Six-monthly de-worming in infants to study effects on growth.

OBJECTIVE: The study was conducted to assess the effectiveness of six monthly albendazole (ABZ) for improving the weight and height of preschool children when initiated at 0.5-1 year of age in populations with a high transmission rate of intestinal roundworm, Ascaris lumbricoides. It was a cluster randomized trial in the urban slums of Lucknow, North India. METHODS: Control children received 2 ml (1 ml to infants) of Vitamin A every six month whereas those in the ABZ areas received, in addition, 400 mg of ABZ suspension (Zentel, SKB) every six month. Sixty-three and sixty-one slum areas were randomized to albendazole (ABZ) or to control groups, respectively. Children aged 0.5-1 year were recruited in April 1996 and followed up for 1.5 years. Of 1022 children recruited from control and 988 from ABZ areas, the loss to follow-up at 1.5 year was 15.6% and 14.6% respectively. Mean (+/- SE) weight gain in Kg in control versus ABZ areas was 3.04 (0.03) versus 3.22 (0.03), (p = 0.01). RESULTS: After controlling for the presence of weight-for age z-score < -2.00 at enrollment in the ordinary least square's regression model, the extra weight gain in 1.5 years in those who received ABZ plus vitamin A was 0.13 Kg (95% CI: 0.004 to 0.26 Kg., p value = 0.043) when compared to those who received only vitamin A; underweight children at enrollment benefiting more than the normal ones. CONCLUSION: It was concluded that there was an improvement in weight with six monthly ABZ over 1.5 years. However, a much larger trial would be needed to determine whether there is any net effect of improvement in weight on under five mortality rate.

Effectiveness and cost-effectiveness of albendazole in improving nutritional status of pre-school children in urban slums.

OBJECTIVE: To study the clinical efficacy and the incremental cost-effectiveness of albendazole in improving the nutritional status of pre-school children. DESIGN: Single blind, placebo-controlled trial with child as the unit of randomization. SETTING: In the Anganwadi centers of the Integrated Child Development Services situated in the urban slums of Lucknow, North India. METHODS: Thirty-two Anganwadi centers were randomly selected for the trial. Included were registered resident children between 1.5 to 3.5 years of age with informed and written parental consent. The intervention group received 600 mg of albendazole powder every six months while the placebo group received same quantity of calcium powder. Enrolled children were contacted once in six months from January 1995 to 1997 and given treatment. The outcome measure were change in the proportion of underweight (weight for age <-2.00z), stunted (height for age <-2.00z) children and the cost per child prevented from becoming stunted. RESULTS: There were 610 and 451 children in the albendazole and placebo groups, respectively. Mean age at recruitment was 31.8 months (SD: 9.7). Follow-up and compliance in both the groups was >95%. During the 2 year follow-up, the proportion of stunted children increased by 11.44% and 2.06% in the placebo and albendazole groups, respectively, and the difference was 9.38% (95% CI 6.01% to 12.75%; p value <0.0001). Direct fecal smear was positive for the ova of ascaris in 41.2% and 55.3% children in the albendazole and placebo groups, respectively at the end of the study (p value <0.001). The annual family expenditure on illness in the recruited child was Rs. 743 (SD: 662) and Rs. 625 (SD: 609) in the albendazole and the placebo groups, respectively. The incremental cost-effectiveness ratio was Rs 543.00 for each case of stunting prevented with albendazole. There was no difference in the various morbidity or cognitive performance, as judged by the revised Denver prescreening questionnaire, in both the groups at enrollment as well as at the end of the study. CONCLUSIONS: Six monthly albendazole reduces the risk of stunting with a small increase in the expenditure on health care from the payer's perspective. Larger trials are needed to study the effect of albendazole on prevention of stunting, cognitive functions and all-cause childhood mortality.

Seasonal pattern of morbidities in preschool slum children in Lucknow, north India.

OBJECTIVE: To quantify the burden of common morbidities for each month in one year, in preschool children. SETTING: Anganwadi centers under the Integrated Child Development Services Scheme (ICDS) in Lucknow, North India. DESIGN: Prospective cohort study, METHODS: From 153 anganwadi centers in urban Lucknow, 32 were selected by random draw. All eligible children registered with the anganwadi worker were enrolled over a period of six months from July 1995 to January 1996. All the subjects were then contacted a second time six months later. SUBJECTS: There were 1061 children (48.3% girls and 51.7% boys) between the ages of 1.5 to 3.5 years. RESULTS: The annual incidence rate (IR) per 100 child-years for respiratory, diarrhea and skin diseases and pneumonia were 167, 79.9, 30.6 and 9.6, respectively. When compared to other seasons, the IR of pneumonia was lowest in the winter months (October to February) while those of diarrhea and skin diseases were the highest in summer (March-June) and monsoon (July to September) months, respectively. Season specific diseases were measles in summer, and fever as the isolated symptom in monsoon. The IR for combined morbidities was the highest in the monsoon as compared to winter months. CONCLUSIONS: Season specific intensification of existing health care resources for these morbidities can be considered. Similar studies are needed from other parts of the country.

Prevalence of malnutrition and intestinal parasites in preschool slum children in Lucknow.

OBJECTIVE: To assess the point prevalence of intestinal parasites and their association with nutritional parameters. SETTING: Anganwadi centers under the Integrated Child Development Scheme (ICDS) in Lucknow, North India. DESIGN: Cross-sectional survey. METHODS: By random draw, 32 out of 153 Anganwadi centers were selected. All eligible subjects registered with the Anganwadi worker were enrolled. These were 1061 children (48.3% girls and 51.7% boys) between the ages of 1.5 to 3.5 years. RESULTS: Of these, 67.6% were underweight (weight for age < -2 SD), 62.8% were stunted (height for age < -2 SD) and 26.5% were wasted (weight for height < -2 SD). Parasites were detected in 17.5% (95% CI 15.3%-19.9%) children by a single direct fecal smear examination. Of these, Ascaris lumbricoides was found in 124 (68.1%) and Giardia lamblia in 60 (32.9%). There was no association between weight or height and parasite positivity. The mean hemoglobin levels for children who were smear positive versus smear negative for ascaris or giardia were 9.1 g/dl and 9.6 g/dl, respectively (p < 0.0001). CONCLUSION: In the urban slums the point prevalence of intestinal parasites is 17.5% in the preschool children. Malnutrition and low hemoglobin levels are also widely prevalent. Urgent remedial steps are needed on community basis to improve their nutritional status and control parasitic infestation.

Under fives mortality in the urban slums of Lucknow.

The main objective of this study was to elicit proportional cause specific mortality in the underfives in the urban slums of Lucknow in North India. The families with under five mortality in the 28 randomly selected slums in 1993 were located from the records of the slum health workers and verbal autopsy was conducted to assign a cause of death. There were 71 deaths among 2796 children. The annual under five mortality was 25.4 and the under five mortality rate was 126.7. After the neonatal period, "high fever" that could not be classified into any other disease incorporated in the verbal autopsy instrument, was the most common symptom associated with death, seen in 21.1% cases (95% C.I.: 15.5-34.4%) followed by these diseases: pneumonia in 19.7%, diarrhea in 18.3% and measles in 11.4%. "High fever" as the leading symptom associated with death is being reported for the first time from the urban slums of India. There is an urgent need to identify the underlying etiologies of death due to "high fever" and the policy implications are that children with fever must receive immediate and continued medical attention till the symptom persists.