Lars Smedman

Equitable Child Health Interventions : The Impact of Improved Water and Sanitation on Inequalities in Child Mortality in Stockholm, 1878 to 1925

Today, many of the 10 million childhood deaths each year are caused by diseases of poverty--diarrhea and pneumonia, for example, which were previously major causes of childhood death in many European countries. Specific analyses of the historical decline of child mortality may shed light on the potential equity impact of interventions to reduce child mortality. In our study of the impact of improved water and sanitation in Stockholm from 1878 to 1925, we examined the decline in overall and diarrhea mortality among children, both in general and by socioeconomic group. We report a decline in overall mortality and of diarrhea mortality and a leveling out of socioeconomic differences in child mortality due to diarrheal diseases, but not of overall mortality. The contribution of general and targeted policies is discussed.

Immunosuppression after measles vaccination

The influence of conventional live attenuated measles vaccine on cellular immune responsiveness was investigated in Sweden and Guinea‐Bissau. Sixteen children in a residential area in Bissau and 16 living in southern Stockholm were examined before and 8–10 days after vaccination. Lymphoproliferation was measured to concanavalin A (con‐A), PPD and tetanus toxoid (TT) using a whole‐blood 3H‐thymidine incorporation assay. Stimulation indices were significantly lower after vaccination than before, in the case of con‐A (p= 0.03) and TT (p= 0.01) in the Guinean children and in the case of PPD (p= 0.009) and TT (p= 0.03) in the Swedish children. Stimulation of lymphocytes from measles‐immune children with measles antigens resulted in weak lymphoproliferative responses. These observations may be relevant to the increased mortality found in children immunized with high‐titre measles vaccines, as compared to controls, in recent studies. The study confirms the applicability and usefulness under field conditions of the whole blood version of the thymidine incorporation assay.

Sub-clinical cerebral oedema does not occur regularly during treatment for diabetic ketoacidosis

Fulminant cerebral oedema is an uncommon, fatal complication of diabetic ketoacidosis (DKA) in children. This study aimed to find out whether the sub‐clinical compression of the brain ventricles found by an earlier study, is a general phenomenon during intravenous treatment for DKA. Four boys and four girls were examined. Blood glucose values ranged from 40 to 24. 6mmol/l, base excess ‐34. 6 to ‐ 13. 6 and capillary blood pH 6. 89–7. 22. The patients received fluids containing both glucose and electrolytes, and insulin intravenously. After about lOh, blood glucose was 8. 7–21. 8mmol/l and base excess had decreased substantially (‐9. 5 to ‐2. 9) in seven of the eight cases. Computerized tomography of the brain was then performed, and again after full recovery. Only two of the patients had an initial decrease in intercaudate distance, which exceeded the variability found in a reference group. Compression of the cerebral ventricles does not occur regularly during treatment for DKA.

Equitable Child Health Interventions

Today, many of the 10 million childhood deaths each year are caused by diseases of poverty--diarrhea and pneumonia, for example, which were previously major causes of childhood death in many European countries. Specific analyses of the historical decline of child mortality may shed light on the potential equity impact of interventions to reduce child mortality. In our study of the impact of improved water and sanitation in Stockholm from 1878 to 1925, we examined the decline in overall and diarrhea mortality among children, both in general and by socioeconomic group. We report a decline in overall mortality and of diarrhea mortality and a leveling out of socioeconomic differences in child mortality due to diarrheal diseases, but not of overall mortality. The contribution of general and targeted policies is discussed.

Selective compartmentalization of γσ-T lymphocytes in human breastmilk

Abstract In human breastmilk, T lymphocytes with γδ‐receptor (TCR) are more frequent than those with αβ‐TCR, in comparison with peripheral blood. Differential representation has also been demonstrated for subpopulations of γδ‐T cells. Reactivity was visualized with three monoclonal antibodies against Vδ1, Vδ2 and Vγ2 on T cells from the breastmilk and peripheral blood of 12 women who had recently given birth. Confirming the results with Vδ1, it was found that Vδ1 (p < 0.01) and Vγ2 (p < 0.05) but not Vδ2 were overrepresented on T cells in milk as compared with blood. This selective compartmentalization seems to reflect the homing of certain cells to the mammary gland.

Nutritional status and measles: a community study in Guinea-Bissau

In an urban settlement area with 6217 inhabitants, 1188 children of 0-71 months of age were weighed and measured in December 1978. Fourteen per cent of those more than nine months old were underweight for age. In February 1979 a measles epidemic started in the area and reached its peak in April. At least 236 of the children initially weighed caught the disease and 59 died of measles. Forty-nine of these had not been underweight in December 1978. In the age interval 9-35 months there was a tendency for measles death to be associated with a relatively low nutritional status. In a geographically-defined sub-population of the studied children, mean weight velocity from December to May was lower in those who had measles in the period than in those who did not contract it. The observations confirm the negative impact of measles on nutritional status. On the other hand, they question the supreme importance given to pre-existing malnutrition in explaining the high measles mortality in West African communities.

Survival 0-6 years of age in a periurban community in Guinea-Bissau: a longitudinal assessment.

In the preparation of a child health-care project in a periurban settlement area with a population of 6200, a census identified 1464 children below 6 years of age. One thousand, one hundred and eighty-eight of these children were examined. They were followed up 12 months later, during which interval there was a current registration of the pregnancies, births and deaths in the area. The 360 newborns in the period were successively included in the follow-up. One hundred and forty-four deaths were documented, including the symptoms preceding their occurrence. Sixty-two of the deaths were due to epidemic measles. The probability of survival through the neonatal period was 0.941, to 12 months of age 0.803, and to 60 months 0.546. The health-work that ensued upon this study emphasizes intra-pregnancy care and immunizations to the young children.

Augmented antibody response to live attenuated measles vaccine in children with Plasmodium falciparum parasitaemia.

The impact of malarial infection on the humoral immunological response to measles virus antigen was studied in 184 children aged 8-19 months in Guinea-Bissau. Pre- and post-immunization measles serology was performed using dried blood on absorbent paper and the ELISA technique. Blood smears obtained at the time of vaccination and 2 and 4 weeks afterwards were examined for malaria parasites. Pre-vaccination antibodies to measles were found in 44 out of 184 children (24%). Plasmodium falciparum was identified in 62 of the 132 initially non-immune children who completed the study. The rate of seroconversion was 127 out of 132 (96%). Post-immunization measles antibody titres were significantly higher in the vaccinees with P. falciparum than in those without malaria parasites in the blood.

Adverse pregnancy outcomes in rural Uganda (1996-2013): trends and associated factors from serial cross sectional surveys.

ObjectiveCommunity based evidence on pregnancy outcomes in rural Africa is lacking yet it is needed to guide maternal and child health interventions. We estimated and compared adverse pregnancy outcomes and associated factors in rural south-western Uganda using two survey methods.MethodsWithin a general population cohort, between 1996 and 2013, women aged 15–49 years were interviewed on their pregnancy outcome in the past 12 months (method 1). During 2012–13, women in the same cohort were interviewed on their lifetime experience of pregnancy outcomes (method 2). Adverse pregnancy outcome was defined as abortions or stillbirths. We used random effects logistic regression for method 1 and negative binomial regression with robust clustered standard errors for method 2 to explore factors associated with adverse outcome.ResultsOne third of women reported an adverse pregnancy outcome; 10.8 % (abortion = 8.4 %, stillbirth = 2.4 %) by method 1 and 8.5 % (abortion = 7.2 %, stillbirth = 1.3 %) by method 2. Abortion rates were similar (10.8 vs 10.5) per 1000 women and stillbirth rates differed (26.2 vs 13.8) per 1000 births by methods 1 and 2 respectively. Abortion risk increased with age of mother, non-attendance of antenatal care and proximity to the road. Lifetime stillbirth risk increased with age. Abortion and stillbirth risk reduced with increasing parity.DiscussionBoth methods had a high level of agreement in estimating abortion rate but were markedly below national estimates. Stillbirth rate estimated by method 1 was double that estimated by method 2 but method 1 estimate was more consistent with the national estimates.ConclusionStrategies to improve prospective community level data collection to reduce reporting biases are needed to guide maternal health interventions.

Age at breast feeding start and postneonatal growth and survival.

Colostrum has important anti-infective properties. It may also somehow promote the development of the childs immunological system. Discarding colostrum, as practised in some cultures, could thus have adverse health consequences beyond the neonatal period. To test this hypothesis, the age at breast feeding start of 734 healthy newborns in urban Guinea-Bissau was ascertained. The children were then prospectively followed up to 3 years of age. Eighty nine deaths occurred during the study. The probability of death in the age interval 28 days to 3 years was about 20%. The childs age at breast feeding start had no statistical impact on postneonatal growth or survival. As a single measure, early breast feeding start is not likely to make much difference for the long term growth or survival of children living under material poverty conditions.