Realistic Food-Based Approaches Alone May Not Ensure Dietary Adequacy for Women and Young Children in South-East Asia

Objectives Micronutrient deficiencies, in southeast Asia (SE Asia), remain a public health challenge. We evaluated whether promoting the consumption of locally available nutritious foods, which is a low-risk micronutrient intervention, alone can ensure dietary adequacy, for women of reproductive age and 6–23 m old children. Methods Representative dietary data from Cambodia, Indonesia, Lao PDR, Thailand and Vietnam were analysed using linear programming analysis to identify nutrients that are likely low in personal food environments (problem nutrients), and to formulate food-based recommendations (FBRs) for three to six target populations per country. Results The number of problem nutrients ranged from zero for 12–23 m olds in Indonesia, Thailand and Vietnam to six for pregnant women in Cambodia. The FBRs selected for each target population, if adopted, would ensure a low percentage of the population was at risk of inadequate intakes for five to ten micronutrients, depending on the country and target population. Of the 11 micronutrients modelled, requirements for iron, calcium and folate were most difficult to meet (≥ 10 of the 24 target populations), using FBRs alone. The number of individual FBRs selected per set, for each target population, ranged from three to eight; and often included meat, fish or eggs, liver/organ meats, vegetables and fruits. Conclusions for practice Intervention strategies need to increase access to nutritious foods, including products fortified with micronutrients, in SE Asia, when aiming to ensure dietary adequacy for most individuals in the population.

     

Improving the performance of Drug and Therapeutics Committees in hospitals – a quasi-experimental study in Laos

Background and objectives Drug and Therapeutics Committees (DTCs), which are essential for ensuring the rational use of drugs (RUD) in hospitals, have recently been established in Laos. Sub-optimal performance had been reported. The aims of this study were to determine those factors in the working environment that relate to DTC performance in Lao hospitals and evaluate whether DTC performance could be improved through an educational intervention utilizing auditing and feedback targeted towards DTC members. Methods This was a quasi-experimental (before and after) study. Two central and seven provincial hospitals and the DTC members from these hospitals participated in the study. Performance of the DTCs was assessed by means of specifically developed indicators on structure and process combined with indicators for RUD and adherence to Standard Treatment Guidelines (STG). Data were collected for a 3-month period at baseline and for three consecutive periods thereafter. The results of the first three data collections were shared and discussed with the DTC members during feedback sessions. The DTC members were also interviewed in order to identify factors they thought may have an impact on DTC performance. Results Following the intervention, there was a significant improvement in the overall score for DTC performance (p<0.001) and, in particular, in general activity and feedback and drug information to staff. The STG scores also improved (p<0.01). Interviews indicated that one negative factor was the experience of the DTC members being overloaded with other work, resulting in DTC meetings being held irregularly and drawing poor attendance. Conclusion Continuous self-monitoring of performance by means of indicators, followed by feedback discussions, is suggested the means of improving the work of the DTC.     

The 'hot-spot' of Hb E [beta26(B8)Glu-->Lys] in Southeast Asia: beta-globin anomalies in the Lao Theung population of southern Laos

Hb E [beta26(B8)Glu-->Lys], is the most common abnormal hemoglobin (Hb) in Southeast Asian populations. The hitherto highest frequencies of the Hb E gene (HBB*E) in large population samples, approximately 0.3, were observed in the southern part of northeastern Thailand. The finding of even higher frequencies in a small, isolated Austroasiatic group in Northeast Thailand prompted us to examine samples of three Austroasiatic populations in southern Laos (official designation: Lao Theung), an area inhabited by numerous ethnic groups belonging to the Mon-Khmer branch. Blood samples were collected from a total of 603 adult subjects. The HBB*E frequencies were 0.426 in the So of Khammuan Province, 0.433 in the Alak/Ngeh of Sekong Province and 0.253 in the Oy of Attapeu Province. The HBB*E frequencies in the So and Alak/Ngeh are the highest observed in Southeast Asia in representative population samples. None of the common Southeast Asian beta-thalassemia (thal) mutations were found. The results are discussed with respect to natural selection by malaria, selection time, effects of beta-thal and the ethnic history of the population of Southeast Asia.     

Dietary and socio-economic factors associated with beriberi in breastfed Lao infants

A case-control study was conducted to investigate the dietary and socio-economic factors associated with beriberi in infants attending three public hospitals in Vientiane, Lao PDR. Forty-three breast-feeding infants with a median (range) age of 3 (1-9) months were admitted with beriberi. This was defined as the presence of signs of congestive heart failure or shock in the absence of fever or other signs of sepsis, hypovolaemia or cardiac abnormalities, with rapid clinical improvement following parenteral thiamine. Subjects were matched by age and diet to 43 breast-feeding healthy control infants. Compared with control mothers, mothers of infants with beriberi had significantly less diet diversity (p <0.001), soaked glutinous rice for significantly longer or were more likely to pour off excess water from non-glutinous rice (p =0.006), had fewer years of schooling (p <0.05), were more likely to report that income was inadequate for basic needs (p <0.001), to perform hard physical labour (p <0.01) and to be married to farmers (p <0.01). Clinically significant thiamine deficiency in breastfed infants in Lao relates to methods of preparing rice, the food selected by lactating mothers and the family's socio-economic status.     

Effectiveness of feedback for improving case management of malaria, diarrhoea and pneumonia--a randomized controlled trial at provincial hospitals in Lao PDR

BACKGROUND: Standard Treatment Guidelines were introduced to all prescribers at provincial hospitals in Lao PDR and treatment indicators were developed within the National Drug Policy programme to monitor compliance. OBJECTIVES: To evaluate the effects of an educational intervention to improve treatment practices of malaria, diarrhoea and pneumonia. METHODS: Randomized controlled trial with prescribers at 24 departments at eight provincial hospitals, matched into four pairs. The three departments of internal medicine, paediatrics and out-patients in each pair were randomized into intervention or control group. The 6-month intervention was conducted by members of the Drug and Therapeutics Committees, and comprised monthly audit sessions in the form of outcome feedback using indicator scores on recorded treatment of malaria, diarrhoea and pneumonia. We measured treatment indicator scores 6 months after the end of the intervention compared with baseline. RESULTS: The aggregated mean scores for all diseases, and for malaria and diarrhoea, improved significantly. For pneumonia, improvement was seen in both the intervention and control groups. Record keeping was improved for all three diseases. For malaria, there were improvements in recording patients' history, and in frequency of microscope testing; for diarrhoea, regarding weight measurements, palpation of the fontanel for children under 2 years, and reduction of irrational use of anti-diarrhoeals and antibiotics; for pneumonia, in recording respiratory count, and reducing irrational use of anti-histamines and anti-cough medications. CONCLUSIONS: Audit-feedback systems to improve quality of care are feasible and effective also in hospital settings in low-income countries.     

Soil-transmitted helminth infections and risk factors in preschool children in southern rural Lao People's Democratic Republic

The current widespread school-based control of soil-transmitted helminth (STH) infections is also advocated for preschool children. The objective of this study was to assess infection with STHs as well as their determinants in preschool children (<60 months) in southern rural Lao People's Democratic Republic (Lao PDR). A cluster survey was carried out from October to December 2006 in three districts of Savannakhet Province. The prevalence of Ascaris lumbricoides, hookworm and Trichuris trichiura was 27.4% (95% CI 27.0-27.6%), 10.9% (95% CI 10.7-11.0%) and 10.9% (95% CI 10.7-11.1%), respectively. Of the children studied, 28.4% had a monoparasitic infection and 9.3% had a polyparasitic infection. Older children had a higher risk for hookworm infection [odds ratio (OR) = 1.75, 95% CI 1.03-3.01; P = 0.041] and multiple infections (OR = 1.81, 95% CI 1.01-3.20; P = 0.044). Low socioeconomic status was associated with A. lumbricoides (OR = 0.61, 95% CI 0.38-0.98; P = 0.043) and monoparasitic infections (OR = 0.62, 95% CI 0.38-0.99; P = 0.049). In Lao PDR, deworming of preschool children is warranted. Preventive measures should address important risk factors. Health education regarding personal hygiene, appropriate water management and the construction and proper use of latrines are additional essential elements.     

Anemia and Related Factors in Preschool Children in the Southern Rural Lao People's Democratic Republic

Anemia is a severe public health problem in the Lao People's Democratic Republic (PDR). Consequently, a new control strategy to reduce the burden of anemia has been introduced for preschool children (aged 6-52 months). The objective of this study was to assess the current prevalence of anemia and related factors in preschool children in southern rural Lao PDR. A population-based cross-sectional study was carried out in six communities in Songkhone district, Savannakheth province, in February 2009. As a result, the prevalence of anemia was found to be 48.9% (95% confidence interval (CI), 43.5-54.3), although most cases were mild. A multiple logistic regression analysis indicated that there was no protective effect of breastfeeding against anemia. The anemia prevalence was higher in 1) children aged 6-23 months (Odds Ratio (OR) = 1.73, 95% CI, 1.02-2.90) than in older children, 2) children in large families (6 or more members) (OR = 1.96, 95% CI, 1.17-3.29), and 3) children in three remote villages with relatively difficult access to markets (OR = 3.01, 95% CI, 1.25-7.47).In Lao PDR, improvement of food practices and home-fortified food supplementation interventions are essential. High-risk groups should be targeted and a long-term health education program that aims to modify food habits implemented. Furthermore, in settings where iron deficiency is not the only cause of anemia, combining an iron supplement with other measures is necessary.