Setting research priorities to reduce mortality and morbidity of childhood diarrhoeal disease in the next 15 years

What more can be done? Prioritizing the most promising antenatal interventions to improve birth weight

BACKGROUND

Low birth weight (LBW) is associated with neonatal mortality and sequelae of lifelong health problems; prioritizing the most promising antenatal interventions may guide resource allocation and improve health outcomes.

OBJECTIVE

We sought to identify the most promising interventions that are not yet included in the policy recommendations of the World Health Organization (WHO) but could complement antenatal care and reduce the prevalence of LBW and related adverse birth outcomes in low- and middle-income settings.

METHODS

We utilized an adapted Child Health and Nutrition Research Initiative (CHNRI) prioritization method.

RESULTS

In addition to procedures already recommended by WHO for the prevention of LBW, we identified six promising antenatal interventions that are not currently recommended by WHO with an indication for LBW prevention, namely: (1) provision of multiple micronutrients; (2) low-dose aspirin; (3) high-dose calcium; (4) prophylactic cervical cerclage; (5) psychosocial support for smoking cessation; and (6) other psychosocial support for targeted populations and settings. We also identified seven interventions for further implementation research and six interventions for efficacy research.

CONCLUSION

These promising interventions, coupled with increasing coverage of currently recommended antenatal care, could accelerate progress toward the global target of a 30% reduction in the number of LBW infants born in 2025 compared to 2006-10.

Zinc supplementation for preventing mortality, morbidity, and growth failure in children aged 6 months to 12 years

BACKGROUND

Zinc deficiency is prevalent in low- and middle-income countries, and is considered a significant risk factor for morbidity, mortality, and linear growth failure. The effectiveness of preventive zinc supplementation in reducing prevalence of zinc deficiency needs to be assessed.

OBJECTIVES

To assess the effects of zinc supplementation for preventing mortality and morbidity, and for promoting growth, in children aged 6 months to 12 years.

SEARCH METHODS

A previous version of this review was published in 2014. In this update, we searched CENTRAL, MEDLINE, Embase, five other databases, and one trials register up to February 2022, together with reference checking and contact with study authors to identify additional studies.

SELECTION CRITERIA

Randomized controlled trials (RCTs) of preventive zinc supplementation in children aged 6 months to 12 years compared with no intervention, a placebo, or a waiting list control. We excluded hospitalized children and children with chronic diseases or conditions. We excluded food fortification or intake, sprinkles, and therapeutic interventions.

DATA COLLECTION AND ANALYSIS

Two review authors screened studies, extracted data, and assessed the risk of bias. We contacted study authors for missing information and used GRADE to assess the certainty of evidence. The primary outcomes of this review were all-cause mortality; and cause-specific mortality, due to all-cause diarrhea, lower respiratory tract infection (LRTI, including pneumonia), and malaria. We also collected information on a number of secondary outcomes, such as those related to diarrhea and LRTI morbidity, growth outcomes and serum levels of micronutrients, and adverse events.

MAIN RESULTS

We included 16 new studies in this review, resulting in a total of 96 RCTs with 219,584 eligible participants. The included studies were conducted in 34 countries; 87 of them in low- or middle-income countries. Most of the children included in this review were under five years of age. The intervention was delivered most commonly in the form of syrup as zinc sulfate, and the most common dose was between 10 mg and 15 mg daily. The median duration of follow-up was 26 weeks. We did not consider that the evidence for the key analyses of morbidity and mortality outcomes was affected by risk of bias. High-certainty evidence showed little to no difference in all-cause mortality with preventive zinc supplementation compared to no zinc (risk ratio (RR) 0.93, 95% confidence interval (CI) 0.84 to 1.03; 16 studies, 17 comparisons, 143,474 participants). Moderate-certainty evidence showed that preventive zinc supplementation compared to no zinc likely results in little to no difference in mortality due to all-cause diarrhea (RR 0.95, 95% CI 0.69 to 1.31; 4 studies, 132,321 participants); but probably reduces mortality due to LRTI (RR 0.86, 95% CI 0.64 to 1.15; 3 studies, 132,063 participants) and mortality due to malaria (RR 0.90, 95% CI 0.77 to 1.06; 2 studies, 42,818 participants); however, the confidence intervals around the summary estimates for these outcomes were wide, and we could not rule out a possibility of increased risk of mortality. Preventive zinc supplementation likely reduces the incidence of all-cause diarrhea (RR 0.91, 95% CI 0.90 to 0.93; 39 studies, 19,468 participants; moderate-certainty evidence) but results in little to no difference in morbidity due to LRTI (RR 1.01, 95% CI 0.95 to 1.08; 19 studies, 10,555 participants; high-certainty evidence) compared to no zinc. There was moderate-certainty evidence that preventive zinc supplementation likely leads to a slight increase in height (standardized mean difference (SMD) 0.12, 95% CI 0.09 to 0.14; 74 studies, 20,720 participants). Zinc supplementation was associated with an increase in the number of participants with at least one vomiting episode (RR 1.29, 95% CI 1.14 to 1.46; 5 studies, 35,192 participants; high-certainty evidence). We report a number of other outcomes, including the effect of zinc supplementation on weight and serum markers such as zinc, hemoglobin, iron, copper, etc. We also performed a number of subgroup analyses and there was a consistent finding for a number of outcomes that co-supplementation of zinc with iron decreased the beneficial effect of zinc.

AUTHORS' CONCLUSIONS

Even though we included 16 new studies in this update, the overall conclusions of the review remain unchanged. Zinc supplementation might help prevent episodes of diarrhea and improve growth slightly, particularly in children aged 6 months to 12 years of age. The benefits of preventive zinc supplementation may outweigh the harms in regions where the risk of zinc deficiency is relatively high.

Zinc Supplementation and the Prevention and Treatment of Sepsis in Young Infants: A Systematic Review and Meta-Analysis

BACKGROUND

Prematurity and low birth weight are major risk factors for neonatal sepsis. Zinc supplements have been previously shown to be beneficial in pregnancy and small for gestational age birth outcomes. There is sparse information, however, on the potential benefits of zinc supplementation to prevent or treat serious infections in this age group.

OBJECTIVE

The aim of this study was to assess the efficacy of preventive and therapeutic zinc supplementation in young infant (<4 months) sepsis.

METHODS

MEDLINE, Cochrane CENTRAL, and other databases were searched from inception until 18 June 2021. Studies assessing preventive and therapeutic zinc supplementation in young infants in relation to incidence and outcomes of suspected sepsis were included. Meta-analyses of pooled effects were calculated for sepsis-related outcomes.

RESULTS

Nine randomized controlled trials involving 2,553 infants were included. Six studies reported therapeutic efficacy, whereas 3 evaluated preventive benefits of zinc supplementation. Preventive studies suggest a protective effect of zinc supplementation on neonatal mortality rate (NMR) (risk ratio (RR) 0.28; 95% CI 0.12-0.67, LOW certainty), but with no effect on the incidence of sepsis, both in preterm neonates. Among young infants, therapeutic zinc was associated with significant reductions in treatment failure (RR 0.61; 95% CI 0.44-0.85; MODERATE certainty) and further subgroup analysis showing significant reduction in infant mortality rate with 3 mg/kg/twice a day dosage only (RR 0.49; 95% CI 0.27-0.87, LOW certainty). Therapeutic zinc supplementation in neonates did not show any effect on hospital stay or NMR.

CONCLUSION

Zinc supplementation could potentially reduce mortality and treatment failure in young infants but has no noteworthy influence on hospital stay and in the prevention of sepsis. Further studies with larger sample sizes are needed to confirm the direction and magnitude of effects if any.

A novel genotyping method for Cryptosporidium hominis

Cryptosporidiosis remains the leading protozoan induced cause of diarrhoea-associated mortality worldwide. Cryptosporidium hominis, the anthroponotically transmitted species within the Cryptosporidium genus, contributes significantly to the global burden of infection, accounting for the majority of clinical cases in many countries. This study applied high resolution melting analysis, a post-real-time PCR application, to the differentiation of six globally prevalent C. hominisgp60-subtypes. This novel method targeted three microsatellite, tandem repeat containing genetic markers, gp60, the genetic marker upon which current Cryptosporidium subtype nomenclature is based, MSB, and MSE, by which to differentiate between C. hominis isolates. This multi-locus approach successfully differentiated between all six C. hominisgp60-subtypes studied, some of which, such as IbA10G2, are known to exhibit global ubiquity. Thus, this method has the potential to be universally employed as a sensitive, cost effective and highly reproducible means to rapidly differentiate between C. hominisgp60-subtypes. Such a method would be of particular utility in epidemiological studies and outbreak scenarios, providing cost effective, clinically accessible alternative to DNA sequencing. The success of this preliminary study also supports further analysis of an expanded C. hominisgp60-subtype range and the potential expansion of the multi-locus panel in order to improve the discriminatory power of this approach.

Everything is not on track in management of diarrhoea in under-five children: Evidence from rural area of India

CONTEXT

Diarrhea is one of the leading causes of death and morbidity in under-five children. Effective management can significantly influence survival of children with diarrhea.

OBJECTIVES

This study was carried out to assess extent of diarrhea, its source of treatment, and type of therapy.

SETTINGS AND DESIGN

This snapshot study was conducted in rural setting of India.

METHODS AND MATERIAL

This study was conducted on 217 under-five children selected through multistage sampling procedure.

STATISTICAL ANALYSIS USED

Statistical association of diarrhea with age and gender of children was established by computing Chi-square.

RESULTS

Period prevalence (Recall period 2 weeks of visit) of diarrhea in rural under-five children was 35.9% (95%C.I. 29.3-42.2%). Highest prevalence in age group 0-12 months (47.8%) and lowest in 49-59 months (18.2%). Number of episode per child is 1.08. Diarrhea was watery in 69.4%. Quacks were treatment provider for 36.4% cases. In 17.6% episodes, no treatment was taken. Only 9.4% episodes were treated in government facilities. For the treatment of diarrhea, antibiotic was used in 71.8% cases, ORS use was 33.3% cases, and zinc was used 21.8% of diarrhea episodes.

CONCLUSIONS

Diarrhea is a significant problem in under-five children from a rural area of India. In spite of existence of National Program for Control of Diarrheal Diseases (NPCDD) since four decades, management of diarrhea is not on track. Focusing on primary care provision to under-five children can help in bringing the management of diarrhea on track.

Prevalence of Rotavirus-Associated Acute Gastroenteritis Cases in Early Childhood in Turkey: Meta-Analysis

BACKGROUND

Rotavirus is globally the most common viral pathogen in childhood gastroenteritis. This study aimed to estimate the number of Turkish children suffering from early-childhood gastroenteritis by rotavirus by performing a meta-analysis.

METHODS

Meta-analysis following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was performed. Following the guidelines, primary studies were found reporting the prevalence of rotavirus gastroenteritis in Turkey. We performed a computerized search of published studies in national and international databases from 1990 to 2018. We selected 38 out of 721 studies for our study. Meta-analysis was carried out using R statistical software. The Cochrane Q statistic was calculated to assess the heterogeneity of the study results. Heterogeneity among studies was evaluated using the I² statistic. Effect-size estimate was reported with 95% confidence interval.

RESULTS

On the basis of 38 selected articles, 80,113 children up to five years of age were diagnosed with symptoms of acute gastroenteritis, of whom the stool samples of 13,651 children were positive for rotavirus. The pooled prevalence of rotavirus was 19% in children younger than five years of age with acute gastroenteritis. In terms of seasonal prevalence, the highest prevalence rate was found in winter.

CONCLUSION

This study supports the major prevalence of early-childhood gastroenteritis by rotavirus among Turkish children. Therefore, the decision to adopt immunization programs to prevent rotavirus infection might be helpful in Turkey.

An ethnographic exploration of diarrheal disease management in public hospitals in Bangladesh: From problems to solutions

INTRODUCTION

Diarrheal disease is one of the most common causes of hospital admission globally. The barriers that influence guideline-adherent care at resource limited hospitals are poorly defined, especially during diarrheal disease outbreaks. The objective of this study was to characterize challenges faced in diarrheal disease management in resource-limited hospitals and identify opportunities to improve care.

METHODS

The study was conducted during a diarrheal disease outbreak period at ten public district hospitals distributed across Bangladesh. A rapid ethnographic approach included observations and informal interviews with clinicians, staff nurses and patients. In the first phase, observations identified common and unique challenges in diarrheal management at the ten sites. In the second phase, four hospitals were purposively selected for additional ethnographic study. Systematic observations over 420 total hours were collected from patient-clinician interactions (n = 76) and informal interviews (n = 138). Applied thematic analysis identified factors that influenced hospitalbased diarrhea management.

RESULTS

Normalization of guideline deviation was observed at all ten sites, including prescription of non-indicated antibiotics and intravenous (IV) fluids. Conflict between 'what should be done' and 'what can be done' was the most common challenge identified. Clinical assessments and patient treatment plans were established at admission in a median of 2 minutes (n = 76), often without a physical examination (57%; n=43/76). Factors that prevented adherence to clinical guidelines included human resource constraints, conflicts of interests, overcrowding, and inadequate hygiene and sanitation in the emergency department and wards.

CONCLUSION

This study identified challenges in hospital-based management of diarrheal disease and opportunities to improve care in seemingly change-resilient hospital settings. The results reveal important areas for intervention and policy engagement that may have additive benefit for both hospitals and their patients. These interventions include targeting barriers to clean-water, sanitation and hygiene that prevent clinicians from adopting guidelines out of concern for hospital acquired infections.

Associations between infant and young child feeding practices and acute respiratory infection and diarrhoea in Ethiopia: A propensity score matching approach

BACKGROUND

Acute respiratory infection (ARI) and diarrhoea are the leading causes of childhood morbidity and mortality in Ethiopia. Understanding the associations between infant and young child feeding (IYCF) and ARI and diarrhoea can inform IYCF policy interventions and advocacy in Ethiopia. This study aimed to investigate the relationship between IYCF practices and ARI and diarrhoea in Ethiopian children.

METHODS

This study used the Ethiopia Demographic and Health Survey (EDHS) data for the years 2000 (n = 3680), 2005 (n = 3528), 2011 (n = 4037), and 2016 (n = 3861). The association between IYCF practices and (i) ARI and (ii) diarrhoea were investigated using propensity score matching and multivariable logistic regression models. The IYCF practices include early initiation of breastfeeding, exclusive breastfeeding (EBF), predominant breastfeeding, introduction of complementary foods, continued breastfeeding at two years and bottle feeding.

RESULTS

Infants and young children who were breastfed within 1-hour of birth and those who were exclusively breastfed had a lower prevalence of ARI. Infants who were exclusively and predominantly breastfed had a lower prevalence of diarrhoea. Early initiation of breastfeeding (Odds ratio [OR]: 0.81; 95% confidence interval [CI]: 0.72, 0.92) and EBF (OR: 0.65; 95% CI: 0.51, 0.83) were associated with lower risk of ARI. Bottle-fed children had higher odds of ARI (OR: 1.36; 95% CI: 1.10, 1.68). Early initiation of breastfeeding and EBF were associated with lower odds of diarrhoea (OR: 0.88; 95% CI: 0.79, 0.94 for Early initiation of breastfeeding and OR: 0.51; 95% CI: 0.39, 0.65 for EBF). Infants who were predominantly breastfed were less likely to experience diarrhoea (OR: 0.69; 95% CI: 0.53, 0.89).

CONCLUSION

The recommended best practices for preventing ARI and diarrhoeal diseases in infants and young children namely: the early initiation of breastfeeding, EBF and avoidance of bottle feeding should be institutionalized and scale-up in Ethiopia as part of implementation science approach to cover the know-do-gaps.

The evolving epidemiology of rotavirus A infection in Brazil a decade after the introduction of universal vaccination with Rotarix®

Background

Brazil introduced the monovalent rotavirus vaccine (Rotarix®) in 2006. This study aimed to assess the epidemiology and genotype distribution of species-A rotavirus (RVA) in Brazil, comparing the pre- and post-vaccination periods.

Methods

Laboratory-based RVA surveillance included 866 municipalities in 22 Brazilian states, over a 21-year period. A total of 16,185 children with diarrheal diseases (DD) aged up to 12 years between 1996 and 2005 (pre-vaccination period, n = 7030) and from 2006 to 2017 (post-vaccination period, n = 9155) were enrolled. RVA was detected using ELISA immune assay and/or polyacrylamide gel electrophoresis and genotyped using nested PCR and/or nucleotide sequencing. RVA-positivity and genotypes detection rates were compared in distinct periods and age groups and Rotarix vaccination status.

Results

RVA-positivity in pre- and post-vaccination periods was, respectively: 4–11 months bracket, 33.3% (668/2006) and 16.3% (415/2547) (p <  0.001); 12–24 months, 28.2% (607/2154) and 22.2% (680/3068) (p <  0.001); 25–48 months, 17.4% (215/1235) and 29.4% (505/1720) (p <  0.001). Genotypes distribution in the pre- and post-vaccination periods was, respectively: G1P [8]/G1P[Not Typed], 417/855 (48.8%) and 118/1835 (6.4%) (p <  0.001); G2P [4]/G2P[NT], 47/855 (5.5%) and 838/1835 (45.7%) (p <  0.001); G3P [8]/G3P[NT], 55/855 (6.4%) and 253/1835 (13.8%) (p <  0.001); G9P [8]/G9P[NT], 238/855 (27.8%) and 152/1835 (8.3%) (p <  0.001); G12P [8]/G129P[NT], 0/871 (0%) and 249/1835(13.6%) (p <  0.001). Concerning infants aged 4–11 months, RVA frequency in fully vaccinated and non-vaccinated individuals was 11.9% (125/1052) and 24.5% (58/237) (p <  0.001), respectively. In children aged 12–24 months, RVA detection rate was 18.1% (253/1395) and 29.6% (77/260) (p <  0.001), for the vaccinated and non-vaccinated individuals, respectively (p <  0.001).

Conclusions

RVA infection was significantly less frequent in children aged ≤2 years with DD after implementing vaccination, mainly among vaccinated children. It was also observed a decrease of P [8] circulation and emergence of G2P[4] in 2005, and afterwards in the post-vaccine era, with spreading of G12P[8] in 2014–2015 and of G3P[8] in 2017. Continuous RVA surveillance must be carried out in this scenario.

Magnitude and pattern of improvement in processes of care for hospitalised children with diarrhoea and dehydration in Kenyan hospitals participating in a clinical network

OBJECTIVE

WHO recommends optimisation of available interventions to reduce deaths of under-five children with diarrhoea and dehydration (DD). Clinical networks may help improve practice across many hospitals but experience with such networks is scarce. We describe magnitude and patterns of changes in processes of care for children with DD over the first 3 years of a clinical network.

METHODS

Observational study involving children aged 2-59 months with DD admitted to 13 hospitals participating in the clinical network. Processes of individual patient care including agreement of assessment, diagnosis and treatment according to WHO guidelines were combined using the composite Paediatric Admission Quality of Care (PAQC) score (range 0-6).

RESULTS

Data from 7657 children were analysed and improvements in PAQC scores were observed. Predicted mean PAQC score for all the hospitals at enrolment was 59.8% (95% CI: 54.7, 64.9) but showed a wide variation (variance 10.7%, 95% CI: 5.8, 19.6). Overall mean PAQC score increased by 13.8% (95% CI: 8.7-18.9, SD between hospitals: ±8.2) in the first 12 months, with an average 0.9% (95% CI: 0.3-1.5, SD ± 1.0) increase per month and plateaued thereafter, and changes were similar in two groups of hospitals joining the network at different times.

CONCLUSION

Adherence to guidelines for children admitted with DD can be improved through participation in a clinical network but improvement is limited, not uniform for all aspects of care and contexts and occurs early. Future research should address these issues.

Trends for Diarrhea Morbidity in the Jasikan District of Ghana: Estimates from District Level Diarrhea Surveillance Data, 2012-2016

About 22% of childhood deaths in developing countries are attributable to diarrhea. In poor resource settings, diarrhea morbidities are correlated with poverty and socio-contextual factors. Diarrhea rates in Ghana are reported to be high, with cases estimated at 113,786 among children under-five years in 2011. This study analyzed the trends of diarrhea morbidity outcomes in the Jasikan District of Ghana. A retrospective analysis of records on diarrhea data for a five years' period (January 2012 to December 2016) was undertaken. There was a total of 17740 diarrhea case reports extracted from District Health Information Management System (DHIMS) II database in an Excel format which was then exported to Stata version 14 for data cleaning, verification, and analysis. Excel version 2016 was used to plot the actual observed cases by years to assess trends and seasonality. There was a period incidence rate of 272.02 per 1000 persons with a decreasing annual growth rate of 1.85%. Declines for diarrhea generally occurred from November to December and increased from January upwards, evidence that most cases of diarrhea in this study were reported in the harmattan season. High incidence of diarrhea was found to be common among under-five children and among females. Decreasing trend of diarrhea incidence which was identified in this research within the five years' period understudied shows that, by the year 2020, there will be a sharp decline in the incidence rate of diarrhea reported cases in Jasikan District, given improvements in the external environmental conditions in the district, all things being equal.

Risk factors for mortality and effect of correct fluid prescription in children with diarrhoea and dehydration without severe acute malnutrition admitted to Kenyan hospitals: an observational, association study

BACKGROUND

Diarrhoea causes many deaths in children younger than 5 years and identification of risk factors for death is considered a global priority. The effectiveness of currently recommended fluid management for dehydration in routine settings has also not been examined.

METHODS

For this observational, association study, we analysed prospective clinical data on admission, immediate treatment, and discharge of children age 1-59 months with diarrhoea and dehydration, which were routinely collected from 13 Kenyan hospitals. We analysed participants with full datasets using multivariable mixed-effects logistic regression to assess risk factors for in-hospital death and effect of correct rehydration on early mortality (within 2 days).

FINDINGS

Between Oct 1, 2013, and Dec 1, 2016, 8562 children with diarrhoea and dehydration were admitted to hospital and eligible for inclusion in this analysis. Overall mortality was 9% (759 of 8562 participants) and case fatality was directly correlated with severity. Most children (7184 [84%] of 8562) with diarrhoea and dehydration had at least one additional diagnosis (comorbidity). Age of 12 months or younger (adjusted odds ratio [AOR] 1·71, 95% CI 1·42-2·06), female sex (1·41, 1·19-1·66), diarrhoea duration of more than 14 days (2·10, 1·42-3·12), abnormal respiratory signs (3·62, 2·95-4·44), abnormal circulatory signs (2·29, 1·89-2·77), pallor (2·15, 1·76-2·62), use of intravenous fluid (proxy for severity; 1·68, 1·41-2·00), and abnormal neurological signs (3·07, 2·54-3·70) were independently associated with in-hospital mortality across hospitals. Signs of dehydration alone were not associated with in-hospital deaths (AOR 1·08, 0·87-1·35). Correct fluid prescription significantly reduced the risk of early mortality (within 2 days) in all subgroups: abnormal respiratory signs (AOR 1·23, 0·68-2·24), abnormal circulatory signs (0·95, 0·53-1·73), pallor (1·70, 0·95-3·02), dehydration signs only (1·50, 0·79-2·88), and abnormal neurological signs (0·86, 0·51-1·48).

INTERPRETATION

Children at risk of in-hospital death are those with complex presentations rather than uncomplicated dehydration, and the prescription of recommended rehydration guidelines reduces risk of death. Strategies to optimise the delivery of recommended guidance should be accompanied by studies on the management of dehydration in children with comorbidities, the vulnerability of young girls, and the delivery of immediate care.

FUNDING

The Wellcome Trust.

Prioritizing research for integrated implementation of early childhood development and maternal, newborn, child and adolescent health and nutrition platforms

Background

Existing health and nutrition services present potential platforms for scaling up delivery of early childhood development (ECD) interventions within sensitive windows across the life course, especially in the first 1000 days from conception to age 2 years. However, there is insufficient knowledge on how to optimize implementation for such strategies in an integrated manner. In light of this knowledge gap, we aimed to systematically identify a set of integrated implementation research priorities for health, nutrition and early child development within the 2015 to 2030 timeframe of the Sustainable Development Goals (SDGs).

Methods

We applied the Child Health and Nutrition Research Initiative method, and consulted a diverse group of global health experts to develop and score 57 research questions against five criteria: answerability, effectiveness, deliverability, impact, and effect on equity. These questions were ranked using a research priority score, and the average expert agreement score was calculated for each question.

Findings

The research priority scores ranged from 61.01 to 93.52, with a median of 82.87. The average expert agreement scores ranged from 0.50 to 0.90, with a median of 0.75. The top–ranked research question were: i) “How can interventions and packages to reduce neonatal mortality be expanded to include ECD and stimulation interventions?”; ii) “How does the integration of ECD and MNCAH&N interventions affect human resource requirements and capacity development in resource–poor settings?”; and iii) “How can integrated interventions be tailored to vulnerable refugee and migrant populations to protect against poor ECD and MNCAH&N outcomes?”. Most highly–ranked research priorities varied across the life course and highlighted key aspects of scaling up coverage of integrated interventions in resource–limited settings, including: workforce and capacity development, cost–effectiveness and strategies to reduce financial barriers, and quality assessment of programs.

Conclusions

Investing in ECD is critical to achieving several of the SDGs, including SDG 2 on ending all forms of malnutrition, SDG 3 on ensuring health and well–being for all, and SDG 4 on ensuring inclusive and equitable quality education and promotion of life–long learning opportunities for all. The generated research agenda is expected to drive action and investment on priority approaches to integrating ECD interventions within existing health and nutrition services.

Estimates of global, regional, and national morbidity, mortality, and aetiologies of diarrhoeal diseases: a systematic analysis for the Global Burden of Disease Study 2015

Background

The Global Burden of Diseases, Injuries, and Risk Factors Study 2015 (GBD 2015) provides an up-to-date analysis of the burden of diarrhoeal diseases. This study assesses cases, deaths, and aetiologies spanning the past 25 years and informs the changing picture of diarrhoeal disease worldwide.

Methods

We estimated diarrhoeal mortality by age, sex, geography, and year using the Cause of Death Ensemble Model (CODEm), a modelling platform shared across most causes of death in the GBD 2015 study. We modelled diarrhoeal morbidity, including incidence and prevalence, using a meta-regression platform called DisMod-MR. We estimated aetiologies for diarrhoeal diseases using a counterfactual approach that incorporates the aetiology-specific risk of diarrhoeal disease and the prevalence of the aetiology in diarrhoea episodes. We used the Socio-demographic Index, a summary indicator derived from measures of income per capita, educational attainment, and fertility, to assess trends in diarrhoeal mortality. The two leading risk factors for diarrhoea—childhood malnutrition and unsafe water, sanitation, and hygiene—were used in a decomposition analysis to establish the relative contribution of changes in diarrhoea disability-adjusted life-years (DALYs).

Findings

Globally, in 2015, we estimate that diarrhoea was a leading cause of death among all ages (1·31 million deaths, 95% uncertainty interval [95% UI] 1·23 million to 1·39 million), as well as a leading cause of DALYs because of its disproportionate impact on young children (71·59 million DALYs, 66·44 million to 77·21 million). Diarrhoea was a common cause of death among children under 5 years old (499 000 deaths, 95% UI 447 000–558 000). The number of deaths due to diarrhoea decreased by an estimated 20·8% (95% UI 15·4–26·1) from 2005 to 2015. Rotavirus was the leading cause of diarrhoea deaths (199 000, 95% UI 165 000–241 000), followed by Shigella spp (164 300, 85 000–278 700) and Salmonella spp (90 300, 95% UI 34 100–183 100). Among children under 5 years old, the three aetiologies responsible for the most deaths were rotavirus, Cryptosporidium spp, and Shigella spp. Improvements in safe water and sanitation have decreased diarrhoeal DALYs by 13·4%, and reductions in childhood undernutrition have decreased diarrhoeal DALYs by 10·0% between 2005 and 2015.

Interpretation

At the global level, deaths due to diarrhoeal diseases have decreased substantially in the past 25 years, although progress has been faster in some countries than others. Diarrhoea remains a largely preventable disease and cause of death, and continued efforts to improve access to safe water, sanitation, and childhood nutrition will be important in reducing the global burden of diarrhoea.

Funding

Bill & Melinda Gates Foundation.

Setting an implementation research agenda for Canadian investments in global maternal, newborn, child and adolescent health: a research prioritization exercise

BACKGROUND

Improving global maternal, newborn, child and adolescent health (MNCAH) is a top development priority in Canada, as shown by the $6.35 billion in pledges toward the Muskoka Initiative since 2010. To guide Canadian research investments, we aimed to systematically identify a set of implementation research priorities for MNCAH in low- and middle-income countries.

METHODS

We adapted the Child Health and Nutrition Research Initiative method. We scanned the Child Health and Nutrition Research Initiative literature and extracted research questions pertaining to delivery of interventions, inviting Canadian experts on MNCAH to generate additional questions. The experts scored a combined list of 97 questions against 5 criteria: answerability, feasibility, deliverability, impact and effect on equity. These questions were ranked using a research priority score, and the average expert agreement score was calculated for each question.

RESULTS

The overall research priority score ranged from 40.14 to 89.25, with a median of 71.84. The average expert agreement scores ranged from 0.51 to 0.82, with a median of 0.64. Highly-ranked research questions varied across the life course and focused on improving detection and care-seeking for childhood illnesses, overcoming barriers to intervention uptake and delivery, effectively implementing human resources and mobile technology, and increasing coverage among at-risk populations. Children were the most represented target population and most questions pertained to interventions delivered at the household or community level.

INTERPRETATION

Investing in implementation research is critical to achieving the Sustainable Development Goal of ensuring health and well-being for all. The proposed research agenda is expected to drive action and Canadian research investments to improve MNCAH.

Health research priority setting in Zambia: a stock taking of approaches conducted from 1998 to 2015

Background

Priority setting in health research is an emerging field. In Zambia, like many other African countries, various priority setting activities have been undertaken with a view to identify research activities to which the available resources can be targeted while at the same time maximising the health impact for resource allocation to support evidence-based decision-making. The aim of this paper is to document the key elements of the various priority setting activities that have been conducted since 1998, identifying the key lessons and providing recommendations to improve the process.

Methods

A comprehensive review of the previous priority setting activities and processes in Zambia was conducted. Both published and unpublished reports were reviewed in order to identify any research priority setting processes that have been undertaken in Zambia. We developed a framework, based on the priority setting literature, to guide our abstraction and synthesis of the literature.

Result

The earliest record of priority setting was conducted in 1998. Various priority setting approaches have been implemented in Zambia; ranging from externally driven, once-off activities to locally (in country) initiated comprehensive processes. However, there has been no systematic national process for priority setting. These priority setting processes in Zambia were characterised by limited stakeholder buy-in of the resulting national research or programmatic research agenda. Most striking was the lack of linkages between the different initiatives. There seems to have been no conscious recognition and building on previous priority-setting experiences of previous initiatives.

Conclusion

There were gaps in the priority setting processes, stakeholder engagement and application of a defined criterion. There is a need for a priority setting framework coupled with local capacity developed across a range of stakeholders.

Rapid, Portable, Multiplexed Detection of Bacterial Pathogens Directly from Clinical Sample Matrices

Enteric and diarrheal diseases are a major cause of childhood illness and death in countries with developing economies. Each year, more than half of a million children under the age of five die from these diseases. We have developed a portable, microfluidic platform capable of simultaneous, multiplexed detection of several of the bacterial pathogens that cause these diseases. This platform can perform fast, sensitive immunoassays directly from relevant, complex clinical matrices such as stool without extensive sample cleanup or preparation. Using only 1 µL of sample per assay, we demonstrate simultaneous multiplexed detection of four bacterial pathogens implicated in diarrheal and enteric diseases in less than 20 min.

Factors associated with declining under-five mortality rates from 2000 to 2013: an ecological analysis of 46 African countries

OBJECTIVE

Inadequate overall progress has been made towards the 4th Millennium Development Goal of reducing under-five mortality rates by two-thirds between 1990 and 2015. Progress has been variable across African countries. We examined health, economic and social factors potentially associated with reductions in under-five mortality (U5M) from 2000 to 2013.

SETTING

Ecological analysis using publicly available data from the 46 nations within the WHO African Region.

OUTCOME MEASURES

We assessed the annual rate of change (ARC) of 70 different factors and their association with the annual rate of reduction (ARR) of U5M rates using robust linear regression models.

RESULTS

Most factors improved over the study period for most countries, with the largest increases seen for economic or technological development and external financing factors. The median (IQR) U5M ARR was 3.6% (2.8 to 5.1%). Only 4 of 70 factors demonstrated a strong and significant association with U5M ARRs, adjusting for potential confounders. Higher ARRs were associated with more rapidly increasing coverage of seeking treatment for acute respiratory infection (β=0.22 (ie, a 1% increase in the ARC was associated with a 0.22% increase in ARR); 90% CI 0.09 to 0.35; p=0.01), increasing health expenditure relative to gross domestic product (β=0.26; 95% CI 0.11 to 0.41; p=0.02), increasing fertility rate (β=0.54; 95% CI 0.07 to 1.02; p=0.07) and decreasing maternal mortality ratio (β=-0.47; 95% CI -0.69 to -0.24; p<0.01). The majority of factors showed no association or raised validity concerns due to missing data from a large number of countries.

CONCLUSIONS

Improvements in sociodemographic, maternal health and governance and financing factors were more likely associated with U5M ARR. These underscore the essential role of contextual factors facilitating child health interventions and services. Surveillance of these factors could help monitor which countries need additional support in reducing U5M.

Setting research priorities to improve global newborn health and prevent stillbirths by 2025

Background

In 2013, an estimated 2.8 million newborns died and 2.7 million were stillborn. A much greater number suffer from long term impairment associated with preterm birth, intrauterine growth restriction, congenital anomalies, and perinatal or infectious causes. With the approaching deadline for the achievement of the Millennium Development Goals (MDGs) in 2015, there was a need to set the new research priorities on newborns and stillbirth with a focus not only on survival but also on health, growth and development. We therefore carried out a systematic exercise to set newborn health research priorities for 2013–2025.

Methods

We used adapted Child Health and Nutrition Research Initiative (CHNRI) methods for this prioritization exercise. We identified and approached the 200 most productive researchers and 400 program experts, and 132 of them submitted research questions online. These were collated into a set of 205 research questions, sent for scoring to the 600 identified experts, and were assessed and scored by 91 experts.

Results

Nine out of top ten identified priorities were in the domain of research on improving delivery of known interventions, with simplified neonatal resuscitation program and clinical algorithms and improved skills of community health workers leading the list. The top 10 priorities in the domain of development were led by ideas on improved Kangaroo Mother Care at community level, how to improve the accuracy of diagnosis by community health workers, and perinatal audits. The 10 leading priorities for discovery research focused on stable surfactant with novel modes of administration for preterm babies, ability to diagnose fetal distress and novel tocolytic agents to delay or stop preterm labour.

Conclusion

These findings will assist both donors and researchers in supporting and conducting research to close the knowledge gaps for reducing neonatal mortality, morbidity and long term impairment. WHO, SNL and other partners will work to generate interest among key national stakeholders, governments, NGOs, and research institutes in these priorities, while encouraging research funders to support them. We will track research funding, relevant requests for proposals and trial registers to monitor if the priorities identified by this exercise are being addressed.

G1P[8] species A rotavirus over 27 years--pre- and post-vaccination eras--in Brazil: full genomic constellation analysis and no evidence for selection pressure by Rotarix® vaccine

Epidemiological data on species A rotavirus (RVA) infections have demonstrated the genetic diversity of strains circulating worldwide. Many G and P genotype combinations have been described over the years, varying regionally and temporally, especially in developing countries. However, the most common G and P genotype combinations identified in RVA human strains worldwide are G1P[8], G2P[4], G3P[8], G4P[8] and G9P[8]. RVA genotype G1P[8] strains are responsible for more than 50% of child infections worldwide and component of the two vaccines (Rotarix® [RV1] and RotaTeq® [RV5]) licensed globally. For a better understanding of the evolutionary mechanisms of this genotype in Brazil, phylogenetic analyses based on the 11 RVA genome segments (genomic constellation) from 90 G1P[8] RVA strains collected in two eras - (i) pre-vaccination with RV1 (1996-February 2006); (ii) post-vaccination (March 2006-2013) - in different Brazilian states were performed. The results showed the Wa-like genomic constellation of the Brazilian G1P[8] strains with a I1-R1-C1-M1-A1-N1-T1-E1-H1 specificity, except for two strains (rj14055-07 and ba19030-10) that belong to a I1-R1-C1-M1-A1-N1-T3-E1-H1 genomic constellation, evidencing the occurrence of reassortment (Wa-like×AU-1-like) of the NSP3 gene. Reassortment events were also demonstrated between Brazilian G1P[8] strains and the RV1 vaccine strain in some genes in vaccinated and unvaccinated children. VP7 and VP8* antigenic site analysis showed that the amino acid substitutions observed in samples collected after the introduction of RV1 in Brazil were already detected in samples collected in the 1980s and 1990s, suggesting that mass Brazilian RV1 vaccination had no impact on the diversity observed inside antigenic sites for these two proteins.

Setting global research priorities for integrated community case management (iCCM): Results from a CHNRI (Child Health and Nutrition Research Initiative) exercise

Aims

To systematically identify global research gaps and resource priorities for integrated community case management (iCCM).

Methods

An iCCM Child Health and Nutrition Research Initiative (CHNRI) Advisory Group, in collaboration with the Community Case Management Operational Research Group (CCM ORG) identified experts to participate in a CHNRI research priority setting exercise. These experts generated and systematically ranked research questions for iCCM. Research questions were ranked using a “Research Priority Score” (RPS) and the “Average Expert Agreement” (AEA) was calculated for every question. Our groups of experts were comprised of both individuals working in Ministries of Health or Non Governmental Organizations (NGOs) in low– and middle–income countries (LMICs) and individuals working in high–income countries (HICs) in academia or NGO headquarters. A Spearman’s Rho was calculated to determine the correlation between the two groups’ research questions’ ranks.

Results

The overall RPS ranged from 64.58 to 89.31, with a median score of 81.43. AEA scores ranged from 0.54 to 0.86. Research questions involving increasing the uptake of iCCM services, research questions concerning the motivation, retention, training and supervision of Community Health Workers (CHWs) and concerning adding additional responsibilities including counselling for infant and young child feeding (IYCF) and treatment of severe acute malnutrition (SAM) ranked highly. There was weak to moderate, statistically significant, correlation between scores by representatives of high–income countries and those working in–country or regionally (Spearman’s ρ = 0.35034, P < 0.01).

Conclusions

Operational research to determine optimal training, supervision and modes of motivation and retention for the CHW is vital for improving iCCM, globally, as is research to motivate caregivers to take advantage of iCCM services. Experts working in–country or regionally in LMICs prioritized different research questions than those working in organization headquarters in HICs. Further exploration is needed to determine the nature of this divergence.

Improving community case management of diarrhoea and pneumonia in district Badin, Pakistan through a cluster randomised study--the NIGRAAN trial protocol

Background

Diarrhoea and pneumonia contribute 30% of deaths in children under 5 in Pakistan. Pakistan’s Lady Health Workers Programme (LHW-P) covers about 60% of the population but has had little impact in reducing morbidity and mortality related to these major childhood killers. An external evaluation of the LHW-P suggests that lack of supportive supervision of LHWs by lady health supervisors (LHSs) is a key determinant of this problem. Project NIGRAAN aims to improve knowledge and skills of LHWs and community caregivers through supervisory strategies employed by LHSs. Ultimately, community case management (CCM) of childhood pneumonia and diarrhoea will improve.

Methods/Design

NIGRAAN is a cluster-randomised trial in District Badin, Pakistan. There are approximately 1100 LHWs supervised by 36 LHSs in Badin. For this study, each LHS serves as a cluster. All LHSs working permanently in Badin who regularly conduct and report field visits are eligible. Thirty-four LHSs have been allocated to either intervention or control arms in a ratio of 1:1 through computer-generated simple randomisation technique. Five LHWs from each LHSs are also randomly picked. All 34 LHSs and 170 LHWs will be actively monitored. The intervention consists of training to build LHS knowledge and skills, clinical mentorship and written feedback to LHWs. Pre- and post-intervention assessments of LHSs, LHWs and community caregivers will be conducted via focus group discussions, in-depth interviews, knowledge assessment questionnaires, skill assessment scorecards and household surveys.

Primary outcome is improvement in CCM practices of childhood diarrhoea and pneumonia and will be assessed at the cluster level.

Discussion

NIGRAAN takes a novel approach to implementation research and explores whether training of LHSs in supervisory skills results in improving the CCM practices of childhood diarrhoea and pneumonia. No significant harm to participants is anticipated. The enablers and barriers towards improved CCM would provide recommendations to policymakers for scale up of this intervention nationally and regionally.

Trial registration

NIGRAAN is registered with the ‘Australian New Zealand Clinical Trials Registry’. Registration Number: ACTRN12613001261707

How are health research priorities set in low and middle income countries? A systematic review of published reports

BACKGROUND

Priority setting is increasingly recognised as essential for directing finite resources to support research that maximizes public health benefits and drives health equity. Priority setting processes have been undertaken in a number of low- and middle-income country (LMIC) settings, using a variety of methods. We undertook a critical review of reports of these processes.

METHODS AND FINDINGS

We searched electronic databases and online for peer reviewed and non-peer reviewed literature. We found 91 initiatives that met inclusion criteria. The majority took place at the global level (46%). For regional or national initiatives, most focused on Sub Saharan Africa (49%), followed by East Asia and Pacific (20%) and Latin America and the Caribbean (18%). A quarter of initiatives aimed to cover all areas of health research, with a further 20% covering communicable diseases. The most frequently used process was a conference or workshop to determine priorities (24%), followed by the Child Health and Nutrition Initiative (CHNRI) method (18%). The majority were initiated by an international organization or collaboration (46%). Researchers and government were the most frequently represented stakeholders. There was limited evidence of any implementation or follow-up strategies. Challenges in priority setting included engagement with stakeholders, data availability, and capacity constraints.

CONCLUSIONS

Health research priority setting (HRPS) has been undertaken in a variety of LMIC settings. While not consistently used, the application of established methods provides a means of identifying health research priorities in a repeatable and transparent manner. In the absence of published information on implementation or evaluation, it is not possible to assess what the impact and effectiveness of health research priority setting may have been.

Preventive zinc supplementation for children, and the effect of additional iron: a systematic review and meta-analysis

OBJECTIVE

Zinc deficiency is widespread, and preventive supplementation may have benefits in young children. Effects for children over 5 years of age, and effects when coadministered with other micronutrients are uncertain. These are obstacles to scale-up. This review seeks to determine if preventive supplementation reduces mortality and morbidity for children aged 6 months to 12 years.

DESIGN

Systematic review conducted with the Cochrane Developmental, Psychosocial and Learning Problems Group. Two reviewers independently assessed studies. Meta-analyses were performed for mortality, illness and side effects.

DATA SOURCES

We searched multiple databases, including CENTRAL and MEDLINE in January 2013. Authors were contacted for missing information.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Randomised trials of preventive zinc supplementation. Hospitalised children and children with chronic diseases were excluded.

RESULTS

80 randomised trials with 205 401 participants were included. There was a small but non-significant effect on all-cause mortality (risk ratio (RR) 0.95 (95% CI 0.86 to 1.05)). Supplementation may reduce incidence of all-cause diarrhoea (RR 0.87 (0.85 to 0.89)), but there was evidence of reporting bias. There was no evidence of an effect of incidence or prevalence of respiratory infections or malaria. There was moderate quality evidence of a very small effect on linear growth (standardised mean difference 0.09 (0.06 to 0.13)) and an increase in vomiting (RR 1.29 (1.14 to 1.46)). There was no evidence of an effect on iron status. Comparing zinc with and without iron cosupplementation and direct comparisons of zinc plus iron versus zinc administered alone favoured cointervention for some outcomes and zinc alone for other outcomes. Effects may be larger for children over 1 year of age, but most differences were not significant.

CONCLUSIONS

Benefits of preventive zinc supplementation may outweigh any potentially adverse effects in areas where risk of zinc deficiency is high. Further research should determine optimal intervention characteristics and delivery strategies.

Assessment of gastroenteric viruses from wastewater directly discharged into Uruguay River, Uruguay

The aim of this study was to assess the viral contamination of group A rotavirus (RVA), norovirus (NoV), and human astrovirus (HAstV) in sewage directly discharged into Uruguay River and to characterize RVA genotypes circulating in Uruguay. For this purpose, sewage samples (n = 96) were collected biweekly from March 2011 to February 2012 in four Uruguayan cities: Bella Unión, Salto, Paysandú, and Fray Bentos. Each sample was concentrated by ultracentrifugation method. Qualitative and quantitative RT-PCR for RVA, NoV, and HAstV were performed. A wide dissemination of gastroenteric viruses was observed in the sewage samples analyzed with 80% of positivity, being NoV (51%) the most frequently detected followed by RVA with a frequency of 49% and HAstV with 45%. Genotypes of RVA were typed using multiplex semi-nested RT-PCR as follows: P[8] (n = 15), P[4] (n = 8), P[10] (n = 1), P[11] (n = 1), G2 (n = 29), and G3 (n = 2). The viral load ranged from 10(3) to 10(7) genomic copies/liter, and they were detected roughly with the same frequency in all participant cities. A peak of RVA and HAstV detection was observed in colder months (June to September), whereas no seasonality was observed for NoV. This study demonstrates for the first time, the high degree of gastroenteric viral contamination in the country; highlighting the importance of developing these analyses as a tool to determine the viral contamination in this hydrographic boundary region used by the local populations for recreation and consumption, establishing an elevated risk of gastroenteric diseases for human health.

Zinc supplementation for preventing mortality, morbidity, and growth failure in children aged 6 months to 12 years of age

BACKGROUND

Zinc deficiency is prevalent in low- and middle-income countries, and contributes to significant diarrhoea-, pneumonia-, and malaria-related morbidity and mortality among young children. Zinc deficiency also impairs growth.

OBJECTIVES

To assess the effects of zinc supplementation for preventing mortality and morbidity, and for promoting growth, in children aged six months to 12 years of age.

SEARCH METHODS

Between December 2012 and January 2013, we searched CENTRAL, MEDLINE, MEDLINE In-Process and Other Non-Indexed Citations, Embase, African Index Medicus, Conference Proceedings Citation Index, Dissertation Abstracts, Global Health, IndMED, LILACS, WHOLIS, metaRegister of Controlled Trials, and WHO ICTRP.

SELECTION CRITERIA

Randomised controlled trials of preventive zinc supplementation in children aged six months to 12 years compared with no intervention, a placebo, or a waiting list control. We excluded hospitalised children and children with chronic diseases or conditions. We excluded food fortification or intake, sprinkles, and therapeutic interventions.

DATA COLLECTION AND ANALYSIS

Two authors screened studies, extracted data, and assessed risk of bias. We contacted trial authors for missing information.

MAIN RESULTS

We included 80 randomised controlled trials with 205,401 eligible participants. We did not consider that the evidence for the key analyses of morbidity and mortality outcomes were affected by risk of bias. The risk ratio (RR) for all-cause mortality was compatible with a reduction and a small increased risk of death with zinc supplementation (RR 0.95, 95% confidence interval (CI) 0.86 to 1.05, 14 studies, high-quality evidence), and also for cause-specific mortality due to diarrhoea (RR 0.95, 95% CI 0.69 to 1.31, four studies, moderate-quality evidence), lower respiratory tract infection (LRTI) (RR 0.86, 95% CI 0.64 to 1.15, three studies, moderate-quality evidence), or malaria (RR 0.90, 95% CI 0.77 to 1.06, two studies, moderate-quality evidence).Supplementation reduced diarrhoea morbidity, including the incidence of all-cause diarrhoea (RR 0.87, 95% CI 0.85 to 0.89, 26 studies, moderate-quality evidence), but the results for LRTI and malaria were imprecise: LRTI (RR 1, 95% CI 0.94 to 1.07, 12 studies, moderate-quality evidence); malaria (RR 1.05, 95% 0.95 to 1.15, four studies, moderate-quality evidence).There was moderate-quality evidence of a very small improvement in height with supplementation (standardised mean difference (SMD) -0.09, 95% CI -0.13 to -0.06; 50 studies), but the size of this effect might not be clinically important. There was a medium to large positive effect on zinc status.Supplementation was associated with an increase in the number of participants with at least one vomiting episode (RR 1.29, 95% CI 1.14 to 1.46, five studies, high-quality evidence). We found no clear evidence of benefit or harm of supplementation with regard to haemoglobin or iron status. Supplementation had a negative effect on copper status.

AUTHORS' CONCLUSIONS

In our opinion, the benefits of preventive zinc supplementation outweigh the harms in areas where the risk of zinc deficiency is relatively high. Further research should determine optimal intervention characteristics such as supplement dose.

Recent advances in understanding the long-term sequelae of childhood infectious diarrhea

Worldwide, early childhood infectious diarrhea continues to be a significant concern. Diarrheal illness affects the world's youngest and most vulnerable citizens disproportionately. Estimates are that over 70 % of deaths from diarrhea occur in people younger than 24 months of age. Diarrhea and environmental enteropathy have been associated with growth failure and stunting. In addition, the burden of enteric disease also leads to cognitive and academic losses, thus resulting in loss of human capital and economic productivity. While considerable progress has been made on preventing and treating childhood diarrheal illness, the mortality and morbidity still remain unacceptably high. This paper reviews recent (mainly from 2013) publications surrounding the global burden of childhood diarrhea and the implications for long-term sequelae.

Developing a sustainable nutrition research agenda in sub-Saharan Africa--findings from the SUNRAY project

Patrick Kolsteren and colleagues present the findings of a collaborative effort by stakeholders in sub-Saharan Africa to identify priorities for nutrition research. They propose a new approach that stimulates demand from policy makers for research and holds them accountable for incorporating research into policy and practice. Please see later in the article for the Editors' Summary

The state of infectious diseases clinical trials: a systematic review of ClinicalTrials.gov

Background

There is a paucity of clinical trials informing specific questions faced by infectious diseases (ID) specialists. The ClinicalTrials.gov registry offers an opportunity to evaluate the ID clinical trials portfolio.

Methods

We examined 40,970 interventional trials registered with ClinicalTrials.gov from 2007–2010, focusing on study conditions and interventions to identify ID-related trials. Relevance to ID was manually confirmed for each programmatically identified trial, yielding 3570 ID trials and 37,400 non-ID trials for analysis.

Results

The number of ID trials was similar to the number of trials identified as belonging to cardiovascular medicine (n = 3437) or mental health (n = 3695) specialties. Slightly over half of ID trials were treatment-oriented trials (53%, vs. 77% for non-ID trials) followed by prevention (38%, vs. 8% in non-ID trials). ID trials tended to be larger than those of other specialties, with a median enrollment of 125 subjects (interquartile range [IQR], 45–400) vs. 60 (IQR, 30–160) for non-ID trials. Most ID studies are randomized (73%) but nonblinded (56%). Industry was the funding source in 51% of ID trials vs. 10% that were primarily NIH-funded. HIV-AIDS trials constitute the largest subset of ID trials (n = 815 [23%]), followed by influenza vaccine (n = 375 [11%]), and hepatitis C (n = 339 [9%]) trials. Relative to U.S. and global mortality rates, HIV-AIDS and hepatitis C virus trials are over-represented, whereas lower respiratory tract infection trials are under-represented in this large sample of ID clinical trials.

Conclusions

This work is the first to characterize ID clinical trials registered in ClinicalTrials.gov, providing a framework to discuss prioritization, methodology, and policy.

Global action plan for childhood diarrhoea: Developing research priorities: Report from a Workshop of the Programme for Global Paediatric Research

Background

Childhood diarrhoea remains a major public health problem responsible for the deaths of approximately 800 000 children annually, worldwide. The present study was undertaken to further define research priorities for the prevention and treatment of diarrhoea in low and middle income countries. We used the Child Health and Nutrition Research Initiative (CHNRI) process for defining research priorities. This provided a transparent, systematic method of obtaining the opinions of experts regarding research priorities in childhood diarrhoea. The present report describes the deliberations of a workshop that reviewed these research priorities by stakeholders including colleagues from: government agencies, academic institutions, major funding agencies and non–governmental organizations.

Methods

The workshop included 38 participants, divided into four groups to consider issues in the categories of description, delivery, development and discovery. Each group received 20 to 23 questions/research priorities previously identified by the CHNRI process. Deliberations and conclusions of each group were summarized in separate reports that were further discussed in a plenary session including all workshop participants.

Results

The reports of the working groups emphasized the following five key points: 1) A common theme was the need to substantially increase the use of oral rehydration salts (ORS) and zinc in the prevention and treatment of diarrhoea. There is a need for better definitions of those factors that supported and interfered with the use of these agents; 2) There is an urgent need to determine the long–term effects of chronic and recurrent bouts of diarrhoea on the physical and intellectual development of affected children; 3) Improvements in water, sanitation and hygiene facilities are critical steps required to reduce the incidence and severity of childhood diarrhoea; 4)Risk factors enhancing the susceptibility and clinical response to diarrhoea were explored; implementation research of modifiable factors is urgently required; 5) More research is required to better understand the causes and pathophysiology of various forms of enteropathy and to define the methods and techniques necessary for their accurate study.

Conclusions

The participants in this workshop determined that use of the CHNRI process had successfully defined those research priorities necessary for the study of childhood diarrhoea. The deliberations of the workshop brought these research priorities to the attention of stakeholders responsible for the implementation of the recommendations. It was concluded that the deliberations of the workshop positively supplemented the research priorities developed by the CHNRI process.

Interventions to address deaths from childhood pneumonia and diarrhoea equitably: what works and at what cost?

Global mortality in children younger than 5 years has fallen substantially in the past two decades from more than 12 million in 1990, to 6·9 million in 2011, but progress is inconsistent between countries. Pneumonia and diarrhoea are the two leading causes of death in this age group and have overlapping risk factors. Several interventions can effectively address these problems, but are not available to those in need. We systematically reviewed evidence showing the effectiveness of various potential preventive and therapeutic interventions against childhood diarrhoea and pneumonia, and relevant delivery strategies. We used the Lives Saved Tool model to assess the effect on mortality when these interventions are applied. We estimate that if implemented at present annual rates of increase in each of the 75 Countdown countries, these interventions and packages of care could save 54% of diarrhoea and 51% of pneumonia deaths by 2025 at a cost of US$3·8 billion. However, if coverage of these key evidence-based interventions were scaled up to at least 80%, and that for immunisations to at least 90%, 95% of diarrhoea and 67% of pneumonia deaths in children younger than 5 years could be eliminated by 2025 at a cost of $6·715 billion. New delivery platforms could promote equitable access and community platforms are important catalysts in this respect. Furthermore, several of these interventions could reduce morbidity and overall burden of disease, with possible benefits for developmental outcomes.