The epidemiology of child homicides in South Africa

Objective

To describe age- and sex-specific rates of child homicide in South Africa.

Methods

A cross-sectional mortuary-based study was conducted in a national sample of 38 medicolegal laboratories operating in 2009. These were sampled in inverse proportion to the number that were operational in each of three strata defined by autopsy volume: < 500, 500–1499 or > 1499 annual autopsies. Child homicide data were collected from mortuary files, autopsy reports and police interviews. Cause of death, evidence of abuse and neglect or of sexual assault, perpetrator characteristics and circumstances surrounding the death were investigated.

Findings

An estimated 1018 (95% confidence interval, CI: 843–1187) child homicides occurred in 2009, for a rate of 5.5 (95% CI: 4.6–6.4) homicides per 100 000 children younger than 18 years. The homicide rate was much higher in boys (6.9 per 100 000; 95% CI: 5.6–8.3) than in girls (3.9 per 100 000; 95% CI: 3.2–4.7). Child abuse and neglect had preceded nearly half (44.5%) of all homicides, but three times more often among girls than among boys. In children aged 15 to 17 years, the homicide rate among boys (21.7 per 100 000; 95% CI: 14.2–29.2) was nearly five times higher than the homicide rate among girls (4.6 per 100 000; 95% CI: 2.4–6.8).

Conclusion

South Africa’s child homicide rate is more than twice the global estimate. Since a background of child abuse and neglect is common, improvement of parenting skills should be part of primary prevention efforts.     

A tuberculosis nationwide prevalence survey in Gambia, 2012

ObjectiveTo estimate the population prevalence of active pulmonary tuberculosis in Gambia.MethodsBetween December 2011 and January 2013, people aged ≥ 15 years participating in a nationwide, multistage cluster survey were screened for active pulmonary tuberculosis with chest radiography and for tuberculosis symptoms. For diagnostic confirmation, sputum samples were collected from those whose screening were positive and subjected to fluorescence microscopy and liquid tuberculosis cultures. Multiple imputation and inverse probability weighting were used to estimate tuberculosis prevalence.FindingsOf 100 678 people enumerated, 55 832 were eligible to participate and 43 100 (77.2%) of those participated. A majority of participants (42 942; 99.6%) were successfully screened for symptoms and by chest X-ray. Only 5948 (13.8%) were eligible for sputum examination, yielding 43 bacteriologically confirmed, 28 definite smear-positive and six probable smear-positive tuberculosis cases. Chest X-ray identified more tuberculosis cases (58/69) than did symptoms alone (43/71). The estimated prevalence of smear-positive and bacteriologically confirmed pulmonary tuberculosis were 90 (95% confidence interval, CI: 53–127) and 212 (95% CI: 152–272) per 100 000 population, respectively. Tuberculosis prevalence was higher in males (333; 95% CI: 233–433) and in the 35–54 year age group (355; 95% CI: 219–490).ConclusionThe burden of tuberculosis remains high in Gambia but lower than earlier estimates of 490 per 100 000 population in 2010. Less than half of all cases would have been identified based on smear microscopy results alone. Successful control efforts will require interventions targeting men, increased access to radiography and more accurate, rapid diagnostic tests.     

Network Exposure and Homicide Victimization in an African American Community

Objectives. We estimated the association of an individual’s exposure to homicide in a social network and the risk of individual homicide victimization across a high-crime African American community.Methods. Combining 5 years of homicide and police records, we analyzed a network of 3718 high-risk individuals that was created by instances of co-offending. We used logistic regression to model the odds of being a gunshot homicide victim by individual characteristics, network position, and indirect exposure to homicide.Results. Forty-one percent of all gun homicides occurred within a network component containing less than 4% of the neighborhood’s population. Network-level indicators reduced the association between individual risk factors and homicide victimization and improved the overall prediction of individual victimization. Network exposure to homicide was strongly associated with victimization: the closer one is to a homicide victim, the greater the risk of victimization. Regression models show that exposure diminished with social distance: each social tie removed from a homicide victim decreased one’s odds of being a homicide victim by 57%.Conclusions. Risk of homicide in urban areas is even more highly concentrated than previously thought. We found that most of the risk of gun violence was concentrated in networks of identifiable individuals. Understanding these networks may improve prediction of individual homicide victimization within disadvantaged communities.More than 10 000 people are killed by firearms each year, and another 40 000 are hospitalized or treated for gunshot injuries.1 Homicide victimization, however, is not evenly distributed across populations or places. Young people are more likely to be murdered than the elderly, African Americans are more likely to be murdered than whites, men are more likely to be murdered than women, gang members are more likely to be murdered than non-gang members, and individuals living in socially and economically disadvantaged neighborhoods are more likely to be murdered than individuals living in more advantaged neighborhoods.2–7Yet, despite decades of research into why certain characteristics and behaviors place individuals at greater risk for homicide, the social and health sciences have not fared as well in explaining why specific individuals within high-risk populations become victims of homicide. Although we know that risk factors such as age, race, gender, gang membership, and living in a poor neighborhood increase one’s risk of being a homicide victim, we cannot explain why a specific young African American male gang member in a high crime neighborhood becomes a murder victim while another young man with the identical risk factors does not. In this article, we argue that one’s position in a distinctive type of risky social network—a co-offending network—and exposure to violence in that network is essential to understanding individual victimization within high-risk populations.Understanding the topographies of risky networks and individuals’ placement within them illuminates analyses of violent victimization in at least 2 important ways. First, a network approach can offer new insight into the uneven distribution of homicide within high-risk communities. Like other social and health behaviors,8–12 homicides cluster within networks.13 Additionally, such networks tend to be fairly homogenous with respect to traditional individual-level risk factors. For example, a recent study of a high-crime community in Boston found that 85% of all gunshot injuries occurred entirely within a network of 763 young minority men (< 2% of the community population), a third of whom were gang members and a third of whom had previous police contact.13 In much the same way, geographic exposure to neighborhood violence is associated with a range of negative outcomes such as posttraumatic stress disorder, depression, and decreased cognitive functioning.14–18 But, like other risk factors, the spatial exposure to homicide in many high crime communities might be quite uniform. In the present study, for example, 40% of the individuals in the sample lived within 350 feet from where a homicide occurred, and 75% lived within roughly 1 city block (690 feet) from where a homicide occurred (see supplemental material, available as a supplement to the online version of this article at http://www.ajph.org). A network approach suggests that victimization is not simply a function of spatial proximity or of individual risk factors such as age, race, gender, or gang affiliation, but also of how people are connected, the structure of the overall network, the types of behaviors occurring in the network, and an individual’s position in the overall structure.Second, social network analysis extends the analysis of violent victimization by providing a means to quantify and measure more precisely the behaviors that are the proximate determinants of homicidal encounters. In most instances, risk factors act as proxies for more dynamic processes, situational dynamics, and risky behaviors. For example, gang membership—typically treated as a binary indicator where one is or is not a gang member—is frequently shown to increase one’s odds of being a victim or perpetrator of a violent crime.3,7,19,20 Yet, qualitative and ethnographic work demonstrates that gang participation is fluid and often changes within the situational contexts of particular interactions.21–23 The true effect of being a gang member is not about a binary label, but about whom one hangs around with, the structure of the network, and group processes within the gang. Network analysis can directly model such processes and structures.The present study investigates how exposure to homicide in one’s network contributes to one’s own probability of victimization. Rather than rely only on risk factors, this study directly measures the contours of a risky network in a high-crime African American community in Chicago, Illinois. The focus is on social distance to a victim—how many handshakes removed one is from a homicide victim in their network. Our hypothesis is that there is a strong association between one’s own risky behaviors (in this study, co-offending arrest) and the risky behavior of one’s associates. The stronger that association—the socially closer one is to a homicide victim—the greater the influence on one’s own victimization. In this sense, homicide is socially contagious, and associating with people engaged in risky behaviors—like carrying a firearm and engaging in criminal activities—increases the probability of victimization. Like needle sharing or unprotected sex in the spread of HIV,24–26 co-offending exposes an individual to situations, behaviors, and people that elevate the probability of homicide victimization. Although we are unable to ascertain the precise mechanisms of transmission in the case of homicide, we maintain that such transmission is heightened as individuals engage in risky behaviors such as, in this case, co-offending.     

Firearm and Nonfirearm Homicide in 5 South African Cities: A Retrospective Population-Based Study

Objective. We assessed the effectiveness of South Africa’s Firearm Control Act (FCA), passed in 2000, on firearm homicide rates compared with rates of nonfirearm homicide across 5 South African cities from 2001 to 2005.Methods. We conducted a retrospective population-based study of 37 067 firearm and nonfirearm homicide cases. Generalized linear models helped estimate and compare time trends of firearm and nonfirearm homicides, adjusting for age, sex, race, day of week, city, year of death, and population size.Results. There was a statistically significant decreasing trend regarding firearm homicides from 2001, with an adjusted year-on-year homicide rate ratio of 0.864 (95% confidence interval [CI] = 0.848, 0.880), representing a decrease of 13.6% per annum. The year-on-year decrease in nonfirearm homicide rates was also significant, but considerably lower at 0.976 (95% CI = 0.954, 0.997). Results suggest that 4585 (95% CI = 4427, 4723) lives were saved across 5 cities from 2001 to 2005 because of the FCA.Conclusions. Strength, timing and consistent decline suggest stricter gun control mediated by the FCA accounted for a significant decrease in homicide overall, and firearm homicide in particular, during the study period.With the revisiting of the gun control debate both in South Africa following the high-profile shooting incident involving celebrity paralympian, Oscar Pistorius, and in the United States after recent the killings at Newtown, Connecticut, it is instructive to assess the impact of stricter gun control applied in South Africa through the Firearms Control Act (FCA) of 2000. The FCA was implemented in response to the prominent role of firearms in violent crime, identified by the National Crime Prevention Strategy adopted in 1996, active lobbying by an alliance of nongovernment organizations and opinion leaders, and a groundswell of popular support.1 It provided a complete overhaul of the existing firearms-control regime and was unambiguous in its intent to reduce the number of firearms in the country, particularly those in civilian hands. It also included provisions for restrictions and prohibition on the ownership of particular types of firearm and background checks to establish an individual’s physical and mental capacity to use a firearm responsibly.In 2000, South Africa had one of the highest homicide rates in the world.2 The National Injury Mortality Surveillance System (NIMSS), a sentinel system comprising mainly urban mortuaries, indicates that until 2003 firearms were the leading external cause of homicide for all age groups from the age of 5 years,3–7 and in 2003, gunshot injuries accounted for 53% of male and 41% of female homicides.6 The South African Police Service has reported a consistent decline in homicide from 1994 to 2012. The NIMSS data, although not comparable year-on-year because of erratic coverage after 2005, suggest that this decrease might be ascribed to fewer firearm deaths—the latest report for 2008 revealed that sharp force injuries (stabbings) accounted for 41% of homicides compared with just 30% for gunshots.8The stricter licensing conditions under the Firearms Control Act No. 60 of 2000 were part of a broader strategy to reduce the number of guns in circulation, and there was a firearm-access gradient between the FCA being passed in 2000 and its full implementation in 2004. The period was characterized by firearm amnesties and hand-ins, in which legal and illegal guns were recovered by the authorities, more rigorous application of existing licensing conditions, and the destruction of surplus and illegal weapons. The South African Defense Force destroyed an estimated 270 000 weapons between January 1998 and May 2001, and the police destroyed 30 000 in 2001.9 It was also notable that there was a 75% increase in the number of firearms recovered by the police in 2003 compared with the previous year (i.e., from 20 000 weapons confiscated and recovered in 2002 to 35 000 in 2003).10 This coincides with the period in which the decline in firearm homicide became evident. After full implementation of the FCA in 2004, this effort was redoubled and a further 100 000 firearms were collected in the first 6 months of 2005.11The aim of the current study was to investigate a decrease in homicide rates over 2001 to 2005 and to assess whether this decrease was specific to firearm homicide or other factors associated with homicide risk. We hypothesized there would be a significant decrease in firearm homicide specifically attributed to the increasingly stricter gun control coinciding with the phased implementation of the FCA that was fully implemented by 2004. The corresponding nonfirearm homicide rate was expected to remain stable.     

Estimating the measles effective reproduction number in Australia from routine notification data

Objective

To estimate the measles effective reproduction number (R) in Australia by modelling routinely collected notification data.

Methods

R was estimated for 2009–2011 by means of three methods, using data from Australia’s National Notifiable Disease Surveillance System. Method 1 estimated R as 1 − P, where P equals the proportion of cases that were imported, as determined from data on place of acquisition. The other methods estimated R by fitting a subcritical branching process that modelled the spread of an infection with a given R to the observed distributions of outbreak sizes (method 2) and generations of spread (method 3). Stata version 12 was used for method 2 and Matlab version R2012 was used for method 3. For all methods, calculation of 95% confidence intervals (CIs) was performed using a normal approximation based on estimated standard errors.

Findings

During 2009–2011, 367 notifiable measles cases occurred in Australia (mean annual rate: 5.5 cases per million population). Data were 100% complete for importation status but 77% complete for outbreak reference number. R was estimated as < 1 for all years and data types, with values of 0.65 (95% CI: 0.60–0.70) obtained by method 1, 0.64 (95% CI: 0.56–0.72) by method 2 and 0.47 (95% CI: 0.38–0.57) by method 3.

Conclusion

The fact that consistent estimates of R were obtained from all three methods enhances confidence in the validity of these methods for determining R.     

Microcephaly in north-east Brazil: a retrospective study on neonates born between 2012 and 2015

ObjectiveTo assess the number of children born with microcephaly in the State of Paraíba, north-east Brazil.MethodsWe contacted 21 maternity centres belonging to a paediatric cardiology network, with access to information regarding more than 100 000 neonates born between 1 January 2012 and 31 December 2015. For 10% of these neonates, nurses were requested to retrieve head circumference measurements data from delivery-room books. We used three separate criteria to classify whether a neonate had microcephaly: (i) the Brazilian Ministry of Health proposed criterion: term neonates (gestational age ≥ 37 weeks) with a head circumference of less than 32 cm; (ii) Fenton curves: neonates with a head circumference of less than −3 standard deviation for age and gender; or (iii) the proportionality criterion: neonates with a head circumference of less than ((height/2))+10) ± 2.FindingsBetween 1 and 31 December 2015, nurses obtained data for 16 208 neonates. Depending on which criterion we used, the number of neonates with microcephaly varied from 678 to 1272 (4.2–8.2%). Two per cent (316) of the neonates fulfilled all three criteria. We observed temporal fluctuations of microcephaly prevalence from late 2012.ConclusionThe numbers of microcephaly reported here are much higher than the 6.4 per 10 000 live births reported by the Brazilian live birth information system. The results raise questions about the notification system, the appropriateness of the diagnostic criteria and future implications for the affected children and their families. More studies are needed to understand the epidemiology and the implications for the Brazilian health system.     

Assessing equity in the geographical distribution of community pharmacies in South Africa in preparation for a national health insurance scheme

Objective

To investigate equity in the geographical distribution of community pharmacies in South Africa and assess whether regulatory reforms have furthered such equity.

Methods

Data on community pharmacies from the national department of health and the South African pharmacy council were used to analyse the change in community pharmacy ownership and density (number per 10 000 residents) between 1994 and 2012 in all nine provinces and 15 selected districts. In addition, the density of public clinics, alone and with community pharmacies, was calculated and compared with a national benchmark of one clinic per 10 000 residents. Interviews were conducted with nine national experts from the pharmacy sector.

Findings

Community pharmacies increased in number by 13% between 1994 and 2012 – less than the 25% population growth. In 2012, community pharmacy density was higher in urban provinces and was eight times higher in the least deprived districts than in the most deprived ones. Maldistribution persisted despite the growth of corporate community pharmacies. In 2012, only two provinces met the 1 per 10 000 benchmark, although all provinces achieved it when community pharmacies and clinics were combined. Experts expressed concerns that a lack of rural incentives, inappropriate licensing criteria and a shortage of pharmacy workers could undermine access to pharmaceutical services, especially in rural areas.

Conclusion

To reduce inequity in the distribution of pharmaceutical services, new policies and legislation are needed to increase the staffing and presence of pharmacies.     

Mortality from neglected tropical diseases in Brazil, 2000–2011

Objective

To describe mortality from neglected tropical diseases (NTDs) in Brazil, 2000–2011.

Methods

We extracted information on cause of death, age, sex, ethnicity and place of residence from the nationwide mortality information system at the Brazilian Ministry of Health. We selected deaths in which the underlying cause of death was a neglected tropical disease (NTD), as defined by the World Health Organization (WHO) and based on its International statistical classification of diseases and related health problems, 10th revision (ICD-10) codes. For specific NTDs, we estimated crude and age-adjusted mortality rates and 95% confidence intervals (CI). We calculated crude and age-adjusted mortality rates and mortality rate ratios by age, sex, ethnicity and geographic area.

Findings

Over the 12-year study period, 12 491 280 deaths were recorded; 76 847 deaths (0.62%) were caused by NTDs. Chagas disease was the most common cause of death (58 928 deaths; 76.7%), followed by schistosomiasis (6319 deaths; 8.2%) and leishmaniasis (3466 deaths; 4.5%). The average annual age-adjusted mortality from all NTDs combined was 4.30 deaths per 100 000 population (95% CI: 4.21–4.40). Rates were higher in males: 4.98 deaths per 100 000; people older than 69 years: 33.12 deaths per 100 000; Afro-Brazilians: 5.25 deaths per 100 000; and residents in the central-west region: 14.71 deaths per 100 000.

Conclusion

NTDs are important causes of death and are a significant public health problem in Brazil. There is a need for intensive integrated control measures in areas of high morbidity and mortality.     

Hepatitis B immunization for indigenous adults,Australia

ObjectiveTo quantify the disparity in incidence of hepatitis B between indigenous and non-indigenous people in Australia, and to estimate the potential impact of a hepatitis B immunization programme targeting non-immune indigenous adults.MethodsUsing national data on persons with newly acquired hepatitis B disease notified between 2005 and 2012, we estimated incident infection rates and rate ratios comparing indigenous and non-indigenous people, with adjustments for underreporting. The potential impact of a hepatitis B immunization programme targeting non-immune indigenous adults was projected using a Markov chain Monte Carlo simulation model.FindingsOf the 54 522 persons with hepatitis B disease notified between 1 January 2005 and 31 December 2012, 1953  infections were newly acquired. Acute hepatitis B infection notification rates were significantly higher for indigenous than non-indigenous Australians. The rates per 100 000 population for all ages were 3.6 (156/4 368 511) and 1.1 (1797/168 449 302) for indigenous and non-indigenous people respectively. The rate ratio of age-standardized notifications was 4.0 (95% confidence interval: 3.7–4.3). If 50% of non-immune indigenous adults (20% of all indigenous adults) were vaccinated over a 10-year programme a projected 527–549 new cases of acute hepatitis B would be prevented.ConclusionThere continues to be significant health inequity between indigenous and non-indigenous Australians in relation to vaccine-preventable hepatitis B disease. An immunization programme targeting indigenous Australian adults could have considerable impact in terms of cases of acute hepatitis B prevented, with a relatively low number needed to vaccinate to prevent each case.     

Post-tuberculosis mortality risk among immigrants to British Columbia,Canada, 1985–2015: a time-dependent Cox regression analysis of linked immigration,public health,and vital statistics data

ObjectiveTo compare non-tuberculosis (non-TB)-cause mortality risk overall and cause-specific mortality risks within the immigrant population of British Columbia (BC) with and without TB diagnosis through time-dependent Cox regressions.MethodsAll people immigrating to BC during 1985–2015 (N = 1,030,873) were included with n = 2435 TB patients, and the remaining as non-TB controls. Outcomes were time-to-mortality for all non-TB causes, respiratory diseases, cardiovascular diseases, cancers, and injuries/poisonings, and were ascertained using ICD-coded vital statistics data. Cox regressions were used, with a time-varying exposure variable for TB diagnosis.ResultsThe non-TB-cause mortality hazard ratio (HR) was 4.01 (95% CI 3.57–4.51) with covariate-adjusted HR of 1.69 (95% CI 1.50–1.91). Cause-specific covariate-adjusted mortality risk was elevated for respiratory diseases (aHR = 2.96; 95% CI 2.18–4.00), cardiovascular diseases (aHR = 1.63; 95% CI 1.32–2.02), cancers (aHR = 1.40; 95% CI 1.13–1.75), and injuries/poisonings (aHR = 1.85; 95% CI 1.25–2.72).ConclusionsIn any given year, if an immigrant to BC was diagnosed with TB, their risk of non-TB mortality was 69% higher than if they were not diagnosed with TB. Healthcare providers should consider multiple potential threats to the long-term health of TB patients during and after TB treatment. TB guidelines in high-income settings should address TB survivor health.Electronic supplementary materialThe online version of this article (10.17269/s41997-020-00345-y) contains supplementary material, which is available to authorized users.     

Delay in childhood vaccinations during the COVID-19 pandemic

ObjectivesIn many jurisdictions, routine medical care was reduced in response to the COVID-19 pandemic. The objective of this study was to determine whether the frequency of on-time routine childhood vaccinations among children age 0–2 years was lower following the COVID-19 declaration of emergency in Ontario, Canada, on March 17, 2020, compared to prior to the pandemic.MethodsWe conducted a longitudinal cohort study of healthy children aged 0–2 years participating in the TARGet Kids! primary care research network in Toronto, Canada. A logistic mixed effects regression model was used to determine odds ratios (ORs) for delayed vaccination (> 30 days vs. ≤ 30 days from the recommended date) before and after the COVID-19 declaration of emergency, adjusted for confounding variables. A Cox proportional hazards model was used to explore the relationship between the declaration of emergency and time to vaccination.ResultsAmong 1277 children, the proportion of on-time vaccinations was 81.8% prior to the COVID-19 declaration of emergency and 62.1% after (p < 0.001). The odds of delayed vaccination increased (odds ratio = 3.77, 95% CI: 2.86–4.96), and the hazard of administration of recommended vaccinations decreased after the declaration of emergency (hazard ratio = 0.75, 95% CI: 0.60–0.92). The median vaccination delay time was 5 days (95% CI: 4–5 days) prior to the declaration of emergency and 17 days (95% CI: 12–22 days) after.ConclusionThe frequency of on-time routine childhood vaccinations was lower during the first wave of the COVID-19 pandemic. Sustained delays in routine vaccinations may lead to an increase in rates of vaccine-preventable diseases.Supplementary InformationThe online version contains supplementary material available at 10.17269/s41997-021-00601-9.     

Drawing the Curtain Back on Injured Commercial Bicyclists

Objectives. We determined the demographic characteristics, behaviors, injuries, and outcomes of commercial bicyclists who were injured while navigating New York City’s (NYC’s) central business district.Methods. Our study involved a secondary analysis of prospectively collected data from a level 1 regional trauma center in 2008 to 2014 of bicyclists struck by motor vehicles. We performed univariable and multivariable logistic regression analyses.Results. Of 819 injured bicyclists, 284 (34.7%) were working. Commercial bicyclists included 24.4% to 45.1% of injured bicyclists annually. Injured commercial bicyclists were more likely Latino (56.7%; 95% confidence interval [CI] = 50.7, 62.8 vs 22.7%; 95% CI = 19.2, 26.5). Commercial bicyclists were less likely to be distracted by electronic devices (5.0%; 95% CI = 2.7, 8.2 vs 12.7%; 95% CI = 9.9, 15.9) or to have consumed alcohol (0.7%; 95% CI = 0.9, 2.5 vs 9.5%; 95% CI = 7.2, 12.3). Commercial and noncommercial bicyclists did not differ in helmet use (38.4%; 95% CI = 32.7, 44.4 vs 30.8%; 95% CI = 26.9, 34.9). Injury severity scores were less severe in commercial bicyclists (odds ratio = 0.412; 95% CI = 0.235, 0.723).Conclusions. Commercial bicyclists represent a unique cohort of vulnerable roadway users. In NYC, minorities, especially Latinos, should be targeted for safety education programs.In the United States in 2012, 726 bicyclists were killed and 49 000 were injured in motor vehicle collisions1–3; these fatalities accounted for 2.2% of motor vehicle–related deaths, but represented a 6.5% increase from 2011.1,2 In New York City (NYC), there were 4207 bicycle collisions in 2012 that resulted in injury, including 20 fatalities.4An estimated 185 000 people bike in NYC daily; of these, 5000 are commercial bicyclists making deliveries.5 Although commercial bicyclists include only 2.7% of bicyclists in NYC, they account for 16% of daily bicycle trips, at an average of 22 trips per day per commercial bicyclist.5 There are an estimated 109 375 food delivery trips made daily across NYC, covering 100 000 miles.5 NYC businesses have been required to provide employee bicyclists with helmets and safety gear, including reflectors, since 2007 and identification cards and reflective vests since 2013.6–9 Following a 10-month safety education initiative for business owners, the NYC Department of Transportation (DOT) increased enforcement of existing commercial bicycling safety laws in April 2013 by deploying inspectors to businesses to issue violations for missing or improper safety equipment and nonadherence to mandatory safety courses.10–12Commercial bicyclists represent a unique population whose characteristics, behaviors, and injuries have not been previously documented. A comprehensive literature search yielded only 3 articles13–15 relevant to the subject matter, emphasizing the need for more data on this population. Furthermore, current New York State and City databases do not identify injured bicyclists as commercial or noncommercial.1,4 Previous work from our trauma center revealed that 43% of injured bicyclists involved in motor vehicle collisions were commercial.16,17 Although commercial bicyclists provide a convenient service in many urban centers, essential information regarding their safety practices, behaviors, and outcomes in the event of injury is lacking. Our hypothesis was that commercial bicyclists represent a distinct cohort of vulnerable roadway users with a high minority representation. The objective of this study was to describe the demographic characteristics, behaviors, injuries, and outcomes of commercial bicyclists who were injured while navigating NYC’s central business district.     

Schistosomiasis in school-age children in Burkina Faso after a decade of preventive chemotherapy

ObjectiveTo assess the impact of a decade of biennial mass administration of praziquantel on schistosomiasis in school-age children in Burkina Faso.MethodsIn 2013, in a national assessment based on 22 sentinel sites, 3514 school children aged 7–11 years were checked for Schistosoma haematobium and Schistosoma mansoni infection by the examination of urine and stool samples, respectively. We analysed the observed prevalence and intensity of infections and compared these with the relevant results of earlier surveys in Burkina Faso.FindingsS. haematobium was detected in 287/3514 school children (adjusted prevalence: 8.76%, range across sentinel sites: 0.0–56.3%; median: 2.5%). The prevalence of S. haematobium infection was higher in the children from the Centre-Est, Est and Sahel regions than in those from Burkina Faso’s other eight regions with sentinel sites (P < 0.001). The adjusted arithmetic mean intensity of S. haematobium infection, among all children, was 6.0 eggs per 10 ml urine. Less than 1% of the children in six regions had heavy S. haematobium infections – i.e. at least 50 eggs per 10 ml urine – but such infections were detected in 8.75% (28/320) and 11.56% (37/320) of the children from the Centre-Est and Sahel regions, respectively. Schistosoma mansoni was only detected in two regions and 43 children – i.e. 1 (0.31%) of the 320 from Centre-Sud and 42 (8.75%) of the 480 from Hauts Bassins.ConclusionBy mass use of preventive chemotherapy, Burkina Faso may have eliminated schistosomiasis as a public health problem in eight regions and controlled schistosome-related morbidity in another three regions.     

Trends in mortality from respiratory disease in Latin America since 1998 and the impact of the 2009 influenza pandemic

Objective

To determine trends in mortality from respiratory disease in several areas of Latin America between 1998 and 2009.

Methods

The numbers of deaths attributed to respiratory disease between 1998 and 2009 were extracted from mortality data from Argentina, southern Brazil, Chile, Costa Rica, Ecuador, Mexico and Paraguay. Robust linear models were then fitted to the rates of mortality from respiratory disease recorded between 2003 and 2009.

Findings

Between 1998 and 2008, rates of mortality from respiratory disease gradually decreased in all age groups in most of the study areas. Among children younger than 5 years, for example, the annual rates of such mortality – across all seven study areas – fell from 56.9 deaths per 100 000 in 1998 to 26.6 deaths per 100 000 in 2008. Over this period, rates of mortality from respiratory disease were generally highest among adults older than 65 years and lowest among individuals aged 5 to 49 years. In 2009, mortality from respiratory disease was either similar to that recorded in 2008 or showed an increase – significant increases were seen among children younger than 5 years in Paraguay, among those aged 5 to 49 years in southern Brazil, Mexico and Paraguay and among adults aged 50 to 64 years in Mexico and Paraguay.

Conclusion

In much of Latin America, mortality from respiratory disease gradually fell between 1998 and 2008. However, this downward trend came to a halt in 2009, probably as a result of the (H1N1) 2009 pandemic.     

Examining weather-related factors on physical activity levels of children from rural communities

ObjectiveThe objective was to examine the influence of weather on moderate-to-vigorous physical activity (MVPA) and light physical activity (LPA) levels of children aged 8–14 years from rural communities, an understudied Canadian population.MethodsChildren (n = 90) from four communities in rural Northwestern Ontario participated in this study between September and December 2016. Children’s MVPA and LPA were measured using an Actical accelerometer and demographic data were gathered from surveys of children and their parents. Weather data were collected from the closest weather station. Cross-classified regression models were used to assess the relationship between weather and children’s MVPA and LPA.ResultsBoys accumulated more MVPA than girls (b = 26.38, p < 0.01), children were more active on weekdays as compared with weekends (b = − 16.23, p < 0.01), children were less active on days with precipitation (b = − 22.88, p < 0.01), and higher temperature led to a significant increase in MVPA (b = 1.33, p  < 0.01). As children aged, they accumulated less LPA (b = − 9.36, p < 0.01) and children who perceived they had higher levels of physical functioning got more LPA (b = 25.18, p = 0.02). Similar to MVPA, children had higher levels of LPA on weekdays (b = − 37.24, p < 0.01) as compared to weekend days and children accumulated less LPA (b = −50.01, p < 0.01) on days with rain.ConclusionThe study findings indicate that weather influences rural children’s MVPA and LPA. Future research is necessary to incorporate these findings into interventions to increase rural children’s overall PA levels and improve their overall health.Electronic supplementary materialThe online version of this article (10.17269/s41997-020-00324-3) contains supplementary material, which is available to authorized users.     

Community-based surveillance of maternal deaths in rural Ghana

Objective

To examine the feasibility and effectiveness of community-based maternal mortality surveillance in rural Ghana, where most information on maternal deaths usually comes from retrospective surveys and hospital records.

Methods

In 2013, community-based surveillance volunteers used a modified reproductive age mortality survey (RAMOS 4+2) to interview family members of women of reproductive age (13–49 years) who died in Bosomtwe district in the previous five years. The survey comprised four yes–no questions and two supplementary questions. Verbal autopsies were done if there was a positive answer to at least one yes–no question. A mortality review committee established the cause of death.

Findings

Survey results were available for 357 women of reproductive age who died in the district. A positive response to at least one yes–no question was recorded for respondents reporting on the deaths of 132 women. These women had either a maternal death or died within one year of termination of pregnancy. Review of 108 available verbal autopsies found that 64 women had a maternal or late maternal death and 36 died of causes unrelated to childbearing. The most common causes of death were haemorrhage (15) and abortion (14). The resulting maternal mortality ratio was 357 per 100 000 live births, compared with 128 per 100 000 live births derived from hospital records.

Conclusion

The community-based mortality survey was effective for ascertaining maternal deaths and identified many deaths not included in hospital records. National surveys could provide the information needed to end preventable maternal mortality by 2030.     

Vital Signs: Changes in Firearm Homicide and Suicide Rates — United States, 2019–2020

IntroductionThe majority of homicides (79%) and suicides (53%) in the United States involved a firearm in 2020. High firearm homicide and suicide rates and corresponding inequities by race and ethnicity and poverty level represent important public health concerns. This study examined changes in firearm homicide and firearm suicide rates coinciding with the emergence of the COVID-19 pandemic in 2020.MethodsNational vital statistics and population data were integrated with urbanization and poverty measures at the county level. Population-based firearm homicide and suicide rates were examined by age, sex, race and ethnicity, geographic area, level of urbanization, and level of poverty.ResultsFrom 2019 to 2020, the overall firearm homicide rate increased 34.6%, from 4.6 to 6.1 per 100,000 persons. The largest increases occurred among non-Hispanic Black or African American males aged 10–44 years and non-Hispanic American Indian or Alaska Native (AI/AN) males aged 25–44 years. Rates of firearm homicide were lowest and increased least at the lowest poverty level and were higher and showed larger increases at higher poverty levels. The overall firearm suicide rate remained relatively unchanged from 2019 to 2020 (7.9 to 8.1); however, in some populations, including AI/AN males aged 10–44 years, rates did increase.Conclusions and Implications for Public Health PracticeDuring the COVID-19 pandemic, the firearm homicide rate in the United States reached its highest level since 1994, with substantial increases among several population subgroups. These increases have widened disparities in rates by race and ethnicity and poverty level. Several increases in firearm suicide rates were also observed. Implementation of comprehensive strategies employing proven approaches that address underlying economic, physical, and social conditions contributing to the risks for violence and suicide is urgently needed to reduce these rates and disparities.     

A prospective study of maternal,fetal and neonatal deaths in low- and middle-income countries

Objective

To quantify maternal, fetal and neonatal mortality in low- and middle-income countries, to identify when deaths occur and to identify relationships between maternal deaths and stillbirths and neonatal deaths.

Methods

A prospective study of pregnancy outcomes was performed in 106 communities at seven sites in Argentina, Guatemala, India, Kenya, Pakistan and Zambia. Pregnant women were enrolled and followed until six weeks postpartum.

Findings

Between 2010 and 2012, 214 070 of 220 235 enrolled women (97.2%) completed follow-up. The maternal mortality ratio was 168 per 100 000 live births, ranging from 69 per 100 000 in Argentina to 316 per 100 000 in Pakistan. Overall, 29% (98/336) of maternal deaths occurred around the time of delivery: most were attributed to haemorrhage (86/336), pre-eclampsia or eclampsia (55/336) or sepsis (39/336). Around 70% (4349/6213) of stillbirths were probably intrapartum; 34% (1804/5230) of neonates died on the day of delivery and 14% (755/5230) died the day after. Stillbirths were more common in women who died than in those alive six weeks postpartum (risk ratio, RR: 9.48; 95% confidence interval, CI: 7.97–11.27), as were perinatal deaths (RR: 4.30; 95% CI: 3.26–5.67) and 7-day (RR: 3.94; 95% CI: 2.74–5.65) and 28-day neonatal deaths (RR: 7.36; 95% CI: 5.54–9.77).

Conclusion

Most maternal, fetal and neonatal deaths occurred at or around delivery and were attributed to preventable causes. Maternal death increased the risk of perinatal and neonatal death. Improving obstetric and neonatal care around the time of birth offers the greatest chance of reducing mortality.