Childhood Mortality In sub-Saharan Africa Research Articles

Azithromycin to Reduce Mortality — An Adaptive Cluster-Randomized Trial

BackgroundTwice-yearly mass distribution of azithromycin to children is a promising intervention to reduce childhood mortality in sub-Saharan Africa. The World Health Organization recommended restricting distribution to infants 1 to 11 months of age to mitigate antimicrobial resistance, although this more limited treatment had not yet been tested.MethodsWe randomly assigned rural communities in Niger to four twice-yearly distributions of azithromycin for children 1 to 59 months of age (child azithromycin group), four twice-yearly distributions of azithromycin for infants 1 to 11 months of age and placebo for children 12 to 59 months of age (infant azithromycin group), or placebo for children 1 to 59 months of age. Census workers who were not aware of the group assignments monitored mortality twice yearly over the course of 2 years. We assessed three primary community-level mortality outcomes (deaths per 1000 person-years), each examining a different age group and pairwise group comparison.ResultsA total of 1273 communities were randomly assigned to the child azithromycin group (1229 were included in the analysis), 773 to the infant azithromycin group (751 included in the analysis), and 954 to the placebo group (929 included in the analysis). Among 382,586 children, 419,440 person-years and 5503 deaths were recorded. Lower mortality among children 1 to 59 months of age was observed in the child azithromycin group (11.9 deaths per 1000 person-years; 95% confidence interval [CI], 11.3 to 12.6) than in the placebo group (13.9 deaths per 1000 person-years; 95% CI, 13.0 to 14.8) (representing 14% lower mortality with azithromycin; 95% CI, 7 to 22; P<0.001). Mortality among infants 1 to 11 months of age was not significantly lower in the infant azithromycin group (22.3 deaths per 1000 person-years; 95% CI, 20.0 to 24.7) than in the placebo group (23.9 deaths per 1000 person-years; 95% CI, 21.6 to 26.2) (representing 6% lower mortality with azithromycin; 95% CI, −8 to 19). Five serious adverse events were reported: three in the placebo group, one in the infant azithromycin group, and one in the child azithromycin group.ConclusionsAzithromycin distributions to children 1 to 59 months of age significantly reduced mortality and was more effective than treatment of infants 1 to 11 months of age. Antimicrobial resistance must be monitored. (Funded by the Bill and Melinda Gates Foundation; AVENIR ClinicalTrials.gov number, NCT04224987.)

A novel locus in CSMD1 gene is associated with increased susceptibility to severe malaria in Malian children

BackgroundPlasmodium falciparum malaria is still a leading cause of child mortality in sub-Saharan Africa. The clinical manifestations of malaria range from asymptomatic infection to severe disease. The variation in clinical presentation is partly attributed to host genetic factors with estimated narrow-sense heritability of 23%. Here, we investigate the associations between candidate gene polymorphisms and the likelihood of severe malaria (SM) in a cohort of Malian children.MethodsBased on our previous genome-wide association studies (GWAS) analysis, candidate genes were selected for in-depth analysis using several criteria including gene-level GWAS scores, functional overlap with malaria pathogenesis, and evidence of association with protection or susceptibility to other infectious or inflammatory diseases. Single Nucleotide Polymorphisms (SNPs) residing within these genes were selected mainly based on p-values from previous severe malaria susceptibility GWAS studies and minor allele frequency (MAF) in West African populations.ResultsOf 182 candidate genes reported in our previous study, 11 genes and 22 SNPs residing in these genes were selected. The selected SNPs were genotyped using KASP technology in 477 DNA samples (87 SM and 390 controls). Logistic regression analysis revealed that a common intron variant, rs13340578 in CUB and Sushi Multi Domain (CSMD1) gene, is associated with increased odds of SM in recessive mode of inheritance (MAF = 0.42, OR = 1.8, 95% CI = [1.78, 1.84], p = 0.029). The SNP is in linkage disequilibrium (LD) with multiple variants with regulatory features.ConclusionTaken together, the current study showed that an intron variant rs13340578, residing in CSMD1 gene, is associated with increased susceptibility to malaria. This finding suggests that modified regulation of complement may contribute to malaria disease severity. Further studies are needed to identify the causal variants and the underlying molecular mechanisms.

Identifying neonates at risk for post-discharge mortality in Dar es Salaam, Tanzania, and Monrovia, Liberia: Derivation and internal validation of a novel risk assessment tool

IntroductionThe immediate period after hospital discharge carries a large burden of childhood mortality in sub-Saharan Africa. Our objective was to derive and internally validate a risk assessment tool to identify...

Mapping evidence on factors contributing to maternal and child mortality in sub-Saharan Africa: A scoping review protocol.

Maternal and child mortality remains a major public health issue in sub-Saharan Africa (SSA), with the region having the highest under-five mortality rates, where approximately 1 in 11 children, dies before the age of 5 years. This is nearly 15 times the average in high-income countries (HICs). This scoping review is aimed at mapping evidence on the factors contributing to maternal and child mortality in SSA. This study will be conducted using a scoping review to map existing literature on the factors contributing to maternal and child mortality in SSA. The search will comprise of peer-reviewed and grey literature, using the EBSCOhost platform. Keyword search from electronic databases such as PubMed/MEDLINE, Google Scholar, Science Direct and World Health Organization library, will be conducted. Information will be obtained from the included studies, using a data charting table. We will use NVIVO version 10 software to analyse the data, and the narrative account of the study will be presented by means of a thematic content analysis. We expect to find relevant literature that can help us in mapping evidence on the factors contributing to maternal and child mortality in SSA. This study results are anticipated to identify research gaps and in turn, guide the design of future primary studies. Open Science Framework registration number (DOI 10.17605/OSF.IO/XF5VN).

The impact of malaria-protective red blood cell polymorphisms on parasite biomass in children with severe Plasmodium falciparum malaria.

Severe falciparum malaria is a major cause of preventable child mortality in sub-Saharan Africa. Plasma concentrations of P. falciparum Histidine-Rich Protein 2 (PfHRP2) have diagnostic and prognostic value in severe malaria. We investigate the potential use of plasma PfHRP2 and the sequestration index (the ratio of PfHRP2 to parasite density) as quantitative traits for case-only genetic association studies of severe malaria. Data from 2198 Kenyan children diagnosed with severe malaria, genotyped for 14 major candidate genes, show that polymorphisms in four major red cell genes that lead to hemoglobin S, O blood group, α-thalassemia, and the Dantu blood group, are associated with substantially lower admission plasma PfHRP2 concentrations, consistent with protective effects against extensive parasitized erythrocyte sequestration. In contrast the known protective ATP2B4 polymorphism is associated with higher plasma PfHRP2 concentrations, lower parasite densities and a higher sequestration index. We provide testable hypotheses for the mechanism of protection of ATP2B4.

Mapping of mothers' suffering and child mortality in Sub-Saharan Africa

Child death and mothers who suffer from child death are a public health concern in Sub-Saharan Africa. The location and associated factors of child death and mothers who suffer child death were not identified. To monitor and prioritize effective interventions, it is important to identify hotspots areas and associated factors. Data from nationally representative demographic and health survey and Multiple Indicator Cluster administrated in 42 Sub-Sahara Africa countries, which comprised a total of 398,574 mothers with 1,521,312 children. Spatial heterogeneity conducted hotspot regions identified. A mixed-effect regression model was run, and the adjusted ratio with corresponding 95% confidence intervals was estimated. The prevalence of mothers who suffer child death 27% and 45–49 year of age mother 48%. In Niger, 47% of mothers were suffering child death. Women being without HIV knowledge, stunted, wasted, uneducated, not household head, poor, from rural, and from subtropical significantly increased the odds of the case (P < 0.05). The spatial analysis can support the design and prioritization of interventions. Multispectral interventions for mothers who suffer from child death are urgently needed, improve maternal health and it will reduce the future risk of cases.

Effect of a single dose of oral azithromycin on malaria parasitaemia in children: a randomized controlled trial

BackgroundAzithromycin has recently been shown to reduce all-cause childhood mortality in sub-Saharan Africa. One potential mechanism of this effect is via the anti-malarial effect of azithromycin, which may help treat or prevent malaria infection. This study evaluated short- and longer-term effects of azithromycin on malaria outcomes in children.MethodsChildren aged 8 days to 59 months were randomized in a 1:1 fashion to a single oral dose of azithromycin (20 mg/kg) or matching placebo. Children were evaluated for malaria via thin and thick smear and rapid diagnostic test (for those with tympanic temperature ≥ 37.5 °C) at baseline and 14 days and 6 months after treatment. Malaria outcomes in children receiving azithromycin versus placebo were compared at each follow-up timepoint separately.ResultsOf 450 children enrolled, 230 were randomized to azithromycin and 220 to placebo. Children were a median of 26 months and 51% were female, and 17% were positive for malaria parasitaemia at baseline. There was no evidence of a difference in malaria parasitaemia at 14 days or 6 months after treatment. In the azithromycin arm, 20% of children were positive for parasitaemia at 14 days compared to 17% in the placebo arm (P = 0.43) and 7.6% vs. 5.6% in the azithromycin compared to placebo arms at 6 months (P = 0.47).ConclusionsAzithromycin did not affect malaria outcomes in this study, possibly due to the individually randomized nature of the trial.Trial registration This study is registered at clinicaltrials.gov (NCT03676751; registered 19 September 2018).

Effect of health systems context on infant and child mortality in sub-Saharan Africa from 1995 to 2015, a longitudinal cohort analysis

Each year, > 3 million children die in sub-Saharan Africa before their fifth birthday. Most deaths are preventable or avoidable through interventions delivered in the primary healthcare system. However, evidence regarding the impact of health system characteristics on child survival is sparse. We assembled a retrospective cohort of > 250,000 children in seven countries in sub-Saharan Africa. We described their health service context at the subnational level using standardized surveys and employed parametric survival models to estimate the effect of three major domains of health services—quality, access, and cost—on infant and child survival, after adjusting for child, maternal, and household characteristics. Between 1995 and 2015 we observed 13,629 deaths in infants and 5149 in children. In fully-adjusted models, the largest effect sizes were related to fees for services. Immunization fees were correlated with poor child survival (HR = 1.20, 95% CI 1.12–1.28) while delivery fees were correlated with poor infant survival (HR = 1.11, 95% CI 1.01–1.21). Accessibility of facilities and greater concentrations of private facilities were associated with improved infant and child survival. The proportion of facilities with a doctor was correlated with increased risk of death in children and infants. We quantify the impact of health service environment on survival up to five years of age. Reducing health care costs and improving the accessibility of health facilities should remain a priority for improving infant and child survival. In the absence of these fundamental investments, more specialized interventions may not achieve their desired impact.

Transition Readiness Assessment of Adolescents with Sickle Cell Disease and Their Caretakers at the Sickle Cell Clinic in Kumasi, Ghana

Background: Sickle Cell Disease (SCD) is associated with high child mortality in sub-Saharan Africa (SSA). Improved medical services within an established SCD program in Kumasi, Ghana have focused on enhanced newborn screening and comprehensive pediatric SCD care (Ohene-Frempong et al., 2008). These efforts have improved SCD survival and increased the need for adolescents to transition to adult care. We sought to understand patient and caretaker perspectives on transition to adult care for adolescents with SCD visiting the Komfo Anokye Teaching Hospital Sickle Cell Clinic (KATH SCC) in Kumasi, Ghana, where the transition occurs by age 15 years.Methods: Structured interviews were conducted with adolescents aged 12-15 years and adults who accompanied them to KATH SCC. Interviews queried 4 areas that are relevant for assessing transition readiness in the U.S.: SCD medical knowledge, symptom self-management, psychosocial impact, transition preparation. Interview questions were adapted from two surveys that assessed transition readiness of adolescents with SCD in the U.S. (Telfair et al., 2004; Treadwell et al., 2016) and modified to fit the Ghanaian context. Interviews were conducted in English or Twi (the prevalent local language), per participant preference. Responses were transcribed during the interview, and later translated into English, as needed, by one interviewer (MKS) for descriptive statistics and qualitative analysis.Results: In total, 46 children (mean age 13 years) and 46 accompanying adults were consented (or assented) and interviewed. Most participants selected Twi for interviews. Adults were either parents (70%) or close relatives, with mean age 39.8 years (range 18-70). SCD type was determined by clinic records: 59% of children interviewed had HbSS, 35% HbSC, and 6% had no SCD type recorded. Most children and their caretakers had some knowledge about SCD and management: 61% of children knew that SCD is a blood disorder, while 74% knew that SCD is an inherited disorder. Majority of children knew what to do to ease pain in crisis (61%), where to go for care (85%), what care is helpful (72%), and could engage with the hospital team independently (87%). Gaps in knowledge were evident for up to one third of children for each question. Their responses were corroborated by at least 46% of adults. Significantly fewer children (39%) knew their SCD type compared to the adults (63%) (p=0.02). Children who reported knowing how to handle a pain crisis used a combination of analgesics, folic acid, penicillin, and a local ointment, but did not understand that folic acid and penicillin are maintenance medications that do not relieve painful episodes. Children appeared more concerned than adults about their current health and social stigmatization than about future health-related challenges. Seventy-six percent of children worried about having SCD, 28% felt like burdens to family, 37% told their friends about having SCD, but 96% had plans for their future. Adults had different perspectives of disease burden, where only 48% and 6% believed their child worried and felt like a burden, respectively. Few children (35%) and adults (37%), were aware of the requirement to switch to adult care by age 15, but most (72% or 74%) were willing to transition when asked to do so.Conclusions: To the best of our knowledge, this is the first study of perspectives about care transition for adolescents with SCD and their caregivers in SSA. Our clinic-based assessment at a single site suggests that the youth and their adult caregivers are informed about SCD but lack information relevant to adequate medical care, are concerned about peer stigmatization and were unaware of the need to transition. Challenges to successful transition in the country may include the relatively young age of transition and gaps in knowledge needed for successful self-management. Future efforts to improve transition to adult SCD care may need to include education of adolescents and families about the disease, self-management, and transition and address sense of self-burden to families and stigmatization among peers. Generalizability of our findings and practical methods to address needs for SCD transition within Africa remain to be tested.Acknowledgments: Support to MKS by David E. Rogers Student Fellowship Award from New York Academy of Medicine and IFAP Global Program of Columbia University. We thank KATH SCC staff for facilitating this research. DisclosuresNo relevant conflicts of interest to declare.

Prevalence and determinants of severity levels of anemia among children aged 6-59 months in sub-Saharan Africa: A multilevel ordinal logistic regression analysis.

Anemia is a major public health problem affecting more than half of children under the age of five globally. It has serious short- and long-term consequences including growth retardation, impaired motor and cognitive development, and increased morbidity and mortality. Despite anemia is the leading cause of child mortality in sub-Saharan Africa, there is limited evidence on the prevalence and determinants of anemia among under-five children in sub-Saharan Africa. Therefore, this study aimed to investigate the prevalence and determinants of severity levels of anemia among children aged 6-59 months in sub-Saharan Africa. This study was based on the most recent Demographic and Health Survey (DHS) data of 32 sub-Saharan African countries. A total weighted sample of 135,619 children aged 6-59 months was included in the study. Considering the hierarchical nature of DHS data and the ordinal nature of anemia, a multilevel ordinal logistic regression model was applied. Proportional odds assumption was tested by Brant test and it was satisfied (p-value = 0.091). Besides, deviance was used for model comparison. Variables with a p-value ≤0.2 in the bivariable analysis were considered for the multivariable analysis. In the multivariable multilevel proportional odds model, the Adjusted Odds Ratio (AOR) with 95% Confidence Interval (CI) were reported for potential determinant factors of severity levels of anemia. The overall prevalence of anemia among children aged 6-59 months in sub-Saharan Africa was 64.1% [95% CI: 63.9%, 64.4%]. Of which, 26.2% were mildly anemic, 34.9% moderately anemic and 3% severely anemic. Poor maternal education, lower household wealth status, large family size, being male child, multiple births, having fever in the last two weeks, having diarrhea in the last two weeks, higher-order birth, maternal anemia, underweight, wasted, and stunted were significantly associated with increased odds of higher levels of anemia. Whereas, being 24-59 months age, taking drugs for an intestinal parasite, and born from mothers aged ≥ 20 years were significantly associated with lower odds of higher levels of anemia. Severity levels of anemia among children aged 6-59 months in sub-Saharan Africa was a major public health problem. Enhancing maternal education, providing drugs for an intestinal parasite, designing interventions that address maternal anemia, febrile illness, and diarrheal disease, and strengthening the economic status of the family are recommended to reduce childhood anemia. Furthermore, it is better to strengthen the strategies of early detection and management of stunted, wasted, and underweight children to decrease childhood anemia.

Estimating Sickle Cell Disease Child Mortality from the 2018 Nigeria Demographic and Health Survey

Background: Sickle cell disease (SCD) child mortality in sub-Saharan Africa (SSA) is presumably high but not well-quantified. This contributes to the neglect of SCD and delays the prioritization of interventions. Nigeria has the world’s largest SCD population. Methods: We used Nigeria’s 2018 Demographic and Health Survey (DHS) data to estimate prevalence and geographic distribution of HbSS and HbSC genotypes. We developed a novel approach for estimating SCD child mortality, combining information on tested children (n=10195) and their untested siblings (n=17205). Mortality differences were decomposed using the inheritance-derived genotypic distribution of untested siblings older than the tested cohort, enabling us to estimate excess SCD mortality for the older-sibling cohort (i.e., born between 2003 and 2013, n=15227). Findings: The average birth prevalence of HbSS and HbSC in Nigeria was 1.20% (95% CI: 1.11-1.32%) and 0.23% (95% CI: 0.18-0.28%), respectively. Children born during 2003-2013 with at least one younger sibling in the survey with SCD suffered about 99 (95% CI: 55,144) excess deaths per 1,000 live births, compared with children whose tested siblings were all HbAA. After decomposition, we estimate that children born in 2003-2013 with SCD suffered 480 (95% CI: 270,700) deaths per 1000 live births, 4.0 times (95%CI: 2.1-6.0) higher than comparable children with HbAA. About 4.2% (95%CI: 1.6%-6.8%) of national U5M was attributable to excess SCD mortality. Interpretation: SCD child mortality burden in Nigeria continues to be disproportionately high. The vast majority of these deaths could be prevented if available focused interventions were implemented. The methodology developed here can be used to estimate the burden elsewhere in Africa and South Asia. Funding Statement: APO and DLC are employees of the Bill & Melinda Gates Foundation; OEN is the Nigeria PI of the Sickle Pan African Research Consortium (NHLBI Grant No 1U24HL135881). Declaration of Interests: FBP declares personal fees from Bluebird Bio, outside of the submitted work. All other authors declare no competing interests.

Trends in sickle cell trait and disease screening in the Republic of Uganda, 2014-2019.

Sickle cell disease is an important public health issue that is increasingly recognised as a substantial contributor to morbidity and early childhood mortality in sub-Saharan Africa. We aimed to provide information from large-scale, long-term sickle cell screening efforts in Africa. We used nationally representative data from the centralised public health laboratory database in Uganda to examine epidemiological trends in sickle cell screening over a five-year period, comparing age and geographic adjustments to prevalence among different testing cohorts of children aged 0-24months, and calculating screening coverage within high-burden districts. A total of 324356 children aged 0-24months were screened for sickle cell trait and disease from February 2014 to March 2019. A high national burden of sickle cell disease (0.9%) was confirmed among a cohort of samples co-tested with HIV. In the cohort of samples referred specifically for sickle cell testing, the overall prevalence of sickle cell disease was 9.7% and particularly elevated in high-burden districts where focused screening occurred. The majority of children were screened before age 4months, but the sickle-specific cohort had a larger proportion of affected children tested between age 5-9months, coincident with onset of disease signs and symptoms. Successful screening coverage of sickle cell disease births was achieved in several high-burden districts. Examination and analysis of national sickle cell screening trends in Uganda documents the successes of focused screening strategies as an important step towards universal screening. With this evidence and increased healthcare provider knowledge, Uganda can optimise sickle cell diagnosis and management across the country.

Mass Azithromycin Use Increases Both Macrolide and Nonmacrolide Resistance Genes

Mass administration of azithromycin to young children has been shown to reduce childhood mortality in sub-Saharan Africa (NEJM JW Infect Dis Aug 2019

Macrolide and Nonmacrolide Resistance with Mass Azithromycin Distribution

BackgroundMass distribution of azithromycin to preschool children twice yearly for 2 years has been shown to reduce childhood mortality in sub-Saharan Africa but at the cost of amplifying macrolide resistance. The effects on the gut resistome, a reservoir of antimicrobial resistance genes in the body, of twice-yearly administration of azithromycin for a longer period are unclear.MethodsWe investigated the gut resistome of children after they received twice-yearly distributions of azithromycin for 4 years. In the Niger site of the MORDOR trial, we enrolled 30 villages in a concurrent trial in which they were randomly assigned to receive mass distribution of either azithromycin or placebo, offered to all children 1 to 59 months of age every 6 months for 4 years. Rectal swabs were collected at baseline, 36 months, and 48 months for analysis of the participants’ gut resistome. The primary outcome was the ratio of macrolide-resistance determinants in the azithromycin group to those in the placebo group at 48 months.ResultsOver the entire 48-month period, the mean (±SD) coverage was 86.6±12% in the villages that received placebo and 83.2±16.4% in the villages that received azithromycin. A total of 3232 samples were collected during the entire trial period; of the samples obtained at the 48-month monitoring visit, 546 samples from 15 villages that received placebo and 504 from 14 villages that received azithromycin were analyzed. Determinants of macrolide resistance were higher in the azithromycin group than in the placebo group: 7.4 times as high (95% confidence interval [CI], 4.0 to 16.7) at 36 months and 7.5 times as high (95% CI, 3.8 to 23.1) at 48 months. Continued mass azithromycin distributions also selected for determinants of nonmacrolide resistance, including resistance to beta-lactam antibiotics, an antibiotic class prescribed frequently in this region of Africa.ConclusionsAmong villages assigned to receive mass distributions of azithromycin or placebo twice yearly for 4 years, antibiotic resistance was more common in the villages that received azithromycin than in those that received placebo. This trial showed that mass azithromycin distributions may propagate antibiotic resistance. (Funded by the Bill and Melinda Gates Foundation and others; ClinicalTrials.gov number, NCT02047981.)

Household factors associated with infant and under-five mortality in sub-Saharan Africa countries

BackgroundChild mortality has become a prominent public health issue in sub-Saharan Africa (SSA). The mortality rates can in part be translated to how communities meet the health needs of children and address key household and environmental risk factors. Though discussions on the trends and magnitude of child mortality continue as to strategize for a lasting solution, large gap exists specifically in family characteristics associated with child death. Moreover, household dynamics of child mortality in SSA is under researched despite the fact that mortality rates remain high. This study aimed to examine the influence of household structure on child mortality in SSA.MethodsSecondary data from birth histories in recent Demographic and Health Survey (DHS) in 35 SSA countries were used in this study. The total sample data of children born in the 5 years prior to the surveys were 384,747 births between 2008 and 2017. Unadjusted and adjusted Cox proportional hazard regression model was fitted to model infant and under-five mortality. The measure of association was hazard ratio (HR) with 95% confidence interval (CI). Statistical test was conducted at p < 0.05 level of significance.ResultsTotal infant mortality rates were highest in Sierra Leone (92 deaths per 1000 live births), Chad (72 deaths per 1000 live births) and Nigeria (69 deaths per 1000 live births), respectively. Furthermore, total rates of under-five mortality across 35 SSA countries were highest in Cameroon (184 deaths per 1000 live births), Sierra Leone (156 deaths per 1000 live births) and Chad (133 deaths per 1000 live births). The risk of infant mortality was higher in households of polygyny, compared with households of monogyny (HR = 1.23; CI 1.16, 1.29). Households with large number of children (3–5 and ≥ 6) had higher risk of infant mortality, compared with those with 1–2 number of children. Infants from mothers with history of multiple union had 16% increase in the risk of infant mortality, compared with those from mothers from only one union (HR = 1.16; CI 1.09, 1.24). Furthermore, under-five from female household headship had 10% significant reduction in the risk of mortality, compared with those from male household headship (HR = 0.90; CI 0.84, 0.96). The risk of under-five mortality was higher in households of polygyny, compared with monogyny (HR = 1.33; CI 1.28, 1.38). Households with large number of children (3–5 and ≥ 6) had higher risk of under-five mortality, compared with those with 1–2 number of children ever born. Under-five from mothers with history of multiple union had 30% increase in the risk of mortality, compared with those from mothers from only one union (HR = 1.30; CI 1.24, 1.36).ConclusionHousehold structure significantly influences child mortality in SSA. Knowledge of drivers of infant and child death is crucial in health policy, programmes designs and implementation. Therefore, we suggest that policies to support strong healthy families are urgently needed to improve children’s survival.

Geographical disparities and determinants of childhood diarrheal illness in Ethiopia: further analysis of 2016 Ethiopian Demographic and Health Survey

BackgroundChildhood diarrheal illness is the second leading cause of child mortality in sub-Saharan Africa, including Ethiopia. Epidemiology of diarrhea has long-term implications with respect to medical, social, and economic consequences. Studies hypothesize that there have been regional differences, and this study aimed to examine the spatial variations and identify the determinants of childhood diarrhea in Ethiopia.MethodsData from the 2016 Demographic and Health Survey of Ethiopia (EDHS), which included 10,337 aged under 5 years were analyzed. The survey was conducted using a two-stage stratified sampling design. The study attempted to detect and test the clustering of diarrhea cases using global Moran’s I and LISA. Descriptive statistics followed by mixed-effect logistic regressions were used to identify factors related to the prevalence of diarrhea.ResultsOverall, 11.87% of the children experienced childhood diarrheal illness. The study showed that the risk was high in the southern and central parts and low in the eastern and western regions of the country. Children aged 6–12 (AOR = 2.66, [95% CI 2.01, 3.52]), 12–23 (AOR = 2.45, [95% CI 1.89, 3.17]), and 24–35 (AOR = 1.53, [95% CI 1.17, 2.01]) months were more likely to suffer from childhood diarrhea than those aged less than 6 months. Children in Tigray (AOR = 1.69 [95% CI 1.01, 2.83]), Amhara (AOR = 1.80, [95% CI 1.06, 3.06]), SNNPR (AOR = 2.04, [95% CI 1.22, 3.42]), and Gambella (AOR = 2.05, [95% CI 1.22, 3.42]) were at higher risk than those in Addis Ababa. The odds of getting diarrhea decreased by 24% among households with ≥ 3 under-five children compared to those with only one under-five child (AOR = 0.76 [95% CI 0.61, 0.94]). The odds of getting diarrheal illness for the children of employed mothers increased by 19% compared to those children of non-employed mothers (AOR = 1.19 [95% CI 1.03, 1.38]).ConclusionsChildhood diarrheal disease is prevalent among under-five children, particularly in the regions of SNNP, Gambella, Oromia, and Benishangul Gumuz, while the regions are generally making progress in reducing childhood illness. Capacity building programs with the best experience sharing and better home environments can be effective in reducing the incidence of childhood diarrhea in Ethiopia.

Investigating persistent measles dynamics in Niger and associations with rainfall.

Measles is a major cause of child mortality in sub-Saharan Africa. Current immunization strategies achieve low coverage in areas where transmission drivers differ substantially from those in high-income countries. A better understanding of measles transmission in areas with measles persistence will increase vaccination coverage and reduce ongoing transmission. We analysed weekly reported measles cases at the district level in Niger from 1995 to 2004 to identify underlying transmission mechanisms. We identified dominant periodicities and the associated spatial clustering patterns. We also investigated associations between reported measles cases and environmental drivers associated with human activities, particularly rainfall. The annual and 2–3-year periodicities dominated the reporting data spectrum. The annual periodicity was strong with contiguous spatial clustering, consistent with the latitudinal gradient of population density, and stable over time. The 2–3-year periodicities were weaker, unstable over time and had spatially fragmented clustering. The rainy season was associated with a lower risk of measles case reporting. The annual periodicity likely reflects seasonal agricultural labour migration, whereas the 2–3-year periodicity potentially results from multiple mechanisms such as reintroductions and vaccine coverage heterogeneity. Our findings suggest that improving vaccine coverage in seasonally mobile populations could reduce strong measles seasonality in Niger and across similar settings.

Rapid Reduction of Campylobacter Species in the Gut Microbiome of Preschool Children after Oral Azithromycin: A Randomized Controlled Trial.

Campylobacter has emerged as a potential important cause of childhood morbidity in sub-Saharan Africa. Biannual mass azithromycin distribution has previously been shown to reduce all-cause child mortality in sub-Saharan Africa. We conducted a randomized controlled trial in Burkina Faso in which children were randomized in a 1:1 fashion to a 5-day course of azithromycin or placebo to investigate the effect of oral antibiotics on the gut microbiome. We evaluated the changes in the gut microbiome of preschool children treated with azithromycin using metagenomic DNA sequencing. We found that three Campylobacter species were reduced with azithromycin treatment compared with placebo. These results were consistent with other studies that have shown decreases in Campylobacter species after azithromycin treatment, generating the hypothesis that a decrease in Campylobacter may contribute to observations of reduction in mortality following azithromycin distribution.

Risk factors for mortality among Tanzanian infants and children

BackgroundDuring the era of the Millennium Development Goals, under 5 mortality rates decreased significantly worldwide; however, reductions were not equally distributed. Children in sub-Saharan Africa still account for more than 50% of the world’s annual childhood deaths among children under 5 years of age. Understanding upstream risk factors for mortality among children may reduce the large burden of childhood mortality in sub-Saharan Africa. Our objective was to identify risk factors for mortality among infants and children in Tanzania.MethodsWe conducted a secondary analysis of data pooled from two randomized-controlled micronutrient supplementation trials. A total of 4787 infants were enrolled in the two trials (n = 2387 HIV-exposed and n = 2400 HIV-unexposed). Predictors of mortality were assessed using unadjusted and adjusted hazard ratios (aHRs).ResultsThere were 307 total deaths, 262 (11%) among children who were HIV-exposed and 45 (2%) among children who were HIV-unexposed (P < 0.001). The most common cause of death was respiratory diseases (n = 109, 35.5%). Causes of death did not significantly differ between HIV-exposed and HIV-unexposed children. In adjusted regression analyses, children with birth weight <2500 g (aHR 1.75, 95% CI 1.21–2.54), Apgar score of ≤7 at 5 min (aHR 2.16, 95% CI 1.29–3.62), or who were HIV-exposed but not infected (aHR 3.35, 95% CI 2.12–5.28) or HIV-infected (aHR 27.56, 95% CI 17.43–43.58) had greater risk of mortality.ConclusionsInfection with HIV, low birthweight, or low Apgar scores were associated with higher mortality risk. Early identification and modification of determinants of mortality among infants and children may be the first step to reducing such deaths.

Housing and child health in sub-Saharan Africa: A cross-sectional analysis.

BackgroundHousing is essential to human well-being but neglected in global health. Today, housing in Africa is rapidly improving alongside economic development, creating an urgent need to understand how these changes can benefit health. We hypothesised that improved housing is associated with better health in children living in sub-Saharan Africa (SSA). We conducted a cross-sectional analysis of housing conditions relative to a range of child health outcomes in SSA.Methods and findingsCross-sectional data were analysed for 824,694 children surveyed in 54 Demographic and Health Surveys, 21 Malaria Indicator Surveys, and two AIDS Indicator Surveys conducted in 33 countries between 2001 and 2017 that measured malaria infection by microscopy or rapid diagnostic test (RDT), diarrhoea, acute respiratory infections (ARIs), stunting, wasting, underweight, or anaemia in children aged 0–5 years. The mean age of children was 2.5 years, and 49.7% were female. Housing was categorised into a binary variable based on a United Nations definition comparing improved housing (with improved drinking water, improved sanitation, sufficient living area, and finished building materials) versus unimproved housing (all other houses). Associations between house type and child health outcomes were determined using conditional logistic regression within surveys, adjusting for prespecified covariables including age, sex, household wealth, insecticide-treated bed net use, and vaccination status. Individual survey odds ratios (ORs) were pooled using random-effects meta-analysis. Across surveys, improved housing was associated with 8%–18% lower odds of all outcomes except ARI (malaria infection by microscopy: adjusted OR [aOR] 0.88, 95% confidence intervals [CIs] 0.80–0.97, p = 0.01; malaria infection by RDT: aOR 0.82, 95% CI 0.77–0.88, p < 0.001; diarrhoea: aOR 0.92, 95% CI 0.88–0.97, p = 0.001; ARI: aOR 0.96, 95% CI 0.87–1.07, p = 0.49; stunting: aOR 0.83, 95% CI 0.77–0.88, p < 0.001; wasting: aOR 0.90, 95% CI 0.83–0.99, p = 0.03; underweight: aOR 0.85, 95% CI 0.80–0.90, p < 0.001; any anaemia: aOR 0.87, 95% CI 0.82–0.92, p < 0.001; severe anaemia: aOR 0.89, 95% CI 0.84–0.95, p < 0.001). In comparison, insecticide-treated net use was associated with 16%–17% lower odds of malaria infection (microscopy: aOR 0.83, 95% CI 0.78–0.88, p < 0.001; RDT: aOR 0.84, 95% CI 0.79–0.88, p < 0.001). Drinking water source and sanitation facility alone were not associated with diarrhoea. The main study limitations are the use of self-reported diarrhoea and ARI, as well as potential residual confounding by socioeconomic position, despite adjustments for household wealth and education.ConclusionsIn this study, we observed that poor housing, which includes inadequate drinking water and sanitation facility, is associated with health outcomes known to increase child mortality in SSA. Improvements to housing may be protective against a number of important childhood infectious diseases as well as poor growth outcomes, with major potential to improve children’s health and survival across SSA.