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Maternal and Child Health. 2018 Sep 8;  p.Promoting exclusive breastfeeding (EBF) is a highly feasible and cost-effective means of improving child health. Regulating the marketing of breastmilk substitutes is critical to protecting EBF. In 1981, the World Health Assembly adopted the World Health Organization International Code of Marketing of Breastmilk Substitutes (the Code), prohibiting the unethical advertising and promotion of breastmilk substitutes. This comparative study aimed to (a) explore the relationships among Code enforcement and legislation, infant formula sales, and EBF in India, Vietnam, and China; (b) identify best practices for Code operationalization; and (c) identify pathways by which Code implementation may influence EBF. We conducted secondary descriptive analysis of available national-level data and seven high level key informant interviews. Findings indicate that the implementation of the Code is a necessary but insufficient step alone to improve breastfeeding outcomes. Other enabling factors, such as adequate maternity leave, training on breastfeeding for health professionals, health systems strengthening through the Baby Friendly Hospital Initiative, and breastfeeding counselling for mothers, are needed. Several infant formula industry strategies with strong conflict of interest were identified as harmful to EBF. Transitioning breastfeeding programmes from donor-led to government-owned is essential for long-term sustainability of Code implementation and enforcement. We conclude that the relationships among the Code, infant formula sales, and EBF in India, Vietnam, and China are dependent on countries' engagement with implementation strategies and the presence of other enabling factors.
A Simplified Regimen Compared with WHO Guidelines Decreases Antenatal Calcium Supplement Intake for Prevention of Preeclampsia in a Cluster-Randomized Noninferiority Trial in Rural Kenya.
Journal of Nutrition. 2017 Oct; 147(10):1986-1991.Background: To prevent preeclampsia, the WHO recommends antenatal calcium supplementation in populations with inadequate habitual intake. The WHO recommends 1500-2000 mg Ca/d with iron-folic acid (IFA) taken separately, a complex pill-taking regimen. Objective: The objective of this study was to test the hypothesis that simpler regimens with lower daily dosages would lead to higher adherence and similar supplement intake.Methods: In the Micronutrient Initiative Calcium Supplementation study, we compared the mean daily supplement intake associated with 2 dosing regimens with the use of a parallel, cluster-randomized noninferiority trial implemented in 16 primary health care facilities in rural Kenya. The standard regimen was 3 x 500 mg Ca/d in 3 pill-taking events, and the low-dose regimen was 2 x 500 mg Ca/d in 2 pill-taking events; both regimens included a 200 IU cholecalciferol and calcium pill and a separate IFA pill. We enrolled 990 pregnant women between 16 and 30 wk of gestation. The primary outcome was supplemental calcium intake measured by pill counts 4 and 8 wk after recruitment. We carried out intention-to-treat analyses with the use of mixed-effect models, with regimen as the fixed effect and health care facilities as a random effect, by using a noninferiority margin of 125 mg Ca/d.Results: Women in facilities assigned to the standard regimen consumed a mean of 1198 mg Ca/d, whereas those assigned to the low-dose regimen consumed 810 mg Ca/d. The difference in intake was 388 mg Ca/d (95% CI = 341, 434 mg Ca/d), exceeding the prespecified margin of 125 mg Ca/d. The overall adherence rate was 80% and did not differ between study arms.Conclusions: Contrary to our expectation, a simpler, lower-dose regimen led to significantly lower supplement intake than the regimen recommended by the WHO. Further studies are needed to precisely characterize the dose-response relation of calcium supplementation and preeclampsia risk and to examine cost effectiveness of lower and simpler regimens in program settings. This trial was registered at clinicaltrials.gov as NCT02238704. (c) 2017 American Society for Nutrition.
Proposal of indicators to evaluate complementary feeding based on World Health Organization indicators.
Nursing and Health Sciences. 2016 Sep; 18(3):334-41.This study compares complementary feeding World Health Organization (WHO) indicators with those built in accordance with Brazilian recommendations (Ten Steps to Healthy Feeding). A cross-sectional study was carried out during the National Immunization Campaign against Poliomyelitis in Guarapuava-Parana, Brazil, in 2012. Feeding data from 1,355 children aged 6-23 months were obtained through the 24 h diet recall. Based on five indicators, the proportion of adequacy was evaluated: introduction of solid, semi-solid, or soft foods; minimum dietary diversity; meal frequency; acceptable diet; and consumption of iron-rich foods. Complementary feeding showed adequacy higher than 85% in most WHO indicators, while review by the Ten Steps assessment method showed a less favorable circumstance and a high intake of unhealthy foods. WHO indicators may not reflect the complementary feeding conditions of children in countries with low malnutrition rates and an increased prevalence of overweight/obesity. The use of indicators according to the Ten Steps can be useful to identify problems and redirect actions aimed at promoting complementary feeding. (c) 2016 John Wiley & Sons Australia, Ltd.
Journal of Community Nutrition & Health. 2013; 2(1):68-75.Objective: This was a prospective comparative study carried out from April 2011 to February 2012 to assess the growth pattern of exclusively breast fed (EBF) and non-exclusively breast fed infants (NEBF) in the first six months of life. Methods: A total of 213 lactating mothers and their neonates (less than 7 days) weighing 2.5kg were consecutively recruited into the study and followed up at 6,14 and 24 weeks, Infants were classified into EBF and NEBF groups based on their current feeding pattern during the follow up. Anthropometric measurements of weight and length were taken and compared with WHO reference curves. Data analysis was carried out using frequencies, percentages, means (SD) and t-test. Results: The rate of exclusive breastfeeding declined from 82.5% at delivery to 23% at the end of 24 weeks. The NEBF infants were heavier and longer at birth (P>0.05). The EBF Infants had higher weight (28 vs 22 g/day) and length gain of (0.77 Vs 0.70 cm/week) from 0 to 14 weeks than their NEBF counterpart (p>0.05). Despite a decline in weight gain of EBF infants after the 14 week, they retained the higher mean weight achieved earlier. Average cumulative weight and length gain of 3.71 kg Vs 3.31 kg and 15.33 cm vs 14.56 cm were recorded for EBF and NEBF infants, respectively during the 24 weeks follow up. The mean weight and length of the EBF infants was comparable to the World Health organization (WHO) reference curve than for the NEBF infants. Conclusion: This study has shown that exclusive breastfeeding supported adequate growth in infants studied during the first six months of life.
Can the UNAIDS modes of transmission model be improved? A comparison of the original and revised model projections using data from a setting in west Africa.
AIDS. 2013 Oct 23; 27(16):2623-35.OBJECTIVE: The UNAIDS modes of transmission model (MoT) is a user-friendly model, developed to predict the distribution of new HIV infections among different subgroups. The model has been used in 29 countries to guide interventions. However, there is the risk that the simplifications inherent in the MoT produce misleading findings. Using input data from Nigeria, we compare projections from the MoT with those from a revised model that incorporates additional heterogeneity. METHODS: We revised the MoT to explicitly incorporate brothel and street-based sex-work, transactional sex, and HIV-discordant couples. Both models were parameterized using behavioural and epidemiological data from Cross River State, Nigeria. Model projections were compared, and the robustness of the revised model projections to different model assumptions, was investigated. RESULTS: The original MoT predicts 21% of new infections occur in most-at-risk-populations (MARPs), compared with 45% (40-75%, 95% Crl) once additional heterogeneity and updated parameterization is incorporated. Discordant couples, a subgroup previously not explicitly modelled, are predicted to contribute a third of new HIV infections. In addition, the new findings suggest that women engaging in transactional sex may be an important but previously less recognized risk group, with 16% of infections occurring in this subgroup. CONCLUSION: The MoT is an accessible model that can inform intervention priorities. However, the current model may be potentially misleading, with our comparisons in Nigeria suggesting that the model lacks resolution, making it challenging for the user to correctly interpret the nature of the epidemic. Our findings highlight the need for a formal review of the MoT.
Comparative effectiveness of congregation- versus clinic-based approach to prevention of mother-to-child HIV transmission: Study protocol for a cluster randomized controlled trial.
Implementation Science. 2013 Jun 8; 8(62):p.Background: A total of 22 priority countries have been identified by the WHO that account for 90% of pregnant women living with HIV. Nigeria is one of only 4 countries among the 22 with an HIV testing rate for pregnant women of less than 20%. Currently, most pregnant women must access a healthcare facility (HF) to be screened and receive available prevention of mother-to-child HIV transmission (PMTCT) interventions. Finding new approaches to increase HIV testing among pregnant women is necessary to realize the WHO/ President's Emergency Plan for AIDS Relief (PEPFAR) goal of eliminating new pediatric infections by 2015. Methods: This cluster randomized trial tests the comparative effectiveness of a congregation-based Healthy Beginning Initiative (HBI) versus a clinic-based approach on the rates of HIV testing and PMTCT completion among a cohort of church attending pregnant women. Recruitment occurs at the level of the churches and participants (in that order), while randomization occurs only at the church level. The trial is unblinded, and the churches are informed of their randomization group. Eligible participants, pregnant women attending study churches, are recruited during prayer sessions. HBI is delivered by trained community health nurses and church-based health advisors and provides free, integrated on-site laboratory tests (HIV plus hemoglobin, malaria, hepatitis B, sickle cell gene, syphilis) during a church-organized 'baby shower.' The baby shower includes refreshments, gifts exchange, and an educational game show testing participants' knowledge of healthy pregnancy habits in addition to HIV acquisition modes, and effective PMTCT interventions. Baby receptions provide a contact point for follow-up after delivery. This approach was designed to reduce barriers to screening including knowledge, access, cost and stigma. The primary aim is to evaluate the effect of HBI on the HIV testing rate among pregnant women. The secondary aims are to evaluate the effect of HBI on the rate of HIV testing among male partners of pregnant women and the rate of PMTCT completion among HIV-infected pregnant women. Discussion: Results of this study will provide further understanding of the most effective strategies for increasing HIV testing among pregnant women in hard-to-reach communities.
Lancet. 2010 May 8; 375(9726):1607-8; author reply 1608.This author's reply defends their report on a randomized non-inferiority trial to compare the efficacy and safety of ulipristal acetate with levonorgestrel for emergency contraception. It concludes that there is good evidence that ulipristal acetate is much more effective than levonorgestrel at preventing ovulation at the time in the cycle when conception is most likely to occur.
Comparison of previous and present World Health Organization clinical staging criteria in HIV-infected Malawian children.
AIDS. 2009 Sep 10; 23(14):1913-6.In many settings, HIV infected children are looked after with limited access to CD4 cell count or viral load. The decision to initiate antiretroviral therapy (ART) is made clinically, based on the WHO paediatric staging criteria, which were revised in 2006. Results of using new and old criteria were compared. Of 694 children, 626 (90.2%) fulfilled criteria to start ART when applying the new WHO staging guidelines, whereas 330 (47.6%) children were eligible for ART when using the old WHO criteria. This signifies a marked rise in the number of paediatric patients qualifying for ART on clinical grounds.
Two vs. three sputum samples for microscopic detection of tuberculosis in a high HIV prevalence population.
International Journal of Tuberculosis and Lung Disease. 2009 Jul; 13(7):842-7.SETTING: A busy urban hospital in Cameroon. OBJECTIVES: To compare the yield in bacteriologically proven tuberculosis (TB) cases examining two morning vs. three spot-morning-spot sputum specimens (MM vs. SMS) by direct microscopy for acid-fast bacilli (AFB). DESIGN: Repeated temporal cross-over between MM and SMS sampling for successive TB suspects, using culture as gold standard. RESULTS: A total of 799 suspects were screened using the MM strategy, identifying 223 smear-positives, and 808 suspects with the SMS strategy, yielding 236 smear-positives. Of the MM, 256 were culture-positive, of whom 195 (76%) were smear-positive. For SMS, these figures were respectively 281 and 206 (73%), a non-significant difference. The MM and SMS strategies also detected respectively 28 and 30 smear-positive cases not confirmed by culture. No cases were lost to treatment with either strategy. CONCLUSIONS: In this population with a high prevalence of human immunodeficiency virus (HIV) with late case presentation, smear microscopy of two morning specimens detected at least as many positive cases as the classical strategy, and no cases were lost before treatment. Two specimens for initial TB suspect screening can thus be recommended, also without excessive workload. Comparative studies in populations presenting with paucibacillary sputum are needed to determine the equivalent quality and yield of an alternative strategy with two spot specimens at consultation.
Comparison of the new World Health Organization growth standards and the National Center for Health Statistics growth reference regarding mortality of malnourished children treated in a 2006 nutrition program in Niger.
Archives of Pediatrics and Adolescent Medicine. 2009 Feb; 163(2):126-30.OBJECTIVE: To compare the National Centre for Health Statistics (NCHS) international growth reference with the new World Health Organization (WHO) growth standards for identification of the malnourished (wasted) children most at risk of death. DESIGN: Retrospective data analysis. SETTING: A Medecins Sans Frontieres (Doctors Without Borders) nutrition program in Maradi, Niger, in 2006 that treated moderately and severely malnourished children. PARTICIPANTS: A total of 53 661 wasted children aged 6 months to 5 years (272 of whom died) in the program were included. INTERVENTIONS: EpiNut (Epi Info 6.0; Centers for Disease Control and Prevention, Atlanta, Georgia) software was used to calculate the percentage of the median for the NCHS reference group, and the WHO (igrowup macro; Geneva, Switzerland) software was used to calculate z scores for the WHO standards group of the 53 661 wasted children. OUTCOME MEASURES: The main outcome measures are the difference in classification of children as either moderate or severely malnourished according to the NCHS growth reference and the new WHO growth standards, specifically focusing on children who died during the program. RESULTS: Of the children classified as moderately wasted using the NCHS reference, 37% would have been classified as severely wasted according to the new WHO growth standards. These children were almost 3 times more likely to die than those classified as moderately wasted by both references, and deaths in this group constituted 47% of all deaths in the program. CONCLUSIONS: The new WHO growth standards identifies more children as severely wasted compared with the NCHS growth reference, including children at high mortality risk who would potentially otherwise be excluded from some therapeutic feeding programs.
Symptom-based screening of child tuberculosis contacts: improved feasibility in resource-limited settings.
Pediatrics. 2008 Jun; 121(6):e1646-52.OBJECTIVE: National tuberculosis programs in tuberculosis-endemic countries rarely implement active tracing and screening of child tuberculosis contacts, mainly because of resource constraints. We aimed to evaluate the safety and feasibility of applying a simple symptom-based approach to screen child tuberculosis contacts for active disease. METHODS: We conducted a prospective observational study from January through December 2004 at 3 clinics in Cape Town, South Africa. All of the children <5 years old in household contact with an adult tuberculosis source case were assessed by documenting current symptoms and tuberculin skin test and chest radiograph results. RESULTS: During the study period, 357 adult tuberculosis cases were identified; 195 cases (54.6%) had sputum smear and/or culture positive results and were in household contact with children aged <5 years. Complete information was available for 252 of 278 children; 176 (69.8%) were asymptomatic at the time of screening. Tuberculosis treatment was administered to 33 (13.1%) of 252; 27 were categorized as radiologically "certain tuberculosis," the majority (n = 22) of which had uncomplicated hilar adenopathy. The negative predictive value of symptom-based screening varied according to the case definition used, with 95.5% including all of the children treated for tuberculosis and 97.1% including only those with radiologically "certain tuberculosis." CONCLUSIONS: Our findings support current World Health Organization recommendations, demonstrating that symptom-based screening of child tuberculosis contacts should improve feasibility in resource-limited settings and seems to be safe.
A trickle or a flood: Commitments and disbursement for HIV / AIDS from the Global Fund, PEPFAR, and the World Bank’s Multi-Country AIDS Program (MAP).
[Washington, D.C.], Center for Global Development, HIV / AIDS Monitor, 2007 Mar 5. 26 p.This paper provides an analytical framework for understanding funders' disbursement policies and practices while also offering an overview of the total volume of resources being committed and disbursed by each funder. The analysis is focused on the global-level, but does provide brief country case studies to help understand some of the implications of these large inflows of funding for HIV/AIDS at the country-level. (excerpt)
Following the funding for HIV / AIDS: a comparative analysis of the funding practices of PEPFAR, the Global Fund and World Bank MAP in Mozambique, Uganda and Zambia.
[Washington, D.C.], Center for Global Development, HIV / AIDS Monitor, 2007 Oct 10.  p.Donor funding for HIV/AIDS has reached levels unprecedented in the history of global health: annual funding for AIDS in low- and middle-income countries increased 30-fold from 1996 to 2006, from US$ 300 million to US$ 8.9 billion. While funding remains far short of the estimated need, international donor commitments for HIV/AIDS are significant, and likely to be so, well into the future. The resources for AIDS are a topic of considerable interest and debate internationally, yet little is understood about how these resources are actually being spent, and whether they are being made available as efficiently and effectively as possible for the fight against AIDS. Through the lens of what is happening in several countries in sub-Saharan Africa, this paper examines the flow of resources from three of the world's largest AIDS donors: the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund), and the World Bank's Multi-Country HIV/AIDS Program for Africa (MAP). Drawing on country-level research undertaken by collaborating local research organizations, we describe the levels and types of funding from these donors, and highlight the procedures through which funds are committed, released and accounted for in three countries in which all of the programs are active: Mozambique, Uganda, and Zambia. Through this close look at how money moves from donor to specific purposes, we describe bottlenecks and other difficulties in the disbursement of funds, document the way their disbursement systems attempt to build national capacity to fight AIDS, and identify specific ways in which the donor agencies could make the resources move more efficiently. (excerpt)
Lancet. 2007 Sep 22; 370(9592):1030-1031.Young Kwang Chae and Jeong Hyun Yun query whether data from our randomised controlled trial of early, high-dose vitamin A supplementation (50 000 I given with the three diphtheria-tetanus-pertussis [DPT] vaccinations at 6, 10, and 14 weeks) in Gambian infants can contribute to the ongoing controversy about whether there might be harmful interactions between vitamin A supplementation and killed vaccines, particularly in girls. Several notes of caution are necessary. The observations by Benn and colleagues that have raised the concerns relate to excess mortality. Our trial is greatly underpowered for this endpoint. There were two postneonatal deaths in the high-dose group (n=99) and none in the standard WHO dose group (n=98). One male infant died of pneumonia and septicaemia at 7 months and one female of unknown causes at 3 months. This overall post-neonatal infant mortality rate equates to 10 in 1000, which is exceptionally low for this region and reflects the high level of monitoring and clinical care offered to the study participants. This point reduces the usefulness of our data in contributing to the debate. In response to Chae and Yun's query as to whether the vitamin A might have exacerbated DTP-related side-effects, we have reanalysed our data in an attempt to identify potentially life-threatening illnesses. In our original paper we restricted the analyses to clinic visits that elicited a treatment. Numerous non-critical conditions such as colds and skin rashes remained. We have now excluded these and repeated the analysis of potentially life-threatening events for the time window between the first DPT vaccination and vitamin A dose at 6 weeks and the first live vaccine (measles at 9 months). We analysed four diseases (malaria, diarrhoea, pneumonia, and septicaemia) separately and combined. There were 73 events in the high-dose group and 79 events in the WHO group. Owing to small numbers of events there were wide confidence intervals and no differences were significant. The closest to significance (pneumonia) was, if anything, lower in the high-dose group. In summary, our trial is under powered to contribute to this important debate, but we will be happy to contribute the data to future meta-analyses. (full text)
Lancet. 2007 Sep 22; 370(9592):1030.In their study of the effectiveness of early supplementation with high-dose vitamin A versus standard WHO protocol in Gambian mothers and infants, Momodou Darboe and colleagues report that the proportion of infants attending the clinic was greater in the high-dose vitamin A group than in the WHO protocol group in the first 6 months of life (p=0.018). However, they do not provide any detailed description of the chief complaints responsible for the differences in clinic attendance. It would be worthwhile to learn whether vitamin A supplementation exacerbated side-effects related to diphtheria-tetanuspertussis (DTP) vaccination, since both DTP vaccination and three out of five scheduled supplementations were done in the first 6 months of life. This finding is also interesting because it is consistent with the findings of previous studies that there is a null or detrimental effect of vitamin A supplementation on infant mortality when supplementation is given close to the DTP vaccination. These reportsare of note since the protective effect of vitamin A supplementation is well established when given with the BCG vaccine (at birth) and with the measles vaccine (after 6 months of life). As Darboe and colleagues mention, Benn and colleagues suggested that vitamin A supplementation could amplify the non-specific effects of vaccines, causing differing effects between killed (DTP) and live (BCG and measles) vaccines. We believe that the findings from this study that high-dose vitamin A supplementation around the time of DTP vaccines revealed no advantageous effect and even a negative effect on clinic visits only buttresses the immune modulatory role of vitamin A supplementation with routine vaccines. (full text)
Journal of Black Studies. 2002; 32(6):615-653.The HIV/AIDS pandemic has afflicted Africa more than any other region of the world. In the United States, the AIDS scourge has disproportionately affected African American communities. In their tragic experiences with HIV/AIDS, both African states and African American communities can benefit from the new communication framework that the United Nations Global AIDS Programme and the Pennsylvania State University have developed to combat the HIV/AIDS pandemic. The framework contains five universal values that are recommended for AIDS intervention programs across the world. The five values are incorporation of government policies, socioeconomic status, culture, gender issues, and spirituality. There are six additional values, two of which apply uniquely to each of the three world regions of Africa, Asia, and Latin America. For Africa, the two unique values are community-based approaches and regional cooperation. The situation in Africa presents valuable lessons for African Americans in the United States. (author's)
Diagnostic accuracy comparison between clinical signs and hemoglobin color scale as screening methods in the diagnosis of anemia in children.
Revista Brasileira de Saude Materno Infantil. 2006 Apr-Jun; 6(2):183-189.The objectives were to compare the validity and reproducibility of clinical signs with the World Health Organization hemoglobin color scale. Two hundred six children in the age range of 6-23 months, at the Instituto Materno Infantil Prof. Fernando Figueira, IMIP, were assessed. Two examiners evaluated the clinical signs and the hemoglobin color scale of each child at the different times. The hemoglobin value was used as a standard for validation. In more than 90% of cases the agreement between the values of the color scale and the laboratorial hemoglobin was <2 g/dL. Between the clinical signs the highest sensitivity level for diagnosing Hb<11 g/dL was presented by the hemoglobin color scale (75.7%). For moderate/severe anemia Hb<9g/dL the highest sensitivity was shown by combined palmar or conjunctival pallor (74.3%) and by the color scale (52.5%), according to the first and second observer, respectively. The highest specificity level for Hb<11 g/dL was presented by palmar pallor in comparison with the mother's palm and conjunctival pallor (100%). For Hb<9 g/dL the highest specificity was presented by the hemoglobin color scale (91.9%). This study suggests that moderate/ severe anemia can be diagnosed either by clinical signs or by the color scale, while, in cases of mild anemia, the better diagnosis tool appears to be the color scale. (author's)
Contraception Report. 1999 Jan; 9(6): p..A recent WHO-sponsored study has demonstrated that the progestin levonorgestrel, used alone, is a highly effective and well-tolerated form of emergency contraception. With the proportion of pregnancies prevented up to 95% - depending on the timeliness of administration - the levonorgestrel regimen proved more effective than the most commonly used regimen, the Yuzpe method. The Yuzpe method employs a dual-hormone (ethinyl estradiol plus levonorgestrel) approach to preventing pregnancy. Despite the Yuzpe regimen's 75% efficacy rate (a weighted average from 10 studies) the method has been associated with drawbacks. About 50% of users experience nausea and 20% report vomiting, which can reduce patient compliance. (excerpt)
International Journal of Gynecology and Obstetrics. 2007 Feb; 96(2):147-150.The objective was to compare two World Health Organization (WHO) partographs -- a composite partograph including latent phase with a simplified one without the latent phase. Comparison of the two partographs in a crossover trial. Eighteen physicians participated in this trial. One or the other partograph was used in 658 parturients. The mean (S.D.) user-friendliness score was lower for the composite partograph (6.2 (0.9) vs. 8.6 (1.0); P = 0.002). Most participants (84%) experienced difficulty "sometimes" with the composite partograph, but no participant reported difficulty with the simplified partograph. While most maternal and perinatal outcomes were similar, labor values crossed the action line significantly more often when the composite partograph was used, and the women were more likely to undergo cesarean deliveries. The simplified WHO partograph was more user-friendly, was more to be completed than the composite partograph, and was associated with better labor outcomes. (author's)
Journal of Nutrition. 2007 Jan; 137(1):144-148.The evaluation of child growth trajectories and the interventions designed to improve child health are highly dependent on the growth charts used. The U.S. CDC and the WHO, in May 2000 and April 2006, respectively, released new growth charts to replace the 1977 NCHS reference. The WHO charts are based for the first time on a prescriptive, prospective, international sample of infants selected to represent optimum growth. This article compares the WHO and CDC curves and evaluates the growth performance of healthy breast-fed infants according to both. As expected, there are important differences between the WHO and CDC charts that vary by age group, growth indicator, and specific Z-score curve. Differences are particularly important during infancy, which is likely due to differences in study design and characteristics of the sample, such as type of feeding. Overall, the CDC charts reflect a heavier, and somewhat shorter, sample than the WHO sample. This results in lower rates of undernutrition (except during the first 6 mo of life) and higher rates of overweight and obesity when based on the WHO standards. Healthy breast-fed infants track along the WHO standard's weight-for-age mean Z-score while appearing to falter on the CDC chart from 2 mo onwards. Shorter measurement intervals in the WHO standards result in a better tool for monitoring the rapid and changing rate of growth in early infancy. Their adoption would have important implications for the assessment of lactation performance and the adequacy of infant feeding and would bring coherence between the tools used to assess growth and U.S. national guidelines that recommend breast-feeding as the optimal source of nutrition during infancy. (author's)
Comparison of the World Health Organization (WHO) Child Growth Standards and the National Center for Health Statistics / WHO international growth reference: implications for child health programmes.
Public Health Nutrition. 2006 Oct; 9(7):942-947.The objectives were to compare growth patterns and estimates of malnutrition based on the World Health Organization (WHO) Child Growth Standards ('the WHO standards') and the National Center for Health Statistics (NCHS)/WHO international growth reference ('the NCHS reference'), and discuss implications for child health programmes. Design: Secondary analysis of longitudinal data to compare growth patterns (birth to 12 months) and data from two cross-sectional surveys to compare estimates of malnutrition among under-fives. Settings: Bangladesh, Dominican Republic and a pooled sample of infants from North America and Northern Europe. Subjects: Respectively 4787, 10 381 and 226 infants and children. Healthy breast-fed infants tracked along the WHO standard's weight-for-age mean Z-score while appearing to falter on the NCHS reference from 2 months onwards. Underweight rates increased during the first six months and thereafter decreased when based on the WHO standards. For all age groups stunting rates were higher according to the WHO standards. Wasting and severe wasting were substantially higher during the first half of infancy. Thereafter, the prevalence of severe wasting continued to be 1.5 to 2.5 times that of the NCHS reference. The increase in overweight rates based on the WHO standards varied by age group, with an overall relative increase of 34%. The WHO standards provide a better tool to monitor the rapid and changing rate of growth in early infancy. Their adoption will have important implications for child health with respect to the assessment of lactation performance and the adequacy of infant feeding. Population estimates of malnutrition will vary by age, growth indicator and the nutritional status of index populations. (author's)
Developing World Bioethics. 2001 Nov; 1(2):121-134.Four key guidance points in the UNAIDS guidance document, Ethical Considerations in HIV Preventive Vaccine Research, are compared with analogous statements in three other recently issued documents dealing with international research. Those documents are: the Declaration of Helsinki, as revised in 2000; the report of the U.S. National Bioethics Advisory Commission, issued in 2001; and a current (2001) draft revision of the 1993 CIOMS International Ethical Guidelines for Biomedical Research Involving Human Subjects. The four guidance points compared with statements on similar issues in the other three documents are Guidance Point 2, which deals with making available a safe and effective vaccine after trials are completed; the second half of Guidance Point 4, which requires that the desired outcome should potentially benefit the population from which research participants are drawn; Guidance Point 11, which discusses what should be provided to a control group in a vaccine trial; and Guidance Point 16, which addresses the care and treatment to be provided for trial participants who become infected with HIV during the trial. The analysis and comparison concludes that the UNAIDS guidance points are at least as ethically sound as analogous points in these other documents, and for the most part are ethically superior in providing greater benefits to research participants and to others. Nevertheless, they are subject to the criticism that they are too `aspirational' and not sufficiently `pragmatic'. (author's)
Comparative analysis: research studies from India and Uganda. HIV and AIDS-related discrimination, stigmatization and denial. Revised.
Geneva, Switzerland, Joint United Nations Programme on HIV / AIDS [UNAIDS], 2001 Aug. 40 p. (UNAIDS Best Practice Collection. Key Material; UNAIDS/01.49E)It goes without saying that HIV/AIDS is as much about social phenomena as it is about biological and medical concerns. Across the world, the global pandemic of HIV/AIDS has shown itself capable of triggering responses of compassion, solidarity and support, bringing out the best in people, their families and communities. But the disease is also associated with stigma, ostracism, repression and discrimination, as individuals affected (or believed to be affected) by HIV have been rejected by their families, their loved ones and their communities. This rejection holds as true in the rich countries of the north as it does in the poorer and developing countries of the south. All over the world, ignorance, lack of knowledge, fear and denial have engendered serious and often tragic consequences, denying people living with HIV/AIDS access to treatments, services and support, as well as making it hard for prevention work to take place. The epidemic of fear, stigmatization and discrimination first described by Jonathan Mann (1987) has undermined the ability of individuals, families and societies to protect themselves and provide support and reassurance to those infected. (excerpt)
Geneva, Switzerland, UNAIDS, 1999 May. 145 p. (UNAIDS Best Practice Collection. Key material; UNAIDS/99.26E)Since early in the epidemic, enquiry into the factors influencing HIV-related vulnerability has been recognized as essential for prevention efforts. While much early work focused on the individual determinants of sexual and drug-related risk-taking, increasingly the contextual factors which render some groups more vulnerable than others has come to be recognized. Factors as diverse as age, gender, social position, economic status, cultural norms, beliefs and expectations determine the risks faced, and enable and constrain individuals in their actions. It is now widely recognized that both individual persuasion and social enablement are essential for programme success, and increasing numbers of prevention programmes and activities are designed on this assumption. The recent UNAIDS report Expanding the Global Response to HIV/AIDS Through Focused Action recognizes the importance of such an approach and seeks to encourage its application in countries across the world. Yet knowing how to develop and fine-tune programmes requires insight into the often complex determinants of behaviour in specific cultural settings and contexts. Good quality social enquiry has a key role to play in providing this information and in supporting the development of work that is attuned to the needs of particular groups. (excerpt)
The practice of antenatal care: comparing four study sites in different parts of the world participating in the WHO Antenatal Care Randomised Controlled Trial. [Práctica de controles prenatales: comparación de cuatro centros de estudio en diferentes lugares del mundo que participaron en el Estudio Controlado Aleatorizado de Control Prenatal de la OMS]
Paediatric and Perinatal Epidemiology. 1998; 12 Suppl 2:116-141.In the preparation of a randomised controlled trial to evaluate a new programme of antenatal care (ANC) in different parts of the world, we conducted a baseline survey of the ANC procedures in all 53 clinics participating in the trial. There were two components of this survey: (1) description of clinic characteristics and services offered: the staff of each clinic was interviewed and direct observation was made by field supervisors, and (2) the actual use of services by pregnant women attending these clinics: we reviewed a random sample of 2913 clinical histories. The clinical units surveyed were offering most of the activities, screening, laboratory tests and interventions recommended as effective according to the Cochrane Pregnancy and Childbirth Database (PCD), although some of these were not available in some sites. On the other hand, some tests and interventions that are considered not effective according to these criteria are reportedly offered. There was a difference across sites in the availability and offer to low-risk women of vaginal examination, evaluation of pelvic size, dental examination, external version for breech presentation and formal risk score classification, and a notable difference in the type of principal provider of ANC. There was a large variation in the actual use of screening and laboratory tests and interventions that should be offered to all women according to Cochrane PCD criteria: some of these are simply not available in a site; others are available, but only a fraction of women attending the clinics are receiving them. The participating sites all purport to follow the traditional `Western' schedule for ANC, but in three sites we found that a high percentage of women initiate their ANC after the first trimester, and therefore do not have either the recommended minimum number of visits during pregnancy or the minimum first trimester evaluation. It is concluded that the variability and heterogeneity of ANC services provided in the four study sites are disturbing to the profession and cast doubts on the rationale of routine ANC. (author's)