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Evidence-based approaches were used in making recommendations for vaccination against vaccine-preventable diseases for HIV-infected and HIV-exposed individuals but with limited substantiation. We conducted a systematic review and meta-analysis with randomized-controlled trials (RCTs), cohort and case-control studies that have efficacy and effectiveness of vaccines in HIV-infected and HIV-exposed children as outcomes. Web of Science, Cochrane Library, PubMed and Scopus databases were searched for articles. Efficacy of 9-valent pneumococcal conjugate vaccine (PCV9) against total vaccine serotype invasive pneumococcal disease was 32% in HIV-infected children and 78% among HIV-uninfected children. Vaccine effectiveness of Bacillus Calmette-Guérin vaccine in preventing tuberculosis in HIV-infected children was zero compared to 59% protection in HIV-unexposed children. Likewise, HIV-uninfected children have better protection against invasive Haemophilus influenzae type b disease than the HIV-infected children. Effectiveness studies of rotavirus vaccines show that HIV-exposed uninfected children have similar protection against rotavirus gastroenteritis compared to the non-exposed children. Children who are severely immunosuppressed are poorly protected against invasive pneumococcal diseases. HIV-infected children tend to have lesser vaccine protection against vaccine-preventable diseases when compared to unexposed children. HIV-infected children who are immunocompetent are more likely to have better vaccine protection against vaccine-preventable diseases than those who are immunosuppressed. The overall quality of the observational studies was very low with very little confidence in the effect estimate. The overall quality of evidence for the RCT outcomes was mainly high. This study reveals a dearth of efficacy and effectiveness studies among HIV-infected and exposed children.

Background: Women's empowerment has a direct impact on maternal and child health care service utilization. Large scope measurement of contraceptive use in several dimensions is paramount, considering the nature of empowerment processes as it relates to improvements in maternal health status. However, multicountry and multilevel analysis of the measurement of women's empowerment indicators and their associations with contraceptive use is vital to make a substantial intervention in the Sub-Saharan Africa context. Therefore, we investigated the impact of women's empowerment on contraceptive use among women in sub-Saharan Africa countries., Methods: Secondary data involving 474,622 women of reproductive age (15-49 years) from the current Demographic and Health Survey (DHS) in 32 Sub-Saharan Africa region was used in this study. Contraceptive use was the primary outcome variable. Multilevel analysis was conducted to examine the impact of women's empowerment on contraceptive use. Percentages were conducted in univariate analysis. Furthermore, multilevel logistic regression models were used to analyze the association between individual, compositional and contextual factors of contraceptive use., Results: Results showed large disparities in the number of women who reportedly ever use contraceptive methods; this range from as low as 6.7% in Chad and as much as 72% in Namibia. More than one-third of the respondents had no formal education and more than half were active labor force. Contraceptive use was significantly more common among respondents from the richest households (28.5% versus 18.9%). Various components of women's empowerment were positively significantly associated with contraceptive use after adjusting for demographic and socioeconomic factors. There was a significant variation in the odds of contraceptive use across the 32 countries (σ 2 = 1.12, 95% CrI 0.67 to 1.87) and across the neighbourhoods (σ 2 = 0.95, 95% CrI 0.92 to 0.98)., Conclusions: Our findings suggest that an increase in contraceptive use and by better extension maternal health care services utilization can be achieved by enhancing women's empowerment. Also, an increase in decision-making autonomy by women, their participation in labour force, reduction in abuse and violence and improved knowledge level are all key issues to be considered. Health-related policies should address inequalities in women's empowerment, education and economic status which would yield benefits to individuals, families, and societies in general.

Background: The lifetime risk of stroke has been calculated in a limited number of selected populations. We sought to estimate the lifetime risk of stroke at the regional, country, and global level using data from a comprehensive study of the prevalence of major diseases., Methods: We used the Global Burden of Disease (GBD) Study 2016 estimates of stroke incidence and the competing risks of death from any cause other than stroke to calculate the cumulative lifetime risks of first stroke, ischemic stroke, or hemorrhagic stroke among adults 25 years of age or older. Estimates of the lifetime risks in the years 1990 and 2016 were compared. Countries were categorized into quintiles of the sociodemographic index (SDI) used in the GBD Study, and the risks were compared across quintiles. Comparisons were made with the use of point estimates and uncertainty intervals representing the 2.5th and 97.5th percentiles around the estimate., Results: The estimated global lifetime risk of stroke from the age of 25 years onward was 24.9% (95% uncertainty interval, 23.5 to 26.2); the risk among men was 24.7% (95% uncertainty interval, 23.3 to 26.0), and the risk among women was 25.1% (95% uncertainty interval, 23.7 to 26.5). The risk of ischemic stroke was 18.3%, and the risk of hemorrhagic stroke was 8.2%. In high-SDI, high-middle-SDI, and low-SDI countries, the estimated lifetime risk of stroke was 23.5%, 31.1% (highest risk), and 13.2% (lowest risk), respectively; the 95% uncertainty intervals did not overlap between these categories. The highest estimated lifetime risks of stroke according to GBD region were in East Asia (38.8%), Central Europe (31.7%), and Eastern Europe (31.6%), and the lowest risk was in eastern sub-Saharan Africa (11.8%). The mean global lifetime risk of stroke increased from 22.8% in 1990 to 24.9% in 2016, a relative increase of 8.9% (95% uncertainty interval, 6.2 to 11.5); the competing risk of death from any cause other than stroke was considered in this calculation., Conclusions: In 2016, the global lifetime risk of stroke from the age of 25 years onward was approximately 25% among both men and women. There was geographic variation in the lifetime risk of stroke, with the highest risks in East Asia, Central Europe, and Eastern Europe. (Funded by the Bill and Melinda Gates Foundation.).

Background: The natural history of neonatal group B Streptococcus (GBS) is poorly understood. Little is known about the bacterial factors influencing the transmission of GBS from mother to neonate, or the development of invasive early-onset GBS disease (EOGBS) in colonized neonates. We reviewed whether bacterial load and molecular markers are associated with GBS vertical transmission and progression to EOGBS., Methods: We searched Medline, Embase, Cochrane and Web of Science from inception to October 10, 2016, for observational studies in English. We also hand-searched reference lists of relevant publications and experts cross-checked included studies. Two reviewers independently screened studies, extracted data and appraised the quality of included studies using the Quality in Prognosis Studies tool. We conducted random-effects meta-analyses where possible and narratively synthesized the evidence in text and tables., Results: Seventeen studies were included from 1107 records retrieved from electronic databases and publication references. Meta-analyses of 3 studies showed that neonates colonized by serotype III had a higher risk of developing EOGBS than serotype Ia (pooled risk ratio: 1.51, 95% confidence interval: 1.12-2.03) and serotype II (risk ratio: 1.95, 95% confidence interval: 1.10-3.45). Eleven studies showed that in heavily colonized mothers, 2-3 times more neonates were colonized, and in heavily colonized neonates, up to 15 times more neonates had EOGBS, compared with light colonization. Most evidence was published before 2000 and was at risk of bias., Conclusions: Acknowledging the difficulty of natural history studies, well-controlled studies are needed to assess the predictive value of pathogen subtype and heavy load; they may be useful for better-targeted prevention.

Purpose: This study aims to estimate the computed tomography (CT) and Magnetic resonance imaging (MRI) uptake, stroke subtypes and 30-days case-fatality in Nigeria., Methods: Stroke diagnosis and mortality data were identified from relevant databases. A random effect meta-analysis was conducted to obtain the pooled percentage uptake of CT/MRI, including 30-days case fatality and a meta-regression-like epidemiological model was applied on all data points., Findings: A total of 24 studies involving 5874 stroke patients conducted in predominantly tertiary referral hospitals met the inclusion criteria. The pooled CT/MRI uptake in the last seven years was 46.66% (95% CI = 15.35 to 77.98, 8 studies). There were significant variations in the prevalence of stroke subtypes. The pooled prevalence ischemic stroke was highest (55.32%, 95% CI 48.67 to 61.97, 16 studies), followed by intracerebral haemorrhage (ICH) (32.69%, 95% CI 25.54 to 39.83, 16 studies), subarachnoid haemorrhage (SAH) (3.76%, 95% CI 2.30 to 5.22, 14 studies). In addition, the stroke of undetermined aetiology was found to be 16.57% (95% CI, 7.44-25.70, 8 studies). Overall, the 24-h, one-week and 30-days case-fatality from stroke were 10.84% (95% CI, 4.48-17.20), 24.62% (95% CI, 17.20-32.04) and 33.28% (95% CI, 27.80-38.77), respectively. There was a moderate negative correlation between prevalence of brain imaging uptake and ischaemic stroke, albeit not statistically significant (Spearman rho = 0.333, p-value = .412)., Conclusion: Uptake of CT/MRI procedure for stroke is poor in Nigeria. Although poverty, inaccessibility and influence of major risk factors remain pronounced, scaling up of effective strategies for stroke prevention and management should be a major public health policy priority in Nigeria., (Crown Copyright © 2018. Published by Elsevier B.V. All rights reserved.)

Background: Current evidence on the decline in the prevalence of female genital mutilation or cutting (FGM/C) has been lacking worldwide. This study analyses the prevalence estimates and secular trends in FGM/C over sustained periods (ie, 1990-2017). Its aim is to provide analytical evidence on the changing prevalence of FGM/C over time among girls aged 0-14 years and examine geographical variations in low-income and middle-income countries., Methods: Analysis on the shift in prevalence of FGM/C was undertaken using the Demographic Health Survey (DHS) and Multiple Indicator Cluster Survey (MICS) data sets from Africa and Middle East. A random-effects model was used to derive overall prevalence estimates. Using Poisson regression models, we conducted time trends analyses on the FGM/C prevalence estimates between 1990 and 2017., Findings: We included 90 DHS and MICS data sets for 208 195 children (0-14 years) from 29 countries spread across Africa and two countries in Western Asia. The prevalence of FGM/C among children varied greatly between countries and regions and also within countries over the survey periods. The percentage decline in the prevalence of FGM/C among children aged 0-14 years old was highest in East Africa, followed by North and West Africa. The prevalence decreased from 71.4% in 1995 to 8.0% in 2016 in East Africa. In North Africa, the prevalence decreased from 57.7% in 1990 to 14.1% in 2015. In West Africa, the prevalence decreased from 73.6% in 1996 to 25.4% in 2017. The results of the trend analysis showed a significant shift downwards in the prevalence of FGM/C among children aged 0-14 years in such regions and subregions of East Africa, North Africa and West Africa. East Africa has experienced a much faster decrease in the prevalence of the practice (trend=-7.3%, 95% CI -7.5% to -7.1%) per year from 1995 to 2014. By contrast, the decline in prevalence has been much slower in North Africa (trend=-4.4%, 95% CI -4.5% to -4.3%) and West Africa (trend=-3.0%, 95% CI -3.1% to -2.9%)., Conclusion: The prevalence of FGM/C among children aged 0-14 years varied greatly between countries and regions and also within countries over the survey periods. There is evidence of huge and significant decline in the prevalence of FGM/C among children across countries and regions. There is a need to sustain comprehensive intervention efforts and further targeted efforts in countries and regions still showing high prevalence of FGM/C among children, where the practice is still pervasive., Competing Interests: Competing interests: None declared.

Background: Under-5 mortality rate in the sub-Saharan region has remained unabated. Worse still, information on the regional trend and associated determinants are not readily available. Knowledge of the trend and determinants of under-5 mortality are essential for effective design of intervention programmes that will enhance their survival. We aimed to examine the mortality patterns in under-5 children and maternal factors associated with under-5 deaths., Methods: Demographic and Health Survey (DHS) data from five sub-Sahara Africa countries; Chad, Democratic Republic of Congo, Mali, Niger and Zimbabwe were used in this study. The sample size consisted of 68,085 women aged 15-49 years with at least one history of childbirth. The outcome variable was under-five mortality rate. Relevant information on maternal factors were extracted for analysis. Multivariable Cox proportional hazards regression was used to model maternal factors associated with under-five mortality., Results: The current under-5 mortality rate (per 1,000 live births) was; 133 in Republic of Chad, 104 in Democratic Republic of Congo, 95 in Mali, 127 in Niger, and 69 in Zimbabwe. Several maternal and child level factors were found to be significantly associated with under-five mortality. Lack of spousal support (not currently married) resulted to increase in under-five mortality (Chad- Hazard Ratio [HR] = 1.11, 95%CI = 0.97-1.25; DR Congo- HR = 1.24, 95%CI = 1.11-1.40; Mali- HR = 2.43, 95%CI = 1.63-3.64; Niger- HR = 1.59, 95%CI = 1.24-2.03; Zimbabwe- HR = 1.33, 95%CI = 1.06-1.67). Delivery by caesarean section was significantly associated with under-five mortality (Chad- HR = 1.32, 95%CI = 1.00-1.77; DR Congo- HR = 1.20, 95%CI = 1.01-1.43; Mali- HR = 1.42, 95%CI = 1.08-1.85; Niger- HR = 1.43, 95%CI = 1.06-1.92; Zimbabwe- HR = 1.49, 95%CI = 1.03-2.15)., Conclusion: Despite concerted effort by government and several stakeholders in health to improve childhood survival, the rate of under-5 mortality is still high. Our findings provided evidence on the contribution of maternal age, place of residence, household wealth index, level of education, employment, marital status, religious background, birth type, birth order and interval, sex and size of child, place and mode of delivery, to Under-5 mortality rate in SSA. The position of prominent risk factors for under-five mortality should be addressed through effective design of timely and efficient intervention aimed at reducing childhood mortality., Competing Interests: The authors have declared that no competing interests exist.

Background: Understanding the socioeconomic discordance associated with the risk factors of non-communicable diseases (NCDs) can help direct effective interventions to end its persistent occurrence. We examined the prevalence of high blood pressure, overweight/obesity, alcohol consumption and tobacco use among women and compared across wealth quintiles in sub-Saharan Africa countries. Methods: This study included 454,080 women of reproductive age (15-49 years) from the current Demographic and Health Survey (DHS) conducted between 2008/09-2017 across 33 sub-Saharan Africa countries. The outcome variables were high blood pressure, overweight/obesity, alcohol consumption and tobacco use. The prevalence of the risk factors of NCDs and sample characteristics across different levels of wealth quintiles were examined. Furthermore, socioeconomic inequalities were measured using concentration index (CI) and Lorenz curve considering urban-rural differentials. Results: The prevalence of high blood pressure and overweight/obesity were 1.2-17.3% and 6.7-44.5% respectively with significant wealth quintile differences. More so, alcohol consumption prevalence was 4.1-47.3% and tobacco use was 0.3-9.9%. The overall prevalence of high blood pressure was 5.5%, overweight/obesity accounted for about 23.1%, alcohol consumption and tobacco users were 23.9 and 2.4%, respectively. The socioeconomic inequalities in high blood pressure (CI = 0.1352, p < 0.001); overweight/obesity (CI = 0.2285, p < 0.001), and alcohol consumption (CI = 0.0278, p < 0.001) were significantly more in the higher socioeconomic group, compared to the lower socioeconomic group. In contrast, the prevalence of tobacco use ( CI = -0.2551, p < 0.001) was significantly more in the lower socioeconomic group, compared to the higher socioeconomic group. The test for differences in rural vs. urban concentration indices for high blood pressure, overweight/obesity, alcohol consumption, and tobacco use were statistically significant in all the health indicators ( p < 0.05). Conclusion: An effective intervention should incorporate a high-risk approach to terminate risk distribution by directing resources to key population women. To improve the benefit to risk ratio and enhance the cost effectiveness of preventive health programmes, it is paramount to understand the worth of equity-based strategies. Integrating equity elements to interventions is a key measure toward ensuring that policies and programmes meet their milestones. Government should strengthen living standards, literacy and healthcare system to curtail the increasing prevalence of the risk factors of NCDs.

Background: Malnutrition and malaria are both significant causes of morbidity and mortality in African children. However, the extent of their spatial comorbidity remains unexplored and an understanding of their spatial correlation structure would inform improvement of integrated interventions. We aimed to determine the spatial correlation between both wasting and low mid upper arm circumference (MUAC) and falciparum malaria among Somalian children aged 6-59 months., Methods: Data were from 49 227 children living in 888 villages between 2007 to 2010. We developed a Bayesian geostatistical shared component model in order to determine the common spatial distributions of wasting and falciparum malaria; and low-MUAC and falciparum malaria at 1 × 1 km spatial resolution., Results: The empirical correlations with malaria were 0.16 and 0.23 for wasting and low-MUAC respectively. Shared spatial residual effects were statistically significant for both wasting and low-MUAC. The posterior spatial relative risk was highest for low-MUAC and malaria (range: 0.19 to 5.40) and relatively lower between wasting and malaria (range: 0.11 to 3.55). Hotspots for both wasting and low-MUAC with malaria occurred in the South Central region in Somalia., Conclusions: The findings demonstrate a relationship between nutritional status and falciparum malaria parasitaemia, and support the use of the relatively simpler MUAC measurement in surveys. Shared spatial distribution and distinct hotspots present opportunities for targeted seasonal chemoprophylaxis and other forms of malaria prevention integrated within nutrition programmes.

Background: Mass media exposure plays a pivotal role in health communication and adoption of a healthy lifestyle. In this study, we aimed to measure the prevalence of malaria prevention behaviour among adult women in eight malaria-endemic countries in sub-Saharan Africa (SSA), and assess the influence of mass media exposure in the adoption of those behaviours., Methods: For this study, we collected cross-sectional data on 46,822 women aged between 15 and 49 years from the Malaria Indicator Surveys (MIS) conducted in Burkina Faso, Ghana, Mali, Malawi, Kenya, Nigeria, Sierra Leone and Uganda. As the outcome variable, malaria prevention behaviour was proxied by the use of insecticide treated nets (ITNs) and uptake of antimalarial drugs in last pregnancy., Results: The overall prevalence of sleeping under ITN and that of taking antimalarial drug during the last pregnancy was respectively 67.9% (95%CI = 66.6-69.2) and 72.8% (95%CI = 71.3-74.2). However, there were disparities in the prevalence of using ITN and antimalarial drug use across the study countries. In the multivariable regression analysis, not receiving malaria related information from radio, poster/billboards, community events, and health workers were found to be significantly associated with reduction in the odds of using ITN the previous night. For the use of antimalarial drugs during last pregnancy, the odds were 23% [OR = 0.773, 95%CI = 0.625-0.956] lower for those who did not receive malaria information on radio compared with those who received., Conclusions: These findings indicate a potentially important role of malaria information received through mass media on utilisation of ITN among women in SSA. More research is needed to explore the factors that limit the accessibility to malaria information through mass media., Competing Interests: Ethics approval for this study was not required since the data is secondary and is available in the public domain. More details regarding DHS data and ethical standards are available at: http://goo.gl/ny8T6X.No consent to publish was needed for this study as we did not use any details, images or videos related to individual participants. In addition data used is available in the public domain.The authors declare that they have no competing interests.

Background: Access to safe Cesarean section (C-section) in resource-constrained settings such as sub-Sahara Africa (SSA) region is a foremost approach to reduce maternal mortality. C-section is an obstetric operative procedure used appropriately to improve delivery outcomes. However, errors in the procedure have enormous potential harm that may outweigh the benefits. This study assessed the prevalence and determinants of C-section in several SSA countries. This study examined the prevalence and determinants associated with cesarean delivery in SSA countries., Methods: Secondary data of women of reproductive age (15-49 years) from the current Demographic and Health Survey (DHS) in 34 SSA countries was utilized in this study. The mode of delivery among women was the primary outcome variable. Percentage and descriptive statistics were used to conduct univariate analyses. Furthermore, multivariable multilevel logistic regression was used to investigate correlates of C-section among SSA women., Results: Results showed disparities in the percentage of C-section among women from 34 SSA countries. C-section at public healthcare settings ranged from 3% in Burkina Faso to 15.6% in Ghana. However, in private healthcare settings, C-section ranged from 0% in Sao Tome and Principe to 64.2% in Rwanda. Overall, C-section was 7.9% from public healthcare and 12.3% from private healthcare facilities respectively. In the adjusted regression model; women aged 35-49 had increase in the odds of C-section, while a unit increase in the number of children ever born had 17 and 20% significant reduction in the odds of C-section in public and private healthcare respectively. Assessing public healthcare settings; women from richer/richest households, male and large size children at birth had increase in the odds of C-section, while those from rich neighbourhood had reduction in the odds of C-section. In private healthcare settings, women with high decision making power and multiple births had increase in the odds of C-section, while those who attended ANC visits had significant reduction in the odds of C-section., Conclusion: The findings from this study would help formulate health policies and implement actions that would improve the outcome of C-section care. Monitoring of emergency obstetric care services is necessary to address issues connected to poor C-section outcomes in resource-constrained settings. Also training of medical personnel including midwives and nurses in emergency obstetric care, ensuring accessibility to life-saving drugs and supplies should be encouraged in health care system., Competing Interests: Ethics approval for this study was not required since the data is secondary and is available in the public domain. More details regarding DHS data and ethical standards are available at: http://goo.gl/ny8T6X.No consent to publish was needed for this study as we did not use any details, images or videos related to individual participants. In addition data used is available in the public domain.The authors declare that they have no competing interests.

Background: It is unknown whether statin use among people living with HIV results in a reduction in all-cause mortality. We aimed to evaluate the effect of statin use on all-cause mortality among people living with HIV., Methods: We conducted comprehensive literature searches of Medline, Embase, CINAHL, the Cochrane Library, and cross-references up to April 2018. We included randomised, quasi-randomised trials and prospective cohort studies that examined the association between statin use and cardio-protective and mortality outcomes among people living with HIV. Two reviewers independently abstracted the data. Hazard ratios (HRs) were pooled using empirical Bayesian random-effect meta-analysis. A number of sensitivity analyses were conducted., Results: We included seven studies with a total of 35,708 participants. The percentage of participants on statins across the studies ranged from 8 to 35%. Where reported, the percentage of participants with hypertension ranged from 14 to 35% and 7 to 10% had been diagnosed with diabetes mellitus. Statin use was associated with a 33% reduction in all-cause mortality (pooled HR = 0.67, 95% Credible Interval 0.39 to 0.96). The probability that statin use conferred a moderate mortality benefit (i.e. decreased risk of mortality of at least 25%, HR ≤ 0.75) was 71.5%. Down-weighting and excluding the lower quality studies resulted in a more conservative estimate of the pooled HR., Conclusion: Statin use appears to confer moderate mortality benefits in people living with HIV.

Background: Ensuring equitable access to maternal health care including antenatal, delivery, postnatal services and fertility control methods, is one of the most critical challenges for public health sector. There are significant disparities in maternal health care indicators across many geographical locations, maternal, economic, socio-demographic factors in many countries in sub-Sahara Africa. In this study, we comparatively explored the utilization level of maternal health care, and examined disparities in the determinants of major maternal health outcomes., Methods: This paper used data from two rounds of Benin Demographic and Health Survey (BDHS) to examine the utilization and disparities in factors of maternal health care indicators using logistic regression models. Participants were 17,794 and 16,599 women aged between15-49 years in 2006 and 2012 respectively. Women's characteristics were reported in percentage, mean and standard deviation., Results: Mean (±SD) age of the participants was 29.0 (±9.0) in both surveys. The percentage of at least 4 ANC visits was approximately 61% without any change between the two rounds of surveys, facility based delivery was 93.5% in 2012, with 4.9% increase from 2006; postnatal care was currently 18.4% and contraceptive use was estimated below one-fifth. The results of multivariable logistic regression models showed disparities in maternal health care service utilization, including antenatal care, facility-based delivery, postnatal care and contraceptive use across selected maternal factors. The current BHDS showed age, region, religion were significantly associated with maternal health care services. Educated women, those from households of high wealth index and women currently working were more likely to utilize maternal health care services, compared to women with no formal education, from poorest households or not currently employed. Women who watch television (TV) were 1.31 (OR = 1.31; 95% CI = 1.13-1.52), 1.69 (OR = 1.69; 95% CI = 1.20-2.37) and 1.38 (OR = 1.38; 95% CI = 1.16-1.65) times as likely to utilize maternal health care services after adjusting for other covariates., Conclusion: The findings would guide stakeholders to address inequalities in maternal health care services. More so, health care programmes and policies should be strengthened to enhance accessibility as well as improve the utilization of maternal care services, especially for the disadvantaged, uneducated and those who live in hard-to-reach rural areas in Benin. The Benin government needs to create strategies that cover both the supply and demand side factors at attain the universal health coverage.

Objective: To examine whether care provided by general practitioners (GPs) to non-urgent patients in the emergency department differs significantly from care provided by usual accident and emergency (A&E) staff in terms of process outcomes and A&E clinical quality indicators., Design: Propensity score matched cohort study., Setting: GPs in A&E colocated within the University Hospitals Coventry and Warwickshire NHS Trust between May 2015 and March 2016., Participants: Non-urgent attendances visits to the A&E department., Main Outcomes: Process outcomes (any investigation, any blood investigation, any radiological investigation, any intervention, admission and referrals) and A&E clinical indicators (spent 4 hours plus, left without being seen and 7-day reattendance)., Results: A total of 5426 patients seen by GPs in A&E were matched with 10 852 patients seen by emergency physicians (ratio 1:2). Compared with standard care in A&E, GPs in A&E significantly: admitted fewer patients (risk ratio (RR) 0.28, 95% CI 0.25 to 0.31), referred fewer patients to other specialists (RR 0.31, 95% CI 0.24 to 0.40), ordered fewer radiological investigations (RR 0.38, 95% CI 0.34 to 0.42), ordered fewer blood tests (0.57, 95% CI 0.52 to 0.61) and ordered fewer investigations (0.93, 95% CI 0.90 to 0.96). However, they intervened more, offered more primary care follow-up (RR 1.78, 95% CI 1.67 to 1.89) and referred more patients to outpatient and other A&E clinics (RR 2.29, 95% CI 2.10 to 2.49). Patients seen by GPs in A&E were on average less likely to spend 4 hours plus in A&E (RR 0.37, 95% CI 0.30 to 0.45) compared with standard care in A&E. There was no difference in reattendance after 7 days (RR 0.96, 95% CI 0.84 to 1.09)., Conclusion: GPs in A&E tended to manage self-reporting minor cases with fewer resources than standard care in A&E, without increasing reattendance rates., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background: Obstetric complications and maternal deaths can be prevented through safe delivery process. Facility based delivery significantly reduces maternal mortality by increasing women's access to skilled personnel attendance. However, in sub-Saharan Africa, most deliveries take place without skilled attendants and outside health facilities. Utilization of facility-based delivery is affected by socio-cultural norms and several other factors including cost, long distance, accessibility and availability of quality services. This study examined country-level variations of the self-reported causes of not choosing to deliver at a health facility., Methods: Cross-sectional data on 37,086 community dwelling women aged between 15-49 years were collected from DHS surveys in Ethiopia (n = 13,053) and Nigeria (n = 24,033). Outcome variables were the self-reported causes of not delivering at health facilities which were regressed against selected sociodemographic and community level determinants. In total eight items complaints were identified for non-use of facility delivery: 1) Cost too much 2) Facility not open, 3) Too far/no transport, 4) don't trust facility/poor service, 5) No female provider, 6) Husband/family didn't allow, 7) Not necessary, 8) Not customary. Multivariable regression methods were used for measuring the associations., Results: In both countries a large proportion of the women mentioned facility delivery as not necessary, 54.9% (52.3-57.9) in Nigeria and 45.4% (42.0-47.5) in Ethiopia. Significant urban-rural variations were observed in the prevalence of the self-reported causes of non-utilisation. Women in the rural areas are more likely to report delivering at health facility as not customary/not necessary and healthy facility too far/no transport. However, urban women were more likely to complain that husband/family did not allow and that the costs were too high., Conclusion: Women in the rural were more likely to regard facility delivery as unnecessary and complain about transportation and financial difficulties. In order to achieving the maternal mortality related targets, addressing regional disparities in accessing maternal healthcare services should be regarded as a priority of health promotion programs in Nigeria and Ethiopia.

Background: Induced pregnancy termination and unintended pregnancy are two commonly occurring phenomena in the discipline of women's reproductive health. In the present study, we explored cross-sectional data pooled from three rounds of Nigeria Demographic and Health Survey (NDHS) to understand the trends of prevalence of pregnancy termination and unintended pregnancy as well as the interplay of various sociodemographic and economic factors whereby these health issues occur., Methods: Study participants were 79 825 currently married women aged 15-49 years. Data were collected from NDHS conducted in 2003, 2008 and 2013. Outcome variables were self-reported history of pregnancy termination and unintended pregnancy for the last birth. Data were analysed using descriptive and multivariable logistic regression methods., Results: Mean (±SD) age of the respondents was 28.7 years (±9.6). The overall prevalence of pregnancy termination and unintended pregnancy were about 11%. Older women had increase in the odds of terminated pregnancies, compared with women aged 15-19 years, while the converse was true for unintended pregnancy in the adjusted model. Educated women had significant higher odds of terminated and unintended pregnancies compared with women with no formal education. Women with higher wealth index were more likely to have unintended and terminated pregnancies after adjusting for other covariates. Remarkably, women who had unintended pregnancy were 1.47 times as likely to have terminated pregnancy compared with those who had no unintended pregnancy (OR=1.47; 95% CI 1.30 to 1.65). Experience of intimate partner violence had significant association with terminated and unintended pregnancies., Conclusion: The findings of this study showed that unintended and terminated pregnancies remain part of the issues to be addressed if the goal of ensuring healthy lives and promoting the well-being for all at all ages must be met. Stakeholders in Nigerian healthcare system should protect the lives of women who are vulnerable to the fatal consequences of unsafe abortion, especially in cases of rape, sexual assault, incest and where continuing a pregnancy would endanger the lives of women., Competing Interests: Competing interests: None declared.

Uptake of intermittent preventive therapy in pregnancy (IPTp) with sulfadoxine-pyrimethamine (IPTp-SP) is a clinically-proven method to prevent the adverse outcomes of malaria in pregnancy (MiP) for the mother, her foetus, and the neonates. The majority of countries in sub-Saharan Africa have introduced IPTp policies for pregnant women during the past decade. Nonetheless, progress towards improving IPTp coverage remains dismal, with widespread regional and socioeconomic disparities in the utilisation of this highly cost-effective service. In the present study, our main objective was to measure the prevalence of IPTp uptake in selected malaria-endemic countries in sub-Saharan Africa, and to investigate the patterns of IPTp uptake among different educational and wealth categories adjusted for relevant sociodemographic factors. For this study, cross-sectional data on 18,603 women aged between 15 and 49 years were collected from the Malaria Indicator Surveys (MIS) conducted in Burkina Faso, Ghana, Mali, Malawi, Kenya, Nigeria, Sierra Leone, and Uganda. The outcome variable was taking three doses of IPTp-SP in the last pregnancy, defined as adequate by the WHO. According to the analysis, the overall prevalence of taking three doses of IPTp-SP in the latest pregnancy was 29.5% (95% CI = 28.2⁻30.5), with the prevalence being highest for Ghana (60%, 95% CI = 57.1⁻62.8), followed by Kenya (37%, 95% CI = 35.3⁻39.2) and Sierra Leone (31%, 95% CI = 29.2⁻33.4). Women from non-poor households (richer-20.7%, middle-21.2%, richest-18.1%) had a slightly higher proportion of taking three doses of IPTp-SP compared with those from poorest (19.0%) and poorer (21.1%) households. Regression analysis revealed an inverse association between uptake of IPTp-SP and educational level. With regard to wealth status, compared with women living in the richest households, those in the poorest, poorer, middle, and richer households had significantly higher odds of not taking at least three doses of IPTp-SP during their last pregnancy. The present study concludes that the prevalence of IPTp-SP is still alarmingly low and is significantly associated with individual education and household wealth gradient. Apart from the key finding of socioeconomic disparities within countries, were the between-country variations that should be regarded as a marker of inadequate policy and healthcare system performance in the respective countries. More in-depth and longitudinal studies are required to understand the barriers to, and preferences of, using IPTp-SP among women from different socioeconomic backgrounds., Competing Interests: The authors declare no conflicts of interest.

Background: Successful antiretroviral therapy (ART) relies on the optimal level of ART adherence to achieve reliable viral suppression, avert HIV drug resistance, and prevent avoidable deaths. It has been shown that there are various groups of people living with HIV at high-risk of non-adherence to ART in sub-Saharan Africa. The objective of this study was to examine the cost effectiveness and value-of-information of directly administered antiretroviral therapy (DAART) versus self-administered ART among people living with HIV, at high risk of non-adherence to ART in sub-Saharan Africa., Methods and Findings: A Markov model was developed that describes the transition between HIV stages based on the CD4 count, along with direct costs, quality of life and the mortality rate associated with DAART in comparison with self-administered ART. Data used in the model were derived from the published literature. A health system perspective was employed using a life-time time horizon. Probabilistic sensitivity analysis was performed to determine the impact of parameter uncertainty. Value of information analysis was also conducted. The expected cost of self-administered ART and DAART were $5,200 and $15,500 and the expected QALYs gained were 8.52 and 9.75 respectively, giving an incremental cost effectiveness ratio of $8,400 per QALY gained. The analysis demonstrated that the annual cost DAART needs to be priced below $200 per patient to be cost-effective. The probability that DAART was cost-effective was 1% for a willingness to pay threshold of $5,096 for sub-Saharan Africa. The value of information associated with the cost of DAART and its effectiveness was substantial., Conclusions: From the perspective of the health care payer in sub-Saharan Africa, DAART cannot be regarded as cost-effective based on current information. The value of information analysis showed that further research will be worthwhile and potentially cost-effective in resolving the uncertainty about whether or not to adopt DAART.

The study determined the prevalence of acute respiratory infections and diarrhoea among sub-Saharan African children. It also examined if there was any significant morbidity benefit conferred by three doses of diphtheria-tetanus-pertussis containing vaccines (DTP3) with respect to maternal HIV status. Data were obtained from the Demographic and Health Survey (DHS) program, United Nations Development Programs, World Bank and Joint United Nations Programme on HIV/AIDS. Pooled odds ratio (OR) and 95% confidence intervals (CI) were calculated for the countries. Test of heterogeneity, sensitivity analyses and meta-regression were also conducted. The prevalence of acute respiratory infections and diarrhoea were similar between the children that were vaccinated and those who were not vaccinated with DTP3. The pooled result shows that children who did not receive DTP3 were more likely to have symptoms of acute respiratory infections than children who had DTP3 (OR 1.09, 95% CI 1.02 to 1.17); with low heterogeneity across the countries. The combined result for diarrhoea shows that children who did not receive DTP3 were less likely to have episodes of diarrhoea than children who received DTP3 (OR 0.83, 95% CI 0.74 to 0.92); with substantial heterogeneity across the countries. There was no difference between the estimates of DTP3 vaccinated and unvaccinated children of HIV seropositive mothers with respect to symptoms of acute respiratory infections or episodes of diarrhoea. Tackling various causes and risk factors for respiratory tract infections and diarrhoeal diseases should be a priority for various stakeholders in sub-Saharan Africa.

Missed opportunities for vaccination (MOV) is an important barrier hindering full immunisation coverage among eligible children. Though factors responsible for MOV are well documented in literature, little attention has been paid to the role of inequalities. The aim of this study is to examine the association between structural or compositional factors and education inequalities in MOV. Blinder-Oaxaca decomposition technique was used to explain the factors contributing to the average gap in missed opportunities for vaccination between uneducated and educated mothers in sub-Saharan Africa using DHS survey data from 35 sub Saharan African countries collected between 2007 and 2016. The sample contained 69,657 children aged 12 to 23 months. We observed a wide variation and inter-country differences in the prevalence of missed opportunity for vaccination across populations and geographical locations. Our results show that the prevalence of MOV in Zimbabwe among uneducated and educated mothers was 9% and 21% respectively while in Gabon corresponding numbers were 85% and 89% respectively. In 15 countries, MOV was significantly prevalent among children born to uneducated mothers (pro-illiterate inequality) while in 5 countries MOV was significantly prevalent among educated mothers (pro-educated inequality). Our results suggest that education-related inequalities in missed opportunities for vaccination are explained by compositional and structural characteristics; and that neighbourhood socio-economic status was the most important contributor to education-related inequalities across countries followed by either the presence of under-five children, media access or household wealth index. The results showed that differential effects such as neighbourhood socio-economic status, presence of under-five children, media access and household wealth index, primarily explained education-related inequality in MOV. Interventions to reduce gaps in education-related inequality in MOV should focus on social determinants of health.

There is an urgent need to examine the magnitude and factors responsible for missed opportunities for vaccination, to rapidly achieve national immunization targets. The objective of the study was to examine the influence of individual, neighbourhood and country level socioeconomic position on missed opportunities for vaccination (MOV) in Sub-Saharan Africa. We used multilevel logistic regression analysis on Demographic and Health Survey data collected between 2007 and 2016 in sub-Saharan Africa. We analysed data on 43,637 children aged 12 to 23 months (Level 1) nested within 15,122 neighbourhoods (Level 2) from 35 countries (Level 3). After adjustment for individual-, neighbourhood- and country-level factors, the following appeared as significant risk factors for increased odds of MOV: high birth order, high number of under-five children in the house, poorest household, lack of maternal education, lack of media access, and living in poorer neighbourhood. According to the intra-country and intra-neighbourhood correlation coefficient, 18.4% and 37.4% of the variance in odds of MOV could be attributed to the country and neighbourhood level factors, respectively; and if a child moved to another country or neighbourhood with a higher probability of MOV, the median increase in their odds of MOV would be 2.47 and 2.56 fold respectively. This study has revealed that the risk of missed opportunities for vaccination in sub-Saharan Africa is influenced by not only individual factors but also by compositional factors such as family's financial capacity, place of birth and upbringing.

We examined the roles of determining factors responsible for acute respiratory infections and diarrhoea among immunised human immunodeficiency virus (HIV)-exposed children in sub-Saharan Africa. This study used demographic and health surveys obtained from 27 sub-Saharan African countries. The outcome variable is defined as symptoms of acute respiratory infections or episode of diarrhoea in the child of an HIV-infected mother who is vaccinated with the third dose of diphtheria-tetanus-pertussis containing vaccines. Multivariable logistic regression models were used to analyse the association between individual and contextual factors. The odds of developing symptoms of acute respiratory infections increased among those living in communities with high unemployment rate (Odds ratio = 1.15, 95% credible interval 1.05 to 1.26). The odds of developing diarrhoea increased among young mothers such that children of women aged 15-24 years were two times likely to develop diarrhoea compared to children of women aged 35-49 years (Odds ratio = 2.22, 95% credible interval 1.66 to 2.93). Public healthcare programmes should target adolescent and young women, and their family members on how to prevent diarrhoea. Efforts should be made to identify the hotspots for development of acute respiratory diseases especially in communities with high rate of unemployment and to develop strategies to combat the diseases in such communities. Initiatives such as the integrated Global Action Plan for the Prevention and Control of Pneumonia and Diarrhoea which recommends an interrelated approach for the elimination of preventable diarrhoea and pneumonia deaths should be adopted.

Several innovations that can improve immunization systems already exist. Some interventions target service consumers within communities to raise awareness, build trust, improve understanding, remind caregivers, reward service users, and improve communication. Other interventions target health facilities to improve access and quality of vaccination services among others. Despite available empirical evidence, there is a delay in translating innovations into routine practice by immunization programmes. Drawing on an existing implementation science framework, we propose an interactive, and multi-perspective model to improve uptake and utilization of available immunization-related innovations in the African region. It is important to stress that our framework is by no means prescriptive. The key intention is to advocate for the entire immunization system to be viewed as an interconnected system of stakeholders, so as to foster better interaction, and proactive transfer of evidence-based innovation into policy and practice.

Understanding the gaps in missed opportunities for vaccination (MOV) in sub-Saharan Africa would inform interventions for improving immunisation coverage to achieving universal childhood immunisation. We aimed to conduct a multicountry analyses to decompose the gap in MOV between poor and non-poor in SSA. We used cross-sectional data from 35 Demographic and Health Surveys in SSA conducted between 2007 and 2016. Descriptive statistics used to understand the gap in MOV between the urban poor and non-poor, and across the selected covariates. Out of the 35 countries included in this analysis, 19 countries showed pro-poor inequality, 5 showed pro-non-poor inequality and remaining 11 countries showed no statistically significant inequality. Among the countries with statistically significant pro-illiterate inequality, the risk difference ranged from 4.2% in DR Congo to 20.1% in Kenya. Important factors responsible for the inequality varied across countries. In Madagascar, the largest contributors to inequality in MOV were media access, number of under-five children, and maternal education. However, in Liberia media access narrowed inequality in MOV between poor and non-poor households. The findings indicate that in most SSA countries, children belonging to poor households are most likely to have MOV and that socio-economic inequality in is determined not only by health system functions, but also by factors beyond the scope of health authorities and care delivery system. The findings suggest the need for addressing social determinants of health.

The aim of this study was to develop and test models for non-uptake of three doses of diphtheria-tetanus-pertussis containing vaccines (DTP3) among children of women living with HIV in sub-Saharan Africa. The study used demographic and health survey data from 27 sub-Saharan African countries that have the required HIV and immunization data sets. Multivariable logistic regression models were used to assess the relationship between individual and contextual factors associated with non-uptake of DTP3 among the children. At the individual level, the odds of non-uptake of DTP3 decreased with formal education, increasing age and access to media. The full model shows that the odds of non-uptake of DTP3 is increased among unemployed women, those living in communities with high illiteracy rate and in countries with low adult literacy level. For a child who moved to another country or community with a higher probability of DTP3 non-uptake, the median increase for the odds of DTP3 non-uptake would be 2.24% and 1.22% respectively for country and community. This study shows that individual and contextual factors contributed significantly to non-uptake of DTP3 among the children of women living with HIV. Interventions should be focused on women living with HIV who are young mothers, unemployed women, those without formal education, individuals living in communities with high illiteracy rate and in countries with low adult literacy rate. The use of mass media tools and creation of more employment opportunities for HIV-infected women could improve vaccination coverage among their children.

We investigated the relationship between maternal HIV status and uptake of the full series of three doses of diphtheria-tetanus-pertussis containing vaccines (DTP3) in sub-Saharan African children. We used data obtained from demographic and health surveys conducted in sub-Saharan Africa. We conducted meta-analysis and calculated pooled odds ratios (OR) for the association between maternal HIV status and DTP3 vaccination status for each country. A total of 4,187 out of 5,537 children of women living with HIV received DTP3 (75.6%), compared to 71,290 of 113,513 (62.8%) children of HIV negative women. National DTP3 coverage among children of HIV-positive women varied between 24% and 96% while among children of HIV negative women it was between 26% and 92%. Overall pooled result showed no significant difference in DTP3 coverage between the two groups (OR = 1.05; 95% confidence interval 0.91 - 1.22), with statistically significant heterogeneity (Chi 2 = 91.63, P = 0.000, I 2 = 71.6%). There was no significant association between DTP3 coverage and maternal HIV status in sub-Saharan Africa. However, DTP3 coverage for both HIV-exposed and non-exposed children were below the required target. Meta-regression revealed no significant association between DTP3 coverage and country characteristics (e.g. HIV prevalence among women, antiretroviral therapy coverage, gross domestic product per capita, human development index, adult literacy rate and sub-region). Improved prevention of mother-to-child transmission services might have contributed to some extent to the higher DTP3 vaccination coverage among the HIV-exposed children. There is also need to address barriers impeding uptake of vaccination among HIV-exposed and non-exposed children.

Background: A substantial reduction in neonatal mortality is the main priority to reduce under-five mortality. A clear understanding of the variation in neonatal mortality and the underlying causes is important for targeted intervention. We aimed to explore variation in neonatal mortality and identify underlying causes of variation in neonatal mortality in sub-Saharan Africa (SSA)., Methods: This ecological study used 2012 publicly available data from WHO, the US Agency for International Development and the World Bank. Variation in neonatal mortality across 49 SSA countries was examined using control chart and explanatory spatial data analysis. Associations between country-level characteristics and neonatal mortality were examined using linear regression analysis., Results: The control chart showed that 28 (57%) SSA countries exhibited special-cause variation, 14 countries were below and 14 above the 99.8% control-limits. The remaining 21 (43%) SSA countries showed common-cause variation. No spatial clustering was observed for neonatal mortality (Global Moran's I statistic -0.10; p=0.74). Linear regression analysis showed HIV/AIDS prevalence among the population of reproductive age to be positively associated with neonatal mortality (β=0.463; 95% CI 0.135 to 0.790; p<0.01). Declining socioeconomic deprivation (β=-0.234; 95% CI -0.424 to -0.044; p<0.05) and high quality of healthcare governance (β=-1.327, 95% CI -2.073 to -0.580; p<0.01) were inversely associated with neonatal mortality., Conclusion: This study shows a wide variation in neonatal mortality in SSA. A substantial part of this variation can be explained by differences in the quality of healthcare governance, prevalence of HIV and socioeconomic deprivation. Future studies should validate our findings using more rigorous epidemiological study designs., Competing Interests: Competing interests: None declared.

Nigeria has made remarkable progress against polio, but 2 wild polio virus cases were reported in August 2016; putting an end to 2 y without reported cases. We examined the extent of geographical disparities in childhren not vaccinated against polio and examined individual- and community-level predictors of non-vaccination in Nigeria. We applied multilevel logistic regression models to the recent Nigeria Demographic and Health Survey. The percentage of children not routinely vaccinated against polio in Nigeria varied greatly and clustered geographically, mainly in north-eastern states, with a great risk of spread of transmission within these states and potential exportation to neighboring states and countries. Only about one-third had received all recommended 4 routine oral polio vaccine doses. Non-vaccinated children tended to have a mother who had no formal education and who was currently not working, live in poorer households and were from neighborhoods with higher maternal illiteracy rates.

Background: There are limited data on adverse effects of tenofovir disoproxil fumarate (TDF)-based antiretroviral therapy (ART) on pregnant women and their infants., Methods: We conducted a systematic review of studies published between January 1980 and January 2017 that compared adverse outcomes in HIV-infected women receiving TDF- vs. non-TDF-based ART during pregnancy. The risk ratio (RR) for associations was pooled using a fixed-effects model., Results: Seventeen studies met the study inclusion criteria. We found that the rate of preterm (<37 weeks gestation) delivery (RR = 0.90, 95% confidence interval [CI]: 0.81 to 0.99, I = 59%) and stillbirth (RR = 0.60, 95% CI: 0.43 to 0.84, I = 72.0%) were significantly lower in women exposed (vs. not) to TDF-based ART regimen. We found no increased risk in maternal severe (grade 3) or potentially life-threatening (grade 4) adverse events (RR = 0.62; 95% CI: 0.30 to 1.29), miscarriage (RR = 1.09; 95% CI: 0.80 to 1.48), very preterm (<34 weeks gestation) delivery (RR = 1.08, 95% CI: 0.72 to 1.62), small for gestational age (RR = 0.87, 95% CI: 0.67 to 1.13), low birth weight (RR = 0.91; 95% CI: 0.80 to 1.04), very low birth weight (RR = 3.18; 95% CI: 0.65 to 15.63), congenital anomalies (RR = 1.03; 95% CI: 0.83 to 1.28), infant adverse outcomes or infant mortality (age >14 days) (RR = 0.65; 95% CI: 0.23 to 1.85), but increased neonatal mortality (age <14 days) risk (RR = 5.64, 95% CI: 1.70 to 18.79) with TDR-based ART exposure. No differences were found for anthropomorphic parameters at birth; one study reported minor differences in z-scores for length and head circumference at age 1 year., Conclusions: TDF-based ART in pregnancy seems generally safe for women and their infants. However, data remain limited and further studies are needed, particularly to assess neonatal mortality and infant growth/bone effects.

The association of antiretroviral therapy (ART) with diabetes is inconsistent and varies widely across primary epidemiological studies. A comprehensive and more precise estimate of this association is fundamental to establishing a plausible causal link between ART and diabetes. We identified epidemiological studies that compared mean fasting plasma glucose (FPG) concentrations and proportions of diabetes and metabolic syndrome between HIV-infected patients naïve and exposed to ART. Mean difference in FPG concentrations and odds ratios of diabetes and metabolic syndrome were pooled using random-effects meta-analyses. Data on 20 178 participants from 41 observational studies were included in the meta-analyses. Mean FPG concentrations (Pooled mean difference: 4.66 mg/dL; 95% confidence interval [CI], 2.52 to 6.80; 24 studies) and the odds of diabetes (Pooled odds ratios: 3.85; 95% CI, 2.93 to 5.07; 10 studies) and metabolic syndrome (Pooled odds ratios: 1.45; 95% CI, 1.03 to 2.03; 18 studies) were significantly higher among ART-exposed patients, compared to their naïve counterparts. ART was also associated with significant increases in FPG levels in studies with mean ART duration ≥18 months (Pooled mean difference: 4.97 mg/dL; 95% CI, 3.10 to 6.84; 14 studies), but not in studies with mean ART duration <18 months (Pooled mean difference: 4.40 mg/dL, 95% CI, -0.59 to 9.38; 7 studies). ART may potentially be the single most consistent determinant of diabetes in people living with HIV worldwide. However, given the preponderance of cross-sectional studies in the meta-analysis, the association between ART and diabetes cannot be interpreted as cause and effect., (Copyright © 2017 John Wiley & Sons, Ltd.)

This study sought to determine the effectiveness of multiple risk factor interventions aimed at modifying major cardiovascular risk factors for the primary prevention of cardiovascular disease in low- and middle-income countries (LMIC). We searched electronic databases for randomized controlled trials of health promotion interventions to achieve behavior change. The pooled effect indicated a reduction in systolic blood pressure (-6.72 mm Hg; 95% confidence interval [CI]: -9.82 to -3.61; I 2 = 91%), diastolic blood pressure (-4.40 mm Hg; 95% CI: -6.47 to -2.34; I 2 = 92%), body mass index (-0.76 kg/m 2 ; 95% CI: -1.29 to -0.22; I 2 = 80%), and waist circumference (-3.31 cm; 95% CI: -4.77 to -1.86; I 2 = 55%) in favor of multiple risk factor interventions. There is some evidence that multiple risk factor interventions may lower blood pressure levels and anthropometrics in populations in LMIC settings at high risk of hypertension and diabetes., (Copyright © 2016 World Heart Federation (Geneva). Published by Elsevier B.V. All rights reserved.)

Background: Haemolysis risk with single dose or short course primaquine was evaluated in glucose-6-phosphate dehydrogenase (G6PD) deficient people., Methods: Major electronic databases (to August 2016) were searched for single or short course 8-aminoquinolines (8-AQ) in (1) randomized comparisons against placebo in G6PD deficient people; and (2) observational comparisons in G6PD deficient compared to replete people. Two authors independently assessed eligibility, risk-of-bias, and extracted data., Results: Five randomized controlled trials and four controlled observational cohorts were included. In G6PD deficient individuals, high-dose (0.75 mg/kg) PQ resulted in lower average haemoglobin levels at 7 days (mean difference [MD] -1.45 g/dl, 95% CI -2.17 to -0.74, 2 trials) and larger percentage fall from baseline to day 7 (MD -10.31%, 95% CI -17.69 to -2.92, 3 trials) compared to placebo. In G6PD deficient compared to replete people, average haemoglobin was lower at 7 days (MD -1.19 g/dl, 95% CI -1.94 to -0.44, 2 trials) and haemoglobin change from baseline to day 7 was greater (MD -9.10%, 95% CI -12.55 to -5.65, 5 trials). One small trial evaluated mid-range PQ dose (0.4-0.5 mg/kg) in G6PD deficient people, with no difference detected in average haemoglobin at day 7 compared to placebo. In one cohort comparing G6PD deficient and replete people there was a greater fall with G6PD deficiency (MD -4.99%, 95% CI -9.96 to -0.02). For low-dose PQ (0.1-0.25 mg/kg) in G6PD deficient people, haemoglobin change from baseline was similar to the placebo group (MD 1.72%, 95% CI -1.89 to 5.34, 2 trials). Comparing low dose PQ in G6PD deficient with replete people, the average haemoglobin was lower in the G6PD deficient group at 7 days (-0.57 g (95% CI -0.97 to -0.17, 1 trial)); although change from baseline was similar (MD -1.45%, 95% CI -5.69 to 2.78, 3 trials)., Conclusions: Falls in average haemoglobin are less marked with the 0.1 to 0.25 mg/kg PQ than with the 0.75 mg/kg dose, and severe haemolytic events are not common. However, data were limited and the evidence GRADE was low or very low certainty.

Background: Adverse events from intrapartum antibiotic prophylaxis (IAP) are poorly documented yet essential to inform clinical practice for neonatal group B Streptococcus (GBS) disease prevention. In this systematic review, we appraised and synthesised the evidence on the adverse events of IAP in the mother and/or her child., Methods: We searched MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, Cochrane, and Science Citation Index from date of inception until October 16th 2016. Reference lists of included studies and relevant systematic reviews were hand-searched. We included primary studies in English that reported any adverse events from intrapartum antibiotics for any prophylactic purpose compared to controls. The search was not restricted to prophylaxis for GBS but excluded women with symptoms of infection or undergoing caesarean section. Two reviewers assessed the methodological quality of studies, using the Cochrane Risk of Bias tool, and the Risk of Bias Assessment Tool for Nonrandomised Studies. Results were synthesised narratively and displayed in text and tables., Results: From 2364 unique records, 30 studies were included. Despite a wide range of adverse events reported in 17 observational studies and 13 randomised controlled trials (RCTs), the evidence was inconsistent and at high risk of bias. Only one RCT investigated the long-term effects of IAP reporting potentially serious outcomes such as cerebral palsy; however, it had limited applicability and unclear biological plausibility. Seven observational studies showed that IAP for maternal GBS colonisation alters the infant microbiome. However, study populations were not followed through to clinical outcomes, therefore clinical significance is unknown. There was also observational evidence for increased antimicrobial resistance, however studies were at high or unclear risk of bias., Conclusions: The evidence base to determine the frequency of adverse events from intrapartum antibiotic prophylaxis for neonatal GBS disease prevention is limited. As RCTs may not be possible, large, better quality, and longitudinal observational studies across countries with widespread IAP could fill this gap., Trial Registration: CRD42016037195 .

Background: Although the rising pandemic of obesity has received major attention in many countries, the effects of this attention on trends and the disease burden of obesity remain uncertain., Methods: We analyzed data from 68.5 million persons to assess the trends in the prevalence of overweight and obesity among children and adults between 1980 and 2015. Using the Global Burden of Disease study data and methods, we also quantified the burden of disease related to high body-mass index (BMI), according to age, sex, cause, and BMI in 195 countries between 1990 and 2015., Results: In 2015, a total of 107.7 million children and 603.7 million adults were obese. Since 1980, the prevalence of obesity has doubled in more than 70 countries and has continuously increased in most other countries. Although the prevalence of obesity among children has been lower than that among adults, the rate of increase in childhood obesity in many countries has been greater than the rate of increase in adult obesity. High BMI accounted for 4.0 million deaths globally, nearly 40% of which occurred in persons who were not obese. More than two thirds of deaths related to high BMI were due to cardiovascular disease. The disease burden related to high BMI has increased since 1990; however, the rate of this increase has been attenuated owing to decreases in underlying rates of death from cardiovascular disease., Conclusions: The rapid increase in the prevalence and disease burden of elevated BMI highlights the need for continued focus on surveillance of BMI and identification, implementation, and evaluation of evidence-based interventions to address this problem. (Funded by the Bill and Melinda Gates Foundation.).

Introduction: In Somalia, protracted conflict and drought have caused population displacement and livelihood destruction. There is also widespread childhood undernutrition. We aimed to determine the independent effects of conflict on wasting and stunting among children aged 6-59 months nationwide in Somalia., Methods: Data were from household surveys during 2007-2010, including 73 778 children in 1066 clusters, the Armed Conflict Location and Event Data project database and remote sensing. We used Bayesian hierarchical spatial-temporal regression to examine the effects of conflict on wasting and stunting. Models included individual, household and environmental covariates and recent (<3 months) or longer term (3-12 months) conflict events., Results: 15 355 (21%) and 22 739 (31%) observations were from wasted and stunted children, respectively. The conflict was associated with undernutrition independently of the individual, household and environmental factors, and its inclusion improved model performance. Recent conflict was associated with wasting (OR 1.37, 95% credible interval (CrI): (1.33, 1.42) and attributable fraction (AF) 7.6%)) and stunting (OR 1.21, 95% CrI (1.15, 1.28), AF 6.9%). Longer term conflict had greater effects on wasting (OR 1.76, 95% CrI (1.71, 1.81), AF 6.0%) and stunting (OR 1.88, 95% CrI = (1.83, 1.94), AF 7.4%). After controlling for conflict, the harmful effect of internal displacement and protective effects of rainfall and vegetation cover on undernutrition were enhanced., Conclusion: Conflict and internal displacement have large effects on undernutrition in ways not fully captured by simply measuring individual, household and environmental factors or drought., Competing Interests: Competing interests None declared.

Data on antiretroviral therapy (ART) adherence among prison inmates are limited and not previously synthesized in a systematic manner. The objective of this study was to provide accurate and up-to-date ART adherence estimates among prison inmates. We searched electronic databases for all studies reporting adherence as a primary or secondary outcome among prison inmates. A random-effects model was used to pool adherence rates; sensitivity, heterogeneity and publication bias were assessed. Eleven studies involving 2895 HIV-infected prison inmates were included. The studies were carried out between 1992 and 2011 and reported between 1998 and 2013. A pooled analysis of all studies indicated a pooled estimate of 54.6% (95% confidence interval 48.1-60.9%) of prison inmates had adequate (≥95%) ART adherence. The adherence estimates were significantly higher among cross-studies and studies that used self-reported measures. In summary, our findings indicate that optimal adherence remains a challenge among prison inmates. It is crucial to monitor ART adherence and develop appropriate interventions to improve adherence among these population.

Objective: To examine the independent contribution of individual, community and state-level factors to health care service utilization for children with acute childhood illnesses in Nigeria., Materials and Methods: The study was based on secondary analyses of cross-sectional population-based data from the 2013 Nigeria Demographic and Health Survey (DHS). Multilevel logistic regression models were applied to the data on 6,427 under-five children who used or did not use health care service when they were sick (level 1), nested within 896 communities (level 2) from 37 states (level 3)., Results: About one-quarter of the mothers were between 15 and 24 years old and almost half of them did not have formal education (47%). While only 30% of the children utilized health service when they were sick, close to 67% lived in the rural area. In the fully adjusted model, mothers with higher education attainment (Adjusted odds ratio [aOR] = 1.63; 95% credible interval [CrI] = 1.31-2.03), from rich households (aOR = 1.76; 95% CrI = 1.35-2.25), with access to media (radio, television or magazine) (aOR = 1.18; 95% CrI = 1.08-1.29), and engaging in employment (aOR = 1.18; 95% CrI = 1.02-1.37) were significantly more likely to have used healthcare services for acute childhood illnesses. On the other hand, women who experienced difficulty getting to health facilities (aOR = 0.87; 95% CrI = 0.75-0.99) were less likely to have used health service for their children., Conclusions: Our findings highlight that utilization of healthcare service for acute childhood illnesses was influenced by not only maternal factors but also community-level factors, suggesting that public health strategies should recognise this complex web of individual composition and contextual composition factors to guide provision of healthcare services. Such interventions could include: increase in female school enrolment, provision of interest-free loans for small and medium scale enterprises, introduction of mobile clinics and establishment of more primary health care centres.

Background: Under-five mortality remains high in sub-Saharan Africa despite global decline. One quarter of these deaths are preventable through interventions such as immunization. The aim of this study was to examine the independent effects of individual-, community- and state-level factors on incomplete childhood immunization in Nigeria, which is one of the 10 countries where most of the incompletely immunised children in the world live., Methods: The study was based on secondary analyses of cross-sectional data from the 2013 Nigeria Demographic and Health Survey (DHS). Multilevel multivariable logistic regression models were applied to the data on 5,754 children aged 12-23 months who were fully immunized or not (level 1), nested within 896 communities (level 2) from 37 states (level 3)., Results: More than three-quarter of the children (76.3%) were not completely immunized. About 83% of children of young mothers (15-24 years) and 94% of those whose mothers are illiterate did not receive full immunization. In the fully adjusted model, the chances of not being fully immunized reduced for children whose mothers attended antenatal clinic (adjusted odds ratio [aOR] = 0.49; 95% credible interval [CrI] = 0.39-0.60), delivered in health facility (aOR = 0.62; 95% CrI = 0.51-0.74) and lived in urban area (aOR = 0.66; 95% CrI = 0.50-0.82). Children whose mothers had difficulty getting to health facility (aOR = 1.28; 95% CrI = 1.02-1.57) and lived in socioeconomically disadvantaged communities (aOR = 2.93; 95% CrI = 1.60-4.71) and states (aOR = 2.69; 955 CrI =1.37-4.73) were more likely to be incompletely immunized., Conclusions: This study has revealed that the risk of children being incompletely immunized in Nigeria was influenced by not only individual factors but also community- and state-level factors. Interventions to improve child immunization uptake should take into consideration these contextual characteristics.

Background: Premenstrual syndrome (PMS) is a psychological and somatic disorder of unknown aetiology, with symptoms typically including irritability, depression, mood swings, bloating, breast tenderness and sleep disturbances. About 3% to 10% of women who experience these symptoms may also meet criteria for premenstrual dysphoric disorder (PMDD). PMS symptoms recur during the luteal phase of the menstrual cycle and reduce by the end of menstruation. PMS results from ovulation and may be due to ovarian steroid interactions relating to neurotransmitter dysfunction. Premenstrual disorders have a devastating effect on women, their families and their work.Several treatment options have been suggested for PMS, including pharmacological and surgical interventions. The treatments thought to be most effective tend to fall into one of two categories: suppressing ovulation or correcting a speculated neuroendocrine anomaly.Transdermal oestradiol by patch, gel or implant effectively stops ovulation and the cyclical hormonal changes which produce the cyclical symptoms. These preparations are normally used for hormone therapy and contain lower doses of oestrogen than found in oral contraceptive pills. A shortened seven-day course of a progestogen is required each month for endometrial protection but can reproduce premenstrual syndrome-type symptoms in these women., Objectives: To determine the effectiveness and safety of non-contraceptive oestrogen-containing preparations in the management of PMS., Search Methods: On 14 March 2016, we searched the following databases: the Cochrane Gynaecology and Fertility Group (CGF) Specialised Register; Cochrane Central Register of Studies (CRSO); MEDLINE; Embase; PsycINFO; CINAHL; ClinicalTrials.gov; metaRegister of Controlled trials (mRCT); and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) Search Portal. In addition, we checked the reference lists of articles retrieved., Selection Criteria: We included published and unpublished randomized placebo or active controlled trials on the efficacy of the use of non-contraceptive oestrogen-containing preparations in the management of premenstrual syndrome in women of reproductive age with PMS diagnosed by at least two prospective cycles without current psychiatric disorder., Data Collection and Analysis: Two review authors independently selected studies, assessed risk of bias, extracted data on premenstrual symptoms and adverse effects and entered data into Review Manager 5 software. Where possible, intention-to-treat or modified intention-to-treat analysis was used. Studies were pooled using a fixed-effect model, analysing cross-over trials as parallel trials. Standardised mean differences (SMDs) with 95% confidence intervals (CIs) were calculated for premenstrual symptom scores. Risk ratios (RRs) with 95% confidence intervals (CIs) were calculated for dichotomous outcomes. The overall quality of the evidence was assessed using the GRADE working group methods., Main Results: The search resulted in 524 potentially relevant articles. Five eligible randomized controlled trials (RCTs) were identified (305 women). Trials using oral tablets, transdermal patches and implants were identified. No trial used gels.One small cross-over trial (11 women, effective sample size 22 women considering cross-over trials) compared oral luteal-phase oestrogen versus placebo. Data were very low quality and unsuitable for analysis, but study authors reported that the intervention was ineffective and might aggravate the symptoms of PMS. They also reported that there were no adverse events.Three studies compared continuous oestrogen with progestogen versus placebo (with or without progestogen). These trials were of reasonable quality, although with a high risk of attrition bias and an unclear risk of bias due to potential carry-over effects in two cross-over trials. Continuous oestrogen had a small to moderate positive effect on global symptom scores (SMD -0.34, 95% CI -0.59 to -0.10, P = 0.005, 3 RCTs, 158 women, effective sample size 267 women, I² = 63%, very low quality evidence). The evidence was too imprecise to determine if the groups differed in withdrawal rates due to adverse effects (RR 0.64, 95% CI 0.26 to 1.58, P = 0.33, 3 RCTs, 196 women, effective sample size 284 women, I² = 0%, very low quality evidence). Similarly, the evidence was very imprecise in measures of specific adverse events, with large uncertainties around the true value of the relative risk. None of the studies reported on long-term risks such as endometrial cancer or breast cancer.One study compared patch dosage (100 vs 200 µg oestrogen, with progestogen in both arms) and had a high risk of performance bias, detection bias and attrition bias. The study did not find evidence that dosage affects global symptoms but there was much uncertainty around the effect estimate (SMD -1.55, 95% CI -8.88 to 5.78, P = 0.68, 1 RCT, 98 women, very low quality evidence). The evidence on rates of withdrawal for adverse events was too imprecise to draw any conclusions (RR 0.70, 95% CI 0.34 to 1.46, P = 0.34, 1 RCT, 107 women, low-quality evidence). However, it appeared that the 100 µg dose might be associated with a lower overall risk of adverse events attributed to oestrogen (RR 0.51, 95% Cl 0.26 to 0.99, P = 0.05, 1 RCT, 107 women, very low quality evidence) with a large uncertainty around the effect estimate.The overall quality of the evidence for all comparisons was very low, mainly due to risk of bias (specifically attrition), imprecision, and statistical and clinical heterogeneity., Authors' Conclusions: We found very low quality evidence to support the effectiveness of continuous oestrogen (transdermal patches or subcutaneous implants) plus progestogen, with a small to moderate effect size. We found very low quality evidence from a study based on 11 women to suggest that luteal-phase oral unopposed oestrogen is probably ineffective and possibly detrimental for controlling the symptoms of PMS. A comparison between 200 µg and 100 µg doses of continuous oestrogen was inconclusive with regard to effectiveness, but suggested that the lower dose was less likely to cause side effects. Uncertainty remains regarding safety, as the identified studies were too small to provide definite answers. Moreover, no included trial addressed adverse effects that might occur beyond the typical trial duration of 2-8 months. This suggests the choice of oestrogen dose and mode of administration could be based on an individual woman's preference and modified according to the effectiveness and tolerability of the chosen regimen.

Health service utilization is an important component of child health promotion. Evidence shows that two-thirds of child deaths in low and middle income countries could be prevented if current interventions were adequately utilized. Aim of this study was to identify determinants of variation in health services utilization for children in communities in Nigeria. Multivariable negative binomial regression model attempting to explain observed variability in health services usage in Nigerian communities was applied to the 2013 Nigeria Demographic and Health Survey data. We included the index of maternal deprivation, gender of child, community environmental factor index, and maternal health seeking behaviour, multiple childhood deprivation index and ethnicity diversity index as the independent variables. The outcome variable was under-fives' hospital attendance rates for acute illness. Of the 7577 children from 896 communities in Nigeria that were sick 1936 (25.6%) were taken to the health care facilities for treatment. The final model revealed that both multiple childhood deprivation (incidence rate ratio [IRR]=1.23, 95% confidence interval [CI] 1.12 to 1.35) and children living in communities with a high ethnic diversity were associated with higher rate of health service use. Maternal health seeking behaviour was associated with a significantly lower rate of health care service use. There are significant variations in health services utilization for sick children across Nigeria communities which appear to be more strongly determined by childhood deprivation factors and maternal health seeking behaviour than by health system functions., (Copyright © 2017 The Authors. Published by Elsevier Inc. All rights reserved.)

The Eastern Mediterranean Region (EMR) is witnessing an increase in chronic disorders, including mental illness. With ongoing unrest, this is expected to rise. This is the first study to quantify the burden of mental disorders in the EMR. We used data from the Global Burden of Disease study (GBD) 2013. DALYs (disability-adjusted life years) allow assessment of both premature mortality (years of life lost-YLLs) and nonfatal outcomes (years lived with disability-YLDs). DALYs are computed by adding YLLs and YLDs for each age-sex-country group. In 2013, mental disorders contributed to 5.6% of the total disease burden in the EMR (1894 DALYS/100,000 population): 2519 DALYS/100,000 (2590/100,000 males, 2426/100,000 females) in high-income countries, 1884 DALYS/100,000 (1618/100,000 males, 2157/100,000 females) in middle-income countries, 1607 DALYS/100,000 (1500/100,000 males, 1717/100,000 females) in low-income countries. Females had a greater proportion of burden due to mental disorders than did males of equivalent ages, except for those under 15 years of age. The highest proportion of DALYs occurred in the 25-49 age group, with a peak in the 35-39 years age group (5344 DALYs/100,000). The burden of mental disorders in EMR increased from 1726 DALYs/100,000 in 1990 to 1912 DALYs/100,000 in 2013 (10.8% increase). Within the mental disorders group in EMR, depressive disorders accounted for most DALYs, followed by anxiety disorders. Among EMR countries, Palestine had the largest burden of mental disorders. Nearly all EMR countries had a higher mental disorder burden compared to the global level. Our findings call for EMR ministries of health to increase provision of mental health services and to address the stigma of mental illness. Moreover, our results showing the accelerating burden of mental health are alarming as the region is seeing an increased level of instability. Indeed, mental health problems, if not properly addressed, will lead to an increased burden of diseases in the region., Competing Interests: We would like to declare the following commercial affiliations: Dr. Anwar Rafay is employed by Contech International health consultants. Syed Danish Ali is employed by SIR Consultants. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

The burden of stroke has been projected to increase in low-and middle-income countries due to the ongoing epidemiological transition. However, community-based stroke prevalence studies are sparse in sub-Saharan Africa particularly in Nigeria. This study aimed to provide a comparative estimate of the prevalence of stroke survivors in the rural Niger Delta region. A three-phased door-to-door survey was conducted using WHO modified instruments. In the first-phase, 2028 adults (≥18years) participants randomly selected from two rural communities were screened by trained health research assistants for probable stroke. In the second phase, suspected cases were screened with stroke-specific tool. Positive cases were made to undergo complete neurological evaluation by two study neurologist in phase-three. Stroke diagnosis was based on clinical evaluation using WHO criteria. Overall, 27 (8 first-ever and 19 recurrent cases) stroke survivors with crude prevalence of 13.31/1000 (95% CI, 8.32-18.31) and a non-significant difference in prevalence between the two study communities were found, (P=0.393I). In addition, age-adjusted prevalence of stroke survivors was 14.6/1000 person, about 7-folds higher than previous estimates outside the Niger Delta region. The prevalence increases significantly with advancing in age, P<0·001. Among others, hypertension (92.59%) was the commonest risk factor and comorbidity found. Improved stroke surveillance and care, as well as better management of the underlying risk factors, primarily undetected or uncontrolled high blood pressure, remains a public health priority., (Copyright © 2016 Elsevier B.V. All rights reserved.)

Importance: Elevated systolic blood (SBP) pressure is a leading global health risk. Quantifying the levels of SBP is important to guide prevention policies and interventions., Objective: To estimate the association between SBP of at least 110 to 115 mm Hg and SBP of 140 mm Hg or higher and the burden of different causes of death and disability by age and sex for 195 countries and territories, 1990-2015., Design: A comparative risk assessment of health loss related to SBP. Estimated distribution of SBP was based on 844 studies from 154 countries (published 1980-2015) of 8.69 million participants. Spatiotemporal Gaussian process regression was used to generate estimates of mean SBP and adjusted variance for each age, sex, country, and year. Diseases with sufficient evidence for a causal relationship with high SBP (eg, ischemic heart disease, ischemic stroke, and hemorrhagic stroke) were included in the primary analysis., Main Outcomes and Measures: Mean SBP level, cause-specific deaths, and health burden related to SBP (≥110-115 mm Hg and also ≥140 mm Hg) by age, sex, country, and year., Results: Between 1990-2015, the rate of SBP of at least 110 to 115 mm Hg increased from 73 119 (95% uncertainty interval [UI], 67 949-78 241) to 81 373 (95% UI, 76 814-85 770) per 100 000, and SBP of 140 mm Hg or higher increased from 17 307 (95% UI, 17 117-17 492) to 20 526 (95% UI, 20 283-20 746) per 100 000. The estimated annual death rate per 100 000 associated with SBP of at least 110 to 115 mm Hg increased from 135.6 (95% UI, 122.4-148.1) to 145.2 (95% UI 130.3-159.9) and the rate for SBP of 140 mm Hg or higher increased from 97.9 (95% UI, 87.5-108.1) to 106.3 (95% UI, 94.6-118.1). For loss of DALYs associated with systolic blood pressure of 140 mm Hg or higher, the loss increased from 95.9 million (95% uncertainty interval [UI], 87.0-104.9 million) to 143.0 million (95% UI, 130.2-157.0 million) [corrected], and for SBP of 140 mm Hg or higher, the loss increased from 5.2 million (95% UI, 4.6-5.7 million) to 7.8 million (95% UI, 7.0-8.7 million). The largest numbers of SBP-related deaths were caused by ischemic heart disease (4.9 million [95% UI, 4.0-5.7 million]; 54.5%), hemorrhagic stroke (2.0 million [95% UI, 1.6-2.3 million]; 58.3%), and ischemic stroke (1.5 million [95% UI, 1.2-1.8 million]; 50.0%). In 2015, China, India, Russia, Indonesia, and the United States accounted for more than half of the global DALYs related to SBP of at least 110 to 115 mm Hg., Conclusions and Relevance: In international surveys, although there is uncertainty in some estimates, the rate of elevated SBP (≥110-115 and ≥140 mm Hg) increased substantially between 1990 and 2015, and DALYs and deaths associated with elevated SBP also increased. Projections based on this sample suggest that in 2015, an estimated 3.5 billion adults had SBP of at least 110 to 115 mm Hg and 874 million adults had SBP of 140 mm Hg or higher.

Background: Although lifelong combination antiretroviral therapy (ART) is recommended for all individuals with HIV, few data exist for pregnancy outcomes associated with ART initiation before conception. We assessed adverse pregnancy outcomes associated with ART initiated before conception compared with that of ART started after conception., Methods: We did a systematic review of studies from low-income, middle-income, and high-income countries by searching the Cochrane Central Register of Controlled Trials, Embase, LILACS, MEDLINE, Toxline, Web of Knowledge, and WHO Global Index Medicus and trials in progress (International Clinical Trials Registry Platform) for randomised trials, quasi-randomised trials, and prospective cohort studies done between Jan 1, 1980, and June 1, 2016, in which timing of ART initiation in pregnant women living with HIV was reported. We used the risk ratio (RR) and corresponding 95% CIs as the primary measure to assess the association between the selected outcomes and ART initiation before conception versus after conception. We used a random-effects model to pool risk ratios., Findings: We included 11 studies with 19 189 mother-infant pairs. Women who started ART before conception were significantly more likely to deliver preterm (pooled RR 1·20, 95% CI 1·01-1·44) or very preterm (1·53, 1·22-1·92), or to have low-birthweight infants (1·30, 1·04-1·62) than were those who began ART after conception. Few data exist for neonatal mortality. The risk of very low birthweight, small for gestational age, severe small for gestational age, stillbirth, and congenital anomalies did not differ significantly between women who were taking ART before conception and those who began ART after conception., Interpretation: The benefits of ART for maternal health and prevention of perinatal transmission outweigh risks, but data for the extent and severity of these risks are scarce and of low quality. As use of ART before conception rapidly increases globally, monitoring for potential adverse pregnancy outcomes will be crucial., Funding: WHO., (Copyright © This is an Open Access article published under the CC BY 3.0 IGO license which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. In any use of this article, there should be no suggestion that WHO endorses any specific organisation, products or services. The use of the WHO logo is not permitted. This notice should be preserved along with the article's original URL.)

Diarrheal diseases (DD) are leading causes of disease burden, death, and disability, especially in children in low-income settings. DD can also impact a child's potential livelihood through stunted physical growth, cognitive impairment, and other sequelae. As part of the Global Burden of Disease Study, we estimated DD burden, and the burden attributable to specific risk factors and particular etiologies, in the Eastern Mediterranean Region (EMR) between 1990 and 2013. For both sexes and all ages, we calculated disability-adjusted life years (DALYs), which are the sum of years of life lost and years lived with disability. We estimate that over 125,000 deaths (3.6% of total deaths) were due to DD in the EMR in 2013, with a greater burden of DD in low- and middle-income countries. Diarrhea deaths per 100,000 children under 5 years of age ranged from one (95% uncertainty interval [UI] = 0-1) in Bahrain and Oman to 471 (95% UI = 245-763) in Somalia. The pattern for diarrhea DALYs among those under 5 years of age closely followed that for diarrheal deaths. DALYs per 100,000 ranged from 739 (95% UI = 520-989) in Syria to 40,869 (95% UI = 21,540-65,823) in Somalia. Our results highlighted a highly inequitable burden of DD in EMR, mainly driven by the lack of access to proper resources such as water and sanitation. Our findings will guide preventive and treatment interventions which are based on evidence and which follow the ultimate goal of reducing the DD burden., (© The American Society of Tropical Medicine and Hygiene.)

Background: The transition from association to causation could represent a fundamental step for taking preventive action against hypertension and its complications, especially among HIV-infected persons on antiretroviral therapy in sub-Saharan African countries., Methods: 406 consecutive HIV-infected adults attending a tertiary HIV clinic in semi-urban Nigeria were prospectively recruited between August and November 2014. These participants were stratified by antiretroviral treatment status. A propensity score matching model was fitted to examine the causal average treatment effects on the treated (ATT) of antiretroviral therapy on blood pressure. Propensity score matching entailed using nearest neighbour matching with a calliper width of 0.2 to achieve similarity in the baseline characteristics between participants naïve and exposed to antiretroviral therapy., Results: Matching HIV-infected patients naïve and exposed to antiretroviral therapy on the propensity score yielded a total of 303 participants - 229 antiretroviral-exposed and 74 antiretroviral-naïve - matched without any residual differences in the baseline characteristics between both groups of patients. In this propensity score-matched sample, the estimated ATT for the effects of antiretroviral therapy on systolic (7.85mmHg, 95% CI 3.72 to 15.68) and diastolic blood pressure (7.45mmHg, 95% CI 4.99 to 13.61) were statistically significant (P<0.001 for each)., Conclusions: There is a high probability that the epidemiological association between antiretroviral therapy and increased blood pressure be causal in nature among people living with HIV in sub-Saharan African settings. HIV-infected patients commencing antiretroviral treatment in these settings may require regular hypertension screening and other cardiovascular risk assessments., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Background: The eastern Mediterranean region is comprised of 22 countries: Afghanistan, Bahrain, Djibouti, Egypt, Iran, Iraq, Jordan, Kuwait, Lebanon, Libya, Morocco, Oman, Pakistan, Palestine, Qatar, Saudi Arabia, Somalia, Sudan, Syria, Tunisia, the United Arab Emirates, and Yemen. Since our Global Burden of Disease Study 2010 (GBD 2010), the region has faced unrest as a result of revolutions, wars, and the so-called Arab uprisings. The objective of this study was to present the burden of diseases, injuries, and risk factors in the eastern Mediterranean region as of 2013., Methods: GBD 2013 includes an annual assessment covering 188 countries from 1990 to 2013. The study covers 306 diseases and injuries, 1233 sequelae, and 79 risk factors. Our GBD 2013 analyses included the addition of new data through updated systematic reviews and through the contribution of unpublished data sources from collaborators, an updated version of modelling software, and several improvements in our methods. In this systematic analysis, we use data from GBD 2013 to analyse the burden of disease and injuries in the eastern Mediterranean region specifically., Findings: The leading cause of death in the region in 2013 was ischaemic heart disease (90·3 deaths per 100 000 people), which increased by 17·2% since 1990. However, diarrhoeal diseases were the leading cause of death in Somalia (186·7 deaths per 100 000 people) in 2013, which decreased by 26·9% since 1990. The leading cause of disability-adjusted life-years (DALYs) was ischaemic heart disease for males and lower respiratory infection for females. High blood pressure was the leading risk factor for DALYs in 2013, with an increase of 83·3% since 1990. Risk factors for DALYs varied by country. In low-income countries, childhood wasting was the leading cause of DALYs in Afghanistan, Somalia, and Yemen, whereas unsafe sex was the leading cause in Djibouti. Non-communicable risk factors were the leading cause of DALYs in high-income and middle-income countries in the region. DALY risk factors varied by age, with child and maternal malnutrition affecting the younger age groups (aged 28 days to 4 years), whereas high bodyweight and systolic blood pressure affected older people (aged 60-80 years). The proportion of DALYs attributed to high body-mass index increased from 3·7% to 7·5% between 1990 and 2013. Burden of mental health problems and drug use increased. Most increases in DALYs, especially from non-communicable diseases, were due to population growth. The crises in Egypt, Yemen, Libya, and Syria have resulted in a reduction in life expectancy; life expectancy in Syria would have been 5 years higher than that recorded for females and 6 years higher for males had the crisis not occurred., Interpretation: Our study shows that the eastern Mediterranean region is going through a crucial health phase. The Arab uprisings and the wars that followed, coupled with ageing and population growth, will have a major impact on the region's health and resources. The region has historically seen improvements in life expectancy and other health indicators, even under stress. However, the current situation will cause deteriorating health conditions for many countries and for many years and will have an impact on the region and the rest of the world. Based on our findings, we call for increased investment in health in the region in addition to reducing the conflicts., Funding: Bill & Melinda Gates Foundation., (Copyright © 2016 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY license. Published by Elsevier Ltd.. All rights reserved.)

Although more than one in two HIV-infected persons may develop central fat accumulation soon after commencing antiretroviral therapy, the association between antiretroviral therapy and body fat changes has not been consistent across primary epidemiological studies. We conducted a systematic review with meta-analyses to estimate the pooled effects of antiretroviral therapy on different measures of body fat, and to examine factors that potentially modify these effects. We searched for studies that compared body mass index, waist circumference, combined overweight/obesity, and central obesity between HIV-infected adults naive and exposed to antiretroviral therapy. Random-effects subgroup and meta-regression analyses were performed to identify potential effect-modifiers of the pooled associations. Sixty studies, comprising data on 53,199 HIV-infected participants, were eligible for the meta-analyses. Antiretroviral therapy was associated with increased body mass index (SMD: 0.17 kg/m2; 95% CI: 0.07-0.26), waist circumference (SMD: 0.20 cm; 95% CI: 0.07-0.33), overweight/obesity (borderline significance: OR: 1.36; 95% CI: 0.99-1.86), and abdominal obesity (OR: 1.49; 95% CI: 1.16-1.90). In addition, antiretroviral therapy was associated with significant increases in body mass index, overweight/obesity, and central obesity among patients with CD4 counts < 350 cells/mm3, but not among patients with higher CD4 counts (Pinteraction < 0.05 for all). Overall, exposure to antiretroviral therapy was associated with increased risks of generalized and central obesity, and risks may be exacerbated by lower CD4 counts. These findings suggest that weight management and obesity prevention programs may be worth considering as part of routine HIV care.

Little is known about the effect of community versus health facility-based interventions to improve and sustain antiretroviral therapy (ART) adherence, virologic suppression, and retention in care among HIV-infected individuals in low- and middle-income countries (LMICs). We systematically searched four electronic databases for all available randomized controlled trials (RCTs) and comparative cohort studies in LMICs comparing community versus health facility-based interventions. Relative risks (RRs) for pre-defined adherence, treatment engagement (linkage and retention in care), and relevant clinical outcomes were pooled using random effect models. Eleven cohort studies and eleven RCTs (N = 97,657) were included. Meta-analysis of the included RCTs comparing community- versus health facility-based interventions found comparable outcomes in terms of ART adherence (RR = 1.02, 95 % CI 0.99 to 1.04), virologic suppression (RR = 1.00, 95 % CI 0.98 to 1.03), and all-cause mortality (RR = 0.93, 95 % CI 0.73 to 1.18). The result of pooled analysis from the RCTs (RR = 1.03, 95 % CI 1.01 to 1.06) and cohort studies (RR = 1.09, 95 % CI 1.03 to 1.15) found that participants assigned to community-based interventions had statistically significantly higher rates of treatment engagement. Two studies found community-based ART delivery model either cost-saving or cost-effective. Community- versus facility-based models of ART delivery resulted in at least comparable outcomes for clinically stable HIV-infected patients on treatment in LMICs and are likely to be cost-effective.