Development and validation of weight, height and age bands to guide the prescription of fixed-dose dispersible tablet formulations

OBJECTIVES

Conversion of pediatric essential drugs from syrup to dispersible tablet formulations would require fixed dose options guided by the weight band in which a child falls or a proxy for weight, such as height or age. The purpose of this study was to determine whether weight, height, or age bands can be created that would lead to greater than 95% of children receiving a therapeutic dose of 6 commonly prescribed essential drugs, including paracetamol, iron sulfate, amoxicillin, co-trimoxazole (i.e., trimethoprim/sulfamethoxazole), ciprofloxacin, and co-artemether (i.e., artemether/lumefantrine).

METHODS

Using World Health Organization growth standards, we created 4 weight bands and then matched them to height and age 50th percentile growth curves. The resulting weight, height, and age bands were then applied to Ugandan and Bangladeshi anthropometric data sets, and the percentage of children who would have received a correct therapeutic dose based upon weight, height, or age was determined. This percentage was interpreted as acceptable if >95%, marginal if 90% to 95% and unacceptable if <90%.

RESULTS

Applying the 4 weight bands to the 6 selected drugs, greater than 95% of children would have received an acceptable therapeutic dose across the 4 weight bands for each of the 6 drugs tested. None of the drugs tested would deliver an acceptable therapeutic dose across all bands based upon height or age among Ugandan children, and only co-trimoxazole would have been delivered at acceptable therapeutic levels based upon these bands in Bangladeshi children.

CONCLUSIONS

For the 6 drugs tested, dispersible tablets prescribed on the basis of a 4-dose regimen determined by weight bands would deliver an acceptable therapeutic dose greater than 95% of the time. Substituting weight for age or height bands would result in unacceptable levels of under- or overdosing.

A framework for addressing implementation gap in global drowning prevention interventions: experiences from Bangladesh

Drowning is the commonest cause of injury-related deaths among under-five children worldwide, and 95% of deaths occur in low- and middle-income countries (LMICs) where there are implementation gaps in the drowning prevention interventions. This article reviews common interventions for drowning prevention, introduces a framework for effective implementation of such interventions, and describes the Saving of Lives from Drowning (SoLiD) Project in Bangladesh, which is based on this framework. A review of the systematic reviews on drowning interventions was conducted, and original research articles were pulled and summarized into broad prevention categories. The implementation framework builds upon two existing frameworks and categorizes the implementing process for drowning prevention interventions into four phases: planning, engaging, executing, and evaluating. Eleven key characteristics are mapped in these phases. The framework was applied to drowning prevention projects that have been undertaken in some LMICs to illustrate major challenges to implementation. The implementation process for the SoLiD Project in Bangladesh is used as an example to illustrate the practical utilization of the framework. Drowning interventions, such as pool fencing and covering of water hazards, are effective in high-income countries; however, most of these interventions have not been tested in LMICs. The critical components of the four phases of implementing drowning prevention interventions may include: (i) planning-global funding, political will, scale, sustainability, and capacity building; (ii) engaging-coordination, involvement of appropriate individuals; (iii) executing-focused action, multisectoral actions, quality of execution; and (iv) evaluating-rigorous monitoring and evaluation. Some of the challenges to implementing drowning prevention interventions in LMICs include insufficient funds, lack of technical capacity, and limited coordination among stakeholders and implementers. The SoLiD Project in Bangladesh incorporates some of these lessons and key features of the proposed framework. The framework presented in this paper was a useful tool for implementing drowning prevention interventions in Bangladesh and may be useful for adaptation in drowning and injury prevention programmes of other LMIC settings.

Neonatal mortality risks among preterm births in a rural Bangladeshi cohort

BACKGROUND

Preterm birth leads to an estimated 35% of neonatal deaths worldwide. Our study analyses neonatal mortality risks among preterm births in rural Bangladesh.

METHODS

Trained community health workers (CHW) prospectively collected data between June 2007 and September 2009.

RESULTS

Among 32 126 livebirths, 22.3% were preterm (delivered at <37 weeks gestation) and almost half (46.4%) of all neonatal deaths occurred among preterm babies. Preterm babies who were born as the first child {[risk ratio (RR) 1.4; 95% confidence interval (CI) 1.1, 1.8]} and in the poorest households [RR 1.7; 95% CI 1.2, 2.4] were at higher mortality risk. Birth and newborn care preparedness was associated with lower risk of mortality [RR 0.3; 95% CI 0.2, 0.4] while preterm infants who had symptoms of infection [RR 5.6; 95% CI 4.3, 7.1] or whose mother suffered antenatal complications [RR 1.4; 95% CI 1.1, 1.8] were at higher mortality risk. Elimination of excess neonatal deaths caused by preterm would decrease population-level neonatal mortality rate by 31.0% [95% CI 27.60%, 34.5%].

CONCLUSION

Given that 87% of preterm births and 60% of preterm deaths were in late or moderate preterm infants, and that 87% preterm babies received a visit from CHW within third day of life, a home-based essential care package delivered by CHWs for sick preterm infants, specifically focused on birth preparedness, skin-to-skin care, immediate breast feeding, early recognition of danger signs, and linked through referral to intensive and quality care in health facilities, could be an effective approach in low resource settings.

Maternal mortality in Bangladesh: a Countdown to 2015 country case study

BACKGROUND

Bangladesh is one of the only nine Countdown countries that are on track to achieve the primary target of Millennium Development Goal (MDG) 5 by 2015. It is also the only low-income or middle-income country with two large, nationally-representative, high-quality household surveys focused on the measurement of maternal mortality and service use.

METHODS

We use data from the 2001 and 2010 Bangladesh Maternal Mortality Surveys to measure change in the maternal mortality ratio (MMR) and from these and six Bangladesh Demographic and Health Surveys to measure changes in factors potentially related to such change. We estimate the changes in risk of maternal death between the two surveys using Poisson regression.

FINDINGS

The MMR fell from 322 deaths per 100,000 livebirths (95% CI 253-391) in 1998-2001 to 194 deaths per 100,000 livebirths (149-238) in 2007-10, an annual rate of decrease of 5·6%. This decrease rate is slightly higher than that required (5·5%) to achieve the MDG target between 1990 and 2015. The key contribution to this decrease was a drop in mortality risk mainly due to improved access to and use of health facilities. Additionally, a number of favourable changes occurred during this period: fertility decreased and the proportion of births associated with high risk to the mother fell; income per head increased sharply and the poverty rate fell; and the education levels of women of reproductive age improved substantially. We estimate that 52% of maternal deaths that would have occurred in 2010 in view of 2001 rates were averted because of decreases in fertility and risk of maternal death.

INTERPRETATION

The decrease in MMR in Bangladesh seems to have been the result of factors both within and outside the health sector. This finding holds important lessons for other countries as the world discusses and decides on the post-MDG goals and strategies. For Bangladesh, this case study provides a strong rationale for the pursuit of a broader developmental agenda alongside increased and accelerated investments in improving access to and quality of public and private health-care facilities providing maternal health in Bangladesh.

FUNDING

United States Agency for International Development, UK Department for International Development, Bill & Melinda Gates Foundation.

Determinants and pattern of care seeking for preterm newborns in a rural Bangladeshi cohort

BACKGROUND

Despite the increased burden of preterm birth and its complications, the dearth of care seeking data for preterm newborns remains a significant knowledge gap. Among preterm babies in rural Bangladesh, we examined: 1) determinants and patterns of care seeking, and 2) risk analysis for care-seeking from qualified and unqualified providers.

METHOD

Trained community health workers collected data prospectively from 27,460 mother-liveborn baby pairs, including 6,090 preterm babies, between June 2007 and September 2009. Statistical analyses included binomial and multinomial logistic regressions.

RESULTS

Only one-fifth (19.7%) of preterm newborns were taken to seek either preventive or curative health care. Among care-seeker preterm newborns, preferred providers included homeopathic practitioners (50.0%), and less than a third (30.9%) sought care from qualified providers. Care-seeking from either unqualified or qualified providers was significantly lower for female preterm babies, compared to male babies [Relative Risk Ratio (RRR) for unqualified care: 0.68; 95% Confidence Interval (CI): 0.58, 0.80; RRR for qualified care: 0.52; 95% CI: 0.41, 0.66]. Among preterm babies, care-seeking was significantly higher among caregivers who recognized symptoms of illness [RR: 2.14; 95% CI: 1.93, 2.38] or signs of local infection (RR: 2.53; 95% CI: 2.23, 2.87), had a history of child death [RR: 1.21; 95% CI: 1.07, 1.37], any antenatal care (ANC) visit [RR: 1.41; 95% CI: 1.25, 1.59]. Birth preparedness (RRR: 1.24; 95% CI: 1.09, 1.68) and any ANC visit (RRR: 1.73; 95% CI: 1.50, 2.49) were also associated with increased likelihood of care seeking for preterm babies from qualified providers.

CONCLUSION

To improve care seeking practices for preterm babies and referral of sick newborns to qualified providers/facilities, we recommend: 1) involving community-preferred health care providers in community-based health education and awareness raising programs; 2) integrating postnatal care seeking messages into antenatal counselling; and 3) further research on care seeking practices for preterm babies.

Monitoring and evaluating progress towards Universal Health Coverage in Bangladesh

This paper is a country case study for the Universal Health Coverage Collection, organized by WHO. Tanvir Mahmudul Huda and colleagues illustrate progress towards UHC and its monitoring and evaluation in Bangladesh. Please see later in the article for the Editors' Summary

Nutritional status and childhood wheezing in rural Bangladesh

OBJECTIVE

To investigate the association between current childhood nutritional status and current wheezing among pre-school children in rural Bangladesh.

DESIGN

Cross-sectional study.

SETTING

Matlab region, rural Bangladesh.

SUBJECTS

Children (n 912) aged 4·5 years. Anthropometric measurements of the mothers and their children were taken during a 1-year period from December 2007 to November 2008. Current wheezing was identified using the International Study of Asthma and Allergies in Childhood questionnaire. Serum total IgE was measured by human IgE quantitative ELISA. IgE specific antibody to dust mites (Dermatophagoides pteronyssinus) was measured by the CAP-FEIA system (Phadia AB, Uppsala, Sweden).

RESULTS

Wheezing at 4·5 years old was significantly associated with stunting (OR = 1·58; 95 % CI 1·13, 2·22) and underweight (OR = 1·39; 95 % CI 1·00, 1·94). The association with stunting remained significant after adjustment for sex, birth weight, birth length, gestational age at birth, mother's parity, maternal BMI, family history of asthma, socio-economic status, season of birth and intervention trial arm (OR = 1·74; 95 % CI 1·19, 2·56).

CONCLUSIONS

Stunting was a significant risk factor for wheezing among rural Bangladeshi children. Further studies will be required to confirm the relationship between nutritional status and allergic illnesses in developing countries.

Validation of a rapid neurodevelopmental assessment tool for 5 to 9 year-old children in Bangladesh

OBJECTIVE

To validate a rapid neurodevelopmental assessment tool for use by child care professionals to determine neurodevelopmental impairments (NDIs) in children ages 5-9 years (61-108 months) in Bangladesh.

STUDY DESIGN

In a convenience sample of community children (n = 18), interrater reliability was determined between 6 testers. Validity was determined in 121 children by simultaneous administration of a test of adaptive behavior (AB) (ie, the Independent Behavior Assessment Scale, or Gold Standard I) and IQ tests (Wechsler Preschool and Primary Scales of Intelligence or the Wechsler Intelligence Scales for Children, or Gold Standard II) by child psychologists.

RESULTS

Interrater reliability was excellent (kappa = 1.00). Significantly lower scores were obtained on AB and IQ tests in those identified with "any (≥1) NDI" and most specific NDIs. Sensitivity and specificity for "any NDI" with (a) "significant difficulties" (defined as AB z-scores < -2 SD and/or IQ < 70) or (b) "mild difficulties included" (AB z scores < -1 SD and/or IQ < 85) were 84% and 57%; and 83% and 70%, respectively.

CONCLUSION

The rapid neurodevelopmental assessment tool shows promise as a tool for use by a range of professionals for identifying NDIs in children of primary school age. Further refinement for identifying specific impairments is needed.

Incidence and risk factors of preterm birth in a rural Bangladeshi cohort

BACKGROUND

Globally, about 15 million neonates are born preterm and about 85% of global preterm birth occurs in Asia and Africa regions. We aimed to estimate the incidence and risk factors for preterm birth in a rural Bangladeshi cohort.

METHODS

Between June 2007 and September 2009, community health workers prospectively collected data from 32,126 mother-live-born baby pairs on household socio-demographic status, pregnancy history, antenatal care seeking and newborn gestational age determined by recall of date of last menstrual period.

RESULTS

Among all live births, 22.3% were delivered prior to 37 weeks of gestation (i.e. preterm); of which 12.3% were born at 35-36 weeks of gestation (late preterm), 7.1% were born at 32-34 weeks (moderate preterm), and 2.9% were born at 28-31 weeks of gestation (very preterm). Overall, the majority of preterm births (55.1%) were late preterm. Risk of preterm birth was lower among women with primary or higher level of education (RR: 0.92; 95% CI: 0.88, 0.97), women who sought antenatal care at least once during the index pregnancy (RR: 0.86; 95% CI: 0.83, 0.90), and women who had completed all birth preparedness steps (RR: 0.32; 95% CI: 0.30, 0.34). In contrast, risk of preterm birth was higher among women with a history of child death (RR: 1.05; 95% CI: 1.01, 1.10), who had mid-upper arm circumference (MUAC) ≤250 mm, indicative of under nutrition (for women having MUAC <214 mm the risk was higher; RR: 1.26; 95% CI: 1.17, 1.35), who reported an antenatal complication (RR: 1.32; 95% CI: 1.14, 1.53), and who received iron-folic acid supplementation for 2-6 months during the index pregnancy (RR: 1.33; 95% CI: 1.24, 1.44).

CONCLUSIONS

In resource poor settings with high burden of preterm birth, alike Bangladesh, preterm birth risk could be reduced by close monitoring and/or frequent follow-up of women with history of child death and antenatal complications, by encouraging women to seek antenatal care from qualified providers, to adopt birth preparedness planning and to maintain good nutritional status. Additional research is needed to further explore the associations of antenatal iron supplementation and maternal nutritional status on preterm birth.

Treating diarrhoeal disease in children under five: the global picture

Rates of childhood mortality due to diarrhoea remain unacceptably high and call for renewed global focus and commitment. Affordable, simple and effective diarrhoeal treatments have already been available for many years, yet a shift in international health priorities has seen coverage of recommended treatments slow to a near-standstill since 1995. This article reviews coverage of recommended childhood diarrhoeal treatments (low-osmolarity oral rehydration solution (ORS) and zinc), globally and regionally, and provides an overview of the major barriers to wide-scale coverage. It is argued that to ensure smooth supply and equitable distribution of ORS and zinc, adequate financing, relevant policy changes, strong public, private and non-government organisation (NGO) collaboration, local manufacturing of pharmaceuticals, mass media awareness and campaigning, in conjunction with strong government support, are necessary for successful treatment scale-up.

Estimation of the herd protection of Haemophilus influenzae type b conjugate vaccine against radiologically confirmed pneumonia in children under 2 years old in Dhaka, Bangladesh

BACKGROUND

Herd protection of Haemophilus influenzae type b (Hib) conjugate vaccine has been associated with excessive decrease of invasive Hib diseases, i.e., pneumonia and meningitis, with increased national or regional Hib vaccine coverage. Only a few studies have examined herd protection at the individual level and even less evidence is available from Asia. We examined Hib vaccine herd protection against radiologically confirmed pneumonia among children less than 2 years old.

METHODS

We incorporated data from a matched case-control study and a vaccine coverage survey in Dhaka, Bangladesh. Pneumonia cases (n=343) were confirmed by radiology. For each case, two controls with conditions other than pneumonia or meningitis were selected from the same hospital. Hib vaccine coverage was calculated as percentages of children who received at least 2 doses of Hib vaccine from a survey in the neighborhood centered on each case and control. Conditional logistic regression was fit to examine the association between vaccine coverage and risk of radiologically confirmed pneumonia.

RESULTS

Neighborhood Hib vaccine coverage varied from 0% to 63.5% for cases and from 8.7% to 61.5% for controls, respectively. Cases were less likely to have neighborhood coverage higher than 20% (OR=0.49, 0.52, 0.55, and 0.69 for coverage 20-29%, 30-39%, 40-49%, and ≥50%, respectively) than coverage <20%, compared to controls, although the estimates for coverage 40-49% and ≥50% were not statistically significant.

CONCLUSIONS

The study indicates that Hib vaccine may provide herd protection, even when the coverage is as low as 20-39%, in a low-income country. Asian countries should consider herd protection in implementing effective vaccine policy with limited resources.

Innovation for universal health coverage in Bangladesh: a call to action

A post-Millennium Development Goals agenda for health in Bangladesh should be defined to encourage a second generation of health-system innovations under the clarion call of universal health coverage. This agenda should draw on the experience of the first generation of innovations that underlie the country's impressive health achievements and creatively address future health challenges. Central to the reform process will be the development of a multipronged strategic approach that: responds to existing demands in a way that assures affordable, equitable, high-quality health care from a pluralistic health system; anticipates health-care needs in a period of rapid health and social transition; and addresses underlying structural issues that otherwise might hamper progress. A pragmatic reform agenda for achieving universal health coverage in Bangladesh should include development of a long-term national human resources policy and action plan, establishment of a national insurance system, building of an interoperable electronic health information system, investment to strengthen the capacity of the Ministry of Health and Family Welfare, and creation of a supraministerial council on health. Greater political, financial, and technical investment to implement this reform agenda offers the prospect of a stronger, more resilient, sustainable, and equitable health system.

Community-based approaches and partnerships: innovations in health-service delivery in Bangladesh

In Bangladesh, rapid advancements in coverage of many health interventions have coincided with impressive reductions in fertility and rates of maternal, infant, and childhood mortality. These advances, which have taken place despite such challenges as widespread poverty, political instability, and frequent natural disasters, warrant careful analysis of Bangladesh's approach to health-service delivery in the past four decades. With reference to success stories, we explore strategies in health-service delivery that have maximised reach and improved health outcomes. We identify three distinctive features that have enabled Bangladesh to improve health-service coverage and health outcomes: (1) experimentation with, and widespread application of, large-scale community-based approaches, especially investment in community health workers using a doorstep delivery approach; (2) experimentation with informal and contractual partnership arrangements that capitalise on the ability of non-governmental organisations to generate community trust, reach the most deprived populations, and address service gaps; and (3) rapid adoption of context-specific innovative technologies and policies that identify country-specific systems and mechanisms. Continued development of innovative, community-based strategies of health-service delivery, and adaptation of new technologies, are needed to address neglected and emerging health challenges, such as increasing access to skilled birth attendance, improvement of coverage of antenatal care and of nutritional status, the effects of climate change, and chronic disease. Past experience should guide future efforts to address rising public health concerns for Bangladesh and other underdeveloped countries.

Local understandings and current barriers to optimal birth intervals among recently delivered women in Sylhet District, Bangladesh

BACKGROUND

Sylhet Division in Bangladesh has the highest proportion of births spaced less than 36 months (46.5%) in Bangladesh.

METHODS

Formative research was conducted on current fertility-related practices in order to explore how to integrate the promotion of healthy fertility practices into a package of maternal and neonatal care interventions. In-depth interviews, focus group discussions and other qualitative methods were utilized with recently delivered women, their families, community health workers and community leaders in Sylhet Division.

RESULTS

Mothers of young children generally understood the benefits of both healthy timing and spacing of pregnancies. However, a variety of factors prevent these desired behaviours from becoming actualized, including the roles of women in the provision of children/grandchildren, local understandings of modern contraceptive methods, perceived side effects, lack of communication regarding healthy fertility practices between partners and extended family members, and limited female autonomy.

CONCLUSIONS

In order to increase families' ability to achieve optimal birth intervals, we propose the promotion and integration of healthy fertility practices into antenatal and newborn care interventions, focusing on providing biomedically correct and culturally appropriate information on modern contraceptive methods to the entire family, while simultaneously encouraging open spousal and family communication patterns regarding timing and spacing of pregnancy.

Economic evaluation of neonatal care packages in a cluster-randomized controlled trial in Sylhet, Bangladesh

OBJECTIVE

To evaluate and compare the cost-effectiveness of two strategies for neonatal care in Sylhet division, Bangladesh.

METHODS

In a cluster-randomized controlled trial, two strategies for neonatal care--known as home care and community care--were compared with existing services. For each study arm, economic costs were estimated from a societal perspective, inclusive of programme costs, provider costs and household out-of-pocket payments on care-seeking. Neonatal mortality in each study arm was determined through household surveys. The incremental cost-effectiveness of each strategy--compared with that of the pre-existing levels of maternal and neonatal care--was then estimated. The levels of uncertainty in our estimates were quantified through probabilistic sensitivity analysis.

FINDINGS

The incremental programme costs of implementing the home-care package were 2939 (95% confidence interval, CI: 1833-7616) United States dollars (US$) per neonatal death averted and US$ 103.49 (95% CI: 64.72-265.93) per disability-adjusted life year (DALY) averted. The corresponding total societal costs were US$ 2971 (95% CI: 1844-7628) and US$ 104.62 (95% CI: 65.15-266.60), respectively. The home-care package was cost-effective--with 95% certainty--if healthy life years were valued above US$ 214 per DALY averted. In contrast, implementation of the community-care strategy led to no reduction in neonatal mortality and did not appear to be cost-effective.

CONCLUSION

The home-care package represents a highly cost-effective intervention strategy that should be considered for replication and scale-up in Bangladesh and similar settings elsewhere.

Animal husbandry practices in rural Bangladesh: potential risk factors for antimicrobial drug resistance and emerging diseases

Antimicrobial drug administration to household livestock may put humans and animals at risk for acquisition of antimicrobial drug-resistant pathogens. To describe animal husbandry practices, including animal healthcare-seeking and antimicrobial drug use in rural Bangladesh, we conducted semi-structured in-depth interviews with key informants, including female household members (n = 79), village doctors (n = 10), and pharmaceutical representatives, veterinarians, and government officials (n = 27), and performed observations at animal health clinics (n = 3). Prevalent animal husbandry practices that may put persons at risk for acquisition of pathogens included shared housing and water for animals and humans, antimicrobial drug use for humans and animals, and crowding. Household members reported seeking human and animal healthcare from unlicensed village doctors rather than formal-sector healthcare providers and cited cost and convenience as reasons. Five times more per household was spent on animal than on human healthcare. Strengthening animal and human disease surveillance systems should be continued. Interventions are recommended to provide vulnerable populations with a means of protecting their livelihood and health.

The effect of umbilical cord cleansing with chlorhexidine on omphalitis and neonatal mortality in community settings in developing countries: a meta-analysis

Background

There is an increased risk of serious neonatal infection arising through exposure of the umbilical cord to invasive pathogen in home and facility births where hygienic practices are difficult to achieve. The World Health Organization currently recommends ‘dry cord care’ because of insufficient data in favor of or against topical application of an antiseptic. The primary objective of this meta-analysis is to evaluate the effects of application of chlorhexidine (CHX) to the umbilical cord to children born in low income countries on cord infection (omphalitis) and neonatal mortality. Standardized guidelines of Child Health Epidemiology Reference Group (CHERG) were followed to generate estimates of effectiveness of topical chlorhexidine application to umbilical cord for prevention of sepsis specific mortality, for inclusion in the Lives Saved Tool (LiST).

Methods

Systematic review and meta-analysis. Data sources included Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, PubMed, CINHAL and WHO international clinical trials registry. Only randomized trials were included. Studies of children in hospital settings were excluded. The comparison group received no application to the umbilical cord (dry cord care), no intervention, or a non-CHX intervention. Primary outcomes were omphalitis and all-cause neonatal mortality.

Results

There were three cluster-randomised community trials (total participants 54,624) conducted in Nepal, Bangladesh and Pakistan that assessed impact of CHX application to the newborn umbilical cord for prevention of cord infection and mortality. Application of any CHX to the umbilical cord of the newborn led to a 23% reduction in all-cause neonatal mortality in the intervention group compared to control [RR 0.77, 95 % CI 0.63, 0.94; random effects model, I²=50 %]. The reduction in omphalitis ranged from 27 % to 56 % compared to control group depending on severity of infection. Based on CHERG rules, effect size for all-cause mortality was used for inclusion to LiST model as a proxy for sepsis specific mortality.

Conclusions

Application of CHX to newborn umbilical cord can significantly reduce incidence of umbilical cord infection and all-cause mortality among home births in community settings. This inexpensive and simple intervention can save a significant number of newborn lives in developing countries.

Elevated manganese concentrations in drinking water may be beneficial for fetal survival

BACKGROUND

Elevated exposure to the essential element manganese (Mn) can be toxic. Manganese concentrations in ground water vary considerably, and reported associations between Mn and early-life mortality and impaired development have raised concern. We assessed the effects of drinking water Mn exposure during pregnancy upon fetal and infant survival.

METHODS

In this population-based cohort study, we identified the outcomes of pregnancies registered between February 2002 and April 2003 in Matlab, Bangladesh. Using inductively coupled plasma mass spectrometry, we measured the concentrations of Mn and other elements in the pregnant women's drinking water.

RESULTS

A total of 1,875 women were included in the analysis of spontaneous abortions (n=158) and 1,887 women in the perinatal mortality analysis (n=70). Water Mn ranged from 3.0-6,550 µg/L (median=217 µg/L). The adjusted odds ratio (OR) for spontaneous abortion was 0.65 (95% CI 0.43-0.99) in the highest water Mn tertile (median=1,292 µg/L) as compared to the lowest tertile (median=56 µg/L). The corresponding OR for perinatal mortality was 0.69 (95% CI 0.28-1.71), which increased to 0.78 (95% CI 0.29-2.08) after adjustment for BMI and place of delivery (home/health facility; n=1,648).

CONCLUSIONS

Elevated water Mn concentrations during pregnancy appear protective for the fetus, particularly in undernourished women. This effect may be due to the element's role in antioxidant defense.

Global and regional burden of hospital admissions for severe acute lower respiratory infections in young children in 2010: a systematic analysis

BACKGROUND

The annual number of hospital admissions and in-hospital deaths due to severe acute lower respiratory infections (ALRI) in young children worldwide is unknown. We aimed to estimate the incidence of admissions and deaths for such infections in children younger than 5 years in 2010.

METHODS

We estimated the incidence of admissions for severe and very severe ALRI in children younger than 5 years, stratified by age and region, with data from a systematic review of studies published between Jan 1, 1990, and March 31, 2012, and from 28 unpublished population-based studies. We applied these incidence estimates to population estimates for 2010, to calculate the global and regional burden in children admitted with severe ALRI in that year. We estimated in-hospital mortality due to severe and very severe ALRI by combining incidence estimates with case fatality ratios from hospital-based studies.

FINDINGS

We identified 89 eligible studies and estimated that in 2010, 11·9 million (95% CI 10·3-13·9 million) episodes of severe and 3·0 million (2·1-4·2 million) episodes of very severe ALRI resulted in hospital admissions in young children worldwide. Incidence was higher in boys than in girls, the sex disparity being greatest in South Asian studies. On the basis of data from 37 hospital studies reporting case fatality ratios for severe ALRI, we estimated that roughly 265,000 (95% CI 160,000-450,000) in-hospital deaths took place in young children, with 99% of these deaths in developing countries. Therefore, the data suggest that although 62% of children with severe ALRI are treated in hospitals, 81% of deaths happen outside hospitals.

INTERPRETATION

Severe ALRI is a substantial burden on health services worldwide and a major cause of hospital referral and admission in young children. Improved hospital access and reduced inequities, such as those related to sex and rural status, could substantially decrease mortality related to such infection. Community-based management of severe disease could be an important complementary strategy to reduce pneumonia mortality and health inequities.

FUNDING

WHO.

Chlorhexidine cleansing of the umbilical cord and separation time: a cluster-randomized trial

OBJECTIVE

Cord cleansing with chlorhexidine reduces neonatal mortality. We aimed to quantify the impact of this intervention on cord separation time and the implications of such an increase on maternal and other caretaker's acceptance of chlorhexidine in future scaled up programs.

METHODS

Between June 2007 and September 2009, 29,760 newborns were randomly assigned within communities in Bangladesh to receive 1 of 3 cord regimens: dry and clean cord care (comparison), single-cleansing, or multiple-cleansing with 4.0% chlorhexidine. Workers recorded separation status during home visits. Mothers of 380 infants in randomly selected clusters reported age at separation and satisfaction with cord regimen.

RESULTS

Compared with dry and clean care (mean 4.78 days), separation time was longer in the single (mean 6.90 days, difference = 2.10; 95% confidence interval: 1.85-2.35) and multiple (mean 7.49 days, difference = 2.69; 95% confidence interval: 2.44-2.95) cleansing groups. Increased separation time was not associated with omphalitis. Mothers in these groups more frequently reported "longer than usual" separation times and dissatisfaction with the separation time (11.1% and 17.6%, respectively) versus the comparison group (2.5%). Overall satisfaction with the received cord care regimen was high (96.2%).

CONCLUSIONS

Topical chlorhexidine increased cord separation time by ∼50%. Caretakers are likely to detect this increase and might express dissatisfaction but still accept the intervention overall. When scaling up chlorhexidine cord cleansing, inclusion of appropriate messaging on expectation and nonrisks of increased cord separation time, in addition to the benefits of reduced infection and improved survival, might improve compliance.

Measuring coverage in MNCH: a prospective validation study in Pakistan and Bangladesh on measuring correct treatment of childhood pneumonia

BACKGROUND

Antibiotic treatment for pneumonia as measured by Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS) is a key indicator for tracking progress in achieving Millennium Development Goal 4. Concerns about the validity of this indicator led us to perform an evaluation in urban and rural settings in Pakistan and Bangladesh.

METHODS AND FINDINGS

Caregivers of 950 children under 5 y with pneumonia and 980 with "no pneumonia" were identified in urban and rural settings and allocated for DHS/MICS questions 2 or 4 wk later. Study physicians assigned a diagnosis of pneumonia as reference standard; the predictive ability of DHS/MICS questions and additional measurement tools to identify pneumonia versus non-pneumonia cases was evaluated. Results at both sites showed suboptimal discriminative power, with no difference between 2- or 4-wk recall. Individual patterns of sensitivity and specificity varied substantially across study sites (sensitivity 66.9% and 45.5%, and specificity 68.8% and 69.5%, for DHS in Pakistan and Bangladesh, respectively). Prescribed antibiotics for pneumonia were correctly recalled by about two-thirds of caregivers using DHS questions, increasing to 72% and 82% in Pakistan and Bangladesh, respectively, using a drug chart and detailed enquiry.

CONCLUSIONS

Monitoring antibiotic treatment of pneumonia is essential for national and global programs. Current (DHS/MICS questions) and proposed new (video and pneumonia score) methods of identifying pneumonia based on maternal recall discriminate poorly between pneumonia and children with cough. Furthermore, these methods have a low yield to identify children who have true pneumonia. Reported antibiotic treatment rates among these children are therefore not a valid proxy indicator of pneumonia treatment rates. These results have important implications for program monitoring and suggest that data in its current format from DHS/MICS surveys should not be used for the purpose of monitoring antibiotic treatment rates in children with pneumonia at the present time.