Treating childhood pneumonia in hard-to-reach areas: A model-based comparison of mobile clinics and community-based care

BACKGROUND: Where hard-to-access populations (such as those living in insecure areas) lack access to basic health services, relief agencies, donors, and ministries of health face a dilemma in selecting the most effective intervention strategy. This paper uses a decision mathematical model to estimate the relative effectiveness of two alternative strategies, mobile clinics and fixed community-based health services, for antibiotic treatment of childhood pneumonia, the world's leading cause of child mortality. METHODS: A "Markov cycle tree" cohort model was developed in Excel with Visual Basic to compare the number of deaths from pneumonia in children aged 1 to 59 months expected under three scenarios: 1) No curative services available, 2) Curative services provided by a highly-skilled but intermittent mobile clinic, and 3) Curative services provided by a low-skilled community health post. Parameter values were informed by literature and expert interviews. Probabilistic sensitivity analyses were conducted for several plausible scenarios. RESULTS: We estimated median pneumonia-specific under-5 mortality rates of 0.51 (95% credible interval: 0.49 to 0.541) deaths per 10,000 child-days without treatment, 0.45 (95% CI: 0.43 to 0.48) with weekly mobile clinics, and 0.31 (95% CI: 0.29 to 0.32) with CHWs in fixed health posts. Sensitivity analyses found the fixed strategy superior, except when mobile clinics visited communities daily, where rates of care-seeking were substantially higher at mobile clinics than fixed posts, or where several variables simultaneously differed substantially from our baseline assumptions. CONCLUSIONS: Current evidence does not support the hypothesis that mobile clinics are more effective than CHWs. A CHW strategy therefore warrants consideration in high-mortality, hard-to-access areas. Uncertainty remains, and parameter values may vary across contexts, but the model allows preliminary findings to be updated as new or context-specific evidence becomes available. Decision analytic modelling can guide needed field-based research efforts in hard-to-access areas and offer evidence-based insights for decision-makers

Perspectiva de alimentação infantil obtida com gestantes atendidas em centros de saúde na cidade de São Paulo Infant feeding expectations according to the pregnant women seen at the healthcare center in the city of São Paulo

OBJETIVOS: conhecer a dieta infantil pretendida por gestantes para o primeiro ano de vida. MÉTODOS: estudo transversal cujos dados foram obtidos em formulário estruturado, aplicado durante entrevista individual com 164 gestantes, usuárias da Assistência pré-natal, de centros de saúde da cidade de São Paulo. Para análise estatística foi aplicado teste do chi2 para verificar associação entre idade, escolaridade, paridade e conhecimento de variedade de frutas, legumes, verduras e carnes. RESULTADOS: todas as mulheres conheciam pelo menos uma variedade de fruta e de legume, enquanto que 20% delas não pretendiam introduzir verduras. Não foram obtidos resultados estatisticamente significantes entre idade, escolaridade, paridade e conhecimento de variedade de frutas e de legumes. Foram obtidos resultados estatisticamente significantes entre idade, paridade e conhecimento de variedade de verduras e de carnes. Os alimentos mais rejeitados, na intenção materna, foram o peixe (85,4%) e o fígado (82,3%). Foram constatados mitos em relação ao teor de ferro de alimentos. CONCLUSÕES: a intenção de oferecer alimentos à criança em idade inferior ao sexto mês de vida foi freqüente. Reafirma-se a importância de se discutir a transição alimentar infantil durante a assistência prestada à mulher.<br>OBJECTIVES: to obtain information from pregnant women on how they planned to feed their infants during the first year of life. METHODS: cross sectional study of the data obtained through structured questionnaires, filled by means of individual interviews with 164 pregnant women assisted by prenatal clinics in Outpatient Centers in the city of São Paulo. Statistical Chi- Square test was used to determine association between age, school level, parity and knowledge on the variety of fruits, vegetables and meats available. RESULTS: all women knew at least one type of fruit and vegetable while 20% of the women did not intend to offer vegetables. Significant statistical results between age, school level, parity and knowledge on the variety of fruits and vegetables available were not determined. The most rejected food, according to the mothers were fish (85.4%) and liver (82.3%). Many myths were determined related to the iron content of food. CONCLUSIONS: the intention of offering food to children under six months old was frequent. The value of discussing the transition of infant feeding during prenatal care was determined as well

Global Review of the Age Distribution of Rotavirus Disease in Children Aged < 5 Years Before the Introduction of Rotavirus Vaccination

International audienceWe sought datasets with granular age distributions of rotavirus-positive disease presentations among children <5 years of age, before the introduction of rotavirus vaccines. We identified 117 datasets and fit parametric age distributions to each country dataset and mortality stratum. We calculated the median age and the cumulative proportion of rotavirus gastroenteritis events expected to occur at ages between birth and 5.0 years. The median age of rotavirus-positive hospital admissions was 38 weeks (interquartile range [IQR], 25-58 weeks) in countries with very high child mortality and 65 weeks (IQR, 40-107 weeks) in countries with very low or low child mortality. In countries with very high child mortality, 69% of rotavirus-positive admissions in children <5 years of age were in the first year of life, with 3% by 10 weeks, 8% by 15 weeks, and 27% by 26 weeks. This information is critical for assessing the potential benefits of alternative rotavirus vaccination schedules in different countries and for monitoring program impact