Economic evaluation of neonatal care packages in a cluster-randomized controlled trial in Sylhet,Bangladesh

Objective

To evaluate and compare the cost-effectiveness of two strategies for neonatal care in Sylhet division, Bangladesh.

Methods

In a cluster-randomized controlled trial, two strategies for neonatal care – known as home care and community care – were compared with existing services. For each study arm, economic costs were estimated from a societal perspective, inclusive of programme costs, provider costs and household out-of-pocket payments on care-seeking. Neonatal mortality in each study arm was determined through household surveys. The incremental cost-effectiveness of each strategy – compared with that of the pre-existing levels of maternal and neonatal care – was then estimated. The levels of uncertainty in our estimates were quantified through probabilistic sensitivity analysis.

Findings

The incremental programme costs of implementing the home-care package were 2939 (95% confidence interval, CI: 1833–7616) United States dollars (US$) per neonatal death averted and US$ 103.49 (95% CI: 64.72–265.93) per disability-adjusted life year (DALY) averted. The corresponding total societal costs were US$ 2971 (95% CI: 1844–7628) and US$ 104.62 (95% CI: 65.15–266.60), respectively. The home-care package was cost-effective – with 95% certainty – if healthy life years were valued above US$ 214 per DALY averted. In contrast, implementation of the community-care strategy led to no reduction in neonatal mortality and did not appear to be cost-effective.

Conclusion

The home-care package represents a highly cost-effective intervention strategy that should be considered for replication and scale-up in Bangladesh and similar settings elsewhere.     

PRURITUS AND HLA IN HEMODIALYSIS PATIENTS

Hepatitis C virus (HCV) infection is known to increase morbidity and mortality in the dialysis population. Renal transplantation is an offered treatment option after a careful pretransplant evaluation. This study assessed the impact of HCV infection on patient and allograft survival rates in a selected group of dialysis patients and kidney transplant recipients.
The study included 252 end-stage renal disease patients who were receiving hemodialysis (HD) treatment or who received renal transplantation at our centre in 1995–96. Of the total, 116 [94 HCV (–) and 22 HCV (+)] underwent transplantation and 134 [106 HCV (–) and 30 HCV (+)] remained on HD. We retrospectively investigated 5 years of follow-up findings in the records of these patients. All 22 HCV (+) individuals underwent liver biopsy to ensure there was no advanced liver disease before transplantation. None of the recipients or HD patients showed decompensation related to liver disease during follow up.
The overall 5-year patient survival rates for the kidney recipient and HD groups were 85.2% and 74.5%, respectively. Comparison of outcomes for the HCV (+) recipients had a significantly higher 5-year survival rate than the HCV (+) HD patients ( P <0.04). The 3-year graft survival rates for the HCV (+) and HCV (–) transplant recipients were comparable, but the risks of chronic rejection and graft loss at 5 years were higher in the HCV (+) group ( P <0.02, P <0.006, respectively). In conclusion, renal transplantation should be the preferred therapy in HCV-infected dialysis patients because it improves the survival rates. HCV infection is associated with increased rates of chronic rejection and graft loss at 5 years post-transplantation.     

Antimicrobial and antispasmodic activity of leaf extract and fractions of Stachytarpheta cayennensis

ObjectiveTo investigate the antimicrobial activity of the methanol leaf extract (ME), n-hexane fraction (HF), ethylacetate fraction (EF) and methanol fraction (MF), of Stachytarpheta cayennensis C. Rich (verbenaceae) as well as to ascertain the antispasmodic effects of the ME and the various fractions (HF, EF and MF) on acetylcholine (Ach) and histamine (H) induced contractions on isolated guinea pig ileum.MethodsThe in vitro agar well diffusion method was used for the antimicrobial studies while the isolated tissue method was employed for the antispasmodic test. Organisms used were all clinical isolates of Bacillus subtilis, Staphylococcus aureus, Pseudomonas aeruginosa, Salmonella paratyphi, Candida albicans and Aspergillus niger.ResultsThe extract and fractions exhibited dose dependent inhibition against all the bacteria tested and also exhibited insignificant antifungal activity against Candida albicans and Aspergillus niger. The minimum inhibitory concentration (MIC) of the extract and fractions (mg/mL) on Bacillus subtilis, Staphylococcus aureus, Pseudomonas aeruginosa and Salmonella paratyphi respectively were ME 5.62, 14.12, 22.38, 2.11; EF 1.25, 6.30, 9.40, 9.40 and MF 3.98, 8.81, 39.80, 21.13. The n-hexane fraction exhibited MIC of 1.07 mg/mL against only Bacillus subtilis. The extract and fractions exhibited significant (P< 0.05) dose dependent attenuation of contractions induced by acetylcholine and histamine on isolated guinea pig ileum. Concentrations of the extract and fractions (μg/mL) which evoked 50% inhibition of maximal response exhibited by Ach were ME 0.64, HF 0.16, EF 0.08 and MF 0.15, while that of histamine included ME 5.12, HF 0.16, EF 0.04 and MF 0.64. Preliminary phytochemical studies on the extract and fractions indicated the presence of carbohydrates, alkaloids, saponins, flavonoids, steroids and terpenoids.ConclusionsThe extract and fractions of Stachytarpheta cayennensis possessed both antibacterial and antispasmodic effects confirming the claimed use in folkloric medicine for wound healing and gastrointestinal ulceration.     

Vulnerability of newborns to environmental factors: findings from community based surveillance data in Bangladesh

Infection is the major cause of neonatal deaths. Home born newborns in rural Bangladeshi communities are exposed to environmental factors increasing their vulnerability to a number of disease agents that may compromise their health. The current analysis was conducted to assess the association of very severe disease (VSD) in newborns in rural communities with temperature, rainfall, and humidity. A total of 12,836 newborns from rural Sylhet and Mirzapur communities were assessed by trained community health workers using a sign based algorithm. Records of temperature, humidity, and rainfall were collected from the nearest meteorological stations. Associations between VSD and environmental factors were estimated. Incidence of VSD was found to be associated with higher temperatures (odds ratios: 1.14, 95% CI: 1.08 to 1.21 in Sylhet and 1.06, 95% CI: 1.04 to 1.07 in Mirzapur) and heat humidity index (odds ratios: 1.06, 95% CI: 1.04 to 1.08 in Sylhet and, 1.03, 95% CI: 1.01 to 1.04 in Mirzapur). Four months (June-September) in Sylhet, and six months in Mirzapur (April-September) had higher odds ratios of incidence of VSD as compared to the remainder of the year (odds ratios: 1.72, 95% CI: 1.32 to 2.23 in Sylhet and, 1.62, 95% CI: 1.33 to 1.96 in Mirzapur). Prevention of VSD in neonates can be enhanced if these interactions are considered in health intervention strategies.     

Risk of high‐level viraemia in HIV‐infected patients on successful antiretroviral treatment for more than 6 months

Objectives

According to the Swiss Federal Commission for HIV/AIDS, HIV‐infected patients on successful antiretroviral treatment have a negligible risk of transmitting HIV sexually. We estimated the risk that patients considered to have an undetectable viral load (VL) are actually viraemic.

Methods

A Danish, population‐based nationwide cohort study of HIV‐infected patients with VL <51 HIV‐1 RNA copies/mL for more than 6 months was carried out for the study period 2000–2008. The observation time was calculated from 6 months after the first VL <51 copies/mL to the last measurement of VL or the first VL >50 copies/mL. The time at risk of transmitting HIV sexually was calculated as 50% of the time from the last VL <51 copies/mL to the subsequent VL if it was >1000 copies/mL. The outcome was the time at risk of transmitting HIV sexually divided by the observation time.

Results

We identified 2680 study subjects contributing 9347.7 years of observation time and 56.4 years of risk of transmitting HIV (VL>1000 copies/mL). In 0.6% [95% confidence interval (CI) 0.5–0.8%] of the overall observation time the patients had VL >1000 copies/mL. In the first 6 months this risk was substantially higher (7.9%; 95% CI 4.5–11.0%), but thereafter decreased and was almost negligible after 5 years (0.03%; 95% CI 0.0–0.2%). The risk was higher in injecting drug users, but otherwise did not differ between subgroups of patients.

Conclusion

The risk of viraemia and therefore the risk of transmitting HIV sexually are high in the first 12 months of successful antiretroviral treatment, but thereafter are low.