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Erchick DJ, Hazel EA, Katz J, Lee ACC, Diaz M, Wu LSF, Yoshida S, Bahl R, Grandi C, Labrique AB, Rashid M, Ahmed S, Roy AD, Haque R, Shaikh S, Baqui AH, Saha SK, Khanam R, Rahman S, Shapiro R, Zash R, Silveira MF, Buffarini R, Kolsteren P, Lachat C, Huybregts L, Roberfroid D, Zeng L, Zhu Z, He J, Qiu X, Gebreyesus SH, Tesfamariam K, Bekele D, Chan G, Baye E, Workneh F, Asante KP, Kaali EB, Adu-Afarwuah S, Dewey KG, Gyaase S, Wylie BJ, Kirkwood BR, Manu A, Thulasiraj RD, Tielsch J, Chowdhury R, Taneja S, Babu GR, Shriyan P, Ashorn P, Maleta K, Ashorn U, Mangani C, Acevedo-Gallegos S, Rodriguez-Sibaja MJ, Khatry SK, LeClerq SC, Mullany LC, Jehan F, Ilyas M, Rogerson SJ, Unger HW, Ghosh R, Musange S, Ramokolo V, Zembe-Mkabile W, Lazzerini M, Rishard M, Wang D, Fawzi WW, Minja DTR, Schmiegelow C, Masanja H, Smith E, Lusingu JPA, Msemo OA, Kabole FM, Slim SN, Keentupthai P, Mongkolchati A, Kajubi R, Kakuru A, Waiswa P, Walker D, Hamer DH, Semrau KEA, Chaponda EB, Chico RM, Banda B, Musokotwane K, Manasyan A, Pry JM, Chasekwa B, Humphrey J, Black RE. Vulnerable newborn types: analysis of subnational, population-based birth cohorts for 541 285 live births in 23 countries, 2000-2021. BJOG 2023. [PMID: 37156239 DOI: 10.1111/1471-0528.17510] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 04/04/2023] [Accepted: 04/07/2023] [Indexed: 05/10/2023]
Abstract
OBJECTIVE To examine prevalence of novel newborn types among 541 285 live births in 23 countries from 2000 to 2021. DESIGN Descriptive multi-country secondary data analysis. SETTING Subnational, population-based birth cohort studies (n = 45) in 23 low- and middle-income countries (LMICs) spanning 2000-2021. POPULATION Liveborn infants. METHODS Subnational, population-based studies with high-quality birth outcome data from LMICs were invited to join the Vulnerable Newborn Measurement Collaboration. We defined distinct newborn types using gestational age (preterm [PT], term [T]), birthweight for gestational age using INTERGROWTH-21st standards (small for gestational age [SGA], appropriate for gestational age [AGA] or large for gestational age [LGA]), and birthweight (low birthweight, LBW [<2500 g], nonLBW) as ten types (using all three outcomes), six types (by excluding the birthweight categorisation), and four types (by collapsing the AGA and LGA categories). We defined small types as those with at least one classification of LBW, PT or SGA. We presented study characteristics, participant characteristics, data missingness, and prevalence of newborn types by region and study. RESULTS Among 541 285 live births, 476 939 (88.1%) had non-missing and plausible values for gestational age, birthweight and sex required to construct the newborn types. The median prevalences of ten types across studies were T+AGA+nonLBW (58.0%), T+LGA+nonLBW (3.3%), T+AGA+LBW (0.5%), T+SGA+nonLBW (14.2%), T+SGA+LBW (7.1%), PT+LGA+nonLBW (1.6%), PT+LGA+LBW (0.2%), PT+AGA+nonLBW (3.7%), PT+AGA+LBW (3.6%) and PT+SGA+LBW (1.0%). The median prevalence of small types (six types, 37.6%) varied across studies and within regions and was higher in Southern Asia (52.4%) than in Sub-Saharan Africa (34.9%). CONCLUSIONS Further investigation is needed to describe the mortality risks associated with newborn types and understand the implications of this framework for local targeting of interventions to prevent adverse pregnancy outcomes in LMICs.
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Affiliation(s)
- D J Erchick
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - E A Hazel
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - J Katz
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - A C C Lee
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - M Diaz
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - L S F Wu
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - S Yoshida
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - R Bahl
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - C Grandi
- Argentine Society of Paediatrics, Ciudad Autónoma de Buenos Aires, Argentina
| | - A B Labrique
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - M Rashid
- IntraHealth International, Dhaka, Bangladesh
| | - S Ahmed
- Projahnmo Research Foundation, Dhaka, Bangladesh
| | - A D Roy
- Projahnmo Research Foundation, Dhaka, Bangladesh
| | - R Haque
- JiVitA Maternal and Child Health Research Project, Rangpur, Bangladesh
| | - S Shaikh
- JiVitA Maternal and Child Health Research Project, Rangpur, Bangladesh
| | - A H Baqui
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - S K Saha
- Child Health Research Foundation, Dhaka, Bangladesh
| | - R Khanam
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - S Rahman
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - R Shapiro
- Department of Immunology and Infectious Diseases, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - R Zash
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - M F Silveira
- Postgraduate Program in Epidemiology, Federal University of Pelotas, Pelotas, Brazil
| | - R Buffarini
- Postgraduate Program in Epidemiology, Federal University of Pelotas, Pelotas, Brazil
| | - P Kolsteren
- Department of Food Technology, Safety and Health, Ghent University, Ghent, Belgium
| | - C Lachat
- Department of Food Technology, Safety and Health, Ghent University, Ghent, Belgium
| | - L Huybregts
- Department of Food Technology, Safety and Health, Ghent University, Ghent, Belgium
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, Washington, DC, USA
| | - D Roberfroid
- Medicine Department, Faculty of Medicine, University of Namur, Namur, Belgium
| | - L Zeng
- Department of Epidemiology and Biostatistics, School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Z Zhu
- Department of Epidemiology and Biostatistics, School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - J He
- Division of Birth Cohort Study, Guangzhou Women and Children's Medical Centre, Guangzhou Medical University, Guangzhou, China
| | - X Qiu
- Division of Birth Cohort Study, Guangzhou Women and Children's Medical Centre, Guangzhou Medical University, Guangzhou, China
| | - S H Gebreyesus
- Department of Nutrition and Dietetics, School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - K Tesfamariam
- Department of Food Technology, Safety and Health, Faculty of Bioscience Engineering, Ghent University, Ghent, Belgium
| | - D Bekele
- Department of Obstetrics and Gynecology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - G Chan
- Department of Obstetrics and Gynecology, St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - E Baye
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - F Workneh
- Addis Continental Institute of Public Health, Addis Ababa, Ethiopia
| | - K P Asante
- Kintampo Health Research Centre, Research and Development Division, Kintampo, Ghana
| | - E B Kaali
- Kintampo Health Research Centre, Research and Development Division, Kintampo, Ghana
| | - S Adu-Afarwuah
- Department of Nutrition and Food Science, University of Ghana, Accra, Ghana
| | - K G Dewey
- Institute for Global Nutrition, Department of Nutrition, University of California, Davis, California, USA
| | - S Gyaase
- Department of Statistics, Kintampo Health Research Centre, Kintampo, Ghana
| | - B J Wylie
- Department of Obstetrics and Gynecology, Columbia University Medical Center, New York, New York, USA
| | - B R Kirkwood
- Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - A Manu
- Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
- University of Ghana School of Public Health, Accra, Ghana
| | | | - J Tielsch
- Department of Global Health, Milken Institute School of Public Health, George Washington University, Washington, DC, USA
| | - R Chowdhury
- Centre for Health Research and Development, Society for Applied Studies, Delhi, India
| | - S Taneja
- Centre for Health Research and Development, Society for Applied Studies, Delhi, India
| | - G R Babu
- Department of Population Medicine, College of Medicine, QU Health, Qatar University, Doha, Qatar
| | - P Shriyan
- Indian Institute of Public Health, Public Health Foundation of India, Bengaluru, India
| | - P Ashorn
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University and Tampere University Hospital, Tampere, Finland
| | - K Maleta
- School of Global and Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - U Ashorn
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University and Tampere University Hospital, Tampere, Finland
| | - C Mangani
- School of Global and Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - S Acevedo-Gallegos
- National Institute of Perinatology, Maternal-Fetal Medicine Department, Mexico City, Mexico
| | - M J Rodriguez-Sibaja
- National Institute of Perinatology, Maternal-Fetal Medicine Department, Mexico City, Mexico
| | - S K Khatry
- Nepal Nutrition Intervention Project - Sarlahi (NNIPS), Kathmandu, Nepal
| | - S C LeClerq
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Nepal Nutrition Intervention Project - Sarlahi (NNIPS), Kathmandu, Nepal
| | - L C Mullany
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - F Jehan
- Department of Paediatrics and Child Health, The Aga Khan University, Karachi, Pakistan
| | - M Ilyas
- The Aga Khan University, Karachi, Pakistan
| | - S J Rogerson
- Department of Infectious Diseases, University of Melbourne, Doherty Institute, Melbourne, Victoria, Australia
| | - H W Unger
- Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | - R Ghosh
- Institute for Global Health Sciences, Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
| | - S Musange
- School of Public Health, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - V Ramokolo
- HIV and Other Infectious Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa
- Gertrude H Sergievsky Center, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, New York, USA
| | - W Zembe-Mkabile
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
- College Graduate of Studies, University of South Africa, Johannesburg, South Africa
| | - M Lazzerini
- Institute for Maternal and Child Health - IRCCS 'Burlo Garofolo', WHO Collaborating Centre for Maternal and Child Health, Trieste, Italy
| | - M Rishard
- University Obstetrics Unit, De Soysa Hospital for Women, Colombo, Sri Lanka
- Department of Obstetrics & Gynaecology, University of Colombo, Colombo, Sri Lanka
| | - D Wang
- Department of Global and Community Health, College of Public Health, George Mason University, Fairfax, Virginia, USA
| | - W W Fawzi
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - D T R Minja
- National Institute for Medical Research, Tanga Centre, Tanga, Tanzania
| | - C Schmiegelow
- Centre for Medical Parasitology, Department for Immunology and Microbiology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - H Masanja
- Ifakara Health Institute, Dar es Salaam, Tanzania
| | - E Smith
- Department of Global Health, Milken Institute School of Public Health, Washington, DC, USA
| | - J P A Lusingu
- National Institute for Medical Research, Dar es Salaam, Tanzania
| | - O A Msemo
- National Institute for Medical Research, Dar es Salaam, Tanzania
| | - F M Kabole
- Ministry of Health Zanzibar, Zanzibar, Tanzania
| | - S N Slim
- Ministry of Health Zanzibar, Zanzibar, Tanzania
| | - P Keentupthai
- College of Medicine and Public Health, Ubon Ratchathani University, Ubon Ratchathani, Thailand
| | - A Mongkolchati
- ASEAN Institute for Health Development, Mahidol University, Salaya, Thailand
| | - R Kajubi
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - A Kakuru
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - P Waiswa
- Department of Health Policy Planning and Management, Makerere University School of Public Health, New Mulago Hospital Complex, Kampala, Uganda
- Division of Global Health, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - D Walker
- Institute for Global Health Sciences and Department of Obstetrics and Gynecology, University of California San Francisco, San Francisco, California, USA
| | - D H Hamer
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, USA
- Section of Infectious Diseases, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
| | - K E A Semrau
- Ariadne Labs, Brigham and Women's Hospital and Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- Division of Global Health Equity & Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - E B Chaponda
- Department of Biological Sciences, School of Natural Sciences, University of Zambia, Lusaka, Zambia
| | - R M Chico
- Department of Disease Control, Faculty of Infectious & Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - B Banda
- Research Unit for Environmental Sciences and Management, North-West University, Potchefstroom, South Africa
| | - K Musokotwane
- Health Specialist PMTCT and Pediatric AIDS, UNICEF, Lusaka, Zambia
| | - A Manasyan
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - J M Pry
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - B Chasekwa
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - J Humphrey
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - R E Black
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Erchick DJ, Rai B, Agrawal NK, Khatry SK, Katz J, LeClerq SC, Reynolds MA, Mullany LC. Oral hygiene, prevalence of gingivitis, and associated risk factors among pregnant women in Sarlahi District, Nepal. BMC Oral Health 2019; 19:2. [PMID: 30611255 PMCID: PMC6321675 DOI: 10.1186/s12903-018-0681-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 11/27/2018] [Indexed: 11/10/2022] Open
Abstract
Background The oral health status of pregnant women in low-resource communities such as Nepal has not been well characterized. This sub-population is also of specific interest given associations between poor oral health and adverse pregnancy outcomes previously documented in other settings. We explored relationships between gingivitis and risk factors among pregnant women in rural Nepal. Methods The design was a community-based, cross-sectional study in a sub-area of Sarlahi District, Nepal. Pregnant women < 26 weeks gestation underwent clinical periodontal exams conducted by community-based oral health workers. Exams included a full mouth assessment measuring bleeding on probing (BOP), probing depth (PD) (six sites per tooth), and gingival recession, the distance from the cemento-enamel junction to the free gingival margin (two direct sites per tooth). Data on participant risk factors were collected through household surveys, including demographic characteristics, oral health behaviors, care seeking, and health attitudes. Multivariable logistic regression modeling was used to assess relationships between gingivitis and risk factors. Results We enrolled 1452 participants, of which 40% (n = 582) had signs of clinical gingivitis and 60% (n = 870) clinical health. Average participant age was 23. Most participants (88%) had never received oral health care. Participants averaged 10% of sites with BOP with most (79%) having ≥1 site with BOP. Nine percent of participants had ≥1 site with PD ≥4 mm, although very few participants (0.7%) had sites with PD ≥5 mm. Few participants (13%) had any recession (≥1 mm). In the final adjusted model, odds of gingivitis increased by 3% for each year of age (aOR 1.03, 95% CI 1.00, 1.06) and were higher for women of short maternal stature (< 150 cm) (aOR 1.43, 95% CI: 1.14, 1.79) and among women reporting cost to be a barrier to seeking dental care (aOR 2.13, 95% CI: 1.09, 4.15). Conclusions Gingivitis was common and associated with age, maternal stature, self-reported high cost of dental care, and other risk factors among pregnant women in rural Nepal. Trial registration ClinicalTrials.gov Identifier: NCT01177111 (Nepal Oil Massage Study) and NCT02788786 (Pilot Trial). Electronic supplementary material The online version of this article (10.1186/s12903-018-0681-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- D J Erchick
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - B Rai
- Nepal Nutrition Intervention Project, Sarlahi (NNIPS), Krishna Galli, Lalitpur, Kathmandu, Nepal
| | - N K Agrawal
- Department of Dentistry, Institute of Medicine, Tribhuhvan University, Kathmandu, Nepal
| | - S K Khatry
- Nepal Nutrition Intervention Project, Sarlahi (NNIPS), Krishna Galli, Lalitpur, Kathmandu, Nepal
| | - J Katz
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - S C LeClerq
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Nepal Nutrition Intervention Project, Sarlahi (NNIPS), Krishna Galli, Lalitpur, Kathmandu, Nepal
| | - M A Reynolds
- Department of Advanced Oral Sciences and Therapeutics, University of Maryland School of Dentistry, Baltimore, MD, USA
| | - L C Mullany
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Lubon AJ, Erchick DJ, Khatry SK, LeClerq SC, Agrawal NK, Reynolds MA, Katz J, Mullany LC. Oral health knowledge, behavior, and care seeking among pregnant and recently-delivered women in rural Nepal: a qualitative study. BMC Oral Health 2018; 18:97. [PMID: 29859084 PMCID: PMC5984796 DOI: 10.1186/s12903-018-0564-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Accepted: 05/23/2018] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND Oral health behavior and attitudes of pregnant women in low-income countries are rarely examined, yet should be considered when designing preventative or therapeutic studies to reduce burden of oral diseases. We aimed to understand dental care-seeking behavior, as well as oral health knowledge and attitudes of oral health among pregnant women in rural Nepal. METHODS Semi-structured in-depth interviews (n = 16) and focus group discussions (3 groups, n = 23) were conducted among pregnant and recently-delivered women in Sarlahi, Nepal. Transcripts were translated from the local language to English then analyzed using a hybrid approach to thematic coding with Atlas.ti version 7. RESULTS Women felt confident describing the signs and symptoms of tooth decay and gum disease, but were not knowledgeable about where to receive care for tooth and/or gum pain and relied heavily on the knowledge of their community. Some women used a toothbrush and toothpaste at least once a day to clean their teeth, but many reported the traditional use of a branch of a local shrub or tree as their teeth cleaning instrument. Women suggested a willingness to consider using an oral rinse throughout pregnancy, perceiving that it might have a positive impact on infant health. CONCLUSIONS Future studies should focus on providing adequate and sustainable resources for pregnant women in Nepal and other low income settings to engage in good oral health behaviors (possibly supported through community-based workers), to maintain dental hygiene, and to access qualified dentists as a means of improving their oral health. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01177111 (Nepal Oil Massage Study) and NCT02788786 (Pilot Trial).
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Affiliation(s)
- A. J. Lubon
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street W5009, Baltimore, MD 21205 USA
| | - D. J. Erchick
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street W5009, Baltimore, MD 21205 USA
| | - S. K. Khatry
- Nepal Nutrition Intervention Project – Sarlahi (NNIPS), Krishna Galli, Lalitpur, Kathmandu Nepal
| | - S. C. LeClerq
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street W5009, Baltimore, MD 21205 USA
- Nepal Nutrition Intervention Project – Sarlahi (NNIPS), Krishna Galli, Lalitpur, Kathmandu Nepal
| | - N. K. Agrawal
- Department of Dentistry, Institute of Medicine, Tribhuhvan University, Kathmandu, Nepal
| | - M. A. Reynolds
- Department of Periodontics, University of Maryland School of Dentistry, Baltimore, MD USA
| | - J. Katz
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street W5009, Baltimore, MD 21205 USA
| | - L. C. Mullany
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street W5009, Baltimore, MD 21205 USA
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Chen C, Barry D, Khatry SK, Klasen EM, Singh M, LeClerq SC, Katz J, Tielsch JM, Mullany LC. Validation of an obstetric fistula screening questionnaire in rural Nepal: a community-based cross-sectional and nested case-control study with clinical examination. BJOG 2017; 124:955-964. [PMID: 27465702 PMCID: PMC5272910 DOI: 10.1111/1471-0528.14202] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/08/2016] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To validate a symptom-based fistula screening questionnaire and estimate obstetric fistula (OF) prevalence in rural Nepal. DESIGN Cross-sectional and nested case-control study. SETTING Sarlahi District, Nepal. POPULATION Parous, reproductive age women. METHODS The questionnaire assessed symptoms of vesicovaginal and rectovaginal fistula (VVF and RVF, respectively), stress and urge urinary incontinence (SUI and UUI, respectively), fecal incontinence (FI), and included interviewer observations on the smell and presence of urine and/or stool. All women who screened positive for OF and a randomly selected group of women who screened negative for OF were included in a nested case-control study (one case, four normal controls, and four incontinent controls) and underwent confirmatory clinical examinations. MAIN OUTCOME MEASURES Clinically confirmed OF, and questionnaire sensitivity (Se) and specificity (Sp). RESULTS Of the 16 893 women who completed cross-sectional screening, 68 were screened-positive cases. Fifty-five (82%) screened-positive cases, 203 screened-negative normal controls, and 203 screened-incontinent controls participated in the case-control study, which confirmed one case of VVF and one case of both VVF and RVF without any false-negative cases. For VVF, the screening tool demonstrated Se 100% (95% CI 34.2-100.0%), Sp 86.9% (95% CI 83.3-89.9%), and estimated VVF prevalence as 12 per 100 000 (95% CI 3-43); for RVF, it demonstrated Se 100% (95% CI 20.7-100.0), Sp 99.8% (95% CI 98.6-100.0), and estimated RVF prevalence as 6 per 100 000 (95% CI 1-34). CONCLUSIONS The OF screening questionnaire demonstrated high sensitivity and specificity in this low-prevalence setting. TWEETABLE ABSTRACT Community-based obstetric fistula screening tool validation study, Nepal, n = 16 893: High Se, Sp & feasibility.
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Affiliation(s)
- Ccg Chen
- Department of Gynecology & Obstetrics, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - D Barry
- Department of Gynecology & Obstetrics, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - S K Khatry
- Nepal Nutrition Intervention Project - Sarlahi, Kathmandu, Nepal
| | - E M Klasen
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - M Singh
- Department of Obstetrics and Gynaecology, Institute of Medicine, Kathmandu, Nepal
| | - S C LeClerq
- Nepal Nutrition Intervention Project - Sarlahi, Kathmandu, Nepal
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - J Katz
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - J M Tielsch
- Milken Institute School of Public Health, George Washington University, Washington, District of Columbia, USA
| | - L C Mullany
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Mergler MJ, Englund JA, Tielsch JM, Kuypers J, Rock M, Edwards KM, Steinhoff MC, Khatry SK, LeClerq SC, Katz J. Pertussis in Infants: Characterization of Risk and Maternal Immunological Protection. Int J Epidemiol 2015. [DOI: 10.1093/ije/dyv096.190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Affiliation(s)
- SD Emmett
- International Health Johns Hopkins Sch Pub HealthUnited States
| | - J Schmitz
- Urban & Environmental Policy Occidental CollUnited States
| | - SK Khatry
- Nepal Nutr Interven ProjSarlahiNepal
| | - L Wu
- International Health Johns Hopkins Sch Pub HealthUnited States
| | - S LeClerq
- International Health Johns Hopkins Sch Pub HealthUnited States
- Nepal Nutr Interven ProjSarlahiNepal
| | - S Karna
- Speech & Hearing Unit Institute of MedNepal
| | - J Pillion
- International Health Johns Hopkins Sch Pub HealthUnited States
| | - KP West
- International Health Johns Hopkins Sch Pub HealthUnited States
- Nepal Nutr Interven ProjSarlahiNepal
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Wu LA, Katz J, Mullany LC, Khatry SK, Darmstadt GL, LeClerq SC, Tielsch JM. The association of preterm birth and small birthweight for gestational age on childhood disability screening using the Ten Questions Plus tool in rural Sarlahi district, southern Nepal. Child Care Health Dev 2012; 38:332-40. [PMID: 21375569 DOI: 10.1111/j.1365-2214.2011.01221.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
CONTEXT The Ten Questions tool was developed in 1984 as a low-cost, simple screen for childhood disability and referral for diagnosis in low-resource settings, and its use in Nepal has not been previously evaluated. Preterm birth and intrauterine growth restriction are potential risk factors for child disability and loss of developmental potential, but there are few studies examining this relationship from developing settings. OBJECTIVE To examine the associations of small for gestational age and preterm birth as predictors of Ten Questions Plus positivity. DESIGN, SETTING AND PARTICIPANTS The Ten Questions Plus questionnaire was administered to caregivers of 680 children between 2 and 5 years of age from August 2007 to March 2008 in rural Sarlahi, southern Nepal. Participants had previously been enrolled in a randomized trial of chlorhexidine cleansing at birth. At 1 month of age, children were then enrolled into a randomized 2 × 2 factorial trial of daily iron and zinc supplementation between October 2001 and January 2006. INTERVENTION None. MAIN OUTCOME MEASURE Positive screen on the Ten Questions Plus tool defined as a positive response to one or more questions. RESULTS Of preterm children, 37 (33.6%) had a positive response to at least one question on the Ten Questions Plus and were considered at risk for disability. One hundred and seventy term children (29.8%) were at risk for disability. CONCLUSIONS The Ten Questions Plus tool can be used in this rural Nepali setting to identify children at increased risk for mental and physical disability to be targeted for further examination. The prevalence of parent-reported disabilities is high in this population (almost one-third of children); children who are both preterm and small-for-gestational age are at increased risk for motor milestone delay, reported learning difficulty, speech and behavioural problems. Intrauterine growth restriction may affect child development and result in disabilities later in childhood.
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Affiliation(s)
- L A Wu
- National Vaccine Program Office, US Department of Health and Human Services, Washington, D.C., USA
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Wu L, Katz J, Mullany LC, Haytmanek E, Khatry SK, Darmstadt GL, West KP, LeClerq SC, Tielsch JM. Association between nutritional status and positive childhood disability screening using the ten questions plus tool in Sarlahi, Nepal. J Health Popul Nutr 2010; 28:585-594. [PMID: 21261204 PMCID: PMC2995027 DOI: 10.3329/jhpn.v28i6.6607] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
The study was conducted to examine the association between the indicators of malnutrition and disability of children as reported by caregivers. The Ten Questions Plus questionnaire was administered to caregivers of 1,902 children aged 1-9 years, during August 2007-March 2008, in rural Nepal. Height and weight of children were also measured. The main outcome was a positive response to one or more questions. In total, 514 (27%) children had a positive response to at least one question. Moderate stunting [odds ratio (OR)=1.47, 95% confidence interval (CI) 1.02-2.12) and severe (OR=2.39, 95% CI 1.60-3.57) stunting were independently associated with reported delay in sitting, standing, or walking. Severe stunting was also associated with report of delayed learning compared to other children of similar age (OR=2.01, 95% CI 1.27-3.20). Parental report of disability was quite prevalent in this setting, with over a quarter of the sample screening positive. Chronic malnutrition may be associated with delayed motor and mental development.
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Affiliation(s)
- L Wu
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205-2103, USA
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Thatte N, Mullany LC, Khatry SK, Katz J, Tielsch JM, Darmstadt GL. Traditional birth attendants in rural Nepal: knowledge, attitudes and practices about maternal and newborn health. Glob Public Health 2009; 4:600-17. [PMID: 19431006 PMCID: PMC2762492 DOI: 10.1080/17441690802472406] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Efforts to formalise the role of traditional birth attendants (TBAs) in maternal and neonatal health programmes have had limited success. TBAs' continued attendance at home deliveries suggests the potential to influence maternal and neonatal outcomes. The objective of this qualitative study was to identify and understand the knowledge, attitudes and practices of TBAs in rural Nepal. Twenty-one trained and untrained TBAs participated in focus groups and in-depth interviews about antenatal care, delivery practices, maternal complications and newborn care. Antenatal care included advice about nutrition and tetanus toxoid (TT) immunisation, but did not include planning ahead for transport in cases of complications. Clean delivery practices were observed by most TBAs, though hand-washing practices differed by training status. There was no standard practice to identify maternal complications, such as excessive bleeding, prolonged labour, or retained placenta, and most referred outside in the event of such complications. Newborn care practices included breastfeeding with supplemental feeds, thermal care after bathing, and mustard seed oil massage. TBAs reported high job satisfaction and desire to improve their skills. Despite uncertainty regarding the role of TBAs to manage maternal complications, TBAs may be strategically placed to make potential contributions to newborn survival.
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Affiliation(s)
- N Thatte
- Department of International Health, International Centre for Advancing Neonatal Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA.
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Christian P, Darmstadt GL, Wu L, Khatry SK, Leclerq SC, Katz J, West KP, Adhikari RK. The effect of maternal micronutrient supplementation on early neonatal morbidity in rural Nepal: a randomised, controlled, community trial. Arch Dis Child 2008; 93:660-4. [PMID: 18644934 DOI: 10.1136/adc.2006.114009] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Micronutrient deficiencies during pregnancy may be linked to poor newborn health and poor host defences against infection. We assessed newborn morbidity to determine the effect of four combinations of antenatal micronutrient supplements. DESIGN Cluster-randomised, double-masked, controlled trial. SETTING Rural community in Nepal. INTERVENTIONS Women received daily supplements from early pregnancy through to 3 months postpartum of vitamin A alone (control) or vitamin A with folic acid, folic acid plus iron, folic acid plus iron plus zinc or a multiple micronutrient supplement containing these and 11 other nutrients. MAIN OUTCOME MEASURES Infants were visited in their home at birth (n = 3927) and for each of 9 days thereafter to elicit a 24-h history of nine infant morbidity symptoms, measure infant respiratory rate and axial temperature, and assess the infant for chest indrawing. At 6 weeks of age, infants were visited again in their homes to elicit a 30-day and 7-day history of 10 morbidity symptoms using parental recall. RESULTS Maternal micronutrient supplementation had no effect on 10-day morbidity or morbidity 30-day and 7-day morbidity assessed at 6 weeks of age all relative risks were close to 1. Symptoms of birth asphyxia increased by about 60% (p<0.05) in infants of women who received the multiple micronutrient supplement compared with the control. Symptoms of combinations of sepsis, preterm and birth asphyxia were associated with 8- to 14-fold increased odds of 6-month infant mortality. CONCLUSIONS None of the combinations of antenatal micronutrient supplements tested improved symptoms of neonatal morbidity in the first 10 days of life or at 6 weeks of age. Further research is needed to elucidate the association and mechanism of increased risk of birth asphyxia following maternal multiple micronutrient supplementation. TRIAL REGISTRATION NUMBERS NCT00115271.
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Affiliation(s)
- P Christian
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Maryland, USA.
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Katz J, West KP, Pradhan EK, LeClerq SC, Khatry SK, Shrestha SR. The impact of a small steady stream of income for women on family health and economic well-being. Glob Public Health 2007; 2:35-52. [PMID: 19280386 DOI: 10.1080/17441690600682024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Our primary aim to evaluate the impact of a small steady stream of income on family health and well-being among rural women employed part-time in a health project in Sarlahi district, Nepal. All 870 women applying for the job of distributing nutritional supplements in their villages completed a questionnaire prior to selection for employment, 350 of whom were hired and 520 who were not. A total of 736 women completed a second questionnaire 2 years later, 341 (97.4%) of whom had been continuously employed during this period, and 395 (76.0%) who had never been employed by the project. Changes in health and well-being over 2 years were compared between women who were and were not hired. Women who were hired were younger and better educated, but were similar in other regards. After adjusting for selection differences, employed women were more likely to save cash, buy jewellery, and buy certain discretionary household goods over 2 years than those who were not hired. Expenditures on children's clothing increased more for employed women, and their children were more likely to be in private schools at follow-up, but there was no impact on health and survival of children. Women with a small steady stream of income did improve their personal economic situation by savings and increased expenditures for children and the household. Longer follow-up may reveal impacts on health access and expenditures, although these were not evident in 2 years of employment.
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Affiliation(s)
- J Katz
- Department of International Health, John Hopkins Bloomberg School of Public Health, Baltimore, MD 21205-2103, USA.
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Mullany LC, Darmstadt GL, Khatry SK, Leclerq SC, Tielsch JM. Relationship between the surrogate anthropometric measures, foot length and chest circumference and birth weight among newborns of Sarlahi, Nepal. Eur J Clin Nutr 2006; 61:40-6. [PMID: 16885929 PMCID: PMC2329807 DOI: 10.1038/sj.ejcn.1602504] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Classification of infants into low birth weight (LBW, <2500 g) or very low birth weight (VLBW, <2000 g) categories is a crucial step in targeting interventions to high-risk infants. OBJECTIVE To compare the validity of chest circumference and foot length as surrogate anthropometric measures for the identification of LBW and VLBW infants. SUBJECTS AND SETTING Newborn infants (n=1640) born between March and June 2004 in 30 Village Development Committees of Sarlahi district, Nepal. DESIGN Chest circumference, foot length and weight (SECA 727, precise to 2 g) of newborns were measured within 72 h after birth. The sensitivity, specificity and predictive values for a range of cutoff points of the anthropometric measures were estimated using the digital scale measurements as the gold standard. RESULTS Among LBW infants (469/1640, 28.6%), chest circumference measures <30.3 cm were 91% sensitive and 83% specific. Similar levels of sensitivity for foot length were achieved only with considerable loss of specificity (<45%). Foot length measurements <6.9 cm were 88% sensitive and 86% specific for the identification of VLBW infants. CONCLUSION Chest circumference was superior to foot length in classification of infants into birth weight categories. For the identification of VLBW infants, foot length performed well, and may be preferable to chest circumference, as the former measure does not require removal of infant swaddling clothes. In the absence of more precise direct measures of birth weight, chest circumference is recommended over foot length for the identification of LBW infants.
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Affiliation(s)
- L C Mullany
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205-2103, USA.
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Siegel EH, Stoltzfus RJ, Khatry SK, Leclerq SC, Katz J, Tielsch JM. Epidemiology of anemia among 4- to 17-month-old children living in south central Nepal. Eur J Clin Nutr 2006; 60:228-35. [PMID: 16234835 PMCID: PMC1360164 DOI: 10.1038/sj.ejcn.1602306] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To describe the distribution of hemoglobin and prevalence of anemia in Nepali children living in the Terai region by potential risk factors for deficiency. DESIGN This was a cross-sectional, community-based study of baseline characteristics of children enrolled in a randomized, placebo-controlled clinical trial between January and March 2002. Participants were weighed and measured and had their blood drawn. Their mothers contributed demographic, morbidity, and feeding data. SUBJECTS There were 569 4- to 17-month-old children. Statistical models were based on 490 children. RESULTS Anemia was prevalent: 58% of the children had a hemoglobin <105 g/l. Iron-deficiency anemia (anemia with erythrocyte protoporphyrin (EP) > or =90 micromol/mol heme) was present in 43% of the children. Severe anemia was rare: less than 2% of the children had a hemoglobin <70 g/l. The mean (s.d.) hemoglobin concentration was 101 (12.5) g/l. Stunting and wasting were prevalent: 30.8% were stunted (length-for-age Z-score <-2) and 18.1% were wasted (weight-for-length Z-score <-2). Bivariate analyses revealed that age, caste, socioeconomic status, dietary diversity, stunting, and underweight were associated with hemoglobin concentration and/or anemia. In multivariate models with and without EP, age and caste were found to be strong predictors of both hemoglobin concentration and anemia. CONCLUSIONS Anemia and iron deficiency increased strongly with age and low-caste status among the study children. The data reveal the importance of targeting interventions to children in the first year of life before they become anemic and iron deficient.
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Affiliation(s)
- E H Siegel
- Division of Nutritional Sciences, Cornell University, Ithaca, NY 14853, USA.
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Mullany LC, Darmstadt GL, Coffey P, Khatry SK, LeClerq SC, Tielsch JM. A low cost, colour coded, hand held spring scale accurately categorises birth weight in low resource settings. Arch Dis Child 2006; 91:410-3. [PMID: 16464960 PMCID: PMC2082743 DOI: 10.1136/adc.2005.088781] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
AIMS To determine the accuracy of a low cost, spring calibrated, hand held scale in classifying newborns into three weight categories (> or =2500 g, 2000-2499 g, <2000 g). METHODS The test device was compared to a gold standard digital baby scale with precision to 2 g. In Sarlahi district, Nepal, 1890 newborns were eligible for the study. Measurements were collected for both the test device and the digital scale from 1820 (96.3%) newborns. RESULTS The overall low birth weight (LBW) prevalence rate for the gold standard digital scale was 28.1% (511/1820). Sensitivity (93.7%) and specificity (97.6%) of the test device was high compared to LBW classifications based on digital weight measurements. Classification of infants into the <2000 g category was 5.0% and 4.7% for the gold standard and test device, respectively. Sensitivity and specificity of the test device in identifying infants <2000 g was 87.8% and 99.6%, respectively. Positive predictive values were high (>91%) for both weight categories CONCLUSIONS This low cost, simple-to-use device classified infants into weight categories with a high degree of consistency and accuracy that exceeds that of surrogate measures. This new device is useful for identifying and targeting life saving interventions for LBW, high risk infants in settings where infants are born in the home and conventional weighing scales are unavailable.
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Affiliation(s)
- L C Mullany
- Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205-2103, USA
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Mullany LC, Darmstadt GL, Katz J, Khatry SK, LeClerq SC, Adhikari RK, Tielsch JM. Development of clinical sign based algorithms for community based assessment of omphalitis. Arch Dis Child Fetal Neonatal Ed 2006; 91:F99-104. [PMID: 16223755 PMCID: PMC1379664 DOI: 10.1136/adc.2005.080093] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/19/2005] [Indexed: 11/04/2022]
Abstract
BACKGROUND In developing countries, newborn omphalitis contributes significantly to morbidity and mortality. Community based identification and management of omphalitis will require standardised clinical sign based definitions. OBJECTIVE To identify optimal sign based algorithms to define omphalitis in the community and to evaluate the reliability and validity of cord assessments by non-specialist health workers for clinical signs of omphalitis. DESIGN Within a trial of the impact of topical antiseptics on umbilical cord infection in rural Nepal, digital images of the umbilical cord were collected. Workers responsible for in-home examinations of the umbilical cord evaluated the images for signs of infection (pus, redness, swelling). Intraworker and interworker agreement was evaluated, and sensitivity and specificity compared with a physician generated gold standard ranking were estimated. RESULTS Sensitivity and specificity of worker evaluations were high for pus (90% and 96% respectively) and moderate for redness (57% and 95% respectively). Swelling was the least reliably identified sign. Measures of observer agreement were similar to that previously recorded between experts evaluating subjective skin conditions. A composite definition for omphalitis that combined pus and redness without regard to swelling was the most sensitive and specific. CONCLUSIONS Two sign based algorithms for defining omphalitis are recommended for use in the community. Focusing on redness extending to the skin around the base of the stump will identify cases of moderate and high severity. Requiring both the presence of pus and redness will result in a definition with very high specificity and moderate to high sensitivity.
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Affiliation(s)
- L C Mullany
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, Suite W5021, Baltimore, MD 21211, USA.
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Christian P, Khatry SK, LeClerq SC, Roess AA, Wu L, Yuenger JD, Zenilman JM. Prevalence and risk factors of chlamydia and gonorrhea among rural Nepali women. Sex Transm Infect 2005; 81:254-8. [PMID: 15923297 PMCID: PMC1744991 DOI: 10.1136/sti.2004.011817] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES The epidemiology of sexually transmitted infections (STI) in rural, developing world populations is poorly understood. We estimated the prevalence and risk factors of Neisseria gonorrhoeae and Chlamydia trachomatis in a female population in rural Nepal. METHODS We conducted a cross sectional study in a sample of 1177 postpartum women participating in a micronutrient supplementation trial in Nepal. Urine samples were collected to test for the two infections using the ligase chain reaction (LCR). RESULTS C trachomatis was detected in 1.0% (95% confidence intervals (CI): 0.4 to 1.5) and N gonorrhoeae in 2.3% (95% CI: 1.2 to 3.4) of women. None of the women tested positive for both. Self report of all three symptoms of lower abdominal pain, pain and burning on urination, and vaginal discharge was associated with the presence of gonorrhoea (odds ratio (OR): 12.1, 95% CI: 1.3 to 115.0). Neonatal eye discharge was associated with maternal gonococcal infection (OR = 5.2, 95% CI: 1.1 to 24.9). Incidence of low birth weight was not related to these maternal infections, but very preterm delivery (<32 weeks) was higher among women positive for gonorrhoea (OR = 4.7, 95% CI: 1.0 to 22.0). In a multivariable analysis, low body mass index (<18.5) and cattle ownership were associated with gonorrhoea (p <0.05), whereas woman's literacy was associated with chlamydia (p = 0.06). CONCLUSION We found the rates of N gonorrhoeae and C trachomatis to be low among women in this rural population of Nepal.
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Affiliation(s)
- P Christian
- Department of International Health, The Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, Room W2041, Baltimore, MD 21205, USA.
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Katz J, Khatry SK, Thapa MD, Schein OD, Kimbrough Pradhan E, LeClerq SC, West KP. A randomised trial of povidone-iodine to reduce visual impairment from corneal ulcers in rural Nepal. Br J Ophthalmol 2004; 88:1487-92. [PMID: 15548795 PMCID: PMC1772431 DOI: 10.1136/bjo.2004.044412] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
AIM To assess whether povidone-iodine provided any benefit over and above a standard regimen of antibiotic therapy for the treatment of corneal ulcers. METHODS All patients diagnosed with corneal ulcers presenting for care at a primary eye care clinic in rural Nepal were randomised to a standard protocol of antibiotic therapy versus standard therapy plus 2.5% povidone-iodine every 2 hours for 2 weeks. The main outcomes were corrected visual acuity and presence, size, and position of corneal scarring in the affected eye at 2-4 months following treatment initiation. RESULTS 358 patients were randomised and 81% were examined at follow up. The two groups were comparable before treatment. At follow up, 3.9% in the standard therapy and 6.9% in the povidone-iodine group had corrected visual acuity worse than 20/400 (relative risk (RR) 1.77, 95% confidence interval (CI) 0.62 to 5.03). 9.4% in the standard therapy and 13.1% in the povidone-iodine group had corrected visual acuity worse than 20/60 (RR 1.39, 95% CI 0.71 to 2.77), and 17.0% and 18.8% had scars in the visual axis in each of these groups, respectively (RR 1.11, 95% CI 0.67 to 1.82). CONCLUSIONS A small proportion of patients with corneal ulceration treated in this setting had poor visual outcomes. The addition of povidone-iodine to standard antibiotic therapy did not improve visual outcomes, although this design was unable to assess whether povidone-iodine on its own would have resulted in comparable visual outcomes to that of standard therapy.
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Affiliation(s)
- J Katz
- Johns Hopkins Bloomberg School of Public Health, Division of Disease Prevention and Control, Department of International Health, Room W5009, 615 N Wolfe Street, Baltimore, MD 21205-2103, USA.
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Abstract
AIMS To estimate the incidence of ocular injury in rural Nepal and identify details about these injuries that predict poor visual outcome. METHODS Reports of ocular trauma were collected from 1995 through 2000 from patients presenting to the only eye care clinic in Sarlahi district, Nepal. Patients were given a standard free eye examination and interviewed about the context of their injury. Follow up examination was performed 2-4 months after the initial injury. RESULTS 525 cases of incident ocular injury were reported, with a mean age of 28 years. Using census data, the incidence was 0.65 per 1000 males per year, and 0.38 per 1000 females per year. The most common types of injury were lacerating and blunt, with the majority occurring at home or in the fields. Upon presentation to the clinic, 26.4% of patients had a best corrected visual acuity worse than 20/60 in the injured eye, while 9.6% had visual acuity worse than 20/400. 82% were examined at follow up: 11.2% of patients had visual acuity worse than 20/60 and 4.6% had vision worse than 20/400. A poor visual outcome was associated with increased age, care sought at a site other than the eye clinic, and severe injury. 3% of patients were referred for further care at an eye hospital at the initial visit; 7% had sought additional care in the interim between visits, with this subset representing a more severe spectrum of injuries. CONCLUSIONS The detrimental effects of delayed care or care outside of the specialty eye clinic may reflect geographic or economic barriers to care. For optimal visual outcomes, patients who are injured in a rural setting should recognise the injury and seek early care at a specialty eye care facility. Findings from our study suggest that trained non-ophthalmologists may be able to clinically manage many eye injuries encountered in a rural setting in the "developing" world, reducing the demand for acute services of ophthalmologists in remote locations of this highly agricultural country.
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Affiliation(s)
- S K Khatry
- Nepal Nutrition Intervention Project-Sarlahi (NNIPS), Nepal Netra Jyoti Sangh, PO Box 335, Tripureswor, Kathmandu, Nepal
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Christian P, West KP, Katz J, Kimbrough-Pradhan E, LeClerq SC, Khatry SK, Shrestha SR. Cigarette smoking during pregnancy in rural Nepal. Risk factors and effects of beta-carotene and vitamin A supplementation. Eur J Clin Nutr 2004; 58:204-11. [PMID: 14749738 DOI: 10.1038/sj.ejcn.1601767] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE We examined risk factors of smoking and the association between smoking and pregnancy-related and 6-month infant mortality in rural Nepal, where 30% women reported smoking during pregnancy. DESIGN Cross-sectional analysis of risk factors associated with smoking status and health consequences of smoking, using prospective data collected as part of a randomized community trial to examine the effect of maternal vitamin A or beta-carotene supplementation on maternal mortality. SETTING Rural, southeastern plains of Nepal. SUBJECTS AND METHODS A total of 17 767 women contributed at least one pregnancy during 3.5 y of the study. Data on cigarette or bidi (rolled tobacco) smoking were collected using a 7-day recall, twice during pregnancy. Associations between smoking status and maternal diet, morbidity profile, household socioeconomic status and serum concentration of retinol, carotenoids and tocopherols were examined. Further, relative risk (RR) and 95% confidence intervals (CI) were calculated to estimate supplement effects on pregnancy-related mortality, stratified by smoking status during pregnancy. RESULTS Smokers were more likely to be older, illiterate and poor compared to nonsmokers. Fruit and vegetable consumption among smokers and nonsmokers did not vary. However, smokers were more likely to consume meat/fish/eggs and less likely to consume milk than nonsmokers. They were also more likely to report symptoms of vaginal bleeding, edema, severe headache and convulsions during pregnancy relative to nonsmokers. Mortality per 100,000 pregnancies appeared to be higher among smokers than nonsmokers in the placebo group (915 vs 584, RR=1.57, 95% CI: 0.80-3.08). beta-Carotene supplementation reduced pregnancy-related mortality both among smokers (RR=0.31 95% CI: 0.11-0.89) and nonsmokers (RR=0.41, 95% CI: 0.19-0.89). Similar results obtained with vitamin A supplementation were not statistically significant. Infant mortality up to 6 months was approximately 30% higher among smokers compared to nonsmokers in the placebo group both before and after adjusting for confounding factors. Neither supplement given to women reduced infant mortality. CONCLUSIONS Cigarette smoking during pregnancy is associated with an increased risk of maternal and infant mortality in rural Nepal. beta-Carotene and to some extent vitamin A may reduce the risk of pregnancy-related mortality, but not infant mortality, among both smokers and nonsmokers.
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Affiliation(s)
- P Christian
- Division of Human Nutrition, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA.
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Khatry SK, Malla OK, Karki DB, Adhikari KP. Cataract Due to Lighting a Case Report. JNMA J Nepal Med Assoc 2003. [DOI: 10.31729/jnma.1708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Abstract
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Schulze KJ, West KP, Gautschi LA, Dreyfuss ML, LeClerq SC, Dahal BR, Wu LSF, Khatry SK. Seasonality in urinary and household salt iodine content among pregnant and lactating women of the plains of Nepal. Eur J Clin Nutr 2003; 57:969-76. [PMID: 12879092 DOI: 10.1038/sj.ejcn.1601632] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To determine the extent and causes of iodine deficiency among women during pregnancy and lactation in the southeastern plains of Nepal. DESIGN, SETTING AND SUBJECTS Urinary iodine (UI) was assessed as an indicator of iodine status in spot urine samples of women participating in a field trial in three rural communities in the plains of southeastern Nepal. Samples were collected during pregnancy (n=1021) and during lactation at 3-4 months postpartum (n=1028) at a central clinic; 613 women were assessed at both times. Salt iodine (SI) content was assessed semiquantitatively at 6-7 months postpartum in households (n=1572). RESULTS During pregnancy and lactation, median UI concentrations were 0.756 and 0.483 micromol/l, respectively, indicating mild iodine deficiency. UI and SI concentrations covaried markedly by season and were highest during hot, dry, premonsoon months and lowest during and following the humid monsoon season. Within women who contributed urine samples during both pregnancy and the postpartum period, iodine status determined by UI was not correlated. The percentage of households with adequately iodized salt (30 ppm) ranged from 85 to 44% from the hot, dry to the humid seasons, respectively. CONCLUSIONS In the rural southern plains of Nepal, iodine deficiency remains a mild-to-moderate public health problem among pregnant and lactating women despite the availability of iodized salt. Marked seasonality in SI content may account for the lack of intraindividual correlation between maternal iodine status during pregnancy and postpartum periods and contribute to periodicity in the risk of iodine deficiency.
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Affiliation(s)
- K J Schulze
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA
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Khatry SK, Christian P, Shrestha SB, Shrestha SR, Padhan EK, LeClerq SC, Pokhrel RP, West KPJ. MATERNAL NIGHT BLINDNESS IN NEPAL : HEALTH RISKS AND CONSEQUENCES. JNMA J Nepal Med Assoc 2003. [DOI: 10.31729/jnma.1175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
ABSTRACT
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Abstract
BACKGROUND Twin pregnancies are common but there are few data on rates of twinning or survival of liveborn twin infants in developing countries. METHODS The rates of multiple births were calculated in a population-based cohort of married women of childbearing age who were enrolled in a randomized community trial to assess the impact of vitamin A or beta-carotene on maternal and infant health and survival. RESULTS The rate of twinning was 16.1 per 1000 pregnancies (7.4 if only twin pregnancies resulting in two liveborn infants were used). The rate for triplets and quadruplets was 0.19 and 0.06 per 1000 pregnancies. Twinning rates were higher among women of higher parity, but were not associated with maternal age. Twinning rates among twins where at least one was live born (or increased in utero survival) were 30% (95% CI : -1%, 71%) and 44% (95% CI : 9%, 89%) higher among women receiving vitamin A and beta-carotene supplements than placebo, after adjusting for maternal age, gestational age, and parity. The perinatal mortality rate was 8.54 times higher for twins than singletons, 7.32 higher for neonatal mortality, and 5.84 higher for cumulative 24-week mortality. This difference was reduced but not erased by adjusting for gestational age. No difference in survival of liveborn twin infants was seen by supplement group. A higher mortality rate among male twins was largely explained by gestational age. CONCLUSIONS Multiple births are relatively common occurrences in rural Nepal, and carry a much higher mortality risk for the infants than for singletons. Vitamin A or beta-carotene supplementation appeared to increase the rate of twinning, or improve the survival of twins in utero, but did not increase twin survival after birth.
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Affiliation(s)
- J Katz
- The Division of Disease Control and Prevention, and the Center for Human Nutrition (CHN), Department of International Health, Johns Hopkins University School of Hygiene and Public Health, Baltimore, MD 21205-2103, USA.
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Christian P, Khatry SK, Yamini S, Stallings R, LeClerq SC, Shrestha SR, Pradhan EK, West KP. Zinc supplementation might potentiate the effect of vitamin A in restoring night vision in pregnant Nepalese women. Am J Clin Nutr 2001; 73:1045-51. [PMID: 11382658 DOI: 10.1093/ajcn/73.6.1045] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Zinc deficiency may result in abnormal dark adaptation or night blindness, a symptom primarily of vitamin A deficiency. During a placebo-controlled trial in Nepal, weekly vitamin A supplementation of women reduced but failed to eliminate the incidence of night blindness during pregnancy, suggesting a role for zinc. OBJECTIVE The study examined the efficacy of daily zinc supplementation in restoring night vision of pregnant women who developed night blindness while routinely receiving either vitamin A, beta-carotene, or placebo in a field trial. DESIGN Women (n = 202) who reported to be night blind during pregnancy were randomly assigned in a double-blind manner, stratified on vitamin A, beta-carotene, or placebo receipt, to receive 25 mg Zn or placebo daily for 3 wk. Thus, the 6 groups studied were as follows: beta-carotene + zinc, beta-carotene alone, vitamin A + zinc, vitamin A alone (vitamin A + placebo), zinc alone (zinc + placebo), and placebo (2 placebos: one for the vitamin A or beta-carotene study and one for the zinc study). Women underwent a clinic-based assessment that included pupillary threshold testing and phlebotomy before and after supplementation. Supplement use and daily history of night blindness were obtained at home twice every week. RESULTS Zinc treatment increased serum zinc concentrations, but alone (zinc alone group), failed to restore night vision or to improve dark adaptation. However, women in the vitamin A + zinc group who had baseline serum zinc concentrations <9.9 micromol/L were 4 times more likely to have their night vision restored (95% CI: 1.1, 17.3) than were women in the placebo group and tended to have a small improvement in pupillary threshold scores (by 0.21 log candela/m2; P = 0.09). CONCLUSION These data suggest that zinc potentiated the effect of vitamin A in restoring night vision among night-blind pregnant women with low initial serum zinc concentrations.
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Affiliation(s)
- P Christian
- Division of Human Nutrition, School of Hygiene and Public Health, The Johns Hopkins University, Baltimore, MD 21205, USA.
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Yamini S, West KP, Wu L, Dreyfuss ML, Yang DX, Khatry SK. Circulating levels of retinol, tocopherol and carotenoid in Nepali pregnant and postpartum women following long-term β-carotene and vitamin A supplementation. Eur J Clin Nutr 2001; 55:252-9. [PMID: 11360129 DOI: 10.1038/sj.ejcn.1601152] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2000] [Revised: 11/02/2000] [Accepted: 11/06/2000] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To characterize circulating carotenoid and tocopherol levels in Nepali women during pregnancy and post-partum and to determine the effects of beta-carotene and vitamin A supplementation on their concentration in serum. DESIGN Randomized community supplementation trial. SETTING The study was carried out from 1994 to 1997 in the Southern, rural plains District of Sarlahi, Nepal. SUBJECTS A total of 1431 married women had an ascertained pregnancy, of whom 1186 (83%) provided an analyzable serum sample during pregnancy; 1098 (77%) provided an analyzable 3-4 months post-partum serum sample. INTERVENTIONS Women received a weekly dose of vitamin A (7000 microg RE), beta-carotene (42 mg) or placebo before, during and after pregnancy. Serum was analyzed for retinol, alpha-tocopherol, gamma-tocopherol, beta-carotene, alpha-carotene, lycopene, lutein + zeaxanthin, and beta-cryptoxanthin concentrations during mid-pregnancy and at approximately 3 months post-partum. RESULTS Compared to placebo, serum retinol, beta-carotene, gamma-tocopherol, beta-cryptoxanthin and lutein + zeaxanthin concentrations were higher among beta-carotene recipients during pregnancy and, except for beta-cryptoxanthin, at postpartum. In the vitamin A group, serum retinol and beta-cryptoxanthin were higher during pregnancy, and retinol and gamma-tocopherol higher at postpartum. Lutein + zeaxanthin was the dominant carotenoid, regardless of treatment group, followed by serum beta-carotene. Serum lycopene level was lowest, and very low compared to the US population. Serum retinol was higher, and carotenoid and alpha-tocopherol lower, at postpartum than during pregnancy in all groups. CONCLUSIONS Pregnant and lactating Nepali women have lower serum carotenoid and tocopherol levels than well-nourished populations. beta-carotene supplementation appeared to increase levels of tocopherol and other carotenoids in this population.
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Affiliation(s)
- S Yamini
- Center for Human Nutrition, Department of International Health and the Sight and Life Institute, The Johns Hopkins School of Public Health, Baltimore, Maryland, USA
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Christian P, West KP, Khatry SK, LeClerq SC, Kimbrough-Pradhan E, Katz J, Shrestha SR. Maternal night blindness increases risk of mortality in the first 6 months of life among infants in Nepal. J Nutr 2001; 131:1510-2. [PMID: 11340108 DOI: 10.1093/jn/131.5.1510] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Night blindness occurs commonly among women during pregnancy in rural NEPAL: We examined the relationship between maternal night blindness and the risk of mortality occurring among infants in the first 6 mo of life. Stratified analysis by maternal night blindness status during pregnancy was done for 10,000 women participating in a randomized, placebo-controlled trial of vitamin A and beta-carotene supplementation. Mortality of infants of non-night blind women in all three supplementation groups was similar, and when combined, was 63/1000 live births. Relative to this, mortality was higher by 63% [95% confidence interval (CI): 9-138%) and 50% (95% CI: -3 to 133%) among infants of night blind women receiving placebo and beta-carotene, respectively, but only by 14% (95% CI: -33 to 93%) among those receiving vitamin A. Thus, 6-mo mortality was higher among infants of women who had night blindness during pregnancy. Maternal receipt of vitamin A reduced this risk.
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Affiliation(s)
- P Christian
- Johns Hopkins School of Public Health, Baltimore, MD 21205, USA.
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Christian P, West KP, Khatry SK, Katz J, LeClerq SC, Kimbrough-Pradhan E, Dali SM, Shrestha SR. Vitamin A or beta-carotene supplementation reduces symptoms of illness in pregnant and lactating Nepali women. J Nutr 2000; 130:2675-82. [PMID: 11053506 DOI: 10.1093/jn/130.11.2675] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
The contribution of nutritional interventions to the reduction in maternal morbidity rates in developing countries is not well known. We assessed the impact of weekly vitamin A and beta-carotene supplementation on the prevalence of pregnancy and postpartum illness symptoms among 15,832 Nepali women in a placebo-controlled, double-masked, cluster-randomized trial. There was no impact of either supplement on morbidity rates reported up to 28 wk of gestation, inclusive. However, in late pregnancy (>28 wk), symptoms of nausea, faintness and night blindness were reduced with vitamin A, but not beta-carotene, supplementation. Vitamin A supplementation shortened the length of labor by 1.5 h 50 min among nulliparous and multiparous women, respectively. Both interventions reduced the postpartum prevalence of at least four loose stools and night blindness. beta-Carotene supplementation also reduced symptoms of high fever postpartum. The mean number of days of any reported illness symptoms was 3-4 per wk throughout pregnancy. Among women receiving vitamin A, the total number of days of illness symptoms accrued over the last 12 wk of pregnancy was lower by 5 d compared with the placebo recipients. We found the burden of pregnancy-related illness symptoms to be high in this rural area of Nepal where antenatal care is poor and most deliveries occur at home. Maternal vitamin A or beta-carotene supplementation resulted in a reduction in the prevalence of selected illness symptoms during late pregnancy, at the time of birth and during 6 mo postpartum, suggesting that a diet adequate in vitamin A may be important for improving women's reproductive health.
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Affiliation(s)
- P Christian
- Johns Hopkins School of Public Health, Baltimore, Maryland, USA
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Congdon NG, Dreyfuss ML, Christian P, Navitsky RC, Sanchez AM, Wu LS, Khatry SK, Thapa MD, Humphrey J, Hazelwood D, West KP. Responsiveness of dark-adaptation threshold to vitamin A and beta-carotene supplementation in pregnant and lactating women in Nepal. Am J Clin Nutr 2000; 72:1004-9. [PMID: 11010944 DOI: 10.1093/ajcn/72.4.1004] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Impaired dark adaptation occurs commonly in vitamin A deficiency. OBJECTIVE We sought to examine the responsiveness of dark-adaptation threshold to vitamin A and beta-carotene supplementation in Nepali women. DESIGN The dark-adapted pupillary response was tested in 298 pregnant women aged 15-45 y in a placebo-controlled trial of vitamin A and beta-carotene; 131 of these women were also tested at 3 mo postpartum. Results were compared with those for 100 nonpregnant US women of similar age. The amount of light required for pupillary constriction was recorded after bleaching and dark adaptation. RESULTS Pregnant women receiving vitamin A had better dark-adaptation thresholds (-1.24 log cd/m(2)) than did those receiving placebo (-1.11 log cd/m(2); P: = 0. 03) or beta-carotene (-1.13 log cd/m(2); P: = 0.05) (t tests with Bonferroni correction). Dark-adaptation threshold was associated with serum retinol concentration in pregnant women receiving placebo (P: = 0.001) and in those receiving beta-carotene (P: = 0.003) but not in those receiving vitamin A. Among women receiving placebo, mean dark-adaptation thresholds were better during the first trimester (-1.23 log cd/m(2)) than during the second and third trimesters (-1.03 log cd/m(2); P: = 0.02, t test). The mean threshold of nonpregnant US women (-1.35 log cd/m(2)) was better than that of all 3 Nepali groups (P: < 0.001, t test, for all 3 groups). CONCLUSIONS During pregnancy, pupillary dark adaptation was strongly associated with serum retinol concentration and improved significantly in response to vitamin A supplementation. This noninvasive testing technique is a valid indicator of population vitamin A status in women of reproductive age.
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Affiliation(s)
- N G Congdon
- Center for Human Nutrition, Department of International Health, The Johns Hopkins School of Hygiene and Public Health, Baltimore, MD, USA
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Dreyfuss ML, Stoltzfus RJ, Shrestha JB, Pradhan EK, LeClerq SC, Khatry SK, Shrestha SR, Katz J, Albonico M, West KP. Hookworms, malaria and vitamin A deficiency contribute to anemia and iron deficiency among pregnant women in the plains of Nepal. J Nutr 2000; 130:2527-36. [PMID: 11015485 DOI: 10.1093/jn/130.10.2527] [Citation(s) in RCA: 170] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Anemia and iron deficiency during pregnancy are prevalent in developing countries, but their causes are not always known. We assessed the prevalence and severity of anemia and iron deficiency and their association with helminths, malaria and vitamin A deficiency in a community-based sample of 336 pregnant women in the plains of Nepal. Hemoglobin, erythrocyte protoporphyrin (EP) and serum ferritin were assessed in venous blood samples. Overall, 72.6% of women were anemic (hemoglobin < 110 g/L), 19.9% had moderate to severe anemia (hemoglobin < 90 g/L) and 80.6% had iron deficiency (EP > 70 micromol/mol heme or serum ferritin < 10 microg/L). Eighty-eight percent of cases of anemia were associated with iron deficiency. More than half of the women (54.2%) had a low serum retinol concentration (<1.05 micromol/L), 74.2% were infected with hookworms and 19.8% had Plasmodium vivax malaria parasitemia. Hemoglobin, EP and serum ferritin concentrations were significantly worse and the prevalence of anemia, elevated EP and low serum ferritin was increased with increasing intensity of hookworm infection. Hookworm infection intensity was the strongest predictor of iron status, especially of depleted iron stores. Low serum retinol was most strongly associated with mild anemia, whereas P. vivax malaria and hookworm infection intensity were stronger predictors of moderate to severe anemia. These findings reinforce the need for programs to consider reducing the prevalence of hookworm, malaria infection and vitamin A deficiency where indicated, in addition to providing iron supplements to effectively control anemia.
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Affiliation(s)
- M L Dreyfuss
- Department of International Health, The Johns Hopkins School of Hygiene and Public Health, Baltimore, MD 21205, USA
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Christian P, West KP, Khatry SK, Kimbrough-Pradhan E, LeClerq SC, Katz J, Shrestha SR, Dali SM, Sommer A. Night blindness during pregnancy and subsequent mortality among women in Nepal: effects of vitamin A and beta-carotene supplementation. Am J Epidemiol 2000; 152:542-7. [PMID: 10997544 DOI: 10.1093/aje/152.6.542] [Citation(s) in RCA: 114] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Night blindness due to vitamin A deficiency is common during pregnancy among women in Nepal. The authors assessed the risk of maternal death during and after a pregnancy with night blindness among women participating in a cluster-randomized, placebo-controlled vitamin A and beta-carotene supplementation trial in Nepal from July 1994 to September 1997. Subjects were 877 women with night blindness and 9,545 women without night blindness during pregnancy. Women were followed from the time they declared that they were pregnant through the end of the study, representing a median follow-up of 90 weeks (interquartile range: 64-121 weeks). Mortality of night-blind women in the placebo group was 3,601 per 100,000 pregnancies. In comparison, the relative risk of dying among nonnight-blind women in the placebo group was 0.26 (95% confidence interval (CI): 0.13, 0.55), and the relative risk among women with or without night blindness in the vitamin A/beta-carotene group was 0.32 (95% CI: 0.10, 0.91) and 0.18 (95% CI: 0.09, 0.36), respectively. Night-blind women were five times (95% CI: 2.20, 10.58) more likely to die from infections than were women who were not night blind. These findings show that night blindness during pregnancy is a risk factor of both short- and long-term mortality among women. Vitamin A/beta-carotene supplementation ameliorates this risk to a large extent.
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Affiliation(s)
- P Christian
- Johns Hopkins School of Public Health, Baltimore, MD 21205, USA
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Katz J, West KP, Khatry SK, Pradhan EK, LeClerq SC, Christian P, Wu LS, Adhikari RK, Shrestha SR, Sommer A. Maternal low-dose vitamin A or beta-carotene supplementation has no effect on fetal loss and early infant mortality: a randomized cluster trial in Nepal. Am J Clin Nutr 2000; 71:1570-6. [PMID: 10837300 DOI: 10.1093/ajcn/71.6.1570] [Citation(s) in RCA: 94] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The effect of vitamin A supplementation on the survival of infants aged <6 mo is unclear. Because most infant deaths occur in the first few month of life, maternal supplementation may improve infant survival. OBJECTIVES The objective was to assess the effect of maternal vitamin A or beta-carotene supplementation on fetal loss and survival of infants <6 mo of age. DESIGN Married women of reproductive age in 270 wards of Sarlahi district, Nepal, were eligible to participate. Wards were randomly assigned to have women receive weekly doses of 7000 microg retinol equivalents as retinyl palmitate (vitamin A), 42 mg all-trans-beta-carotene, or placebo. Pregnancies were followed until miscarriage, stillbirth, maternal death, or live birth of one or more infants, who were followed through 24 wk of age. RESULTS A total of 43559 women were enrolled; 15832 contributed 17373 pregnancies and 15987 live born infants to the trial. The rate of fetal loss was 92.0/1000 pregnancies in the placebo group, comparable with rates in the vitamin A and beta-carotene groups, which had relative risks of 1.06 (95% CI: 0.91, 1.25) and 1.03 (95% CI: 0.87, 1.19), respectively. The 24-wk mortality rate was 70.8/1000 live births in the placebo group, comparable with rates in the vitamin A and beta-carotene groups, which had relative risks of 1.05 (95% CI: 0.87, 1.25) and 1.03 (95% CI: 0.86, 1.22), respectively. CONCLUSIONS Small weekly doses of vitamin A or beta-carotene given to women before conception, during pregnancy, and through 24 wk postpartum did not improve fetal or early infant survival in Nepal.
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Affiliation(s)
- J Katz
- Department of International Health, the Center for Human Nutrition, the Sight and Life Institute, and the Dean's Office, Johns Hopkins School of Hygiene and Public Health, Baltimore, MD 21205-2103, USA.
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West KP, Katz J, Khatry SK, LeClerq SC, Pradhan EK, Shrestha SR, Connor PB, Dali SM, Christian P, Pokhrel RP, Sommer A. Double blind, cluster randomised trial of low dose supplementation with vitamin A or beta carotene on mortality related to pregnancy in Nepal. The NNIPS-2 Study Group. BMJ 1999; 318:570-5. [PMID: 10037634 PMCID: PMC27760 DOI: 10.1136/bmj.318.7183.570] [Citation(s) in RCA: 352] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To assess the impact on mortality related to pregnancy of supplementing women of reproductive age each week with a recommended dietary allowance of vitamin A, either preformed or as beta carotene. DESIGN Double blind, cluster randomised, placebo controlled field trial. SETTING Rural southeast central plains of Nepal (Sarlahi district). SUBJECTS 44 646 married women, of whom 20 119 became pregnant 22 189 times. INTERVENTION 270 wards randomised to 3 groups of 90 each for women to receive weekly a single oral supplement of placebo, vitamin A (7000 micrograms retinol equivalents) or beta carotene (42 mg, or 7000 micrograms retinol equivalents) for over 31/2 years. MAIN OUTCOME MEASURES All cause mortality in women during pregnancy up to 12 weeks post partum (pregnancy related mortality) and mortality during pregnancy to 6 weeks postpartum, excluding deaths apparently related to injury (maternal mortality). RESULTS Mortality related to pregnancy in the placebo, vitamin A, and beta carotene groups was 704, 426, and 361 deaths per 100 000 pregnancies, yielding relative risks (95% confidence intervals) of 0. 60 (0.37 to 0.97) and 0.51 (0.30 to 0.86). This represented reductions of 40% (P<0.04) and 49% (P<0.01) among those who received vitamin A and beta carotene. Combined, vitamin A or beta carotene lowered mortality by 44% (0.56 (0.37 to 0.84), P<0.005) and reduced the maternal mortality ratio from 645 to 385 deaths per 100 000 live births, or by 40% (P<0.02). Differences in cause of death could not be reliably distinguished between supplemented and placebo groups. CONCLUSION Supplementation of women with either vitamin A or beta carotene at recommended dietary amounts during childbearing years can lower mortality related to pregnancy in rural, undernourished populations of south Asia.
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Affiliation(s)
- K P West
- Johns Hopkins School of Hygiene and Public Health, Division of Human Nutrition, Room 2041, 615 N Wolfe Street, Baltimore, MD 21205, USA.
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Christian P, West KP, Khatry SK, Katz J, LeClerq S, Pradhan EK, Shrestha SR. Vitamin A or beta-carotene supplementation reduces but does not eliminate maternal night blindness in Nepal. J Nutr 1998; 128:1458-63. [PMID: 9732305 DOI: 10.1093/jn/128.9.1458] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
We investigated the effect of supplementing women weekly with 7000 microg retinol equivalents as preformed vitamin A or beta-carotene vs. a placebo, on the incidence of night blindness during pregnancy and the postpartum period in the rural plains of Nepal. Over a period of approximately 3 y, approximately 29,000 women of child-bearing age, living in 171 wards that were randomized to one of the three supplements, contributed 9932 first pregnancies. A prospective, weekly surveillance identified night blindness in pregnant women, verified further by detailed questioning about nighttime vision. After delivery, women were also interviewed at approximately 3 and approximately 6 mo postpartum to elicit a night blindness history over the preceding 3 mo. Vitamin A supplementation reduced the incidence of night blindness during pregnancy from 10.7% among controls to 6.7% (relative risk 0.62, 95% confidence interval: 0.45-0.85). beta-Carotene supplementation had less of an effect (0. 83, 0.63-1.11). Among women who took >95% of their vitamin A supplements during pregnancy, incidence of verified night blindness was reduced by 67%. Incidence (per 100 person-years) of night blindness during the first 3 mo postpartum was 11.3 in the control, 4.3 in the vitamin A and 8.7 in the beta-carotene groups, yielding corresponding relative risks of 0.38 (0.26-0.55) and 0.77 (0.57-1. 04). In the second 3 mo postpartum, both vitamin A and beta-carotene reduced night blindness by approximately 50%. Vitamin A intakes approaching a recommended amount for pregnancy markedly reduced but did not eliminate night blindness in Nepali women. Greater intakes of vitamin A than provided and/or other nutrients may be needed to prevent maternal night blindness in rural South Asia.
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Affiliation(s)
- P Christian
- Center for Human Nutrition, Department of International Health, School of Hygiene & Public Health, Johns Hopkins University, Baltimore, MD 21205, USA
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Katz J, West KP, LeClerq SC, Thapa MD, Khatry SK, Shresta SR, Pradhan EK, Pohkrel RP. Agreement between clinical examination and parental morbidity histories for children in Nepal. J Trop Pediatr 1998; 44:225-9. [PMID: 9718909 DOI: 10.1093/tropej/44.4.225] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Parental histories are often used to estimate the prevalence and the impact of interventions on child morbidity, but few studies have examined the agreement between parental histories and clinical examination. We compared clinical findings with a same-day parental morbidity history for pre-school-age children in rural Nepal. A 15 per cent sample of children from 40 wards in Sarlahi district, Nepal, was selected for participation and 814 same-day morbidity histories were obtained from parents. A clinician, masked to the parent's history, visited the household 2-4 h later and examined the child for signs of morbidity symptoms about which the parent had previously been questioned. Signs included measurement of temperature, respiratory rate, examination of stools, ear discharge, and presence of persistent cough. Agreement between the history and clinical examination was excellent for ear infection (kappa = 0.75) and history of measles rash (kappa = 0.74), moderate to poor for diarrhoea (kappa = 0.21) and fever (kappa = 0.31), and there was no evidence of agreement for dysentery (kappa = -0.01), rapid breathing (kappa = 0.06), and cough (kappa = 0.09). The prevalence of dysentery, fever, cough, and rapid breathing was lower if clinical signs rather than histories were used. The prevalence of diarrhoea was higher if the presence of a loose stool in a cup rather than a history was used. The prevalence of ear infections and measles was comparable with both methods. The agreement between histories and clinical examination varies by morbidity type, as does the prevalence of morbidity estimated by one or other method.
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Affiliation(s)
- J Katz
- Department of International Health, Johns Hopkins School of Hygiene and Public Health, Baltimore, MD 21205-2103, USA
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Christian P, Thorne-Lyman AL, West KP, Bentley ME, Khatry SK, Pradhan EK, LeClerq SC, Shrestha SR. Working after the sun goes down: exploring how night blindness impairs women's work activities in rural Nepal. Eur J Clin Nutr 1998; 52:519-24. [PMID: 9683335 DOI: 10.1038/sj.ejcn.1600600] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To explore the influence of night blindness during pregnancy on nighttime work activities of women. DESIGN AND SUBJECTS A community based case-control study was used to compare nighttime activities of night blind (cases) and non-night blind pregnant women (controls) using a 24h recall method to measure work activities (n=116 pairs). SETTING Rural South-Eastern district in the plains of Nepal. RESULTS Approximately one third of the night blind women reported being 'inactive' the previous night, not participating in any of the inquired work activities, as compared with only 15% of the control group (P < 0.031). The type of work that was significantly affected was the outdoor kind such as fetching water and washing dishes. Logistic regression analysis showed that night blind women were half as likely (odds ratio=0.49, 95% confidence interval=0.25-0.98) to work at night than women without night blindness after controlling for the effects of confounding variables including gestational age, season, and protein energy malnutrition which were significantly associated with nighttime work activity. CONCLUSIONS Night blindness during pregnancy, an indicator of vitamin A deficiency, reduces the number and type of work activities women perform at night, thus impairing women's ability to participate in normal subsistence activities by reducing their 'work day'.
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Affiliation(s)
- P Christian
- Center for Human Nutrition, and the Department of International Health, School of Hygiene and Public Health, Johns Hopkins University, Baltimore, MD, USA
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Navitsky RC, Dreyfuss ML, Shrestha J, Khatry SK, Stoltzfus RJ, Albonico M. Ancylostoma duodenale is responsible for hookworm infections among pregnant women in the rural plains of Nepal. J Parasitol 1998; 84:647-51. [PMID: 9645880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Fecal specimens from 292 pregnant women (ages 15-40 yr) and 129 infants (ages 10-20 wk) were examined for helminth eggs by the Kato-Katz method and cultured for helminth larvae identification using a modified Harada Mori method. These specimens were collected from June 1995 through July 1996 in Sarlahi District in the southern rural plains of Nepal. Among pregnant women, the prevalence of helminth infection by the Kato-Katz method was 78.8%, 56.2%, and 7.9% for hookworm, Ascaris lumbricoides, and Trichuris trichiura, respectively. Using the modified Harada-Mori method, 66.1% and 2.0% of women's fecal cultures were positive for hookworm and Strongyloides stercoralis, respectively. All of the cultured hookworm larvae were identified as Ancylostoma duodenale. Among infants, 1 specimen was positive for hookworm and 1 for A. lumbricoides using the Kato-Katz method. The modified Harada Mori method detected no larvae in specimens from infants. There was 81.8% agreement between the 2 methods for the detection of hookworm infection. Ancylostoma duodenale is endemic in this study population and highly prevalent in pregnant women.
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Affiliation(s)
- R C Navitsky
- Center for Human Nutrition, School of Hygiene and Public Health, Johns Hopkins University, Baltimore, Maryland 21205-2103, USA
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Navitsky RC, Dreyfuss ML, Shrestha J, Khatry SK, Stoltzfus RJ, Albonico. Ancylostoma duodenale Is Responsible for Hookworm Infections among Pregnant Women in the Rural Plains of Nepal. J Parasitol 1998. [DOI: 10.2307/3284746] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Christian P, West KP, Khatry SK, Katz J, Shrestha SR, Pradhan EK, LeClerq SC, Pokhrel RP. Night blindness of pregnancy in rural Nepal--nutritional and health risks. Int J Epidemiol 1998; 27:231-7. [PMID: 9602403 DOI: 10.1093/ije/27.2.231] [Citation(s) in RCA: 133] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Night blindness (XN) is the most common clinical symptom of vitamin A deficiency among children in developing countries. Yet little is known about the aetiology or associated risks of maternal XN. Emerging evidence from South East Asia suggests that it may be more frequent than previously thought in women of reproductive age, especially during pregnancy. METHODS A population-based, case-control study was conducted to reveal the epidemiology of XN among pregnant Nepali women. Night blind cases were identified by history through a weekly community surveillance system. Controls were randomly selected from a pool of pregnant women without XN and pair-matched for gestational age of the cases. A home-based assessment was done within a week of selection, at which 7-day food frequency and morbidity histories were collected, anthropometry measured, and capillary blood drawn for serum retinol, beta-carotene and haemoglobin (Hb) estimation. RESULTS Cases and controls did not differ by age or number of previous pregnancies. However, cases were more likely to be from the lower castes, be illiterate, live in poorer quality homes, and own no land. The mean serum retinol level of cases was approximately 0.30 mumol/l lower than controls (P < 0.001), indicating a low vitamin A status of night blind pregnant women. Mean Hb level was significantly lower (by 0.7 g/dl, P < 0.004), and the risk of severe anaemia (Hb < 7.0 g/dl) higher among cases than controls (odds ratio = 3.0, 95% CI: 1.25-7.23). Cases were more under-nourished than controls reflected by lower mean weight (-2.6 kg), body mass index (-0.8), arm circumference (-0.9 cm) and triceps skinfold (-0.8 mm). Night blindness was associated with less frequent consumption of preformed vitamin A (milk products, fish and meat) and provitamin A (dark green leafy vegetables and mangoes) foods, especially in summer. Night blind women were 2-3 times more likely to report symptoms of urinary/reproductive tract infections such as lower abdominal pain, painful and burning urination, or vaginal discharge, symptoms of diarrhoea/dysentery, of pre-eclampsia or eclampsia, and of nausea, vomiting or poor appetite throughout pregnancy than controls. CONCLUSION Women who experience XN during pregnancy have a low vitamin A status, although several other risk factors appear to cluster among these women as well. Night blind women are also more likely to be anaemic, ill, and acutely under-nourished, and to be consuming a nutritionally poorer diet in pregnancy than non-night blind pregnant women. A simple history of XN can identify women at high risk during pregnancy who may require special nutritional support, antenatal care and counselling.
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Affiliation(s)
- P Christian
- Center for Human Nutrition, School of Hygiene and Public Health, Johns Hopkins University, Baltimore, MD 21205, USA
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West KP, LeClerq SC, Shrestha SR, Wu LS, Pradhan EK, Khatry SK, Katz J, Adhikari R, Sommer A. Effects of vitamin A on growth of vitamin A-deficient children: field studies in Nepal. J Nutr 1997; 127:1957-65. [PMID: 9311951 DOI: 10.1093/jn/127.10.1957] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Inconsistencies have been observed in the impact of vitamin A (VA) supplementation on early child growth. To help clarify this issue, a cohort of 3377 rural Nepalese, nonxerophthalmic children 12-60 mo of age were randomized by ward to receive vitamin A [60,000 microg retinol equivalents (RE)] or placebo-control (300 RE) supplementation once every 4 mo and followed for 16 mo. VA had no impact on annual weight gain or linear growth. However, arm circumference (AC) and muscle area (MA) growth improved in VA recipients, by 0.13 cm and 25 mm2, respectively, over controls. Growth of children with xerophthalmia, who were treated with >/= 120, 000 RE at base line, was also compared to that of nonxerophthalmic children, stratified by initial wasting status, and adjusted for sex, baseline age and measurement status. Among initially nonwasted children (AC >/= 13.5 cm), VA-treated xerophthalmic children (n = 86) gained 0.7 cm more in linear growth than nonxerophthalmic children. Among initially wasted children (AC < 13.5 cm), VA-treated children (n = 34) gained additional weight (672 g), height (approximately 1 cm), muscle (76 mm2) and fat (79 mm2) areas, and subscapular skinfold (1.3 mm) compared to changes observed in nonxerophthalmic children. Relative increments in soft tissue growth occurred within 4 mo of VA treatment, while the effect on linear growth was gradual. Moderate-to-severe VA deficiency, marked by xerophthalmia, is likely to impair normal physical growth, but milder stages of deficiency may not have this effect in rural South Asia.
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Affiliation(s)
- K P West
- The Center for Human Nutrition (CHN), Department of International Health and the Dana Center for Preventive Ophthalmology (DCPO), the Johns Hopkins Schools of Public Health and Medicine, Baltimore, MD 21205, USA
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Katz J, West KP, Khatry SK, LeClerq SC, Pradhan EK, Thapa MD, Ram Shrestha S, Taylor HR. Prevalence and risk factors for trachoma in Sarlahi district, Nepal. Br J Ophthalmol 1996; 80:1037-41. [PMID: 9059265 PMCID: PMC505698 DOI: 10.1136/bjo.80.12.1037] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
AIMS To estimate the prevalence of trachoma in preschool children in Sarlahi district, Nepal, and to identify risk factors for the disease. METHODS A stratified random sample of 40 wards was selected for participation in a trachoma survey. Within each ward, a systematic 20% sample of children 24-76 months of age was chosen to determine the presence and severity of trachoma using the World Health Organisation grading system. RESULTS A total of 891 children were selected and 836 (93.8%) were examined for trachoma from December 1990 to March 1991. The prevalence of active trachoma was 23.6% (21.9% follicular and 1.7% intense inflammatory). Cicatricial trachoma was not seen in this age group. The prevalence of trachoma ranged from 0 to 50% across wards with certain communities at much higher risk for trachoma than others. Three year old children had the highest prevalence of follicular (25.5%) and intense inflammatory trachoma (4.3%). Males and females had similar prevalence rates. Wards without any tube wells were at higher risk than those with one or more tube wells. Lower rates of trachoma were seen in families who lived in cement houses, had fewer people per room, more servants, more household goods, animals, and land. Hence, less access to water, crowding and lower socioeconomic status were risk factors for trachoma. CONCLUSIONS Although follicular trachoma is prevalent, intense inflammatory trachoma is relatively rare and scarring was not observed in this preschool population. Hence, this population may not be at high risk for repeat infections leading to blindness in adulthood.
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Affiliation(s)
- J Katz
- Department of International Health, Johns Hopkins University, School of Hygiene and Public Health, Baltimore, MD 21205-2103, USA
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Katz J, West KP, Khatry SK, Thapa MD, LeClerq SC, Pradhan EK, Pokhrel RP, Sommer A. Impact of vitamin A supplementation on prevalence and incidence of xerophthalmia in Nepal. Invest Ophthalmol Vis Sci 1995; 36:2577-83. [PMID: 7499080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
PURPOSE To assess the impact of vitamin A supplementation at 4-month intervals on the prevalence and incidence of xerophthalmia among preschool-age children. METHODS A stratified, random sample of 40 wards with 4766 children in Sarlahi district of Nepal was selected to participate in a randomized, controlled, community trial. In the vitamin A group, at 4-month intervals, neonates received 50,000 IU, 1- to 11-month-old infants received 100,000 IU, and children 1 through 4 years of age received 200,000 IU. Children underwent eye examination before the intervention and 16 months later. RESULTS Before the intervention, 4318 children were examined for xerophthalmia. The prevalence was 2.3% in the vitamin A group and 3.3% in the placebo group. All children with xerophthalmia were treated with vitamin A at the time of the examination. Of those examined at baseline, 38 in the vitamin A group and 48 in the placebo group died in the 16 months after intervention. There were 1871 (84%) surviving children in the vitamin A group and 1711 (85%) in the placebo group examined at follow-up. After adjustment for the baseline prevalence of xerophthalmia, vitamin A reduced the prevalence at follow-up by 63% (95% confidence interval, 21% to 83%). The apparent incidence was 3.2/1000 per year in the vitamin A group and 9.2/1000 per year in the placebo group, an adjusted reduction of 62% (95% confidence interval, 0% to 86%). CONCLUSIONS Supplementation was effective at reducing the prevalence and incidence of xerophthalmia.
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Affiliation(s)
- J Katz
- Dana Center for Preventive Ophthalmology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Katz J, Khatry SK, West KP, Humphrey JH, Leclerq SC, Kimbrough E, Pohkrel PR, Sommer A. Night blindness is prevalent during pregnancy and lactation in rural Nepal. J Nutr 1995; 125:2122-7. [PMID: 7643246 DOI: 10.1093/jn/125.8.2122] [Citation(s) in RCA: 79] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
The prevalence of night blindness during pregnancy and lactation was assessed in a sample of 426 women living in the rural terai of Nepal. These women were also examined for ocular signs of vitamin A deficiency. Among 241 lactating women, 16.2% reported experiencing night blindness at some time during the pregnancy that produced the infant they were now breast-feeding. Among 185 pregnant women, 8.1% reported being night-blind at the time of the interview. The odds of night blindness in the current pregnancy were six times greater for women who reported night blindness in their previous pregnancy. Night-blind women were more likely to come from households with lower socioeconomic status. Teenage women and those over the age of 30 were at highest risk, particularly those of higher parity within these age groups. Vitamin A deficiency, for which night blindness is a marker, seems to be a problem in this population of pregnant and lactating women, with potential health consequences for women and their infants.
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Affiliation(s)
- J Katz
- Department of International Health, Johns Hopkins School of Hygiene and Public Health, Baltimore, MD 21205-2103, USA
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West KP, Katz J, Shrestha SR, LeClerq SC, Khatry SK, Pradhan EK, Adhikari R, Wu LS, Pokhrel RP, Sommer A. Mortality of infants < 6 mo of age supplemented with vitamin A: a randomized, double-masked trial in Nepal. Am J Clin Nutr 1995; 62:143-8. [PMID: 7598058 DOI: 10.1093/ajcn/62.1.143] [Citation(s) in RCA: 120] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
The effect of supplementing 11,918 infants < 1 mo and 1-5 mo of age with vitamin A (15,000 and 30,000 micrograms retinol equivalents or 50,000 and 100,000 IU, respectively) or a placebo on subsequent 4-mo mortality was assessed in a randomized, double-masked community trial in the rural plains of Nepal. There were 130 deaths (51.6/1000 child-y) in the control group and 150 deaths (57.1/1000 child-y) in the vitamin A group, yielding a relative risk of 1.11 (95% CI: 0.86, 1.42), which is indicative of no overall effect on early infant mortality. There was a tendency for the relative risk of mortality among vitamin A recipients to rise with improved nutritional status. These results suggest that distribution of a large oral dose of vitamin A to infants < 5-6 mo of age may not benefit short-term survival. This is in contrast with the results of trials in which older infants and children in this same population were supplemented.
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Affiliation(s)
- K P West
- Department of International Health, Johns Hopkins School of Hygiene and Public Health, Baltimore, MD 21205, USA
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Khatry SK, West KP, Katz J, LeClerq SC, Pradhan EK, Wu LS, Thapa MD, Pokhrel RP. Epidemiology of xerophthalmia in Nepal. A pattern of household poverty, childhood illness, and mortality. The Sarlahi Study Group. Arch Ophthalmol 1995; 113:425-9. [PMID: 7710390 DOI: 10.1001/archopht.1995.01100040039024] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
A case-control study of xerophthalmia (120 cases, two with corneal disease; 3377 children without xerophthalmia, 12 to 60 months of age) was conducted in the rural plains of Nepal. Relative household wealth (ownership of animals and goods, house quality) and social standing (parental education, nondaily laboring, more affluent castes) were inversely related to risk of xerophthalmia. Mothers of cases were more likely to have had children die than mothers of controls (odds ratio, 1.85; 95% confidence interval, 1.22 to 2.78); case households were more likely to have had a young child die in the past year (odds ratio, 2.85; 95% confidence interval, 1.43 to 5.67). Children with xerophthalmia were more wasted and stunted than controls, although these associations largely disappeared after adjusting for socioeconomic influences. Frequency of breast-feeding was highly protective against xerophthalmia in a dose-response manner (odds ratio, 0.32 for 1 to 10 times a day, 0.12 for > 10 times a day) after adjusting for age and other factors. The risk of xerophthalmia rose directly with reported duration of dysentery in the previous week (odds ratio, 2.13 and 5.81 for durations of 1 to 6 days and > or = 7 days, respectively, vs none). Mild xerophthalmia is reflective of a lower, local standard of living within which child health, nutrition, and survival are compromised.
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Affiliation(s)
- S K Khatry
- National Society for the Prevention of Blindness, Kathmandu, Nepal
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West KP, Khatry SK, LeClerq SC, Adhikari R, See L, Katz J, Shrestha SR, Pradhan EK, Pokhrel RP, Sommer A. Tolerance of young infants to a single, large dose of vitamin A: a randomized community trial in Nepal. Bull World Health Organ 1992; 70:733-9. [PMID: 1486669 PMCID: PMC2393418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
A randomized, double-masked trial was carried out in rural Nepal to investigate the incidence and severity of acute side-effects among neonates ( < 1 month of age) and infants aged 1-6 months who received a large, oral dose of vitamin A (15,000 retinol equivalents (RE) (50,000 IU) and 30,000 RE (100,000 IU), respectively) or placebo (75 RE (250 IU) and 150 RE (500 IU), respectively) in oil. Infants (vitamin A group, n = 1461; controls, n = 1379) were assessed for vomiting, loose stools, fever, and irritability during the 24 hours before and after dosing. Fontanelles were palpated 24 hours after dosing. Neonates exhibited no excess risk of adverse side-effects after receiving 15,000 RE. Compared with controls the older infants who ingested 30,000 RE had a 1.6% excess rate of vomiting (95% confidence interval (CI): 0.2-3.0%) and a 0.5% excess rate (95% CI: -0.1 to 1.1%) in the occurrence of bulging fontanelles. There were no other significant differences in the older infants. The controlled, periodic distribution of a single 15,000 RE dose of vitamin A therefore confers no apparent acute risk to young infants; a 30,000 RE dose is associated with a minimum risk of transient, acute side-effects.
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Affiliation(s)
- K P West
- School of Medicine, Johns Hopkins University, Baltimore, MD
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West KP, Pokhrel RP, Katz J, LeClerq SC, Khatry SK, Shrestha SR, Pradhan EK, Tielsch JM, Pandey MR, Sommer A. Efficacy of vitamin A in reducing preschool child mortality in Nepal. Lancet 1991; 338:67-71. [PMID: 1676467 DOI: 10.1016/0140-6736(91)90070-6] [Citation(s) in RCA: 250] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Community trials of the efficacy of vitamin A supplementation in reducing preschool childhood mortality have produced conflicting results. To resolve the question, a randomised, double-masked, placebo-controlled community trial of 28,630 children aged 6-72 months was carried out in rural Nepal, an area representative of the Gangetic flood plain of South Asia. Randomisation was carried out by administrative ward; the vitamin-A-supplemented children received 60,000 retinol equivalents every 4 months and placebo-treated children received identical capsules containing 300 retinol equivalents. After 12 months, the relative risk of death in the vitamin-A-supplemented compared with the control group was 0.70 (95% confidence interval 0.56-0.88), equivalent to a 30% reduction in mortality. The trial, which had been planned to last 2 years, was discontinued. The reduction in mortality was present in both sexes (relative risk for boys 0.77; for girls 0.65), at all ages (range of relative risks 0.83-0.50), and throughout the year (0.76-0.67). The reduction in mortality risk was not affected by acute nutritional status, as measured by arm circumference. Thus, periodic vitamin A delivery in the community can greatly reduce child mortality in developing countries.
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Affiliation(s)
- K P West
- Dana Center for Preventive Ophthalmology, Wilmer Eye Institute, Baltimore, Maryland 21205
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