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.

Developing an interactive STD-prevention program for youth: lessons from a north Indian slum.

An intervention developed to teach young men in the urban slums of Lucknow, India, about sexually transmitted diseases is described in detail. This community-based intervention was designed to impart core educational messages and to address preexisting ideas about sexual health and STD-prevention practices among participants. Indicators of knowledge recorded before and after the intervention are presented and evaluated against the scores of a control group. Levels of sexual activity and factors associated with risky sex are discussed. The intervention was successful in raising the young men's awareness of STDs significantly in all areas except for the length of time that symptoms take to manifest following risky sex and the ineffectiveness of washing one's genitals after sex to avoid acquiring STDs. Lessons learned during the intervention are described as a means of informing future STD-education programs, and issues requiring prompt attention are identified.

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.

Family expenditure on sickness episodes of pre-school children in urban slums of Lucknow, north India.

This study investigated family expenditure on the sickness episodes of pre-school children in 32 urban slums of Lucknow, North India. Between July 1995 and January 1996, 396 children between the ages of 1.5 to 3.5 years were contacted. The main objective was to discover the direct medical cost of illness incurred by their families in the preceding months. Point prevalence of major morbidities, in the preceding month, were as follows: 17.2% respiratory and 6.3% diarrhoeal. A health care provider saw 31.4% [95% confidence interval (CI): 26.9-36.01] children. In > 95% of the cases, the health care provider was a self-employed, non-governmental dispenser (NGD). More than half of NGDs did not have a recognized medical degree. The mean family expenditure on sickness in 1 month was RS 12.27 [standard deviation (SD): RS 23.81], approximately 1% of their income (1 US $ = RS 32). Respiratory illness was the primary cause of financial burden to the community. The isolated symptoms of fever was the most expensive to treat, with diarrhoea and dysentery costs being similar. Immunizing a child saved money. We conclude that since the NGDs are the predominant health care providers in the urban slums, and since neither the nature of medicines dispensed by them nor their additional costs can be ascertained, steps must be taken to monitor their dispensing practices and to educate them about rational drug therapy.

Cause-specific mortality in under fives in the urban slums of Lucknow, north India.

We recorded the causes of death in the preceding 3 years in a slum population of 24,196 children less than 5 years of age in Lucknow, North India. Of 1469 deaths recorded, 298 were stillbirths. For each death, a 'verbal autopsy' was conducted by interviewing the parents to ascertain the cause of death. 71.8 per cent of deaths were at home; 94.5 per cent of hospital deaths had no death certificate. Excluding stillbirths, 69.9 per cent of deaths were in the first year of life. Leading causes of death in the neonatal period were prematurity (38.5 per cent) and tetanus (36.4 per cent). Beyond the neonatal period, the leading causes of death were pneumonia (23.4 per cent), diarrhoeal disease (20.9 per cent), and malnutrition and/or anaemia (11.4 per cent). The existent mortality-recording system was under-reporting at least one third of the deaths. We conclude that stillbirths and neonatal mortality can be reduced by improved antenatal and natal care. In the postnatal period, since most of the mortality is due either to infective diseases or malnutrition, interventions to improve the nutritional status of preschool children can reduce this.

Sexual behavior patterns and knowledge of sexually transmitted diseases in adolescent boys in urban slums of Lucknow, north India.

PIP: A cross-sectional survey was conducted in the Integrated Child Development Scheme (ICDS) to assess the sexual behavior patterns and knowledge of sexually transmitted diseases (STDs) among 15-21 year old boys with a goal of developing a community-based reproductive educational health program in India. About 221 boys from 35 Anganwadi centers were interviewed twice; on the first interview the educational, socioeconomic and marital status was determined, while questions about their health, substance abuse, sexual activity, condom use, number of sexual partners, and STD symptoms were asked during the second interview. Findings revealed that premarital sex was practiced by 7.9% and 7.6% of boys aged 18 or younger and over 18, respectively, living in the urban slum areas of Lucknow, North India. The boys engaged in high-risk sexual behavior and had a poor knowledge of STD symptoms and prevention. Furthermore, substance use has been associated with irregular condom use and also with STDs. These findings reveal that there is an urgent need for initiating reproductive health counseling programs targeted at these high-risk adolescents.^ieng

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.

PIP: Findings are reported from a study conducted to assess the prevalence of intestinal parasites and their association with malnutrition in a sample of preschool children from 32 randomly chosen anganwadi centers in urban Lucknow, India. Overall, there are 153 anganwadi centers in the city. All eligible children registered with the anganwadi worker were enrolled. Findings are based upon the study of 549 boys and 512 girls aged 1.5-3.5 years. 67.6% were underweight, 62.8% were stunted, and 26.5% were wasted. Parasites were detected in 17.5% of children by a single direct fecal smear examination. Of those, 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 rather than smear negative for ascaris or giardia were 9.1 g/dl and 9.6 g/dl, respectively. Urgent steps are needed in this setting at the community level to improve children's nutritional status and control parasite infestation.

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.

PIP: Findings are reported from a study conducted to quantify the burden of common morbidities in each month in 1 year among preschool children at 32 randomly chosen anganwadi centers in urban Lucknow, India. Overall, there are 153 anganwadi centers in the city. All eligible children registered with the anganwadi worker were enrolled over a period of 6 months from July 1995 to January 1996, and then contacted again 6 months later. Findings are based upon the study of 549 boys and 512 girls aged 1.5-3.5 years. 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 during October-February, the winter months, while those of diarrhea and skin diseases were the highest during March-June and July-September, respectively. Season-specific diseases were measles in summer, and fever as the isolated symptom in monsoon season. The IR for combined morbidities was the highest during the monsoon season. These findings warrant the consideration of season-specific intensification of existing health care resources for such morbidity.

Blood lead in pregnant women in the urban slums of Lucknow, India.

OBJECTIVES: To determine the concentrations of blood lead (PbB) in pregnant women in the slums of Lucknow, north India. METHODS: Of the 203 designated municipal slums in Lucknow, 70 were randomly selected for study and a cohort of 500 pregnant women was enrolled. Each participant was interviewed with questions on possible sources of exposure to lead, surrogates of nutritional status were measured, and PbB was measured. RESULTS: The mean PbB was 14.3 micrograms/dl and 19.2% of women had PbB > or = 20 micrograms/dl. PbB was not associated with age, height, weight, gestation, or history of abortions, although higher PbB was associated with higher parity. Women living inner city neighbourhoods near heavy vehicular traffic had PbB 2.2 micrograms/dl higher (95% confidence interval (95% CI) 0.8 to 3.6) than those living in other neighbourhoods. The PbB was not associated with reported use of piped water or the presence of paint in homes, and increasing PbB was unexpectedly associated with decreasing use of eye cosmetic "surma" and the duration of gestation. CONCLUSIONS: The high PbB found in this population raises concern about fetal development and points to the urgent need to reduce exposure to lead.

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.