Assuntos
Doenças dos Animais/epidemiologia , Surtos de Doenças/veterinária , Vigilância de Evento Sentinela/veterinária , Animais , Doenças das Aves/epidemiologia , Bovinos , Doenças dos Bovinos/epidemiologia , Columbidae , Morte Súbita/veterinária , Cervos , Patos , Disenteria/mortalidade , Disenteria/veterinária , Feminino , Masculino , Doenças das Aves Domésticas/epidemiologia , Gravidez , Escócia/epidemiologia , Ovinos , Doenças dos Ovinos/epidemiologia , Suínos , Doenças dos Suínos/epidemiologiaRESUMO
OBJETIVO: descrever a morbimortalidade e a sazonalidade das doenças diarreicas nos menores de 10 anos de idade residentes no Distrito Federal, Brasil, de 2003 a 2012. MÉTODOS: estudo descritivo, com dados dos Sistemas de Informações Hospitalares do Sistema Único de Saúde (SIH/SUS), sobre Mortalidade (SIM), de Vigilância Epidemiológica das Doenças Diarreicas Agudas (Sivep-DDA) e planilhas de monitoramento da diarreia. RESULTADOS: foram contabilizados 558.737 casos de diarreia, com maior incidência entre menores de 1 ano (32,3 casos/100 crianças em 2003); no período, reduziram-se as taxas de hospitalização (de 6,5 para 3,0 internações/1000 crianças), mortalidade (de 4,5 para 1,5 óbitos/100 mil crianças) e letalidade hospitalar (de 0,70 para 0,49/100 crianças), com queda mais acentuada após a implantação da vacina contra rotavírus em 2006; as maiores taxas de internações ocorreram entre julho e setembro. CONCLUSÃO: houve redução de morbimortalidade por diarreia, principalmente em menores de 1 ano, com predomínio de internações na estação seca.
OBJECTIVE: to describe diarrhoeal disease morbidity, mortality and seasonality in children aged under 10 resident in Brazil's Federal District, 2003-2012. METHODS: this was a descriptive study using National Hospital Information System (SIH/SUS), Mortality Information System (SIM), Acute Diarrhoeal Disease Epidemiological Surveillance System (Sivep-DDA) as well as diarrhoea monitoring spreadsheets. RESULTS: 558,737 diarrhoea cases were registered with the highest incidence among children with less than one year old (32.3 cases/100 children in 2003); during the period there was a reduction in the hospitalization rates (from 6.5 to 3.0 hospitalizations/1,000 children), mortality rates (from 4.5 to 1.5 deaths/100,000 children) and hospital lethality (from 0.70 to 0.49/100 children), with a sharper decline after the implementation of rotavirus vaccine in 2006; highest hospitalization rates occurred between July and September. CONCLUSION: morbidity and mortality from diarrhoea reduced, particularly in children under one year old. Hospitalizations were more frequent during in the dry season.
OBJETIVO: describir la morbimortalidad y temporalidad de las enfermedades diarreicas agudas en niños menores de 10 años, residentes del Distrito Federal, Brasil, de 2003 a 2012. MÉTODO: estudio descriptivo, con datos del Sistema de Informaciones Hospitalarios (SIH/SUS), sobre Mortalidad (SIM), Vigilancia Epidemiológica de Enfermedades Diarreicas Agudas (SIVEP-DDA) y planillas de monitoreo de diarrea. RESULTADOS: fueron contabilizados 558.737 casos de diarrea, con mayor incidencia en niños menores de 1 año (32,3 casos/100 niños en 2003); en el período hubo reducción de las tasas de hospitalización (6,5 a 3,0 hospitalizaciones/1.000 niños), mortalidad (de 4,5 a 1,5 muertes/100 mil niños) y letalidad (de 0,70 a 0,49/100 niños), con declive más agudo después de la implantación de la vacuna contra rotavirus en 2006; las tasas de hospitalización más altos han ocurrido entre julio y septiembre. CONCLUSIÓN: hubo reducción de la morbimortalidad por diarrea, especialmente en niños menores de 1 año, con predominio de hospitalizaciones en la estación seca.
Assuntos
Humanos , Masculino , Feminino , Recém-Nascido , Lactente , Pré-Escolar , Criança , Diarreia Infantil/epidemiologia , Diarreia Infantil/mortalidade , Disenteria/epidemiologia , Disenteria/mortalidade , Mortalidade/tendências , Brasil , Epidemiologia Descritiva , Hospitalização , Sistemas de Informação , Estações do AnoRESUMO
Seasonal fluctuations in mortality and their causes in the nineteenth century Polish rural populations: wealthy, agriculturally and economically advanced populations from Wielkopolska, and poor populations from Silesia and Galicia (southern Poland) were described. Data-sources included parish death registers from the Roman Catholic parish of Dziekanowice in the region of Wielkopolska, Prussian statistical yearbooks for the Pozna Province as well as information from previous publications regarding Silesia and Galicia. The 19th century patterns were compared with those in present-day Poland. The occurrence of seasonality of deaths was assessed with: the Chi-squared test, the Kolmogorov-Smirnov test, and the Autoregressive Integrated Moving Average Models (ARIMA). In all populations there was a winter maximum of the number of deaths, while the minimum occurred in early summer. In the poor populations of Silesia and Galicia another statistically significant increase in the incidence of deaths was observed in the early spring. In the rich and modern villages of Wielkopolska there was no spring increase in the number of deaths, however, in all populations of Wielkopolska, irrespective of a particular pattern, a secondary mortality peak occurred in the late summer and autumn. Statistical tests used in this study did not show any clear differences in the distribution of the seasonality of deaths between the populations of Wielkopolska on the one hand, and the populations from Galicia and Silesia, on the other hand. The statistical significance of differences was, however, evident between populations representing the two distinguished by secondary peaks death seasonality patterns. Seasonal death increase split the populations under study into two groups according to the criterion of wealth.
Assuntos
Mortalidade/história , Sistema de Registros , Estações do Ano , Acidentes/história , Acidentes/mortalidade , Adolescente , Adulto , Causas de Morte/tendências , Criança , Pré-Escolar , Cólera/história , Cólera/mortalidade , Disenteria/história , Disenteria/mortalidade , Feminino , História do Século XIX , Homicídio/história , Homicídio/estatística & dados numéricos , Humanos , Incidência , Lactente , Recém-Nascido , Masculino , Pessoa de Meia-Idade , Mortalidade/tendências , Mortalidade Perinatal/história , Mortalidade Perinatal/tendências , Polônia/epidemiologia , Pobreza , População Rural , Natimorto/epidemiologia , Suicídio/história , Suicídio/estatística & dados numéricos , Tuberculose/história , Tuberculose/mortalidade , Adulto JovemRESUMO
OBJECTIVES: To estimate premature mortality by age, sex and cause of death in India. BACKGROUND: Studies on premature mortality in India are limited. Although evidence suggests recent reductions in infant and child mortality, little is known about the age and sex patterns of premature deaths in India. METHODS: Secondary data from the Sample Registration System and, census of India and report on cause of death. A set of indices are used to estimate the premature mortality were analysed. PRIMARY AND SECONDARY OUTCOME MEASURES: Standardised years of potential life lost (YPLL), premature years of potential life lost (PYPLL) and working years of potential life lost (WYPLL) for broad age groups and by selected causes of death. RESULTS: From 1991 to 2011, the age-standardised rate of YPLL (per 1000 population) declined from 310 to 235 for males and from 307 to 206 for females. The estimated YPLL (in millions) declined from 134 to 147 for males and from 123 to 108 for females, the YPLL for adults (aged 15-65) increased by 32% for males and 28% for females, the standardised PYPLL (per 1000 population) declined from 259 to 137 for males and from 258 to 115 for females, the estimated PYPLL increased by 13% for all adult males and by 32% for 30-45-year-old adult males, and the standardised rate of WYPLL declined from 274 to 131 for males and from 295 to 91 for females. These findings suggest a significant improvement in early childhood mortality and increasing mortality trends in 30-45-year-old adult males. The YPLL and WYPLL standardised rates for males and females were highest for cardiovascular disease. CONCLUSIONS: The increasing share of premature deaths among adults and high levels of premature mortality suggest an improvement in child survival increased attention should be given to prevention and treatment of non-communicable diseases in order to avoid premature deaths in India.
Assuntos
Acidentes/mortalidade , Doenças Cardiovasculares/mortalidade , Disenteria/mortalidade , Mortalidade Prematura/tendências , Neoplasias/mortalidade , Adolescente , Adulto , Causas de Morte/tendências , Feminino , Humanos , Índia/epidemiologia , Expectativa de Vida , Masculino , Pessoa de Meia-Idade , Vigilância da PopulaçãoRESUMO
The purpose of this study was to determine the association between deaths owing to terrorism, civil war and one-sided violence from 1994-2000 and disability-adjusted life years (DALYs) attributable to diarrheal and related diseases, schistosomiasis, trachoma and the nematode infections (DSTN diseases) in 2002 among World Health Organization Member States. Deaths resulting from terrorism, civil war and one-sided violence were significantly related to DSTN DALYs across the majority of sex-age subgroups of the populace, after controlling for baseline levels of improved water/sanitation and a variety of economic measures: overall, a 1.0% increase in deaths owing to terrorism and related violence was associated with an increase of 0.16% in DALYs lost to DSTN diseases. Associations were greatest among 0-to-4-year olds. The results of the present study suggest that DSTN disease control efforts should target conflict-affected populations with particular attention to young children who suffer disproportionately from DSTN diseases in these settings. In view of the evidence that terrorism and related violence may influence DSTN DALYs in the longer term, control strategies should move beyond immediate responses to decrease the incidence and severity of DSTN diseases to seek solutions through bolstering health systems infrastructure development among conflict-affected populations.
Assuntos
Disenteria/mortalidade , Infecções por Nematoides/mortalidade , Esquistossomose/mortalidade , Terrorismo , Tracoma/mortalidade , Violência , Guerra , Saúde Global/economia , Saúde Global/estatística & dados numéricos , Humanos , Anos de Vida Ajustados por Qualidade de Vida , Análise de Regressão , Saneamento/estatística & dados numéricos , Abastecimento de Água/estatística & dados numéricosRESUMO
Calf mortality control is vitally important for farmers, not only to improve animal welfare, but also to increase productivity. High calf mortality rates can be related to larger numbers of calves in a herd, employee performance, severe weather, and the neonatal period covering the first 4 weeks of life. Although the basic premise of preventing newborn calf mortality is early detection and treatment of calves at risk for failure of passive transfer of immunoglobulins, calf mortality due to infectious diseases such as acute diarrhea increases in the presence of these physical and psychological stressors. This suggests that farmers should not ignore the effects of secondary environmental factors. For prevention rather than cure, the quality of the environment should be improved, which will improve not only animal welfare but also productivity. This paper presents a review of the literature on newborn calf mortality and discusses its productivity implications.
Assuntos
Bem-Estar do Animal , Animais Recém-Nascidos , Doenças dos Bovinos/mortalidade , Bovinos , Colostro/imunologia , Disenteria/mortalidade , Disenteria/veterinária , Infecções Respiratórias/mortalidade , Infecções Respiratórias/veterinária , Criação de Animais Domésticos , Animais , Colostro/metabolismo , Meio Ambiente , Feminino , Imunoglobulinas/metabolismo , Gravidez , Estações do AnoRESUMO
BACKGROUND: Our objective was to develop a methodology to estimate causes of death among children age 1-59 months in high child mortality countries without adequate vital registration (VR) systems. METHODS: We systematically reviewed community-based studies reporting at least two causes of death among children 1-59 months of age identified from published and unpublished sources. We included (i) studies conducted after 1979, (ii) for duration of 12 months or an exact multiple, (iii) with > or =25 deaths in children <5 years, (iv) each death represented once and (v) <25% of deaths due to unknown causes. A study-based multinomial logistic regression model was applied to country-level data to estimate causes of child death. RESULTS: Of the 216 studies reviewed, 81 were included in the analysis comprising 79 067 under-5 deaths from 25 countries. After adjusting for risk factors and intervention coverage, the estimated distribution of causes of deaths in children 1-59 months of age in sub-Saharan Africa and Southeast Asia was: pneumonia (21 and 31%), diarrhoea (25 and 31%), malaria (26 and 2%), injury (3 and 4%), meningitis (3 and 4%), measles (3 and 2%) and other causes (20 and 27%), respectively. CONCLUSION: From studies reporting as few as two different causes of death, statistical modelling can be used to estimate the causes of child mortality for settings with incomplete VR. Pneumonia and diarrhoea remain the leading causes of death among children 1-59 months of age in sub-Saharan Africa and Southeast Asia.
Assuntos
Atestado de Óbito , Disenteria/mortalidade , Pneumonia/mortalidade , África Subsaariana/epidemiologia , Algoritmos , Sudeste Asiático/epidemiologia , Causas de Morte , Pré-Escolar , Diarreia Infantil/mortalidade , Humanos , Lactente , Recém-Nascido , Modelos EstatísticosRESUMO
BACKGROUND: Ciprofloxacin, ceftriaxone and pivmecillinam are the antibiotics currently recommended by the World Health Organization (WHO) for the treatment of dysentery in children; yet there have been no reviews of the clinical effectiveness of these antibiotics in recent years. METHODS: We reviewed all literature reporting the effect of ciprofloxacin, ceftriaxone and pivmecillinam for the treatment of dysentery in children in the developing countries. We used a standardized abstraction and grading format and performed meta-analyses to determine the effect of treatment with these antibiotics on rates of treatment failure, bacteriological failure and bacteriological relapse. The CHERG Standard Rules were applied to determine the final effect of treatment with these antibiotics on diarrhoea mortality. RESULTS: Eight papers were selected for abstraction. Treatment with ciprofloxacin, ceftriaxone or pivmecillinam resulted in a cure rate of >99% while assessing clinical failure, bacteriological failure and bacteriological relapse. CONCLUSIONS: The antibiotics recommended by the WHO--ciprofloxacin, ceftriaxone and pivmecillinam--are effective in reducing the clinical and bacteriological signs and symptoms of dysentery and thus can be expected to decrease diarrhoea mortality attributable to dysentery.
Assuntos
Antibacterianos/uso terapêutico , Disenteria/tratamento farmacológico , Disenteria/mortalidade , Andinocilina Pivoxil/uso terapêutico , Ceftriaxona/uso terapêutico , Pré-Escolar , Ciprofloxacina/uso terapêutico , Disenteria Bacilar/tratamento farmacológico , Disenteria Bacilar/mortalidade , Feminino , Humanos , Lactente , Masculino , Ensaios Clínicos Controlados Aleatórios como Assunto , Infecções por Salmonella/tratamento farmacológico , Infecções por Salmonella/mortalidade , Shigella dysenteriae , Resultado do TratamentoRESUMO
In terms of deaths due to disease, the Mexican War (1846-48) was the deadliest of all American wars. Nearly 13% of the entire U.S. force perished from disease. Of the total 12,535 war deaths, 10,986 (88%) were due to infectious diseases (overwhelmingly dysentery, both bacterial and amoebic); seven men died from disease for every man killed by Mexican musket balls. Camp pollution was the greatest error committed by U.S. troops in the Mexican War. The indifference of line officers and recruits to the need for proper sanitation and military hygiene fueled the dysentery outbreaks, and the poor conditions in military hospitals contributed further to the spread of disease. This defect in military culture undermined the health of the army and led to medical disaster. Disease caused an enormous drain on the U.S. Army's resources, eroded troop morale, and influenced strategy and tactics. As we enter the 21st century, dysentery is still a major public health threat, killing hundreds of thousands of people annually-primarily children in developing countries where personal hygiene is poor and disposal of human and animal wastes is indiscriminate.
Assuntos
Disenteria/história , Armas de Fogo/história , Medicina Militar/história , Militares/história , Guerra , Ferimentos por Arma de Fogo/história , Doença Aguda , Doença Crônica , Disenteria/microbiologia , Disenteria/mortalidade , História do Século XIX , Humanos , México , Saneamento/história , Estados Unidos , Ferimentos por Arma de Fogo/mortalidadeRESUMO
BACKGROUND: Shigella dysenteriae type 1 (Sd1) is a cause of major dysentery outbreaks, particularly among children and displaced populations in tropical countries. Although outbreaks continue, the characteristics of such outbreaks have rarely been documented. Here, we describe the Sd1 outbreaks occurring between 1993 and 1995 in 11 refugee settlements in Rwanda, Tanzania and Democratic Republic of the Congo (DRC). We also explored the links between the different types of the camps and the magnitude of the outbreaks. METHODOLOGY/PRINCIPAL FINDINGS: Number of cases of bloody diarrhea and deaths were collected on a weekly basis in 11 refugee camps, and analyzed retrospectively. Between November 1993 and February 1995, 181,921 cases of bloody diarrhea were reported. Attack rates ranged from 6.3% to 39.1% and case fatality ratios (CFRs) from 1.5% to 9.0% (available for 5 camps). The CFRs were higher in children under age 5. In Tanzania where the response was rapidly deployed, the mean attack rate was lower than in camps in the region of Goma without an immediate response (13.3% versus 32.1% respectively). CONCLUSIONS/SIGNIFICANCE: This description, and the areas where data is missing, highlight both the importance of collecting data in future epidemics, difficulties in documenting outbreaks occurring in complex emergencies and most importantly, the need to assure that minimal requirements are met.
Assuntos
Surtos de Doenças , Disenteria/epidemiologia , Refugiados , Shigella dysenteriae/patogenicidade , África Central/epidemiologia , Criança , Pré-Escolar , Diarreia/epidemiologia , Disenteria/mortalidade , HumanosRESUMO
BACKGROUND: Comparative characterization of genome-wide transcriptional changes during infection can help elucidate the mechanisms underlying host susceptibility. In this study, transcriptional profiling of the mouse colon was carried out in two cognate lines of mice that differ in their response to Citrobacter rodentium infection; susceptible inbred FVB/N and resistant outbred Swiss Webster mice. Gene expression in the distal colon was determined prior to infection, and at four and nine days post-inoculation using a whole mouse genome Affymetrix array. RESULTS: Computational analysis identified 462 probe sets more than 2-fold differentially expressed between uninoculated resistant and susceptible mice. In response to C. rodentium infection, 5,123 probe sets were differentially expressed in one or both lines of mice. Microarray data were validated by quantitative real-time RT-PCR for 35 selected genes and were found to have a 94% concordance rate. Transcripts represented by 1,547 probe sets were differentially expressed between susceptible and resistant mice regardless of infection status, a host effect. Genes associated with transport were over-represented to a greater extent than even immune response-related genes. Electrolyte analysis revealed reduction in serum levels of chloride and sodium in susceptible animals. CONCLUSION: The results support the hypothesis that mortality in C. rodentium-infected susceptible mice is associated with impaired intestinal ion transport and development of fatal fluid loss and dehydration. These studies contribute to our understanding of the pathogenesis of C. rodentium and suggest novel strategies for the prevention and treatment of diarrhea associated with intestinal bacterial infections.
Assuntos
Colite/genética , Diarreia/genética , Disenteria/genética , Animais , Antiporters/genética , Anidrase Carbônica IV/genética , Citrobacter rodentium , Colite/microbiologia , Colite/mortalidade , Diarreia/microbiologia , Diarreia/mortalidade , Modelos Animais de Doenças , Disenteria/microbiologia , Disenteria/mortalidade , Eletrólitos/sangue , Perfilação da Expressão Gênica , Predisposição Genética para Doença , Genômica , Intestinos/fisiopatologia , Transporte de Íons/genética , Camundongos , Camundongos Endogâmicos , Análise de Sequência com Séries de Oligonucleotídeos , Reação em Cadeia da Polimerase , Transportadores de SulfatoRESUMO
In order to assess the lethality of Clostridium difficile-associated disease (CDAD) and the PCR ribotypes prevalent in Austria, the Austrian Agency for Health and Food Safety requested isolates of C. difficile from patients in a structured but arbitrary sampling scheme. In the allocated period from February 2006 to January 2007, local hospital laboratories within each of the nine provinces were asked to submit C. difficile isolates from at least ten cases of CDAD. Confirmation of species identification, toxin detection, susceptibility testing against four antimicrobial agents and typing using a PCR ribotyping method were performed at the reference laboratory. In total, 149 isolates of putative C. difficile were submitted, from which 142 were included for study. Antimicrobial susceptibility patterns revealed resistance to clindamycin in 57% and high-level resistance to moxifloxacin in 38% of isolates tested. CDAD manifested as diarrhoea (including eight cases of bloody diarrhoea) in 126 cases (88.7%), as pseudomembranous colitis in 15 cases (10.6%) and as toxic megacolon in one case. Twelve of the 142 patients died within 30 days of specimen collection (8.45% lethality). A lethal outcome occurred in 2/15 cases (13.3%) when pseudomembranous colitis was present and in 10/126 cases (7.9%) in the absence of pseudomembranous colitis or toxic megacolon. Among the 142 isolates from 25 health-care facilities, 41 PCR ribotype patterns were found. The most frequent ribotypes were AI-5 (including six lethal cases out of 26 patients), 014 (two out of 24) and 053 (one out of 24). The typing patterns demonstrated the occurrence of clusters in hospitals.
Assuntos
Clostridioides difficile/genética , Infecções por Clostridium/microbiologia , Adolescente , Adulto , Idoso , Antibacterianos/farmacologia , Áustria/epidemiologia , Criança , Pré-Escolar , Clostridioides difficile/classificação , Clostridioides difficile/efeitos dos fármacos , Infecções por Clostridium/epidemiologia , Infecções por Clostridium/mortalidade , Farmacorresistência Bacteriana , Disenteria/epidemiologia , Disenteria/microbiologia , Disenteria/mortalidade , Enterocolite Pseudomembranosa/epidemiologia , Enterocolite Pseudomembranosa/microbiologia , Enterocolite Pseudomembranosa/mortalidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Reação em Cadeia da Polimerase , Estudos Prospectivos , Ribotipagem , Fatores de RiscoAssuntos
Clostridioides difficile/patogenicidade , Disenteria/mortalidade , Enterocolite Pseudomembranosa/mortalidade , Adulto , Idoso , Idoso de 80 Anos ou mais , Disenteria/microbiologia , Inglaterra/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Mortalidade , País de Gales/epidemiologiaRESUMO
BACKGROUND: Disease maps can serve to display incidence rates geographically, to inform on public health provision about the success or failure of interventions, and to make hypothesis or to provide evidences concerning disease etiology. Poisson kriging was recently introduced to filter the noise attached to rates recorded over sparsely populated administrative units. Its benefit over simple population-weighted averages and empirical Bayesian smoothers was demonstrated by simulation studies using county-level cancer mortality rates. This paper presents the first application of Poisson kriging to the spatial interpolation of local disease rates, resulting in continuous maps of disease rate estimates and the associated prediction variance. The methodology is illustrated using cholera and dysentery data collected in a cholera endemic area (Matlab) of Bangladesh. RESULTS: The spatial analysis was confined to patrilineally-related clusters of households, known as baris, located within 9 kilometers from the Matlab hospital to avoid underestimating the risk of disease incidence, since patients far away from the medical facilities are less likely to travel. Semivariogram models reveal a range of autocorrelation of 1.1 km for dysentery and 0.37 km for cholera. This result translates into a cholera risk map that is patchier than the dysentery map that shows a large zone of high incidence in the south-central part of the study area, which is quasi-urban. On both maps, lower risk values are found in the Northern part of the study area, which is also the most distant from the Matlab hospital. The weaker spatial continuity of cholera versus dysentery incidence rates resulted in larger kriging variance across the study area. CONCLUSION: The approach presented in this paper enables researchers to incorporate the pattern of spatial dependence of incidence rates into the mapping of risk values and the quantification of the associated uncertainty. Differences in spatial patterns, in particular the range of spatial autocorrelation, reflect differences in the mode of transmission of cholera and dysentery. Our risk maps for cholera and dysentery incidences should help identifying putative factors of increased disease incidence, leading to more effective prevention and remedial actions in endemic areas.
Assuntos
Cólera/epidemiologia , Disenteria/epidemiologia , Distribuição de Poisson , Vigilância da População/métodos , Bangladesh/epidemiologia , Cólera/mortalidade , Disenteria/mortalidade , Sistemas de Informação Geográfica , Acessibilidade aos Serviços de Saúde , Hospitalização/estatística & dados numéricos , Humanos , IncidênciaRESUMO
OBJECTIVE: To analyse the incremental costs, effects and cost-effectiveness of zinc used as adjunct therapy to standard treatment of acute childhood diarrhoea, including dysentery, and to reassess the cost-effectiveness of standard case management with oral rehydration salt (ORS). METHODS: A decision tree was used to model expected clinical outcomes and expected costs under four alternative treatment strategies. The best available epidemiological, clinical and economic evidence was used in the calculations, and the United Republic of Tanzania was the reference setting. Probabilistic cost-effectiveness analysis was performed using a Monte-Carlo simulation technique and the potential impacts of uncertainty in single parameters were explored in one-way sensitivity analyses. FINDINGS: ORS was found to be less cost-effective than previously thought. The use of zinc as adjunct therapy significantly improved the cost-effectiveness of standard management of diarrhoea for dysenteric as well as non-dysenteric illness. The results were particularly sensitive to mortality rates in non-dysenteric diarrhoea, but the alternative interventions can be defined as highly cost-effective even in pessimistic scenarios. CONCLUSION: There is sufficient evidence to recommend the inclusion of zinc into standard case management of both dysenteric and non-dysenteric acute diarrhoea.A direct transfer of our findings from the United Republic of Tanzania to other settings is not justified, but there are no indications of large geographical differences in the efficacy of zinc. It is therefore plausible that our findings are also applicable to other developing countries.
Assuntos
Países em Desenvolvimento , Diarreia Infantil/tratamento farmacológico , Disenteria/tratamento farmacológico , Zinco/uso terapêutico , Doença Aguda , Antibacterianos/uso terapêutico , Criança , Pré-Escolar , Efeitos Psicossociais da Doença , Análise Custo-Benefício , Árvores de Decisões , Diarreia Infantil/complicações , Diarreia Infantil/economia , Diarreia Infantil/mortalidade , Quimioterapia Combinada , Disenteria/complicações , Disenteria/economia , Disenteria/mortalidade , Hidratação/economia , Humanos , Lactente , Soluções para Reidratação/economia , Sensibilidade e Especificidade , Tanzânia , Incerteza , Zinco/economiaRESUMO
OBJECTIVE: To evaluate the effect on morbidity and mortality of providing daily zinc for 14 days to children with diarrhoea. DESIGN: Cluster randomised comparison. SETTING: Matlab field site of International Center for Diarrhoeal Disease Research, Bangladesh. PARTICIPANTS: 8070 children aged 3-59 months contributed 11 881 child years of observation during a two year period. INTERVENTION: Children with diarrhoea in the intervention clusters were treated with zinc (20 mg per day for 14 days); all children with diarrhoea were treated with oral rehydration therapy. MAIN OUTCOME MEASURES: Duration of episode of diarrhoea, incidence of diarrhoea and acute lower respiratory infections, admission to hospital for diarrhoea or acute lower respiratory infections, and child mortality. RESULTS: About 40% (399/1007) of diarrhoeal episodes were treated with zinc in the first four months of the trial; the rate rose to 67% (350/526) in month 5 and to >80% (364/434) in month 7 and was sustained at that level. Children from the intervention cluster received zinc for about seven days on average during each episode of diarrhoea. They had a shorter duration (hazard ratio 0.76, 95% confidence interval 0.65 to 0.90) and lower incidence of diarrhoea (rate ratio 0.85, 0.76 to 0.96) than children in the comparison group. Incidence of acute lower respiratory infection was reduced in the intervention group but not in the comparison group. Admission to hospital of children with diarrhoea was lower in the intervention group than in the comparison group (0.76, 0.59 to 0.98). Admission for acute lower respiratory infection was lower in the intervention group, but this was not statistically significant (0.81, 0.53 to 1.23). The rate of non-injury deaths in the intervention clusters was considerably lower (0.49, 0.25 to 0.94). CONCLUSIONS: The lower rates of child morbidity and mortality with zinc treatment represent substantial benefits from a simple and inexpensive intervention that can be incorporated in existing efforts to control diarrhoeal disease.
Assuntos
Antidiarreicos/administração & dosagem , Diarreia Infantil/terapia , Hidratação/métodos , Zinco/administração & dosagem , Bangladesh/epidemiologia , Análise por Conglomerados , Diarreia Infantil/mortalidade , Disenteria/mortalidade , Disenteria/terapia , Humanos , Incidência , Lactente , Prognóstico , Modelos de Riscos Proporcionais , Estudos Prospectivos , Taxa de Sobrevida , Zinco/deficiênciaRESUMO
This paper reports the validation of a 'best-judgement' standardised questionnaire using guidelines and algorithms developed by an expert working group conducted in Nicaragua between 1995 and 1997. Prospective hospital data, including standardised medical recording of selected signs and symptoms, laboratory and radiographic test results and physician diagnoses were collected for children < 5 years admitted with any serious life-threatening condition in 3 study hospitals. The mothers or caregivers of the children were later traced and interviewed using the 'best-judgement' questionnaire. Interviews were completed 1-22 months after admission to hospital for 1115 children (400 who died during the stay in hospital and 715 who were discharged alive). The cause of death or admission to hospital was determined by an expert algorithm applied to hospital data. A similar procedure was used to derive the cause using the answers to questions from interviews. Hospital causes were compared with interview causes and sensitivity and specificity calculated, together with the estimated cause-specific fraction for diarrhoea and pneumonia. Multiple diagnoses were allowed; 378 children in the sample (104 deaths, 274 survivors) had a reference diagnosis of diarrhoeal illness, and 506 (168 deaths, 338 survivors) a reference diagnosis of pneumonia. When results for deaths and survivors in all age groups were combined, the expert algorithms had sensitivity between 86% and 88% and specificity between 81% and 83% for any diarrhoeal illness; and sensitivity between 74% and 87% and specificity between 37% and 72% for pneumonia. Algorithms tested in previous validation studies were also applied to data obtained in this study, and the results are compared. Despite less than perfect sensitivity and specificity, reasonably accurate estimates of the cause-specific mortality and morbidity fractions for diarrhoea were obtained, although the accuracy of estimates in other settings using the same instrument will depend on the true cause-specific fraction in those settings. The algorithms tested for pneumonia did not produce accurate estimates of the cause-specific fraction, and are not recommended for use in community settings.
Assuntos
Diarreia/epidemiologia , Pneumonia/epidemiologia , Inquéritos e Questionários , Algoritmos , Pré-Escolar , Diarreia/mortalidade , Disenteria/epidemiologia , Disenteria/mortalidade , Estudos de Avaliação como Assunto , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Nicarágua/epidemiologia , Pneumonia/mortalidade , Estudos Prospectivos , Sensibilidade e EspecificidadeRESUMO
OBJECTIVE: To audit paediatric medical admissions to a rural district hospital in order to help define intervention priorities and allocate district resources. DESIGN: Prospective audit of consecutive admissions to the paediatric medical service of Hlabisa Hospital, KwaZulu-Natal, between March 1995 and February 1996. MAIN OUTCOME MEASURES: Number of admissions, month of admission, age, sex, diagnosis, nutritional status, HIV status, outcome and length of stay. RESULTS: Of 1,364 children admitted, 995 (73%) were aged under 24 months and 584 (43%) were either underweight for age or severely malnourished. Acute respiratory tract infection (384, 28%), acute diarrhoea (200, 15%), dysentery (168, 12%) and severe malnutrition (149, 11%) were the major causes for admission and were responsible for most deaths (113, 75%). The overall case fatality rate was 11% and most (90, 60%) died within 48 hours of admission. Forty-five per cent of the 332 children tested were HIV-positive. CONCLUSION: Most severe morbidity and mortality result from four common conditions, reflecting poor socioeconomic conditions in the area. Opportunities for clincial intervention to reduce their impact include identification of 'at risk' children, focusing care early in admissions, use of standardised protocols of care, and integrated management of the sick child.