Global Consensus Recommendations on Prevention and Management of Nutritional Rickets

"BACKGROUND: Vitamin D and calcium deficiencies are common worldwide, causing nutritional rickets and osteomalacia, which have a major impact on health, growth, and development of infants, children, and adolescents; the consequences can be lethal or can last into adulthood. The goals of this evidence-based consensus document are to provide health care professionals with guidance for prevention, diagnosis, and management of nutritional rickets and to provide policy makers with a framework to work toward its eradication. EVIDENCE: A systematic literature search examining the definition, diagnosis, treatment, and prevention of nutritional rickets in children was conducted. Evidence-based recommendations were developed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system that describes the strength of the recommendation and the quality of supporting evidence. PROCESS: Thirty-three nominated experts in pediatric endocrinology, pediatrics, nutrition, epidemiology, public health, and health economics evaluated the evidence on specific questions within five working groups. The consensus group, representing 11 international scientific organizations, participated in a multiday conference in May 2014 to reach a global evidence-based consensus. RESULTS: This consensus document defines nutritional rickets and its diagnostic criteria and describes the clinical management of rickets and osteomalacia. Risk factors, particularly in mothers and infants, are ranked, and specific prevention recommendations including food fortification and supplementation are offered for both the clinical and public health contexts. CONCLUSION: Rickets, osteomalacia, and vitamin D and calcium deficiencies are preventable global public health problems in infants, children, and adolescents. Implementation of international rickets prevention programs, including supplementation and food fortification, is urgently required."

The Ashkelon Hypertension Detection and Control Program (AHDC Program): a community approach to reducing cardiovascular mortality.

BACKGROUND: Blood pressure (BP) reduction is crucial in reducing cardiovascular (CV) morbidity and mortality in the community. Subjects aged 20-65 seldom visit the primary care clinics, so they are unlikely to be detected without an active outreach screening program. The aim of the project was to prepare a professional doctor-nurse screening team, who will instruct those found to be at high risk in control of their risk factors, in order to reduce CV morbidity and mortality. METHODS: During a 10-year period (1980-1990), teams examined 12,202 subjects, (mean age 51 +/- 7 years, range 20-65 years) accounting for 23.4% of the total regional population. High risk subjects underwent an intensive CV risk factor control program. RESULTS: Subjects (3,506 or 28.6%) were found to have one or more CV risk factors (hypertension, obesity, smoking, hypercholesterolemia). During an average of 2 years, follow-up BP, weight reduction, and smoking cessation remained statistically significant. Total cholesterol was unchanged. Over this period, the standardized mortality ratio (SMR) in the area for acute MI fell from 100 to 76 (P < 0.01), for CV disease from 129 to 107 (P < 0.0001), and for hypertension from 121 to 87 (P < 0.1 NS). The project saved many life-years at no additional net cost to society, and cost effectiveness analysis showed positive results. CONCLUSIONS: A community approach with mainly nonpharmacological treatment is feasible and cost effective in reducing CV morbidity and mortality.

Risk factor profile and achievement of treatment goals among hypertensive patients from the Israeli Blood Pressure Control (IBPC) program--initial cost utility analysis.

AIMS: Blood pressure (BP) reduction is crucial in reducing cardiovascular morbidity and mortality. The IBPC (Israeli Blood Pressure Control) program was initiated in order to enhance the control of modifiable risk factors among high-risk hypertensive patients under follow-up by general practitioners in Israel. The cost effectiveness of an intervention program is an important factor in the decision-making process of its implementation and therefore was evaluated here. The objective of this evaluation is to estimate the costs, monetary savings and benefits in terms of QALYs (quality-adjusted life years) that would be expected if the program were to be expanded to 100 clinics nationwide, enabling around 14800 persons to be treated. METHODS: Hypertensive patients were screened in 30 general practice clinics, supervised by specialists in family medicine, each seeing 1000-5000 patients; 50-250 hypertensive patients were diagnosed at each participating clinic. BP levels, body mass index (BMI), lipid and glucose levels, as well as target organ damage and medications were recorded for all patients. RESULTS: A total of 4948 (2079, 42% males) were registered. Mean age was 64.8 +/- 12 years. After 1 year of follow-up versus baseline, the various parameters were as follows: BP control was achieved in 46.4% vs 29% of all hypertensive patients. LDL control (JNC VI criteria) was achieved in 41.7% vs 31.2% of all patients. Fasting plasma glucose control (glucose < 126 mg/dl) was achieved in 22% vs 19% of diabetic patients and 5.2% vs 3.1% of the diabetics had fasting plasma glucose levels > 200 mg/dl. Obesity (BMI > 30 kg/m2) was noted in 36.7% vs 43.8% at baseline. The cost utility analysis of the reduction in risk factors was calculated based on the international dicta applied to the reduction in risk factors as a result of treatment. For 100 clinics nationwide and 14800 persons to be treated the net saving to health services would be $977993 and the increase in QALYs would be 602 years. CONCLUSIONS: Better risk factor control in hypertensive patients by general practitioners could reduce morbidity and mortality as well as be cost effective.

[Hemoglobin level among infants in Akko sub-district].

OBJECTIVES: To determine the prevalence of anemia among infants born in 1995 within the Akko sub-district and to investigate the association between anemia and socio-demographic variables. SUBJECTS AND METHODS: In 1995, 7920 children were born in the Akko sub-district. Recommendations for prophylactic doses of iron preparations were given to all the infants aged 4-12 months screened by the "Mother and Child" clinic's team. Procedures at the "Mother and Child" clinic require the clinic's nurses to perform a routine hemoglobin test for each child at the age of 12 months. Anemia was defined as a level of hemoglobin less than 11 g/dl. The chi-square test was used for statistical analyses. RESULTS: A hemoglobin test was performed on 5703 infants. The finding showed that 30.8% of these infants had a hemoglobin level below 11 g/dl, 24% had a hemoglobin level between 10.0-10.9 g/dl, 6%--between 9.0-9.9 g/dl and less then 1% of the infants had a level of hemoglobin below 9.0 g/dl. Statistical analysis was performed on the results obtained from 5535 infants of non-Jewish origin. An association was found between the rate of anemia and ethnicity (Arabs more than Druze, p = 0.02) and between the rate of anemia and the type of settlement (p = 0.001). Arab settlements of higher socio-economic level showed a lower rate of anemia than those of low socio-economic level. The highest rate of anemia was found within Bedouin settlements. The number of children in the family was significantly associated with anemia rates (p = 0.0005), showing dose response effect. There was inverse correlation between maternal education and anemia rate (p = 0.001). No association was found between birth weight and anemia rates. CONCLUSIONS: A high rate of anemia was found among non-Jewish infants in the Akko sub-district. This finding indicates the necessity for an intervention program to reduce this high rate of anemia and its associated damage in order to facilitate the optimal psychomotor development of the children.

Geographic variation in groundwater iodine and iodine deficiency in Israel, The West Bank and Gaza.

BACKGROUND: Iodine deficiency during pregnancy and infancy is the world's most common preventable cause of mental retardation. Previous studies have shown a high incidence of goiter and low groundwater iodine concentrations in northern Israel. OBJECTIVE: We examined the relationship between low groundwater iodine and iodine deficiency in pregnant women and schoolchildren. SUBJECTS AND METHODS: We measured the urinary iodine excretion of school-children in the West Bank and Gaza and rural and urban pregnant women in Western Galilee (an area known to have low groundwater iodine concentrations). We also measured iodine concentrations in groundwater in various locations in the West Bank and Gaza. RESULTS: Lower urinary iodine excretion was found among pregnant Arab women living in rural Western Galilee (101+/-7 microg iodine/g creatinine). 20% of them excreted <50 microg I/g creatinine. This is relatively less than found among pregnant Jewish women living in cities in the same area (154+/-13 microg I/g creatinine). Low iodine concentrations (<5 microg/l) were found in groundwater in the Nablus, Ramallah, Bethlehem highlands, as compared to normal concentrations in the lowland districts of the West Bank and Gaza. In a cohort of 728 schoolchildren aged 8-10, 10% (range 8-13%) of children from areas of low groundwater iodine had low levels of urinary iodine excretion, as compared to only <5% of those from districts with groundwater iodine concentrations >10 microg/l. CONCLUSIONS: Lower concentrations of groundwater iodine are related to low urinary iodine excretion in Israel, the West Bank and Gaza.

Safety of community drinking-water and outbreaks of waterborne enteric disease: Israel, 1976-97.

Waterborne disease remains a major public health problem in many countries. We report findings on nearly three decades of waterborne disease in Israel and the part these diseases play in the total national burden of enteric disease. During the 1970s and 1980s, Israel's community water supplies were frequently of poor quality according to the microbiological standards at that time, and the country experienced many outbreaks of waterborne enteric disease. New regulations raised water quality standards and made chlorination of community water supplies mandatory, as well as imposing more stringent guidelines on maintaining water sources and distribution systems for both surface water and groundwater. This was followed by improved compliance and water quality, and a marked decline in the number of outbreaks of waterborne disease; no outbreaks were detected between 1992 and 1997. The incidence of waterborne salmonellosis, shigellosis, and typhoid declined markedly as proportions of the total burden of these diseases, but peaked during the time in which there were frequent outbreaks of waterborne disease (1980-85). Long-term trends in the total incidence of reported infectious enteric diseases from all sources, including typhoid, shigellosis, and viral hepatitis (all types) declined, while the total incidence of salmonellosis increased. Mandatory chlorination has had an important impact on improving water quality, in reducing outbreaks of waterborne disease in Israel, and reducing the total burden of enteric disease in the country.

Malignant mesothelioma in Israel, 1961-1992.

The authors monitored time trends in the incidences and distributions of malignant mesotheliomas during 1961-92 in 223 Israeli persons, including 21 men from a cohort of 3,057 asbestos-cement workers (83,122 person-years). The annual incidence rates of malignant mesotheliomas in Jewish men ranged between 2.5 per million in 1961-82 and 4.6 per million in 1985-92. The male-to-female incidence ratio rose from 1.2 in the 1960s to 2.9 during 1985-92, as a result of increases in risk among Israeli-born males. Females accounted for 37.6% of all cases, after exclusion of the cohort of asbestos workers. Of the 223 cases, 202 (91%) had no indication of direct occupational exposure to asbestos. In Jewish females, the incidence of malignant mesotheliomas did not increase after 1961. The mean age at diagnosis in all cases was lowest in the Israeli-born (53.0 years). High levels of asbestos exposure in the 1970s and the relatively early age of onset of the disease indicate that exposure began at a younger age in Israel than in European countries. Asbestos manufacture and use peaked in Israel during the mid-1970s, so the maximum impact of these trends has yet to be seen.

Cancer in ex-asbestos cement workers in Israel, 1953-1992.

A cohort of 3,057 male workers employed in an asbestos-cement plant using 90% chrysotile-10% crocidolite, located in Northern Israel, was followed from 1953-1992 for incidence and mortality from cancer. In the years 1978-1992, the cohort had an elevated risk for all malignant neoplasms combined (n = 153, SIR = 117, ns), lung cancer (n = 28, SIR = 135, ns), mesothelioma (n = 21; SIR > 5000, p < .0001), unspecified pleural cancer (n = 5; SIR = 278, P < .0001), and liver cancer (n = 7, SIR 290, ns). Risks for colo-rectal (n = 19; SIR = 79, ns), bladder (n = 12, SIR 69) and renal cancers (n = 5, SIR 104) were less than expected. Risk for mesothelioma showed a sharp risk gradient with duration of exposure, increasing from 1 per 625 for those employed less than 2 years to 1 per 4.5 workers employed over 30 years. The ratio of mesothelioma to excess lung cancer cases was 2.9 to 1, or 3.6 to 1, if pleural cases of unspecified origin were included; the pleura to peritoneum ratio of verified mesothelioma cases was 20 to 1. This atypically high ratio of mesothelioma to excess lung cancer cases is suggested to be the combined result of high past asbestos exposures in the workers and their low prior risk for lung cancer, and possibly, relatively early smoking cessation in relation to asbestos exposure.

Cost-benefit analysis of a national thalassaemia prevention programme in Israel.

OBJECTIVE: In Israel (population 5.7 million) there are around 200 known living subjects with thalassaemia major, of whom around 80% are from the northern district. This study aims at examining the costs and benefits of a national screening programme to prevent thalassaemia in Israel. MEASUREMENTS AND MAIN RESULTS: The lifetime healthcare costs of caring for a person born with thalassaemia major are $284,154. The costs of the home infusion service (33.1%) actually exceed the costs of the chelating agent itself (22.1%). The remaining 44.8% of costs are due to stay in hospital, operations, outpatient visits, laboratory tests, therapists, etc. Lost earnings and premature mortality costs account for a further $51,843 and $141,944 respectively for each case. A national screening programme would cost $900,197 and prevent around 13.4 homozygotes being born, at a cost of $67,369 for each birth prevented. The benefit-cost ratio of the programme to the health services is 4.22:1, which increases to 6.01:1 when a societal perspective is taken. However, around 13.0 homozygote births are still expected to occur, the majority owing to lack of compliance of patients at various stages in the screening process. The addition of a national health education programme for the higher risk non-Jewish population either nationally or in selected regions will incur extra costs, which may be covered by increased benefits as a result of better compliance with the screening programme. CONCLUSION: Israel should start to provide a nationwide thalassaemia screening programme as the monetary benefits to society (and even to the health services alone) will exceed the screening programmes costs.

A successful, preventive-oriented village health worker program in Hebron, the West Bank, 1985-1996.

Village health rooms (VHRs) were established in villages with no on-site health facilities in the Hebron District of the West Bank, beginning in 1985. By 1991, the program served a total population of 40,000 in 49 VHRs and by the end of 1996 covered 69 villages in Hebron and 20 in other districts that were previously served by visiting vaccination teams and nearby clinics. The VHRs provide close contact with the population of mothers for well child and pregnancy care, health education and provide visiting doctor/nurse teams for backup services and supervision. Data on coverage, utilization, costs, and outcome measures are presented. The program is accepted and grows despite adverse social and political conditions.

A community based study of failure to thrive in Israel.

OBJECTIVE: To examine the characteristics of infants suffering from failure to thrive in a community based cohort in Israel and to ascertain the effect of failure to thrive on their cognitive development. METHODS: By review of records maintained at maternal and child health clinics in Jerusalem and the two of Beit Shemesh, epidemiological data were obtained at age 15 months on a cohort of all babies born in 1991. For each case of failure to thrive, a matched control was selected from the same maternal and child health clinic. At age 20 months, cognitive development was measured, and at 25 months a home visit was carried out to assess maternal psychiatric status by questionnaire, and the HOME assessment was performed to assess the home environment. RESULTS: 3.9% of infants were found to have fallen below the third centile in weight for at least three months during the first year of life. Infants with failure to thrive did not differ from the general population in terms of obstetric or neonatal complications, birth order, or parents' ethnic origin, age, or years of education. The infants with failure to thrive did have lower birthweights and marginally smaller head circumferences at birth. Developmental assessment at 20 months of age showed a DQ of 99.7 v 107.2 in the matched controls, with 11.5% having a DQ below 80, as opposed to only 4.6% of the controls. No differences were found in maternal psychiatric problems as measured by a self report questionnaire. There were, however, significant differences in subscales of the HOME scale. CONCLUSIONS: (1) Infants who suffered from failure to thrive had some physiological predispositions that put them at risk; (2) failure to thrive may be an early marker of families providing suboptimal developmental stimulation.

Addressing the epidemiologic transition in the former Soviet Union: strategies for health system and public health reform in Russia.

OBJECTIVES: This paper reviews Russia's health crisis, financing, and organization and public health reform needs. METHODS: The structure, policy, supply of services, and health status indicators of Russia's health system are examined. RESULTS: Longevity is declining; mortality rates from cardiovascular diseases and trauma are high and rising; maternal and infant mortality are high. Vaccine-preventable diseases have reappeared in epidemic form. Nutrition status is problematic. CONCLUSIONS: The crisis relates to Russia's economic transition, but it also goes deep into the former Soviet health system. The epidemiologic transition from a predominance of infectious to noninfectious diseases was addressed by increasing the quantity of services. The health system lacked mechanisms for epidemiologic or economic analysis and accountability to the public. Policy and funding favored hospitals over ambulatory care and individual routine checkups over community-oriented preventive approaches. Reform since 1991 has centered on national health insurance and decentralized management of services. A national health strategy to address fundamental public health problems is recommended.

Gender differences in nutritional status and feeding patterns among infants in the Gaza Strip.

OBJECTIVES: This study examined gender variation in nutritional treatment and anthropometric status of infants in the Gaza Strip. Numerous studies have documented gender differences in health status in developing areas, generally finding boys to be at an advantage over girls. Social and economic characteristics in Gaza suggest that one might expect preferential treatment of boys there. METHODS: The study used data on two samples of infants 0 to 18 months of age collected from five health centers in Gaza. A variety of different analytic methods were used to look for gender differences in feeding patterns, prevalence of malnutrition, and anthropometric status. RESULTS: Although some differences in nutritional treatment and anthropometric outcome for infants of different socioeconomic status and between the earlier and later samples were found, no consistent gender differences were revealed. CONCLUSIONS: The findings are consistent with several different explanations. First, expectations of finding gender differences may have been unfounded. Alternatively, such differences may have existed previously but have been eliminated through successful public health intervention, rising levels of education, and economic development.