Mortality and use of health services surveys in rural Zaire.

The Combatting Childhood Communicable Disease (CCCD) project is a comprehensive public health programme designed to reduce child mortality by 25% through the use of the following strategies: vaccination, oral rehydration therapy, and prompt treatment for malaria. To evaluate this programme, cross-sectional surveys were conducted in neighbouring health zones in Zaire in 1984 to determine the use of selected medical services by the population and to estimate the child mortality rate before the CCCD programme began. A reinterview survey was conducted on a subsample of women previously interviewed to determine the reliability of the mortality estimates. In both health zones 84-85% of women used antenatal services, 45% of children under age 6 who had had fewer were treated with an anti-malarial drug, 19-22% of children age 12-23 months had been vaccinated against measles, and virtually no children who had had diarrhoea were treated with oral rehydration therapy. Women's underreporting of births and deaths resulted in low estimates of mortality in both surveys. The reinterview survey provided more accurate estimates of mortality and led to a better understanding of the factors influencing underreporting. The estimated infant mortality rate was 74 deaths per 1000 livebirths; and the probability of dying before age 5 was 191 per 1000. Because births and deaths reported with incomplete dates were excluded from analysis, the mortality rates from the reinterview survey are underestimates. Given the difficulty in obtaining accurate estimates of mortality, primary importance should be given to developing and improving routine health information systems that measure changes in health status and provide information to evaluate programmes.

Role of nongovernmental agencies in vaccine delivery.

Zaire, a large central African country with a population of more than 30 million, has had much experience with nongovernmental agencies in its health sector. Of special importance have been missionary groups that established health facilities and conduct "mobile" health activities in rural areas. They established efficient communications and supply networks, and because they could refrigerate vaccines, they were among the first groups to deliver vaccines in rural areas. Expansion of Expanded Programme on Immunization services to rural areas was only made possible through the efforts of nongovernmental agencies.

Measles control efforts in urban Africa complicated by high incidence of measles in the first year of life.

A measles vaccination coverage of between 50 and 60% has been achieved in Kinshasa, Zaire, from 1980-1985. During that interval, the annual number of measles cases and the incidence rate of measles reported by a surveillance system remained similar, and measles epidemics occurred in alternating years. The estimated number of measles cases in Kinshasa is 87,600 per year. Of reported measles cases, 27% occurred in children under nine months of age, younger than the recommended age at vaccination. Two results expected in a partially vaccinated population, a reduction in measles incidence greater than the level of vaccination coverage and a shift in the age distribution of measles to older children, have not been observed. Measles control in Kinshasa will require a vaccination coverage of higher than 60%. In addition, given the age-specific risk of measles infection here, a measles vaccine that would be effective when given before nine months of age would be an important element in controlling measles transmission. Because the epidemiology of measles in Kinshasa is a likely consequence of its urban environment, such a vaccine would represent a significant advance toward the control of measles in urban Africa.

Malaria infection in pregnant women in Zaire: the effects and the potential for intervention.

In five maternity centres in urban and rural Zaire we evaluated the maternal prevalence of Plasmodium falciparum parasitaemia and recorded fever, the frequency of abortions and stillbirths, newborn birth weights and the feasibility of delivering antimalarial chemoprophylaxis. Women in their first and second pregnancy, compared to others (greater than or equal to third pregnancies), had a higher frequency of parasitaemia (38 v. 15%, respectively, P less than 0.001), higher parasite densities (geometric mean densities 927 per mm3 v. 277 per mm3, respectively, P = 0.01), higher rates of stillbirths and low birth weight babies (24% v. 6.4%, P less than 0.001). On average, pregnant women first attended prenatal clinics in the sixth to seventh month of gestation and made three to four visits before delivery. In these areas of Zaire, antimalarial interventions during pregnancy would have the largest impact if they were targeted to women in their first and second pregnancy. In the study areas, maternal attitudes and prenatal care-seeking behaviours do not appear to be barriers to providing an antimalarial intervention.

Response of children with Plasmodium falciparum to chloroquine and development of a national malaria treatment policy in Zaire.

In vivo sensitivity of Plasmodium falciparum to chloroquine was evaluated in 4 of 9 regions of Zaire in 1985 to develop a national strategy for treatment of malaria. Children less than 5 years of age were treated with either a single dose of chloroquine base, 10 mg/kg, or a dose of 25 mg/kg given over 3 d. A modified 7-day World Health Organization in vivo test was used with follow-up 2, 3 and 7 d after the start of treatment. 339 children were studied. In Bwamanda 92% of children were aparasitaemic 7 days after chloroquine, 10 mg/kg, but in Kinshasa only 44% were free of parasites after 25 mg/kg chloroquine. The mean drop in parasite density among those who did not clear parasites by day 7 was greater than 98% of the initial value. Although the parasite density decreased markedly, the failure of most subjects to become aparasitaemic indicated a marked decrease in parasite sensitivity since 1983. Only one child of 51 who were initially febrile remained febrile, although 14 (28%) of these had resistant parasites. The decrease in parasitaemia and temperature, even among children with resistant strains, led the Ministry of Health to recommend 25 mg/kg chloroquine as first line treatment for fever/malaria in their national malaria control plan. The plan includes drug sensitivity surveillance and a referral system for patients who do not respond to chloroquine treatment.