Search

Despite a reduction in the magnitude of endemic malaria reported in recent years, malaria and protein-energy malnutrition (PEM) still remain major causes of morbidity and mortality in sub-Saharan Africa among children under five. The relationship between malaria and malnutrition remains a topic of controversy. We aimed to investigate malaria infection according to nutritional status in a community-based survey.A cohort of 790 children aged 6 to 59 months and residing in eastern Democratic Republic of the Congo was followed-up from April 2009 to March 2010 with monthly visits. Data on nutritional status, morbidity between visits, use of insecticide-treated nets and malaria parasitemia were collected at each visit. The Z scores height for age, weight for age and weight for height were computed using the reference population defined by the WHO in 2006. Thresholds for Z scores were defined at -3 and -2. A binary logistic model of the generalized estimating equation (GEE) was used to quantify the association between PEM indicators and malaria parasitemia. Odds ratio (OR) and their 95% confidence interval (95% CI) were computed.After adjustment for season, children with severe stunting (height for age Z score-3) were at lower risk of malaria parasitemia greater or equal to 5000 trophozoits/μL of blood as compared to those in with a better nutritional status (height for age Z score≥-2) (OR=0.48, 95% CI: 0.25-0.91).Severely stunted children are at a lower risk of high-level malaria parasitemia.

In the Kivu region located in east of the Democratic Republic of the Congo, malnutrition and malaria is a major cause of morbidity and mortality. The relationship between malaria and malnutrition is unclear and has never been studied in the Kivu region. This report presents an analysis of data from 5695 children aged 0 to 5 years, admitted to the paediatric ward of Lwiro hospital between November 1992 and February 2004. The weight/age (W/A) index and weight/height (W/H) index expressed with standard deviation in relation to the reference median were calculated (Z score). The association between protein-energetic malnutrition and malaria infection and nutritional indicators was measured based on prevalence ratios determined by univariate analysis and adjusted Odds Ratio (OR) derived using a multivariate model. The prevalence of malaria at the time of admission was 35.8 % (n=5695). The W/A and W/H indexes and serum albumin level were correlated with malaria-related morbidity. Logistic regression showed that high malaria OR was associated with both anthropometric nutritional indicators [WHZ-2: OR (CI 95 %) 1.7 (1.4-2.2)] [WAZ-2: OR (CI 95 %) 1.3 (1.1-1.6)] and biological nutritional indicators [serum albuminor = 23 g/L: OR (CI 95 %) 1.6 (1.2-2.1)]. Our findings indicate that malnourished children at admission have a lower risk of malaria infection.

To evaluate the impact of spiruline on nutritional rehabilitation.Systematic search in medical and scientific databases (Medline, Cochrane, Embase) and other specific databases (PhD theses, reports...).We selected studies in which spiruline was used as supplementation in malnourished patients, irrespective of the form and dose of spiruline and in controlled trials or not. Two persons made the selection separately. Nutritional status was estimated by anthropometric and biological measures.Thirty-one references were identified and seven studies were retained for this review; three randomized controlled and four non-controlled trials. Spiruline had a positive impact on weight in all studies. In non-controlled trials, the other parameters: arm circumference, height, albumin, prealbumin, protein and hemoglobin improved after spiruline supplementation. For these studies, methodology was the main drawback. None of the studies retained for analysis were double-blinded clinical trials and all involved small samples. Four of them did not have a control group for comparison.The impact of spiruline was positive for most of the considered variables. However, the studies taken into account in this review are of poor-methodological quality. A randomized, a large-sized double-blind controlled clinical trial with a longer follow-up should be conducted to improve current knowledge on the potential impact of spiruline on nutritional rehabilitation.

Management of acute severe malnutrition greatly contributes to the reduction of childhood mortality rate. In developing countries, where malnutrition is common, number of acute severe malnutrition cases exceeds inpatient treatment capacity. Recent success of community-based therapeutic care put back on agenda the management of acute severe malnutrition. We analysed key issues of inpatient management of severe malnutrition to suggest appropriate global approach.Data of 1322 malnourished children, admitted in an urban nutritional rehabilitation center, in Burkina Faso, from 1999 to 2003 were analyzed. The nutritional status was assessed using anthropometrics indexes. Association between mortality and variables was measured by relative risks. Kaplan-Meier survival curves and Cox model were used.From the 1322 hospitalized children, 8.5% dropped out. Daily weight gain was 10.18 (+/-7.05) g/kg/d. Among hospitalized malnourished children, 16% died. Patients were at high risk of early death, as 80% of deaths occurred during the first week. The risk of dying was highest among the severely malnourished: weight-for-height-4 standard deviation (SD), RR=2.55 P0,001; low MUAC-for-age, RR=2.05 P0.001. Kaplan-Meier survival curves and Cox model showed that the variables most strongly associated with mortality were weight-for-height and MUAC-for-age. Among children discharged from the nutritional rehabilitation centre, 10.9% had weight-for-height-3 SD.The nutrition rehabilitation centre is confronted with extremely ill children with high risk of death. There is need to support those units for appropriate management of acute severe malnutrition. It is also important to implement community-based therapeutic care for management of children still malnourished at discharge from nutritional rehabilitation centre. These programs will contribute to reduce mortality rate and number of severely malnourished children attending inpatient nutrition rehabilitation centers, by prevention and early management.

This study aimed to assess the prevention and treatment effectiveness of underweight in less than two years old children admitted in 2001 to community nutrition programme of Mono area in Benin.A longitudinal retrospective survey took place in 30 villages chosen at random. It concerned a sample of 1799 children. Inside of those children, during the 2001 year, when they were admitted to the programme, 1545 were without underweight, have had more than one month following visit and about them the underweight effectiveness prevention had been analyzed; the others 111 were underweighted, have had more than one month following visit and about them the underweight treatment had been assessed. The 143 other children have been followed for only one month. The prevention effectiveness had been explored by the evolution of the cumulative incidence of underweight according to the number of following visit and the underweight incidence density. The treatment effectiveness has been analysed by calculating the recovery rate and incidence density.During 2001, there have been observed 10% for the underweight cumulative incidence and 51.4% for the cumulative incidence of underweight recovery. The underweight and recovery incidence density were respectively 14 cases for 1000 persons-months of following and 118 cases for 1000 persons-months of following. The children with serious underweight at their last following visit have had the number of following visits lower than those who were with moderate underweight. The recovery was arrived after two to twelve months. There was a significant increase of underweight prevalence with the increase of following visit number inside the children with a normal weight at their admission into the programme.During the 2001 following, the underweight prevention and treatment activities of community nutrition workers have been little effectiveness. The low level of instruction of community nutrition workers, their low level of knowledge of essential community nutrition activities, their multiple tasks and the not used appropriate foods for the treatment of underweight are the possible causes of the poor performance observed.

This study aimed to assess the effectiveness of a protein-energetic malnutrition prevention and treatment community program on the nutritional status of 18 to 36-month-old children in the poor communities of the Mono Region in Benin.Two cross sectional anthropometric surveys were conducted. The first survey took place in 1998, before the implementation of the program; the second survey was conducted three years later. At each survey, cluster samples proportional to the population size was done; the sizes of the samples were 617 in 1998 and 648 in 2001. The nutritional status of 18 to 36 month-old-children was assessed by z-score of the indexes height-for-age, weight-for-age and weight-for-height and the cut-off point of -2 standard deviation was used to identify children who had stunting, wasting or underweight; children with serious stunting, wasting or underweight were identified with the cut-off point of -3 standard deviation.From 1998 to 2001, there was a significant reduction in the prevalence of growth retardation (-13.1%) and underweight (-13.0%). The reductions observed for the three types of protein-energetic malnutrition were more pronounced in the 30 to 36 months age group than in the others age groups.Substantial improvement was observed during the three years activities. This improvement cannot be attributed to the program unconditionally, because there was no difference between the nutritional status of participant and non participant children.

The process of referral between the first and the second level of the health system in the Democratic Republic of Congo is poorly understood. This report intends to study the association between the referral and the hospital perinatal outcomes.Delivery outcomes in a retrospective cohort of 1162 women admitted between June 95 and May 96, in two referral hospitals in Kivu were analyzed according to the referral status and the women's characteristics.Forty-three percent (n=492)of women admitted, corresponding to 2.3% of expected pregnant women, were referred. Referred women had higher risks of obstetrical complications (OR=2.0; CI95%: 1.3-3.1) and intervention (OR=1.5; CI95%: 1.0-2.3) and similar risks of low birth weight and perinatal mortality. Women with complications during the antenatal period had a double risk of intervention and perinatal mortality. The risk of obstetrical intervention was lower when women had attended 2 visits (OR=0.5; CI95%: 0.3-0.8); the risk of low birth weight was lowest only for mothers who had attended one visit (OR=0.5; CI95%: 0.3-0.9). Distanceor =90 minutes walking from home to hospital raised the risk of obstetrical complication (OR=1.7; CI95%: 1.1-2.5), the risk of obstetrical intervention (OR=1.5; CI95%: 1.0-2.1), and the risk of perinatal mortality (OR=1.6; CI95%: 1.0-2.7). Late admission raised the risk of perinatal mortality (OR=1.8; CI95%: 1.2-2.9) and lowered the risk of obstetrical complication (OR=0.7; CI95%: 0.5-1.0). Part payment of care was associated with higher risks of low birth weight (OR=1.9; CI95%: 1.3-2.9), perinatal mortality (OR=2.2; CI95%: 1.4-3.5) and obstetrical intervention (OR=2.4; CI95%: 1.7-3.4).These results suggest a deficit of referred cases considering that 15% of pregnant women in the area covered by the referral hospitals should have been referred. They confirm the negative influence of economic and geographic constraints on the delivery outcomes. They point out the relevance of making reorganization of the referral system a priority.

A retrospective cohort study was carried out on a sample of 2625 Belgian's children, examined at 12 and 15 year, to analyze the impact of school visual screening on social inequalities for visual acuity. Although uncorrected visual acuity decreased with increase in social class, visual acuity tested with the child's usual correction increased with social class. This social inequalities became more pronounced 2 years after the school visual screening. The lack of accessibility at some levels of health care cancels the reduction of inequalities expected from the school screening.

Since the eighties, the North Kivu Province socio-economic environment has been deteriorating. This province also faced an influx of Rwandan refugees in July 1994. The objective of the paper is to show how a rural health district has been able to adjust and maintain its medical activities under unfavourable conditions.Performances of the local health system were assessed through the analysis of routine medical data collected in the Rutshuru Health District (RHD) between 1985 and 1995. Specific data collected during the Rwandan refugee crisis measured the workload of RHD due to the refugees.For 11 years, health infrastructures have remained accessible and functional in RHD. The curative utilization and preventive coverage rates increased. Obstetrical activities were intensified from a quantitative as well as from a qualitative point of view. Between July and October 1994, the RHD treated 65000 cases of various pathological conditions in Rwandan refugees settled outside the camps. This corresponds to 9.3% of consultations for Rwandan refugees settled on RHD's territory and represents a 400% increase in the curative workload for the RHD health services. Human and financial resources remained at a very low level, especially when compared with those available in the camps through relief agencies.The RHD was severely affected by various stresses but its services managed to provide significant and efficient response to these crises. Health district systems may constitute an effective tool to provide health care under adverse conditions.

To assess pre-school age children's vitamin A status in a population where protein-energy malnutrition is endemic and serum retinol binding protein and transtyretin concentrations are low.A cross-sectional study.Health district of Katana, South-Kivu, Zaire.415 pre-school age children.Three methods were used to assess vitamin A status: ophtalmological examination, retinol serum concentration and Relative Dose Response (RDR) test.The only ophthalmological signs of vitamin A deficiency appeared in two cases of night blindness, which represents a prevalence of 0.7%. Deficient serum retinol concentration (0.35 mumol/l) was found in 19.7% of the whole study population and in 10.4% of non-infected children in good nutritional status. RDR test carried out on a reduced sample of 79 subjects was abnormal for 7.6% of the children but showed a low sensitivity when compared with serum retinol concentration.This survey suggests that in this population of the South-Kivu Province in Zaire, vitamin A deficiency co-exists with protein-energy malnutrition and is a public health problem even with non-malnourished and non-infected children.

2423 medical school files of adolescents aged 14 to 18 years were analysed according to five socio-economic categories in order to assess existing disparities in vaccine coverage. The poliomyelitis, tetanus and mumps vaccination coverage decreased progressively with decreasing social class. Depending on the type of vaccination, the risk of not being vaccinated was 1.5 to 4 times higher in children in the lowest socio-economic class than in those in the highest class. Disparities in vaccine coverage observed among very young children continued during childhood. Almost one quarter of adolescents in the lowest socio-economic category were not correctly vaccinated against tetanus and more than one third had not received the fourth dose of oral poliomyelitis vaccine which is recommended at the age of 6. Rubella vaccination in girls was the only type of vaccination which did not show any social gradient. Vaccination at school, such as that currently carried out for rubella, would be an effective strategy for reducing the social disparities in vaccine coverage. School health services should be able to play a more active role in preventing social inequalities in vaccination.

Biological markers were used in an attempt to predict mortality in children admitted to the hospital in Kivu, Zaire, for protein energy malnutrition. Data for 39 children who died (16.4%) showed significantly lower levels of albumin (1.61 vs. 2.53 g/dl; p < 0.001), transferrin (82.1 vs. 167.7 mg/dl; p < 0.001), and transthyretin (6.49 vs. 9.87 mg/dl; p < 0.001), but not or retinol-binding protein, than for the 199 survivors. Since albumin and transferrin were correlated, a Cox model was used to see whether albumin or transferrin has a significant predictive value independent of transthyretin. The relative risk predicted by each indicator was of the same order of magnitude, approximately 4. We conclude that specific biological markers help to discriminate among hospitalized subjects at risk and to identify those in need of more intensive nutritional support to prevent early death.

OBJECTIVE--To measure the prognostic value of clinical, anthropometric, and biological indicators of protein energy malnutrition in hospitalised children. DESIGN--Hospital based follow up study from admission to discharge or death of a cohort of children. SETTING-Paediatric hospital in Zaire. SUBJECTS--1129 children consecutively admitted between August 1986 and October 1988. MAIN OUTCOME MEASURES--Height, weight, arm circumference, skinfold thicknesses, serum albumin concentration, and mortality. RESULTS--Mortality was higher in wasted children and in those with a mid-upper arm circumference < 125 mm, a serum albumin concentration < 16 g/l, and oedema. After multivariate analysis, serum albumin concentration was the best predictor of subsequent risk of dying. Mid-upper arm circumference and oedema, however, still contributed considerably to evaluation of mortality. CONCLUSIONS--In this specific environment of central Africa an isolated clinical sign such as oedema is not enough to detect children with a high risk of dying among those admitted to paediatric wards with severe protein energy malnutrition. Measurement of additional indicators such as arm circumference and serum albumin concentration seems to be of crucial importance.

From 1986 to 1988, 1,129 children were hospitalized in Lwiro (South-Kivu, Zaïre) 3/4 of which were severely malnourished. Anthropometric, clinical and biological indicators were measured at admission. Observed mortality rate was 17.4%. Survival curves differ significantly for each anthropometric parameter measured at inclusion. In multivariate analysis, weight for age calculated with local reference or arm circumference is significantly associated with survival. The addition of serum albumin concentration to the multivariate model, shows this variable to be important. However, the use of an anthropometric indicator, such as weight for age or arm circumference is still important because it maintains an independent and significant effect on survival.

The target population is a key concept for the planning and evaluation of health services. However, in developing countries, health professionals in the field are often uneasy with the determination of the population denominator. In Zaire, where reliable demographic data are hardly available, we make use of two different methods aimed to the determination of the size of the target population: (1) an exhaustive population based survey performed by trained interviewers, and (2) a rapid census of the target population performed by community health workers. This paper presents both the results of a demographic survey organized in 1984, and two consecutive census performed by community health workers in 1986 an 1988, in the same area (Northern-Kivu, Zaire). Our results suggest that community health workers under close supervision are able to perform rapidly and at low cost a reliable collection of the demographic data needed for the implementation and monitoring of health programmes at the local level.

Reported are the results of a case study from Kirotshe rural health district, Northern Kivu, Zaire, where a workshop on the causal model approach to nutrition was organized in 1987. The model has since been used in the field for research design, training of health professionals, nutrition intervention, and community development. The rationale behind this approach is reviewed, the experience accumulated from Kirotshe district is described, and the ways in which the causal model contributes to comprehensive health and nutrition care are discussed. The broad range of possible policy implications of this approach underlines its usefulness for future action.

Results of a series of historical and recent studies of human milk and its protective antibodies against several bacterial and viral diseases and infantile diarrhea are presented. First, 1476 infants from Lahore, Pakistan from 3 socioeconomic groups, were observed and 300 mothers were given instruction on exclusive breast feeding. The prevalence of diarrhea indicated 60-80% protection to consistency of breast feeding, especially in summer when mothers replace breast milk with other liquids. Historically, secretory immunoglobulins (S-IgA) were first isolated from human milk, traced to intestinal antigen exposure, and local production in gut lymph nodes, from which lymphocytes migrate to the breast to secrete antibodies in milk. Specific S-IgA have been shown against Vibrio cholerae and the ETEC E. coli in milk. It is interesting that parental vaccination of a mother will boost milk IgA, but oral exposure stimulates serum antibodies more than milk IgA. Vaccination of mothers will whole cell cholera vaccine booster titers, but not avidities of S-IgA in milk. Avidities of S-IgA were higher in milk secreted for premature infants and in colostrum than in mature milk. Other research demonstrated that breast-fed infants were better able to mount their own antibody response to diphtheria, tetanus, and polio, as measured in their fecal, salivary, and serum antibodies. Breast feeding is advocated to improve infant survival, and thereby to decrease population growth.

In rural areas of Central Africa, on an average infants are breast fed 13 times per day during first 12 months. This is considered to be due to the poor nutritional status of mothers, and lack of milk is compensate for by frequent breast-feeding. Postpartum amenorrhoea is exceptionally prolonged, up to two years after childbirth, and certain indications suggest that mother's poor nutritional state is in a large part responsible for this. There is an influence of nutritional state on reappearance of menstruation in the postpartum period and also on length of fertility. Infanticide and permanent abandonment of infants was widespread in many levels of western society up to the beginning of 20th century. Physicians reestablished the mother-child relationship and advocated breast-feeding as the best way to nourish a baby. Recently a trend towards promoting maternal breast-feeding has developed and it is likely to observe new changes in infants' diet in next 10 years. A study showed all mothers nursed their infants at birth but urban mothers produced more milk compared to mothers in rural areas, whereas the latter had shorter duration of post partum amenorrhoea. In the city, mothers who have to leave their children for some part of the day cannot breast-feed in optimal fashion; and the economic level does not allow for a sufficient diet for baby based on commercial baby food. Many of the babies who do not die are drawn into a vicious cycle of malnutrition and disease that will leave them physically and intellectually stunted for life. There are factors other than formula feeding which is responsible for a decrease in breast-feeding practice.