Continuities and changes in spatial patterns of under-five mortality at the district level in India (1991–2011)

Background

India has the largest number of under-five deaths globally, and large variations in under-five mortality persist between states and districts. Relationships between under-five mortality and numerous socioeconomic, development and environmental health factors have been explored at the national and state levels, but the possible spatial heterogeneity in these relationships has seldom been investigated at the district level. This study seeks to unravel local variation in key determinants of under-five mortality based on the 1991 and 2011 censuses.

Methods

Using geocoded district-level data from the last two census rounds (1991 and 2011) and ordinary least squares and geographically weighted regressions, we identify district-specific relationships between under-five mortality rate and a series of determinants for two periods separated by 20 years (1986–1987 and 2006–2007). To identify spatial groupings of coefficients, we perform a cluster analysis based on t-values of the geographically weighted regression.

Results

The geographically weighted regression analysis shows that relationships between the under-five mortality rate and factors for socioeconomic, development, and environmental health factors vary spatially in terms of direction, strength, and extent when considering: female literacy and labor force participation; share of scheduled castes and scheduled tribes; access to electricity; safe water and sanitation; road infrastructure; and medical facilities. This spatial heterogeneity is accompanied by significant changes over time in the roles that these factors play in under-five mortality. Important local determinants of under-five mortality in 2011 were female literacy, female labor force participation, access to sanitation facilities and electricity; while the key local determinants in 1991 were road infrastructure, safe water, and medical facilities. We identify six different clusters based on geographically weighted regression coefficients that broadly encompass the same districts in both periods; but these clusters do not follow the regional boundaries suggested by the previous studies. In particular, the high mortality states of India that are often typically classified as high focus states were classified into three different clusters based on the relationship of the factors associated with under-five mortality.

Conclusion

This study demonstrates the utility of combining geographically weighted regression and cluster analyses as a methodological approach to study local-level variation in public health indicators, and it could be applied in any country using aggregate-level information from census or survey data. Identifying local predictors of under-five mortality is important for designing interventions in specific districts. Additional reduction in under-five mortality will only be possible with intervention programs designed at the local level, which take into consideration local level determinants of under-five mortality.

     

Trends in prevalence of diabetes mellitus and mean fasting glucose in Portugal (1987–2009): a systematic review

Objectives

To assess time trends of the prevalence of diabetes and mean blood glucose in Portuguese adults.

Study design

Systematic review.

Methods

The search strategy included Pubmed search and screening of bibliographic references of the review articles. Sex-specific linear regression models, with survey year and participants' age as independent variables, were used to predict prevalence estimates of self-reported diabetes and mean fasting glucose.

Results

Twenty-seven eligible studies were identified. Time trends of objectively defined diabetes could not be quantified due to the heterogeneity of the diagnostic criteria. Between 1987 and 2009, the prevalence of self-reported diabetes remained approximately constant in young adults, while it increased in middle-aged and older adults, more than two-fold among women and three-fold among men. In the same period, mean fasting glucose increased 7 mg/dL among women and 8 mg/dL among men.

Conclusions

The prevalence of self-reported diabetes and mean fasting glucose increased in the last two decades, demanding for effective strategies to reverse this tendency and to manage the increasing number of people with diabetes in the Portuguese population.     

Effectiveness of a community-based water,sanitation, and hygiene (WASH) intervention in reduction of diarrhoea among under-five children: Evidence from a repeated cross-sectional study (2007–2015) in rural Bangladesh

Diarrhoea, the most common disease directly related to water, sanitation, and hygiene (WASH), still remains one of the most significant health problems among children under-five worldwide. In this reality, BRAC, the largest NGO in the world initiated a comprehensive WASH intervention in 50 upazilas (sub-districts) of Bangladesh in 2007 which was later scaled up to cover 150 upazilas in two subsequent phases. The intervention period of the programme was 2007–2011.The present study encompassed 30 upazilas of the first phase of intervention. The aim of the study was to investigate the effectiveness of this intervention on reduction of diarrhoea among under-five children, and to identify the factors associated with childhood diarrhoea. A repeated cross-sectional study design was followed, and a population-based survey was carried out on four occasions: baseline (2007), midline (2009), endline (2011), and post-endline (2015) among 4,775 households. This analysis considers only households having at least one under-five children.Absence of handwashing practice with soap after defecation and before eating food, unclean latrine condition, and unsafe disposal of child faeces were identified as significant risk factors associated with under-five diarrhoea from Log-binomial regression. The prevalence of under-five diarrhoea within the past 2 weeks of the survey declined from 13.7% at baseline to 3.6% at end-line (p < 0.001) in the WASH intervention area. However, the progress seemingly stalled after 2011, which may have occurred due to the lack of improvement in unsafe disposal of child faeces and unclean latrine condition after the intervention period.Study findings suggest that, to reduce the prevalence of childhood diarrhoea it is important to promote safe disposal of child faeces, maintaining cleanliness of latrines, and washing hand with soap at critical times, beyond merely increasing the sanitation coverage. Findings also underline the necessity of maintaining a small-scale monitoring component involving local community, such as a WatSan committee (a local committee comprising the user communities for supervising WASH related activities) for periodic monitoring at household level for a certain period after the program intervention works to make the behavioural change more sustainable and to keep the reduction rate of under-five diarrhoeal prevalence steady.     

The evolution of breast cancer mortality and morbidity in Spain (1977–1988)

A study of breast cancer mortality and cancer morbidity has been carried out in Spain recently for the period 1977–1988, covering the population of the 17 Autonomous Communities and 50 provinces of the country. Data was obtained from INE, Instituto Nacional de Estadistica (National Institute of Statistics), with age standardization using the indirect method. The different Autonomous Communities and provinces were compared in order to establish possible significant differences. The crude mean mortality rate was 21 cases per 100,000 inhabitants/year; Las Palmas, Gerona, Barcelona, the Balearic Islands, Navarra and Zaragoza have the highest mortality rates, with a proportional increment of 54% in that period. The crude national mean morbidity rate for the considered period was 64.0 cases per 100,000 inhabitants, and the proportional increment 180%. According to provincial figures, Alava had the highest fitted mean morbidity rate, 135 cases per 100,000 inhabitants, whilst the highest fitted mean rate was Las Palmas (28 cases/100,000 inhabitants), and the highest proportional increment was the rate for the province of Huesca (169%). When using the ANOVA test on the mean rate of the period, for mortality as well as morbidity, we observed significant differences among provinces and among Autonomous Communities (p 0.05).     

Characterization of GII.4 noroviruses circulating among children with acute gastroenteritis in Pune,India: 2005–2013

Genogroup II genotype 4 noroviruses (GII.4 NoVs), an important cause of sporadic childhood gastroenteritis worldwide, undergo continuous evolution leading to the periodic emergence of novel variants. The present study was undertaken for surveillance of GII.4 NoVs and identification and characterization of GII.4 variants circulating among children with sporadic gastroenteritis in Pune, India during 2005–2013. Among the 12 GII genotypes detected in the study, GII.4 was predominant. Sequencing and phylogenetic analysis of ORF2 (major capsid protein VP1 gene) of the GII.4 NoVs revealed circulation of seven GII.4 variants, Hunter_2004 (2005–2007), Yerseke_2006a (2006), DenHaag_2006b (2007), Osaka_2007 (2007–2009), Apeldoorn_2007 (2008), New Orleans_2009 (2008–2012) and Sydney_2012 (2013), with the Pune strains grouping with the contemporary global reference strains. The Hunter_2004, Osaka_2007 and New Orleans_2009 variants showed prolonged circulation, with the Hunter_2004 and New Orleans_2009 variants differentiating into temporally separated sub-clusters. Analysis of VP1 sequences and predicted structures of the GII.4 variants identified variant specific amino acid positions, particularly in and near (within 8A^°) the epitopes A-E, displaying differences in the sequence and physicochemical characteristics of the different variants. Comparison with the reference strains of each of the GII.4 variants revealed up to 11 amino acid substitutions at the variant specific positions in the GII.4 strains from Pune. Amino acid variations were also noted among the strains of the same GII.4 variant in Pune. The strains of different sub-clusters identified in the Hunter_2004 and New Orleans_2009 variants showed differences in sequence and physicochemical properties of either or all of the epitopes A, C and E. The study thus describes the temporal variations and diversity of the GII.4 strains in Pune and emphasizes continuous monitoring and analysis of the GII.4 variants.     

Incidence of acute respiratory tract infections (2006–2015) and influenza (2006–2013) among French armed forces

ObjectivesWe aimed to assess the incidence of respiratory tract infections in military settings between 2006 and 2015.Patients and methodsWe performed a retrospective epidemiological study of the entire military population from 2006 to 2015. Comprehensive data was collected from all medical centers, operational medical units, naval services, and army training hospitals and provided by the epidemiological surveillance of the armies.ResultsThe annual average population of the study was 331,394 soldiers. For acute respiratory tract infections (2006–2015), 22,818 cases were reported in metropolitan France, 3,211 cases in French overseas territories, 1,595 cases in the French Navy, and 1,318 cases in external military operations for a total of 28,942 cases. For influenza (2006–2013), 934 cases were reported in metropolitan France, 101 cases in French overseas territories, and 23 cases in external operations, for a total of 1,058 cases. The mean incidence rate of acute respiratory tract infections expressed as case number per 1,000 person-years (PY) was 8.7 PY (95% CI [8.6–8.8]) with an exceptional increased incidence rate in 2009 (25.9 PY, 95% CI [25.4–26.4]). The mean incidence rate of influenza was 0.35 PY (95% CI [0.33–0.37]) with a peak incidence rate of 1.9 PY in 2009.ConclusionAcute respiratory tract infections are at the forefront of infectious episodes in the French armies. Although not necessarily severe, current prevention measures are not enough to reduce the incidence threshold of these infections and need to be improved.     

Incidence and epidemiology of intussusception among children under 2 years of age in Chenzhou and Kaifeng,China, 2009–2013

IntroductionIn China, rotavirus is the leading cause of diarrhea hospitalizations among children aged <5 years. A locally manufactured rotavirus vaccine is available for private market use, but little is known about its coverage. Given the impending availability of newer rotavirus vaccines, we evaluated intussusception rates among children aged <2 years to better understand intussusception epidemiology for future vaccine safety monitoring.MethodsWe conducted a retrospective review at 4 hospitals in Chenzhou City of Hunan Province and Kaifeng City of Henan Province. We identified intussusception cases admitted during 2009–2013 by reviewing medical records with the ICD-10 discharge code for intussusception and extracting demographic and clinical information from the electronic clinical record systems.ResultsDuring 2009–2013, 1715 intussusception hospitalizations among 1,487,215 children aged <2 years occurred in both cities. The average annual intussusception hospitalization incidence was 112.9 per 100,000 children aged <2 years (181.8 per 100,000 children <1 year; 56 per 100,000 children 1 to <2 years). Intussusception incidence was low among infants aged <3 months and peaked at age 6–8 months. No clear seasonality was observed. Ultrasound was used to diagnose 95.9% of cases. Enema reduction was performed in 80% cases; 25% of cases in Chenzhou and 16% in Kaifeng required surgical intervention. No deaths were reported. The median time between symptom onset and admission was 1 day.ConclusionsThis study provides information on intussusception incidence and epidemiology in two cities of China during 2009–2013. Monitoring intussusception rates in this population will be important in the post-rotavirus vaccine era.     

Molecular epidemiology of human respiratory syncytial virus and human metapneumovirus in hospitalized children with acute respiratory infections in Croatia, 2014–2017

Acute respiratory infection (ARI) is the most common infection in children under 5 years of age and it is frequently caused by two pneumoviruses, human respiratory syncytial virus (HRSV) and human metapneumovirus (HMPV). Epidemic seasons of these viruses overlap and disease manifestations are highly similar, including severe lower ARI such as bronchiolitis or pneumonia. Reinfections with pneumoviruses are frequent and limited prevention treatment is available. Genetic diversity of HRSV and HMPV strains circulating in Croatia was monitored during four consecutive years (2014–2017). Co-circulation of multiple lineages was observed for both viruses. Within HRSV group A, ON1 strains gained strong predominance during the 4-year period, while previously dominant genotype NA1 was detected only sporadically. Similarly, newly occurring HMPV genotype A2c gained predominance over genotype A2b during this period, resulting in all infection in 2017 being caused by A2c. Along with phylogenetic analysis based on the commonly used fragments for detection and genotyping of these viruses, full length G and SH genes were also analysed. Evolutionary dynamics showed that inferred substitution rates of HRSV and HMPV are between 2.51 × 10⁻³ and 3.61 × 10⁻³ substitutions/site/year. This study established presence of recently described HMPV strains containing large duplications in the G gene in Croatia. Viruses with either of the two duplications belong to a subcluster A2c, which has completely replaced all other group A subclusters in 2017.     

Streptococcus pneumoniae as cause of acute otitis media (AOM) in Slovak children in the pneumococcal conjugate vaccine era (2008–2019)

AimLittle data is available on pneumococcal serotypes and their antimicrobial resistance in the pneumococcal conjugate vaccination era in young children with acute otitis media (AOM). Here such data is provided from Slovakia, a country with sequential introduction and parallel-use of the three commercially available pneumococcal conjugate vaccines (PCVs; PCV7; PCV13; PCV10).MethodsThis observational study takes advantage of the fact that tympanocentesis is the standard of care in children with AOM in Slovakia. Over the 12 year observation period, participating pediatric ENT specialists sent samples taken during tympanocentesis from children with AOM to their local MEDIRIX laboratories for identification of bacteria. Pneumcoccal isolates were serotyped and tested for antimicrobial resistance. Incidence data could be calculated from 1 region.ResultsStudy participation and completeness of typing increased over time. Based on testing of 1,131 isolates over 12 years, PCV7-serotypes rapidly waned after PCV7 introduction in 2009 and had virtually disappeared in 2014. The maximum fraction of PCV10-only isolates (1, 5, 7F) was 2.7 % (2009) whereas the additional 3 PCV-serotypes (3, 6A, 19A) in PCV13 represented the largest proportion of pneumococcal AOM cases as of 2010. This finding remained unchanged during the period of highest PCV10-market share (2012–2017) and even until the end of the observation period (2019). The fraction of untypeable pneumococci (<6 %) and non-PCV13-serotypes (16–34 %) increased 2012–2017, but decreased again thereafter. Serotype 19A evolved as the most relevant (multidrug-) resistant pneumococcal serotype, again particularly during the time with high sales of PCV10 (2012–2017). Incidence data from the Bratislava region document a huge impact of PCV use (77 % vaccine uptake: mainly PCV13) on AOM in children < 6 years. Serotypes 19A and 3 remain the only relevant pneumococcal serotypes in young Slovakian children with AOM.ConclusionsAs AOM is one of the most common bacterial infections in children < 6 years, the observed benefits of PCVs in reducing vaccine serotypes have been tremendous. With sequential / parallel-use of PCVs, serotypes 3 and (MDR-) 19A today make the largest proportion (about 2/3) of pneumococcal AOM in Slovakia. This data will help to further guide the choice of pneumococcal conjugate vaccines for pediatricians and parents.     

Estimating the Burden of Prematurity on Infant Mortality: A Comparison of Death Certificates and Child Fatality Review in Ohio, 2009–2013

Maternal and Child Health Journal - Introduction Infant mortality is a key population health indicator, and accurate cause of death reporting is necessary to design infant mortality prevention...     

The relevance of spatial aggregation level and of applied methods in the analysis of geographical distribution of cancer mortality in mainland Portugal (2009–2013)

Background

Knowledge regarding the geographical distribution of diseases is essential in public health in order to define strategies to improve the health of populations and quality of life.The present study aims to establish a methodology to choose a suitable geographic aggregation level of data and an appropriated method which allow us to analyze disease spatial patterns in mainland Portugal, avoiding the “small numbers problem.” Malignant cancer mortality data for 2009–2013 was used as a case study.

Methods

To achieve our aims, we used official data regarding the mortality by all malignant cancer, between 2009 and 2013, and the mainland Portuguese resident population in 2011. Three different spatial aggregation levels were applied: Nomenclature of Territorial Units for Statistics, level III (28 areas), municipalities (278 areas), and parishes (4050 areas).Standardized Mortality Ratio (SMR) and relative risk (RR) were computed with Besag, York and Mollié model (BYM) for the evaluation of geographic patterns of mortality data. We also estimated Global Moran’s I, Local Moran’s I, and posterior probability (PP) for the spatial cluster analysis.

Results

Our results show that the occurrence of lower and higher extreme values of the standardized mortality ratio tend to increase with the decrease of data spatial aggregation. In addition, the number of local clusters is higher at small spatial aggregation levels, although the area of each cluster is generally smaller. Regarding global clustering, data forms clusters at all considered levels.Relative risk (RR) computed by Besag, York and Mollié model, in turn, also shows different results at the municipalities and parishes levels. However, the difference is smaller than the difference obtained by SMR computation. This statement is supported by the coefficient variation values.

Conclusions

Our findings show that the choice of spatial data aggregation level has high importance in the research results, as different aggregation levels can lead to distinct results.In terms of the case study, we conclude that for the period of 2009–2013, cancer mortality in mainland Portugal formed clusters. The most suitable applicable spatial scale and method seemed to be at the municipalities level and Besag, York and Mollié model, respectively. However, further studies should be conducted in order to provide greater support to these results.

     

Decrease in the incidence and in hospital mortality of community-acquired pneumonia among children in Spain (2001–2014)

ObjectivesTo describe trends in the incidence and outcomes of community-acquired pneumonia (CAP) hospitalizations among Spanish children from 2001 to 2014 and to assess the effect of the pneumococcal vaccination (PCV) coverage in this period.MethodsThis study was conducted using the Spanish National Hospital Database from 2001 to 2014 including subjects <18 years. We selected discharges with a primary diagnosis of CAP.Study variable included age, sex, comorbid conditions, procedures, isolated pathogens and hospital outcome variables.In order to estimate the effect of coverage of pneumococcal vaccination in hospitalizations for CAP, we used the number of commercialized doses of PCV (PCV7 PCV10, and PCV13) for each year.Incidence rates of admissions for CAP were calculated by dividing the number of admissions per year, sex, and age group by the corresponding number of people in that population group according to the census data.ResultsWe identified 194,419 admissions for CAP. Incidence rate was highest among children younger than 2 years and decreased significantly by 3.67% per year over the study period in this age group. Among children aged 2–4 years incidence of CAP seem to decrease after year 2009. S. pneumoniae isolations decreased significantly over time but virus isolations increased. In children aged <2 years and 2–4 years increase in PVC was associated to a decrease in the incidence of CAP hospitalizations.Overall crude in hospital mortality following CAP fell significantly from 4.1‰ in 2001–2003 to 2.8‰ in 2012–2014.ConclusionsCAP incidence rates decreased significantly among children <2 years of age from 2001 to 2014. S. pneumoniae isolations decreased significantly over time but virus isolations increased. In hospital mortality paralleling CAP fell significantly in children and adolescents from 2001 to 2014. Improvement in vaccination coverage seems to have a mitigating effect on hospitalizations and outcomes for CAP in children.     

Why do general practitioners prescribe antibiotics for acute infective conjunctivitis in children? Qualitative interviews with GPs and a questionnaire survey of parents and teachers

BACKGROUND: Acute infective conjunctivitis in children is a common presentation in primary care. Treatment is usually with antibiotics and prescribing may be affected by non-clinical factors. AIMS: To investigate the non-clinical determinants of the management of acute infective conjunctivitis in children. DESIGN: Qualitative interviews with GPs and a questionnaire survey of parents of children with acute infective conjunctivitis and teachers. SETTING: GPs in Sheffield and Berkshire and parents of children with acute infective conjunctivitis and schools in Oxfordshire. METHODS: Semi-structured telephone interviews of 39 GPs. Questionnaire survey of 326 parents of children enrolled into a trial of acute infective conjunctivitis treatment. Questionnaire survey of 223 nurseries and primary schools in Oxfordshire. RESULTS: All three groups agreed that acute infective conjunctivitis was a mild condition. Parents were certain about the benefits of antibiotic treatment and sought early consultations with their GP in a desire to get their child back to school. GPs sometimes collude with a parent's request to prescribe to enable school attendance. Despite this 54.2% (95%CI 48.5-59.8%) children missed a mean of 1.85 days from school and 28.6% of parents (95%CI 23.5-33.7%) missed a mean of 1.5 days off work. CONCLUSION: Social factors, including the need for children to attend day care or school and parents to go to work, contribute to the decision to prescribe antibiotics for children with acute infective conjunctivitis. Understanding these issues and changing school policies in line with national guidance may reduce pressure on GPs to prescribe for this condition.