Blood lead level association with lower body weight in NHANES 1999-2006

BACKGROUND Lead exposure is associated with low birth-weight. The objective of this study is to determine whether lead exposure is associated with lower body weight in children, adolescents and adults. METHODS We analyzed data from NHANES 1999-2006 for participants aged ≥3 using multiple logistic and multivariate linear regression. Using age- and sex-standardized BMI Z-scores, overweight and obese children (ages 3-19) were classified by BMI ≥85 th and ≥95 th percentiles, respectively. The adult population (age ≥20) was classified as overweight and obese with BMI measures of 25-29.9 and ≥30, respectively. Blood lead level (BLL) was categorized by weighted quartiles. RESULTS Multivariate linear regressions revealed a lower BMI Z-score in children and adolescents when the highest lead quartile was compared to the lowest lead quartile (β (SE)=-0.33 (0.07), p<0.001), and a decreased BMI in adults (β (SE)=-2.58 (0.25), p<0.001). Multiple logistic analyses in children and adolescents found a negative association between BLL and the percentage of obese and overweight with BLL in the highest quartile compared to the lowest quartile (OR=0.42, 95% CI: 0.30-0.59; and OR=0.67, 95% CI: 0.52-0.88, respectively). Adults in the highest lead quartile were less likely to be obese (OR=0.42, 95% CI: 0.35-0.50) compared to those in the lowest lead quartile. Further analyses with blood lead as restricted cubic splines, confirmed the dose-relationship between blood lead and body weight outcomes. CONCLUSIONS BLLs are associated with lower body mass index and obesity in children, adolescents and adults.

Intensive care for extreme prematurity--moving beyond gestational age.

BACKGROUND: Decisions regarding whether to administer intensive care to extremely premature infants are often based on gestational age alone. However, other factors also affect the prognosis for these patients. METHODS: We prospectively studied a cohort of 4446 infants born at 22 to 25 weeks' gestation (determined on the basis of the best obstetrical estimate) in the Neonatal Research Network of the National Institute of Child Health and Human Development to relate risk factors assessable at or before birth to the likelihood of survival, survival without profound neurodevelopmental impairment, and survival without neurodevelopmental impairment at a corrected age of 18 to 22 months. RESULTS: Among study infants, 3702 (83%) received intensive care in the form of mechanical ventilation. Among the 4192 study infants (94%) for whom outcomes were determined at 18 to 22 months, 49% died, 61% died or had profound impairment, and 73% died or had impairment. In multivariable analyses of infants who received intensive care, exposure to antenatal corticosteroids, female sex, singleton birth, and higher birth weight (per each 100-g increment) were each associated with reductions in the risk of death and the risk of death or profound or any neurodevelopmental impairment; these reductions were similar to those associated with a 1-week increase in gestational age. At the same estimated likelihood of a favorable outcome, girls were less likely than boys to receive intensive care. The outcomes for infants who underwent ventilation were better predicted with the use of the above factors than with use of gestational age alone. CONCLUSIONS: The likelihood of a favorable outcome with intensive care can be better estimated by consideration of four factors in addition to gestational age: sex, exposure or nonexposure to antenatal corticosteroids, whether single or multiple birth, and birth weight. (ClinicalTrials.gov numbers, NCT00063063 [ClinicalTrials.gov] and NCT00009633 [ClinicalTrials.gov].).

Patterns of care and outcomes for pregnant inmates and their infants in Texas state prisons: Epidemiologic and ethnographic analyses

Female inmates make up the fastest growing segment in our criminal justice system today. The rapidly increasing trend for female prisoners calls for enhanced efforts to strategically plan the correctional facilities that address the needs of this growing population, and to work with communities to prevent crime in women. The incarcerated women in the U.S. have an estimated 145,000 minor children who are predisposed to unique psychosocial problems as a result of parental incarceration.^ This study examined the patterns of care and outcomes for pregnant inmates and their infants in Texas state prisons between 1994 and 1996. The study population consists of 202 pregnant inmates who delivered in a 2-year period, and a randomly sampled comparison cohort of 804 women from general Texas population, matched on race and educational levels. Both quantitative and qualitative data were used to elucidate the inmates' risk-factor profile, delivery/birth outcomes, and the patterns of care during pregnancy. The continuity-of-care issues for this population were also explored.^ Epidemiologic data were derived from multiple record systems to establish the comparison between two cohorts. A significantly great proportion of the inmates have prior lifestyle risk-factors (smoking, alcohol, and illicit drug abuse), poorer health status, and worse medical history. However, most of these existing risk-factors seem to show little manifestation in their current pregnancy. On the basis of maternal labor/delivery outcome and a number of neonatal indicators, this study found some evidence of a better pregnancy outcome for the inmate cohort when compared to the comparison group. Some possible explanations of this paradox were discussed. Seventeen percent of inmates gave birth to infants with suspected congenital syphilis. The placement patterns for the infants' care immediately after birth were elucidated.^ In addition to the quantitative data, an ethnographic approach was used to collect qualitative data from a subset of the inmate cohort (n = 20) and 12 care providers. The qualitative data were analyzed for their contents and themes, giving rise to a detailed description of the inmates' pregnancy experience. Eleven themes emerged from the study's thematic analysis, which provides the context for interpreting the epidemiologic data.^ Meaningful findings in this study were presented in a three-dimensional matrix to shed light on the apparent relationship between outcome indicators and their potential determinants. The suspected "linkages" between the outcome and their determinants can be used to generate hypotheses for future studies. ^

Incidence, etiology and risk factors of neonatal seizures Harris County, Texas, 1992--1994

This study was conducted to determine the incidence and etiology of neonatal seizures, and evaluate risk factors for this condition in Harris County, Texas, between 1992 and 1994. Potential cases were ascertained from four sources: discharge diagnoses at local hospitals, birth certificates, death certificates, and a clinical study of neonatal seizures conducted concurrent with this study at a large tertiary care center in Houston, Texas. The neonatal period was defined as the first 28 days of life for term infants, and up to 44 weeks gestation for preterm infants.^ There were 207 cases of neonatal seizures ascertained among 116,048 live births, yielding and incidence of 1.8 per 1000. Half of the seizures occurred by the third day of life, 70% within the first week, and 93% within the first 28 days of life. Among 48 preterm infants with seizures 15 had their initial seizure after the 28th day of life. About 25% of all seizures occurred after discharge from the hospital of birth.^ Idiopathic seizures occurred most frequently (0.5/1000 births), followed by seizures attributed to perinatal hypoxia/ischemia (0.4/1000 births), intracranial hemorrhage (0.2/1000 births), infection of the central nervous system (0.2/1000 births), and metabolic abnormalities (0.1/1000 births).^ Risk factors were evaluated based on birth certificate information, using univariate and multivariate analysis (logistic regression). Factors considered included birth weight, gender, ethnicity, place of birth, mother's age, method of delivery, parity, multiple birth and, among term infants, small birth weight for gestational age (SGA). Among preterm infants, very low birth weight (VLBW, $<$1500 grams) was the strongest risk factor, followed by birth in private/university hospitals with a Level III nursery compared with hospitals with a Level II nursery (RR = 2.9), and male sex (RR = 1.8). The effect of very low birth weight varied according to ethnicity. Compared to preterm infants weighing 2000-2999 grams, non-white VLBW infants were 12.0 times as likely to have seizures; whereas white VLBW infants were 2.5 times as likely. Among term infants, significant risk factors included SGA (RR = 1.8), birth in Level III nursery private/university hospitals versus hospitals with Level II nursery (RR = 2.0), and birth by cesarean section (RR = 2.2). ^

Intravitreal ranibizumab monotherapy to treat retinopathy of prematurity zone II, stage 3 with plus disease.

BACKGROUND Treatment of retinopathy of prematurity (ROP) stage 3 plus with bevacizumab is still very controversial. We report the outcome of 6 eyes of 4 premature infants with ROP stage 3 plus disease treated with ranibizumab monotherapy. METHODS Six eyes of 4 premature infants with threshold ROP 3 plus disease in zone II, were treated with one intravitreal injection of 0.03 ml ranibizumab. No prior laser or other intravitreal therapy was done. Fundus examination was performed prior to the intervention and at each follow-up visit. Changes in various mean vital parameters one week post intervention compared to one week pre-intervention were assessed. RESULTS The gestational age (GA) of patient 1, 2, 3, and 4 at birth was 24 5/7, 24 5/7, 24 4/7, and 26 1/7 weeks, respectively. The birth weight was 500 grams, 450 grams, 665 grams, and 745 grams, respectively. The GA at the date of treatment ranged from 34 3/7 to 38 6/7 weeks. In one infant, upper air way infection was observed 2 days post injection of the second eye. Three eyes required paracentesis to reduce the intraocular pressure after injection and to restore central artery perfusion. After six months, all eyes showed complete retinal vascularisation without any signs of disease recurrence. CONCLUSIONS Treatment of ROP 3 plus disease with intravitreal ranibizumab was effective in all cases and should be considered for treatment. One infant developed an upper air way infection suspicious for nasopharyngitis, which might be a possible side effect of ranibizumab. Another frequent complication was intraocular pressure rise after injection. More patients with longer follow-up duration are mandatory to confirm the safety and efficacy of this treatment. TRIAL REGISTRATION NUMBER NCT02164604 ; Date of registration: 13.06.2014.

Outcome in neonates with necrotizing enterocolitis and patent ductus arteriosus.

BACKGROUND There is no agreement of the influence of patent ductus arteriosus (PDA) on outcomes in patients with necrotizing enterocolitis (NEC). In this study, we assessed the influence of PDA on NEC outcomes. METHODS A retrospective study of 131 infants with established NEC was performed. Outcomes (death, disease severity, need for surgery, hospitalization duration), as well as multiple clinical parameters were compared between NEC patients with no congenital heart disease (n=102) and those with isolated PDA (n=29). Univariate, multivariate and stepwise logistic regression analyses were performed. RESULTS Birth weight and gestational age were significantly lower in patients with PDA [median (95% CI): 1120 g (1009-1562 g), 28.4 wk (27.8-30.5 wk)] than in those without PDA [median (95% CI): 1580 g (1593-1905 g), 32.4 wk (31.8-33.5 wk); P<0.05]. The risk of NEC-attributable fatality was higher in NEC patients with PDA (35%) than in NEC patients without PDA (14%)[univariate odds ratio (OR)=3.3, 95% CI: 1.8-8.6, P<0.05; multivariate OR=2.4, 95% CI: 0.82-2.39, P=0.111]. Significant independent predictors for nonsurvival within the entire cohort were advanced disease severity stage III (OR=27.9, 95% CI: 7.4-105, P<0.001) and birth weight below 1100 g (OR=5.7, 95% CI: 1.7-19.4, P<0.01). CONCLUSIONS In patients with NEC, the presence of PDA is associated with an increased risk of death. However, when important differences between the two study groups are controlled, only birth weight and disease severity may independently predict mortality.

Right ventricular dysfunction in children and adolescents conceived by assisted reproductive technologies.

Assisted reproductive technologies (ART) predispose the offspring to vascular dysfunction, arterial hypertension, and hypoxic pulmonary hypertension. Recently, cardiac remodeling and dysfunction during fetal and early postnatal life have been reported in offspring of ART, but it is not known whether these cardiac alterations persist later in life and whether confounding factors contribute to this problem. We, therefore, assessed cardiac function and pulmonary artery pressure by echocardiography in 54 healthy children conceived by ART (mean age 11.5 ± 2.4 yr) and 54 age-matched (12.2 ± 2.3 yr) and sex-matched control children. Because ART is often associated with low birth weight and prematurity, two potential confounders associated with cardiac dysfunction, only singletons born with normal birth weight at term were studied. Moreover, because cardiac remodeling in infants conceived by ART was observed in utero, a situation associated with increased right heart load, we also assessed cardiac function during high-altitude exposure, a condition associated with hypoxic pulmonary hypertension-induced right ventricular overload. We found that, while at low altitude cardiac morphometry and function was not different between children conceived by ART and control children, under the stressful conditions of high-altitude-induced pressure overload and hypoxia, larger right ventricular end-diastolic area and diastolic dysfunction (evidenced by lower E-wave tissue Doppler velocity and A-wave tissue Doppler velocity of the lateral tricuspid annulus) were detectable in children and adolescents conceived by ART. In conclusion, right ventricular dysfunction persists in children and adolescents conceived by ART. These cardiac alterations appear to be related to ART per se rather than to low birth weight or prematurity.

Breastfeeding-Associated Hypernatremia: A Systematic Review of the Literature.

There are increasing reports on hypernatremia, a potentially devastating condition, in exclusively breastfed newborn infants. Our purposes were to describe the clinical features of the condition and identify the risk factors for it. We performed a review of the existing literature in the National Library of Medicine database and in the search engine Google Scholar. A total of 115 reports were included in the final analysis. Breastfeeding-associated neonatal hypernatremia was recognized in infants who were ≤ 21 days of age and had ≥ 10% weight loss of birth weight. Cesarean delivery, primiparity, breast anomalies or breastfeeding problems, excessive prepregnancy maternal weight, delayed first breastfeeding, lack of previous breastfeeding experience, and low maternal education level were significantly associated with breastfeeding-associated hypernatremia. In addition to excessive weight loss (≥ 10%), the following clinical findings were observed: poor feeding, poor hydration state, jaundice, excessive body temperature, irritability or lethargy, decreased urine output, and epileptic seizures. In conclusion, the present survey of the literature identifies the following risk factors for breastfeeding-associated neonatal hypernatremia: cesarean delivery, primiparity, breastfeeding problems, excessive maternal body weight, delayed breastfeeding, lack of previous breastfeeding experience, and low maternal education level.

A multinational case-control study on childhood brain tumours, anthropogenic factors, birth characteristics and prenatal exposures: A validation of interview data.

Little is known about the aetiology of childhood brain tumours. We investigated anthropometric factors (birth weight, length, maternal age), birth characteristics (e.g. vacuum extraction, preterm delivery, birth order) and exposures during pregnancy (e.g. maternal: smoking, working, dietary supplement intake) in relation to risk of brain tumour diagnosis among 7-19 year olds. The multinational case-control study in Denmark, Sweden, Norway and Switzerland (CEFALO) included interviews with 352 (participation rate=83.2%) eligible cases and 646 (71.1%) population-based controls. Interview data were complemented with data from birth registries and validated by assessing agreement (Cohen's Kappa). We used conditional logistic regression models matched on age, sex and geographical region (adjusted for maternal age and parental education) to explore associations between birth factors and childhood brain tumour risk. Agreement between interview and birth registry data ranged from moderate (Kappa=0.54; worked during pregnancy) to almost perfect (Kappa=0.98; birth weight). Neither anthropogenic factors nor birth characteristics were associated with childhood brain tumour risk. Maternal vitamin intake during pregnancy was indicative of a protective effect (OR 0.75, 95%-CI: 0.56-1.01). No association was seen for maternal smoking during pregnancy or working during pregnancy. We found little evidence that the considered birth factors were related to brain tumour risk among children and adolescents.

Epidemiology of isolated obstructive genitourinary defect in Texas: 1999--2003

Background. Obstructive genitourinary defects include all anomalies causing obstruction anywhere along the urinary tract. Previous studies have noted a large excess of males among infants affected by these types of defects. This is the first epidemiologic study focused solely on obstructive genitourinary defects (OGD). ^ Methods. Data on 1,683 mild and 302 severe cases of isolated OGD born between 1999 and 2003 and ascertained by the Texas Birth Defects Registry were compared to all births in Texas during the same time period. Adjusted prevalence odds ratios (POR) were calculated for infant sex, birth weight, gestational age, mother’s race/ethnicity, mother’s age, mother’s education, parity, birth year, start of prenatal care, multiple birth, and public health region of birth. Severe cases were defined as those cases that died prior to birth, died after birth, or underwent surgery for OGD in the first year of life. Cases of OGD that had other major birth defects besides OGD were excluded from this study. ^ Results. Severe cases of OGD were more likely than mild cases to have multiple obstructive genitourinary anomalies (37.8% vs. 18.9%) and bilateral defects (40.9% vs. 31.3%). Males had a significantly greater risk of OGD than females for both severe and mild cases: adjusted POR = 3.26 (95% CI = 2.45-4.33) and adjusted POR = 2.60 (95% CI = 2.33-2.90), respectively. Infants with both severe and mild OGD were more likely to be very preterm birth at birth compared with infants without OGD: crude POR of 16.19 (95% CI = 10.60-24.74) and 4.75 (95% CI = 3.54-6.37), respectively. Among the severe group, minority races had a decreased risk of OGD with an adjusted POR of 0.74 (95% CI = 0.55-0.98) compared with whites. Among the mild cases, increased rates of OGD were found in older mothers (adjusted POR = 1.10, 95% CI = 1.05-1.15), college/higher educated mothers (adjusted POR = 1.07, 95% CI = 1.01-1.13) and multiple births (adjusted POR = 1.28, 95% CI = 1.01-1.62). There was also a decreased risk of mild cases among black mothers compared to whites (adjusted POR = 0.63, 95% CI = 0.52-0.76). Compared to 1999, the prevalence of mild cases of OGD increased significantly over the 5 year study period with an adjusted POR of 1.10 (95% CI = 1.06-1.15) by 2003. ^ Conclusion. Risk factors of OGD for both severe and mild forms were male sex and preterm birth. Severe cases were more likely to have multiple OGD defects and be affected bilaterally. An increase in prevalence of mild cases of OGD over time and differences in rates of black, older, and higher educated mothers in mild cases may be attributed to ultrasound use. ^

The association between maternal use of selective serotonin reuptake inhibitors during pregnancy and adverse pregnancy outcomes

Maternal use of SSRIs for depression and anxiety during pregnancy has increased over the last decade. Recent studies have questioned the safety of these antidepressants when used in during pregnancy. The aim of this project is to assess the associations between maternal SSRI use and GH, SGA, and preterm birth using data from a U.S. population-based study with self-reported exposure information. ^ The study population is comprised of mothers of control infants from the NBDPS, an ongoing, multi-state, population-based case-control study. Mothers were asked about any use of medications during pregnancy, including the dates they started and stopped taking each medication. Maternal GH was self-reported, while gestational age and birth weight were calculated from information on birth certificates or medical records. ^ Our study found that women exposed to SSRIs in the first trimester and beyond had a higher odds of GH compared to unexposed women (aOR=1.96, 95% CI=1.02-3.74). Women who used SSRIs only in the first trimester had no increased odds of GH (aOR=0.77, 95% CI=0.24-2.50). Women who used SSRIs throughout their entire pregnancy had a two-fold increase in the odds of delivering an SGA infant compared to unexposed women (aOR=2.16, 95% CI=1.01-4.62), while women who reported SSRI use only in the first trimester had a decreased odds of delivering an SGA infant (aOR=0.56, 95% CI=0.14-2.34). Finally, both women who used SSRIs in the first trimester only (aOR=1.58, 95% CI=0.71-3.51) and women who used SSRIs in the first trimester and beyond (aOR=1.49, 95% CI=0.76-2.90) had an increased odds of delivering preterm compared to unexposed women. ^ Results from our study suggest that women who use SSRIs in the first trimester and beyond have an increased and significant odds of GH and SGA. An increase in the odds of preterm birth was also observed among women exposed in this period and is consistent with the results of previous studies which had much larger sample sizes. Women who use SSRIs only in the first trimester appear to have no increased odds of GH or SGA, but may have an increased odds of preterm birth. These findings are consistent with previous studies and highlight how exposure to SSRIs at different points in gestation may result in different risks for these outcomes. ^

Infant breastfeeding patterns by sex: Do males feed more?

Background: Most studies have looked at breastfeeding practices from the point of view of the maternal behavior only, however in counseling women who choose to breastfeed it is important to be aware of general infant feeding patterns in order to adequately provide information about what to expect. Available literature on the differences in infant breastfeeding behavior by sex is minimal and therefore requires further investigation. Objectives: This study determined if at the age of 2 months there were differences in the amount of breast milk consumed, duration of breastfeeding, and infant satiety by infant sex. It also assessed whether infant sex is an independent predictor of initiation of breastfeeding. Methods: This is a secondary analysis of data obtained from the Infant Feeding Practices Survey II (IFPS II) which was a longitudinal study carried out from May 2005 through June 2007 by the Food and Drug Administration and the Centers for Disease Control and Prevention. The questionnaires asked about demography, prenatal care, mode of delivery, birth weight, infant sex, and breastfeeding patterns. A total of 3,033 and 2,552 mothers completed the neonatal and post-neonatal questionnaires respectively. ^ Results: There was no significant difference in the initiation of breastfeeding by infant sex. About 85% of the male infants initiated breastfeeding compared with 84% of female infants. The odds ratio of ever initiating breastfeeding by male infants was 0.93 but the difference was not significant with a p-value of 0.49. None of the other infant feeding patterns differed by infant gender. ^ Conclusion: This study found no evidence that male infants feed more or that their mothers are more likely to initiate breastfeeding. Each baby is an individual and therefore will have a unique feeding pattern. Based on these findings, the major determining factors for breastfeeding continue to be maternal factors therefore more effort should be invested in promoting breastfeeding among mothers of all ethnic groups and social classes.^

Sudden Infant Death disparities: A systematic review on health education and policy recommendations for decreasing Sudden Infant Death in the African-American community

Objective: To perform a systematic review of the literature on SIDS and SUID deaths concentrated in the African-American community, describe health education and policy recommendations and recommend a new approach that may aid in decreasing the disparity of infant mortality in the African-American community. ^ Methods: The PubMed database was systematically searched to identify relevant articles for final review and analysis. Using the CASP 2006 system to critique literature, twelve articles were found that met inclusion and exclusion criteria. ^ Results: Evidence in the literature confirmed there was a current disparity among African Americans' infant mortality rates in comparison to other US ethnic groups. The underlying reasons for these disparities included the following maternal and infant characteristics: mothers younger than eighteen, having more than one live infant, having a high school education or less, never been married, and have infants born preterm or with low birth weight. Maternal smoking, substance abuse, and breastfeeding did not have a significant impact on infant sleep environments among African Americans. ^ Conclusion: Tailored health education programs at the community level, better access to pre-pregnancy and prenatal care, and increased maternal perception of risk that is relevant to the infants sleeping environment are all possible solutions that may decrease African American infant mortality rates.^

Score de riesgo para recién nacidos prematuros.

En países en vías de desarrollo como Argentina, la sobrevida de prematuros de peso inferior a 1000 gramos dista mucho de los resultados reportados por países desarrolladas. Controles prenatales deficitarios, recursos técnicos limitados y la saturación de los servicios de Neonatología son en parte responsables de estas diferencias. Una de las situaciones frecuentemente asociada a decisiones éticas en neonatología se produce en torno al prematuro extremo. Las preguntas más difíciles de responder son si existe un límite de peso o edad gestacional por debajo del cual no se deban iniciar o agregar terapéuticas encaminadas a salvar la vida, por considerarlas inútiles para el niño, prolongan sin esperanza la vida, hacen sufrir al paciente y su familia y ocupar una unidad que priva de atención a otro niño con mayores posibilidades de sobrevida. En el presente estudio se elaboró un score de riesgo neonatal constituido por variables que caracterizan a muchas poblaciones de nuestros países latinoamericanos y que fue validado estadísticamente.El score es de rápida y fácil realización. Permite predecir si el prematuro grave es recuperable o no, posibilitando tomar decisiones éticas basadas en una técnica validada, que permite actuar en el mayor beneficio del niño y su familia, al mismo tiempo que se hace un uso más equitativo de los recursos.

Intracranial haemorrhage due to late onset vitamin K deficiency bleeding in Hanoi province, Vietnam

Background: In many developing countries vitamin K prophylaxis is not routinely administered at birth. There are insufficient data to assess the cost effectiveness of its implementation in such countries. Objective: To estimate the burden of intracranial haemorrhage caused by late onset vitamin K deficiency bleeding in Hanoi, Vietnam. Methods: Cases of intracranial haemorrhage in infants aged 1 - 13 weeks were identified in Hanoi province for 5 years ( 1995 - 1999), and evidence for vitamin K deficiency was sought. The data were compared with those on vitamin K deficiency bleeding in developed countries and used to obtain an approximation to the incidence of intracranial haemorrhage caused by vitamin K deficiency bleeding in Hanoi. Results: The estimated incidence of late onset vitamin K deficiency bleeding in infants who received no prophylaxis was unexpectedly high ( 116 per 100 000 births) with 142 and 81 per 100 000 births in rural and urban areas respectively. Mortality was 9%. Of the surviving infants, 42% were neurologically abnormal at the time of hospital discharge. Identified associations were rural residence, male sex, and low birth weight. A significant reduction in the incidence was observed in urban Hanoi during 1998 and 1999, after vitamin K prophylaxis was introduced at one urban obstetric hospital. Conclusions: Vitamin K deficiency bleeding is a major public health problem in Hanoi. The results indicate that routine vitamin K prophylaxis would significantly reduce infant morbidity and mortality in Vietnam and, costing an estimated US$87 (pound48, E72) per disability adjusted life year saved, is a highly cost effective intervention.