Anirban Chatterjee

Implementing services for Early Infant Diagnosis (EID) of HIV: a comparative descriptive analysis of national programs in four countries.

BackgroundThere is a significant increase in survival for HIV-infected children who have early access to diagnosis and treatment. The goal of this multi-country review was to examine when and where HIV-exposed infants and children are being diagnosed, and whether the EID service is being maximally utilized to improve health outcomes for HIV-exposed children.MethodsIn four countries across Africa and Asia existing documents and data were reviewed and key informant interviews were conducted. EID testing data was gathered from the central testing laboratories and was then complemented by health facility level data extraction which took place using a standardized and validated questionnaireResultsIn the four countries reviewed from 2006 to 2009 EID sample volumes rose dramatically to an average of >100 samples per quarter in Cambodia and Senegal, >7,000 samples per quarter in Uganda, and >2,000 samples per quarter in Namibia. Geographic coverage of sites also rapidly expanded to 525 sites in Uganda, 205 in Namibia, 48 in Senegal, and 26 in Cambodia in 2009. However, only a small proportion of testing was done at lower-level health facilities: in Uganda Health Center IIs and IIIs comprised 47% of the EID collection sites, but only 11% of the total tests, and in Namibia 15% of EID sites collected >93% of all samples. In all countries except for Namibia, more than 50% of the EID testing was done after 2 months of age. Few sites had robust referral mechanisms between EID and ART. In a sub-sample of children, we noted significant attrition of infants along the continuum of care post testing. Only 22% (Senegal), 37% (Uganda), and 38% (Cambodia) of infants testing positive by PCR were subsequently initiated onto treatment. In Namibia, which had almost universal EID coverage, more than 70% of PCR-positive infants initiated ART in 2008.ConclusionsWhile EID testing has expanded dramatically, a large proportion of PCR- positive infants are initiated on treatment. As EID services continue to scale-up, more programmatic attention and support is needed to retain HIV-exposed infants in care and ensure that those testing positive initiate treatment in a timely manner. Namibias experience demonstrates that it is feasible for a rural, low-income country to achieve high national coverage of infant testing and treatment.

Maternal disease stage and child undernutrition in relation to mortality among children born to HIV-infected women in Tanzania.

Objective:To examine whether maternal HIV disease stage during pregnancy and child malnutrition are associated with child mortality. Design:Prospective cohort study in Tanzania. Methods:Indicators of disease stage were assessed for 939 HIV-infected women during pregnancy and at delivery, and childrens anthropometric status was obtained at scheduled monthly clinic visits after delivery. Children were followed up for survival status until 24 months after birth. Results:Advanced maternal HIV disease during pregnancy (CD4 count <350 vs. ≥350 cells/mm3) was associated with increased risk of child mortality through 24 months of age (hazard ratio [HR] = 1.74, 95% confidence interval [CI]: 1.32 to 2.30). CD4 count <350 cells/mm3 was also associated with an increased risk of death among children who remained HIV-negative during follow-up (HR = 2.00, 95% CI: 1.36 to 2.94). Low maternal hemoglobin concentration and child undernutrition were related to an increased risk of mortality in this cohort of children. Conclusions:Low maternal CD4 cell count during pregnancy is related to increased risk of mortality in children born to HIV-infected women. Care and treatment for HIV disease, including highly active antiretroviral therapy to pregnant women, could improve child survival. Prevention and treatment of undernutrition in children remain critical interventions in settings with high HIV prevalence.

Evaluation of a universal long-lasting insecticidal net (LLIN) distribution campaign in Ghana: cost effectiveness of distribution and hang-up activities

BackgroundBetween May 2010 and October 2012, approximately 12.5 million long-lasting insecticidal nets (LLINs) were distributed through a national universal mass distribution campaign in Ghana. The campaign included pre-registration of persons and sleeping places, door-to-door distribution of LLINs with ‘hang-up’ activities by volunteers and post-distribution ‘keep-up’ behaviour change communication activities. Hang-up activities were included to encourage high and sustained use.MethodsThe cost and cost-effectiveness of the LLIN Campaign were evaluated using a before-after design in three regions: Brong Ahafo, Central and Western. The incremental cost effectiveness of the ‘hang-up’ component was estimated using reported variation in the implementation of hang-up activities and LLIN use. Economic costs were estimated from a societal perspective assuming LLINs would be replaced after three years, and included the time of unpaid volunteers and household contributions given to volunteers.ResultsAcross the three regions, 3.6 million campaign LLINs were distributed, and 45.5% of households reported the LLINs received were hung-up by a volunteer. The financial cost of the campaign was USD 6.51 per LLIN delivered. The average annual economic cost was USD 2.90 per LLIN delivered and USD 6,619 per additional child death averted by the campaign. The cost-effectiveness of the campaign was sensitive to the price, lifespan and protective efficacy of LLINs.Hang-up activities constituted 7% of the annual economic cost, though the additional financial cost was modest given the use of volunteers. LLIN use was greater in households in which one or more campaign LLINs were hung by a volunteer (OR = 1.57; 95% CI = 1.09, 2.27; p = 0.02). The additional economic cost of the hang-up activities was USD 0.23 per LLIN delivered, and achieved a net saving per LLIN used and per death averted.ConclusionIn this campaign, hang-up activities were estimated to be net saving if hang-up increased LLIN use by 10% or more. This suggests hang-up activities can make a LLIN campaign more cost-effective.

Vitamin A and vitamin B-12 concentrations in relation to mortality and morbidity among children born to HIV-infected women.

Vitamin A supplementation starting at 6 months of age is an important child survival intervention; however, not much is known about the association between vitamin A status before 6 months and mortality among children born to HIV-infected women. Plasma concentrations of vitamins A and B-12 were available at 6 weeks of age (n = 576 and 529, respectively) for children born to HIV-infected women and they were followed up for morbidity and survival status until 24 months after birth. Children in the highest quartile of vitamin A had a 49% lower risk of death by 24 months of age compared to the lowest quartile (HR: 0.51, 95% CI: 0.29-0.90; P-value for trend = 0.01). Higher vitamin A levels were protective in the sub-groups of HIV-infected and un-infected children but this was statistically significant only in the HIV-uninfected subgroup. Higher vitamin A concentrations in plasma are protective against mortality in children born to HIV-infected women.

Predictors and consequences of anaemia among antiretroviral-naïve HIV-infected and HIV-uninfected children in Tanzania

OBJECTIVE Predictors and consequences of childhood anaemia in settings with high HIV prevalence are not well known. The aims of the present study were to identify maternal and child predictors of anaemia among children born to HIV-infected women and to study the association between childhood anaemia and mortality. DESIGN Prospective cohort study. Maternal characteristics during pregnancy and Hb measurements at 3-month intervals from birth were available for children. Information was also collected on malaria and HIV infection in the children, who were followed up for survival status until 24 months after birth. SETTING Dar es Salaam, Tanzania. SUBJECTS The study sample consisted of 829 children born to HIV-positive women. RESULTS Advanced maternal clinical HIV disease (relative risk (RR) for stage > or =2 v. stage 1: 1.31, 95 % CI 1.14, 1.51) and low CD4 cell counts during pregnancy (RR for <350 cells/mm3 v. > or =350 cells/mm3: 1.58, 95 % CI 1.05, 2.37) were associated with increased risk of anaemia among children. Birth weight <2500 g, preterm birth (<34 weeks), malaria parasitaemia and HIV infection in the children also increased the risk of anaemia. Fe-deficiency anaemia in children was an independent predictor of mortality in the first two years of life (hazard ratio 1.99, 95 % CI 1.06, 3.72). CONCLUSIONS Comprehensive care including highly active antiretroviral therapy to eligible HIV-infected women during pregnancy could reduce the burden of anaemia in children. Programmes for the prevention of mother-to-child transmission of HIV and antimalarial treatment to children could improve child survival in settings with high HIV prevalence.

Polio Outbreak Investigation and Response in Somalia, 2013

BACKGROUND For >2 decades, conflicts and recurrent natural disasters have maintained Somalia in a chronic humanitarian crisis. For nearly 5 years, 1 million children <10 years have not had access to lifesaving health services, including vaccination, resulting in the accumulation by 2012 of the largest geographically concentrated cohort of unvaccinated children in the world. This article reviews the epidemiology, risk, and program response to what is now known as the 2013 wild poliovirus (WPV) outbreak in Somalia and highlights the challenges that the program will face in making Somalia free of polio once again. METHODS A case of acute flaccid paralysis (AFP) was defined as a child <15 years of age with sudden onset of fever and paralysis. Polio cases were defined as AFP cases with stool specimens positive for WPV. RESULTS From 9 May to 31 December 2013, 189 cases of WPV type 1 (WPV1) were reported from 46 districts of Somalia; 42% were from Banadir region (Mogadishu), 60% were males, and 93% were <5 years of age. All Somalian polio cases belonged to cluster N5A, which is known to have been circulating in northern Nigeria since 2011. In response to the outbreak, 8 supplementary immunization activities were conducted with oral polio vaccine (OPV; trivalent OPV was used initially, followed subsequently by bivalent OPV) targeting various age groups, including children aged <5 years, children aged <10 years, and individuals of any age. CONCLUSIONS The current polio outbreak erupted after a polio-free period of >6 years (the last case was reported in March 2007). Somalia interrupted indigenous WPV transmission in 2002, was removed from the list of polio-endemic countries a year later, and has since demonstrated its ability to control polio outbreaks resulting from importation. This outbreak reiterates that the threat of large polio outbreaks resulting from WPV importation will remain constant unless polio transmission is interrupted in the remaining polio-endemic countries.

The production and costs of health service across four African countries: Ghana, Kenya, Uganda, and Zambia

Abstract Background Few data exist for the production or costs of health service in developing countries. Consequently, researchers and policy makers have not been able to clearly identify technical or allocative inefficiencies in the provision of care. To remedy this shortcoming, the Institute for Health Metrics and Evaluation, UNICEF, and others have collaborated on de-novo costing exercises across a dozen developing countries. This project has engaged in-country partners to survey over 2300 health facilities. These facilities range from large, referral hospitals to small clinics and pharmacies. Facility-level data are supplemented by centralised information from ministries of health and other national-level financing agents. In most countries, panel data were collected, from 2007 to 2011. Methods Data collection and analysis is ongoing in many countries, but it is complete for a subset, including four African countries: Ghana, Kenya, Uganda, and Zambia. This work will report descriptive values of costs and provision across these countries, as well as results from country-level and cross-country production and cost functions. We particularly focus on quantifying technical inefficiencies in service provision, and on identifying how the degree of those inefficiencies has changed over time. Findings Patterns in expenditure and levels of service provision vary across countries, and these differences are in part explained by each countrys level of economic development. Personnel expenditure is more important in less-developed countries and less-sophisticated facilities, and in general levels of service provision have increased at a faster rate than either personnel counts or expenditure. Interpretation These data and subsequent analyses are critically important to in-country policy makers and international donors. Undoubtedly, the demand for health service will increase in these countries along with population growth and economic wealth. To maintain (let alone improve) current service levels, policy makers must understand the sources and degrees of inefficiency in service provision, and have reliable estimates of the costs of expanding service. This study is the most comprehensive exercise conducted to date to understand these issues across countries. Funding Bill & Melinda Gates Foundation.