 to 4 years.

Conclusion

The introduction of the PCV7 in Australia was associated with a substantial decrease in hospitalizations for childhood pneumonia and a small increase in hospitalizations for empyema.     

National dengue surveillance in Cambodia 1980�C2008: epidemiological and virological trends and the impact of vector control

Objective

Dengue has been reportable in Cambodia since 1980. Virological surveillance began in 2000 and sentinel surveillance was established at six hospitals in 2001. Currently, national surveillance comprises passive and active data collection and reporting on hospitalized children aged 0–15 years. This report summarizes surveillance data collected since 1980.

Methods

Crude data for 1980–2001 are presented, while data from 2002–2008 are used to describe disease trends and the effect of vector control interventions. Trends in dengue incidence were analysed using the Prais–Winsten generalized linear regression model for time series.

Findings

During 1980–2001, epidemics occurred in cycles of 3–4 years, with the cycles subsequently becoming less prominent. For 2002–2008 data, linear regression analysis detected no significant trend in the annual reported age-adjusted incidence of dengue (incidence range: 0.7–3.0 per 1000 population). The incidence declined in 2.7% of the 185 districts studied, was unchanged in 86.2% and increased in 9.6%. The age-specific incidence was highest in infants aged < 1 year and children aged 4–6 years. The incidence was higher during rainy seasons. All four dengue virus (DENV) serotypes were permanently in circulation, though the predominant serotype has alternated between DENV-3 and DENV-2 since 2000. Although larvicide has been distributed in 94 districts since 2002, logistic regression analysis showed no association between the intervention and dengue incidence.

Conclusion

The dengue burden remained high among young children in Cambodia, which reflects intense transmission. The national vector control programme appeared to have little impact on disease incidence.     

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.     

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.     

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.     

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.     

Elimination of paediatric HIV in KwaZulu-Natal, South Africa: large-scale assessment of interventions for the prevention of mother-to-child transmission

Objective

To report the rates of mother-to-child transmission (MTCT) of the human immunodeficiency virus (HIV), and the coverage of interventions designed to prevent such transmission, in KwaZulu-Natal.

Methods

Mothers with infants aged ≤ 16 weeks and fathers or legal guardians with infants aged 4–8 weeks who, between May 2008 and April 2009, attended immunization clinics in six districts of KwaZulu-Natal were included. The mothers’ uptake of interventions for the prevention of MTCT was explored. Blood samples from infants aged 4–8 weeks were tested for anti-HIV antibodies and, if antibody-positive, for HIV desoxyribonucleic acid (DNA).

Findings

Of the 19 494 mothers investigated, 89·9% reported having had an HIV test in their recent pregnancy. Of the 19 138 mothers who reported ever having had an HIV test, 34.4% reported that they had been found HIV-positive and, of these, 13.7% had started lifelong antiretroviral treatment and 67.2% had received zidovudine and nevirapine. Overall, 40.4% of the 7981 infants tested were found positive for anti-HIV antibodies, indicating HIV exposure. Just 7.1% of the infants checked for HIV DNA (equating to 2.8% of the infants tested for anti-HIV antibodies) were found positive.

Conclusion

The low levels of MTCT observed among the infants indicate the rapid, successful implementation of interventions for the prevention of such transmission. Sampling at immunization clinics appears to offer a robust method of estimating the impact of interventions designed to reduce such transmission. Large-scale elimination of paediatric HIV infections appears feasible, although this goal has not yet been fully achieved in KwaZulu-Natal.     

Diagnostic performance of visible severe wasting for identifying severe acute malnutrition in children admitted to hospital in Kenya

Objective

To determine the diagnostic value of visible severe wasting in identifying severe acute malnutrition at two public hospitals in Kenya.

Methods

This was a cross-sectional study of children aged 6 to 59.9 months admitted to one rural and one urban hospital. On admission, mid-upper arm circumference (MUAC), weight and height were measured and the presence of visible severe wasting was assessed. The diagnostic performance of visible severe wasting was evaluated against anthropometric criteria.

Findings

Of 11 166 children admitted, 563 (5%) had kwashiorkor and 1406 (12.5%) were severely wasted (MUAC < 11.5 cm). The combined sensitivity and specificity of visible severe wasting at the two hospitals, as assessed against a MUAC < 11.5 cm, were 54% (95% confidence interval, CI: 51–56) and 96% (95% CI: 96–97), respectively; at one hospital, its sensitivity and specificity against a weight-for-height z-score below −3 were 44.7% (95% CI: 42–48) and 96.5% (95% CI: 96–97), respectively. Severely wasted children who were correctly identified by visible severe wasting were consistently older, more severely wasted, more often having kwashiorkor, more often positive to the human immunodeficiency virus, ill for a longer period and at greater risk of death. Visible severe wasting had lower sensitivity for determining the risk of death than the anthropometric measures. There was no evidence to support measuring both MUAC and weight-for-height z-score.

Conclusion

Visible severe wasting failed to detect approximately half of the children admitted to hospital with severe acute malnutrition diagnosed anthropometrically. Routine screening by MUAC is quick, simple and inexpensive and should be part of the standard assessment of all paediatric hospital admissions in the study setting.     

Mid-upper arm circumference at age of routine infant vaccination to identify infants at elevated risk of death: a retrospective cohort study in the Gambia

Objective

To determine the predictive value for death before 12 months of age of mid-upper arm circumference (MUAC) and weight-for-length Z score (WFLz).

Methods

A retrospective cohort analysis of infants living in Keneba, in rural Gambia, was conducted. Anthropometric measures were obtained from demographic surveillance system records for infants registered between February 1974 and July 2008 who had had MUAC and WFLz recorded at 6–14 weeks of age and vital status recorded at least once more. Hazard ratios (HRs), population attributable fractions and areas under receiver operating characteristic (ROC) curves were estimated to assess the predictive value for death in infancy of MUAC and WFLz.

Findings

Of 2876 infants included in the analysis, 40 died before the age of 12 months. The HR for death in this group versus in well-nourished infants was 5.8 (95% confidence interval, CI: 1.6–21) for a WFLz < −3. HRs for MUACs below the thresholds of 115 mm, 110 mm and 105 mm were 4.5 (95% CI: 1.4–15), 9.5 (95% CI: 2.6–35) and 23 (95% CI: 4.2–122), respectively. The attributable fractions for a MUAC < 130 mm and a WFLz < 0 were 51% and 13%, respectively. The areas under the ROC curve for death in infancy were 0.55 (95% CI: 0.46 to 0.64) for WFLz and 0.64 (95% CI: 0.55 to 0.73) for MUAC.

Conclusion

Among infants aged 6 to 14 weeks, unadjusted MUAC showed good performance in identifying infants at increased risk of death.     

Scaling up antiretroviral therapy for HIV-infected children in C?te d’Ivoire: determinants of survival and loss to programme

Objective

To investigate deaths and losses to follow-up in a programme designed to scale up antiretroviral therapy (ART) for HIV-infected children in Côte d’Ivoire.

Methods

Between 2004 and 2007, HIV-exposed children at 19 centres were offered free HIV serum tests (polymerase chain reaction tests in those aged < 18 months) and ART. Computerized monitoring was used to determine: (i) the number of confirmed HIV infections, (ii) losses to the programme (i.e. death or loss to follow-up) before ART, (iii) mortality and loss-to-programme rates during 12 months of ART, and (iv) determinants of mortality and losses to the programme.

Findings

The analysis included 3876 ART-naïve children. Of the 1766 with HIV-1 infections (17% aged < 18 months), 124 (7.0%) died, 52 (2.9%) left the programme, 354 (20%) were lost to follow-up before ART, 259 (15%) remained in care without ART, and 977 (55%) started ART (median age: 63 months). The overall mortality rate during ART was significantly higher in the first 3 months than in months 4–12: 32.8 and 6.9 per 100 child-years of follow-up, respectively. Loss-to-programme rates were roughly double mortality rates and followed the same trend with duration of ART. Independent predictors of 12-month mortality on ART were pre-ART weight-for-age z-score < –2, percentage of CD4+ T lymphocytes < 10, World Health Organization HIV/AIDS clinical stage 3 or 4, and blood haemoglobin < 8 g/dl.

Conclusion

The large-scale programme to scale up paediatric ART in Côte d’Ivoire was effective. However, ART was often given too late, and early mortality and losses to programme before and just after ART initiation were major problems.     

Potential cardiovascular mortality reductions with stricter food policies in the United Kingdom of Great Britain and Northern Ireland

Objective

To estimate how much more cardiovascular disease (CVD) mortality could be reduced in the United Kingdom through more progressive nutritional targets.

Methods

Potential reductions in CVD mortality in the United Kingdom between 2006 (baseline) and 2015 were estimated by synthesizing data on population, diet and mortality among adults aged 25 to 84 years. The effect of specific dietary changes on CVD mortality was obtained from recent meta-analyses. The potential reduction in CVD deaths was then estimated for two dietary policy scenarios: (i) modest improvements (simply assuming recent trends will continue until 2015) and (ii) more substantial but feasible reductions (already seen in several countries) in saturated fats, industrial trans fats and salt consumption, plus increased fruit and vegetable intake. A probabilistic sensitivity analysis was conducted. Results were stratified by age and sex.

Findings

The first scenario would result in approximately 12 500 fewer CVD deaths per year (range: 5500–30 300). Approximately 4800 fewer deaths from coronary heart disease and 1800 fewer deaths from stroke would occur among men, and 3500 and 2400 fewer, respectively, would occur among women. More substantial dietary improvements (no industrial trans fats, reduction in saturated fats and salt and substantial increases in fruit and vegetable intake) could result in approximately 30 000 fewer (range: 13 300–74 900) CVD deaths.

Conclusion

Excess dietary trans fats, saturated fats and salt, along with insufficient fruits and vegetables, generate a substantial burden of CVD in the United Kingdom. Further improvements resembling those attained by other countries are achievable through stricter dietary policies.     

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.