How many child deaths can we prevent this year

Background
Malaria is an important cause of illness and death in many parts of the world, especially in sub-Saharan Africa. There has been a renewed emphasis on preventive measures at community and individual levels. Insecticide-treated nets (ITNs) are the most prominent malaria preventive measure for large-scale deployment in highly endemic areas.

Objectives
To assess the impact of insecticide-treated bed nets or curtains on mortality, malarial illness (life-threatening and mild), malaria parasitaemia, anaemia, and spleen rates.

Search methods
I searched the Cochrane Infectious Diseases Group trials register (January 2003), CENTRAL (The Cochrane Library, Issue 1, 2003), MEDLINE (1966 to October 2003), EMBASE (1974 to November 2002), LILACS (1982 to January 2003), and reference lists of reviews, books, and trials. I handsearched journals, contacted researchers, funding agencies, and net and insecticide manufacturers.

Selection criteria
Individual and cluster randomized controlled trials of insecticide-treated bed nets or curtains compared to nets without insecticide or no nets. Trials including only pregnant women were excluded.

Data collection and analysis
The reviewer and two independent assessors reviewed trials for inclusion. The reviewer assessed the risk of bias in the trials, and extracted and analysed data.

Main results
Fourteen cluster randomized and eight individually randomized controlled trials met the inclusion criteria. Five trials measured child mortality: ITNs provided 17% protective efficacy (PE) compared to no nets (relative rate 0.83, 95% confidence interval (CI) 0.76 to 0.90), and 23% PE compared to untreated nets (relative rate 0.77, 95% CI 0.63 to 0.95). About 5.5 lives (95% CI 3.39 to 7.67) can be saved each year for every 1000 children protected with ITNs. In areas with stable malaria, ITNs reduced the incidence of uncomplicated malarial episodes in areas of stable malaria by 50% compared to no nets, and 39% compared to untreated nets; and in areas of unstable malaria: by 62% for compared to no nets and 43% compared to untreated nets for Plasmodium falciparum episodes, and by 52% compared to no nets and 11% compared to untreated nets for P. vivax episodes. When compared to no nets and in areas of stable malaria, ITNs also had an impact on severe malaria (45% PE, 95% CI 20 to 63), parasite prevalence (13% PE), high parasitaemia (29% PE), splenomegaly (30% PE), and their use improved the average haemoglobin level in children by 1.7% packed cell volume.

Authors' conclusions
ITNs are highly effective in reducing childhood mortality and morbidity from malaria. Widespread access to ITNs is currently being advocated by Roll Back Malaria, but universal deployment will require major financial, technical, and operational inputs.

Insecticide‐treated bed nets and curtains for preventing malaria

http://math.arizona.edu/~cushing/DeterminingImportantParametersInTheSpreadofMalaria%20BMB2008.pdf

Determining important parameters in the spread of malaria through the sensitivity analysis of a mathematical model.

Naturally acquired immunity to falciparum malaria protects millions of people routinely exposed to Plasmodium falciparum infection from severe disease and death. There is no clear concept about how this protection works. There is no general agreement about the rate of onset of acquired immunity or what constitutes the key determinants of protection; much less is there a consensus regarding the mechanism(s) of protection. This review summarizes what is understood about naturally acquired and experimentally induced immunity against malaria with the help of evolving insights provided by biotechnology and places these insights in the context of historical, clinical, and epidemiological observations. We advocate that naturally acquired immunity should be appreciated as being virtually 100% effective against severe disease and death among heavily exposed adults. Even the immunity that occurs in exposed infants may exceed 90% effectiveness. The induction of an adult-like immune status among high-risk infants in sub-Saharan Africa would greatly diminish disease and death caused by P. falciparum. The mechanism of naturally acquired immunity that occurs among adults living in areas of hyper- to holoendemicity should be understood with a view toward duplicating such protection in infants and young children in areas of endemicity.

/pdf/acquired-immunity-to-malaria-5g7lwizvd6.pdf

Acquired immunity to malaria.

BACKGROUND

The Roll Back Malaria strategy recommends a combination of interventions for malaria control. Zanzibar implemented artemisinin-based combination therapy (ACT) for uncomplicated malaria in late 2003 and long-lasting insecticidal nets (LLINs) from early 2006. ACT is provided free of charge to all malaria patients, while LLINs are distributed free to children under age 5 y ("under five") and pregnant women. We investigated temporal trends in Plasmodium falciparum prevalence and malaria-related health parameters following the implementation of these two malaria control interventions in Zanzibar.

METHODS AND FINDINGS

Cross-sectional clinical and parasitological surveys in children under the age of 14 y were conducted in North A District in May 2003, 2005, and 2006. Survey data were analyzed in a logistic regression model and adjusted for complex sampling design and potential confounders. Records from all 13 public health facilities in North A District were analyzed for malaria-related outpatient visits and admissions. Mortality and demographic data were obtained from District Commissioner's Office. P. falciparum prevalence decreased in children under five between 2003 and 2006; using 2003 as the reference year, odds ratios (ORs) and 95% confidence intervals (CIs) were, for 2005, 0.55 (0.28-1.08), and for 2006, 0.03 (0.00-0.27); p for trend < 0.001. Between 2002 and 2005 crude under-five, infant (under age 1 y), and child (aged 1-4 y) mortality decreased by 52%, 33%, and 71%, respectively. Similarly, malaria-related admissions, blood transfusions, and malaria-attributed mortality decreased significantly by 77%, 67% and 75%, respectively, between 2002 and 2005 in children under five. Climatic conditions favorable for malaria transmission persisted throughout the observational period.

CONCLUSIONS

Following deployment of ACT in Zanzibar 2003, malaria-associated morbidity and mortality decreased dramatically within two years. Additional distribution of LLINs in early 2006 resulted in a 10-fold reduction of malaria parasite prevalence. The results indicate that the Millennium Development Goals of reducing mortality in children under five and alleviating the burden of malaria are achievable in tropical Africa with high coverage of combined malaria control interventions.

http://lib.gdpu.edu.cn/cyzy/tssjk/CXXKNY/CXXKNY_WWWX/201110/P020111020566820000121.pdf

Impact of artemisinin-based combination therapy and insecticide-treated nets on malaria burden in Zanzibar.

A group-randomized controlled trial of insecticide (permethrin)-treated bed nets (ITNs) was conducted in an area of high perennial malaria transmission in western Kenya to test the effect of ITNs on all-cause mortality in children 1-59 months of age. Child deaths were monitored over a two-year period by biannual household census in Asembo (1997-1998) and in Gem (1998-1999). Overall, 1,722 deaths occurred in children 1-59 months followed for 35,932 child-years. Crude mortality rates/1,000 child-years were 51.9 versus 43.9 in control and ITN villages in children 1-59 months old. The protective efficacy (PE) (95% confidence interval) adjusted for age, study year, study site, and season was 16% (6-25%). Corresponding figures in 1-11- and 12-59-month-old children in control and ITN villages were 133.3 versus 102.3, PE = 23% (11-34%) and 31.1 versus 28.7, PE = 7% (-6-19%). The numbers of lives saved/1,000 child-years were 8, 31, and 2 for the groups 1-59, 1-11, and 12-59 months old, respectively. Stratified analysis by time to insecticide re-treatment showed that the PE of ITNs re-treated per study protocol (every six months) was 20% (10-29%), overall and 26% (12-37%) and 14% (-1-26%) in 1-11- and 12-59-month-old children, respectively. ITNs prevent approximately one in four infant deaths in areas of intense perennial malaria transmission, but their efficacy is compromised if re-treatment is delayed beyond six months.

Efficacy of permethrin-treated bed nets in the prevention of mortality in young children in an area of high perennial malaria transmission in western Kenya.

Estimates of mortality in children less than five years old using government civil registration statistics (passive surveillance) were compared against statistics generated by active demographic surveillance during a randomized controlled trial of permethrin-treated bed nets (ITNs) in western Kenya. Mortality rates were two-fold lower when estimated through civil registration compared with active prospective surveillance (rate ratio [RR] = 0.51, 95% confidence interval [CI] = 0.44-0.59). While civil registration underestimated deaths, particularly in the neonatal period, the age distribution of deaths in children 1-59 months of age was the same as with active surveillance. Seasonal mortality trends were also similar. There was no agreement between cause of death recorded by active and passive surveillance. Verbal autopsy estimated that half of all deaths were associated with malaria and pneumonia, but civil registration markedly under-reported these illnesses; incidence RR (95% CI) = 0.18 (0.14-0.24), and 0.05 (0.03-0.08), respectively, while over-reporting deaths due to measles (RR = 15.5 [95% CI = 7.3-33.2]). Government statistics under-represent mortality, particularly neonatal mortality, in children less than five years of age in rural areas of Kenya. They can provide accurate information on the age-distribution of deaths among children 1-59 months old, and on seasonal trends, but not on disease-specific mortality.

Comparison of government statistics and demographic surveillance to monitor mortality in children less than five years old in rural western Kenya

Purpose: This study was conducted to establish determinants of diet and fluid adherence among ERSD patients undergoing hemodialysis at Moi Teaching and Referral HospitalUasingishu county. Kenya. Methods: A descriptive cross-sectional study design was applied. Using Fisher’s formula, a sample size of 145 participants were conveniently recruited. Data collection was done by use of modified end stage renal disease adherence questionnaire (ESRD-AQ). Chi-square (χ2) was used to test statistical significance. Frequency tables and bar graphs were used for data presentation. SPSS version 22.0 was used for data analysis. Results: The study revealed that knowledge on nutritional requirements for renal patients was marginally associated with dietary and fluid intake with a higher proportion of those with low nutritional knowledge (83.6%) adhering to diet and a relatively smaller proportion in the same category (58.9%) complying with fluid intake. A significant relationship with dietary adherence was observed where participants practiced fluid restrictions (p=0.003) and the frequency in which health staff talk about the importance of following proper diet (p <0.0001). On social support domain, a significant association was observed in patients who agreed that various social support aspects help improve depression, self-esteem, selfmanagement, etc. and who adhered to diet scored a significantly higher mean of 5.6 (95% CI = 5.5 – 5.6) in contrast to non-adherent counterparts who had a mean of 5.5 (p = 0.0006). Among the economic factors with significant association with diet adherence were; use of bus for transport (p=0.02); income of less than KSH. 30,000 (p=0.006); treatment cost (p=0.007) and ability to access material support that helps in adherence (p=0.003). Those who claimed that lack of transport was the main reason for missing dialysis practiced fluid adherence (p=0.01) with a smaller proportion (44%) adhering to fluid restriction in comparison to 70.8% who had transport and were nonadherent. Unique contribution to theory, practice and policy: The study findings are unique to the study site and it’s hoped that it can be used to inform hospital policy makers in addressing adherence challenges in ESRD patients on hemodialysis. The study recommends a holistic study on determinants of adherence to hemodialysis, medication use, dietary, and fluid compliance among patients undergoing HD at MTRH should be conducted in order to produce generalized results.

/pdf/determinants-of-diet-and-fluid-adherence-among-end-stage-87xbvvoyqy.pdf

Determinants of diet and fluid adherence among end stage renal disease patients undergoing haemodialysis at moi teaching and referral hospital, uasin gishu county, kenya

John Arudo

Papers

Efficacy of permethrin-treated bed nets in the prevention of mortality in young children in an area of high perennial malaria transmission in western Kenya.

Comparison of government statistics and demographic surveillance to monitor mortality in children less than five years old in rural western Kenya

Determinants of diet and fluid adherence among end stage renal disease patients undergoing haemodialysis at moi teaching and referral hospital, uasin gishu county, kenya