Childhood diarrhoeal deaths in seven low- and middle-income countries

Objective

To investigate the clinical characteristics of children who died from diarrhoea in low- and middle-income countries, such as the duration of diarrhoea, comorbid conditions, care-seeking behaviour and oral rehydration therapy use.

Methods

The study included verbal autopsy data on children who died from diarrhoea between 2000 and 2012 at seven sites in Bangladesh, Ethiopia, Ghana, India, Pakistan, Uganda and the United Republic of Tanzania, respectively. Data came from demographic surveillance sites, randomized trials and an extended Demographic and Health Survey. The type of diarrhoea was classified as acute watery, acute bloody or persistent and risk factors were identified. Deaths in children aged 1 to 11 months and 1 to 4 years were analysed separately.

Findings

The proportion of childhood deaths due to diarrhoea varied considerably across the seven sites from less than 3% to 30%. Among children aged 1–4 years, acute watery diarrhoea accounted for 31–69% of diarrhoeal deaths, acute bloody diarrhoea for 12–28%, and persistent diarrhoea for 12–56%. Among infants aged 1–11 months, persistent diarrhoea accounted for over 30% of diarrhoeal deaths in Ethiopia, India, Pakistan, Uganda and the United Republic of Tanzania. At most sites, more than 40% of children who died from persistent diarrhoea were malnourished.

Conclusion

Persistent diarrhoea remains an important cause of diarrhoeal death in young children in low- and middle-income countries. Research is needed on the public health burden of persistent diarrhoea and current treatment practices to understand why children are still dying from the condition.     

Enablers and inhibitors: A review of the situation regarding mHealth adoption in low- and middle-income countries

Objective

The objective of this review is to identify enabling and inhibiting factors for mHealth adoption in low resource settings, by giving emphasis on the stakeholders representing the caregiving side. Another objective of this study is to support implementation agencies (governmental and non-governmental) in designing scalable mHealth interventions.

Using pneumococcal carriage studies to monitor vaccine impact in low- and middle-income countries

Pneumococcal disease is a leading cause of childhood mortality, globally. The pneumococcal conjugate vaccine (PCV) has been introduced to many countries worldwide. However there are few studies evaluating PCV impacts in low- and middle-income countries (LMIC) because measuring the impact of PCV on pneumococcal disease in LMICs is challenging. We review the role of pneumococcal carriage studies for the evaluation of PCVs in LMICs and discuss optimal methods for conducting these studies. Fifteen carriage studies from 13 LMICs quantified the effects of PCV on carriage, and identified replacement carriage serotypes in the post-PCV era. Ten studies reported on the indirect effects of PCV on carriage. Results can be used to inform cost-effectiveness evaluations, guide policy decisions on dosing and product, and monitor equity in program implementation. Critically, we highlight gaps in our understanding of serotype replacement disease in LMICs and identify priorities for research to address this gap.     

Human papillomavirus vaccine delivery strategies that achieved high coverage in low- and middle-income countries

Objective

To assess human papillomavirus (HPV) vaccination coverage after demonstration projects conducted in India, Peru, Uganda and Viet Nam by PATH and national governments and to explore the reasons for vaccine acceptance or refusal.

Methods

Vaccines were delivered through schools or health centres or in combination with other health interventions, and either monthly or through campaigns at fixed time points. Using a two-stage cluster sample design, the authors selected households in demonstration project areas and interviewed over 7000 parents or guardians of adolescent girls to assess coverage and acceptability. They defined full vaccination as the receipt of all three vaccine doses and used an open-ended question to explore acceptability.

Findings

Vaccination coverage in school-based programmes was 82.6% (95% confidence interval, CI: 79.3–85.6) in Peru, 88.9% (95% CI: 84.7–92.4) in 2009 in Uganda and 96.1% (95% CI: 93.0–97.8) in 2009 in Viet Nam. In India, a campaign approach achieved 77.2% (95% CI: 72.4–81.6) to 87.8% (95% CI: 84.3–91.3) coverage, whereas monthly delivery achieved 68.4% (95% CI: 63.4–73.4) to 83.3% (95% CI: 79.3–87.3) coverage. More than two thirds of respondents gave as reasons for accepting the HPV vaccine that: (i) it protects against cervical cancer; (ii) it prevents disease, or (iii) vaccines are good. Refusal was more often driven by programmatic considerations (e.g. school absenteeism) than by opposition to the vaccine.

Conclusion

High coverage with HPV vaccine among young adolescent girls was achieved through various delivery strategies in the developing countries studied. Reinforcing positive motivators for vaccine acceptance is likely to facilitate uptake.     

Cost of vaccine delivery strategies in low- and middle-income countries during the COVID-19 pandemic

BackgroundThe COVID-19 pandemic has disrupted immunization services critical to the prevention of vaccine-preventable diseases in many low- and middle- income countries around the world. These services will need to be modified in order to minimize COVID-19 transmission and ensure the safety of health workers and the community. Additional budget will be required to implement these modifications that ensure safe delivery.MethodsUsing a simple modeling analysis, we estimated the additional resource requirements associated with modifications to supplementary immunization activities (campaigns) and routine immunization services via fixed sites and outreach in 2020 US dollars. We considered the following four categories of costs: (1) personal protective equipment (PPE) & infection prevention and control (IPC) measures for immunization sessions; (2) physical distancing and screening during immunization sessions; (3) delivery strategy changes, such as changes in session sizes and frequency; and (4) other operational cost increases, including additional social mobilization, training, and hazard pay to compensate health workers.ResultsWe found that implementing a range of measures to protect health workers and communities from COVID-19 transmission could result in a per-facility start-up cost of $466–799 for routine fixed-site delivery and $12–220 for routine outreach delivery, and $12–108 per immunization campaign site. A recurrent monthly cost of $137–1,024 for fixed-site delivery and $152–848 for outreach delivery per facility could be incurred, and a $0.32–0.85 increase in the cost per dose during campaigns.ConclusionsBy illustrating potential cost implications of providing immunization services through a range of strategies in a safe manner, these estimates can provide a benchmark for program managers and policy makers on the additional budget required. These findings can help country practitioners and global development partners planning the continuation of immunization services in the context of COVID-19.     

Agriculture and musculoskeletal disorders in low- and middle-income countries

Objectives: To systematically explore and summarize the risk factors of work-related musculoskeletal disorders (WMSDs) among the agricultural workers in low- and middle-income countries (LMIC). In addition, to identify and analyze the methodological flaws in the reviewed studies.

Methods: A comprehensive electronic literature search was conducted using PubMed, Medline, SCOPUS, CINAHL, Science Direct, Embase, Wiley Online Library, Google Scholar, and Web of Science databases. Three-phased screening process was undertaken to eliminate irrelevant publications. Assessment of methodological quality was done using a standardized assessment tool.

Results: Eighteen cross-sectional studies were included in the narrative synthesis. Based on the median score of 38%, nine publications were classified as having higher methodological quality. Eight countries were represented in this review, mainly the South East Asia countries. Majority of the participants were rice farmers. Most common risk factors associated with WMSDs were physical factors (n = 10), followed by individual (n = 6) and psychosocial (n = 5) risk factors. A majority of the studies investigated the risk factors for spinal region. Several methodological weaknesses were noticed in the studies concerning outcome definition, assessment of potential confounders, generalizability, selection bias, information bias, and statistical analysis. Extensive heterogeneity across the studies prevented statistical pooling.

Conclusions: The common anatomical region evaluated was the spine and the most reported risk factors were physical risk factors. Future researches in the LMIC should focus on conducting longitudinal studies that could infer temporality. Researchers should give more attention in defining the study population, evaluating the exposure and outcome in an unbiased way, and in executing reliable statistical analysis.     

Financing mental health services in low- and middle-income countries

Mental disorders account for a significant and growing proportion of the global burden of disease and yet remain a low priority for public financing in health systems globally. In many low-income countries, formal mental health services are paid for directly by patients out-of-pocket and in middle-income countries undergoing transition there has been a decline in coverage. The paper explores the impact of health care financing arrangements on the efficient and equitable utilization of mental health services. Through a review of the literature and a number of country case studies, the paper examines the impact of financing mental health services from out-of-pocket payments, private health insurance, social health insurance and taxation. The implications for the development of financing systems in low- and middle-income countries are discussed. International evidence suggests that charging patients for mental health services results in levels of use which are below socially efficient levels as the benefits of the services are distributed according to ability to pay, resulting in inequitable access to care. Private health insurance poses three main problems for mental health service users: exclusion of mental health benefits, limited access to those without employment and refusal to insure pre-existing conditions. Social health insurance may offer protection to those with mental health problems. However, in many low- and middle-income countries, eligibility is based on contributions and limited to those in formal employment (therefore excluding many with mental health problems). Tax-funded systems provide universal coverage in theory. However, the quality and distribution of publicly financed health care services makes access difficult in practice, particularly for rural poor communities.     

Cancer control capacity in 50 low- and middle-income countries

Within the World Health Organization-International Atomic Energy Agency (WHO-IAEA) collaboration for delivery of technical assistance to its Member States, the National Cancer Control Programme/Plan (NCCP) Core Capacity Self-Assessment Tool has been used to obtain a simple and quick qualitative overview of national cancer control planning and on-going activities. The NCCP tool was applied in 50 Member States, which were classified as low- and middle-income countries in 2012. Results show that half of these countries reported having officially endorsed an NCCP and 42% were in the process of preparing or updating one. Overall, the most relevant cancer control interventions reported to be partially developed or well established in most countries were related to the cancer prevention, early detection of cervical and breast cancers, as well as diagnosis and treatment of curable cancers. Contrarily, patient's rehabilitation, psychosocial support, human papilloma virus vaccination, breast cancer screening with mammography and control of occupational carcinogens were noted as being in early development phases. The availability of crucial resources to support interventions was perceived to be the highest in upper middle-income countries. These findings highlight specific areas where WHO, IAEA and partners could strengthen collaboration with countries to leverage on-going interventions and improve availability of resources.     

The neglected burden of caregiving in low- and middle-income countries

BackgroundThe number of persons with disability worldwide is estimated at more than one billion, and low- and middle-income countries (LMIC's) have particularly high prevalence. The consequences of disability have garnered growing attention, but the burden of caregiving for persons with disease or disability remains largely unquantified especially in LMIC's.ObjectiveThe goal of this paper is to report the results of a review of literature on caregiving in LMIC's, describing the characteristics of caregivers and of persons with disease or disability for whom care is provided, and the burden of caregiving in several domains.MethodsWe reviewed electronically available literature up to March 2012. Data were extracted pertaining to the following categories: caregiver demographics, caregiving activities, psychological burden, social burden, financial burden, physical burden, and time burden.ResultsOur review demonstrates that there is considerable and neglected burden on caregivers in LMIC's in physical, psychological, social, time, and financial realms. Existing literature is limited by the small volume of published research available on this topic, diverse methodologies, and lack of consensus on how to define and measure caregiver burden. However the evidence is clear that there are adverse consequences that arise as a result of the role of caregiver in this setting.ConclusionsIn light of the mounting evidence of the significant burden placed on caregivers of persons with disease and disability, it is imperative that the opportunity be taken to ensure that evidence informs best practice and policy in order to provide the support and services necessary to make an impact.     

Pathogens transmitted in animal feces in low- and middle-income countries

Animals found in close proximity to humans in low-and middle-income countries (LMICs) harbor many pathogens capable of infecting humans, transmissible via their feces. Contact with animal feces poses a currently unquantified—though likely substantial—risk to human health. In LMIC settings, human exposure to animal feces may explain some of the limited success of recent water, sanitation, and hygiene interventions that have focused on limiting exposure to human excreta, with less attention to containing animal feces.We conducted a review to identify pathogens that may substantially contribute to the global burden of disease in humans through their spread in animal feces in the domestic environment in LMICs. Of the 65 potentially pathogenic organisms considered, 15 were deemed relevant, based on burden of disease and potential for zoonotic transmission. Of these, five were considered of highest concern based on a substantial burden of disease for which transmission in animal feces is potentially important: Campylobacter, non-typhoidal Salmonella (NTS), Lassa virus, Cryptosporidium, and Toxoplasma gondii. Most of these have a wide range of animal hosts, except Lassa virus, which is spread through the feces of rats indigenous to sub-Saharan Africa. Combined, these five pathogens cause close to one million deaths annually. More than half of these deaths are attributed to invasive NTS. We do not estimate an overall burden of disease from improperly managed animal feces in LMICs, because it is unknown what proportion of illnesses caused by these pathogens can be attributed to contact with animal feces.Typical water quantity, water quality, and handwashing interventions promoted in public health and development address transmission routes for both human and animal feces; however, sanitation interventions typically focus on containing human waste, often neglecting the residual burden of disease from pathogens transmitted via animal feces. This review compiles evidence on which pathogens may contribute to the burden of disease through transmission in animal feces; these data will help prioritize intervention types and regions that could most benefit from interventions aimed at reducing human contact with animal feces.     

Inequalities in full immunization coverage: trends in low- and middle-income countries

ObjectiveTo investigate disparities in full immunization coverage across and within 86 low- and middle-income countries.MethodsIn May 2015, using data from the most recent Demographic and Health Surveys and Multiple Indicator Cluster Surveys, we investigated inequalities in full immunization coverage – i.e. one dose of bacille Calmette-Guérin vaccine, one dose of measles vaccine, three doses of vaccine against diphtheria, pertussis and tetanus and three doses of polio vaccine – in 86 low- or middle-income countries. We then investigated temporal trends in the level and inequality of such coverage in eight of the countries.FindingsIn each of the World Health Organization’s regions, it appeared that about 56–69% of eligible children in the low- and middle-income countries had received full immunization. However, within each region, the mean recorded level of such coverage varied greatly. In the African Region, for example, it varied from 11.4% in Chad to 90.3% in Rwanda. We detected pro-rich inequality in such coverage in 45 of the 83 countries for which the relevant data were available and pro-urban inequality in 35 of the 86 study countries. Among the countries in which we investigated coverage trends, Madagascar and Mozambique appeared to have made the greatest progress in improving levels of full immunization coverage over the last two decades, particularly among the poorest quintiles of their populations.ConclusionMost low- and middle-income countries are affected by pro-rich and pro-urban inequalities in full immunization coverage that are not apparent when only national mean values of such coverage are reported.     

Responsive feeding and child undernutrition in low- and middle-income countries

Growth faltering and nutritional deficiencies continue to be highly prevalent in infants and young children (IYC) living in low- and middle-income (LAMI) countries. There is increasing recognition that feeding behaviors and styles, particularly responsive feeding (RF), could influence acceptance of food and dietary intake and thus the growth of IYC. This paper presents the evolution of RF research and the strength of the evidence for RF on child undernutrition in LAMI countries. Multiple approaches were used to identify studies, including keyword searches in many databases, hand searches of retrieved articles, and consultation with experts in the field. Articles were included if they contained a RF exposure and child undernutrition outcome. In total, we identified 21 studies: 15 on child growth, 4 on dietary intake, 3 on disease, and 8 on eating behaviors. Most studies were conducted among children <36 mo of age and were published in the last 10 y. Cross-study comparisons were difficult due to multiple definitions of RF. One-half of the studies were observational with cross-sectional designs and few interventions were designed to isolate the effect of RF on child undernutrition. Overall, few studies have demonstrated a positive association between RF and child undernutrition, although there is promising evidence that positive caregiver verbalizations during feeding increase child acceptance of food. Recommendations for future research include consensus on the definition and measurement of RF, longitudinal studies that begin early in infancy, and randomized controlled trials that isolate the effect of RF on child undernutrition.