Integrating Vitamin A Supplementation at 6 months into the Expanded Program of Immunization in Sierra Leone.

Since 2004, twice-yearly mass vitamin A supplementation (VAS) has equitably reached over 85% of children 6-59 months old in Sierra Leone. However infants who turn 6 months after the event may wait until they are 11 months old to receive their first dose. The effectiveness of integrating VAS at 6 months into the Expanded Program of Immunization (EPI) in a revised child health card was studied. Health facilities matched according to staff cadre and work load were assigned to provide either a 'mini package' of VAS and infant and young child feeding (IYCF), a 'full package' of VAS, IYCF and family planning (FP), or 'child health card' only. 400 neonates were enrolled into each group, caregivers given the new child health card and followed until they were 12 months old. More infants in the full: 74.5% and mini: 71.7% group received VAS between 6 and 7 months of age compared with the new CH card only group: 60.2% (p = 0.002, p < 0.001 respectively). FP commodities were provided to 44.5% of caregivers in the full compared with <2.5% in the mini and new child health card only groups (p < 0.0001). Integration of VAS within the EPI schedule achieved >60% coverage for infants between 6 and 7 months of age. Provision of FP and/or IYCF further improved coverage. Funding was provided by the Canadian Department of Foreign Affairs, Trade and Development who had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript.

Comparison of the estimated cost-effectiveness of preventive and therapeutic zinc supplementation strategies for reducing child morbidity and mortality in sub-Saharan Africa.

BACKGROUND: Zinc supplementation of young children in lower-income countries reduces morbidity from diarrhea and pneumonia and all-cause mortality, but the most cost-effective approach for distributing zinc supplements is unknown. OBJECTIVE: To examine the potential impact of four possible strategies for delivering zinc supplements on disease prevention and deaths averted among children 6 to 59 months of age in sub-Saharan Africa. METHODS: We analyzed different zinc supplementation strategies to assess their likely impact on morbidity and mortality of preschool children in sub-Saharan Africa and to estimate their possible costs. RESULTS: Preventive zinc supplementation reduces diarrhea incidence by 27% among children 12 to 59 months of age, pneumonia incidence by 21% among children 6 to 59 months of age, and all-cause mortality by 18% among children 12 to 59 months of age. The likely average total program costs of zinc supplementation programs were estimated from the outlays of existing service delivery platforms, such as child health days, community-based nutrition programs, and clinic-based treatment of diarrhea, assuming different levels of coverage and target age ranges of children. CONCLUSIONS: We found that the average total costs per life saved ranged from approximately US$462 to US$3,111, and the most cost-effective interventions were weekly or intermittent preventive zinc supplementation, because of the possibility of high coverage and fewer supplements required. Empirical data from zinc supplementation programs will be needed to confirm these estimates.

Results of Fortification Rapid Assessment Tool (FRAT) surveys in sub-Saharan Africa and suggestions for future modifications of the survey instrument.

BACKGROUND: Food fortification has been increasingly recognized as a promising approach to prevent micronutrient deficiencies. The Fortification Rapid Assessment Tool (FRAT) was developed to assist public health program managers to acquire the information needed to implement an effective mass food fortification program. Multiple countries have conducted FRAT surveys, but information on results and experiences with the FRAT tool has been available only at the national level. OBJECTIVE: To summarize the findings of the FRAT surveys previously conducted in sub-Saharan Africa. METHODS: Surveys from 12 sub-Saharan African countries (Burkina Faso, Cameroon, Congo, Guinea, Malawi, Mali, Mauritania, Mozambique, Niger, Rwanda, Senegal, Uganda) were identified. Information on consumption patterns for wheat flour, vegetable oil, sugar, and bouillon cubes was reviewed and summarized. RESULTS: Most surveys found that a moderate to high proportion of women reported consuming wheat flour (48% to 93%), vegetable oil (44% to 98%), sugar (55% to 99%), and bouillon cubes (79% to 99%) in the past 7 days, although consumption was more common and more frequent in urban areas than in rural areas. Similarly, the reported amounts consumed during the previous 24 hours were generally higher in urban settings. CONCLUSIONS: The FRAT instrument has been successfully used in multiple countries, and the results obtained have helped in planning national food fortification programs. However, the recommended sampling scheme may need to be reconsidered, and the guidelines should be revised to clarify important aspects of fieldworker training, implementation, data analysis and interpretation, and reporting of the results.

The surgical management of cataract: barriers, best practices and outcomes.

Cataract is the leading cause of blindness in the world. Cataract surgery has been shown by multiple studies to be one of the most cost-effective health interventions, and leads to a dramatic increase in quality of life and productivity for many patients. Though there has been marked improvement in the last several decades, surgical delivery services in developing nations are still suboptimal, and a large backlog in cataract cases continues to grow. To decrease this backlog, barriers to surgery, such as direct and indirect patient costs, geographic access to surgical facilities and surgeons, cultural factors, and patient education, must be addressed. In particular, access to services by women and rural patients needs to be improved. It is clear that extracapsular techniques are cost-effective and lead to better post-operative outcomes than intracapsular cataract extraction with aphakic correction. In addition, monitoring surgical outcomes is essential for improving the quality of surgical services. However, other issues regarding the delivery of cataract surgical services, including the role of average power intraocular lenses and the role of non-physician surgeons, are yet unresolved. Information about the true cost of surgery, including costs of surgeon training, equipment, and patient outreach programs, is needed so that the goal of self-sustaining programs may be obtained.

Vitamin A deficiency and child survival in sub-Saharan Africa: a reappraisal of challenges and opportunities.

BACKGROUND: Children with vitamin A deficiency have higher risk of morbidity and mortality than vitamin A-sufficient children. Estimates on the potential child survival benefits of vitamin A deficiency control are needed for policy and program advocacy. OBJECTIVE: To determine the current prevalence of children at risk for vitamin A deficiency in sub-Saharan Africa in order to estimate the potential child-survival benefits of effective and sustained policies and programs for the control of vitamin A deficiency in this region. METHODS: Estimates of the prevalence of vitamin A deficiency generated in 1998, data from 11 nationally representative vitamin A deficiency surveys conducted in sub-Saharan Africa between 1997 and 2003, and the measured effects of vitamin A deficiency on child mortality were combined to estimate the prevalence of children at risk for vitamin A deficiency in sub-Saharan Africa and the potential child-survival benefits of effective and sustained policies and programs for the control of vitamin A deficiency in this region. RESULTS: Our analysis shows that in the absence of effective and sustained policies and programs for the control of vitamin A deficiency, an estimated 42.4% of children 0 to 59 months of age in sub-Saharan Africa (43.2 million children) are at risk for vitamin A deficiency. Such effective and sustained policy and program action for the control of vitamin A deficiency can bring about a potential 25% reduction in mortality in children 0 to 59 months with respect to 1995 mortality levels (i.e., before the onset of large-scale vitamin A supplementation programs in sub-Saharan Africa). CONCLUSIONS: Effective and sustained control of vitamin A deficiency has the potential to be among the most cost-effective and high-impact child-survival interventions in sub-Saharan Africa. A stronger political commitment and a more appropriate level of investment in the effective control of vitamin A deficiency could make a large contribution toward the attainment of the Millennium Development Goal for the reduction of child mortality rates by two-thirds between 1990 and 2015. Among the many challenges that Africa will need to face in the coming years, vitamin A deficiency is one that can be overcome. The need is urgent, and the solutions are known, effective, and affordable.

Delivery of nutrition services in health systems in sub-Saharan Africa: opportunities in Burkina Faso, Mozambique and Niger.

BACKGROUND: In sub-Saharan Africa, underweight and micronutrient deficiencies account for an estimated 25% of the burden of disease. As the coverage of national health systems expands, increased opportunities exist to address the needs of children and women, the most vulnerable to these deficiencies, through high-quality nutrition services. OBJECTIVES: To assess health providers' knowledge and practice with regard to essential nutrition services for women and children in Burkina Faso, Mozambique and Niger, in order to assist the development of a standard guide and tools to assess and monitor the quality of the nutrition services delivered through national health systems. FINDINGS: The three surveys reveal the extent of missed opportunities to deliver nutrition services during routine prenatal, postnatal and child-care consultations for the prevention and treatment of highly prevalent nutritional deficiencies. CONCLUSION: A commitment to improving the quality of facility-based nutrition services is necessary to impact on the health outcomes of women and children 'covered' by national health systems. Rigorous assessment and monitoring of the quality of nutrition services should inform health programme and policy development. Building on the lessons learned in these three assessments, Helen Keller International has developed a standard Guide and Tools to assess the quality of the nutrition services delivered through national health systems. These tools can be adapted to assess ongoing nutrition services in health facilities, provide a framework for nutrition programming, inform the development of pre-service as well as in-service nutrition training curricula for providers, and evaluate the impact of nutrition training on providers' practices.