Summary Background WHO estimates exposure to air pollution from cooking with solid fuels is associated with over 4 million premature deaths worldwide every year including half a million children ...under the age of 5 years from pneumonia. We hypothesised that replacing open fires with cleaner burning biomass-fuelled cookstoves would reduce pneumonia incidence in young children. Methods We did a community-level open cluster randomised controlled trial to compare the effects of a cleaner burning biomass-fuelled cookstove intervention to continuation of open fire cooking on pneumonia in children living in two rural districts, Chikhwawa and Karonga, of Malawi. Clusters were randomly allocated to intervention and control groups using a computer-generated randomisation schedule with stratification by site, distance from health centre, and size of cluster. Within clusters, households with a child under the age of 4·5 years were eligible. Intervention households received two biomass-fuelled cookstoves and a solar panel. The primary outcome was WHO Integrated Management of Childhood Illness (IMCI)-defined pneumonia episodes in children under 5 years of age. Efficacy and safety analyses were by intention to treat. The trial is registered with ISRCTN, number ISRCTN59448623. Findings We enrolled 10 750 children from 8626 households across 150 clusters between Dec 9, 2013, and Feb 28, 2016. 10 543 children from 8470 households contributed 15 991 child-years of follow-up data to the intention-to-treat analysis. The IMCI pneumonia incidence rate in the intervention group was 15·76 (95% CI 14·89–16·63) per 100 child-years and in the control group 15·58 (95% CI 14·72–16·45) per 100 child-years, with an intervention versus control incidence rate ratio (IRR) of 1·01 (95% CI 0·91–1·13; p=0·80). Cooking-related serious adverse events (burns) were seen in 19 children; nine in the intervention and ten (one death) in the control group (IRR 0·91 95% CI 0·37–2·23; p=0·83). Interpretation We found no evidence that an intervention comprising cleaner burning biomass-fuelled cookstoves reduced the risk of pneumonia in young children in rural Malawi. Effective strategies to reduce the adverse health effects of household air pollution are needed. Funding Medical Research Council, UK Department for International Development, and Wellcome Trust.
To estimate the prevalence of World Health Organization-defined chronic suppurative otitis media (CSOM) and mild hearing impairment in a population representative sample of school-entry age children ...in rural Malawi. A secondary objective was to explore factors associated with CSOM in this population.
We performed a community-based cross-sectional study of children aged 4-6 years in Chikhwawa District, Southern Malawi, utilising a village-level cluster design. Participants underwent a structured clinical assessment, including video-otoscopy and screening audiometry. Diagnoses were made remotely by two otolaryngologists who independently reviewed clinical data and images collected in the field. Hearing impairment was classified as failure to hear a pure tone of 25dB or greater at 1, 2 or 4kHz.
We recruited 281 children across 10 clusters. The prevalence estimates of CSOM, unilateral hearing impairment and bilateral hearing impairment were 5.4% (95%CI 2.2-8.6), 24.5% (95%CI 16.3-30.0), and 12.5% (95%CI 6.2-16.9) respectively. Middle ear disease was seen in 46.9% of children with hearing impairment. A trend towards increased risk of CSOM was observed with sleeping in a house with >2 other children.
We found a high burden of middle ear disease and preventable hearing impairment in our sample of school-entry age children in rural Malawi. There are important public health implications of these findings as CSOM and hearing impairment can affect educational outcomes, and may impact subsequent development. The identification and management of middle ear disease and hearing impairment represent major unmet needs in this population.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
IMPORTANCE: Pneumonia is the leading infectious killer of children. Rigorous evidence supporting antibiotic treatment of children with nonsevere fast-breathing pneumonia in low-resource African ...settings is lacking. OBJECTIVE: To assess whether treatment with placebo for nonsevere fast-breathing pneumonia is substantively less effective than 3 days of treatment with amoxicillin. DESIGN, SETTING, AND PARTICIPANTS: This double-blind, 2-arm, randomized clinical noninferiority trial with follow-up of 14 days screened 1343 HIV-uninfected children aged 2 to 59 months with nonsevere fast-breathing pneumonia at outpatient departments of hospitals in Lilongwe, Malawi, Africa, between June 2016 and June 2017. INTERVENTIONS: Placebo or amoxicillin dispersible tablets administered twice daily for 3 days. MAIN OUTCOMES AND MEASURES: The primary end point was the proportion of children failing treatment by day 4 with a relative noninferiority margin of 1.5 times the failure rate in the amoxicillin group. Primary analyses were performed based on the intention-to-treat principle. Planned secondary analyses included treatment failure or relapse by day 14. RESULTS: In total, 1126 children were randomized to 3 days of amoxicillin (n = 564) or placebo (n = 562) therapy. Baseline demographic and clinical characteristics were similar between the groups. For the entire study population, the mean (SD) age was 21.3 (15.1) months, and 601 (53.4%) were female. After an interim analysis, the data safety monitoring board stopped the study because children receiving amoxicillin had a 4.0% (22 of 552 with outcome data) treatment failure rate by day 4, whereas children receiving placebo had a 7.0% (38 of 543) treatment failure rate (adjusted relative risk, 1.78; 95% CI, 1.07%-2.97%; adjusted absolute difference, 3.0%; 95% CI, 0.4%-5.7%). Among children with known day 14 outcomes, 56 of 552 (10.1%) receiving amoxicillin and 64 of 543 (11.8%) receiving placebo had either treatment failure by day 4 or relapse by day 14 (relative risk, 1.16; 95% CI, 0.83%-1.63%; absolute difference, 1.6%; 95% CI, −2.1% to 5.4%). There were no deaths. CONCLUSIONS AND RELEVANCE: In HIV-uninfected children aged 2 to 59 months in a malaria-endemic region of Malawi, placebo treatment of nonsevere fast-breathing pneumonia was significantly inferior to treatment with amoxicillin. However, by day 4, approximately 93% of children receiving placebo were without treatment failure, and there was no significant difference between groups in treatment failure or relapse by day 14. The number of children with nonsevere fast-breathing pneumonia that needed amoxicillin treatment for 1 child to benefit was 33. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02760420
Children in Malawi with chest-indrawing pneumonia were randomly assigned to a 3-day or a 5-day regimen of amoxicillin. The 3-day regimen was noninferior to the 5-day regimen with respect to the ...incidence of treatment failure (5.9% vs. 5.2%). The frequency of adverse events was similar in the two groups.
We used national facility-level data from all government hospitals in Malawi to examine the effects of the second and third COVID-19 waves on maternal and neonatal outcomes and access to care during ...September 6, 2020–October 31, 2021. The COVID-19 pandemic affected maternal and neonatal health not only through direct infections but also through disruption of the health system, which could have wider indirect effects on critical maternal and neonatal outcomes. In an interrupted time series analysis, we noted a cumulative 15.4% relative increase (63 more deaths) in maternal deaths than anticipated across the 2 COVID-19 waves. We observed a 41% decrease in postnatal care visits at the onset of the second COVID-19 wave and 0.2% by the third wave, cumulative to 36,809 fewer visits than anticipated. Our findings demonstrate the need for strengthening health systems, particularly in resource-constrained settings, to prepare for future pandemic threats.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, ODKLJ, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
IntroductionAir pollution through cooking on open fires or inefficient cookstoves using biomass fuels has been linked with impaired lung health and with over 4 million premature deaths per annum. ...However, use of cleaner cookstoves is often sporadic and there are indications that longer-term health benefits are not prioritised by users. There is also limited information about how recipients of cookstoves perceive the health benefits of clean cooking interventions. We therefore conducted a qualitative study alongside the Cooking and Pneumonia Study (CAPS).MethodsQualitative methods and the participatory methodology Photovoice were used in an in-depth examination of health perceptions and understandings of CAPS trial participants. Fifty participants in five CAPS intervention villages collected images about cooking. These were discussed in village-level focus groups and in interviews with 12 representative participants. Village community representatives were also interviewed. Four female and eight male CAPS fieldworkers took part in gender-specific focus groups and two female and two male fieldworkers were interviewed. A thematic content approach was used for data analysis.ResultsWe found a disconnect between locally situated perceptions of health and the biomedically focused trial model. This included the development of potentially harmful understandings such as that pneumonia was no longer a threat and potential confusion between the symptoms of pneumonia and malaria. Study participants perceived health and well-being benefits including: cookstoves saved bodily energy; quick cooking helped maintain family harmony.ConclusionA deeper understanding of narratives of health within CAPS showed how context-specific perceptions of the health benefits of cookstoves were developed. This highlighted the conflicting priorities of cookstove intervention researchers and participants, and unintended and potentially harmful health understandings. The study also emphasises the importance of including qualitative explorations in similar complex interventions where potential pathways to beneficial (and harmful) effects, cannot be completely explicated through biomedical models alone.
As part of a randomised controlled trial of treatment with placebo
3 days of amoxicillin for nonsevere fast-breathing pneumonia among Malawian children aged 2-59 months, a subset of children was ...hospitalised for observation. We sought to characterise the progression of fast-breathing pneumonia among children undergoing repeat assessments to better understand which children do and do not deteriorate.
Vital signs and physical examination findings, including respiratory rate, arterial oxygen saturation measured by pulse oximetry (
), chest indrawing and temperature were assessed every 3 h for the duration of hospitalisation. Children were assessed for treatment failure during study visits on days 1, 2, 3 and 4.
Hospital monitoring data from 436 children were included. While no children had
90-93% at baseline, 7.4% (16 of 215) of children receiving amoxicillin and 9.5% (21 of 221) receiving placebo developed
90-93% during monitoring. Similarly, no children had chest indrawing at enrolment, but 6.6% (14 of 215) in the amoxicillin group and 7.2% (16 of 221) in the placebo group went on to develop chest indrawing during hospitalisation.
Repeat monitoring of children with fast-breathing pneumonia identified vital and physical examination signs not present at baseline, including
90-93% and chest indrawing. This information may support providers and policymakers in developing guidance for care of children with nonsevere pneumonia.
Exposure to particulate matter (PM) from burning of biomass for cooking is associated with adverse health effects. It is unknown whether or not cleaner burning biomass-fuelled cookstoves reduce the ...amount of PM inhaled by women compared with traditional open fires.
We sought to assess whether airway macrophage black carbon (AMBC) - a marker of inhaled dose of carbonaceous PM from biomass and fossil fuel combustion - is lower in Malawian women using a cleaner burning biomass-fuelled cookstove compared with those using open fires for cooking. AMBC was assessed in induced sputum samples using image analysis and personal exposure to carbon monoxide (CO) and PM were measured using Aprovecho Indoor Air Pollution meters. A fossil-fuel exposed group of UK women was also studied.
Induced sputum samples were obtained from 57 women from which AMBC was determined in 31. Median AMBC was 6.87μm2 (IQR 4.47–18.5) and 4.37μm2 (IQR 2.57–7.38) in the open fire (n=11) and cleaner burning cookstove groups (n=20), respectively (p=0.028). There was no difference in personal exposure to CO and PM between the two groups. UK women (n=5) had lower AMBC (median 0.89μm2, IQR 0.56–1.13) compared with both Malawi women using traditional cookstoves (p<0.001) and those using cleaner cookstoves (p=0.022).
We conclude that use of a cleaner burning biomass-fuelled cookstove reduces inhaled PM dose in a way that is not necessarily reflected by personal exposure monitoring.
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•Sputum induction to assess airway macrophage black carbon is feasible in the field.•Airway macrophage black carbon represents a way to assess internal dose of particulate matter exposure.•Cleaner burning biomass-fuelled cookstoves reduce inhaled PM dose.
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