Serene A. Joseph

Stunting and helminth infection in early preschool-age children in a resource-poor community in the Amazon lowlands of Peru.

The World Health Organization recommends deworming of children aged 12-24 months in highly endemic areas. Our research objectives were to: 1) examine prevalence patterns of helminth infection in early childhood; 2) assess the association between helminth infection and socio-demographic characteristics; and 3) examine the effect of the intensity of helminth infection on stunting and anemia. A survey of children (7-9 and 12-14 months) living in Belén (Peru) was undertaken between July 2007 and February 2008. A questionnaire was administered to obtain socio-demographic characteristics, blood and stool samples were collected, and length-for-age Z scores were calculated. The Kato-Katz method was used to determine the prevalence and intensity of Ascaris, Trichuris, and hookworm infections. Of 370 participating children, 349 had parasitological results. Infections first appeared in children at 8 months of age. The prevalence of any helminth infection increased linearly to approximately 37.0% (95%CI: 24.3-51.3%) by 14 months of age. Multivariate analysis showed that age, female sex, and residing in the floodplain were significant determinants of helminth infection. Among infected children, moderate-to-heavy infection of any helminth was associated with stunting (βadjusted=-0.84; 95%CI: -1.48, -0.20). These results support the implementation of deworming programs aimed at young children in highly endemic areas.

Parasite and maternal risk factors for malnutrition in preschool-age children in Belen, Peru using the new WHO Child Growth Standards.

Child malnutrition, including wasting, underweight and stunting, is associated with infections, poor nutrient intake, and environmental and socio-demographic factors. Preschool-age children are especially vulnerable due to their high growth requirements. To target interventions for preschool-age children in a community of extreme poverty in Peru, we conducted a household survey between October 2005 and January 2006 to determine the prevalence of malnutrition and its risk factors. Of 252 children < 5 years old, the prevalence of wasting, underweight and stunting was 26.6, 28.6 and 32.1 %, respectively, based on the new WHO Child Growth Standards. Risk factors for wasting were: (1) moderate-high intensity Trichuris infection (OR 2.50; 95 % CI 1.06, 5.93); (2) hookworm infection (OR 6.67; 95 % CI 1.08, 41.05); (3) age (OR6-month 1.27; 95 % CI 1.11, 1.46); (4) maternal education (secondary incomplete) (OR 5.77; 95 % CI 2.38, 13.99); and (5) decreasing maternal BMI (OR1 kg/m2 1.12; 95 % CI 1.02, 1.23). Risk factors for underweight were: (1) moderate-high intensity Trichuris infection (OR 4.74; 95 % CI 1.99, 11.32); (2) age (OR6-month 1.22; 95 % CI 1.07, 1.38); (3) maternal education (secondary incomplete) (OR 2.92; 95 % CI 1.40, 6.12); and (4) decreasing maternal BMI (OR1 kg/m2 1.11; 95 % CI 1.02, 1.21). Risk factors for stunting were: (1) age (OR6-month 1.14; 95 % CI 1.02, 1.27) and (2) decreasing maternal height (OR1 cm 1.12; 95 % CI 1.06, 1.20). Overall, risk factors for malnutrition included both child and maternal determinants. Based on these data, locally appropriate and cost-effective dietary, de-worming and educational programmes should be targeted to mothers and preschool-age children.

Multidisciplinary and participatory workshops with stakeholders in a community of extreme poverty in the Peruvian Amazon: Development of priority concerns and potential health, nutrition and education interventions

BackgroundCommunities of extreme poverty suffer disproportionately from a wide range of adverse outcomes, but are often neglected or underserved by organized services and research attention. In order to target the first Millennium Development Goal of eradicating extreme poverty, thereby reducing health inequalities, participatory research in these communities is needed. Therefore, the purpose of this study was to determine the priority problems and respective potential cost-effective interventions in Belen, a community of extreme poverty in the Peruvian Amazon, using a multidisciplinary and participatory focus.MethodsTwo multidisciplinary and participatory workshops were conducted with important stakeholders from government, non-government and community organizations, national institutes and academic institutions. In Workshop 1, participants prioritized the main health and health-related problems in the community of Belen. Problem trees were developed to show perceived causes and effects for the top six problems. In Workshop 2, following presentations describing data from recently completed field research in school and household populations of Belen, participants listed potential interventions for the priority problems, including associated barriers, enabling factors, costs and benefits.ResultsThe top ten priority problems in Belen were identified as: 1) infant malnutrition; 2) adolescent pregnancy; 3) diarrhoea; 4) anaemia; 5) parasites; 6) lack of basic sanitation; 7) low level of education; 8) sexually transmitted diseases; 9) domestic violence; and 10) delayed school entry. Causes and effects for the top six problems, proposed interventions, and factors relating to the implementation of interventions were multidisciplinary in nature and included health, nutrition, education, social and environmental issues.ConclusionThe two workshops provided valuable insight into the main health and health-related problems facing the community of Belen. The participatory focus of the workshops ensured the active involvement of important stakeholders from Belen. Based on the results of the workshops, effective and essential interventions are now being planned which will contribute to reducing health inequalities in the community.

Timing of umbilical cord-clamping and infant anaemia: the role of maternal anaemia.

Abstract Background: Evidence from randomized controlled trials has shown that delayed cord-clamping is beneficial to infant iron status. The role of maternal anaemia in this relationship, however, has not been established. Objective: To determine the effect of maternal anaemia at delivery on the association between timing of umbilical cord-clamping and infant anaemia at 4 and 8 months of age. Methods: A cohort of pregnant women admitted to the labour room of Hospital Iquitos (Iquitos, Peru) and their newborns were recruited into the study during two time periods (18 May to 3 June and 6–20 July 2009). Between the two recruitment periods, the hospital’s policy changed from early to delayed umbilical cord-clamping. Maternal haemoglobin levels were measured before delivery, and the time between delivery and cord-clamping was recorded at delivery for the entire cohort. Mother–infant pairs were followed-up at 4 (n = 207) and 8 months (n = 184) post partum. Infant haemoglobin levels were measured at follow-up visits. Data were analysed using logistic regression models. Results: The prevalence of maternal anaemia (Hb <11·0 g/dl) at delivery was 22%. Infant haemoglobin levels at 4 and 8 months of age were 10·4 g/dl and 10·3 g/dl, respectively. Infant haemoglobin levels did not differ significantly between infants born to anaemic mothers and those born to non-anaemic mothers at either 4 or 8 months of age. However, the association between the timing of cord-clamping and infant anaemia was modified by the mother’s anaemia status. Significant benefits of delayed cord-clamping in preventing anaemia were found in infants born to anaemic mothers at both 4 months (aOR = 0·59, 95% CI 0·36–0·99) and 8 months (aOR = 0·38, 95% CI 0·19–0·76) of age. Conclusion: The study contributes additional evidence in support of delayed cord-clamping. This intervention is likely to have most public health impact in areas with a high prevalence of anaemia during pregnancy.

The Effect of Deworming on Growth in One-Year-Old Children Living in a Soil-Transmitted Helminth-Endemic Area of Peru: A Randomized Controlled Trial.

Background Appropriate health and nutrition interventions to prevent long-term adverse effects in children are necessary before two years of age. One such intervention may include population-based deworming, recommended as of 12 months of age by the World Health Organization in soil-transmitted helminth (STH)-endemic areas; however, the benefit of deworming has been understudied in early preschool-age children. Methodology/Principal Findings A randomized, double-blind, placebo-controlled trial was conducted to determine the effect of deworming (500 mg single-dose crushed mebendazole tablet) on growth in one-year-old children in Iquitos, Peru. Children were enrolled during their routine 12-month growth and development clinic visit and followed up at their 18 and 24-month visits. Children were randomly allocated to: Group 1: deworming at 12 months and placebo at 18 months; Group 2: placebo at 12 months and deworming at 18 months; Group 3: deworming at both 12 and 18 months; or Group 4: placebo at both 12 and 18 months (i.e. control group). The primary outcome was weight gain at the 24-month visit. An intention-to-treat approach was used. A total of 1760 children were enrolled between September 2011 and June 2012. Follow-up of 1563 children (88.8%) was completed by July 2013. STH infection was of low prevalence and predominantly light intensity in the study population. All groups gained between 1.93 and 2.05 kg on average over 12 months; the average difference in weight gain (kg) compared to placebo was: 0.05 (95% CI: -0.05, 0.17) in Group 1; -0.07 (95%CI: -0.17, 0.04) in Group 2; and 0.04 (95%CI: -0.06, 0.14) in Group 3. There was no statistically significant difference in weight gain in any of the deworming intervention groups compared to the control group. Conclusions Overall, with one year of follow-up, no effect of deworming on growth could be detected in this population of preschool-age children. Low baseline STH prevalence and intensity and/or access to deworming drugs outside of the trial may have diluted the potential effect of the intervention. Additional research is required to overcome these challenges and to contribute to strengthening the evidence base on deworming. Trial Registration ClinicalTrials.gov (NCT01314937)

Risk Factors Associated with Malnutrition in One-Year-Old Children Living in the Peruvian Amazon

Background Children under two years of age are in the most critical window for growth and development. As mobility increases, this time period also coincides with first exposure to soil-transmitted helminth (STH) infections in tropical and sub-tropical environments. The association between malnutrition and STH infection, however, has been understudied in this vulnerable age group. Methodology/Principal Findings A nested cross-sectional survey was conducted in 12 and 13-month old children participating in a deworming trial in Iquitos, an STH-endemic area of the Peruvian Amazon. An extensive socio-demo-epi questionnaire was administered to the childs parent. Length and weight were measured, and the Bayley Scales of Infant and Toddler Development were administered to measure cognition, language, and fine motor development. Stool specimens were collected to determine the presence of STH. The association between malnutrition (i.e. stunting and underweight) and STH infection, and other child, maternal, and household characteristics, was analyzed using multivariable Poisson regression. A total of 1760 children were recruited between September 2011 and June 2012. Baseline data showed a prevalence of stunting and underweight of 24.2% and 8.6%, respectively. In a subgroup of 880 randomly-allocated children whose specimens were analyzed by the Kato-Katz method, the prevalence of any STH infection was 14.5%. Risk factors for stunting in these 880 children included infection with at least one STH species (aRR = 1.37; 95% CI 1.01, 1.86) and a lower development score (aRR = 0.97; 95% CI: 0.95, 0.99). A lower development score was also a significant risk factor for underweight (aRR = 0.92; 95% CI: 0.89, 0.95). Conclusions The high prevalence of malnutrition, particularly stunting, and its association with STH infection and lower developmental attainment in early preschool-age children is of concern. Emphasis should be placed on determining the most cost-effective, integrated interventions to reduce disease and malnutrition burdens in this vulnerable age group.

A Hospital Policy Change Toward Delayed Cord Clamping is Effective in Improving Hemoglobin Levels and Anemia Status of 8-month-old Peruvian Infants

OBJECTIVE To assess the effectiveness of a hospital policy change toward delayed cord clamping on infant hemoglobin (Hb) levels and anemia status at 4 and 8 months of age. METHODS A cohort of Peruvian mothers and infants, originating from a pre/post study investigating a change in hospital policy from early to delayed cord clamping, was followed until 8 months postpartum. Infant hemoglobin levels and anemia status were measured at 4 and 8 months postpartum. RESULTS Following the hospital policy change, adjusted mean infant Hb levels improved by 0.89 gdl(-1) [95% confidence interval (95% CI) 0.57-1.22] and anemia was significantly reduced (aOR = 0.38; 95% CI 0.19-0.78) at 8 months postpartum. CONCLUSIONS A hospital policy change toward delayed cord clamping is effective in improving Hb levels and the anemia status of 8-month-old infants. Prior to scaling-up this intervention, issues related to training, monitoring, safety, additional long-term benefits and specific local conditions should be investigated.

Determinants of time from Hiv infection to linkage-to-care in rural Kwazulu-natal, South Africa.

Objective: To estimate time from HIV infection to linkage-to-care and its determinants. Linkage-to-care is usually assessed using the date of HIV diagnosis as the starting point for exposure time. However, timing of diagnosis is likely endogenous to linkage, leading to bias in linkage estimation. Design: We used longitudinal HIV serosurvey data from a large population-based HIV incidence cohort in KwaZulu-Natal (2004–2013) to estimate time of HIV infection. We linked these data to patient records from a public-sector HIV treatment and care program to determine time from infection to linkage (defined using the date of the first CD4+ cell count). Methods: We used Cox proportional hazards models to estimate time from infection to linkage and the effects of the following covariates on this time: sex, age, education, food security, socioeconomic status, area of residence, distance to clinics, knowledge of HIV status, and whether other household members have initiated antiretroviral therapy. Results: We estimated that it would take an average of 4.9 years for 50% of HIV seroconverters to be linked to care (95% confidence intervals: 4.2–5.7). Among all cohort members who were linked to care, the median CD4+ cell count at linkage was 350 cells/&mgr;l (95% confidence interval: 330–380). Men and participants aged less than 30 years were found to have the slowest rates of linkage-to-care. Time to linkage became shorter over calendar time. Conclusion: Average time from HIV infection to linkage-to-care is long and needs to be reduced to ensure that HIV treatment-as-prevention policies are effective. Targeted interventions for men and young individuals have the largest potential to improve linkage rates.

Inadequate prenatal care and the risk of stillbirth in the Peruvian Amazon

Major risk factors for stillbirth include lack of skilled birth attendants, low socioeconomic status, poor nutrition, prior stillbirth, advanced maternal age, and the lack of prenatal care [1]. The World Health Organization has published a prenatal care model that includes 4 routine visits for women with no specific risk condition or risk factor, and additional visits for women with health problems or risk factors [2]. During these visits, risk factors should be ascertained (e.g., syphilis screening, measurement of blood pressure) and treatments administered (e.g., iron supplementation). In Peru, the Ministry of Health recommends a schedule of 6 routine prenatal care visits with a series of assessments or interventions to be performed at specific visits [3]. However, for various reasons, the availability, accessibility, and utilization of prenatal care services may be less than optimal. In order to best inform prenatal care services in the Amazon region of Peru, where poverty remains high, we sought to identify risk factors associated with stillbirth in women delivering at the Hospital Iquitos “César Garayar Garcia” in Iquitos, the capital city of Loreto. Data were obtained from a cohort study of birth outcomes, where a random sample of mother–baby medical records had been drawn from the hospital birth registry [4]. Demographic information, admission diagnosis, observations during delivery, and discharge diagnosis were

Progress towards the Millennium Development Goals in a community of extreme poverty: local vs. national disparities in Peru.

Objectives  Standard indicators are being used worldwide to track progress towards achieving the Millennium Development Goals (MDGs). These are usually at country level and do not accurately reflect within‐country variability of progress towards the targets. This may lead to lack of attention and under‐resourcing of the most vulnerable populations. Therefore, the objective of this study was to compare selected standard MDG indicators at country level and community level in Peru.