Nossal Institute for Global Health - Theses

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    Anaemia among young children in rural India
    Pasricha, Sant-Rayn Singh ( 2012)
    The World Health Organization estimates that globally, over 1.6 billion people are anaemic, with the prevalence highest among preschool children. Almost one third of the 293 million anaemic preschool children worldwide live in India. Despite rapid economic growth and long-standing anaemia control policies, the burden of anaemia in Indian children remains undiminished. In rural India, 80.9% of children aged 6-35 months are anaemic. Iron deficiency is believed to be the most important cause of anaemia in this population. However, other conditions, including deficiencies of folate, vitamins B12 and A, malarial and hookworm infection, and haemoglobinopathies, may also cause anaemia. The relative contribution of nutritional, infectious and genetic conditions to the burden of anaemia among Indian children has not been determined. A comprehensive understanding of the determinants of anaemia, including an appreciation of the performance of anaemia control programmes, is needed to address anaemia among young children in rural India. This thesis comprises two studies that aim to ultimately inform policy by understanding the determinants of anaemia, evaluating implementation of anaemia control strategies in the field, and ascertaining the value of screening for anaemia. The first project comprises a cross-sectional study investigating the determinants of anaemia and micronutrient concentrations, and evaluating the performance of anaemia control strategies in children 12-23 months of age in rural Karnataka, India. Of 401 children sampled, 75.3% were anaemic. A multiple regression model identified independent, positive associations between children’s haemoglobin and their ferritin, folate, age, maternal haemoglobin, and either family wealth or food security status; and negative associations with presence of beta thalassaemia trait, C-Reactive Protein (CRP) and male sex. Children’s ferritin was positively associated with maternal haemoglobin, iron intake and CRP, and negatively with continued breastfeeding and child’s energy intake. Children continuing to receive breastmilk had lower ferritin, B12 and vitamin A concentrations than their fully weaned counterparts, received less nutrition from complementary feeds and belonged to poorer, more food insecure families. Only 41.5% of children had ever received iron supplementation, and only 11.5% had received iron from a government source. Children who had received iron were more likely to be male, from wealthier families, and have mothers who had received iron. We found that measuring haemoglobin was not useful for identifying iron deficiency in this population. The second study investigated serum hepcidin as a new diagnostic test of iron deficiency. As this assay could not be performed using the Indian samples, this study was performed in a prospectively recruited sample of 261 adult Australian female blood donors. The AUCROC for hepcidin compared with the transferrin receptorferritin index was 0.89. A reference range for hepcidin and clinically useful cut-offs to diagnose iron deficiency were determined. Our findings suggest that improving iron intake is essential to alleviation of anaemia in this population, but that current policies are being inadequately implemented. Equitable delivery of iron, strategies that improve maternal haemoglobin, and efforts to reduce poverty and improve food security may help control the burden of anaemia among Indian children.
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    Epidemiology of pulmonary tuberculosis in Beira city, Mozambique
    Objectives: The present study had the following objectives: to identify risk factors associated with diagnostic and treatment delay and with poor treatment outcomes among patients with pulmonary tuberculosis; to describe the role of health workers in the management of patients with tuberculosis; and to describe the genotypic characteristics of Mycobacterium tuberculosis strains circulating among patients with pulmonary tuberculosis. Methods: The study was carried out in Beira city, Mozambique using a mix of quantitative and qualitative methods. The quantitative component was based on a consecutive cohort of newly registered pulmonary tuberculosis patients recruited from five diagnostic and treatment centres. Patients were included in the study if they were at least 18 years of age at enrolment and lived in Beira City. The qualitative study was carried out in one TB clinic and it was based on an ethnographic study of health workers. Results: TB delay was assessed in 774 patients. Total delay, defined as the sum of patient delay and health system delay, varied from 30 to 780 days and the median total delay for new smear-positive, new smear-negative and retreatment patients was 123, 180 and 150 days, respectively. The median patient delay for new smear-positive patients, new smear-negative patients and re-treatment patients was 56 days, 68 days and 58 days, respectively. The median health system delay for new smear-positive patients, new smear-negative patients and re-treatment patients was 52 days, 73 days and 65 days, respectively. Patient delay was associated with farming, visiting first a traditional healer, low TB knowledge and presence of a concomitant chronic disease. Health system delay was associated with multiple visits to primary health care facilities, farming and presence of a concomitant chronic disease. Age, negative sputum smear result and poor access to health services also played a role in total delay. The treatment outcomes of 843 patients were assessed. The treatment success rate for new smear-positive, new smear-negative and relapse patients was 91.4 percent, 95.5 percent and 82.0 percent, respectively. Male sex and HIV infection had a strong association with a poor treatment outcome and total delay was associated with an increased rate of death. The death rate for new smear-positive, new smear-negative and retreatment patients was 30, 23 and 34 per 100 000 population, respectively. The identification and characterization of genotype families was based on samples obtained from 67 patients. A method known as mycobacterial interspersed repeat units-variable number of tandem repeats was used and the results showed that the M. tuberculosis strains circulating in Beira city are a mix of ancestral and modern strains, with a predominance of the East African-Indian and Latin American families. Ancestral strains are characterized by the presence of the TbD1 region which is absent in the modern strain. Among both the ancestral and modern strains, a high genetic diversity was observed, suggesting that these strains have been in circulation in Beira city for a long period of time. This was the first study carried out in Mozambique that used an ethnographic approach to identify enabling factors and barriers to a successful management of TB patients. The study was based on participant observation of one TB clinic and interviews with seven key informants. The high level of organization of the TB clinic; the low level of perceived TB stigma; the presence of auxiliary workers; and the appropriateness of the TB messages provided to patients found in this study were considered enabling factors. Potential barriers included the presence of misconceptions related to TB; the difficulties in the classification of retreatment patients and management of side effects; treatment interruptions; the lack of clarity in relation to infection control measures; and the lost opportunity to screen TB patients for co-morbidities other than those related to HIV & AIDS. Conclusions: The TB programme in Beira city is strong and well organized and it has been very successful in treating patients. However, there is a need to implement interventions to reduce patient delay and to improve TB diagnosis at the health facility level, especially at the primary health care level.