Risk factors and patterns of household clusters of respiratory viruses in rural Nepal.

Viral pneumonia is an important cause of death and morbidity among infants worldwide. Transmission of non-influenza respiratory viruses in households can inform preventative interventions and has not been well-characterised in South Asia. From April 2011 to April 2012, household members of pregnant women enrolled in a randomised trial of influenza vaccine in rural Nepal were surveyed weekly for respiratory illness until 180 days after birth. Nasal swabs were tested by polymerase chain reaction for respiratory viruses in symptomatic individuals. A transmission event was defined as a secondary case of the same virus within 14 days of initial infection within a household. From 555 households, 825 initial viral illness episodes occurred, resulting in 79 transmission events. The overall incidence of transmission was 1.14 events per 100 person-weeks. Risk of transmission incidence was associated with an index case age 1-4 years (incidence rate ratio (IRR) 2.35; 95% confidence interval (CI) 1.40-3.96), coinfection as initial infection (IRR 1.94; 95% CI 1.05-3.61) and no electricity in household (IRR 2.70; 95% CI 1.41-5.00). Preventive interventions targeting preschool-age children in households in resource-limited settings may decrease the risk of transmission to vulnerable household members, such as young infants.

Oral hygiene, prevalence of gingivitis, and associated risk factors among pregnant women in Sarlahi District, Nepal.

BACKGROUND: The oral health status of pregnant women in low-resource communities such as Nepal has not been well characterized. This sub-population is also of specific interest given associations between poor oral health and adverse pregnancy outcomes previously documented in other settings. We explored relationships between gingivitis and risk factors among pregnant women in rural Nepal. METHODS: The design was a community-based, cross-sectional study in a sub-area of Sarlahi District, Nepal. Pregnant women < 26 weeks gestation underwent clinical periodontal exams conducted by community-based oral health workers. Exams included a full mouth assessment measuring bleeding on probing (BOP), probing depth (PD) (six sites per tooth), and gingival recession, the distance from the cemento-enamel junction to the free gingival margin (two direct sites per tooth). Data on participant risk factors were collected through household surveys, including demographic characteristics, oral health behaviors, care seeking, and health attitudes. Multivariable logistic regression modeling was used to assess relationships between gingivitis and risk factors. RESULTS: We enrolled 1452 participants, of which 40% (n = 582) had signs of clinical gingivitis and 60% (n = 870) clinical health. Average participant age was 23. Most participants (88%) had never received oral health care. Participants averaged 10% of sites with BOP with most (79%) having ≥1 site with BOP. Nine percent of participants had ≥1 site with PD ≥4 mm, although very few participants (0.7%) had sites with PD ≥5 mm. Few participants (13%) had any recession (≥1 mm). In the final adjusted model, odds of gingivitis increased by 3% for each year of age (aOR 1.03, 95% CI 1.00, 1.06) and were higher for women of short maternal stature (< 150 cm) (aOR 1.43, 95% CI: 1.14, 1.79) and among women reporting cost to be a barrier to seeking dental care (aOR 2.13, 95% CI: 1.09, 4.15). CONCLUSIONS: Gingivitis was common and associated with age, maternal stature, self-reported high cost of dental care, and other risk factors among pregnant women in rural Nepal. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01177111 (Nepal Oil Massage Study) and NCT02788786 (Pilot Trial).

Oral health knowledge, behavior, and care seeking among pregnant and recently-delivered women in rural Nepal: a qualitative study.

BACKGROUND: Oral health behavior and attitudes of pregnant women in low-income countries are rarely examined, yet should be considered when designing preventative or therapeutic studies to reduce burden of oral diseases. We aimed to understand dental care-seeking behavior, as well as oral health knowledge and attitudes of oral health among pregnant women in rural Nepal. METHODS: Semi-structured in-depth interviews (n = 16) and focus group discussions (3 groups, n = 23) were conducted among pregnant and recently-delivered women in Sarlahi, Nepal. Transcripts were translated from the local language to English then analyzed using a hybrid approach to thematic coding with Atlas.ti version 7. RESULTS: Women felt confident describing the signs and symptoms of tooth decay and gum disease, but were not knowledgeable about where to receive care for tooth and/or gum pain and relied heavily on the knowledge of their community. Some women used a toothbrush and toothpaste at least once a day to clean their teeth, but many reported the traditional use of a branch of a local shrub or tree as their teeth cleaning instrument. Women suggested a willingness to consider using an oral rinse throughout pregnancy, perceiving that it might have a positive impact on infant health. CONCLUSIONS: Future studies should focus on providing adequate and sustainable resources for pregnant women in Nepal and other low income settings to engage in good oral health behaviors (possibly supported through community-based workers), to maintain dental hygiene, and to access qualified dentists as a means of improving their oral health. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01177111 (Nepal Oil Massage Study) and NCT02788786 (Pilot Trial).

Validation of an obstetric fistula screening questionnaire in rural Nepal: a community-based cross-sectional and nested case-control study with clinical examination.

OBJECTIVE: To validate a symptom-based fistula screening questionnaire and estimate obstetric fistula (OF) prevalence in rural Nepal. DESIGN: Cross-sectional and nested case-control study. SETTING: Sarlahi District, Nepal. POPULATION: Parous, reproductive age women. METHODS: The questionnaire assessed symptoms of vesicovaginal and rectovaginal fistula (VVF and RVF, respectively), stress and urge urinary incontinence (SUI and UUI, respectively), fecal incontinence (FI), and included interviewer observations on the smell and presence of urine and/or stool. All women who screened positive for OF and a randomly selected group of women who screened negative for OF were included in a nested case-control study (one case, four normal controls, and four incontinent controls) and underwent confirmatory clinical examinations. MAIN OUTCOME MEASURES: Clinically confirmed OF, and questionnaire sensitivity (Se) and specificity (Sp). RESULTS: Of the 16 893 women who completed cross-sectional screening, 68 were screened-positive cases. Fifty-five (82%) screened-positive cases, 203 screened-negative normal controls, and 203 screened-incontinent controls participated in the case-control study, which confirmed one case of VVF and one case of both VVF and RVF without any false-negative cases. For VVF, the screening tool demonstrated Se 100% (95% CI 34.2-100.0%), Sp 86.9% (95% CI 83.3-89.9%), and estimated VVF prevalence as 12 per 100 000 (95% CI 3-43); for RVF, it demonstrated Se 100% (95% CI 20.7-100.0), Sp 99.8% (95% CI 98.6-100.0), and estimated RVF prevalence as 6 per 100 000 (95% CI 1-34). CONCLUSIONS: The OF screening questionnaire demonstrated high sensitivity and specificity in this low-prevalence setting. TWEETABLE ABSTRACT: Community-based obstetric fistula screening tool validation study, Nepal, n = 16 893: High Se, Sp & feasibility.

The association of preterm birth and small birthweight for gestational age on childhood disability screening using the Ten Questions Plus tool in rural Sarlahi district, southern Nepal.

CONTEXT: The Ten Questions tool was developed in 1984 as a low-cost, simple screen for childhood disability and referral for diagnosis in low-resource settings, and its use in Nepal has not been previously evaluated. Preterm birth and intrauterine growth restriction are potential risk factors for child disability and loss of developmental potential, but there are few studies examining this relationship from developing settings. OBJECTIVE: To examine the associations of small for gestational age and preterm birth as predictors of Ten Questions Plus positivity. DESIGN, SETTING AND PARTICIPANTS: The Ten Questions Plus questionnaire was administered to caregivers of 680 children between 2 and 5 years of age from August 2007 to March 2008 in rural Sarlahi, southern Nepal. Participants had previously been enrolled in a randomized trial of chlorhexidine cleansing at birth. At 1 month of age, children were then enrolled into a randomized 2 × 2 factorial trial of daily iron and zinc supplementation between October 2001 and January 2006. INTERVENTION: None. MAIN OUTCOME MEASURE: Positive screen on the Ten Questions Plus tool defined as a positive response to one or more questions. RESULTS: Of preterm children, 37 (33.6%) had a positive response to at least one question on the Ten Questions Plus and were considered at risk for disability. One hundred and seventy term children (29.8%) were at risk for disability. CONCLUSIONS: The Ten Questions Plus tool can be used in this rural Nepali setting to identify children at increased risk for mental and physical disability to be targeted for further examination. The prevalence of parent-reported disabilities is high in this population (almost one-third of children); children who are both preterm and small-for-gestational age are at increased risk for motor milestone delay, reported learning difficulty, speech and behavioural problems. Intrauterine growth restriction may affect child development and result in disabilities later in childhood.

Association between nutritional status and positive childhood disability screening using the ten questions plus tool in Sarlahi, Nepal.

The study was conducted to examine the association between the indicators of malnutrition and disability of children as reported by caregivers. The Ten Questions Plus questionnaire was administered to caregivers of 1,902 children aged 1-9 years, during August 2007-March 2008, in rural Nepal. Height and weight of children were also measured. The main outcome was a positive response to one or more questions. In total, 514 (27%) children had a positive response to at least one question. Moderate stunting [odds ratio (OR)=1.47, 95% confidence interval (CI) 1.02-2.12) and severe (OR=2.39, 95% CI 1.60-3.57) stunting were independently associated with reported delay in sitting, standing, or walking. Severe stunting was also associated with report of delayed learning compared to other children of similar age (OR=2.01, 95% CI 1.27-3.20). Parental report of disability was quite prevalent in this setting, with over a quarter of the sample screening positive. Chronic malnutrition may be associated with delayed motor and mental development.

Indicators of skin barrier integrity among newborns massaged with mustard oil in rural Nepal.

OBJECTIVE: The objective of this study was to determine the skin barrier changes during postnatal month 1 among infants receiving routine mustard oil massage in the humid conditions of rural Nepal. STUDY DESIGN: This was an observational study among 500 live-born neonates receiving mustard oil massage. Skin integrity such as erythema, rash, dryness, skin pH, stratum corneum protein concentration and transepidermal water loss was measured on days 1, 3, 7, 14 and 28. RESULTS: Erythema and rash increased (worsened) during weeks 1 and 2, then decreased over weeks 3 and 4. Skin pH (6.1±0.5 to 5.0±0.6) and stratum corneum protein (16.6±7.9 to 13.5±5.9 µg cm-2) decreased. Transepidermal water loss increased from 33.2±23.5 to 43.0±24.5 g m-2 h-1 at day 28. Skin pH and stratum corneum protein were higher for early versus late premature infants. CONCLUSION: Premature and full-term skin condition was generally poor especially during the first 2 weeks, improving thereafter. Maturational changes were evident.

Relationship between the surrogate anthropometric measures, foot length and chest circumference and birth weight among newborns of Sarlahi, Nepal.

BACKGROUND: Classification of infants into low birth weight (LBW, <2500 g) or very low birth weight (VLBW, <2000 g) categories is a crucial step in targeting interventions to high-risk infants. OBJECTIVE: To compare the validity of chest circumference and foot length as surrogate anthropometric measures for the identification of LBW and VLBW infants. SUBJECTS AND SETTING: Newborn infants (n=1640) born between March and June 2004 in 30 Village Development Committees of Sarlahi district, Nepal. DESIGN: Chest circumference, foot length and weight (SECA 727, precise to 2 g) of newborns were measured within 72 h after birth. The sensitivity, specificity and predictive values for a range of cutoff points of the anthropometric measures were estimated using the digital scale measurements as the gold standard. RESULTS: Among LBW infants (469/1640, 28.6%), chest circumference measures <30.3 cm were 91% sensitive and 83% specific. Similar levels of sensitivity for foot length were achieved only with considerable loss of specificity (<45%). Foot length measurements <6.9 cm were 88% sensitive and 86% specific for the identification of VLBW infants. CONCLUSION: Chest circumference was superior to foot length in classification of infants into birth weight categories. For the identification of VLBW infants, foot length performed well, and may be preferable to chest circumference, as the former measure does not require removal of infant swaddling clothes. In the absence of more precise direct measures of birth weight, chest circumference is recommended over foot length for the identification of LBW infants.

Epidemiology of anemia among 4- to 17-month-old children living in south central Nepal.

OBJECTIVE: To describe the distribution of hemoglobin and prevalence of anemia in Nepali children living in the Terai region by potential risk factors for deficiency. DESIGN: This was a cross-sectional, community-based study of baseline characteristics of children enrolled in a randomized, placebo-controlled clinical trial between January and March 2002. Participants were weighed and measured and had their blood drawn. Their mothers contributed demographic, morbidity, and feeding data. SUBJECTS: There were 569 4- to 17-month-old children. Statistical models were based on 490 children. RESULTS: Anemia was prevalent: 58% of the children had a hemoglobin <105 g/l. Iron-deficiency anemia (anemia with erythrocyte protoporphyrin (EP) > or =90 micromol/mol heme) was present in 43% of the children. Severe anemia was rare: less than 2% of the children had a hemoglobin <70 g/l. The mean (s.d.) hemoglobin concentration was 101 (12.5) g/l. Stunting and wasting were prevalent: 30.8% were stunted (length-for-age Z-score <-2) and 18.1% were wasted (weight-for-length Z-score <-2). Bivariate analyses revealed that age, caste, socioeconomic status, dietary diversity, stunting, and underweight were associated with hemoglobin concentration and/or anemia. In multivariate models with and without EP, age and caste were found to be strong predictors of both hemoglobin concentration and anemia. CONCLUSIONS: Anemia and iron deficiency increased strongly with age and low-caste status among the study children. The data reveal the importance of targeting interventions to children in the first year of life before they become anemic and iron deficient.

Development of clinical sign based algorithms for community based assessment of omphalitis.

BACKGROUND: In developing countries, newborn omphalitis contributes significantly to morbidity and mortality. Community based identification and management of omphalitis will require standardised clinical sign based definitions. OBJECTIVE: To identify optimal sign based algorithms to define omphalitis in the community and to evaluate the reliability and validity of cord assessments by non-specialist health workers for clinical signs of omphalitis. DESIGN: Within a trial of the impact of topical antiseptics on umbilical cord infection in rural Nepal, digital images of the umbilical cord were collected. Workers responsible for in-home examinations of the umbilical cord evaluated the images for signs of infection (pus, redness, swelling). Intraworker and interworker agreement was evaluated, and sensitivity and specificity compared with a physician generated gold standard ranking were estimated. RESULTS: Sensitivity and specificity of worker evaluations were high for pus (90% and 96% respectively) and moderate for redness (57% and 95% respectively). Swelling was the least reliably identified sign. Measures of observer agreement were similar to that previously recorded between experts evaluating subjective skin conditions. A composite definition for omphalitis that combined pus and redness without regard to swelling was the most sensitive and specific. CONCLUSIONS: Two sign based algorithms for defining omphalitis are recommended for use in the community. Focusing on redness extending to the skin around the base of the stump will identify cases of moderate and high severity. Requiring both the presence of pus and redness will result in a definition with very high specificity and moderate to high sensitivity.

Sex differences in the early life correlates of natural antibody concentrations.

Innate-like B1a lymphocytes arise from long-lived progenitors produced exclusively by fetal stem cells. Any insults coinciding with this early lymphopoietic wave could have a permanent impact on the B1a population and its unique protein products, the natural antibodies (NAb). We investigated early life nutritional influences on NAb concentrations of pre-adolescent children (n=290) in rural Nepal for whom we had extensive information on exposures from pregnancy and early infancy. Infant size and growth were strongly associated with NAb concentrations at 9-13 years of age among males (e.g., for neonatal weight: ßBOYS=0.43; P<0.001), but not females (e.g., for neonatal weight: ßGIRLS=-0.16; P=0.26). In females, season of birth was associated with NAb concentrations, with marked reductions among girls born during the pre-monsoon (March-May; ßGIRLS=-0.39; P=0.01) and pre-harvest (September-November; ßGIRLS=-0.35; P=0.03) seasons. Our findings suggest that nutritional or other environmental influences on immune development may vary by sex, with potential consequences for immune function during infancy and long-term risk of immune-mediated disease.

Zinc supplementation might potentiate the effect of vitamin A in restoring night vision in pregnant Nepalese women.

BACKGROUND: Zinc deficiency may result in abnormal dark adaptation or night blindness, a symptom primarily of vitamin A deficiency. During a placebo-controlled trial in Nepal, weekly vitamin A supplementation of women reduced but failed to eliminate the incidence of night blindness during pregnancy, suggesting a role for zinc. OBJECTIVE: The study examined the efficacy of daily zinc supplementation in restoring night vision of pregnant women who developed night blindness while routinely receiving either vitamin A, beta-carotene, or placebo in a field trial. DESIGN: Women (n = 202) who reported to be night blind during pregnancy were randomly assigned in a double-blind manner, stratified on vitamin A, beta-carotene, or placebo receipt, to receive 25 mg Zn or placebo daily for 3 wk. Thus, the 6 groups studied were as follows: beta-carotene + zinc, beta-carotene alone, vitamin A + zinc, vitamin A alone (vitamin A + placebo), zinc alone (zinc + placebo), and placebo (2 placebos: one for the vitamin A or beta-carotene study and one for the zinc study). Women underwent a clinic-based assessment that included pupillary threshold testing and phlebotomy before and after supplementation. Supplement use and daily history of night blindness were obtained at home twice every week. RESULTS: Zinc treatment increased serum zinc concentrations, but alone (zinc alone group), failed to restore night vision or to improve dark adaptation. However, women in the vitamin A + zinc group who had baseline serum zinc concentrations <9.9 micromol/L were 4 times more likely to have their night vision restored (95% CI: 1.1, 17.3) than were women in the placebo group and tended to have a small improvement in pupillary threshold scores (by 0.21 log candela/m2; P = 0.09). CONCLUSION: These data suggest that zinc potentiated the effect of vitamin A in restoring night vision among night-blind pregnant women with low initial serum zinc concentrations.

Responsiveness of dark-adaptation threshold to vitamin A and beta-carotene supplementation in pregnant and lactating women in Nepal.

BACKGROUND: Impaired dark adaptation occurs commonly in vitamin A deficiency. OBJECTIVE: We sought to examine the responsiveness of dark-adaptation threshold to vitamin A and beta-carotene supplementation in Nepali women. DESIGN: The dark-adapted pupillary response was tested in 298 pregnant women aged 15-45 y in a placebo-controlled trial of vitamin A and beta-carotene; 131 of these women were also tested at 3 mo postpartum. Results were compared with those for 100 nonpregnant US women of similar age. The amount of light required for pupillary constriction was recorded after bleaching and dark adaptation. RESULTS: Pregnant women receiving vitamin A had better dark-adaptation thresholds (-1.24 log cd/m(2)) than did those receiving placebo (-1.11 log cd/m(2); P: = 0. 03) or beta-carotene (-1.13 log cd/m(2); P: = 0.05) (t tests with Bonferroni correction). Dark-adaptation threshold was associated with serum retinol concentration in pregnant women receiving placebo (P: = 0.001) and in those receiving beta-carotene (P: = 0.003) but not in those receiving vitamin A. Among women receiving placebo, mean dark-adaptation thresholds were better during the first trimester (-1.23 log cd/m(2)) than during the second and third trimesters (-1.03 log cd/m(2); P: = 0.02, t test). The mean threshold of nonpregnant US women (-1.35 log cd/m(2)) was better than that of all 3 Nepali groups (P: < 0.001, t test, for all 3 groups). CONCLUSIONS: During pregnancy, pupillary dark adaptation was strongly associated with serum retinol concentration and improved significantly in response to vitamin A supplementation. This noninvasive testing technique is a valid indicator of population vitamin A status in women of reproductive age.

Mortality of infants < 6 mo of age supplemented with vitamin A: a randomized, double-masked trial in Nepal.

The effect of supplementing 11,918 infants < 1 mo and 1-5 mo of age with vitamin A (15,000 and 30,000 micrograms retinol equivalents or 50,000 and 100,000 IU, respectively) or a placebo on subsequent 4-mo mortality was assessed in a randomized, double-masked community trial in the rural plains of Nepal. There were 130 deaths (51.6/1000 child-y) in the control group and 150 deaths (57.1/1000 child-y) in the vitamin A group, yielding a relative risk of 1.11 (95% CI: 0.86, 1.42), which is indicative of no overall effect on early infant mortality. There was a tendency for the relative risk of mortality among vitamin A recipients to rise with improved nutritional status. These results suggest that distribution of a large oral dose of vitamin A to infants < 5-6 mo of age may not benefit short-term survival. This is in contrast with the results of trials in which older infants and children in this same population were supplemented.

Maternal low-dose vitamin A or beta-carotene supplementation has no effect on fetal loss and early infant mortality: a randomized cluster trial in Nepal.

BACKGROUND: The effect of vitamin A supplementation on the survival of infants aged <6 mo is unclear. Because most infant deaths occur in the first few month of life, maternal supplementation may improve infant survival. OBJECTIVES: The objective was to assess the effect of maternal vitamin A or beta-carotene supplementation on fetal loss and survival of infants <6 mo of age. DESIGN: Married women of reproductive age in 270 wards of Sarlahi district, Nepal, were eligible to participate. Wards were randomly assigned to have women receive weekly doses of 7000 microg retinol equivalents as retinyl palmitate (vitamin A), 42 mg all-trans-beta-carotene, or placebo. Pregnancies were followed until miscarriage, stillbirth, maternal death, or live birth of one or more infants, who were followed through 24 wk of age. RESULTS: A total of 43559 women were enrolled; 15832 contributed 17373 pregnancies and 15987 live born infants to the trial. The rate of fetal loss was 92.0/1000 pregnancies in the placebo group, comparable with rates in the vitamin A and beta-carotene groups, which had relative risks of 1.06 (95% CI: 0.91, 1.25) and 1.03 (95% CI: 0.87, 1.19), respectively. The 24-wk mortality rate was 70.8/1000 live births in the placebo group, comparable with rates in the vitamin A and beta-carotene groups, which had relative risks of 1.05 (95% CI: 0.87, 1.25) and 1.03 (95% CI: 0.86, 1.22), respectively. CONCLUSIONS: Small weekly doses of vitamin A or beta-carotene given to women before conception, during pregnancy, and through 24 wk postpartum did not improve fetal or early infant survival in Nepal.

Impact of vitamin A supplementation on prevalence and incidence of xerophthalmia in Nepal.

PURPOSE: To assess the impact of vitamin A supplementation at 4-month intervals on the prevalence and incidence of xerophthalmia among preschool-age children. METHODS: A stratified, random sample of 40 wards with 4766 children in Sarlahi district of Nepal was selected to participate in a randomized, controlled, community trial. In the vitamin A group, at 4-month intervals, neonates received 50,000 IU, 1- to 11-month-old infants received 100,000 IU, and children 1 through 4 years of age received 200,000 IU. Children underwent eye examination before the intervention and 16 months later. RESULTS: Before the intervention, 4318 children were examined for xerophthalmia. The prevalence was 2.3% in the vitamin A group and 3.3% in the placebo group. All children with xerophthalmia were treated with vitamin A at the time of the examination. Of those examined at baseline, 38 in the vitamin A group and 48 in the placebo group died in the 16 months after intervention. There were 1871 (84%) surviving children in the vitamin A group and 1711 (85%) in the placebo group examined at follow-up. After adjustment for the baseline prevalence of xerophthalmia, vitamin A reduced the prevalence at follow-up by 63% (95% confidence interval, 21% to 83%). The apparent incidence was 3.2/1000 per year in the vitamin A group and 9.2/1000 per year in the placebo group, an adjusted reduction of 62% (95% confidence interval, 0% to 86%). CONCLUSIONS: Supplementation was effective at reducing the prevalence and incidence of xerophthalmia.

Night blindness of pregnancy in rural Nepal--nutritional and health risks.

BACKGROUND: Night blindness (XN) is the most common clinical symptom of vitamin A deficiency among children in developing countries. Yet little is known about the aetiology or associated risks of maternal XN. Emerging evidence from South East Asia suggests that it may be more frequent than previously thought in women of reproductive age, especially during pregnancy. METHODS: A population-based, case-control study was conducted to reveal the epidemiology of XN among pregnant Nepali women. Night blind cases were identified by history through a weekly community surveillance system. Controls were randomly selected from a pool of pregnant women without XN and pair-matched for gestational age of the cases. A home-based assessment was done within a week of selection, at which 7-day food frequency and morbidity histories were collected, anthropometry measured, and capillary blood drawn for serum retinol, beta-carotene and haemoglobin (Hb) estimation. RESULTS: Cases and controls did not differ by age or number of previous pregnancies. However, cases were more likely to be from the lower castes, be illiterate, live in poorer quality homes, and own no land. The mean serum retinol level of cases was approximately 0.30 mumol/l lower than controls (P < 0.001), indicating a low vitamin A status of night blind pregnant women. Mean Hb level was significantly lower (by 0.7 g/dl, P < 0.004), and the risk of severe anaemia (Hb < 7.0 g/dl) higher among cases than controls (odds ratio = 3.0, 95% CI: 1.25-7.23). Cases were more under-nourished than controls reflected by lower mean weight (-2.6 kg), body mass index (-0.8), arm circumference (-0.9 cm) and triceps skinfold (-0.8 mm). Night blindness was associated with less frequent consumption of preformed vitamin A (milk products, fish and meat) and provitamin A (dark green leafy vegetables and mangoes) foods, especially in summer. Night blind women were 2-3 times more likely to report symptoms of urinary/reproductive tract infections such as lower abdominal pain, painful and burning urination, or vaginal discharge, symptoms of diarrhoea/dysentery, of pre-eclampsia or eclampsia, and of nausea, vomiting or poor appetite throughout pregnancy than controls. CONCLUSION: Women who experience XN during pregnancy have a low vitamin A status, although several other risk factors appear to cluster among these women as well. Night blind women are also more likely to be anaemic, ill, and acutely under-nourished, and to be consuming a nutritionally poorer diet in pregnancy than non-night blind pregnant women. A simple history of XN can identify women at high risk during pregnancy who may require special nutritional support, antenatal care and counselling.

Twinning rates and survival of twins in rural Nepal.

BACKGROUND: Twin pregnancies are common but there are few data on rates of twinning or survival of liveborn twin infants in developing countries. METHODS: The rates of multiple births were calculated in a population-based cohort of married women of childbearing age who were enrolled in a randomized community trial to assess the impact of vitamin A or beta-carotene on maternal and infant health and survival. RESULTS: The rate of twinning was 16.1 per 1000 pregnancies (7.4 if only twin pregnancies resulting in two liveborn infants were used). The rate for triplets and quadruplets was 0.19 and 0.06 per 1000 pregnancies. Twinning rates were higher among women of higher parity, but were not associated with maternal age. Twinning rates among twins where at least one was live born (or increased in utero survival) were 30% (95% CI : -1%, 71%) and 44% (95% CI : 9%, 89%) higher among women receiving vitamin A and beta-carotene supplements than placebo, after adjusting for maternal age, gestational age, and parity. The perinatal mortality rate was 8.54 times higher for twins than singletons, 7.32 higher for neonatal mortality, and 5.84 higher for cumulative 24-week mortality. This difference was reduced but not erased by adjusting for gestational age. No difference in survival of liveborn twin infants was seen by supplement group. A higher mortality rate among male twins was largely explained by gestational age. CONCLUSIONS: Multiple births are relatively common occurrences in rural Nepal, and carry a much higher mortality risk for the infants than for singletons. Vitamin A or beta-carotene supplementation appeared to increase the rate of twinning, or improve the survival of twins in utero, but did not increase twin survival after birth.

Epidemiology of xerophthalmia in Nepal. A pattern of household poverty, childhood illness, and mortality. The Sarlahi Study Group.

A case-control study of xerophthalmia (120 cases, two with corneal disease; 3377 children without xerophthalmia, 12 to 60 months of age) was conducted in the rural plains of Nepal. Relative household wealth (ownership of animals and goods, house quality) and social standing (parental education, nondaily laboring, more affluent castes) were inversely related to risk of xerophthalmia. Mothers of cases were more likely to have had children die than mothers of controls (odds ratio, 1.85; 95% confidence interval, 1.22 to 2.78); case households were more likely to have had a young child die in the past year (odds ratio, 2.85; 95% confidence interval, 1.43 to 5.67). Children with xerophthalmia were more wasted and stunted than controls, although these associations largely disappeared after adjusting for socioeconomic influences. Frequency of breast-feeding was highly protective against xerophthalmia in a dose-response manner (odds ratio, 0.32 for 1 to 10 times a day, 0.12 for > 10 times a day) after adjusting for age and other factors. The risk of xerophthalmia rose directly with reported duration of dysentery in the previous week (odds ratio, 2.13 and 5.81 for durations of 1 to 6 days and > or = 7 days, respectively, vs none). Mild xerophthalmia is reflective of a lower, local standard of living within which child health, nutrition, and survival are compromised.

A randomised trial of povidone-iodine to reduce visual impairment from corneal ulcers in rural Nepal.

AIM: To assess whether povidone-iodine provided any benefit over and above a standard regimen of antibiotic therapy for the treatment of corneal ulcers. METHODS: All patients diagnosed with corneal ulcers presenting for care at a primary eye care clinic in rural Nepal were randomised to a standard protocol of antibiotic therapy versus standard therapy plus 2.5% povidone-iodine every 2 hours for 2 weeks. The main outcomes were corrected visual acuity and presence, size, and position of corneal scarring in the affected eye at 2-4 months following treatment initiation. RESULTS: 358 patients were randomised and 81% were examined at follow up. The two groups were comparable before treatment. At follow up, 3.9% in the standard therapy and 6.9% in the povidone-iodine group had corrected visual acuity worse than 20/400 (relative risk (RR) 1.77, 95% confidence interval (CI) 0.62 to 5.03). 9.4% in the standard therapy and 13.1% in the povidone-iodine group had corrected visual acuity worse than 20/60 (RR 1.39, 95% CI 0.71 to 2.77), and 17.0% and 18.8% had scars in the visual axis in each of these groups, respectively (RR 1.11, 95% CI 0.67 to 1.82). CONCLUSIONS: A small proportion of patients with corneal ulceration treated in this setting had poor visual outcomes. The addition of povidone-iodine to standard antibiotic therapy did not improve visual outcomes, although this design was unable to assess whether povidone-iodine on its own would have resulted in comparable visual outcomes to that of standard therapy.