Estimation of COVID-19 vaccine effectiveness against infections and severe outcomes using routine surveillance data in Kosovo, July-September 2021.

BACKGROUND: COVID-19 vaccines have proven effective against severe outcomes in many settings, yet vaccine effectiveness (VE) estimates remain lacking for Kosovo. We aimed to estimate VE against COVID-19 infections, hospitalisations, and deaths for one and two vaccine doses during the fourth pandemic wave in July-September 2021, the period when vaccination initially became widely available. METHODS: We analysed routine surveillance data to define cases and vaccination status as partially (one dose) or completely (two doses) vaccinated. We used the screening method to calculate the proportion of cases with the outcomes vaccinated (PCV). The proportion of the population vaccinated (PPV) was based on numbers vaccinated and the Kosovo population estimate on 30/09/2021. RESULTS: Between July-September 2021, 51,804 COVID-19 cases were reported in Kosovo with 9.3% of cases partially and 3.4% completely vaccinated. Estimated vaccine effectiveness for one dose was 93.1% (95%CI:92.9-93.2%) for infections, 90.3% (95%CI:88.8-91.7%) for hospitalisations, and 90.3% (95%CI:88.4-92.1%) for deaths. Estimated vaccine effectiveness for two doses was 97.8% (95%CI:97.6-97.9%) for infections, 94.5% (95%CI:93.3-95.6%) for hospitalisations, and 94.2% (95%CI: 93.7-96.5%) for deaths. CONCLUSIONS: This study provides real-world evidence for COVID-19 vaccine effectiveness in Kosovo using routine administrative data sources and the screening method. COVID-19 vaccine effectiveness against infections and severe outcomes in Kosovo was higher with two vaccine doses than one dose, which is in accordance with findings from other study designs and settings. Using the screening method in our study reflects an important initial methodology for estimating vaccine effectiveness with routine surveillance that may be particularly important for low- and middle-income settings with less robust surveillance systems or fewer opportunities to conduct more robust vaccine effectiveness study designs.

Increased number of cryptosporidiosis cases with travel history to Croatia might be related to swimming pools, Germany, 2023.

In August and September 2023, an unusually high number of cryptosporidiosis cases identified by routine German surveillance had travelled to Croatia (n = 23). Nine cases had stayed in the same camping resort and seven further cases had stayed at other camping sites within 15 km. Based on our standardised questionnaires, the most likely source of infection was swimming pools (93%). Further environmental investigations on site might reveal potential common sources of contamination that could be targeted by control measures.

Direct and indirect vaccination effects on SARS-CoV-2 infection in day-care centres: Evaluating the policy for early vaccination of day-care staff in Germany, 2021.

To mitigate the known high transmission risk in day-care facilities for children aged 0-6 years, day-care staff were given priority for SARS-CoV-2 vaccination in Rhineland-Palatinate, Germany, in March 2021. This study assessed direct and indirect effects of early vaccination of day-care staff on SARS-CoV-2 transmission in daycares with the aim to provide a basis for the prioritisation of scarce vaccines in the future. Data came from statutory infectious disease notifications in educational institutions and from in-depth investigations by the district public health authorities. Using interrupted time series analyses, we measured the effect of mRNA-based vaccination of day-care staff on SARS-CoV-2 infections and transmission. Among 566 index cases from day-care centres, the mean number of secondary SARS-CoV-2 infections per index case dropped by -0.60 case per month after March 2021. The proportion of staff among all cases reported from daycares was around 60% in the pre-interruption phase and significantly decreased by 27 percentage points immediately in March 2021 and by further 6 percentage points each month in the post-interruption phase. Early vaccination of day-care staff reduced SARS-CoV-2 cases in the overall day-care setting and thus also protected unvaccinated children. This should inform future decisions on vaccination prioritisation.

Associations between antenatal maternal diet and other health aspects with infant temperament in a large multiethnic cohort study: a path analysis approach.

OBJECTIVES: The aim of this study was to assess the association of antenatal maternal dietary patterns (DPs) and other health aspects with infant temperament in a large multiethnic cohort, taking maternal personality and prenatal stress into account. DESIGN AND METHODS: Using data from 3968 children born in 2009/2010 and their mothers from the Growing Up in New Zealand cohort, infant temperament was assessed at 9 months using the Infant Behavior Questionnaire-Revised Very Short Form. Maternal antenatal diet and other health aspects were assessed antenatally. Maternal DPs (n=4) were derived using principal components analysis based on food intake reported on a 44-item food frequency questionnaire. Path analyses investigated factors associated with infant temperament, namely maternal personality, prenatal maternal stress, DPs and other health aspects, including potential inter-relations and mediating effects. RESULTS: Women who scored higher in the fusion DP (standardised beta (ß)=0.05; 95% CI 0.02 to 0.09) and healthy DP (ß=0.05; 95% CI 0.02 to 0.09), who exercised more (ß=0.04; 95% CI 0.01 to 0.07), and who drank less alcohol (ß=-0.05; 95% CI -0.08 to -0.02) were more likely to have infants with an overall less difficult temperament. Sex-specific differences were found in the associations between maternal DP and infant temperament. Maternal personality and prenatal stress were significantly associated with all dimensions of infant temperament. The strongest predictors for a more difficult temperament were prenatal stress (ß=0.12; 95% CI 0.08 to 0.15) and the personality dimensions neuroticism (ß=0.10; 95% CI 0.07 to 0.14) and extraversion (ß=-0.09; 95% CI -0.12 to -0.06). CONCLUSIONS: Associations of antenatal maternal diet and health aspects with infant temperament were statistically significant but small. While they should not be overinterpreted as being deterministic, the findings of this study support the link between maternal modifiable health-related behaviours and infant temperament outcomes.

Ethnic diversity and mortality in northwest Burkina Faso: An analysis of the Nouna health and demographic surveillance system from 2000 to 2012.

Ethnic diversity has been a topic of contention across the globe, contrasted with economic development, social security, and political stability. The link between health and ethnic diversity is not yet well established especially in low-middle- income countries. Our study aims to explore the association between ethnic diversity and all-cause mortality in rural areas of Burkina Faso. We used data from the Nouna Health & Demographic Surveillance System (HDSS) collected between 2000 and 2012. To derive Standardized Mortality Ratios (SMR), the observed number of deaths was compared to the expected deaths based on the entire HDSS taking into account sex, age, rainy season, calendar year, and village. SMR were calculated for ethnic and religious diversity on a village level (using the Simpson Index), sub-region, wealth, and distance to Healthcare Facilities (HCF). Furthermore, we modeled SMR with a multilevel random intercept Poisson regression considering individual ethnic and religious groups in addition to the above-mentioned village-level information. Village wealth (poorest fifth: SMR 1.07; 95% CI: 1.02-1.13, richest fifth: SMR 0.85; 95% CI: 0.82-0.88), distance to HCF (within the village: SMR 0.88; 95% CI: 0.85-0.91, further than 5km: SMR 1.13; 95% CI: 1.10-1.16), and sub-region showed significant associations with overall mortality. Villages belonging to the third with the highest ethnic diversity had lowered SMR (0.86; 95% CI: 0.84-0.89) compared to the entire HDSS, while those belonging to the lowest diversity third yielded elevated SMR (1.13; 95% CI: 1.09-1.17). The multilevel model confirmed the association. Our study showed that historically established ethnic diversity in rural areas of Burkina Faso was associated with lower all-cause mortality. Generally, the literature suffers from a lack of standardization in defining ethnic diversity, along with measuring it. More research is needed to understand this relation and to establish it in different settings.

Surveillance of SARS-CoV-2 transmission in educational institutions, August to December 2020, Germany.

This study aims at providing estimates on the transmission risk of SARS-CoV-2 in schools and day-care centres. We calculated secondary attack rates (SARs) using individual-level data from state-wide mandatory notification of index cases in educational institutions, followed by contact tracing and PCR-testing of high-risk contacts. From August to December 2020, every sixth of overall 784 independent index cases was associated with secondary cases in educational institutions. Monitoring of 14 594 institutional high-risk contacts (89% PCR-tested) of 441 index cases during quarantine revealed 196 secondary cases (SAR 1.34%, 0.99-1.78). SARS-CoV-2 infection among high-risk contacts was more likely around teacher-indexes compared to student-/child-indexes (incidence rate ratio (IRR) 3.17, 1.79-5.59), and in day-care centres compared to secondary schools (IRR 3.23, 1.76-5.91), mainly due to clusters around teacher-indexes in day-care containing a higher mean number of secondary cases per index case (142/113 = 1.26) than clusters around student-indexes in schools (82/474 = 0.17). In 2020, SARS-CoV-2 transmission risk in educational settings was low overall, but varied strongly between setting and role of the index case, indicating the chance for targeted intervention. Surveillance of SARS-CoV-2 transmission in educational institutions can powerfully inform public health policy and improve educational justice during the pandemic.

Does facility birth reduce maternal and perinatal mortality in Brong Ahafo, Ghana? A secondary analysis using data on 119 244 pregnancies from two cluster-randomised controlled trials.

BACKGROUND: Maternal and perinatal mortality are still unacceptably high in many countries despite steep increases in facility birth. The evidence that childbirth in facilities reduces mortality is weak, mainly because of the scarcity of robust study designs and data. We aimed to assess this link by quantifying the influence of major determinants of facility birth (cluster-level facility birth, wealth, education, and distance to childbirth care) on several mortality outcomes, while also considering quality of care. METHODS: Our study is a secondary analysis of surveillance data on 119 244 pregnancies from two large population-based cluster-randomised controlled trials in Brong Ahafo, Ghana. In addition, we specifically collected data to assess quality of care at all 64 childbirth facilities in the study area. Outcomes were direct maternal mortality, perinatal mortality, first-day and early neonatal mortality, and antepartum and intrapartum stillbirth. We calculated cluster-level facility birth as the percentage of facility births in a woman's village over the preceding 2 years, and we computed distances from women's regular residence to health facilities in a geospatial database. Associations between determinants of facility birth and mortality outcomes were assessed in crude and multivariable multilevel logistic regression models. We stratified perinatal mortality effects by three policy periods, using April 1, 2005, and July 1, 2008, as cutoff points, when delivery-fee exemption and free health insurance were introduced in Ghana. These policies increased facility birth and potentially reduced quality of care. FINDINGS: Higher proportions of facility births in a cluster were not linked to reductions in any of the mortality outcomes. In women who were wealthier, facility births were much more common than in those who were poorer, but mortality was not lower among them or their babies. Women with higher education had lower mortality risks than less-educated women, except first-day and early neonatal mortality. A substantially higher proportion of women living in areas closer to childbirth facilities had facility births and caesarean sections than women living further from childbirth facilities, but mortality risks were not lower despite this increased service use. Among women who lived in areas closer to facilities offering comprehensive emergency obstetric care (CEmOC), emergency newborn care, or high-quality routine care, or to facilities that had providers with satisfactory competence, we found a lower risk of intrapartum stillbirth (14·2 per 1000 deliveries at >20 km from a CEmOC facility vs 10·4 per 1000 deliveries at ≤1 km; odds ratio [OR] 1·13, 95% CI 1·06-1·21) and of composite mortality outcomes than among women living in areas where these services were further away. Protective effects of facility birth were restricted to the two earlier policy periods (from June 1, 2003, to June 30, 2008), whereas there was evidence for higher perinatal mortality with increasing wealth (OR 1·09, 1·03-1·14) and lower perinatal mortality with increasing distance from childbirth facilities (OR 0·93, 0·89-0·98) after free health insurance was introduced in July 1, 2008. INTERPRETATION: Facility birth does not necessarily convey a survival benefit for women or babies and should only be recommended in facilities capable of providing emergency obstetric and newborn care and capable of safe-guarding uncomplicated births. FUNDING: The Baden-Württemberg Foundation, the Daimler and Benz Foundation, the European Social Fund and Ministry of Science, Research, and the Arts Baden-Württemberg, WHO, US Agency for International Development, Save the Children, the Bill & Melinda Gates Foundation, and the UK Department for International Development.

Effect of results-based financing on facility-based maternal mortality at birth: an interrupted time-series analysis with independent controls in Malawi.

INTRODUCTION: The aim of this study was to assess the impact of a results-based financing (RBF) programme on the reduction of facility-based maternal mortality at birth. Malawi is a low-income country with high maternal mortality. The Results-Based Financing For Maternal and Newborn Health (RBF4MNH) Initiative was introduced at obstetric care facilities in four districts to improve quality and utilisation of maternal and newborn health services. The RBF4MNH Initiative was launched in April 2013 as a combined supply-side and demand-side RBF. Programme expansion occurred in October 2014. METHODS: Controlled interrupted time series was used to estimate the effect of the RBF4MNH on reducing facility-based maternal mortality at birth. The study sample consisted of all obstetric care facilities in 4 intervention and 19 control districts, which constituted all non-urban mainland districts in Malawi. Data for obstetric care facilities were extracted from the Malawi Health Management Information System. Facility-based maternal mortality at birth was calculated as the number of maternal deaths per all deliveries at a facility in a given time period. RESULTS: The RBF4MNH effectively reduced facility-based maternal mortality by 4.8 (-10.3 to 0.7, p<0.1) maternal deaths/100 000 facility-based deliveries/month after reaching full operational capacity in October 2014. Immediate effects (changes in level rather than slope) attributable to the RBF4MNH were not statistically significant. CONCLUSION: This is the first study evaluating the effect of a combined supply-side and demand-side RBF on maternal mortality outcomes and demonstrates the positive role financial incentives can play in improving health outcomes. This study further shows that timeframes spanning several years might be necessary to fully evaluate the impact of health-financing programmes on health outcomes. Further research is needed to assess the extent to which the observed reduction in facility-based mortality at birth contributes to all-cause maternal mortality in the country.

Clustering of Infant Mortality Within Families in Rural Burkina Faso.

In this study, we analyze clustering of infant deaths within families living in a rural part of western Burkina Faso. The study included 9,220 infants, born between 1993 and 2009 in Nouna Health and Demographic Surveillance System (HDSS). A clustering of infant deaths in families was explored by calculating observed versus expected number of infant deaths within families for a given family size. In addition, risk ratios were calculated for infant death depending on the vital status of the previous sibling. We observed 470 infant deaths, yielding an overall infant mortality risk of 51/1,000 births. Clustering of infant deaths within families was observed (P = 0.004). In smaller families, the mortality of firstborns was higher than for the following siblings. The infant mortality risk was higher when the preceding sibling died in infancy (P = 0.03). The study supports the hypothesis of infant death clustering existing within rural families in West Africa. Further studies are needed to shed more light on these findings with the goal to develop effective interventions directed toward the families who already lost a child.

Prenatal alcohol consumption and infant and child behavior: Evidence from the Growing Up in New Zealand Cohort.

BACKGROUND: High levels of alcohol exposure during pregnancy can damage developing brains and influence child behavior and learning. AIM: To examine the effects of lower levels of alcohol and very early exposure to alcohol on infant temperament and child behavior. STUDY DESIGN, SUBJECTS, AND OUTCOME MEASURES: The Growing Up in New Zealand study involves a prospective birth cohort of 6822 pregnant women of whom 6156 provided information on their child's temperament using the Infant Behavior Questionnaire-Revised (IBQ-R VSF) at 9 months and their child's behavior using the Strengths and Difficulties Questionnaire at 2 years. RESULTS: A series of adjusted linear regression models controlling for socio-demographic factors found alcohol consumption during pregnancy was most consistently related to Lower Positive Affect, Affiliation/Regulation, and Orienting Capacity temperament scores. Mothers who stopped drinking after becoming aware of their pregnancy, but had an unplanned pregnancy (hence may have a baby exposed to alcohol for longer), also reported infants with lower Orienting Capacity, Affiliation/Regulation, and Fear temperament scores compared to those that did not drink. Children whose mothers drank four or more drinks per week during pregnancy were more likely to report their child as having conduct problems, with higher total difficulties scores at age 2. CONCLUSIONS: Alcohol consumption during pregnancy has a negative effect especially on infant temperament, even if small amounts of alcohol are consumed. Our findings have implications for men and women who drink, medical professionals, and for the availability of contraception to those who drink, but do not plan to get pregnant.

Ramadan Exposure In Utero and Child Mortality in Burkina Faso: Analysis of a Population-Based Cohort Including 41,025 Children.

Ramadan exposure in utero can be regarded as a natural experiment with which to study how nutritional conditions in utero influence susceptibility to disease later in life. We analyzed data from rural Burkina Faso on 41,025 children born between 1993 and 2012, of whom 25,093 were born to Muslim mothers. Ramadan exposure was assigned on the basis of overlap between Ramadan dates and gestation, creating 7 exclusive categories. We used proportional hazards regression with difference-in-differences analysis to estimate the association between Ramadan exposure at different gestational ages and mortality among children under 5 years of age. Under-5 mortality was 32 deaths per 1,000 child-years. Under-5 mortality among Muslims was 15% higher than that among non-Muslims (P < 0.001). In the difference-in-differences analysis, the occurrence of Ramadan during conception or the first or second trimester was associated with higher under-5 mortality rates among Muslims only. The mortality rates of children born to Muslim mothers were 33%, 29%, and 22% higher when Ramadan occurred during conception, the first trimester, and the second trimester, respectively, compared with children of non-Muslim mothers born at the same time (P = 0.01, P < 0.001, and P = 0.007). Having a Muslim mother was not associated with mortality when the child was not exposed to Ramadan, born during Ramadan, or exposed during the third trimester. Observance of Ramadan during early pregnancy can have detrimental consequences for the future health of the unborn child.

No effect of an additional early dose of measles vaccine on hospitalization or mortality in children: A randomized controlled trial.

BACKGROUND: Non-specific effects (NSEs) of vaccines have increasingly gained attention in recent years. Recent studies suggest that live vaccines, such as measles vaccine (MV), have beneficial effects on health, while inactivated vaccines, such as the diphtheria-tetanus-pertussis (DTP) vaccine, may have harmful effects. If this is the case, it should improve child health to move MV closer to the last vaccination with DTP. The objective of this study was to investigate the NSEs of an additional early dose of MV on hospitalization or mortality. METHODS: Children were randomized to receive either the standard MV at 9 months (control) or an additional early dose of MV 4 weeks after the third dose of DTP-containing Pentavalent vaccine and the standard MV at 9 months (intervention). In this analysis of a secondary outcome in the trial, we investigated the effect of the intervention on a composite endpoint of over-night hospitalization with or without recovery, or death without previous hospitalization, in children between 4.5 and 36 months of age in the Nouna HDSS in Burkina Faso. We used Cox proportional hazards regression with repeated events and time since study enrolment as underlying time-scale. RESULTS: Among 2258 children in the intervention and 2238 children in the control group we observed a total of 464 episodes of hospitalization or mortality. There was no difference between intervention and control group (HR = 1.00, 95% Confidence Interval (CI) 0.83-1.20). Results from the per-protocol and intention-to-treat analysis were similar. Although no significant, results suggest a possible beneficial effect of early MV in children that had not been exposed to an OPV campaign after enrolment (HR = 0.83, 95% CI 0.55-1.29). CONCLUSIONS: We did not detect any effect of early MV on subsequent hospitalization or mortality. However, possible effects of early MV could have been obscured by NSEs of the frequent OPV campaigns. Registration: The trial was registered at ClinicalTrials.gov, NCT01644721.

A Two-Center Randomized Trial of an Additional Early Dose of Measles Vaccine: Effects on Mortality and Measles Antibody Levels.

Background: In addition to protecting against measles, measles vaccine (MV) may have beneficial nonspecific effects. We tested the effect of an additional early MV on mortality and measles antibody levels. Methods: Children aged 4-7 months at rural health and demographic surveillance sites in Burkina Faso and Guinea-Bissau were randomized 1:1 to an extra early standard dose of MV (Edmonston-Zagreb strain) or no extra MV 4 weeks after the third diphtheria-tetanus-pertussis-hepatitis B-Haemophilus influenzae type b vaccine. All children received routine MV at 9 months. We assessed mortality through home visits and compared mortality from enrollment to age 3 years using Cox proportional hazards models, censoring for subsequent nontrial MV. Subgroups of participants had blood sampled to assess measles antibody levels. Results: Among 8309 children enrolled from 18 July 2012 to 3 December 2015, we registered 145 deaths (mortality rate: 16/1000 person-years). The mortality was lower than anticipated and did not differ by randomization group (hazard ratio, 1.05; 95% confidence interval, 0.75-1.46). At enrollment, 4% (16/447) of children in Burkina Faso and 21% (90/422) in Guinea-Bissau had protective measles antibody levels. By age 9 months, no measles-unvaccinated/-unexposed child had protective levels, while 92% (306/333) of early MV recipients had protective levels. At final follow-up, 98% (186/189) in the early MV group and 97% (196/202) in the control group had protective levels. Conclusions: Early MV did not reduce all-cause mortality. Most children were susceptible to measles infection at age 4-7 months and responded with high antibody levels to early MV. Clinical Trials Registration: NCT01644721.

Vaccination coverage and factors associated with adherence to the vaccination schedule in young children of a rural area in Burkina Faso.

BACKGROUND: Vaccination is an important tool for reducing infectious disease morbidity and mortality. In the past, less than 80% of children 12-23 months of age were fully immunized in Burkina Faso. OBJECTIVES: To describe coverage and assess factors associated with adherence to the vaccination schedule in rural area Burkina Faso. METHODS: The study population was extracted from the Nouna Health and Demographic surveillance system cohort. Data from four rounds of interviews conducted between November 2012 and June 2014 were considered. This study included 4016 children aged 12-23 months. We assessed the effects of several background factors, including sex, factors reflecting access to health care (residence, place of birth), and maternal factors (age, education, marital status), on being fully immunized defined as having received Bacillus Calmette-Guérin (BCG), three doses of diphtheria-tetanus-pertussis and oral polio vaccine, and measles vaccine by 12 months of age. The associations were studied using binomial regression to derive prevalence ratios (PRs) in univariate and multivariate regression models. RESULTS: The full vaccination coverage increased significantly over time (72% in 2012, 79% in 2013, and 81% in 2014, p = 0.003), and the coverage was significantly lower in urban than in rural areas (PR 0.84; 0.80-0.89). Vaccination coverage was neither influenced by sex nor influenced by place of birth or by maternal factors. CONCLUSION: The study documented a further improvement in full vaccination coverage in Burkina Faso in recent years and better vaccination coverage in rural than in urban areas. The organization of healthcare systems with systematic outreach activities in the rural areas may explain the difference between rural and urban areas.

Decreasing child mortality, spatial clustering and decreasing disparity in North-Western Burkina Faso.

Within relatively small areas, there exist high spatial variations of mortality between villages. In rural Burkina Faso, with data from 1993 to 1998, clusters of particularly high child mortality were identified in the population of the Nouna Health and Demographic Surveillance System (HDSS), a member of the INDEPTH Network. In this paper, we report child mortality with respect to temporal trends, spatial clustering and disparity in this HDSS from 1993 to 2012. Poisson regression was used to describe village-specific child mortality rates and time trends in mortality. The spatial scan statistic was used to identify villages or village clusters with higher child mortality. Clustering of mortality in the area is still present, but not as strong as before. The disparity of child mortality between villages has decreased. The decrease occurred in the context of an overall halving of child mortality in the rural area of Nouna HDSS between 1993 and 2012. Extrapolated to the Millennium Development Goals target period 1990-2015, this yields an estimated reduction of 54%, which is not too far off the aim of a two-thirds reduction.

An insecticide-treated bed-net campaign and childhood malaria in Burkina Faso.

OBJECTIVE: To investigate if the first national insecticide-treated bed-net campaign in Burkina Faso, done in 2010, was followed by a decrease in childhood malaria in a district with high baseline transmission of the disease. METHODS: We obtained data on the prevalence of Plasmodium falciparum parasitaemia in children aged 2 weeks to 36 months from malaria surveys in 2009 and 2011. We assessed morbidity in children younger than 5 years by comparing data from the Nouna health district's health management information system before and after the campaign in 2010. We analysed mortality data from 2008 to 2012 from Nouna's health and demographic surveillance system. FINDINGS: The bed-net campaign was associated with an increase in the reported use of insecticide-treated nets. In 2009, 73% (630/869) of children reportedly slept under nets. In 2011, 92% (449/487) did. The campaign had no effect on the proportion of young children with P. falciparum parasitaemia after the rainy season; 52% (442/858) in 2009 and 53% (263/499) in 2011. Cases of malaria increased markedly after the campaign, as did the number of children presenting with other diseases. The campaign was not associated with any changes in child mortality. CONCLUSION: The 2010 insecticide-treated net campaign in Burkina Faso was not associated with a decrease in care-seeking for malaria or all-cause mortality in children younger than 5 years. The most likely explanation is the high coverage of nets in the study area before the campaign which could have had an effect on mosquito vectors, limiting the campaign's impact.

Health insurance and child mortality in rural Burkina Faso.

BACKGROUND: Micro health insurance schemes have been implemented across developing countries as a means of facilitating access to modern medical care, with the ultimate aim of improving health. This effect, however, has not been explored sufficiently. OBJECTIVE: We investigated the effect of enrolment into community-based health insurance on mortality in children under 5 years of age in a health and demographic surveillance system in Nouna, Burkina Faso. DESIGN: We analysed the effect of health insurance enrolment on child mortality with a Cox regression model. We adjusted for variables that we found to be related to the enrolment in health insurance in a preceding analysis. RESULTS: Based on the analysis of 33,500 children, the risk of mortality was 46% lower in children enrolled in health insurance as compared to the non-enrolled children (HR=0.54, 95% CI 0.43-0.68) after adjustment for possible confounders. We identified socioeconomic status, father's education, distance to the health facility, year of birth, and insurance status of the mother at time of birth as the major determinants of health insurance enrolment. CONCLUSIONS: The strong effect of health insurance enrolment on child mortality may be explained by increased utilisation of health services by enrolled children; however, other non-observed factors cannot be excluded. Because malaria is a main cause of death in the study area, early consultation of health services in case of infection could prevent many deaths. Concerning the magnitude of the effect, implementation of health insurance could be a major driving factor of reduction in child mortality in the developing world.

Decreasing disparities in infant survival using surveillance data from Burkina Faso.

We assessed changes in the effect size of risk factors for infant mortality comparing a birth cohort from 2005 to 2010 with a birth cohort from 1993 to 1999 in the Nouna Health and Demographic Surveillance System (HDSS) in Burkina Faso. Single- and three-level Cox proportional hazards regression models were used for analysis. Independent variables among others included year of birth, ethnicity, religion, age of the mother, birth order, death of the mother, being a twin, and distance to the closest health facility. We observed an infant mortality rate of about 51/1,000 person-years. The strongest risk factors were death of the mother and being a twin, which were also the strongest risk factors from the previous analysis period. Compared with the period 1993-1999, the effect of most risk factors decreased, notably ethnicity, religious affiliation, distance to the closest health facility, birth order, and season of birth. The strongest reduction in mortality occurred in the groups with the previously highest infant mortality rates in 1993-1999.

Childhood mortality and its association with household wealth in rural and semi-urban Burkina Faso.

BACKGROUND: This study aimed to investigate the relationship between household wealth and under-5 year mortality in rural and semi-urban Burkina Faso. METHODS: The study included 15 543 children born between 2005 and 2010 in the Nouna Health and Demographic Surveillance System. Information on household wealth was collected in 2009. Two separate wealth indicators were calculated by principal components analysis for the rural and the semi-urban households, which were then divided into quintiles accordingly. Multivariable Cox proportional hazards regression was used to study the effect of the respective wealth measure on under-5 mortality. RESULTS: We observed 1201 childhood deaths, corresponding to 5-year survival probability of 93.6% and 88% in the semi-urban and rural area, respectively. In the semi-urban area, household wealth was significantly related to under-5 mortality after adjustment for confounding. There was a similar but non-significant effect of household wealth on infant mortality, too. There was no effect of household wealth on under-5 mortality in rural children. CONCLUSIONS: Results from this study indicate that the more privileged children from the semi-urban area with access to piped water and electricity have an advantage in under-5 survival, while under-5 mortality in the rural area is rather homogeneous and still relatively high.