Burden of infectious diseases in South Asia
http://www.100md.com
《英国医生杂志》
1 Department of Paediatrics, Aga Khan University, Karachi 74800, Pakistan, 2 Department of Paediatrics, King George Medical University, Lucknow, India, 3 Department of Medicine, Faculty of Medicine, University of Kelaniya, Sri Lanka
Correspondence to: A K M Zaidi Anita.zaidi@aku.edu
Infectious diseases are a major cause of death in South Asia, with children incurring a disproportionate share of the burden. This review discusses the underlying causes of some of the more common diseases and strategies to improve their detection and control
Introduction
Evidence based decision making in health requires the availability of sound data, but good quality information on the occurrence of infectious diseases is unavailable from most of South Asia, especially on premature mortality and loss of healthy life years in adult populations. Thus calculations of disease burden using techniques such as disability adjusted life years (DALYs) are fraught with difficulty; deaths and disability caused by infections such as meningitis, encephalitis, chronic hepatitis, leishmaniasis, congenital infections, rabies, and post-streptococcal rheumatic heart disease in South Asian populations remain hidden and unmeasured.
Summary points
Acute respiratory infections, diarrhoea, and neonatal infections remain major child killers
India has the second highest burden of HIV and AIDS in the world, with 4.58 million people infected with HIV
Antibiotic misuse has resulted in high rates of antimicrobial resistance
Only half of all South Asian children receive routine immunisations, and many new vaccines have not been introduced in mass immunisation programmes
Lack of surveillance systems and poorly functioning public health systems hinder progress in infectious disease control in South Asia
Sri Lanka is the only country in South Asia which has developed and sustained a well functioning public health system, resulting in progress in control of infectious diseases
Major child killers
Acute respiratory infections and diarrhoea
Interventions targeted at diarrhoea and acute respiratory infections have resulted in substantial declines in deaths in South Asian children, although these diseases still account for almost half of the deaths (figure).7 2 Many children do not receive timely and appropriate care (table 1). WHO and Unicef's strategy for reducing deaths due to these conditions is centred on the integrated management of childhood illness (IMCI) initiative—a holistic approach encompassing prevention, early detection, and treatment of common childhood infections in countries with limited resources.8 Although South Asian countries have adopted the IMCI strategy in principle, implementation remains weak because of poorly functioning health systems and fragmented referral pathways. Use of vaccines against common pathogens of diarrhoea and pneumonia—rotavirus, pneumococcus, and Haemophilus influenzae type b—has the potential to significantly reduce morbidity and mortality due to diarrhoea and acute respiratory infections.
Progress in survival of children aged under 5 years (per 1000 live births) in South Asian countries
Table 1 Selected indicators of infectious disease in South Asian children
Neonatal infections
Neonatal infections are also a common cause of death in South Asia and are under-recognised as a public health problem. Regional neonatal mortality (deaths in the first 28 days of life) is 46.3 per 1000 live births, and an estimated 30-40% of these deaths are from infections9 10; 300 000 to 400 000 deaths in India alone each year can be attributed to neonatal infections (table 1). Determinants include lack of antenatal care and tetanus immunisation, unskilled birth attendants, unclean delivery practices and poor infection control, low birthweight babies, lack of exclusive breast feeding, and low levels of carer seeking for sick neonates.10-12
Integrated perinatal approaches based on solid evidence, similar to the IMCI initiative, are urgently needed to improve the survival of newborn babies in South Asia. Community based approaches to prevent and treat neonatal infections are especially important and are being tested in the field in several South Asian countries.12
The challenge of HIV and AIDS and the control of tuberculosis
India is in the midst of an HIV and AIDS crisis, with over 4.58 million infected people, the highest burden in the world after South Africa.13 Half a million people are projected to die from AIDS in India next year, and 600 000 are in urgent need of antiretroviral therapy.14 Prevalence rates are lower in other South Asian countries but rising slowly, especially in Nepal and Pakistan (table 2).13 14
Table 2 Burden of HIV, AIDS, and tuberculosis in South Asian countries
The prevalence of HIV in India is heterogeneous, the epidemic being concentrated in some (mainly) southern states while most of India has low rates of infection.14 In the states with the highest prevalence (more than 1% of women presenting for antenatal check ups test positive for HIV antibodies)—Maharashtra, Tamil Nadu, Karnataka, Andhara Pradesh, Manipur, and Nagaland—public health systems are overwhelmed.14 The pattern of spread is also diverse, with heterosexual transmission predominating in some areas and intravenous drug use in others. As a result, planning and implementing effective HIV prevention programmes pose a major challenge for Indian health officials. Locally relevant intervention programmes are urgently needed rather than a one size fits all approach. As a first step, behavioural surveillance programmes have been initiated in some areas in the Indian AIDS II project to improve understanding of transmission patterns.14
The presence of large numbers of people with AIDS in a region where tuberculosis is highly endemic creates a volatile situation for further spread of tuberculosis. South Asian countries are struggling to control tuberculosis through the implementation of WHO's directly observed therapy short course (DOTS) strategy. Although some progress has been made in expanding coverage, tuberculosis remains highly prevalent in most of South Asia, with Afghanistan having the highest rates (see table 2).15 Pakistan has been particularly unsuccessful in its efforts at tuberculosis control, with only 24% of the population covered under the WHO's strategy, and low case notification rates.15 Major constraints to tuberculosis control include weak public health infrastructure, staff shortages, inadequate funding, lack of awareness about the strategy among private practitioners, and multidrug resistant tuberculosis.15
The unmeasured burden of malaria, typhoid, and dengue
High rates of hepatitis B infection in many South Asian countries are attributed to unsafe blood supply, reuse of contaminated syringes, lack of maternal screening to prevent perinatal transmission, and delay in the introduction of hepatitis B vaccine. India, Pakistan, and Bangladesh have the highest rates of infection, with prevalence ranging from 2% to 8% in different population groups.20 Prevalence rates in Sri Lanka are under 1%.21 Hepatitis C infections in South Asia are also rising, and chronic liver diseases increasingly burden the region's health systems.21 22 Prevalence rates were estimated to be 1-2.4% in 1999.22 Infections seem to be acquired at an early age, and reuse of contaminated syringes is strongly implicated in transmission of hepatitis B and hepatitis C infection.23 24
Antimicrobial drug resistance and untreatable infections
Only Sri Lanka has been able to sustain high levels of immunisation coverage among its children (table 3). The regional average for children receiving three doses of diphtheria, pertussis, and tetanus vaccine in South Asia is only 58%.7 Only half of South Asian children receive a single dose of measles vaccine, and measles eradication has not received priority attention.7 Poor routine immunisation coverage is responsible for the delay in polio eradication—India, Pakistan, and Afghanistan are now among only a few countries in the world with wild-type polio (see table 3).30 Good news is the recent introduction of hepatitis B vaccine in immunisation programmes through the support of the Global Alliance for Vaccines and Immunization. Future funding of hepatitis B vaccination, however, remains uncertain.
Table 3 Comparison of selected indicators for immunisation in children in South Asia
As South Asian countries struggle to immunise their children with these basic vaccines, children in industrialised countries are being protected against an increasing array of infectious agents through use of new vaccines against H influenzae type b, pneumococci, meningococci, hepatitis A, and varicella and other vaccines, such as against rotavirus, are soon to be licensed. Poor routine immunisation coverage and lack of access to newer vaccines have created a huge gap in immunisation between children living in industrialised countries and those living in developing countries.
Reducing the burden of infectious diseases
In the short term a few simple and proved interventions may reduce the number of deaths and disabilities caused by many infectious diseases. These include promotion of exclusive breast feeding, hand washing, clean water, use of oral rehydration therapy for diarrhoea, improving nutritional status among mothers and young children, better immunisation coverage including addition of effective new vaccines, provision of good antenatal care and clean delivery, and improving care seeking behaviour for serious illness.31-33 Tuberculosis, HIV, and hepatitis prevention activities (for example, increasing awareness, behaviour modification, use of autodestruct syringes) should be integrated within an essential health package delivered through a strengthened public health system in the region. In this, Sri Lanka and Kerala (India) have shown the way.
Additional educational resources
Unicef (www.childinfo.org) Information on child health and survival
World Health Report 2003—Shaping the Future. Geneva: WHO. (http://www.who.int/whr/en/) Information on burden of diseases
Bellagio Child Survival Study Group, Lancet 2003 Series of articles on child survival
Information for patients
Children's Vaccine Program (www.childrensvaccine.com/html/parents_teens.htm) Information on vaccines for parents
Surveillance systems
Unicef Child Mortality Statistics. www.childinfo.org/cmr/revis/db2.htm (accessed 17 Feb 2004).
Black RE, Morris SS, Bryce J. Where and why are 10 million children dying every year? Lancet 2003;361: 2226-34.
Lopez AD. Causes of death in industrial and developing countries: estimates for 1985-1990. In: Jamison DT, Mosley WH, Measham AR, Bobadilla JL, eds. Disease control priorities in developing countries. Washington, DC: World Bank and Oxford University Press, 1993.
Fishman SM, Caulfield LE, de Onis M, Bl?ssner M, Hyder AA, Mullany L, et al. Childhood and maternal underweight. In: Ezzati M, Lopez AD, Rodgers A, Murray CJL, eds. Comparative quantification of health risks: global and regional burden of disease attributable to selected major risk factors. Geneva: World Health Organization (in press).
Rice AL, West KP, Black RE. Vitamin A deficiency. In: Ezzati M, Lopez AD, Rodgers A, Murray CJL, eds. Comparative quantification of health risks: global and regional burden of disease attributable to selected major risk factors. Geneva: World Health Organization (in press).
Caulfield L, Black RE. Zinc deficiency. In: Ezzati M, Lopez AD, Rodgers A, Murray CJL, eds. Comparative quantification of health risks: global and regional burden of disease attributable to selected major risk factors. Geneva: World Health Organization (in press).
Unicef. Progress since the world summit for children: a statistical review. New York: Unicef, 2001. www.unicef.org/pubsgen/wethechildren-stats/sgreport_adapted_stats_eng.pdf (accessed 17 Feb 2004).
World Health Organization. Integrated management of childhood illness handbook. Geneva: WHO and Unicef, 2000.
Hyder AA, Wali SA, McGuckin J. The burden of disease from neonatal mortality: a review of South Asia and Sub-Saharan Africa. Br J Obstet Gynaecol 2003;110: 894-901.
Stoll BJ. The global impact of neonatal infection. Clin Perinatol 1997;24: 1-21.
Bang AT, Bang RA, Baitule S, Deshmukh M, Reddy MH. Burden of morbidities and the unmet need for health care in rural neonates—a prospective observational study in Gadchiroli, India. Indian Pediatr 2001;38: 952-65.
Bang AT, Bang RA, Baitule SB, Reddy MH, Deshmukh MD. Effect of home-based neonatal care and management of sepsis on neonatal mortality: field trial in rural India. Lancet 1999;354: 1955-61.
World Health Organization. Facts about HIV/AIDS—South-east Asia region. http://w3.whosea.org/hivaids/fact1.htm (accessed 28 Feb 2004).
World Health Organization. HIV/AIDS in Asia and the Pacific Region 2001. w3.whosea.org/hivaids/asia2.htm (accessed 28 Feb 2004).
World Health Organization. Global tuberculosis control—WHO report 2003. www.who.int/gtb/publications/globrep/index.html (accessed 28 Feb 2004).
World Health Organization. Dengue fever in India: update. www.who.int/csr/don/2003_11_12/en/ (accessed 13 Mar 2004).
Sinha A, Sazawal S, Kumar R, Sood S, Reddaiah VP, Singh B, et al. Typhoid fever in children less than 5 years. Lancet 1999;354: 734-7.
Bhutta ZA. Therapeutic aspects of typhoidal salmonellosis in childhood: the Karachi experience. Ann Trop Paediatr 1996 Dec: 299-306.
Saha SK, Baqui AH, Hanif M, Darmstadt GL, Ruhulamin M, Nagatake T, et al. Typhoid fever in Bangladesh: implications for vaccination policy. Pediatr Infect Dis J 2001;20: 521-4.
World Health Organization. Hepatitis B. www.who.int/emc-documents/hepatitis/docs/whocdscsrlyo20022/index.html (accessed 28 Feb 2004).
Khan M, Ahmad N. Epidemiology of hepatitis B in SAARC countries. In: Sarin SK, Okuda K, eds. Hepatitis B and C: carrier to cancer. New Dehli: Harcourt 2002; 19-23.
World Health Organization. Hepatitis C—global prevalence (update). www.who.int/docstore/wer/pdf/2000/wer7503.pdf (accessed 28 Feb 2004).
Usman HR, Akhtar S, Rahbar MH, Hamid S, Moattar T, Luby SP. Injections in health care settings: a risk factor for acute hepatitis B virus infection in Karachi, Pakistan. Epidemiol Infect 2003;130: 293-300.
Khan AJ, Luby SP, Fikree F, Karim A, Obaid S, Dellawala S, et al. Unsafe injections and the transmission of hepatitis B and C in a periurban community in Pakistan. Bull WHO 2000;78: 956-63.
Qazi SA. Antibiotic strategies for developing countries: experience with acute respiratory tract infections in Pakistan. Clin Infect Dis 1999;28: 214-8.
Shears P. Antibiotic resistance in the tropics. Epidemiology and surveillance of antimicrobial resistance in the tropics. Trans R Soc Trop Med Hyg 2001;95: 127-30.
Zaidi AK, Hasan R, Bhutta ZA. Typhoid fever. N Engl J Med 2003;348: 1182-4.
Okeke IN, Lamikanra A, Edelman R. Socioeconomic and behavioral factors leading to acquired bacterial resistance to antibiotics in developing countries. Emerg Infect Dis 1999;5: 18-27.
Couper MR. Strategies for the rational use of antimicrobials. Clin Infect Dis 1997;24(suppl 1): S154-6.
Centres for Disease Control and Prevention. Global polio eradication initiative strategic plan, 2004. MMWR Morb Mortal Wkly Rep 2004;53: 107-8.
Jones G, Steketee RW, Black RE, Bhutta ZA, Morris SS, Bellagio Child Survival Study Group. How many child deaths can we prevent this year? Lancet 2003;362: 65-71.
Bryce J, Arifeen S, Pariyo G, Lanata CF, Gwatkin D, Habicht JP, et al. Reducing child mortality: can public health deliver? Lancet 2003;362: 159-64.
Bellagio Study Group on Child Survival. Knowledge into action for child survival. Lancet 2003;362: 323-7.
John TJ, Samuel R, Balraj V, John R. Disease surveillance at district level: a model for developing countries. Lancet 1998;352: 58-61.(Anita K M Zaidi, associat)
Correspondence to: A K M Zaidi Anita.zaidi@aku.edu
Infectious diseases are a major cause of death in South Asia, with children incurring a disproportionate share of the burden. This review discusses the underlying causes of some of the more common diseases and strategies to improve their detection and control
Introduction
Evidence based decision making in health requires the availability of sound data, but good quality information on the occurrence of infectious diseases is unavailable from most of South Asia, especially on premature mortality and loss of healthy life years in adult populations. Thus calculations of disease burden using techniques such as disability adjusted life years (DALYs) are fraught with difficulty; deaths and disability caused by infections such as meningitis, encephalitis, chronic hepatitis, leishmaniasis, congenital infections, rabies, and post-streptococcal rheumatic heart disease in South Asian populations remain hidden and unmeasured.
Summary points
Acute respiratory infections, diarrhoea, and neonatal infections remain major child killers
India has the second highest burden of HIV and AIDS in the world, with 4.58 million people infected with HIV
Antibiotic misuse has resulted in high rates of antimicrobial resistance
Only half of all South Asian children receive routine immunisations, and many new vaccines have not been introduced in mass immunisation programmes
Lack of surveillance systems and poorly functioning public health systems hinder progress in infectious disease control in South Asia
Sri Lanka is the only country in South Asia which has developed and sustained a well functioning public health system, resulting in progress in control of infectious diseases
Major child killers
Acute respiratory infections and diarrhoea
Interventions targeted at diarrhoea and acute respiratory infections have resulted in substantial declines in deaths in South Asian children, although these diseases still account for almost half of the deaths (figure).7 2 Many children do not receive timely and appropriate care (table 1). WHO and Unicef's strategy for reducing deaths due to these conditions is centred on the integrated management of childhood illness (IMCI) initiative—a holistic approach encompassing prevention, early detection, and treatment of common childhood infections in countries with limited resources.8 Although South Asian countries have adopted the IMCI strategy in principle, implementation remains weak because of poorly functioning health systems and fragmented referral pathways. Use of vaccines against common pathogens of diarrhoea and pneumonia—rotavirus, pneumococcus, and Haemophilus influenzae type b—has the potential to significantly reduce morbidity and mortality due to diarrhoea and acute respiratory infections.
Progress in survival of children aged under 5 years (per 1000 live births) in South Asian countries
Table 1 Selected indicators of infectious disease in South Asian children
Neonatal infections
Neonatal infections are also a common cause of death in South Asia and are under-recognised as a public health problem. Regional neonatal mortality (deaths in the first 28 days of life) is 46.3 per 1000 live births, and an estimated 30-40% of these deaths are from infections9 10; 300 000 to 400 000 deaths in India alone each year can be attributed to neonatal infections (table 1). Determinants include lack of antenatal care and tetanus immunisation, unskilled birth attendants, unclean delivery practices and poor infection control, low birthweight babies, lack of exclusive breast feeding, and low levels of carer seeking for sick neonates.10-12
Integrated perinatal approaches based on solid evidence, similar to the IMCI initiative, are urgently needed to improve the survival of newborn babies in South Asia. Community based approaches to prevent and treat neonatal infections are especially important and are being tested in the field in several South Asian countries.12
The challenge of HIV and AIDS and the control of tuberculosis
India is in the midst of an HIV and AIDS crisis, with over 4.58 million infected people, the highest burden in the world after South Africa.13 Half a million people are projected to die from AIDS in India next year, and 600 000 are in urgent need of antiretroviral therapy.14 Prevalence rates are lower in other South Asian countries but rising slowly, especially in Nepal and Pakistan (table 2).13 14
Table 2 Burden of HIV, AIDS, and tuberculosis in South Asian countries
The prevalence of HIV in India is heterogeneous, the epidemic being concentrated in some (mainly) southern states while most of India has low rates of infection.14 In the states with the highest prevalence (more than 1% of women presenting for antenatal check ups test positive for HIV antibodies)—Maharashtra, Tamil Nadu, Karnataka, Andhara Pradesh, Manipur, and Nagaland—public health systems are overwhelmed.14 The pattern of spread is also diverse, with heterosexual transmission predominating in some areas and intravenous drug use in others. As a result, planning and implementing effective HIV prevention programmes pose a major challenge for Indian health officials. Locally relevant intervention programmes are urgently needed rather than a one size fits all approach. As a first step, behavioural surveillance programmes have been initiated in some areas in the Indian AIDS II project to improve understanding of transmission patterns.14
The presence of large numbers of people with AIDS in a region where tuberculosis is highly endemic creates a volatile situation for further spread of tuberculosis. South Asian countries are struggling to control tuberculosis through the implementation of WHO's directly observed therapy short course (DOTS) strategy. Although some progress has been made in expanding coverage, tuberculosis remains highly prevalent in most of South Asia, with Afghanistan having the highest rates (see table 2).15 Pakistan has been particularly unsuccessful in its efforts at tuberculosis control, with only 24% of the population covered under the WHO's strategy, and low case notification rates.15 Major constraints to tuberculosis control include weak public health infrastructure, staff shortages, inadequate funding, lack of awareness about the strategy among private practitioners, and multidrug resistant tuberculosis.15
The unmeasured burden of malaria, typhoid, and dengue
High rates of hepatitis B infection in many South Asian countries are attributed to unsafe blood supply, reuse of contaminated syringes, lack of maternal screening to prevent perinatal transmission, and delay in the introduction of hepatitis B vaccine. India, Pakistan, and Bangladesh have the highest rates of infection, with prevalence ranging from 2% to 8% in different population groups.20 Prevalence rates in Sri Lanka are under 1%.21 Hepatitis C infections in South Asia are also rising, and chronic liver diseases increasingly burden the region's health systems.21 22 Prevalence rates were estimated to be 1-2.4% in 1999.22 Infections seem to be acquired at an early age, and reuse of contaminated syringes is strongly implicated in transmission of hepatitis B and hepatitis C infection.23 24
Antimicrobial drug resistance and untreatable infections
Only Sri Lanka has been able to sustain high levels of immunisation coverage among its children (table 3). The regional average for children receiving three doses of diphtheria, pertussis, and tetanus vaccine in South Asia is only 58%.7 Only half of South Asian children receive a single dose of measles vaccine, and measles eradication has not received priority attention.7 Poor routine immunisation coverage is responsible for the delay in polio eradication—India, Pakistan, and Afghanistan are now among only a few countries in the world with wild-type polio (see table 3).30 Good news is the recent introduction of hepatitis B vaccine in immunisation programmes through the support of the Global Alliance for Vaccines and Immunization. Future funding of hepatitis B vaccination, however, remains uncertain.
Table 3 Comparison of selected indicators for immunisation in children in South Asia
As South Asian countries struggle to immunise their children with these basic vaccines, children in industrialised countries are being protected against an increasing array of infectious agents through use of new vaccines against H influenzae type b, pneumococci, meningococci, hepatitis A, and varicella and other vaccines, such as against rotavirus, are soon to be licensed. Poor routine immunisation coverage and lack of access to newer vaccines have created a huge gap in immunisation between children living in industrialised countries and those living in developing countries.
Reducing the burden of infectious diseases
In the short term a few simple and proved interventions may reduce the number of deaths and disabilities caused by many infectious diseases. These include promotion of exclusive breast feeding, hand washing, clean water, use of oral rehydration therapy for diarrhoea, improving nutritional status among mothers and young children, better immunisation coverage including addition of effective new vaccines, provision of good antenatal care and clean delivery, and improving care seeking behaviour for serious illness.31-33 Tuberculosis, HIV, and hepatitis prevention activities (for example, increasing awareness, behaviour modification, use of autodestruct syringes) should be integrated within an essential health package delivered through a strengthened public health system in the region. In this, Sri Lanka and Kerala (India) have shown the way.
Additional educational resources
Unicef (www.childinfo.org) Information on child health and survival
World Health Report 2003—Shaping the Future. Geneva: WHO. (http://www.who.int/whr/en/) Information on burden of diseases
Bellagio Child Survival Study Group, Lancet 2003 Series of articles on child survival
Information for patients
Children's Vaccine Program (www.childrensvaccine.com/html/parents_teens.htm) Information on vaccines for parents
Surveillance systems
Unicef Child Mortality Statistics. www.childinfo.org/cmr/revis/db2.htm (accessed 17 Feb 2004).
Black RE, Morris SS, Bryce J. Where and why are 10 million children dying every year? Lancet 2003;361: 2226-34.
Lopez AD. Causes of death in industrial and developing countries: estimates for 1985-1990. In: Jamison DT, Mosley WH, Measham AR, Bobadilla JL, eds. Disease control priorities in developing countries. Washington, DC: World Bank and Oxford University Press, 1993.
Fishman SM, Caulfield LE, de Onis M, Bl?ssner M, Hyder AA, Mullany L, et al. Childhood and maternal underweight. In: Ezzati M, Lopez AD, Rodgers A, Murray CJL, eds. Comparative quantification of health risks: global and regional burden of disease attributable to selected major risk factors. Geneva: World Health Organization (in press).
Rice AL, West KP, Black RE. Vitamin A deficiency. In: Ezzati M, Lopez AD, Rodgers A, Murray CJL, eds. Comparative quantification of health risks: global and regional burden of disease attributable to selected major risk factors. Geneva: World Health Organization (in press).
Caulfield L, Black RE. Zinc deficiency. In: Ezzati M, Lopez AD, Rodgers A, Murray CJL, eds. Comparative quantification of health risks: global and regional burden of disease attributable to selected major risk factors. Geneva: World Health Organization (in press).
Unicef. Progress since the world summit for children: a statistical review. New York: Unicef, 2001. www.unicef.org/pubsgen/wethechildren-stats/sgreport_adapted_stats_eng.pdf (accessed 17 Feb 2004).
World Health Organization. Integrated management of childhood illness handbook. Geneva: WHO and Unicef, 2000.
Hyder AA, Wali SA, McGuckin J. The burden of disease from neonatal mortality: a review of South Asia and Sub-Saharan Africa. Br J Obstet Gynaecol 2003;110: 894-901.
Stoll BJ. The global impact of neonatal infection. Clin Perinatol 1997;24: 1-21.
Bang AT, Bang RA, Baitule S, Deshmukh M, Reddy MH. Burden of morbidities and the unmet need for health care in rural neonates—a prospective observational study in Gadchiroli, India. Indian Pediatr 2001;38: 952-65.
Bang AT, Bang RA, Baitule SB, Reddy MH, Deshmukh MD. Effect of home-based neonatal care and management of sepsis on neonatal mortality: field trial in rural India. Lancet 1999;354: 1955-61.
World Health Organization. Facts about HIV/AIDS—South-east Asia region. http://w3.whosea.org/hivaids/fact1.htm (accessed 28 Feb 2004).
World Health Organization. HIV/AIDS in Asia and the Pacific Region 2001. w3.whosea.org/hivaids/asia2.htm (accessed 28 Feb 2004).
World Health Organization. Global tuberculosis control—WHO report 2003. www.who.int/gtb/publications/globrep/index.html (accessed 28 Feb 2004).
World Health Organization. Dengue fever in India: update. www.who.int/csr/don/2003_11_12/en/ (accessed 13 Mar 2004).
Sinha A, Sazawal S, Kumar R, Sood S, Reddaiah VP, Singh B, et al. Typhoid fever in children less than 5 years. Lancet 1999;354: 734-7.
Bhutta ZA. Therapeutic aspects of typhoidal salmonellosis in childhood: the Karachi experience. Ann Trop Paediatr 1996 Dec: 299-306.
Saha SK, Baqui AH, Hanif M, Darmstadt GL, Ruhulamin M, Nagatake T, et al. Typhoid fever in Bangladesh: implications for vaccination policy. Pediatr Infect Dis J 2001;20: 521-4.
World Health Organization. Hepatitis B. www.who.int/emc-documents/hepatitis/docs/whocdscsrlyo20022/index.html (accessed 28 Feb 2004).
Khan M, Ahmad N. Epidemiology of hepatitis B in SAARC countries. In: Sarin SK, Okuda K, eds. Hepatitis B and C: carrier to cancer. New Dehli: Harcourt 2002; 19-23.
World Health Organization. Hepatitis C—global prevalence (update). www.who.int/docstore/wer/pdf/2000/wer7503.pdf (accessed 28 Feb 2004).
Usman HR, Akhtar S, Rahbar MH, Hamid S, Moattar T, Luby SP. Injections in health care settings: a risk factor for acute hepatitis B virus infection in Karachi, Pakistan. Epidemiol Infect 2003;130: 293-300.
Khan AJ, Luby SP, Fikree F, Karim A, Obaid S, Dellawala S, et al. Unsafe injections and the transmission of hepatitis B and C in a periurban community in Pakistan. Bull WHO 2000;78: 956-63.
Qazi SA. Antibiotic strategies for developing countries: experience with acute respiratory tract infections in Pakistan. Clin Infect Dis 1999;28: 214-8.
Shears P. Antibiotic resistance in the tropics. Epidemiology and surveillance of antimicrobial resistance in the tropics. Trans R Soc Trop Med Hyg 2001;95: 127-30.
Zaidi AK, Hasan R, Bhutta ZA. Typhoid fever. N Engl J Med 2003;348: 1182-4.
Okeke IN, Lamikanra A, Edelman R. Socioeconomic and behavioral factors leading to acquired bacterial resistance to antibiotics in developing countries. Emerg Infect Dis 1999;5: 18-27.
Couper MR. Strategies for the rational use of antimicrobials. Clin Infect Dis 1997;24(suppl 1): S154-6.
Centres for Disease Control and Prevention. Global polio eradication initiative strategic plan, 2004. MMWR Morb Mortal Wkly Rep 2004;53: 107-8.
Jones G, Steketee RW, Black RE, Bhutta ZA, Morris SS, Bellagio Child Survival Study Group. How many child deaths can we prevent this year? Lancet 2003;362: 65-71.
Bryce J, Arifeen S, Pariyo G, Lanata CF, Gwatkin D, Habicht JP, et al. Reducing child mortality: can public health deliver? Lancet 2003;362: 159-64.
Bellagio Study Group on Child Survival. Knowledge into action for child survival. Lancet 2003;362: 323-7.
John TJ, Samuel R, Balraj V, John R. Disease surveillance at district level: a model for developing countries. Lancet 1998;352: 58-61.(Anita K M Zaidi, associat)