Llamamiento a adoptar medidas urgentes para limitar los aumentos de temperatura en el mundo, restablecer la diversidad biológica y proteger la salud / Call for emergency action to limit global temperature increases, restore biodiversity, and protect health

La publicación de este artículo es una iniciativa organizada por la Alianza Global por el Clima y la Salud (GCHA, por sus siglas en inglés) a través de la Alianza de Salud del Reino Unido sobre el Cambio Climático (UKHACC, por sus siglas en inglés) y los miembros del Grupo de Trabajo Latinoamericano sobre Cambio Climático y Salud. La convocatoria tiene un doble objetivo: que los líderes mundiales acuerden los cambios necesarios para mantener el aumento de la temperatura global por debajo de 1,5°C y que los profesionales de la salud adquieran una mayor relevancia en el debate global sobre la crisis climática y la pérdida de la biodiversidad. La convocatoria se desarrolla en el contexto de la próxima celebración de la Asamblea General de Naciones Unidas que se iniciará el 14 de septiembre de 2021, así como también de la celebración de la conferencia climática COP26 que este año se realizará en Glasgow. Este artículo, cuya autoría pertenece principalmente a editores de 18 prestigiosas revistas científicas ampliamente representativas de los continentes y disciplinas de la salud del mundo, ya ha sido publicada simultáneamente en más de 200 revistas científicas internacionales (https://www.bmj.com/content/full-list-authors-and-signatories-climate-emergency-editorial-september-2021). En esta ocasión, la Revista Argentina de Salud Pública se suma a esta iniciativa conjunta a través de la publicación del artículo en español, con el fin de promover su difusión en los países de la Región. El editorial expresa también la necesidad de restablecer la diversidad biológica y proteger la salud, y de que los países de altos ingresos hagan mayores recortes en sus emisiones de carbono y transfieran fondos a los países de ingresos bajos y medianos. Además, exhorta a la intervención de los gobiernos en el rediseño de los sistemas de transporte, las ciudades, la producción y distribución de alimentos, los mercados para las inversiones financieras, los sistemas de salud, entre otros aspectos, lo que redundaría en amplios beneficios para la salud.

Community-based Health Workers Achieve High Coverage in Neonatal Intervention Trials: A Case Study from Sylhet, Bangladesh.

A large proportion of four million neonatal deaths occur each year during the first 24 hours of life. Research is particularly needed to determine the efficacy of interventions during the first 24 hours. Large cadres of community-based workers are required in newborn-care research both to deliver these interventions in a standardized manner in the home and to measure the outcomes of the study. In a large-scale community-based efficacy trial of chlorhexidine for cleansing the cord in north-eastern rural Bangladesh, a two-tiered system of community-based workers was established to deliver a package of essential maternal and newborn-care interventions and one of three umbilical cord-care regimens. At any given time, the trial employed approximately 133 community health workers—each responsible for 4-5 village health workers and a population of approximately 4,000. Over the entire trial period, 29,760 neonates were enrolled, and 87% of them received the intervention (their assigned cord-care regimen) within 24 hours of birth. Approaches to recruitment, training, and supervision in the study are described. Key lessons included the importance of supportive processes for community-based workers, including a strong training and field supervisory system, community acceptance of the study, consideration of the setting, study objectives, and human resources available.

Vitamin D Status of Infants in Northeastern Rural Bangladesh: Preliminary Observations and a Review of Potential Determinants.

Vitamin D deficiency is a global public-health concern, even in tropical regions where the risk of deficiency was previously assumed to be low due to cutaneous vitamin D synthesis stimulated by exposure to sun. Poor vitamin D status, indicated by low serum concentrations of 25-hydroxyvitamin D [25(OH)D], has been observed in South Asian populations. However, limited information is available on the vitamin D status of young infants in this region. Therefore, to gain preliminary insights into the vitamin D status of infants in rural Bangladesh, 25(OH)D was assessed in a group of community-sampled control participants in a pneumonia case-control study in rural Sylhet, Bangladesh (25°N) during the winter dry season (January-February). Among 29 infants aged 1-6 months, the mean 25(OH)D was 36.7 nmol/L [95% confidence interval (CI) 30.2-43.2]. The proportion of infants with vitamin D deficiency defined by 25(OH)D <25 nmol/L was 28% (95% CI 10-45), 59% (95% CI 40-78) had 25(OH)D<40 nmol/L, and all were below 80 nmol/L. From one to six months, there was a positive correlation between age and 25(OH)D (Spearman=0.65; p=0.0001). Within a larger group of 74 infants and toddlers aged 1-17 months (cases and controls recruited for the pneumonia study), young age was the only significant risk factor for vitamin D deficiency [25(OH)D <25 nmol/L]. Since conservative maternal clothing practices (i.e. veiling) and low frequency of intake of foods from animal source (other than fish) were common among the mothers of the participants, determinants of low maternal-infant 25(OH)D in Bangladesh deserve more detailed consideration in future studies. In conclusion, the vitamin D status in young infants in rural Sylhet, Bangladesh, was poorer than might be expected based on geographic considerations. The causes and consequences of low 25(OH)D in infancy and early childhood in this setting remain to be established.

Birth Preparedness and Complication Readiness among Slum Women in Indore City, India.

Three hundred twelve mothers of infants aged 2-4 months in 11 slums of Indore, India, were interviewed to assess birth preparedness and complication readiness (BPACR) among them. The mothers were asked whether they followed the desired four steps while pregnant: identified a trained birth attendant, identified a health facility, arranged for transport, and saved money for emergency. Taking at least three steps was considered being well-prepared. Taking two or less steps was considered being less-prepared. One hundred forty-nine mothers (47.8%) were well-prepared. Factors associated with well-preparedness were assessed using adjusted multivariate models. Factors associated with well-preparedness were maternal literacy [odds ratio (OR)=1.9, (95%) confidence interval (CI) 1.1-3.4] and availing of antenatal services (OR=1.7, CI 1.05- 2.8). Deliveries in the slum-home were high (56.4%). Among these, skilled attendance was low (7.4%); 77.3% of them were assisted by traditional birth attendants. Skilled attendance during delivery was three times higher in well-prepared mothers compared to less-prepared mothers (OR: 3.0, CI 1.6-5.4) Antenatal outreach sessions can be used for promoting BPACR. It will be important to increase the competency of slum-based traditional birth attendants, along with promoting institutional deliveries.

Human touch to detect hypothermia in neonates in indian slum dwellings.

Objective. To assess the validity of human touch (HT) method to measure hypothermia compared against axillary digital thermometry (ADT) and study association of hypothermia with poor suckle and underweight status in newborns and environmental temperature in 11 slums of Indore city, India. Methods. Field supervisors of slum-based health volunteers measured body temperature of 152 newborns by HT and ADT, observed suckling and weighed newborns. Underweight status was determined using WHO growth standards. Results. Hypothermia prevalence (axillary temperature <36.5oC) was 30.9%. Prevalence varied by season but insignificantly. Hypothermia was insignificantly associated with poor suckle (31% vs 19.7%, p=0.21) and undernutrition (33.3% vs 25.3%, p=0.4). HT had moderate diagnostic accuracy when compared with ADT (kappa: 0.38, sensitivity: 74.5%, specificity: 68.5%). Conclusions. HT emerged simpler and programmatically feasible. There is a need to examine whether trained and supervised community-based health workers and mothers can use HT accurately to identify and manage hypothermia and other simple signs of newborn illness using minimal algorithm at home and more confidently refer such newborns to proximal facilities linked to the program to ensure prompt management of illness.

Gender differences in perception and care-seeking for illness of newborns in rural Uttar Pradesh, India.

Although gender-based health disparities are prevalent in India, very little data are available on care-seeking patterns for newborns. In total, 255 mothers were prospectively interviewed about their perceptions and action surrounding the health of their newborns in rural Uttar Pradesh, India. Perception of illness was significantly lower in incidence (adjusted odds ratio=0.56, 95% confidence interval 0.33-0.94) among households with female versus male newborns. While the overall use of healthcare providers was similar across gender, the average expenditure for healthcare during the neonatal period was nearly four-fold higher in households with males (Rs 243.3 +/- 537.2) compared to females (Rs 65.7 +/- 100.7) (p=0.07). Households with female newborns used cheaper public care providers whereas those with males preferred to use private unqualified providers perceived to deliver more satisfactory care. These results suggest that, during the neonatal period, care-seeking for girls is neglected compared to boys, laying a foundation for programmes and further research to address gender differences in neonatal health in India.

Early-life determinants of stunted adolescent girls and boys in Matlab, Bangladesh.

This paper presents the results of a longitudinal study, conducted in Matlab, Bangladesh, that examined to what extent the level of stunting in adolescence can be predicted by nutritional status in early childhood and maternal height. A linked set of data collected from the same individuals at two moments in time, i.e. early childhood (1988-1989) and adolescence (2001), was analyzed. The study found that the odds of being stunted in adolescence could be explained by the combined effect of being stunted in childhood and having a mother whose height was less than 145 cm. Also, girls were more likely than boys to be stunted in childhood, whereas boys were more likely than girls to be stunted in adolescence. The latter is probably attributable to differences in the pace of maturation. In terms of policy and (reproductive health) programmes, it is important to recall that adolescent girls whose height and weight were subnormal (weight <45 kg and height <145 cm) might run an obstetric risk. Following these cut-off points, 83% and 23% of 16-year-old girls in this study would face obstetric risk, respectively, for weight and height if they marry and become pregnant soon.

Does age affect the response to zinc therapy for diarrhoea in Bangladeshi infants?

The benefit of zinc for the treatment of diarrhoea in a cluster-randomized trial of children, aged 3-59 months, living in rural Bangladesh was previously reported. Here, the benefits of zinc stratified by age--3-5 months, 6-11 months, and 12-59 months--are reported. Although the sample sizes in the stratified groups were too small to detect statistical significance in the 3-5-month and 6-11-month age-groups, the trends suggest that there may be a benefit of zinc for the treatment of diarrhoea on the duration of diarrhoea and on subsequent morbidity and mortality. Additional research is needed to better understand the effect of zinc for the treatment of diarrhoea among infants aged less than six months.

Sex and socioeconomic differentials in child health in rural Bangladesh: findings from a baseline survey for evaluating Integrated Management of Childhood Illness.

This paper reports on a population-based sample survey of 2,289 children aged less than five years (under-five children) conducted in 2000 as a baseline for the Bangladesh component of the Multi-country Evaluation (MCE) of the Integrated Management of Childhood Illness strategy. Of interest were rates and differentials by sex and socioeconomic status for three aspects of child health in rural Bangladesh: morbidity and hospitalizations, including severity of illness; care-seeking for childhood illness; and home-care for illness. The survey was carried out among a population of about 380,000 in Matlab upazila (subdistrict). Generic MCE Household Survey tools were adapted, translated, and pretested. Trained interviewers conducted the survey in the study areas. In total, 2,289 under-five children were included in the survey. Results showed a very high prevalence of illness among Bangladeshi children, with over two-thirds reported to have had at least one illness during the two weeks preceding the survey. Most sick children in this population had multiple symptoms, suggesting that the use of the IMCI clinical guidelines will lead to improved quality of care. Contrary to expectations, there were no significant differences in the prevalence of illness either by sex or by socioeconomic status. About one-third of the children with a reported illness did not receive any care outside the home. Of those for whom outside care was sought, 42% were taken to a village doctor. Only 8% were taken to an appropriate provider, i.e. a health facility, a hospital, a doctor, a paramedic, or a community-based health worker. Poorer children than less-poor children were less likely to be taken to an appropriate healthcare provider. The findings indicated that children with severe illness in the least poor households were three times more likely to seek care from a trained provider than children in the poorest households. Any evidence of gender inequities in child healthcare, either in terms of prevalence of illness or care-seeking patterns, was not found. Care-seeking patterns were associated with the perceived severity of illness, the presence of danger signs, and the duration and number of symptoms. The results highlight the challenges that will need to be addressed as IMCI is implemented in health facilities and extended to address key family and community practices, including extremely low rates of use of the formal health sector for the management of sick children. Child health planners and researchers must find ways to address the apparent population preference for untrained and traditional providers which is determined by various factors, including the actual and perceived quality of care, and the differentials in care-seeking practices that discriminate against the poorest households.

A population-based study of hospital admission incidence rate and bacterial aetiology of acute lower respiratory infections in children aged less than five years in Bangladesh.

The research was carried out to study the rate of population-based hospital admissions due to acute lower respiratory infections (ALRIs) and bacterial aetiology of ALRIs in children aged less than five years in Bangladesh. A cohort of children aged less than five years in a rural surveillance population in Matlab, Bangladesh, was studied for two years. Cases were children admitted to the Matlab Hospital of ICDDR,B with a diagnosis of severe ALRIs. Bacterial aetiology was determined by blood culture. Antimicrobial resistance patterns of Haemophilus influenzae type b (Hib) and Streptococcus pneumoniae (Spn) isolates were determined using the disc-diffusion method. In total, 18,983 children aged less than five years contributed to 24,902 child-years of observation (CYO). The incidence of ALRI-related hospital admissions was 50.2 per 1,000 CYO. The incidences of ALRI were 67% higher in males than in females and were higher in children aged less than two years than in older children. About 34% of the cases received antibiotics prior to hospitalization. Of 840 blood samples cultured, 39.4% grew a bacterial isolate; 11.3% were potential respiratory pathogens, and the rest were considered contaminants. The predominant isolates were Staphylococcus aureus (4.5%). Hib (0.4%) and Spn (0.8%) were rarely isolated; however, resistance of both these pathogens to trimethoprim-sulphamethoxazole was common. The rate of ALRI-related hospitalizations was high. The high rate of contamination, coupled with high background antibiotic use, might have contributed to an underestimation of the burden of Hib and Spn. Future studies should use more sensitive methods and more systematically look for resistance patterns of other pathogens in addition to Hib and Spn.

Asthma in rural Bangladeshi children.

OBJECTIVE: Although bronchial asthma causes a great deal of morbidity among children in Bangladesh, few epidemiological studies addressed this problem. The study aims to determine the prevalence of wheezing and its association with environmental and host factors. METHODS: A total of 1587 children aged 60-71 mth living in 50 villages in rural Bangladesh at Matlab was studied. Trained field workers interviewed caretakers of these children to diagnose wheezing using an adopted questionnaire of the International Studies of Asthma and Allergies in Childhood (ISAAC). History of pneumonia among wheezing and non-wheezing children during their childhood was obtained from the surveillance records. RESULTS: The prevalence of wheezing in the last 12 mth prior to survey was 16.1% (95% CI: 14.3%, 18.0%), significantly higher among children who had attacks of pneumonia during their infancy compared to children who did not (23.0% vs 14.6%, p< 0.0001). Risk factors associated with wheezing were pneumonia at ages 0-12 m (OR= 1.50, 95% CI 1.08, 2.10) and 13-24 m (OR= 2.12, 1.46, 3.08), maternal asthma (OR=3.01, 95% CI 2.02, 4.47), paternal asthma (OR= 3.12, 95% CI 1.85, 5.26), maternal eczema (OR=1.81, 95% CI 1.14, 2.87) and family income 100 pounds US$ (OR for US$ 51-99= 1.63, 95% CI 1.05, 2.53; OR for US$ 50 pounds = 2.12, 95% CI 1.31, 3.44). CONCLUSION: Our results suggest that wheezing is a significant cause of morbidity among children in rural Bangladesh. Greater efforts are needed to prevent pneumonia among children during their infancy to reduce the chances of subsequent development of wheezing.

Trends in use of referral hospital services for care of sick newborns in a community-based intervention in Tangail District, Bangladesh.

The Projahnmo-II Project in Mirzapur upazila (sub-district), Tangail district, Bangladesh, is promoting care-seeking for sick newborns through health education of families, identification and referral of sick newborns in the community by community health workers (CHWs), and strengthening of neonatal care in Kumudini Hospital, Mirzapur. Data were drawn from records maintained by the CHWs, referral hospital registers, a baseline household survey of recently-delivered women conducted from March to June 2003, and two interim household surveys in January and September 2005. Increases were observed in self-referral of sick newborns for care, compliance after referral by the CHWs, and care-seeking from qualified providers and from the Kumudini Hospital, and decreases were observed in care-seeking from unqualified providers in the intervention arm. An active surveillance for illness by the CHWs in the home, education of families by them on recognition of danger signs and counselling to seek immediate care for serious illness, and improved linkages between the community and the hospital can produce substantial increases in care-seeking for sick newborns.

Zinc supplementation and serum zinc during diarrhea.

OBJECTIVE: Zinc deficiency is very common in developing countries and is more pronounced during an episode of diarrhea. Supplementation with zinc improves diarrhea and might correct zinc deficiency in both the short and longer term. METHOD: We conducted a nested study within a cluster randomized treatment trial. Fifty children with diarrhea living in the zinc treated clusters, 50 children with diarrhea living in control clusters, and 50 healthy children living in the control clusters were enrolled. We assessed serum zinc at the start of the diarrhea episode, which was 1-3 days after supplementation began in zinc treated children, and again one week after the diarrhea ended and supplementation ceased. Baseline characteristics and serum zinc concentration were assessed. RESULTS: Serum zinc was low in 44% of healthy children at the first blood draw. Compared to healthy controls, serum zinc was 3.1 mmol/L higher among children with diarrhea who were supplemented with zinc at first blood draw and 1.3 mmol/L higher 3 weeks later. CONCLUSION: Zinc supplementation enhances serum zinc concentration when given as a treatment for diarrhea and helps children maintain a more adequate zinc status during the convalescent period.

Zinc therapy for diarrhoea increased the use of oral rehydration therapy and reduced the use of antibiotics in Bangladeshi children.

Excessive use of antibiotics for diarrhoea is a major contributing factor towards increasing rates of antimicrobial resistance in developing countries. Zinc therapy for diarrhoea has been shown to be beneficial in controlled efficacy trials, and it is of interest to determine if availability of zinc syrup for treatment of diarrhoea would satisfy the demand for a 'medicine' for diarrhoea, thus reducing the use of antibiotics, without competing with the use of oral rehydration therapy (ORT). This community-based controlled trial was conducted from November 1998 to October 2000, and all children aged 3-59 months in the study area were included. In this trial, the availability of zinc supplements, along with ORT and appropriate education programmes, was associated with significantly higher use of ORT and lower use of antibiotics.