XVII International AIDS Conference: From Evidence to Action - Epidemiology

As the epidemic matures, accurate information about where new infections are occurring, and in which populations, is becoming increasingly critical in designing effective, targeted interventions relevant to current epidemiological trends. Although the quality and accuracy of HIV surveillance data and methodology have improved, in many cases the second generation WHO/UNAIDS surveillance system has not been fully implemented at the national level. National surveillance systems in many low and middle-income countries often do not collect disaggregated data on some most at risk populations, which is critical to developing targeted prevention interventions

Efficacy of chloroquine, sulphadoxine-pyrimethamine and amodiaquine for treatment of uncomplicated Plasmodium falciparum malaria in Kajo Keji county, Sudan.

To provide advice on the rational use of antimalarial drugs, Médecins Sans Frontières conducted a randomized, an open label efficacy study in Kajo Keji, an area of high transmission of malaria in southern Sudan. The efficacy of chloroquine (CQ), sulphadoxine-pyrimethamine (SP) and amodiaquine (AQ) were measured in a 28-day in vivo study, with results corrected by PCR genotyping. Of 2010 children screened, 115 children aged 6-59 months with uncomplicated Plasmodium falciparum malaria were randomized into each group to receive a supervised course of treatment. Of these, 114, 103 and 111 were analysed in the CQ, SP and AQ groups, respectively. The overall parasitological failure rates at day 28 were 93.9% [95% confidence interval (CI) 87.3-97.3] for CQ, 69.9% (95% CI 60.0-78.3) for SP, and 25.2% (95% CI 17.7-34.5) for AQ. These results provide important missing data on antimalarial drug efficacy in southern Sudan. They indicate that none of the drugs could be used in monotherapy and suggest that even in combination with artemisinin, cure rates might not be efficacious enough. We recommend a combination of artemether and lumefantrine as first-line treatment for uncomplicated P. falciparum malaria cases in Kajo Keji county

Low castes have poor access to visceral leishmaniasis treatment in Bihar, India

Objectives  Bihar, the poorest state in India, concentrates most of the visceral leishmaniasis (VL) cases in the country. A large proportion of the poor rural communities where VL is endemic are marginalized by their socio-economic status, intrinsically related to the caste system. In this study, we evaluated whether people from low socio-economic strata had difficulties accessing VL treatment in Bihar. As a secondary outcome, we evaluated whether people delaying their VL treatment had poorer clinical indicators at admission. Methods  Data on 2187 patients with VL treated by Médecins Sans Frontières (MSF) in Vaishali district from July 2007 to December 2008 were analysed. Patients who reported having onset of symptoms ≥8 weeks before admission were defined as 'late presenters'. Logistic regression models were used to evaluate whether low castes had higher risk to be 'late presenters' compared to the rest of castes and whether 'late presenters' had poorer indicators at admission (i.e. haemoglobin level, spleen size). Results  After adjusting for age, gender and distance to VL treatment facility, Mushars (the lowest caste in Bihar) had twice the odds to be 'late presenters' compared to the rest of castes (OR 2.05, 95% CI: 1.24-2.38). Subjects that had VL symptoms for ≥8 weeks had a larger spleen and lower haemoglobin level than those that were treated earlier. Conclusion  Low castes have poor access to VL treatment in Bihar, and late presenters have poorer clinical indicators at admission. These findings have implications at individual and community levels and should stimulate targeted VL control programmes to ensure that marginalized communities in Bihar are properly treated

Progress towards the achievement of MDG4 in the Commonwealth of Independent States: uncertain data, clear priorities

Data on under five mortality in the twelve countries of the Commonwealth of Independent States show important fluctuations over time due to variations in quality of data, definitions of neonatal deaths and methods of mortality estimation. Despite the uncertainties regarding mortality trends, the analysis of health and social information from different sources offers clues to identify priority areas and key strategic directions for accelerating the achievement of the 4th Millennium Development Goal. Neonatal deaths represent from 40% to over 50% of under five deaths in all these countries. Maternal mortality was above 50 per 100,000 in 2005, despite the good coverage with antenatal care and births assisted by skilled birth attendants. The scanty information on quality of perinatal care indicates widespread substandard care at all levels. Stunting in children under five is above 10% in ten out of twelve countries and coexists with emerging overweight. Exclusivity and duration of breastfeeding fall short of what is recommended. There are important inequalities in child and maternal mortality, malnutrition and access and use of health services within countries. Taken as a whole, the available information clearly indicates that priority should be given to improvement of the health of women in reproductive age and of the quality of perinatal care, including the establishment of reliable data collection systems. To achieve this, action will need to focus on strengthening the capacity of the health system to improve the technical content of service provision, and on improving access and appropriate use of services by the most disadvantaged groups. The involvement of other sectors will be necessary to improve reproductive health and nutrition at community level and to tackle inequity. Comparisons between countries with similar socioeconomic background but different health policies seem to indicate that gradual progression towards universal coverage with essential health care through a national health insurance system is associated with larger reduction of child mortality than troubled transition towards a privatized and unregulated health system

Female genital mutilation/cutting in Mali and Mauritania: understanding trends and evaluating policies

Despite international commitments to end female genital mutilation/cutting (FGM/C), very little is known about the effectiveness of national policies in contributing to the abandonment of this harmful practice. To help address this gap in knowledge, we apply a quasi-experimental research design to study two west African countries, Mali and Mauritania. These countries have marked similarities with respect to practices of FGM/C, but differing legal contexts. A law banning FGM/C was introduced in Mauritania in 2005; in Mali, there is no legal ban on FGM/C. We use nationally representative survey data to reconstruct trends in FGM/C prevalence in both countries, from 1997 to 2011, and then use a difference-in-difference method to evaluate the impact of the 2005 law in Mauritania. FGM/C prevalence in Mauritania began to decline slowly for girls born in the early 2000s, with the decline accelerating for girls born after 2005. However, a similar trend is observable in Mali, where no equivalent law has been passed. Additional statistical analysis confirms that the 2005 law did not have a significant impact on reducing FGM/C prevalence in Mauritania. These findings suggest that legal change alone is insufficient for behavioral change with regard to FGM/C. This study demonstrates how it is possible to evaluate national policies using readily available survey data in resource-poor settings

Improved salt iodation methods for small-scale salt producers in low-resource settings in Tanzania

Background: Universal salt iodation will prevent iodine deficiency disorders (IDD). Globally, salt-iodation technologies mostly target large and medium-scale salt-producers. Since most producers in low-income countries are small-scale, we examined and improved the performance of hand and knapsack-sprayers used locally in Tanzania. Methods: We studied three salt facilities on the Bagamoyo coast, investigating procedures for preparing potassium-iodate solution, salt spraying and mixing. Different concentrations of solution were prepared and tested using different iodation methods, with the aim of attaining correct and homogeneous iodine levels under real-life conditions. Levels achieved by manual mixing were compared to those achieved by machine mixing. Results: The overall median iodation level in samples of salt iodated using previously existing methods was 10.6 ppm (range 1.1 – 110.0 ppm), with much higher levels in the top than the bottom layers of the salt bags, p < 0.0001. Experimentation using knapsack-sprayers and manual mixing led to the reliable achievement of levels (60.9 ppm ± 7.4) that fell within the recommended range of 40 – 80 ppm. The improved methods yielded homogenous iodine concentrations in all layers of salt-bags (p = 0.58) with 96% of the samples (n = 45) falling within 40 – 80 ppm compared to only 9% (n = 45) before the experiment and training (p < 0.0001). For knapsack-spraying, a machine mixer improved the iodine levels and homogeneity slightly compared to manual mixing (p = 0.05). Conclusion: Supervised, standardized salt iodation procedures adapted to local circumstances can yield homogeneous iodine levels within the required range, overcoming a major obstacle to universal salt iodation

Percent Fat Mass Increases with Recovery, But Does Not Vary According to Dietary Therapy in Young Malian Children Treated for Moderate Acute Malnutrition.

BackgroundModerate acute malnutrition (MAM) affects 34.1 million children globally. Treatment effectiveness is generally determined by the amount and rate of weight gain. Body composition (BC) assessment provides more detailed information on nutritional stores and the type of tissue accrual than traditional weight measurements alone.ObjectiveThe aim of this study was to compare the change in percentage fat mass (%FM) and other BC parameters among young Malian children with MAM according to receipt of 1 of 4 dietary supplements, and recovery status at the end of the 12-wk intervention period.MethodsBC was assessed using the deuterium oxide dilution method in a subgroup of 286 children aged 6-35 mo who participated in a 12-wk community-based, cluster-randomized effectiveness trial of 4 dietary supplements for the treatment of MAM: 1) lipid-based, ready-to-use supplementary food (RUSF); 2) special corn-soy blend "plus plus" (CSB++); 3) locally processed, fortified flour (MI); or 4) locally milled flours plus oil, sugar, and micronutrient powder (LMF). Multivariate linear regression modeling was used to evaluate change in BC parameters by treatment group and recovery status.ResultsMean&nbsp;±&nbsp;SD %FM at baseline was 28.6%&nbsp;±&nbsp;5.32%. Change in %FM did not vary between groups. Children who received RUSF vs. MI gained more (mean; 95% CI) weight (1.43; 1.13, 1.74 kg compared with 0.84; 0.66, 1.03 kg; P&nbsp;=&nbsp;0.02), FM (0.70; 0.45, 0.96 kg compared with 0.20; 0.05, 0.36 kg; P&nbsp;=&nbsp;0.01), and weight-for-length z score (1.23; 0.79, 1.54 compared with 0.49; 0.34, 0.71; P&nbsp;=&nbsp;0.03). Children who recovered from MAM exhibited greater increases in all BC parameters, including %FM, than children who did not recover.ConclusionsIn this study population, children had higher than expected %FM at baseline. There were no differences in %FM change between groups. International BC reference data are needed to assess the utility of BC assessment in community-based management of acute malnutrition programs. This trial was registered at clinicaltrials.gov as NCT01015950

Achieving the Millennium Development Goal of reducing maternal mortality in rural Africa: an experience from Burundi.

OBJECTIVES: To estimate the reduction in maternal mortality associated with the emergency obstetric care provided by Médecins Sans Frontières (MSF) and to compare this to the fifth Millennium Development Goal of reducing maternal mortality. METHODS: The impact of MSF's intervention was approximated by estimating how many deaths were averted among women transferred to and treated at MSF's emergency obstetric care facility in Kabezi, Burundi, with a severe acute maternal morbidity. Using this estimate, the resulting theoretical maternal mortality ratio in Kabezi was calculated and compared to the Millennium Development Goal for Burundi. RESULTS: In 2011, 1385 women from Kabezi were transferred to the MSF facility, of whom 55% had a severe acute maternal morbidity. We estimated that the MSF intervention averted 74% (range 55-99%) of maternal deaths in Kabezi district, equating to a district maternal mortality rate of 208 (range 8-360) deaths/100 000 live births. This lies very near to the 2015 MDG 5 target for Burundi (285 deaths/100 000 live births). CONCLUSION: Provision of quality emergency obstetric care combined with a functional patient transfer system can be associated with a rapid and substantial reduction in maternal mortality, and may thus be a possible way to achieve Millennium Development Goal 5 in rural Africa

Comparison of two sources of iodine delivery on breast milk iodine and maternal and infant urinary iodine concentrations in southern Ethiopia: A randomized trial

Iodine deficiency during pregnancy and lactation could expose the infant to severe iodine deficiency disorders. A randomized supplementation trial among rural lactating women was conducted in Sidama zone, southern Ethiopia, to compare the methods of iodine delivery on breast milk iodine, and on maternal and infant urinary iodine concentrations. Women were randomly assigned either to receive 225 μg iodine as potassium iodide capsule daily for 6 months or 450 g of appropriately iodized salt (30–40 μg I as KIO3/g of salt) weekly for household consumption for 6 months. Breast milk iodine concentration (BMIC) and maternal and infant urinary iodine concentration (UIC) were measured at baseline and at 6 months. The women did not differ in BMIC and UIC, and infants did not differ in UIC in a time by treatment interaction. Median (IQR, interquartile range, IQR) BMIC at baseline was 154 [43, 252] μg/L and at 6 months was 105 [36, 198] μg/L, maternal UIC at baseline was 107 [71, 161] μg/L and at 6 months was 130 [80, 208] μg/L; infant UIC at baseline was 218 [108, 356] μg/L and at 6 months was 222 [117, 369] μg/L. Significant correlations among the three variables were obtained in both groups at both times. We conclude that for lactating women an adequate amount of appropriately iodized salt (30–40 μg I/g) had similar effects as a daily supplement of 225 μg I on BMIC and on maternal and infant UIC