In low-income countries with high mortality, DTP as the last vaccine received may be associated with slightly increased mortality. Since the pattern was inversed for BCG, the effect is unlikely to be due to higher-risk children having received vaccination. The role of DTP in high mortality areas needs to be clarified.
Objective To study the effects on children of humanitarian aid agencies restricting help to refugee families (internally displaced people). Design Follow up study of 3 months. Setting Prabis peninsular outside Bissau, the capital of Guinea-Bissau, which has functioned as a refugee area for internally displaced people in the ongoing war, and the study area of the Bandim health project in Bissau. Participants 422 children aged 9-23 months in 30 clusters. Main outcome measures Mid-upper arm circumference and survival in relation to residence status. Results During the refugee situation all children deteriorated nutritionally, and mortality was high (3.0% in a 6 week period). Rice consumption was higher in families resident in Prabis than in refugees from Bissau but there was no difference in food expenditure. Nutritional status, measured by midupper arm circumference, was not associated with rice consumption levels in the family, and the decline in circumference was significantly worse for resident than for refugee children; the mid-upper arm circumference of refugee children increased faster than that of resident children. For resident children, mortality was 4.5 times higher (95% confidence interval 1.1 to 30.0) than for refugee children. Mortality for both resident and refugee children was 7.2 times higher (1.3 to 133.9) during the refugee's stay in Prabis compared with the period after the departure of the refugees. Conclusion In a non-camp setting, residents may be more malnourished and have higher mortality than refugees. Major improvements in nutritional status and a reduction in mortality occurred in resident and refugee children as soon as refugees returned home despite the fact that there was no improvement in food availability.
Objective-To evaluate the impact on mortality of standard Schwarz measles immunisation before 9 months ofage.Design-Children vaccinated in 1980-3 at 4-5, 6-8, and 9-11 months of age were followed to migration, death, or the age of5 years.Setting-One urban district and nine villages in two rural areas ofGuinea-Bissau.Subjects-307 children vaccinated at 4-8 months and 256 at 9-11 months.Main outcome measures-Mortality from 9 months to 5 years of age for children immunised at 4-5, 6-8, and 9-11 months.Results-Mortality was significantly lower in children vaccinated at 6-8 months than at 9-11 months (mortality ratio=0-63, (95% confidence interval 0-41 to 0.97), p0-0047). As vaccination was provided in semiannual or annual campaigns it is unlikely that age at vaccination reflected a selection bias. The trend was the same in all three study areas. Improved survival after early immunisation was not related to better protection against measles infection. With a Cox multivariate regression model to adjust for age, sex, season at risk, season at birth, measles infection, and region, children vaccinated at 4-8 months had a mortality ratio of 0-61 (0.40 to 0-92, p=0O020) compared with children vaccinated at 9-11 months'. Reinmunised children tended to have lower mortality than children who received only one vaccine (0 59 (0.28 to 1-27, p=0.176)).Conchusion-Standard measles vaccination before 9 months is not associated with higher childhood mortality than is the currently recommended strategy of immunising from 9 months, and it may reduce mortality. This has implications for measles immunisation strategy in developing countries.
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