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.

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.

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.

Beneficial effects of zinc supplementation on head circumference of Nepalese infants and toddlers: a randomized controlled trial.

BACKGROUND/OBJECTIVE: To assess the effects of micronutrient supplementation on head circumference of rural Nepali infants and children. SUBJECTS/METHODS: We used a randomized controlled trial to assess the effects of micronutrient supplementation on head circumference in 569 rural Nepali infants and children aged 4-17 months. Children were randomized to: (1) zinc, (2) iron-folic acid, (3) zinc plus iron-folic acid or (4) a placebo group. Data on head circumference were collected during five visits at ∼3 month intervals over the course of a year. We calculated change in head circumference in treatment groups receiving zinc and iron comparing the first and fifth visits as well as used generalized estimating equations (GEE) to take advantage of data from all points in time. Models were adjusted for covariates unbalanced in the randomization and for baseline head circumference. RESULTS: Estimating differences in head circumference between baseline and visit 5, children in the zinc treatment group showed smaller decreases in head circumference z-score compared with placebo (adjusted ß=0.13, 95% confidence interval (CI): 0.03 to 0.23). Using GEE, zinc treatment was associated with 0.11 (95% CI: 0.05 to 0.17) decrease in the rate of decline in head circumference z-score across visits as compared with placebo. Iron-folic acid supplementation was not associated with head circumference z-scores when comparing visits 1 with 5 or including data across all visits in adjusted models. CONCLUSION: Our results suggest that zinc supplementation confers a beneficial effect on the rate of head growth in Nepali infants.

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.

Supplementation with vitamin A early in life and subsequent risk of asthma.

Animal models suggest that vitamin A deficiency affects lung development adversely and promotes airway hyperresponsiveness, and may predispose to an increased risk of asthma. We examined the long-term effects of vitamin A supplementation early in life on later asthma risk. In 2006-2008, we revisited participants from two cohorts in rural Nepal who were enrolled in randomised trials of vitamin A supplementation. The first cohort received vitamin A or placebo for <16 months during their pre-school years (1989-1991). The second cohort was born to mothers who received vitamin A, ß-carotene or placebo before, during and after pregnancy (1994-1997). At follow-up, we asked about asthma symptoms and performed spirometry. Out of 6,421 subjects eligible to participate, 5,430 (85%) responded to our respiratory survey. Wheezing prevalence during the previous year was 4.8% in participants aged 9-13 yrs and 6.6% in participants aged 14-23 yrs. We found no differences between the vitamin A supplemented and placebo groups from either trial in the prevalence of lifetime or current asthma and wheeze or in spirometric indices of obstruction (p ≥ 0.12 for all comparisons). Vitamin A supplementation early in life was not associated with a decreased risk of asthma in an area with chronic vitamin A deficiency.

Breast-feeding initiation time and neonatal mortality risk among newborns in South India.

OBJECTIVE: To examine the association between breast-feeding initiation time and neonatal mortality in India, where breast-feeding initiation varies widely from region to region. STUDY DESIGN: Data were collected as part of a community-based, randomized, placebo-controlled trial of the impact of vitamin A supplementation in rural villages of Tamil Nadu, India. Multivariate binomial regression analysis was used to estimate the association between neonatal mortality and breast-feeding initiation time (<12 h, 12 to 24 h, >24 h) among infants surviving a minimum of 48 h. RESULT: Among 10 464 newborns, 82.1% were first breast-fed before 12 h, 13.8% were breast-fed between 12 and 24 h, and 4.1% were breast-fed after 24 h. After adjusting for birth weight, gestational age and other covariates, late initiators (>24 h) were at ∼78% higher risk of death (relative risk=1.78 (95% confidence interval (CI)=1.03 to 3.10)). There was no difference in mortality risk when comparing babies fed in the first 12 h compared with the second 1 h after birth. CONCLUSION: Late (>24 h) initiation of breast-feeding is associated with a higher risk of neonatal mortality in Tamil Nadu. Emphasis on breast-feeding promotion programs in low-resource settings of India where early initiation is low could significantly reduce neonatal mortality.

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.

Traditional birth attendants in rural Nepal: knowledge, attitudes and practices about maternal and newborn health.

Efforts to formalise the role of traditional birth attendants (TBAs) in maternal and neonatal health programmes have had limited success. TBAs' continued attendance at home deliveries suggests the potential to influence maternal and neonatal outcomes. The objective of this qualitative study was to identify and understand the knowledge, attitudes and practices of TBAs in rural Nepal. Twenty-one trained and untrained TBAs participated in focus groups and in-depth interviews about antenatal care, delivery practices, maternal complications and newborn care. Antenatal care included advice about nutrition and tetanus toxoid (TT) immunisation, but did not include planning ahead for transport in cases of complications. Clean delivery practices were observed by most TBAs, though hand-washing practices differed by training status. There was no standard practice to identify maternal complications, such as excessive bleeding, prolonged labour, or retained placenta, and most referred outside in the event of such complications. Newborn care practices included breastfeeding with supplemental feeds, thermal care after bathing, and mustard seed oil massage. TBAs reported high job satisfaction and desire to improve their skills. Despite uncertainty regarding the role of TBAs to manage maternal complications, TBAs may be strategically placed to make potential contributions to newborn survival.

The metabolic syndrome and retinal microvascular signs in a Japanese population: the Funagata study.

AIMS: To determine the relationship of metabolic syndrome and its components with retinopathy and other retinal microvascular signs in a Japanese population. METHODS: The Funagata study recruited 1961 (53.3% of eligible) Japanese aged 35 or older. The metabolic syndrome was diagnosed primarily using definitions of the International Diabetes Federation. Retinopathy and retinal microvascular signs were assessed from fundus photographs. Retinal arteriolar and venular diameters were measured using a computer-assisted programme. RESULTS: Data were available for analysis in 1638 persons for retinopathy and retinal microvascular signs and 921 persons for retinal vessel diameters. Various components of the metabolic syndrome were associated with retinal microvascular signs: a larger waist circumference was associated with wider venular diameter and retinopathy lesions; a higher blood pressure level was associated with focal arteriolar narrowing, arteriovenous nicking, enhanced arteriolar wall reflex and narrower arteriolar diameter; and a higher triglyceride level was associated with enhanced arteriolar wall reflex. Overall, persons with the metabolic syndrome were more likely to have retinopathy (odds ratio 1.64, 95% CI: 1.02 to 2.64) and wider venular diameter 4.69 microm (95% CI: 1.20 to 8.19 microm) than persons without the metabolic syndrome. CONCLUSION: We report associations of metabolic syndrome components with retinopathy and wider venular diameter in Japanese adults. These data suggest that metabolic abnormalities, indicated by metabolic syndrome components, are associated with microvascular changes in the retina. There was no synergistic effect of the metabolic syndrome on retinal microvascular changes beyond its individual components.

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.

Measurement of blood loss at childbirth and postpartum.

OBJECTIVE: To accurately measure blood loss during childbirth in a developing country. METHOD: The alkaline hematin technique was used to quantify blood lost during delivery and 24 h postpartum in 158 women in Pemba Island, Zanzibar. RESULT: Women were found to lose less blood during childbirth and 24 h postpartum than previously reported. Compared with laboratory values, nurse-midwives approximated blood loss accurately (mean difference, i.e., mean underestimation by nurse-midwives, 4.90 mL); however, their imprecision was greater for higher laboratory values. CONCLUSION: This study may prompt further investigation, as no comparable data exist for developing countries where maternal mortality is high and severe anemia prevalent.

A low cost, colour coded, hand held spring scale accurately categorises birth weight in low resource settings.

AIMS: To determine the accuracy of a low cost, spring calibrated, hand held scale in classifying newborns into three weight categories (> or =2500 g, 2000-2499 g, <2000 g). METHODS: The test device was compared to a gold standard digital baby scale with precision to 2 g. In Sarlahi district, Nepal, 1890 newborns were eligible for the study. Measurements were collected for both the test device and the digital scale from 1820 (96.3%) newborns. RESULTS: The overall low birth weight (LBW) prevalence rate for the gold standard digital scale was 28.1% (511/1820). Sensitivity (93.7%) and specificity (97.6%) of the test device was high compared to LBW classifications based on digital weight measurements. Classification of infants into the <2000 g category was 5.0% and 4.7% for the gold standard and test device, respectively. Sensitivity and specificity of the test device in identifying infants <2000 g was 87.8% and 99.6%, respectively. Positive predictive values were high (>91%) for both weight categories CONCLUSIONS: This low cost, simple-to-use device classified infants into weight categories with a high degree of consistency and accuracy that exceeds that of surrogate measures. This new device is useful for identifying and targeting life saving interventions for LBW, high risk infants in settings where infants are born in the home and conventional weighing scales are unavailable.

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.

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.

Risk factors for age related cataract in a rural population of southern India: the Aravind Comprehensive Eye Study.

AIM: To determine risk factors for lens opacities and age related cataract in an older rural population of southern India. METHODS: A cross sectional population based study of 5150 people aged 40 years and above from 50 clusters from three districts in southern India. The lens was graded and classified after dilation using LOCS III system at the slit lamp for cataract. Definite cataract was defined as nuclear opalescence >/=3.0 and/or cortical cataract >/=3.0 and/or PSC >/=2.0. RESULTS: Definite cataracts were found in 2449 (47.5%) of 5150 subjects and the prevalence of cataract increased with age. The age adjusted prevalence of cataract was significantly lower in males (p = 0.0002). Demographic risk factors-increasing age and illiteracy-were common for the three subtypes of cataract; females were more likely to have cortical cataracts and nuclear cataracts. Additionally, nuclear cataracts were associated with moderate smoking (OR:1.28, 95% CI:1.01 to 1.64), lean body mass indices (OR: 1.37, 95% CI: 1.17 to 1.59) and higher waist to hip ratios (OR: 0.67, 95% CI: 0.54 to 0.82); cortical cataracts with hypertension (OR: 1.39 95% CI:1.11 to 1.72), pseudoexfoliation (OR:1.53,95% CI:1.17 to 2.01), and moderate to heavy smoking; and posterior subcapsular cataracts with diabetes (OR:1.55, 95% CI:1.12 to 2.15), lean body mass (OR:1.32, 95% CI:1.11 to 1.57), and high waist to hip ratios (OR: 0.77, 95% CI: 0.62 to 0.94). CONCLUSIONS: Risk factors for age related cataract in this population do not appear to be different from those reported in other populations. Further studies are required to identify the reason for the high prevalence of age related cataract and to understand better the role of each risk factor for cataractogenesis in this population.

Retinal microvascular abnormalities and blood pressure in older people: the Cardiovascular Health Study.

AIM: To examine the relation between blood pressure and retinal microvascular abnormalities in older people. METHODS: The Cardiovascular Health Study is a prospective cohort study conducted in four US communities initiated in 1989 to 1990. Blood pressure was measured according to standardised protocols at each examination. During the 1997-8 examination, retinal photographs were taken of 2405 people aged 69-97 years (2056 without diabetes and 349 with diabetes). Signs of focal microvascular abnormalities (focal arteriolar narrowing, arteriovenous nicking, and retinopathy) were evaluated from photographs according to standardised methods. To quantify generalised arteriolar narrowing, the photographs were digitised and diameters of individual arterioles were measured and summarised. RESULTS: In non-diabetic people, elevated concurrent blood pressure taken at the time of retinal photography was strongly associated with presence of all retinal microvascular lesions. The multivariable adjusted odds ratios, comparing the highest to lowest quintile of concurrent systolic blood pressure, were 4.0 (95% confidence intervals (CI): 2.4 to 6.9, p test of trend<0.001) for focal arteriolar narrowing, 2.9 (95% CI: 1.6 to 5.3, p<0.001) for arteriovenous nicking, 2.8 (95% CI: 1.5 to 5.2, p<0.001) for retinopathy, and 2.1 (95% CI: 1.4 to 3.1, p<0.001) for generalised arteriolar narrowing. Generalised arteriolar narrowing and possibly arteriovenous nicking were also significantly associated with past blood pressure measured up to 8 years before retinal photography, even after adjustment for concurrent blood pressure. These associations were somewhat weaker in people with diabetes. CONCLUSIONS: Retinal microvascular abnormalities are related to elevated concurrent blood pressure in older people. Additionally, generalised retinal arteriolar narrowing and possibly arteriovenous nicking are related to previously elevated blood pressure, independent of concurrent blood pressure. These data suggest that retinal microvascular changes reflect severity and duration of hypertension.

VF-14 item specific responses in patients undergoing first eye cataract surgery: can the length of the VF-14 be reduced?

AIMS: To report the item specific responses of the VF-14 in a population of patients undergoing cataract surgery in their first eye and to determine whether or not the VF-14 can be reduced without compromising its performance as an index of cataract related visual impairment. METHODS: The item specific responses to the VF-14 were analysed before (771 patients) and 4 months after (552 patients) cataract surgery in one eye to determine if the VF-14 index can be reduced without compromising its performance. Patients studied were selected from a cross sectional longitudinal study of patients undergoing cataract surgery in 72 ophthalmologist's offices located in three metropolitan regions of the United States. RESULTS: Pairwise correlations between items in the VF-14 were all less than 0.6, indicating that no items could be removed solely on the basis of redundancy. 10 items correlated moderately with change in trouble, and 11 correlated moderately with change in satisfaction (r >0.15) at 4 months after cataract extraction. Eleven items demonstrated an effect size >0.4 at 4 months. These 11 items were either important for detecting cataract related functional disability or for quantifying the extent to which cataract impaired function. Additionally, 11 items were needed to detect adequately individuals with functional impairment. Three items (recognising people, cooking, and reading large print) were less responsive to cataract extraction and were more strongly associated with ocular comorbidities. CONCLUSIONS: While previous reports indicate that the VF-14 can be significantly shortened, our analysis only justifies removing three items. While the resulting VF-11 has properties similar to the VF-14, the limited time savings do not justify altering this already validated instrument.

Nasopharyngeal carriage of resistant pneumococci in young South Indian infants.

Streptococcus pneumoniae is the leading bacterial cause of life-threatening infections in infants. Although antibiotic resistance affects management of pneumococcal infections, few data on patterns of resistance are available for India. We examined nasopharyngeal carriage of antibiotic-resistant pneumococci in 464 South Indian infants between 2 and 6 months. Newly acquired serotypes were screened for susceptibility to cotrimoxazole, erythromycin and penicillin using disk diffusion. Cumulative prevalence of pneumococcal carriage rose from 53.9% at 2 months to 70.2% at 6 months. The prevalence of strains that were not susceptible to penicillin, cotrimoxazole and erythromycin was 34, 81.1 and 37.2%, respectively. Carriage of erythromycin non-susceptible strains declined significantly between ages 4 months and 6 months (44.1 vs. 10.7%). More than 87% of the isolates screened were non-susceptible to > or = 1 antibiotic. Serogroups/types that were most frequently non-susceptible to 1 or more antibiotics were 6, 9, 14, 19 and 23. Less than 1% of the isolates were multi-drug resistant. Widespread use of antibiotics in South India has resulted in S. pneumoniae becoming non-susceptible to some commonly used antibiotics. Monitoring trends in antibiotic susceptibility and making antibiotics available only through prescription from a health care worker may slow the spread of resistant pneumococci and improve management of pneumococcal infections in South India.

Effects of iron supplementation and anthelmintic treatment on motor and language development of preschool children in Zanzibar: double blind, placebo controlled study.

OBJECTIVE: To measure the effects of iron supplementation and anthelmintic treatment on iron status, anaemia, growth, morbidity, and development of children aged 6-59 months. DESIGN: Double blind, placebo controlled randomised factorial trial of iron supplementation and anthelmintic treatment. SETTING: Community in Pemba Island, Zanzibar. PARTICIPANTS: 614 preschool children aged 6-59 months. MAIN OUTCOME MEASURES: Development of language and motor skills assessed by parental interview before and after treatment in age appropriate subgroups. RESULTS: Before intervention, anaemia was prevalent and severe, and geohelminth infections were prevalent and light-Plasmodium falciparum infection was nearly universal. Iron supplementation significantly improved iron status, but not haemoglobin status. Iron supplementation improved language development by 0.8 (95% confidence interval 0.2 to 1.4) points on the 20 point scale. Iron supplementation also improved motor development, but this effect was modified by baseline haemoglobin concentrations (P=0.015 for interaction term) and was apparent only in children with baseline haemoglobin concentrations <90 g/l. In children with a baseline haemoglobin concentration of 68 g/l (one standard deviation below the mean value), iron treatment increased scores by 1.1 (0.1 to 2.1) points on the 18 point motor scale. Mebendazole significantly reduced the number and severity of infections caused by Ascaris lumbricoides and Trichuris trichiura, but not by hookworms. Mebendazole increased development scores by 0.4 (-0.3 to 1.1) points on the motor scale and 0.3 (-0.3 to 0.9) points on the language scale. CONCLUSIONS: Iron supplementation improved motor and language development of preschool children in rural Africa. The effects of iron on motor development were limited to children with more severe anaemia (baseline haemoglobin concentration <90 g/l). Mebendazole had a positive effect on motor and language development, but this was not statistically significant.