Gaps in treatment of epileptic seizures in a Zambian rural area.

BACKGROUND: Epilepsy is a multifactorial neurological disorder, including parasitic infections of the brain such as neurocysticercosis (NCC). People with epileptic seizures (PWES) in low and middle-income countries often do not receive appropriate treatment, which besides epileptic seizures, may also lead to reduced quality of life and possibly death. The objective of this study was to describe gaps in treatment of epileptic seizures in a Zambian rural area. METHODS: A cross-sectional study was conducted in Sinda district of Zambia between August and October 2018. PWES identified from clinic records and with the help of community healthcare workers were recruited. Two questionnaires, one to PWES and the other to local healthcare workers, were administered to describe the treatment gap. RESULTS: A total of 146 PWES and 43 healthcare workers were interviewed. Of the 146 PWES, 131 had taken anti-seizure medication (ASM) at some point since their seizure onset, of which 49.6% were on current treatment. Only 18.3% were on continuous ASM, an overall treatment gap of 83.6%. Over 55% of healthcare workers did not know the relationship between epilepsy and NCC. The risk factors associated with lack of appropriate treatment were stock-outs of ASMs, lack of diagnostic equipment, poor patient follow-up, and PWES opting for traditional medicine. CONCLUSION: The treatment gap is substantial in Sinda district. The causes are multifactorial, involving shortcomings at the level of healthcare facilities, communities, and individuals. Directed training of healthcare workers and significant improvements in the supply and dispensing of ASMs will be key in substantially reducing the gap.

Cost-effectiveness analysis of introducing malaria diagnostic testing in drug shops: A cluster-randomised trial in Uganda.

BACKGROUND: Private sector drug shops are an important source of malaria treatment in Africa, yet diagnosis without parasitological testing is common among these providers. Accurate rapid diagnostic tests for malaria (mRDTs) require limited training and present an opportunity to increase access to correct diagnosis. The present study was a cost-effectiveness analysis of the introduction of mRDTs in Ugandan drug shops. METHODS: Drug shop vendors were trained to perform and sell subsidised mRDTs and artemisinin-based combination therapies (ACTs) in the intervention arm while vendors offered ACTs following presumptive diagnosis of malaria in the control arm. The effect on the proportion of customers with fever 'appropriately treated of malaria with ACT' was captured during a randomised trial in drug shops in Mukono District, Uganda. Health sector costs included: training of drug shop vendors, community sensitisation, supervision and provision of mRDTs and ACTs to drug shops. Household costs of treatment-seeking were captured in a representative sample of drug shop customers. FINDINGS: The introduction of mRDTs in drug shops was associated with a large improvement of diagnosis and treatment of malaria, resulting in low incremental costs for the health sector at US$0.55 per patient appropriately treated of malaria. High expenditure on non-ACT drugs by households contributed to higher incremental societal costs of US$3.83. Sensitivity analysis showed that mRDTs would become less cost-effective compared to presumptive diagnosis with increasing malaria prevalence and lower adherence to negative mRDT results. CONCLUSION: mRDTs in drug shops improved the targeting of ACTs to malaria patients and are likely to be considered cost-effective compared to presumptive diagnosis, although the increased costs borne by households when the test result is negative are a concern.

A new strategy and its effect on adherence to intermittent preventive treatment of malaria in pregnancy in Uganda.

BACKGROUND: Few women in Uganda access intermittent preventive treatment of malaria in pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP). Previous studies have shown that high costs, frequent stock-out of drugs, supplies and poor quality of care are the greatest hindrance for women to access health services. In order to increase adherence to IPTp, we conceptualised an intervention that offset delivery care costs through providing a mama kit, created awareness on health benefits of IPTp and built trust between the provider and the client. METHODS: The new strategy was conceived along four constructs namely: 1) creating awareness by training midwives to explain the benefits of SP and the importance of adhering to the two doses of SP as IPTp to all pregnant women who attended ANC and consented to the study. Midwives were trained for two days in customer care and to provide a friendly environment. The pregnant women were also informed of the benefits of attending ANC and delivering at health facilities. 2) Each woman was promised a mama kit during ANC; 3) trust was built by showing the mama kit to each woman and branding it with her name; 4) keeping the promise by providing the mama kit when women came to deliver. The strategy to increase adherence to two doses of SP and encourage women to deliver at health facilities was implemented at two health facilities in Mukono district (Kawolo hospital and Mukono health centre IV). The inclusion criteria were women who: i) consented to the study and ii) were in the second trimester of pregnancy. All pregnant women in the second trimester (4-6 months gestation) who attended ANC and consented to participate in the study were informed of the benefits of SP, the importance of delivering at health facilities, were advised to attend the scheduled visits, promised a mama kit and ensured the kit was available at delivery. The primary outcome was the proportion of pregnant women adhering to a two dose SP regimen. RESULTS: A total of 2,276 women received the first dose of SP and 1,656 (72.8%) came back for the second dose. 1,069 women were involved in the evaluation (384 had participated in the intervention while 685 had not). The main reasons that enabled those who participated in the intervention to adhere to the two doses of IPTp and deliver at the study facilities were: an explanation provided on the benefits of IPTp and delivering at health facilities (25.1%), availability of a mama kit at delivery (24.6%), kind midwives (19.8%) and fearing complications of pregnancy (8.5%). Overall, 78.0% of these women reported that they were influenced to adhere to IPTp by the intervention. In a multivariable regression, nearby facility, P = 0. 007, promising a mama kit, P = 0.002, kind midwives, P = 0.0001 and husbands' encouragement, P = 0.0001 were the significant factors influencing adherence to IPTp with SP. CONCLUSION: The new strategy was a good incentive for women to attend scheduled ANC visits, adhere to IPTp and deliver at the study facilities. Policy implications include the urgent need for developing a motivation package based on the Health-Trust Model to increase access and adherence to IPTp.

The effect of energy-protein supplementation on weight, body composition and handgrip strength among pulmonary tuberculosis HIV-co-infected patients: randomised controlled trial in Mwanza, Tanzania.

Undernutrition is common among smear-positive pulmonary tuberculosis (PTB+) patients. Micronutrient supplementation may improve treatment outcomes, but it is unclear whether additional energy-protein would be beneficial. The present study aimed to assess the effect of energy-protein supplementation on weight, body composition and handgrip strength against a background of high micronutrient intake during tuberculosis (TB) treatment. A total of 377 PTB+ patients co-infected with HIV were randomly allocated one or six biscuits daily for 60 d during TB treatment. Weight, arm fat area, arm muscle area and handgrip strength were assessed at baseline and 2 and 5 months. There were no effects on any outcome at 2 months, but energy-protein supplementation was associated with a 1·3 (95 % CI - 0·1, 2·8) kg marginally significant gain in handgrip strength at 5 months. However, after 2 months, energy-protein supplementation led to a weight gain of 1·9 (95 % CI 0·1, 3·7) kg among patients with cluster of differentiation 4 (CD4) counts ≥ 350 cells/µl, but not among patients with low CD4 counts ( - 0·2 kg; 95 % CI - 1·3, 0·8, Pinteraction = 0·03). Similarly, at 5 months, energy-protein supplementation led to a 2·3 (95 % CI 0·6, 4·1) kg higher handgrip strength gain among patients with CD4 counts < 350 cells/µl, but not in those with high CD4 counts (Pinteraction = 0·04). In conclusion, energy-protein supplementation to PTB+ HIV-co-infected patients had no overall effects on weight and body composition, but was associated with marginally significant gain in handgrip strength. More research is needed to develop an effective supplement, before it is recommended to TB programmes.

Impact of community-directed treatment on soil transmitted helminth infections in children aged 12 to 59 months in Mazabuka District, Zambia.

This study assessed the impact of adding community-directed treatment (ComDT) to the routine health facility (HF)-based treatment on prevalence and intensity of soil transmitted helminth (STH) infections among children aged 12 to 59 months. Repeated cross-sectional surveys were conducted among randomly selected children of this age group from the intervention area (HF+ComDT area) and the comparison area (HF area) at baseline (n=986), 12 months (n=796) and 18 months (n=788) follow-up. The prevalence of Ascaris lumbricoides was significantly higher in the HF+ComDT as compared to the HF area at baseline (P=0·048), but not at 12 and 18 months follow-up. At baseline the HF+ComDT area had significantly higher intensities of A. lumbricoides compared to the HF area (P<0·001), but not at 12 and 18 months follow-ups. Prevalence and intensity of hookworm did not differ significantly between treatment arms at any time. Analysis of trends showed a significant decrease in prevalence of A. lumbricoides and hookworm in the HF+ComDT area (P<0·001), of hookworm in the HF area (P<0·05), but not of A. lumbricoides in the HF area. It is concluded that the ComDT approach generally enhanced the treatment effect among under-five year children and that this alternative approach may also have advantages in other geographical settings.

Daily multi-micronutrient supplementation during tuberculosis treatment increases weight and grip strength among HIV-uninfected but not HIV-infected patients in Mwanza, Tanzania.

Undernutrition is common among tuberculosis (TB) patients. The objective of this study was to assess the effect of multi-micronutrient supplementation during TB treatment on weight, body composition, and handgrip strength. A total of 865 patients with smear-positive (PTB+) or -negative (PTB-) pulmonary TB were randomly allocated to receive a daily biscuit with or without multi-micronutrients for 60 d during the intensive phase of TB treatment. Weight, arm fat area, arm muscle area, and handgrip strength were assessed at baseline and after 2 and 5 mo. At 2 mo, the multi-micronutrient supplementation led to a higher handgrip gain (1.22 kg; 95% CI = 0.50, 1.94; P = 0.001) but had no effects on other outcomes. The effects of multi-micronutrient supplementation were modified by HIV infection (P-interaction = 0.002). Among HIV- patients, multi-micronutrient supplementation increased weight gain by 590 g (95% CI = -40, 1210; P = 0.07) and handgrip strength by 1.6 kg (95% CI = 0.78, 2.47; P < 0.001), whereas among HIV+ patients, it reduced weight gain by 1440 g (95% CI = 290, 2590; P = 0.002) and had no effect on handgrip strength (0.07 kg; 95% CI = -1.30, 1.46; P = 0.91). The reduced weight gain among HIV+ patients receiving multi-micronutrient supplementation seemed to be explained by a higher proportion of patients reporting fever. At 5 mo, the effects on weight were sustained, whereas there was no effect on handgrip strength. In conclusion, multi-micronutrient supplementation given as a biscuit is beneficial among HIV- PTB patients and may be recommended to TB programs. More research is needed to develop an effective supplement for HIV+ PTB patients.

The combined effect of the Lymphatic Filariasis Elimination Programme and the Schistosomiasis and Soil-transmitted Helminthiasis Control Programme on soil-transmitted helminthiasis in schoolchildren in Tanzania.

The combined effect of the Lymphatic Filariasis Elimination Programme (LFEP) and the National Schistosomiasis and Soil-transmitted Helminthiasis Control Programme (NSSCP) on soil-transmitted helminthiasis (STH) was evaluated. In September 2004, before mass drug administration (MDA) with ivermectin and albendazole by the LFEP in October, the prevalence and intensity of STH were recorded in 228 pupils in one primary school. After 8 months, all available pupils were re-examined, and the prevalence of Ascaris lumbricoides, Trichuris trichiura and hookworm had decreased from 0.9 to 0.7% (P=0.84), from 4.8 to 0.7% (P=0.004) and from 45.6 to 11.9% (P<0.001), respectively. Overall, 81.2% of the schoolchildren stated that they were treated by the LFEP in October 2004. After the 8 months follow-up, pupils were treated with praziquantel and albendazole by the present project (substitute for the NSSCP). After another 4 months (at 12 months follow-up), the prevalence of hookworm infection was reduced to 4.8% (P=0.003), while the prevalence of T. trichiura was reduced to 0.3% (P=0.54) and the prevalence of A. lumbricoides remained unchanged. Mass co-administration of ivermectin and albendazole by the LFEP had a significant effect on STH, which was further amplified by treatment with praziquantel and albendazole 4 months later.

The effect of the community-directed treatment approach versus the school-based treatment approach on the prevalence and intensity of schistosomiasis and soil-transmitted helminthiasis among schoolchildren in Tanzania.

This study compared the effect of the community-directed treatment (ComDT) approach and the school-based treatment approach on the prevalence and intensity of schistosomiasis and soil-transmitted helminthiasis (STH) among schoolchildren. Following a parasitological survey in a randomly selected sample of 1140 schoolchildren, school-age children in 10 study villages received one dose of praziquantel (40 mg/kg body weight) against schistosomiasis and one dose of albendazole (400mg) against STH. Five of these villages implemented the ComDT approach and received treatment by community drug distributors, while school teachers administered treatment in five other villages using the school-based approach. At 12 months follow-up, the prevalence of Schistosoma mansoni and Trichuris trichiura infections were similar between the ComDT and the school-based approaches when examined in randomly selected schoolchildren (10.1 vs. 9.4%, P=0.66 and 0.8 vs. 1.4%, P=0.37). However, the prevalence of S. haematobium and hookworm infections were significantly lower in the ComDT approach villages compared to the school-based approach villages (10.6 vs. 16.3%, P=0.005 and 2.9 vs. 5.8%, P=0.01, respectively). The results showed that the ComDT approach is at least as effective as the school-based approach in reducing prevalence and intensity of schistosomiasis and STH among schoolchildren.

Efficacy of ivermectin and albendazole alone and in combination for treatment of soil-transmitted helminths in pregnancy and adverse events: a randomized open label controlled intervention trial in Masindi district, western Uganda.

A randomized open-label trial, including 834 pregnant women, examined efficacy and recorded adverse events of ivermectin (ivc) and albendazole (alb) alone and combined (comb) on soil-transmitted helminth infections (STHs) in the second trimester of pregnancy. One abortion occurred in the alb group and 10 stillbirths (1, 5, 3, and 1) in the ivc, alb, comb, and the reference group (ref) with no STHs, respectively. Two babies were born with congenital abnormalities (1 [ivc] and 1 [ref]). The prevalence of anemia at first antenatal care (ANC) visit was 20.6% (23.7% [ivc], 21.1% [alb], 22.2% [comb], and 16.1% [ref]). Anemia was reduced to 8.5% at 36 weeks of gestation with 10.9% (ivc), 11.5% (alb), 7.7% (comb), and 6.9% (ref). Hookworm cure rates were 29.4% (ivc), 95.5% (alb), and 92.6% (comb). No severe adverse events were reported by the women after the administration of ivc, alb, or comb during the second trimester of pregnancy, but long-term pharmacovigillance is needed to assess safety of ivc, alb, or comb in pregnancy.

Intermittent preventive treatment of malaria in pregnancy: a community-based delivery system and its effect on parasitemia, anemia and low birth weight in Uganda.

OBJECTIVE: The main objective of the study was to assess the impact of a community-based delivery system of intermittent preventive treatment (IPT) for malaria in pregnancy with sulfadoxine-pyrimethamine (SP) on access, parasitemia, anemia and low birth weight as primary outcome measures. METHODS: A study was designed to test the community-based delivery system of IPT through traditional birth attendants (TBAs), drug-shop vendors (DSVs), community reproductive health workers (CRHWs) and adolescent peer mobilizers (APMs), and to compare these with IPT at health units in an area of high malaria transmission - Mukono District, Uganda. RESULTS: Two thousand seven hundred and eighty-five pregnant women participated in the study. The majority of the women (92.4%) at the community-based approaches received their first dose of IPT during their second trimester compared to 76.1% at health units (p<0.0001). At both health units and the community-based approaches, IPT increased mean hemoglobin by 6.7% (p<0.0001) for all parities and by 10.2% among primigravidae. IPT reduced the prevalence of severe anemia from 5.7% to 3.1% (p<0.04). The prevalence of parasitemia was reduced from 24.5% to 16.1% (p<0.001), and parasite density reduced significantly (p<0.02) after the first dose and remained stable with the second dose. Overall the proportion of low birth weight was 6.3% (8.3% at health units versus 6.0% at the community-based approaches, p<0.03) highlighting the importance of access and adherence to IPT. This intervention was acceptable to 89.6% of the women at the community-based approaches intending to use IPT in the future, while 48.1% of them had recommended it to other women. CONCLUSIONS: The community-based approaches increased access and adherence to IPT with an effect on anemia, severe anemia, parasitemia and low birth weight. However the reduced effect of IPT on parasitemia points to drug resistance with SP and this requires further evaluation; research into the identification of other more efficacious drugs for malaria prevention in pregnancy is also required.

A community-based delivery system of intermittent preventive treatment of malaria in pregnancy and its effect on use of essential maternity care at health units in Uganda.

Community delivery of intermittent preventive treatment of malaria in pregnancy (IPTp) is one potential option that could mitigate malaria in pregnancy. However, there is concern that this approach may lead to complacency among women with low access to essential care at health units. A non-randomised community trial assessed a new delivery system of IPTp through traditional birth attendants, drug shop vendors, community reproductive health workers and adolescent peer mobilisers (the intervention) compared with IPTp at health units (control). The study enrolled a total of 2081 pregnant women with the new approaches. Data on care-seeking practices before and after the intervention were collected. The majority of women with the new approaches accessed IPTp in the second trimester and adhered to two doses of sulfadoxine/pyrimethamine (SP) (1404/2081; 67.5%). Antenatal care (four recommended visits) increased from 3.4% (27/805) to 56.8% (558/983) (P<0.001). The proportion of women delivering at health units increased from 34.3% (276/805) to 41.5% (434/1045) (P=0.02), whilst the proportion of women seeking care for malaria at health units increased from 16.7% (128/767) to 36.0% (146/405) (P<0.001). Similarly, use of insecticide-treated nets increased from 7.7% (160/2081) to 22.4% (236/1055) (P<0.001). In conclusion, the community-based system was effective in delivering IPTp, whilst women still accessed and benefited from essential care at health units.

Intermittent preventive treatment of malaria in pregnancy: the effect of new delivery approaches on access and compliance rates in Uganda.

OBJECTIVE: To assess whether traditional birth attendants, drug-shop vendors, community reproductive health workers and adolescent peer mobilizers can administer intermittent preventive treatment (IPT) with sulfadoxine-pyremethamine to pregnant women, and reach those most at risk of malaria and increase access and compliance to it. METHODS: The study was designed to assess new approaches of delivering IPT through these groups and compare it with IPT at health units. The primary outcome measures were: the proportion of adolescents and primigravidae accessed; gestational age at recruitment and the proportion of women who completed two doses of sulfadoxine-pyremethamine. RESULTS: Two thousand seven hundred and eighty-five pregnant women (78% of those in the study area) participated. With new approaches, 92.4% of the women received IPT during the second trimester as recommended by the policy, vs. 76.1% at health units, P < 0.0001. Of the women who received two doses of sulfadoxine-pyremethamine, 39.9% were at health units (control) vs. 67.5% through new approaches (P < 0.0001). Women using the new approaches also accessed IPT early: the mean gestational age when receiving the first dose of sulfadoxine-pyremethamine was 21.0 weeks vs. 23.1 weeks at health units (P < 0.0001). However, the health units were used by a higher proportion of primigravidae (23.6% vs. 20.0%, P < 0.04), and this was also the case for adolescents (28.4% vs. 25.0%, P < 0.03). This intervention was acceptable with 89.1% of the women at the new approaches intending to use IPT in future. CONCLUSIONS: The new approaches increased access to and compliance with IPT. We recommend a review of the policy to allow the provision of IPT through the new approaches.

Intermittent preventive treatment of malaria in pregnancy: evaluation of a new delivery approach and the policy implications for malaria control in Uganda.

The impact of intermittent preventive treatment (IPT) on malaria in pregnancy is well known. In countries where this policy is implemented, poor access and low compliance to this intervention has been widely reported. A study was designed to assess a new approach to deliver IPT to pregnant women through traditional birth attendants (TBAs), drug-shop vendors (DSVs), community reproductive health workers (CRHWs) and adolescent peer mobilisers (APMs); and compared this approach with IPT at health units. We evaluated this approach to assess user perceptions, its acceptability and sustainability. Results show that the new approach increased access and compliance to IPT. Mean gestational age at first dose of IPT was 21.0 weeks with the community approaches versus 23.1 weeks at health units, P>0.0001. Health units accessed a high proportion of adolescents, 28.4%, versus 25.0% at the new approaches, P<0.03; most primigravidae, 23.6%, versus 20.0% at the new approaches, P<0.04. The proportion of women who received two doses of SP was 67.5.2% with the new approaches versus 39.9% at health units, P<0.0001. The new approach was associated with a three-fold increase in use of ITNs from 8.8% at baseline to 23.4%. The factors that most influenced acceptability and use of IPT were trusted and easy accessible resource persons, their ability to make home visits especially with CRHWs and APMs; the support of spouses. Another factor was the high awareness on dangers of malaria in pregnancy and the benefits of IPT created by the resource persons. The women perceived better health using the first dose of sulphadoxine-pyremethamine (SP) and this compelled them to go for the second dose. IPT with this approach was highly acceptable with 89.1% of women at the new approaches intending to use it for the next pregnancy, while 48.0% of them had recommended it to other women. We suggest a review of the current policy on malaria prevention in pregnancy to allow provision of IPT through community structures that are feasible, practical and acceptable.

The effect of multi-vitamin/mineral supplementation on mortality during treatment of pulmonary tuberculosis: a randomised two-by-two factorial trial in Mwanza, Tanzania.

Malnutrition is common in pulmonary tuberculosis (TB), and may impair survival. The objective of this study was to assess effects of multi-vitamin/mineral (MVM) and zinc (Zn) supplementation during TB treatment on mortality. Patients diagnosed with sputum-positive pulmonary TB in Mwanza, Tanzania, were randomised, using a two-by-two factorial design, to Zn (45 mg) or placebo, and MVM (vitamins A, B, C, D, E, and selenium and copper) or placebo. Survival status was ascertained at the end of the 8-month TB treatment and supplementation period. Of 499 TB patients, 213 (43 %) had HIV. The mean weight gain at 7 months was 6.88 kg (95 % CI 6.36, 7.41). Zn and MVM combined, but neither alone (interaction, P=0.03), increased weight gain by 2.37 kg (95 % CI 0.91, 3.83), irrespective of HIV status. Survival status at 8 months was determined for 422 patients (84.6 %), of which fifty-two (12.3 %) had died. Among fifty-two deaths, there were no effects of MVM (relative risk (RR) 0.73; 95 % CI 0.43, 1.23) and Zn (RR 0.76; 95 % CI 0.46, 1.28). However, among HIV co-infected patients, marginally significant effects of both MVM (RR 0.60; 95 % CI 0.34, 1.05) and Zn (RR 0.63, 95 % CI 0.37, 1.08) were seen, and MVM and Zn combined reduced mortality (RR 0.29; 95 % CI 0.10, 0.80; interaction ratio 0.52). In conclusion, supplementation with MVM, including Zn, during treatment of pulmonary TB may reduce mortality in those co-infected with HIV. A randomised trial of the effect of the combined intervention used in this study should be conducted in a different setting to confirm the finding.

The effect of micronutrient supplementation on treatment outcome in patients with pulmonary tuberculosis: a randomized controlled trial in Mwanza, Tanzania.

OBJECTIVE: The aim of the study was to assess the effects of micronutrient supplementation on culture conversion in tuberculosis (TB) patients. DESIGN: The study was a randomized, double-blind placebo-controlled 2 x 2 trial of zinc and multi-micronutrient (MMN) supplementation in pulmonary TB patients in Tanzania. RESULTS: A total of 499 pulmonary TB patients were included in the trial after being confirmed sputum-positive by microscopy or culture. At 8 weeks, 25% were sputum-smear positive but only 11% were culture-positive (P<0.0001). No significant differences were observed in culture conversion rate among those allocated to MMN or placebo (89.5 vs. 86.2%, P=0.29) at 8 weeks, although at week 4 those allocated to MMN had a slightly reduced culture conversion rate (42.8 vs. 52.8%, P=0.058). Zinc had no effects on culture conversion. MMN increased weight gain by 0.78 kg [95% confidence interval (CI): 0.12--1.43] at week 8, while zinc supplementation had no effect. The effects of MMN and zinc did not interact and neither MMN nor zinc interacted with human immunodeficiency virus status, sex and culture-intensity at baseline. CONCLUSION: Neither zinc nor MMN supplementation had significant effects on culture conversion, but MMN supplementation increased weight gain in TB patients.

Effects of multimicronutrient supplementation on helminth reinfection: a randomized, controlled trial in Kenyan schoolchildren.

A randomized, placebo-controlled, double-blind, two-by-two factorial trial was carried out among 977 schoolchildren from 19 primary schools in Nyanza Province, Kenya from February 1995 to February 1996. The interventions were multimicronutrient supplementation (vitamin A, 1000 micrograms; vitamin B1, 1.4 mg; vitamin B2, 1.6 mg; vitamin B6, 1.7 mg; vitamin B12, 2.0 micrograms; folate, 150 micrograms; niacin, 16 mg; vitamin C, 50 mg; vitamin D, 5 micrograms; vitamin E, 8 mg; iron, 18 mg; zinc, 20 mg; copper, 2.0 mg; iodine, 150 micrograms; selenium, 40 micrograms) and multihelminth chemotherapy (albendazole 600 mg in a single dose and/or praziquantel 40 mg/kg in a single dose). This paper reports the effects of the supplementation given on all school days on reinfection with hookworm, Ascaris lumbricoides, Trichuris trichiura and Schistosoma mansoni after 11 months. Baseline prevalence and geometric mean intensity for hookworm, A. lumbricoides, T. trichiura and S. mansoni in all children investigated were 54.7%, 13.8%, 45.6% and 70.0%, respectively and 8.6, 2.7, 5.9 and 19.4 eggs per gram (epg), respectively. Children received a mean of 2.3 multimicronutrient/placebo tablets per school week, giving a compliance rate of 46%. Children given multimicronutrients had a slightly, but significantly, lower intensity of S. mansoni reinfection compared with children given placebo (5.5 epg vs. 7.7 epg, P = 0.047). Multiple linear regression analyses controlling for baseline infection status confirmed this, as children who received micronutrients were reinfected with S. mansoni at only 69% of the intensity of those who received placebo. Multiple logistic regression analyses revealed that micronutrient supplementation was associated with a lower S. mansoni reinfection rate (odds ratio = 0.7) although this was only of borderline significance (P = 0.090). There were no significant differences in reinfection rates or intensities of hookworm, A. lumbricoides and T. trichiura. The effect on S. mansoni infection intensity is particularly interesting given the low compliance, suggesting that full micronutrient supplementation might have a role to play in S. mansoni control programmes.

Prevention of anaemia in pregnancy using insecticide-treated bednets and sulfadoxine-pyrimethamine in a highly malarious area of Kenya: a randomized controlled trial.

To compare the effects of intermittent treatment with sulfadoxine-pyrimethamine (SP) given during the second and third trimester of pregnancy, the use of insecticide-treated nets (ITN), or the combination of both on haemoglobin (Hb) levels during pregnancy, a randomized, placebo-controlled intervention trial was conducted in a malaria-endemic area of western Kenya from July 1997 to September 1999. Primigravidae and secundigravidae were enrolled into the study and randomized into 4 intervention groups: (i) ITNs and SP, (ii) ITNs and placebo SP, (iii) SP alone, and (iv) placebo SP. All groups were offered case management and iron and folic acid supplementation. Seven hundred and fifty-two women were followed until delivery (53.2% were primigravidae and 46.8% secundigravidae). Among primigravidae in all the groups there was a significant improvement in Hb levels at delivery (107.6 g/L) compared with recruitment (101.9 g/L) (P < 0.006) with the greatest improvement in the combination ITNs + SP group. The protective efficacy of ITNs + SP on anaemia was 55.8% (95% CI 30.6-71.8), of SP alone 50.9% (95% CI 22.2-69.0), and of ITNs 41.6% (95% CI 9.8-62.3). Among secundigravidae, Hb levels were slightly lower at delivery compared with recruitment (P = 0.03). It was concluded that malaria is a major cause of anaemia in primigravidae but that other causes play a more significant role in secundigravidae, and that intermittent treatment with SP or use of ITNs benefits primigravidae more than secundigravidae.