Coverage and timing of children's vaccination: an evaluation of the expanded programme on immunisation in The Gambia.

OBJECTIVE: To evaluate the coverage and timeliness of the Expanded Programme on Immunisation (EPI) in The Gambia. METHODS: Vaccination data were obtained between January 2005 and December 2012 from the Farafenni Health and Demographic Surveillance System (FHDSS), the Basse Health and Demographic Surveillance System (BHDSS), the Kiang West Demographic surveillance system (KWDSS), a cluster survey in the more urban Western Health Region (WR) and a cross sectional study in four clinics in the semi-urban Greater Banjul area of WR. Kaplan-Meier survival function was used to estimate the proportion vaccinated by age and to assess timeliness to vaccination. FINDINGS: BCG vaccine uptake was over 95% in all regions. Coverage of DPT1 ranged from 93.2% in BHDSS to 99.8% in the WR. Coverage decreased with increasing number of DPT doses; DPT3 coverage ranged from 81.7% in BHDSS to 99.0% in WR. Measles vaccination coverage ranged from 83.3% in BHDSS to 97.0% in WR. DPT4 booster coverage was low and ranged from 43.9% in the WR to 82.8% in KWDSS. Across all regions, delaying on previous vaccinations increased the likelihood of being delayed for the subsequent vaccination. CONCLUSIONS: The Gambia health system achieves high vaccine coverage in the first year of life. However, there continues to be a delay to vaccination which may impact on the introduction of new vaccines. Examples of effectively functioning EPI programmes such as The Gambia one may well be important models for other low income countries struggling to achieve high routine vaccination coverage

Effect of moderate anaemia on later mortality in rural African children.

Severe anaemia in childhood is associated with increased mortality, although evidence relating moderate anaemia to child survival is scarce. We aimed to investigate this association. We did a case-control study of children with moderate anaemia, and compared haemoglobin concentrations measured up to a year before death for 403 children (age range 28 days to 15 years) with those from children who survived (matched for age and sex). Data were obtained from long-term health records (1950-97) of a rural Gambian research centre. Excluding an acute effect in this last week of life, no evidence was recorded of lower haemoglobin concentrations in the children who died than in survivors, or of any general or disease-specific effects of non-severe anaemia (70-110 g/L) on mortality

Mid-upper arm circumference at age of routine infant vaccination to identify infants at elevated risk of death: a retrospective cohort study in the Gambia.

OBJECTIVE: To determine the predictive value for death before 12 months of age of mid-upper arm circumference (MUAC) and weight-for-length Z score (WFLz). METHODS: A retrospective cohort analysis of infants living in Keneba, in rural Gambia, was conducted. Anthropometric measures were obtained from demographic surveillance system records for infants registered between February 1974 and July 2008 who had had MUAC and WFLz recorded at 6-14 weeks of age and vital status recorded at least once more. Hazard ratios (HRs), population attributable fractions and areas under receiver operating characteristic (ROC) curves were estimated to assess the predictive value for death in infancy of MUAC and WFLz. FINDINGS: Of 2876 infants included in the analysis, 40 died before the age of 12 months. The HR for death in this group versus in well-nourished infants was 5.8 (95% confidence interval, CI: 1.6-21) for a WFLz < -3. HRs for MUACs below the thresholds of 115 mm, 110 mm and 105 mm were 4.5 (95% CI: 1.4-15), 9.5 (95% CI: 2.6-35) and 23 (95% CI: 4.2-122), respectively. The attributable fractions for a MUAC < 130 mm and a WFLz < 0 were 51% and 13%, respectively. The areas under the ROC curve for death in infancy were 0.55 (95% CI: 0.46 to 0.64) for WFLz and 0.64 (95% CI: 0.55 to 0.73) for MUAC. CONCLUSION: Among infants aged 6 to 14 weeks, unadjusted MUAC showed good performance in identifying infants at increased risk of death

Gestational diabetes, comparison of women diagnosed in second and third trimester of pregnancy with non GDM women: Analysis of a cohort study.

UNLABELLED: Pregnant women are normally screened for Gestational diabetes (GDM) at week 24 of pregnancy. However some women develop the disease later on their pregnancies. No study has analyzed women developing GDM later in pregnancy. OBJECTIVE: To analyze data on a cohort study and compare women diagnosed with GDM in second and third trimester of pregnancy with women without GDM. RESULTS: GDM women diagnosed during their first two trimesters of pregnancy were older (p = 0.0008) and had higher body mass index (BMI) (p = 0.0007) than non GDM women. However, the only risk factor in women diagnosed in their third trimester of pregnancy was having first degree relatives with type 2 DM and this was independent of age and BMI (OR of 2.7, 95% CI 1.2 - 6.0). CONCLUSIONS: Women who develop GDM in their second trimester of pregnancy have known risk factors for diabetes mellitus such as age and higher BMI, however, the only recognised risk factor between non GDM women and women developing GDM late in pregnancy is family history of type 2 DM. Two populations of GDM may exist and future studies should focus on analysing short and long term complications of these women to support the need to diagnosed and treat them all

Model behaviour

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A stochastic model for MRSA transmission within a hospital ward incorporating environmental contamination

Methicillin-resistant Staphylococcus aureus (MRSA) transmission in hospital wards is associated with adverse outcomes for patients and increased costs for hospitals. The transmission process is inherently stochastic and the randomness emphasized by the small population sizes involved. As such, a stochastic model was proposed to describe the MRSA transmission process, taking into account the related contribution and modelling of the associated microbiological environmental contamination. The model was used to evaluate the performance of five common interventions and their combinations on six potential outcome measures of interest under two hypothetical disease burden settings. The model showed that the optimal intervention combination varied depending on the outcome measure and burden setting. In particular, it was found that certain outcomes only required a small subset of targeted interventions to control the outcome measure, while other outcomes still reported reduction in the outcome distribution with up to all five interventions included. This study describes a new stochastic model for MRSA transmission within a ward and highlights the use of the generalized Mann–Whitney statistic to compare the distribution of the outcome measures under different intervention combinations to assist in planning future interventions in hospital wards under different potential outcome measures and disease burden

Model behaviour

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Association between hemolysis and albuminuria in adults with sickle cell anemia

Studies have questioned whether renal dysfunction in sickle cell disease is linked to hemolysis-associated vasculopathy. We have investigated renal function and markers of hemolysis in a cohort of 424 adult African-British patients with sickle cell disease. While significant associations were found in HbSS and HbSβ(0) (sickle cell anemia) patients with and without controlling for covariates between hemolytic markers and albuminuria, the associations were not significant in patients with HbSC. Estimated glomerular filtration rate, a marker of renal function, correlated significantly with reticulocyte count and bilirubin. Alpha thalassemia, present in 34% of the sickle cell anaemia patients, had a protective effect against albuminuria in this group. Altogether, the incidence of hyperfiltration was 71% and microalbuminuria 37%, making nephropathy a common complication of sickle cell anemia