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Towards the WHO target of zero childhood tuberculosis deaths: an analysis of mortality in 13 locations in Africa and Asia.
International Journal of Tuberculosis and Lung Disease. 2013 Dec; 17(12):1518-23.SETTING: Achieving the World Health Organization (WHO) target of zero paediatric tuberculosis (TB) deaths will require an understanding of the underlying risk factors for mortality. OBJECTIVE: To identify risk factors for mortality and assess the impact of human immunodeficiency virus (HIV) testing during anti-tuberculosis treatment in children in 13 TB-HIV programmes run by Medecins Sans Frontieres. DESIGN: In a retrospective cohort study, we recorded mortality and analysed risk factors using descriptive statistics and logistic regression. Diagnosis was based on WHO algorithm and smear microscopy. RESULTS: A total of 2451 children (mean age 5.2 years, SD 3.9) were treated for TB. Half (51.0%) lived in Asia, the remainder in sub-Saharan Africa; 56.0% had pulmonary TB; 6.4% were diagnosed using smear microscopy; 211 (8.6%) died. Of 1513 children tested for HIV, 935 (61.8%) were positive; 120 (12.8%) died compared with 30/578 (5.2%) HIV-negative children. Risk factors included being HIV-positive (OR 2.6, 95%CI 1.6-4.2), age <5 years (1.7, 95%CI 1.2-2.5) and having tuberculous meningitis (2.6, 95%CI 1.0-6.8). Risk was higher in African children of unknown HIV status than in those who were confirmed HIV-negative (1.9, 95%CI 1.1-3.3). CONCLUSIONS: Strategies to eliminate childhood TB deaths should include addressing the high-risk groups identified in this study, enhanced TB prevention, universal HIV testing and the development of a rapid diagnostic test.
Children with severe malnutrition: Can those at highest risk of death be identified with the WHO protocol?
PLoS Medicine. 2006 Dec; 3(12):e500.With strict adherence to international recommended treatment guidelines, the case fatality for severe malnutrition ought to be less than 5%. In African hospitals, fatality rates of 20% are common and are often attributed to poor training and faulty case management. Improving outcome will depend upon the identification of those at greatest risk and targeting limited health resources. We retrospectively examined the major risk factors associated with early (< 48 h) and late in-hospital death in children with severe malnutrition with the aim of identifying admission features that could distinguish a high-risk group in relation to the World Health Organization (WHO) guidelines. Of 920 children in the study, 176 (19%) died, with 59 (33%) deaths occurring within 48 h of admission. Bacteraemia complicated 27% of all deaths: 52% died before 48 h despite 85% in vitro antibiotic susceptibility of cultured organisms. The sensitivity, specificity, and likelihood ratio of the WHO-recommended ''danger signs'' (lethargy, hypothermia, or hypoglycaemia) to predict early mortality was 52%, 84%, and 3.4% (95% confidence interval [CI] = 2.2 to 5.1), respectively. In addition, four bedside features were associated with early case fatality: bradycardia, capillary refill time greater than 2 s, weak pulse volume, and impaired consciousness level; the presence of two or more features was associated with an odds ratio of 9.6 (95% CI = 4.8 to 19) for early fatality (p < 0.0001). Conversely, the group of children without any of these seven features, or signs of dehydration, severe acidosis, or electrolyte derangements, had a low fatality (7%). Formal assessment of these features as emergency signs to improve triage and to rationalize manpower resources toward the high-risk groups is required. In addition, basic clinical research is necessary to identify and test appropriate supportive treatments. (author's)
East African Medical Journal. 2006 Jan; 83(1):1-3.At the Millennium Summit in September 2000, world leaders adopted the United Nations Millennium Declaration, which included attainment of the eight Millennium Development Goals (MDGs) by 2015. The first seven MDGs are aimed at reducing poverty and promoting human development while the eighth MDG recognises the essence of global partnership in achieving the first seven. The three MDGs directly related to health (MDGs 4-6) are interdependent so concerted efforts are needed to achieve them. (excerpt)
Bulletin of the World Health Organization. 2004 Feb; 82(2):83.Certification of death is the foundation for monitoring mortality patterns and documenting the leading causes of death, with the results being used to inform health policies and improve prevention strategies. It has been vital to our understanding of the demographic transition. Despite efforts made by the United Nations, the International Institute for Vital Registration and Statistics and WHO to facilitate the organization and management of civil registration and to standardize reporting and coding practices of cause of death, death registration remains inadequate in several countries and mortality patterns are based on vague estimates. Factors contributing to deficient registration systems include incomplete coverage, late registration, missing data, and errors in reporting or classifying the cause of death. (excerpt)
Public Health Reports. 2002 Nov-Dec; 117(6):592.A study, conducted from March to July 2002 by UNICEF and the CDC in conjunction with the Afghanistan Ministry of Health, determined that Afghan women suffer from one of the highest levels of maternal mortality in the world. Almost half of the deaths among women from the ages of 15 to 49 are a result of pregnancy and childbirth. This study, the largest of its kind ever conducted in Afghanistan, was conducted in four provinces in Afghanistan-Kabul, Laghman, Kandahar, and Badakshan-ranging from rural to urban settings. The surveys found that on average there were 1,600 maternal deaths per 100,000 live births in Afghan women. Linda Bartlett, MD-a medical officer with CDC's reproductive health program and the leader of the surveys-stated, "These women are dying needlessly. Most of these deaths could have been avoided, which suggests important opportunities for prevention." The study examined data from 13,000 households, which included an estimated 85,000 women. UNICEF and the CDC recommended the following as a result of the findings of this study: there is a need to establish properly equipped health care services in remote areas and to encourage women's use of such facilities; the need to train skilled female birth attendants; and to rebuild and repair roads to improve access to these facilities. (excerpt)
Public Health. 2003 Jul; 117(4):221-227.This study describes urban and rural trends of infant, child and under-five mortality in Mozambique (1973–1997) by mother’s place of residence. A direct method of estimation was applied to the 1997 Mozambican Demographic and Health Survey data. The levels of infant, child and under-five mortality were considerably higher in rural than in urban areas. The difference in mortality between urban and rural areas increased over time until 1988–1992 and thereafter diminished. Possible causes of the different trends (e.g. the impact of civil war, drought, migration, adjustment programme and HIV/AIDS) are discussed. The increase in mortality in urban areas during the last few years before the survey may have been related to the immigration to urban areas of mothers whose children had high levels of mortality. Higher levels of infant, child and under-five mortality still prevail, particularly in rural areas. Further studies are needed to investigate the differentials of infant and child mortality by mother’s place of residence. (author's)
Safe Motherhood Initiative: meeting of interested parties, World Health Organization, Executive Board Room, Geneva, Thursday, 7 July 1988.
[Unpublished] 1988. 25 p. (FHE/SMI/MIP/88.2)Given the multiple causes of maternal mortality, the World Health Organization's (WHO) Program of Maternal and Child Health addresses 4 factors: 1) social equality for female children and women; 2) universally accessible family planning to avert high-risk or unwanted pregnancies; 3) adequate prenatal care, including nutrition, with early recognition and referral of women with high-risk pregnancies; and 4) access to required obstetric care for women with emergencies that occur during pregnancy, delivery, or in the immediate postpartum period. WHO's Safe Motherhood activities are aimed at reducing maternal mortality by at least 50% by the year 2000. Toward this end, WHO is working to assist countries to determine the magnitude of their maternal mortality problem, identify the immediate underlying causes of maternal deaths, reach decisions about action priorities, evaluate innovations in maternal health care, conduct staff training, and support resource mobilization by national authorities so that programs can be implemented adequately. Research, information analysis and dissemination, technical support, and training comprise the foci of WHO's interventions in maternal health at present. If the Safe Motherhood Initiative is to be achieved, greater coordination and technical support at the global level and collaboration among agencies and national authorities at the country level will be required. The lack of sensitivity and responsiveness on the part of health staff to the perceived needs and perspective of women still comprises an obstacle to women's use of available maternal health services and must be addressed through training. To maintain the pace of its Safe Motherhood activities, WHO required US $4.5 million in extrabudgetary support.
JOURNAL OF THE INTERNATIONAL ASSOCIATION OF PHYSICIANS IN AIDS CARE. 1995 Jun; 1(5):34.Tuberculosis (TB) is the leading killer, globally, of persons who are infected with human immunodeficiency virus (HIV); however, few countries are prepared to deal with this. In response, research experts on acquired immunodeficiency syndrome (AIDS) and TB met the first week of June to identify the best way to improve TB control in areas where HIV is prevalent or increasing. Dr. Arata Kochi, Director of the Global TB Program of the World Health Organization, warned that TB would kill almost one-third of those infected with HIV and would infect many of their contacts, both negative and positive for the virus, as the incidence of HIV rose in Asia. By the end of the decade, around one-third of all deaths among HIV-positive people will result from TB, according to Global TB Program estimates. In Abidjan, 32% of AIDS cases were considered to have died from TB. HIV is spreading more rapidly in Asia, where TB is more widespread than in Africa. Anthony Harries, a physician at Queen Elizabeth Central Hospital in Malawi, states that the co-epidemic complicates efforts to care for AIDS patients and to identify and treat TB patients. While caseloads are increasing, health workers are faced with a shortage of manpower and funds and a lack of appropriate technology. The meeting was convened by the Global Tuberculosis Program.
INTEGRATION. 1992 Jun; (32):22-3.By January 1992, almost 450,000 AIDS cases had been reported to the Global Program on AIDS of the World Health Organization (GPA/WHO), but the estimated number of adult cases was 1.5 million based on about 1000 available HIV serological survey data and HIV data bases. 2 million people in the Americas, 1/2 million in Western Europe, over 6.5 million in Sub=Saharan Africa, and 1 million in South and Southeast Asia have been infected since the pandemic started. In North America and Western Europe, the incidence has been declining since the mid-1980s (50,000 cases/year in the US, several times more in the early 1980s). During 1991 in sub=Saharan Africa, 200,000 adult AIDS cases occurred in accordance with the 10-years latency of the disease. The estimated figures of HIV infection as of early 1992 were 5-7 million men and 3-5 million women with 1.5 million full-blown AIDS cases, 90% of whom have died. In sub-Saharan Africa, 1 out of 3 children born to infected mothers become infected, and almost 1 million infected children have been born in the world since the pandemic started. The peak incidence of AIDS cases is expected in the mid-1990s in developed countries because of high HIV infection rate in the early 1980s. A steady increase of heterosexual transmission is projected depending on the effectiveness of HIV/AIDS prevention programs. In developing countries, AIDS cases and attendant mortality are expected to increase substantially in the 1990s and beyond with AIDS becoming the leading cause of death among adults in productive life. In sub-Saharan African cities, HIV seropositivity may range from under 10% to 30% in the 15-49 age group. The improvement of surveillance and estimation methods of HIV/AIDS prevalence is a prerequisite of AIDS programs of health care systems.
[Unpublished] 1991. Presented at the 119th Annual Meeting of the American Public Health Association [APHA], Atlanta, Georgia, November 11-14, 1991. 46,  p.The effects of the aftermath of the August 2nd, 1990 Iraqi invasion of Kuwait, the UN Security Council imposed sanctions, and the UN military offensive against Iraq on Iraq's maternal and child health sector and its public health infrastructure are examined. A review of the UN sanctions and dates of implementation are provided. A series of international responses ensued and are described. By February 1991, Baghdad had <5% of a normal water supply and the system was in collapse. Families, particularly women and children, suffered food shortages including infant formula, burns from makeshift cooking devices, e.g., epidemiologic and disease reporting ceased, drugs and vaccines were in short supply or absent, and sanitation and sewage systems were dysfunctional. It is concluded that OAS and US action against Haiti in the form of sanctions and military action would place a tremendous burden on the poor, and it is suggested that careful consideration be given before steps are taken. Also, discussed is the modern method of conflict resolution which is fueled by weapons technology and the profit incentive. There is a called to action for developing a realistic conception framework for the study and conduct of relationships with nations. There is a need to guide change peacefully and to resolve conflict without threat to life and the public's health, human environment, and ecosystem. The modern weapons technology and the protocols allowable under the UN Charter did not accomplish this in Iraq.
[Child mortality in the developing countries of Africa] Smertnost detei v razvivaiushchikhsia stranakh Afriki.
SOVETSKOE ZDRAVOOKHRANENIE. 1989; (3):58-63.Infant mortality statistics in developing African countries are reviewed. According to the World Health Organization (WHO) surveys, there was an overall decrease in infant mortality from 1960-1986, although the infant mortality rate in the African region remains higher than in other WHO regions (119.4, compared with 40.6 in the European region, 11.8 in the Eastern Mediterranean region, 110.2 in the South- Eastern Asia, 49.7 in the American Region, and 44.5 in the Western part of the Pacific ocean). In infants younger than 28 days old, mortality is associated with pregnancy and labor complications, congenital birth defects, and birth trauma. In Algeria, Sierra Leone, Nigeria, Mozambique, Malawi, and Zimbabwe, 70-90% of all deaths were caused by tetanus (70-80% of African women give birth at home without any medical help). In a 1 month to 1 year old age group, the leading cause of mortality is diarrhea (52% in Sudan, 29.2% in Sierra Leone); other causes of death are measles (15.8%), acute respiratory diseases (14.3%), malaria (8.5%), and infectious meningitis (6%). In a 1-4 years old age group, leading cause of mortality is nutritional deficiencies (9%). In addition to medical causes, infant mortality is also associated with a number of socioeconomic factors: insufficient nutrition of mothers, heavy physical work during pregnancy, young age of mothers and short interval between pregnancies, lack of proper medical care during pregnancy and labor, and early switching to infant formula not following proper hygienic recommendations.
The Population Council's research program on infant and child mortality in Southeast Asia: a case study of the relationship between contamination of infant weaning foods, household food handling practices, morbidity, and growth faltering in a rural Thai population.
Bangkok, Thailand, Population Council, Regional Office for South and East Asia, 1986 Aug. 24 p. (Population Council Regional Research Papers. South and East Asia)This booklet describes the overall plan of the research program on infant and child mortality in Southeast Asia, sponsored by the Population Council, the Ford Foundation, the Australian Development Assistance Bureau, and the Canadian International Development Research Center. The objectives are to gain scientific knowledge about the socioeconomic, behavioral and medical factors in mortality; to increase awareness through networking and publication; and to evaluate the effectiveness of interventions at the household and community levels. It is assumed that a small number of simple techniques will prevent over half of child deaths. Applied social science or operations research will be used primarily, rather than clinical or demographic studies. Statistical sociological correlations between a variety of environmental characteristics and mortality as the dependent variable will point to determinants of mortality. The 5 chief determinants are: maternal factors, environmental contamination, nutrient deficiencies, injury, and personal illness controls. The concerns reflected in the projects funded so far include: to focus on some combination of determinants of child survival; to focus on a specific location; to use multiple approaches to data collection; to produce results that can be applied as interventions. As an example, the study on the relationship of contamination of infant weaning foods to morbidity and infant growth in a rural Thai population is summarized.
Population Bulletin of the United Nations. 1986; (18):34-40.The author uses U.N., Unesco, and World Bank data to examine factors contributing to the mortality decline in developing countries since the middle of the 1960s. The primary aim of the paper is to present an analysis of developments in the recent period similar to earlier studies by the same author concerning factors influencing mortality declines during the period from the 1930s to the 1960s. "The study finds that, contrary to previous periods, the social and economic variables of income, literacy and nutrition were the dominating factors in explaining mortality decline during the 1965-1969 to 1975-1979 decade....The exogenous factors appear to have operated with sharply reduced intensity in the more recent period. Reduced international commitment to health in developing countries may be one explanation; surely Governments and international agencies continue to have many tools available for improving health. Results also suggest the major role that can be played by educational change in fostering mortality gains." (EXCERPT)