Too far to walk : maternal mortality in context

Current estimates of the global burden of disease for diarrhoea are reported and compared with previous estimates made using data collected in 1954-79 and 1980-89. A structured literature review was used to identify studies that characterized morbidity rates by prospective surveillance of stable populations and studies that characterized mortality attributable to diarrhoea through active surveillance. For children under 5 years of age in developing areas and countries, there was a median of 3.2 episodes of diarrhoea per child-year. This indicated little change from previously described incidences. Estimates of mortality revealed that 4.9 children per 1000 per year in these areas and countries died as a result of diarrhoeal illness in the first 5 years of life, a decline from the previous estimates of 13.6 and 5.6 per 1000 per year. The decrease was most pronounced in children aged under 1 year. Despite improving trends in mortality rates, diarrhoea accounted for a median of 21% of all deaths of children aged under 5 years in these areas and countries, being responsible for 2.5 million deaths per year. There has not been a concurrent decrease in morbidity rates attributable to diarrhoea. As population growth is focused in the poorest areas, the total morbidity component of the disease burden is greater than previously.

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The global burden of diarrhoeal disease, as estimated from studies published between 1992 and 2000

Few studies provide data on the global morbidity and mortality caused by infection with Shigella spp.; such estimates are needed, however, to plan strategies of prevention and treatment. Here we report the results of a review of the literature published between 1966 and 1997 on Shigella infection. The data obtained permit calculation of the number of cases of Shigella infection and the associated mortality occurring worldwide each year, by age, and (as a proxy for disease severity) by clinical category, i.e. mild cases remaining at home, moderate cases requiring outpatient care, and severe cases demanding hospitalization. A sensitivity analysis was performed to estimate the high and low range of morbid and fatal cases in each category. Finally, the frequency distribution of Shigella infection, by serogroup and serotype and by region of the world, was determined. The annual number of Shigella episodes throughout the world was estimated to be 164.7 million, of which 163.2 million were in developing countries (with 1.1 million deaths) and 1.5 million in industrialized countries. A total of 69% of all episodes and 61% of all deaths attributable to shigellosis involved children under 5 years of age. The median percentages of isolates of S. flexneri, S. sonnei, S. boydii, and S. dysenteriae were, respectively, 60%, 15%, 6%, and 6% (30% of S. dysenteriae cases were type 1) in developing countries; and 16%, 77%, 2%, and 1% in industrialized countries. In developing countries, the predominant serotype of S. flexneri is 2a, followed by 1b, 3a, 4a, and 6. In industrialized countries, most isolates are S. flexneri 2a or other unspecified type 2 strains. Shigellosis, which continues to have an important global impact, cannot be adequately controlled with the existing prevention and treatment measures. Innovative strategies, including development of vaccines against the most common serotypes, could provide substantial benefits.

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Global Burden of Shigella Infections: Implications for Vaccine Development and Implementation of Control Strategies

Data from 24 published studies were anlayzed in order to estimate the annual morbidity and mortality from acute diarrheal diseases in the developing world. 22 of the studies involved frequent surveillance through home visits to families in communities; the other 2 were multicountry studies in which diarrhea mortality was calculated on the basis of death certificate information. Morbidity rates were found to be highest in the 6-11 month age group while the mortality rates were greatest in infants under 1 year of age and children 1 year old. For children under 5 years of age the median incidence of diarhhea was 2.2 episodes/child/year for all studies and 3.0 episodes/child/year for the studies that had the smallest populations and most frequent surveillance. Using 1980 population estimates the estimated total yearly morbidity and mortality from diarrheal diseases for children under 5 years of age in Africa Asia (excluding China) and Latin America were 744-1000 million episodes and 4.6 million deaths. (authors) (summary in FRE)

The magnitude of the global problem of acute diarrhoeal disease: a review of active surveillance data.

Methods Two sources of neonatal cause-of-death data were examined: VR datasets for countries with high coverage (.90%), and published and unpublished studies identified through systematic searches. Multinomial regression was used to model the distribution of neonatal deaths. A VR-based model was used to estimate the distribution of causes of death for 37 low-mortality countries without national data. A study-based model was applied to obtain estimates for 111 high-mortality countries. Uncertainty estimates were derived using the jackknife approach. Results Data from 44 countries with VR (96 797 neonatal deaths) and from 56 studies (29 countries, 13 685 neonatal deaths) met inclusion criteria. The distribution of reported causes of death varied substantially between countries and across studies. Based on 193 countries, the major causes of neonatal death globally were estimated to be infections (sepsis/pneumonia, tetanus, and diarrhoea, 35%), preterm birth (28%), and asphyxia (23%). Regional variation is important. Substantial uncertainty surrounds these estimates. Conclusions This exercise highlights the lack of reliable cause-of-death data in the settings in which most neonatal deaths occur. Complex statistical models are not a panacea. Representative data with comparable case definitions and consistent hierarchical cause-of-death attribution are required.

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Estimating the causes of 4 million neonatal deaths in the year 2000

Attendance rates at a diarrhea clinic were monitored in a defined population in rural Bangladesh. Weekly home visits were also carried out to determine diarrheal attacks in communities within six miles of the clinic. Within the first one mile radius, 90 per cent of diarrheal cases came to the clinic for treatment. At two miles the attendance fell to 70 per cent for males and 40 per cent for females. On an average, the greater the distance to the clinic, the more severe was the degree of dehydration on presentation, requiring more frequent use of intravenous fluid. Mortality secondary to diarrhea was significantly reduced only within a two-mile radius of the clinic.

A diarrhea clinic in rural Bangladesh: influence of distance, age, and sex on attendance and diarrheal mortality

Diarrhœal mortality in two bangladeshi villages with and without community-based oral rehydration therapy

Reports on a study undertaken in Chittagong district of Bangladesh to examine the causes and some of the factors contributing to neonatal and postneonatal mortality and to identify the population at highest risk. A cohort of 1351 infants born between July 1976 and June 1977 was longitudinally followed up for 1 year in the Teknaf Dysentery Project demographic surveillance system. Results of the survey show an overall infant mortality rate of 160/1000 live births. Neonatal and postneonatal components were 89 and 71/1000 births respectively. Major causes of neonatal and postneonatal death were: tetanus (21%); pneumonia (19%); prematurity (12%); malnutrition (8%); diarrheal diseases (7%); and fever (6%). Tetanus premaurity and congenital abnormalities were the commonest causes of neonatal death whereas pneumonia malnutrition diarrheal disease and fever were the most important causes during the postneonatal period. Complications in delivery were significantly correlated with increased risk of neonatal mortality. The age of the mother was also a determinant of neonatal and mortality. The age of the mother was also a determinant of neonatal and postneonatal viability with mothers under the age of 20 having the greatest risk of death of her newborn. The age range 25-29 years conferred the greatest protection on neonates and postneonates. When the age of the mother is controlled parity is positively related to neonatal postneonatal and infant mortality rate. Large family size also correlates positively with the mortality rate.

Infant mortality in rural Bangladesh: an analysis of causes during neonatal and postneonatal periods.

Untrained personnel attend 2/3 of all births in the world. In many villages and urban areas of Asia; Africa and Latin America TBAs (traditional birth attendants) deliver majority of births. This paper reports the type of birth attendants; methods of cutting and dressing the umbilical cords and their relationship with the incidence of neonatal tetanus for a cohort of 1351 infants born between 7/76 to 6/77 in Teknaf area of rural Bangladesh. Most of the deliveries were conducted by untrained birth attendants and only <1% were delivered by trained midwives or physicians. 32% of the births were delivered by dais or TBAs; 35% by neighboring women; 30% by relations of the women and 3% were unattended. Razor blades were used to cut the umbilical cords in 22% and bamboo splits in 78%. Overall neonatal mortality rate due to tetanus was 27/100 live births. Among neonates whose umbilical cords were cut by razor blades mortality rate was 21/1000 live births compared to 29/1000 live births for those cut by bamboo splits. These rates were not considered statistically signficant. Mortality rate due to tetanus was significantly higher among the neonates whose umbilical cords were not tied with a thread than those tied with a thread. Incidence of neonatal tetanus can be lo considerably through improvement of rural sanitation and delivery techniques in home. Tetanus toxoid immunization of mothers was suggested as an effective remedy for the prevention of neonatal tetanus.

Birth care practice and neonatal tetanus in a rural area of Bangladesh.

Attendance rates at a diarrhea clinic were monitored in a defined population in rural Bangladesh. Communities within 7 miles of the clinic were followed. Within the 1st 1 mile radius 90% of diarrheal cases came to the clinic for treatment. At 3 miles the attendance fell to 70% for males and 40% for females. On an average the greater the distance to the clinic more severe was the degree of dehydration on presentation. Mortality secondary to diarrhea was significantly reduced within 4 mile radius of the clinic. (Authors)

Y. Patwari

Papers

A diarrhea clinic in rural Bangladesh: influence of distance, age, and sex on attendance and diarrheal mortality

Diarrhœal mortality in two bangladeshi villages with and without community-based oral rehydration therapy

Infant mortality in rural Bangladesh: an analysis of causes during neonatal and postneonatal periods.

Birth care practice and neonatal tetanus in a rural area of Bangladesh.

Utilisation of a diarrhoea clinic in rural Bangladesh: influences of distance, age and sex on attendance and diarrhoeal mortality.