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Inferiority of single-dose sulfadoxine-pyrimethamine intermittent preventive therapy for malaria during pregnancy among HIV-positive Zambian women.
Journal of Infectious Diseases. 2007 Dec 1; 196(11):1577-1584.The World Health Organization advocates 2-3 doses of sulfadoxine-pyrimethamine (SP) for intermittent preventive treatment of malaria (SP IPTp). The optimal number of doses and the consequences of singledose therapy remain unclear. Data were from a randomized, controlled study of human immunodeficiency virus-positive Zambian women comparing monthly versus 2-dose SP IPTp. We compared maternal and neonatal birth outcomes as a function of how many doses the mothers received (1 to >/= 4 doses). Of 387 deliveries, 34 received 1 dose of SP. Single-dose SP was significantly associated with higher proportions of maternal anemia, peripheral and cord blood parasitemia, infant prematurity, and low birth weight. SP conferred dose-dependent benefits, particularly in the transition from 1 to 2 doses of SP. Women randomized to the standard 2-dose regimen were much more likely to receive only 1 dose than were women randomized to monthly IPT (relative risk, 16.4 [95% confidence interval, 4.0-68.3]). Single-dose SP was a common result of trying to implement the standard 2-dose regimen and was inferior to all other dosing regimens. At a programmatic level, this implies that monthly SP IPTp may ultimately be more effective than the standard regimen by reducing the risk of inadvertently underdosing mothers. (author's)
Antiretroviral treatment and prevention of peripartum and postnatal HIV transmission in West Africa: Evaluation of a two-tiered approach.
PLoS Medicine. 2007 Aug; 4(8):e257.Highly active antiretroviral treatment (HAART) has only been recently recommended for HIV-infected pregnant women requiring treatment for their own health in resource-limited settings. However, there are few documented experiences from African countries. We evaluated the short-term (4 wk) and long-term (12 mo) effectiveness of a two-tiered strategy of prevention of mother-to-child transmission of HIV (PMTCT) in Africa: women meeting the eligibility criteria of the World Health Organization (WHO) received HAART, and women with less advanced HIV disease received short-course antiretroviral (scARV) PMTCT regimens. The MTCT-Plus Initiative is a multi-country, family-centred HIV care and treatment program for pregnant and postpartum women and their families. Pregnant women enrolled in Abidjan, Cote d'Ivoire received either HAART for their own health or short-course antiretroviral (scARV) PMTCT regimens according to their clinical and immunological status. Plasma HIV-RNA viral load (VL) was measured to diagnose peripartum infection when infants were 4 wk of age, and HIV final status was documented either by rapid antibody testing when infants were aged >/= 12 mo or by plasma VL earlier. The Kaplan-Meier method was used to estimate the rate of HIV transmission and HIV-free survival. Between August 2003 and June 2005, 107 women began HAART at a median of 30 wk of gestation, 102 of them with zidovudine (ZDV), lamivudine (3TC), and nevirapine (NVP) and they continued treatment postpartum; 143 other women received scARV for PMTCT, 103 of them with sc(ZDV+3TC) with single-dose NVP during labour. Most (75%) of the infants were breast-fed for a median of 5 mo. Overall, the rate of peripartum HIV transmission was 2.2% (95% confidence interval [CI] 0.3%-4.2%) and the cumulative rate at 12 mo was 5.7% (95% CI 2.5%-9.0%). The overall probability of infant death or infection with HIV was 4.3% (95% CI 1.7%-7.0%) at age week 4 wk and 11.7% (95% CI 7.5%-15.9%) at 12 mo. This two-tiered strategy appears to be safe and highly effective for short- and long-term PMTCT in resource-constrained settings. These results indicate a further benefit of access to HAART for pregnant women who need treatment for their own health. (author's)
Evaluation of the Food and Agriculture Organization's global school-based nutrition education initiative, Feeding Minds, Fighting Hunger (FMFH), in schools of Hyderabad, India.
Public Health Nutrition. 2006 Dec; 9(8):991-995.The objective was to assess the efficacy of the Food and Agriculture Organization's global school-based nutrition education initiative, Feeding Minds, Fighting Hunger (FMFH), in improving nutrition-related knowledge levels of schoolchildren. Design: Adopting the cluster randomisation technique, five schools each in experimental and control groups were randomly chosen from the member schools of a voluntary organisation. Repeated measures of knowledge levels were carried out at three points in time to assess pre-, post-intervention and retention of knowledge gained during the intervention. Children from experimental schools were given nutrition education by teachers in the classroom setting using FMFH material. Subjects/settings: Schoolchildren (n = 358 in the control group and n = 312 in the experimental group) of grades VIII and IX from schools in Hyderabad, India. The classroom-based intervention resulted in a significant improvement (P < 0.01) in nutrition knowledge levels of schoolchildren in the experimental group. Significant improvement in knowledge was also observed in the control group. The effect size indicated that the improvement in knowledge levels of schoolchildren in experimental schools over control schools was medium (d = 0.40), indicating the efficacy of the FMFH programme in improving nutrition-related knowledge. No significant decrease (P > 0.05) in knowledge levels was observed after 2 months, indicating retention of the knowledge acquired through the intervention. The FMFH programme provides an opportunity for schoolchildren to learn more about nutrition through their teachers in a classroom setting if the lesson plans are adapted to the local circumstances. Furthermore, it has the potential to make nutrition education interactive, effective and sustainable. (author's)
[Washington, D.C.], Population Council, Frontiers in Reproductive Health, 2006 Jun.  p. (USAID Cooperative Agreement No. HRN-A-00-98-00012-00)The Government of Ghana has adopted the WHO focused antenatal care (ANC) package in a move to improve access, quality and continuity of ANC services to pregnant women. As part of these efforts, the Government has exempted fees for ANC clients. The main objective of this study, undertaken by Noguchi Memorial Institute for Medical Research in collaboration with the Ghana Health Service (GHS), FRONTIERS, and with USAID funding, was to examine the extent to which adaptation of the package influenced quality of care received by pregnant women and its acceptability to both providers and clients. The study used a policy analysis and a situation analysis in ten intervention clinics in which the package had been introduced and four comparison clinics. Data were collected through key informant interviews, focused group discussions, client exit interviews, client card reviews, observations of provider-client interactions and review of facility records. (excerpt)
Paediatric and Perinatal Epidemiology. 1998 Apr; 12(2):176-181.In children, the treatment of acute diarrhoea with the World Health Organization (WHO) standard oral rehydration solution (ORS) provides effective rehydration but does not reduce the severity of diarrhoea. In community practice, carob bean has been used to treat diarrhoeal diseases in Anatolia since ancient times. In order to test clinical antidiarrhoeal effects of carob bean juice (CBJ), 80 children, aged 4±48 months, who were admitted to SSK Tepecik Teaching Hospital with acute diarrhoea and mild or moderate dehydration, were randomly assigned to receive treatment with either standard WHO ORS alone or a combination of standard WHO ORS and CBJ. Three patients were excluded from the study because of excessive vomiting. In the children receiving ORS + CBJ the duration of diarrhoea was shortened by 45%, stool output was reduced by 44% and ORS requirement was decreased by 38% compared with children receiving ORS alone. Weight gain was similar in the two groups at 24 h after the initiation of the study. Hypernatraemia was detected in three patients in the ORS group but in none of those in the ORS + CBJ group. The use of CBJ in combination with ORS did not lead to any clinical metabolic problem. We therefore conclude that CBJ may have a role in the treatment of children's diarrhoea after it has been technologically processed, and that further studies would be justified. (author's)
Contraception. 2003 Oct; 68(4):233-238.Contraception choices may be limited for lactating women due to concerns about hormonal effects on quality and quantity of milk, passage of hormones to the infant and infant growth. We conducted a systematic review of randomized controlled trials to determine the effect of hormonal contraception on lactation. We sought all randomized controlled trials, reported in any language, that included any form of hormonal contraception compared with another form of hormonal contraception, nonhormonal contraception or placebo during lactation. Seven reports from five randomized controlled trials met the inclusion criteria. Most of the five trials did not specify their method used to generate a random sequence, method of allocation concealment, blinding of treatments or use of an intention-to-treat analysis. Additionally, high loss-to-follow-up rates invalidated at least two trials. The findings from two trials comparing oral contraceptives to placebo during lactation were conflicting. Another trial found no inhibitory effects on lactation from progestin-only contraceptives. Finally, the World Health Organization trial found a statistically significant decline in breast milk volume in women using combined oral contraceptives compared to women using progestin-only pills. However, infant growth for the two groups did not differ. The limited evidence from randomized controlled trials on the effect of hormonal contraceptives during lactation is of poor quality and insufficient to establish an effect of hormonal contraception, if any, on milk quality and quantity. At least one properly conducted randomized controlled trial of adequate size is urgently needed to make recommendations regarding hormonal contraceptive use for lactating women. (author's)
DOTS versus self administered therapy (SAT) for patients of pulmonary tuberculosis: a randomised trial at a tertiary care hospital.
Indian Journal of Medical Sciences. 2002 Jan; 56(1):19-21.Tuberculosis is a major public health problem in India, and it is being made worse by poor adherence to and frequent interruption of antitubercular treatment. Directly observed therapy short course (DOTS), is one of the key elements in the WHO global tuberculosis control programme strategy and has been widely publicized as a breakthrough and strongly promoted globally by WHO. However little or no randomised data exists of comparison between DOTS versus self administered therapy (SAT). The present study is an effort in this direction to compare adherence and outcome after random allocation of patients to directly observed therapy (DOTS) or self administered therapy (SAT). (author's)
SCN News. 2002 Dec; (25):4-30.This paper addresses the most common nutrition and health problems in turn, assessing the extent of the problem; the impact of the condition on overall development, and what programmatic responses can be taken to remedy the problem through the school sys- tern. The paper also acknowledges that an estimated 113m children of school-age are not in school, the majority of these children living in Sub-Saharan Africa and South-East Asia. Poor health and nutrition that differentially affects this population is also discussed. (excerpt)
[Third generation oral contraceptives and risk of venous thrombosis] Tredjegenerations-p-piller og risikoen for venose tromboser.
Ugeskrift for Laeger. 2002 Jan 14; 164(3):346.The third-generation pill was introduced as a better option than the second-generation pill due to its improved effect on the lipid profile of the user. It thus came as a surprise that the great international case control study of the WHO showed a greater risk of venous thrombosis associated with the use of the third-generation pill, compared to the second-generation pill. (excerpt)
In: Operations research family planning database project summaries, [compiled by] Population Council. New York, New York, Population Council, 1993 Mar.  p. (DMA-02)Teenage pregnancies have been a major health concern in Dominica. Although fertility rates were declining overall, 26% of all live births in 1984 were to teenagers 19 years old and under, the majority of whom were unmarried. Family planning (FP) services were available on request to teens at most clinics but the Ministry of Health (MOH) initiated plans to make contraception more accessible to this age group by establishing youth clinics in collaboration with the UNFPA and the International Planned Parenthood Federation. Tulane University was asked to design and implement an operations research study to test the feasibility of operating these clinics with the objective of reducing teenage pregnancy by providing sex education and making contraceptives readily available. The project was designed at a cost of US $17,326 to test 2 alternative strategies in 6 communities. One rural and one urban community were assigned to each of 2 treatment groups, and another urban community and rural community formed the control group. Treatment group 1 had a separate youth clinic facility established, open 2 days a week to teen clients. Services provided included family life education, FP counseling, distribution of contraceptive methods, and general health care. Group 2 had youth clinics which operated from the existing health centers, with different hours for the teen clients. In the control group, there were no special services provided for the younger age group, although FP services were provided at the local health center or clinic. Although the 4 clinics were established, there was official reluctance to publicize the fact that contraceptives were among the services available. As a result, the project was terminated early. Using a quasi-experimental design, the study was to be based on pre/post-intervention surveys and the collection of service statistics. The baseline survey indicated that knowledge about the reproductive process was higher among older teens, but 90% of all respondents did not know the most fertile time for a woman. Knowledge of FP methods increased with age among both males and females. Over 90% of all teens knew at least one contraceptive method. 78% of males claimed to have had sex as did 46% of females. The reported use of contraceptives during first sexual encounter was significantly higher for females than males. Over 50% of the males who claimed to have had sex said they disapproved of premarital sex, as did nearly 66% of the females. More than 75% of respondents wanted more information on sexually transmitted diseases and contraceptive methods and thought sex education should be taught in schools.
Obstetrics and Gynecology. 2002 Jun; 99(6):1100-1112.The objective of this study is to review new evidence regarding 10 controversial issues in the use of contraceptive methods among women with special conditions and to present WHO recommendations derived in part from this evidence. The authors searched MEDLINE and PREMEDLINE databases for English-language articles, published between January 1995 and December 2001, for evidence relevant to 10 key contraceptive method and condition combinations: combined oral contraceptive (OC) use among women with hypertension or headaches, combined OC use for emergency contraception and adverse events, progestogen-only contraception use among young women and among breastfeeding women, tubal sterilization among young women, hormonal contraception and IUD use among women who are HIV positive, have AIDS, or are at high risk of HIV infection. Search terms included: "contraception," "contraceptives, oral," "progestational hormones," "medroxyprogesterone-17" acetate," "norenthindrone," "levonorgestrel," "Norplant," "contraceptives, postcoital," "sterilization, tubal," "IUDs," "hypertension," "stroke," "myocardial infarction," "thrombosis," "headache," "migraine," "adverse effects," "bone mineral density," "breastfeeding," "lactation," "age factors," "regret," and "HIV". From 205 articles, the authors identified 33 studies published in peer-reviewed journals that specifically examined risks of contraceptive use among women with pre-existing conditions. Combined OC users with hypertension appear to be at increased risk of myocardial infarction and stroke relative to users without hypertension. Combined OC users with migraine appear to be at increased risk of stroke relative to non-users with migraine. The evidence for the other eight method and condition combinations was either insufficient to draw conclusions or identified no excess risk. Of the 10 contraceptive method and condition combinations assessed, the evidence supported an increased risk of cardiovascular complications with combined OC use by women with hypertension or migraine. As a new evidence becomes available, assessment of risk and recommendations for use of contraceptive methods can be revised accordingly. (author's)
JOURNAL OF EPIDEMIOLOGY AND COMMUNITY HEALTH. 1998 Dec; 52(12):775-85.The World Health Organization (WHO) Collaborative Study of Cardiovascular Disease and Steroid Hormone Contraception has quantified the risks of idiopathic venous thromboembolism (VTE), ischemic and hemorrhagic stroke, and acute myocardial infarction (AMI) associated with use of combined oral contraceptives (OCs). The present case-control study estimated the age-specific incidence and mortality of these four diseases among women with no cardiovascular risk factors and modelled the risks attributable to OC use, smoking, and the interaction of the two. Data sources included relative risk estimates from the WHO study and observed incidence rates obtained from hospitals in UK's Oxford region in 1989-93. The increased risk of VTE associated with OC use among nonsmokers contributed over 90% of all cardiovascular events among women 20-24 years and more than 60% in those 40-44 years. Among OC users who smoked, hemorrhagic stroke and AMI accounted for 80% of cardiovascular deaths in the 20-24 year group and 97% among those 40-44 years. Cardiovascular mortality associated with smoking exceeded that associated with OC use at all ages. Attributable risk associated with OC use was 1 death/year/370,000 users aged 20-24 years, 1/170,000 users aged 30-34 years, and 1/37,000 users aged 40-44 years. Among smokers, annual cardiovascular mortality attributable to OC use was estimated at about 1/100,000 users among women under 35 years old and 1/10,000 users among those 35 years of age and older. Among healthy women 35 years and older, the additional mortality associated with OC use is 1.4/100,000/year compared with 5.4/100,000 among smokers and 14/100,000 women who both use OCs and smoke. Any potential reduction in AMI or stroke risk associated with third-generation OCs would be a more important consideration in older women, especially smokers. However, the mortality associated with smoking is far greater than that associated with use of all types of OCs at all ages.
Cardiovascular disease and use of oral and injectable progestogen-only contraceptives and combined injectable contraceptives. Results of an international, multicenter, case-control study. World Health Organization Collaborative Study of Cardiovascular Disease and Steroid Hormone Contraception.
CONTRACEPTION. 1998 May; 57(5):315-24.As part of a World Health Organization Collaborative Study conducted at 21 centers in Africa, Asia, Europe, and Latin America in 1989-93, the risks of cardiovascular disease associated with use of oral and injectable progestogen-only and combined injectable contraceptives were investigated. 3697 cases of cardiovascular disease (59% stroke, 31% venous thromboembolism, and 10% acute myocardial infarction) were available for analysis and age-matched with up to three controls. 53 cases were current users of oral progestogen-only contraception, 37 were using an injectable progestogen-only method, and 13 were using combined injectable contraception. The adjusted odds ratios for all cardiovascular diseases compared with nonusers of any type of steroid hormone contraceptive were 1.4 (95% confidence interval (CI), 0.79-1.63) for current users of oral progestogen-only methods, 1.02 (95% CI, 0.68-1.54) for users of injectable progestogen-only contraceptives, and 0.95 (95% CI, 0.49-1.86) for use of combined injectable contraceptives. No significant changes in risk for stroke, venous thromboembolism, or acute myocardial infarction or these three conditions combined was apparent in association with any of the contraceptive methods. However, a nonsignificant increase in risk of venous thromboembolism was apparent for both types of progestogen-only contraceptives. Among women with a history of hypertension, the odds ratio for stroke rose from 7.2 (95% CI, 6.1-8.5) among nonusers of any type of steroid hormonal contraceptive method to 12.4 (95% CI, 4.1-37.6) among current users of all oral progestogens.
JOURNAL OF DIARRHOEAL DISEASES RESEARCH. 1995 Dec; 13(4):207-11.A randomized clinical trial compared the efficacy of an oral rehydration solution (ORS) formulated with commercial rice powder at 50 g/l (case group of 13 boys and 11 girls) with that of glucose-based WHO/UNICEF-recommended ORS (control group of 13 boys and 11 girls) in the management of 48 patients aged 3-24 months with acute dehydrating watery diarrhea in the pediatric ward of the Universidad Catolica Clinical Hospital, Chile. Enteropathogens were found in 94% of the patients. Rotavirus was present in 85% of the patients, either as a single pathogen (58%) or in association with other agents (27%). Enteropathogenic Escherichia coli (EPEC) was recovered in 33% of the patients; in 8% of the cases it occurred as a single pathogen and in 25% of the cases it was associated with rotavirus. 7 patients (29%) in the control group and 4 (17%) in the study group required intravenous fluids at some point in the course of the study. Mean fecal losses were generally higher in the rice-ORS patients throughout the study. The stool output (ml/kg) in the first 24 hours was 213 (153-353) [geometric mean (95% confidence interval)] in the rice-ORS group vs. 146 (108-232) in the glucose-ORS group, while the total stool output was 455 (298-933) vs. 307 (209-625) (p value not significant). The mean [+or- standard deviation (SD)] duration of diarrhea in hospital was: 72 +or- 10 hours in the study group vs. 77 +or- 12 hours in the control group (p value not significant). The ORS formulated with a commercial rice powder used in this trial is not superior to the standard glucose-ORS advocated by WHO/UNICEF in the treatment of infants with watery non-cholera dehydrating diarrhea. In some cases, ORS formulated with the commercial cereal-based products might actually increase the stool losses in infants with high-output non-cholera diarrhea.
CONTRACEPTION REPORT. 1996 Nov; 7(4):4-9.Two recent studies provide confirmation of the safety of low-dose oral contraceptives (OCs) with respect to stroke. The first study (Petitti et al.) investigated all strokes that occurred in 1991-94 among women 15-44 years of age who were members of the Kaiser Permanente Medical Care Programs of Northern and Southern California. A total of 408 confirmed strokes occurred among 1.1 million women during 3.6 million women-years of observation. There was no increased risk of ischemic or hemorrhagic stroke among current low-dose OC users. The adjusted odds ratio (OR) for ischemic stroke among current users compared to former users and never users was 1.2 (95% confidence interval (CI), 0.5-2.6). The adjusted OR for hemorrhagic stroke was 1.1 (95% CI, 0.6-2.2). Past users had a significantly decreased ischemic stroke risk compared to never users (OR, 0.5; 95% CI, 0.3-0.98). For subarachnoid hemorrhage, the OR was 1.5 (95% CI, 0.6-3.6) for current users compared to former and never users. The second study (World Health Organization Collaborative Study of Cardiovascular Disease and Steroid Hormone Contraception) investigated 3792 cases of stroke, myocardial infarction, and venous thromboembolism and 10,281 hospitalized controls. Current OC use significantly increased the risk of ischemic stroke in both Europe (OR, 3.0; 95% CI, 1.7-5.4.0) and developing countries (OR, 2.9; 95% CI, 2.1-4.0). Current OC use was associated with hemorrhagic stroke in developing countries (OR, 1.8; 95% CI, 1.3-2.3), but not in Europe (OR, 1.4; 95% CI, 0.8-2.3). European users of low-dose OCs showed no excess risk of stroke. Both smoking and hypertension were independent risk factors for stroke.
JOURNAL OF REPRODUCTIVE MEDICINE. 1996 May; 41(5 Suppl):419-25.This article reviews recent epidemiological data assessing the risk of breast, endometrial, ovarian, and cervical cancer in women using the injectable contraceptive depot medroxyprogesterone acetate (DMPA). A review is also provided of epidemiological and biostatistical concepts which relate to the literature on the relationship between the use of hormonal contraception and cancer. Breast cancer is a common and lethal disease in the US, and evidence suggests that gonadal steroids play a role in the development of breast cancer. Two major case control studies (one in New Zealand and the other under the auspices of the World Health Organization [WHO]) as well as a pooled analysis of these studies found no increased overall breast cancer risk in DMPA users. A currently unexplained pattern of increased risk in recent users mimics that seen with oral contraceptive (OC) use and term pregnancy. A WHO hospital-based study of the relationship between endometrial cancer and DMPA use found a protective effect of DMPA which appeared to be longterm and as great as that associated with OCs. Whereas it is plausible that DMPA, which suppresses ovulation, would lower the risk of ovarian cancer in users, a WHO case-control and hospital-based study failed to uncover such a protective effect. Studies of the routine use of DMPA in nulliparous women (who have higher risk of ovarian cancer) will shed more light on any effect DMPA may have on ovarian cancer. The unique epidemiology of cervical cancer (including number of sexual partners, use of barrier contraception, and frequent screening) makes it difficult to assess any association with contraceptive use. However, a large population-based, case-control study in Costa Rica; a WHO hospital-based, case-control study in Thailand, Mexico, and Kenya; and a study in New Zealand indicate that the risk of cervical neoplasia does not appear to be affected by DMPA use. While some issues regarding DMPA and the risk of reproductive tract carcinoma remain to be resolved, clinicians can be reassured that, for appropriately selected clients, the substantial benefits of DMPA outweigh any risks.
Family Planning Perspectives. 1992 Sep-Oct; 24(5):239-40.The findings of a World Health Organization (WHO) case-control study conducted in Kenya, Mexico, and Thailand suggest that Depo-Provera users are at no greater risk of invasive cervical cancer than non-users (relative risk, 1.1), regardless of duration of use. Women who had used Depo-Provera for 4-8 years were only 10% more likely than non-users to develop cervical cancer, and there was no elevation in risk among women who received their first injection more than 12 years before the interview. The WHO Collaborative Study of Neoplasia and Steroid Contraceptives compared 2009 cervical cancer patients with 9583 controls hospitalized for non-gynecologic conditions. In the Thai and Mexican studies, the cervical cancer risk was slightly but not significantly elevated among women with a history of anal or genital warts (relative risks, 1.24 and 1.61, respectively), but significantly increased among those with herpes simplex type 2 antibodies (relative risk, 1.67). However, these history variables, as well as husband's sexual behavior, had no confounding effect on the association between Depo-Provera use and cervical cancer. There was no alteration in cancer risk among Depo-Provera users according to oral contraceptive use, sexually transmitted disease history, herpes antibody status, age at first intercourse, or husband's exposure to prostitutes.
Drs. Thomas and Noonan reply re "Comparison of Recalled and Validated Oral Contraceptive Histories" [letter]
AMERICAN JOURNAL OF EPIDEMIOLOGY. 1995 Apr 15; 141(8):791.Dr. Realini asserts in his letter that the results of the WHO Collaborative Study of Neoplasia and Steroid Contraceptives concerning oral contraceptives and breast cancer could have been biased as a result of better recall of prior oral contraceptive use by cases in comparison to controls. Although this is a possibility in any case-control study based on data collected by interviews, being able to validate positive oral contraceptive histories of more cases than controls does not necessarily mean more cases than controls who were users of oral contraceptives gave a history of such use. The issue of bias due to recall was discussed in the original paper. The medical records of women who claimed contraceptive use were checked for brand names and duration of use; the medical records of women who did not were not checked. This procedure did not alter their classification as users or nonusers. Since few combined oral contraceptives were available, and erroneous reports of use of combined or noncombined preparations were corrected, the estimated values of the relative risk of breast cancer in women who ever used combined oral contraceptives could not be appreciably influenced by any differences in the proportion of cases or controls whose oral contraceptive histories were supplemented by information from medical records. However, such differences could alter estimated values of the relative risk in relation to duration, latency, or recency. Information was obtained from the medical records of users in 27% of cases and 18% of controls. These percentages varied with center (0-94% of cases, 0-89% of controls). Information was most frequently obtained from the medical records of long-term and current or recent users in both groups. Similar results were obtained separately from countries in which information from medical records was obtained for relatively high and low proportions of users, and in individuals whose use was ascertained solely from interviews and from both interviews and medical records.
AMERICAN JOURNAL OF EPIDEMIOLOGY. 1994 Nov 15; 140(10):956.A paper by Nischan and colleagues, "Comparison of Recalled and Validated Oral Contraceptive Histories," which examines the accuracy of the histories of oral contraceptive use (defined as agreement with gynecologists' records concerning duration of use, times since first and last use, and individual preparations used) in a WHO case-control study of breast cancer, "WHO Collaborative Study of Neoplasia and Steroid Contraceptives," fails to comment on the more frequent validity of the histories among those persons with breast cancer. Of 253 contraceptive histories from persons with breast cancer, for whom responses from at least 1 gynecologist were available, 234 (92.4%) were confirmed; of those from 621 controls, 524 were. The difference is statistically significant (chi-square test, p < 0.01). This better recall of ever-use of oral contraceptives among breast cancer patients creates a bias that makes an association between breast cancer and ever-use of oral contraceptives stronger than it is. The slight elevation in breast cancer risk associated with ever-use of oral contraceptives found in the WHO study may be due to this. There is no information about the accuracy of negative oral contraceptive histories.
BULLETIN OF THE WORLD HEALTH ORGANIZATION. 1993; 71(3-4):421-8.Worldwide coverage of measles vaccine is about 80%, but many communities and countries have considerably lower coverage rates. WHO is concerned about measles occurring in infants between 6 and 12 months old, especially in densely populated African cities. Measles rarely occurs in infants under 6 months old, but the measles case fatality rate is greatest in the 1st year of life. WHO aims for an effective measles vaccine to be administered at 6 months old. A high titer vaccine appears to reduce survival among children receiving it. Some countries have reduced measles incidence by as much as 90% by achieving coverage levels greater than 90% with a single dose measles vaccine. Another method to prevent early measles cases and later vaccine failures is administration of the 1st dose around 6 months and a 2nd dose no earlier than 12 months. Measles vaccine policy in the US and some countries in Europe is routine 2-dose measles schedules: 1st dose between 12-19 months and 2nd dose at school entry. This schedule is appropriate in developed countries with good immunization coverage. Other countries schedule the 1st dose anywhere between 6-9 months and the 2nd dose between 12 months and 7 years. All mathematical models of the effects of 2-dose schedules indicate that 2-dose schedule are a great benefit. The literature shows that developing countries with high immunization coverage and well-managed immunization programs can effectively execute and sustain 2-dose measles schedules. Measles vaccination early in life sometimes results in a blunted antibody response. The 2-dose schedules are probably more expensive than 1-dose schedules and require more cold storage space. No field trials have looked at clinical efficacy of 2-dose measles schedules in developing countries. Ideal field trials would be randomized controlled trials. Demonstration projects can evaluate operational issues, e.g., dropout rates, cost, and vaccine usage. Case control studies can address technical and epidemiological issues.
Impact of community-based case management of pneumonia on infant and child mortality: a meta-analysis of six intervention trials.
In: Child health priorities for the 1990s. Report of a seminar held June 20-22, 1991 at the Johns Hopkins University School of Hygiene and Public Health, Baltimore, Maryland, edited by Kenneth Hill. Baltimore, Maryland, Johns Hopkins University, School of Hygiene and Public Health, Institute for International Programs, 1992 Oct. 161-90.Respiratory tract infections, and pneumonia in particular, account for 25-33% (4-5 million/year) of all childhood deaths in developing countries. There have been 7 published studies of WHO child survival intervention trials for evaluating pneumonia case management strategy out of 9 possible studies; 6 were used in this review. Statistical analysis was performed for the combination of studies. The objectives were to ascertain a stable estimate of the intervention effect, to examine variability among trials, to resolve conflicting results, and to help decision makers in research or pneumonia case control programs. Methods of report collection are indicated and the process of data abstraction delineated. An evaluation framework was established to assess the design and methodology of studies; the detailed checklist is provided in the appendix. The analytical strategy of the meta-analysis centered on an impact assessment using the absolute difference scale. Rate differences were computed for each study at concurrent, before, and after time periods for 12 causes of mortality by age group (infants, 1-4 years, 0-4 years). Cocharan's Q test was used to evaluate the homogeneity of intervention impact across studies. Estimated and summary odds ratios and 95% confidence limits with exact conditional maximum likelihood estimates were generated to determine the association between the impact and the co-intervention of these studies. The Breslow and Day method was used to analyze homogeneity and the Miettinen method was used for confirmation were estimated using the DerSimonian and Laird modified Cocharan method. The generalizable results were that pneumonia case management is an effective intervention for reducing childhood mortality. The impact may be greater than oral rehydration therapy and comparable to measles vaccination impact. The pooled infant mortality. For children 1-4 years, the pooled impact on total mortality was 5.1 and on ALRI specific mortality 1.1. The estimated cumulative reduction in mortality of those under 5 year old was 36 deaths/1000 births or a 25% reduction. The analysis is limited by the quality of the studies and the difficulty is distinguishing the case management strategy of pneumonia itself because of the multiple focus of interventions.
AMERICAN JOURNAL OF OBSTETRICS AND GYNECOLOGY. 1992 Oct; 167(4 Pt 2):1171-6.The largest case control study on the association between oral contraceptive (OC) use and cancer is the US Cancer and Steroid Hormone (CASH) study. Since it did not use hospital-based patients as controls, it eliminated some biases. Since OCs suppress ovulation and suppressed ovulation is linked with reduced risk of ovarian cancer, scientists believe OCs may reduce this cancer risk. The CASH study shows that OC use indeed decreases the risk of ovarian cancer 40% (relative risk [RR]=.6 and this protection lasts for more than 10 years after OC discontinuation. Protection increases with duration of OC use (<1 year RR=.6 and >10 years RR=.2). Estrogenic stimulation of the endometrium without ample progestational protection causes endometrial cancer. Thus combined OCs which have estrogen and progestin components should reduce the risk of endometrial cancer. The CASH study reveals OC use for at least 12 months reduces this risk 50%. OCs have a protective effect for at least 15 years after stopping OC use. In addition, UK national mortality data show OC use caused the decline in ovarian cancer mortality and a 40% decrease in endometrial cancer mortality over the last 20 years. A WHO 7-county case control study indicates that OC users in developing countries have the same protective effect against ovarian and endometrial cancer as those in developed countries. Studies of OC use and cervical cancer have had conflicting results due to 3 biases: cervical cancer is associated with sexual behavior and is therefore a sexually transmitted disease; detection bias. A study in Costa Rica conducted by CDC study has addressed the 1st and 3rd biases. It found no increased risk of invasive cervical cancer or carcinoma in situ with OC use. Studies of OC use and breast cancer have also had conflicting results, but the data clearly indicate that OC use does not increase the overall risk of breast cancer. In fact, OC benefits surpass breast cancer risks.
SOUTH AFRICAN MEDICAL JOURNAL. 1992 May 2; 81(9):444-5.The advantages and side effects of the injectable contraceptive, Depo-Provera, are highlighted. It has been available to women in South Africa and in about 90 developing and developed countries for 20 years. It is an effective and convenient contraceptive with no serious side effects. Its failure rate is 0.2-0.6/100 woman years. Nevertheless there is still concern that it may cause breast cancer because original tests of Depo-Provera using beagles indicated that it may increase breast cancer risk. WHO and the UK Committee on Safety of Medicines have since dropped the requirement of testing of beagles since they cannot predict the effects of steroids on women. A 12-year WHO multinational, hospital-based case-control study on neoplasia and hormonal contraceptives reassures Depo-Provera's safety. For example, the risk of breast cancer did not increase with duration or in women who had used it for >5 years. The risk was higher, however, among women who had used it for <4 years, particularly <35-year old women. The same holds true for oral contraceptive (OC) users. It has been suggested that this slight increase is because Depo-Provera and OCs may accelerate growth of some existing, previously undetected breast tumors. The WHO study verifies that the benefits of Depo-Provera surpass the side effects which include disturbed bleeding patterns, weight gain, and headaches. For example, it decreases the risk of ovarian and endometrial cancer. It is even more beneficial in developing countries where women often suffer from anemia because it increases hemoglobin levels. Further since women in developing countries cannot always comply and take their OCs, Depo-Provera can grant them the protection they need against pregnancy thus saving many lives. Depo-Provera should be available in developed as well as in developing countries.
CONTRACEPTION. 1992 Apr; 45(4):363-8.Researchers analyzed interview and physician records' data on 45 women with breast cancer (cases) admitted to the Central Institute of Cancer Research in Berlin, East Germany between November 1982-June 1986 and born in 1983 or later and 194 women (controls) admitted to the Klinikum Berlin-Buch also in East Germany for conditions other than breast cancer to compare recall accuracy in women who had ever used an IUD. These women were drawn from case control study of the relationship between breast cancer and oral contraceptive use was part of the WHO Collaborative Study of Neoplasia and Steroid Contraceptives. Agreement between patient recall and physician records was exceptional for duration of IUD use (p<.001), number of IUD episodes (kappa=0.79), time since 1st IUD and time since last IUD use (p<.001). Agreement rates did not differ between cases and controls. 75% of the women could not name the IUD brand used so the researcher could not examine agreement of brand name. Thus, other than brand name, this study showed that validity of information on IUD use obtained from interviews is significant. In fact, it also pointed out that case control studies probably yield sound relative risk estimates.
AMERICAN JOURNAL OF EPIDEMIOLOGY. 1992 Mar 1; 135(5):541-51.Researchers conducted a age matched case control study from May-October 1989 of <5 year old Cambodian refugees with diarrhea examined at Greenhill hospital at Site B UN resettlement camp near Surin, Thailand on the Thai-Cambodian border to determine the etiology of the diarrhea and to identify potential risk factors. The age specific diarrheal disease rate stood at 63 episodes/1000 <5 year old children and 123/1000 for <1 year old infants. Incidence was 9.5/1000 <5 year old children and 17/1000 for <1 year old infants. Rotavirus was responsible for 24% of the 487 children with diarrhea. Campylobacter species and enterotoxigenic Escherichia coli caused the most frequent bacterial infections. The same enteric pathogens infected children with persistent diarrhea as well as those with acute diarrhea. Children with persistent diarrhea tended to not shed the same pathogen the entire time. 1 patient did excrete Cryptosporidium for an extended period, however. 37% of the children with persistent diarrhea received antibiotics after a positive culture, but they did not stop diarrhea. Besides 98% of the Shigella strains in children with acute diarrhea and all 4 strains in those with persistent diarrhea were resistant to sulfamethoxazole-trimethoprim. All Shigella strains were resistant to nalidixic acid. Further all aggregative adherent E. coli were resistant to colistin. Oral rehydration solution use and readily available medical care limited the number of deaths from diarrhea to 1. Living with other young children and malnutrition (<3rd percentile weight/height standard) were the most significant risk factors for diarrhea (odds ration=2 and 2.6 respectively). In fact, with each percentile increment in weight for height, the risk for persistent diarrhea fell 1%. The hands of both mothers and children harbored enteric pathogens. Enteric pathogens were also isolated from water and animals, especially cats. Thus preventive measures should include hand washing, reduce overcrowding, and supplemental feeding.