[Improvement of child survival in Mexico: the diagonal approach]. / Aumento de la sobrevida en menores de cinco años en México: la estrategia diagonal.

Public health interventions aimed at children in Mexico have placed the country among the seven countries on track to achieve the goal of child mortality reduction by 2015. We analysed census data, mortality registries, the nominal registry of children, national nutrition surveys, and explored temporal association and biological plausibility to explain the reduction of child, infant, and neonatal mortality rates. During the past 25 years, child mortality rates declined from 64 to 23 per 1000 livebirths. A dramatic decline in diarrhoea mortality rates was recorded. Polio, diphtheria, and measles were eliminated. Nutritional status of children improved significantly for wasting, stunting, and underweight. A selection of highly cost-effective interventions bridging clinics and homes, what we called the diagonal approach, were central to this progress. Although a causal link to the reduction of child mortality was not possible to establish, we saw evidence of temporal association and biological plausibility to the high level of coverage of public health interventions, as well as significant association to the investments in women education, social protection, water, and sanitation. Leadership and continuity of public health policies, along with investments on institutions and human resources strengthening, were also among the reasons for these achievements.

Aumento de la sobrevida en menores de cinco años en México: la estrategia diagonal / Improvement of child survival in Mexico: the diagonal approach

Las intervenciones en salud pública dirigidas a niños en México han ubicado a este país entre los siete países encaminados a cumplir las metas de reducción de la mortalidad infantil para 2015. La información para este estudio se ha tomado de diferentes fuentes: los censos poblacionales; los registros de mortalidad de la Secretaría de Salud y del Instituto Nacional de Estadística, Geografía e Informática; el registro nominal de niños recolectado por el Programa de Vacunación Universal; y las encuestas nacionales de nutrición. Con estos datos se estudió la asociación temporal y la plausibilidad biológica de las diferentes intervenciones en salud pública, para explicar la reducción de las tasas de mortalidad entre niños, infantes y recién nacidos. Las tasas de mortalidad en menores de cinco años han descendido de casi 64 muertes a menos de 23 por cada 1 000 niños nacidos vivos registrados en los últimos 25 años. Se observó una reducción drástica en las tasas de mortalidad por diarrea, junto con la eliminación de polio, difteria y sarampión. El estado nutricional de los niños mejoró de manera significativa en cuanto a bajo peso para la talla, baja talla para la edad y bajo peso para la edad. En los últimos 25 años, se mantuvieron intervenciones altamente costo-efectivas que acercaron los servicios de salud de atención primaria a los hogares, lo que aquí se ha llamado estrategia diagonal. A pesar de que no es posible establecer una relación de causalidad entre la reducción de la mortalidad en menores de cinco años y los factores investigados, se presenta evidencia basada en la asociación temporal y en la plausibilidad biológica que indica que la alta cobertura de las intervenciones de salud pública, los avances en educación de las mujeres, protección social, disponibilidad de agua potable y saneamiento, así como nutrición, impactaron en el resultado observado. Por otro lado, el liderazgo y la continuidad de las políticas de salud pública junto...

Public health interventions aimed at children in Mexico have placed the country among the seven countries on track to achieve the goal of child mortality reduction by 2015. We analysed census data, mortality registries, the nominal registry of children, national nutrition surveys, and explored temporal association and biological plausibility to explain the reduction of child, infant, and neonatal mortality rates. During the past 25 years, child mortality rates declined from 64 to 23 per 1000 livebirths. A dramatic decline in diarrhoea mortality rates was recorded. Polio, diphtheria, and measles were eliminated. Nutritional status of children improved significantly for wasting, stunting, and underweight. A selection of highly cost-effective interventions bridging clinics and homes, what we called the diagonal approach, were central to this progress. Although a causal link to the reduction of child mortality was not possible to establish, we saw evidence of temporal association and biological plausibility to the high level of coverage of public health interventions, as well as significant association to the investments in women education, social protection, water, and sanitation. Leadership and continuity of public health policies, along with investments on institutions and human resources strengthening, were also among the reasons for these achievements.

Aerosolized measles and measles-rubella vaccines induce better measles antibody booster responses than injected vaccines: randomized trials in Mexican schoolchildren.

OBJECTIVE: To compare antibody responses and side-effects of aerosolized and injected measles vaccines after revaccination of children enrolling in elementary schools. METHODS: Vaccines for measles (Edmonston-Zagreb) or measles-rubella (Edmonston-Zagreb with RA27/3) were given by aerosol or injection to four groups of children. An additional group received Schwarz measles vaccine by injection. These five groups received vaccines in usual standard titre doses. A sixth group received only 1000 plaque-forming units of Edmonston-Zagreb vaccine by aerosol. The groups were randomized by school. Concentrations of neutralizing antibodies were determined in blood specimens taken at baseline and four months after vaccination from randomized subgroups (n = 28-31) of children in each group. FINDINGS: After baseline antibody titres were controlled for, the frequencies of fourfold or greater increases in neutralizing antibodies did not differ significantly between the three groups that received vaccine by aerosol (range 52%-64%), but they were significantly higher than those for the three groups that received injected vaccine (range 4%-23%). Mean increases in titres and post-vaccination geometric mean titres paralleled these findings. Fewer side-effects were noted after aerosol than injection administration of vaccine. CONCLUSION: Immunogenicity of measles vaccine when administered by aerosol is superior to that when the vaccine is given by injection. This advantage persists with aerosolized doses less than or equal to one-fifth of usual injected doses. The efficacy and cost-effectiveness of measles vaccination by aerosol should be further evaluated in mass campaigns.