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Shigellosis remains a major cause of diarrheal disease in developing countries and causes substantial morbidity and mortality in children. Vaccination represents a promising preventive measure to fight the burden of the disease, but despite enormous efforts, an efficacious vaccine is not available to date. The use of an innovative biosynthetic Escherichia coli glycosylation system substantially simplifies the production of a multivalent conjugate vaccine to prevent shigellosis. This bioconjugation approach has been used to produce the Shigella dysenteriae type O1 conjugate that has been successfully tested in a phase I clinical study in humans. In this report, we describe a similar approach for the production of an additional serotype required for a broadly protective shigellosis vaccine candidate. The Shigella flexneri 2a O-polysaccharide is conjugated to introduced asparagine residues of the carrier protein exotoxin A (EPA) from Pseudomonas aeruginosa by co-expression with the PglB oligosaccharyltransferase. The bioconjugate was purified, characterized using physicochemical methods and subjected to preclinical evaluation in rats. The bioconjugate elicited functional antibodies as shown by a bactericidal assay for S. flexneri 2a. This study confirms the applicability of bioconjugation for the S. flexneri 2a O-antigen, which provides an intrinsic advantage over chemical conjugates due to the simplicity of a single production step and ease of characterization of the homogenous monomeric conjugate formed. In addition, it shows that bioconjugates are able to raise functional antibodies against the polysaccharide antigen. [ABSTRACT FROM AUTHOR]

Background There are limited data on the epidemiology of very late-onset schizophrenia-like psychosis (VLOSLP) and how this relates to potential risk factors including migration, sensory impairment, traumatic life events, and social isolation. Methods We followed up a cohort of 3 007 378 people living in Sweden, born 1920–1949, from their 60th birthday (earliest: January 15, 1980) until December 30 2011, emigration, death, or first recorded diagnosis of nonaffective psychosis. We examined VLOSLP incidence by age, sex, region of origin, income, partner or child death, birth period, and sensory impairments. Results We identified 14 977 cases and an overall incidence of 37.7 per 100 000 person-years at-risk (95% CI = 37.1–38.3), with evidence that rates increased more sharply with age for women (likelihood ratio test: χ2(6) = 31.56, P <.001). After adjustment for confounders, rates of VLOSLP were higher among migrants from Africa (hazard ratio [HR] = 2.0, 95% CI = 1.4–2.7), North America (HR = 1.4, 95% CI = 1.0–1.9, P =.04), Europe (HR = 1.3, 95% CI = 1.2–1.4), Russian-Baltic regions (HR = 1.6, 95% CI = 1.4–1.9), and Finland (HR = 1.6, 95% CI = 1.5–1.7). VLOSLP risk was highest for those in the lowest income quartile (HR = 3.1, 95% CI = 2.9–3.3). Rates were raised in those whose partner died 2 years before cohort exit (HR = 1.1, 95% CI = 1.0–1.3, P =.02) or whose child died in infancy (HR = 1.2, 95% CI = 1.0–1.4, P =.05), those without a partner (HR = 1.9, 95% CI = 1.8–1.9) or children (HR = 2.4, 95% CI = 2.3–2.5), and those whose child had a psychotic disorder (HR = 2.4, 95% CI = 2.2–2.6). Interpretation We identified a substantial burden of psychosis incidence in old age, with a higher preponderance in women and most migrant groups. Life course exposure to environmental factors including markers of deprivation, isolation, and adversity were associated with VLOSLP risk. [ABSTRACT FROM AUTHOR]

Background The aim of this article is to determine the factors associated with under-5 mortality and their evolution from 1993 to 2010 and to analyse the contributors of socioeconomic inequalities in mortality of children under-5 years during the same period. Data and methods The data used in this study were derived from the four rounds of Demographic and Health Survey (DHS) conducted in Burkina Faso in 1993, 1998 and 2010. Concentration measurement, logistics regression and Oaxaca–Blinder decomposition method were used to analyse data. Results Multivariate analysis revealed that being the first child (odds ratio = 1.8 for 1993, 1.7 for 1998, 1.2 for 2003 and 1.3 for 2010) or a twin (odds ratio = 4.5 for 1993, 2.8 for 1998, 2.7 for 2003 and 4.8 for 2010) were also significantly associated with the probability of dying. The variable (parity) was the main contributor to the part of the inequality due to differences in group characteristics and that would be due to the fact that women from poor households have greater parity compared to those from rich households. Conclusion For a reduction in mortality and inequalities related to mortality, the implementation of actions in favour of poor households and promotion of family planning programmes for birth spacing will be required. [ABSTRACT FROM AUTHOR]

Background: Many low- and middle-income countries are experiencing high and increasing exposure to ambient fine particulate air pollution (PM2.5). The effect of PM2.5 on infant and child mortality is usually modelled using concentration response curves extrapolated from studies conducted in settings with low ambient air pollution, which may not capture its full effect.Methods: We pool data on more than half a million births from 69 nationally representative Demographic and Health Surveys that were conducted in 43 low- and middle-income countries between 1998 and 2014, and we calculate early-life exposure (exposure in utero and post partum) to ambient PM2.5 using high-resolution calibrated satellite data matched to the child's place of residence. We estimate the association between the log of early-life PM2.5 exposure, both overall and separated by type, and the odds of neonatal and infant mortality, adjusting for child-level, parent-level and household-level characteristics.Results: We find little evidence that early-life exposure to overall PM2.5 is associated with higher odds of mortality relative to low exposure to PM2.5. However, about half of PM2.5 is naturally occurring dust and sea-salt whereas half is from other sources, comprising mainly carbon-based compounds, which are mostly due to human activity. We find a very strong association between exposure to carbonaceous PM2.5 and infant mortality, particularly neonatal mortality, i.e. mortality in the first 28 days after birth. We estimate that, at the mean level of exposure in the sample to carbonaceous PM2.5-10.9 µg/m3-the odds of neonatal mortality are over 50% higher than in the absence of pollution.Conclusion: Our results suggest that the current World Health Organization guideline of limiting the overall ambient PM2.5 level to less than 10 µg/m³ should be augmented with a lower limit for harmful carbonaceous PM2.5. [ABSTRACT FROM AUTHOR]

Background Acute lower respiratory tract infections (ALRIs) especially severe ALRIs, constitute a global high burden of morbidity and mortality in children <5 y of age and respiratory syncytial virus (RSV) has been documented to a play a major aetiological role. However, Nigerian reports on severe childhood RSV ALRIs are rare and most reports are old. With recent advances in RSV preventive strategy, arises the need for a recent appraisal of RSV infection in children with severe ALRI. The current study thus set out to determine the prevalence of RSV infection among hospitalized children <5 y of age and describe the related social determinants. Methods We performed a descriptive cross-sectional study conducted over 1 y of 120 children, ages 2–59 months, diagnosed with ALRI. Relevant data were obtained and an antigen detection assay was used for viral studies. Results The prevalence of RSV infection was 34.2% and its peak was in the rainy months. The proportion of infants in the RSV-positive group was significantly higher than that in the RSV-negative group (82.9% vs 54.4%; p=0.002). These findings were largely consistent with those of earlier reports. Conclusions RSV has remained a common cause of severe ALRI in infants, especially during the rainy months in Nigeria. It is thus suggested that more effort be focused towards implementing the current global recommendations for the prevention of RSV-associated LRI, particularly in infants. [ABSTRACT FROM AUTHOR]

Pneumonia is a significant cause of death for children, particularly those in developing countries. The records of children who were hospitalized because of pneumonia between January 2003 and December 2015 were retrospectively reviewed, and patients who met the recurrent pneumonia criteria were included in this study. During this 13-year period, 1395 patients were hospitalized with pneumonia; of these, 129 (9.2%) met the criteria for recurrent pneumonia. Underlying diseases were detected in 95 (73.6%) patients, with aspiration syndrome (21.7%) being the most common. Rhinovirus (30.5%), adenovirus (17.2%) and respiratory syncytial virus (13.9%) were the most frequent infectious agents. These results demonstrate that underlying diseases can cause recurrent pneumonia in children. Viruses are also commonly seen in recurrent pneumonia. Appropriate treatments should be chosen based on an analysis of the underlying disease, the patient's clinical condition and the laboratory and radiological data. [ABSTRACT FROM AUTHOR]

Background Most research on parental bereavement and health have analysed health consequences of parental loss in childhood, while collateral health in adulthood has been less studied. Methods Using register-based population data from Finland, we analyse adult offspring aged 18–50 years with discrete-time hazard models that adjust for offspring and parental socioeconomic and demographic characteristics. In focus are adult children whose parents were alive and lived together at the beginning of the observation period. We compare two culturally distinct but otherwise similar ethno-linguistic groups, Finnish speakers and Swedish speakers. Results The results suggest that bereaved men have an approximately 30% higher death risk than non-bereaved men, while there is practically no difference in women. Associations between parental and child deaths are, as expected, stronger for concordant causes of death than for discordant causes of death. However, some associations for discordant causes of death remain, which may indicate causality. Among Swedish speakers, who have notably higher family stability than Finnish speakers, the death of one or both parents shows a stronger association with own mortality. Conclusions The estimated associations found are generally larger than in the neighbouring country Sweden, which may be due to a stronger obedience to traditional family values and patriarchal family roles in Finland. These findings suggest that the association between parental death and mortality in adult offspring may depend on the societal context as well as on cultural practices. These factors should be increasingly acknowledged in future studies on collateral health. [ABSTRACT FROM AUTHOR]

Background In 2010, Brazil introduced child restraint legislation (CRL). We assessed the effectiveness of CRL in reducing child (aged 0–8 years) injuries and fatalities by race. We performed an evaluation study with an interrupted time–series design. Methods We measured the effect of CRL on two outcomes—number of child deaths and number of child injured in traffic collisions per child population, stratified by race, from 2008 to 2014. We controlled for time, unemployment rate and oil consumption (barrels/day in thousands). Results The CRL was associated with a 3% reduction in the rate of child injuries among whites (incidence rate ratio (IRR): 0.97; 95% CI: 0.96–0.99), but no reduction in child injuries among non-whites (IRR: 0.99; 95% CI: 0.99–1.00). In the first month after the implementation of Brazil's CRL we observed a 39% reduction in all child fatalities (IRR: 0.61; 95% CI: 0.44–0.84), including a 52% reduction among whites (IRR: 0.48; 95% CI: 0.33–0.68), but no reduction in non-white fatalities (IRR: 0.87; 95% CI: 0.55–1.37). Conclusions Our results support the hypothesis that socially advantaged populations were more likely to consistently adopt and employ restraint devices following the reform. Countries should also consider complementary policies that facilitate an equitable distribution of safety devices that reach vulnerable populations. [ABSTRACT FROM AUTHOR]

View large Download slide View large Download slide OBJECTIVES Publications on the paediatric Berlin Heart EXCOR ventricular assist device have revealed that low body weight <10 kg is a significant risk factor for mortality with children weighing <5 kg being at the highest risk. However, these studies are limited to implantation periods prior to 2011. Since then, progress has been made in the optimization of patient selection and management. This study investigated whether the survival of children weighing <10 kg supported with the EXCOR assist device has improved in recent years and sought to determine the risk factors for mortality. METHODS The Berlin Heart EXCOR prospective registry (n  = 1832) was retrospectively reviewed between 2000 and 2017 to compare the outcomes of different weight cohorts: A (<5 kg; n  = 204), B (5–10 kg; n  = 633) and C (>10 kg; n  = 995) in different eras [era 1: January 2000–December 2012 (n  = 1089) and era 2: January 2013–June 2017 (n  = 743)]. RESULTS Overall survival in groups A and B significantly increased from era 1 to era 2 (group A 51% vs 65%, P  < 0.001; group B 74% vs 78%, P  = 0.001), whereas it remained stable in group C (78% vs 73%). In era 2, the survival of group B was not significantly different from group C. On the multivariable analysis of children weighing <5 kg, congenital heart disease, preoperative extracorporeal life support and biventricular support were independently associated with increased mortality in era 1 [hazard ratio 2.04 (95% confidence interval 1.18–3.53); 2.44 (1.36–4.37) and 1.93 (1.11–3.34), respectively] but not in era 2. CONCLUSIONS Paediatric EXCOR ventricular assist device therapy has significantly improved for patients weighing <10 kg. Withholding a ventricular assist device is not justified on the basis of the body weight alone. [ABSTRACT FROM AUTHOR]

Background: Consensus is growing that policy reform programmes by the International Monetary Fund (IMF)-an international organization mandated with upholding global financial stability and assisting countries in economic turmoil-produce adverse effects on public health. However, this consensus is unclear about which policies of these programmes underlie these effects. This article fills parts of this gap by examining the impact of four kinds of IMF policies (fiscal policy, public-sector employment, privatization of state-owned enterprises and price liberalization) on public-health expenditure, child vaccination and child mortality.Methods: We conducted time-series cross-section analyses for up to 128 developing countries over the 1980-2014 period using observational data on health outcomes and IMF conditionality for different policy areas. IMF effectiveness research faces two types of potential biases: self-selection into IMF programmes and IMF policy conditions. We deployed instrumental variables in a seemingly unrelated regression framework to address both types of endogeneity, besides traditional remedies such as the use of fixed effects on countries and years.Results: IMF policy conditions on public-sector employment are negatively related to child health. A change from the minimum to the maximum number of such policy conditions decreases vaccination (which ranges from 0 to 100) by 10.97% [95% confidence interval (CI): 1.16 to 20.79]. This effect is robust against different sets of control variables. In addition, IMF programmes increase the share of government expenditure devoted to public health in developing countries by 0.91 percentage points (95% CI: 0.15 to 1.68).Conclusions: These findings suggest that IMF policies-particularly those that require public-sector reforms-undermine health by weakening the capacity of states to deliver vaccination. Therefore, international financial institutions need to increase their awareness of the public-health impact of their policy prescriptions. Strengthening state capacity in times of economic crisis would ensure that increased health spending also delivers quality healthcare. [ABSTRACT FROM AUTHOR]

Background: Worldwide, reduction in under-five mortality has not sufficiently included neonates, who represent 45% of deaths in children of age under five years. The least progress has been observed in resource-limited settings.Methods: This mixed methods study conducted at a Cambodian non-governmental paediatric hospital described the key priorities of the ongoing neonatal service. Routinely collected data from the hospital and microbiology databases included the number of admissions, discharges and deaths and the number of cases of bacteraemias (2011-2016). Semi-structured interviews with the management staff explored the essential features of the service.Results: There were 2127 neonatal admissions and 247 deaths. The incidence of facility-based neonatal mortality decreased by 81%. Bacteraemic healthcare-associated infections decreased by 68%. A dedicated area for neonatal care was perceived as crucial, allowing better infection control and delivery of staff training.Conclusions: In this hospital, the neonatal service prioritized basic measures, particularly, having a dedicated neonatal area. Facility-based mortality and bacteraemic healthcare-associated infections decreased. [ABSTRACT FROM AUTHOR]

This article examines variation in the association between maternal education and infant mortality across the 50 U.S. states. An analysis of 22,967,018 Vital Statistics records from 1997-2002, reveals evidence of dramatic cross-state differences. In some states, infants born to mothers with less than 12 years of schooling are more than twice as likely to die as infants of mothers with 4 years of college or more. Other states see far more equality between these groups. I then evaluate two components of state medical systems that are predicted to be associated with this variation in the magnitude of inequalities in infant mortality: neonatal intensive care units and primary care physician supply. More widespread availability of neonatal intensive care is associated with reduced inequalities in infant mortality. In contrast, the supply of primary care is linked to slightly larger differences in infant mortality between mothers with low and high education. [ABSTRACT FROM AUTHOR]

At least one‐third of infants born in sub‐Saharan Africa have been exposed to the effects of maternal HIV infection and antiretroviral treatment. Intrauterine HIV exposure is associated with increased rates of morbidity and mortality in children. Although the mechanisms responsible for poor infant health with HIV‐1 exposure are likely to be multifactorial, we posit that the maternal environment during gestation and in the perinatal period results in altered infant immunity and is possibly the strongest contributing factor responsible for the disproportionally high infectious events among HIV‐exposed infants who remain HIV uninfected. This review provides a synthesis of studies reporting the impact of intrauterine HIV exposure, feeding practices, and microbiota on immune ontogeny in the first year of life in HIV‐exposed uninfected infants. Review on the impact of HIV exposure, feeding practices and microbiota on immune ontogeny in HIV exposed uninfected infants. [ABSTRACT FROM AUTHOR]

Despite numerous international and national efforts, only 12 countries in the World Health Organization's African Region met the Millennium Development Goal #4 (MDG#4) to reduce under-five mortality by two-thirds by 2015. Given the variability across sub-Saharan Africa, a four-country study was undertaken to examine barriers and facilitators of child survival prior to 2015. Liberia and Zambia were chosen to represent countries making substantial progress towards MDG#4, while Kenya and Zimbabwe represented countries making less progress. Our individual case studies suggested that strong health governance and leadership (HGL) was a significant driver of the greater success in Liberia and Zambia compared with Kenya and Zimbabwe. To elucidate specific components of national HGL that may have substantially influenced the pace of reductions in child mortality, we conducted a cross-country analysis of national policies and strategies pertaining to maternal, neonatal and child health (MNCH) and qualitative interviews with individuals working in MNCH in each of the four study countries. The three aspects of HGL identified in this study which most consistently contributed to the different progress towards MDG#4 among the four study countries were (1) establishing child survival as a top national priority backed by a comprehensive policy and strategy framework and sufficient human, financial and material resources; (2) bringing together donors, strategic partners, health and non-health stakeholders and beneficiaries to collaborate in strategic planning, decision-making, resource-allocation and coordination of services; and (3) maintaining accountability through a 'monitor-review-act' approach to improve MNCH. Although child mortality in sub-Saharan Africa remains high, this comparative study suggests key health leadership and governance factors that can facilitate reduction of child mortality and may prove useful in tackling current Sustainable Development Goals. [ABSTRACT FROM AUTHOR]

Ramadan exposure in utero can be regarded as a natural experiment with which to study how nutritional conditions in utero influence susceptibility to disease later in life. We analyzed data from rural Burkina Faso on 41,025 children born between 1993 and 2012, of whom 25,093 were born to Muslim mothers. Ramadan exposure was assigned on the basis of overlap between Ramadan dates and gestation, creating 7 exclusive categories. We used proportional hazards regression with difference-in-differences analysis to estimate the association between Ramadan exposure at different gestational ages and mortality among children under 5 years of age. Under-5 mortality was 32 deaths per 1,000 child-years. Under-5 mortality among Muslims was 15% higher than that among non-Muslims (P < 0.001). In the difference-in-differences analysis, the occurrence of Ramadan during conception or the first or second trimester was associated with higher under-5 mortality rates among Muslims only. The mortality rates of children born to Muslim mothers were 33%, 29%, and 22% higher when Ramadan occurred during conception, the first trimester, and the second trimester, respectively, compared with children of non-Muslim mothers born at the same time (P = 0.01, P < 0.001, and P = 0.007). Having a Muslim mother was not associated with mortality when the child was not exposed to Ramadan, born during Ramadan, or exposed during the third trimester. Observance of Ramadan during early pregnancy can have detrimental consequences for the future health of the unborn child. [ABSTRACT FROM AUTHOR]

Maternal and child mortality rates remain unacceptably high globally, particularly in sub-Saharan Africa. A popular approach to counter these high rates is interventions delivered using mobile phones (mHealth). However, few mHealth interventions have been implemented nationwide and there has been little evaluation of their effectiveness, particularly at scale. Therefore, we evaluated the Rwanda RapidSMS programme-one of the few mHealth programmes in Africa that is currently operating nationwide. Using interrupted time series analysis and monthly data routinely reported by public health centres (n = 461) between 2012 and 2016, we studied the impact of RapidSMS on four indicators: completion of four antenatal care visits, deliveries in a health facility, postnatal care visits and malnutrition screening. We stratified all analyses based on whether the district received concurrent additional supports, including staff and equipment (10 out of 30 Districts). We found that community health workers in Rwanda sent more than 9.3 million messages using RapidSMS, suggesting the programme was successfully implemented. We found that the implementation of the RapidSMS system combined with additional support including training, supervision and equipment provision increased the use of maternal and child health services. In contrast, implementing the RapidSMS system alone was ineffective. This suggests that mHealth programmes alone may be insufficient to improve the use of health services. Instead, they should be considered as a part of more comprehensive interventions that provide the necessary equipment and health system capacity to support them. [ABSTRACT FROM AUTHOR]

An editorial is presented on the address the health of children at the border. Topics inlcude the complex medical challenges that children who immigrate to the U.S. with their families and subsequently held at the southern border for prolonged periods face, the conditions at the border being infectious diseases physician's nightmare has cramped living conditions, and the delayed access to medical care, and no access to vaccinations that could prevent the spread of transmissible diseases.

Before September 2018, no child had died in United States Border Patrol custody in a decade. Since then, 7 detained children have died in the past 10 months. Migrant children's bodies have become the latest political battlefield, and these children have been caught in the crossfire. This piece focuses on the recent deaths of several migrant children from overwhelming infections in United States detainment centers. The circumstances surrounding these illnesses bring to the fore concerns about the care of these children, suggesting infectious disease outbreaks in these detainment centers, delays in bringing children to medical attention, and inadequate medical expertise in their care. There is an urgent need for advocacy by clinicians and professional societies to resolve this crisis. [ABSTRACT FROM AUTHOR]

Current understanding of the causes of under-5 childhood deaths in low- and middle-income countries relies heavily on country-level vital registration data and verbal autopsies. Reliable data on specific causes of deaths are crucial to target interventions more effectively and achieve rapid reductions in under-5 mortality. The Child Health and Mortality Prevention Surveillance (CHAMPS) network aims to systematically describe causes of child death and stillbirth in low- and middle-income countries using minimally invasive tissue sampling. The articles in this supplement introduce the set of foundational epidemiologic, demographic surveillance, social behavioral science, and laboratory methods. Undergirding the CHAMPS surveillance system designed to determine causes of child mortality. [ABSTRACT FROM AUTHOR]

Background Two doses of measles vaccine (MV) might reduce the nonmeasles mortality rate more than 1 dose of MV does. The effect of 2 versus 1 dose on morbidity has not been examined. Within a randomized trial of the effect of 2 doses versus 1 dose of MV on mortality in Guinea-Bissau, we investigated the effect on hospital admissions. Methods Children were randomly assigned 1:2 to receive MV at 4.5 and 9 months of age or the currently recommended dose at 9 months. We compared hospital admission rates among children between 9 and 18 months of age in a Cox regression model with age as the underlying time scale. Half of the children had received neonatal vitamin A supplementation (NVAS) in another trial. The beneficial effect of MV at 4.5 and 9 months on mortality was limited to children who had not received NVAS; therefore, we investigated the interaction of MV with NVAS on admission rates. Results Among 5626 children (2 doses of MV, 1960 children; 1 dose of MV, 3666), we identified 311 hospital admissions of children between 9 and 18 months of age. Overall, compared to 1 dose of MV, 2 doses reduced the risk of hospital admission for children who had not received NVAS (hazard ratio [HR], 0.66 [95% confidence interval (CI), 0.47–0.93]), but we found no effect among NVAS recipients (HR, 1.16 [95% CI, 0.82–1.63]) (P =.02 for interaction). Conclusions The benefit of 2 doses of MV was limited to children who had not received NVAS. NVAS is not generally recommended; hence, an early 2-dose measles vaccination policy might reduce hospital admissions more than the current policy of providing the first MV at 9 months of age. Trial registration ClinicalTrials.gov identifier NCT00168558. [ABSTRACT FROM AUTHOR]

Background: Metrics that quantify economic and social spatial polarization at multiple geographical levels are not routinely used by health agencies, despite rising inequalities.Methods: We employed the Index of Concentration at the Extremes (ICE), which quantifies how persons in a specified area are concentrated into the top vs bottom of a specified societal distribution, to examine associations with Massachusetts mortality data (2010-14). Our a priori hypotheses were that these associations would: be greater at the local [census tract (CT)] compared with city/town level; vary by race/ethnicity but not gender; and be greatest for our new ICE for racialized economic segregation. Mortality outcomes comprised: child (< 5 years); premature (< 65 years); and cause-specific (cancer; cardiovascular; diabetes; suicide; HIV/AIDS; accidental poisoning; smoking-attributable).Results: As illustrated by child mortality, in multilevel models jointly including CT and city/town metrics, the rate ratio comparing the worst to best-off ICE quintile for the total population ranged from 2.2 [95% confidence interval (CI) 1.6, 3.0] for the CT-level ICE for racialized economic segregation down to 1.1 (95% CI 0.8, 1.7) for the city/town-level ICE for racial segregation; similar patterns occurred by gender and for the non-Hispanic White population. Larger associations for the ICE for racialized economic segregation were at the CT-level for the Black non-Hispanic population (6.9; 95% CI 1.3, 36.9) and at the city/town level for the Hispanic population (6.4; 95% CI 1.2, 35.4).Conclusions: Results indicate that health agencies should employ measures of spatial social polarization at multiple levels to monitor health inequities. [ABSTRACT FROM AUTHOR]

Background: Reducing child mortality remains a key objective in the Sustainable Development Goals. Although remarkable progress has been made with respect to under-5 mortality over the last 25 years, little is known regarding the relative contributions of public health interventions and general improvements in socioeconomic status during this time period.Methods: We combined all available data from the Demographic and Health Survey (DHS) to construct a longitudinal, multi-level dataset with information on subnational-level key intervention coverage, household socioeconomic status and child health outcomes in sub-Saharan Africa. The dataset covers 562 896 child records and 769 region-year observations across 24 countries. We used multi-level multivariable logistics regression models to assess the associations between child mortality and changes in the coverage of 17 key reproductive, maternal, newborn and child health interventions such as bednets, water and sanitation infrastructure, vaccination and breastfeeding practices, as well as concurrent improvements in social and economic development.Results: Full vaccination coverage was associated with a 30% decrease in the odds of child mortality [odds ratio (OR) 0.698, 95% confidence interval (CI) 0.564, 0.864], and continued breastfeeding was associated with a 24% decrease in the odds of child mortality (OR 0.759, 95% CI 0.642, 0.898). Our results suggest that changes in vaccination coverage, as well as increases in female education and economic development, made the largest contributions to the positive mortality trends observed. Breastfeeding was associated with child survival but accounts for little of the observed declines in mortality due to declining coverage levels during our study period.Conclusions: Our findings suggest that a large amount of progress has been made with respect to coverage levels of key health interventions. Whereas all socioeconomic variables considered appear to strongly predict health outcomes, the same was true only for very few health coverage indicators. [ABSTRACT FROM AUTHOR]

Background. In addition to protecting against measles, measles vaccine (MV) may have beneficial nonspecific effects. We tested the effect of an additional early MV on mortality and measles antibody levels. Methods. Children aged 4-7 months at rural health and demographic surveillance sites in Burkina Faso and Guinea- Bissau were randomized 1:1 to an extra early standard dose of MV (Edmonston-Zagreb strain) or no extra MV 4 weeks after the third diphtheria-tetanus-pertussis-hepatitis B-Haemophilus influenzae type b vaccine. All children received routine MV at 9 months. We assessed mortality through home visits and compared mortality from enrollment to age 3 years using Cox proportional hazards models, censoring for subsequent nontrial MV. Subgroups of participants had blood sampled to assess measles antibody levels. Results. Among 8309 children enrolled from 18 July 2012 to 3 December 2015, we registered 145 deaths (mortality rate: 16/1000 person-years). The mortality was lower than anticipated and did not differ by randomization group (hazard ratio, 1.05; 95% confidence interval, 0.75-1.46). At enrollment, 4% (16/447) of children in Burkina Faso and 21% (90/422) in Guinea-Bissau had protective measles antibody levels. By age 9 months, no measles-unvaccinated/-unexposed child had protective levels, while 92% (306/333) of early MV recipients had protective levels. At final follow-up, 98% (186/189) in the early MV group and 97% (196/202) in the control group had protective levels. Conclusions. Early MV did not reduce all-cause mortality. Most children were susceptible to measles infection at age 4-7 months and responded with high antibody levels to early MV. Clinical Trials Registration. NCT01644721. [ABSTRACT FROM AUTHOR]

Early mortality and morbidity remain high in children initiating antiretroviral therapy (ART), especially in sub-Saharan Africa. Many children still present with advanced human immunodeficiency virus (HIV) disease. Tuberculosis, pneumonia, and severe bacterial infections are the main causes of hospital admission in HIV-infected children. In contrast to adults with advanced HIV disease, cryptococcal disease is not common in childhood, although there is a peak in infancy and adolescence. Interventions such as TB screening in symptomatic children, and isoniazid and cotrimoxazole prophylaxis should be implemented. There is evidence suggesting that rapid initiation (within 1 week) of ART in children with severe malnutrition or those with advanced HIV disease admitted to hospital is not beneficial and should be delayed until their condition has been stabilized. Research informing the prevention of severe bacterial infections, the management of pediatric immune reconstitution inflammatory syndrome, and other potential strategies to decrease morbidity and mortality in HIV-infected children are urgently needed. [ABSTRACT FROM AUTHOR]

Background: the number of childless older people is increasing in China, but relatively little is known about the role of childlessness in health outcomes. This study investigates the relationship between childlessness and three health outcomes: difficulty with Instrumental Activities of Daily Living (IADLs), self-rated health and depression. Methods: this study includes 13,171 individuals aged 50 and above from national survey data of the second wave of the China Family Panel Study (2012). Binary/multinomial logistic and ordinary least squares regression models are presented. Results: childless individuals whose children have all died exhibit worse health outcomes than individuals with children, but this effect is influenced by demographic characteristics, socio-economic status and social security. On the other hand, individuals who are childless due to other reasons (involuntary or voluntary) are less likely to report difficulty with IADLs and to report depression than older people with all children alive after controlling for demographic and socio-economic and social security factors. Conclusions: the death of a child has an adverse effect on people's health for both childless people whose children have all died and those who have lost a child but have other children alive. These two groups are in the most vulnerable position, which could also suggest that their children have died because they grew up in a vulnerable family. The government needs to improve the social security for these two groups and provide social services (particularly mental health services) to older people who have lost a child; these could contribute to alleviating some of the adverse effects of the death of a child. [ABSTRACT FROM AUTHOR]

Background: Three randomized trials (RCTs) in low-weight (<2.5 kg) infants have shown that Bacille Calmette-Guérin (BCG) vaccine nonspecifically reduces all-cause mortality in the neonatal period.Methods: Using data from 3 RCTs of early BCG (n = 6583) we examined potential sex differences in the timing of the mortality reduction in the neonatal period, presenting metaestimates of the main outcome mortality rate ratios (MRR) for BCG-vaccinated and controls.Results: Among controls, boys had a particularly high mortality during the first week after randomization: male-female MRR 2.71 (95% CI, 1.70-4.50). During the first week, BCG had a marked beneficial effect for boys, reducing mortality 3-fold (MRR [BCG/no BCG] = 0.36 [0.20-0.67]). In weeks 2-4 the effect waned for boys (MRR = 0.91 [0.51-1.69]). In girls, the pattern was opposite with a limited effect in the first week (MRR = 0.85 [0.46-1.54]), but a significant reduction in weeks 2-4 (MRR = 0.56 [0.31-1.00]). This was consistent in all 3 trials. Verbal autopsies linked early benefit to fewer sepsis-related deaths among BCG-vaccinated boys.Discussion: The marked reduction in mortality in the days after BCG vaccination in boys emphasizes the importance of providing BCG soon after birth.Trial registration numbers: ClinicalTrials.gov (NCT00146302) and ClinicalTrials.gov (NCT00625482). [ABSTRACT FROM AUTHOR]

The article talks about the global crisis of social reproduction that has resulted in an urgency to global political life. Topics discussed include the relationship between low investment by the state in health care and education and higher maternal and child mortality rates, and the politics of poverty and solidarity.

Whether year-to-year variation in crop yields affects the nutrition, health, and survival of subsistence-farming populations is relevant to the understanding of the potential impacts of climate change. However, the empirical evidence is limited. We examined the associations of child survival with interannual variation in food crop yield and middle-upper arm circumference (MUAC) in a subsistence-farming population of rural Burkina Faso. The study was of 44, 616 children aged <5 years included in the Nouna Health and Demographic Surveillance System, 1992-2012, whose survival was analyzed in relation to the food crop yield in the year of birth (which ranged from 65% to 120% of the period average) and, for a subset of 16, 698 children, to MUAC, using shared-frailty Cox proportional hazards models. Survival was appreciably worse in children born in years with low yield (full-adjustment hazard ratio = 1.11 (95% confidence interval: 1.02, 1.20) for a 90th- to 10th-centile decrease in annual crop yield) and in children with small MUAC (hazard ratio = 2.72 (95% confidence interval: 2.15, 3.44) for a 90th- to 10th-centile decrease in MUAC). These results suggest an adverse impact of variations in crop yields, which could increase under climate change. [ABSTRACT FROM AUTHOR]

Child-abuse-related deaths (CARD) and child mortality rates (CMR) are important issues in every culture. This paper examines both CARD and CMR in seventeen former communist countries (FCCs) since the end of the Russian hegemony, with two Western comparator countries: the USA and the UK. World Health Organisation CARD and CMR data (birth to four years) between 1988-90 and 2012-14 have been extrapolated. Chi-square tests compare each FCC mortality outcome with the Western comparators over the period. To avoid under-reporting of CARD, undetermined deaths are also analysed and combined with confirmed CARD to provide a maximum estimate of abuse-related deaths. Combined CARD fell substantially in all FCCs, on average by 66 per cent. Russia had the least successful reduction (-25 per cent). Combined CARD fell significantly more in sixteen FCCs than in the USA. CMR in FCCs fell on average by 66 per cent over the period. Moldova, Russia and FRY Macedonia have the highest current CMR. Thirteen FCCs had significantly greater CMR reductions than the Western comparators. All but one FCCs met the UN millennium 2 per cent per annum reduction target for CMR but not the USA and Bulgaria. Most FCCs have made substantial improvements in reducing CARD and CMR. Country-specific research is required to investigate the major differences between FCCs and Western comparator outcomes. [ABSTRACT FROM AUTHOR]

Extensive scholarship addresses whether and how social movements can have consequences for outcomes of interest to them. Though divided in its conclusions, existing research generally shares a focus on potential contributions of movements to the codification of rights and adoption of policies, rather than their actual implementation. Often, however, palpable enactment of the crystallized laws and policies that movements demand is far from guaranteed, raising salient questions about whether and how movements can matter for implementation outcomes as well. To address such questions, the article uses a mixed-methods analysis to examine consequences of subnational office-holding by "sanitarista" activists from the Sanitarist Movement--contemporary Brazil's most important health movement--for rates of primary public health coverage and childhood mortality. Before reviewing existing theories and conceptualizing movement office-holding, it briefly describes the movement's role in codifying Brazil's constitutional right to health and demanding new local democratic institutions for enacting that right. Then, Prais-Winsten regression analyses of all major Brazilian capitals between 1995 and 2014 show that sanitarista office-holding atop a key subnational institution was associated with broader health service coverage and lower mortality. Comparative case-study analysis illustrates that office-holding sanitaristas helped generate these improvements by leveraging new democratic offices to marshal support of subnational executives for the movement's modest but effective state-building project in the municipal health sector. Ultimately, theories of movement consequences benefit from considering how in certain democratic contexts, subnational office-holding can constitute an important standalone outcome with considerable promise to also improve policy implementation and social development. [ABSTRACT FROM AUTHOR]

Background Socioeconomic inequality in child mortality highlights opportunities for policies to reduce child deaths. Methods We used singleton birth, death and maternity records from Scotland, 1981-2011, to examine mortality rate differences by age across deprivation quintiles over time. We measured the difference between the most and least deprived quintiles (Q5-Q1) and the slope index of inequality (SII) across all quintiles--measures of the absolute deprivation gap, providing an indication of the public health impact. Results Q5--Q1 remained relatively constant from 1990 onwards for early neonates, widened in the mid-2000s for late neonates, increased in the 1990 s then decreased in the 2000 s in the post-neonates and declined over time in early childhood. The trend over time in SII showed no significant change for early neonates (P = 0.440), significant decrease for post-neonates (P = 0.010) and early childhood (P = 0.043), and significant increase for late neonates (P = 0.011). Conclusions Over three decades, the absolute deprivation gap in mortality widened in late neonates but stabilized or declined at other ages. This may reflect improved survival beyond the early neonatal period of babies with conditions related to socioeconomic inequality such as prematurity. Monitoring birth cohort data could enhance understanding of this vulnerable group. [ABSTRACT FROM AUTHOR]

Background. Pneumonia is now the second leading cause of death for children aged <5 years worldwide. However, analyses of the long-term evolution of under-5 mortality from pneumonia are still scarce in the literature. We aimed to explore long-term trends of under-5 mortality from pneumonia in 56 countries from 1960 to 2012. Methods. Data on under-5 mortality from pneumonia were extracted from the World Health Organization mortality database. Long-term trends were assessed for 56 countries and for 4 national income transition groups. We also used joinpoint regression analysis to detect distinct period segments of long-term trends and estimate the annual percent of changes of each period segment. Results. The average mortality rate from pneumonia for children aged 0-4 years in 56 countries declined from 163.0 per 100 000 children (95% confidence interval [CI], 119.4 to 212.8) in 1960 to 9.9 per 100 000 children (95% CI, 6.4 to 13.4) in 2012, with an average annual percent of change of-5.6% (95% CI,-7.2% to-3.9%). The temporal trends of childhood mortality were different between national income transition groups. Conclusions. Our findings suggest a striking overall downward trend in under-5 mortality from pneumonia between 1960 and 2012. However, the rate and absolute terms of decline differ by national income transition group. These variable patterns between national income transition groups may inform further intervention setting and priority setting. [ABSTRACT FROM AUTHOR]

Inspired by the historical English experience, we modify the Beckerian paradigm of fertility by incorporating costly, societal influence on contraception. Heterogeneous, generationally-linked households choose between 'traditional' and 'modern' contraception. The modern has a higher fixed but lower variable cost of averting childbirths. Initially the rich adopt the modern, which unleashes society-wide diffusion. Eventually everyone switches, lowering fertility further and across households. Hastening the switch is falling child mortality. Quantitative experiments suggest contraception was a vital link between the historical mortality and fertility transitions, though not the latter's proximate cause. Implications for more recent transitions are discussed. [ABSTRACT FROM AUTHOR]

Two rotavirus vaccines, Rotarix (RV1) and RotaTeq (RV5), were licensed for global use in 2006. A systematic review of 48 peerreviewed articles with postlicensure data from 24 countries showed a median RV1 vaccine effectiveness (VE) of 84%, 75%, and 57% in countries with low, medium, and high child mortality, respectively, and RV5 VE of 90% and 45% in countries with low and high child mortality, respectively. A partial vaccine series provided considerable protection, but not to the same level as a full series. VE tended to decline in the second year of life, particularly in medium- and high-mortality settings, and tended to be greater against more severe rotavirus disease. Postlicensure data from countries across geographic regions and with different child mortality levels demonstrate that under routine use, both RV1 and RV5 are effective against rotavirus disease, supporting the World Health Organization recommendation that all countries introduce rotavirus vaccine into their national immunization program. [ABSTRACT FROM AUTHOR]

We study the short-run and long-run economic impact of one of the largest losses that an individual can face; the death of a child. We utilise unique registers on the entire Swedish population, combining information on the date and cause of death with parental outcomes. We exploit the longitudinal dimension of the data and deal with several selection issues. Losing a child has adverse effects on labour income, employment status, marital status and hospitalisation. The value of policy measures aimed at preventing mortal accidents of children is underestimated if it does not take bereavement effects on parents into account. [ABSTRACT FROM AUTHOR]

Child mortality is one of the most pressing global health and policy issues in the developing world. The leading drivers of death-pneumonia, diarrhea and malaria-are preventable and treatable. However, these illnesses are exacerbated by a lack of accessible nutrition, water, basic and preventive health services, and sanitary living conditions-all factors which are more likely to disproportionately impact the poor. We examine whether Kenya's largest social protection impacts children's incidence of upper respiratory illness. The Kenya Cash Transfer for Orphans and Vulnerable Children was designed to support orphans affected by HIV/AIDS and has covered over 240,000 households as of 2014. Using longitudinal, cluster-randomized program data from 2007 to 2009, we run a generalized linear latent and mixed method estimation model on a sample of children 0-7 years and under-5 years of age. We find that the program is associated with a decrease in illness in children 0-7 years of age (P < 0.05), but found no effects on a stratified sample of under-5 children. Furthermore, no impacts on health care seeking in the event of illness were detected. This study is one of few examining children's health using data from a large scale unconditional cash transfer program. With the widespread adoption of over 123 cash transfer programs across sub-Saharan Africa, these findings suggest social cash transfer programs are capable of promoting the multidimensional well-being for the world's most vulnerable populations. [ABSTRACT FROM AUTHOR]

Background Invasive non-typhoidal Salmonella (iNTS) disease is a well-described cause of mortality in children and human immunodeficiency virus (HIV)-infected adults in sub-Saharan Africa. Additionally, there is an ill-defined burden of iNTS disease in Southeast Asia. Methods Aiming to investigate the causative serovars of non-invasive and iNTS disease and their associated antimicrobial susceptibility profiles in the Lao People's Democratic Republic, we performed multilocus sequence typing and antimicrobial susceptibility profiling on 168 NTS (63 blood and 105 faecal) organisms isolated in Lao between 2000 and 2012. Results Six different serovars were isolated from blood; Salmonella enterica serovar Enteritidis (n=28), S. enterica serovar Typhimurium (n=19) and S. enterica serovar Choleraesuis (n=11) accounted for >90% (58/63) of the iNTS disease cases. In contrast, the isolates from diarrhoeal faeces were comprised of 18 different serovars, the mostly commonly identified being S. enterica Typhimurium (n=28), S. enterica Weltevreden (n=14) and S. enterica Stanley (n=15). S. enterica Enteritidis and S. enterica Choleraesuis were significantly more associated with systemic disease than diarrhoeal disease in this patient group (p<0.001). Conclusions We find a differing distribution of Salmonella sequence types/serovars between those causing iNTS disease and non-invasive disease in Lao. We conclude that there is a small but not insignificant burden of iNTS disease in Lao. Further clinical and epidemiological investigations are required to assess mortality and the role of comorbidities such as HIV. [ABSTRACT FROM AUTHOR]

Background. Pneumonia, the leading infectious cause of child mortality globally, mainly afflicts developing countries. This prospective observational study aimed to assess the microorganisms associated with pneumonia in children aged <5 years in developing and emerging countries. Methods. A multicenter, case-control study by the GABRIEL (Global Approach to Biological Research, Infectious diseases and Epidemics in Low-income countries) network was conducted between 2010 and 2014 in Cambodia, China, Haiti, India (2 sites), Madagascar, Mali, Mongolia, and Paraguay. Cases were hospitalized children with radiologically confirmed pneumonia; controls were children from the same setting without any features suggestive of pneumonia. Nasopharyngeal swabs were collected from all subjects; 19 viruses and 5 bacteria were identified by reverse-transcription polymerase chain reaction. Associations between microorganisms and pneumonia were quantified by calculating the adjusted population attributable fraction (aPAF) after multivariate logistic regression analysis adjusted for sex, age, time period, other pathogens, and site. Results. Overall, 888 cases and 870 controls were analyzed; ≥1 microorganism was detected in respiratory samples in 93.0% of cases and 74.4% of controls (P < .001). Streptococcus pneumoniae, Mycoplasma pneumoniae, human metapneumovirus, rhinovirus, respiratory syncytial virus (RSV), parainfluenza virus 1, 3, and 4, and influenza virus A and B were independently associated with pneumonia; aPAF was 42.2% (95% confidence interval [CI], 35.5%-48.2%) for S. pneumoniae, 18.2% (95% CI, 17.4%-19.0%) for RSV, and 11.2% (95% CI, 7.5%-14.7%) for rhinovirus. Conclusions. Streptococcus pneumoniae, RSV, and rhinovirus may be the major microorganisms associated with pneumonia infections in children <5 years of age from developing and emerging countries. Increasing S. pneumoniae vaccination coverage may substantially reduce the burden of pneumonia among children in developing countries. [ABSTRACT FROM AUTHOR]

Background: Accelerating reduction in infant and other child mortality rates calls for comprehensive child survival strategies. Early recognition of illness and timely seeking of treatment are critical elements to prevent child deaths, and cultural explanation for these care-seeking behaviours is important. The present article reports (i) mothers' recognition of illness and (ii) triggers of treatment related to some childhood illnesses among a migrant tribal community living in Bhubaneswar city, India.Methods: From the four tribal dominated slums, 175 Santal tribal households were selected based on the criteria, viz. (i) the family should have migrated within the past 12 years and (ii) having a child aged 0-14 years. Semi-structured interviews were conducted with mothers for data related to illnesses occurred to their youngest child during past 1 year.Results: The recognition of illness was made based on multiple symptoms. Triggers of treatment and care-seeking behaviour vary from illness to illness. Usually people wait for 2-3 days after onset of any illness, expecting the symptoms to subside automatically. Late onset symptoms and severity trigger mother to take child for treatment.Conclusion: Mothers were able to recognize the childhood illnesses. There was substantial delay in seeking care. Hence, provision of primary health care and health education-based interventions are needed to improve the mothers' recognition and care-seeking behaviour. [ABSTRACT FROM AUTHOR]

Objectives: The objectives of this study are (i) to evaluate the feasibility of using an inexpensive air pump to maintain reliable oxygen concentration in a continuous positive airway pressure (CPAP) system and (ii) to evaluate whether an inexpensive air pump can maintain infant 02 sats >90%.Methods: This prospective study, which included 19 babies in pilot phase and 90 during extension phase, was conducted at a neonatal intensive care unit in a resource-poor academic medical center in India. The intervention involved introduction of an air pump in the CPAP delivery system. Outcome measures were oxygen concentration in the air-oxygen blend and oxygen saturation of the study babies.Results: Oxygen concentration at the outlets ranged between 56 and 70% and in the blend between 42 and 51%. Oxygen saturation ranged between 90 and 97%.Conclusion: A simple and inexpensive air pump can work as a safe and effective oxygen blender. [ABSTRACT FROM AUTHOR]

Background. Pneumococcal conjugate vaccines (PCVs) are highly effective in preventing invasive pneumococcal disease (IPD), but deaths due to IPD still occur. We aimed to describe children who died of IPD since PCV introduction in England and Wales. Methods. Public Health England conducts enhanced IPD surveillance in England and Wales. IPD cases in PCV-eligible children aged <5 years (born since 4 September 2004 and diagnosed between 4 September 2006 and 3 September 2014) were actively followed up by postal questionnaires and, for fatal cases, detailed information was requested prospectively from multiple sources. Results. During the 8-year period, there were 3146 IPD cases and 150 IPD-related deaths (case fatality rate, 4.8%). Overall, 132 isolates from fatal cases were serotyped (88%) and 35 distinct serotypes were identified, with no serotype predominance. Most deaths occurred in children aged <1 year (88/150 [59%]) and 1-year-olds (36/150 [24%]). One-third (53/150 [35%]) had a known risk factor for IPD. Clinical presentation varied with age but not by serotypes in the different conjugate vaccines. Meningitis was diagnosed in nearly half the fatal cases (71/150 [47%]). The IPD-related mortality rate declined after 7-valent PCV introduction from 1.25/100 000 children in 2006-2007 to 0.60/100 000 in 2009-2010, with a further reduction following 13-valent PCV introduction from April 2010 to 0.39/100 000 in 2013-2014 (14 deaths; incidence rate ratio, 0.31 [95% confidence interval, .16-.61]; P = .0003), when most deaths were due to nonvaccine serotypes or in neonates. Conclusions. Most fatal IPD cases are currently not vaccine-preventable. Additional strategies will be required to reduce childhood pneumococcal deaths in countries with established pneumococcal vaccination programs. [ABSTRACT FROM AUTHOR]

Background. Induced sputum (IS) may provide diagnostic information about the etiology of pneumonia. The safety of this procedure across a heterogeneous population with severe pneumonia in low- and middle-income countries has not been described. Methods. IS specimens were obtained as part a 7-country study of the etiology of severe and very severe pneumonia in hospitalized children <5 years of age. Rigorous clinical monitoring was done before, during, and after the procedure to record oxygen requirement, oxygen saturation, respiratory rate, consciousness level, and other evidence of clinical deterioration. Criteria for IS contraindications were predefined and serious adverse events (SAEs) were reported to ethics committees and a central safety monitor. Results. A total of 4653 IS procedures were done among 3802 children. Thirteen SAEs were reported in relation to collection of IS, or 0.34% of children with at least 1 IS specimen collected (95% confidence interval, 0.15%–0.53%). A drop in oxygen saturation that required supplemental oxygen was the most common SAE. One child died after feeding was reinitiated 2 hours after undergoing sputum induction; this death was categorized as “possibly related” to the procedure. Conclusions. The overall frequency of SAEs was very low, and the nature of most SAEs was manageable, demonstrating a lowrisk safety profile for IS collection even among severely ill children in low-income-country settings. Healthcare providers should monitor oxygen saturation and requirements during and after IS collection, and assess patients prior to reinitiating feeding after the IS procedure, to ensure patient safety. [ABSTRACT FROM AUTHOR]

Background: Access to health facilities remains limited in many resource-poor settings, and women and their children often have to travel far to seek care. However, data on distance are scarce, and it is unclear whether distance is associated with worse child health outcomes. We estimate the relationships between distance to facility, service utilization and child mortality in low- and middle-income countries.Methods: Population-representative data are pooled from 29 demographic and health surveys across 21 low- and middle-income countries. Multivariable logistic models and meta-analysis regressions are used to estimate associations between facility distance, child mortality, and health care utilization in the pooled sample as well as for each survey.Results: Compared with children who live within 1 km of a facility, children living within 2 km, 3 km, and 5 km of a facility have a 7.7% [95% confidence interval (CI): 0.927 - 1.251], 16.3% (95% CI: 1.020 - 1.327) and 25% (95% CI: 1.087 - 1.439) higher odds of neonatal mortality, respectively; children living farther than 10 km have a 26.6% (95% CI: 1.108 - 1.445) higher odds of neonatal mortality. Women living farther than 10 km from a facility have a 55.3% lower odds of in-facility delivery compared with women who live within 1 km [odds ratio (OR): 0.447; 95% CI: 0.394 - 0.508].Conclusions: Even relatively small distances from health facilities are associated with substantial mortality penalties for children. Policies that reduce travel distances and travel times are likely to increase utilization of health services and reduce neonatal mortality. [ABSTRACT FROM AUTHOR]

Scrub typhus can produce multiple organ dysfunction syndrome (MODS). Early recognition of the patients at risk of MODS would be helpful in providing timely management and reducing the mortality. In all, 449 children with scrub typhus were enrolled at three hospitals in Yunnan, China from January 2010 to January 2015. The patients' clinical status of organ system dysfunction was evaluated on the day of discharge from hospital by using standard criteria. The patients were classified into MODS present (64 cases, 14.3%) or MODS absent (385 cases, 85.7%). Multivariate logistic regression analyses revealed that the prognostic factors for MODS included skin rash (odds ratio, OR = 3.3, p = 0.037), time interval form treatment to defervescence (OR = 1.2, p = 0.035), hemoglobin (OR = 0.54, p = 0.041), platelet counts (OR = 0.06, p < 0.001), aspartate-aminotransferase (OR = 4.7, p = 0.011) and total bilirubin (OR = 2.3, p = 0.013). By describing risk factors resulting in MODS in pediatric scrub typhus, our study provides clinicians with important information to improve the clinical monitoring and prognostication of MODS. [ABSTRACT FROM AUTHOR]

Despite notable progress reducing global under-five mortality rates, insufficient progress in most sub-Saharan African nations has prevented the achievement of Millennium Development Goal four (MDG#4) to reduce under-five mortality by two-thirds between 1990 and 2015. Country-level assessments of factors underlying why some African countries have not been able to achieve MDG#4 have not been published. Zimbabwe was included in a four-country study examining barriers and facilitators of under-five survival between 2000 and 2013 due to its comparatively slow progress towards MDG#4. A review of national health policy and strategy documents and analysis of qualitative data identified Zimbabwe's critical shortage of health workers and diminished opportunities for professional training and education as an overarching challenge. Moreover, this insufficient health workforce severely limited the availability, quality, and utilization of life-saving health services for pregnant women and children during the study period. The impact of these challenges was most evident in Zimbabwe's persistently high neonatal mortality rate, and was likely compounded by policy gaps failing to authorize midwives to deliver life-saving interventions and to ensure health staff make home post-natal care visits soon after birth. Similarly, the lack of a national policy authorizing lower-level cadres of health workers to provide community-based treatment of pneumonia contributed to low coverage of this effective intervention and high child mortality. Zimbabwe has recently begun to address these challenges through comprehensive policies and strategies targeting improved recruitment and retention of experienced senior providers and by shifting responsibility of basic maternal, neonatal and child health services to lower-level cadres and community health workers that require less training, are geographically broadly distributed, and are more cost-effective, however the impact of these interventions could not be assessed within the scope and timeframe of the current study. [ABSTRACT FROM AUTHOR]

Reductions in under-five mortality in Africa have not been sufficient to meet the Millennium Development Goal #4 (MDG#4) of reducing under-five mortality by two-thirds by 2015. Nevertheless, 12 African countries have met MDG#4. We undertook a four country study to examine barriers and facilitators of child survival prior to 2015, seeking to better understand variability in success across countries. The current analysis presents indicator, national document, and qualitative data from key informants and community women describing the factors that have enabled Zambia to successfully reduce under-five mortality over the last 15 years and achieve MDG#4. Results identified a Zambian national commitment to ongoing reform of national health strategic plans and efforts to ensure universal access to effective maternal, neonatal and child health (MNCH) interventions, creating an environment that has promoted child health. Zambia has also focused on bringing health services as close to the family as possible through specific community health strategies. This includes actively involving community health workers to provide health education, basic MNCH services, and linking women to health facilities, while supplementing community and health facility work with twice-yearly Child Health Weeks. External partners have contributed greatly to Zambia's MNCH services, and their relationships with the government are generally positive. As government funding increases to sustain MNCH services, national health strategies/plans are being used to specify how partners can fill gaps in resources. Zambia's continuing MNCH challenges include basic transportation, access-to-care, workforce shortages, and financing limitations. We highlight policies, programs, and implementation that facilitated reductions in under-five mortality in Zambia. These findings may inform how other countries in the African Region can increase progress in child survival in the post-MDG period. [ABSTRACT FROM AUTHOR]

Natural selection presumably conserved mechanisms that allow females to block or terminate gestation when environmental circumstances threaten the survival of offspring. One example of this adaptive reproductive suppression, the Bruce effect, has been identified in several species, both in the laboratory and in the wild. Although descriptive epidemiology reports low fertility among women experiencing stressful circumstances, attempts to detect a Bruce effect in humans have been rare and limited. We contribute to this limited work by examining the relationship between the odds of child death and the sex ratio at birth in Sweden for the years 1751-1840. We find evidence of a generalized Bruce effect in humans in that unexpected changes in child mortality predict opposite unexpected changes in the secondary sex ratio in the following year, even after adjusting for period life expectancy. Our analysis broadens the scope of the Bruce effect literature to include humans, suggesting that women, through noncognitive decisional biology, adjust reproductive strategies and investments in response to changing environmental conditions. [ABSTRACT FROM AUTHOR]