Innovative strategies for the surveillance, prevention, and management of pediatric infections applied to low-income settings

INTRODUCTION

Infectious diseases still cause a significant burden of morbidity and mortality among children in low- and middle-income countries (LMICs). There are ample opportunities for innovation in surveillance, prevention, and management, with the ultimate goal of improving survival.

AREAS COVERED

This review discusses the current status in the use and development of innovative strategies for pediatric infectious diseases in LMICs by focusing on surveillance, diagnosis, prevention, and management. Topics covered are: Minimally Invasive Tissue Sampling as a technique to accurately ascertain the cause of death; Genetic Surveillance to trace the pathogen genomic diversity and emergence of resistance; Artificial Intelligence as a multidisciplinary tool; Portable noninvasive imaging methods; and Prognostic Biomarkers to triage and risk stratify pediatric patients.

EXPERT OPINION

To overcome the specific hurdles in child health for LMICs, some innovative strategies appear at the forefront of research. If the development of these next-generation tools remains focused on accessibility, sustainability and capacity building, reshaping epidemiological surveillance, diagnosis, and treatment in LMICs, can become a reality and result in a significant public health impact. Their integration with existing healthcare infrastructures may revolutionize disease detection and surveillance, and improve child health and survival.

A cross-sectional study quantifies the independent contribution of nurses and midwives in child health outcomes

INTRODUCTION

As the largest profession within the healthcare industry, nursing and midwifery workforce (NMW) provides comprehensive healthcare to children and their families. This study quantified the independent role of NMW in reducing under-5 mortality rate (U5MR) worldwide.

DESIGN

A retrospective, observational and correlational study to examine the independent role of NMW in protecting against U5MR.

METHODS

Within 266 "countries", the cross-sectional correlations between NMW and U5MR were examined with scatter plots, Pearson's r, nonparametric, partial correlation and multiple regression. The affluence, education and urban advantages were considered as the potential competing factors for the NMW-U5MR relationship. The NMW-U5MR correlations in both developing and developed countries were explored and compared.

RESULTS

Bivariate correlations revealed that NMW negatively and significantly correlated to U5MR worldwide. When the contributing effects of economic affluence, urbanization and education were removed, the independent NMW role in reducing U5MR remained significant. NMW independently explained 9.36% U5MR variance. Multilinear regression selected NMW as a significant factor contributing an extra 3% of explanation to U5MR variance when NMW, affluence, education and urban advantage were incorporated as the predicting variables. NMW correlated with U5MR significantly more strongly in developing countries than in developed countries.

CONCLUSION

NMW, indexing nursing and midwifery service, was a significant factor for reducing U5MR worldwide. This beneficial effect explained 9.36% of U5MR variance which was independent of economic affluence, urbanization and education. The NMW may be a more significant risk factor for protecting children from dying under 5 years old in developing countries. As a strategic response to the advocacy of the United Nations to reduce child mortality, it is worthy for health authorities to consider a further extension of nurses and midwives' practice scope to enable communities to have more access to NMW healthcare services.

Health insurance and child mortality: Evidence from India

Although less than a third of the population in developing countries is covered by health insurance, the number has been on the rise. Many countries have implemented national insurance policies in the past decade. However, there is limited evidence on their impact on child mortality in low- and middle-income contexts. Here we document the child mortality reducing effects of an at-scale national level health insurance policy in India. The Rashtriya Swasthya Bima Yojana (RSBY), was rolled out across India between 2008 and 2013. Leveraging the temporal and spatial variation in program implementation, we demonstrate that it lowered infant mortality by 6% and child under five mortality by 5%. The effects are largely concentrated among urban poor households. In terms of mechanisms, we find that the program effects seem to be driven by increased usage of reproductive health services by mothers. We also demonstrate a rise in usage of complementary health services that were were not covered under the policy (such as child immunizations), which suggests that RSBY had significant positive spillover effects on health care usage.

Discovering Subgroups of Children With High Mortality in Urban Guinea-Bissau: Exploratory and Validation Cohort Study

BACKGROUND

The decline in global child mortality is an important public health achievement, yet child mortality remains disproportionally high in many low-income countries like Guinea-Bissau. The persisting high mortality rates necessitate targeted research to identify vulnerable subgroups of children and formulate effective interventions.

OBJECTIVE

This study aimed to discover subgroups of children at an elevated risk of mortality in the urban setting of Bissau, Guinea-Bissau, West Africa. By identifying these groups, we intend to provide a foundation for developing targeted health interventions and inform public health policy.

METHODS

We used data from the health and demographic surveillance site, Bandim Health Project, covering 2003 to 2019. We identified baseline variables recorded before children reached the age of 6 weeks. The focus was on determining factors consistently linked with increased mortality up to the age of 3 years. Our multifaceted methodological approach incorporated spatial analysis for visualizing geographical variations in mortality risk, causally adjusted regression analysis to single out specific risk factors, and machine learning techniques for identifying clusters of multifactorial risk factors. To ensure robustness and validity, we divided the data set temporally, assessing the persistence of identified subgroups over different periods. The reassessment of mortality risk used the targeted maximum likelihood estimation (TMLE) method to achieve more robust causal modeling.

RESULTS

We analyzed data from 21,005 children. The mortality risk (6 weeks to 3 years of age) was 5.2% (95% CI 4.8%-5.6%) for children born between 2003 and 2011, and 2.9% (95% CI 2.5%-3.3%) for children born between 2012 and 2016. Our findings revealed 3 distinct high-risk subgroups with notably higher mortality rates, children residing in a specific urban area (adjusted mortality risk difference of 3.4%, 95% CI 0.3%-6.5%), children born to mothers with no prenatal consultations (adjusted mortality risk difference of 5.8%, 95% CI 2.6%-8.9%), and children from polygamous families born during the dry season (adjusted mortality risk difference of 1.7%, 95% CI 0.4%-2.9%). These subgroups, though small, showed a consistent pattern of higher mortality risk over time. Common social and economic factors were linked to a larger share of the total child deaths.

CONCLUSIONS

The study's results underscore the need for targeted interventions to address the specific risks faced by these identified high-risk subgroups. These interventions should be designed to work to complement broader public health strategies, creating a comprehensive approach to reducing child mortality. We suggest future research that focuses on developing, testing, and comparing targeted intervention strategies unraveling the proposed hypotheses found in this study. The ultimate aim is to optimize health outcomes for all children in high-mortality settings, leveraging a strategic mix of targeted and general health interventions to address the varied needs of different child subgroups.

Implementing Community-Based Strategies for Improved Pneumonia Care in Children: Insights From a Pilot Study

INTRODUCTION

Respiratory ailments, encompassing a spectrum of disorders, are a leading cause of mortality and morbidity in children, with pneumonia being particularly significant, accounting for 16% of child mortality. To ensure timely engagement with healthcare services, it is imperative to instill awareness through Information, Education, and Communication (IEC) initiatives targeting mothers of children under five. The primary objective of this pilot study is to assess the feasibility of a community-based intervention on health-seeking behaviour, knowledge, and practice measures concerning the management and prevention of pneumonia in children.

METHODOLOGY

The pilot study mirrored the main study's procedures in two villages, Bhuvanahalli and Gavanahalli, each randomly assigned as either an experimental or a control group. We selected 12 mothers with children under the age of five who had community-acquired pneumonia, employing a straightforward random technique, with six mothers from each group. These mothers were interviewed using a structured questionnaire focusing on health-seeking behaviour, knowledge, and practices related to the management and prevention of pneumonia. Mothers in the experimental group received a community-based intervention, specifically an educational set focusing on health-seeking behaviour, knowledge, and practice measures concerning the management and prevention of pneumonia in children, while those in the control group continued with their routine practices. We collected post-test data from the mothers in both groups at the 2nd, 4th, and 6th months of the intervention. The data analysis was conducted using the IBM SPSS Statistics for Windows, Version 28 (Released 2021; IBM Corp., Armonk, New York) software. The Mann-Whitney test and Kruskal-Wallis analyses indicated a notable and statistically significant shift in health-seeking behaviour, knowledge, and practices pertaining to the management and prevention of pneumonia in children as a result of the community-based educational intervention implemented in the experimental group (P<0.05).

CONCLUSION

Community-based intervention is crucial to preventing mortality and morbidity in children. The findings of the pilot study affirm its feasibility and lay a strong foundation for further investigation and implementation.

Organ Dysfunction in Children With Blood Culture-Proven Sepsis: Comparative Performance of Four Scores in a National Cohort Study

OBJECTIVES

Previous studies applying Sepsis-3 criteria to children were based on retrospective analyses of PICU cohorts. We aimed to compare organ dysfunction criteria in children with blood culture-proven sepsis, including emergency department, PICU, and ward patients, and to assess relevance of organ dysfunctions for mortality prediction.

DESIGN

We have carried out a nonprespecified, secondary analysis of a prospective dataset collected from September 2011 to December 2015.

SETTING

Emergency departments, wards, and PICUs in 10 tertiary children's hospitals in Switzerland.

PATIENTS

Children younger than 17 years old with blood culture-proven sepsis. We excluded preterm infants and term infants younger than 7 days old.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We compared the 2005 International Pediatric Sepsis Consensus Conference (IPSCC), Pediatric Logistic Organ Dysfunction-2 (PELOD-2), pediatric Sequential Organ Failure Assessment (pSOFA), and Pediatric Organ Dysfunction Information Update Mandate (PODIUM) scores, measured at blood culture sampling, to predict 30-day mortality. We analyzed 877 sepsis episodes in 807 children, with a 30-day mortality of 4.3%. Percentage with organ dysfunction ranged from 32.7% (IPSCC) to 55.3% (pSOFA). In adjusted analyses, the accuracy for identification of 30-day mortality was area under the curve (AUC) 0.87 (95% CI, 0.82-0.92) for IPSCC, 0.83 (0.76-0.89) for PELOD-2, 0.85 (0.78-0.92) for pSOFA, and 0.85 (0.78-0.91) for PODIUM. When restricting scores to neurologic, respiratory, and cardiovascular dysfunction, the adjusted AUC was 0.89 (0.84-0.94) for IPSCC, 0.85 (0.79-0.91) for PELOD-2, 0.87 (0.81-0.93) for pSOFA, and 0.88 (0.83-0.93) for PODIUM.

CONCLUSIONS

IPSCC, PELOD-2, pSOFA, and PODIUM performed similarly to predict 30-day mortality. Simplified scores restricted to neurologic, respiratory, and cardiovascular dysfunction yielded comparable performance.

Exploring adjunctive therapies for cerebral malaria

Cerebral malaria (CM) is one of the most severe complications of malaria infection characterized by coma and neurological effects. Despite standardized treatment of malaria infection with artemisinin-based combination therapies (ACT), the mortality rate is still high, and it primarily affects pediatric patients. ACT reduces parasitemia but fails to adequately target the pathogenic mechanisms underlying CM, including blood-brain-barrier (BBB) disruption, endothelial activation/dysfunction, and hyperinflammation. The need for adjunctive therapies to specifically treat this form of severe malaria is critical as hundreds of thousands of people continue to die each year from this disease. Here we present a summary of some potential promising therapeutic targets and treatments for CM, as well as some that have been tested and deemed ineffective or, in some cases, even deleterious. Further exploration into these therapeutic agents is warranted to assess the effectiveness of these potential treatments for CM patients.

Infant mortality in Ghana: investing in health care infrastructure and systems

Child and infant mortality is a global problem. Almost half of deaths of children under age 5 years occur in the neonatal period, the first 28 days of life, with 2.4 million neonatal deaths globally in 2020. Sub-Saharan Africa has disproportionately high numbers of neonatal deaths. Ghana's neonatal mortality rate is 22.8 per 1000 live births and remains behind targets set by the United Nations Sustainable Development Goals. Quality antenatal care, postnatal monitoring, breastfeeding support, and postnatal family planning are important in preventing neonatal deaths. While Ghana has made progress in making care more financially accessible, it has not been matched with the improvements in the critical infrastructure required to ensure quality health care. The improvements have also not eliminated out-of-pocket costs for care, which have hindered progress in decreasing infant mortality. Policymakers should consider investments in health care infrastructure, including expanding public-private partnerships. Policies that improve workforce development programs, transportation infrastructure, and health insurance systems improvements are needed.

Ethnic inequality and public health

We examine the association between ethnic inequality and various key health outcomes for a global set of developed and developing countries. Our results show that higher ethnic inequality is associated with a poor state of public health, such as higher child and maternal mortality, increased stillbirths and child stunting, and reduced life expectancy at birth. This set of effects is found to be predominant mainly in developing countries, and Sub-Saharan African countries. Results remain robust to the inclusion of various other measures of inequality, ethnic composition indices, geographic endowments, and other relevant controls. We argue that lower contraceptive usage and poor vaccination rates are potential mechanisms through which ethnic inequality affects health outcomes. Policies targeted at improving public health may need to focus more on these key intermediate channels in ethnic minority regions.

Infant Mortality Screening and Prevention Initiatives in Nepal

Infant mortality is one of the leading public health crises in Nepal. While Nepal has made significant advances in mitigating under-five mortality, much work is still needed to be done regarding the healthcare of infants. The Nepalese government has identified this as a problem and has introduced a series of interventions to improve the health outcomes of infants. The aim of this review is to identify the goals, interventions, and effectiveness of major infant mortality prevention programs around the country. A comprehensive literature search was performed using PubMed and Google Scholar. The literature search revealed six programs that Nepal has utilized to combat infant mortality. The Community Based Management of Childhood Illness (CB-IMCI) program utilizes specially trained community workers to help identify and treat children with common childhood illnesses. The National Neonatal Health Strategy (NNHS) links families to the community and then to the broader healthcare system, with success found in its referral system. The Safe Delivery Incentives Program (SDIP) has found success with monetizing safe delivery practices, and shown an increase in safe deliveries with skilled healthcare workers present. Free Newborn Care (FNC) services were aimed at treating sick newborns for free, but ongoing concerns for program sustainability have led to further revision. The Every Newborn Action Plan (ENAP) is another plan aimed at preventing newborn deaths through improving health system administration and finances, but with limited efficacy data, it is hard to determine its success due to the lack of objective benchmark markers and data collected. Finally, the Birth Preparedness Package (BPP) is a highly efficacious program that encourages communities to plan for pregnancies by planning for delay barriers. Nepal has made significant strides in reducing infant mortality; however, much work still needs to be done. From 1990 to 2020, Nepal has reduced the under-five mortality rate from 138.8 deaths per 1,000 live births to 28.2 deaths per 1,000 live births.

Terrorism and child mortality

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

Closing the pneumococcal conjugate vaccine (PCV) introduction gap: an archetype analysis of last-mile countries

BACKGROUND

Pneumonia remains the leading infectious cause of global childhood deaths, despite the availability of pneumococcal conjugate vaccine (PCV) products and widespread evidence of their safety and efficacy.

OBJECTIVE

To map the landscape of countries that are yet to fully include PCV in their National Immunization Programs, we conducted an archetype analysis of country indicators related to barriers and facilitators for PCV decision-making.

METHODS

We created a country matrix focused on three key domains - health characteristics, immunisation factors, and policy framework, and identified ten related indicators. We scored countries based on indicator performance and subsequently ranked and grouped them into three archetypes of low-, moderate-, and high-barrier countries with regard to PCV introduction.

RESULTS

Our results indicated 39 countries (33 low- and middle-income countries [LMICs] and 6 high-income countries) that are yet to introduce PCV. Among LMICs, 15 countries were classified as 'low-barrier,' indicating factors favourable for PCV introduction such as high immunisation coverage of common childhood vaccines, supportive governments, and substantial disease burden and eligibility for Gavi support. Countries classified in the 'moderate-barrier' (12) and 'high-barrier' (6) archetypes demonstrated adequate capacity in immunisation systems but had competing national priorities and cost barriers that impeded policy decision-making on PCV introduction.

CONCLUSIONS

The current health and policy indicator-based categorisation provides an actionable framework to design tailored PCV advocacy within these last-mile countries. Policy approaches emerging from this framework can lead to strengthened decision-making on vaccine introduction and sustained vaccine access that can enhance child survival worldwide.

Do Pentavalent (DTwP-Hib-HBV) vaccines have sex-differential nonspecific effects? An observational study

Vaccines may alter the ability to combat infections unrelated to the target disease, i.e. have "nonspecific effects." The non-live Diphtheria-Tetanus-Pertussis vaccine (DTP) has been associated with increased child mortality, especially for females. In 2008, the DTP-containing Pentavalent vaccine replaced DTP vaccine in Guinea-Bissau. We investigate female relative to male mortality after Penta vaccination. In Guinea-Bissau, Bandim Health Project (BHP) registered children's vaccination and vital status at biannual village visits and provided vaccines. Among children Penta-vaccinated by BHP, we compared mortality of males and females in Cox proportional hazards models. Children aged 6 weeks to 8 months entered the analysis at the date of vaccination and were followed for up to 6 months. Between September 2008 and December 2017, 33,989 children aged 6 weeks to 8 months were under surveillance. Of these 12,753 (females: 6,363; males: 6,390) received Penta by the BHP and entered the study contributing with 19,667 observations. The mortality rate following Penta vaccination was 25.2 per 1,000 person years for females and 26.6 for males, resulting in an adjusted Female/Male mortality rate ratio of (F/M aMRR) 1.01 (0.82-1.25). The association between sex and mortality differed by timeliness of vaccination, F/M aMRR: 0.62 (0.41-0.93) for children vaccinated below median age, and F/M aMRR: 1.38 (0.90-2.13) for children vaccinated above median age. We did not find higher overall mortality in females than males after Penta vaccination. Our findings suggest that mortality differences between males and females following Penta vaccination may depend on timeliness of Penta vaccination.

Sudden Unexplained Death in Childhood: Current Understanding

Sudden, Unexplained Death in Childhood (SUDC) is a term that encompasses apparently natural deaths in children over one year of age with no discernible cause despite a thorough assessment. Definitive underlying causes vary but most cases remain largely unexplained. Research has furthered the view that SUDC is not an accident, but rather a sentinel medical event for which a thorough postmortem investigation is indicated. Emerging evidence in genetics, neurology, and neuropathology point to heterogeneous causes that in some cases share features of recognized diseases.

Implication of the 2014 World Health Organization Integrated Management of Childhood Illness Pneumonia Guidelines with and without pulse oximetry use in Malawi: A retrospective cohort study

Background

Under-5 pneumonia mortality remains high in low-income countries. In 2014 the World Health Organization (WHO) advised that children with chest indrawing pneumonia, but without danger signs or peripheral oxygen saturation (SpO 2) < 90% be treated in the community, rather than hospitalized. In Malawi there is limited pulse oximetry availability.

Methods

Secondary analysis of 13,413 under-5 pneumonia cases in Malawi. Pneumonia associated case fatality ratios (CFR) were calculated by disease severity under the assumptions of the 2005 and 2014 WHO Integrated Management of Childhood Illness (IMCI) guidelines, with and without pulse oximetry. We investigated if pulse oximetry readings were missing not at random (MNAR).

Results

The CFR of patients classified as having non-severe pneumonia per the 2014 IMCI guidelines doubled under the assumption that pulse oximetry was not available (1.5% without pulse oximetry vs 0.7% with pulse oximetry, P<0.001). When 2014 IMCI guidelines were applied with pulse oximetry and a SpO 2 < 90% as the threshold for referral and/or admission, the number of cases meeting hospitalization criteria decreased by 70.3%. Unrecorded pulse oximetry readings were MNAR with an adjusted odds for mortality of 4.9 (3.8, 6.3), similar to that of a SpO 2 < 90%. Although fewer girls were hospitalized, female sex was an independent mortality risk factor.

Conclusions

In Malawi, implementation of the 2014 WHO IMCI pneumonia guidelines, without pulse oximetry, will miss high risk cases. Alternatively, implementation of pulse oximetry may result in a large reduction in hospitalization rates without significantly increasing non-severe pneumonia associated CFR if the inability to obtain a pulse oximetry reading is considered a WHO danger sign.

Impact of kinship support on child mortality in the Upper East Region of Ghana: assessing the Grandmother Hypothesis

BACKGROUND

The grandmother is an important kin member whose contribution to childcare and survival has been recognized in the literature, hence the Grandmother Hypothesis. This article examines the effect of the presence of a grandmother on child mortality.

METHODS

Data were obtained from the Navrongo Health and Demographic Surveillance System, located in the Upper East Region of Ghana. Children born between January 1999 and December 2018 were included in the analysis. Person-months lived for each child were generated. The multilevel Poisson regression technique was employed to investigate the effect of a grandmother on child survival.

RESULTS

In all, 57 116 children were included in the analysis, of which 7% died before age 5 y. Person-months were generated for the children, which produced 2.7 million records, with about 487 800 person-years. After controlling for confounders, results showed that children in households with paternal grandmothers are 11% less likely to die compared with those without paternal grandmothers. However, when other confounders were taken into accounts, the beneficial effect of maternal grandmothers disappeared.

CONCLUSIONS

We conclude that the presence of grandmothers improves child survival, thus sustaining the Grandmother Hypothesis. The experiences of these grandmothers should be tapped to improve child survival, particularly in rural areas.

Burden of respiratory failure in pediatric patients: Analysis of a prospective multicenter cohort in Bogotá, Colombia

Background and Aims

The approach to the burden of disease is a demographic, economic, and a health problem, which requires the design and application of specific measures of cost of the disease, such as disability-adjusted life years (DALYs), to establish better public health policies in the pediatric population. The aim of this study is to approach the burden of disease in children with acute respiratory failure (ARF) through the calculation of DALYs.

Methods

This study was conducted in the framework of a prospective, multicenter cohort in Bogotá, Colombia. Inclusion criteria were all pediatric patients admitted to the emergency department, hospitalization, and intensive care unit with respiratory distress; eligible patients were all those who developed ARF between April 2020 and December 2021. They were followed-up during hospitalization, at 30 and 60 days after admission. The Infant/Toddler Quality of Life Questionnaire and KIDSCREEN quality of life scales were applied for follow-up according to the age group. The results were used to calculate DALYs.

Results

Six hundred and eighty-five eligible patients, 296 (43.08%) developed ARF, of these 22 (6.08%) patients died (mortality rate = 7.43%). The total DALYs was 277.164 years. For younger than 9 years, the DALYs were 302.64 years, while for older than 10 years were 40.49 years.

Conclusion

ARF is one of the main causes of preventable mortality in pediatrics, its progression to respiratory failure is a highly prevalent condition in pediatric age, a condition that has a great impact on mortality, morbidity, and disability in our patients.

Temporal trend of mortality from infectious respiratory diseases in childhood in Minas Gerais, Brazil, 2000-2020

MAIN RESULTS

From 2000 to 2020, there was a downward trend in mortality due to infectious respiratory disease in children living in Minas Gerais - even in 2020, the year of the COVID-19 pandemic.

IMPLICATIONS FOR SERVICES

There was a reduction in child deaths due to respiratory infections; health services should be alerted as to the considerable presence of ill-defined or inconclusive codes (garbage codes) on death certificates.

PERSPECTIVES

It is necessary to maintain the effectiveness of health actions among the mother and child population and to improve the records held on the Mortality Information System, in order to enable better monitoring of mortality as well as to enable analytical studies to be conducted.

OBJECTIVE

to analyze temporal trends in mortality due to infectious respiratory disease in children under 12 years old in Minas Gerais, Brazil, from 2000 to 2020.

METHODS

this was an ecological study using data on infectious respiratory disease in children under 12 years old registered on the Mortality Information System; the variables studied were etiological agent, anatomical site of infection and sex; trends were analyzed by joinpoint regression.

RESULTS

of the 4,688 registered deaths, the etiological agent of the disease was unspecified for 84.5% of them, and 88% were due to lower respiratory tract infections; there was a decreasing trend in deaths and in the proportion of deaths due to unspecified etiologic agents; in 2020, there was an increase in deaths with viral etiology and systemic involvement.

CONCLUSION

in addition to the change in the etiologic profile, there was a reduction in mortality due to infectious respiratory diseases in children, even considering 2020, the year of the COVID-19 pandemic.

Factors associated with mortality after snakebite envenoming in children: a scoping review

Snakebite envenoming is an important public health issue in many tropical and subtropical countries, where the burden of morbidity and mortality falls particularly on impoverished rural communities. Children are an especially vulnerable group. This scoping review provides an overview of the extent, type and content of peer-reviewed evidence regarding factors associated with mortality in snakebite-envenomed children. A comprehensive literature search of MEDLINE and the Global Index Medicus yielded 623 articles, of which 15 met the criteria for inclusion; 67% of studies were conducted in India, with the remaining studies taking place in Papua New Guinea, Morocco and The Gambia. There was a notable scarcity of eligible studies from sub-Saharan Africa and Latin America despite the high burden of envenoming in these regions. The risk factors for mortality that were identified by the greatest number of studies were younger patient age (n=4), delay in administration of antivenom (n=4) and acute kidney injury (n=3). Identification of poor prognostic factors can assist clinicians in making timely referrals to centres with paediatric critical care capability. Future research must address the lack of studies from key geographical regions so that evidence-based improvements to the care of this vulnerable group can be implemented.

Predictive analytics in smart healthcare for child mortality prediction using a machine learning approach

In developing countries, child health and restraining under-five child mortality are one of the fundamental concerns. UNICEF adopted sustainable development goal 3 (SDG3) to reduce the under-five child mortality rate globally to 25 deaths per 1,000 live births. The under-five mortality rate is 69 deaths per 1,000 live child-births in Pakistan as reported by the Demographic and Health Survey (2018). Predictive analytics has the power to transform the healthcare industry, personalizing care for every individual. Pakistan Demographic Health Survey (2017-2018), the publicly available dataset, is used in this study and multiple imputation methods are adopted for the treatment of missing values. The information gain, a feature selection method, ranked the information-rich features and examine their impact on child mortality prediction. The synthetic minority over-sampling method (SMOTE) balanced the training dataset, and four supervised machine learning classifiers have been used, namely the decision tree classifier, random forest classifier, naive Bayes classifier, and extreme gradient boosting classifier. For comparative analysis, accuracy, precision, recall, and F1-score have been used. Eventually, a predictive analytics framework is built that predicts whether the child is alive or dead. The number under-five children in a household, preceding birth interval, family members, mother age, age of mother at first birth, antenatal care visits, breastfeeding, child size at birth, and place of delivery were found to be critical risk factors for child mortality. The random forest classifier performed efficiently and predicted under-five child mortality with accuracy (93.8%), precision (0.964), recall (0.971), and F1-score (0.967). The findings could greatly assist child health intervention programs in decision-making.

Child Survival and Annual Crop Yield Reductions in Rural Burkina Faso: Critical Windows of Vulnerability Around Early-Life Development

Populations that are reliant on subsistence farming are particularly vulnerable to climatic effects on crop yields. However, empirical evidence on the role of the timing of exposure to crop yield deficits in early-life development is limited. We examined the relationship between child survival and annual crop yield reductions at different stages of early-life development in a subsistence farming population in Burkina Faso. Using shared frailty Cox proportional hazards models adjusting for confounders, we analyzed 57,288 children under 5 years of age followed by the Nouna Health and Demographic Surveillance System (1994-2016) in relation to provincial food-crop yield levels experienced in 5 nonoverlapping time windows (12 months before conception, gestation, birth-age 5.9 months, ages 6.0 months-1.9 years, and ages 2.0-4.9 years) and their aggregates (birth-1.9 years, first 1,000 days from conception, and birth-4.9 years). Of the nonoverlapping windows, point estimates were largest for child survival related to food-crop yields for the time window of 6.0 months-1.9 years: The adjusted mortality hazard ratio was 1.10 (95% confidence interval: 1.03, 1.19) for a 90th-to-10th percentile yield reduction. These findings suggest that child survival in this setting is particularly vulnerable to cereal-crop yield reductions during the period of nonexclusive breastfeeding.

Clustering of child deaths among families in low and middle-income countries: A meta-analysis

Background and Aims

Several studies have examined the phenomenon of "death clustering," in which two or more children born to the same mother or from the same family die at an early age. Therefore, a scientific examination of the results is essential to understand how the survival status of the older siblings affects the survival of the younger siblings. By using meta-analysis, this study aims to provide a quantitative synthesis of the results of studies on "child death clustering" in low- and middle-income countries (LMICs).

Methods

This study followed the PRISMA-P 2015 guidelines. We used four electronic databases-PubMed, Medline, Scopus, and Google Scholar with search and citation analysis capabilities. Initially, 140 studies were identified, but only 27 met the eligibility criteria eventually. These were studies that had used the death of a previous child as a covariate to determine the survival status of the index child. The heterogeneity and the publication bias of the studies were examined using the Cochran test, I ² statistic, and Egger's meta-regression test.

Results

The pooled estimate of 114 study estimates for LMICs contains some bias. India's 37 study estimates were distributed more or less equally along the middle line, indicating no publication bias, while there was a slight bias in the estimates for Africa, Latin America, and Bangladesh. The odds of experiencing the death of the index child in the selected LMICs were 2.3 times higher for mothers who had lost any prior child as compared to those mothers who had not had any prior child loss. For African mothers, the odds were five times higher, whereas for Indian mothers, the odds were 1.66 times higher. Mothers' characteristics, such as education, occupation, health-seeking behavior, and maternal competence, significantly affect the child's survival status.

Conclusion

Achieving the sustainable development goals would not be possible if mothers in countries experiencing high levels of under-five mortality are not provided with better health and nutrition facilities. Mothers who have lost multiple children should be targeted for assistance.

In Utero Exposure to Hormonal Contraception and Mortality in Offspring with and without Cancer: A Nationwide Cohort Study

Approximately 400 million women of reproductive age use hormonal contraceptives worldwide. Eventually, pregnancy sometimes occurs due to irregular use. Use in early pregnancy is found to be associated with child morbidities including cancer, the main reason for disease-related death in children. Here, we add the missing piece about in utero exposure to hormonal contraception and mortality in offspring, including assessments of prognosis in children with cancer. In utero exposure to hormonal contraception may be associated with death since we found a hazard ratio (HR) of 1.22 (95% confidence interval (CI) 1.01-1.48) compared to children of mothers with previous use. The HRs were 1.22 (95% CI 0.99-1.13) for oral combined products and 2.92 (95% CI 1.21-7.04) for non-oral progestin-only products. A poorer prognosis was also found in exposed children with leukemia (3.62 (95% CI: 1.33-9.87)). If causal, hormonal contraception in pregnancy seems detrimental for offspring health and a marker of poorer prognosis in children with leukemia.

Stillbirth and early neonatal mortality rates may be underestimated using recall information: A comparison of demographic surveillance methodologies

OBJECTIVE

Child mortality and stillbirth rates (SBR) remain high in low-income countries but may be underestimated due to incomplete reporting of child deaths in retrospective pregnancy/birth histories. The aim of this study is to compare stillbirth and mortality estimates derived using two different methods: the method assuming full information and the prospective method.

METHODS

Bandim Health Project's Health and Demographic Surveillance Systems (HDSS) follows women of reproductive age and children under five through routine home visits every 1, 2 or 6 months. Between 2012 and 2020, we estimated and compared early neonatal (ENMR, <7 days), neonatal (NMR, <28 days), and infant mortality (IMR, <1 year) per 1000 live births and SBR per 1000 births. Risk time for children born to registered women was calculated from birth (the method assuming full information) versus date of first observation in the HDSS (the prospective method), either at birth (for pregnancy registration) or registration. Rates were calculated using the Kaplan-Meier estimator and compared in generalised linear models allowing for within-child correlation obtaining relative risks (RR).

RESULTS

We registered and followed 29,413 infants (1380 deaths; 1459 stillbirths) prospectively. An additional 164 infant deaths and 129 stillbirths were registered retrospectively and included in the method assuming full information. The ENMR was 24.5 (95%CI: 22.6-26.4) for the method assuming full information and 25.8 (23.7-27.8) for the prospective method, RR = 0.96 (0.93-0.99). Differences were smaller for the NMRs and IMRs. For SBRs, the estimates were 53.5 (50.9-56.0) and 58.6 (55.7-61.5); RR = 0.91 (0.90-0.93). The difference between methods became more pronounced when the analysis was limited to areas visited every 6 months: RR for ENMR: 0.91 (0.86-0.96) and RR for SBR: 0.85 (0.83-0.87).

CONCLUSIONS

Assuming full information underestimates SBR and ENMR. Accounting for omissions of stillbirths and early neonatal deaths may lead to more accurate estimates and improved ability to monitor mortality.

Compulsory education reform and child mortality in Peru

The government of Peru amended its constitution to increase compulsory education from six to 11 years in 1993. This constitutional amendment provides a natural experiment to investigate the impact of maternal education on child mortality. Exploiting differences in the reform exposure by age, I find that mothers who were exposed to the reform were less likely to experience the death of a child. There is also evidence that the reform caused a decline in infant mortality. These results are not driven by the age difference between mothers who were treated by the reform and those who were not treated. Additional analyses reveal that the reform increased age at first birth, decreased desired fertility, reduced smoking, and improved economic opportunities for women. The results demonstrate that compulsory schooling may be a useful policy tool to improve women's education, which can, in turn, enhance the survival of their children.

The Interaction Effect of Birth Spacing and Maternal Healthcare Services on Child Mortality in Pakistan

There is widespread agreement that improved health should be regarded as a means and an end in the context of the development process. The health of the populace and the equitable provision of healthcare are two indicators of a society's level of development. A variety of factors influences child mortality. This study investigated the causes of child death and the interaction effect of birth spacing (B.S.) and maternal health care services (MHCS) on child mortality. Using SPSS version 20, we used the Pakistan Demographic and Health Survey (PDHS) 2017-2018 data set to investigate the associated factors of child mortality and the moderating influence of birth spacing using binary logistic regression. The outcome variable is categorical with two categories. The findings indicated that the risk of infant death decreased with adequate B.S. between two pregnancies and access to maternal health care services. Birth spacing was found to moderate the link between access to maternal health care services (MHCS) and child mortality. Our research leads us to conclude that the amount of time between children's births significantly reduces infant mortality. When the birth spacing is at least 33 months, the relationship between maternal health care services and child mortality becomes more evident and negative.

Although in shortage, nursing workforce is still a significant contributor to life expectancy at birth

OBJECTIVES

Previous studies have not fully reported the strength and independency of the correlation of nursing workforce to life expectancy. This study advances that nursing workforce is a major independent contributor to life expectancy at birth (LEB) globally and regionally.

DESIGN

A cross-sectional study was conducted at population level.

SAMPLE

Ecological data were extracted from the United Nations agencies for 215 populations. Each population is considered a research subject.

MEASUREMENTS

The correlation between nursing workforce and LEB was analyzed with scatter plots, bivariate correlation, partial correlation, and multiple linear regression analyses, Analysis of Variance post hoc and independent T-test. Economic affluence, urban lifestyle and obesity were included as the potential confounders in this study.

INTERVENTION

Not applicable RESULTS: Nursing workforce correlated to LEB and this relationship remained regardless of the competition of economic affluence, urbanization, and obesity. Second to economic affluence, nursing workforce showed the greatest influence on LEB. In total, 64.50% of LEB was explained in this study. Nursing workforce was a determinant of regional variations of LEB.

CONCLUSIONS

Nursing workforce may be a significant contributor to LEB globally and regionally. This contribution was independent of the potential confounding effects of economic affluence, urbanization, and obesity.

Spatiotemporal trends in neonatal, infant, and child mortality (1990-2019) based on Bayesian spatiotemporal modeling

Background

Neonatal mortality rate (NMR), infant mortality rate (IMR), and child mortality rate (CMR) show a huge difference across countries, which has been posing challenges for public health policies and medical resource allocation.

Methods

Bayesian spatiotemporal model is applied to assess the detailed spatiotemporal evolution of NMR, IMR, and CMR from a global perspective. Panel data from 185 countries from 1990 to 2019 are collected.

Results

The continuously decreasing trend of NMR, IMR, and CMR indicated a great improvement in neonatal, infant, and child mortality worldwide. Further, huge differences in the NMR, IMR, and CMR still exist across countries. In addition, the gap of NMR, IMR, and CMR across the countries presented a widening trend from the perspective of dispersion degree and kernel densities. The spatiotemporal heterogeneities demonstrated that the decline degree among these three indicators could be observed as CMR > IMR > NMR. Countries such as Brazil, Sweden, Libya, Myanmar, Thailand, Uzbekistan, Greece, and Zimbabwe showed the highest values of b_1i , indicating a weaker downward trend compared to the overall downward trend in the world.

Conclusions

This study revealed the spatiotemporal patterns and trends in the levels and improvement of NMR, IMR, and CMR across countries. Further, NMR, IMR, and CMR show a continuously decreasing trend, but the differences in improvement degree present a widening trend across countries. This study provides further implications for policy in newborns, infants, and children's health to reduce health inequality worldwide.

How do hospitalised children die? The context of death and end-of-life decision-making

AIM

The decrease in childhood mortality, the growing clinical complexity and the greater technification of intensive care units have changed the circumstances of death of paediatric patients. The aim of this study is to describe the context of death and end-of-life decision-making.

METHODS

Single-centre, retrospective, observational study of deaths in inpatients or home hospitalised children under 18 years old between 2011 and 2021. Demographic data, pathological history and circumstances of death were obtained from the medical record. The whole study period was divided into two halves for the analysis of the temporal trends.

RESULTS

A total of 358 patients died, 63.2% under the age of 1 year old; 86.9% had underlying life-limiting illnesses and 73.2% died in the intensive care unit, with no differences between the two time periods. Death at home was significantly higher in the second study period (3.8% vs. 9%). A total of 20.1% died during advanced cardiopulmonary resuscitation. Life-sustaining treatment was withheld or withdrawn in 53.6%, with no differences between the time courses. Life-sustaining treatment was withheld mainly in patients with neurological, metabolic and oncological conditions, and less frequently in patients with cardiovascular or respiratory diseases or who were previously healthy. Most patients coded as palliative care (PC) or followed up by PC teams had an advance care plan (ACP) recorded, while in the others it was infrequent. PC coding, following by PC teams and ACP recording increased in the last years of the study.

CONCLUSIONS

Death of children in our setting usually occurs in relation to complex underlying pathology and after the decision of withdrawing or withholding life-sustaining treatment. In this context, PC and ACP acquire greater importance. In our study, PC involvement resulted in better documentation of ACP and PC coding.

Predictors of Mortality Among Children with Confirmed and Suspected Cases of COVID-19 in East Java, Indonesia

Introduction

Coronavirus disease 2019 (COVID-19) increases rapidly and causes mortality in all groups, including children. However, the predictive risk factors of mortality among children remain inconclusive. This study aimed to analyse the predictors related to mortality among children with COVID-19.

Methods

Secondary data analysis was conducted using provincial COVID-19 data from April 2020 to May 2021. We selected 6441 children under age 18 to be included in this study. Chi-square and binary logistic regression were used to evaluate the predictors of mortality in children with COVID-19.

Results

This study showed that the prevalence of children who died COVID-19 was 2.7%. Age, case definition, treatment status, severity of illness, and travel history had a significant relationship with survival status in children with COVID-19. As the increasing age, the risk of death with COVID-19 will decrease [AOR=0.94; CI 95%=0.91-0.97]. Otherwise, suspected status [AOR=2.12; 95% CI=1.48-3.04], hospitalization with ventilators [AOR=22.25; 95% CI=5.73-86.42], severe illness [AOR=46.76; 95% CI=21.69-100.80], and travel history [AOR=1.78; 95% CI=1.22-2.60] were significantly related with an increased risk of death in children with COVID-19.

Discussion

Severe illness in children was the strongest predictor of mortality. Disease prevention and health promotion programs are the key to preventing hospitalizations in children and decreasing the mortality rate.

Severity of illness and mortality among children admitted to a tertiary referral hospital in Botswana: A secondary data analysis of a prospective cohort study

Objectives

Data on triage practices of children admitted to Princess Marina Hospital in Gaborone, Botswana is limited. The inpatient triage, assessment, and treatment score was developed for low resource settings to predict mortality in children. We assess its performance among children admitted to Princess Marina Hospital and their demographic, clinical, and risk factors for death.

Methods

This was a secondary data analysis of a prospective cohort study comprising 299 children ages 1 month to 13 years admitted June to September 2018. Descriptive statistics, bivariate analysis, and multivariate logistic regression were used. Sensitivity and specificity data were generated for the inpatient triage, assessment, and treatment score.

Results

Thirteen children died (13/284, 4.6%). Comorbidity (adjusted odds ratio 4.0, p = 0.020) and high inpatient triage, assessment, and treatment score (adjusted odds ratio 5.0, p = 0.017) increased odds of death. The area under the receiver operating characteristic curve was 0.81. Using inpatient triage, assessment, and treatment cutoff of 4, the sensitivity, specificity, and likelihood ratio were 31%, 94%, and 5.0, respectively.

Conclusion

Implementing the inpatient triage, assessment, and treatment score in low resource settings may improve identification, treatment, and evaluation of the sickest children.

Extended Risk of Mortality in Children with Inborn Errors of Metabolism: A Longitudinal Cohort Study

OBJECTIVES

To determine the long-term risk of mortality among children with inborn errors of metabolism.

STUDY DESIGN

We conducted a retrospective cohort study of 1750 children with inborn errors of metabolism (excluding mitochondrial disorders) and 1 036 668 children without errors of metabolism who were born in Quebec, Canada, between 2006 and 2019. Main outcome measures included all-cause and cause-specific mortality between birth and 14 years of age. We used adjusted survival regression models to estimate HRs and 95% CIs for the association between inborn errors of metabolism and mortality over time.

RESULTS

Mortality rates were greater for children with errors of metabolism than for unaffected children (69.1 vs 3.2 deaths per 10 000 person-years). During 7 702 179 person-years of follow-up, inborn errors of metabolism were associated with 21.2 times the risk of mortality compared with no error of metabolism (95% CI 17.23-26.11). Disorders of mineral metabolism were associated with greater mortality the first 28 days of life (HR 60.62, 95% CI 10.04-365.98), and disorders of sphingolipid metabolism were associated with greater mortality by 1 year (HR 284.73, 95% CI 139.20-582.44) and 14 years (HR 1066.00, 95% CI 298.91-3801.63). Errors of metabolism were disproportionately associated with death from hepatic/digestive (HR 208.21, 95% CI 90.28-480.22), respiratory (HR 116.57, 95% CI 71.06-191.23), and infectious causes (HR 119.83, 95% CI 40.56-354.04).

CONCLUSIONS

Children with errors of metabolism have a considerably elevated risk of mortality before 14 years, including death from hepatic/digestive, respiratory, and infectious causes. Targeting these causes of death may help improve long-term survival.

Impacts of micronutrient intervention programs on effective coverage and lives saved: Modeled evidence from Cameroon

Policymakers are committed to improving nutritional status and to saving lives. Some micronutrient intervention programs (MIPs) can do both, but not to the same degrees. We apply the Micronutrient Intervention Modeling tool to compare sets of MIPs for (1) achieving dietary adequacy separately for zinc, vitamin A (VA), and folate for children and women of reproductive age (WRA), and (2) saving children's lives via combinations of MIPs. We used 24-h dietary recall data from Cameroon to estimate usual intake distributions of zinc and VA for children 6-59 months and of folate for WRA. We simulated the effects on dietary inadequacy and lives saved of four fortified foods and two VA supplementation (VAS) platforms. We estimated program costs over 10 years. To promote micronutrient-specific dietary adequacy, the economic optimization model (EOM) selected zinc- and folic acid-fortified wheat flour, VA-fortified edible oils, and bouillon cubes, and VAS via Child Health Days in the North macroregion. A different set of cost-effective MIPs emerged for reducing child mortality, shifting away from VA and toward more zinc for children and more folic acid for WRA. The EOM identified more efficient sets of MIPs than the business-as-usual MIPs, especially among programs aiming to save lives.

Nosocomial RSV-related In-hospital Mortality in Children <5 Years: A Global Case Series

BACKGROUND

According to the World Health Organization, the global burden of nosocomial infections is poorly characterized as surveillance systems are lacking. Nosocomial infections occur at higher rates in low- and lower-middle-income countries (LMICs) than in high-income countries (HICs). Current global RSV burden estimates are largely based on community-acquired infection. We aimed to characterize children with nosocomial RSV-related mortality and to understand the potential impact of RSV immunization strategies.

MATERIALS

RSV GOLD is a global registry of children younger than 5 years who died with laboratory-confirmed RSV infection. We compared clinical and demographic characteristics of children with nosocomial and community-acquired RSV in-hospital mortality.

RESULTS

We included 231 nosocomial and 931 community-acquired RSV-related in-hospital from deaths from 65 countries. Age at death was similar for both groups (5.4 vs. 6 months). A higher proportion of nosocomial deaths had comorbidities (87% vs. 57%; P < 0.001) or was born preterm (46% vs. 24%; P < 0.001) than community-acquired deaths. The proportion of nosocomial deaths among all RSV deaths was lower in LMICs than in upper-middle-income countries (UMICs) and HICs (12% vs. 18% and 26%, respectively).

CONCLUSIONS

This is the first global case series of children dying with nosocomial RSV infection. Future infant-targeted immunization strategies could prevent the majority of nosocomial RSV-related deaths. Although nosocomial RSV deaths are expected to occur at highest rates in LMICs, the number of reported nosocomial RSV deaths was low in these countries. Hospital-based surveillance is needed to capture the full burden of nosocomial RSV mortality in LMICs.

Infant & Child Mortality in Pakistan and its Determinants: A Review

Over the years, several developing countries have been suffering from high infant and child mortality rates, however, according to the recent statistics, Pakistan falls high on the list. Our narrative review of copious research on this topic highlights that several factors, such as complications associated with premature births, high prevalence of birth defects, lack of vaccination, unsafe deliveries, poor breastfeeding practices, complications during delivery, sudden infant death syndrome (SIDS), poor socioeconomic conditions, and a struggling healthcare system, have influenced these rates. Bearing in mind the urgency of addressing the increased infant and child mortality rate in Pakistan, multiple steps must be taken in order to prevent unnecessary deaths. An effective initiative could be spreading awareness and education among women, as a lack of education among women has been indirectly linked to increased child mortality in Pakistan across many researches conducted on the issue. Furthermore, the government should invest in healthcare by hiring more physicians and providing better supplies and improving infrastructure, especially in underdeveloped areas, to decrease child mortality due to lack of clean water and poor hygiene. Lastly, telemedicine should be made common in order to provide easy access to women who cannot visit the hospital.

Understanding inequities in child mortality in Egypt: Socioeconomic and proximate factors

While there have been notable advancements in child health in Egypt, disparities in child mortality still exist. Understanding these disparities is crucial to addressing them. The objective of this study is to explore the factors linked to child mortality in Egypt, providing a comprehensive understanding of the disparities in child mortality rates. The study utilises cross-sectional data from Egypt's Demographic and Health Survey (EDHS) in 2014 to examine child mortality. The dataset consists of 15,848 observations from mothers with children born within five years prior to the survey. The choice of explanatory variables was guided by the Mosely and Chen Framework and logistic multivariate regression was used to conduct the analyses. The study finds lower education, early childbearing, insufficient birth spacing, lack of breastfeeding, and absence of improved toilet facilities (proxy for living conditions) were all significantly linked to an increased likelihood of child loss. Additionally, poorer people in rural settings experienced the worst child mortality. The findings align with the World Health Organization's Conceptual Framework for Action on the Social Determinants of Health (CSDH). Recommended policy interventions include targeting women in rural areas, improving living conditions and removing financial/other barriers to accessing care.

An analysis of factors associated with neonatal, post-neonatal and child mortality in Haiti, including breastfeeding as a time-dependent variable

AIM

The main objective of the study was to identify factors associated with neonatal, post-neonatal and child mortality. The study also investigated breastfeeding status as a time-dependent variable.

METHODS

The 2016-2017 Haitian Demographic and Health Survey was analysed. The analysis was done on 6530 live births. Time-constant and time-dependent multivariable Royston-Parmar spline models were used to identify associated factors for all three age groups. Restricted mean survival times were calculated for the different levels of the breastfeeding variable for each age group.

RESULTS

Neonates and post-neonates who were not breastfed were associated with increased mortality, hazard ratio (HR) 22.13 (95% confidence interval (CI), 16.40-29.87) and HR 4.99 (95% CI, 3.29-7.56), respectively. Males in the child age group were associated with increased mortality, HR 2.04 (95% CI, 1.29-3.23) and HR 2.03 (95% CI, 1.28-3.21) under the time-constant and time-dependent models, respectively.

CONCLUSIONS

Early initiation of breastfeeding and breastfeeding throughout the post-neonatal period is recommended. Outreach programmes that provide support and education for vulnerable families are also recommended.

Cytomegalovirus Viremia Predicts Postdischarge Mortality in Kenyan HIV-Exposed Uninfected Children

BACKGROUND

Cytomegalovirus (CMV) viremia is associated with mortality in severely ill immunocompetent adults and hospitalized children with HIV (CWH). We measured CMV viremia in HIV-exposed and -unexposed Kenyan children aged 1-59 months discharged from hospital and determined its relationship with postdischarge mortality.

METHODS

CMV DNA levels were measured in plasma from 1024 children (97 of which were HIV exposed uninfected [HEU], and 15 CWH). Poisson and Cox proportional hazards regression models were used to identify correlates of CMV viremia ≥ 1000 IU/mL 
and estimate associations with 6-month mortality, respectively.

RESULTS

CMV viremia was detected in 31% of children, with levels ≥ 1000 IU/mL in 5.8%. HIV infection, age < 2 years, breastfeeding, and midupper arm circumference < 12.5 cm were associated with CMV viremia ≥ 1000 IU/mL. Among HEU children, CMV ≥ 1000 IU/mL (hazard ratio [HR] = 32.0; 95% confidence interval [CI], 2.9-354.0; P = .005) and each 1-log increase in CMV viral load (HR = 5.04; 95% CI, 1.7-14.6; P = .003) were associated with increased risk of mortality. CMV viremia was not significantly associated with mortality in HIV-unexposed children.

CONCLUSIONS

CMV levels at hospital postdischarge predict increased risk of 6-month mortality in Kenyan HEU children. CMV suppression may be a novel target to reduce mortality in HEU children.

CLINICAL TRIAL REGISTRATION

NCT02414399.

Prognostic Significance of Serum Biochemistry Profile in Children With Severe Acute Malnutrition

Background Malnutrition is a condition caused by defective nutrition in which either deficiency or excess of energy, protein, or micronutrients cause any measurable adverse effects on tissues/body form (body shape, size, composition), function, and clinical outcome. Children with a weight-for-height below -3 standard deviations (SD) of the mean based on the WHO standards have a high risk of death exceeding nine-fold that of children with a weight-for-height above 1 SD. In severe acute malnutrition (SAM) liver function tests, renal function tests, and serum electrolytes are deranged but their correlation with the prognosis is not well defined. So, there was a need for a study to know the prognostic significance. For this purpose, the current study was conducted in the pediatric ward of Uttar Pradesh University of Medical Sciences (UPUMS), Saifai, UP, India. Method This is an observational cross-sectional study conducted in the Department of Pediatrics, UPUMS (Saifai, UP, India) from January 2018 to July 2019 after approval from the institutional ethical committee. We enrolled 100 children with SAM who fulfilled the inclusion criterion after obtaining proper and well-informed consent. Result We studied children aged six to 59 months. The mean age of admitted patients in our study was nearly 24 months (24.18 months). The median age that was most common at the time of admission is nearly 1 year (13 months). In our study relation of serum sodium and serum potassium with the survival of SAM was found statistically significant. Conclusion Severe acute malnutrition is both a medical and social disorder. The risk of mortality increases as the severity of malnutrition increases. High-risk cases can be identified and can be treated aggressively and on a priority basis. Serum electrolyte disturbances in SAM are one of the most important predictors of the severity.

Determinants of Under-Five Mortality in an Armed Conflict Setting: Empirical Findings from the Demographic and Health Surveys

Insurgencies like Boko Haram may impact the physical health and well-being of adults and children living in geographic areas under their political control. However, it is difficult to obtain reliable health data in conflict-affected areas. This study explored the potential to use data from the Demographic and Health Surveys (DHS) to examine the determinants of under-five mortality in Northern Nigeria. Data were derived from DHS conducted before and after the start of the Boko Haram insurgency in 2009. A multi-level mixed effects logistic regression model was used to identify predictors of under-five mortality in an armed conflict setting. Results were reported as adjusted odds ratios (aOR) and 95% confidence intervals (CI). Residence in an armed conflict setting was not significantly associated with under-five mortality (aOR = 1.06; 95% CI: 1.00, 1.10). However, twin gestation (aOR = 3.18; 95% CI:2.96, 3.42), wealth index of family (richest versus poorest: aOR = 0.42; 95% CI: 0.37, 0.47), religion of mother (Islam versus Christianity: aOR = 1.50; 95% CI: 1.43, 1.57); highest educational level of mother (higher versus none: aOR = 0.33; 95% CI: 0.29, 0.37), and parity of mother, significantly predicted death before the fifth birthday. Repeated studies are needed to assess the impact of Boko Haram insurgency on physical health outcomes, particularly in areas where primary data collection is difficult or impossible.

One vaccine to counter many diseases? Modeling the economics of oral polio vaccine against child mortality and COVID-19

Introduction

Recent reviews summarize evidence that some vaccines have heterologous or non-specific effects (NSE), potentially offering protection against multiple pathogens. Numerous economic evaluations examine vaccines' pathogen-specific effects, but less than a handful focus on NSE. This paper addresses that gap by reporting economic evaluations of the NSE of oral polio vaccine (OPV) against under-five mortality and COVID-19.

Materials and methods

We studied two settings: (1) reducing child mortality in a high-mortality setting (Guinea-Bissau) and (2) preventing COVID-19 in India. In the former, the intervention involves three annual campaigns in which children receive OPV incremental to routine immunization. In the latter, a susceptible-exposed-infectious-recovered model was developed to estimate the population benefits of two scenarios, in which OPV would be co-administered alongside COVID-19 vaccines. Incremental cost-effectiveness and benefit-cost ratios were modeled for ranges of intervention effectiveness estimates to supplement the headline numbers and account for heterogeneity and uncertainty.

Results

For child mortality, headline cost-effectiveness was $650 per child death averted. For COVID-19, assuming OPV had 20% effectiveness, incremental cost per death averted was $23,000-65,000 if it were administered simultaneously with a COVID-19 vaccine <200 days into a wave of the epidemic. If the COVID-19 vaccine availability were delayed, the cost per averted death would decrease to $2600-6100. Estimated benefit-to-cost ratios vary but are consistently high.

Discussion

Economic evaluation suggests the potential of OPV to efficiently reduce child mortality in high mortality environments. Likewise, within a broad range of assumed effect sizes, OPV (or another vaccine with NSE) could play an economically attractive role against COVID-19 in countries facing COVID-19 vaccine delays.

Funding

The contribution by DTJ was supported through grants from Trond Mohn Foundation (BFS2019MT02) and Norad (RAF-18/0009) through the Bergen Center for Ethics and Priority Setting.

Predictors of Poor Neonatal Outcomes among Pregnant Women in Indonesia: A Systematic Review and Meta-Analysis

Objectives: This study aimed to examine the association between maternal health behaviors and neonatal outcomes among the Indonesian population. Methods: Articles were collected from PubMed, EBSCO, ProQuest, DOAJ, and GARUDA. Funnel plots and Egger’s tests analyzed indications of publication bias. A Mantel–Haenszel random-effects model was used to see the overall effect size of exposures on outcomes. Heterogeneity was seen based on I². Data collected from articles included the author, year of publication, location of the study, study design, number of samples, risk factors, and effect sizes. Results: We identified 24 relevant studies, including eight from the primary databases and 16 from an additional database. A total of 12 studies were included in the meta-analysis, examining the association between maternal health behaviors and neonatal outcomes. The pooled odds ratio (OR) for passive smoking and low-birth-weight (LBW) was 3.41 (95% CI: 1.75–6.63, I² = 40%, four studies). The pooled OR for incomplete antenatal care (ANC) and LBW was 6.29 (95% CI: 2.11–18.82, I² = 70%, four studies). The pooled OR for incomplete ANC and neonatal mortality was 2.59 (95% CI: 1.01–6.66, I² = 93%, four studies). Conclusions: The results indicated that pregnant women with incomplete ANC had a higher risk of LBW and neonatal mortality, and those who were passively exposed to smoking had a higher risk of LBW. Further investigations are needed, considering the high heterogeneity found, and additional meta-analyses should be based on the variations of socio-demographic conditions.

Estimates of child mortality reductions attributed to vitamin A supplementation in sub-Saharan Africa: scale up, scale back, or refocus?

BACKGROUND

Vitamin A supplementation (VAS) has been implemented in over 82 countries globally, primarily because of its beneficial effect in preventing child mortality. Secular reductions in child mortality and the implementation of alternative programs to promote vitamin A intake have led to questions on the need for national VAS programs.

OBJECTIVES

This study aimed to estimate child mortality changes related to VAS using current, scale-back, and scale-up coverage scenarios.

METHODS

Data related to demographic characteristics, fertility, intervention coverage, anthropometry, child mortality and cause-of-death structure were integrated into the Lives Saved Tool (LiST). We estimated the cause-specific (LiST model) and all-cause mortality reductions related to VAS based on evidence from recent meta-analyses.

RESULTS

Between 2008 and 2018, VAS coverage declined in most sub-Saharan African (SSA) countries. In 2019 alone, 12% and 24% reductions in all-cause mortality related to VAS were expected to avert from 105,332 to 234,704 child deaths, respectively, in SSA; whereas the cause-specific mortality model (LiST) estimated that 141,670 child deaths were averted in 2019. Estimates of VAS-related child mortality reductions were highly variable among countries. Our scaling-back scenario led to highly variable country-level results, with expected increases in mortality rates, from a low of 0.04/1000 live births to as high as 49.3/1000 live births, suggesting that some countries could start considering scaling back, while others need to scale up.

CONCLUSIONS

Excess child mortality that would be preventable by VAS has declined, but is still significant in many SSA countries. While scale-up of VAS is needed for most of the countries, scaling back can also be considered in some countries. Policy decisions, however, should be guided by more recent data on food consumption, vitamin A statuses, child health, and vitamin A fortification coverage.

Trends and Factors Associated with Under-5 Mortality in Northwest Nigeria (2008-2018)

Background:

The Nigeria Demographic and Health Survey (NDHS) revealed that the under-five mortality rate (U5MR) in the northwest geopolitical zone (NWGZ), Nigeria, increased by 1.1% from 185 to 187 deaths per 1,000 live births between 2013 and 2018, indicating a setback to the previously reported modest improvement in U5MR.

Objectives:

This study sought to examine trends and factors related to under-5 mortality (U5M) in NWGZ from 2008 to 2018.

Methods:

A combined NWGZ dataset extracted from the 2008, 2013 and 2018 NDHSs, with a sample of 32,015 singleton live births, including 3,745 under-5 deaths, was used. The U5MRs for each survey year and potential independent factors were obtained using the STATA “syncrmrates” command, and then the trends were examined. A logistic regression generalised linear latent and mixed model was used to explore the potential factors associated with U5M in NWGZ.

Findings:

In NWGZ, the U5MR declined by only 8.2% (from 195 to 179 per 1,000 live births between 2008 and 2018, respectively), with a similar trend observed among its seven states. Multivariable analyses indicated that maternal education (no formal or primary education), maternal non-use of contraception, a mother’s perception of the baby being small or very small, birth order (second to fourth or higher) with a shorter birth interval (≤2 years), younger or older maternal age (<20 years or ≥40 years old) and rural residence were significantly associated with U5M in NWGZ.

Conclusion:

Interventional initiatives including educating mothers on the benefits of contraceptive use, child spacing, kangaroo mother care of small-sized babies and promoting regular check-ups for older mothers will substantially reduce U5M in NWGZ.

Assessing Individual- and Community-Level Variability in Predictors of Neonatal, Infant, and Under-Five Child Mortality in Ethiopia Using a Multilevel Modeling Approach

Background: In low-and middle-income countries, child mortality rates are basic indicators of a country’s socio-economic situation and quality of life. The Ethiopian government is currently working to reduce child mortality to accomplish its long-term development goals. Using data from the Ethiopian Mini Demographic and Health Survey, 2019, this study analyzed the determinants of child mortality in Ethiopia. Methods: A total of 4806 children were considered in the final analyses. Multivariate analysis was used to estimate the effects of the predictors simultaneously on each child mortality outcome. Results: The findings revealed that 31.6% of children died during the neonatal stage, 39.1% during the infant stage, and 48.5% during the under-five stage. Variation in child mortality was discovered between Ethiopian community clusters, with the result of heterogeneity between clusters on newborn mortality (χ2 = 202.4, p-value < 0.0001), (χ2 = 777.35, p-value < 0.0001), and (χ2 = 112.92, p-value < 0.0001). Children’s neonatal, infant, and under-five mortality intracluster correlation coefficient (ICC) were 0.35, 0.33, and 0.36, respectively, across communities. Conclusions: In Ethiopia, under-five mortality remains a serious public health issue, with wide variations and high rates among community clusters. Intervention measures focusing on lowering rates of household poverty, increasing education opportunities, and improving access to health care could assist in reducing child mortality in Ethiopia.

Rainfall shocks, child mortality, and water infrastructure

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

Child mortality after the Ebola virus disease outbreak across Guinea, Liberia, and Sierra Leone

OBJECTIVES

The Ebola virus disease outbreak in 2014-2016 had a substantial impact on population health in Guinea, Liberia, and Sierra Leone. This study aimed to assess whether the impact continued after the outbreak ended in regards to child mortality.

METHODS

Cross-sectional logistic regressions were run using data from the Demographic and Health Surveys in the three countries.

RESULTS

The average child mortality rate was significantly lower for children born after the outbreak ended than those born before. However, the association of the child mortality rate with an increase in the number of cases per 100,000 was significantly stronger for children born after the outbreak ended. Also, the change in the utilization of maternal health services after the outbreak varied across health services.

CONCLUSIONS

Restoring disrupted child health services to pre-Ebola levels may be more difficult in areas that suffered a higher number of cases. The recovery of maternal health services after the outbreak might be affected by factors such as the resilience of health systems at the subnational level. This study suggests that strengthening health system is crucial to fully recover from the Ebola outbreak and to cope with future epidemics.

Then and Now: Investigating Anthropometrics and Child Mortality among Females in Malawi

Information on the concentration of body mass index and child death among females in Malawi, where the epidemics of weight gain have been disconcerting and preventable deaths among children linger, is limited. Therefore, the study examined the polarity of body mass index and the death of children among females. Using data from the Malawian Demographic and Health Survey from 2000 to 2015–2016, the study applied for the first time the index of concentration at the extremes and indirect demographic techniques to estimate the polarity of body mass index and child mortality among 65,499 females aged 15 to 49 years. The preponderance of obesity more than doubled from 2000 to 2015–2016 and was highest among females who were older (35–49 years), urban dwellers, rich, and located in districts within the central and southern regions. In addition, child survival was low among underweight, overweight, and obese females. While national-, regional-, and individual-level statistics are in development, these findings provide helpful information for health experts and other stakeholders to initiate appropriate age-region specific programs and interventions in Malawi, including targeting females in the high socio-economic bracket.

Diagnosing Rickets in Early Modern England: Statistical Evidence and Social Response

Seventeenth-century UK experienced an epidemic of the newly recognised disease rickets, its nutritional and environmental causes then unknown. This is evident from parish burial registers, the London Bills of Mortality, and contemporary medical descriptions and treatments. Rickets appeared to be killing 2-8 per cent of urbanites, especially wealthy children. Rickets emerged as a threat to child health in early modern UK as a result of coal dependency and climate, and social differences in infant and child feeding. Physicians investigating rickets showed concern for rich children's diets. Lack of breastfeeding promoted calcium deficiency among wealthy infants, while poorer children's meagre childhood diet retarded recovery. The seasonality and age incidence of rickets deaths corroborate this diagnosis, but after 1700 rickets deaths dwindled even as medical treatises and osteological evidence suggest rickets morbidity increased. Chronology and share of mortality of other causes relating to rickets morbidity are considered: scurvy, hydrocephalus and whooping cough.

Corruption and Population Health in the European Union Countries-An Institutionalist Perspective

Even though the European Union (EU) is considered one of the best performers in the world in fighting corruption, the situation changes when the analysis is shifted to the national dimension of its member states, with significant differences concerning the effects of corruption on population health. Using the theory of New Institutional Economics as a complementary tool that provides additional representativeness to this phenomenon, the aim of this paper is to empirically investigate the impact of corruption on population health, considering also other demographic and socio-economic determinants. Using data collected at the EU level registered between 2000–2019, we employ panel date models to validate the ongoing effect of perceived corruption on population health. Our empirical findings fully validate the institutionalist perspective, according to which countries with inclusive institutions better control the anomaly of corruption while benefitting from higher life expectancy and reducing child mortality rates. Conversely, the EU countries with rather extractive institutions suffer in terms of both longevity of population and infant mortality. Our study emphasizes that in tackling corruption pressure on population health, the most effective way is to improve the quality of governance in countries with fragile institutions.