Rachel B. Kaufmann

Water, sanitation, and hygiene interventions to reduce diarrhoea in less developed countries: a systematic review and meta-analysis

Many studies have reported the results of interventions to reduce illness through improvements in drinking water, sanitation facilities, and hygiene practices in less developed countries. There has, however, been no formal systematic review and meta-analysis comparing the evidence of the relative effectiveness of these interventions. We developed a comprehensive search strategy designed to identify all peer-reviewed articles, in any language, that presented water, sanitation, or hygiene interventions. We examined only those articles with specific measurement of diarrhoea morbidity as a health outcome in non-outbreak conditions. We screened the titles and, where necessary, the abstracts of 2120 publications. 46 studies were judged to contain relevant evidence and were reviewed in detail. Data were extracted from these studies and pooled by meta-analysis to provide summary estimates of the effectiveness of each type of intervention. All of the interventions studied were found to reduce significantly the risks of diarrhoeal illness. Most of the interventions had a similar degree of impact on diarrhoeal illness, with the relative risk estimates from the overall meta-analyses ranging between 0.63 and 0.75. The results generally agree with those from previous reviews, but water quality interventions (point-of-use water treatment) were found to be more effective than previously thought, and multiple interventions (consisting of combined water, sanitation, and hygiene measures) were not more effective than interventions with a single focus. There is some evidence of publication bias in the findings from the hygiene and water treatment interventions.

The use of condoms with other contraceptive methods among young men and women.

In a nationally representative sample of sexually experienced youths aged 14-22, 37% of young women and 52% of young men said the condom was the primary method used to prevent pregnancy at last intercourse; an additional 8% and 7%, respectively, said they used a condom at last intercourse; much of this represents dual use [corrected]. Condom use at last intercourse was reported by 25% of young men whose partner was using the pill. Significant independent predictors of condom use with the pill among men included younger age, black race, engaging in fewer nonsexual risk behaviors and having received instruction about HIV in school. Among young women, 21% of those relying on the pill reported also using a condom at last intercourse. For women, independent predictors of dual use included younger age, black race, older age at first sex, fewer nonsexual risk behaviors, having no partners in the previous three months and having talked to parents or other adult relatives about HIV.

Blood lead concentration and children's anthropometric dimensions in the Third National Health and Nutrition Examination survey (NHANES III), 1988-1994

OBJECTIVE To assess the association between lead exposure and childrens physical growth. DESIGN Cross-sectional analysis of data from the Third National Health and Nutrition Examination Survey, 1988-1994. PARTICIPANTS A total of 4391 non-Hispanic white, non-Hispanic black, and Mexican-American children age 1 to 7 years. MEASUREMENTS AND RESULTS We investigated the association between blood lead concentration and stature, head circumference, weight, and body mass index with multiple regression analysis adjusting for sex, ethnic group, iron status, dietary intake, medical history, sociodemographic factors, and household characteristics. Blood lead concentration was significantly negatively associated with stature and head circumference. Regression models predicted reductions of 1. 57 cm in stature and 0.52 cm in head circumference for each 0.48 micromol/L (10 micrograms/dL) increase in blood lead concentration. We did not find significant associations between blood lead concentration and weight or body mass index. CONCLUSIONS The significant negative associations between blood lead concentration and stature and head circumference among children age 1 through 7 years, similar in magnitude to those reported for the Second National Health and Nutrition Examination Survey, 1976-1980, suggest that although mean blood lead concentrations of children have been declining in the United States for 2 decades, lead exposure may continue to affect the growth of some children.

Medicaid coverage for tobacco dependence treatments in Massachusetts and associated decreases in smoking prevalence.

Background Approximately 50% of smokers die prematurely from tobacco-related diseases. In July 2006, the Massachusetts health care reform law mandated tobacco cessation coverage for the Massachusetts Medicaid population. The new benefit included behavioral counseling and all medications approved for tobacco cessation treatment by the U.S. Food and Drug Administration (FDA). Between July 1, 2006 and December 31, 2008, a total of 70,140 unique Massachusetts Medicaid subscribers used the newly available benefit, which is approximately 37% of all Massachusetts Medicaid smokers. Given the high utilization rate, the objective of this study is to determine if smoking prevalence decreased significantly after the initiation of tobacco cessation coverage. Methods and Findings Smoking prevalence was evaluated pre- to post-benefit using 1999 through 2008 data from the Massachusetts Behavioral Risk Factor Survey (BRFSS). The crude smoking rate decreased from 38.3% (95% C.I. 33.6%–42.9%) in the pre-benefit period compared to 28.3% (95% C.I.: 24.0%–32.7%) in the post-benefit period, representing a decline of 26 percent. A demographically adjusted smoking rate showed a similar decrease in the post-benefit period. Trend analyses reflected prevalence decreases that accrued over time. Specifically, a joinpoint analysis of smoking prevalence among Massachusetts Medicaid benefit-eligible members (age 18–64) from 1999 through 2008 found a decreasing trend that was coincident with the implementation of the benefit. Finally, a logistic regression that controlled for demographic factors also showed that the trend in smoking decreased significantly from July 1, 2006 to December 31, 2008. Conclusion These findings suggest that a tobacco cessation benefit that includes coverage for medications and behavioral treatments, has few barriers to access, and involves broad promotion can significantly reduce smoking prevalence.

The Decline in US Teen Pregnancy Rates, 1990–1995

Objectives. Estimate pregnancy, abortion, and birth rates for 1990 to 1995 for all teens, sexually experienced teens, and sexually active teens. Design. Retrospective analysis of national data on pregnancies, abortions, and births. Participants. US women aged 15 to 19 years. Outcome Measures. Annual pregnancy, abortion, and birth rates for 1990 to 1995 for women aged 15 to 19 years, with and without adjustments for sexual experience (ever had intercourse), and sexual activity (had intercourse within last 3 months). Results. Approximately 40% of women aged 15 to 19 years were sexually active in 1995. Teen pregnancy rates were constant from 1990 to 1991. From 1991 to 1995, the annual pregnancy rate for women aged 15 to 19 years decreased by 13% to 83.6 per 1000. The percentage of teen pregnancies that ended in induced abortions decreased yearly; thus, the abortion rate decreased more than the birth rate (21% vs 9%). From 1988 to 1995, the proportion of sexually experienced teens decreased nonsignificantly. Conclusions. After a 9% rise from 1985 to 1990, teen pregnancy rates reached a turning point in 1991 and are now declining. Physicians should counsel their adolescent patients about responsible sexual behavior, including abstinence and proper use of regular and emergency contraception.

Deaths related to lead poisoning in the United States, 1979-1998.

This study was conducted to describe trends in US lead poisoning-related deaths between 1979 and 1998. The predictive value of relevant ICD-9 codes was also evaluated. Multiple cause-of-death files were searched for records containing relevant ICD-9 codes, and underlying causes and demographic characteristics were assessed. For 1979-1988, death certificates were reviewed; lead source information was abstracted and accuracy of coding was determined. An estimated 200 lead poisoning-related deaths occurred from 1979 to 1998. Most were among males (74%), Blacks (67%), adults of age >/=45 years (76%), and Southerners (70%). The death rate was significantly lower in more recent years. An alcohol-related code was a contributing cause for 28% of adults. Only three of nine ICD-9 codes for lead poisoning were highly predictive of lead poisoning-related deaths. In conclusion, lead poisoning-related death rates have dropped dramatically since earlier decades and are continuing to decline. However, the findings imply that moonshine ingestion remains a source of high-dose lead exposure in adults.

Trends in Tobacco Smoke Exposure and Blood Lead Levels Among Youths and Adults in the United States: The National Health and Nutrition Examination Survey, 1999–2008

Introduction Tobacco smoke is a source of exposure to thousands of toxic chemicals including lead, a chemical of longstanding public health concern. We assessed trends in blood lead levels in youths and adults with cotinine-verified tobacco smoke exposure by using 10 years of data from the National Health and Nutrition Examination Survey. Methods Geometric mean levels of blood lead are presented for increasing levels of tobacco smoke exposure. Regression models for lead included age, race/ethnicity, poverty, survey year, sex, age of home, birth country, and, for adults, alcohol consumption. Lead levels were evaluated for smokers and nonsmokers on the basis of age of residence and occupation. Results Positive trend tests indicate that a linear relationship exists between smoke exposure and blood lead levels in youths and adults and that secondhand smoke exposure contributes to blood lead levels above the level caused by smoking. Conclusion Youths with secondhand smoke exposure had blood lead levels suggestive of the potential for adverse cognitive outcomes. Despite remediation efforts in housing and the environment and declining smoking rates and secondhand smoke exposure in the United States, tobacco smoke continues to be a substantial source of exposure to lead in vulnerable populations and the population in general.

Is home renovation or repair a risk factor for exposure to lead among children residing in New York City

Children can be lead poisoned when leaded paint is disturbed during home renovation or repair. We conducted a case-control study to assess the association between elevated blood lead levels (BLLs) in children younger than 5 years of age and renovation or repair of homes built before 1950 in New York City. In 1998, we interviewed parents of 106 case children (BLLs)≥10 μg/dL) and 159 control children (BLLs≤5 μg/dL) living in selected New York City neighborhoods. We then used logistic regression methods to estimate odds ratios (ORs) for elevated BLLs among children living in housing that had undergone varous renovations or repairs in the 6 months before the blood lead test, and we adjusted for age and test month. Case children were only slightly more likely than control children to live in a house that had undergone any renovation (OR=1.2, 95% confidence interval [95% CI]=0.7, 2.1). Case children were more likely to (1) live in housing that had interior surfaces prepared for painting, especially by hand sanding (OR=3.5, 95% CI=1.1, 10.9; population attributable risk [PAR%]=10.4%, 95% CI=0.5% 19.3%); and (2) have work-created dust throughout their housing unit (OR =6.3, 95% CI=1.2, 32.3; PAR%=6.8%, 95% CI=0.0%, 13.1%). The risk for excess lead exposure is increased by home renovation or repair work involving interior paint preparation or reported dispersal of dust beyond the work area. The proportion of cases related to this exposure is high enough to merit preventive measures.

Elevated blood lead levels associated with the consumption of moonshine among emergency department patients in Atlanta, Georgia

STUDY OBJECTIVES In February and March 2000, 4 adult emergency care patients were identified with potentially lethal lead toxicity at Grady Memorial Hospital, an urban Atlanta, GA, hospital. All were moonshine drinkers, prompting concern that lead exposure from moonshine was underrecognized in this setting. METHODS We conducted a 2-phased, nested, cross-sectional study throughout a 14-day period in the emergency care center of Grady Memorial Hospital. The prevalence phase consisted of demographic data collection, eligibility screening, and a brief interview pertaining to alcohol and moonshine consumption. During the nested phase, a full interview and blood lead analyses were conducted on all consenting moonshine drinkers and a time-matched comparison group of non-moonshine drinkers. RESULTS In the prevalence phase, of 581 patients interviewed, 8.6% reported consuming moonshine in the past 5 years. Moonshine drinkers were predominantly men between the ages of 40 and 59 years. In the nested phase, the median blood lead levels among moonshine drinkers and nondrinkers were 11.0 microg/dL (0.531 micromol/L) and 2.5 microg/dL (0.121 micromol/L), respectively. Moonshine drinkers were significantly more likely to have blood lead levels of 10 microg/dL (0.483 micromol/L) or greater (odds ratio [OR] 10.94; 95% confidence interval 3.76 to 31.85). Patients who consumed moonshine in the previous week were significantly more likely to have a blood lead level of 10 microg/dL (0.483 micromol/L) or greater than were individuals who reported less recent consumption. Patients who consumed moonshine more than once a month were significantly more likely to have a blood lead level of 10 microg/dL (0.483 micromol/L) or greater than were those reporting less frequent use. Moonshine users were more likely to report heavy alcohol use. CONCLUSION Moonshine consumption was more prevalent than expected in our patient population and was strongly associated with elevated blood lead levels, particularly among recent moonshine drinkers.