Measles in rural Bangladesh: issues of validation and age distribution.

In the Third World, scientists have described thoroughly the pattern of measles in Africa. In Asia, however, the epidemiology of measles has been poorly described. In 1989, a measles surveillance system was initiated in Matlab, rural Bangladesh in order to monitor measles incidence in the area. The population (100,000), which has relatively low immunization coverage, has an excellent demographic surveillance system which allows accurate follow-up. The system works through trained community health workers who visit all households every fortnight and report possible cases of measles. Medical doctors review a proportion of index cases and cases in infants soon after the appearance of the rash. Of the 4673 cases reported in all age groups, 18% were visited by medics. Confirmation of diagnosis was related to the age at onset and overreporting by community health workers is documented. The incidence of measles was estimated at 43% of children < 5 years old. Of cases < 5 years of age, 14% occurred below the age at vaccination (incidence rate = 5.5%). A strong seasonal pattern is reported. Case-fatality rates are low. This is the first report which shows the effect of age on reliability of reported measles. It shows the misclassification likely to occur when reporting measles in large-scale surveys, particularly in infants. It also shows that the pattern of measles in this community resembles the pattern reported for African communities and calls for a review of immunization strategies with vaccination below 9 months of age.

Diarrhoea mortality in rural Bangladeshi children.

Diarrhoeal mortality and hospital admissions for diarrhoea are described among children under the age of 5 years in a large rural Bangladeshi community during 1986-87. Acute watery (dehydrating) diarrhoea was associated with 11 per cent of all deaths among infants aged 1-11 months and 5 per cent among children aged 1-4 years. Acute non-watery diarrhoea, including bloody dysentery and diarrhoea with mucoid stools, was associated with 16 per cent of all deaths among children aged 1-4 years. In this age group, persistent diarrhoea, particularly when accompanied by recent and/or severe wasting, was associated with 63 per cent of all diarrhoeal deaths and 34 per cent of all deaths. These data suggest that exclusive emphasis on ORT will have little impact on diarrhoea mortality among children in rural Bangladesh. A broader strategy, both preventive and curative, including measles immunization, nutrition education, dietary management of diarrhoea, and the treatment of dysentery in the community, carries a greater potential.

Measles among under-9-month-olds in rural Bangladesh: its significance for age at immunization.

Any decision to modify measles immunization strategies away from the use of the conventional vaccine given to children at 9 months of age to the adoption of recently proposed vaccine strains that can be given to 4-6-month-olds will depend on the age distribution of severe cases of measles in the community. Reported are the results of an analysis of two community-based measles surveillance systems in rural Bangladesh, which found that 17% of all measles cases reported for under-5-year-olds in a nonvaccinated population involved infants aged less than 9 months. In a vaccinated population from the same area, 31% of all measles cases reported for under-5-year-olds occurred among under-9-month-olds. Using a rather restrictive definition for measles-related deaths (those occurring within 6 weeks of the onset of the rash), the proportion of measles-related deaths that occurred before 9 months of age was 13% of all such deaths that were reported.

Perinatal mortality in Matlab, Bangladesh: a community-based study.

Perinatal deaths, comprising stillbirths and deaths during the first week of life, were monitored over the eight-year period 1979 to 1986 in a rural Bangladeshi population of 196,000. The perinatal mortality rate was 75 per 1000 total births. The rate was 13% higher in males than females. Stillbirth and early neonatal mortality rates were 37 and 38 per 1000 total births, respectively. The major causes of perinatal deaths are presented, as well as some of the maternal determinants. During the period under study, perinatal mortality declined regularly and significantly over time in an area covered by an intensive Family Planning and Health Services programme, but not in the adjacent control area. This raises the issue of the impact of such a programme upon perinatal mortality, and the need to include a strong maternity care component into primary healthcare strategies if further reductions of perinatal mortality are to be achieved.

PIP: In 1986, as part of the ongoing Demographic Surveillance System of the International Centre for Diarrhoeal Disease Research, Bangladesh, health workers regularly visited households in Matlab district to record vital events and other demographic data. They recorded 497 fetal deaths and early neonatal deaths. Low birth weight contributed to 25% of fetal deaths followed by prolonged labor (19%), maternal medical problems (13%), malpresentation at term (12%), and twins (2%). The cause of fetal death for 28% could not be determined. Similarly, low birth weight causes 63% of very early neonatal deaths followed by prolonged labor (31%) and 37% and 15% respectively in 4-7 day old neonates. The 2nd leading cause of death for 4-7 day old neonates was neonatal tetanus (25%w0. Males were more likely to die from tetanus than females (relative risk=4.3; p=.015). The women at lowest risk included those 20-24 years old who were pregnant for the 2nd-3rd time, those 25-29 years old who were pregnant for the 4th-5th time, and those 30-34-years old who were pregnant for the 6th-7th time. Even though the perinatal mortality rates in the study and comparison areas in Matlab did not significantly differ (74 and 75 total births/1000), the rate fell significantly from 82 (1979) to 65 (1986) in the area where maternal and child health and family planning services (MCH-FP) existed (p.001). Further, the rate declined significantly more in the 2nd half of the study period (1983-1986) than in the 1st half (1979-1982) in the MCH-FP area (p.002). Moreover the difference between the 2 areas was only significant in the 2nd half (p.04). Perinatal mortality was highest from August to December. The researchers credit the tetanus toxoid as having more of an impact on reducing the perinatal mortality in the study area than family planning interventions.

The effect of maternal and child health and family planning services on mortality: is prevention enough?

OBJECTIVE: To examine the impact on mortality of a child survival strategy, mostly based on preventive interventions. DESIGN: Cross sectional comparison of cause specific mortality in two communities differing in the type, coverage, and quality of maternal and child health and family planning services. In the intervention area the services were mainly preventive, community based, and home delivered. SUBJECTS: Neonates, infants, children, and mothers in two contiguous areas of rural Bangladesh. INTERVENTIONS: In the intervention area community health workers provided advice on contraception and on feeding and weaning babies; distributed oral rehydration solution, vitamin A tablets for children under 5, and ferrous fumarate and folic acid during pregnancy; immunised children; trained birth attendants in safe delivery and when to refer; treated minor ailments; and referred seriously ill people and malnourished children to a central clinic. MAIN OUTCOME MEASURES: Overall and age and cause specific death rates, obtained by a multiple step "verbal autopsy" process. RESULTS: During the two years covered by the study overall mortality was 17% lower among neonates, 9% lower among infants aged 1-5 months, 30% lower among children aged 6-35 months, and 19% lower among women living in the study area than in those living in the control area. These differences were mainly due to fewer deaths from neonatal tetanus, measles, persistent diarrhoea with severe malnutrition among children, and fewer abortions among women. CONCLUSIONS: The programme was effective in preventing some deaths. In addition to preventive components such as tetanus and measles immunisation, health and nutrition education, and family planning, curative services are needed to reduce mortality further.

Use of tetanus toxoid for the prevention of neonatal tetanus. 1. Reduction of neonatal mortality by immunization of non-pregnant and pregnant women in rural Bangladesh.

PIP: 1 approach to the prevention of tetanus neonatorum (a leading cause of infant death throughout the world) is improving the quality of prenatal, obstetric, and postnatal maternal and child health services. Another complementary approach is the active immunization of women before or during pregnancy with tetanus toxoid. Work in progress at the Matlab field station of the International Center for Diarrheal Disease Research in Bangladesh (ICDDR,B) provided a unique opportunity to study the effectiveness of certain aspects of these 2 strategies. In 1974, during a field trial of cholera toxoid vaccine, 2 injections of an aluminum phosphate tetanus-diphtheria toxoid were provided as a control to a randomly assigned group of nonpregnant women. Beginning in June 1978, a program of immunizing women during pregnancy with aluminum phosphate-absorbed tetanus toxoid was initiated in conjunction with the implementation of a village based maternal and child health and family planning program in half of the same Matlab surveillance area. Throughout the period of these 2 programs, the ICDDR,B maintained an independent, longitudinal, vital registration system, identifying all births and deaths in the study area. In this analysis, all live births registered in the Maternal and Child Health-Family Planning and comparison areas during the September 1, 1978 until December 31, 1979 period were identified. These records were linked with any deaths recorded within 28 days of birth. The acceptance of tetanus vaccination during the 1974 cholera vaccine trial, by the mothers of these live births, was ascertained from the 1974 vaccine registers. The acceptance of vaccination during the 1978-1979 program was obtained from the field registers. For infants whose mothers had received 2 tetanus injections 48-64 months prior to delivery, the neonatal mortality rate was 63.8/l000 live births compared with 78.3/1000 for infants whose mothers did not receive tetanus immunization. Immunization of women with 2 tetanus injections during pregnancy reduced neonatal mortality rates to 42.8/1000, a reduction of 35.5/1000. Mortality on days 4-14 was reduced by about 70%. 1 injection during pregnancy did not appear to provide protection against tetanus neonatorum.^ieng

Prevalence of residual paralysis from paralytic poliomyelitis in a rural population of Bangladesh.

To estimate the prevalence of residual paralysis from poliomyelitis in children in one area of rural Bangladesh, a survey of the amount and original cause of lameness was undertaken. The International Center for Diarrhoeal Disease Research, Bangladesh Matlab field area, which has been under demographic surveillance for 13 years, provided the study population of 25,000 children aged 5--14 years. The cause of the lameness identified for a child in the survey was based on criteria obtained from a health history questionnaire and a physical examination performed by a physician. The prevalence rate for residual paralysis of poliomyelitis estimated from the lameness survey was 0.84/1,000 children aged 5--14 years. Since lower extremity paralysis occurs in only about 80% of children with paralytic poliomyelitis, the prevalence rate for all cases of residual paralysis of poliomyelitis was calculated to be 1.05/1,000 children in this age group.

Epidemiology and causes of death among children in a rural area of Bangladesh.

From a longitudinal surveillance programme among a rural Bangladesh population of 260,000, the epidemiology and causes of child death (under age 5) over 3 years (1975-1977) were analyzed. The most significant causes of death were diarrhoea (watery and dysentery), tetanus, measles, fever, respiratory disease, drowning, skin disease, and other causes. Of an infant mortality rate of 142.6/1000 live births, neonatal tetanus (37.4/1000), diarrhoea (19.6/1000), and respiratory disease (10.4/1000) were the most significant identifiable causes. Many infant deaths (62.2/1000) were unidentified, taking place during the neonatal (1-28 days) period. The 1-4 year mortality averaged 34.3/1 000. Diarrhoea (15.1/1 000), measles (4.5/1 000), fever (2.9/1 000) and respiratory disease (1.6/1 000) accounted for most 1-4 year deaths. Mortality trends over the past 10 years showed sharp temporary fluctuations in response to 2 disasters but no definitive long-term trend. Most causes of death displayed seasonal fluctuation, and sex differentials were marked with female deaths exceeding male deaths for all ages after the neonatal period. Malnourished children from low socioeconomic status families had higher mortality rates than their better nourished and wealthier counterparts. Overall, the data suggest that the delivery of a few basic health measures (oral hydration and immunization) could result in substantial reduction of under 5 mortality.

PIP: From a longitudinal surveillance program among a rural Bangladesh population of 260,000, the epidemiology and causes of child death (under age 5) over 3 years (1975-77) were analyzed. The most significant causes of death were diarrhea (watery and dysentery), tetanus, measles, fever, respiratory diseases, drowning, skin disease, and other causes. Of an infant mortality rate of 142.6/1000 live births, neonatal tetanus (37.4/1000), diarrhea (19.6/1000), and respiratory disease (10.4/1000) were the most significant identifiable causes. Many infant deaths (62.2/1000) were unidentified, taking place during the neonatal period (1-28 days). The 1-4 year mortality averaged 34.3/1000. Diarrhea (15.1/1000), measles (4.5/1000), fever (2.9/1000), and respiratory disease (1.6/1000) accounted for most 1-4 year deaths. Mortality trends over the past 10 years showed sharp temporary fluctuations in response to 2 disasters but no definitive long-term trend. Most casues of death displayed seasonal fluctuation, and sex differentials were marked with female deaths exceeding male deaths for all ages after the neonatal period. Malnourished children from low socioeconomic status families had higher mortality rates than their better nourished and wealthier counterparts. Overall, the data suggest that the delivery of a few basic health measures (oral hydration and immunization) could result in substantial reduction of under 5 mortality.

Village-based distribution of oral rehydration therapy packets in Bangladesh.

The distribution of sucrose-electrolyte oral therapy packets (1 liter) by community-based workers in a rural Bangladesh population of 157,000 was evaluated. A similar population of 134,000 served as a comparison group. The locally-produced packets showed satisfactory chemical composition with a shelf-life of up to 3 months and a cost of U.S. $0.05. After 4 months the workers were distributing an average of 70 packets/1,000 population per month. Most patients used one packet for each episode of diarrhea; 13% of children used two packets, and 15% and 8% of adults used, respectively, two and three packets. The electrolyte composition of the oral fluids prepared by field workers and mothers showed substantial variation, but no hyperconcentrated solutions were noted. A comparison of the hospitalization rate from the two study areas suggested a 29% reduction in hospitalization for diarrhea during the 4 months of distribution.