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BackgroundA shortage of community health workers to triage sick neonates and poor recognition of neonatal illness by mothers contribute significantly toward neonatal deaths in low- and middle-income countries. Providing low-resource communities with the tools and knowledge to recognize signs of neonatal distress can lead to early care-seeking behavior. To empower and educate mothers to recognize signs of neonatal illness, we developed a neonatal health assessment device consisting of a smartphone app and a wearable sensor (the NeMo system). ObjectiveThe aim of this study was to determine if mothers in rural Uganda were willing and able to use the NeMo system during the first week of their infant’s life. We also assessed mothers’ responses to the device’s recommendation to seek care. MethodsA total of 20 mothers were enrolled in the study after giving birth in the Iganga District Hospital. Each mother was trained to use the NeMo system to assess her infant for signs of illness before leaving the hospital and was given the NeMo system to use at home for 1 week. Throughout the week, the smartphone tracked the mothers’ usage of NeMo, and the study team visited twice to observe mothers’ ability to use NeMo. Each mother was interviewed at the end of 1 week to gather qualitative feedback on her experience with the NeMo system. ResultsIn total, 18 mothers completed the study; 2 mothers were withdrawn during the week because of extenuating health circumstances. Moreover, 1 day after enrollment and training, 75% (15/20) of mothers used NeMo properly with no mistakes. Three days after enrollment and training, only 1 mother placed the wearable sensor improperly on her infant. On the final study day, only 1 mother connected the device improperly. Mothers used NeMo an average of 11.67 (SD 5.70) times on their own at home during the 5 full study days. Although the frequency of use per day decreased from day 1 to day 5 of the study (P=.04), 72% (13/18) of mothers used NeMo at least once per day. In total, 64% (9/14) of mothers who received an alert from the NeMo system to seek care for their infants either called the health care professional working with the study team or reused the system immediately and found no danger signs. All 18 mothers agreed or strongly agreed that the NeMo system was easy to use and helped them know when to seek care for their babies. ConclusionsNeMo is a feasible and acceptable tool to aid mothers in rural Uganda to assess their infant’s health.

BackgroundDespite the rapid proliferation of health interventions that employ digital tools, the evidence on the effectiveness of such approaches remains insufficient and of variable quality. To address gaps in the comprehensiveness and quality of reporting on the effectiveness of digital programs, the mHealth Technical Evidence Review Group (mTERG), convened by the World Health Organization, proposed the mHealth Evidence Reporting and Assessment (mERA) checklist to address existing gaps in the comprehensiveness and quality of reporting on the effectiveness of digital health programs. ObjectiveWe present an overview of the mERA checklist and encourage researchers working in the digital health space to use the mERA checklist for reporting their research. MethodsThe development of the mERA checklist consisted of convening an expert group to recommend an appropriate approach, convening a global expert review panel for checklist development, and pilot-testing the checklist. ResultsThe mERA checklist consists of 16 core mHealth items that define what the mHealth intervention is (content), where it is being implemented (context), and how it was implemented (technical features). Additionally, a 29-item methodology checklist guides authors on reporting critical aspects of the research methodology employed in the study. We recommend that the core mERA checklist is used in conjunction with an appropriate study-design specific checklist. ConclusionsThe mERA checklist aims to assist authors in reporting on digital health research, guide reviewers and policymakers in synthesizing evidence, and guide journal editors in assessing the completeness in reporting on digital health studies. An increase in transparent and rigorous reporting can help identify gaps in the conduct of research and understand the effects of digital health interventions as a field of inquiry.

BackgroundIn utero or early-life exposure to aflatoxin, which contaminates staple crops in disadvantaged settings, may compromise pregnancy and infant outcomes, but investigations into the extent, persistence, and determinants of aflatoxin exposure at these life stages have lacked longitudinal data collection and broad geographic representation.ObjectivesAflatoxin exposure and selected determinants thereof were characterized in mother-child dyads with serial plasma/serum samples in prenatal, perinatal, and early life in Malawi and Bangladesh.MethodsCirculating aflatoxin B1 (AFB1)-lysine albumin adducts were measured in dyads from Bangladesh (n = 573; maternal first and third trimester, 3 mo postpartum, cord blood, infant 24 mo) and Malawi (n = 255; maternal second and third trimester, 6 mo postpartum, infant 6 and 18 mo) with isotope dilution mass spectrometry. We examined AFB1-lysine adduct magnitude, persistence, seasonality, and associations with infant feeding, and estimated daily AFB1 intake.ResultsMaternal AFB1-lysine was higher in Malawi (98% detectable; median: 0.469, IQR: 0.225-1.027 pg/µL) than in Bangladesh (59%; 0.030, nondetectable [nd]-0.077 pg/µL). Although estimated dietary exposure in Malawi was temporally stable (648 ng AFB1/day), estimated intake in Bangladesh was reduced by 94% between rainy and winter seasons (98 to 6 ng/day). AFB1-lysine was low in cord blood from Bangladesh (15% detectable; 0.045, 0.031-0.088 pg/µL among detectable) and in Malawian infants at 6 mo of age (0.072, nd-0.236 pg/µL), but reached maternal concentrations by 18 or 24 mo (Bangladesh: 0.034, nd-0.063 pg/µL; Malawi: 0.370, 0.195-0.964 pg/µL). In Malawian infants, exclusive breastfeeding at 3 mo was associated with 58% lower AFB1-lysine concentrations at 6 mo compared with other feeding modes (P = 0.010).ConclusionsAmong pregnant women, aflatoxin exposure was persistently high in Malawi, while lower and seasonal in Bangladesh. Infants were partially protected from exposure in utero and with exclusive breastfeeding, but exposures reached adult levels by 18-24 mo of age. The Bangladesh and Malawi trials are registered at clinicaltrials.gov as NCT00860470 and NCT01239693.

ContextApproximately 7.3 million births occur annually among adolescents in low- and middle-income countries. Pregnant adolescents constitute a nutritionally vulnerable group that could benefit from intervention to mitigate the mortality and adverse birth outcomes associated with adolescent pregnancy.ObjectiveThe aim of this systematic review and meta-analysis was to assess the following: (1) the effect of multiple-micronutrient (MMN) supplementation vs iron and folic acid (IFA) supplementation among adolescents on maternal morbidity, birth outcomes, and mortality outcomes, (2) the effects of MMN supplementation in adolescents compared with the effects in adult women, and (3) the effect modification, if any, of MMN supplementation by baseline and geographic characteristics of adolescents.Data sourcesMEDLINE and Cochrane databases were searched, along with the reference lists of relevant reviews.Study selectionMultiple-micronutrient supplementation trials in pregnancy that were conducted in a low- or middle-income country and had included at least 100 adolescents (10-19 years of age) were eligible for inclusion. Two independent reviewers assessed study eligibility.Data extractionThirteen randomized controlled trials conducted in Africa and Asia were identified from 1792 reviews and 1578 original trials. Individual-level data was shared by study collaborators and was checked for completeness and extreme values. One- and two-stage individual participant data meta-analyses were conducted using data from randomized controlled trials of MMN supplementation.ResultsA total of 15 283 adolescents and 44 499 adult women with singleton births were included in the individual participant data meta-analyses of MMN supplementation vs IFA supplementation. In adolescents, MMN supplementation reduced low birth weight (1-stage OR = 0.87, 95%CI 0.77-0.97; 2-stage OR = 0.81; 95%CI 0.74-0.88), preterm birth (1-stage OR = 0.88, 95%CI 0.80-0.98; 2-stage OR = 0.86, 95%CI 0.79-0.95), and small-for-gestational-age births (1-stage OR = 0.90, 95%CI 0.81-1.00; 2-stage OR = 0.86, 95%CI 0.79-0.95) when compared with IFA supplementation. The effects of MMN supplementation did not differ between adolescents and older women, although a potentially greater reduction in small-for-gestational-age births was observed among adolescents. Effect modification by baseline characteristics and geographic region was inconclusive.ConclusionsMultiple-micronutrient supplementation can improve birth outcomes among pregnant adolescents in low- and middle-income countries. Policy related to antenatal care in these settings should prioritize MMN supplementation over the currently recommended IFA supplementation for all pregnant women, especially adolescents.

Objective To describe a systematic process of transforming paper registers into a digital system optimized to enhance service provision and fulfil reporting requirements. Methods We designed a formative study around primary health workers providing reproductive, maternal, newborn and child health services in three countries in Bangladesh, Indonesia and Pakistan. The study ran from November 2014 to June 2018. We developed a prototype digital application after conducting a needs assessment of health workers' responsibilities, workflows, routine data requirements and service delivery needs. Methods included desk reviews, focus group discussions, in-depth interviews; data mapping of paper registers; observations of health workers; co-design workshops with health workers; and usability testing. Finally, we conducted an observational feasibility assessment to monitor uptake of the application. Findings Researchers reviewed a total of 17 paper registers across the sites, which we transformed into seven modules within a digital application running on mobile devices. Modules corresponded to the services provided, including household enumeration, antenatal care, family planning, immunization, nutrition and child health. A total of 65 health workers used the modules during the feasibility assessment, and average weekly form submissions ranged from 8 to 234, depending on the health worker and their responsibilities. We also observed variability in the use of modules, requiring consistent monitoring support for health workers. Conclusion Lessons learnt from this study shaped key global initiatives and resulted in a software global good. The deployment of digital systems requires well-designed applications, change management and strengthening human resources to realize and sustain health system gains. Objectif Decrire un processus methodique de transformation des registres papier en systeme numerique optimise, en vue d'ameliorer la fourniture de services et de remplir les exigences relatives a l'etablissement de rapports. Methodes Nous avons concu une etude formative consacree aux professionnels des soins primaires proposant des services de sante reproductive et maternelle, de sante des nouveau-nes et de sante infantile dans trois pays: le Bangladesh, l'Indonesie et le Pakistan. Cette etude a ete menee entre novembre 2014 et juin 2018. Nous avons mis au point un prototype d'application numerique apres avoir evalue les besoins des soignants, leurs responsabilites, leur charge de travail, les donnees necessaires a leurs activites quotidiennes et les imperatifs lies a leurs prestations de service. Parmi les methodes employees figuraient des examens documentaires, des discussions de groupes, des entretiens approfondis; une cartographie des donnees fondee sur les registres papier; une observation des professionnels de la sante; des ateliers de cocreation avec les soignants; et enfin, des tests d'utilisabilite. Pour terminer, nous avons effectue une analyse de faisabilite observationnelle afin de mesurer le taux d'adhesion a l'application. Resultats Les chercheurs ont passe au crible un total de 17 registres papier sur l'ensemble des sites, que nous avons transformes en sept modules repris dans une application numerique compatible avec les appareils mobiles. Ces modules correspondaient aux services proposes, dont le recensement des menages, les soins prenatals, la planification familiale, la vaccination, la nutrition et la sante infantile. Au total, 65 soignants ont utilise les modules au cours de l'analyse de faisabilite et le nombre moyen de formulaires soumis chaque semaine etait compris entre 8 et 234, en fonction du soignant et de ses responsabilites. Nous avons egalement observe des variations dans l'utilisation des modules, ce qui montre la necessite d'assurer un suivi permanent aupres des professionnels de la sante. Conclusion Les lecons tirees de cette etude ont permis de faconner des initiatives internationales majeures et d'elaborer un logiciel d'interet mondial. Le deploiement de dispositifs numeriques requiert des applications bien pensees, une bonne gestion du changement et un renforcement des ressources humaines afin d'obtenir et de preserver les avantages pour le systeme de sante. Objetivo Describir un proceso sistematico que permita transformar los registros en papel en un sistema digital optimizado para mejorar la prestacion de servicios y cumplir con los requisitos de informacion. Metodos Se diseno un estudio formativo en torno a los profesionales de la salud primaria que prestan servicios de salud reproductiva, materna, neonatal e infantil en tres paises: de Bangladesh, Indonesia y Pakistan. El estudio se realizodesarrollo entre noviembre de 2014 y junio de 2018. Se desarrollo un prototipo de aplicacion digital despues de realizar una evaluacion sobre las necesidades de las responsabilidades de los profesionales sanitarios, los flujos de trabajo, los requisitos de datos rutinarios y las necesidades de prestacion de servicios. Los metodos incluyeron revisiones de documentos, grupos de discusion, entrevistas en profundidad; mapeo de datos de los registros en papel; observaciones de los profesionales sanitarios; talleres de codiseno con los profesionales sanitarios; y pruebas de usabilidad. Por ultimo, se llevo a cabo una evaluacion de viabilidad observacional para supervisar la aceptacion de la aplicacion. Resultados Los investigadores revisaron un total de 17 registros en papel en todos los sitios, que se adaptaron a siete modulos dentro de una aplicacion digital que funcionaba en dispositivos moviles. Los modulos correspondian a los servicios prestados, como la enumeracion de los hogares, la atencion prenatal, la planificacion familiar, la inmunizacion, la nutricion y la salud infantil. Un total de 65 profesionales sanitarios utilizaron los modulos durante la evaluacion de viabilidad, y la media de envios de formularios semanales oscilo entre 8 y 234, dependiendo del profesional sanitario y de sus responsabilidades. Tambien se observo una variabilidad en el uso de los modulos, lo que requirio un apoyo de seguimiento constante por parte de los profesionales sanitarios. Conclusion Las lecciones aprendidas de este estudio dieron forma a iniciativas globales clave y permitieron crear un programa informatico de interes mundial. El despliegue de los sistemas digitales requiere aplicaciones bien disenadas, la gestion del cambio y el fortalecimiento de los recursos humanos para realizar y mantener los beneficios del sistema sanitario., Introduction Global agencies advocate for the use of information and communication technologies to accelerate progress on priorities, such as the sustainable development goals, the Roadmap for Measurement and Accountability, and [...]

BackgroundHepatitis E virus (HEV) infection causes significant morbidity and mortality worldwide, particularly among pregnant women. In clinical settings blood-based testing protocols are commonly used to diagnose HEV infection, but in community settings such invasive sampling can hinder study participation and limit discovery of the ecology and natural history of HEV infection. Oral fluid is a non-invasive biospecimen that can harbor pathogen-specific antibodies and has the potential to replace blood-based testing protocols.ObjectivesTo develop an immunoassay to assess past and recent HEV infection that uses oral fluid instead of serum or plasma.MethodsThe assay was validated using paired oral fluid and serum samples collected from 141 patients who presented either with (n=76) or without (n=65) symptoms of acute viral hepatitis at a clinical diagnostics center in Dhaka, Bangladesh. The sensitivity and specificity of the oral fluid-based immunoassay for HEV IgG (past HEV infection) and HEV IgA (recent HEV infection) antibodies was calculated in reference to Wantai's (Beijing Wantai) serum-based HEV enzyme-linked immunosorbent assay (ELISA) kits for IgG and IgM antibodies, respectively.ResultsThe sensitivity and specificity of the oral fluid-based immunoassay for HEV-IgG antibodies were 98.7% and 98.4%, respectively. The sensitivity and specificity of the oral fluid-based immunoassay for HEV IgA were 89.5% and 98.3%, respectively.ConclusionsThe high concordance of our non-invasive oral fluid-based immunoassays (HEV IgG and HEV IgA) with commercial high-performance serum HEV ELISA kits (IgG and IgM) means that population-based surveillance of past and recent HEV infection could be expanded to improve understanding of its ecology and natural history.

The United Nations Secretary-General has stated that the safe deployment of new technologies, including artificial intelligence, can help the world to achieve the sustainable development goals. (1) The rapid diffusion [...]