Estimates of measles case fatality ratios: a comprehensive review of community-based studies.

BACKGROUND: Global deaths from measles have decreased notably in past decades, due to both increases in immunization rates and decreases in measles case fatality ratios (CFRs). While some aspects of the reduction in measles mortality can be monitored through increases in immunization coverage, estimating the level of measles deaths (in absolute terms) is problematic, particularly since incidence-based methods of estimation rely on accurate measures of measles CFRs. These ratios vary widely by geographic and epidemiologic context and even within the same community from year-to-year. METHODS: To understand better the variations in CFRs, we reviewed community-based studies published between 1980 and 2008 reporting age-specific measles CFRs. RESULTS: The results of the search consistently document that measles CFRs are highest in unvaccinated children under age 5 years; in outbreaks; the lowest CFRs occur in vaccinated children regardless of setting. The broad range of case and death definitions, study populations and geography highlight the complexities in extrapolating results for global public health planning. CONCLUSIONS: Values for measles CFRs remain imprecise, resulting in continued uncertainty about the actual toll measles exacts

Lower mortality for female-female twins than male-male and male-female twins in rural Senegal

Twins have been registered prospectively for 12–22 years in 42 small villages in the Bandafassi area of Eastern Senegal. We studied 98 pairs of twins to test whether twins in opposite-sex pairs have higher postneonatal mortality than same-sex twins. Neonatal mortality for twins was 41.3%; mortality for infants and for children under age 5 years was 53.0% and 66.8%, respectively. Neonatal mortality was identical for same-sex and opposite-sex twin pairs, but much higher for boys than girls [relative risk = 1.8; 95% confidence interval (CI) = 1.2–2.6]. There was clustering of double neonatal deaths for all types of twins. In the postneonatal period, female-female twins had lower mortality than other twin types. Twins had higher postneonatal mortality as long as the co-twin was alive [mortality rate ratio (MR) = 2.6; 95% CI = 1.0–6.7]. Girls had excess mortality when the co-twin was of the opposite sex (MR = 4.3; 95% CI = 1.2–15.3), whereas there was no difference for boys. In conclusion, contact with a co-twin of the opposite sex increased child mortality for female twins. Our data are not sufficient to determine whether this difference is specific for girls or applies to boys as well

Temporal trends (1977-2007) and ethnic inequity in child mortality in rural villages of southern Guinea Bissau

Background Guinea Bissau is one of the poorest countries in the world, with one of the highest under-5 mortality rate. Despite its importance for policy planning, data on child mortality are often not available or of poor quality in low-income countries like Guinea Bissau. Our aim in this study was to use the baseline survey to estimate child mortality in rural villages in southern Guinea Bissau for a 30 years period prior to a planned cluster randomised intervention. We aimed to investigate temporal trends with emphasis on historical events and the effect of ethnicity, polygyny and distance to the health centre on child mortality. Methods A baseline survey was conducted prior to a planned cluster randomised intervention to estimate child mortality in 241 rural villages in southern Guinea Bissau between 1977 and 2007. Crude child mortality rates were estimated by Kaplan-Meier method from birth history of 7854 women. Cox regression models were used to investigate the effects of birth periods with emphasis on historical events, ethnicity, polygyny and distance to the health centre on child mortality. Results High levels of child mortality were found at all ages under five with a significant reduction in child mortality over the time periods of birth except for 1997-2001. That period comprises the 1998/99 civil war interval, when child mortality was 1.5% higher than in the previous period. Children of Balanta ethnic group had higher hazard of dying under five years of age than children from other groups until 2001. Between 2002 and 2007, Fula children showed the highest mortality. Increasing walking distance to the nearest health centre increased the hazard, though not substantially, and polygyny had a negligible and statistically not significant effect on the hazard. Conclusion Child mortality is strongly associated with ethnicity and it should be considered in health policy planning. Child mortality, though considerably decreased during the past 30 years, remains high in rural Guinea Bissau. Temporal trends also suggest that civil wars have detrimental effects on child mortality. Trial Registration Current Controlled Trials ISRCTN5243333

MRI and clinical resolution of a suspected intracranial toxoplasma granuloma with medical treatment in a domestic short hair cat

A two-year-old cat was presented with a left paradoxical vestibular syndrome. MRI of the brain revealed an extra-axial homogenously contrast enhancing mass in the region of the left caudal cerebellar peduncle. Toxoplasma serology was consistent with active infection and the lesion was suspected to be a toxoplasma granuloma. Following eight weeks of tapering oral prednisolone and 11 weeks of oral clindamycin treatment, repeat MRI revealed resolution of the lesion. Eighteen months after initial diagnosis, the cat remained neurologically normal. Differential diagnoses for a solitary, extra-axial, contrast enhancing mass lesion in the feline brain should include toxoplasma granuloma, which can undergo MRI and clinical resolution with medical treatment

Child mortality following standard, medium or high titre measles immunization in West Africa

The World Health Organization (WHO) recommended the use of high titre measles vaccine in 1989. Subsequent long term follow-up of several trials yielded results suggesting higher mortality among children inoculated with medium and high titre vaccines compared to standard titre vaccines, although none of the individual trials found significant differences in mortality. Long term survival after standard, medium and high titre measles vaccines has been investigated in a combined analysis of all West African trials with mortality date. In trials from Guinea-Bissau, The Gambia and Senegal, children received medium or high titre vaccines from 4 months of age and were compared to control groups recruited at the same time later receiving standard titre vaccine from 9 months of age. All children were followed up to at least 3 years old. Combining trials of high titre vaccines showed higher mortality among the high titre group compared to the standard group : mortality ratio (MR) = 1.33 (95 % CI : 1.02-1.73). Mortality among recipients of medium titre vaccines was not different from that in the standard vaccine group, MR = 1.11 (95 % CI : 0.54-2,27). In a combined analysis by sex, the adjusted mortality ratios comparing high titre vaccine with standard vaccine were 1.86 ( 95 % CI : 1.28-2.70) for females and 0.91 ( 95 % CI : 0.61-1.35) for males. The trials were not designed to study long term mortality. Adjustments for several possible sources of bias did not alter the results. The combined analysis showed a decreased survival related to hith titre measles vaccine compared with standard titre vaccines, though solely among females. As a result of these studies from West Africa and a study from Haiti, WHO has recommended that high titre measles vaccine no longer be used. (Résumé d'auteur

Household experience and costs of seeking measles vaccination in rural Guinea-Bissau.

OBJECTIVES: Children younger than 12 months of age are eligible for childhood vaccines through the public health system in Guinea-Bissau. To limit open vial wastage, a restrictive vial opening policy has been implemented; 10-dose measles vaccine vials are only opened if six or more children aged 9-11 months are present at the vaccination post. Consequently, mothers who bring their child for measles vaccination can be told to return another day. We aimed to describe the household experience and estimate household costs of seeking measles vaccination in rural Guinea-Bissau. METHODS: Within a national sample of village clusters under demographic surveillance, we interviewed mothers of children aged 9-21 months about their experience with seeking measles vaccination. From information about time and money spent, we calculated household costs of seeking measles vaccination. RESULTS: We interviewed mothers of 1308 children of whom 1043 (80%) had sought measles vaccination at least once. Measles vaccination coverage was 70% (910/1308). Coverage decreased with increasing distance to the health centre. On average, mothers who had taken their child for vaccination took their child 1.4 times. Mean costs of achieving 70% coverage were 2.04 USD (SD 3.86) per child taken for vaccination. Half of the mothers spent more than 2 h seeking vaccination and 11% spent money on transportation. CONCLUSIONS: We found several indications of missed opportunities for measles vaccination resulting in suboptimal coverage. The household costs comprised 3.3% of the average monthly income and should be taken into account when assessing the costs of delivering vaccinations

Campaigns with oral polio vaccine may lower mortality and create unexpected results.

Three studies from Guinea-Bissau found conflicting effects of OPV-at-birth (OPV0) on child survival. One study from 2004 suggested excess male mortality among children receiving OPV0 compared with children receiving NoOPV0 during a period of shortage of OPV. However, two subsequent studies showed beneficial effects of OPV0. In 2004, two national OPV-campaigns had been conducted in Guinea-Bissau. In a reanalysis of the 2004-study, in a survival analysis the age-adjusted mortality rate of study participants was 67% (95% CI=42-81%) lower after the OPV-campaigns than before the campaigns. In the OPV0 group only 22% (655/3031 person-years (pyrs)) of follow-up time was "after" the OPV-campaigns whereas 55% (473/859 pyrs) of the time in the NoOPV0 group was post-campaign (p<0.0001, Chi2). Censoring for OPV-campaigns in the original study removed excess male mortality and made the three studies more homogeneous. Overall, there is now considerable evidence that OPV, like other live vaccines, has important beneficial non-specific effects