Measles complications: the importance of their management in reducing mortality attributed to measles

A clinical study of the effects and management of measles in Zimbabwean children.Measles is among the commonest and most serious disease conditions in childhood accounting for an estimated 1.4 million measles deaths annually.1-2 However, in recent years measles deaths have been declining world wide. This decline has been attributed to many factors including improved care of complicated cases.2 In the city of Gweru, Zimbabwe, mortality attributed to measles has been declining since 1967.3 This paper examines the occurrence of complicated measles in Gweru and the effect of the care of these cases on measles mortality in the period 1967 to 89

Calcium supplementation commencing before or early in pregnancy, or food fortification with calcium, for preventing hypertensive disorders of pregnancy

Background Pre-eclampsia is considerably more prevalent in low- than high-income countries. One possible explanation for this discrepancy is dietary diKerences, particularly calcium deficiency. Calcium supplementation in the second half of pregnancy reduces the serious consequences of pre-eclampsia and is recommended by the WorldHealthOrganization (WHO) for women with low dietary calcium intake, but has limited eKect on the overallrisk of pre-eclampsia. It is important to establish whether calcium supplementation before and in early pregnancy has added benefit. Such evidence would be justification for population-level fortification of staple foods with calcium. Objectives To determine the eKect of calcium supplementation or food fortification with calcium, commenced before or early in pregnancy and continued at least until mid-pregnancy, on pre-eclampsia and other hypertensive disorders, maternal morbidity and mortality, as well as fetal and neonatal outcomes. Search methods We searched the Cochrane Pregnancy and Childbirth Trials Register (10 August 2017), PubMed (29 June 2017), ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (10 August 2017) and reference lists of retrieved studies. Selection criteria Randomised controlled trials of calcium supplementation orfood fortification which include women of child bearing age not yet pregnant, or in early pregnancy. Cluster-RCTs, quasi-RCTs and trials published in abstract form only would have been eligible for inclusion in this review but none were identified. Cross-over designs are not appropriate for this intervention. The scope of this review is to consider interventions including calcium supplementation with or without additional supplements or treatments, compared with placebo or no intervention. Data collection and analysis Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. Main results This review is based on one RCT (involving 60 women) which looked at calcium plus additional supplements versus control. The women (who had lowantioxidant status)were in the early stages of pregnancy.We did notidentify any studieswhere supplementation commenced pre-pregnancy. Another RCT comparing calcium versus placebo is ongoing but not yet complete. We did not identify any studies looking at any of our other planned comparisons. Calcium plus antioxidants and other supplements versus placebo We included one small study (involving 60 women with low antioxidantlevels) which was conducted in an academic hospital in Indondesia. The study was at low risk of bias for all domains with the exception of selective reporting, for which it was unclear. Women in the intervention group received calcium (800 mg) plus N-acetylcysteine (200 mg), Cu (2 mg), Zn (15 mg), Mn (0.5 mg) and selenium (100 mcg) and vitamins A (1000 IU), B6 (2.2 mg), B12 (2.2 mcg), C (200 mg), and E (400 IU) versus the placebo control group of women who received similar looking tablets containing iron and folic acid. Both groups received iron (30 mg) and folic acid (400 mcg). Tablets were taken twice daily from eight to 12 weeks of gestation and then throughout pregnancy. The included study found that calcium supplementation plus antioxidants and other supplements may slightly reduce pre-eclampsia (gestational hypertension and proteinuria) (risk ratio (RR) 0.24, 95% confidence interval (CI) 0.06 to 1.01; low-quality evidence), but this is uncertain due to wide confidence intervals just crossing the line of no eKect, and small sample size. It appears that earlypregnancy loss before 20 weeks' gestation (RR 0.06, 95% CI 0.00 to 1.04; moderate-quality evidence) may be slightly reduced by calcium plus antioxidants and other supplements, but this outcome also has wide confidence intervals, which just cross the line of no eKect. Very few events were reported under the composite outcome, severe maternal morbidity and mortality index and no clear diKerence was seen between groups (RR 0.36, 95% CI 0.04 to 3.23; low-quality evidence). However, the included study observed a reduction in the composite outcome pre-eclampsia and/or pregnancy loss at any gestational age (RR 0.13, 95% CI 0.03 to 0.50; moderate-quality evidence), and pregnancy loss/stillbirth at any gestational age (RR 0.06, 95% CI 0.00 to 0.92;moderate-quality evidence)in the calcium plus antioxidant/supplement group. Other outcomes reported (placental abruption, severe pre-eclampsia and preterm birth (less than 37 weeks' gestation)) were too infrequent for meaningful analysis. No data were reported for the outcomes caesarean section, birthweight less 2500 g, Apgar score less than seven at five minutes, death or admission to neonatal intensive care unit (ICU), or pregnancy loss, stillbirth or neonatal death before discharge from hospital. Authors' conclusions The results of this review are based on one small study in which the calcium intervention group also received antioxidants and other supplements. Therefore, we are uncertain whether any of the eKects observed in the study were due to calcium supplementation or not. The evidence in this review was graded low to moderate due to imprecision. There is insuKicient evidence on the eKectiveness or otherwise of pre- or early-pregnancy calcium supplementation, or food fortification for preventing hypertensive disorders of pregnancy. Furtherresearch is needed to determine whether pre- or early-pregnancy supplementation, orfood fortification with calcium is associated with a reduction in adverse pregnancy outcomes such as pre-eclampsia and pregnancy loss. Such studies should be adequately powered, limited to calcium supplementation, placebo-controlled, and include relevant outcomes such as those chosen for this review. There is one ongoing study of calcium supplementation alone versus placebo and this may provide additional evidence in future update

Participant recruitment and retention in longitudinal preconception randomized trials: lessons learnt from the Calcium And Pre-eclampsia (CAP) trial.

BACKGROUND: The preconception period has the potential to influence pregnancy outcomes and randomized controlled trials (RCTs) are needed to evaluate a variety of potentially beneficial preconception interventions. However, RCTs commencing before pregnancy have significant participant recruitment and retention challenges. The Calcium And Pre-eclampsia trial (CAP trial) is a World Health Organization multi-country RCT of calcium supplementation commenced before pregnancy to prevent recurrent pre-eclampsia in which non-pregnant participants are recruited and followed up until childbirth. This sub-study explores recruitment methods and preconception retention of participants of the CAP trial to inform future trials. METHODS: Recruiters at the study sites in Argentina, South Africa and Zimbabwe completed post-recruitment phase questionnaires on recruitment methods used. Qualitative data from these questionnaires and quantitative data on pre-pregnancy trial visit attendance and pregnancy rates up to September 2016 are reported in this paper. RStudio (Version 0.99.903 https://www.rstudio.org ) statistical software was used for summary statistics. RESULTS: Between July 2011 and 8 September 2016, 1354 women with previous pre-eclampsia were recruited. Recruitment took 2 years longer than expected and was facilitated mainly through medical record/register and maternity ward/clinic-based strategies. Recruiters highlighted difficulties associated with inadequate medical records, redundant patient contact details, and follow-up of temporarily ineligible women as some of the challenges faced. Whilst the attendance rates at pre-pregnancy visits were high (78% or more), visits often occurred later than scheduled. Forty-five percent of participants became pregnant (614/1354), 33.5% (454/1354) within 1 year of randomization. CONCLUSIONS: In preconception trials, both retrospective and prospective methods are useful for recruiting eligible women with certain conditions. However, these are time-consuming in low-resource settings with suboptimal medical records and other challenges. Trial planners should ensure that trial budgets cover sufficient on-site researchers with pre-trial training, and should consider using mobile phone and web-based electronic tools to optimize recruitment and retention. This should lead to greater efficiency and shorter trial durations. TRIAL REGISTRATION: Pan-African Clinical Trials Registry, Registration Number: PACTR201105000267371 . The trial was registered on 6 December 2016

Long-term changes in organic matter of woodland soils cleared for arable cropping in Zimbabwe

Subsistence farmers in Africa depend largely on the soil organic matter to sustain crop productivity. Long-term changes in soil organic carbon and nitrogen were measured after woodland clearance for smallholder subsistence farming or for commercial farming. The contents of organic carbon and nitrogen in soil under reference woodlands were largest (53.3 t C ha-1, 4.88 t N ha-1) in a red clay soil (~ 50% clay + silt), followed by a granitic sand (~ 12% clay + silt; 22.8 t C ha-1, 1.47 t N ha -1) and least (19.5 t C ha-1, 0.88 t N ha-1) in a Kalahari sand (~ 5% clay + silt). Organic carbon declined rapidly under cultivation to attain new equilibria within 10 years on all smallholdings. Greatest losses occurred in soils that initially contained most carbon and nitrogen in the order: red clay (22.4 t C ha-1 and 1.0 t N ha -1) > granitic sand (13.2 t C ha-1 and 0.8 t N ha -1) > Kalahari sand (10.6 t C ha-1 and 0.5 t N ha -1). On the clay soil, commercial farming with intensive use of mineral fertilizers and incorporation of maize stover led to more gradual decline: at equilibrium, contents of carbon and nitrogen were 15 t C ha -1 and 1.7 t N ha-1 greater than on smallholdings with similar soil and climate. In the Kalahari sand the ¿13C of organic C remained constant after woodland clearance, and maize contributed less than 10% of the total C even after 55 years. The ¿13C signature increased slightly with increasing duration of cultivation by smallholders in the granitic sands and red clay soil where maize contributed 29% and 35% of the C at equilibrium. Under more productive commercial farming, the carbon derived from maize accounted for 50% of the total after 10 years of cultivation and 67% at equilibrium. The persistence of woodland carbon in the sandy soil is attributed to chemical stabilization resulting from large concentrations of lignin and polyphenols in the tree litter, or as charcoal

FACTORS ASSOCIATED WITH MEASLES COMPLICATIONS IN GWERU, ZIMBABWE

Objective: To investigate factors associated with complications or death among measles cases.Design: A cross-sectional study.Setting: Health facilities in the city of Gweru, Zimbabwe.Subjects: Six hundred and thirty seven measles cases randomly selected from measlessurveillance data.Main outcome measures: (a) Associations of respiratory complications and diarrhoea withdeath among complicated cases; (b) associations of age at infection, gender of cases andvaccination status of cases with occurrence of either respiratory complications or diarrhoeaor death among measles cases.Results: Among cases with respiratory complications, twenty two (29%) had died, while five(5%)had died among those with diarrhoea (OR=7.06,95% CI=2.55-22.35, p<0.001). On ratesof respiratory complications among cases, age groups 24-59 and 60+ months were protectiveby 57% (95% CI=ll-79%) and 76% (95% CI=52-88%) respectively compared to the agegroup <24 months, and vaccination was protective by 42% (95% CI=2-65%) compared tothose unvaccinated. Concerning rates of diarrhoea among cases, the age group 60+ monthswas protective by 80% (95% CI=62-89%) compared to age group <60 months, whilevaccination was protective by 64% (95% CI=42-77%) compared to those unvaccinated. Withrespect to rates of mortality among cases, age was protective by six per cent (95% CI=3-9%)for every year older.Conclusion: It was concluded that: (a) the risk of death was higher in cases with respiratorycomplications than diarrhoea; (b) the risk of complications and death was inversely related toage at infection and older age groups were protective against occurrence of complications ordeath; (c) the risk of complications was higher in unvaccinated cases and vaccination wasprotective against occurrence of complications

The effect of calcium supplementation on blood pressure in non-pregnant women with previous pre-eclampsia: An exploratory, randomized placebo controlled study

Background Epidemiological findings suggest that the link between poverty and pre-eclampsia might be dietary calcium deficiency. Calcium supplementation has been associated with a modest reduction in pre-eclampsia, and also in blood pressure (BP). Methods This exploratory sub-study of the WHO Calcium and Pre-eclampsia (CAP) trial aims to determine the effect of 500 mg/day elemental calcium on the blood pressure of non-pregnant women with previous pre-eclampsia. Non-pregnant women with at least one subsequent follow-up trial visit at approximately 12 or 24 weeks after randomization were included. Results Of 836 women randomized by 9 September 2014, 1st visit data were available in 367 women of whom 217 had previously had severe pre-eclampsia, 2nd visit data were available in 201 women. There was an overall trend to reduced BP in the calcium supplementation group (1-2.5 mmHg) although differences were small and not statistically significant. In the subgroup with previous severe pre-eclampsia, the mean diastolic BP change in the calcium group (-2.6 mmHg) was statistically larger than in the placebo group (+0.8 mmHg), (mean difference -3.4, 95% CI -0.4 to -6.4; p = 0.025). The effect of calcium on diastolic BP at 12 weeks was greater than in those with non-severe pre-eclampsia (p = 0.020, ANOVA analysis). Conclusions There is an overall trend to reduced BP but only statistically significant in the diastolic BP of women with previous severe pre-eclampsia. This is consistent with our hypothesis that this group is more sensitive to calcium supplementation, however results need to be interpreted with caution.Fil: Hofmeyr, G. J.. University of the Witwatersrand; SudáfricaFil: Seuc, A. H.. World Health Organization; SuizaFil: Betrán, A. P.. World Health Organization; SuizaFil: Purnat, T. D.. World Health Organization; DinamarcaFil: Ciganda, Álvaro. Instituto de Efectividad Clínica y Sanitaria; ArgentinaFil: Munjanja, S. P.. University of Zimbabwe; ZimbabueFil: Manyame, S.. University of Zimbabwe; ZimbabueFil: Singata, M.. Fort Hare University; SudáfricaFil: Fawcus, S.. University of Cape Town; Sudáfrica. Mowbray Maternity Hospital; SudáfricaFil: Frank, K.. University of the Witwatersrand; SudáfricaFil: Hall, D. R.. Stellenbosch University; Sudáfrica. Tygerberg Hospital; SudáfricaFil: Cormick, Gabriela. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. Centro de Investigaciones en Epidemiología y Salud Pública. Instituto de Efectividad Clínica y Sanitaria. Centro de Investigaciones en Epidemiología y Salud Pública; ArgentinaFil: Roberts, J. M.. University of Pittsburgh; Estados UnidosFil: Bergel, Eduardo F.. Instituto de Efectividad Clínica y Sanitaria; ArgentinaFil: Drebit, S.K.. University of British Columbia; CanadáFil: von Dadelszen, P.. University of British Columbia; CanadáFil: Belizan, Jose. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. Centro de Investigaciones en Epidemiología y Salud Pública. Instituto de Efectividad Clínica y Sanitaria. Centro de Investigaciones en Epidemiología y Salud Pública; ArgentinaFil: Calcium and Pre-eclampsia Study Group. No especifica