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abstract of
the Lancet
Volume 370, 8 & 15 Dec, 2007 - Number 9603 & 9604 Lancet- Vol.370 9603&9604) 8&15 Dec, 2007 1 table of contents
WORLD REPORT
Adjuvant chemotherapy versus observation in Reconstructing Afghanistan’s health system.
patients with colorectal cancer: a randomised study.
SERIES, Chronic Diseases
The burden and costs of chronic diseases in low- Abegunde, D.O., Colin D Mathers, Taghreed Adam,Monica Ortegon, and Khaleen Strong. The battle to reform health-care coverage inCalifornia.
Chronic disease prevention: health effects and financial costs of strategies to reduce salt intakeand control tobacco use.
ARTICLES
Asaria, P., Dan Chisholm, Colon Mathers, Majid Ezzati,and Robert Beaglehole. Effectiveness and safety of baclofen formaintenance of alcohol abstinence in alcohol- Prevention of cardiovascular disease in high-risk individuals in low-income and middle-income randomised, double-blind controlled study.
countries: health effects and costs.
Addolorato, G., Lorenzo Leggio, Anna Ferrulli, Silvia Lim, S.S., Thomas A Gaziano, Emmanuela Gakidou, K Cardone, Luisa Vonghia, Antonio Mirijello, Ludovido Srinath Reddy, Farshad Farzadfar, Rafael Lozano, and Abenavoli, Cristina D’Angelo, Fabio Caputo, Antonella Zambon, Paul S Haber and Giovanni Gasbarrini. Scaling up interventions for chronic disease Cardiotoxicity associated with tyrosine kinase Gaziano, T.A., Gauden Galea, and K Srinath Reddy. Chu, T.F., Maria A Rupnick, Risto Kerkela, Susan MDallabrida, David Zurakowsi, Lisa Nguyen, Khaleen Woulfe, Elka Pravda, Flavia Cassiola, Jayesh Desai,Suzanne George, Jeffery A Morgan, David M Harris, Nasreen S Ismail, Jey-Hsin Chen, Frederick J Schoen, Roper, M.H., Jos H Vandelaer, and francois L Gasse. Annick D Van den Abbeelee, George D Demetri,Thomas Force, and Ming Hui Chen. PUBLIC HEALTH
A wearable haemodialysis device for patients with Risk of authoritarianism: fibrinogen-transmitted end-stage renal failure: a pilot study.
Davenport, A., Victor Gura, Claudoi Ronco, Masoud Beizai, Carlos Ezon, and Edmond Rambod. Effects of radiotherapy and of differences in theextent of surgery for early breast cancer on localrecurrence and 15-year survival: an overview ofthe randomised trials.
Early Breast Cancer Trialists’ Collaborative Group. Tuberculosis.
Maarteens, G., and Robert J Wilkinson. Risk of extensive virological failure to the threeoriginal antiretroviral drug classes over long-termfollow-up from the start of therapy in patients withHIV infection: an observational cohort study.
Phillips, A.N., Clifford Leen, Alan Wilson, JaneAnderson, David Dunn, Achim Schwenk, Chloe Orkin,Teresa Hill, Martin Fisher, John Walsh, Deenan Pillay,Loveleen Bansi, Brian Gazzard, Philippa Easterbrook,Richard Gilson, Margaret Johnson, and CarolineA Sabin. Lancet- Vol.370 (9603&9604) 8&15 Dec, 2007 2 WORLD REPORT
once cut to pieces, were roasted in a giant cookingpot by members of the rebel army. The LRA, who Bistol, N. (2007). Reconstructing Afghanistan’s
want to run the country by rules similar to the health system. The Lancet, 370 (9603), biblical Ten Commandments, have been at war with
2075-2076.
the government of President Yoweri Meseveni for 25 years of conflict has left Afghanistan’s health system in pieces. The health ministry has issuedan urgent call to expat doctors to come back to help MacReady, N. (2007). The battle to reform health-
provide essential health care. But, despite an care coverage in California. The Lancet,
enthusiastic response from Afghans abroad, 370 (9604), 1749-1750.
finances are hurting the plan. Nellie Bristol reports.
In trying to reform the health-care system in US doctor Homaira Behsudi returned to Kabul University, where she had earned her medical Schwarzenegger is taking on a monster worthy of degree, and found it decimated. There was no the Terminator. His main demon is one that equipment, no training materials, and few books.
bedevils health-care coverage throughout the USA: The chairs and ceilings were gone. Even the affordability. Norra MacReady reports. About 47 electrical wiring had been pulled out of the walls.
million people in the USA, or more than 15% of the “The shocking thing was the anatomy lab”, she population, lack health insurance. Nearly 7 million says, recalling her first visit to her native of those individuals reside in California, so the rest Afghanistan after a 14-year absence.
of the nation is watching closely as governor ArnoldSchwarzenegger, a Republican, and State Assembly Chatterjee, P. (2007). Hong Kong battens down
Speaker Fabian Nuñez, a Democrat, try to cobble the hatches. The Lancet, 370 (9603),
together a plan that will ensure coverage for virtually 2073-2074.
everyone in the state. For their part, state Hong Kong’s experience with SARS in 2003 has left policymakers are looking for lessons from it with an enviable reputation for public health Massachusetts, which passed its own health-care preparedness. When it comes to avian influenza, however, its proximity to several bird flu hotspots
means that even the best laid plans may not keep ARTICLES
the disease at bay. Patralekha Chatterjee reports.
Hong Kong may be only a couple of hours’ plane
Addolorato, G., Lorenzo Leggio, Anna Ferrulli,
ride from areas where avian influenza has been Silvia Cardone, Luisa Vonghia, Antonio
circulating for the past 2 years, but its residents Mirijello, Ludovido Abenavoli, Cristina
remain broadly confident about their Special D’Angelo, Fabio Caputo, Antonella Zambon,
Administrative Region’s (SAR’s) capacity to protect Paul S Haber and Giovanni Gasbarrini.
them. This confidence is partly because the region (2007). Effectiveness and safety of
has sufficient resources to fund preparatory baclofen for maintenance of alcohol
measures, but it is also a reflection of Hong Kong’s abstinence in alcohol-dependent patients
enviable reputation as being among the best- with liver cirrhosis: randomised, double-
prepared regions to meet the threat of emerging blind controlled study. The Lancet, 370
(9603), 1915-1922.
Intervention to achieve alcohol abstinence Lane, R. (2007). Northern Uganda: looking for
represents the most effective treatment for alcohol- peace. The Lancet, 370 (9604), 1749-
dependent patients with liver cirrhosis; however, 1750.
anticraving drugs might worsen liver disease. We After two decades of civil war, the Ugandan aimed to investigate the effectiveness and safety of Government and the rebel Lords Resistance Army baclofen in achieving and maintaining alcohol could be close to a peace agreement, raising hopes abstinence in patients with liver cirrhosis. Between that people in the north of the country can begin to October, 2003, and November, 2006, 148 alcohol- recover from the mental and physical trauma dependent patients with liver cirrhosis were referred caused by a brutal conflict. Richard Lane reports. A to the Institute of Internal Medicine, Rome, Italy.
small wooden monument stands in the tiny village 84 were randomly allocated either oral baclofen or of Geregere, in the Pader district of northern placebo for 12 weeks. Primary outcome was proportion of patients achieving and maintaining commemorates the massacre of 27 local people 5 alcohol abstinence. Measures of this outcome were years earlier by the rebel Lords Resistance Army total alcohol abstinence and cumulative abstinence (LRA). All the victims’ names are listed, three of duration, which were assessed at outpatient visits.
Relapse was defined as alcohol intake of more than questions the names in red, the answer seems four drinks per day or overall consumption of 14 or hardly credible. The bodies of the three individuals, more drinks per week over a period of at least 4 Lancet- Vol.370 9603&9604) 8&15 Dec, 2007 3 weeks. Analysis was by intention to treat. Of 42 Davenport, A., Victor Gura, Claudoi Ronco,
patients allocated baclofen, 30 (71%) achieved and Masoud Beizai, Carlos Ezon, and Edmond
maintained abstinence compared with 12 (29%) of Rambod. (2007). A wearable
42 assigned placebo (odds ratio 6·3 [95% CI 2·4–16·1]; haemodialysis device for patients with end-
p=0·0001). The number of dropouts (termination of stage renal failure: a pilot study. The
treatment) did not differ between the baclofen (6/ Lancet, 370 (9604), 2005-2010.
42 [14%]) and placebo (13/42 [31%]) groups (p=0·12).
More frequent haemodialysis can improve both Cumulative abstinence duration was about twofold survival and quality of life of patients with chronic higher in patients allocated baclofen than in those kidney disease. However, there is little capacity in assigned placebo (mean 62·8 [SE 5·4] vs 30·8 [5·5] the UK to allow patients to have more frequent days; p=0·001). No hepatic side-effects were haemodialysis treatments in hospital and satellite haemodialysis units. New means of deliveringhaemodialysis are therefore required. Our aim was Chu, T.F., Maria A Rupnick, Risto Kerkela, Susan
to assess the safety and efficiency of a wearable M Dallabrida, David Zurakowsi, Lisa
haemodialysis device. Eight patients with end-stage Nguyen, Khaleen Woulfe, Elka Pravda,
kidney failure (five men, three women, mean age Flavia Cassiola, Jayesh Desai, Suzanne
51·7 [SD 13·8] years) who were established on George, Jeffery A Morgan, David M Harris, regular haemodialysis were fitted with a wearable
Nasreen S Ismail, Jey-Hsin Chen, haemodialysis device for 4–8 h. Patients were given
Frederick J Schoen, Annick D Van den
unfractionated heparin for anticoagulation, as they Abbeelee, George D Demetri, Thomas
would be for standard haemodialysis. There were Force, and Ming Hui Chen. (2007).
no important cardiovascular changes and no Cardiotoxicity associated with tyrosine
adverse changes in serum electrolytes or acid-base kinase inhibitor sunitinib. The Lancet,
balance. There was no evidence of clinically 370 (9604), 2011-2019.
significant haemolysis in any patient. Mean blood Sunitinib, a multitargeted tyrosine-kinase flow was 58·6 (SD 11·7) mL/min, with a dialysate inhibitor, which is approved by both US and flow of 47·1 (7·8) mL/min. The mean plasma urea European Commission regulatory agencies for clearance rate was 22·7 (5·2) mL/min and the mean clinical use, extends survival of patients with plasma creatinine clearance rate was 20·7 (4·8) mL/min. Clotting of the vascular access occurred gastrointestinal stromal tumours, but concerns in two patients when the dose of heparin was have arisen about its cardiac safety. We therefore decreased and the partial thromboplastin time assessed the cardiovascular risk associated with returned towards the normal reference range in gastrointestinal stromal tumours. Weretrospectively reviewed all cardiovascular events Early Breast Cancer Trialists’ Collaborative
in 75 patients with imatinib-resistant, metastatic, Group. (2007). Effects of radiotherapy and
gastrointestinal stromal tumours who had been of differences in the extent of surgery for
enrolled in a phase I/II trial investigating the early breast cancer on local recurrence
efficacy of sunitinib. The composite cardiovascular and 15-year survival: an overview of the
endpoint was cardiac death, myocardial infarction, randomised trials. The Lancet, 370 (9603),
and congestive heart failure. We also examined 2087-2106.
sunitinib’s effects on left ventricular ejection In early breast cancer, variations in local treatment fraction (LVEF) and blood pressure. We investigated that substantially affect the risk of locoregionalpotential mechanisms of sunitinib-associated recurrence could also affect long-term breast cancercardiac effects by studies in isolated rat cardiomyocytes and in mice. Eight of 75 (11%) collaborative meta-analyses were undertaken, patients given repeating cycles of sunitinib in the based on individual patient data, of the relevant phase I/II trial had a cardiovascular event, with randomised trials that began by 1995. Information congestive heart failure recorded in six of 75 (8%).
was available on 42?000 women in 78 randomised Ten of 36 (28%) patients treated at the approved treatment comparisons (radiotherapy vs no sunitinib dose had absolute LVEF reductions in radiotherapy, 23?500; more vs less surgery, 9300; ejection fraction (EF) of at least 10%, and seven of more surgery vs radiotherapy, 9300). 24 types of local 36 (19%) had LVEF reductions of 15 EF% or more.
treatment comparison were identified. To help Sunitinib induced increases in mean systolic and relate the effect on local (ie, locoregional) diastolic blood pressure, and 35 of 75 (47%) recurrence to that on breast cancer mortality, these individuals developed hypertension (>150/100 were grouped according to whether or not the 5- year local recurrence risk exceeded 10% (<10%,17?000 women; >10%, 25?000 women). About three-quarters of the eventual local recurrence risk Lancet- Vol.370 (9603&9604) 8&15 Dec, 2007 4 occurred during the first 5 years. In the comparisons that involved little (<10%) differencein 5-year local recurrence risk there was little Phillips, A.N., Clifford Leen, Alan Wilson, Jane
difference in 15-year breast cancer mortality.
Anderson, David Dunn, Achim Schwenk,
Among the 25?000 women in the comparisons that Chloe Orkin, Teresa Hill, Martin Fisher,
involved substantial (>10%) differences, however, John Walsh, Deenan Pillay, Loveleen
5-year local recurrence risks were 7% active versus 26% control (absolute reduction 19%), and Philippa Easterbrook,Richard Gilson,
15-year breast cancer mortality risks were 44·6% Margaret Johnson, and Caroline A Sabin.
versus 49·5% (absolute reduction 5·0%, SE 0·8, (2007). Risk of extensive virological
2p<0·00001). These 25?000 women included 7300 failure to the three original antiretroviral
with breast-conserving surgery (BCS) in trials of classes over long-term follow-up
radiotherapy (generally just to the conserved from the start of therapy in patients with
breast), with 5-year local recurrence risks (mainly HIV infection: an observational cohort
in the conserved breast, as most had axillary study. The Lancet, 370 (9603), 1923-1928.
clearance and node-negative disease) 7% versus The long-term durability of viral-load suppression 26% (reduction 19%), and 15-year breast cancer provided by the three original antiretroviral drugs mortality risks 30·5% versus 35·9% (reduction 5·4%, is not well characterised. We estimated the SE 1·7, 2p=0·0002; overall mortality reduction 5·3%, proportion of patients who had extensive triple-class SE 1·8, 2p=0·005). They also included 8500 with failure during long-term follow-up and examined mastectomy, axillary clearance, and node-positive characteristics associated with an increased rate disease in trials of radiotherapy (generally to the of failure. 7916 patients who started antiretroviral chest wall and regional lymph nodes), with similar therapy with three or more drugs were followed up absolute gains from radiotherapy; 5-year local from the time that therapy started until the last viral- recurrence risks (mainly at these sites) 6% versus load measure. Extensive triple-class virological 23% (reduction 17%), and 15-year breast cancer failure was defined by failure of three subclasses of mortality risks 54·7% versus 60·1% (reduction 5·4%, nucleoside reverse transcriptase inhibitors, a non- SE 1·3, 2p=0·0002; overall mortality reduction 4·4%, nucleoside reverse transcriptase inhibitor, and a ritonavir-boosted protease inhibitor.
Maarteens, G., and Robert J Wilkinson. (2007).
QUASAR Collaborative Group. (2007). Adjuvant
Tuberculosis. The Lancet, 370 (9604),
chemotherapy versus observation in
2030-2043.
patients with colorectal cancer: a
Tuberculosis is still a leading cause of death in randomised study. The Lancet, 370 (9604),
2020-2029.
especially those of sub-Saharan Africa where The aim of the QUASAR trial was to determine the tuberculosis is an epidemic because of the size and duration of any survival benefit from increased susceptibility conferred by HIV infection.
adjuvant chemotherapy for patients with colorectal The effectiveness of the Bacille Calmette Guérin cancer at low risk of recurrence, for whom the (BCG) vaccine is partial, and that of treatment of indication for such treatment is unclear. After latent tuberculosis is unclear in high-incidence apparently curative resections of colon or rectal settings. The routine diagnostic methods that are cancer, 3239 patients (2963 [91%] with stage II [node used in many parts of the world are still very similar negative] disease, 2291 [71%] with colon cancer, to those used 100 years ago. Multidrug treatment, median age 63 [IQR 56–68] years) enrolled between within the context of structured, directly observed May, 1994, and December, 2003, from 150 centrestherapy, is a cost-effective control strategy.
in 19 countries were randomly assigned to receive Nevertheless, the duration of treatment needed chemotherapy with fluorouracil and folinic acidreduces its effectiveness, as does the emergence (n=1622) or to observation (with chemotherapy of multidrug-resistant and extensively drug- considered on recurrence; n=1617). Chemotherapy resistant disease; the latter has recently become was delivered as six 5-day courses every 4 weeks or widespread. The rapid expansion of basic, clinical, and operational research, in addition to increasing fluorouracil (370 mg/m2) with high-dose (175 mg) knowledge of tuberculosis, is providing new L-folinic acid or low-dose (25 mg) L-folinic acid. Until diagnostic, treatment, and preventive measures.
1997, levamisole (12 courses of 450 mg over 3 days The challenge is to apply these advances to the repeated every 2 weeks) or placebo was added. After populations most at risk. The development of a 1997, patients who were assigned to receive comprehensive worldwide plan to stop tuberculosis chemotherapy were given fluorouracil and low-dose might facilitate this process by coordinating the folinic acid only. The primary outcome was all-cause work of health agencies. However, massive effort, mortality. Analyses were done by intention to treat.
political will, and resources are needed for this plan At the time of analysis, 61 (3·8%) patients in the Lancet- Vol.370 9603&9604) 8&15 Dec, 2007 5 the projected loss in national income over the next observation group had missing follow-up. After a median follow-up of 5·5 (range 0–10·6) years, therewere 311 deaths in the chemotherapy group and Asaria, P., Dan Chisholm, Colon Mathers, Majid
370 in the observation group; the relative risk of Ezzati, and Robert Beaglehole. (2007).
death from any cause with chemotherapy versus Chronic disease prevention: health
observation alone was 0·82 (95% CI 0·70–0·95; effects and financial costs of strategies
p=0·008). There were 293 recurrences in the to reduce salt intake and control tobacco
chemotherapy group and 359 in the observation use. The Lancet, 370 (9604), 2044-2053.
group; the relative risk of recurrence with In 2005, WHO set a global goal to reduce rates of chemotherapy versus observation alone was 0·78 death from chronic (non-communicable) disease by (0·67–0·91; p=0·001). Treatment efficacy did not an additional 2% every year. To this end, we differ significantly by tumour site, stage, sex, age, investigated how many deaths could potentially be or chemotherapy schedule. Eight (0·5%) patients averted over 10 years by implementation of selected in the chemotherapy group and four (0·25%) in the population-based interventions, and calculated the observation group died from non-colorectal cancer financial costs of their implementation. We selected causes within 30 weeks of randomisation; only one two interventions: to reduce salt intake in the of these deaths was deemed to be possibly population by 15% and to implement four key elements of the WHO Framework Convention on fluorouracil and folinic acid could improve survival Tobacco Control (FCTC). We used methods from the of patients with stage II colorectal cancer, although WHO Comparative Risk Assessment project to the absolute improvements are small: assuming estimate shifts in the distribution of risk factors 5-year mortality without chemotherapy is 20%, the associated with salt intake and tobacco use, and to relative risk of death seen here translates into an model the effects on chronic disease mortality for absolute improvement in survival of 3·6% (95% CI 23 countries that account for 80% of chronic disease burden in the developing world. We showedthat, over 10 years (2006–2015), 13·8 million deaths SERIES, Chronic Diseases
could be averted by implementation of theseinterventions, at a cost of less than US$0·40 per Abegunde, D.O., Colin D Mathers, Taghreed person per year in low-income and lower middle-
Adam, Monica Ortegon, and Khaleen
income countries, and US$0·50–1·00 per person per Strong. (2007). The burden and costs of
year in upper middle-income countries (as of 2005).
chronic diseases in low-income and
These two population-based intervention strategies middle-income countries. The Lancet, 370
could therefore substantially reduce mortality from (9603), 1929-1938.
chronic diseases, and make a major (and affordable) This paper estimates the disease burden and loss contribution towards achievement of the global goal of economic output associated with chronic to prevent and control chronic diseases.
diseases—mainly cardiovascular diseases, cancer,chronic respiratory diseases, and diabetes—in 23 Gaziano, T.A., Gauden Galea, and K Srinath Reddy.
selected countries which account for around 80% (2007). Scaling up interventions for
of the total burden of chronic disease mortality in chronic disease prevention: the evidence.
developing countries. In these 23 selected low- The Lancet, 370 (9603),1939-1946.
income and middle-income countries, chronic Interventions to prevent morbidity and mortality diseases were responsible for 50% of the total from chronic diseases need to be cost effective and disease burden in 2005. For 15 of the selected financially feasible in countries of low or middle countries where death registration data are income before recommendations for their scale-up available, the estimated age-standardised death can be made. We review the cost-effectiveness rates for chronic diseases in 2005 were 54% higher estimates on policy interventions (both population- for men and 86% higher for women than those for based and personal) that are likely to lead to men and women in high-income countries. If substantial reductions in chronic diseases—in nothing is done to reduce the risk of chronic particular, cardiovascular disease, diabetes, cancer, diseases, an estimated US$84 billion of economic and chronic respiratory disease. We reviewed data production will be lost from heart disease, stroke, from regions of low, middle, and high income, where and diabetes alone in these 23 countries between available, as well as the evidence for making policy 2006 and 2015. Achievement of a global goal for interventions where available effectiveness or cost- chronic disease prevention and control—an additional 2% yearly reduction in chronic diseasedeath rates over the next 10 years—would avert 24million deaths in these countries, and would savean estimated $8 billion, which is almost 10% of Lancet- Vol.370 (9603&9604) 8&15 Dec, 2007 6 Lim, S.S., Thomas A Gaziano, Emmanuela
with tetanus toxoid to women of childbearing age.
Gakidou, K Srinath Reddy, Farshad The ultimate goal of this initiative is the worldwide
Farzadfar, Rafael Lozano, and Anthony
elimination of maternal and neonatal tetanus.
Roggers. (2007). Prevention of
Since tetanus spores cannot be removed from the cardiovascular disease in high-risk
environment, sustaining elimination will require individuals in low-income and middle-
income countries: health effects and
immunisation and health-service infrastructures, costs. The Lancet, 370 (9604), 1749-1750. and universal access to those services. The renewed
In 2005, a global goal of reducing chronic disease worldwide commitment to the reduction of maternal death rates by an additional 2% per year was and child mortality, if translated into effective action, established. Scaling up coverage of evidence-based could help to provide the systemic changes neededinterventions to prevent cardiovascular disease in for long-term elimination of maternal and neonatal high-risk individuals in low-income and middle- income countries could play a major part inreaching this goal. We aimed to estimate the PUBLIC HEALTH
number of deaths that could be averted and thefinancial cost of scaling up, above current coverage Yasunaga, H. (2007). Risk of authoritarianism:
levels, a multidrug regimen for prevention of fibrinogen-transmitted hepatitis C in
cardiovascular disease (a statin, aspirin, and two Japan. The Lancet, 370 (9604), 2063-2067.
blood-pressure-lowering medicines) in 23 such In 1977, the US Food and Drug Administration countries. Identification of individuals was limited revoked all licences for fibrinogen concentrateto those already accessing health services, and because of the risk for hepatitis infection and treatment eligibility was based on the presence of suspected lack of effectiveness. However, in Japan, existing cardiovascular disease or absolute risk of fibrinogen concentrate was used routinely for cardiovascular disease by use of easily measurable treatment of obstetric bleeding until 1988. Even in risk factors. Over a 10-year period, scaling up this 1997, academic texts by Japanese authorities in multidrug regimen could avert 17·9 million deaths obstetrics still recommended that obstetricians use from cardiovascular disease (95% uncertainty the product. An estimated 10?000 cases of hepatitis interval 7·4 million–25·7 million). 56% of deaths C infection are attributable to use of fibrinogen in averted would be in those younger than 70 years, Japan and are a result of authoritarianism that with more deaths averted in women than in men hindered effective policy changes. Scientists have owing to larger absolute numbers of women at older a duty to refine repeatedly the quality of their ages. The 10-year financial cost would be US$47 evidence, and policymakers need to adjust existing billion ($33 billion–$61 billion) or an average yearly policies continually to accord with the latest cost per head of $1·08 ($0·75–1·40), ranging from $0·43 to $0·90 across low-income countries and
from $0·54 to $2·93 across middle-income countries.
SEMINAR
Roper, M.H., Jos H Vandelaer, and francois L
Gasse. (2007). Maternal and neonatal
tetanus. The Lancet, 370 (9603), 1947-
1959.
Maternal and neonatal tetanus are importantcauses of maternal and neonatal mortality,claiming about 180?000 lives worldwide every year,almost exclusively in developing countries.
Although easily prevented by maternalimmunisation with tetanus toxoid vaccine, andaseptic obstetric and postnatal umbilical-cord carepractices, maternal and neonatal tetanus persistas public-health problems in 48 countries, mainlyin Asia and Africa. Survival of tetanus patients hasimproved substantially for those treated in hospitalswith modern intensive-care facilities; however,such facilities are often unavailable where thetetanus burden is highest. The Maternal andNeonatal Tetanus Elimination Initiative assistscountries in which maternal and neonatal tetanushas not been eliminated to provide immunisation Lancet- Vol.370 9603&9604) 8&15 Dec, 2007 7

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