Reducing diarrhoea deaths in South Africa: costs and effects of scaling up essential interventions to prevent and treat diarrhoea in under-five children

Exploration of Infant Food Microbial Composition from Formal and Informal Settings Using Viable Counts and 16S rRNA Gene Amplicon Sequencing in Johannesburg, South Africa

Diarrhoea is a considerable agent of disease and loss of life in children below age five in South Africa. Soweto, South Africa is an urban township in Johannesburg, with most of its population living in informal settlements. Informal settlements in areas such as Soweto are often impoverished communities that do not get water easily, inadequate sanitation is pervasive, and poor hygiene common (risk factors for diarrhoeal diseases). Among the age groups, infants are most vulnerable to diarrhoeal infection, mainly through the ingestion of food and water. The presence of undesirable microbiota is a food safety and health challenge. This study investigated the microbiome of infant food samples collected from formal (n = 19) and informal (n = 11) households in Soweto. A non-culture-dependent technique was used to characterise the bacterial diversity and composition of the infant food samples. The results indicated that household type did not influence microbial diversity and composition in Soweto. South Africa. Firmicutes, Proteobacteria, Cyanobacteria, and Tenericutes dominated the phyla rank in food samples from formal and informal households. Potential pathogens of public health significance, including diarrhoeal disease agents such as Salmonella spp., E. coli, and Campylobacter spp., were detected within the foods. We concluded that the infant food samples showed rich bacterial diversity, and the presence of potential pathogens of public health significance suggests a disease risk that infants may face upon consuming the foods.

Infection, nutritional status, and body composition: Associations at birth and 6 months postnatally in Soweto, South Africa

INTRODUCTION

The impact of infection on infant nutritional status, body size, and growth is well documented. However, research into the impact of infection on infant body composition is limited. Greater understanding is, therefore, needed on the effects of infection in early life.

METHODS

Associations between a composite morbidity index consisting of the sum of the cumulative tallies for a range of symptoms representing infection and morbidity in the infants and nutritional status (height-for-age (HAZ), and weight-for-height (WHZ)), and body composition (fat-free mass (FFM), fat mass (FM), fat-free mass index (FFMI), and fat mass index (FMI)) at 6 months of age were investigated using hierarchical regression analysis.

RESULTS

The sample comprised data between birth and 6 months postnatally, of 156 infants who were a priori born healthy in Soweto, South Africa. Morbidity, over the cumulative period of birth to 6 months, was associated with lower FMI (β = -1.77) and lower FM (β = -0.61), and conversely with higher FFM (β = 0.94), in infants at 6 months. No associations were found between the morbidity index and FFMI, HAZ, and WHZ. Increased birthweight was associated with a higher FFM (β = 0.66), HAZ (β = 1.14), and WHZ (β = 0.87). Finally, safely managed sanitation facilities, representative of reduced environmental exposure to fecal-oral transmission pathways were associated with a higher HAZ (β = 1.21).

DISCUSSION

Reduction in FMI and FM and exposure to inflammatory cytokines associated with mounting an immune response could alter phenotypic trajectories during to this period of plasticity. From a public health perspective, these results imply that it is important to intensify efforts to prevent infection in infants in the first 6 months postnatally, and that these efforts should concentrate on access to safely managed sanitation facilities.

Social and Environmental Determinants of Diarrheal Diseases among Children under Five Years in Epworth Township, Harare

Children five years or younger in low- and middle-income countries (LMICs) are severely affected by diarrheal disease, especially in the sub-Saharan region. Hence, this study aimed at determining the prevalence and determinants of diarrhoea disease among children under 5 years in Epworth Township, Zimbabwe. A descriptive cross-sectional study was conducted at a local clinic in Epworth Township, Harare. A convenience sampling strategy was used to recruit study participants for participation, and 386 children were enrolled in the study. The majority were male children (n = 229; 59.3%), whereas there were more female caregivers (n = 370; 95.9%) than male caregivers (n = 16; 4.1%). The prevalence of diarrhoea disease in the study was 25.1%. The determinants associated with diarrhoea were being partially vaccinated (AOR 2.38, CI: 95% 2.80-8.22), collecting water more than 1 kilometre from a household (AOR 4.55; CI: 95% 2.10-9.85), and using untreated water (AOR 6.22; CI: 95% 2.13-18.20). The age of the caregiver (being older than 21) and using a clean water container (AOR 0.05; CI: 95% 0.02-0.13) were protective factors. Provision of primary health care, especially the prevention of a disease through immunization and rendering environmental health services, could reduce the prevalence of diarrhoea in disadvantaged townships.

Exploring the Association between Ambient Temperature and Daily Hospital Admissions for Diarrhea in Mopani District, Limpopo Province, South Africa

Diarrhea contributes significantly to global morbidity and mortality. There is evidence that diarrhea prevalence is associated with ambient temperature. This study aimed to determine if there was an association between ambient temperature and diarrhea at a rural site in South Africa. Daily diarrheal hospital admissions (2007 to 2016) at two large district hospitals in Mopani district, Limpopo province were compared to average daily temperature and apparent temperature (Tapp, 'real-feel' temperature that combined temperature, relative humidity, and wind speed). Linear regression and threshold regression, age-stratified to participants ≤5 years and >5 years old, considered changes in daily admissions by unit °C increase in Tapp. Daily ranges in ambient temperature and Tapp were 2-42 °C and -5-34 °C, respectively. For every 1 °C increase in average daily temperature, there was a 6% increase in hospital admissions for diarrhea for individuals of all ages (95% CI: 0.04-0.08; p < 0.001) and a 4% increase in admissions for individuals older than 5 years (95% CI: 0.02-0.05; p < 0.001). A positive linear relationship between average daily Tapp and all daily diarrheal admissions for children ≤5 years old was not statistically significant (95% CI: -0.00-0.03; p = 0.107). Diarrhea is common in children ≤5 years old, however, is more likely triggered by factors other than temperature/Tapp, while it is likely associated with increased temperature in individuals >5 years old. We are limited by lack of data on confounders and effect modifiers, thus, our findings are exploratory. To fully quantify how temperature affects hospital admission counts for diarrhea, future studies should include socio-economic-demographic factors as well as WASH-related data such as personal hygiene practices and access to clean water.

High Burden of Co-Infection with Multiple Enteric Pathogens in Children Suffering with Diarrhoea from Rural and Peri-Urban Communities in South Africa

Infectious diarrhoea contributes to high morbidity and mortality in young children from sub-Saharan Africa. The aim of this study was to assess the prevalence of single and multiple diarrhoeal-causing pathogen combinations in children suffering from diarrhoea from rural and peri-urban communities in South Africa. A total of 275 diarrhoea stool specimens were collected between 2014 and 2016 from Hospitals and Primary Health Care clinics. The BioFire^® FilmArray^® Gastrointestinal panel was used to simultaneously detect 22 diarrhoea pathogens (viruses, bacteria, parasites) known to cause diarrhoea. A total of 82% (226/275) enteric pathogens were detected in the stool specimens. The two most detected bacterial, viral and parasitic pathogens each included: EAEC (42%), EPEC (32%), Adenovirus F40/41 (19%), Norovirus (15%), Giardia (8%) and Cryptosporidium (6%), respectively. Single enteric pathogen infections were recorded in 24% (65/275) specimens with EAEC, and Norovirus was found in 26% (17/65) and 14% (9/65) of the specimens, respectively. Multiple enteric pathogen combinations were recorded in 59% (161/275) of the stool specimens with 53% (85/161) containing two pathogens, 22% (35/161) containing three pathogens and 25% (41/161) containing four or more pathogens. The results from this study demonstrated the complex nature of pathogen co-infections in diarrhoeal episodes which could have an impact on treatment effectiveness.

Diarrhoea among Children Aged 5 Years and Microbial Drinking Water Quality Compliance: Trends Analysis Study in South Africa (2008-2018)

In developing countries such as South Africa, diarrhoeal diseases are reported to be linked to inadequate drinking water quality, sanitation, and hygiene behaviours. The consumption of microbiologically contaminated drinking water has been reported to cause diarrhoea, mortality, and morbidity in children under the age of five years. This study evaluated the microbiological pathogens detected in municipal drinking water and diarrhoea trends for children under 5 years of age in South Africa between 2008 and 2018. A trends analysis study was conducted using secondary data on diarrhoea for children under the age of five years and microbial drinking water quality compliance. A negative correlation was found between the occurrence of microbial pathogens in water, morbidity, and mortality rates of children under the age of 5 years in South Africa. As compliance status improved, the mortality rate among children under 5 years old decreased by 31% over the study period. A conclusion can thus be drawn that the microbiological pathogens detected in drinking water at levels complying with SANS 241:2015 Edition 2 standards and diarrhoea incidences were not the primary cause of the mortality of children under 5 years old in South Africa between 2008 and 2018.

Diarrhoeal prevalence and handwashing practices of children attending early childhood development centres in KwaZulu-Natal, South Africa

Background

Diarrhoea, a leading cause of childhood morbidity and mortality, spread through contaminated food or water or from person to person, is a major cause of hospitalisation in South African children.

Aim

To determine if hygiene practices of parents or guardians and early childhood development centre (ECD) educators contributed to diarrhoea in children attending the centres.

Setting

The study was conducted at ECD centres in Mpumalanga Township of KwaZulu-Natal province, South Africa.

Methods

A descriptive cross-sectional study was conducted at 10 ECD centres. Parents or guardians (n = 385) and educators (n = 121) answered self-administered questionnaires. Frequencies, bivariate associations and multivariate regression modelling were conducted.

Results

The prevalence of diarrhoea in children ≤ 5 years was 67.3%. Most parents or guardians washed their hands after defecating and handling a child's faeces as well as before preparing food. Handwashing after urination was low. Washing of children's hands after these events was lower. Although all educators reported always washing the child's hands after defecating and before handling or eating food, they were less likely to wash the children's hands after urination (p = 0.003). Childhood diarrhoea was associated with the type of toilet, households with pit latrines having a higher prevalence of diarrhoea (p < 0.001). It was also associated with washing of children's hands after urination (p = 0.014), before handling or eating food (p = 0.001) and with increased number of children in the household (p = 0.001).

Conclusion

In this population, the high prevalence of diarrhoea is related to the number of children in a household and handwashing practices.

Contribution

This study highlights the importance of handwashing practices in the prevention of diarrhoea in children.

Determinants of diarrhoeal infections among users of shared sanitation in informal settlements in Durban, South Africa

Diarrhoeal disease continues to be a major health problem in many parts of the world, especially in developing countries, mainly due to the lack of access to sanitation, water, and hygienic living conditions. Identifying the determinants of diarrhoeal infections continues to be a challenge in developing countries. In this study, we ascertained the factors behind diarrhoea among inhabitants of informal settlements in the city of Durban, South Africa. Prevalence of diarrhoea in the study area varied between 7-year historical clinical records and data collected during the current study (primary data), with the primary data giving the highest monthly prevalence odds ratio (POR) up to 18.1 (±1.6)%. The main factors associated with diarrhoeal infections were open defaecation (POR = 1.8; 95% confidence interval (CI): 0.9-3.12), use of shared sanitation (POR = 1.7; 95%; CI: 1.05-2.26), and exposure to faecal matter around the homes (POR = 1.69; 95% CI: 1.25-3.10). Several other factors were also determined to be associated with diarrhoeal infections, such as hygiene practices in the communities, the non-treatment of water before use, and the presence of solid waste and faecal materials around the households. This study shows that diarrhoeal disease infections in informal settlements could be multifactorial; therefore, a multifactorial approach is needed to reduce these infections. These could include improving education on hygiene practices within the home setting as well as in public places, such as the community ablution blocks.

Development and Implementation of an Integrated Framework for Undergraduate Pharmacy Training in Maternal and Child Health at a South African University

The South African Pharmacy Council (SAPC) regulates undergraduate pharmacy education and pharmacy practice. The SAPC Good Pharmacy Practice manual describes the role of pharmacists in maternal and child health (MCH) in line with the recommendation of international health regulatory bodies. However, baseline study findings in 2017 supported literature from around the world that indicated a need for curriculum review and integration to address the knowledge and skills gap in pharmacists’ MCH training. This paper describes the development and implementation of an integrated framework for MCH training across the four years of a Bachelor of Pharmacy program. The intervention included didactic lectures, skills practical on infant growth assessment, and an experiential learning component at primary health care clinics and pharmacies. Knowledge and skills assessment on contraception, maternal and antenatal care, and neonatal and child care were carried out pre, eight weeks post, and two years post intervention using the same questionnaire. ANOVA and post hoc analyses showed that participants’ knowledge and skills increased post intervention but decreased significantly two years later except in contraception where students experienced longitudinal integration of the MCH component. Generally, participants performed above the university average except in maternal and antenatal care.

Prevention, Management and Risk Factors for Diarrhoeal Disease in under-Fives in Cape Town

BACKGROUND

In South Africa, Cape Town's health facilities are stretched by the volume of cases of diarrhoea during the summer months, particularly with severely dehydrated children, who often require complex inpatient management. The prevalence of severe disease in children living in the settlements around Cape Town is particularly high.

METHODS

An observational study of a systematic sample of children under 5 who presented to any primary care facility in Khayelitsha, an informal settlement of Cape Town, with diarrhoea and referred to secondary care between 1 November 2015 and 30 April 2016. We recruited participants from the sub-district office and identified risk factors associated with the index presentation, captured the triage and management of patients in primary care and investigated post-discharge follow-up.

RESULTS

We recruited 87 children into the study, out of a total of 115 cases of severe dehydration. There was a significantly higher number of households in this group with no income than in Khayelitsha overall (65% vs. 47.4%; p < 0.001). In the sample, HIV-exposed, uninfected children were younger than unexposed children (median 9.44 months in exposed vs. 17.36 months in unexposed; p = 0.0015) and were more likely to be malnourished (weight-for-age Z-score; WAZ score < -2) [13 cases exposed vs. 8 cases unexposed (p = 0.04)]. Outreach staff were able to trace only 33.3% of children at home following discharge, yet 65% of children attended follow-up appointments in clinics.

CONCLUSIONS

This cohort of children with diarrhoeal disease complicated by severe dehydration was a particularly socially deprived group. The results demonstrating zero vertical transmission of HIV in this very socioeconomically deprived area of Cape Town are encouraging. In the HIV-exposed, uninfected group, children were younger and had a higher prevalence of malnutrition, which should be the subject of future research, especially given existing evidence for immunological differences in children exposed to HIV in utero. Locating children with severe diarrhoea post-discharge was challenging and further research is needed on the cost-effectiveness and outcomes of different follow-up approaches.

An Integrated Approach to Hygiene, Sanitation, and Storage Practices for Improving Microbial Quality of Drinking Water Treated at Point of Use: A Case Study in Makwane Village, South Africa

This study assessed the impact of sanitation practices, hygienic and storage conditions on the quality of drinking water treated at point-of-use in Makwane Village. Subsequent to implementation of low-cost Household Water Treatment Devices which are the biosand filter with zeolite-silver (BSZ-SICG) and silver-impregnated porous pot (SIPP) filters in Makwane village, a structured questionnaire was designed to collect the following information: age of caretakers, number of children under the age of five, water storage conditions, sanitation amenities, and hygiene practices. Water quality from the sources to household level was assessed using culture-based and molecular techniques. The results revealed a significant association between the presence of Escherichia coli in treated drinking water with the age group of caregivers and the number of children ofless than the age of five [OR (95% CI) = 8.4737 (0.147–3.3497), p = 0.0141923 and OR (95% CI) = 9.1667 (0.1848–3.0159); p = 0.0165830, respectively]. Moreover, significant association was noted between hygiene practices (washing of hands with/without soap) and water quality in storage containers [OR (95% CI) = 16.000 (0.6763–3.9495), p = 0.0000125]. These findings further prove that there is still a dire need for reconsidering hygiene education in rural areas as the health benefits of water treated at point of use (POU) coupled with safe-storage condition interventions might not be guaranteed without proper hygiene. The results further highlighted the importance of washing hands in improving microbial quality of drinking water, which is the key factor for fighting against infectious diseases.

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.

Characterization and Antibiotic Susceptibility Profiles of Pathogenic Escherichia Coli Isolated from Diarrhea Samples within the Buffalo City Metropolitan Municipality, Eastern Cape, South Africa

Objectives:

Developing countries like South Africa are still faced with numerous challenges such as poor environmental sanitation, lack of clean drinking water and inadequate hygiene which have contributed largely to diarrheal infections and deaths in children. This study was aimed at investigating the prevalence of pathotypes, antimicrobial resistance and drug resistance determinants among Escherichia coli (E. coli) isolates from diarrhea stool samples within Buffalo City Municipality, Eastern Cape, South Africa.

Methods:

Fresh diarrheal stool samples were collected from 140 patients attending public health centres within the Municipality and presumptive E. coli isolates were obtained from the stool samples using E. coli chromogenic agar while PCR amplification methods were used to confirm the presumptive isolates as well as delineate them into pathotypes based on the presence of certain virulence genes. In addition, antimicrobial susceptibility and screening of some of the antimicrobial resistant determinants were performed on all the confirmed isolates.

Results:

A total of 394 presumptive E. coli isolates from 140 diarrhea stool samples were subjected to polymerase chain reaction amplification, of which 265 were confirmed positive as E. coli. Pathotypes delineation of the positive E. coli isolates validated the presence of ETEC 106 (40%), EAEC 48 (18%), DAEC 37 (14%), and EPEC 31 (11%) while no EIEC pathotype was detected. All E. coli isolates exhibited maximum susceptibility to gentamicin (95%), amikacin (91%), nitrofurantoin (91%), meropenem (90%), chloramphenicol (91%) norfloxacin (84%) and imipenem (83%). However, the isolates showed multidrug resistance to penicillin G, ampicillin, trimethoprim, tetracycline, doxycycline, and erythromycin, with over 71% of the isolates resistant to the drugs. The prevalence and distribution of the five resistance determinants assessed were as follow; sulphonamides; sulII (12%), beta lactams; [ampC (22%); blaTEM, (25%)], and tetracyclines (tetA (35%).

Conclusion:

The results from this study suggest the probable involvement of E. coli pathotypes as an etiologic agent of diarrhea in the study area and revealed high levels of multidrug resistance among the isolates, which could be a major health burden.

Water, sanitation, and hygiene (WASH) factors associated with growth between birth and 1 year of age in children in Soweto, South Africa: results from the Soweto Baby WASH study

Interventions to reduce undernutrition and improve child growth have incorporated improved water, sanitation, and hygiene (WASH) as part of disease transmission prevention strategies. Knowledge gaps still exist, namely, when and which WASH factors are determinants for growth faltering, and when WASH interventions are most effective at improving growth. This study drew cross-sectional data from a longitudinal cohort study and used hierarchical regression analyses to assess associations between WASH factors: water index, sanitation, hygiene index, and growth: height-for-age (HAZ), weight-for-age (WAZ), weight-for-height (WHZ) at 1, 6, and 12 months postpartum among infants a priori born healthy in Soweto, Johannesburg. Household access to sanitation facilities that were not safely managed was associated with a decrease in HAZ scores at 1 month (β = -2.24) and 6 months (β = -0.96); a decrease in WAZ at 1 month (β = -1.21), 6 months (β = -1.57), and 12 months (β = -1.92); and finally, with WHZ scores at 12 months (β = -1.94). Counterintuitively, poorer scores on the hygiene index were associated with an increase at 1 month for both HAZ (β = 0.53) and WAZ (β = 0.44). Provision of safely managed sanitation at household and community levels may be required before improvements in growth-related outcomes are obtained.

Intersectoral (in)activity: towards an understanding of public sector department links between water, sanitation and hygiene (WASH) and childhood undernutrition in South Africa

Associations between different forms of malnutrition and environmental conditions, including water, sanitation and hygiene (WASH), contribute to poor child health, nutritional status and physical growth. The primary responsibility for the provision of water and sanitation, as a basic service and human right, lies with the State, as such, a number of stakeholders are involved. Despite relatively high levels of WASH infrastructure coverage in South Africa, enteric infections and stunting remain high for a middle-income country. The aim of this study is to elucidate the landscape of WASH in South Africa in relation to nutritional status of children under the age of 5 years in the South African, Gauteng and City of Johannesburg contexts. The authors detailed the national and provincial public sector departments and through purposive sampling proceeded to map the various departments and associated policies that are responsible for the provision of WASH facilities, as well the nutritional status of children. Of the six policies identified for review, three mentioned WASH, nutrition and children; however, none explicitly linked WASH to nutritional status in children. An in-depth review and analysis of these three crucial policy documents was conducted. Finally, a set of expert interviews were conducted and a consensus development conference convened, with experts at the intersection between WASH and nutritional status. The authors found that the public sector would benefit from better integration of the concept of WASH into their policy, planning and implementation frameworks. The WASH sector should emphasize the role in which WASH plans consider the impact of WASH on the nutritional status of children. The various public sector departments involved in WASH service provision, and other WASH stakeholders, including community-based organizations, non-governmental organizations and intergovernmental organizations, should be involved in the decision-making of the nutrition sector.

Global, regional and national burden of emergency medical diseases using specific emergency disease indicators: analysis of the 2015 Global Burden of Disease Study

Objective

There are currently no metrics for measuring population-level burden of emergency medical diseases (EMDs). This study presents an analysis of the burden of EMDs using two metrics: the emergency disease mortality rate (EDMR) and the emergency disease burden (EDB) per 1000 population at the national, regional and global levels.

Methods

We used the 1990 and 2015 Global Burden of Disease Study for morbidity and mortality data on 249 medical conditions in 195 countries. Thirty-one diseases were classified as 'emergency medical diseases' based on earlier published work. We developed two indicators, one focused on mortality (EDMR) and the other on burden (EDB). We compared the EDMR and EDB across countries, regions and income groups and compared these metrics from 1990 to 2015.

Results

In 2015, globally, there were 28.3 million deaths due to EMDs. EMDs contributed to 50.7% of mortality and 41.5% of all burden of diseases. The EDB in low-income countries is 4.4 times that of high-income countries. The EDB in the African region is 273 disability-adjusted life years (DALYs) per 1000 compared with 100 DALYs per 1000 in the European region. There has been a 6% increase in overall mortality due to EMDs from 1990 to 2015. Globally, injuries (22%), ischaemic heart disease (17%), lower respiratory infections (11%) and haemorrhagic strokes (7%) made up about 60% of EMDs in 2015.

Conclusion

Globally, EMDs contributed to more than half of all years of life lost. There is a significant disparity between the EDMR and EDB between regions and socioeconomic groups at the global level.

Why is mother to child transmission (MTCT) of HIV a continual threat to new-borns in sub-Saharan Africa (SSA)

Sub-Saharan Africa (SSA) accounts for more than two thirds of the world's HIV infection. Despite scaled-up prevention of mother-to-child transmission of HIV (PMTCT) programmes, mother to child transmission of HIV (MTCT) continues to escalate. We describe the challenges faced by PMTCT in MTCT in SSA. The study reviewed articles and reports published online. The most common barriers and challenges were non-disclosure of HIV status, late initiation of ARVs treatment/adherence, STIs screening, long clinics waiting time, non-involvement of men in ANC/PMTCT, infant feeding methods and sensitization of community members on ANC/PMTCT programmes. The study highlights the need to expand PMTCT coverage and the implementation of the 90-90-90 programme toward MTCT elimination in SSA. That is " ≥90% of pregnant and breast-feeding mothers must know their HIV status; ≥90% of those that are positive are enrolled on ARVs treatment and care; ≥90% of those on ARVs treatment and care are virally suppressed.

Enhancing Personal Hygiene Behavior and Competency of Elementary School Adolescents through Peer-Led Approach and School-Friendly: A Quasi-Experimental Study

Background

Recent studies showed that poor personal hygiene practices play a major role in the increment of communicable disease burden in developing countries. In Ethiopia, 60% of the disease burden is related to poor sanitation practices. This school based study was aimed to assess the effectiveness of school-friendly and peer-led approach in improving personal hygiene practices of school adolescents in Jimma Zone, Southwest of Ethiopia.

Methods

A total of 1000 students from 10 to 19 years were included into the study. The intervention was done using peer-led approach, health clubs and linking the school events with parents. Data were collected at baseline, midline and end-line using structured questionnaires. Repeated measurement analysis was done and statistical significance was considered at alpha 0.05.

Results

The findings of this study indicated that there was a significant difference in personal hygiene practices and knowledge between the intervention and control groups (P<0.001). A significant difference was also observed with the duration of time in the intervention schools (P<0.05). The proportion of adolescents who reported illness before the baseline survey was significantly high among the intervention schools (P<0.01). However, at midline of the survey, the proportion of self-reported illness was significantly high among the control group(P<0.001).

Conclusion

The findings of this study showed that there was a significant improvement in personal hygiene knowledge and practice of students in the intervention schools. Therefore, there is a need for proper health education intervention through the framework of schools for the students to improve their personal hygiene knowledge and practices.

Dramatic Reduction in Diarrhoeal Diseases through Implementation of Cost-Effective Household Drinking Water Treatment Systems in Makwane Village, Limpopo Province, South Africa

The main purpose of this study was to implement cost-effective household water treatment systems in every household of Makwane Village for the reduction of diarrhoeal diseases. These household water treatment systems were constructed with locally available materials and consisted of the biosand zeolite-silver impregnated granular clay filters and the silver-impregnated porous pot filters. During the study period (April 2015 to September 2015), the entire village had 88 households with a population size of 480. Prior to the implementation, a survey was conducted and results revealed that 75% (360/480) of the Makwane residents suffered from diarrhoeal disease and the majority of the cases were reported in children that were less than five years of age. Out of the 480 participants, 372 (77.5%) from 70 households accepted the installation of the systems (intervention group) and 108 (25.5%) from 18 households were reluctant to use the systems (the control group). To date, in the intervention group, only 3.8% (14/372) of participants reported cases of diarrhoea. In the control group, 57.4% (62/108) participants reported cases of diarrhoea and most of the episodes of diarrhoea were reported in children of less than five years old (85%), followed by the group aged ≥56 years (75%). The findings of the current study unequivocally demonstrated that the BSZ-SICG and SIPP filters were able to reduce the incidence of diarrhoea by 96.2%. These findings further demonstrate the importance of household water treatment systems (HWTS) interventions in rural areas to bring about meaningful reductions in diarrhoeal diseases by providing safe potable water.

The global problem of childhood diarrhoeal diseases: emerging strategies in prevention and management

Acute diarrhoeal diseases remain a leading cause of global morbidity and mortality particularly among young children in resource-limited countries. Recent large studies utilizing case-control design, prospective sampling and more sensitive and broad diagnostic techniques have shed light on particular pathogens of importance and highlighted the previously under recognized impact of these infections on post-acute illness mortality and growth. Vaccination, particularly against rotavirus, has emerged as a key effective means of preventing significant morbidity and mortality from childhood diarrhoeal disease. Other candidate vaccines against leading diarrhoeal pathogens, such as enterotoxigenic Escherichia coli and Shigella spp., also hold significant promise in further ameliorating the burden of enteric infections in children. Large studies are also currently underway evaluating novel and potential easy-to-implement water, sanitation and hygiene (WASH) preventive strategies. Given the ongoing global burden of this illness, the paucity of new advances in case management over the last several decades remains a challenge. The increasing recognition of post-acute illness mortality and growth impairment has highlighted the need for interventions that go beyond management of dehydration and electrolyte disturbances. The few trials of novel promising interventions such as probiotics have mainly been conducted in high-income settings. Trials of antimicrobials have also been primarily conducted in high-income settings or in travellers from high-income settings. Bloody diarrhoea has been shown to be a poor marker of potentially treatable bacterial enteritis, and rising antimicrobial resistance has also made empiric antimicrobial therapy more challenging in many settings. Novel effective and sustainable interventions and diagnostic strategies are clearly needed to help improve case management. Diarrhoeal disease and other enteric infections remain an unmet challenge in global child health. Most promising recent developments have been focused around preventive measures, in particular vaccination. Further advances in prevention and case management including the possible use of targeted antimicrobial treatment are also required to fully address this critical burden on child health and human potential.

Lives Saved Tool (LiST) costing: a module to examine costs and prioritize interventions

Background

Achieving the Sustainable Development Goals will require careful allocation of resources in order to achieve the highest impact. The Lives Saved Tool (LiST) has been used widely to calculate the impact of maternal, neonatal and child health (MNCH) interventions for program planning and multi-country estimation in several Lancet Series commissions. As use of the LiST model increases, many have expressed a desire to cost interventions within the model, in order to support budgeting and prioritization of interventions by countries. A limited LiST costing module was introduced several years ago, but with gaps in cost types. Updates to inputs have now been added to make the module fully functional for a range of uses.

Methods

This paper builds on previous work that developed an initial version of the LiST costing module to provide costs for MNCH interventions using an ingredients-based costing approach. Here, we update in 2016 the previous econometric estimates from 2013 with newly-available data and also include above-facility level costs such as program management. The updated econometric estimates inform percentages of intervention-level costs for some direct costs and indirect costs. These estimates add to existing values for direct cost requirements for items such as drugs and supplies and required provider time which were already available in LiST Costing.

Results

Results generated by the LiST costing module include costs for each intervention, as well as disaggregated costs by intervention including drug and supply costs, labor costs, other recurrent costs, capital costs, and above-service delivery costs. These results can be combined with mortality estimates to support prioritization of interventions by countries.

Conclusions

The LiST costing module provides an option for countries to identify resource requirements for scaling up a maternal, neonatal, and child health program, and to examine the financial impact of different resource allocation strategies. It can be a useful tool for countries as they seek to identify the best investments for scarce resources. The purpose of the LiST model is to provide a tool to make resource allocation decisions in a strategic planning process through prioritizing interventions based on resulting impact on maternal and child mortality and morbidity.

Electronic supplementary material

The online version of this article (10.1186/s12889-017-4738-1) contains supplementary material, which is available to authorized users.

Interactions between intestinal pathogens, enteropathy and malnutrition in developing countries

Purpose of review

This review focuses on recent data highlighting the interactions between intestinal pathogens, enteropathy and malnutrition in developing countries, which drive morbidity and mortality and hinder the long-term developmental potential of children.

Recent findings

Diarrhoea remains the second commonest cause of death in children below 5 years, and malnutrition underlies 45% of all child deaths. Even in the absence of diarrhoea, subclinical pathogen carriage and enteropathy are almost universal in developing countries. Here, we review recent studies addressing the causes and consequences of diarrhoea; emerging data on environmental influences that govern postnatal development of the gut and microbiota; current concepts of environmental enteric dysfunction; and recent intervention trials in the field. We highlight the interactions between these processes, whereby intestinal pathogens drive a cycle of gut damage, malabsorption, chronic inflammation and failed mucosal regeneration, leading to malnutrition and susceptibility to further enteric infections.

Summary

Efforts to improve child survival and long-term developmental potential need to address the overlapping and interacting effects of diarrhoea, enteropathy and malnutrition. Recent insights from human and animal studies suggest potential targets for intervention.

Modelling the cost of community interventions to reduce child mortality in South Africa using the Lives Saved Tool (LiST)

OBJECTIVE

To estimate the costs and impact on reducing child mortality of scaling up interventions that can be delivered by community health workers at community level from a provider's perspective.

SETTING

In this study, we used the Lives Saved Tool (LiST), a module in the spectrum software. Within the spectrum software, LiST interacts with other modules, the AIDS Impact Module, Family Planning Module and Demography Projections Module (Dem Proj), to model the impact of more than 60 interventions that affect cause-specific mortality.

PARTICIPANTS

DemProj Based on National South African Data.

INTERVENTIONS

A total of nine interventions namely, breastfeeding promotion, complementary feeding, vitamin supplementation, hand washing with soap, hygienic disposal of children's stools, oral rehydration solution, oral antibiotics for the treatment of pneumonia, therapeutic feeding for wasting and treatment for moderate malnutrition.

PRIMARY AND SECONDARY OUTCOME MEASURES

Reducing child mortality.

RESULTS

A total of 9 interventions can prevent 8891 deaths by 2030. Hand washing with soap (21%) accounts for the highest number of deaths prevented, followed by therapeutic feeding (19%) and oral rehydration therapy (16%). The top 5 interventions account for 77% of all deaths prevented. At scale, an estimated cost of US$169.5 million (US$3 per capita) per year will be required in community health worker costs.

CONCLUSION

The use of community health workers offers enormous opportunities for saving lives. These programmes require appropriate financial investments. Findings from this study show what can be achieved if concerted effort is channelled towards the identified set of life-saving interventions.

Economic evaluations of interventions to reduce neonatal morbidity and mortality: a review of the evidence in LMICs and its implications for South Africa

BACKGROUND

Newborn mortality, comprising a third of all under-5 deaths, has hardly changed in low and middle income countries (LMICs) including South Africa over the past decade. To attain the MDG 4 target, greater emphasis must be placed on wide-scale implementation of proven, cost-effective interventions. This paper reviews economic evidence on effective neonatal health interventions in LMICs from 2000-2013; documents lessons for South African policy on neonatal health; and identifies gaps and areas for future research.

METHODS

A narrative review was performed in leading public health databases for full economic evaluations conducted between 2000 and 2013. Data extraction from the articles included in the review was guided by the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist, and the quality of the included economic evaluations was assessed using the Quality of Health Economics Studies Instrument (QHES).

RESULTS

Twenty-seven economic evaluations were identified, from South East Asia and sub-Saharan Africa, with those from sub-Saharan Africa primarily focused on HIV/AIDS. Packages of care to prevent neonatal mortality were more cost-effective than vertical interventions. A wide variability in methodological approaches challenges the comparability of study results between countries. In South Africa, there is limited cost-effectiveness evidence for the interventions proposed by the National Perinatal Morbidity and Mortality Committee.

CONCLUSIONS

Neonatal strategies have a strong health system focus but this review suggests that strengthening community care could be an additional component for averting neonatal deaths. While some evidence exists, having a more complete understanding of how to most effectively deploy scarce resources for neonatal health in South Africa in the post-2015 era is essential.

Strategic planning for saving the lives of mothers, newborns and children and preventing stillbirths in KwaZulu-Natal province South Africa: modelling using the Lives Saved Tool (LiST)

Background

KwaZulu-Natal province in South Africa has the largest population of children under the age of five and experiences the highest number of child births per annum in the country. Its population has also been ravaged by the dual epidemics of HIV and TB and it has struggled to meet targets for maternal and child mortality. In South Africa’s federal system, provinces have decision-making power on the prioritization and allocation of resources within their jurisdiction. As part of strategic planning for 2015–2019, KwaZulu-Natal provincial authorities requested an assessment of current mortality levels in the province and identification and costing of priority interventions for saving additional maternal, newborn and child lives, as well as preventing stillbirths in the province.

Methods

The Lives Saved Tool (LiST) was used to determine the set of interventions, which could save the most additional maternal and child lives and prevent stillbirths from 2015–2019, and the costs of these. The impact of family planning was assessed using two scenarios by increasing baseline coverage of modern contraception by 0.5 percentage points or 1 percentage point per annum.

Results

A total of 7,043 additional child and 297 additional maternal lives could be saved, and 2,000 stillbirths could be prevented over five years. Seventeen interventions account for 75 % of additional lives saved. Increasing family planning contributes to a further reduction of up to 137 maternal and 3,168 child deaths. The set of priority interventions scaled up to achievable levels, with no increase in contraception would require an additional US$91 million over five years or US$1.72 per capita population per year. By increasing contraceptive prevalence by one percentage point per year, overall costs to scale up to achievable coverage package, decrease by US$24 million over five years.

Conclusion

Focused attention on a set of key interventions could have a significant impact on averting stillbirths and maternal and neonatal mortality in KwaZulu-Natal. Concerted effort to prioritize family planning will save more lives overall and has the potential to decrease costs in other areas of maternal and child care.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-015-2661-x) contains supplementary material, which is available to authorized users.

Counting the cost of child mortality in the World Health Organization African region

BACKGROUND

Worldwide, a total of 6.282 million deaths occurred among children aged less than 5 years in 2013. About 47.4 % of those were borne by the 47 Member States of the World Health Organization (WHO) African Region. Sadly, even as we approach the end date for the 2015 Millennium Development Goals (MDGs), only eight African countries are on track to achieve the MDG 4 target 4A of reducing under-five mortality by two thirds between 1990 and 2015. The post-2015 Sustainable Development Goal (SDG) 3 target is "by 2030, end preventable deaths of new-borns and children under 5 years of age". There is urgent need for increased advocacy among governments, the private sector and development partners to provide the resources needed to build resilient national health systems to deliver an integrated package of people-centred interventions to end preventable child morbidity and mortality and other structures to address all the basic needs for a healthy population. The specific objective of this study was to estimate expected/future productivity losses from child deaths in the WHO African Region in 2013 for use in advocacy for increased investments in child health services and other basic services that address children's welfare.

METHODS

A cost-of-illness method was used to estimate future non-health GDP losses related to child deaths. Future non-health GDP losses were discounted at 3 %. The analysis was undertaken with the countries categorized under three income groups: Group 1 consisted of nine high and upper middle income countries, Group 2 of 13 lower middle income countries, and Group 3 of 25 low income countries. One-way sensitivity analysis at 5 % and 10 % discount rates assessed the impact of the expected non-health GDP loss.

RESULTS

The discounted value of future non-health GDP loss due to the deaths of children under 5 years old in 2013 will be in the order of Int$ 150.3 billion. Approximately 27.3 % of the loss will be borne by Group 1 countries, 47.1 % by Group 2 and 25.7 % by Group 3. The average non-health GDP lost per child death will be Int$ 174 310 for Group 1, Int$ 57 584 for Group 2 and Int$ 25 508 for Group 3.

CONCLUSIONS

It is estimated that the African Region will incur a loss of approximately 6 % of its non-health GDP from the future years of life lost among the 2 976 000 child deaths that occurred in 2013. Therefore, countries and development partners should in solidarity sustainably provide the resources essential to build resilient national health systems and systems to address the determinants of health and meet the other basic needs such as for clothing, education, food, shelter, sanitation and clean water to end preventable child morbidity and mortality.