Trauma-Related Mortality among Adults in Rural Western Kenya: Characterising Deaths Using Data from a Health and Demographic Surveillance System

Background

Information on trauma-related deaths in low and middle income countries is limited but needed to target public health interventions. Data from a health and demographic surveillance system (HDSS) were examined to characterise such deaths in rural western Kenya.

Methods And Findings

Verbal autopsy data were analysed. Of 11,147 adult deaths between 2003 and 2008, 447 (4%) were attributed to trauma; 71% of these were in males. Trauma contributed 17% of all deaths in males 15 to 24 years; on a population basis mortality rates were greatest in persons over 65 years. Intentional causes accounted for a higher proportion of male than female deaths (RR 2.04, 1.37-3.04) and a higher proportion of deaths of those aged 15 to 65 than older people. Main causes in males were assaults (n=79, 25%) and road traffic injuries (n=47, 15%); and falls for females (n=17, 13%). A significantly greater proportion of deaths from poisoning (RR 5.0, 2.7-9.4) and assault (RR 1.8, 1.2-2.6) occurred among regular consumers of alcohol than among non-regular drinkers. In multivariate analysis, males had a 4-fold higher risk of death from trauma than females (Adjusted Relative Risk; ARR 4.0; 95% CI 1.7-9.4); risk of a trauma death rose with age, with the elderly at 7-fold higher risk (ARR 7.3, 1.1-49.2). Absence of care was the strongest predictor of trauma death (ARR 12.2, 9.4-15.8). Trauma-related deaths were higher among regular alcohol drinkers (ARR 1.5, 1.1-1.9) compared with non-regular drinkers.

Conclusions

While trauma accounts for a small proportion of deaths in this rural area with a high prevalence of HIV, TB and malaria, preventive interventions such as improved road safety, home safety strategies for the elderly, and curbing harmful use of alcohol, are available and could help diminish this burden. Improvements in systems to record underlying causes of death from trauma are required.     

Mortality Trends from 2003 to 2009 among Adolescents and Young Adults in Rural Western Kenya Using a Health and Demographic Surveillance System

Background

Targeted global efforts to improve survival of young adults need information on mortality trends; contributions from health and demographic surveillance system (HDSS) are required.

Methods and Findings

This study aimed to explore changing trends in deaths among adolescents (15–19 years) and young adults (20–24 years), using census and verbal autopsy data in rural western Kenya using a HDSS. Mid-year population estimates were used to generate all-cause mortality rates per 100,000 population by age and gender, by communicable (CD) and non-communicable disease (NCD) causes. Linear trends from 2003 to 2009 were examined. In 2003, all-cause mortality rates of adolescents and young adults were 403 and 1,613 per 100,000 population, respectively, among females; and 217 and 716 per 100,000, respectively, among males. CD mortality rates among females and males 15–24 years were 500 and 191 per 100,000 (relative risk [RR] 2.6; 95% confidence intervals [CI] 1.7–4.0; p<0.001). NCD mortality rates in same aged females and males were similar (141 and 128 per 100,000, respectively; p = 0.76). By 2009, young adult female all-cause mortality rates fell 53% (χ² for linear trend 30.4; p<0.001) and 61.5% among adolescent females (χ² for linear trend 11.9; p<0.001). No significant CD mortality reductions occurred among males or for NCD mortality in either gender. By 2009, all-cause, CD, and NCD mortality rates were not significantly different between males and females, and among males, injuries equalled HIV as the top cause of death.

Conclusions

This study found significant reductions in adolescent and young adult female mortality rates, evidencing the effects of targeted public health programmes, however, all-cause and CD mortality rates among females remain alarmingly high. These data underscore the need to strengthen programmes and target strategies to reach both males and females, and to promote NCD as well as CD initiatives to reduce the mortality burden amongst both gender.     

Causes of Death among Adults in Northern Ethiopia: Evidence from Verbal Autopsy Data in Health and Demographic Surveillance System

Background

In countries where registration of vital events is lacking and the proportion of people who die at home without medical care is high, verbal autopsy is used to determine and estimate causes of death.

Methods

We conducted 723 verbal autopsy interviews of adult (15 years of age and above) deaths from September 2009 to January 2013. Trained physicians interpreted the collected verbal autopsy data, and assigned causes of death according to the international classification of diseases (ICD-10). We did analysis of specific as well as broad causes of death (i.e. non-communicable diseases, communicable diseases and external causes of death) by sex and age using Stata version 11.1. We performed logistic regression to identify socio-demographic predictors using odds ratio with 95% confidence interval and a p-value of 0.05.

Findings

Tuberculosis, cerebrovascular diseases and accidental falls were leading specific causes of death accounting for 15.9%, 7.3% and 3.9% of all deaths. Two hundred sixty three (36.4% [95% CI: 32.9, 39.9]), 252 (34.9% [95% CI: 31.4, 38.4]) and 89 (12.3% [95% CI: 10.1, 14.9]) deaths were due to non-communicable, communicable diseases, and external causes, respectively. Females had 1.5 times (AOR = 1.53 [95% CI: 1.10, 2.15]) higher odds of dying due to communicable diseases than males. The odds of dying due to external causes were 4 times higher among 15–49 years of age (AOR = 4.02 [95% CI: 2.25, 7.18]) compared to older ages. Males also had 1.7 times (AOR = 1.70 [95% CI: 1.01, 2.85]) higher odds of dying due to external causes than females.

Conclusion

Tuberculosis, cerebrovascular diseases and accidental falls were the top three causes of death among adults. Efforts to prevent tuberculosis and cerebrovascular diseases related deaths should be improved and safety efforts to reduce accidents should also receive attention.     

Remotely Sensed Environmental Conditions and Malaria Mortality in Three Malaria Endemic Regions in Western Kenya

BackgroundMalaria is an important cause of morbidity and mortality in malaria endemic countries. The malaria mosquito vectors depend on environmental conditions, such as temperature and rainfall, for reproduction and survival. To investigate the potential for weather driven early warning systems to prevent disease occurrence, the disease relationship to weather conditions need to be carefully investigated. Where meteorological observations are scarce, satellite derived products provide new opportunities to study the disease patterns depending on remotely sensed variables. In this study, we explored the lagged association of Normalized Difference Vegetation Index (NVDI), day Land Surface Temperature (LST) and precipitation on malaria mortality in three areas in Western Kenya.ConclusionThis study identified lag patterns and association of remote- sensing environmental factors and malaria mortality in three malaria endemic regions in Western Kenya. Our results show that rainfall has the most consistent predictive pattern to malaria transmission in the endemic study area. Results highlight a potential for development of locally based early warning forecasts that could potentially reduce the disease burden by enabling timely control actions.     

Association between Maternal and Child Dietary Diversity: An Analysis of the Ghana Demographic and Health Survey

Objective (s)

This study examined the association between maternal and child dietary diversity in a population-based national sample in Ghana.

Methods

The data for this analysis are from the 2008 Ghana Demographic and Health Survey. We used data obtained from 1187 dyads comprised of mothers’ ages 15–49 and their youngest child (ages 6–36 months). Maternal and child dietary diversity scores (DDS) were created based on the mother’s recall of her own and her child’s consumption of 15 food groups, during the 24 hours prior to the in-home survey. The same food groups were used to compose both maternal and child DDS. Linear regression was used to assess the relationship between the predicted outcome – child DDS -- and maternal DDS, taking into account child age and sex, maternal factors (age, education, occupation, literacy, empowerment, number of antenatal visits as an indicator of health care use), household Wealth Index, and urban/rural place of residence.

Results

There was a statistically significant positive association between child and maternal DDS, after adjusting for all other variables. A difference of one food group in mother’s consumption was associated with a difference of 0.72 food groups in the child’s food consumption (95% CI: 0.63, 0.82). Also, statistically significant positive associations were observed such that higher child DDS was associated with older child age, and with greater women’s empowerment.

Conclusions

The results show a significant positive association between child and maternal DD, after accounting for the influence of child, maternal and household level factors. Since the likely path of influence is that maternal DDS impacts child DDS, public health efforts to improve child health may be strengthened by promoting maternal DDS due to its potential for a widened effect on the entire family.     

Development of an Intelligent Mobile Health Monitoring System for the Health Surveillance System in Indonesia

Mobile phone applications have been widely used in various fields, including health care. Generally, this technology is used to overcome problems in health care by utilising mobile phone features for facilitating basic needs in health services. This study proposes an intelligent mobile health monitoring system that can be used in rural and remote areas where health services are still lacking. The system was made based on client/server architecture. Nine symptoms of typhoid, cough and diarrhoea from 30 patients were gathered from a hospital. Based on this data, a machine learning model using Support Vector Machine (SVM) was performed to distinguish these diseases. To find the best model parameters of the SVM, three different kernels (linear, polynomial, and Radial Basis Function (RBF)) were analysed. The result showed that RBF with degree 2 provided the best result in this particular application. The system was designed to receive input from patients about symptoms of the disease they have. The mobile phone application sends the data of the symptoms using Short Message Service (SMS) to the server. Furthermore, a machine algorithm module in the server identifies to which disease it belongs to based on the machine learning model created before. The prediction result is accessible to the doctor and the nearest Community Health Center (CHC). Based on the result, the doctor proposes a treatment plan for the patient to be recorded and sent to the patient by CHC. The proposed mobile health monitoring system has run properly and is ready to be evaluated in a real situation.     

Time Trends and Inequalities of Under-Five Mortality in Nepal: A Secondary Data Analysis of Four Demographic and Health Surveys between 1996 and 2011

Background

Inequalities in progress towards achievement of Millennium Development Goal four (MDG-4) reflect unequal access to child health services.

Objective

To examine the time trends, socio-economic and regional inequalities of under-five mortality rate (U5MR) in Nepal.

Methods

We analyzed the data from complete birth histories of four Nepal Demographic and Health Surveys (NDHS) done in the years 1996, 2001, 2006 and 2011. For each livebirth, we computed survival period from birth until either fifth birthday or the survey date. Using direct methods i.e. by constructing life tables, we calculated yearly U5MRs from 1991 to 2010. Projections were made for the years 2011 to 2015. For each NDHS, U5MRs were calculated according to child''s sex, mother’s education, household wealth index, rural/urban residence, development regions and ecological zones. Inequalities were calculated as rate difference, rate ratio, population attributable risk and hazard ratio.

Results

Yearly U5MR (per 1000 live births) had decreased from 157.3 (95% CIs 178.0-138.9) in 1991 to 43.2 (95% CIs 59.1-31.5) in 2010 i.e. 114.1 reduction in absolute risk. Projected U5MR for the year 2015 was 54.33. U5MRs had decreased in absolute terms in all sub groups but relative inequalities had reduced for gender and rural/urban residence only. Wide inequalities existed by wealth and education and increased between 1996 and 2011. For lowest wealth quintile (as compared to highest quintile) hazard ratio (HR) increased from 1.37 (95% CIs 1.27, 1.49) to 2.54 ( 95% CIs 2.25, 2.86) and for mothers having no education (as compared to higher education) HR increased from 2.55 (95% CIs 1.95, 3.33) to 3.75 (95% CIs 3.17, 4.44). Changes in regional inequities were marginal and irregular.

Conclusions

Nepal is most likely to achieve MDG-4 but eductional and wealth inequalities may widen further. National health policies should address to reduce inequalities in U5MR through ‘inclusive policies''.     

Analysis of Binary Multivariate Longitudinal Data via 2-Dimensional Orbits: An Application to the Agincourt Health and Socio-Demographic Surveillance System in South Africa

We analyse demographic longitudinal survey data of South African (SA) and Mozambican (MOZ) rural households from the Agincourt Health and Socio-Demographic Surveillance System in South Africa. In particular, we determine whether absolute poverty status (APS) is associated with selected household variables pertaining to socio-economic determination, namely household head age, household size, cumulative death, adults to minor ratio, and influx. For comparative purposes, households are classified according to household head nationality (SA or MOZ) and APS (rich or poor). The longitudinal data of each of the four subpopulations (SA rich, SA poor, MOZ rich, and MOZ poor) is a five-dimensional space defined by binary variables (questions), subjects, and time. We use the orbit method to represent binary multivariate longitudinal data (BMLD) of each household as a two-dimensional orbit and to visualise dynamics and behaviour of the population. At each time step, a point (x, y) from the orbit of a household corresponds to the observation of the household, where x is a binary sequence of responses and y is an ordering of variables. The ordering of variables is dynamically rearranged such that clusters and holes associated to least and frequently changing variables in the state space respectively, are exposed. Analysis of orbits reveals information of change at both individual- and population-level, change patterns in the data, capacity of states in the state space, and density of state transitions in the orbits. Analysis of household orbits of the four subpopulations show association between (i) households headed by older adults and rich households, (ii) large household size and poor households, and (iii) households with more minors than adults and poor households. Our results are compared to other methods of BMLD analysis.     

Demographic status of elephants in the Samburu and Buffalo Springs National Reserves, Kenya

Individual based demographic records of the elephants utilizing Samburu and Buffalo Springs National Reserves were collected from 1998 through 2003 and indicate that this elephant population was increasing at an average rate of 4.6% per year. Although the majority of carcasses were not found, known sources of mortality include disease, injury, and predation by lions and humans. Poaching did occur during the study period, however the population is increasing and thus our findings indicate ivory poaching has limited impact on the demographic status of these elephants. This population is part of the Samburu/Laikipia MIKE Site and thus its status is relevant to CITES ligislation.     

Using Health Surveillance Systems Data to Assess the Impact of AIDS and Antiretroviral Treatment on Adult Morbidity and Mortality in Botswana

Introduction

Botswana''s AIDS response included free antiretroviral treatment (ART) since 2002, achieving 80% coverage of persons with CD4<350 cells/µl by 2009–10. We explored impact on mortality and HIV prevalence, analyzing surveillance and civil registration data.

Methods

Hospital natural cause admissions and deaths from the Health Statistics Unit (HSU) over 1990–2009, all-cause deaths from Midnight Bed Census (MNC) over 1990–2011, institutional and non-institutional deaths recorded in the Registry of Birth and Deaths (RBD) over 2003–2010, and antenatal sentinel surveillance (ANC) over 1992–2011 were compared to numbers of persons receiving ART. Mortality was adjusted for differential coverage and completeness of institutional and non-institutional deaths, and compared to WHO and UNAIDS Spectrum projections.

Results

HSU deaths per 1000 admissions declined 49% in adults 15–64 years over 2003–2009. RBD mortality declined 44% (807 to 452/100,000 population in adults 15–64 years) over 2003–2010, similarly in males and females. Generally, death rates were higher in males; declines were greater and earlier in younger adults, and in females. In contrast, death rates in adults 65+, particularly females increased over 2003–2006. MNC all-age post-neonatal mortality declined 46% and 63% in primary and secondary level hospitals, over 2003–2011. We estimated RBD captured 80% of adult deaths over 2006–2011. Comparing empirical, completeness-adjusted deaths to Spectrum estimates, declines over 2003–2009 were similar overall (47% vs. 54%); however, Spectrum projected larger and earlier declines particularly in women. Following stabilization and modest decreases over 1998–2002, HIV prevalence in pregnant women 15–24 and 25–29-years declined by >50% and >30% through 2011, while continuing to increase in older women.

Conclusions

Adult mortality in Botswana fell markedly as ART coverage increased. HIV prevalence declines may reflect ART-associated reductions in sexual transmission. Triangulation of surveillance system data offers a reasonable approach to evaluate impact of HIV/AIDS interventions, complementing cohort approaches that monitor individual-level health outcomes.     

The Prevalence and Determinants of Chronic Non-Communicable Disease Risk Factors amongst Adults in the Dikgale Health Demographic and Surveillance System (HDSS) Site,Limpopo Province of South Africa

Background

The aim of the study was to determine the prevalence and determinants of chronic non-communicable disease (NCD) risk factors in a rural community in the Limpopo Province of South Africa.

Methods

This survey was conducted using the WHO "STEPwise approach to the surveillance of non-communicable diseases" (STEPS) methodology. Participants were residents of the Dikgale HDSS site and standardised international protocols were used to measure behavioural risk factors (smoking, alcohol consumption, fruit and vegetable intake and, physical activity) and physical characteristics (weight, height, waist and hip circumferences and blood pressure–BP). Fasting blood glucose, triglyceride, cholesterol and HDL-C were determined in 732 participants. Data were analysed using STATA 12 for Windows.

Results

The prevalence of current smokers amongst the participants was 13.7%, of which 81.3% were daily smokers. Alcohol was consumed by 16.3% of the participants. The majority of participants (88.6%) had low daily intake of fruit and vegetables and low physical activity (66.5%). The prevalence of hypertension amongst the participants was 38.2%. Overweight, obesity and high waist circumference were prevalent in females. The cardio-metabolic risk profile was not significantly different between men and women. People who were older than 40 years, overweight or obese and those who consumed alcohol were more likely to be hypertensive. Smoking was associated significantly with older age, males, never married and divorced people. Alcohol consumption was associated with older age, males, low educational status and low income.

Conclusion

High levels of risk factors for NCDs among adults in the Dikgale HDSS suggest an urgent need for health interventions to control these risk factors at the population level in order to reduce the prevalence of NCDs.     

Postmortem investigations and identification of multiple causes of child deaths: An analysis of findings from the Child Health and Mortality Prevention Surveillance (CHAMPS) network

BackgroundThe current burden of >5 million deaths yearly is the focus of the Sustainable Development Goal (SDG) to end preventable deaths of newborns and children under 5 years old by 2030. To accelerate progression toward this goal, data are needed that accurately quantify the leading causes of death, so that interventions can target the common causes. By adding postmortem pathology and microbiology studies to other available data, the Child Health and Mortality Prevention Surveillance (CHAMPS) network provides comprehensive evaluations of conditions leading to death, in contrast to standard methods that rely on data from medical records and verbal autopsy and report only a single underlying condition. We analyzed CHAMPS data to characterize the value of considering multiple causes of death.Methods and findingsWe examined deaths identified from December 2016 through November 2020 from 7 CHAMPS sites (in Bangladesh, Ethiopia, Kenya, Mali, Mozambique, Sierra Leone, and South Africa), including 741 neonatal, 278 infant, and 241 child <5 years deaths for which results from Determination of Cause of Death (DeCoDe) panels were complete. DeCoDe panelists included all conditions in the causal chain according to the ICD-10 guidelines and assessed if prevention or effective management of the condition would have prevented the death. We analyzed the distribution of all conditions listed as causal, including underlying, antecedent, and immediate causes of death. Among 1,232 deaths with an underlying condition determined, we found a range of 0 to 6 (mean 1.5, IQR 0 to 2) additional conditions in the causal chain leading to death. While pathology provides very helpful clues, we cannot always be certain that conditions identified led to death or occurred in an agonal stage of death. For neonates, preterm birth complications (most commonly respiratory distress syndrome) were the most common underlying condition (n = 282, 38%); among those with preterm birth complications, 256 (91%) had additional conditions in causal chains, including 184 (65%) with a different preterm birth complication, 128 (45%) with neonatal sepsis, 69 (24%) with lower respiratory infection (LRI), 60 (21%) with meningitis, and 25 (9%) with perinatal asphyxia/hypoxia. Of the 278 infant deaths, 212 (79%) had ≥1 additional cause of death (CoD) beyond the underlying cause. The 2 most common underlying conditions in infants were malnutrition and congenital birth defects; LRI and sepsis were the most common additional conditions in causal chains, each accounting for approximately half of deaths with either underlying condition. Of the 241 child deaths, 178 (75%) had ≥1 additional condition. Among 46 child deaths with malnutrition as the underlying condition, all had ≥1 other condition in the causal chain, most commonly sepsis, followed by LRI, malaria, and diarrheal disease. Including all positions in the causal chain for neonatal deaths resulted in 19-fold and 11-fold increases in attributable roles for meningitis and LRI, respectively. For infant deaths, the proportion caused by meningitis and sepsis increased by 16-fold and 11-fold, respectively; for child deaths, sepsis and LRI are increased 12-fold and 10-fold, respectively. While comprehensive CoD determinations were done for a substantial number of deaths, there is potential for bias regarding which deaths in surveillance areas underwent minimally invasive tissue sampling (MITS), potentially reducing representativeness of findings.ConclusionsIncluding conditions that appear anywhere in the causal chain, rather than considering underlying condition alone, markedly changed the proportion of deaths attributed to various diagnoses, especially LRI, sepsis, and meningitis. While CHAMPS methods cannot determine when 2 conditions cause death independently or may be synergistic, our findings suggest that considering the chain of events leading to death can better guide research and prevention priorities aimed at reducing child deaths.

In an analysis of data from the Child Health and Mortality Prevention Surveillance (CHAMPS) network, Robert Breiman, Dianna Blau, and colleagues investigate how considering all conditions in the causal chain leading to death informs the identification of deaths attributable to various diagnoses.     

Demographic Consequences of Poison-Related Mortality in a Threatened Bird of Prey

Evidence for decline or threat of wild populations typically comes from multiple sources and methods that allow optimal integration of the available information, representing a major advance in planning management actions. We used integrated population modelling and perturbation analyses to assess the demographic consequences of the illegal use of poison for an insular population of Red Kites, Milvus milvus. We first pooled into a single statistical framework the annual census of breeding pairs, the available individual-based data, the average productivity and the number of birds admitted annually to the local rehabilitation centre. By combining these four types of information we were able to increase estimate precision and to obtain an estimate of the proportion of breeding adults, an important parameter that was not directly measured in the field and that is often difficult to assess. Subsequently, we used perturbation analyses to measure the expected change in the population growth rate due to a change in poison-related mortality. We found that poison accounted for 0.43 to 0.76 of the total mortality, for yearlings and older birds, respectively. Results from the deterministic population model indicated that this mortality suppressed the population growth rate by 20%. Despite this, the population was estimated to increase, albeit slowly. This positive trend was likely maintained by a very high productivity (1.83 fledglings per breeding pair) possibly promoted by supplementary feeding, a situation which is likely to be common to many large obligate or facultative European scavengers. Under this hypothetical scenario of double societal costs (poisoning of a threatened species and feeding programs), increasing poison control would help to lower the public cost of maintaining supplementary feeding stations.     

The Neighbourhood Method for Measuring Differences in Maternal Mortality,Infant Mortality and Other Rare Demographic Events

In the absence of reliable systems for registering rare types of vital events large surveys are required to measure changes in their rates. However some events such as maternal deaths are widely known about in the community. This study examined the utility of asking respondents about events in their neighbourhood as an efficient method for measuring relative rates of rare health events such as maternal and infant deaths. A survey was conducted in the health and demographic surveillance system (HDSS) in Matlab, Bangladesh, which includes two areas with different health care regimes. Adult women were asked about any maternal deaths; multiple births; infant deaths, live births and some other events they knew of in a small specified area around their home. Agreement between HDSS records and survey responses was moderate or better (kappa≥0.44) for all the events and greatest for maternal deaths (kappa = 0.77) with 84% being reported. Most events were more likely to be reported if they were recent (p<0.05). Infant mortality rate in one area was 0.56 times that in the other which was well reflected by the ratio of survey results (0.53). Simulations were used to study the ability of the method to detect differences in maternal mortality ratio. These suggested that a sample size around 5000 would give 80% power to detect a 50% decrease from a baseline of 183 which compared well with an estimated sample size around 10 times larger using the direct sisterhood method. The findings suggest that the Neighbourhood Method has potential for monitoring relative differences between areas or changes over time in the rates of rare demographic events, requiring considerably smaller sample sizes than traditional methods. This raises the possibility for interventions to demonstrate real effects on outcomes such as maternal deaths where previously this was only feasible by indirect methods.     

Sampling-Based Approaches to Improve Estimation of Mortality among Patient Dropouts: Experience from a Large PEPFAR-Funded Program in Western Kenya

Background

Monitoring and evaluation (M&E) of HIV care and treatment programs is impacted by losses to follow-up (LTFU) in the patient population. The severity of this effect is undeniable but its extent unknown. Tracing all lost patients addresses this but census methods are not feasible in programs involving rapid scale-up of HIV treatment in the developing world. Sampling-based approaches and statistical adjustment are the only scaleable methods permitting accurate estimation of M&E indices.

Methodology/Principal Findings

In a large antiretroviral therapy (ART) program in western Kenya, we assessed the impact of LTFU on estimating patient mortality among 8,977 adult clients of whom, 3,624 were LTFU. Overall, dropouts were more likely male (36.8% versus 33.7%; p = 0.003), and younger than non-dropouts (35.3 versus 35.7 years old; p = 0.020), with lower median CD4 count at enrollment (160 versus 189 cells/ml; p<0.001) and WHO stage 3–4 disease (47.5% versus 41.1%; p<0.001). Urban clinic clients were 75.0% of non-dropouts but 70.3% of dropouts (p<0.001). Of the 3,624 dropouts, 1,143 were sought and 621 had their vital status ascertained. Statistical techniques were used to adjust mortality estimates based on information obtained from located LTFU patients. Observed mortality estimates one year after enrollment were 1.7% (95% CI 1.3%–2.0%), revised to 2.8% (2.3%–3.1%) when deaths discovered through outreach were added and adjusted to 9.2% (7.8%–10.6%) and 9.9% (8.4%–11.5%) through statistical modeling depending on the method used. The estimates 12 months after ART initiation were 1.7% (1.3%–2.2%), 3.4% (2.9%–4.0%), 10.5% (8.7%–12.3%) and 10.7% (8.9%–12.6%) respectively.

Conclusions/Significance Abstract

Assessment of the impact of LTFU is critical in program M&E as estimated mortality based on passive monitoring may underestimate true mortality by up to 80%. This bias can be ameliorated by tracing a sample of dropouts and statistically adjust the mortality estimates to properly evaluate and guide large HIV care and treatment programs.     

Submicroscopic Gametocytes and the Transmission of Antifolate-Resistant Plasmodium falciparum in Western Kenya

Background

Single nucleotide polymorphisms (SNPs) in the dhfr and dhps genes are associated with sulphadoxine-pyrimethamine (SP) treatment failure and gametocyte carriage. This may result in enhanced transmission of mutant malaria parasites, as previously shown for chloroquine resistant parasites. In the present study, we determine the association between parasite mutations, submicroscopic P. falciparum gametocytemia and malaria transmission to mosquitoes.

Methodology/Principal Findings

Samples from children treated with SP alone or in combination with artesunate (AS) or amodiaquine were genotyped for SNPs in the dhfr and dhps genes. Gametocytemia was determined by microscopy and Pfs25 RNA–based quantitative nucleic acid sequence–based amplification (Pfs25 QT-NASBA). Transmission was determined by membrane-feeding assays. We observed no wild type infections, 66.5% (127/191) of the infections expressed mutations at all three dhfr codons prior to treatment. The presence of all three mutations was not related to higher Pfs25 QT-NASBA gametocyte prevalence or density during follow-up, compared to double mutant infections. The proportion of infected mosquitoes or oocyst burden was also not related to the number of mutations. Addition of AS to SP reduced gametocytemia and malaria transmission during follow-up.

Conclusions/Significance

In our study population where all infections had at least a double mutation in the dhfr gene, additional mutations were not related to increased submicroscopic gametocytemia or enhanced malaria transmission. The absence of wild-type infections is likely to have reduced our power to detect differences. Our data further support the use of ACT to reduce the transmission of drug-resistant malaria parasites.     

Sources and Patterns of Wolverine Mortality in Western Montana

ABSTRACT We instrumented 36 wolverines (Gulo gulo) on 2 study areas in western Montana and one study area on the Idaho-Montana (USA) border: 14 (9 M, 5 F) on the Pioneer study area, 19 (11 M, 8 F) on the Glacier study area, and 3 (2 M, 1 F) on the Clearwater study area. During 2002–2005, harvest from licensed trapping accounted for 9 (6 M, 3 F) of 14 mortalities, including individuals from all 3 study areas. Based on Akaike's Information Criterion adjusted for small sample sizes (AIC_c) rankings of 8 a priori models, a trapping model and a trapping-by-sex interaction model were equally supported (ΔAIC_c < 2) in explaining wolverine survival. Estimated annual survival was 0.80 when we did not consider harvest, whereas additive mortality from harvest reduced annual survival to 0.57. Glacier National Park in the Glacier study area provided some refuge as evidenced by an annual survival rate of 0.77 compared to 0.51 for the Pioneer Mountain study area. We incorporated these survival rates into a simple Lefkovitch stage-based model to examine rates of population change. The finite rate of population change (Λ) for the Glacier study area was 1.1, indicating a stable to slightly increasing population, whereas Λ for the Pioneer study area was 0.7, indicating a 30% annual population decrease during our study. Changes in Λ for both study areas were most sensitive to adult survival. In 2004, we used a Lincoln Index to estimate that 12.8 ± 2.9 (95% CI) wolverines resided in the 4 mountain ranges comprising the Pioneer study area, suggesting that small, island ranges in western Montana supported few individuals. Our results suggest that if wolverines are harvested, they should be managed within individual mountain ranges or small groupings of mountain ranges to limit mortality to within biologically defined limits in recognition of the increased vulnerabilities owing to low fecundity and low population numbers in small mountain ranges. We found that refugia, such as Glacier National Park, were important by reducing trap mortality and providing immigrants to the surrounding population, but even large parks were inadequate to provide complete protection to wolverines from trapping as they ranged outside park borders.     

Assessing the Potential of Indigenous-Run Demographic/Health Surveys: the 2005 Shuar Survey,Ecuador

Despite improved national censuses and “micro-demographic” studies, demographic processes and health conditions among indigenous populations in Amazonia and elsewhere in lowland Latin America are not well understood. A new source of demographic and health data has emerged in the past decade, namely meso-scale surveys initiated and administered by indigenous organizations. These surveys offer the potential for filling information gaps, shedding light on culturally specific factors that shape demographic processes and health, and empowering indigenous organizations with data that could inform health initiatives. This article assesses the indigenous-run survey “2005 Health Analysis of the Shuar and Achuar Nations” of eastern Ecuador in which the authors were involved, which reached 1,943 households in 257 communities in Morona-Santiago Province. We present findings on fertility, migration, sanitation, and health, and assess the strengths and weaknesses of the survey. We argue that despite flaws in the survey design and implementation, this survey revealed important linkages among fertility, migration, and health. Such surveys have the potential to provide much needed detail, representativeness, and cultural specificity that macro and micro data sources cannot provide. We conclude with recommendations to improve surveys of this type.