Mapping 123 million neonatal, infant and child deaths between 2000 and 2017

Rainfall shocks, child mortality, and water infrastructure

I study the effect of rainfall shocks on child mortality at a sub-national level for a global set of developing countries. I establish that negative (positive) shocks to rainfall lead to an increase (drop) in child deaths overall. Low-income countries (LICs) and the group of countries reliant on agriculture are affected the most due to negative rainfall shocks. In LICs, the impact of negative rainfall shocks is mitigated by around 60% in districts located downstream to dams, an effect predominant among less affluent districts; in addition, the effect of rainfall fluctuations is persistent, lasting for up to three years following the shock. Results remain robust to the inclusion of relevant controls, to the consideration of relevant issues such as selective fertility and migration, and various other robustness tests.

Tracing of Heavy Metals Embedded in Indoor Dust Particles from the Industrial City of Asaluyeh, South of Iran

Assessment of indoor air quality is especially important, since people spend substantial amounts of time indoors, either at home or at work. This study analyzes concentrations of selected heavy metals in 40 indoor dust samples obtained from houses in the highly-industrialized Asaluyeh city, south Iran in spring and summer seasons (20 samples each). Furthermore, the health risk due to exposure to indoor air pollution is investigated for both children and adults, in a city with several oil refineries and petrochemical industries. The chemical analysis revealed that in both seasons the concentrations of heavy metals followed the order of Cr > Ni > Pb > As > Co > Cd. A significant difference was observed in the concentrations of potential toxic elements (PTEs) such as Cr, As and Ni, since the mean (±stdev) summer levels were at 60.2 ± 9.1 mg kg−1, 5.6 ± 2.7 mg kg−1 and 16.4 ± 1.9 mg kg−1, respectively, while the concentrations were significantly lower in spring (17.6 ± 9.7 mg kg−1, 3.0 ± 1.7 mg kg−1 and 13.5 ± 2.4 mg kg−1 for Cr, As and Ni, respectively). Although the hazard index (HI) values, which denote the possibility of non-carcinogenic risk due to exposure to household heavy metals, were generally low for both children and adults (HI < 1), the carcinogenic risks of arsenic and chromium were found to be above the safe limit of 1 × 10−4 for children through the ingestion pathway, indicating a high cancer risk due to household dust in Asaluyeh, especially in summer.

Impact of Air Pollution on Child Health in India and the Way Forward

Recent research in epidemiological modelling reveals that air pollution affects child health in various ways resulting in low birthweight, stillbirth, preterm birth, developmental delay, growth failure, poor respiratory and cardiovascular health, and a higher risk of anemia. India has embarked on the national clean air program, but a much stronger coordinated multi-sectoral approach is required to minimize the child health burden caused by air pollution. Air pollution should be treated as a public health crisis that can only be managed with policy backed by science, gradual transition to clean energy use, emission reduction supported by clean air technologies, long-term commitment from the Government, and cooperation of the citizens.

Vascular Disorders of Pregnancy Increase Susceptibility to Neonatal Pulmonary Hypertension in High-Altitude Populations

BACKGROUND

Preeclampsia and fetal growth restriction increase cardiopulmonary disease risk for affected offspring and occur more frequently at high-altitude (≥2500 m). Retrospective studies indicate that birth to a preeclampsia woman at high altitude increases the risk of pulmonary hypertension (PH) in later life. This prospective study asked whether preeclampsia with or without fetal growth restriction exaggerated fetal hypoxia and impaired angiogenesis in the fetal lung, leading to neonatal cardiopulmonary circulation abnormalities and neonatal or infantile PH.

METHODS AND RESULTS

We studied 79 maternal-infant pairs (39 preeclampsia, 40 controls) in Bolivia (3600-4100 m). Cord blood erythropoietin, hemoglobin, and umbilical artery and venous blood gases were measured as indices of fetal hypoxia. Maternal and cord plasma levels of angiogenic (VEGF [vascular endothelial growth factor]) and antiangiogenic (sFlt1 [soluble fms-like tyrosine kinase]) factors were determined. Postnatal echocardiography (1 week and 6-9 months) assessed pulmonary hemodynamics and PH. Preeclampsia augmented fetal hypoxia and increased the risk of PH in the neonate but not later in infancy. Pulmonary abnormalities were confined to preeclampsia cases with fetal growth restriction. Maternal and fetal plasma sFlt1 levels were higher in preeclampsia than controls and positively associated with PH.

CONCLUSIONS

The effect of preeclampsia with fetal growth restriction to increase fetal hypoxia and sFlt1 levels may impede normal development of the pulmonary circulation at high altitude, leading to adverse neonatal pulmonary vascular outcomes. Our observations highlight important temporal windows for the prevention of pulmonary vascular disease among babies born to highland residents or those with exaggerated hypoxia in utero or newborn life.

Pediatric Scrub Typhus Manifesting with Multisystem Inflammatory Syndrome: A New Cause for Confusion or Concern—A Case Series

The pandemic of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has discovered a new disease called multisystem inflammatory syndrome in children (MIS-C). In developing nations, pediatricians must be mindful of the similarities between MIS-C and other tropical fevers such as scrub typhus. Not only should such patients be kept on high alert to rule out tropical diseases and receive appropriate treatment, such as steroids or immunomodulatory medications, but this is also concerning because, if rickettsial or bacterial infection is not detected through cultures and serology, steroid, or immunomodulatory treatment alone can be fatal.

How to cite this article: Bhardwaj P, Sood M, Singh R. Pediatric Scrub Typhus Manifesting with Multisystem Inflammatory Syndrome: A New Cause for Confusion or Concern—A Case Series. Indian J Crit Care Med 2022;26(6):723–727.

Accumulating Birth Histories Across Surveys for Improved Estimates of Child Mortality

Producing reliable estimates for childhood mortality rates is essential to monitor progress towards the United Nations Sustainable Development Goals (UN SDGs) and correctly evaluate policies designed to reduce childhood mortality rates. Different model-based approaches have been proposed to assess levels and trends in childhood mortality indicators. In this paper, we propose a design-based complement that accumulates birth histories across different household surveys to increase the precision of childhood mortality rates estimates. We accumulate birth histories across different cross-sectional Demographic Health Surveys/Multiple Cluster Indicator Surveys collected in Senegal and Malawi and estimate pooled childhood mortality rates based on calendar years. We show that accumulating birth histories smoothens fluctuations in time series for national and sub-national mortality rates, establishes more stable and reliable time trends, and results in estimated standard errors of the cumulated rates that are about 50–60% lower than their counterparts from separate surveys.

Geographical disparities in infant mortality in the rural areas of China: a descriptive study, 2010-2018

BACKGROUND

The infant mortality rate (IMR) is considered a basic measure of public health for countries around the world. The specific aim of our study was to provide an updated description of infant mortality rate among different regions in rural China, and assess the trends and causes of the IMR geographical disparities.

METHODS

Data were collected from China's Under-5 Child Mortality Surveillance System(U5CMSS). The annual number of deaths and causes of death were adjusted using a 3-year moving average underreporting rate based on annual national data quality control results. The average annual decline rate (AADR) and the relative risk (RR) of the IMR and cause-specific infant mortality were calculated by Poisson regression and the Cochran-Mantel-Haenszel method. Data analysis was completed by SAS software.

RESULTS

There was an apparent decrease in infant mortality in rural China from 2010 to 2018, at the AADR of 11.0% (95%CI 9.6-12.4), 11.2% (95%CI 10.3-12.1) and 6.6% (95%CI 6.0-7.3) in the eastern, central and western rural areas, respectively. The IMR was highest in the western rural area, followed by the central and eastern rural areas. Compared with the eastern rural area, the RR of infant mortality in the central rural area remained at 1.4-1.6 and increased from 2.4 (95%CI 2.3-2.6) in 2010-2012 to 3.1 (95% CI 2.9-3.4) in 2016-2018 in the western rural area. Pneumonia, preterm birth /LBW and birth asphyxia were the leading causes of infant deaths in the western rural area. Mortality rates of these three causes fell significantly in 2010-2018 but contributed to a higher proportion of deaths in the western rural area than in the central and western rural ares.

CONCLUSIONS

Our study indicated that the infant mortality rate dropped significantly from 2010 to 2018, however, geographical disparities of IMR in rural China are still persist. Therefore, there is an urgent need for public health programmes and policy interventions for infants in western rural China.

Risk Prediction for Stillbirth and Neonatal Mortality in Low-resource Settings

High stillbirth and neonatal mortality are major public health problems, particularly in low-resource settings in low- and middle-income countries (LMIC). Despite sustained efforts by national and international organizations over the last several decades, quality intrapartum and neonatal care is not universally available, especially in these low-resource settings. A few studies identify risk factors for adverse perinatal outcomes in low-resource settings in LMICs. This review highlights the evidence of risk prediction for stillbirth and neonatal death. Evidence using advanced machine-learning statistical models built on data from low-resource settings in LMICs suggests that the predictive accuracy for intrapartum stillbirth and neonatal mortality using prenatal and pre-delivery data is low. Models with delivery and post-delivery data have good predictive accuracy of the risk for neonatal mortality. Birth weight is the most important predictor of neonatal mortality. Further validation and testing of the models in other low-resource settings and subsequent development and testing of possible interventions could advance the field.

WU Polyomavirus Infection in Children With Acute Lower Respiratory Tract Infections in China, 2017 to 2019: Case Reports and Multicentre Epidemiological Survey

WU polyomavirus (WUPyV) is a novel member of the family Polyomaviridae recently detected in respiratory tract specimens. So far, it has not been proven whether WUPyV is a real causative agent for respiratory diseases. In this study, we described two patients with fatal infection who had WUPyV detected in their nasopharyngeal swabs. Furthermore, we conducted a multicentre study in six hospitals from different districts of China. WUPyV was detected by real-time polymerase chain reaction assays, and the clinical and molecular epidemiological characteristics of WUPyV strains among hospitalized children with acute lower respiratory tract infections all around China from 2017 to 2019 were analysed. Two complete WUPyV genome sequences were assembled from fatal patients’ airway specimens. Phylogenetic tree analysis revealed that they were most closely related to strains derived from Fujian and Chongqing, China, in 2008 and 2013, respectively. In 2017–2019, a total of 1,812 samples from children with acute lower respiratory tract infections were detected for WUPyV, of which 11 (0.6%) were positive. Children aged ≤5 were more susceptible to WUPyV infection. A total of 81.8% of WUPyV-positive patients were coinfected with other viruses, of which rhinovirus enjoyed the highest frequency. The main clinical symptoms of infected patients include fever, coughing and sputum expectoration. Most patients were diagnosed with pneumonia, followed by bronchial surgery. Three patients manifested severe infection, and all patients improved and were discharged. Our results show that WUPyV persistently circulates in China. Further investigations on the clinical role and pathogenicity of WUPyV are necessary.

Growing up and moving out: Migration and the demographic transition in low- and middle-income nations

International migration has increased since 1990, with increasing numbers of migrants originating from low- and middle-income countries (LMICs). Efforts to explain this compositional shift have focused on wage gaps and other push and pull factors but have not adequately considered the role of demographic factors. In many LMICs, child mortality has fallen without commensurate economic growth and amid high fertility. This combination increases young adult populations and is associated with greater outmigration: in the poorest countries, we estimate that a one-percentage-point increase in the five-year lagged growth rate of the population of 15–24-year-olds was associated with a 15 per cent increase in all-age outmigrants, controlling for other factors. Increases in growth of young adult populations led to 20.4 million additional outmigrants across 80 countries between 1990 and 2015. Understanding the determinants of these migration shifts should help policymakers in origin and destination countries to maximize their potential positive effects.

Neonatal mortality in a public referral hospital in southern Haiti: a retrospective cohort study

Background

Haiti has the highest rate of neonatal mortality in the Latin America and Caribbean region. While the rate of facility births in Haiti has doubled over the past two decades, there have been no comparable reductions in maternal or neonatal mortality. Little data is available on the clinical characteristics of complications and morbidities among newborns requiring hospitalization after birth and their contribution to neonatal mortality. There is a need to better understand the status of newborn clinical care capacity in Haiti to prioritize training and resources.

Methods

We performed a retrospective observational cohort study of neonates admitted to a large public referral hospital in southern Haiti in the first 2 years of operation of a new neonatal unit that we established. All neonate cases hospitalized in the unit in these 2 years were reviewed and analyzed to identify their clinical characteristics and outcomes. Multivariable logistic regression was used to identify independent risk factors of hospital mortality. We present the outcomes for 1399 neonates admitted to the unit during August 2017 and August 2019.

Results

The leading cause of death was prematurity, followed by hypoxia and infection. Inborn neonates had better rates of hospital survival than those born elsewhere; they were also more likely to be born via cesarean section and to be admitted immediately following birth. There were no differences between the proportion of premature or low-birth-weight babies born at the hospital or elsewhere. Mortality in the second year of the unit’s operation was 12%, almost half that of the first year (21%). Multivariable regression analysis showed that mortality was consistently higher among premature and very low birthweight babies.

Conclusions

With modest investments, we were able to halve the mortality on a neonatal unit in Haiti. Resources are needed to address prematurity as an important outcome since hospital mortality was significant in this group. To this end, investment in uninterrupted supplies of oxygen and antibiotics, as well as ensuring adequate newborn resuscitation, infection control, laboratory testing, and timely morbidity and mortality reviews would go a long way toward lowering hospital mortality in Haiti.

Aberrant upregulation of the glycolytic enzyme PFKFB3 in CLN7 neuronal ceroid lipofuscinosis

CLN7 neuronal ceroid lipofuscinosis is an inherited lysosomal storage neurodegenerative disease highly prevalent in children. CLN7/MFSD8 gene encodes a lysosomal membrane glycoprotein, but the biochemical processes affected by CLN7-loss of function are unexplored thus preventing development of potential treatments. Here, we found, in the Cln7∆ex2 mouse model of CLN7 disease, that failure in autophagy causes accumulation of structurally and bioenergetically impaired neuronal mitochondria. In vivo genetic approach reveals elevated mitochondrial reactive oxygen species (mROS) in Cln7∆ex2 neurons that mediates glycolytic enzyme PFKFB3 activation and contributes to CLN7 pathogenesis. Mechanistically, mROS sustains a signaling cascade leading to protein stabilization of PFKFB3, normally unstable in healthy neurons. Administration of the highly selective PFKFB3 inhibitor AZ67 in Cln7∆ex2 mouse brain in vivo and in CLN7 patients-derived cells rectifies key disease hallmarks. Thus, aberrant upregulation of the glycolytic enzyme PFKFB3 in neurons may contribute to CLN7 pathogenesis and targeting PFKFB3 could alleviate this and other lysosomal storage diseases.

Uncertainties in the path to 2030: Increasing trends of under-five mortality in the aftermath of Millennium Development Goal in Eastern Ethiopia

Background

Although Ethiopia was applauded for achieving the Millennium Development Goal (MDG) target of reducing child mortality, whether the gains sustained beyond the MDG era was rarely studied. In this study, we reported the trends and determinants of under-five mortality (U5M) from 2015 to 2020 in a population based cohort under the Kersa Health and Demographic Surveillance System (HDSS), eastern Ethiopia.

Methods

We followed pregnant women and their pregnancy outcomes from 2015 to 2020. Each year, data related to death and live births among the follow up population was retrieved. Automated verbal autopsy (InterVA-4) was used to assign the cause of death and Stata 14 was used for analysis. U5M rate was calculated as death among under five children divided by all live births during the study period and described per 1000 live births along with 95% Confidence Interval (CI). A multivariable Cox proportional regression model was used to identify determinant of U5M using adjusted hazard ratio (AHR). Finally, P value <0.05 was considered for declaring statistically significant association.

Results

From January 2015 to December 2020, a total of 28 870 live births were registered under the Kersa HDSS, of whom 1335 died before their fifth birthday. The overall U5M rate was 46.3 per 1000 live births (95% confidence interval (CI) = 43.79-48.79), with significant increase from 27.9 in 2015 to 54.7 in 2020 (P < 0.041). Diarrheal diseases, acute respiratory tract infection including pneumonia, meningitis and encephalitis, and HIV related deaths were the leading causes of U5M. The hazard of death was higher among children born to poor household (AHR = 1.52; 95% CI = 1.27-1.81), rural residents (AHR = 6.0; 95% CI = 3.65-9.91), born to adolescent mothers (AHR = 1.41; 95% CI = 1.02-1.95), whose mother didn’t receive antenatal care (AHR = 1.43; 95% CI = 1.21-1.69), were born preterm (AHR = 14.1; 95% CI = 9.96-19.89) and had low birth-weight (AHR = 1.74; 95% CI = 1.39-2.18).

Conclusion

We found high level of U5M rate with an increasing trend in the aftermath of the praised MDG4 achievement. Achieving the ambitious U5M of 25 per 1000 live births by 2030 requires addressing diarrheal disease, and respiratory tract infections, and HIV/AIDS. Reasons behind the persistent increase over the study period require further inquiry.

Variation in excess all-cause mortality by age, sex, and province during the first wave of the COVID-19 pandemic in Italy

Although previous evidence suggests that the infection fatality rate from COVID-19 varies by age and sex, and that transmission intensity varies geographically within countries, no study has yet explored the age-sex-space distribution of excess mortality associated with the COVID pandemic. By applying the principles of small-area estimation to existing model formulations for excess mortality, this study develops a novel method for assessing excess mortality across small populations and assesses the pattern of COVID excess mortality by province, year, week, age group, and sex in Italy from March through May 2020. We estimate that 53,200 excess deaths occurred across Italy during this time period, compared to just 35,500 deaths where COVID-19 was registered as the underlying cause of death. Out of the total excess mortality burden, 97% of excess deaths occurred among adults over age 60, and 68% of excess deaths were concentrated among adults over age 80. The burden of excess mortality was unevenly distributed across the country, with just three of Italy’s 107 provinces accounting for 32% of all excess mortality. This method for estimating excess mortality can be adapted to other countries where COVID-19 diagnostic capacity is still insufficient, and could be incorporated into public health rapid response systems.

Quantifying within-city inequalities in child mortality across neighbourhoods in Accra, Ghana: a Bayesian spatial analysis

OBJECTIVE

Countries in sub-Saharan Africa suffer the highest rates of child mortality worldwide. Urban areas tend to have lower mortality than rural areas, but these comparisons likely mask large within-city inequalities. We aimed to estimate rates of under-five mortality (U5M) at the neighbourhood level for Ghana's Greater Accra Metropolitan Area (GAMA) and measure the extent of intraurban inequalities.

METHODS

We accessed data on >700 000 women aged 25-49 years living in GAMA using the most recent Ghana census (2010). We summarised counts of child births and deaths by five-year age group of women and neighbourhood (n=406) and applied indirect demographic methods to convert the summaries to yearly probabilities of death before age five years. We fitted a Bayesian spatiotemporal model to the neighbourhood U5M probabilities to obtain estimates for the year 2010 and examined their correlations with indicators of neighbourhood living and socioeconomic conditions.

RESULTS

U5M varied almost five-fold across neighbourhoods in GAMA in 2010, ranging from 28 (95% credible interval (CrI) 8 to 63) to 138 (95% CrI 111 to 167) deaths per 1000 live births. U5M was highest in neighbourhoods of the central urban core and industrial areas, with an average of 95 deaths per 1000 live births across these neighbourhoods. Peri-urban neighbourhoods performed better, on average, but rates varied more across neighbourhoods compared with neighbourhoods in the central urban areas. U5M was negatively correlated with multiple indicators of improved living and socioeconomic conditions among peri-urban neighbourhoods. Among urban neighbourhoods, correlations with these factors were weaker or, in some cases, reversed, including with median household consumption and women's schooling.

CONCLUSION

Reducing child mortality in high-burden urban neighbourhoods in GAMA, where a substantial portion of the urban population resides, should be prioritised as part of continued efforts to meet the Sustainable Development Goal national target of less than 25 deaths per 1000 live births.

Artificial intelligence and medical education: A global mixed-methods study of medical students’ perspectives

Objective

Medical students, as clinicians and healthcare leaders of the future, are key stakeholders in the clinical roll-out of artificial intelligence-driven technologies. The authors aim to provide the first report on the state of artificial intelligence in medical education globally by exploring the perspectives of medical students.

Methods

The authors carried out a mixed-methods study of focus groups and surveys with 128 medical students from 48 countries. The study explored knowledge around artificial intelligence as well as what students wished to learn about artificial intelligence and how they wished to learn this. A combined qualitative and quantitative analysis was used.

Results

Support for incorporating teaching on artificial intelligence into core curricula was ubiquitous across the globe, but few students had received teaching on artificial intelligence. Students showed knowledge on the applications of artificial intelligence in clinical medicine as well as on artificial intelligence ethics. They were interested in learning about clinical applications, algorithm development, coding and algorithm appraisal. Hackathon-style projects and multidisciplinary education involving computer science students were suggested for incorporation into the curriculum.

Conclusions

Medical students from all countries should be provided teaching on artificial intelligence as part of their curriculum to develop skills and knowledge around artificial intelligence to ensure a patient-centred digital future in medicine. This teaching should focus on the applications of artificial intelligence in clinical medicine. Students should also be given the opportunity to be involved in algorithm development. Students in low- and middle-income countries require the foundational technology as well as robust teaching on artificial intelligence to ensure that they can drive innovation in their healthcare settings.

Neonatal Resuscitation Research Priorities in Low- and Middle-Income Countries

Several critical physiological changes occur during birth. Optimal and timely resuscitation is essential to avoid morbidity and mortality. The International Liaison Committee on Resuscitation (ILCOR) is a multinational committee that publishes evidence-based consensus and treatment recommendations for resuscitation in various scenarios including that for neonatal resuscitation. The majority of perinatal deaths occur in low- and middle-income countries (LMICs); however, there is limited research output from LMICs to generate evidence-based practice recommendations specific for LMICs. The current review identifies key areas of neonatal resuscitation-related research needed from LMICs to inform evidence-based resuscitation of neonates in LMICs.

Global antibiotic consumption and usage in humans, 2000-18: a spatial modelling study

BACKGROUND

Antimicrobial resistance (AMR) is a serious threat to global public health. WHO emphasises the need for countries to monitor antibiotic consumption to combat AMR. Many low-income and middle-income countries (LMICs) lack surveillance capacity; we aimed to use multiple data sources and statistical models to estimate global antibiotic consumption.

METHODS

In this spatial modelling study, we used individual-level data from household surveys to inform a Bayesian geostatistical model of antibiotic usage in children (aged <5 years) with lower respiratory tract infections in LMICs. Antibiotic consumption data were obtained from multiple sources, including IQVIA, WHO, and the European Surveillance of Antimicrobial Consumption Network (ESAC-Net). The estimates of the antibiotic usage model were used alongside sociodemographic and health covariates to inform a model of total antibiotic consumption in LMICs. This was combined with a single model of antibiotic consumption in high-income countries to produce estimates of antibiotic consumption covering 204 countries and 19 years.

FINDINGS

We analysed 209 surveys done between 2000 and 2018, covering 284 045 children with lower respiratory tract infections. We identified large national and subnational variations of antibiotic usage in LMICs, with the lowest levels estimated in sub-Saharan Africa and the highest in eastern Europe and central Asia. We estimated a global antibiotic consumption rate of 14·3 (95% uncertainty interval 13·2-15·6) defined daily doses (DDD) per 1000 population per day in 2018 (40·2 [37·2-43·7] billion DDD), an increase of 46% from 9·8 (9·2-10·5) DDD per 1000 per day in 2000. We identified large spatial disparities, with antibiotic consumption rates varying from 5·0 (4·8-5·3) DDD per 1000 per day in the Philippines to 45·9 DDD per 1000 per day in Greece in 2018. Additionally, we present trends in consumption of different classes of antibiotics for selected Global Burden of Disease study regions using the IQVIA, WHO, and ESAC-net input data. We identified large increases in the consumption of fluoroquinolones and third-generation cephalosporins in North Africa and Middle East, and south Asia.

INTERPRETATION

To our knowledge, this is the first study that incorporates antibiotic usage and consumption data and uses geostatistical modelling techniques to estimate antibiotic consumption for 204 countries from 2000 to 2018. Our analysis identifies both high rates of antibiotic consumption and a lack of access to antibiotics, providing a benchmark for future interventions.

FUNDING

Fleming Fund, UK Department of Health and Social Care; Wellcome Trust; and Bill & Melinda Gates Foundation.

Cord serum elementomics profiling of 56 elements depicts risk of preterm birth: Evidence from a prospective birth cohort in rural Bangladesh

Maternal exposure to some individual rare earth elements and trace elements is associated with preterm birth, but few elements have been studied and little is known about the potential effect of simultaneous exposure to multiple elements. We examined individual and mixture effects of elements on preterm birth among 745 pregnant women in a prospective birth cohort in Bangladesh (2008-2011). We measured 56 elements in umbilical cord blood collected during delivery using inductively coupled plasma-mass spectrometry. Using elastic net (ENET) regularization and multivariate logistic regression, we examined independent associations between element concentrations and preterm birth. Bayesian kernel machine regression identified mixture effects of elements most critical to preterm birth, accounting for correlated exposure and interaction. ENET identified titanium (Ti), arsenic (As), and barium (Ba) as the most important predictors of shortened gestational age and preterm birth. In adjusted models, cord blood Ti (OR = 2.52; 95% CI: 1.08-5.93; P = 0.033), As (odds ratio (OR) = 1.34; 95% CI: 1.04-1.73; P = 0.023), and Ba (OR = 1.18; 95% CI: 1.02-1.38; P = 0.029) were significantly associated with preterm birth. Bayesian kernel machine regression suggested an interaction effect between As and Ba. Further, we constructed an element risk score (ERS) using estimated weights from a multivariate regression model for Ti, As, and Ba and regressed preterm birth by this score (OR = 2.72, 95% CI: 1.57-4.69; P = 3.35 × 10-4). Additionally, we observed a significant modification effect of child marriage on ERS, which means marriage before the age of 18 (Pinteraction = 0.0438). This study identified element exposures profiles in cord blood and constructed metal risk score that are jointly associated with the risk of preterm birth. Ti, As, and Ba exposure may adversely affect birth outcomes as well as child marriage may be a modifiable factor potentially affecting environmental element exposure and preterm birth.

Anemia prevalence in women of reproductive age in low- and middle-income countries between 2000 and 2018

Anemia is a globally widespread condition in women and is associated with reduced economic productivity and increased mortality worldwide. Here we map annual 2000-2018 geospatial estimates of anemia prevalence in women of reproductive age (15-49 years) across 82 low- and middle-income countries (LMICs), stratify anemia by severity and aggregate results to policy-relevant administrative and national levels. Additionally, we provide subnational disparity analyses to provide a comprehensive overview of anemia prevalence inequalities within these countries and predict progress toward the World Health Organization's Global Nutrition Target (WHO GNT) to reduce anemia by half by 2030. Our results demonstrate widespread moderate improvements in overall anemia prevalence but identify only three LMICs with a high probability of achieving the WHO GNT by 2030 at a national scale, and no LMIC is expected to achieve the target in all their subnational administrative units. Our maps show where large within-country disparities occur, as well as areas likely to fall short of the WHO GNT, offering precision public health tools so that adequate resource allocation and subsequent interventions can be targeted to the most vulnerable populations.

Immunization status of children in Nepal and associated factors, 2016

BACKGROUND

Nepal has made substantial improvements in childhood immunization uptake. However, vaccination levels are still below the country-specific Sustainable Development Goal target of 94.8% coverage by 2025 for children aged 12-23 months who received all immunizations recommended in the national immunization schedule by their first birthday. A better understanding of the predictors of full immunization can inform successful programmatic interventions to improve coverage while also guiding resource allocation to ensure all children are fully vaccinated. This study estimates childhood immunization coverage in Nepal and characterizes the association between immunization status and various sociodemographic predictors.

METHODS

Data from the 2016 Nepal Demographic and Health Survey were used to examine the immunization status of children aged 12-23 months. Immunization status was categorized as fully immunized (receiving all recommended doses), under-immunized (receiving at least one, but not all, recommended doses), and un-immunized (not receiving any doses of any vaccine). Associations between full and under-immunization and potential sociodemographic predictors were assessed using logistic regression.

RESULTS

Among 976 children, 78.2% were fully immunized, 21% were under-immunized, and 0.8% were un-immunized. Retention of an immunization card was significantly associated with full immunization status. Mothers who had completed a formal education above secondary school and mothers who were working at time of interview had increased odds of full immunization. Birthing in an institutional setting was also associated with higher odds of full immunization.

CONCLUSIONS

Overall, immunization coverage in Nepal is relatively high, although it varies by dose and sociodemographic factors. Almost 25% of Nepalese children were not fully immunized, leaving them at increased risk for vaccine-preventable disease related morbidity and mortality. Nepal must continue focused efforts to reach every child and minimize the equity gap; programs may focus on advocating for the use of immunization cards, education and empowerment for girls, and delivery in institutional settings.

Global, regional, and national progress towards Sustainable Development Goal 3.2 for neonatal and child health: all-cause and cause-specific mortality findings from the Global Burden of Disease Study 2019

BACKGROUND

Sustainable Development Goal 3.2 has targeted elimination of preventable child mortality, reduction of neonatal death to less than 12 per 1000 livebirths, and reduction of death of children younger than 5 years to less than 25 per 1000 livebirths, for each country by 2030. To understand current rates, recent trends, and potential trajectories of child mortality for the next decade, we present the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 findings for all-cause mortality and cause-specific mortality in children younger than 5 years of age, with multiple scenarios for child mortality in 2030 that include the consideration of potential effects of COVID-19, and a novel framework for quantifying optimal child survival.

METHODS

We completed all-cause mortality and cause-specific mortality analyses from 204 countries and territories for detailed age groups separately, with aggregated mortality probabilities per 1000 livebirths computed for neonatal mortality rate (NMR) and under-5 mortality rate (U5MR). Scenarios for 2030 represent different potential trajectories, notably including potential effects of the COVID-19 pandemic and the potential impact of improvements preferentially targeting neonatal survival. Optimal child survival metrics were developed by age, sex, and cause of death across all GBD location-years. The first metric is a global optimum and is based on the lowest observed mortality, and the second is a survival potential frontier that is based on stochastic frontier analysis of observed mortality and Healthcare Access and Quality Index.

FINDINGS

Global U5MR decreased from 71·2 deaths per 1000 livebirths (95% uncertainty interval [UI] 68·3-74·0) in 2000 to 37·1 (33·2-41·7) in 2019 while global NMR correspondingly declined more slowly from 28·0 deaths per 1000 live births (26·8-29·5) in 2000 to 17·9 (16·3-19·8) in 2019. In 2019, 136 (67%) of 204 countries had a U5MR at or below the SDG 3.2 threshold and 133 (65%) had an NMR at or below the SDG 3.2 threshold, and the reference scenario suggests that by 2030, 154 (75%) of all countries could meet the U5MR targets, and 139 (68%) could meet the NMR targets. Deaths of children younger than 5 years totalled 9·65 million (95% UI 9·05-10·30) in 2000 and 5·05 million (4·27-6·02) in 2019, with the neonatal fraction of these deaths increasing from 39% (3·76 million [95% UI 3·53-4·02]) in 2000 to 48% (2·42 million; 2·06-2·86) in 2019. NMR and U5MR were generally higher in males than in females, although there was no statistically significant difference at the global level. Neonatal disorders remained the leading cause of death in children younger than 5 years in 2019, followed by lower respiratory infections, diarrhoeal diseases, congenital birth defects, and malaria. The global optimum analysis suggests NMR could be reduced to as low as 0·80 (95% UI 0·71-0·86) deaths per 1000 livebirths and U5MR to 1·44 (95% UI 1·27-1·58) deaths per 1000 livebirths, and in 2019, there were as many as 1·87 million (95% UI 1·35-2·58; 37% [95% UI 32-43]) of 5·05 million more deaths of children younger than 5 years than the survival potential frontier.

INTERPRETATION

Global child mortality declined by almost half between 2000 and 2019, but progress remains slower in neonates and 65 (32%) of 204 countries, mostly in sub-Saharan Africa and south Asia, are not on track to meet either SDG 3.2 target by 2030. Focused improvements in perinatal and newborn care, continued and expanded delivery of essential interventions such as vaccination and infection prevention, an enhanced focus on equity, continued focus on poverty reduction and education, and investment in strengthening health systems across the development spectrum have the potential to substantially improve U5MR. Given the widespread effects of COVID-19, considerable effort will be required to maintain and accelerate progress.

FUNDING

Bill & Melinda Gates Foundation.

Associations between exposure to landscape fire smoke and child mortality in low-income and middle-income countries: a matched case-control study

BACKGROUND

The prevalence of landscape fires has increased, particularly in low-income and middle-income countries (LMICs). We aimed to assess the impact of exposure to landscape fire smoke (LFS) on the health of children.

METHODS

We conducted a sibling-matched case-control study and selected 552 155 children (aged <18 years) from Demographic and Health Surveys in 55 LMICs from 2000 to 2014. Each deceased child was matched with their sibling(s). The exposure indicators were fire-sourced PM_2·5 and dry-matter emissions. We associated these exposure indicators with child mortality using conditional regressions, and derived an exposure-response function using a non-linear model. Based on the association, we quantified the global burden of fire-attributable child deaths in LMICs from 2000 to 2014.

FINDINGS

Each 1 μg/m³ increment of fire-sourced PM_2·5 was associated with a 2·31% (95% CI 1·50-3·13) increased risk of child mortality. The association was robust to different models. The exposure-response function was superlinear and suggested per-unit exposure to larger fires was more toxic. Based on our non-linear exposure-response function, we estimated that between 2000 and 2014, the five countries with the largest number of child deaths associated with fire-sourced PM_2·5 were Nigeria (164 000 [126 000 to 209 000] annual deaths), Democratic Republic of the Congo (126 000 [95% CI 114 000 to 139 000] annual deaths), India (65 900 [-22 200 to 147 000] annual deaths), Uganda (30 200 [24 500 to 36 300] annual deaths), and Indonesia (28 900 [19 100 to 38 400]).

INTERPRETATION

Exposure to landscape fire smoke contributes substantially to the global burden of child mortality.

FUNDING

National Natural Science Foundation of China, Ministry of Science and Technology of China, Peking University, UK National Institute for Health Research Health Protection Research Unit, Leverhulme Center for Wildfires, Environment and Society, and National Environment Research Council National Capability funding to National Centre for Earth Observation and Energy Foundation.

"Assessing Today for a Better Tomorrow": An observational cohort study about quality of care, mortality and morbidity among newborn infants admitted to neonatal intensive care in Guinea

Background

Neonatal mortality in Guinea accounts for about 30% of all fatalities in children younger than five years. Countrywide, specialized neonatal intensive care is provided in one single clinic with markedly limited resources. To implement targeted measures, prospective data on patient characteristics and factors of neonatal death are needed.

Objective

To determine the rates of morbidity and mortality, to describe clinical characteristics of admitted newborns requiring intensive care, to assess the quality of disease management, and to identify factors contributing to neonatal mortality.

Methods

Prospective observational cohort study of newborns admitted to the hospital between mid-February and mid-March 2019 after birth in other institutions. Data were collected on maternal/prenatal history, delivery, and in-hospital care via convenience sampling. Associations of patient characteristics with in-hospital death were assessed using cause-specific Cox proportional-hazards models.

Results

Half of the 168 admitted newborns underwent postnatal cardiopulmonary resuscitation. Reasons for admission included respiratory distress (49.4%), poor postnatal adaptation (45.8%), prematurity (46.2%), and infections (37.1%). 101 newborns (61.2%) arrived in serious/critical general condition; 90 children (53.9%) showed clinical signs of neurological damage. Quality of care was poor: Only 59.4% of the 64 newborns admitted with hypothermia were externally heated; likewise, 57.1% of 45 jaundiced infants did not receive phototherapy. Death occurred in 56 children (33.3%) due to birth asphyxia (42.9%), prematurity (33.9%), and sepsis (12.5%). Newborns in serious/critical general condition at admission had about a fivefold higher hazard to die than those admitted in good condition (HR 5.21 95%-CI 2.42–11.25, p = <0.0001). Hypothermia at admission was also associated with a higher hazard of death (HR 2.00, 95%-CI 1.10–3.65, p = 0.023).

Conclusion

Neonatal mortality was strikingly high. Birth asphyxia, prematurity, and infection accounted for 89.3% of death, aggravated by poor quality of in-hospital care. Children with serious general condition at admission had poor chances of survival. The whole concept of perinatal care in Guinea requires reconsideration.

The Truman Show for protozoan parasites: A review of in vitro cultivation platforms

Protozoan parasites are responsible for severe disease and suffering in humans worldwide. Apart from disease transmission via insect vectors and contaminated soil, food, or water, transmission may occur congenitally or by way of blood transfusion and organ transplantation. Several recent outbreaks associated with fresh produce and potable water emphasize the need for vigilance and monitoring of protozoan parasites that cause severe disease in humans globally. Apart from the tropical parasite Plasmodium spp., other protozoa causing debilitating and fatal diseases such as Trypanosoma spp. and Naegleria fowleri need to be studied in more detail. Climate change and socioeconomic issues such as migration continue to be major drivers for the spread of these neglected tropical diseases beyond endemic zones. Due to the complex life cycles of protozoa involving multiple hosts, vectors, and stringent growth conditions, studying these parasites has been challenging. While in vivo models may provide insights into host–parasite interaction, the ethical aspects of laboratory animal use and the challenge of ready availability of parasite life stages underline the need for in vitro models as valid alternatives for culturing and maintaining protozoan parasites. To our knowledge, this review is the first of its kind to highlight available in vitro models for protozoa causing highly infectious diseases. In recent years, several research efforts using new technologies such as 3D organoid and spheroid systems for protozoan parasites have been introduced that provide valuable tools to advance complex culturing models and offer new opportunities toward the advancement of parasite in vitro studies. In vitro models aid scientists and healthcare providers in gaining insights into parasite infection biology, ultimately enabling the use of novel strategies for preventing and treating these diseases.

In light of the far-reaching social and economic repercussions of communicable, zoonotic parasitic diseases on human health, it is imperative to continue to strive toward developing in vitro models for in-depth scrutiny and understanding of pathogenicity, as well as for innovations toward combating these infections. This review, to our knowledge, is the first to offer a qualitative summary of the existing models for culturing protozoan parasites with major relevance to human health in vitro. The present work aims to provide a reference guide on the current state of in vitro culture of these protozoan parasites and offers a foundation to facilitate exchange of expertise among researchers, clinicians, and healthcare workers. This comprehensive review would aid in enabling discussions on new intervention approaches to fill in the knowledge gaps in the field of parasitic diseases affecting the global population.

A novel approach to modeling epidemic vulnerability, applied to Aedes aegypti-vectored diseases in Perú

Background

A proactive approach to preventing and responding to emerging infectious diseases is critical to global health security. We present a three-stage approach to modeling the spatial distribution of outbreak vulnerability to Aedes aegypti-vectored diseases in Perú.

Methods

Extending a framework developed for modeling hemorrhagic fever vulnerability in Africa, we modeled outbreak vulnerability in three stages: index case potential (stage 1), outbreak receptivity (stage 2), and epidemic potential (stage 3), stratifying scores on season and El Niño events. Subsequently, we evaluated the validity of these scores using dengue surveillance data and spatial models.

Results

We found high validity for stage 1 and 2 scores, but not stage 3 scores. Vulnerability was highest in Selva Baja and Costa, and in summer and during El Niño events, with index case potential (stage 1) being high in both regions but outbreak receptivity (stage 2) being generally high in Selva Baja only.

Conclusions

Stage 1 and 2 scores are well-suited to predicting outbreaks of Ae. aegypti-vectored diseases in this setting, however stage 3 scores appear better suited to diseases with direct human-to-human transmission. To prevent outbreaks, measures to detect index cases should be targeted to both Selva Baja and Costa, while Selva Baja should be prioritized for healthcare system strengthening. Successful extension of this framework from hemorrhagic fevers in Africa to an arbovirus in Latin America indicates its broad utility for outbreak and pandemic preparedness and response activities.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-021-06530-9.

Effect of health systems context on infant and child mortality in sub-Saharan Africa from 1995 to 2015, a longitudinal cohort analysis

Each year, > 3 million children die in sub-Saharan Africa before their fifth birthday. Most deaths are preventable or avoidable through interventions delivered in the primary healthcare system. However, evidence regarding the impact of health system characteristics on child survival is sparse. We assembled a retrospective cohort of > 250,000 children in seven countries in sub-Saharan Africa. We described their health service context at the subnational level using standardized surveys and employed parametric survival models to estimate the effect of three major domains of health services—quality, access, and cost—on infant and child survival, after adjusting for child, maternal, and household characteristics. Between 1995 and 2015 we observed 13,629 deaths in infants and 5149 in children. In fully-adjusted models, the largest effect sizes were related to fees for services. Immunization fees were correlated with poor child survival (HR = 1.20, 95% CI 1.12–1.28) while delivery fees were correlated with poor infant survival (HR = 1.11, 95% CI 1.01–1.21). Accessibility of facilities and greater concentrations of private facilities were associated with improved infant and child survival. The proportion of facilities with a doctor was correlated with increased risk of death in children and infants. We quantify the impact of health service environment on survival up to five years of age. Reducing health care costs and improving the accessibility of health facilities should remain a priority for improving infant and child survival. In the absence of these fundamental investments, more specialized interventions may not achieve their desired impact.

AK, Murki S, Roehr CC. ELBW and ELGAN outcomes in developing nations-Systematic review and meta-analysis

Context

Morbidity and mortality amongst extremely low birth weight (ELBW) and extremely low gestational age neonates (ELGANs) in developing nations has not been well studied.

Objectives

Evaluate survival until discharge, short- and long-term morbidities of ELBW and ELGANs in LMICs.

Data sources

CENTRAL, EMBASE, MEDLINE and Web of Science.

Study selection

Prospective and retrospective observational studies were included.

Data extraction and synthesis

Four authors extracted data independently. Random-effects meta-analysis of proportions was used to synthesize data, modified QUIPS scale to evaluate quality of studies and GRADE approach to ascertain the certainty of evidence (CoE).

Results

192 studies enrolling 22,278 ELBW and 18,338 ELGANs were included. Survival was 34% (95% CI: 31% - 37%) (CoE–low) for ELBW and 39% (34% - 44%) (CoE—moderate) for ELGANs. For ELBW neonates, the survival for low-income (LI), lower middle-income (LMI) and upper middle income (UMI) countries was 18% (11% - 28%), 28% (21% - 35%) and 39% (36% - 42%), respectively. For ELGANs, it was 13% (8% - 20%) for LI, 28% (21% - 36%) for LMI and 48% (42% - 53%) for UMI countries. There was no difference in survival between two epochs: 2000–2009 and 2010–2020. Except for necrotising enterocolitis [ELBW and ELGANs—8% (7% - 10%)] and periventricular leukomalacia [ELBW—7% (4% - 11%); ELGANs—6% (5%-7%)], rates of all other morbidities were higher compared to developed nations. Rates of neurodevelopmental impairment was 17% (7% - 34%) in ELBW neonates and 29% (23% - 37%) in ELGANs.

Limitations

CoE was very low to low for all secondary outcomes.

Conclusions

Mortality and morbidity amongst ELBW and ELGANs is still a significant burden in LMICs. CoE was very low to low for all the secondary outcomes, emphasizing the need for high quality prospective cohort studies.

Trial registration

PROSPERO (CRD42020222873).

Neonatal surgical outcomes: a prospective observational study at a Tertiary Academic Hospital in Johannesburg, South Africa

PURPOSE

The neonatal period is the most vulnerable period for a child. There is a paucity of data on the burden of neonatal surgical disease in our setting. The aim of this study was to describe the frequency with which index neonatal surgical conditions are seen within our setting and to document the 30-day outcome of these patients.

METHODS

This was a single-centre prospective observational study in which all neonates with paediatric surgical pathology referred to the paediatric surgical unit with a corrected gestational age of 28 days were included.

RESULTS

Necrotising enterocolitis was the most frequent reason for referral to the paediatric surgical unit (n = 68, 34.34%). Gastroschisis was the most frequent congenital anomaly referred (n = 20, 10.10%). The overall morbidity was 57.58%. Surgical complications contributed to 18.51% of morbidities. The development of gram negative nosocomial sepsis was the most frequent cause of morbidity (n = 98, 50.78%). Mortality at 30 days was 21.74% (n = 40). Sepsis contributed to mortality in 35 patients (87.5%), 16 of which had gram negative sepsis.

CONCLUSION

Gram-negative sepsis was a major contributing factor in the development of morbidity and mortality in our cohort. Prevention and improvement in infection control are imperative if we are to improve outcomes in our surgical neonates.

Mapping inequalities in exclusive breastfeeding in low- and middle-income countries, 2000-2018

Exclusive breastfeeding (EBF)-giving infants only breast-milk for the first 6 months of life-is a component of optimal breastfeeding practices effective in preventing child morbidity and mortality. EBF practices are known to vary by population and comparable subnational estimates of prevalence and progress across low- and middle-income countries (LMICs) are required for planning policy and interventions. Here we present a geospatial analysis of EBF prevalence estimates from 2000 to 2018 across 94 LMICs mapped to policy-relevant administrative units (for example, districts), quantify subnational inequalities and their changes over time, and estimate probabilities of meeting the World Health Organization's Global Nutrition Target (WHO GNT) of ≥70% EBF prevalence by 2030. While six LMICs are projected to meet the WHO GNT of ≥70% EBF prevalence at a national scale, only three are predicted to meet the target in all their district-level units by 2030.

The introduction of clinical genetic testing in Ethiopia: Experiences and lessons learned

Limited data are available on genetic testing laboratories in low- and middle-income countries including those in sub-Saharan Africa (SSA). To characterize the need for genetic testing in SSA we describe the experience of MRC-ET Advanced Laboratory, a genetic testing laboratory in Ethiopia. Test results were analyzed based on indication(s) for testing, referral category, and diagnostic yield. A total of 1311 tests were run using the full MRC-Holland catalogue of Multiplex-Ligation Probe Amplification assays. Of all samples, 77% were postnatal samples, 15% products of conception (POC), and 8% amniotic samples. Of postnatal samples, the most common testing categories were multiple congenital anomalies (32%), disorders of sex development (17%), and Obstetrics/Gynecology (16%). Forty-three percent of postnatal samples were diagnostic, 11% were variants of uncertain significance (VUS), and 46% were normal with Trisomy 21 the most common diagnosis. Of POC samples, 10% were diagnostic, 34% revealed VUSs, and 55% were normal with Trisomy 18 the most common diagnosis. Of amniotic samples 17.5% were diagnostic, 3% revealed VUSs, and 79% were normal with Trisomy 18 the most common diagnosis. There is increasing demand for genetic testing in Ethiopia. Diagnostic genetic testing in SSA deserves increased attention as testing platforms become more affordable.

Impact of Air Pollution (PM2.5) on Child Mortality: Evidence from Sixteen Asian Countries

Air pollution in Asian countries represents one of the biggest health threats given the varied levels of economic and population growth in the recent past. The quantification of air pollution (PM_2.5) vis à vis health problems has important policy implications in tackling its health effects. This paper investigates the relationship between air pollution (PM_2.5) and child mortality in sixteen Asian countries using panel data from 2000 to 2017. We adopt a two-stage least squares approach that exploits variations in PM_2.5 attributable to economic growth in estimating the effect on child mortality. We find that a one-unit annual increase in PM_2.5 leads to a nearly 14.5% increase in the number of children dying before the age of five, suggesting the severity of the effects of particulate matter (PM_2.5) on health outcomes in sixteen Asian countries considered in this study. The results of this study suggest the need for strict policy interventions by governments in Asian countries to reduce PM_2.5 concentration alongside environment-friendly policies for economic growth.

Geostatistical analysis, web-based mapping, and environmental determinants of under-5 stunting: evidence from the 2014 Ghana Demographic and Health Survey

BACKGROUND

Stunting rates in children younger than 5 years are among the most important health indicators globally. At the national level, malnutrition accounts for about 40% of under-5 deaths in Ghana. Disease risk mapping provides opportunities for disease surveillance and targeted interventions. We aimed to estimate and map under-5 stunting prevalence in Ghana, with the goal of identifying communities at higher risk where interventions and further research can be targeted.

METHODS

For this modelling study, we used data from the 2014 Ghana Demographic and Health Survey. Analyses were done on 2734 children residing in 415 geographical clusters. The outcome variable was the number of stunted children younger than 5 years in each sampled cluster. We employed a Bayesian geostatistical model to investigate both measured and unmeasured spatial risk factors for child stunting, comparing the performance of non-spatial (adjusting for selected covariates without spatial correlation), spatial (including spatial correlation), and null spatial (without the selected covariates) models. We then visualised the stunting prevalence across Ghana by mapping the predicted prevalence and exceedance probabilities to resolutions as refined as 5 km × 5 km.

FINDINGS

In 2014, 535 (19·6%) of 2734 children surveyed in Ghana were stunted. Elevation (log odds mean -0·0017, 95% credible interval -0·0034 to -0·0001), precipitation (0·0403, 0·0192 to 0·0615), and aridity (-3·7013, -6·5478 to -0·8723) were environmental and climatic factors associated with stunting in the non-spatial model, but were not significant in the spatial model. Substantial geographical variations in prevalence of childhood stunting were found. The predicted mean stunting prevalence was 27·7% (SD 3·7%) with predicted prevalence ranging from 4·2% to 45·1% across Ghana. Children residing in parts of the Northern region were at highest risk of stunting, whereas parts of the Greater Accra, Brong-Ahafo, Ashanti, and Eastern regions showed some of the lowest prevalence.

INTERPRETATION

There are substantial geographical differences in childhood stunting across Ghana. Our prevalence maps can be used as an effective tool to identify communities that require targeted interventions by programme managers and implementers, as part of an overall strategy to reduce the burden of malnutrition in a country with limited public health resources.

FUNDING

None.

Modelling the potential cost-effectiveness of food-based programs to reduce malnutrition

Poor quality diets contribute to malnutrition globally, but evidence is weak on the cost-effectiveness of food-based interventions that shift diets. This study assessed 11 candidate interventions developed through Delphi techniques to improve diets in India, Nigeria, and Ethiopia. A Markov simulation model incorporated time, individual-level, nutrition, and policy parameters to estimate health impacts and cost-effectiveness for reducing stunting, anaemia, diarrhea, and mortality in preschool children. At an assumed 80% coverage, interventions considered would potentially save between 0·16 and 3·20 years of life per child. The average cost-effectiveness ratio ranged from US$9 to US$2000 per life year saved. This approach, linking expert knowledge, known costs, and modelling, offers potential for estimating cost-effective investments for better informed policy choice where empirical evidence is limited.

•

Few studies estimate the potential cost-effectiveness of programs for improving health through diets.

•

Expert knowledge linked to modelling offers a basis for assessing potential alternatives where data are lacking.

•

Our analysis assessed 11 candidate interventions for Ethiopia, India, and Nigeria derived from local expert opinion.

•

Modelling demonstrates these programs' potential health impacts and cost-effectiveness.

•

The modelling of estimated benefits can support best-buy policy and program choices.

Age-based targeting of biannual azithromycin distribution for child survival in Niger: an adaptive cluster-randomized trial protocol (AVENIR)

BACKGROUND

Biannual distribution of azithromycin to children 1-59 months old reduced mortality by 14% in a cluster-randomized trial. The World Health Organization has proposed targeting this intervention to the subgroup of children 1-11 months old to reduce selection for antimicrobial resistance. Here, we describe a trial designed to determine the impact of age-based targeting of biannual azithromycin on mortality and antimicrobial resistance.

METHODS

AVENIR is a cluster-randomized, placebo-controlled, double-masked, response-adaptive large simple trial in Niger. During the 2.5-year study period, 3350 communities are targeted for enrollment. In the first year, communities in the Dosso region will be randomized 1:1:1 to 1) azithromycin 1-11: biannual azithromycin to children 1-11 months old with placebo to children 12-59 months old, 2) azithromycin 1-59: biannual azithromycin to children 1-59 months old, or 3) placebo: biannual placebo to children 1-59 months old. Regions enrolled after the first year will be randomized with an updated allocation based on the probability of mortality in children 1-59 months in each arm during the preceding study period. A biannual door-to-door census will be conducted to enumerate the population, distribute azithromycin and placebo, and monitor vital status. Primary mortality outcomes are defined as all-cause mortality rate (deaths per 1000 person-years) after 2.5 years from the first enrollment in 1) children 1-59 months old comparing the azithromycin 1-59 and placebo arms, 2) children 1-11 months old comparing the azithromycin 1-11 and placebo arm, and 3) children 12-59 months in the azithromycin 1-11 and azithromycin 1-59 arms. In the Dosso region, 50 communities from each arm will be followed to monitor antimicrobial resistance. Primary resistance outcomes will be assessed after 2 years of distributions and include 1) prevalence of genetic determinants of macrolide resistance in nasopharyngeal samples from children 1-59 months old, and 2) load of genetic determinants of macrolide resistance in rectal samples from children 1-59 months old.

DISCUSSION

As high-mortality settings consider this intervention, the results of this trial will provide evidence to support programmatic and policy decision-making on age-based strategies for azithromycin distribution to promote child survival.

TRIAL REGISTRATION

This trial was registered on January 13, 2020 (clinicaltrials.gov: NCT04224987 ).

Space-time modeling of child mortality at the Admin-2 level in a low and middle income countries context

The Sustainable Development Goals call for a total reduction of preventable child mortality before 2030. Further, the goals state the desirability to have subnational mortality estimates. Estimates at this level are required for health interventions at the subnational level. In a low and middle income countries context, the data on mortality typically consist of household surveys, which are carried out with a stratified, cluster design, and census microsamples. Most household surveys collect full birth history (FBH) data on birth and death dates of a mother's children, but censuses collect summary birth history (SBH) data which consist only of the number of children born and the number that died. In previous work, direct (survey-weighted) estimates with associated variances were derived from FBH data and smoothed in space and time. Unfortunately, the FBH data from household surveys are usually not sufficiently abundant to obtain yearly estimates at the Admin-2 level (at which interventions are often made). In this paper we describe four extensions to previous work: (i) combining SBH data with FBH data, (ii) modeling on a yearly scale, to combine data on a yearly scale with data at coarser time scales, (iii) adjusting direct estimates in Admin-2 areas where we do not observe any deaths due to small sample sizes, (iv) acknowledge differences in data sources by modeling potential bias arising from the various data sources. The methods are illustrated using household survey and census data from Kenya and Malawi, to produce mortality estimates from 1980 to the time of the most recent survey, and predictions to 2020.

Inequalities in the Universal Right to Health

Child health inequalities violate children's rights to optimal wellbeing. Different issues worldwide affect children's physical and mental health as well as their development, influencing their future as adults. Inequities are avoidable inequalities. Despite improvements in the past two decades, the ambitious goals of global agendas have, for the most part, remained as expectations with regard to childhood rights, social justice, and health equity in practice. The concept of social determinants of health has become part of the common language in certain settings, but this is still too little to improve health in practice on a global scale, particularly for underprivileged subgroups of the community, as children and adolescents often are. Pediatric health professionals and their organizations are also responsible for guaranteeing children's and adolescents' right to health and better wellbeing, helping to reduce health inequalities.

Distance to primary care facilities and healthcare utilization for preschool children in rural northwestern Burkina Faso: results from a surveillance cohort

Background

Delays in care-seeking for childhood illness may lead to more severe outcomes. We evaluated whether community distance from a primary healthcare facility was associated with decreased healthcare utilization in a rural district of northwestern Burkina Faso.

Methods

We conducted passive surveillance of all government-run primary healthcare facilities in Nouna District, Burkina Faso from March 1 through May 31, 2020. All healthcare visits for children under 5 years of age were recorded on a standardized form for sick children. We recorded the age, sex, and community of residence of the child as well as any diagnoses and treatments administered. We calculated healthcare utilization per 100 child-months by linking the aggregate number of visits at the community level to the community’s population of children under 5 months per a census that was conducted from August 2019 through February 2020. We calculated the distance between each community and its corresponding healthcare facility and assessed the relationship between distance and the rate of healthcare utilization.

Results

In 226 study communities, 12,676 primary healthcare visits were recorded over the three-month period. The median distance between the community and primary healthcare facility was 5.0 km (IQR 2.6 to 6.9 km), and median number of healthcare visits per 100 child-months at the community level was 6.7 (IQR 3.7 to 12.3). The rate of primary healthcare visits declined with increasing distance from clinic (Spearman’s rho − 0.42, 95% CI − 0.54 to − 0.31, P < 0.0001). This relationship was similar for cause-specific clinic visits (including pneumonia, malaria, and diarrhea) and for antibiotic prescriptions.

Conclusions

We documented a distance decay effect between community distance from a primary healthcare facility and the rate of healthcare visits for children under 5. Decreasing distance-related barriers, for example by increasing the number of facilities or targeting outreach to more distant communities, may improve healthcare utilization for young children in similar settings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06226-5.

Climate change and child health: a scoping review and an expanded conceptual framework

Climate change can have detrimental effects on child health and wellbeing. Despite the imperative for a fuller understanding of how climate change affects child health and wellbeing, a systematic approach and focus solely on children (aged <18 years) has been lacking. In this Scoping Review, we did a literature search on the impacts of climate change on child health from January, 2000, to June, 2019. The included studies explicitly linked an alteration of an exposure to a risk factor for child health to climate change or climate variability. In total, 2970 original articles, reviews, and other documents were identified, of which 371 were analysed. Employing an expanded framework, our analysis showed that the effects of climate change on child health act through direct and indirect pathways, with implications for determinants of child health as well as morbidity and mortality from a range of diseases. This understanding can be further enhanced by using a broader range of research methods, studying overlooked populations and geographical regions, investigating the costs and benefits of mitigation and adaptation for child health, and considering the position of climate change and child health within the UN Sustainable Development Goals. Present and future generations of children bear and will continue to bear an unacceptably high disease burden from climate change.

COVID-19: Rethinking the Lockdown Groupthink

The Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) has caused the Coronavirus Disease 2019 (COVID-19) worldwide pandemic in 2020. In response, most countries in the world implemented lockdowns, restricting their population's movements, work, education, gatherings, and general activities in attempt to "flatten the curve" of COVID-19 cases. The public health goal of lockdowns was to save the population from COVID-19 cases and deaths, and to prevent overwhelming health care systems with COVID-19 patients. In this narrative review I explain why I changed my mind about supporting lockdowns. The initial modeling predictions induced fear and crowd-effects (i.e., groupthink). Over time, important information emerged relevant to the modeling, including the lower infection fatality rate (median 0.23%), clarification of high-risk groups (specifically, those 70 years of age and older), lower herd immunity thresholds (likely 20-40% population immunity), and the difficult exit strategies. In addition, information emerged on significant collateral damage due to the response to the pandemic, adversely affecting many millions of people with poverty, food insecurity, loneliness, unemployment, school closures, and interrupted healthcare. Raw numbers of COVID-19 cases and deaths were difficult to interpret, and may be tempered by information placing the number of COVID-19 deaths in proper context and perspective relative to background rates. Considering this information, a cost-benefit analysis of the response to COVID-19 finds that lockdowns are far more harmful to public health (at least 5-10 times so in terms of wellbeing years) than COVID-19 can be. Controversies and objections about the main points made are considered and addressed. Progress in the response to COVID-19 depends on considering the trade-offs discussed here that determine the wellbeing of populations. I close with some suggestions for moving forward, including focused protection of those truly at high risk, opening of schools, and building back better with a economy.

A Systematic Review and Appraisal of Epidemiological Studies on Household Fuel Use and Its Health Effects Using Demographic and Health Surveys

The domestic combustion of polluting fuels is associated with an estimated 3 million premature deaths each year and contributes to climate change. In many low- and middle-income countries (LMICs), valid and representative estimates of people exposed to household air pollution (HAP) are scarce. The Demographic and Health Survey (DHS) is an important and consistent source of data on household fuel use for cooking and has facilitated studies of health effects. However, the body of research based on DHS data has not been systematically identified, nor its strengths and limitations critically assessed as a whole. We aimed to systematically review epidemiological studies using DHS data that considered cooking fuel type as the main exposure, including the assessment of the extent and key drivers of bias. Following PRISMA guidelines, we searched PubMed, Web of Science, Scopus and the DHS publication portal. We assessed the quality and risk of bias (RoB) of studies using a novel tool. Of 2748 records remaining after removing duplicates, 63 were read in full. A total of 45 out of 63 studies were included in our review, spanning 11 different health outcomes and representing 50 unique analyses. In total, 41 of 45 (91%) studies analysed health outcomes in children <5 years of age, including respiratory infections (n = 17), death (all-cause) (n = 14), low birthweight (n = 5), stunting and anaemia (n = 5). Inconsistencies were observed between studies in how cooking fuels were classified into relatively high- and low-polluting. Overall, 36/50 (80%) studies reported statistically significant adverse associations between polluting fuels and health outcomes. In total, 18/50 (36%) of the analyses were scored as having moderate RoB, while 16/50 (32%) analyses were scored as having serious or critical RoB. Although HAP exposure assessment is not the main focus of the DHS, it is the main, often only, source of information in many LMICs. An appreciable proportion of studies using it to analyse the association between cooking fuel use and health have potential for high RoB, mostly related to confounder control, exposure assessment and misclassification, and outcome ascertainment. Based on our findings, we provide some suggestions for ways in which revising the information collected by the DHS could make it even more amenable to studies of household fuel use and health, and reduce the RoB, without being onerous to collect and analyse.

Harmonizing child mortality data at disparate geographic levels

There is an increasing focus on reducing inequalities in health outcomes in developing countries. Subnational variation is of particular interest, with geographically-indexed data being used to understand the spatial risk of detrimental outcomes and to identify who is at greatest risk. While some health surveys provide observations with associated geographic coordinates (point data), many others provide data that have their locations masked and instead only report the strata (polygon information) within which the data resides (masked data). How to harmonize these data sources for spatial analysis has been previously considered although only ad hoc methods and comparison of methods is lacking. In this paper, we present a new method for analyzing masked survey data, using a method that is consistent with the data-generating process. In addition, we critique two previously proposed approaches to analyzing masked data and illustrate that they are fundamentally flawed methodologically. To validate our method, we compare our approach with previously formulated solutions in several realistic simulation environments in which the underlying structure of the risk field is known. We simulate samples from spatiotemporal fields in a way that mimics the sampling frame implemented in the most common health surveys in low- and middle-income countries, the Demographic and Health Surveys and Multiple Indicator Cluster Surveys. In simulations, the newly proposed approach outperforms previously proposed approaches in terms of minimizing error while increasing the precision of estimates. The approaches are subsequently compared using child mortality data from the Dominican Republic where our findings are reinforced. The ability to accurately increase precision of child mortality estimates, and health outcomes in general, by leveraging various types of data, improves our ability to implement precision public health initiatives and better understand the landscape of geographic health inequalities.

Mapping subnational HIV mortality in six Latin American countries with incomplete vital registration systems

BACKGROUND

Human immunodeficiency virus (HIV) remains a public health priority in Latin America. While the burden of HIV is historically concentrated in urban areas and high-risk groups, subnational estimates that cover multiple countries and years are missing. This paucity is partially due to incomplete vital registration (VR) systems and statistical challenges related to estimating mortality rates in areas with low numbers of HIV deaths. In this analysis, we address this gap and provide novel estimates of the HIV mortality rate and the number of HIV deaths by age group, sex, and municipality in Brazil, Colombia, Costa Rica, Ecuador, Guatemala, and Mexico.

METHODS

We performed an ecological study using VR data ranging from 2000 to 2017, dependent on individual country data availability. We modeled HIV mortality using a Bayesian spatially explicit mixed-effects regression model that incorporates prior information on VR completeness. We calibrated our results to the Global Burden of Disease Study 2017.

RESULTS

All countries displayed over a 40-fold difference in HIV mortality between municipalities with the highest and lowest age-standardized HIV mortality rate in the last year of study for men, and over a 20-fold difference for women. Despite decreases in national HIV mortality in all countries-apart from Ecuador-across the period of study, we found broad variation in relative changes in HIV mortality at the municipality level and increasing relative inequality over time in all countries. In all six countries included in this analysis, 50% or more HIV deaths were concentrated in fewer than 10% of municipalities in the latest year of study. In addition, national age patterns reflected shifts in mortality to older age groups-the median age group among decedents ranged from 30 to 45 years of age at the municipality level in Brazil, Colombia, and Mexico in 2017.

CONCLUSIONS

Our subnational estimates of HIV mortality revealed significant spatial variation and diverging local trends in HIV mortality over time and by age. This analysis provides a framework for incorporating data and uncertainty from incomplete VR systems and can help guide more geographically precise public health intervention to support HIV-related care and reduce HIV-related deaths.

Joint Modeling of Singleton Preterm Birth and Perinatal Death Using Birth Registry Cohort Data in Northern Tanzania

Understanding independent and joint predictors of adverse pregnancy outcomes is essential to inform interventions toward achieving sustainable development goals. We aimed to determine the joint predictors of preterm birth and perinatal death among singleton births in northern Tanzania based on cohort data from the Kilimanjaro Christian Medical Center (KCMC) zonal referral hospital birth registry between 2000 and 2017. We determined the joint predictors of preterm birth and perinatal death using the random-effects models to account for the correlation between these outcomes. The joint predictors of higher preterm birth and perinatal death risk were inadequate (<4) antenatal care (ANC) visits, referred for delivery, experiencing pre-eclampsia/eclampsia, postpartum hemorrhage, low birth weight, abruption placenta, and breech presentation. Younger maternal age (15-24 years), premature rupture of membranes, placenta previa, and male children had higher odds of preterm birth but a lessened likelihood of perinatal death. These findings suggest ANC is a critical entry point for delivering the recommended interventions to pregnant women, especially those at high risk of experiencing adverse pregnancy outcomes. Improved management of complications during pregnancy and childbirth and the postnatal period may eventually lead to a substantial reduction of adverse perinatal outcomes and improving maternal and child health.

Vitamin D deficiency is associated with painful diabetic neuropathy

BACKGROUND

The aetiology of painful diabetic neuropathy is unclear. We have evaluated vitamin D levels in diabetic patients with and without painful neuropathy.

METHODS

Forty-three patients with type 1 diabetes and painless (DPN) (n = 20) or painful (PDN) (n = 23) neuropathy and 14 non-diabetic healthy control subjects (C) underwent assessment of neurologic deficits, quantitative sensory testing (QST), electrophysiology, skin biopsy, corneal confocal microscopy (CCM) and measurement of serum 25(OH)D.

RESULTS

There were no significant differences for age, BMI, HbA_1c , lipids, neurological deficits, QST, electrophysiology, intra-epidermal nerve fibre density (IENFD) and corneal nerve morphology between patients with DPN and PDN. Both positive (hyperalgesia and allodynia) and negative symptoms (paraesthesia and numbness) of diabetic neuropathy were greater in PDN compared with DPN (P = .009 and P = .02, respectively). Serum 25(OH)D levels were significantly lower in PDN (24.0 ± 14.1 ng/mL) compared with DPN (34.6 ± 15.0 ng/mL, P = .01) and controls (34.1 ± 8.6 ng/mL, P = .03). The odds ratio in favour of painful diabetic neuropathy was 9.8 [P = .003 (95% CI, 2.2-76.4)] for vitamin D deficiency (<20 ng/mL) and 4.4 [P = .03 (95% CI, 1.1-19.8)] for vitamin D insufficiency (<30 ng/mL).

CONCLUSIONS

This study suggests that vitamin D deficiency and insufficiency are associated with painful diabetic neuropathy.

Estimation of pregnancy losses attributable to exposure to ambient fine particles in south Asia: an epidemiological case-control study

BACKGROUND

Maternal exposure to ambient particulate matter (PM_2·5) is associated with pregnancy loss (ie, stillbirth and miscarriage). South Asia has the highest burden of pregnancy loss globally and is one of the most PM_2·5 polluted regions in the world. However, knowledge of the relevant exposure-response function for mothers is insufficient.

METHODS

In this epidemiological case-control study, we collected data from Demographic and Health Surveys from India, Pakistan, and Bangladesh for the period 1998-2016 for women who reported at least one pregnancy loss and one or more livebirths. We assessed ambient exposure during gestation with satellite-based PM_2·5 measurements for the period. To derive the exposure-response function, we did a self-compared case-control study in which each case of pregnancy loss was compared with a successful livebirth control or controls by the same mother. Using the estimated exposure-response function, we quantified pregnancy losses attributable to PM_2·5 in the region for the period 2000-16 using a standard risk assessment approach.

FINDINGS

We assessed data for 34 197 mothers, who had at least one pregnancy loss and one or more livebirth, of whom 26 282 (76·9%) were from India, 4228 (12·4%) were from Pakistan, and 3687 (10·8%) were from Bangladesh. The 34 197 cases of pregnancy loss were matched with 76 282 livebirth controls. The mean level of PM_2·5 exposure was 56·00 μg/m³ (SD 30·82) for cases and 54·57 μg/m³ (31·73) for controls. After adjustment for maternal age, non-linear terms for temperature and humidity, seasonal variation, and long-term trends, each 10 μg/m³ increment in PM_2·5 was associated with an odds ratio for pregnancy loss of 1·03 (95% CI 1·02-1·05). According to the estimated non-linear exposure-response function by age and urban residence versus rural residence, for the period 2000-16, an estimated 349 681 (95% CI 152 932-489 493) pregnancy losses per year were attributed to ambient air exposure of more than 40 μg/m³ (the annual PM_2·5 standard of India), accounting for 7·1% (95% CI 3·3-31·2) of the total annual pregnancy loss burden in south Asia for this period. However, our estimates could be biased because of the limitations of the data (eg, misclassification of induced and spontaneous pregnancy losses).

INTERPRETATION

Our findings add to epidemiological evidence of the association between pregnancy loss and PM_2·5. Suboptimal air quality contributes to a considerable fraction of total pregnancy loss in south Asia. Controlling PM_2·5 pollution will promote maternal health in south Asia.

FUNDING

Chinese Natural Science Foundation and Ministry of Science and Technology of China.

Mapping routine measles vaccination in low- and middle-income countries

The safe, highly effective measles vaccine has been recommended globally since 1974, yet in 2017 there were more than 17 million cases of measles and 83,400 deaths in children under 5 years old, and more than 99% of both occurred in low- and middle-income countries (LMICs)1-4. Globally comparable, annual, local estimates of routine first-dose measles-containing vaccine (MCV1) coverage are critical for understanding geographically precise immunity patterns, progress towards the targets of the Global Vaccine Action Plan (GVAP), and high-risk areas amid disruptions to vaccination programmes caused by coronavirus disease 2019 (COVID-19)5-8. Here we generated annual estimates of routine childhood MCV1 coverage at 5 × 5-km2 pixel and second administrative levels from 2000 to 2019 in 101 LMICs, quantified geographical inequality and assessed vaccination status by geographical remoteness. After widespread MCV1 gains from 2000 to 2010, coverage regressed in more than half of the districts between 2010 and 2019, leaving many LMICs far from the GVAP goal of 80% coverage in all districts by 2019. MCV1 coverage was lower in rural than in urban locations, although a larger proportion of unvaccinated children overall lived in urban locations; strategies to provide essential vaccination services should address both geographical contexts. These results provide a tool for decision-makers to strengthen routine MCV1 immunization programmes and provide equitable disease protection for all children.

Correlates of Health Care Workers' Knowledge and HIV-Exposed Infant Immunization Counseling Practice in Northern Nigeria

BACKGROUND

Human Immunodeficiency Virus (HIV)-exposed and HIV-infected infants are at increased risk of vaccine-preventable diseases. However, little is known about health care workers' knowledge and immunization counseling practices in this population. We determined the predictors of health care workers' knowledge of vertical transmission risks, HIV exposed/infected infant immunization, and counseling practices in a tertiary center in Northern Nigeria.

METHODS

A cross-section of 297 health workers were interviewed using a structured, validated questionnaire. Knowledge and HIV-exposed infant immunization counseling practices were analyzed, and adjusted odds ratios for predictors were derived from logistic regression models.

RESULTS

Of the 297 participating health care workers, (32.3%, n=96) had adequate knowledge of HIV-exposed/infected infant immunization. Two-thirds (67%, n=199) of the participants appropriately identified the timing of infant diagnosis, while (73%, n=217) and (56.2%, n=167) correctly categorized infants as HIV-exposed and HIV-infected, respectively. Only (19.5%, n=58) participants had ever counselled a HIV-positive mother on infant immunization. Knowledge was predicted by work unit (HIV clinic vs. Obstetrics & Gynecology clinic), (Adjusted Odds Ratio (AOR) =3.78, 95% CI: 1.27-5.54), age (30-39 vs. <30 years), (AOR=2.24, 95% CI:1.19-5.67), years of experience (≥10 vs. <5), (AOR=1.76, 95% CI: 1.15-6.04), number of children (1 vs. 0), (AOR=1.73, 95% CI:1.14-4.23), infant immunization training (yes vs. no), (AOR=1.57, 95% CI:1.12-5.43), female sex (AOR = 1.17, 95% CI:1.06-2.21), profession (nurse/midwife vs. physician), (AOR=0.44, 95% CI:0.21-0.94) and previous HIV test (no vs. yes), (AOR=0.67, 95% CI:0.21-0.83).

CONCLUSION AND GLOBAL HEALTH IMPLICATIONS

Knowledge of HIV-exposed infant immunization was low and counseling practices were sub-optimal. Both immunization knowledge and counseling practices were predicted by demographic, professional, and training variables. Our findings indicate the need for educating health care workers on HIV exposed/infected infant immunization policy and improving counseling skills through capacity-building programs.

Oral rehydration therapies in Senegal, Mali, and Sierra Leone: a spatial analysis of changes over time and implications for policy

BACKGROUND

Oral rehydration solution (ORS) is a simple intervention that can prevent childhood deaths from severe diarrhea and dehydration. In a previous study, we mapped the use of ORS treatment subnationally and found that ORS coverage increased over time, while the use of home-made alternatives or recommended home fluids (RHF) decreased, in many countries. These patterns were particularly striking within Senegal, Mali, and Sierra Leone. It was unclear, however, whether ORS replaced RHF in these locations or if children were left untreated, and if these patterns were associated with health policy changes.

METHODS

We used a Bayesian geostatistical model and data from household surveys to map the percentage of children with diarrhea that received (1) any ORS, (2) only RHF, or (3) no oral rehydration treatment between 2000 and 2018. This approach allowed examination of whether RHF was replaced with ORS before and after interventions, policies, and external events that may have impacted healthcare access.

RESULTS

We found that RHF was replaced with ORS in most Sierra Leone districts, except those most impacted by the Ebola outbreak. In addition, RHF was replaced in northern but not in southern Mali, and RHF was not replaced anywhere in Senegal. In Senegal, there was no statistical evidence that a national policy promoting ORS use was associated with increases in coverage. In Sierra Leone, ORS coverage increased following a national policy change that abolished health costs for children.

CONCLUSIONS

Children in parts of Mali and Senegal have been left behind during ORS scale-up. Improved messaging on effective diarrhea treatment and/or increased ORS access such as through reducing treatment costs may be needed to prevent child deaths in these areas.