Tag Archives: BMJ

A little incentive goes a long way when it comes to vaccine uptake

Offering people free lentils and metal food dishes substantially improves the number of young children that receive a full course of childhood immunisations in resource poor areas, and is more cost effective than just improving the vaccine services available in the region, according to a new study published free in the British Medical Journal.

Abhijit Vinayak Banerjee and colleagues wanted to assess how effective non-financial incentives—1 kg raw lentils per vaccine and a set of metal thali plates once a child has received all their immunisations—and increased availability of vaccine services were at improving immunisation rates in young children in rural Rajasthan, India. Their study included 1,640 children (aged 1–3 years) from 134 villages who were randomly assigned to three groups:

–          the ‘immunisation camp’ who received reliable, monthly vaccinations from healthcare professionals

–          the ‘immunisation plus camp’ who in addition to reliable, monthly vaccines were also offered cheap little extras of free lentils (costing about $1) for every vaccine and a set of thalis (a snip at $1.50) for a complete set of vaccines (BCG, diphtheria-pertussis, tetanus, polio and measles) received by the children

–          a control group who did not receive any interventions

Taken from Banerjee, A. V. et al. BMJ 2010;340:c2220

The researchers showed that immunisation rates were higher in the children that were offered reliable immunisations plus a little extra (39%) compared with the rates in children who were just offered the reliable immunisations (16%). Interestingly, children in districts neighbouring the immunisation plus camp also had bigger improvements in immunisation rates than those living near the immunisation camp villages. Not only that, these small incentives were cost effective (costing an estimated $17.35 per fully immunised child in camps with incentives compared with $25.18 per fully immunised child in camps without these extras).

The findings from this study by Banerjee et al. could have important implications for vaccine policies. Moreover, the authors question whether offering lentils can even be considered a “cost” as they clearly will have immediate, nutritional benefits to both the vaccinated children and their families.

ResearchBlogging.orgBanerjee, A., Duflo, E., Glennerster, R., & Kothari, D. (2010). Improving immunisation coverage in rural India: clustered randomised controlled evaluation of immunisation campaigns with and without incentives BMJ, 340 (may17 1) DOI: 10.1136/bmj.c2220

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Cooling reduces death and disability in newborns deprived of oxygen at birth

Therapeutic hypothermia reduces risk of death and disability in infants with hypoxic-ischaemic encephalopathy, according to a new study by David Edwards and colleagues published in the British Medical Journal.

Hypoxic-ischaemic encephalopathy (damage to cells in the brain and spinal cord because of lack of oxygen) is a major cause of death and disability worldwide but there currently is no specific treatment available for it. Therapeutic hypothermia (cooling the body below the normal temperature of 37oC) has been reviewed previously and tested in several clinical trials for newborns with hypoxic-ischemic encephalopathy but the results have so far been inconclusive and consensus in the medical profession has not been reached.

Edwards and colleagues carried out a meta-analysis which took advantage of new studies, including results from the TOBY trial, and recently available additional data from previously reported studies to determine whether moderate hypothermia after hypoxic-ischemia encephalopathy in newborns improves survival and neurological outcome 18 months later.

The researchers analysed data from 1320 infants in 10 different randomised controlled trials (studies which reported at least mortality data). They also assessed data from a subset of three trials which had similar entry requirements—evidence of oxygen deprivation of birth and moderate and severe encephalopathy— which investigated neurological outcomes up to 18 months of age in 767 infants.

The investigators found that therapeutic hypothermia significantly reduced the combined death and severe disability rates in the subset of three trials with outcome data at 18 months. Cooling newborns deprived of oxygen at birth not only increased survival with normal neurological function but also reduced the rates of severe disability, cerebral palsy, severe neuromotor delay, severe neurodevelopmental delay and blindness. They observed no association between the severity of encephalopathy and the effect of cooling treatment. In their analysis of all the 10 different trials, the researchers showed that hypothermia therapy significantly reduced mortality.

“In the absence of any specific intervention to improve the dismal prognosis of infants with hypoxic-ischaemic encephalopathy, clinical enthusiasm for a novel treatment is understandable,” write the investigators, “this new meta-analysis … provides the highest level evidence that moderate hypothermia is efficacious in infants with hypoxic-ischaemic encephalopathy”. More work is needed to follow up the infants enrolled in these therapeutic hypothermia studies to determine whether they continue to reap the benefits of cooling therapy in later childhood.

ResearchBlogging.orgEdwards, A., Brocklehurst, P., Gunn, A., Halliday, H., Juszczak, E., Levene, M., Strohm, B., Thoresen, M., Whitelaw, A., & Azzopardi, D. (2010). Neurological outcomes at 18 months of age after moderate hypothermia for perinatal hypoxic ischaemic encephalopathy: synthesis and meta-analysis of trial data BMJ, 340 (feb09 3) DOI: 10.1136/bmj.c363

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Reducing speed really does save lives

Traffic speed zones of 20 mph reduce road injuries and deaths according to research by Grundy and colleagues published in the British Medical Journal.

Road traffic accidents (RTA) are a significant, but often neglected, cause of injury and death worldwide. The WHO estimates that 1.2 million people are killed worldwide in road crashes and up to 50 million people are injured every year. Worryingly, it is predicted that these numbers will increase by 65% over the next 20 years, with a particular burden on public health in low- and middle-income countries.

The researchers analysed road casualties (including fatal and serious injuries) in 119,029 segments of road in London with at least one RTA casualty over a 20 year period (from 1986-2006). The study determined whether the introduction of 20 mph speed zones had an effect on road casualties in these areas (mainly minor roads but including some A and B) and in adjacent roads. There was a steady decline in all road casualties over the 20 yr study period and the length of roads in 20 mph zones has increased. Restricting traffic speeds to 20 mph was associated with a 41.9% reduction in road casualties, with the greatest reductions seen in road casualties involving children. Furthermore, the severity of RTA injuries was reduced with decreased numbers of killed or seriously injured road casualties (including injuries to pedestrians and cyclists). Finally, limiting traffic speeds to 20 mph also slightly decreased road casualties (by 8%) in roads adjacent to the 20 mph zone and there was no displacement of casualties to nearby roads after the implementation of speed restrictions in certain areas.

This study suggests that speed restrictions are an effective means to reduce road casualties in major metropolitan areas like London. However, these restrictions are not appropriate for major roads (A and B roads) and more work is needed to assess alternative strategies to reduce road casualties.

ResearchBlogging.orgGrundy, C., Steinbach, R., Edwards, P., Green, J., Armstrong, B., & Wilkinson, P. (2009). Effect of 20 mph traffic speed zones on road injuries in London, 1986-2006: controlled interrupted time series analysis BMJ, 339 (dec10 3) DOI: 10.1136/bmj.b4469

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