Prevalence and correlates of paediatric guideline non-adherence for initial empirical care in six low and middle-income settings: a hospital-based cross-sectional study

OBJECTIVES

This study evaluated the prevalence and correlates of guideline non-adherence for common childhood illnesses in low-resource settings.

DESIGN AND SETTING

We used secondary cross-sectional data from eight healthcare facilities in six Asian and African countries.

PARTICIPANTS

A total of 2796 children aged 2-23 months hospitalised between November 2016 and January 2019 with pneumonia, diarrhoea or severe malnutrition (SM) and without HIV infection were included in this study.

PRIMARY OUTCOME MEASURES

We identified children treated with full, partial or non-adherent initial inpatient care according to site-specific standard-of-care guidelines for pneumonia, diarrhoea and SM within the first 24 hours of admission. Correlates of guideline non-adherence were identified using generalised estimating equations.

RESULTS

Fully adherent care was delivered to 32% of children admitted with diarrhoea, 34% of children with pneumonia and 28% of children with SM when a strict definition of adherence was applied. Non-adherence to recommendations was most common for oxygen and antibiotics for pneumonia; fluid, zinc and antibiotics for diarrhoea; and vitamin A and zinc for SM. Non-adherence varied by site. Pneumonia guideline non-adherence was more likely among patients with severe disease (OR 1.82; 95% CI 1.38, 2.34) compared with non-severe disease. Diarrhoea guideline non-adherence was more likely among lower asset quintile groups (OR 1.16; 95% CI 1.01, 1.35), older children (OR 1.10; 95% CI 1.06, 1.13) and children presenting with wasting (OR 6.44; 95% CI 4.33, 9.57) compared with those with higher assets, younger age and not wasted.

CONCLUSIONS

Non-adherence to paediatric guidelines was common and associated with older age, disease severity, and comorbidities, and lower household economic status. These findings highlight opportunities to improve guidelines by adding clarity to specific recommendations.

Mothers' Willingness to Use Workplace Lactation Supports: Evidence from Formally Employed Mothers in Central Kenya

Background

Formally employed mothers are vulnerable to early cessation of exclusive breastfeeding. Kenyan national policy requires employer-provided maternity benefits and workplace lactation supports.

Objective

The objective of this study was to evaluate willingness to use nationally mandated workplace lactation supports among formally employed women in Kenya.

Methods

We conducted a cross-sectional survey among 304 mothers of children ages ≤12 mo in Naivasha, Kenya, who were currently formally employed and employed before delivery of the most recent child to assess availability of and willingness to use current and potential future workplace lactation supports.

Results

The most available reported workplace lactation supports were schedule flexibility to arrive late or leave early (87.8%) or visit a child to nurse during lunch (24.7%), followed by company-funded community-based daycare (7.6%). Few (<4.0%) reported the availability of lactation rooms, on-site daycares, transportation to breastfeed during lunch, refrigerators for expressed milk, or manual or electric breastmilk pumps. If made available, >80% of mothers reported moderate or strong willingness to use flexible schedules to arrive late or leave early, break during lunch, and transportation to visit a child to nurse. A moderate proportion reported strong willingness to use on-site daycares (63.8%), company-funded community-based daycare (56.9%), on-site lactation rooms (60.5%), refrigeration for expressed milk (49.3%), manual (40.5%), and electric pumps (27.6%). Mothers expressed fear of missing production targets and reported more willingness to use on-site compared with off-site daycare to save transportation time but noted concerns about chemical exposures and early arrival times with young infants. Hesitations regarding the use of on-site lactation rooms included concerns about privacy, milk identification and storage, and use and sharing of pumps.

Conclusions

Flexible schedules were the workplace lactation supports in highest demand among formally employed mothers. Maternal willingness to use lactation rooms, refrigeration, and pumping equipment was moderate to low, suggesting sensitization may help to increase demand as the implementation of Kenyan policies moves forward.

Optimising scale-up for public health impact: a multimethod implementation science research protocol to improve infant health outcomes in Ethiopia

INTRODUCTION

Child mortality rates remain high in sub-Saharan Africa, including Ethiopia. We are conducting a cluster randomised control trial in the Gondar zone of the Amhara region to determine the impact of pairing Orthodox priests with community health workers, known locally as the Health Development Army (HDA), on newborns' nutritional status, early illness identification and treatment, and vaccination completeness.Ensuring intervention efficacy with scientific rigour is essential, but there are often delays in adopting evidence into policy and programmes. Here, we present a protocol for conducting parallel implementation research alongside an efficacy study to understand intervention implementability and scalability. This will help develop a scale-up strategy for effective elements of the intervention to ensure rapid implementation at scale.

METHODS AND ANALYSIS

We will conduct a stakeholder analysis of key implementation stakeholders and readiness surveys to assess their readiness to scale up the intervention. We will conduct semistructured interviews and focus group discussions with stakeholders, including HDA members, health workers, Orthodox priests, and caregivers, to determine the core intervention elements that need to be scaled, barriers and facilitators to scaling up the intervention in diverse sociocultural settings, as well as the human and technical requirements for national and regional implementation. Finally, to determine the financial resources necessary for sustaining and scaling the intervention, we will conduct activity-based costing to estimate implementation costs from the provider's perspective.

ETHICS AND DISSEMINATION

The study received approval from the University of Gondar Institutional Review Board (approval no: VP/RTT/05/1030/2022) and the University of Washington Human Subjects Division (approval no: STUDY00015369). Participants will consent to participate. Results will be disseminated through workshops with stakeholders, local community meetings, presentations at local and international conferences, and journal publications. The study will provide evidence for factors to consider in developing a scale-up strategy to integrate the intervention into routine health system practices.

Representativeness of a mobile phone-based coverage evaluation survey following mass drug administration for soil-transmitted helminths: a comparison of participation between two cross-sectional surveys

OBJECTIVES

With increasing mobile phone subscriptions, phone-based surveys are gaining popularity with public health programmes. Despite advantages, systematic exclusion of participants may limit representativeness. Similar to control programmes for neglected tropical diseases (NTDs), the DeWorm3 trial of biannual community-wide mass drug administration (MDA) for elimination of soil-transmitted helminth infection used in-person coverage evaluation surveys to measure the proportion of the at-risk population treated during MDA. Due to lockdown during the COVID-19 pandemic, a phone-based coverage evaluation survey was necessary, providing an opportunity for the current study to compare representativeness and implementation (including non-response) of these two survey modes.

DESIGN

Comparison of two cross-sectional surveys.

SETTING

The DeWorm3 trial site in Tamil Nadu, India, includes Timiri, a rural subsite, and Jawadhu Hills, a hilly, hard-to-reach subsite inhabited predominantly by a tribal population.

PARTICIPANTS

In the phone-based and in-person coverage evaluation surveys, all individuals residing in 2000 randomly selected households (50 in each of the 40 trial clusters) were eligible to participate. Here, we characterise household participation.

RESULTS

Of 2000 households, 1780 (89.0%) participated during the in-person survey. Of 2000 households selected for the phone survey, 346 (17.3%) could not be contacted as they had not provided a telephone number during the census and 1144 (57.2%) participated. Smaller households, households with lower socioeconomic status and those with older, women or less educated household-heads were under-represented in the phone-based survey compared with censused households. Regression analysis revealed non-response in the phone-based survey was higher among households from the poorest socioeconomic quintile (prevalence ratio (PR) 2.3, 95% CI 2.0 to 2.7) and lower when heads of households had completed secondary school or higher education (PR 0.7, 95% CI 0.6 to 0.8).

CONCLUSIONS

Our findings suggest phone-based surveys under-represent households likely to be at higher risk of NTDs and in-person surveys are more appropriate for measuring MDA coverage within programmatic settings.

TRIAL REGISTRATION NUMBER

NCT03014167.

The Childhood Acute Illness and Nutrition (CHAIN) network nested case-cohort study protocol: a multi-omics approach to understanding mortality among children in sub-Saharan Africa and South Asia

Introduction: Many acutely ill children in low- and middle-income settings have a high risk of mortality both during and after hospitalisation despite guideline-based care. Understanding the biological mechanisms underpinning mortality may suggest optimal pathways to target for interventions to further reduce mortality. The Childhood Acute Illness and Nutrition (CHAIN) Network ( www.chainnnetwork.org) Nested Case-Cohort Study (CNCC) aims to investigate biological mechanisms leading to inpatient and post-discharge mortality through an integrated multi-omic approach. Methods and analysis; The CNCC comprises a subset of participants from the CHAIN cohort (1278/3101 hospitalised participants, including 350 children who died and 658 survivors, and 270/1140 well community children of similar age and household location) from nine sites in six countries across sub-Saharan Africa and South Asia. Systemic proteome, metabolome, lipidome, lipopolysaccharides, haemoglobin variants, toxins, pathogens, intestinal microbiome and biomarkers of enteropathy will be determined. Computational systems biology analysis will include machine learning and multivariate predictive modelling with stacked generalization approaches accounting for the different characteristics of each biological modality. This systems approach is anticipated to yield mechanistic insights, show interactions and behaviours of the components of biological entities, and help develop interventions to reduce mortality among acutely ill children. Ethics and dissemination. The CHAIN Network cohort and CNCC was approved by institutional review boards of all partner sites. Results will be published in open access, peer reviewed scientific journals and presented to academic and policy stakeholders. Data will be made publicly available, including uploading to recognised omics databases. Trial registration NCT03208725.

The Childhood Acute Illness and Nutrition (CHAIN) network nested case-cohort study protocol: a multi-omics approach to understanding mortality among children in sub-Saharan Africa and South Asia

Introduction: Many acutely ill children in low- and middle-income settings have a high risk of mortality both during and after hospitalisation despite guideline-based care. Understanding the biological mechanisms underpinning mortality may suggest optimal pathways to target for interventions to further reduce mortality. The Childhood Acute Illness and Nutrition (CHAIN) Network ( www.chainnnetwork.org) Nested Case-Cohort Study (CNCC) aims to investigate biological mechanisms leading to inpatient and post-discharge mortality through an integrated multi-omic approach. Methods and analysis; The CNCC comprises a subset of participants from the CHAIN cohort (1278/3101 hospitalised participants, including 350 children who died and 658 survivors, and 270/1140 well community children of similar age and household location) from nine sites in six countries across sub-Saharan Africa and South Asia. Systemic proteome, metabolome, lipidome, lipopolysaccharides, haemoglobin variants, toxins, pathogens, intestinal microbiome and biomarkers of enteropathy will be determined. Computational systems biology analysis will include machine learning and multivariate predictive modelling with stacked generalization approaches accounting for the different characteristics of each biological modality. This systems approach is anticipated to yield mechanistic insights, show interactions and behaviours of the components of biological entities, and help develop interventions to reduce mortality among acutely ill children. Ethics and dissemination. The CHAIN Network cohort and CNCC was approved by institutional review boards of all partner sites. Results will be published in open access, peer reviewed scientific journals and presented to academic and policy stakeholders. Data will be made publicly available, including uploading to recognised omics databases. Trial registration NCT03208725.

Costs of community-wide mass drug administration and school-based deworming for soil-transmitted helminths: evidence from a randomised controlled trial in Benin, India and Malawi

OBJECTIVES

Current guidelines for the control of soil-transmitted helminths (STH) recommend deworming children and other high-risk groups, primarily using school-based deworming (SBD) programmes. However, targeting individuals of all ages through community-wide mass drug administration (cMDA) may interrupt STH transmission in some settings. We compared the costs of cMDA to SBD to inform decision-making about future updates to STH policy.

DESIGN

We conducted activity-based microcosting of cMDA and SBD for 2 years in Benin, India and Malawi within an ongoing cMDA trial.

SETTING

Field sites and collaborating research institutions.

PRIMARY AND SECONDARY OUTCOMES

We calculated total financial and opportunity costs and costs per treatment administered (unit costs in 2019 USD ($)) from the service provider perspective, including costs related to community drug distributors and other volunteers.

RESULTS

On average, cMDA unit costs were more expensive than SBD in India ($1.17 vs $0.72) and Malawi ($2.26 vs $1.69), and comparable in Benin ($2.45 vs $2.47). cMDA was more expensive than SBD in part because most costs (~60%) were 'supportive costs' needed to deliver treatment with high coverage, such as additional supervision and electronic data capture. A smaller fraction of cMDA costs (~30%) was routine expenditures (eg, drug distributor allowances). The remaining cMDA costs (~10%) were opportunity costs of staff and volunteer time. A larger percentage of SBD costs was opportunity costs for teachers and other government staff (between ~25% and 75%). Unit costs varied over time and were sensitive to the number of treatments administered.

CONCLUSIONS

cMDA was generally more expensive than SBD. Accounting for local staff time (volunteers, teachers, health workers) in community programmes is important and drives higher cost estimates than commonly recognised in the literature. Costs may be lower outside of a trial setting, given a reduction in supportive costs used to drive higher treatment coverage and economies of scale.

TRIAL REGISTRATION NUMBER

NCT03014167.

Mothers’ Willingness to Use Breastfeeding Supports: Evidence From Formally Employed Mothers in Central Kenya

Objectives

We aimed to understand mothers' willingness to use currently available breastfeeding supports at their workplaces and expected use if new supports were made available.

Methods

We conducted a cross-sectional survey with closed and open-ended questions among 300 formally employed mothers of children ages 12 months and younger at two public healthcare facilities in Naivasha, Kenya, and community transportation sites for commercials farms and hotels. We surveyed maternal demographics, healthcare access and utilization, employment history, mother's awareness of current breastfeeding supports at her workplace, and self-reported willingness to use additional breastfeeding supports.

Results

The most available reported current workplace supports were schedule flexibility to arrive late or leave early (87.8%), opportunity to return home during lunch (24.7%), and company-funded daycare in the community (7.6%). Few mothers reported availability of lactation rooms (3.6%), on-site daycare (3.3%), transportation to breastfeed during lunch (2.3%), a refrigerator for expressed milk (1.6%), a manual breastmilk pump (1.0%), or an electric breastmilk pump (0.7%). When asked about willingness to use if made available, mothers were most willing (>80% agreement) to use flexible work schedules to arrive late, leave early, break during lunch, and use transportation to return home to breastfeed. A moderate proportion were willing to use on-site daycare (63.8%), company-funded community daycare (56.9%), on-site lactation rooms (60.5%), refrigeration for expressed milk (49.3%), manual (40.5%) and electric pumps (27.6%).

Conclusions

The currently available workplace breastfeeding supports do not align well with mothers’ demand for or willingness to use certain supports. Current resources – such as on-site daycare – are rare at workplaces but are among the most demanded supports by mothers. Lactation rooms are also rare, but demanded less by mothers than on-site daycare or flexible work schedules.

Funding Sources

Supported by the National Institutes of Health Fogarty International Center.

Experiences With Antenatal Care, Breastfeeding Education, and Employment During the COVID-19 Pandemic: Perspectives From Mothers and Healthcare Workers in Kenya

Objectives

The impact of the COVID-19 pandemic on breastfeeding practices in low and middle-income countries is not well understood. Modifications in breastfeeding guidelines and delivery platforms for breastfeeding education are hypothesized to have affected breastfeeding practices during the COVID-19 pandemic. We aimed to understand the experiences with perinatal care, breastfeeding education and practice among mothers who delivered infants during the COVID-19 pandemic.

Methods

We conducted key informant interviews among 35 mothers with deliveries since March 2020 and 10 healthcare workers (HCW) from two public health facilities in Naivasha, Kenya.

Results

Mothers described COVID-related income loss and lack of support from family and friends as a worse challenge to practicing EBF as they wished or planned. While mothers noted that HCWs provided quality care and breastfeeding messaging, one-on-one perinatal breastfeeding education was cited to be less frequent than before the pandemic due to altered conditions in health facilities and COVID safety protocols. Knowledge among mothers about the safety of breastfeeding in the context of COVID was limited, with few key informants reporting of specific receipt of information such as COVID transmission through human milk and the safety of nursing during a COVID infection. Mothers stated that some HCW messages emphasized the immunologic importance of BF. COVID restrictions limited or prevented familial support at facilities and home, causing stress and fatigue for mothers. In some cases, mothers noted income loss due to furloughs and layoffs, time spent seeking new means of employment, and food insecurity as causes for perceived milk insufficiency, which was, in turn, connected to introducing weaning foods and liquids before six months.

Conclusions

The COVID-19 pandemic created changes to the perinatal experience for mothers. While messages the importance of practicing exclusive breastfeeding were provided, altered HCW education delivery methods, social support and food insecurity limit EBF practices in for mothers in this context. Mothers lacked consistent knowledge about the safety of breastfeeding in the context of COVID-19.

Funding Sources

National Institutes of Health Fogarty International Center.

The repurposing of Tebipenem pivoxil as alternative therapy for severe gastrointestinal infections caused by extensively drug resistant Shigella spp

Background:

Diarrhoea remains one of the leading causes of childhood mortality globally. Recent epidemiological studies conducted in low-middle income countries (LMICs) identified Shigella spp. as the first and second most predominant agent of dysentery and moderate diarrhoea, respectively. Antimicrobial therapy is often necessary for Shigella infections; however, we are reaching a crisis point with efficacious antimicrobials. The rapid emergence of resistance against existing antimicrobials in Shigella spp. poses a serious global health problem.

Methods:

Aiming to identify alternative antimicrobial chemicals with activity against antimicrobial resistant Shigella, we initiated a collaborative academia-industry drug discovery project, applying high-throughput phenotypic screening across broad chemical diversity and followed a lead compound through in vitro and in vivo characterisation.

Results:

We identified several known antimicrobial compound classes with antibacterial activity against Shigella. These compounds included the oral carbapenem Tebipenem, which was found to be highly potent against broadly susceptible Shigella and contemporary MDR variants for which we perform detailed pre-clinical testing. Additional in vitro screening demonstrated that Tebipenem had activity against a wide range of other non-Shigella enteric bacteria. Cognisant of the risk for the development of resistance against monotherapy, we identified synergistic behaviour of two different drug combinations incorporating Tebipenem. We found the orally bioavailable prodrug (Tebipenem pivoxil) had ideal pharmacokinetic properties for treating enteric pathogens and was effective in clearing the gut of infecting organisms when administered to Shigella-infected mice and gnotobiotic piglets.

Conclusions:

Our data highlight the emerging antimicrobial resistance crisis and shows that Tebipenem pivoxil (licenced for paediatric respiratory tract infections in Japan) should be accelerated into human trials and could be repurposed as an effective treatment for severe diarrhoea caused by MDR Shigella and other enteric pathogens in LMICs.

Funding:

Tres Cantos Open Lab Foundation (projects TC239 and TC246), the Bill and Melinda Gates Foundation (grant OPP1172483) and Wellcome (215515/Z/19/Z).

Soil-transmitted helminth infections after mass drug administration for lymphatic filariasis in rural southern India

OBJECTIVES

Targeted deworming is the current strategy for control of morbidity associated with soil-transmitted helminths (STH) among at-risk populations: preschool-aged children, school-aged children and women of childbearing age. We report the prevalence and intensity of STH in a district after lymphatic filariasis (LF) mass drug administration (MDA) in southern India where albendazole was co-administered from 2001.

METHODS

Children aged 2 to 15 years and adults (defined as ≥15 years) in a rural administrative block of Tamil Nadu were recruited using a probability proportional to size method. Stool samples were screened and eggs per gram (EPG) determined by Kato-Katz method. Multilevel logistic regression (MLR) and multilevel negative binomial regression (MNBR) analyses were used to identify factors associated with infection and intensity, respectively.

RESULTS

Of 862 participants who provided samples, 60 (7.0%; 95% confidence interval (CI): 5.3-8.7) were positive for STH with a predominance of hookworm infections (n = 57, 6.6%; 95% CI: 5.0-8.3). Increasing age (odds ratio (OR): 1.09; 95% CI: 1.04-1.15) and regular usage of the toilet (OR: 0.32; 95% CI: 0.12-0.88) were independently associated with hookworm infection and age was significantly associated with increasing intensity of hookworm infection (infection intensity ratio (IIR): 1.28; 95% CI: 1.19-1.37). A brief review of STH prevalence in endemic settings before and after the stoppage of LF MDA indicated that, in most settings, a substantial reduction in STH prevalence is seen.

CONCLUSION

Community-wide MDA in all age groups in these post-LF MDA districts with low prevalence and light intensity infections could result in transmission interruption of STH.

Tebipenem as an oral alternative for the treatment of typhoid caused by XDR Salmonella Typhi

BACKGROUND

Antimicrobial therapy is essential for the treatment of enteric fever, the infection caused by Salmonella serovars Typhi and Paratyphi A. However, an increase in resistance to key antimicrobials and the emergence of MDR and XDR in Salmonella Typhi poses a major threat for efficacious outpatient treatments.

OBJECTIVES

We recently identified tebipenem, an oral carbapenem licensed for use for respiratory tract infections in Japan, as a potential alternative treatment for MDR/XDR Shigella spp. Here, we aimed to test the in vitro antibacterial efficacy of this drug against MDR and XDR typhoidal Salmonella.

METHODS

We determined the in vitro activity of tebipenem in time-kill assays against a collection of non-XDR and XDR Salmonella Typhi and Salmonella Paratyphi A (non-XDR) isolated in Nepal and Bangladesh. We also tested the efficacy of tebipenem in combination with other antimicrobials.

RESULTS

We found that both XDR and non-XDR Salmonella Typhi and Salmonella Paratyphi A are susceptible to tebipenem, exhibiting low MICs, and were killed within 8-24 h at 2-4×MIC. Additionally, tebipenem demonstrated synergy with two other antimicrobials and could efficiently induce bacterial killing.

CONCLUSIONS

Salmonella Paratyphi A and XDR Salmonella Typhi display in vitro susceptibility to the oral carbapenem tebipenem, while synergistic activity with other antimicrobials may limit the emergence of resistance. The broad-spectrum activity of this drug against MDR/XDR organisms renders tebipenem a good candidate for clinical trials.

Costing interventions in the field: preliminary cost estimates and lessons learned from an evaluation of community-wide mass drug administration for elimination of soil-transmitted helminths in the DeWorm3 trial

OBJECTIVE

To present a costing study integrated within the DeWorm3 multi-country field trial of community-wide mass drug administration (cMDA) for elimination of soil-transmitted helminths.

DESIGN

Tailored data collection instruments covering resource use, expenditure and operational details were developed for each site. These were populated alongside field activities by on-site staff. Data quality control and validation processes were established. Programmed routines were used to clean, standardise and analyse data to derive costs of cMDA and supportive activities.

SETTING

Field site and collaborating research institutions.

PRIMARY AND SECONDARY OUTCOME MEASURES

A strategy for costing interventions in parallel with field activities was discussed. Interim estimates of cMDA costs obtained with the strategy were presented for one of the trial sites.

RESULTS

The study demonstrated that it was both feasible and advantageous to collect data alongside field activities. Practical decisions on implementing the strategy and the trade-offs involved varied by site; trialists and local partners were key to tailoring data collection to the technical and operational realities in the field. The strategy capitalised on the established processes for routine financial reporting at sites, benefitted from high recall and gathered operational insight that facilitated interpretation of the estimates derived. The methodology produced granular costs that aligned with the literature and allowed exploration of relevant scenarios. In the first year of the trial, net of drugs, the incremental financial cost of extending deworming of school-aged children to the whole community in India site averaged US$1.14 (USD, 2018) per person per round. A hypothesised at-scale routine implementation scenario yielded a much lower estimate of US$0.11 per person treated per round.

CONCLUSIONS

We showed that costing interventions alongside field activities offers unique opportunities for collecting rich data to inform policy toward optimising health interventions and for facilitating transfer of economic evidence from the field to the programme.

TRIAL REGISTRATION NUMBER

NCT03014167; Pre-results.

Social Support, Maternal Agency, Postnatal Depression, and Domestic Violence Influence the Formal Employment-Exclusive Breastfeeding Relationship: Evidence From Kenya

Objectives

We previously demonstrated that formal employment among mothers in Kenya is associated with a lower prevalence and odds of exclusive breastfeeding (EBF). This study evaluated the influence of maternal social support, agency, postnatal depression, and domestic violence on the association between formal employment and EBF in Naivasha, Kenya, where many women work in agricultural labor.

Methods

Using cross-sectional data (n = 1,186), we examined validated scales of social support, agency, domestic violence, and postnatal depression as effect modifiers in adjusted, stratified models of the association between employment and EBF. We hypothesized that higher social support and agency would attenuate the odds ratios that evaluated employment and EBF, and domestic violence and depression would further decrease the odds of EBF based on employment.

Results

Comparing formally employed to non-formally employed mothers, women with higher social support were more likely to practice EBF at 14 weeks: OR high (95%CI) = 0.22 (0.09, 0.51) and OR low = 0.12 (0.05, 0.29). The same trend was observed at 24 weeks. Among mothers with higher maternal agency compared to those with lower agency, the negative association between formal and EBF was decreased at both 14 weeks [OR high = 0.21 (0.09, 0.47) versus OR low = 0.16 (0.06, 0.44)] and 24 weeks. Comparing mothers who reported experiencing domestic violence to those who had not, the negative association between formal and EBF was increased at both 14 weeks [OR = 0.06 (0.01, 0.31) versus OR No violence = 0.18 (0.09, 0.36)] and 24 weeks. At 14 weeks, mothers with depression decreased the association between employment and EBF: [OR dep = 0.11 (0.03,0.45) versus OR no depression = 0.16 (0.08, 0.33). At 24 weeks, the employment-EBF relationship was non-significant among mothers with depression: [OR dep = 0.31 (0.08, 1.30) but remained significant among mothers without depression: OR no dep = 0.22 (0.12, 0.40).

Conclusions

Among formally employed mothers, maternal social support and agency improve the employment-breastfeeding relationship, while women exposed to domestic violence or postnatal depression experienced a further decrease in the likelihood of EBF. Supportive interventions to improve EBF and other maternal health factors are needed in the postpartum period for employed mothers.

Funding Sources

NIH Fogarty International Center

Effect of Access to Workplace Supports for Breastfeeding Among Formally Employed Mothers in Kenya

Objectives

We evaluated the availability of workplace breastfeeding (BF) supports, and the associations between these supports and BF practices among formally employed mothers in Kenya – where many women work in horticulture farms and legislation requiring workplace BF supports is being implemented. We hypothesized that the availability of supports would be associated with a higher prevalence and greater odds of exclusive breastfeeding (EBF).

Methods

We conducted repeated cross-sectional surveys among formally employed mothers at 1–4 days, 6 weeks, 14 weeks, and 36 weeks (to estimate 24 weeks) postpartum at 3 health facilities in Naivasha from Sept. 2018 to Oct. 2019, 13 months after the 2017 Kenyan Health Act, which requires workplace BF support, was passed. We evaluated the associations of workplace BF supports with EBF practices using tests of proportions and adjusted logistic regression.

Results

Among formally employed mothers (n = 564), reported workplace supports included on-site housing (16.8%), on-site daycare (9.4%), and private lactation spaces (2.8%). Mothers who used workplace on-site childcare were more likely to practice EBF than mothers who used community- or home-based childcare at both 6 weeks (95.7% versus 82.4%, p = 0.030) and 14 weeks (60.6% versus 22.2%, p &lt; 0.001; [aOR (95% CI) = 5.11 (2.3, 11.7)]. Likewise, mothers who visited daycares at or near workplaces were more likely to practice EBF (70.0%) compared to those who did not visit a daycare (34.7%, p = 0.005) at 14-weeks. Among all mothers, 84.6% with access to workplace private lactation spaces practiced EBF, compared to 55.6% without such spaces, p = 0.037. Mothers who live in on-site housing were twice as likely [aOR (95% CI) = 2.06 (1.25, 3.41)] to practice EBF compared to those without access to on-site housing.

Conclusions

Formally employed mothers in Kenya who used on-site childcare, lived in on-site housing, and had access to private workplace lactation rooms are more likely to practice EBF than mothers who lack these supports, while the use of community-based childcare in this context is associated with a lower prevalence of EBF. As the Kenya Health Act is implemented, provision of these supports and strategies to help women visit their children in daycare can enable EBF among employed mothers.

Funding Sources

NIH Fogarty International Center.

Lower Prevalence of Exclusive Breastfeeding Among Employed Mothers: Results from a Cross-Sectional Survey in Naivasha, Kenya

Objectives

We compared the prevalence of exclusive (EBF) and continued breastfeeding (BF) among formally employed, informally/self-employed, and non-employed mothers in Naivasha, Kenya, where the commercial agriculture and hospitality industries employ many women.

Methods

We conducted a cross-sectional survey from Sept. 2018 to Oct. 2019. Mothers of infants presenting to 3 health facilities were asked about their BF status and reasons for EBF cessation at four postpartum points: prior to discharge (n = 296), 6-weeks (n = 298), 14-weeks (n = 295), and 36-weeks (n = 297). BF status at 24-weeks was estimated at the 36-week visit. We used separate multivariable logistic regression models to compare the prevalence of early initiation (within 1-hr of birth) and EBF, between groups at each time-point, controlling for maternal age, education, HIV status, delivery setting, delivery type, and infant morbidity. We collapsed the non-employed, informal and self-employed groups into one category due to a lack of differences between these groups across all analyses.

Results

65.6% of those formally employed reported early initiation of BF, compared to 75.6% without formal employment, although differences were not significant in adjusted models [OR = 0.62, 95% CI = 0.35, 1.14]. Upon hospital discharge, &gt;96% in both groups reported practicing EBF. At 6 weeks, EBF prevalence did not significantly differ between mothers with (94.0%) and without formal employment (86.6%), [OR = 2.00, 95% CI = 0.81, 4.95]. By 14-weeks, formally employed mothers had a lower EBF prevalence compared to mothers without formal employment, 47.2% versus 78.8%, [OR = 0.19, 95% CI = 0.11, 0.33]. The lower EBF prevalence among formally employed mothers was also observed at 24-weeks (15.8% versus 48.9% [OR = 0.72, 95% CI = 0.11, 0.33]. At 36-weeks, the prevalence of continued BF was ≥98% in both groups [OR = 0.72, 95% CI = 0.11, 4.89].

The primary reasons reported for early EBF cessation were return to work (46.5%), belief that it is appropriate to feed other foods based on the child's age (33.5%), and perceived milk insufficiency (13.7%).

Conclusions

Formally employed mothers in Kenya experience shorter durations of EBF compared to mothers who are not formally employed by 14-weeks postpartum. These mothers may benefit from additional supports to help prolong the period of EBF.

Funding Sources

NIH Fogarty International Center.

Are Play Items and Interaction Activities at Home Associated with Developmental Outcomes in Children with Moderate Acute Malnutrition?

Objectives

To assess the association between play and interaction, and developmental outcomes in children with moderate acute malnutrition (MAM) in a prospective cohort of hospitalized children in Malawi and Uganda (http://www.chainnetwork.org).

Methods

Children (age 2– 23 months) requiring hospitalization for acute illness were enrolled from January 2017 till December 2018. Children meeting WHO criteria for MAM by mean upper arm circumference (MUAC) were included in this sub-analysis. Child development was assessed using the Malawi Developmental Assessment Tool at discharge and 180-day follow-up. The Family Care Indicator (FCI) evaluated the number of play items and interactions in the home. Developmental outcomes at discharge and follow-up were assessed using paired t-test. Linear regression analysis examined associations between FCI score and developmental outcomes at follow-up, with adjustment for sex, prematurity, height-for-age z-score and HIV status, parental education, household assets, and maternal mental health.

Results

128 children with MAM (52.3% male, mean age 11.3 months (±4.5) were included (mean MUAC 120 mm ± 3.2). Children were excluded for: pre-existing neurodisability (n = 5), death during follow-up (n = 4), and loss to follow-up (n = 22). At discharge 24.4% of the children had delays in the gross motor domain, 18.7% in the fine motor domain, 4.1% in the language domain and 7.3% in the social domain. Over the 6-month study period, significant improvements (P &lt; 0.001) in the mean difference of gross motor (1.3), fine motor (0.83) and social domain (0.59) Z-scores were observed. No significant change was identified in the language domain Z-score. Adjusted linear regression revealed that a one-point increase in the number of play items was associated with an increase in gross motor z-score of 0.16 (95% CI 0.01–0.32, P = 0.04) and a one point increase in interaction activities was associated with an increase in language z-score of 0.27 (95% CI 0.03–0.51, P = 0.03) at follow-up.

Conclusions

Children with MAM admitted for an acute illness showed significant improvements in developmental outcomes at 180-day follow-up. The role of play and interaction activities at home should be further investigated for their potential to promote developmental outcomes in children with MAM.

Funding Sources

Bill and Melinda Gates Foundation.

Enteric Function as a Determinant of Nutritional and Clinical Recovery from Acute Illness Among Children in Kenya and Pakistan

Objectives

In low- and middle-income countries (LMICs), acutely ill undernourished children remain at high risk of mortality for months following discharge from hospital. Community-based studies suggest that enteric dysfunction (ED), including permeability and impaired absorption, is associated with poor outcomes. We used the lactulose rhamnose ratio (L: R) test, which provides a functional assessment of gut integrity, to determine if ED influences clinical and nutritional recovery in the post-discharge period.

Methods

Children aged 2–24 months without diarrhea were recruited from Civil Hospital Karachi, Pakistan and Migori County Referral Hospital, Kenya. L: R tests were administered after children were clinically stable (oral feeds, not dehydrated, no oxygen needs) and pre-discharge. Similarly aged children were pseudo-randomly selected from homes near those of children being discharged and were also tested. Prior to administration of sugars, urine was collected to detect background levels, followed by a two-hour collection. Samples were analyzed by high-performance chromatography mass spectroscopy. Crude L: R distributions were compared using the Mann-Whitney test. A priori determined confounders (age, mid-upper arm circumference [MUAC], HIV status, site) were adjusted for in linear regression of log-transformed L: R.

Results

156 hospitalized and 91 community children were recruited. Median age was nine months in each group. Hospitalized children had lower median MUAC (12.4 vs 13.5 cm) and higher HIV infection prevalence (5% vs 1%). Both sugars were largely undetectable in pre-dose samples. Urinary median L: R among children being discharged (0.36 (interquartile range [IQR] 0.20–0.87)) was significantly higher compared to community peers (0.30 (IQR: 0.17–0.48, P = 0.038)). This difference remained significant in the adjusted model (p: 0.008).

Conclusions

Children at discharge from hospital in LMICs appear to have worse enteric function than community peers, and this difference does not appear to be attributable to young age or nutritional or HIV status. This analysis will be expanded to include L: R association with mortality, morbidity and growth outcomes prior to the conference.

Funding Sources

Thrasher Research Foundation 14,466, the Bill & Melinda Gates Foundation OPP 1,131,320.

Development and validation of a tool to assess appetite of children in low income settings

Reliable and validated tools for measuring appetite of children in South Asia are not available. This study aimed to develop and validate a tool for assessing appetite level of under-five children. Based on literature review and findings from focus group discussions (FGDs), an initial 27-item interview-based tool, the "Early Childhood Appetite and Satiety Tool (ECAST)" was developed in Bangladesh. Fourteen FGDs were carried out in rural and urban settings and constructs for inclusion were derived from the themes and coding of FGDs and appetite assessment tools used in Western contexts. For structural validation, the ECAST-27-was administered on 150 mothers/primary caregivers of children aged 6-59 months, living in urban and rural areas. To validate the association with other variables, the ECAST was administered on mothers of children aged 12-24 months in the community (N = 50), and two groups of wasted, hospitalized children (Weight-for-length, Z score <-2SD) [group1: twenty acutely ill children aged 6-59 months; group 2: twenty children in nutritional rehabilitation aged 18-24 months]. Reliability of ECAST was estimated using Cronbach's alpha and Pearson's correlation coefficient. Kaiser-Meyer-Olkin = 0.73 and the Bartlett's test of sphericity, χ²(253) = 755.791, p < 0.001 indicated that the raw data were suitable. Given the convergence of the Scree plot, Kaiser's criterion and dropping of cross loading items, a 16-item ECAST was produced with three sub scales: Appetite cue; Food responsiveness and Emotion and preference, which were internally valid and had good test-retest reliability (Cronbach's alpha 0.6 and test-retest reliability 0.797). Total ECAST scores of wasted children with good appetite were significantly higher from those with poor appetite (p = 0.004 and 0.001 for two wasted groups respectively). Results suggest that ECAST may provide a useful measure to assess the appetite level of under-five children.

Mortality after inpatient treatment for diarrhea in children: a cohort study

BACKGROUND

There is an increasing recognition that children remain at elevated risk of death following discharge from health facilities in resource-poor settings. Diarrhea has previously been highlighted as a risk factor for post-discharge mortality.

METHODS

A retrospective cohort study was conducted to estimate the incidence and demographic, clinical, and biochemical features associated with inpatient and 1-year post-discharge mortality amongst children aged 2-59 months admitted with diarrhea from 2007 to 2015 at Kilifi County Hospital and who were residents of Kilifi Health and Demographic Surveillance System (KHDSS). Log-binomial regression was used to identify risk factors for inpatient mortality. Time at risk was from the date of discharge to the date of death, out-migration, or 365 days later. Post-discharge mortality rate was computed per 1000 child-years of observation, and Cox proportion regression used to identify risk factors for mortality.

RESULTS

Two thousand six hundred twenty-six child KHDSS residents were admitted with diarrhea, median age 13 (IQR 8-21) months, of which 415 (16%) were severely malnourished and 130 (5.0%) had a positive HIV test. One hundred twenty-one (4.6%) died in the hospital, and of 2505 children discharged alive, 49 (2.1%) died after discharge: 21.4 (95% CI 16.1-28.3) deaths per 1000 child-years. Admission with signs of both diarrhea and severe pneumonia or severe pneumonia alone had a higher risk of both inpatient and post-discharge mortality than admission for diarrhea alone. There was no significant difference in inpatient and post-discharge mortality between children admitted with diarrhea alone and those with other diagnoses excluding severe pneumonia. HIV, low mid-upper arm circumference (MUAC), and bacteremia were associated with both inpatient and post-discharge mortality. Signs of circulatory impairment, sepsis, and abnormal electrolytes were associated with inpatient but not post-discharge mortality. Prior admission and lower chest wall indrawing were associated with post-discharge mortality but not inpatient mortality. Age, stuntedness, and persistent or bloody diarrhea were not associated with mortality before or after discharge.

CONCLUSIONS

Our results accentuate the need for research to improve the uptake and outcomes of services for malnutrition and HIV as well as to elucidate causal pathways and test interventions to mitigate these risks.

Systematic Review of Tools and Methods to Measure Appetite in Undernourished Children in the Context of Low- and Middle-Income Countries

Child undernutrition has multifactorial causes, ranging from food insecurity to etiologies refractory to conventional nutritional approaches, such as infections, environmental enteric dysfunction, and other conditions that lead to systemic inflammation. Poor appetite may be an important symptom of these causes and may be a useful marker of an undernourished child's ability to recover. We conducted a systematic review to characterize the methods and tools to measure appetite among children <5 y old in low- and middle-income countries. A systematic search of 8 databases identified 23 eligible studies published since 1995. Thirteen described methods based on direct feeding observation or quantification of nutrient intake from caregiver report, 16 described tools that assessed caregiver perceptions of appetite, and 6 reported assessments in both categories. Four studies that gauged caregiver perceptions assessed multiple appetite domains, whereas 12 assessed 1 domain-often with a single question. Only 6 studies reported validation processes, the most common of which compared an observed test meal with daily energy intake. No studies reported the use of a method or tool that was validated in multiple cultural or linguistic contexts. Although dietary intake measures and observed feeding tests have shown validity in some contexts, they are resource intensive. Subjective caregiver questionnaires may offer a more efficient appetite evaluation method, but they have been evaluated less consistently. A rigorously developed and validated tool to rapidly assess child appetite is needed and could be best addressed by a questionnaire that leverages the multiple domains of appetite. The application of interventions that target causes of undernutrition that are not amenable to food-based interventions in clinical or research contexts could be facilitated by an efficient appetite screening tool to identify appetite-related causes of undernutrition and to monitor children's response to such interventions.

Strategies to improve treatment coverage in community-based public health programs: A systematic review of the literature

Background

Community-based public health campaigns, such as those used in mass deworming, vitamin A supplementation and child immunization programs, provide key healthcare interventions to targeted populations at scale. However, these programs often fall short of established coverage targets. The purpose of this systematic review was to evaluate the impact of strategies used to increase treatment coverage in community-based public health campaigns.

Methodology/ principal findings

We systematically searched CAB Direct, Embase, and PubMed archives for studies utilizing specific interventions to increase coverage of community-based distribution of drugs, vaccines, or other public health services. We identified 5,637 articles, from which 79 full texts were evaluated according to pre-defined inclusion and exclusion criteria. Twenty-eight articles met inclusion criteria and data were abstracted regarding strategy-specific changes in coverage from these sources. Strategies used to increase coverage included community-directed treatment (n = 6, pooled percent change in coverage: +26.2%), distributor incentives (n = 2, +25.3%), distribution along kinship networks (n = 1, +24.5%), intensified information, education, and communication activities (n = 8, +21.6%), fixed-point delivery (n = 1, +21.4%), door-to-door delivery (n = 1, +14.0%), integrated service distribution (n = 9, +12.7%), conversion from school- to community-based delivery (n = 3, +11.9%), and management by a non-governmental organization (n = 1, +5.8%).

Conclusions/significance

Strategies that target improving community member ownership of distribution appear to have a large impact on increasing treatment coverage. However, all strategies used to increase coverage successfully did so. These results may be useful to National Ministries, programs, and implementing partners in optimizing treatment coverage in community-based public health programs.

Many public health platforms provide decentralized interventions outside of health facilities, including mass drug administration for neglected tropical diseases, immunizations, vitamin supplementation, and others. The purpose of these community-based public health platforms is to reach large proportions of populations in need with important preventative healthcare. However the platforms require high treatment coverage of targeted populations in order to achieve health impact. And, in many cases, targeted populations are low-income, rural, and hard to reach with large health campaigns. The purpose of this systematic review is to evaluate strategies for achieving high treatment coverage in public health service distribution programs. We identified nine different strategies used to increase coverage of distribution programs. Community-directed distribution was associated with the largest increase in treatment coverage. Similarly, incentivizing distributors also had a strong influence on increasing treatment coverage. These findings have important implications for governments, implementers, and funders who aim to provide health services at scale.

Multi-drug resistant non-typhoidal Salmonella associated with invasive disease in western Kenya

Non-typhoidal Salmonella (NTS) is a leading cause of bloodstream infections in Africa, but the various contributions of host susceptibility versus unique pathogen virulence factors are unclear. We used data from a population-based surveillance platform (population ~25,000) between 2007–2014 and NTS genome-sequencing to compare host and pathogen-specific factors between individuals presenting with NTS bacteremia and those presenting with NTS diarrhea. Salmonella Typhimurium ST313 and Salmonella Enteritidis ST11 were the most common isolates. Multi-drug resistant strains of NTS were more commonly isolated from patients presenting with NTS bacteremia compared to NTS diarrhea. This relationship was observed in patients under age five [aOR = 15.16, 95% CI (2.84–81.05), P = 0.001], in patients five years and older, [aOR = 6.70 95% CI (2.25–19.89), P = 0.001], in HIV-uninfected patients, [aOR = 21.61, 95% CI (2.53–185.0), P = 0.005], and in patients infected with Salmonella serogroup B [aOR = 5.96, 95% CI (2.28–15.56), P < 0.001] and serogroup D [aOR = 14.15, 95% CI (1.10–182.7), P = 0.042]. Thus, multi-drug-resistant NTS was strongly associated with bacteremia compared to diarrhea among children and adults. This association was seen in HIV-uninfected individuals infected with either S. Typhimurium or S. Enteritidis. Risk of developing bacteremia from NTS infection may be driven by virulence properties of the Salmonella pathogen.

Though NTS is normally associated with self-limiting gastroenteritis in humans, it is a leading cause of bloodstream infection in Africa. The biological mechanisms that contribute to invasiveness in NTS in Africa are unclear. In this paper we address which specific host and pathogen risk factors are associated with blood stream infection from non-typhoidal Salmonella in rural Kenya. We found that multi-drug resistant (MDR) strains of NTS were associated with NTS bacteremia, even after controlling for known host-factors including HIV, age, and NTS serogroup (a taxonomic grouping). Our results suggest that multi-drug resistant NTS is associated with blood stream infection even in the immune-competent host. Salmonella Typhimurium sequence type ST313, an emerging genotype in sub-Saharan Africa, was the most common cause of blood stream infection in children and adults, followed by Salmonella Enteritidis sequence type ST11. The increasing prevalence of commonly circulating non-typhoidal Salmonella poses a major challenge to the control of highly pathogenic NTS serovars. The specific biological and epidemiological mechanisms driving invasiveness from infection with drug-resistant NTS warrant further investigation.

Evaluating the sustainability, scalability, and replicability of an STH transmission interruption intervention: The DeWorm3 implementation science protocol

Hybrid trials that include both clinical and implementation science outcomes are increasingly relevant for public health researchers that aim to rapidly translate study findings into evidence-based practice. The DeWorm3 Project is a series of hybrid trials testing the feasibility of interrupting the transmission of soil transmitted helminths (STH), while conducting implementation science research that contextualizes clinical research findings and provides guidance on opportunities to optimize delivery of STH interventions. The purpose of DeWorm3 implementation science studies is to ensure rapid and efficient translation of evidence into practice. DeWorm3 will use stakeholder mapping to identify individuals who influence or are influenced by school-based or community-wide mass drug administration (MDA) for STH and to evaluate network dynamics that may affect study outcomes and future policy development. Individual interviews and focus groups will generate the qualitative data needed to identify factors that shape, contextualize, and explain DeWorm3 trial outputs and outcomes. Structural readiness surveys will be used to evaluate the factors that drive health system readiness to implement novel interventions, such as community-wide MDA for STH, in order to target change management activities and identify opportunities for sustaining or scaling the intervention. Process mapping will be used to understand what aspects of the intervention are adaptable across heterogeneous implementation settings and to identify contextually-relevant modifiable bottlenecks that may be addressed to improve the intervention delivery process and to achieve intervention outputs. Lastly, intervention costs and incremental cost-effectiveness will be evaluated to compare the efficiency of community-wide MDA to standard-of-care targeted MDA both over the duration of the trial and over a longer elimination time horizon.

Evidence-based approaches to childhood stunting in low and middle income countries: a systematic review

OBJECTIVE

We systematically evaluated health and nutrition programmes to identify context-specific interventional packages that might help to prioritise the implementation of programmes for reducing stunting in low and middle income countries (LMICs).

METHODS

Electronic databases were used to systematically review the literature published between 1980 and 2015. Additional articles were identified from the reference lists and grey literature. Programmes were identified in which nutrition-specific and nutrition-sensitive interventions had been implemented for children under 5 years of age in LMICs. The primary outcome was a change in stunting prevalence, estimated as the average annual rate of reduction (AARR). A realist approach was applied to identify mechanisms underpinning programme success in particular contexts and settings.

FINDINGS

Fourteen programmes, which demonstrated reductions in stunting, were identified from 19 LMICs. The AARR varied from 0.6 to 8.4. The interventions most commonly implemented were nutrition education and counselling, growth monitoring and promotion, immunisation, water, sanitation and hygiene, and social safety nets. A programme was considered to have effectively reduced stunting when AARR≥3%. Successful interventions were characterised by a combination of political commitment, multi-sectoral collaboration, community engagement, community-based service delivery platform, and wider programme coverage and compliance. Even for similar interventions the outcome could be compromised if the context differed.

INTERPRETATION

For all settings, a combination of interventions was associated with success when they included health and nutrition outcomes and social safety nets. An effective programme for stunting reduction embraced country-level commitment together with community engagement and programme context, reflecting the complex nature of exposures of relevance.

PROSPERO REGISTRATION NUMBER

CRD42016043772.

Piecing together the stunting puzzle: a framework for attributable factors of child stunting

Reducing the burden of stunting in childhood is critical to improving health in low- and middle-income settings. However, because many aetiologies underlie linear growth failure, stunting has proved difficult to prevent and reverse. Understanding the contributions these aetiologies make to the burden of stunting can help the development of targeted, effective interventions. To begin to frame these causes, a qualitative and a quantitative framework of the primary drivers of stunting in low-resource settings were developed. Population attributable fractions (PAF) were estimated to inform the quantitative framework. According to these estimates, infectious diseases were responsible for large attributable fractions in all settings, and a combination of dietary indicators also comprised a large fraction in Africa. However, the PAF calculation was found to have several limitations, including a requirement for a binary outcome and sensitivity to confounding, which necessitate broad interpretation of the results. More robust tools to model complex causality are needed in order to understand the causal aetiology of stunting.

"Those who care much, understand much." Maternal perceptions of children's appetite: Perspectives from urban and rural caregivers of diverse parenting experience in Bangladesh

Appetite in children is an important determinant of nutritional intake and growth. The information used by caregivers to understand children's appetite can help inform infant and young child feeding promotion and appetite assessment. We conducted a qualitative study to (a) explore maternal perceptions and responses to children's appetite and (b) to identify how these factors differ by type of caregiver, level of maternal experience, and urban versus rural context. We used purposive sampling to recruit mothers and alternate caregivers into 14 total focus group discussions (six to eight participants in each group; N = 95) in both urban and rural settings in Bangladesh. To understand children's appetite, caregivers monitor children's dietary patterns, emotional signs, and physical and verbal cues. Healthy appetite was observed by willingness to eat diverse foods, finish offered portions, and by acceptance of foods without excessive prompting. Child illness was cited for a cause of low appetite, which was manifested through fussiness, and avoiding commonly consumed foods. Mothers described a limited set of feeding practices (offering diverse foods, playing, and cheering children with videos) to encourage consumption when children lacked appetite. Mothers' stress related to work was noted as a barrier to identifying appetite cues. Urban mothers described a lower access to instrumental social support for child feeding but informational support than mothers in the rural setting. Understanding caregivers' perceptions of children's appetite may inform strategies to improve responsive feeding and tool development to assess changes in appetite as early indicators of change in health or nutrition status among high-risk children.

Assessing the interruption of the transmission of human helminths with mass drug administration alone: optimizing the design of cluster randomized trials

BACKGROUND

A method is outlined for the use of an individual-based stochastic model of parasite transmission dynamics to assess different designs for a cluster randomized trial in which mass drug administration (MDA) is employed in attempts to eliminate the transmission of soil-transmitted helminths (STH) in defined geographic locations. The hypothesis to be tested is: Can MDA alone interrupt the transmission of STH species in defined settings? Clustering is at a village level and the choice of clusters of villages is stratified by transmission intensity (low, medium and high) and parasite species mix (either Ascaris, Trichuris or hookworm dominant).

RESULTS

The methodological approach first uses an age-structured deterministic model to predict the MDA coverage required for treating pre-school aged children (Pre-SAC), school aged children (SAC) and adults (Adults) to eliminate transmission (crossing the breakpoint in transmission created by sexual mating in dioecious helminths) with 3 rounds of annual MDA. Stochastic individual-based models are then used to calculate the positive and negative predictive values (PPV and NPV, respectively, for observing elimination or the bounce back of infection) for a defined prevalence of infection 2 years post the cessation of MDA. For the arm only involving the treatment of Pre-SAC and SAC, the failure rate is predicted to be very high (particularly for hookworm-infected villages) unless transmission intensity is very low (R0, or the effective reproductive number R, just above unity in value).

CONCLUSIONS

The calculations are designed to consider various trial arms and stratifications; namely, community-based treatment and Pre-SAC and SAC only treatment (the two arms of the trial), different STH transmission settings of low, medium and high, and different STH species mixes. Results are considered in the light of the complications introduced by the choice of statistic to define success or failure, varying adherence to treatment, migration and parameter uncertainty.

Cotrimoxazole Prophylaxis Discontinuation among Antiretroviral-Treated HIV-1-Infected Adults in Kenya: A Randomized Non-inferiority Trial

BACKGROUND

Cotrimoxazole (CTX) prophylaxis is recommended by the World Health Organization (WHO) for HIV-1-infected individuals in settings with high infectious disease prevalence. The WHO 2006 guidelines were developed prior to the scale-up of antiretroviral therapy (ART). The threshold for CTX discontinuation following ART is undefined in resource-limited settings.

METHODS AND FINDINGS

Between 1 February 2012 and 30 September 2013, we conducted an unblinded non-inferiority randomized controlled trial of CTX prophylaxis cessation versus continuation among HIV-1-infected adults on ART for ≥ 18 mo with CD4 count > 350 cells/mm3 in a malaria-endemic region in Kenya. Participants were randomized and followed up at 3-mo intervals for 12 mo. The primary endpoint was a composite of morbidity (malaria, pneumonia, and diarrhea) and mortality. Incidence rate ratios (IRRs) were estimated using Poisson regression. Among 538 ART-treated adults screened, 500 were enrolled and randomized, 250 per arm. Median age was 40 y, 361 (72%) were women, and 442 (88%) reported insecticide-treated bednet use. Combined morbidity/mortality was significantly higher in the CTX discontinuation arm (IRR = 2.27, 95% CI 1.52-3.38; p < 0.001), driven by malaria morbidity. There were 34 cases of malaria, with 33 in the CTX discontinuation arm (IRR = 33.02, 95% CI 4.52-241.02; p = 0.001). Diarrhea and pneumonia rates did not differ significantly between arms (IRR = 1.36, 95% CI 0.82-2.27, and IRR = 1.43, 95% CI 0.54-3.75, respectively). Study limitations include a lack of placebo and a lower incidence of morbidity events than expected.

CONCLUSIONS

CTX discontinuation among ART-treated, immune-reconstituted adults in a malaria-endemic region resulted in increased incidence of malaria but not pneumonia or diarrhea. Malaria endemicity may be the most relevant factor to consider in the decision to stop CTX after ART-induced immune reconstitution in regions with high infectious disease prevalence. These data support the 2014 WHO CTX guidelines.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01425073.

Wheeze as an adverse event in pediatric vaccine and drug randomized controlled trials: A systematic review

INTRODUCTION

Wheeze is an important sign indicating a potentially severe adverse event in vaccine and drug trials, particularly in children. However, there are currently no consensus definitions of wheeze or associated respiratory compromise in randomized controlled trials (RCTs).

OBJECTIVE

To identify definitions and severity grading scales of wheeze as an adverse event in vaccine and drug RCTs enrolling children <5 years and to determine their diagnostic performance based on sensitivity, specificity and inter-observer agreement.

METHODS

We performed a systematic review of electronic databases and reference lists with restrictions for trial settings, English language and publication date ≥1970. Wheeze definitions and severity grading were abstracted and ranked by a diagnostic certainty score based on sensitivity, specificity and inter-observer agreement.

RESULTS

Of 1205 articles identified using our broad search terms, we identified 58 eligible trials conducted in 38 countries, mainly in high-income settings. Vaccines made up the majority (90%) of interventions, particularly influenza vaccines (65%). Only 15 trials provided explicit definitions of wheeze. Of 24 studies that described severity, 11 described wheeze severity in the context of an explicit wheeze definition. The remaining 13 studies described wheeze severity where wheeze was defined as part of a respiratory illness or a wheeze equivalent. Wheeze descriptions were elicited from caregiver reports (14%), physical examination by a health worker (45%) or a combination (41%). There were 21/58 studies in which wheeze definitions included combined caregiver report and healthcare worker assessment. The use of these two methods appeared to have the highest combined sensitivity and specificity.

CONCLUSION

Standardized wheeze definitions and severity grading scales for use in pediatric vaccine or drug trials are lacking. Standardized definitions of wheeze are needed for assessment of possible adverse events as new vaccines and drugs are evaluated.

Scaling up integrated prevention campaigns for global health: costs and cost-effectiveness in 70 countries

OBJECTIVE

This study estimated the health impact, cost and cost-effectiveness of an integrated prevention campaign (IPC) focused on diarrhoea, malaria and HIV in 70 countries ranked by per capita disability-adjusted life-year (DALY) burden for the three diseases.

METHODS

We constructed a deterministic cost-effectiveness model portraying an IPC combining counselling and testing, cotrimoxazole prophylaxis, referral to treatment and condom distribution for HIV prevention; bed nets for malaria prevention; and provision of household water filters for diarrhoea prevention. We developed a mix of empirical and modelled cost and health impact estimates applied to all 70 countries. One-way, multiway and scenario sensitivity analyses were conducted to document the strength of our findings. We used a healthcare payer's perspective, discounted costs and DALYs at 3% per year and denominated cost in 2012 US dollars.

PRIMARY AND SECONDARY OUTCOMES

The primary outcome was cost-effectiveness expressed as net cost per DALY averted. Other outcomes included cost of the IPC; net IPC costs adjusted for averted and additional medical costs and DALYs averted.

RESULTS

Implementation of the IPC in the 10 most cost-effective countries at 15% population coverage would cost US$583 million over 3 years (adjusted costs of US$398 million), averting 8.0 million DALYs. Extending IPC programmes to all 70 of the identified high-burden countries at 15% coverage would cost an adjusted US$51.3 billion and avert 78.7 million DALYs. Incremental cost-effectiveness ranged from US$49 per DALY averted for the 10 countries with the most favourable cost-effectiveness to US$119, US$181, US$335, US$1692 and US$8340 per DALY averted as each successive group of 10 countries is added ordered by decreasing cost-effectiveness.

CONCLUSIONS

IPC appears cost-effective in many settings, and has the potential to substantially reduce the burden of disease in resource-poor countries. This study increases confidence that IPC can be an important new approach for enhancing global health.

Integrated disease prevention campaigns: assessing country opportunity for implementation via an index approach

OBJECTIVES

To help stakeholders identify and prioritise countries with the best opportunities for implementation of an integrated prevention campaign (IPC) focused on diarrhoea, malaria and HIV prevention.

DESIGN

Cross-sectional analysis of country-specific epidemiological data using an index tool developed for this purpose.

SETTING

We calculated the total disability-adjusted life years (DALYs) attributed to diarrhoea, malaria and HIV for 214 World Bank economies. Criteria for inclusion were: low-income and middle-income countries, and total annual DALY burden in the top tertile (≥87 000 DALYs). 70 countries met inclusion criteria and were included in our opportunity analysis.

OUTCOME MEASURES

We synthesised data on 10 indicators related to the potential reduction in burden and new coverage achievable by an IPC. We scored and ranked countries based on three summary opportunity metrics: DALYs per capita across the diseases, a composite score of tertile rankings of burden for each disease, and a score combining burden and intervention opportunity.

RESULTS

We estimated the total annual global burden attributable to diarrhoea, malaria and HIV at 135 million DALYs. All of the countries with the highest opportunity for implementation of a diarrhoea, malaria and HIV IPC are in sub-Saharan Africa, regardless of opportunity metric used. Although the overall rank order changes, 16 countries rank among the top 23 highest opportunity countries for all three metrics.

CONCLUSIONS

Stakeholders can use this objective metric-based approach to prioritise countries for IPC scale-up. Priority countries are largely robust to the opportunity metric chosen.

The association between malaria and iron status or supplementation in pregnancy: a systematic review and meta-analysis

Introduction

Malaria prevention and iron supplementation are associated with improved maternal and infant outcomes. However, evidence from studies in children suggests iron may adversely modify the risk of malaria. We reviewed the evidence in pregnancy of the association between malaria and markers of iron status, iron supplementation or parenteral treatment.

Methods and Findings

We searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, the Global Health Library, and the Malaria in Pregnancy library to identify studies that investigated the association between iron status, iron treatment or supplementation during pregnancy and malaria. Thirty one studies contributed to the analysis; 3 experimental and 28 observational studies. Iron supplementation was not associated with an increased risk of P. falciparum malaria during pregnancy or delivery in Africa (summary Relative Risk = 0.89, 95% Confidence Interval (CI) 0.66–1.20, I² = 78.8%, 5 studies). One study in Asia reported an increased risk of P. vivax within 30 days of iron supplementation (e.g. adjusted Hazard Ratio = 1.75, 95% CI 1.14–2.70 for 1–15 days), but not after 60 days. Iron deficiency (based on ferritin and C-reactive protein) was associated with lower odds for malaria infection (summary Odds Ratio = 0.35, 0.24–0.51, I² = 59.2%, 5 studies). With the exception of the acute phase protein ferritin, biomarkers of iron deficiency were generally not associated with malaria infection.

Conclusions

Iron supplementation was associated with a temporal increase in P vivax, but not with an increased risk of P. falciparum; however, data are insufficient to rule out the potential for an increased risk of P. falciparum. Iron deficiency was associated with a decreased malaria risk in pregnancy only when measured with ferritin. Until there is more evidence, it is prudent to provide iron in combination with malaria prevention during pregnancy.

Stigma in Ethiopia: association with depressive symptoms in people with HIV

Rates of depression among people living with HIV can be as high as 50%. In many settings, HIV-related stigma has been associated with depressive symptoms which may lead to poor engagement in care and ultimately, poorer health outcomes. Stigma is a major issue in Ethiopia but data examining the relationship between stigma and depression in Ethiopia are lacking. We performed a mixed-methods cross-sectional study to examine the relationship between stigma of HIV/AIDS and depressive symptoms in Gondar, Ethiopia. We interviewed patients who presented for routine HIV care at Gondar University Hospital during the study period, examining depressive symptoms and HIV/AIDS-related stigma using standardized measures. Multiple-regression was used to assess the relationship between depressive symptoms, stigma, and gender. Of 55 patients included in this analysis, 63.6% were female and most participants had limited formal education (69%, less than 12th grade education). The majority reported experiencing both stigma (78%) and depressive symptoms (60%) ranging in severity from mild to moderately severe. Higher levels of HIV-related stigma were significantly associated with higher levels of depressive symptoms (β = 0.464, p ≤ 0.001). Although gender was associated with stigma, it was not associated with depressive symptoms (β = -0.027, p > 0.05). Results suggest the importance of psychosocial issues in the lives of people with HIV in Ethiopia.

Sexually transmitted infections among HIV-infected adults in HIV care programs in Kenya: a national sample of HIV clinics

BACKGROUND

Identifying sexually transmitted infections (STI) in HIV-infected individuals has potential to benefit individual and public health. There are few guidelines regarding routine STI screening in sub-Saharan African HIV programs. We determined sexual risk behavior and prevalence and correlates of STI in a national survey of large HIV treatment programs in Kenya.

METHODS

A mobile screening team visited 39 (95%) of the 42 largest HIV care programs in Kenya and enrolled participants using population-proportionate systematic sampling. Participants provided behavioral and clinical data. Genital and blood specimens were tested for trichomoniasis, gonorrhea, chlamydia, syphilis, and CD4 T-lymphocyte counts.

RESULTS

Among 1661 adults, 41% reported no sexual partners in the past 3 months. Among those who reported sex in the past 3 months, 63% of women reported condom use during this encounter compared with 77% of men (P < 0.001). Trichomoniasis was the most common STI in women (10.9%) and men (2.8%); prevalences of gonorrhea, chlamydia, and syphilis were low (<1%-2%). Among women, younger age (adjusted odds ratio [OR], 0.96 per year; 95% confidence interval [CI], 0.94-0.98) and primary school education or lower level (adjusted OR, 2.16; 95% CI, 1.37-3.40) were independently associated with trichomoniasis, whereas CD4 count, cotrimoxazole use, and reported condom use were not. Reported condom use at last sex was associated with reporting that the clinic provided condoms among both women (OR, 1.7; 95% CI, 1.17-2.35) and men (OR, 2.4; 95% CI, 1.18-4.82).

CONCLUSIONS

Women attending Kenyan HIV care programs had a 10.9% prevalence of trichomoniasis, suggesting that screening for this infection may be useful. Condom provision at clinics may enhance secondary HIV prevention efforts.

Provision of bednets and water filters to delay HIV-1 progression: cost-effectiveness analysis of a Kenyan multisite study

OBJECTIVE

To estimate the effectiveness, costs and cost-effectiveness of providing long-lasting insecticide-treated nets (LLINs) and point-of-use water filters to antiretroviral therapy (ART)-naïve HIV-infected adults and their family members, in the context of a multisite study in Kenya of 589 HIV-positive adults followed on average for 1.7 years.

METHODS

The effectiveness, costs and cost-effectiveness of the intervention were estimated using an epidemiologic-cost model. Model epidemiologic inputs were derived from the Kenya multisite study data, local epidemiological data and from the published literature. Model cost inputs were derived from published literature specific to Kenya. Uncertainty in the model estimates was assessed through univariate and multivariate sensitivity analyses.

RESULTS

We estimated net cost savings of about US$ 26 000 for the intervention, over 1.7 years. Even when ignoring net cost savings, the intervention was found to be very cost-effective at a cost of US$ 3100 per death averted or US$ 99 per disability-adjusted life year (DALY) averted. The findings were robust to the sensitivity analysis and remained most sensitive to both the duration of ART use and the cost of ART per person-year.

CONCLUSIONS

The provision of LLINs and water filters to ART-naïve HIV-infected adults in the Kenyan study resulted in substantial net cost savings, due to the delay in the initiation of ART. The addition of an LLIN and a point-of-use water filter to the existing package of care provided to ART-naïve HIV-infected adults could bring substantial cost savings to resource-constrained health systems in low- and middle-income countries.

Empiric deworming to delay HIV disease progression in adults with HIV who are ineligible for initiation of antiretroviral treatment (the HEAT study): a multi-site, randomised trial

BACKGROUND

Co-infection with HIV and helminths is common in sub-Saharan Africa and findings from previous studies have suggested that anthelmintic treatment might delay immunosuppression in people with HIV. We aimed to assess the efficacy of empiric deworming of adults with HIV in delaying HIV disease progression.

METHODS

In this non-blinded randomised trial, we enrolled adults (aged ≥18 years) with HIV who did not meet criteria for the initiation of antiretroviral treatment from three sites in Kenya. Using a computer-generated sequence, we randomly assigned (1:1) eligible participants to either empiric albendazole every 3 months plus praziquantel annually (treatment group) or to standard care (control group). Participants were followed up for 24 months. We measured CD4 cell counts every 6 months and plasma HIV RNA annually. The primary endpoints were a CD4 count of less than 350 cells per μL and a composite endpoint consisting of the first occurrence of a CD4 count of less than 350 cells per μL, first reported use of antiretroviral treatment, and non-traumatic deaths. We compared these measures by use of Cox proportional hazards regression and Kaplan-Meier survival analyses. Primary analysis was done by intention to treat. The trial was registered with ClinicalTrials.gov, number NCT0050722.

FINDINGS

Between Feb 6, 2008, and June 21, 2011, we enrolled and followed-up 948 participants; 469 were allocated to the treatment group and 479 to the control group. All participants were provided with co-trimoxazole prophylaxis. Median baseline CD4 cell counts and HIV RNA concentrations did not differ between groups. We recorded no statistically significant difference between the treatment and control groups in the number of people reaching a CD4 count of fewer than 350 cells per μL (41·6 events per 100 person-years vs 46·2 events per 100 person-years; hazard ratio 0·89, 95% CI 0·75-1·06, p=0·2) or the composite endpoint (44·0 events per 100 person-years vs 49·8 events per 100 person-years; 0·88, 0·74-1·04, p=0·1). Serious adverse events, none of which thought to be treatment-related, occurred at a similar frequency in both groups.

INTERPRETATION

Our findings do not suggest an effect of empiric deworming in the delaying of HIV disease progression in adults with HIV in an area where helminth infection is common. Alternative approaches are needed to delay HIV disease progression in areas where co-infections are common.

Prevalence and correlates of insecticide-treated bednet use among HIV-1-infected adults in Kenya

HIV-1-infected adults are at increased risk for malaria. Insecticide-treated bednets protect individuals from malaria. Little is known about correlates of ownership and use of bednets among HIV-1-infected individuals. We conducted a cross-sectional survey of 388 HIV-1-infected adults recruited from three sites in Kenya (Kilifi, Kisii, and Kisumu) to determine factors associated with ownership and use of optimal bednets. We defined an optimal bednet as an untorn, insecticide-treated bednet. Of 388 participants, 134(34.5%) reported owning an optimal bednet. Of those that owned optimal bednets, most (76.9%) reported using it daily. In a multivariate model, higher socioeconomic status as defined as postsecondary education [OR = 2.8 (95% CI: 1.3-6.4), p = 0.01] and living in a permanent home [OR = 1.7(1.03-2.9), p = 0.04] were significantly associated with optimal bednet ownership. Among individuals who owned bednets, employed individuals were less likely [OR = 0.2(0.04-0.8), p = 0.01] and participants from Kilifi were more likely to use bednets [OR = 2.9 (95% CI 1.04-8.1), p = 0.04] in univariate analysis. Participants from Kilifi had the least education, lowest income, and lowest rate of employment. Our findings suggest that lower socioeconomic status is a barrier to ownership of an optimal bednet. However, consistent use is high once individuals are in possession of an optimal bednet. Increasing access to optimal bednets will lead to high uptake and use.