Variation in Childhood Diarrheal Morbidity and Mortality in Africa, 2000-2015

Etiology-specific incidence and mortality of diarrheal diseases in the African region: a systematic review and meta-analysis

BACKGROUND

Diarrheal diseases substantially affect public health impact in low- and middle-income countries (LMIC), particularly in Africa, where previous studies have indicated a lack of comprehensive data. With a growing number of primary studies on enteric infections in Africa, this study aimed to estimate the incidence and mortality of diarrheal pathogens across all ages in Africa in the year 2020. We also explored different methodological assumptions to allow comparison with other approaches.

METHODS

Through a systematic review and meta-analysis of data from African LMICs, we estimated the etiology proportions for diarrheal diseases and deaths. We combined the etiology proportions with incidence data collected from a population survey in Africa from 2020 and mortality data from the Global Health Observatory of WHO.

RESULTS

We estimated 1,008 billion diarrhea cases (95% UI 447 million-1,4 billion) and 515,031 diarrhea deaths (95% UI 248,983-1,007,641) in the African region in 2020. In children under five, enteroaggregative E. coli (EAEC) (44,073 cases per 100,000 people, 95% UI 18,818 - 60,922) and G. lamblia (36,116 cases per 100,000 people, 95% UI 15,245 - 49,961) were the leading causes of illness. Enteroinvasive E. coli (EIEC) (155 deaths per 100,000 people, 95% UI 106.5-252.9) and rotavirus (61.5 deaths per 100,000 people, 95% UI 42.3-100.3) were the primary causes of deaths. For children over five and adults, Salmonella spp. caused the largest number of diarrheal cases in the population of children ≥ 5 and adults (122,090 cases per 100,000 people, 95% UI 51,833 - 168,822), while rotavirus (16.4 deaths per 100,000 people, 95% UI 4.2-36.7) and enteroaggregative E. coli (EAEC) (14.6 deaths per 100,000 people, 95% UI 3.9-32.9) causing the most deaths. Geographically, the highest incidence of diarrhea was in Eastern Africa for children under five (114,389 cases per 100,000 people, 95% UI 34,771 - 172,884) and Central Africa for children over five and adults (117,820 cases per 100,000 people, 95% UI 75,111-157,584). Diarrheal mortality was highest in Western Africa for both children below five and above (children < 5: 194.5 deaths per 100,000 people, 95% UI 120-325.4; children ≥ 5 and above: 33.5 deaths per 100,000 people, 95% UI 12.9-75.1).

CONCLUSION

These findings provide new information on the incidence and mortality of sixteen pathogens and highlight the need for surveillance and control of diarrheal infectious diseases in Africa. The cause-specific estimates are crucial for prioritizing diarrheal disease prevention in the region.

Detection of spatial, temporal and spatiotemporal distribution of diarrhea incidence among under-five children in Central Gondar zone, Northwest Ethiopia: a time-series study (2019-2022)

Under-five children's diarrhea is a significant public health threat and the World Health Organization (WHO) reported it as the second leading cause of children's death worldwide. In this study area, little is known about the spatiotemporal distribution of under-5 diarrhea incidence. This study was therefore, conducted among all districts in the Central Gondar zone to assess the spatial, temporal, and spatiotemporal variation in diarrhea incidence among under-five children in the Central Gondar zone. The data for children under 5 years of age with diarrhea was obtained from Central Gondar Zone Health Department diarrhea reports from January 2019 to December 2022. All districts were included and geo-coded. The spatial data were created in ArcGIS 10.8.1. Global and local spatial autocorrelation were used to detect hot spots and cold spots. The Poisson model was generated by applying the Kulldorff method in SaTScan™9.6 to analyse the the purely temporal, spatial, and space-time clusters. The study revealed spatial variation of under-5 diarrhea where Gondar City, Gondar Zuria, East Dembia, and Lay Armacho districts were the high-rate spatial clusters during the study period. A year search window for temporal scan statistic identified 01 January 2020-30 December 2021 as risk periods across all districts. Spatiotemporal scan statistics detected high-rate clusters at Gondar City, Gondar Zuria, East Dembia, Lay Armacho, and Alefa between 2019 and 2022. In conclusion, there has been a spatial, temporal, and spatiotemporal variability of under-5 children's diarrhea in the Central Gondar Zone. Interventional and preventive strategies should be developed and given priority to the areas that has been detected as a hotspot in this study to reduce the mortality and morbidity of under 5 children.

Global burden of 288 causes of death and life expectancy decomposition in 204 countries and territories and 811 subnational locations, 1990-2021: a systematic analysis for the Global Burden of Disease Study 2021

BACKGROUND

Regular, detailed reporting on population health by underlying cause of death is fundamental for public health decision making. Cause-specific estimates of mortality and the subsequent effects on life expectancy worldwide are valuable metrics to gauge progress in reducing mortality rates. These estimates are particularly important following large-scale mortality spikes, such as the COVID-19 pandemic. When systematically analysed, mortality rates and life expectancy allow comparisons of the consequences of causes of death globally and over time, providing a nuanced understanding of the effect of these causes on global populations.

METHODS

The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 cause-of-death analysis estimated mortality and years of life lost (YLLs) from 288 causes of death by age-sex-location-year in 204 countries and territories and 811 subnational locations for each year from 1990 until 2021. The analysis used 56 604 data sources, including data from vital registration and verbal autopsy as well as surveys, censuses, surveillance systems, and cancer registries, among others. As with previous GBD rounds, cause-specific death rates for most causes were estimated using the Cause of Death Ensemble model-a modelling tool developed for GBD to assess the out-of-sample predictive validity of different statistical models and covariate permutations and combine those results to produce cause-specific mortality estimates-with alternative strategies adapted to model causes with insufficient data, substantial changes in reporting over the study period, or unusual epidemiology. YLLs were computed as the product of the number of deaths for each cause-age-sex-location-year and the standard life expectancy at each age. As part of the modelling process, uncertainty intervals (UIs) were generated using the 2·5th and 97·5th percentiles from a 1000-draw distribution for each metric. We decomposed life expectancy by cause of death, location, and year to show cause-specific effects on life expectancy from 1990 to 2021. We also used the coefficient of variation and the fraction of population affected by 90% of deaths to highlight concentrations of mortality. Findings are reported in counts and age-standardised rates. Methodological improvements for cause-of-death estimates in GBD 2021 include the expansion of under-5-years age group to include four new age groups, enhanced methods to account for stochastic variation of sparse data, and the inclusion of COVID-19 and other pandemic-related mortality-which includes excess mortality associated with the pandemic, excluding COVID-19, lower respiratory infections, measles, malaria, and pertussis. For this analysis, 199 new country-years of vital registration cause-of-death data, 5 country-years of surveillance data, 21 country-years of verbal autopsy data, and 94 country-years of other data types were added to those used in previous GBD rounds.

FINDINGS

The leading causes of age-standardised deaths globally were the same in 2019 as they were in 1990; in descending order, these were, ischaemic heart disease, stroke, chronic obstructive pulmonary disease, and lower respiratory infections. In 2021, however, COVID-19 replaced stroke as the second-leading age-standardised cause of death, with 94·0 deaths (95% UI 89·2-100·0) per 100 000 population. The COVID-19 pandemic shifted the rankings of the leading five causes, lowering stroke to the third-leading and chronic obstructive pulmonary disease to the fourth-leading position. In 2021, the highest age-standardised death rates from COVID-19 occurred in sub-Saharan Africa (271·0 deaths [250·1-290·7] per 100 000 population) and Latin America and the Caribbean (195·4 deaths [182·1-211·4] per 100 000 population). The lowest age-standardised death rates from COVID-19 were in the high-income super-region (48·1 deaths [47·4-48·8] per 100 000 population) and southeast Asia, east Asia, and Oceania (23·2 deaths [16·3-37·2] per 100 000 population). Globally, life expectancy steadily improved between 1990 and 2019 for 18 of the 22 investigated causes. Decomposition of global and regional life expectancy showed the positive effect that reductions in deaths from enteric infections, lower respiratory infections, stroke, and neonatal deaths, among others have contributed to improved survival over the study period. However, a net reduction of 1·6 years occurred in global life expectancy between 2019 and 2021, primarily due to increased death rates from COVID-19 and other pandemic-related mortality. Life expectancy was highly variable between super-regions over the study period, with southeast Asia, east Asia, and Oceania gaining 8·3 years (6·7-9·9) overall, while having the smallest reduction in life expectancy due to COVID-19 (0·4 years). The largest reduction in life expectancy due to COVID-19 occurred in Latin America and the Caribbean (3·6 years). Additionally, 53 of the 288 causes of death were highly concentrated in locations with less than 50% of the global population as of 2021, and these causes of death became progressively more concentrated since 1990, when only 44 causes showed this pattern. The concentration phenomenon is discussed heuristically with respect to enteric and lower respiratory infections, malaria, HIV/AIDS, neonatal disorders, tuberculosis, and measles.

INTERPRETATION

Long-standing gains in life expectancy and reductions in many of the leading causes of death have been disrupted by the COVID-19 pandemic, the adverse effects of which were spread unevenly among populations. Despite the pandemic, there has been continued progress in combatting several notable causes of death, leading to improved global life expectancy over the study period. Each of the seven GBD super-regions showed an overall improvement from 1990 and 2021, obscuring the negative effect in the years of the pandemic. Additionally, our findings regarding regional variation in causes of death driving increases in life expectancy hold clear policy utility. Analyses of shifting mortality trends reveal that several causes, once widespread globally, are now increasingly concentrated geographically. These changes in mortality concentration, alongside further investigation of changing risks, interventions, and relevant policy, present an important opportunity to deepen our understanding of mortality-reduction strategies. Examining patterns in mortality concentration might reveal areas where successful public health interventions have been implemented. Translating these successes to locations where certain causes of death remain entrenched can inform policies that work to improve life expectancy for people everywhere.

FUNDING

Bill & Melinda Gates Foundation.

Severe outcomes of malaria in children under time-varying exposure

In malaria epidemiology, interpolation frameworks based on available observations are critical for policy decisions and interpreting disease burden. Updating our understanding of the empirical evidence across different populations, settings, and timeframes is crucial to improving inference for supporting public health. Here, via individual-based modeling, we evaluate a large, multicountry, contemporary Plasmodium falciparum severe malaria dataset to better understand the relationship between prevalence and incidence of malaria pediatric hospitalizations - a proxy of malaria severe outcomes- in East-Africa. We find that life-long exposure dynamics, and subsequent protection patterns in children, substantially determine the likelihood of malaria hospitalizations relative to ongoing prevalence at the population level. Unsteady transmission patterns over a lifetime in children -increasing or decreasing- lead to an exponential relationship of hospitalization rates versus prevalence rather than the asymptotic pattern observed under steady transmission. Addressing this increase in the complexity of malaria epidemiology is crucial to update burden assessments via inference models that guide current and future policy decisions.

Changes in the epidemiology and clinical characteristics of viral gastroenteritis among hospitalized children in the Mainland of China: a retrospective study from 2016 to 2020

BACKGROUND

Acute gastroenteritis (AGE) causes significant morbidity in children worldwide; however, the disease burden of children hospitalized with viral gastroenteritis in China has been rarely described. Through this study, we analyzed the data of hospitalized children with viral gastroenteritis to explore the changes in the epidemiology and clinical characteristics of viral gastroenteritis in the mainland of China.

METHODS

Data were extracted from Futang Children's Medical Development Research Center (FRCPD), between 2016 and 2020, across 27 hospitals in 7 regions. The demographics, geographic distribution, pathogenic examination results, complications, hospital admission date, length of hospital stays, hospitalization charges and outcomes were collected and analyzed.

RESULTS

Viral etiological agents included rotavirus (RV), adenovirus (ADV), norovirus (NV) and coxsackievirus (CV) that were detected in 25,274 (89.6%), 1,047 (3.7%), 441 (1.5%) and 83 (0.3%) cases. There was a higher prevalence of RV and NV infection among children younger than 3 years of age. RV and NV had the highest detection rates in winter, while ADV in summer. Children with viral gastroenteritis were often accompanied by other diseases, such as myocardial diseases (10.98-31.04%), upper respiratory tract diseases (1.20-20.15%), and seizures (2.41-14.51%). Among those cases, the co-infection rate with other pathogens was 6.28%, with Mycoplasma pneumoniae (M. pneumoniae), Epstein-Barr virus (EBV), and influenza virus (FLU) being the most common pathogens. The median length of stay was 5 days, and the median cost of hospitalization corresponded to587 US dollars.

CONCLUSIONS

This finding suggests that viral gastroenteritis, especially those caused by RV, is a prevalent illness among younger children. Co-infections and the presence of other diseases are common. The seasonality and regional variation of viral etiological agents highlight the need for targeted prevention and control measures. Although viral gastroenteritis rarely leads to death, it also results in a significant economic burden on healthcare systems.

Interviewer biases in medical survey data: The example of blood pressure measurements

Health agencies rely upon survey-based physical measures to estimate the prevalence of key global health indicators such as hypertension. Such measures are usually collected by nonhealthcare worker personnel and are potentially subject to measurement error due to variations in interviewer technique and setting, termed "interviewer effects." In the context of physical measurements, particularly in low- and middle-income countries, interviewer-induced biases have not yet been examined. Using blood pressure as a case study, we aimed to determine the relative contribution of interviewer effects on the total variance of blood pressure measurements in three large nationally representative health surveys from the Global South. We utilized 169,681 observations between 2008 and 2019 from three health surveys (Indonesia Family Life Survey, National Income Dynamics Study of South Africa, and Longitudinal Aging Study in India). In a linear mixed model, we modeled systolic blood pressure as a continuous dependent variable and interviewer effects as random effects alongside individual factors as covariates. To quantify the interviewer effect-induced uncertainty in hypertension prevalence, we utilized a bootstrap approach comparing subsamples of observed blood pressure measurements to their adjusted counterparts. Our analysis revealed that the proportion of variation contributed by interviewers to blood pressure measurements was statistically significant but small: ∼ 0.24 - - 2.2 % depending on the cohort. Thus, hypertension prevalence estimates were not substantially impacted at national scales. However, individual extreme interviewers could account for measurement divergences as high as 12%. Thus, highly biased interviewers could have important impacts on hypertension estimates at the subdistrict level.

Epidemiology of Enterotoxigenic Escherichia coli among Children and Adults Seeking Care at Hospitals in Two Geographically Distinct Rural Areas in Bangladesh

Enterotoxigenic Escherichia coli (ETEC) infections undeniably continue to have substantial morbidity and mortality in younger children; however, limited data are available on the disease burden of older children and adults and on ETEC epidemiology by geographical location at the subnational level. Facility-based surveillance over the years was established to identify patients with ETEC diarrhea in two geographically distinct areas in rural Bangladesh, Chhatak in the north and Mathbaria in the southern coastal area. ETEC was highly prevalent in both areas, while the proportions, toxin types and colonization factors varied by location, season and age groups. Children < 5 years old and adults between 20 and 60 years old were at the highest risk of ETEC diarrhea which required urgent care. This study underscores the importance of capturing subnational and seasonal variations in ETEC epidemiology. ETEC vaccine developers and public health stakeholders may need to target adults between 20 and 60 years of age in addition to young children as new vaccines currently under development become licensed and introduction begins.

Urbanicity and child health in 26 sub-Saharan African countries: Settlement type and its association with mortality and morbidity

Urbanization and changing settlement patterns have affected health environments in African countries. A profound understanding of the intricate association between urbanicity and health is imperative for formulating effective interventions. This study aims to classify settlement types based on urbanicity and assess their effects on child health in 26 African countries, utilizing data from the Demographic and Health Survey and the Global Human Settlements Layer. The advanced settlement classification incorporates a multidimensional urbanicity scale and globally standardized urban extents, along with identifying urban slums. This approach derives six distinct settlement types: urban center, urban cluster, deprived urban settlement, rural town, rural cluster, and rural village. A multilevel logistic regression model examines the relationship between settlement types and health outcomes, encompassing mortality, fever, anemia, diarrhea, and cough in children under five. The analysis reveals that children living in rural villages and deprived urban settlements face a high burden of adverse health conditions. However, the size and direction of urbanicity's effects vary depending on the specific outcome. These findings highlight the significance of tailored interventions acknowledging health environments within each settlement to promote health equity.

Terrorism and child mortality

How does terrorism affect child mortality? We use geo-coded data on terrorism and spatially disaggregated data on child mortality to study the relationship between both variables for 52 African countries between 2000 and 2017 at the 0.5 × 0.5° grid level. Our estimates suggest that moderate increases in terrorism are linked to several thousand additional annual deaths of children under the age of five. A panel event-study points to economic effects that are larger and compound over time. Interrogating our data, we show that the direct impact of terrorism tends to be very small. Instead, we theorize that terrorism causes child mortality primarily by triggering adverse behavioral responses by parents, medical workers, and policymakers. We provide tentative evidence in support of this argument.

Improved household flooring is associated with lower odds of enteric and parasitic infections in low- and middle-income countries: A systematic review and meta-analysis

Enteric and parasitic infections such as soil-transmitted helminths cause considerable mortality and morbidity in low- and middle-income settings. Earthen household floors are common in many of these settings and could serve as a reservoir for enteric and parasitic pathogens, which can easily be transmitted to new hosts through direct or indirect contact. We conducted a systematic review and meta-analysis to establish whether and to what extent improved household floors decrease the odds of enteric and parasitic infections among occupants compared with occupants living in households with unimproved floors. Following the PRISMA guidelines, we comprehensively searched four electronic databases for studies in low- and middle-income settings measuring household flooring as an exposure and self-reported diarrhoea or any type of enteric or intestinal-parasitic infection as an outcome. Metadata from eligible studies were extracted and transposed on to a study database before being imported into the R software platform for analysis. Study quality was assessed using an adapted version of the Newcastle-Ottawa Quality Assessment Scale. In total 110 studies were eligible for inclusion in the systematic review, of which 65 were eligible for inclusion in the meta-analysis after applying study quality cut-offs. Random-effects meta-analysis suggested that households with improved floors had 0.75 times (95CI: 0.67-0.83) the odds of infection with any type of enteric or parasitic infection compared with household with unimproved floors. Improved floors gave a pooled protective OR of 0.68 (95CI: 0.58-0.8) for helminthic infections and 0.82 OR (95CI: 0.75-0.9) for bacterial or protozoan infections. Overall study quality was poor and there is an urgent need for high-quality experimental studies investigating this relationship. Nevertheless, this study indicates that household flooring may meaningfully contribute towards a substantial portion of the burden of disease for enteric and parasitic infections in low- and middle-income settings.

A multilevel analysis of the predictors of diarrhea among children under 5 years of age in Eswatini

Diarrhea remains a public health challenge and persistently affect children under 5 years of age, primarily in developing countries. The aim of the study was to investigate the effects of individual, household and community level factors on child diarrhea. Using combined data 2010 and 2014 Eswatini Multiple Indicator Cluster surveys, data for 4,363 under five children was analysed. Univariable, bivariable and multivariable multilevel logistic regression models were used for data analysis. We found that the prevalence of diarrhea was 16.2%, (95% confidence interval (CI): 15.3-18.1). Higher odds of diarrhea were observed among children aged 6-11 months (AOR: 2.67, 95% CI: 1.93, 3.71) and 12-23 months (AOR=2.12, 95% CI: 1.56, 2.87) compared to those aged less than 6 months. However, lower odds of diarrhea were observed among children aged 36-47 months (AOR=0.68, 95% CI: 0.48, 0.97) and 48-59 months (AOR=0.39, 95% CI: 0.26, 0.58), compared to children aged less than 6 months. Children born to mothers aged 35-39 years had lower odds of having diarrhea, (AOR=0.48, 95%CI: 0.30, 0.79) compared to those born to mothers aged 15-19 years. Higher odds of having diarrhea were observed among children from communities with a low proportion of households with improved toilet facility (AOR=1.29, 95% CI: 1.01, 1.66) compared to those from communities with a high proportion of households with improved toilet facility. We found that individual- and community-level factors were associated with child diarrhea in Eswatini. Programmes and policies that aim to mitigate child morbidity due to diarrhea should pay attention to the individual and community factors.

Occurrence of Diarrheagenic Pathogens and Their Coinfection Profiles in Diarrheic Under Five Children and Tracked Human Contacts in Urban and Rural Settings of Eastern Ethiopia

Diarrheagenic Escherichia coli, Campylobacter, Nontyphoidal Salmonella, and Shigella are common cause of childhood diarrhea in countries like Ethiopia, but data on their sources and coinfection profiles is limited. A cross sectional study was conducted from November 2021 to January 2023 to determine the prevalence, coinfection, and monthly occurrence rates of major diarrheagenic bacteria in diarrheic under five children and asymptomatic contacts at urban and rural settings in Ethiopia. A total of 345 stool samples were collected from; 262 diarrheic children visiting Hiwot Fana Hospital, Kersa, and Adelle Health Centers; and 83 caretakers and siblings through case based contact tracing. Samples were analyzed using standard laboratory procedures and the overall prevalence of enteric pathogens was 26.96%, with the highest isolation rate during the winter and peaks of 73.91% in February. The occurrence of the pathogens in children and tracked contacts was 27.86 and 24.09%, respectively. In our study, 8.53% coinfection and 23.66% single pathogen infection was recorded in diarrheic children. The study also showed 4.51 and 3.88% of diarrhea in children from urban and rural had attributed to bacterial coinfection, respectively. The most prevalent pathogen in diarrheic children was Diarrheagenic E. coli (10.31%), and followed by Campylobacter. On the other hand, Diarrheagenic E. coli was the second dominant bacteria following Shigella in the traced contacts, with prevalence of 8.43% and 9.64%, respectively. Based on the study site, the prevalence of Diarrheagenic E. coli and Nontyphoidal Salmonella was higher in children from urban than those from rural. However, the occurrence of each pathogen had no significant differences (P > .05) between settings. The high pathogens occurrence rate in the current study indicates the need for strong control strategies and better child carrying and treatment of diarrheal diseases at both urban and rural settings. Further studies on possible sources and factors attributing to the occurrence of enteric pathogens in children are also recommended.

Effects of prebiotics on the gut microbiota in vitro associated with functional diarrhea in children

Purpose

Diarrhea is among the top five causes of morbidity and mortality in children. Dysbiosis of the gut microbiota is considered the most important risk factor for diarrhea. Prebiotics have shown efficacy in treating diarrhea by regulating the balance of the gut microbiota in vivo.

Methods

In this study, we used an in vitro fermentation system to prevent the interference of host-gut microbe interactions during in vivo examination and investigated the effect of fructo-oligosaccharides (FOS) on gut microbiota composition and metabolism in 39 pediatric patients with functional diarrhea.

Results

16S rRNA sequencing revealed that FOS significantly improved α- and β-diversity in volunteers with pediatric diarrhea (p < 0.05). This improvement manifested as a significant increase (LDA > 2, p < 0.05) in probiotic bacteria (e.g., Bifidobacterium) and a significant inhibition (LDA > 2, p < 0.05) of harmful bacteria (e.g., Escherichia-Shigella). Notably, the analysis of bacterial metabolites after FOS treatment showed that the decrease in isobutyric acid, isovaleric acid, NH3, and H2S levels was positively correlated with the relative abundance of Lachnoclostridium. This decrease also showed the greatest negative correlation with the abundance of Streptococcus. Random forest analysis and ROC curve validation demonstrated that gut microbiota composition and metabolites were distinct between the FOS treatment and control groups (area under the curve [AUC] > 0.8). Functional prediction using PICRUSt 2 revealed that the FOS-induced alteration of gut microbiota was most likely mediated by effects on starch and sucrose metabolism.

Conclusion

This study is the first to evince that FOS can modulate gut microbial disorders in children with functional diarrhea. Our findings provide a framework for the application of FOS to alleviate functional diarrhea in children and reduce the use of antibiotics for managing functional diarrhea-induced disturbances in the gut microbiota.

Prevalence of colistin-resistant mcr-1-positive Escherichia coli isolated from children patients with diarrhoea in Shanghai, 2016-2021

OBJECTIVES

The emergence of the plasmid-mediated colistin resistance 1 (mcr-1) of Escherichia coli has become a global health concern. This study reports the prevalence of mcr-1 among E. coli isolates from patients with diarrheal disease in Shanghai and the genetic characterization of mcr-1-harbouring plasmids.

METHODS

A total of 1723 E. coli strains were collected from the faeces of patients with diarrheal disease in all sentinel hospitals in Shanghai from 2016 to 2021. Antimicrobial susceptibility testing was performed by broth microdilution and plasmid conjunction transfer assay was carried out using E. coli C600 as the recipient. The mcr-1-positive E. coli strains (MCRPEC) were subjected to molecular characterization and bioinformatic analysis of the mcr-1-bearing plasmids that they harboured.

RESULTS

Only 5 (0.28%) strains were found to harbour the mcr-1 gene using PCR screening. Plasmid conjugation assay and whole-genome sequencing indicated that EC16500, one MCRPEC strain that co-exhibited mcr-1, blaTEM-1, blaOXA-1, qnrS1, qnrS2, arr-3, and catB3, could be conjugated to EC C600 by horizontal transfer with an average efficiency of 3.2 × 10-5. The plasmid pEC16500 harboured similar backbones as p70_2_15, pECGD-8-33, pNCYU-29-19-1_MCR1, and pIBMC_mcr1, and was shown to be encoded within a type IV secretion system (T4SS)-containing 32.6 kbp IncX4, next to the pap2-like membrane-associated gene, to form a 2.4-kb cassette. Furthermore, sequencing and phylogenetic analyses revealed a similarity between other MCR-1-homolog proteins, indicating that the five E. coli isolates were colistin-resistant.

CONCLUSION

Our data represents a significant snapshot of colistin resistance mcr-1 genes and highlights the need to increase active surveillance, especially among children under five years of age, in Shanghai. Great effort needs to be taken to avoid further dissemination of plasmid-mediated colistin resistance among clinically relevant Gram-negative bacterial pathogens.

Mining for crypto protection: a search for Cryptosporidium antibodies reveals antigens associated with immunity

Infectious diarrhea is a major cause of morbidity and mortality, particularly for children in low- and middle-income countries. Cryptosporidium is a diarrheal pathogen for which there is no vaccine and current therapies are only partially effective. In this issue of the JCI, Gilchrist, Campo, and colleagues surveyed a large cohort of Bangladeshi children to profile antibody responses against an array of Cryptosporidium proteins. They discovered 233 proteins to which children developed antibodies, identified seven as being associated with protection from reinfection, and provided insights regarding the longevity of Cryptosporidium antibodies and the development of antibody breadth. In this commentary, we discuss the burden of disease caused by Cryptosporidium and how these studies highlight the strategies to better manage this parasite.

A small area model to assess temporal trends and sub-national disparities in healthcare quality

Monitoring subnational healthcare quality is important for identifying and addressing geographic inequities. Yet, health facility surveys are rarely powered to support the generation of estimates at more local levels. With this study, we propose an analytical approach for estimating both temporal and subnational patterns of healthcare quality indicators from health facility survey data. This method uses random effects to account for differences between survey instruments; space-time processes to leverage correlations in space and time; and covariates to incorporate auxiliary information. We applied this method for three countries in which at least four health facility surveys had been conducted since 1999 - Kenya, Senegal, and Tanzania - and estimated measures of sick-child care quality per WHO Service Availability and Readiness Assessment (SARA) guidelines at programmatic subnational level, between 1999 and 2020. Model performance metrics indicated good out-of-sample predictive validity, illustrating the potential utility of geospatial statistical models for health facility data. This method offers a way to jointly estimate indicators of healthcare quality over space and time, which could then provide insights to decision-makers and health service program managers.

Comparative study on epidemiological and etiological characteristics of patients with acute diarrhea with febrile or non-febrile symptoms in China

BACKGROUND

Acute diarrhea with fever can potentially represent a more severe form of the disease compared to non-febrile diarrhea. This study was to investigate the epidemiological characteristics and enteric pathogen composition of febrile-diarrheal patients, and to explore factors including pathogens associated with fever by age group.

METHODS

A nationwide surveillance study of acute diarrheal patients of all ages was conducted in 217 sentinel hospitals from 31 provinces (autonomous regions or municipalities) in China between 2011 and 2020. Seventeen diarrhea-related pathogens, including seven viruses and ten bacteria, were investigated and their association with occurrence of fever symptoms was assessed using multivariate logistic analysis.

RESULTS

A total of 146,296 patients with acute diarrhea (18.6% with fever) were tested. Th diarrheal children below 5 years had the highest frequency of fever (24.2%), and related to significantly higher prevalence of viral enteropathogens (40.2%) as compared with other age groups (P < 0.001). Within each age group, the febrile-diarrheal patients were associated with a significantly higher prevalence of bacterial pathogens than afebrile-diarrheal patients (all P < 0.01). There was discrepancy when each pathogen was compared, i.e., nontyphoidal Salmonella (NTS) was overrepresented in febrile vs non-febrile patients of all age groups, while the febrile vs non-febrile difference for diarrheagenic Escherichia coli (DEC) was only significant for adult groups. The multivariate analysis revealed significant association between fever and infection with rotavirus A among children [odds ratio (OR) = 1.60], for DEC in adult groups (OR = 1.64), for NTS in both children (OR = 2.95) and adults (OR = 3.59).

CONCLUSIONS

There are significant discrepancy of the infected enteric pathogens in patients with acute diarrhea with fever between age groups, and it is valuable for priority detection of NTS and rotavirus A in patients with children < 5 years old and NTS and DEC in adult patients. The results may be useful in identifying dominant pathogen candidates for the application of diagnostic assays and prevention control.

Conservation, abundance, glycosylation profile, and localization of the TSP protein family in Cryptosporidium parvum

Cryptosporidium parvum is a zoonotic apicomplexan parasite and a common cause of diarrheal disease worldwide. The development of vaccines to prevent or limit infection remains an important goal for tackling cryptosporidiosis. At present, the only approved vaccine against any apicomplexan parasite targets a conserved adhesin possessing a thrombospondin repeat domain. C. parvum possesses 12 orthologous thrombospondin repeat domain-containing proteins known as CpTSP1-12, though little is known about these potentially important antigens. Here, we explore the architecture and conservation of the CpTSP protein family, as well as their abundance at the protein level within the sporozoite stage of the life cycle. We examine the glycosylation states of these proteins using a combination of glycopeptide enrichment techniques to demonstrate that these proteins are modified with C-, O-, and N-linked glycans. Using expansion microscopy, and an antibody against the C-linked mannose that is unique to the CpTSP protein family within C. parvum, we show that these proteins are found both on the cell surface and in structures that resemble the secretory pathway of C. parvum sporozoites. Finally, we generated a polyclonal antibody against CpTSP1 to show that it is found at the cell surface and within micronemes, in a pattern reminiscent of other apicomplexan motility-associated adhesins, and is present both in sporozoites and meronts. This work sheds new light on an understudied family of C. parvum proteins that are likely to be important to both parasite biology and the development of vaccines against cryptosporidiosis.

Gastrointestinal parasites in Africa: A review

Data on human gastrointestinal parasites (GIP) infections in the african sub-regions and countries are mainly lacking in terms of prevalence and population stratification by afflicted age group, symptomatology, multi-parasitism, and diagnostic methods. This study aims to describe the GIP reported in african countries and discuss the extent of the burden in the african context. Only 68.42% (39/57) of african countries reported human cases of GIP with helminths (45%, CI: 40-50%, I²: 99.79%) as the predominant parasitic group infecting the african population. On a regional scale, Central Africa had the highest pooled prevalence for GIP (43%, CI: 32-54%, I²: 99.74%), while the Central African Republic led all countries with a pooled prevalence of 90% (CI: 89-92%, I²: 99.96%). The vulnerable population (patients who are minorities, children, old, poor, underfunded, or have particular medical conditions) was the most affected (50%, CI: 37-62%, I²: 99.33%), with the predominance of GIP in the 6 to <20 years age group (48%, CI: 43-54%, I²: 99.68%). Reports on multi-parasitism (44%, CI: 40-48%, I²: 99.73%) were almost double the reports of single infections (43%, CI: 27-59%, I²: 99.77%) with combined molecular and non-molecular techniques demonstrating the best performance for GIP identification. The current review spans more than 40 years of GIP reports from the african continent. Geographical characteristics, environmental factors, habits of its inhabitants, and their health status play a crucial role in GIP modulation and behaviour in its captive hosts. Strategies for regular and enhanced surveillance, policy formation, and high-level community awareness are necessary to identify the true incidence in Africa and the transmission of the pathogens via water and food.

Association between women's empowerment and diarrhoea in children under five years: evidence from the 2017/18 Benin Demographic and Health Survey

Globally, diarrhoea is the third leading cause of death for under five-children. Women's empowerment can significantly reduce under-five mortality due to diarrhoea. This study investigated the association between women's empowerment and childhood diarrhoea in Benin using data from the 2017/18 Benin Demographic and Health Survey. A total of 7979 currently married women were included in the study. A logistic regression model was used to control for possible confounders. The prevalence of diarrhoea among children under five years of age was 13.6%. About 36.3% of the currently married women decided either alone or together with their husband on their own health, purchase of large household items and visiting family/relatives. Close to 65.4% of currently married women disagreed with all five reasons to justify wife-beating. The children of mothers who had decision-making power were less likely to have diarrhoea (aOR = 0.74, 95% CI: 0.57-0.96) than the children of mothers who had no decision-making power. Moreover, the children of mothers who disagreed with all five reasons to justify wife-beating (aOR = 0.79, 95% CI: 0.65-0.96) were less likely to have diarrhoea than the children of mothers who accepted wife-beating as a part of life. Women's age, educational level, wealth index and region were associated with childhood diarrhoea in Benin. The role of women's empowerment, as determined by decision-making power and wife-beating attitude, was found to be significantly associated with the risk of childhood diarrhoea in Benin, after adjusting for other variables. Therefore, it is essential for policymakers in Benin to reinforce strategies and interventions focusing on women's empowerment to avert childhood mortality caused by diarrhoea. This includes improving household economic status, women's education and decision-making power and enhancing awareness of women's human and democratic rights.

Prevalence of diarrheal disease and associated factors among under-five children in flood-prone settlements of Northwest Ethiopia: A cross-sectional community-based study

BACKGROUND

Diarrheal illnesses are a long-standing public health problem in developing countries due to numerous sanitation issues and a lack of safe drinking water. Floods exacerbate public health issues by spreading water-borne infectious diseases such as diarrhea through the destruction of sanitation facilities and contamination of drinking water. There has been a shortage of studies regarding the magnitude of diarrheal disease in flood-prone areas. Therefore, this research aimed to evaluate the prevalence of diarrheal disease and its predictors among under-five children living in flood-prone localities in the south Gondar zone of Northwest Ethiopia.

METHOD

A community-based cross-sectional research was carried out in flood-prone villages of the Fogera and Libokemkem districts from March 17 to March 30, 2021. Purposive and systematic sampling techniques were used to select six kebeles and 717 study units, respectively. Structured and pretested questionnaires were used to collect the data. A multivariable analysis was performed to determine the predictors of diarrheal disease, with P-value <0.05 used as the cut-off point to declare the association.

RESULT

The prevalence of a diarrheal disease among under-five children was 29.0%. The regular cleaning of the compound [AOR: 2.13; 95% CI (1.25, 3.62)], source of drinking water [AOR: 2.36; 95% CI: (1.26, 4.41)], animal access to water storage site [AOR: 3.04; 95% CI: (1.76, 5.24)], vector around food storage sites [AOR: 9.13; 95% CI: (4.06, 20.52)], use of leftover food [AOR: 4.31; 95% CI: (2.64, 7.04)], and fecal contamination of water [AOR: 12.56; 95% CI: (6.83, 23.20)] remained to have a significant association with diarrheal diseases.

CONCLUSION

The present study found that the prevalence of the diarrheal disease among under-five children was high. Routine compound cleaning, the source of drinking water, animal access to a water storage site, vectors near food storage sites, consumption of leftover food, and fecal contamination of water were significant predictors of diarrheal disease. Therefore, it is advised to provide improved water sources, encourage routine cleaning of the living area, and offer health education about water, hygiene, and sanitation.

Water Resources in Africa under Global Change: Monitoring Surface Waters from Space

ABSTRACT

The African continent hosts some of the largest freshwater systems worldwide, characterized by a large distribution and variability of surface waters that play a key role in the water, energy and carbon cycles and are of major importance to the global climate and water resources. Freshwater availability in Africa has now become of major concern under the combined effect of climate change, environmental alterations and anthropogenic pressure. However, the hydrology of the African river basins remains one of the least studied worldwide and a better monitoring and understanding of the hydrological processes across the continent become fundamental. Earth Observation, that offers a cost-effective means for monitoring the terrestrial water cycle, plays a major role in supporting surface hydrology investigations. Remote sensing advances are therefore a game changer to develop comprehensive observing systems to monitor Africa's land water and manage its water resources. Here, we review the achievements of more than three decades of advances using remote sensing to study surface waters in Africa, highlighting the current benefits and difficulties. We show how the availability of a large number of sensors and observations, coupled with models, offers new possibilities to monitor a continent with scarce gauged stations. In the context of upcoming satellite missions dedicated to surface hydrology, such as the Surface Water and Ocean Topography (SWOT), we discuss future opportunities and how the use of remote sensing could benefit scientific and societal applications, such as water resource management, flood risk prevention and environment monitoring under current global change.

ARTICLE HIGHLIGHTS

The hydrology of African surface water is of global importance, yet it remains poorly monitored and understoodComprehensive review of remote sensing and modeling advances to monitor Africa's surface water and water resourcesFuture opportunities with upcoming satellite missions and to translate scientific advances into societal applications.

The overlapping burden of the three leading causes of disability and death in sub-Saharan African children

Despite substantial declines since 2000, lower respiratory infections (LRIs), diarrhoeal diseases, and malaria remain among the leading causes of nonfatal and fatal disease burden for children under 5 years of age (under 5), primarily in sub-Saharan Africa (SSA). The spatial burden of each of these diseases has been estimated subnationally across SSA, yet no prior analyses have examined the pattern of their combined burden. Here we synthesise subnational estimates of the burden of LRIs, diarrhoea, and malaria in children under-5 from 2000 to 2017 for 43 sub-Saharan countries. Some units faced a relatively equal burden from each of the three diseases, while others had one or two dominant sources of unit-level burden, with no consistent pattern geographically across the entire subcontinent. Using a subnational counterfactual analysis, we show that nearly 300 million DALYs could have been averted since 2000 by raising all units to their national average. Our findings are directly relevant for decision-makers in determining which and targeting where the most appropriate interventions are for increasing child survival.

Assessing performance of the Healthcare Access and Quality Index, overall and by select age groups, for 204 countries and territories, 1990-2019: a systematic analysis from the Global Burden of Disease Study 2019

BACKGROUND

Health-care needs change throughout the life course. It is thus crucial to assess whether health systems provide access to quality health care for all ages. Drawing from the Global Burden of Diseases, Injuries, and Risk Factors Study 2019 (GBD 2019), we measured the Healthcare Access and Quality (HAQ) Index overall and for select age groups in 204 locations from 1990 to 2019.

METHODS

We distinguished the overall HAQ Index (ages 0-74 years) from scores for select age groups: the young (ages 0-14 years), working (ages 15-64 years), and post-working (ages 65-74 years) groups. For GBD 2019, HAQ Index construction methods were updated to use the arithmetic mean of scaled mortality-to-incidence ratios (MIRs) and risk-standardised death rates (RSDRs) for 32 causes of death that should not occur in the presence of timely, quality health care. Across locations and years, MIRs and RSDRs were scaled from 0 (worst) to 100 (best) separately, putting the HAQ Index on a different relative scale for each age group. We estimated absolute convergence for each group on the basis of whether the HAQ Index grew faster in absolute terms between 1990 and 2019 in countries with lower 1990 HAQ Index scores than countries with higher 1990 HAQ Index scores and by Socio-demographic Index (SDI) quintile. SDI is a summary metric of overall development.

FINDINGS

Between 1990 and 2019, the HAQ Index increased overall (by 19·6 points, 95% uncertainty interval 17·9-21·3), as well as among the young (22·5, 19·9-24·7), working (17·2, 15·2-19·1), and post-working (15·1, 13·2-17·0) age groups. Large differences in HAQ Index scores were present across SDI levels in 2019, with the overall index ranging from 30·7 (28·6-33·0) on average in low-SDI countries to 83·4 (82·4-84·3) on average in high-SDI countries. Similarly large ranges between low-SDI and high-SDI countries, respectively, were estimated in the HAQ Index for the young (40·4-89·0), working (33·8-82·8), and post-working (30·4-79·1) groups. Absolute convergence in HAQ Index was estimated in the young group only. In contrast, divergence was estimated among the working and post-working groups, driven by slow progress in low-SDI countries.

INTERPRETATION

Although major gaps remain across levels of social and economic development, convergence in the young group is an encouraging sign of reduced disparities in health-care access and quality. However, divergence in the working and post-working groups indicates that health-care access and quality is lagging at lower levels of social and economic development. To meet the needs of ageing populations, health systems need to improve health-care access and quality for working-age adults and older populations while continuing to realise gains among the young.

FUNDING

Bill & Melinda Gates Foundation.

The magnitude of oral rehydration salt utilization in diarrhea hot spot regions of Ethiopia and its associated factors among under-five children: A multilevel analysis based on Bayesian approach

Background

Diarrhea leads the children to severe dehydration or death as a result of the loss of water and electrolytes (namely, potassium, chloride, sodium, and bicarbonate). To compensate for the losses, ORS is given to children who experienced diarrhea.

Objective

To estimate the magnitude of ORS utilization in diarrhea hotspot regions of Ethiopia and to assess its associated factors among under-five children.

Methods

To conduct this study, we used the 2016 Ethiopian demographic and health survey data. A total of 1,079 weighted sample children were selected. Each sample was selected randomly. Then, to identify factors associated with ORS utilization in diarrhea hotspot regions of Ethiopia, a multilevel analysis based on the Bayesian approach was applied. Finally, the credible interval of AOR that does not include 1 was considered statistically significant.

Results

The magnitude of ORS utilization for children in diarrhea hotspot regions of Ethiopia was 28%. Being urban resident (AOR = 1.92; 95% CrI: 1.13-3.3), woman household head (AOR = 2.11; 95% CrI: 1.3-3.9), having higher educational level (AOR = 1.52; 95% CrI: 1.04-2.22), member of health insurance (AOR = 1.73; 95% CrI: 1.14-2.43), and being exposed for media (AOR = 1.43; 95% CrI: 1.18-2.5) increases ORS utilization for diarrhea management.

Conclusion

Residence, educational level, health insurance, and media exposure were the factors of ORS utilization. So, to increase the practice of ORS utilization for diarrhea management in Ethiopia, the Ministry of Health and the Government of Ethiopia should consider those factors when they design diarrhea prevention and control strategies.

Solar water disinfection in large-volume containers: from the laboratory to the field. A case study in Tigray, Ethiopia

The lack of safe drinking water affects communities in low-to-medium-income countries most. This barrier can be overcome by using sustainable point-of-use water treatments. Solar energy has been used to disinfect water for decades, and several efforts have been made to optimise the standard procedure of solar water disinfection (SODIS process). However, the Health Impact Assessment of implementing advanced technologies in the field is also a critical step in evaluating the success of the optimisation. This work reports a sustainable scaling-up of SODIS from standard 2 L bottles to 25 L transparent jerrycans (TJC) and a 12-month field implementation in four sites of Tigray in Ethiopia, where 80.5% of the population lives without reliable access to safe drinking water and whose initial baseline average rate of diarrhoeal disease in children under 5 years was 13.5%. The UVA dose required for 3-log reduction of E. coli was always lower than the minimum UVA daily dose received in Tigray (9411 ± 55 Wh/m²). Results confirmed a similar decrease in cases of diarrhoea in children in the implementation (25 L PET TJC) and control (2 L PET bottles) groups, supporting the feasibility of increasing the volume of the SODIS water containers to produce safer drinking water with a sustainable and user-friendly process.

Prevalence and predictors of oral rehydration therapy, zinc, and other treatments for diarrhoea among children under-five in sub-Saharan Africa

Background

Despite the evidence-based effectiveness of diarrhoea treatment in preventing diarrhoea-related child mortality, the accessibility and utilization of diarrhoea treatments remain low in sub-Saharan Africa, even though these treatments are available. Therefore, this study aimed to assess the prevalence and predictors of diarrhoea treatment among under-five children in sub-Saharan Africa.

Methods

This study involved cross-sectional analyses of secondary data from the most recent Demographic and Health Surveys of 30 countries in sub-Saharan Africa. Percentages with their respective 95% confidence intervals (CI) were used to summarise the prevalence of diarrhoea treatment. A multivariable multilevel binary logistic regression analysis was employed to examine the predictors of diarrhoea treatment among children under five years in sub-Saharan Africa. The regression results were presented using adjusted odds ratio with their accompanying 95% confidence intervals. Statistical significance was set at p<0.05. Stata software version 16.0 was used for the analyses.

Results

The overall prevalence of diarrhoea treatment among under-five children in sub-Saharan Africa was 49.07% (95% CI = 44.50–53.64). The prevalence of diarrhoea treatment ranged from 23.93% (95% CI = 20.92–26.94) in Zimbabwe to 66.32% (95% CI = 61.67–70.97) in Liberia. Children aged 1 to 4 years, those whose mothers had at least primary education, those whose mothers had postnatal care visits, those whose mothers believed that permission to go and get medical help for self was a big problem, and those whose mothers’ partners had at least primary education were more likely to undergo diarrhoea treatment as compared to their counterparts. The odds of diarrhoea treatment increased with increasing wealth index with the highest odds among those in the richest quintile. Also, the odds of diarrhoea treatment was higher in the Central, Eastern, and Western geographical subregions compared to those in the Southern geographical subregion. However, children whose mothers were cohabiting, those whose mothers were exposed to watching television, and those living in female-headed households were less likely to undergo diarrhoea treatment.

Conclusion

The study found that the prevalence of diarrhoea treatment among children in sub-Saharan Africa was relatively low and varied across countries. The sub-regional estimates of diarrhoea treatment and identified associated factors can support country-specific needs assessments targeted at improving policy makers’ understanding of within-country disparities in diarrhoea treatment. Planned interventions (e.g., provision of quality and affordable supply of oral rehydration salts and zinc) should seek to scale up diarrhoea treatment uptake among under-five children in sub-Saharan Africa with much focus on the factors identified in this study.

Household access to basic drinking water, sanitation and hygiene facilities: secondary analysis of data from the demographic and health survey V, 2017-2018

BACKGROUND

In Benin, access to water, sanitation and hygiene (WASH) remains an issue. This study aims to provide an overview of household access to basic WASH services based on nationally representative data.

METHOD

Secondary analyses were run using the 'HOUSEHOLD' dataset of the fifth Demographic and Health Survey 2017-2018. The dependent variables were household access to individual and combined basic WASH services. The characteristics of the household head and those related to the composition, wealth and environment of the household were independent variables. After a descriptive analysis of all study variables, multivariate logistic regression was performed to identify predictors of outcome variables.

RESULTS

The study included 14,156 households. Of these, 63.98% (95% CI = 61.63-66.26), 13.28% (95% CI = 12.10-14.57) and 10.11% (95% CI = 9.19-11.11) had access to individual basic water, sanitation and hygiene facilities, respectively. Also, 3% (95% CI = 2.53-3.56) of households had access to combined basic WASH services. Overall, the richest households and few, and those headed by people aged 30 and over, female and with higher levels of education, were the most likely to have access to individual and combined basic WASH services. In addition, disparities based on the department of residence were observed.

CONCLUSION

The authors suggest a multifactorial approach that addresses the identified determinants.

Infectious Disease Control and Management in Ethiopia: A Case Study of Cholera

Cholera remains a significant public health problem among the vulnerable populations living in many resource-limited settings with poor access to safe and clean water and hygiene practice. Around 2.86 million cholera cases and 95,000 deaths are estimated to occur in endemic countries. In Ethiopia, cholera has been one of the major epidemic diseases since 1634 when the first cholera outbreak was recorded in-country. Several cholera epidemics occurred with recent outbreaks in 2019–2021. Cholera has been often reported as acute watery diarrhea due to limited diagnostic capacity in remote areas in Ethiopia and sensitivities around cholera outbreaks. The government of Ethiopia has been executing several phases of multi-year health sector development plan in the past decades and has recently developed a national cholera control plan. Here, we aim to present the existing cholera control guidelines and health system in Ethiopia, including case detection and reporting, outbreak declaration, case management, and transmission control. Challenges and way forward on further research and public health interventions are also discussed to address the knowledge and health service gaps related to cholera control in Ethiopia.

Childhood diarrhoea in southwestern Nigeria: Predictors of low osmolarity ORS and zinc use among mothers

Objectives

Diarrhoea is a leading cause of mortality among children in resource-limited countries. However, very scarce literature exists regarding the factors influencing the awareness and use of low osmolarity oral rehydration salts (Lo-ORS) and zinc supplementation in the management of childhood diarrhoea among mothers of children under 5 years of age in southwestern Nigeria. This study, performed in Lagos, Nigeria, aimed to address this lack of knowledge.

Methods

Through a cross-sectional survey design, 336 mothers of children under 5 years of age were selected through a multi-stage sampling procedure. Data were collected with a pretested, semi-structured interviewer administered questionnaire and analysed in SPSS version 23. Descriptive and inferential statistical techniques were used for data analysis.

Results

A total of 10.4% of the mothers were aware of Lo-ORS, whereas 6.5% had ever used it; 53.3% were aware of zinc supplementation, whereas 42% had ever used it. Awareness was influenced by educational level (AOR: 2.017; 95% CI: 1.123–3.626) and the age of the child (AOR: 2.257; 95% CI: 1.237–4.117) for Lo-ORS, and by average monthly income (AOR: 1.582; 95% CI: 1.144–2.187) for zinc supplementation. The utilisation level was associated with educational level (p = 0.039) and awareness (p < 0.001) for Lo-ORS, and with marital status (p = 0.018) and awareness (p < 0.001) for zinc supplementation.

Conclusion

Awareness and use of Lo-ORS was poorer than that of zinc supplementation among the mothers. Efforts to promote awareness regarding these treatments among mothers and health workers should be intensified to promote their use and help bridge the gap between policy change and effectiveness.

Incidence of Asymptomatic Shigella Infection and Association with the Composite Index of Anthropometric Failure among Children Aged 1–24 Months in Low-Resource Settings

Asymptomatic or subclinical infection by diarrheal enteropathogens during childhood has been linked to poor health and nutritional outcomes. In this study, we aimed to assess the impact of asymptomatic Shigella infection on different forms of childhood malnutrition including the composite index of anthropometric failure (CIAF). We used data from 1715 children enrolled in the multi-country birth cohort study, MAL-ED, from November 2009 to February 2012. Monthly non-diarrheal stools were collected and assessed using TaqMan Array Cards (TAC). Poisson regression was used to calculate incidence rates of asymptomatic Shigella infection. Generalized estimating equations (GEE) were used to assess the association between asymptomatic Shigella infection and nutritional indicators after adjusting for relevant covariates. Incidence rates per 100 child-months were higher in Tanzania, Bangladesh and Peru. Overall, after adjusting for relevant covariates, asymptomatic Shigella infection was significantly associated with stunting (aOR 1.60; 95% CI: 1.50, 1.70), wasting (aOR 1.26; 95% CI: 1.09, 1.46), underweight (aOR 1.45; 95% CI: 1.35, 1.56), and CIAF (aOR 1.55; 95% CI: 1.46, 1.65) in all the study sites except for Brazil. The high incidence rates of asymptomatic Shigella infection underscore the immediate need for Shigella vaccines to avert the long-term sequelae involving childhood growth.

Climate variability, water supply, sanitation and diarrhea among children under five in Sub-Saharan Africa: a multilevel analysis

Climate variability is expected to increase the risk of diarrhea diseases, a leading cause of child mortality and morbidity in Sub-Saharan Africa (SSA). The risk of diarrhea is more acute when populations have poor access to improved water and sanitation. This study seeks to determine individual and joint effects of climate variation, water supply and sanitation on the occurrence of diarrhea among children under five in SSA using multilevel mixed-effect Poisson regression including cross-level interaction. We merged 57 Demographic and Health Surveys (DHS) from 25 SSA countries covering the period 2000-2019 with climatic data from the DHS geolocation databases. The results of the research indicate that 77.7% of the variation in the occurrence of diarrhea in Sub-Saharan households is due to climatic differences between clusters. Also, a household residing in a cluster with a high incidence of diarrhea is 1.567 times more likely to have diarrhea cases than a household from a cluster with a low incidence. In addition, when average temperature and rainfall increase, households using unimproved sanitation or unimproved water have more cases of diarrhea. For SSA, the results of the multilevel analysis suggest the adoption at both levels; macro (national) and micro (household), of climate change adaption measures in the water sector to reduce the prevalence of diarrhea.

Cumulative Antibiotic Exposure in the First Five Years of Life: Estimates for 45 Low- and Middle-income Countries from Demographic and Health Survey Data

BACKGROUND

Estimates of the total cumulative exposure to antibiotics of children in low-resource settings, and the source of these treatments, are limited.

METHODS

We estimated the average number of antibiotic treatments children received in the first five years of life in 45 low- and middle-income countries (LMICs) using Demographic and Health Survey (DHS) data. The two-week point prevalence of fever, diarrhea or cough and antibiotic treatment for these illnesses were estimated for ages 0-59 months and aggregated to estimate cumulative illness and antibiotic treatment for each country. We estimated treatment rates and contribution to total antibiotic use attributable to medical care, informal care, and self-medication.

RESULTS

Forty-five countries contributed 438,140 child-observations. The proportion of illness episodes treated with antibiotics ranged from 10% (95% CI: 9-12) (Niger) to 72% (95% CI: 69-75) (Jordan). A mean of 42·7% (95% CI: 42.1-43.3) of febrile and 32.9% of non-febrile illness (95% CI: 32.4-33.5) episodes received antibiotics. In their first five years, we estimate children received 18.5 antibiotics treatments on average (IQR: 11.6-24.6) in LMICs. Cumulative antibiotic exposure ranged from 3.7 treatments in Niger (95% CI: 2.8-4.6) to 38·6 treatments in DR Congo (95% CI: 34.7-42.4). A median of 9.0% of antibiotic treatment was attributable to informal care (IQR: 5.9-21.2), and 16.9% to self-medication (IQR: 9.5-26.2).

CONCLUSIONS

Childhood antibiotic exposure is high in some LMICs, with considerable variability. While access to antibiotics for children is still not universal, important opportunities for reducing excess use also exist, particularly with respect to the informal care sector and self-medication.

Patterns, Outcomes and Predictors of Pediatric Medical Admissions at Gadarif Hospital in Eastern Sudan

BACKGROUND

The reduction of childhood mortality is a reliable indicator of a national health system's progress and improvement. Sudan's population is still suffering from communicable diseases, with a considerably higher mortality rate among children. Efforts are therefore needed to reduce mortality and achieve the Millennium Development Goals and Sustainable Development Goals. This study was conducted to determine the morbidity, mortality and outcomes of children admitted to Gadarif Hospital in eastern Sudan.

METHOD

A retrospective study was conducted by reviewing the medical files of pediatric patients who were admitted to Gadarif Hospital between March 1, 2019 and March 31, 2020.

RESULT

A total of 740 medical files were reviewed. Most, 453 (61.2%) of the admissions were males. The median (interquartile range) age was 3.0 (8.0) years and 433 (58.8%) of the admissions were under 5 years of age. The median (interquartile range) of the length of hospital stay was 9.0 (12.0) days. Visceral leishmaniasis, malnutrition, severe malaria, sickle cell disease, acute watery diarrhea, severe anemia (regardless of its cause), septicemia and acute respiratory infection were the most common causes of admission. The mortality rate was 5.7%, and it was significantly higher in females than males [24/287 (8.4%) vs. 18/453 (4.0%), P = 0.01] and in children under 5 years [36/433 (8.3%) vs. 6/307 (2.0%), P < 0.001]. Malnutrition, visceral leishmaniasis, septicemia and meningitis/encephalitis were the main diseases causing death in the study population. The case fatality rate was not significantly different in malnutrition than in visceral leishmaniasis [9/93 (9.7%) vs. 7/178 (3.9%), P = 0.05].

CONCLUSION

The main causes of morbidity and mortality for children admitted to Gadarif Pediatric Hospital were communicable diseases. The mortality rate was 5.7%. Females and children under 5 years were the most vulnerable groups for fatality.

OUP accepted manuscript

BACKGROUND

Diarrhoea is a leading cause of preventable childhood morbidity and mortality worldwide. Unfortunately, Pakistan has the third-highest burden of diarrhoea-related deaths in children <5 y of age. Therefore we aimed to evaluate factors associated with diarrhoea among Pakistani children.

METHODS

A retrospective 1:2 matched case-control study nested in a baseline cross-sectional survey was conducted from October to December 2018 in Taluka Kotri, a two-thirds urban locality in the Jamshoro district. Children between the ages of 0 and 23 months with a history of diarrhoea in the 2 weeks preceding the survey were labelled as cases. Age-matched controls were children without symptoms of diarrhoea. Univariate and multivariable conditional logistic regression was performed to identify diarrhoea-related factors.

RESULTS

A total of 1558 cases were matched with 3116 controls. Factors significantly associated with lower odds of diarrhoea in the multivariate analysis included increasing maternal age (odds ratio [OR] 0.78 [95% confidence interval {CI} 0.67 to 0.90]), breastfeeding (OR 0.77 [95% CI 0.66 to 0.90]), higher paternal education (OR 0.79 [95% CI 0.65 to 0.97]) and belonging to the rich (OR 0.66 [95% CI 0.54 to 0.80]) and richest quintiles (OR 0.54 [95% CI 0.44 to 0.66]).

CONCLUSIONS

This study identifies risk factors associated with diarrhoea in children <23 months of age, including younger maternal age, higher paternal education, not breastfeeding and poverty, which has implications for developing preventive programs and strategies that target populations with a higher risk of diarrhoea.

Water, Sanitation, and Hygiene Risk Factors on the Prevalence of Diarrhea among Under-Five Children in the Rural Community of Dangila District, Northwest Ethiopia

Background

Under-five diarrhea is one of the major causes of morbidity and mortality in developing countries. Despite the tremendous achievement in reducing child mortality and morbidity in the last two decades, diarrhea is still the major causes of morbidity and mortality in resource-limited countries like Ethiopia due to the absence of clean water and poor sanitation and hygiene.

Objective

This study aimed to assess the association of water, sanitation, and hygiene on the prevalence of diarrhea among under-five children in the rural community of Ethiopia.

Methods

A cross-sectional study was conducted among randomly selected 419 under-five children from October to December 2021 in Dangila district, Northwest Ethiopia. A structured questionnaire was used to collect sociodemographic, environmental, and behavioral data. Data were entered into Epi Info and analyzed using SPSS software. Descriptive analysis was used to calculate the prevalence of diarrhea. Univariate and multivariate logistic regression were used to compute the association of water, sanitation, and hygiene with diarrhea. Statistical significance was considered if P < 0.05.

Results

Among 419 participants, the prevalence of diarrhea was 106 (25.3%). The absence of handwashing habit of children (AOR = 7.70; 95% CI: 2.71–21.79) and caregivers after toilet (AOR = 19.10; 95% CI: 5.46–66.52), absence of latrine (AOR = 3.87; 95% CI: 1.24–12.08), playing with soil (AOR = 8.40; 95% CI: 4.58–36.66), and eating soil (AOR = 6.24; 95% CI: 1.99–19.78) were significantly associated with under-five diarrhea. Children who drink unprotected water were 2.21 times (AOR = 2.21; 95% CI: 0.51–9.69) more exposed to under-five diarrhea than who drink protected water, but it is not statistically significant (P = 0.29).

Conclusion

The prevalence of under-five diarrhea is high in Dangila district. The absence of clean water and poor handwashing practice and the absence of latrine are the main factors associated with diarrhea. Therefore, strengthening water, sanitation, and hygiene strategy in the rural community should be prioritized.

Confronting challenges to enterotoxigenic Escherichia coli vaccine development

The enterotoxigenic Escherichia coli (ETEC) are a diverse and genetically plastic pathologic variant (pathovar) of E. coli defined by their production of heat-labile (LT) and heat-stable (ST) enterotoxins. These pathogens, which came to recognition more than four decades ago in patients presenting with severe cholera-like diarrhea, are now known to cause hundreds of millions of cases of symptomatic infection annually. Children in low-middle income regions of the world lacking access to clean water and basic sanitation are disproportionately affected by ETEC. In addition to acute diarrheal morbidity, these pathogens remain a significant cause of mortality in children under the age of five years and have also been linked repeatedly to sequelae of childhood malnutrition and growth stunting. Vaccines that could prevent ETEC infections therefore remain a high priority. Despite several decades of effort, a licensed vaccine that protects against the breadth of these pathogens remains an aspirational goal, and the underlying genetic plasticity of E. coli has posed a fundamental challenge to development of a vaccine that can encompass the complete antigenic spectrum of ETEC. Nevertheless, novel strategies that include toxoids, a more complete understanding of ETEC molecular pathogenesis, structural details of target immunogens, and the discovery of more highly conserved antigens essential for virulence should accelerate progress and make a broadly protective vaccine feasible.

Therapeutic supplementation with zinc in the management of COVID-19-related diarrhea and ageusia/dysgeusia: mechanisms and clues for a personalized dosage regimen

Zinc supplementation is indicated for diarrhea and taste disorders, which are both features of COVID-19. Nevertheless, this strategy has not been tested for the treatment of these secondary complications in the current pandemic. Through an updated review, a practical appraisal was considered as a means of providing a medical nexus of therapeutic zinc regimens as an adjunct in the management of COVID-19–related diarrhea and ageusia/dysgeusia. While diarrhea and taste disorders are consequences of COVID-19, zinc supplementation is useful for non–COVID-19 patients with these clinical problems. The overwhelming evidence for supplementing with zinc in diarrhea and pneumonia is associated with the treatment of children, while for taste disorders the use of supplementing with zinc is more examined in adults. Whereas COVID-19 is more prevalent in adults, precautions should be exercised not to translate the zinc dosage used for children with diarrhea and taste disorders into the current pandemic. Therapeutic doses of zinc used for adults (∼50–150 mg/day of elemental zinc) could be included in the treatment strategies for COVID-19, but this proposal should be examined through randomized studies.

The African Network for Improved Diagnostics, Epidemiology and Management of common infectious Agents

Background

In sub-Saharan Africa, acute respiratory infections (ARI), acute gastrointestinal infections (GI) and acute febrile disease of unknown cause (AFDUC) have a large disease burden, especially among children, while respective aetiologies often remain unresolved. The need for robust infectious disease surveillance to detect emerging pathogens along with common human pathogens has been highlighted by the ongoing novel coronavirus disease 2019 (COVID-19) pandemic. The African Network for Improved Diagnostics, Epidemiology and Management of Common Infectious Agents (ANDEMIA) is a sentinel surveillance study on the aetiology and clinical characteristics of ARI, GI and AFDUC in sub-Saharan Africa.

Methods

ANDEMIA includes 12 urban and rural health care facilities in four African countries (Côte d’Ivoire, Burkina Faso, Democratic Republic of the Congo and Republic of South Africa). It was piloted in 2018 in Côte d’Ivoire and the initial phase will run from 2019 to 2021. Case definitions for ARI, GI and AFDUC were established, as well as syndrome-specific sampling algorithms including the collection of blood, naso- and oropharyngeal swabs and stool. Samples are tested using comprehensive diagnostic protocols, ranging from classic bacteriology and antimicrobial resistance screening to multiplex real-time polymerase chain reaction (PCR) systems and High Throughput Sequencing. In March 2020, PCR testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and analysis of full genomic information was included in the study. Standardised questionnaires collect relevant clinical, demographic, socio-economic and behavioural data for epidemiologic analyses. Controls are enrolled over a 12-month period for a nested case-control study. Data will be assessed descriptively and aetiologies will be evaluated using a latent class analysis among cases. Among cases and controls, an integrated analytic approach using logistic regression and Bayesian estimation will be employed to improve the assessment of aetiology and associated risk factors.

Discussion

ANDEMIA aims to expand our understanding of ARI, GI and AFDUC aetiologies in sub-Saharan Africa using a comprehensive laboratory diagnostics strategy. It will foster early detection of emerging threats and continued monitoring of important common pathogens. The network collaboration will be strengthened and site diagnostic capacities will be reinforced to improve quality management and patient care.

Diarrhoea among Children Aged under Five Years and Risk Factors in Informal Settlements: A Cross-Sectional Study in Cape Town, South Africa

Background: There is limited data on the association between diarrhoea among children aged under five years (U5D) and water use, sanitation, hygiene, and socio-economics factors in low-income communities. The study investigated U5D and the associated risk factors in the Zeekoe catchment in Cape Town, South Africa. Methods: A cross-sectional study was conducted in 707 households in six informal settlements (IS) two formal settlements (FS) (March–June 2017). Results: Most IS households used public taps (74.4%) and shared toilets (93.0%), while FS households used piped water on premises (89.6%) and private toilets (98.3%). IS respondents had higher average hand-washing scores than those of FS (0.04 vs. −0.14, p = 0.02). The overall U5D prevalence was 15.3% (range: 8.6%–24.2%) and was higher in FS than in IS (21.2% vs. 13.4%, respectively, p = 0.01). Water storage >12 h was associated with increasing U5D (OR = 1.88, 95% CI 1.00–3.55, p = 0.05). Water treatment (OR = 0.57, 95%CI 0.34–0.97, p = 0.04), good hand-washing practices (OR = 0.59, 95%CI 0.42–0.82, p = 0.002) and Hepatitis A vaccination (OR = 0.51, 95%CI 0.28–0.9, p = 0.02) had significant preventing effects on U5D. Conclusions: The study highlights that good hygiene practice is a key intervention against U5D in informal settlements. The promotion of hand-washing, proper water storage, and hygienic breastfeeding is highly recommended.

Precision mapping child undernutrition for nearly 600,000 inhabited census villages in India

There are emerging opportunities to assess health indicators at truly small areas with increasing availability of data geocoded to micro geographic units and advanced modeling techniques. The utility of such fine-grained data can be fully leveraged if linked to local governance units that are accountable for implementation of programs and interventions. We used data from the 2011 Indian Census for village-level demographic and amenities features and the 2016 Indian Demographic and Health Survey in a bias-corrected semisupervised regression framework to predict child anthropometric failures for all villages in India. Of the total geographic variation in predicted child anthropometric failure estimates, 54.2 to 72.3% were attributed to the village level followed by 20.6 to 39.5% to the state level. The mean predicted stunting was 37.9% (SD: 10.1%; IQR: 31.2 to 44.7%), and substantial variation was found across villages ranging from less than 5% for 691 villages to over 70% in 453 villages. Estimates at the village level can potentially shift the paradigm of policy discussion in India by enabling more informed prioritization and precise targeting. The proposed methodology can be adapted and applied to diverse population health indicators, and in other contexts, to reveal spatial heterogeneity at a finer geographic scale and identify local areas with the greatest needs and with direct implications for actions to take place.

Etiological, epidemiological, and clinical features of acute diarrhea in China

National-based prospective surveillance of all-age patients with acute diarrhea was conducted in China between 2009‒2018. Here we report the etiological, epidemiological, and clinical features of the 152,792 eligible patients enrolled in this analysis. Rotavirus A and norovirus are the two leading viral pathogens detected in the patients, followed by adenovirus and astrovirus. Diarrheagenic Escherichia coli and nontyphoidal Salmonella are the two leading bacterial pathogens, followed by Shigella and Vibrio parahaemolyticus. Patients aged <5 years had higher overall positive rate of viral pathogens, while bacterial pathogens were more common in patients aged 18‒45 years. A joinpoint analysis revealed the age-specific positivity rate and how this varied for individual pathogens. Our findings fill crucial gaps of how the distributions of enteropathogens change across China in patients with diarrhea. This allows enhanced identification of the predominant diarrheal pathogen candidates for diagnosis in clinical practice and more targeted application of prevention and control measures.

Aetiology of acute diarrhoea in children in Shanghai, 2015-2018

Diarrhoea remains a major cause of childhood morbidity and mortality worldwide. This study aimed to monitor the aetiology of acute diarrhoea in children in Shanghai. Paediatric outpatients with acute diarrhoea were enrolled in the study from Jan 2015 to Dec 2018. Faecal samples were collected for testing. Enteric bacteria were identified and typed by culture and serotyping, respectively. Enteric viruses were identified by real-time PCR. Enteric pathogens were identified in 1572 (58.4%) of the 2692 enrolled children with acute diarrhoea. Viruses were detected more frequently than bacteria (41.3% versus 25.0%). Nontyphoidal Salmonella spp. (NTS) was the most common (10.3%) bacteria isolated, followed by enteropathogenic Escherichia coli (EPEC) (6.5%), enteroaggregative Escherichia coli (EAEC) (6.2%), Campylobacter spp. (3.6%), enterotoxigenic Escherichia coli (ETEC) (1.1%), Shigella spp. (0.2%), and enterohemorrhagic Escherichia coli (EHEC) (0.1%). Rotavirus was the most common (16.0%) virus detected, followed by norovirus (15.5%), adenovirus (7.2%), sapovirus (3.0%) and astrovirus (2.7%). Rotavirus, norovirus and NTS were the major pathogens responsible for diarrhoea in Shanghainese children. Improving uptake of the rotavirus vaccine and strengthening foodborne-pathogen prevention will aid in reducing the burden of diarrhoeal disease in children in Shanghai.

Socio-demographic, not environmental, risk factors explain fine-scale spatial patterns of diarrhoeal disease in Ifanadiana, rural Madagascar

Precision health mapping is a technique that uses spatial relationships between socio-ecological variables and disease to map the spatial distribution of disease, particularly for diseases with strong environmental signatures, such as diarrhoeal disease (DD). While some studies use GPS-tagged location data, other precision health mapping efforts rely heavily on data collected at coarse-spatial scales and may not produce operationally relevant predictions at fine enough spatio-temporal scales to inform local health programmes. We use two fine-scale health datasets collected in a rural district of Madagascar to identify socio-ecological covariates associated with childhood DD. We constructed generalized linear mixed models including socio-demographic, climatic and landcover variables and estimated variable importance via multi-model inference. We find that socio-demographic variables, and not environmental variables, are strong predictors of the spatial distribution of disease risk at both individual and commune-level (cluster of villages) spatial scales. Climatic variables predicted strong seasonality in DD, with the highest incidence in colder, drier months, but did not explain spatial patterns. Interestingly, the occurrence of a national holiday was highly predictive of increased DD incidence, highlighting the need for including cultural factors in modelling efforts. Our findings suggest that precision health mapping efforts that do not include socio-demographic covariates may have reduced explanatory power at the local scale. More research is needed to better define the set of conditions under which the application of precision health mapping can be operationally useful to local public health professionals.

The Microbiome of Size-Fractionated Airborne Particles from the Sahara Region

Diverse airborne microbes affect human health and biodiversity, and the Sahara region of West Africa is a globally important source region for atmospheric dust. We collected size-fractionated (>10, 10-2.5, 2.5-1.0, 1.0-0.5, and <0.5 μm) atmospheric particles in Mali, West Africa and conducted the first cultivation-independent study of airborne microbes in this region using 16S rRNA gene sequencing. Abundant and diverse microbes were detected in all particle size fractions at levels higher than those previously hypothesized for desert regions. Average daily abundance was 1.94 × 10⁵ 16S rRNA copies/m³. Daily patterns in abundance for particles <0.5 μm differed significantly from other size fractions likely because they form mainly in the atmosphere and have limited surface resuspension. Particles >10 μm contained the greatest fraction of daily abundance (51-62%) and had significantly greater diversity than smaller particles. Greater bacterial abundance of particles >2.5 μm that are bigger than the average bacterium suggests that most airborne bacteria are present as aggregates or attached to particles rather than as free-floating cells. Particles >10 μm have very short atmospheric lifetimes and thus tend to have more localized origins. We confirmed the presence of several potential pathogens using polymerase chain reaction that are candidates for viability and strain testing in future studies. These species were detected on all particle sizes tested, including particles <2.5 μm that are expected to undergo long-range transport. Overall, our results suggest that the composition and sources of airborne microbes can be better discriminated by collecting size-fractionated samples.

Trends and determinants of diarrhea among under-five children in Ethiopia: cross-sectional study: multivariate decomposition and multilevel analysis based on Bayesian approach evidenced by EDHS 2000-2016 data

BACKGROUND

Despite significant progress in the reduction of under-five child deaths over the last decades in Ethiopia, still diarrhea remains the second cause of morbidity and mortality among under five children next to pneumonia.

OBJECTIVE

To show trends and determinants of diarrhea among under five children in Ethiopia based on the four Ethiopian Demographic and health surveys data (2000-2016).

METHODS

A total of 10,753 in 2000, 10,039 in 2005, 10,946 in 2011 and 10,337 in 2016 under five age children were involved in this study. Multivariate decomposition and multilevel analysis based on Bayesian approach was performed.

RESULTS

Ninety seven percent of the change in diarrhea prevalence over time was attributable to difference in behavior. Being twin (AOR = 1.3; 95% CrI 1.1-1.5), big weight (AOR = 1.63; 95% CrI 1.62-2.02), not vaccinated for rotavirus (AOR = 1.44; 95% CrI 1.12-1.9) and for measles (AOR = 1.2; 95% CrI 1.1-1.33), poor wealth status (AOR 2.6; 95% CrI 1.7-4.06), having more than three under-five children (AOR 1.3; 95% CrI 1.1-1.61), member of health insurance (AOR 2.2; 95% CrI 1.3-3.8) and long distance from the health facility (AOR 2.7; 95% CrI 2.2-3.5) were more likely to experience diarrhea.

CONCLUSION

The prevalence of diarrhea was significantly declined over the last sixteen years and the decline was due to difference in behavior between the surveys. Being twin, weight of child at birth, vaccinated for measles and rotavirus, number of under-five children, wealth status, distance to health facility, health insurance and child waste disposal method were significantly associated with diarrhea among under five children in Ethiopia. Therefore Ethiopian government should focus on the strengthening and scaling up of behavioral change packages of the community regarding to keeping hygiene and sanitation of the community and their environment, vaccinating their children, accessing health care services to prevent diarrheal disease.

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.

Comorbid patterns of anaemia and diarrhoea among children aged under 5 years in Ghana: a multivariate complex sample logistic regression analysis and spatial mapping visualisation

Background

Anaemia and diarrhoea are known independent causes of under-five morbidity and mortality. This study sought to investigate predictors of comorbid patterns of anaemia and diarrhoea using the 2014 Ghana Demographic and Health Survey (GDHS).

Methods

The study employed analysis of secondary data from the 2014 GDHS. We performed a multivariate complex sample logistic regression and spatial analysis.

Results

The weighted prevalence of comorbid anaemia and diarrhoea was 9.28% with the highest burden (16.45%) found in the Upper West region. Independent predictors (risk factors) of comorbid patterns of anaemia and diarrhoea were children aged 6–23 mo (OR=2.17, 95% CI 1.42 to 3.33), male gender (OR=1.50, 95% C1 1.04 to 2.16), history of fever (OR=4.37, 95% CI 2.94 to 6.50) and living in a household with two children aged <5 y (OR=1.80, 95% CI 1.14 to 2.84). Protective factors were having a father with secondary or higher education (OR=0.57, 95% CI 0.33 to 0.97), living in a household with ≥6 members (OR=0.46, 95% CI 0.28 to 0.75) and living in a richer household (OR=0.38, 95% CI 0.16 to 0.89). Surface maps revealed inter-regional and subregional variations.

Conclusion

The study shows that the independent predictors of comorbid patterns of anaemia and diarrhoea among children aged <5 y in Ghana are age, gender, history of fever, the number of children aged <5 y in the household, parental education, household size and household wealth. The study identified zones to be targeted for cost-effective policy interventions.

Vitamin A supplementation and estimated number of averted child deaths in Ethiopia: 15 years in practice (2005-2019)

Vitamin A supplementation (VAS), started as a short‐term strategy pending dietary improvements, has been implemented in Ethiopia for the last 15 years. We aimed to describe the trends in VAS coverage and estimated the associated reductions in child mortality. VAS coverage data obtained from the District Health Information System and the Demographic and Health Surveys were linked to child mortality data from the United Nations Interagency Group for Child Mortality Estimation (UN IGME). The number of child deaths averted was modelled assuming 12% and 24% reductions in all‐cause mortality. From 2006 to 2011, VAS was delivered through campaigns, and coverage was above 85%. However, from 2011 onwards, VAS delivery was integrated to the routine health system, and the coverage declined to <60% with significant disparities by wealth quintile and rural–urban residence. VAS has saved between 167,563 to 376,030 child lives (2005–2019), but additional lives (>42,000) could have been saved with a universal coverage (95%). Inconsistent supply of vitamin A capsules, but more importantly, low access to health care, and the limited contact opportunities for children after 24 months may have contributed to the declining VAS coverage. Any changes in target or scale‐up should thus consider these spatial and socioeconomic variations. Increasing the coverage of VAS and closing the equity gap in access to nutrition services is critical. However, with alternative programmes like vitamin A fortification being set‐up, the benefits and safety of VAS need to be closely monitored, particularly in areas where there will be overlap.