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In low-income countries, infectious diseases still account for a large proportion of deaths, highlighting health inequities largely caused by economic differences. Vaccination can cut health-care costs and reduce these inequities. Disease control, elimination or eradication can save billions of US dollars for communities and countries. Vaccines have lowered the incidence of hepatocellular carcinoma and will control cervical cancer. Travellers can be protected against "exotic" diseases by appropriate vaccination. Vaccines are considered indispensable against bioterrorism. They can combat resistance to antibiotics in some pathogens. Noncommunicable diseases, such as ischaemic heart disease, could also be reduced by influenza vaccination. Immunization programmes have improved the primary care infrastructure in developing countries, lowered mortality in childhood and empowered women to better plan their families, with consequent health, social and economic benefits. Vaccination helps economic growth everywhere, because of lower morbidity and mortality. The annual return on investment in vaccination has been calculated to be between 12% and 18%. Vaccination leads to increased life expectancy. Long healthy lives are now recognized as a prerequisite for wealth, and wealth promotes health. Vaccines are thus efficient tools to reduce disparities in wealth and inequities in health. Dans les pays a faible revenu, les maladies infectieuses representent encore une forte proportion des deces, mettant en lumiere des inegalites sur le plan sanitaire resultant dans une large mesure d&apos;ecarts economiques. La vaccination peut faire baisser les couts des soins de sante et reduire ces inegalites. La lutte contre les maladies, leur elimination ou leur eradication permettent aux communautes et aux pays d&apos;epargner des milliards de doltars des Etats-Unis. Les vaccins ont egalement fait baisser l&apos;incidence du carcinome hepatocellulaire et permettront d&apos;endiguer le cancer du col uterin. Les voyageurs sont proteges contre les maladies << exotiques >> par une vaccination appropriee. Les vaccins sont consideres comme indispensables dans la lutte contre le bioterrorisme, lis peuvent s&apos;opposer au developpement d&apos;une resistance aux antibiotiques pour certains agents pathogenes. La vaccination antigrippale pourrait aussi faire reculer des maladies non transmissibles, comme les cardiopathies ischemiques. Les programmes de vaccination ont permis d&apos;ameliorer l&apos;infrastructure de soins de sante primaire dans les pays en developpement, de faire baisser la mortalite infanto-juvenile et de favoriser l&apos;autonomie des femmes dans le cadre d&apos;une meilleure planification familiale, avec des benefices sanitaires, sociaux et economiques consequents. La vaccination contribue partout a la croissance economique, grace aux baisses de morbidite et de mortalite. On a calcule que le retour annuel sur investissement de cette intervention se situait entre 12 et 18 %. Elle entraine egalement une augmentation de l&apos;esperance de vie. Il est maintenant reconnu que des vies longues et en bonne sante sont un prealable a la richesse et la richesse favorise a son tour la sante. Les vaccins constituent ainsi des outils efficaces pour reduire les inegalites en matiere de richesse et de sante. En los paises de ingresos bajos, las enfermedades infecciosas representan todavia una gran proporcion de las defunciones, lo que pone de manifiesto unas inequidades sanitarias cuya causa fundamental son las desigualdades economicas. La vacunacion puede reducir los costos de la atencion de salud y reducir esas inequidades. El control, la eliminacion y la erradicacion de enfermedades permiten ahorrar miles de millones de dolares estadounidenses en beneficio de las comunidades y los paises. Las vacunas han reducido la incidencia de carcinoma hepatocelular y permitiran controlar el cancer cervicouterino. Los viajeros pueden protegerse contra enfermedades <> mediante la vacunacion apropiada. Las vacunas son un arma imprescindible contra el bioterrorismo. En el caso de algunos agentes patogenos, pueden dificultar la aparicion de resistencia a los antibioticos. Algunas enfermedades no transmisibles, como la cardiopatia isquemica, tambien podrian reducirse mediante la vacunacion contra la gripe. Los programas de inmunizacion han mejorado la infraestructura de atencion primaria en los paises en desarrollo, reducido la mortalidad en la ninez y empoderado a las mujeres para planificar mejor su familia, con los consiguientes beneficios sanitarios, sociales y economicos. La vacunacion contribuye al crecimiento economico en todas partes, debido a la menor morbilidad y mortalidad. Se estima que las ganancias que reportan anualmente las inversiones en inmunizacion ascienden a un 12%-18%. La vacunacion propicia una mayor esperanza de vida, y es un hecho admitido hoy dia que las vidas longevas y sanas son una condicion de la riqueza, y que esta favorece a su vez la salud. Las vacunas constituyen por consiguiente un instrumento eficiente para mitigar las disparidades de riqueza y las inequidades en salud. [TEXT NOT REPRODUCIBLE IN ASCII], Introduction Vaccination has greatly reduced the burden of infectious diseases. Only clean water, also considered to be a basic human right, performs better. (1) Paradoxically, a vociferous antivaccine lobby thrives [...]

Objective To assess the rates, timing and causes of neonatal deaths and the burden of stillbirths in rural Uttar Pradesh, India. We discuss the implications of our findings for neonatal interventions. Methods We used verbal autopsy interviews to investigate 1048 neonatal deaths and stillbirths. Findings There were 430 stillbirths reported, comprising 41% of all deaths in the sample. Of the 618 live births, 32% deaths were on the day of birth, 50% occurred during the first 3 days of life and 71% were during the first week. The primary causes of death on the first day of life (i.e. day 0) were birth asphyxia or injury (31%) and preterm birth (26%). During aays 1-6, the most frequent causes of death were preterm birth (30%) and sepsis or pneumonia (25%). Half of all deaths caused by sepsis or pneumonia occurred during the first week of life. The proportion of deaths attributed to sepsis or pneumonia increased to 45% and 36% during days 7-13 and 14-27, respectively. Conclusion Stillbirths and deaths on the clay of birth represent a large proportion of perinatal and neonatal deaths, highlighting an urgent need to improve coverage with skilled birth attendants and to ensure access to emergency obstetric care. Health interventions to improve essential neonatalcare and care-seeking behavior are also needed, particularly for preterm neonates in the early postnatal period. Objectivo Evaluar las taux, la repartition dans le temps et les causes des deces neonataux et de la charge de mortinatalite dans une population rurale de l&apos;Uttar Pradesh, en Inde. Les implications des resultats de l&apos;etude pour les interventions en sante neonatale sont ensuite examinees. Methodes On a analyse 1048 cas d&apos;enfants mort-nes ou decedes pendant la periode neonatale a partir des interrogatoires realises dans le cadre des autopsies verbales. Resultats Le nombre de cas d&apos;enfants mort-nes notifies s&apos;elevait a 430, soit 41% de l&apos;ensemble des deces dans l&apos;echantillon. Sur les 618 enfants nes vivants, 32 % sont morts le jour de la naissance, 50 % au cours des 3 premiers jours de vie et 71% pendant la premiere semaine. Les principales causes de deces au premier jour de vie (appele jour 0) etaient l&apos;asphyxie ou les traumatismes a la naissance (31%) et la naissance avant terme (26 %). Pendant les jours 1 a 6, les causes de deces les plus frequentes etaient la naissance avant terme (30 %) et la presence d&apos;une infection grave ou d&apos;une pneumonie (25 %). La moitie des deces par infection grave ou par pneumonie se produisaient pendant la premiere semaine de vie. La proportion de deces attribuables a une infection grave ou a une pneumonie passait a 45 % et a 36 % pour les periodes allant du 7e au 13e jours et du 14e au 27e jours respectivement. Conclusion La mortinatalite et les deces intervenant le jour de la naissance representent une fraction importante des deces perinataux et neonataux, ce qui met en lumiere la necessite urgente d&apos;ameliorer la couverture des naissances par des accoucheurs competents et de garantir l&apos;acces a des soins obstetricaux d&apos;urgence. Des interventions sanitaires visant a ameliorer les soins neonataux essentiels et les comportements en matiere de recours aux soins, en particulier pour les nouveaux-nes prematures au debut de la periode postnatale, s&apos;imposent egalement. Objetivo Evaluar las tasas, el momento y las causas de la mortalidad neonatal y la carga de mortinatalidad en zonas rurales de Uttar Pradesh (India). Consideramos aqui las implicaciones de nuestros resultados para las intervenciones neonatales. Metodos Utilizamos entrevistas de autopsias verbales para investigar 1048 defunciones neonatales y prenatales. Resultados Se notificaron 430 casos de muerte prenatal, que suponian el 41% de todas las defunciones de la muestra. Entre los 618 nacidos vivos, el 32% de las defunciones se produjeron en el mismo dia de nacimiento, el 50% se produjeron durante los 3 primeros dias de vida, y el 71% se registraron durante la primera semana. Las causas principales de defuncion en el primer dia de vida (dia O) fueron la asfixia y los traumatismos (31%) y la prematuridad (26%). Durante los dias 1 a 6, las causas mas frecuentes de muerte fueron la prematuridad (30%) y una septicemia o neumonia (25%). La mitad de todas las defunciones por septicemia o neumonia se produjeron durante la primera semana de vida. La proporcion de defunciones atribuidas a septicemia o neumonia aumento al 45% y el 36% durante los dias 7-13 y 14-27, respectivamente. Conclusion Las muertes prenatales o en el primer dia de vida representan una gran proporcion de las defunciones perinatales y neonatales, lo que pone de manifiesto la necesidad urgente de mejorar la cobertura con parteras calificadas y de garantizar el acceso a la atencion obstetrica de urgencia. Tambien es necesario implementar intervenciones de salud que mejoren la atencion neonatal basica y el comportamiento de busqueda de atencion, en particular para los recien nacidos prematuros en el periodo posnatal temprano., Introduction Every year, there are an estimated 4 million neonatal deaths, accounting for almost 40% of deaths in children younger than 5 years. (l,2) About a quarter of global neonatal [...]

A randomized, double-blind, placebo-controlled trial was conducted to evaluate the effect of simultaneous vitamin A supplementation and diphtheria, pertussis and tetanus (DPT) vaccination on the antibody levels. Infants aged 6-17 wk (n = 56) were randomly given 15 mg oral vitamin A or placebo at the time of their DPT immunization. Three such doses were given at monthly intervals. Immunoglobulin (Ig) G antibodies to diphtheria, pertussis and tetanus were assayed on enrollment and 1 mo after the third dose. Baseline antibody concentrations to diphtheria, pertussis and tetanus did not differ between the vitamin A-supplemented and placebo-treated groups. The postdose antibody to diphtheria level was significantly greater in the vitamin A than in the placebo-treated group. The geometric mean +/- SEM antibody levels (mg/L) were 22.9 +/- 1.2 and 11.0 +/- 1.3 in the vitamin A and placebo groups, respectively (P = 0.029). The postsupplementation concentrations of antibodies to pertussis and tetanus did not differ between the two groups. These results suggest that antibody response to diphtheria vaccination was potentiated by simultaneous vitamin A administration and DPT immunization.

Brooks WA, Yunus M, Santosham M, et al. Lancet 2004;363:1683-1688. BACKGROUND: Pneumonia is a leading cause of morbidity and mortality in young children. Early reversal of severity signs--chest indrawing, hypoxia, [...]

BACKGROUND: To validate a clinical algorithm for community health workers (CHWs) during routine household surveillance for neonatal illness in rural Bangladesh. METHODS: Surveillance was conducted in the intervention arm of a trial of newborn interventions. CHWs assessed 7587 neonates on postnatal days 0, 2, 5 and 8 and identified neonates with very severe disease (VSD) using an 11-sign algorithm. A nested prospective study was conducted to validate the algorithm (n=395). Physicians evaluated neonates to determine whether newborns with VSD needed referral. The authors calculated algorithm sensitivity and specificity in identifying (1) neonates needing referral and (2) mortality during the first 10 days of life. RESULTS: The 11-sign algorithm had sensitivity of 50.0% (95% CI 24.7% to 75.3%) and specificity of 98.4% (96.6% to 99.4%) for identifying neonates needing referral-level care. A simplified 6-sign algorithm had sensitivity of 81.3% (54.4% to 96.0%) and specificity of 96.0% (93.6% to 97.8%) for identifying referral need and sensitivity of 58.0% (45.5% to 69.8%) and specificity of 93.2% (92.5% to 93.7%) for screening mortality. Compared to our 6-sign algorithm, the Young Infant Study 7-sign (YIS7) algorithm with minor modifications had similar sensitivity and specificity. CONCLUSION: Community-based surveillance for neonatal illness by CHWs using a simple 6-sign clinical algorithm is a promising strategy to effectively identify neonates at risk of mortality and needing referral to hospital. The YIS7 algorithm was also validated with high sensitivity and specificity at community level, and is recommended for routine household surveillance for newborn illness. ClinicalTrials.gov no. NCT00198627. [ABSTRACT FROM AUTHOR]

Objective: To describe the utilization and perceptions of existing neonatal health services in rural Uttar Pradesh, India.Design: A prospective observational study.Setting: The study was located in Shivgarh, a rural block of Uttar Pradesh, India.Participants: One hundred and fifty-three households that utilized a healthcare provider for their sick neonates.Interventions: None.Main Outcome Measure: Perceived neonatal health improvement after utilization of neonatal health services; satisfaction with aspects of neonatal health services: 'overall care', 'interaction with provider', 'waiting time' and 'explanations of immediate care and follow-up care'.Results: Unqualified allopathically oriented providers (UAOPs) were utilized by 110 households (71.8%), while qualified allopathically oriented providers (QAOPs) by 43 households (28.2%). The odds of perceived neonatal health improvement were significantly higher among households utilizing UAOPs (n = 88/110, 80.0%) than those using QAOPs (n = 23/43, 53.5%) [adjusted odds ratio (OR): 3.3, 95% confidence interval (CI): 1.5-7.5]. The median healthcare fee charged was higher for UAOPs (Rs. 25) than those for QAOPs (Rs. 1). Household satisfaction with 'overall care' of neonatal health service was significantly higher among households that utilized UAOPs compared with those that used QAOPs (OR: 2.4, 95% CI: 1.2-5.0).Conclusion: Households that utilized UAOPs reported better perceived neonatal health outcomes and higher satisfaction levels than those that used QAOPs, despite higher costs for the former. Future research should assess what dimensions of neonatal care are important to households and identify incentive structures that promote healthcare providers to deliver better perceived care in high-mortality settings such as rural Uttar Pradesh, India. [ABSTRACT FROM AUTHOR]

A household survey, conducted in three rural sub-districts of northeastern Bangladesh, revealed a markedly lower neonatal mortality rate (NMR) in one sub-district compared to two adjacent sub-districts. This study examines the degree to which the differential in NMR can be explained by factors that could be improved by maternal and newborn health programmes, such as knowledge of danger signs and use of antenatal, delivery, and postnatal care. Use of a skilled birth attendant in uncomplicated deliveries, mothers' knowledge of newborn complications, and use of health care for sick newborns accounted for 32% of the differential in NMR. Pregnancy and delivery complications were associated with increased risk of neonatal mortality, and distance to nearest emergency obstetric care facility was significantly associated with lower risk of neonatal mortality. Therefore, health programmes to improve mothers' knowledge of newborn complications, to increase access to emergency obstetric care, and to promote appropriate use of health care could significantly reduce neonatal mortality in impoverished communities. [ABSTRACT FROM AUTHOR]

Widespread use of 7-valent pneumococcal conjugate vaccine (PCV7) has led to significant reductions in disease while changing pneumococcal population dynamics via herd immunity and serotype replacement. We performed multilocus sequence typing (MLST) on 590 pneumococcal isolates obtained during the American Indian clinical trial of PCV7, in which communities were randomized for eligible children to receive either PCV7 or a meningococcal conjugate vaccine (MCV). Sequence types (STs) were analyzed to determine the impact of the vaccine on pneumococcal population structure and to assess the possible impact of pneumococcal genetic background on vaccine effects. One hundred forty-three STs were obtained, the most frequent being ST199, the only one that included vaccine serotypes (VTs), non-vaccine-associated nonvaccine serotypes (NVA/NVTs), and vaccine-associated serotypes (VATs). Serotype replacement observed in the PCV communities was due to a diverse population of STs, most of which also existed in the MCV communities. Possible capsular switching to create novel ST associations with NVA/NVTs was detected only once. Reductions in VTs and changes in VATs in PCV communities did not show evidence of variation by ST, after accounting for lower vaccine effectiveness against serotype 19F. These observations suggest the hypothesis that the vaccine acts as a "serotype filter": its effect on a particular strain can be predicted on the basis of the serotype of the strain, with little effect of genetic background (as assessed by MLST) over and above capsule. If sustained, such patterns provide some cause for optimism that rapid evolution of PCV escape strains with drug resistance or high virulence is unlikely. [ABSTRACT FROM AUTHOR]

When a sufficiently high proportion of a population is immunized with a vaccine, reduction in secondary transmission of disease can confer significant protection to unimmunized population members. We propose a straightforward method to estimate the degree of this indirect effect of vaccination in the context of a community-randomized vaccine trial. A conditional logistic regression model that accounts for within-randomization unit correlation over time is described, which models risk of disease as a function of community-level covariates. The approach is applied to an example data set from a pneumococcal conjugate vaccine study, with study arm and immunization levels forming the covariates of interest for the investigation of indirect effects. [ABSTRACT FROM AUTHOR]

BACKGROUND: Recent studies reported that zinc significantly reduced the duration and volume of acute watery diarrhea in children aged >/=4 mo, but there were no data specifically on infants aged <6 mo. OBJECTIVE: This study investigated the effect of zinc on the duration of illness and the stool quantity in acute watery diarrhea of infants aged 1-6 mo by comparing a 20 mg Zn/d dose with a 5 mg Zn/d dose. DESIGN: Infants hospitalized with at least some dehydration (by World Health Organization classification) were enrolled in a double-blind, randomized, placebo-controlled trial. Infants were randomly assigned to receive 20 mg Zn (acetate)/d, 5 mg Zn/d, or placebo for the duration of illness. RESULTS: Two hundred seventy-five infants were enrolled between 20 September 1998 and 18 December 2000. Neither diarrhea duration nor mean stool volume differed between groups. There were no significant differences in fluid intake, the need for unscheduled intravenous fluid, weight gain, or vomiting rates between the groups. CONCLUSIONS: Zinc supplementation did not affect diarrhea duration or stool volume in young infants. Young infants tolerated both zinc doses. A beneficial effect on subsequent illness cannot be ruled out. Copyright © 2005 American Society for Clinical Nutrition [ABSTRACT FROM AUTHOR]

Streptococcus pneumoniae is the most common cause of invasive bacterial disease among children worldwide. The authors aimed to determine the incidence, clinical characteristics, and serotype distribution of invasive pneumococcal disease (IPD) among Navajo children in the southwestern United States. Active population-based laboratory surveillance for IPD among resident members of the Navajo Nation under 18 years of age was conducted between 1989 and 1996. During this 8-year period, 706 cases of IPD were identified. The rate of disease varied by age, with the highest rate being observed among children aged 6-11 months (727 cases/100,000 person-years), followed by children aged 0-11 months, 0-23 months, and 0-59 months (568, 537, and 272 cases/100,000 person-years, respectively). Among children aged 0-23 months, 60.3% of cases were caused by serotypes in the seven-valent conjugate pneumococcal vaccine (71.5% from 1989-1993 and 58.3% from 1994-1996). Navajo children are at increased risk of IPD in comparison with the general US population. The distribution of disease-causing serotypes is similar to that of many countries in the developing world. Prevention strategies should include the use of licensed pneumococcal protein conjugate vaccine; however, a substantial proportion of disease is caused by nonvaccine serotypes. These data are critical for assessing the impact of these vaccines in this high-risk population. [ABSTRACT FROM AUTHOR]

Unlabelled: Topical therapy to enhance skin barrier function may be a simple, low-cost, effective strategy to improve outcome of preterm infants with a developmentally compromised epidermal barrier, as lipid constituents of topical products may act as a mechanical barrier and augment synthesis of barrier lipids. Natural oils are applied topically as part of a traditional oil massage to neonates in many developing countries. We sought to identify inexpensive, safe, vegetable oils available in developing countries that improved epidermal barrier function. The impact of oils on mouse epidermal barrier function (rate of transepidermal water loss over time following acute barrier disruption by tape-stripping) and ultrastructure was determined. A single application of sunflower seed oil significantly accelerated skin barrier recovery within 1 h; the effect was sustained 5 h after application. In contrast, the other vegetable oils tested (mustard, olive and soybean oils) all significantly delayed recovery of barrier function compared with control- or Aquaphor-treated skin. Twice-daily applications of mustard oil for 7 d resulted in sustained delay of barrier recovery. Moreover, adverse ultrastructural changes were seen under transmission electron microscopy in keratin intermediate filament, mitochondrial, nuclear, and nuclear envelope structure following a single application of mustard oil.Conclusion: Our data suggest that topical application of linoleate-enriched oil such as sunflower seed oil might enhance skin barrier function and improve outcome in neonates with compromised barrier function. Mustard oil, used routinely in newborn care throughout South Asia, has toxic effects on the epidermal barrier that warrant further investigation. [ABSTRACT FROM AUTHOR]

OBJECTIVES: This report describes the epidemiology of Haemophilus influenzae type b (Hib) invasive disease and oropharyngeal colonization among Navajo and White Mountain Apache children younger than 7 years in an era of widespread immunization. METHODS: We conducted active surveillance for invasive H influenzae disease from 1992 to 1999 and an oropharyngeal carriage study from 1997 to 1999. The predominant vaccine used was PedvaxHib. RESULTS: The average annual incidence of invasive Hib disease among children younger than 24 months was 22 cases per 100,000. Of 381 children younger than 7 years, only 1 (0.3%; 95% confidence interval = 0.0%, 1.3%) was colonized with Hib; 370 (97%) had received 2 or more doses of Hib conjugate vaccine. CONCLUSIONS: Among Navajo and White Mountain Apache children, Hib conjugate vaccines have led to a sustained reduction in invasive Hib disease and a reduction in oropharyngeal Hib carriage. The disease incidence among children younger than 24 months remains 20 times higher than in the general US population. Hib elimination will require additional characterization of colonization and disease in these high-risk populations. [ABSTRACT FROM AUTHOR]

Background: Oropharyngeal carriage studies of Haemophilus influenzae type b (Hib) and the rapid drop in Hib invasive disease in countries with widespread Hib conjugate vaccine immunization programmes for infants have indicated there may be significant indirect effects (herd immunity) associated with these vaccines. Our goal was to quantify the magnitude of these effects in an American Indian population during its early years of Hib immunization.Methods: In a synthetic case-cohort study, we combined data from an efficacy trial, an immunization uptake records survey, and ongoing surveillance for Hib disease on the Navajo Nation from 1988 to 1992. Decline in the incidence of invasive Hib disease among children <2 years old was estimated via proportional hazards survival models as a function of individual immunization status and the proportion of immunized children in a community.Results: The predominant vaccine during the study period was Hib-OMPC (92% of immunizations). The effectiveness of receipt of at least one dose was 97.2%. Compared to communities with 0-20% coverage with at least one dose, residence in communities with 20-40% and 40-60% coverage was associated with risk reductions of 56.5% and 73.2%, respectively.Conclusions: The results indicate substantial indirect effects of Hib-OMPC immunization may occur even at relatively low levels of immunization coverage. Countries that implement Hib immunization programmes may receive greater benefits at the community level than those due to the direct protection conferred to the individual through vaccination. [ABSTRACT FROM AUTHOR]

Apache Indian infants have a high frequency of `Haemophilus influenzae' type B (Hib) and pneumococcal infections, and forty percent of Hib infections in these infants occur before the age of six months, when active immunization may not be protective. After testing to evaluate the efficacy of passive immunization with a human hyperimmune globulin, it was concluded that BPIG given at four-month intervals provided significant protection.

Describes a double-blind, placebo-controlled trial among Navajo infants to evaluate the efficacy of the `Haemophilus influenzae' type b polysaccharide and `Neisseria meningitides' outer-membrane protein complex vaccine. Background and methods; Results; Conclusions.

Describes a study that examined the impaired antibody response to `Haemophilus influenzae' type b polysaccharide and low IgG2 and IgG4 concentrations in Apache children. Background and methods; Results; Conclusions.