Tag Archives: PLoS Medicine

Scale up diarrhoea prevention to save lives

A widespread scale up of existing low-cost and effective tools to prevent and treat diarrhoea could substantially reduce diarrhoeal deaths and could be a major step towards achieving the Millenium Development Goal 4 of reducing child mortality by 2015, according to research published in PLoS Medicine.

Depressingly, in this modern era, diarrhoea—three or more loose bowel movements a day—is still a common cause of death in developing countries and is the 2nd biggest killer of young children (under 5 years) worldwide. Poor hygiene, inadequate sanitation and lack of clean, safe drinking water all contribute to the spread of the harmful viruses, bacteria and parasites that cause diarrhoea. Now, Fischer Walker and colleagues use their Lives Saved Tool (LiST) to estimate the potential lives saved after implementing two different scale-up scenarios for key diarrhoeal prevention (breastfeeding, vitamin A supplements, basic water, sanitation, hygiene, and rotavirus vaccination) and treatment (oral rehydration salts, zinc supplementation, and antibiotics for dysentery) intervention strategies in 68 countries with high childhood mortality.

The researchers put forward two scenarios for the priority countries, which included Bangladesh, China and Haiti, for a 5-year period (between 2010 and 2015)—the “ambitious” (which assumed feasible improvement in all interventions) and the “universal” (which assumed near 100% coverage for all interventions). By 2015, diarrhoeal deaths could be reduced by 78% and 92% in the ambitious and universal scenarios, respectively. With the universal scenario, nearly 5 million deaths could be averted at an additional costs of US$0.80 per capita using some of the key diarrhoea prevention and treatment interventions (such as rotavirus vaccination and oral rehydration salts) and $3.24 per capita when all sanitation and water interventions (such as handwashing, improved sanitation and access to safe, clean water) implemented.

Fischer Walker and co-workers argue that “real progress” could be made in the treatment and management of diarrhoeal diseases if intervention strategies are made an international priority and the global health community works together to eliminate this harmful disease. Furthermore, the research acts as a pertinent reminder that we already have the technologies and interventions needed to prevent and reduce the devastating effects of diarrhoea, we just need to use them in the right scenario.

ResearchBlogging.orgWalker, C., Friberg, I., Binkin, N., Young, M., Walker, N., Fontaine, O., Weissman, E., Gupta, A., & Black, R. (2011). Scaling Up Diarrhea Prevention and Treatment Interventions: A Lives Saved Tool Analysis PLoS Medicine, 8 (3) DOI: 10.1371/journal.pmed.1000428


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Prophylactic antibiotics do not prevent preterm birth

Routine prophylaxis with antibiotics does not prevent preterm birth in high risk populations according to research by van den Broek and colleagues published in PLoS Medicine.

Most pregnancies last about 40 weeks, babies born before 37 weeks of completed pregnancy are considered premature. Premature birth is a major cause of infant mortality and morbidity in high- and low-income countries. Babies born prematurely often have long-term health problems and disabilities. There are many causes of preterm birth but it has been previously shown that infection (especially ascending genital tract infection) is an important contributing factor.

This study investigated whether prophylactic antibiotics (in this case Azithromycin), given to pregnant women regardless of whether they are showing signs of infection, prevented premature birth. The researchers enrolled 2,297 pregnant women in Southern Malawi in the Azithromycin for the Prevention of Preterm Labor (APPle) study. This was a randomised, community-based, placebo-controlled trial; half the women were given azithromycin at 16-24wks and 28-32wks whilst the rest received a placebo tablet at similar times. The health of both mother (such as malarial status and anaemia) and baby (gestational age at delivery and birth weight) was monitored up to 6 wks after delivery. There were no significant differences in outcome (including preterm birth, mean gestational age at birth, mean birth weight, perinatal death and maternal anaemia) between the azithromycin and placebo groups of women. Furthermore, meta-analysis (combining results of several studies) of these results with seven other similar studies showed that prophylactic antibiotics in pregnancy had no effect on preterm birth.

Clearly, these findings do not the support the use of antibiotics as prophylaxis to prevent preterm birth. It is unknown why these results are negative given the fact that infection has been associated with preterm birth. More work is needed to determine whether different antibiotics or doses might be useful, and to identify alternative strategies for the prevention of preterm birth.

van den Broek, N., White, S., Goodall, M., Ntonya, C., Kayira, E., Kafulafula, G., & Neilson, J. (2009). The APPLe Study: A Randomized, Community-Based, Placebo-Controlled Trial of Azithromycin for the Prevention of Preterm Birth, with Meta-Analysis PLoS Medicine, 6 (12) DOI: 10.1371/journal.pmed.1000191

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Pneumonia is world’s biggest childhood killer

Pneumonia is an acute respiratory infection of the lungs caused by viruses, bacteria and fungi. Despite pneumonia being treatable and preventable, estimates suggest that over 2 million children die every year from pneumonia, making it the leading cause of childhood death worldwide.

On the 2nd November the World Health Organisation and the United Nations Children’s Fund launched the Global Action Plan for Prevention and Control of Pneumonia (GAPP) to raise awareness of the devastating death toll from pneumonia and call on governments, public health policy-makers, charities, non-governmental organisations and the public to work together to implement their action plan.

The GAPP aims to:

  • protect children from pneumonia by providing an environment with low risk of pneumonia (strategies include increasing hand-washing or providing adequate nutrition)
  • prevent pneumonia in children (with vaccinations against the microorganisms that cause it such as Streptococcus pneumonia and Haemophilus influenzae b)
  • Treat children sick with pneumonia with the correct healthcare and antibiotics.

If successful their plan could save 5.3 million children from dying of pneumonia by 2015.

A new “Health in Action” article in this week’s PLoS Medicine by Enarson and colleagues describes efforts by the government in Malawi to introduce a national programme to cut childhood deaths from pneumonia. This strategy, known as standard case management (or SCM), aims to ensure that children with pneumonia in Malawi receive effective treatment, like antibiotics and oxygen therapy.

The SCM strategy for treatment of children with pneumonia in Malawi was based on a similar programme established by the International Union against Tuberculosis and Lung Disease. This was a cost-effective health intervention that has been successfully used to prevent and control tuberculosis in 190 countries. To improve the management of severe and very severe pneumonia in children admitted to district hospitals (accessible to the whole population) the Child Lung Health Programme (CLHP) for pneumonia in Malawi focused on:

  • getting lasting commitment from the government to sustain the health programme
  • establishing diagnosis and treatment based on the SCM
  • teaching clinical staff the SCM
  • safeguarding uninterrupted supplies of standardised drugs and equipment needed for pneumonia treatment
  • recording and reporting clinical outcomes of pneumonia
  • supervising and evaluating the programme

The CLHP in Malawi has been in place since 1999 and was funded by the Malawi government and support from the Bill and Melinda Gates foundation. The CLHP was gradually scaled-up across the entire country over the next 5 years. Between Oct 2000 and Dec 2005, the CLHP successfully trained 312 health workers (including nurses and medical assistants) in SCM and there was a consistent increase in the numbers of children receiving pneumonia treatment in district and central hospitals. Furthermore, the proportion of children dying from pneumonia dropped from 18.6% to 8.4%. The CLHP is now successfully maintained by the Malawi government after the end of external funding for the project. However, there are still ongoing challenges that need to be addressed, such as a shortage of healthcare workers and the effects of malnutrition, malaria, HIV/AIDS and anaemia on the outcome of pneumonia infection.

The reduction of child mortality by two-thirds by 2015 is a major challenge set by the United Nations Millenium Development goals and programmes, like the CLHP in Malawi to reduce deaths from pneumonia, will make a significant contribution to this goal.

Enarson, P., Gie, R., Enarson, D., & Mwansambo, C. (2009). Development and Implementation of a National Programme for the Management of Severe and Very Severe Pneumonia in Children in Malawi PLoS Medicine, 6 (11) DOI: 10.1371/journal.pmed.1000137


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