J. Patrick Vaughan

EVIDENCE FOR PROTECTION BY BREAST-FEEDING AGAINST INFANT DEATHS FROM INFECTIOUS DISEASES IN BRAZIL

In a population-based case-control study of infant mortality in two urban areas of southern Brazil, the type of milk in an infants diet was found to be an important risk factor for deaths from diarrhoeal and respiratory infections. Compared with infants who were breast-fed with no milk supplements, and after adjusting for confounding variables, those completely weaned had 14.2 and 3.6 times the risk of death from diarrhoea and respiratory infections, respectively. Part-weaning was associated with corresponding relative risks (RR) of 4.2 and 1.6. The risk of death from infections other than diarrhoea or respiratory infection was less clearly associated with breast-feeding (completely weaned, RR = 2.5; partly weaned, RR = 0.4). Cows and formula milk seemed to be equally hazardous. For deaths due to diarrhoea the increased risk associated with not breast-feeding was greatest in the first two months of life (RR for completely weaned vs breast-fed without supplementary milk = 23.3).

The challenge of reducing neonatal mortality in middle-income countries: findings from three Brazilian birth cohorts in 1982, 1993, and 2004

BACKGROUND Middle-income countries will need to drastically reduce neonatal deaths to achieve the Millennium Development Goal for child survival. The evolution of antenatal and perinatal care indicators in the Brazilian city of Pelotas from 1982 to 2004 provides a useful case study of potential challenges. METHODS We prospectively studied three birth cohorts representing all urban births in 1982, 1993, and from January to July, 2004. The same methods were used in all three studies. FINDINGS Despite improvements in maternal characteristics, prevalence of preterm births increased from 6.3% (294 of 4665) in 1982 to 16.2% (342 of 2112) in 2004, corresponding to a 47 g reduction in mean birthweight. Average number of antenatal visits in 2004 was 8.3 per woman, but quality of care was still inadequate--97% of women had an ultrasound scan, but only 1830 (77%) had a vaginal examination and 559 of 1748 non-immunised women did not receive tetanus toxoid. Rate of caesarean sections increased greatly, from 28% (1632 of 5914) in 1982 to 43% (1039 of 2403) in 2004, reaching 374 of 456 (82%) of all private deliveries in 2004. The increased rate of preterm births seemed to result largely from caesarean sections or inductions. Newborn care improved, and gestational-age-specific mortality rates had fallen by about 50% since 1982. As a result, neonatal mortality rates had been stable since 1990, despite the increase in preterm deliveries. INTERPRETATION Excessive medicalisation--including labour induction, caesarean sections, and inaccurate ultrasound scans--led by an unregulated private sector with spill-over effects to the public sector, might offset the gains resulting from improved maternal health and newborn survival. These challenges will have to be faced by middle-income countries striving to achieve the child survival Millennium Development Goal.

Effect of zinc supplementation started during diarrhoea on morbidity and mortality in Bangladeshi children: community randomised trial

Abstract Objective: To evaluate the effect on morbidity and mortality of providing daily zinc for 14 days to children with diarrhoea. Design: Cluster randomised comparison. Setting: Matlab field site of International Center for Diarrhoeal Disease Research, Bangladesh. Participants: 8070 children aged 3-59 months contributed 11 881 child years of observation during a two year period. Intervention: Children with diarrhoea in the intervention clusters were treated with zinc (20 mg per day for 14 days); all children with diarrhoea were treated with oral rehydration therapy. Main outcome measures: Duration of episode of diarrhoea, incidence of diarrhoea and acute lower respiratory infections, admission to hospital for diarrhoea or acute lower respiratory infections, and child mortality. Results: About 40% (399/1007) of diarrhoeal episodes were treated with zinc in the first four months of the trial; the rate rose to 67% (350/526) in month 5 and to >80% (364/434) in month 7 and was sustained at that level. Children from the intervention cluster received zinc for about seven days on average during each episode of diarrhoea. They had a shorter duration (hazard ratio 0.76, 95% confidence interval 0.65 to 0.90) and lower incidence of diarrhoea (rate ratio 0.85, 0.76 to 0.96) than children in the comparison group. Incidence of acute lower respiratory infection was reduced in the intervention group but not in the comparison group. Admission to hospital of children with diarrhoea was lower in the intervention group than in the comparison group (0.76, 0.59 to 0.98). Admission for acute lower respiratory infection was lower in the intervention group, but this was not statistically significant (0.81, 0.53 to 1.23). The rate of non-injury deaths in the intervention clusters was considerably lower (0.49, 0.25 to 0.94). Conclusions: The lower rates of child morbidity and mortality with zinc treatment represent substantial benefits from a simple and inexpensive intervention that can be incorporated in existing efforts to control diarrhoeal disease. What is already known on this topic Zinc deficiency is highly prevalent in children in developing countries Zinc supplements given during diarrhoea reduce the duration and severity of treated episodes If given for 14 days during and after diarrhoea, zinc reduces the incidence of diarrhoea and pneumonia in the subsequent two to three months What this study adds Zinc used as a treatment for diarrhoea reduces mortality in children Zinc reduces admissions to hospital for diarrhoea The impact of zinc on mortality and morbidity can be achieved in a realistic large scale public health programme

Achieving universal coverage with health interventions

Cost-effective public health interventions are not reaching developing country populations who need them. Programmes to deliver these interventions are too often patchy, low quality, inequitable, and short-lived. We review the challenges of going to scale, building on known, effective interventions to achieve universal coverage. One challenge is to choose interventions consistent with the epidemiological profile of the population. A second is to plan for context-specific delivery mechanisms effective in going to scale, and to avoid uniform approaches. A third is to develop innovative delivery mechanisms that move incrementally along the vertical-to-horizontal axis as health systems gain capacity in service delivery. The availability of sufficient funds is essential, but constraints to reaching universal coverage go well beyond financial issues. Accurate estimates of resource requirements need a full understanding of the factors that limit intervention delivery. Sound decisions need to be made about the choice of delivery mechanisms, the sequence of action, and the pace at which services can be expanded. Strong health systems are required, and the time frames and funding cycles of national and international agencies are often unrealistically short.

The multi-country evaluation of the integrated management of childhood illness strategy: lessons for the evaluation of public health interventions.

The Multi-Country Evaluation of the Integrated Management of Childhood Illness (IMCI) includes studies of the effectiveness, cost, and impact of the IMCI strategy in Bangladesh, Brazil, Peru, Tanzania, and Uganda. Seven questions were addressed when the evaluation was designed: who would be in charge, through what mechanisms IMCI could affect child health, whether the focus would be efficacy or effectiveness, what indicators would be measured, what types of inference would be made, how costs would be incorporated, and what elements would constitute the plan of analysis. We describe how these questions were answered, the challenges encountered in implementing the evaluation, and the 5 study designs. The methodological insights gained can improve future evaluations of public health programs.

Maternal education in relation to early and late child health outcomes: Findings from a Brazilian cohort study

In a population-based cohort of approximately 6000 Brazilian children, the associations between maternal education and a number of child health outcomes were studied while controlling for potentially confounding variables such as family income and education of the husband. In the crude analyses, maternal education was associated with perinatal and infant mortality, hospital admissions in the first 20 months of life and the three nutritional indicators (length-for-age, weight-for-age and weight-for-length) at mean age 20 months. After adjustment for confounding, the apparent associations with outcomes in early infancy--birthweight and perinatal mortality--were no longer present, while that with infant mortality persisted despite being reduced. Strong associations remained with later outcomes including hospital admissions, length-for-age and weight-for-age at mean age 20 months. Among infants born to women with little or no schooling, deaths due to diarrhoea, pneumonia and other infectious diseases were particularly common. These findings support the hypothesis that maternal education has an effect on child health which is partly independent from that of other socioeconomic factors; they also suggest that maternal care is more important than the biological characteristics of the mothers since stronger effects were observed for the late (postneonatal mortality, hospital admissions and nutritional status) than for the early (birthweight, perinatal mortality) outcomes.

The Pelotas birth cohort study, Rio Grande do Sul, Brazil, 1982-2001

Given the growing recognition of the importance of the life course approach for the determination of chronic diseases, birth cohort studies are becoming increasingly important. This paper describes the methods used in the 1982 Pelotas (Brazil) birth cohort study, one of the largest and longest studies of this type in developing countries. All 5,914 hospital births occurring in Pelotas in 1982 (over 99% of all deliveries) were studied prospectively. The main stages of the study took place in 1983, 1984, 1986, 1995, 1997, 2000, and 2001. More than two thousand variables are available for each subject who participated in all stages of the study. Recent phases of the study included the examination of 2,250 males when presenting for the army recruitment exam in 2000, the study of a 27% sample of men and women in 2001 through household visits, and the study of over 400 children born to the cohort women. Follow-up rates in the recent stages of the cohort were 78.9% for the army examination and 69.0% for the household visits. Ethnographic and oral health studies were conducted in sub-samples. Some recent results on blood pressure, adolescent pregnancy, and asthma are presented as examples of utilization of the data. Suggestions on lessons learned for other cohort studies are proposed.

Cost-effectiveness of community health workers in tuberculosis control in Bangladesh

OBJECTIVE To compare the cost-effectiveness of the tuberculosis (TB) programme run by the Bangladesh Rural Advancement Committee (BRAC), which uses community health workers (CHWs), with that of the government TB programme which does not use CHWs. METHODS TB control statistics and cost data for July 1996 - June 1997 were collected from both government and BRAC thanas (subdistricts) in rural Bangladesh. To measure the cost per patient cured, total costs were divided by the total number of patients cured. FINDINGS In the BRAC and government areas, respectively, a total of 186 and 185 TB patients were identified over one year, with cure rates among sputum-positive patients of 84% and 82%. However, the cost per patient cured was US

Estudo longitudinal da população materno-infantil da região urbana do Sul do Brasil, 1993: aspectos metodológicos e resultados preliminares

64 in the BRAC area compared to US

Tendências e diferenciais na saúde materno-infantil: delineamento e metodologia das coortes de 1982 e 1993 de mães e crianças de Pelotas, Rio Grande do Sul

96 in the government area. CONCLUSION The government programme was 50% more expensive for similar outcomes. Although both the BRAC and government TB control programmes appeared to achieve satisfactory cure rates using DOTS (a five-point strategy), the involvement of CHWs was found to be more cost-effective in rural Bangladesh. With the same budget, the BRAC programme could cure three TB patients for every two in the government programme.