Children In Low- And Middle-income Countries Research Articles

Toll-Like Receptor-Induced Immune Responses During Early Childhood and Their Associations With Clinical Outcomes Following Acute Illness Among Infants in Sub-Saharan Africa.

Severely ill children in low- and middle-income countries (LMICs) experience high rates of mortality from a broad range of infectious diseases, with the risk of infection-related death compounded by co-existing undernutrition. How undernutrition and acute illness impact immune responses in young children in LMICs remains understudied, and it is unclear what aspects of immunity are compromised in this highly vulnerable population. To address this knowledge gap, we profiled longitudinal whole blood cytokine responses to Toll-like receptor (TLR) ligands among severely ill children (n=63; 2-23 months old) with varied nutritional backgrounds, enrolled in the CHAIN Network cohort from Kampala, Uganda, and Kilifi, Kenya, and compared these responses to similar-aged well children in local communities (n=41). Cytokine responses to ligands for TLR-4 and TLR-7/8, as well as Staphylococcus enterotoxin B (SEB), demonstrated transient impairment in T cell function among acutely ill children, whereas innate cytokine responses were exaggerated during both acute illness and following clinical recovery. Nutritional status was associated with the magnitude of cytokine responses in all stimulated conditions. Among children who died following hospital discharge or required hospital re-admission, exaggerated production of interleukin-7 (IL-7) to all stimulation conditions, as well as leukopenia with reduced lymphocyte and monocyte counts, were observed. Overall, our findings demonstrate exaggerated innate immune responses to pathogen-associated molecules among acutely ill young children that persist during recovery. Heightened innate immune responses to TLR ligands may contribute to chronic systemic inflammation and dysregulated responses to subsequent infectious challenges. Further delineating mechanisms of innate immune dysregulation in this population should be prioritized to identify novel interventions that promote immune homeostasis and improve outcomes.

Animal-source foods as a suitable complementary food for improved physical growth in 6 to 24-month-old children in low- and middle-income countries: a systematic review and meta-analysis of randomised controlled trials.

Although animal-source foods are suitable complementary food for child growth in low- and middle-income countries (LMICs), their efficacy is still under discussion. This systematic review and meta-analysis was done to investigate the suitability of animal-source foods intake on child physical growth in LMICs. A systematic literature search was done using electronic databases and scanning the reference list of included studies, previous meta-analysis and systematic reviews. Paper selection was based on the PICO (ST) criteria. Papers were selected if based on 6 to 24-month-old children, if they were randomised controlled trials evaluating the effect of complementary animal-based food supplementation of any natural origin, if reporting at least a measure of body size and published after 2000. The PRISMA guidelines for reporting systematic review was followed in the paper selection. Fourteen papers were included in the systematic review and eight were considered for the meta-analysis. Animal-based food supplementation resulted in a higher length-for-age LAZ and weight-for-age (WAZ) Z-scores compared with the control group with random effect size of 0·15 (95 % CI 0·02, 0·27) and 0·20 (95 % CI 0·03, 0·36), respectively. Results were confirmed after influence analyses, and publication bias resulted as negligible. An increased effect on LAZ and WAZ was observed when the food supplementation was based on egg with effect size of 0·31 (95 % CI = -0·03, 0·64) and 0·36 (95 % CI = -0·03, 0·75), respectively. Animal-source foods are a suitable complementary food to improve growth in 6 to 24-month-old children in LMICs.

Examining relations between performance on non-verbal executive function and verbal self-regulation tasks in demographically-diverse populations.

Self-regulation is a widely studied construct, generally assumed to be cognitively supported by executive functions (EFs). There is a lack of clarity and consensus over the roles of specific components of EFs in self-regulation. The current study examines the relations between performance on (a) a self-regulation task (Heads, Toes, Knees Shoulders Task) and (b) two EF tasks (Knox Cube and Beads Tasks) that measure different components of updating: working memory and short-term memory, respectively. We compared 107 8- to 13-year-old children (64 females) across demographically-diverse populations in four low and middle-income countries, including: Tanna, Vanuatu; Keningau, Malaysia; Saltpond, Ghana; and Natal, Brazil. The communities we studied vary in market integration/urbanicity as well as level of access, structure, and quality of schooling. We found that performance on the visuospatial working memory task (Knox Cube) and the visuospatial short-term memory task (Beads) are each independently associated with performance on the self-regulation task, even when controlling for schooling and location effects. These effects were robust across demographically-diverse populations of children in low-and middle-income countries. We conclude that this study found evidence supporting visuospatial working memory and visuospatial short-term memory as distinct cognitive processes which each support the development of self-regulation.

Providing care to children from low and middle-income countries with complex surgical problems: An 18 year review

PurposeThe burden of surgical disease in children from low and middle-income countries (LMICs) is becoming more recognized as significant and undertreated. We recently reviewed our health system's experience with providing quaternary-level surgical care to children from LMICs through a partnership with World Pediatric Project (WPP), a not-for-profit organization. MethodsA retrospective review was performed of all WPP-sponsored patients who received surgical care at our children's hospital from LMICs in the Caribbean and Central America from July 2000 to August 2018. ResultsTwo hundred and fifty-five patients (average age: 5.9 ± 5.3 years; range: <1–18 years) from 14 countries received a total of 371 moderately to significantly complex operations from 10 pediatric surgical subspecialties, with cardiac, neurosurgery, craniofacial and general/thoracic surgical subspecialties being the most common. The average length of hospital stay was 10.7 ± 18.9 days. All patients had the opportunity to follow-up with local providers and/or visiting WPP-sponsored surgical teams. 227 patients (93.8%) were seen by WPP providers or released to an in-country physician partnering with WPP. There were 21 (8.2%) total, minor and major, postoperative complications. Five deaths (2.0%) occurred at our institution and 7 from disease progression, after returning to their home country. ConclusionsProviding complex surgical care to LMIC children in the US may help address a significant global burden. This care can be provided by multiple subspecialists with excellent outcomes, good follow-up, and low complication and mortality rates. Having a supportive health care system, volunteer surgeons, and an organization that manages logistics and provides financial support is essential. Type of StudyClinical research, retrospective review Level of EvidenceLevel IV

Prevalence of Paediatric Surgical Conditions in Eastern Uganda: A Cross-Sectional Study

BackgroundThe role of surgery in global health has gained greater attention in recent years. Approximately 1.8 billion children below 15 years live in low- and middle-income countries (LMIC). Many surgical conditions affect children. Therefore, paediatric surgery requires specific emphasis. Left unattended, the consequences can be dire. Despite this, there is a paucity of data regarding prevalence of surgical conditions in children in LMIC. The present objective was to investigate the prevalence of paediatric surgical conditions in children in a defined geographical area in Eastern Uganda.MethodA cross-sectional study was carried out in the Iganga-Mayuge Health and Demographic Surveillance Site located in Eastern Uganda. Through a two-stage, cluster-based sampling process, 490 households from 49 villages were randomly selected, generating a study population of 1581 children. The children’s caregivers were interviewed, and the children were physically examined by two medical doctors to identify any surgical conditions.ResultsThe interview was performed with 1581 children, and 1054 were physically examined. Among these, the overall prevalence of any surgical condition was 16.0 per cent (n = 169). Of these, 39 per cent had an unmet surgical need (66 of 169). This is equivalent to a 6.3 per cent prevalence of current unmet surgical need. The most common groups of surgical condition were congenital anomalies and trauma-related conditions.ConclusionSurgical conditions in children are common in eastern Uganda. The unmet need for surgery is high. With a growing population, the need for paediatric surgical capacity will increase even further. The health care system must be reinforced to provide services for children with surgical conditions if United Nations Sustainability Development Goal 3 is to be achieved by 2030.

Digital Social and Emotional Literacy Intervention for Vulnerable Children in Brazil: Participants’ Experiences

Social emotional literacy (SEL) interventions are widely implemented through schools, with growing evidence for a range of positive child outcomes. Increasingly, such interventions are delivered on online platforms. To date, there is limited evidence about digital SEL interventions in low- and middle-income countries (LMIC). The aim of this study was to explore the perceptions and experiences of children, parents and facilitator of the potential value of addressing SEL via tailored digital intervention. The intervention was designed to help children, in Brazil, to cope during the first COVID-19 pandemic lockdown. The intervention was delivered via a digital platform to groups of three children for 45 min per week for nine. Thirteen children, nine parents and nine facilitators were interviewed following the completion of the intervention. The data was analysed through a codebook thematic approach, which led to three themes: empowerment, participatory aspects of the intervention and digital adaptation. Overall, children’s SEL development was reported to be supported during the COVID-19 pandemic, by the application of new skills outside the sessions. Children reported a number of empowering factors such as being heard and belonging. A range of useful participatory tools were identified including storytelling, games, drawings and videos. Blended SEL interventions involving both face-to-face and web-based facilitation could be developed within a tiered model of universal mental health promotion and targeted prevention. Access to online platforms would increase reach to large numbers of children in LMIC, especially in contexts of disadvantage.

The First Signs of Change: Predicting Clinical Deterioration and Mortality at Different Stages During Hospital Admission. A Systematic Review of Risk Prediction Models in Children in Low-And Middle-Income Countries

The First Signs of Change: Predicting Clinical Deterioration and Mortality at Different Stages During Hospital Admission. A Systematic Review of Risk Prediction Models in Children in Low-And Middle-Income Countries

Experiences of private sector quality care amongst mothers, newborns, and children in low- and middle-income countries: a systematic review

BackgroundExperience of care is a pillar of quality care; positive experiences are essential during health care encounters and integral to quality health service delivery. Yet, we lack synthesised knowledge of how private sector delivery of quality care affects experiences of care amongst mothers, newborns, and children. To fill this gap, we conducted a systematic review that examined quantitative, qualitative, and mixed-methods studies on the provision of maternal, newborn, and child health (MNCH) care by private providers in low- and middle-income countries (LMICs). This manuscript focuses on experience of care, including respectful care, and satisfaction with care.MethodsOur protocol followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Searches were conducted in eight electronic databases (Cumulative Index to Nursing and Allied Health, EconLit, Excerpta Medica Database, International Bibliography of the Social Sciences, Popline, PubMed, ScienceDirect, and Web of Science) and two websites and supplemented with hand-searches and expert recommendations. For inclusion, studies examining private sector delivery of quality care amongst mothers, newborns, and children in LMICs must have examined maternal, newborn, and/or child morbidity or mortality; quality of care; experience of care; and/or service utilisation. Data were extracted for descriptive statistics and thematic analysis.ResultsOf the 139 studies included, 45 studies reported data on experience of care. Most studies reporting experience of care were conducted in India, Bangladesh, and Uganda. Experiences of private care amongst mothers, newborns, and children aligned with four components of quality of care: patient-centeredness, timeliness, effectiveness, and equity. Interpersonal relationships with health care workers were essential to experience of care, in particular staff friendliness, positive attitudes, and time spent with health care providers. Experience of care can be a stronger determining factor in MNCH-related decision-making than the quality of services provided.ConclusionPositive experiences of care in private facilities can be linked more broadly to privileges of private care that allow for shorter waiting times and more provider time spent with mothers, newborns, and children. Little is known about experiences of private sector care amongst children.Trial registrationThis systematic review was registered with the PROSPERO international prospective register of systematic reviews (registration number CRD42019143383).

Family Structure Transitions: Prevalence and Physical Health Effects in Ethiopia, India, Peru, and Vietnam

This study aimed to identify the prevalence and physical health consequences of family structure transitions among children in Ethiopia, India, Peru, and Vietnam. In many high-income countries, family structure transitions are common, and research suggests that they can lead to worse physical health for children. However, we know little about either the prevalence or consequences of family structure transitions for children in low-and middle-income countries, who make up the vast majority of the world’s children. First, we estimated the number of family structure transitions by age 12 using four rounds of Young Lives data from four low-and middle-income countries (N = 8062, Ethiopia, India, Peru, and Vietnam) and validated our prevalence estimates with another dataset from these same countries. The proportion of children experiencing a family structure transition by age 12 was: 14.8% in Ethiopia, 5.6% in India, 22.0% in Peru, and 7.7% in Vietnam. We put these estimates in context by comparing them to 17 high- and upper-middle-income countries. Second, using linear mixed models, we found that family structure transitions were not directly associated with worse physical health for children in Ethiopia, India, Peru, and Vietnam. Children in Peru experienced higher rates of family structure transitions relative to children in the other Young Lives countries, and similar rates to many of the 17 comparison countries, yet physical health was unaffected. It is possible that in low-and middle-income countries, the environment may overwhelm family stability as a determinant of physical health.

Animal source foods, rich in essential amino acids, are important for linear growth and development of young children in low- and middle-income countries.

Growth faltering under 5 years of age is unacceptably high worldwide, and even more children, while not stunted, fail to reach their growth potential. The time between conception and 2 years of age is critical for development. The period from 6 to 23 months, when complementary foods are introduced, coincides with a time when growth faltering and delayed neurocognitive developments are most common. Fortunately, this is also the period when diet exercises its greatest influence. Growing up in an adverse environment, with a deficient diet, as typically seen in low‐ and middle‐income countries (LMICs), hampers growth and development of children and prevents them from realising their full developmental and economic future potential. Sufficient nutrient availability and utilisation are paramount to a child's growth and development trajectory, especially in the period after breastfeeding. This review highlights the importance of essential amino acids (EAAs) in early life for linear growth and, likely, neurocognitive development. The paper further discusses signalling through mammalian target of rapamycin complex 1 (mTORC1) as one of the main amino acid (AA)‐sensing hubs and the master regulator of both growth and neurocognitive development. Children in LMICs, despite consuming sufficient total protein, do not meet their EAA requirements due to poor diet diversity and low‐quality dietary protein. AA deficiencies in early life can cause reductions in linear growth and cognition. Ensuring AA adequacy in diets, particularly through inclusion of nutrient‐dense animal source foods from 6 to 23 months, is strongly encouraged in LMICs in order to compensate for less than optimal growth during complementary feeding.

Which public health interventions are effective in reducing morbidity, mortality and health inequalities from infectious diseases amongst children in low- and middle-income countries (LMICs): An umbrella review.

Despite significant progress in the last few decades, infectious diseases remain a major threat to child health in low- and middle-income countries (LMICs)-particularly amongst more disadvantaged groups. It is imperative to understand the best available evidence concerning which public health interventions reduce morbidity, mortality and health inequalities in children aged under five years. To address this gap, we carried out an umbrella review (a systematic reviews of reviews) to identify evidence on the effects of public health interventions (promotion, protection, prevention) on morbidity, mortality and/or health inequalities due to infectious diseases amongst children in LMICs. Ten databases were searched for records published between 2014-2021 alongside a manual search of gray literature. Articles were quality-assessed using the Assessment of Multiple Systematic Reviews tool (AMSTAR 2). A narrative synthesis was conducted. We identified 60 systematic reviews synthesizing 453 individual primary studies. A majority of the reviews reported on preventive interventions (n = 48), with a minority on promotion (n = 17) and almost no reviews covering health protection interventions (n = 2). Effective interventions for improving child health across the whole population, as well as the most disadvantaged included communication, education and social mobilization for specific preventive services or tools, such as immunization or bed nets. For all other interventions, the effects were either unclear, unknown or detrimental, either at the overall population level or regarding health inequalities. We found few reviews reporting health inequalities information and the quality of the evidence base was generally low. Our umbrella review identified some prevention interventions that might be useful in reducing under five mortality from infectious diseases in LMICs, particularly amongst the most disadvantaged groups.

The effectiveness of technology‐supported personalised learning in low‐ and middle‐income countries: A meta‐analysis

AbstractDigital technology offers the potential to address educational challenges in resource‐poor settings. This meta‐analysis examines the impact of students' use of technology that personalises and adapts to learning level in low‐ and middle‐income countries. Following a systematic search for research between 2007 and 2020, 16 randomised controlled trials were identified in five countries. Studies involved 53,029 learners aged 6–15 years. Coding examined learning domain (mathematics and literacy); personalisation level and delivery; technology use; and intervention duration and intensity. Overall, technology‐supported personalised learning was found to have a statistically significant—if moderate—positive effect size of 0.18 on learning (p = 0.001). Meta‐regression reveals how more personalised approaches which adapt or adjust to learners' level led to significantly greater impact (an effect size of 0.35) than those only linking to learners' interests or providing personalised feedback, support, and/or assessment. Avenues for future research include investigating cost implications, optimum programme length, and teachers' role in making personalised learning with technology effective. Practitioner notesWhat is already known about this topic? Promoting personalised learning is an established aim of educators. Using technology to support personalised learning in low‐ and middle‐income countries (LMICs) could play an important role in ensuring more inclusive and equitable access to education, particularly in the aftermath of COVID‐19. There is currently no rigorous overview of evidence on the effectiveness of using technology to enable personalised learning in LMICs. What this paper adds? The meta‐analysis is the first to evaluate the effectiveness of technology‐supported personalised learning in improving learning outcomes for school‐aged children in LMICs. Technology‐supported personalised learning has a statistically significant, positive effect on learning outcomes. Interventions are similarly effective for mathematics and literacy and whether or not teachers also have an active role in the personalisation. Personalised approaches that adapt or adjust to the learner led to significantly greater impact, although whether these warrant the additional investment likely necessary for implementation at scale needs to be investigated. Personalised technology implementation of moderate duration and intensity had similar positive effects to that of stronger duration and intensity, although further research is needed to confirm this. Implications for practice and/or policy: The inclusion of more adaptive personalisation features in technology‐assisted learning environments can lead to greater learning gains. Personalised technology approaches featuring moderate personalisation may also yield learning rewards. While it is not known whether personalised technology can be scaled in a cost‐effective and contextually appropriate way, there are indications that this is possible. The appropriateness of teachers integrating personalised approaches in their practice should be explored given ‘supplementary’ uses of personalised technology (ie, additional sessions involving technology outside of regular instruction) are common.

Hierarchical disentanglement of contextual from compositional risk factors of diarrhoea among under-five children in low- and middle-income countries

Several studies have documented the burden and risk factors associated with diarrhoea in low and middle-income countries (LMIC). To the best of our knowledge, the contextual and compositional factors associated with diarrhoea across LMIC were poorly operationalized, explored and understood in these studies. We investigated multilevel risk factors associated with diarrhoea among under-five children in LMIC. We analysed diarrhoea-related information of 796,150 under-five children (Level 1) nested within 63,378 neighbourhoods (Level 2) from 57 LMIC (Level 3) using the latest data from cross-sectional and nationally representative Demographic Health Survey conducted between 2010 and 2018. We used multivariable hierarchical Bayesian logistic regression models for data analysis. The overall prevalence of diarrhoea was 14.4% (95% confidence interval 14.2–14.7) ranging from 3.8% in Armenia to 31.4% in Yemen. The odds of diarrhoea was highest among male children, infants, having small birth weights, households in poorer wealth quintiles, children whose mothers had only primary education, and children who had no access to media. Children from neighbourhoods with high illiteracy [adjusted odds ratio (aOR) = 1.07, 95% credible interval (CrI) 1.04–1.10] rates were more likely to have diarrhoea. At the country-level, the odds of diarrhoea nearly doubled (aOR = 1.88, 95% CrI 1.23–2.83) and tripled (aOR = 2.66, 95% CrI 1.65–3.89) among children from countries with middle and lowest human development index respectively. Diarrhoea remains a major health challenge among under-five children in most LMIC. We identified diverse individual-level, community-level and national-level factors associated with the development of diarrhoea among under-five children in these countries and disentangled the associated contextual risk factors from the compositional risk factors. Our findings underscore the need to revitalize existing policies on child and maternal health and implement interventions to prevent diarrhoea at the individual-, community- and societal-levels. The current study showed how the drive to the attainment of SDGs 1, 2, 4, 6 and 10 will enhance the attainment of SDG 3.

Gender-related influences on adherence to advice and treatment-seeking guidance for infants and young children post-hospital discharge in Bangladesh

BackgroundPost-hospital discharge mortality risk is high among young children in many low and middle-income countries (LMICs). The available literature suggests that child, caregiver and health care provider gender all play important roles in post-discharge adherence to medical advice, treatment-seeking and recovery for ill children in LMICs, including those with undernutrition.MethodsA qualitative study was embedded within a larger multi-country multi-disciplinary observational cohort study involving children aged less than 2 years conducted by the Childhood Acute Illness and Nutrition (CHAIN) Network. Primary data were collected from family members of 22 purposively selected cohort children. Family members were interviewed several times in their homes over the 6 months following hospital discharge (total n = 78 visits to homes). These in-depth interviews were complemented by semi-structured individual interviews with 6 community representatives, 11 community health workers and 12 facility-based health workers, and three group discussions with a total of 24 community representatives. Data were analysed using NVivo11 software, using both narrative and thematic approaches.ResultsWe identified gender-related influences at health service/system and household/community levels. These influences interplayed to family members’ adherence to medical advice and treatment-seeking after hospital discharge, with potentially important implications for children’s recovery. Health service/system level influences included: fewer female medical practitioners in healthcare facilities, which influenced mothers’ interest and ability to consult them promptly for their child’s illnesses; gender-related challenges for community health workers in supporting mothers with counselling and advice; and male caregivers’ being largely absent from the paediatric wards where information sessions to support post-discharge care are offered. Gendered household/community level influences included: women’s role as primary caretakers for children and available levels of support; male family members having a dominant role in decision-making related to food and treatment-seeking behaviour; and greater reluctance among parents to invest money and time in the treatment of female children, as compared to male children.ConclusionsA complex web of gender related influences at health systems/services and household/community levels have important implications for young children’s recovery post-discharge. Immediate interventions with potential for positive impact include awareness-raising among all stakeholders – including male family members - on how gender influences child health and recovery, and how to reduce adverse consequences of gender-based discrimination. Specific interventions could include communication interventions in facilities and homes, and changes in routine practices such as who is present in facility interactions. To maximise and sustain the impact of immediate actions and interventions, the structural drivers of women’s position in society and gender inequity must also be tackled. This requires interventions to ensure equal equitable opportunities for men and women in all aspects of life, including access to education and income generation activities. Given patriarchal norms locally and globally, men will likely need special targeting and support in achieving these objectives.

Mental Health Among Children and Adolescents in Rural China: A Large-Scale Epidemiological Study

Background: Although children living in low-and middle-income countries (LMICs) account for 90% of the global population of children, mental health among children in LMICs has been understudied. This study examines the prevalence of depression and anxiety and their associations with biological and psychosocial factors among children across China, with a focus on rural areas. Methods: We conduct a large-scale epidemiological study among 53,421 elementary and junior high school-aged children across China’s rural areas. Findings: The results show that 20% are at risk for depression, 6% are at risk for generalized anxiety, and 68% are at risk for at least one type of anxiety. Girls and junior high school students show higher risk for mental health problems; socioeconomic status has varying associations to mental health. Our results also show robust correlations between mental health and cognition. Interpretation: These findings underscore the importance of identification, prevention, and treatment of youth mental health problems in underdeveloped areas. As China constitutes 15% of the global population of children under age 18, this study offers valuable information to the field of Global Mental Health, especially given its findings of high prevalence for multiple mental health problems and robust correlations between mental health and cognition. Funding Statement: This work was supported by the Enlight Foundation. Declaration of Interests: The authors have no conflicts of interest. Ethics Approval Statement: The six surveys conducted by the authors and their colleagues were approved by the Stanford University Institutional Review Board. Study permissions were also obtained from the Chinese government. In accordance with IRB requirements, all children involved in the surveys provided oral assent for the project, and the school principals – who serve as the children’s legal guardians while they are in school—also provided their written consent.

Association between Household Crowding and Violent Discipline and Neglect of Children: Analysis of Multiple Indicator Cluster Surveys in 26 Low- and Middle-Income Countries.

The influence of household crowding on physical and mental health has been well documented. However, research on the influence of household crowding on violent discipline and neglect of children is scarce. Therefore, we aimed to investigate whether household crowding was associated with violent discipline and neglect of children in low- and- middle-income countries (LMICs). Cross-sectional data for 280,005 and 73,030 children in 26 LMICs surveyed using the Multiple Indicator Cluster Survey were analyzed for (1) violent discipline and (2) neglect, respectively. In each country, we used logistic regression models to estimate the effects of household crowding on multiple forms of violent discipline and stimulation activities (as a proxy of the level of child neglect). Estimates were pooled using random effects meta-analyses. After adjusting for confounding variables, household crowding was associated with higher odds of any violent discipline (odds ratio (OR) = 1.09, 95% CI 1.03 to 1.15, p = 0.002) and lower odds of engaging in four or more stimulation activities (OR = 0.88, 95% CI 0.83 to 0.94, p < 0.001). The associations were stronger for urban children and children living in low- and lower-middle-income countries. The findings suggest that screenings and interventions aimed at reducing the effects of household crowding might be effective in preventing and controlling violent discipline and neglect of children in LMICs.

Whole-Genome Analyses Identifies Multiple Reassortant Rotavirus Strains in Rwanda Post-Vaccine Introduction

Children in low-and middle-income countries, including Rwanda, experience a greater burden of rotavirus disease relative to developed countries. Evolutionary mechanisms leading to multiple reassortant rotavirus strains have been documented over time which influence the diversity and evolutionary dynamics of novel rotaviruses. Comprehensive rotavirus whole-genome analysis was conducted on 158 rotavirus group A (RVA) samples collected pre- and post-vaccine introduction in children less than five years in Rwanda. Of these RVA positive samples, five strains with the genotype constellations G4P[4]-I1-R2-C2-M2-A2-N2-T1-E1-H2 (n = 1), G9P[4]-I1-R2-C2-M2-A1-N1-T1-E1-H1 (n = 1), G12P[8]-I1-R2-C2-M1-A1-N2-T1-E2-H3 (n = 2) and G12P[8]-I1-R1-C1-M1-A2-N2-T2-E1-H1 (n = 1), with double and triple gene reassortant rotavirus strains were identified. Phylogenetic analysis revealed a close relationship between the Rwandan strains and cognate human RVA strains as well as the RotaTeq® vaccine strains in the VP1, VP2, NSP2, NSP4 and NSP5 gene segments. Pairwise analyses revealed multiple differences in amino acid residues of the VP7 and VP4 antigenic regions of the RotaTeq® vaccine strain and representative Rwandan study strains. Although the impact of such amino acid changes on the effectiveness of rotavirus vaccines has not been fully explored, this analysis underlines the potential of rotavirus whole-genome analysis by enhancing knowledge and understanding of intergenogroup reassortant strains circulating in Rwanda post vaccine introduction.

Cancer in children: The tip of the iceberg.

Pediatric cancer outcomes have improved dramatically in high-income countries (HICs) with more than 80% of patients surviving. This has been achieved through early diagnosis, the formation of collaborative research groups, and government policies. However, most children with cancer in low and middle-income countries (LMICs) do not survive due to multiple factors including lack of resources, manpower, and national level pediatric cancer policy. If we need to improve the overall outcome of children with cancer then we need to focus our attention on children in LMICs as they constitute 80% of the worldwide disease burden. This article looks at the burden of pediatric cancer, examines pediatric oncology policy paralysis, and offers possible solutions for improving care for children with cancer.

Pediatric Mercury Exposure Among Children Involved in Artisanal and Small-Scale Gold Mining

Background: Artisanal and small-scale gold mining (ASGM) accounts for approximately 15 to 25% of the world’s gold production and is one of the largest sources of mercury released into the environment among low- and middle-income countries (LMICs).1 The International Labour Organization states that there are 4 to 5 million women and children working in ASGM. Mercury vapor produced from heating mercury-gold amalgam can lead to tremors, memory loss, and respiratory dysfunction. As of March 2020, 128 signatories have ratified the Minamata Convention, an aggressive policy action designed to protect human and environmental health from adverse effects of mercury. Despite this action, ~1,400 tons of mercury emissions annually from more than 70 countries. Methods: Published literature was examined to summarize adverse pediatric health outcomes associated with gold mining. The literature review included identifying data gaps needed to conduct cohort studies including the age of workers, frequency of exposure, and personal protective equipment utilized, among other indicators. Results: Our preliminary analysis indicates mercury exposure is not only a significant health threat to children in LMICs, but also ASGM has lax child labor standards, and therefore, requires more attention by policy decision-makers and governmental organizations. Countries are not required to provide a comprehensive registry and there is an absence of any reliable census of those engaged in these operations.Conclusions: As a result of our assessment, the total disease burden is likely unknown, limiting what is known to be a neglected broad public health problem. Surveillance is immediately needed, not only to estimate the global burden of disease but also to conduct urgent field testing in highly exposed nations. Given that comprehensive official registries are needed, a journal article and corresponding policy guide are being drafted to detail mechanisms to increase transparency and monitoring of child labor and working conditions in ASGM.

Interventions for reducing violence against children in low- and middle-income countries: An evidence and gap map.

More than half of the children in the world experience some form of interpersonal violence every year. As compared with high-income countries, policy responses in low- and middle-income countries (LMICs) are limited due to resource constraints and paucity of evidence for effective interventions to reduce violence against children in their own contexts, amongst other factors. The aim of this evidence and gap map (EGM) is to provide an overview of the existing evidence available and to identify gaps in the evidence base on the effectiveness of interventions to reduce violence against children in LMICs. This report covers evidence published in English; a follow-up study is under preparation focusing on evidence in five additional languages-Arabic, Chinese, French, Portuguese and Spanish. The intervention-outcome framework for this EGM is based on INSPIRE-Seven Strategies for Ending Violence against Children, published by WHO and other partners in 2016. The seven strategies includeimplementation and enforcement of laws; norms and values, safe environment; parent-child and caregiver support; income and economic strengthening; response and support services; education and life skills. The search included both academic and grey literature available online. We included impact evaluations and systematic reviews that assessed the effectiveness of interventions to reduce interpersonal violence against children (0-18 years) in LMICs (World Bank, 2018b). Interventions targeting subpopulation of parents, teachers and caregivers of 0-18 years' age group were also included. A critical appraisal of all included studies was carried out using standardised tools. The map includes 152 studies published in English of which 55 are systematic reviews and 97 are impact evaluations. Most studies in the map are from Sub-Saharan Africa. Education and life skills are the most widely populated intervention area of the map followed by income and economic strengthening interventions. Very few studies measure impact on economic and social outcomes, and few conduct cost-analysis. More studies focusing on low-income and fragile and conflict-affected settings (FCS) and studying and reporting on cost-analysis are required to address gaps in the evidence. Most interventions covered in the literature focused on addressing a wide range of forms of violence and harm, which limited understanding of how and for whom the interventions work in a given context, for specific forms of violence. More impact evaluation studies are required that assess specific forms of violence, gendered effects of interventions and on diverse social groups in a given context, utilising mixed methods.