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Mertens A, Benjamin-Chung J, Colford JM, Coyle J, van der Laan MJ, Hubbard AE, Rosete S, Malenica I, Hejazi N, Sofrygin O, Cai W, Li H, Nguyen A, Pokpongkiat NN, Djajadi S, Seth A, Jung E, Chung EO, Jilek W, Subramoney V, Hafen R, Häggström J, Norman T, Brown KH, Christian P, Arnold BF. Causes and consequences of child growth faltering in low-resource settings. Nature 2023; 621:568-576. [PMID: 37704722 PMCID: PMC10511328 DOI: 10.1038/s41586-023-06501-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 07/31/2023] [Indexed: 09/15/2023]
Abstract
Growth faltering in children (low length for age or low weight for length) during the first 1,000 days of life (from conception to 2 years of age) influences short-term and long-term health and survival1,2. Interventions such as nutritional supplementation during pregnancy and the postnatal period could help prevent growth faltering, but programmatic action has been insufficient to eliminate the high burden of stunting and wasting in low- and middle-income countries. Identification of age windows and population subgroups on which to focus will benefit future preventive efforts. Here we use a population intervention effects analysis of 33 longitudinal cohorts (83,671 children, 662,763 measurements) and 30 separate exposures to show that improving maternal anthropometry and child condition at birth accounted for population increases in length-for-age z-scores of up to 0.40 and weight-for-length z-scores of up to 0.15 by 24 months of age. Boys had consistently higher risk of all forms of growth faltering than girls. Early postnatal growth faltering predisposed children to subsequent and persistent growth faltering. Children with multiple growth deficits exhibited higher mortality rates from birth to 2 years of age than children without growth deficits (hazard ratios 1.9 to 8.7). The importance of prenatal causes and severe consequences for children who experienced early growth faltering support a focus on pre-conception and pregnancy as a key opportunity for new preventive interventions.
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Affiliation(s)
- Andrew Mertens
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA.
| | - Jade Benjamin-Chung
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
- Department of Epidemiology and Population Health, Stanford University, Stanford, CA, USA
- Chan Zuckerberg Biohub, San Francisco, CA, USA
| | - John M Colford
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Jeremy Coyle
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Mark J van der Laan
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Alan E Hubbard
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Sonali Rosete
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Ivana Malenica
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Nima Hejazi
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Oleg Sofrygin
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Wilson Cai
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Haodong Li
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Anna Nguyen
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Nolan N Pokpongkiat
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Stephanie Djajadi
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Anmol Seth
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Esther Jung
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Esther O Chung
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Wendy Jilek
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | | | - Ryan Hafen
- Hafen Consulting, West Richland, WA, USA
| | | | - Thea Norman
- Quantitative Sciences, Bill & Melinda Gates Foundation, Seattle, WA, USA
| | - Kenneth H Brown
- Department of Nutrition, University of California, Davis, Davis, CA, USA
| | - Parul Christian
- Center for Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Benjamin F Arnold
- Francis I. Proctor Foundation, University of California, San Francisco, San Francisco, CA, USA.
- Department of Ophthalmology, University of California, San Francisco, San Francisco, CA, USA.
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2
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Mertens A, Benjamin-Chung J, Colford JM, Hubbard AE, van der Laan MJ, Coyle J, Sofrygin O, Cai W, Jilek W, Rosete S, Nguyen A, Pokpongkiat NN, Djajadi S, Seth A, Jung E, Chung EO, Malenica I, Hejazi N, Li H, Hafen R, Subramoney V, Häggström J, Norman T, Christian P, Brown KH, Arnold BF. Child wasting and concurrent stunting in low- and middle-income countries. Nature 2023; 621:558-567. [PMID: 37704720 PMCID: PMC10511327 DOI: 10.1038/s41586-023-06480-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 07/25/2023] [Indexed: 09/15/2023]
Abstract
Sustainable Development Goal 2.2-to end malnutrition by 2030-includes the elimination of child wasting, defined as a weight-for-length z-score that is more than two standard deviations below the median of the World Health Organization standards for child growth1. Prevailing methods to measure wasting rely on cross-sectional surveys that cannot measure onset, recovery and persistence-key features that inform preventive interventions and estimates of disease burden. Here we analyse 21 longitudinal cohorts and show that wasting is a highly dynamic process of onset and recovery, with incidence peaking between birth and 3 months. Many more children experience an episode of wasting at some point during their first 24 months than prevalent cases at a single point in time suggest. For example, at the age of 24 months, 5.6% of children were wasted, but by the same age (24 months), 29.2% of children had experienced at least one wasting episode and 10.0% had experienced two or more episodes. Children who were wasted before the age of 6 months had a faster recovery and shorter episodes than did children who were wasted at older ages; however, early wasting increased the risk of later growth faltering, including concurrent wasting and stunting (low length-for-age z-score), and thus increased the risk of mortality. In diverse populations with high seasonal rainfall, the population average weight-for-length z-score varied substantially (more than 0.5 z in some cohorts), with the lowest mean z-scores occurring during the rainiest months; this indicates that seasonally targeted interventions could be considered. Our results show the importance of establishing interventions to prevent wasting from birth to the age of 6 months, probably through improved maternal nutrition, to complement current programmes that focus on children aged 6-59 months.
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Affiliation(s)
- Andrew Mertens
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA.
| | - Jade Benjamin-Chung
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
- Department of Epidemiology and Population Health, Stanford University, Stanford, CA, USA
- Chan Zuckerberg Biohub, San Francisco, CA, USA
| | - John M Colford
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Alan E Hubbard
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Mark J van der Laan
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Jeremy Coyle
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Oleg Sofrygin
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Wilson Cai
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Wendy Jilek
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Sonali Rosete
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Anna Nguyen
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Nolan N Pokpongkiat
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Stephanie Djajadi
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Anmol Seth
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Esther Jung
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Esther O Chung
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Ivana Malenica
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Nima Hejazi
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Haodong Li
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley, CA, USA
| | - Ryan Hafen
- Hafen Consulting, West Richland, WA, USA
| | | | | | - Thea Norman
- Quantitative Sciences, Bill & Melinda Gates Foundation, Seattle, WA, USA
| | - Parul Christian
- Center for Human Nutrition, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Kenneth H Brown
- Department of Nutrition, University of California, Davis, Davis, CA, USA
| | - Benjamin F Arnold
- Francis I. Proctor Foundation, University of California, San Francisco, CA, USA.
- Department of Ophthalmology, University of California, San Francisco, CA, USA.
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3
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Mdoe P, Katengu S, Guga G, Daudi V, Kiligo IE, Gidabayda J, Massay C, Mkini F, Mduma E. Perinatal mortality audit in a rural referral hospital in Tanzania to inform future interventions: A descriptive study. PLoS One 2022; 17:e0264904. [PMID: 35275941 PMCID: PMC8916676 DOI: 10.1371/journal.pone.0264904] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 02/21/2022] [Indexed: 11/19/2022] Open
Abstract
Background Clear evidence exists that perinatal audit and feedback can lead to important improvements in practice. The death audit can lead to the identification of existing potential delays which are the decision to seek medical care, reaching an appropriate facility, and receiving timely adequate care at the facility. Such an audit potentially initiates a positive discussion, which may foster the implementation of changes that aims at saving more lives. Objective To review the perinatal deaths case notes and identify potential gaps in care provision and health-seeking behavior to foster best practice. Methods The stillbirths and neonatal death case notes that occurred between January 2019 and May 2020 at the hospital were reviewed using an adapted WHO checklist. The completed review case notes were entered into an electronic system and a quality control check-up was done. Data were analysed descriptively, and findings were presented in tables. Results There were 4,898 births, and 1,175 neonatal admissions, out of these there were 135 recorded stillbirths (2.8%) and 201(4.1% of the total hospital births) early neonatal deaths. Out of the 1,175 neonates, 635 (54%) were born within the hospital and 540 (46%) were admitted from other facilities and home deliveries. In total 86 stillbirths and 140 early neonatal deaths case notes were retrieved and audited. Out of 86 stillbirths’ case notes audited, 30 (34.9%) seemed to have died during labor, and of these 5 had audible fetal heart rate during admission. Apgar scores less than 7 at 5 minutes, prematurity, and meconium aspiration were the top three recorded causes of neonatal deaths. Inadequate/late antenatal care visits and home delivery were the maternal factors likely to have contributed to perinatal deaths. Inadequate labor monitoring (12%) and documentation (62%) were among the providers’ factors likely to have contributed to perinatal deaths. Conclusion This audit shows that there are high rates of preventable intrapartum stillbirths and early neonatal deaths. Both women and providers’ factors were found to have contributed to the stillbirths and neonatal deaths. There is a need to encourage women to adequately attend antenatal care, utilize health facilities during birth, and improve maternity and neonatal care at the health facilities.
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Affiliation(s)
- Paschal Mdoe
- Department of Obstetrics and Gynecology, Haydom Lutheran Hospital, Haydom, Tanzania
- * E-mail:
| | | | - Godfrey Guga
- Research, Haydom Lutheran Hospital, Haydom, Tanzania
| | | | | | - Joshua Gidabayda
- Department of Pediatrics, Haydom Lutheran Hospital, Haydom, Tanzania
| | - Catherine Massay
- Department of Obstetrics and Gynecology, Haydom Lutheran Hospital, Haydom, Tanzania
| | - Felix Mkini
- Research and Advocacy, Haydom Lutheran Hospital, Haydom, Tanzania
| | - Estomih Mduma
- Research, Haydom Lutheran Hospital, Haydom, Tanzania
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DeBoer MD, Elwood SE, Platts-Mills JA, Rogawski McQuade ET, McDermid JM, Scharf RJ, Jatosh S, Mduma E. Sex Differences in Early Childhood Growth in a Resource-Limited Setting: A Secondary Analysis of the Early Life Interventions in Childhood Growth and Development in Tanzania (ELICIT) Study. J Nutr 2022; 152:579-586. [PMID: 34647600 DOI: 10.1093/jn/nxab369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 09/17/2021] [Accepted: 10/08/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND In population-based growth surveys in sub-Saharan Africa, boys have higher rates of growth failure than girls. OBJECTIVES Our goal was to assess for the presence, timing, and potential etiology of sex-based differences in length-for-age z score (LAZ), weight-for-age z score (WAZ), and head circumference-for-age z score (HCZ) in a birth cohort in rural Tanzania. METHODS We performed a secondary analysis of randomized controlled trial data on 1084 children followed from age <2 wk to 18 mo, assessing anthropometry (measured every 3 mo), illness (hospitalization and monthly maternal report of symptoms), and feeding [monthly maternal report of exclusive breastfeeding (EBF) and complementary solids and liquids (CSLs)]. We used linear regression to assess sex differences in LAZ, WAZ, and HCZ over time. RESULTS Although male and female infants had similar anthropometry measures at study entry, males exhibited poorer growth through 6 mo (e.g., 3-mo mean LAZ: males -0.94, females -0.74, P < 0.01; 3-mo mean WAZ: males -0.63, females -0.48, P < 0.05), without significant worsening from 6 to 18 mo. Males had lower HCZ only at 9 mo. In evaluating possible etiologies, mediation analysis failed to identify illness or hospitalization as mediators of poorer growth among males, although at age 3 mo, males with recently reported illness exhibited greater decline in WAZ than females with illness (ΔWAZ: males -0.24, females 0.03, heterogeneity test P = 0.01). Differences in EBF and introduction of CSL did not explain the sex-based growth outcomes. CONCLUSIONS In longitudinal analysis, males exhibited more severe growth failure by 3 mo than girls and did not exhibit catchup growth between 6 and 18 mo. Reported symptoms of illness and early introduction of CSL did not appear to be mediators of these sex-based differences, although likely not all sickness was captured by monthly maternal report. Given the early nature of these deficits, LAZ and WAZ measures at 6 mo may be good outcomes for intervention studies targeting improvements in early childhood growth and thriving.
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Affiliation(s)
- Mark D DeBoer
- Department of Pediatrics, University of Virginia, Charlottesville, VA, USA
| | - Sarah E Elwood
- Division of Infectious Diseases & International Health, University of Virginia, Charlottesville, VA, USA
| | - James A Platts-Mills
- Division of Infectious Diseases & International Health, University of Virginia, Charlottesville, VA, USA
| | | | - Joann M McDermid
- Division of Infectious Diseases & International Health, University of Virginia, Charlottesville, VA, USA
| | - Rebecca J Scharf
- Department of Pediatrics, University of Virginia, Charlottesville, VA, USA.,Division of Infectious Diseases & International Health, University of Virginia, Charlottesville, VA, USA
| | - Samwel Jatosh
- Haydom Global Health Research Centre, Haydom Lutheran Hospital, Haydom, Tanzania
| | - Estomih Mduma
- Haydom Global Health Research Centre, Haydom Lutheran Hospital, Haydom, Tanzania
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5
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Colston JM, Taniuchi M, Ahmed T, Ferdousi T, Kabir F, Mduma E, Nshama R, Iqbal NT, Haque R, Ahmed T, Ali Bhutta Z, Kosek MN, Platts-Mills JA. Intestinal Colonization With Bifidobacterium longum Subspecies Is Associated With Length at Birth, Exclusive Breastfeeding, and Decreased Risk of Enteric Virus Infections, but Not With Histo-Blood Group Antigens, Oral Vaccine Response or Later Growth in Three Birth Cohorts. Front Pediatr 2022; 10:804798. [PMID: 35252058 PMCID: PMC8888871 DOI: 10.3389/fped.2022.804798] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 01/13/2022] [Indexed: 11/30/2022] Open
Abstract
Bifidobacterium longum subspecies detected in infant stool have been associated with numerous subsequent health outcomes and are potential early markers of deviation from healthy developmental trajectories. This analysis derived indicators of carriage and early colonization with B. infantis and B. longum and quantified their associations with a panel of early-life exposures and outcomes. In a sub-study nested within a multi-site birth cohort, extant stool samples from infants in Bangladesh, Pakistan and Tanzania were tested for presence and quantity of two Bifidobacterium longum subspecies. The results were matched to indicators of nutritional status, enteropathogen infection, histo-blood group antigens, vaccine response and feeding status and regression models were fitted to test for associations while adjusting for covariates. B. infantis was associated with lower quantity of and decreased odds of colonization with B. longum, and vice versa. Length at birth was associated with a 0.36 increase in log10 B. infantis and a 0.28 decrease in B. longum quantity at 1 month of age. B. infantis colonization was associated with fewer viral infections and small reductions in the risk of rotavirus and sapovirus infections, but not reduced overall diarrheal disease risk. No associations with vaccine responses, HBGAs or later nutritional status were identified. Suboptimal intrauterine growth and a shorter duration of exclusive breastfeeding may predispose infants to early intestinal colonization with the B. longum subspecies at the expense of B. infantis, thus denying them potential benefits of reduced enteric virus episodes.
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Affiliation(s)
- Josh M Colston
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA, United States
| | - Mami Taniuchi
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA, United States
| | - Tahmina Ahmed
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA, United States
| | - Tania Ferdousi
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Furqan Kabir
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Estomih Mduma
- Haydom Global Health Research Centre, Haydom, Tanzania
| | | | - Najeeha Talat Iqbal
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Rashidul Haque
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Tahmeed Ahmed
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Zulfiqar Ali Bhutta
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - Margaret N Kosek
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA, United States.,Department of Public Health Sciences, University of Virginia School of Medicine, Charlottesville, VA, United States
| | - James A Platts-Mills
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA, United States
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DeBoer MD, Platts-Mills JA, Elwood SE, Scharf RJ, McDermid JM, Wanjuhi AW, Jatosh S, Katengu S, Parpia TC, Rogawski McQuade ET, Gratz J, Svensen E, Swann JR, Donowitz JR, Mdoe P, Kivuyo S, Houpt ER, Mduma E. Effect of scheduled antimicrobial and nicotinamide treatment on linear growth in children in rural Tanzania: A factorial randomized, double-blind, placebo-controlled trial. PLoS Med 2021; 18:e1003617. [PMID: 34582462 PMCID: PMC8478246 DOI: 10.1371/journal.pmed.1003617] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 04/09/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Stunting among children in low-resource settings is associated with enteric pathogen carriage and micronutrient deficiencies. Our goal was to test whether administration of scheduled antimicrobials and daily nicotinamide improved linear growth in a region with a high prevalence of stunting and enteric pathogen carriage. METHODS AND FINDINGS We performed a randomized, 2 × 2 factorial, double-blind, placebo-controlled trial in the area around Haydom, Tanzania. Mother-child dyads were enrolled by age 14 days and followed with monthly home visits and every 3-month anthropometry assessments through 18 months. Those randomized to the antimicrobial arm received 2 medications (versus corresponding placebos): azithromycin (single dose of 20 mg/kg) at months 6, 9, 12, and 15 and nitazoxanide (3-day course of 100 mg twice daily) at months 12 and 15. Those randomized to nicotinamide arm received daily nicotinamide to the mother (250 mg pills months 0 to 6) and to the child (100 mg sachets months 6 to 18). Primary outcome was length-for-age z-score (LAZ) at 18 months in the modified intention-to-treat group. Between September 5, 2017 and August 31, 2018, 1,188 children were randomized, of whom 1,084 (n = 277 placebo/placebo, 273 antimicrobial/placebo, 274 placebo/nicotinamide, and 260 antimicrobial/nicotinamide) were included in the modified intention-to-treat analysis. The study was suspended for a 3-month period by the Tanzanian National Institute for Medical Research (NIMR) because of concerns related to the timing of laboratory testing and the total number of serious adverse events (SAEs); this resulted in some participants receiving their final study assessment late. There was a high prevalence of stunting overall (533/1,084, 49.2%). Mean 18-month LAZ did not differ between groups for either intervention (mean LAZ with 95% confidence interval [CI]: antimicrobial: -2.05 CI -2.13, -1.96, placebo: -2.05 CI -2.14, -1.97; mean difference: 0.01 CI -0.13, 0.11, p = 0.91; nicotinamide: -2.06 CI -2.13, -1.95, placebo: -2.04 CI -2.14, -1.98, mean difference 0.03 CI -0.15, 0.09, p = 0.66). There was no difference in LAZ for either intervention after adjusting for possible confounders (baseline LAZ, age in days at 18-month measurement, ward, hospital birth, birth month, years of maternal education, socioeconomic status (SES) quartile category, sex, whether the mother was a member of the Datoga tribe, and mother's height). Adverse events (AEs) and SAEs were overall similar between treatment groups for both the nicotinamide and antimicrobial interventions. Key limitations include the absence of laboratory measures of pathogen carriage and nicotinamide metabolism to provide context for the negative findings. CONCLUSIONS In this study, we observed that neither scheduled administration of azithromycin and nitazoxanide nor daily provision of nicotinamide was associated with improved growth in this resource-poor setting with a high force of enteric infections. Further research remains critical to identify interventions toward improved early childhood growth in challenging conditions. TRIAL REGISTRATION ClinicalTrials.gov NCT03268902.
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Affiliation(s)
- Mark D. DeBoer
- Department of Pediatrics, University of Virginia, Charlottesville, Virginia, United States of America
- * E-mail:
| | - James A. Platts-Mills
- Division of Infectious Diseases & International Health, University of Virginia, Charlottesville, Virginia, United States of America
| | - Sarah E. Elwood
- Division of Infectious Diseases & International Health, University of Virginia, Charlottesville, Virginia, United States of America
| | - Rebecca J. Scharf
- Department of Pediatrics, University of Virginia, Charlottesville, Virginia, United States of America
- Division of Infectious Diseases & International Health, University of Virginia, Charlottesville, Virginia, United States of America
| | - Joann M. McDermid
- Division of Infectious Diseases & International Health, University of Virginia, Charlottesville, Virginia, United States of America
| | - Anne W. Wanjuhi
- Division of Infectious Diseases & International Health, University of Virginia, Charlottesville, Virginia, United States of America
| | - Samwel Jatosh
- Haydom Global Health Research Centre, Haydom Lutheran Hospital, Haydom, Tanzania
| | - Siphael Katengu
- Haydom Global Health Research Centre, Haydom Lutheran Hospital, Haydom, Tanzania
| | - Tarina C. Parpia
- Division of Infectious Diseases & International Health, University of Virginia, Charlottesville, Virginia, United States of America
| | - Elizabeth T. Rogawski McQuade
- Division of Infectious Diseases & International Health, University of Virginia, Charlottesville, Virginia, United States of America
| | - Jean Gratz
- Division of Infectious Diseases & International Health, University of Virginia, Charlottesville, Virginia, United States of America
| | | | - Jonathan R. Swann
- School of Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
- Department of Surgery & Cancer, Imperial College London, London, United Kingdom
| | - Jeffrey R. Donowitz
- Division of Infectious Disease, Children’s Hospital of Richmond at Virginia Commonwealth University, Richmond, Virginia, United States of America
| | - Paschal Mdoe
- Haydom Global Health Research Centre, Haydom Lutheran Hospital, Haydom, Tanzania
| | - Sokoine Kivuyo
- National Institute for Medical Research, Muhimbili Medical Research Centre, Dar es Salaam, Tanzania
| | - Eric R. Houpt
- Division of Infectious Diseases & International Health, University of Virginia, Charlottesville, Virginia, United States of America
| | - Estomih Mduma
- Haydom Global Health Research Centre, Haydom Lutheran Hospital, Haydom, Tanzania
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7
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Occurrence of Intestinal Parasites of Public Health Significance in Fresh Horticultural Products Sold in Maputo Markets and Supermarkets, Mozambique. Microorganisms 2021; 9:microorganisms9091806. [PMID: 34576702 PMCID: PMC8469142 DOI: 10.3390/microorganisms9091806] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 08/23/2021] [Accepted: 08/23/2021] [Indexed: 11/26/2022] Open
Abstract
(1) Background: Giardia duodenalis and Cryptosporidium are important neglected parasites associated with diarrhea, such as the emerging Enterocytozoon bieneusi. All three are foodborne parasites raising concerns in public health. This study intended to understand the intestinal parasite occurrence with emphasis on G. duodenalis, Cryptosporidium, and E. bieneusi in fresh fruits/vegetables sold in the main municipal markets of Maputo city, Mozambique. (2) Methods: A total of 321 fresh horticultural products were purchased in the rainy and dry seasons (five markets/two supermarkets/one agricultural zone). Light microscopy (LM) and PCR analysis were performed. (3) Results: By LM and/or PCR, 29.3% of the samples presented at least one parasite (rainy season: 22.9%; dry season: 35.1%). The most contaminated horticultural products: collected in dry season, from Zimpeto and Fajardo markets, lettuce and pointed white cabbage. Overall, 3.7% of G. duodenalis, 1.3% of E. bieneusi, and other intestinal parasites (pathogenic and non-pathogenic) were identified. (4) Conclusions: Important pathogenic intestinal parasites were identified in fruits/vegetables commercially purchased in Maputo City. This fact must be taken into consideration when planning the management of these horticultural markets, in order to reduce the risk of contamination of fresh produce by intestinal parasites, and to prevent foodborne diseases.
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8
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Rogawski McQuade ET, Benjamin-Chung J, Westreich D, Arnold BF. Population intervention effects in observational studies to emulate target trial results: reconciling the effects of improved sanitation on child growth. Int J Epidemiol 2021; 51:279-290. [PMID: 34151953 DOI: 10.1093/ije/dyab070] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 03/17/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Improved sanitation has been associated with improved child growth in observational studies, but multiple randomized trials that delivered improved sanitation found no effect on child growth. We assessed to what extent differences in the effect estimated in the two study designs (the effect of treatment in observational studies and the effect of treatment assignment in trials) could explain the contradictory results. METHODS We used parametric g-computation in five prospective studies (n = 21 524) and 59 cross-sectional Demographic and Health Surveys (DHS; n = 158 439). We compared the average treatment effect (ATE) for improved sanitation on mean length-for-age z-score (LAZ) among children aged <2 years to population intervention effects (PIEs), which are the observational analogue of the effect estimated in trials in which some participants are already exposed. RESULTS The ATE was >0.15 z-scores, a clinically meaningful difference, in most prospective studies but in <20% of DHS surveys. The PIE was always smaller than the ATE, and the magnitude of difference depended on the baseline prevalence of the improved sanitation. Interventions with suboptimal coverage and interventions delivered in populations with higher mean LAZ had a smaller effect on population-level LAZ. CONCLUSIONS Estimates of PIEs corresponding to anticipated trial results were often smaller than clinically meaningful effects. Incongruence between observational associations and null trial results may in part be explained by expected differences between the effects estimated. Using observational ATEs to set expectations for trials may overestimate the impact that sanitation interventions can achieve. PIEs predict realistic effects and should be more routinely estimated.
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Affiliation(s)
- Elizabeth T Rogawski McQuade
- Department of Public Health Sciences, University of Virginia, Charlottesville, VA, USA.,Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA, USA
| | - Jade Benjamin-Chung
- Department of Epidemiology & Biostatistics, University of California, Berkeley, CA, USA
| | - Daniel Westreich
- Division of Epidemiology, University of North Carolina-Chapel Hill, NC, USA
| | - Benjamin F Arnold
- Francis I. Proctor Foundation, University of California, San Francisco, CA, USA.,Department of Ophthalmology, University of California, San Francisco, CA, USA
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9
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Urban-Rural Disparities in the Magnitude and Determinants of Stunting among Children under Five in Tanzania: Based on Tanzania Demographic and Health Surveys 1991-2016. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18105184. [PMID: 34068222 PMCID: PMC8153115 DOI: 10.3390/ijerph18105184] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 05/07/2021] [Accepted: 05/08/2021] [Indexed: 12/31/2022]
Abstract
Our study aims to examine the disparity of under-5 child stunting prevalence between urban and rural areas of Tanzania in the past three decades, and to explore factors affecting the rural–urban disparity. Secondary analyses of Tanzania Demographic and Health Surveys (TDHS) data drawn from 1991–1992, 1996, 1999, 2004–2005, 2009–2010, and 2015–2016 surveys were conducted. Under-5 child stunting prevalence was calculated separately for rural and urban children and its decline trends were examined by chi-square tests. Descriptive analyses were used to present the individual-level, household-level, and societal-level characteristics of children, while multivariable logistic regression analyses were performed to examine determinants of stunting in rural and urban areas, respectively. Additive interaction effects were estimated between residence and other covariates. The results showed that total stunting prevalence was declining in Tanzania, but urban–rural disparity has widened since the decline was slower in the rural area. No interaction effect existed between residence and other determinants, and the urban–rural disparity was mainly caused by the discrepancy of the individual-level and household-level factors between rural and urban households. As various types of determinants exist, multisector nutritional intervention strategies are required to address the child stunting problem. Meanwhile, the intervention should focus on targeting vulnerable children, rather than implementing different policies in rural and urban areas.
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10
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Kuwelker K, Langeland N, Löhr IH, Gidion J, Manyahi J, Moyo SJ, Blomberg B, Klingenberg C. Use of probiotics to reduce infections and death and prevent colonization with extended-spectrum beta-lactamase (ESBL)-producing bacteria among newborn infants in Tanzania (ProRIDE Trial): study protocol for a randomized controlled clinical trial. Trials 2021; 22:312. [PMID: 33926519 PMCID: PMC8082054 DOI: 10.1186/s13063-021-05251-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 04/07/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-E) has emerged as an urgent global health threat and is by the World Health Organization ranked as priority 1 among pathogens in need of new treatment. Studies have shown high mortality in Tanzanian children with ESBL-E infections. Gut colonization of ESBL-E, which is a potential risk factor of ESBL-E infections, is reported to be very high among children in Tanzania. Probiotics may potentially reduce gut colonization of multidrug-resistant bacteria. However, there is limited data on whether probiotics may reduce ESBL-E carriage in infants. The ProRIDE Trial aims to evaluate whether the use of probiotics can reduce morbidity and mortality among infants in Haydom, Tanzania, and whether this effect is associated with a reduction in ESBL-E colonization and/or infections. METHODS/DESIGN This large randomized double-blinded placebo-controlled trial aims to recruit 2000 newborn infants at Haydom Lutheran Hospital and the surrounding area in the period of November 2020 to November 2021. Participants will be enrolled from days 0 to 3 after birth and randomized to receive probiotics or placebo for 4 weeks. Participants will be followed-up for 6 months, during which three visits will be made to collect clinical and demographic information, as well as rectal swabs and fecal samples which will be subjected to laboratory analysis. The primary composite outcome is the prevalence of death and/or hospitalization at 6 months of age. DISCUSSION As the use of probiotics may give a more favorable gut composition, and thereby improve health and reduce morbidity and mortality, the results may have implications for future therapy guidelines in Africa and internationally. TRIAL REGISTRATION ClinicalTrials.gov NCT04172012. Registered on November 21, 2019.
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Affiliation(s)
- Kanika Kuwelker
- Norwegian National Advisory Unit on Tropical Infectious Diseases, Haukeland University Hospital, Haukelandsbakken, 5009 Bergen, Norway
| | - Nina Langeland
- Norwegian National Advisory Unit on Tropical Infectious Diseases, Haukeland University Hospital, Haukelandsbakken, 5009 Bergen, Norway
- Department of Clinical Science, University of Bergen, Laboratory Building, Haukeland University Hospital, Jonas Lies veg 87, 5021 Bergen, Norway
| | - Iren Høyland Löhr
- Department of Medical Microbiology, Stavanger University Hospital, Gerd Ragna Bloch Thorsens gate, 4011 Stavanger, Norway
| | - Joshua Gidion
- Department of Paediatrics, Haydom Lutheran Hospital, Mbulu, Manyara Tanzania
| | - Joel Manyahi
- Department of Clinical Science, University of Bergen, Laboratory Building, Haukeland University Hospital, Jonas Lies veg 87, 5021 Bergen, Norway
- Department of Microbiology and Immunology, Muhimbili University of Health and Allied Sciences, MUHAS, P.O. Box 65005, Dar es Salaam, Tanzania
| | - Sabrina John Moyo
- Department of Clinical Science, University of Bergen, Laboratory Building, Haukeland University Hospital, Jonas Lies veg 87, 5021 Bergen, Norway
- Department of Microbiology and Immunology, Muhimbili University of Health and Allied Sciences, MUHAS, P.O. Box 65005, Dar es Salaam, Tanzania
| | - Bjørn Blomberg
- Norwegian National Advisory Unit on Tropical Infectious Diseases, Haukeland University Hospital, Haukelandsbakken, 5009 Bergen, Norway
- Department of Clinical Science, University of Bergen, Laboratory Building, Haukeland University Hospital, Jonas Lies veg 87, 5021 Bergen, Norway
| | - Claus Klingenberg
- Department of Paediatrics and Adolescence Medicine, University Hospital of North Norway, Tromsø, Norway
- Paediatric Research Group, Faculty of Health Sciences, University of Tromsø-Arctic University of Norway, Tromsø, Norway
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11
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Vossius C, Mduma E, Moshiro R, Mdoe P, Kvaløy JT, Kidanto H, Lyanga S, Ersdal H. The impact of introducing ambulance and delivery fees in a rural hospital in Tanzania. BMC Health Serv Res 2021; 21:99. [PMID: 33509195 PMCID: PMC7844989 DOI: 10.1186/s12913-021-06107-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 01/20/2021] [Indexed: 11/24/2022] Open
Abstract
Background Access to health care facilities is a key requirement to enhance safety for mothers and newborns during labour and delivery. Haydom Lutheran Hospital (HLH) is a regional hospital in rural Tanzania with a catchment area of about two million inhabitants. Up to June 2013 ambulance transport and delivery at HLH were free of charge, while a user fee for both services was introduced from January 2014. We aimed to explore the impact of introducing user fees on the population of women giving birth at HLH in order to document potentially unwanted consequences in the period after introduction of fees. Methods Retrospective analysis of data from a prospective observational study. Data was compared between the period before introduction of fees from February 2010 through June 2013 and the period after from January 2014 through January 2017. Logistic regression modelling was used to construct risk-adjusted variable-life adjusted display (VLAD) and cumulative sum (CUSUM) plots to monitor changes. Results A total of 28,601 births were observed. The monthly number of births was reduced by 17.3% during the post-introduction period. Spontaneous vaginal deliveries were registered less frequently with a decrease of about 17/1000 births in non-cephalic presentations. Labour complications and caesarean sections increased with about 80/1000 births. There was a reduction in newborns with birth weight less than 2500 g. The observed changes were stable over time. For most variables, a significant change could be detected after a few weeks. Conclusion After the introduction of ambulance and delivery fees, an increase in labour complications and caesarean sections and a decrease in newborns with low birthweight were observed. This might indicate that women delay the decision to seek skilled birth attendance or do not seek help at all, possibly due to financial reasons. Lower rates of births in a safe health care facility like HLH is of great concern, as access to skilled birth attendance is a key requirement in order to further reduce perinatal mortality. Therefore, free delivery care should be a high priority.
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Affiliation(s)
- Corinna Vossius
- Critical Care and Anaesthesiology Research Group, Stavanger University Hospital, PB 8100, 4068, Stavanger, Norway.
| | - Estomih Mduma
- Haydom Global Health Research Center, Haydom Lutheran Hospital, Haydom, Tanzania.,Department of Research, Stavanger University Hospital, Stavanger, Norway.,Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
| | - Robert Moshiro
- Haydom Global Health Research Center, Haydom Lutheran Hospital, Haydom, Tanzania.,Faculty of Health Sciences, University of Stavanger, Stavanger, Norway.,Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Paschal Mdoe
- Haydom Global Health Research Center, Haydom Lutheran Hospital, Haydom, Tanzania.,Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
| | - Jan Terje Kvaløy
- Department of Research, Stavanger University Hospital, Stavanger, Norway.,Department of Mathematics and Physics, University of Stavanger, Stavanger, Norway
| | - Hussein Kidanto
- Department of Research, Stavanger University Hospital, Stavanger, Norway.,Medical College, Aga Khan University, Dar es Salaam, Tanzania
| | - Sara Lyanga
- Haydom Global Health Research Center, Haydom Lutheran Hospital, Haydom, Tanzania
| | - Hege Ersdal
- Critical Care and Anaesthesiology Research Group, Stavanger University Hospital, PB 8100, 4068, Stavanger, Norway.,Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
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12
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Lewis FI, Guga G, Mdoe P, Mduma E, Mahopo C, Bessong P, Richard SA, McCormick BJJ. Introducing a drift and diffusion framework for childhood growth research. Gates Open Res 2020; 4:71. [PMID: 33490877 PMCID: PMC7791186 DOI: 10.12688/gatesopenres.13123.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/18/2020] [Indexed: 11/24/2022] Open
Abstract
Background: Growth trajectories are highly variable between children, making epidemiological analyses challenging both to the identification of malnutrition interventions at the population level and also risk assessment at individual level. We introduce stochastic differential equation (SDE) models into child growth research. SDEs describe flexible dynamic processes comprising: drift - gradual smooth changes - such as physiology or gut microbiome, and diffusion - sudden perturbations, such as illness or infection. Methods: We present a case study applying SDE models to child growth trajectory data from the Haydom, Tanzania and Venda, South Africa sites within the MAL-ED cohort. These data comprise n=460 children aged 0-24 months. A comparison with classical curve fitting (linear mixed models) is also presented. Results: The SDE models offered a wide range of new flexible shapes and parameterizations compared to classical additive models, with performance as good or better than standard approaches. The predictions from the SDE models suggest distinct longitudinal clusters that form distinct 'streams' hidden by the large between-child variability. Conclusions: Using SDE models to predict future growth trajectories revealed new insights in the observed data, where trajectories appear to cluster together in bands, which may have a future risk assessment application. SDEs offer an attractive approach for child growth modelling and potentially offer new insights.
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Affiliation(s)
| | | | | | - Esto Mduma
- Haydom Lutheran Hospital, Haydom, Tanzania
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13
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Parpia TC, Elwood SE, Scharf RJ, McDermid JM, Wanjuhi AW, Rogawski McQuade ET, Gratz J, Svensen E, Swann JR, Donowitz JR, Jatosh S, Katengu S, Mdoe P, Kivuyo S, Houpt ER, DeBoer MD, Mduma E, Platts-Mills JA. Baseline Characteristics of Study Participants in the Early Life Interventions for Childhood Growth and Development in Tanzania (ELICIT) Trial. Am J Trop Med Hyg 2020; 103:1397-1404. [PMID: 32783799 PMCID: PMC7543831 DOI: 10.4269/ajtmh.19-0918] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Recurrent enteric infections and micronutrient deficiencies, including deficiencies in the tryptophan–kynurenine–niacin pathway, have been associated with environmental enteric dysfunction, potentially contributing to poor child growth and development. We are conducting a randomized, placebo-controlled, 2 × 2 factorial interventional trial in a rural population in Haydom, Tanzania, to determine the effect of 1) antimicrobials (azithromycin and nitazoxanide) and/or 2) nicotinamide, a niacin vitamer, on attained length at 18 months. Mother/infant dyads were enrolled within 14 days of the infant’s birth from September 2017 to September 2018, with the follow-up to be completed in February 2020. Here, we describe the baseline characteristics of the study cohort, risk factors for low enrollment weight, and neonatal adverse events (AEs). Risk factors for a low enrollment weight included being a firstborn child (−0.54 difference in weight-for-age z-score [WAZ] versus other children, 95% CI: −0.71, −0.37), lower socioeconomic status (−0.28, 95% CI: −0.43, −0.12 difference in WAZ), and birth during the preharvest season (November to March) (−0.22, 95% CI: −0.33, −0.11 difference in WAZ). The most common neonatal serious AEs were respiratory tract infections and neonatal sepsis (2.2 and 1.4 events per 100 child-months, respectively). The study cohort represents a high-risk population for whom interventions to improve child growth and development are urgently needed. Further analyses are needed to understand the persistent impacts of seasonal malnutrition and the interactions between seasonality, socioeconomic status, and the study interventions.
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Affiliation(s)
- Tarina C Parpia
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia
| | - Sarah E Elwood
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia
| | - Rebecca J Scharf
- Department of Pediatrics, University of Virginia, Charlottesville, Virginia
| | - Joann M McDermid
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia
| | - Anne W Wanjuhi
- Department of Pediatrics, University of Virginia, Charlottesville, Virginia
| | | | - Jean Gratz
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia
| | | | - Jonathan R Swann
- School of Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Jeffrey R Donowitz
- Division of Infectious Disease, Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, Virginia
| | - Samwel Jatosh
- Haydom Global Health Research Centre, Haydom Lutheran Hospital, Haydom, Tanzania
| | - Siphael Katengu
- Haydom Global Health Research Centre, Haydom Lutheran Hospital, Haydom, Tanzania
| | - Paschal Mdoe
- Haydom Global Health Research Centre, Haydom Lutheran Hospital, Haydom, Tanzania
| | - Sokoine Kivuyo
- National Institute for Medical Research, Muhimbili Medical Research Centre, Dar es Salaam, Tanzania
| | - Eric R Houpt
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia
| | - Mark D DeBoer
- Department of Pediatrics, University of Virginia, Charlottesville, Virginia
| | - Estomih Mduma
- Haydom Global Health Research Centre, Haydom Lutheran Hospital, Haydom, Tanzania
| | - James A Platts-Mills
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia
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14
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Lewis FI, Guga G, Mdoe P, Mduma E, Mahopo C, Bessong P, Richard SA, McCormick BJJ. Introducing a drift and diffusion framework for childhood growth research. Gates Open Res 2020; 4:71. [PMID: 33490877 PMCID: PMC7791186 DOI: 10.12688/gatesopenres.13123.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/22/2020] [Indexed: 04/01/2024] Open
Abstract
Background: Growth trajectories are highly variable between children, making epidemiological analyses challenging both to the identification of malnutrition interventions at the population level and also risk assessment at individual level. We introduce stochastic differential equation (SDE) models into child growth research. SDEs describe flexible dynamic processes comprising: drift - gradual smooth changes - such as physiology or gut microbiome, and diffusion - sudden perturbations, such as illness or infection. Methods: We present a case study applying SDE models to child growth trajectory data from the Haydom, Tanzania and Venda, South Africa sites within the MAL-ED cohort. These data comprise n=460 children aged 0-24 months. A comparison with classical curve fitting (linear mixed models) is also presented. Results: The SDE models offered a wide range of new flexible shapes and parameterizations compared to classical additive models, with performance as good or better than standard approaches. The predictions from the SDE models suggest distinct longitudinal clusters that form distinct 'streams' hidden by the large between-child variability. Conclusions: Using SDE models to predict future growth trajectories revealed new insights in the observed data, where trajectories appear to cluster together in bands, which may have a future risk assessment application. SDEs offer an attractive approach for child growth modelling and potentially offer new insights.
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Affiliation(s)
| | | | | | - Esto Mduma
- Haydom Lutheran Hospital, Haydom, Tanzania
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15
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Drago F, Scharf RJ, Maphula A, Nyathi E, Mahopo TC, Svensen E, Mduma E, Bessong P, Rogawski McQuade ET. Psychosocial and environmental determinants of child cognitive development in rural south africa and tanzania: findings from the mal-ed cohort. BMC Public Health 2020; 20:505. [PMID: 32299410 PMCID: PMC7164138 DOI: 10.1186/s12889-020-08598-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 03/26/2020] [Indexed: 01/17/2023] Open
Abstract
Background Approximately 66% of children under the age of 5 in Sub-Saharan African countries do not reach their full cognitive potential, the highest percentage in the world. Because the majority of studies investigating child cognitive development have been conducted in high-income countries (HICs), there is limited knowledge regarding the determinants of child development in low- and middle-income countries (LMICs). Methods This analysis includes 401 mother-child dyads from the South Africa and Tanzania sites of the Etiology, Risk Factors, and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health and Development (MAL-ED) longitudinal birth cohort study. We investigated the effect of psychosocial and environmental determinants on child cognitive development measured by the Wechsler Preschool Primary Scales of Intelligence (WPPSI) at 5 years of age using multivariable linear regression. Results Socioeconomic status was most strongly associated with child cognitive development (WPSSI Score Difference (SD):14.27, 95% CI:1.96, 26.59). Modest associations between the organization of the home environment and its opportunities for cognitive stimulation and child cognitive development were also found (SD: 3.08, 95% CI: 0.65, 5.52 and SD: 3.18, 95% CI: 0.59, 5.76, respectively). Conclusion This study shows a stronger association with child cognitive development at 5 years of age for socioeconomic status compared to more proximal measures of psychosocial and environmental determinants. A better understanding of the role of these factors is needed to inform interventions aiming to alleviate the burden of compromised cognitive development for children in LMICs.
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Affiliation(s)
- Fabrizio Drago
- University of Virginia School of Medicine, Cardiovascular Research Center, 415 Lane Rd (MR5), Room: G231, PO Box 801394, Charlottesville, VA, 22908, USA.
| | - Rebecca J Scharf
- Department of Pediatrics, University of Virginia, Charlottesville, USA
| | - Angelina Maphula
- Department of Psychology, University of Venda, Thohoyandou, South Africa
| | - Emanuel Nyathi
- Department of Animal Science, University of Venda, Thohoyandou, South Africa
| | - Tjale C Mahopo
- Department of Nutrition, University of Venda, Thohoyandou, South Africa
| | - Erling Svensen
- Centre for International Health, University of Bergen, Bergen, Norway
| | - Estomih Mduma
- Haydom Global Health Research Centre, Haydom, Tanzania
| | - Pascal Bessong
- Department of Microbiology, University of Venda, Thohoyandou, South Africa
| | - Elizabeth T Rogawski McQuade
- Department of Public Health Sciences and Division of Infectious Diseases & International Health, University of Virginia, Charlottesville, USA
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16
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Giallourou N, Fardus-Reid F, Panic G, Veselkov K, McCormick BJJ, Olortegui MP, Ahmed T, Mduma E, Yori PP, Mahfuz M, Svensen E, Ahmed MMM, Colston JM, Kosek MN, Swann JR. Metabolic maturation in the first 2 years of life in resource-constrained settings and its association with postnatal growths. SCIENCE ADVANCES 2020; 6:eaay5969. [PMID: 32284996 PMCID: PMC7141821 DOI: 10.1126/sciadv.aay5969] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 01/14/2020] [Indexed: 05/10/2023]
Abstract
Malnutrition continues to affect the growth and development of millions of children worldwide, and chronic undernutrition has proven to be largely refractory to interventions. Improved understanding of metabolic development in infancy and how it differs in growth-constrained children may provide insights to inform more timely, targeted, and effective interventions. Here, the metabolome of healthy infants was compared to that of growth-constrained infants from three continents over the first 2 years of life to identify metabolic signatures of aging. Predictive models demonstrated that growth-constrained children lag in their metabolic maturity relative to their healthier peers and that metabolic maturity can predict growth 6 months into the future. Our results provide a metabolic framework from which future nutritional programs may be more precisely constructed and evaluated.
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Affiliation(s)
- N. Giallourou
- Division of Integrative Systems Medicine and Digestive Diseases, Imperial College London, London, UK
| | - F. Fardus-Reid
- Division of Integrative Systems Medicine and Digestive Diseases, Imperial College London, London, UK
| | - G. Panic
- Division of Integrative Systems Medicine and Digestive Diseases, Imperial College London, London, UK
| | - K. Veselkov
- Division of Integrative Systems Medicine and Digestive Diseases, Imperial College London, London, UK
| | | | - M. P. Olortegui
- Asociación Benéfica PRISMA, Unidad de Investigación Biomedica, Iquitos, Peru
| | - T. Ahmed
- International Center for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - E. Mduma
- Haydom Global Health Institute, Haydom, Tanzania
| | - P. P. Yori
- Asociación Benéfica PRISMA, Unidad de Investigación Biomedica, Iquitos, Peru
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA, USA
| | - M. Mahfuz
- International Center for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - E. Svensen
- Haydom Global Health Institute, Haydom, Tanzania
- Haukeland University Hospital, Bergen, Norway
| | - M. M. M. Ahmed
- International Center for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - J. M. Colston
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA, USA
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - M. N. Kosek
- Asociación Benéfica PRISMA, Unidad de Investigación Biomedica, Iquitos, Peru
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA, USA
- Corresponding author.
| | - J. R. Swann
- Division of Integrative Systems Medicine and Digestive Diseases, Imperial College London, London, UK
- School of Human Development and Health, Faculty of Medicine, University of Southampton, UK
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17
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Fleece ME, Nshama R, Walongo T, Kimathi C, Gratz J, Rogawski McQuade ET, Liu J, Pholwat S, Mduma E, Houpt ER, Platts-Mills JA. Longitudinal Assessment of Antibiotic Resistance in Fecal Escherichia coli in Tanzanian Children. Am J Trop Med Hyg 2020; 100:1110-1114. [PMID: 30834886 DOI: 10.4269/ajtmh.18-0789] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Antibiotic-resistant bacterial infections are a major public health problem, and children in low-resource settings represent a particularly high-risk group. Few data are available on the dynamics of and risk factors for gastrointestinal carriage of antibiotic-resistant bacteria in these vulnerable populations. In this study, we described the antibiotic susceptibility profiles of Escherichia coli isolated from stool specimens collected from children aged 6 to 60 months enrolled in a birth cohort study in Haydom, Tanzania. We estimated the association between sociodemographic risk factors, child illnesses, and antibiotic exposure and E. coli drug resistance. Carriage of antibiotic-resistant E. coli was common starting early in life and did not clearly increase with age. The majority of isolates were resistant to ampicillin (749/837; 89.5%), cefazolin (742/837; 88.6%), and cotrimoxazole (721/837; 86.1%). Resistance to amoxicillin/clavulanate (361/836; 43.2%), ampicillin/sulbactam (178/819; 21.7%), nalidixic acid (131/831; 15.8%), and azithromycin (115/837; 13.7%) was also seen. Only 1.8% (15/837) of the pooled E. coli isolates met the criteria for extended-spectrum beta-lactamase production. High antibiotic use (0.26 additional resistant antibiotic classes; 95% CI: 0.05, 0.47) and high income (0.28 additional resistant antibiotic classes; 95% CI: 0.06, 0.50) were associated with the carriage of antibiotic-resistant E. coli, whereas hospital birth, crowding in the home, improved drinking water and sanitation, and common childhood illnesses were not. In this setting, the carriage of antibiotic-resistant E. coli was common. Other than recent antibiotic exposure and high income, individual risk factors for the acquisition and carriage of resistance could not be identified, suggesting that population-level interventions are needed.
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Affiliation(s)
- Molly E Fleece
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia
| | | | | | | | - Jean Gratz
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia
| | | | - Jie Liu
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia
| | - Suporn Pholwat
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia
| | - Esto Mduma
- Haydom Global Health Institute, Haydom, Tanzania
| | - Eric R Houpt
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia
| | - James A Platts-Mills
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia
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18
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Alam MA, Richard SA, Fahim SM, Mahfuz M, Nahar B, Das S, Shrestha B, Koshy B, Mduma E, Seidman JC, Murray-Kolb LE, Caulfield LE, Ahmed T. Impact of early-onset persistent stunting on cognitive development at 5 years of age: Results from a multi-country cohort study. PLoS One 2020; 15:e0227839. [PMID: 31978156 PMCID: PMC6980491 DOI: 10.1371/journal.pone.0227839] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 12/30/2019] [Indexed: 01/01/2023] Open
Abstract
Background Globally more than 150 million children under age 5 years were stunted in 2018, primarily in low- and middle-income countries (LMICs), and the impact of early-onset, persistent stunting has not been well explored. To explore the association between early-onset persistent stunting in children and cognitive development at 5 years of age, and to identify the factors associated with early-onset stunting. Methods and findings Children from the MAL-ED cohort study were followed from birth to 5 years of age in six LMICs. The Wechsler Preschool Primary Scales of Intelligence (WPPSI) was used to assess cognitive abilities (fluid reasoning) at 5 years and was adapted for each culture. Stunting was categorized as early-onset persistent (first stunted at 1–6 months and persisting at 60 months), early-onset recovered (first stunted at 1–6 months and not stunted at 60 months), late-onset persistent (first stunted at 7–24 months and persisting at 60 months), late-onset recovered (first stunted at 7–24 months and not stunted at 60 months), and never (never stunted). Mixed effects linear models were used to estimate the relationship between stunting status and cognitive development. Children with early-onset persistent stunting had significantly lower cognitive scores (-2.10 (95% CI: -3.85, -0.35)) compared with those who were never stunted. Transferrin receptor (TfR) was also negatively associated with cognitive development (-0.31 (95% CI: -0.49, -0.13)), while the HOME inventory, an index of quality of the home environment (0.46 (95% CI: 0.21, 0.72)) and socio-economic status (1.50 (95% CI: 1.03, 1.98)) were positively associated with cognitive development. Conclusions Early-onset persistent stunting was associated with lower cognitive development in children at 5 years of age in this cohort of children.
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Affiliation(s)
- Md Ashraful Alam
- icddr,b, Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka, Bangladesh
| | - Stephanie A. Richard
- Fogarty International Center/National Institutes of Health, Bethesda, MD, United States of America
| | | | - Mustafa Mahfuz
- icddr,b, Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka, Bangladesh
- * E-mail:
| | - Baitun Nahar
- icddr,b, Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka, Bangladesh
| | - Subhasish Das
- icddr,b, Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka, Bangladesh
| | - Binod Shrestha
- Water Reed/AFRIMS Research Unit Nepal (WARUN), Kathmandu, Nepal
| | | | | | - Jessica C. Seidman
- Fogarty International Center/National Institutes of Health, Bethesda, MD, United States of America
| | - Laura E. Murray-Kolb
- The Pennsylvania State University, University Park, PA, United States of America
| | | | - Tahmeed Ahmed
- icddr,b, Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka, Bangladesh
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19
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Rogawski McQuade ET, Clark S, Bayo E, Scharf RJ, DeBoer MD, Patil CL, Gratz JC, Houpt ER, Svensen E, Mduma ER, Platts-Mills JA. Seasonal Food Insecurity in Haydom, Tanzania, Is Associated with Low Birthweight and Acute Malnutrition: Results from the MAL-ED Study. Am J Trop Med Hyg 2020; 100:681-687. [PMID: 30608052 PMCID: PMC6402900 DOI: 10.4269/ajtmh.18-0547] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
In rural agricultural communities in Africa, particularly those with a single annual harvest, the preharvest period has been associated with increased food insecurity. We estimated the association between seasonal food insecurity and childhood malnutrition in Haydom, Tanzania. Children enrolled in a birth cohort study were followed twice weekly to document food intake and monthly for anthropometry until the age of 2 years. Household food insecurity was reported by caregivers every 6 months. We modeled the seasonality of food insecurity and food consumption, and estimated the impact of birth season on enrollment weight and subsequent malnutrition. Finally, we described the seasonality of admissions for acute malnutrition at a local referral hospital (Haydom Lutheran Hospital) from 2010 to 2015. Food insecurity was highly seasonal, with a peak from December to February. Children born during these 3 months had an average 0.35 z-score (95% CI: 0.12, 0.58) lower enrollment weight than children born in other months. In addition, weight-for-length z-scores measured in these months were on average 0.15 z-scores lower (95% CI: 0.10, 0.20) than that in other months, adjusting for enrollment weight and seasonal infectious diseases, and this disparity was sustained up to the age of 2 years. Correspondingly, the number of admissions with acute malnutrition at the local hospital was highest at this time, with twice as many cases in December–February compared with June–August. We identified acute and chronic malnutrition associated with seasonal food insecurity and intake. Targeting of prenatal care and child-feeding interventions during high food insecurity months may help reduce child malnutrition.
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Affiliation(s)
- Elizabeth T Rogawski McQuade
- Department of Public Health Sciences, University of Virginia, Charlottesville, Virginia.,Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia
| | - Stephen Clark
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia
| | - Eliwaza Bayo
- Global Health Research Centre, Haydom Lutheran Hospital, Manyara Region, Tanzania
| | - Rebecca J Scharf
- Department of Pediatrics, University of Virginia, Charlottesville, Virginia
| | - Mark D DeBoer
- Department of Pediatrics, University of Virginia, Charlottesville, Virginia
| | - Crystal L Patil
- Department of Women, Children and Family Health Science, College of Nursing, University of Illinois at Chicago, Illinois
| | - Jean C Gratz
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia
| | - Eric R Houpt
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia
| | - Erling Svensen
- Haukeland University Hospital, Bergen, Norway.,Global Health Research Centre, Haydom Lutheran Hospital, Manyara Region, Tanzania
| | - Estomih R Mduma
- Global Health Research Centre, Haydom Lutheran Hospital, Manyara Region, Tanzania
| | - James A Platts-Mills
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, Virginia
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20
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Korpe PS, Valencia C, Haque R, Mahfuz M, McGrath M, Houpt E, Kosek M, McCormick BJJ, Penataro Yori P, Babji S, Kang G, Lang D, Gottlieb M, Samie A, Bessong P, Faruque ASG, Mduma E, Nshama R, Havt A, Lima IFN, Lima AAM, Bodhidatta L, Shreshtha A, Petri WA, Ahmed T, Duggal P. Epidemiology and Risk Factors for Cryptosporidiosis in Children From 8 Low-income Sites: Results From the MAL-ED Study. Clin Infect Dis 2019; 67:1660-1669. [PMID: 29701852 PMCID: PMC6233690 DOI: 10.1093/cid/ciy355] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Accepted: 04/24/2018] [Indexed: 12/20/2022] Open
Abstract
Background Cryptosporidium species are enteric protozoa that cause significant morbidity and mortality in children worldwide. We characterized the epidemiology of Cryptosporidium in children from 8 resource-limited sites in Africa, Asia, and South America. Methods Children were enrolled within 17 days of birth and followed twice weekly for 24 months. Diarrheal and monthly surveillance stool samples were tested for Cryptosporidium by enzyme-linked immunosorbent assay. Socioeconomic data were collected by survey, and anthropometry was measured monthly. Results Sixty-five percent (962/1486) of children had a Cryptosporidium infection and 54% (802/1486) had at least 1 Cryptosporidium-associated diarrheal episode. Cryptosporidium diarrhea was more likely to be associated with dehydration (16.5% vs 8.3%, P < .01). Rates of Cryptosporidium diarrhea were highest in the Peru (10.9%) and Pakistan (9.2%) sites. In multivariable regression analysis, overcrowding at home was a significant risk factor for infection in the Bangladesh site (odds ratio, 2.3 [95% confidence interval {CI}, 1.2-4.6]). Multiple linear regression demonstrated a decreased length-for-age z score at 24 months in Cryptosporidium-positive children in the India (β = -.26 [95% CI, -.51 to -.01]) and Bangladesh (β = -.20 [95% CI, -.44 to .05]) sites. Conclusions This multicountry cohort study confirmed the association of Cryptosporidium infection with stunting in 2 South Asian sites, highlighting the significance of cryptosporidiosis as a risk factor for poor growth. We observed that the rate, age of onset, and number of repeat infections varied per site; future interventions should be targeted per region to maximize success.
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Affiliation(s)
- Poonum S Korpe
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Cristian Valencia
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Rashidul Haque
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka
| | - Mustafa Mahfuz
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka
| | - Monica McGrath
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland.,Fogarty International Center, Bethesda, Maryland
| | - Eric Houpt
- University of Virginia School of Medicine, Charlottesville
| | - Margaret Kosek
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | | | - Pablo Penataro Yori
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | | | | | - Dennis Lang
- Foundation for the National Institutes of Health, Bethesda, Maryland
| | - Michael Gottlieb
- Foundation for the National Institutes of Health, Bethesda, Maryland
| | | | | | - A S G Faruque
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka
| | - Esto Mduma
- Haydom Global Health Institute, Tanzania
| | | | - Alexandre Havt
- Clinical Research Unit and Institute of Biomedicine, Universidade Federal do Ceara, Fortaleza, Brazil
| | - Ila F N Lima
- Clinical Research Unit and Institute of Biomedicine, Universidade Federal do Ceara, Fortaleza, Brazil
| | - Aldo A M Lima
- Clinical Research Unit and Institute of Biomedicine, Universidade Federal do Ceara, Fortaleza, Brazil
| | | | | | | | - Tahmeed Ahmed
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka
| | - Priya Duggal
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
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21
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Mduma E, Kvaløy JT, Soreide E, Svensen E, Mdoe P, Perlman J, Johnson C, Kidanto HL, Ersdal HL. Frequent refresher training on newborn resuscitation and potential impact on perinatal outcome over time in a rural Tanzanian hospital: an observational study. BMJ Open 2019; 9:e030572. [PMID: 31562152 PMCID: PMC6773328 DOI: 10.1136/bmjopen-2019-030572] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES Globally, perinatal mortality remains high, especially in sub-Saharan countries, mainly because of inadequate obstetric and newborn care. Helping Babies Breathe (HBB) resuscitation training as part of a continuous quality improvement (CQI) programme may improve outcomes. The aim of this study was to describe observed changes in perinatal survival during a 6-year period, while adjusting for relevant perinatal risk factors. SETTING Delivery rooms and operating theatre in a rural referral hospital in northern-central Tanzania providing comprehensive obstetric and basic newborn care 24 hours a day. The hospital serves approximately 2 million people comprising low social-economic status. PARTICIPANTS All newborns (n=31 122) born in the hospital from February 2010 through January 2017; 4893 were born in the 1-year baseline period (February 2010 through January 2011), 26 229 in the following CQI period. INTERVENTIONS The HBB CQI project, including frequent HBB training, was implemented from February 2011. This is a quality assessment analysis of prospectively collected observational data including patient, process and outcome measures of every delivery. Logistic regression modelling was used to construct risk-adjusted variable life adjusted display (VLAD) and cumulative sum (CUSUM) plots to monitor changes in perinatal survival (primary outcome). RESULTS During the 6-year CQI period, the unadjusted number of extra lives saved according to the VLAD plot was 150 despite more women admitted with pregnancy and labour complications and more caesarean deliveries. After adjusting for these risk factors, the risk-adjusted VLAD plot indicated that an estimated 250 extra lives were saved. The risk-adjusted CUSUM plot confirmed a persistent and steady increase in perinatal survival. CONCLUSIONS The risk-adjusted statistical process control methods indicate significant improvement in perinatal survival after initiation of the HBB CQI project with continuous focus on newborn resuscitation training during the period, despite a concomitant increase in high-risk deliveries. Risk-adjusted VLAD and CUSUM are useful methods to quantify, illustrate and demonstrate persistent changes in outcome over time.
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Affiliation(s)
- Estomih Mduma
- Haydom Lutheran Hospital, Haydom, Tanzania
- Department of Health, Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
| | - Jan Terje Kvaløy
- Research, Stavanger University Hospital, Stavanger, Norway
- Department of Mathematics and Physics, University of Stavanger Department of Mathematics and Natural Science, Stavanger, Norway
| | - Eldar Soreide
- Critical Care and Anaesthesiology Research Group, Department of Clinical Medicine, Stavanger University Hospital, Stavanger, Norway
- Faculty of Medicine, University of Bergen, Bergen, Norway
| | | | - Paschal Mdoe
- Haydom Lutheran Hospital, Haydom, Tanzania
- Faculty of Social Science, University of Stavanger, Stavanger, Norway
| | - Jeffrey Perlman
- Pediatrics, Weill Cornell Medical College, New York Presbyterian Hospital, New York City, New York, USA
| | - Caroline Johnson
- Department of Mathematics and Natural Science, University of Stavanger, Stavanger, Norway
| | - Hussein Lessio Kidanto
- School of Medicine, Aga Khan University, Dar es Salaam, Tanzania
- Helse Stavanger HF, Stavanger, Norway
| | - Hege Langli Ersdal
- Department of Anaesthesiology and Intensive Care, Stavanger University Hospital, Stavanger, Norway
- Faculty of Health Sciences, University of Stavanger, Stavanger, Norway
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22
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Mackinnon E, Ayah R, Taylor R, Owor M, Ssempebwa J, Olago LD, Kubalako R, Dia AT, Gaye C, C Campos L, Fottrell E. 21st century research in urban WASH and health in sub-Saharan Africa: methods and outcomes in transition. INTERNATIONAL JOURNAL OF ENVIRONMENTAL HEALTH RESEARCH 2019; 29:457-478. [PMID: 30545246 DOI: 10.1080/09603123.2018.1550193] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Accepted: 11/15/2018] [Indexed: 06/09/2023]
Abstract
Tackling global inequalities in access to Water, Sanitation and Hygiene (WASH) remains an urgent issue - 58% of annual diarrhoeal deaths are caused by inadequate WASH provision. A global context of increasing urbanisation, changing demographics and health transitions demands an understanding and impact of WASH on a broad set of health outcomes. We examine the literature, in terms of health outcomes, considering WASH access and interventions in urban sub-Saharan Africa from 2000 to 2017. Our review of studies which evaluate the effectiveness of specific WASH interventions, reveals an emphasis of WASH research on acute communicable diseases, particularly diarrhoeal diseases. In contrast, chronic communicable and non-communicable health outcomes were notable gaps in the literature as well as a lack of focus on cross-cutting issues, such as ageing, well-being and gender equality. We recommend a broader focus of WASH research and interventions in urban Africa to better reflect the demographic and health transitions happening. Abbreviations: CBA: Controlled Before and After; GSD: Government Service Delivery; IWDSSD: International Drinking-Water, Supply and Sanitation Decade (IDWSSD); KAP: Knowledge, Attitudes and Practices; IBD: Irritable Bowel Diseases; MDG: Millennium Development Goals; NTD: Neglected Tropical Diseases; PSSD: Private Sector Service Delivery; SDG: Sustainable Development Goals; SSA: Sub Saharan Africa; SODIS: Solar Disinfection System; STH: Soil Transmitted Helminths; RCT: Randomised Control Trial; WASH: Water Sanitation and Hygiene; WHO: World Health Organization.
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Affiliation(s)
- Eve Mackinnon
- a Civil, Environmental and Geomatic Engineering , University College London , London , United Kingdom of Great Britain and Northern Ireland
| | - Richard Ayah
- b Faculty of Science Engineering and Health , Daystar University Nairobi , Nairobi , Kenya
| | - Richard Taylor
- c Department of Geography , University College London , London , United Kingdom of Great Britain and Northern Ireland
| | - Michael Owor
- d Department of Geology and Petroleum Studies , Makerere University , Kampala , Uganda
| | - John Ssempebwa
- e College of Agricultural and Environmental Sciences , Makerere University , Kampala , Uganda
| | - L Daniel Olago
- b Faculty of Science Engineering and Health , Daystar University Nairobi , Nairobi , Kenya
| | - Robinah Kubalako
- e College of Agricultural and Environmental Sciences , Makerere University , Kampala , Uganda
| | - Anta Tal Dia
- f Department of Geology, FST , Universite Cheikh Anta Diop , Dakar , Senegal
| | - Cheikh Gaye
- f Department of Geology, FST , Universite Cheikh Anta Diop , Dakar , Senegal
| | - Luiza C Campos
- a Civil, Environmental and Geomatic Engineering , University College London , London , United Kingdom of Great Britain and Northern Ireland
| | - Edward Fottrell
- g University College, London Institute of Global Health , London , United Kingdom of Great Britain and Northern Ireland
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23
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Platts-Mills JA, Amour C, Gratz J, Nshama R, Walongo T, Mujaga B, Maro A, McMurry TL, Liu J, Mduma E, Houpt ER. Impact of Rotavirus Vaccine Introduction and Postintroduction Etiology of Diarrhea Requiring Hospital Admission in Haydom, Tanzania, a Rural African Setting. Clin Infect Dis 2019; 65:1144-1151. [PMID: 28575304 PMCID: PMC5850044 DOI: 10.1093/cid/cix494] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 05/25/2017] [Indexed: 02/05/2023] Open
Abstract
Background No data are available on the etiology of diarrhea requiring hospitalization after rotavirus vaccine introduction in Africa. The monovalent rotavirus vaccine was introduced in Tanzania on 1 January 2013. We performed a vaccine impact and effectiveness study as well as a quantitative polymerase chain reaction (qPCR)–based etiology study at a rural Tanzanian hospital. Methods We obtained data on admissions among children <5 years to Haydom Lutheran Hospital between 1 January 2010 and 31 December 2015 and estimated the impact of vaccine introduction on all-cause diarrhea admissions. We then performed a vaccine effectiveness study using the test-negative design. Finally, we tested diarrheal specimens during 2015 by qPCR for a broad range of enteropathogens and calculated pathogen-specific attributable fractions (AFs). Results Vaccine introduction was associated with a 44.9% (95% confidence interval [CI], 17.6%–97.4%) reduction in diarrhea admissions in 2015, as well as delay of the rotavirus season. The effectiveness of 2 doses of vaccine was 74.8% (95% CI, –8.2% to 94.1%) using an enzyme immunoassay–based case definition and 85.1% (95% CI, 26.5%–97.0%) using a qPCR-based case definition. Among 146 children enrolled in 2015, rotavirus remained the leading etiology of diarrhea requiring hospitalization (AF, 25.8% [95% CI, 24.4%–26.7%]), followed by heat-stable enterotoxin-producing Escherichia coli (AF, 18.4% [95% CI, 12.9%–21.9%]), Shigella/enteroinvasive E. coli (AF, 14.5% [95% CI, 10.2%–22.8%]), and Cryptosporidium (AF, 7.9% [95% CI, 6.2%–9.3%]). Conclusions Despite the clear impact of vaccine introduction in this setting, rotavirus remained the leading etiology of diarrhea requiring hospitalization. Further efforts to maximize vaccine coverage and improve vaccine performance in these settings are warranted.
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Affiliation(s)
- James A Platts-Mills
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville
| | - Caroline Amour
- Haydom Global Health Research Centre, Haydom Lutheran Hospital, and
| | - Jean Gratz
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville.,Haydom Global Health Research Centre, Haydom Lutheran Hospital, and
| | - Rosemary Nshama
- Haydom Global Health Research Centre, Haydom Lutheran Hospital, and
| | - Thomas Walongo
- Haydom Global Health Research Centre, Haydom Lutheran Hospital, and
| | - Buliga Mujaga
- Haydom Global Health Research Centre, Haydom Lutheran Hospital, and
| | - Athanasia Maro
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania; and
| | - Timothy L McMurry
- Department of Public Health Sciences, University of Virginia, Charlottesville
| | - Jie Liu
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville
| | - Estomih Mduma
- Haydom Global Health Research Centre, Haydom Lutheran Hospital, and
| | - Eric R Houpt
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania; and
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24
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Colston JM, Francois R, Pisanic N, Peñataro Yori P, McCormick BJJ, Olortegui MP, Gazi MA, Svensen E, Ahmed MMM, Mduma E, Liu J, Houpt ER, Klapheke R, Schwarz JW, Atmar RL, Black RE, Kosek MN. Effects of Child and Maternal Histo-Blood Group Antigen Status on Symptomatic and Asymptomatic Enteric Infections in Early Childhood. J Infect Dis 2019; 220:151-162. [PMID: 30768135 PMCID: PMC6548901 DOI: 10.1093/infdis/jiz072] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 02/13/2019] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Histo-blood group antigens (HBGAs) such as fucosyltransferase (FUT)2 and 3 may act as innate host factors that differentially influence susceptibility of individuals and their offspring to pediatric enteric infections. METHODS In 3 community-based birth cohorts, FUT2 and FUT3 statuses were ascertained for mother-child dyads. Quantitative polymerase chain reaction panels tested 3663 diarrheal and 18 148 asymptomatic stool samples for 29 enteropathogens. Cumulative diarrhea and infection incidence were compared by child (n = 520) and mothers' (n = 519) HBGA status and hazard ratios (HRs) derived for all-cause diarrhea and specific enteropathogens. RESULTS Children of secretor (FUT2 positive) mothers had a 38% increased adjusted risk of all-cause diarrhea (HR = 1.38; 95% confidence interval (CI), 1.15-1.66) and significantly reduced time to first diarrheal episode. Child FUT2 and FUT3 positivity reduced the risk for all-cause diarrhea by 29% (HR = 0.81; 95% CI, 0.71-0.93) and 27% (HR = 0.83; 95% CI, 0.74-0.92), respectively. Strong associations between HBGAs and pathogen-specific infection and diarrhea were observed, particularly for noroviruses, rotaviruses, enterotoxigenic Escherichia coli, and Campylobacter jejuni/coli. CONCLUSIONS Histo-blood group antigens affect incidence of all-cause diarrhea and enteric infections at magnitudes comparable to many common disease control interventions. Studies measuring impacts of interventions on childhood enteric disease should account for both child and mothers' HBGA status.
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Affiliation(s)
- Josh M Colston
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Ruthly Francois
- Department of International Health, Johns Hopkins School of Public Health, Baltimore, Maryland
| | - Nora Pisanic
- Department of Environmental Health and Engineering, Johns Hopkins School of Public Health, Baltimore, Maryland
| | - Pablo Peñataro Yori
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville
| | | | | | - Md Amran Gazi
- International Centre for Diarrhoeal Disease Research, Bangladesh
| | | | | | - Esto Mduma
- Haydom Global Health Institute, Haydom, Tanzania
| | - Jie Liu
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville
| | - Eric R Houpt
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville
| | | | | | | | - Robert E Black
- Department of International Health, Johns Hopkins School of Public Health, Baltimore, Maryland
| | - Margaret N Kosek
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville
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25
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Colston JM, Zaitchik B, Kang G, Peñataro Yori P, Ahmed T, Lima A, Turab A, Mduma E, Sunder Shrestha P, Bessong P, Peng RD, Black RE, Moulton LH, Kosek MN. Use of earth observation-derived hydrometeorological variables to model and predict rotavirus infection (MAL-ED): a multisite cohort study. Lancet Planet Health 2019; 3:e248-e258. [PMID: 31229000 PMCID: PMC6650544 DOI: 10.1016/s2542-5196(19)30084-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 04/08/2019] [Accepted: 04/09/2019] [Indexed: 05/25/2023]
Abstract
BACKGROUND Climate change threatens to undermine recent progress in reducing global deaths from diarrhoeal disease in children. However, the scarcity of evidence about how individual environmental factors affect transmission of specific pathogens makes prediction of trends under different climate scenarios challenging. We aimed to model associations between daily estimates of a suite of hydrometeorological variables and rotavirus infection status ascertained through community-based surveillance. METHODS For this analysis of multisite cohort data, rotavirus infection status was ascertained through community-based surveillance of infants in the eight-site MAL-ED cohort study, and matched by date with earth observation estimates of nine hydrometeorological variables from the Global Land Data Assimilation System: daily total precipitation volume (mm), daily total surface runoff (mm), surface pressure (mbar), wind speed (m/s), relative humidity (%), soil moisture (%), solar radiation (W/m2), specific humidity (kg/kg), and average daily temperatures (°C). Lag relationships, independent effects, and interactions were characterised by use of modified Poisson models and compared with and without adjustment for seasonality and between-site variation. Final models were created with stepwise selection of main effects and interactions and their validity assessed by excluding each site in turn and calculating Tjur's Coefficients of Determination. FINDINGS All nine hydrometeorological variables were significantly associated with rotavirus infection after adjusting for seasonality and between-site variation over multiple consecutive or non-consecutive lags, showing complex, often non-linear associations that differed by symptom status and showed considerable mutual interaction. The final models explained 5·9% to 6·2% of the variability in rotavirus infection in the pooled data and their predictions explained between 0·0% and 14·1% of the variability at individual study sites. INTERPRETATION These results suggest that the effect of climate on rotavirus transmission was mediated by four independent mechanisms: waterborne dispersal, airborne dispersal, virus survival on soil and surfaces, and host factors. Earth observation data products available at a global scale and at subdaily resolution can be combined with longitudinal surveillance data to test hypotheses about routes and drivers of transmission but showed little potential for making predictions in this setting. FUNDING Bill & Melinda Gates Foundation; Foundation for the National Institutes of Health, National Institutes of Health, Fogarty International Center; Sherrilyn and Ken Fisher Center for Environmental Infectious Diseases, Johns Hopkins School of Medicine; and NASA's Group on Earth Observations Work Programme.
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Affiliation(s)
- Josh M Colston
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Benjamin Zaitchik
- Department of Earth and Planetary Sciences, Johns Hopkins Krieger School of Arts and Sciences, Baltimore, MD, USA
| | | | - Pablo Peñataro Yori
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Tahmeed Ahmed
- Nutrition & Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Aldo Lima
- Federal University of Ceará, Fortaleza, Brazil
| | - Ali Turab
- Interactive Research and Development, Maternal and Child Health (MCH) Program, Karachi, Pakistan
| | - Esto Mduma
- Haydom Global Health Institute, Haydom, Tanzania
| | | | | | - Roger D Peng
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Robert E Black
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Lawrence H Moulton
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Margaret N Kosek
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
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Nutritional Status of Children Aged 12 to 36 Months in a Rural District of Hungyen Province, Vietnam. BIOMED RESEARCH INTERNATIONAL 2019; 2019:6293184. [PMID: 31111061 PMCID: PMC6487150 DOI: 10.1155/2019/6293184] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 03/08/2019] [Accepted: 03/28/2019] [Indexed: 01/04/2023]
Abstract
Objective To evaluate the nutritional status of children from 12 to 36 months of age in Kimdong, a rural district in Hungyen Province, Northern Vietnam, in 2017. Subjects and Methods A cross-sectional study was carried out on 327 children aged 12-36 months. The data collected included anthropometric measurement, serum hemoglobin (Hb), and vitamin D concentration. Blood analysis was done at the Center Laboratory of Hungyen Obstetrics and Pediatrics Hospital. Underweight, stunted, and wasted children were classified based on z-scores cut-off less than -2 SD of weight for age (WAZ), height for age (HAZ), and weight for height (WHZ), respectively. Overweight and obese children were defined if WHZ was more than + 2SD. Anemic child was applied when Hb concentration was less than 110 g/L while vitamin D deficiency was termed for level less than 20 ng/L. Results The prevalence of underweight, stunted, wasted, and overweight/obese children was 7.6%, 23.5%, 6.7%, and 1.2%, respectively. The prevalence of anemia and vitamin D deficiency was 33.3% and 47.7%, respectively. Malnutrition, anemia, and vitamin D deficiency were not statistically different by sex. Malnutrition and vitamin D deficiency were not statistically different by age group but anemia by age groups was significantly different. Conclusions Stunting is still prevalent in children aged 12-36 months in Kimdong. Moreover, anemia and vitamin D deficiency also affected children in this area. Some interventions should be conducted to improve the nutritional status of children in Kimdong district.
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Justine M, Yeconia A, Nicodemu I, Augustino D, Gratz J, Mduma E, Heysell SK, Kivuyo S, Mfinanga S, Peloquin CA, Zagurski T, Kibiki GS, Mmbaga B, Houpt ER, Thomas TA. Pharmacokinetics of First-Line Drugs Among Children With Tuberculosis in Rural Tanzania. J Pediatric Infect Dis Soc 2018; 9:14-20. [PMID: 30395239 PMCID: PMC7317157 DOI: 10.1093/jpids/piy106] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 10/17/2018] [Indexed: 11/13/2022]
Abstract
BACKGROUND Dosing recommendations for treating childhood tuberculosis (TB) were revised by the World Health Organization, yet so far, pharmacokinetic studies that have evaluated these changes are relatively limited. We evaluated plasma drug concentrations of rifampicin (RIF), isoniazid (INH), pyrazinamide (PZA), and ethambutol (EMB) among children undergoing TB treatment in Tanzania when these dosing recommendations were being implemented. METHODS At the end of intensive-phase TB therapy, blood was obtained 2 hours after witnessed medication administration to estimate the peak drug concentration (C2h), measured using high-performance liquid chromatography or liquid chromatography-tandem mass spectrometry methods. Differences in median drug concentrations were compared on the basis of the weight-based dosing strategy using the Mann-Whitney U test. Risk factors for low drug concentrations were analyzed using multivariate regression analysis. RESULTS We enrolled 51 human immunodeficiency virus-negative children (median age, 5.3 years [range, 0.75-14 years]). The median C2hs were below the target range for each TB drug studied. Compared with children who received the "old" dosages, those who received the "revised" WHO dosages had a higher median C2h for RIF (P = .049) and PZA (P = .015) but not for INH (P = .624) or EMB (P = .143); however, these revised dosages did not result in the target range for RIF, INH, and EMB being achieved. A low starting dose was associated with a low C2h for RIF (P = .005) and PZA (P = .005). Malnutrition was associated with a low C2h for RIF (P = .001) and INH (P = .001). CONCLUSIONS Among this cohort of human immunodeficiency virus-negative Tanzanian children, use of the revised dosing strategy for treating childhood TB did not result in the target drug concentration for RIF, INH, or EMB being reached.
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Affiliation(s)
- Museveni Justine
- Center for Global Health Research, Haydom Lutheran Hospital, Haydom, Tanzania
| | - Anita Yeconia
- Center for Global Health Research, Haydom Lutheran Hospital, Haydom, Tanzania
| | - Ingi Nicodemu
- Center for Global Health Research, Haydom Lutheran Hospital, Haydom, Tanzania
| | - Domitila Augustino
- Center for Global Health Research, Haydom Lutheran Hospital, Haydom, Tanzania
| | - Jean Gratz
- Center for Global Health Research, Haydom Lutheran Hospital, Haydom, Tanzania,Division of Infectious Diseases and International Health, University of Virginia, Charlottesville
| | - Estomih Mduma
- Center for Global Health Research, Haydom Lutheran Hospital, Haydom, Tanzania
| | - Scott K Heysell
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville
| | - Sokoine Kivuyo
- National Institute of Medical Research Muhimbili, Dar es Salaam, Tanzania
| | - Sayoki Mfinanga
- National Institute of Medical Research Muhimbili, Dar es Salaam, Tanzania
| | - Charles A Peloquin
- Infectious Disease Pharmacokinetic Laboratory, University of Florida, Gainesville
| | - Theodore Zagurski
- Infectious Disease Pharmacokinetic Laboratory, University of Florida, Gainesville
| | - Gibson S Kibiki
- East African Health Research Commission, East African Community, Arusha, Tanzania
| | - Blandina Mmbaga
- Kilimanjaro Clinical Research Institute, Kilimanjaro Christian Medical College, Moshi, Tanzania
| | - Eric R Houpt
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville
| | - Tania A Thomas
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville,Correspondence: T. A. Thomas, MD, MPH, University of Virginia, Division of Infectious Diseases and International Health, PO Box 801340, Charlottesville, VA 22908 ()
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Mduma ER, Ersdal H, Kvaloy JT, Svensen E, Mdoe P, Perlman J, Kidanto HL, Soreide E. Using statistical process control methods to trace small changes in perinatal mortality after a training program in a low-resource setting. Int J Qual Health Care 2018; 30:271-275. [PMID: 29385461 DOI: 10.1093/intqhc/mzy003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 01/08/2018] [Indexed: 11/12/2022] Open
Abstract
Objective To trace and document smaller changes in perinatal survival over time. Design Prospective observational study, with retrospective analysis. Setting Labor ward and operating theater at Haydom Lutheran Hospital in rural north-central Tanzania. Participants All women giving birth and birth attendants. Intervention Helping Babies Breathe (HBB) simulation training on newborn care and resuscitation and some other efforts to improve perinatal outcome. Main outcome measure Perinatal survival, including fresh stillbirths and early (24-h) newborn survival. Result The variable life-adjusted plot and cumulative sum chart revealed a steady improvement in survival over time, after the baseline period. There were some variations throughout the study period, and some of these could be linked to different interventions and events. Conclusion To our knowledge, this is the first time statistical process control methods have been used to document changes in perinatal mortality over time in a rural Sub-Saharan hospital, showing a steady increase in survival. These methods can be utilized to continuously monitor and describe changes in patient outcomes.
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Affiliation(s)
- Estomih R Mduma
- Haydom Global Health Research Centre, Haydom Lutheran Hospital, Haydom Manyara, Tanzania
| | - Hege Ersdal
- Stavanger University Hospital, Stavanger, Norway
| | - Jan Terje Kvaloy
- Department of Mathematics and Natural Sciences, University of Stavanger, 4036 Stavanger, Norway.,Research Department, Stavanger University Hospital, Stavanger, Norway
| | | | - Paschal Mdoe
- Haydom Lutheran Hospital, Haydom, Manyara, Tanzania
| | - Jeffrey Perlman
- Pediatrics, Weill Cornell Medicine, New York Presbyterian Hospital, 525 East 68th Street, N 506, New York, NY, USA
| | - Hussein Lessio Kidanto
- Ministry of Health, Community Development, Gender, Elderly and Children, Dar es Salaam, Tanzania
| | - Eldar Soreide
- Department of Intensive Care, Stavanger University Hospital, Norway
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Colston JM, Ahmed T, Mahopo C, Kang G, Kosek M, de Sousa Junior F, Shrestha PS, Svensen E, Turab A, Zaitchik B. Evaluating meteorological data from weather stations, and from satellites and global models for a multi-site epidemiological study. ENVIRONMENTAL RESEARCH 2018; 165:91-109. [PMID: 29684739 PMCID: PMC6024078 DOI: 10.1016/j.envres.2018.02.027] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Revised: 02/07/2018] [Accepted: 02/19/2018] [Indexed: 05/03/2023]
Abstract
BACKGROUND Longitudinal and time series analyses are needed to characterize the associations between hydrometeorological parameters and health outcomes. Earth Observation (EO) climate data products derived from satellites and global model-based reanalysis have the potential to be used as surrogates in situations and locations where weather-station based observations are inadequate or incomplete. However, these products often lack direct evaluation at specific sites of epidemiological interest. METHODS Standard evaluation metrics of correlation, agreement, bias and error were applied to a set of ten hydrometeorological variables extracted from two quasi-global, commonly used climate data products - the Global Land Data Assimilation System (GLDAS) and Climate Hazards Group InfraRed Precipitation with Stations (CHIRPS) - to evaluate their performance relative to weather-station derived estimates at the specific geographic locations of the eight sites in a multi-site cohort study. These metrics were calculated for both daily estimates and 7-day averages and for a rotavirus-peak-season subset. Then the variables from the two sources were each used as predictors in longitudinal regression models to test their association with rotavirus infection in the cohort after adjusting for covariates. RESULTS The availability and completeness of station-based validation data varied depending on the variable and study site. The performance of the two gridded climate models varied considerably within the same location and for the same variable across locations, according to different evaluation criteria and for the peak-season compared to the full dataset in ways that showed no obvious pattern. They also differed in the statistical significance of their association with the rotavirus outcome. For some variables, the station-based records showed a strong association while the EO-derived estimates showed none, while for others, the opposite was true. CONCLUSION Researchers wishing to utilize publicly available climate data - whether EO-derived or station based - are advised to recognize their specific limitations both in the analysis and the interpretation of the results. Epidemiologists engaged in prospective research into environmentally driven diseases should install their own weather monitoring stations at their study sites whenever possible, in order to circumvent the constraints of choosing between distant or incomplete station data or unverified EO estimates.
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Affiliation(s)
- Josh M Colston
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Tahmeed Ahmed
- Nutrition & Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B), Dhaka, Bangladesh.
| | - Cloupas Mahopo
- Department of Nutrition, University of Venda, South Africa.
| | | | - Margaret Kosek
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | | | - Prakash Sunder Shrestha
- Department of Child Health, Institute of Medicine of Tribhuvan University, Kathmandu, Nepal.
| | | | - Ali Turab
- Research and Development, Maternal and Child Health (MCH) Program, Karachi, Pakistan.
| | - Benjamin Zaitchik
- Department of Earth and Planetary Sciences, Johns Hopkins Krieger School of Arts and Sciences, Baltimore, MD, USA.
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DeBoer MD, Platts-Mills JA, Scharf RJ, McDermid JM, Wanjuhi AW, Gratz J, Svensen E, Swann JR, Donowitz JR, Jatosh S, Houpt ER, Mduma E. Early Life Interventions for Childhood Growth and Development in Tanzania (ELICIT): a protocol for a randomised factorial, double-blind, placebo-controlled trial of azithromycin, nitazoxanide and nicotinamide. BMJ Open 2018; 8:e021817. [PMID: 29982218 PMCID: PMC6042604 DOI: 10.1136/bmjopen-2018-021817] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION In many developing areas in the world, a high burden of enteric pathogens in early childhood are associated with growth deficits. The tryptophan-kynurenine-niacin pathway has been linked to enteric inflammatory responses to intestinal infections. However, it is not known in these settings whether scheduled antimicrobial intervention to reduce subclinical enteric pathogen carriage or repletion of the tryptophan-kynurenine-niacin pathway improves linear growth and development. METHODS AND ANALYSIS We are conducting a randomised, placebo-controlled, factorial intervention trial in the rural setting of Haydom, Tanzania. We are recruiting 1188 children within the first 14 days of life, who will be randomised in a 2×2 factorial design to administration of antimicrobials (azithromycin and nitazoxanide, randomised together) and nicotinamide. The nicotinamide is administered as a daily oral dose, which for breast-feeding children aged 0-6 months is given to the mother and for children aged 6-18 months is given to the child directly. Azithromycin is given to the child as a single oral dose at months 6, 9, 12 and 15; nitazoxanide is given as a 3-day course at months 12 and 15. Mother/child pairs are followed via monthly in-home visits. The primary outcome is the child's length-for-age Z-score at 18 months. Secondary outcomes for the child include additional anthropometry measures; stool pathogen burden and bacterial microbiome; systemic and enteric inflammation; blood metabolomics, growth factors, inflammation and nutrition; hydrogen breath assessment to estimate small-intestinal bacterial overgrowth and assessment of cognitive development. Secondary outcomes for the mother include breastmilk content of nicotinamide, other vitamins and amino acids; blood measures of tryptophan-kynurenine-niacin pathway and stool pathogens. ETHICS AND DISSEMINATION This trial has been approved by the Tanzanian National Institute for Medical Research, the Tanzanian FDA and the University of Virginia IRB. Findings will be presented at national and international conferences and published in peer-review journals. PROTOCOL VERSION 5.0, 4 December 2017. PROTOCOL SPONSOR Haydom Lutheran Hospital, Haydom, Manyara, Tanzania. TRIAL REGISTRATION NUMBER NCT03268902; Pre-results.
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Affiliation(s)
- Mark Daniel DeBoer
- Department of Pediatrics, University of Virginia, Charlottesville, Virginia, USA
| | | | - Rebecca J Scharf
- Department of Pediatrics, University of Virginia, Charlottesville, Virginia, USA
- Department of Medicine, University of Virginia, Charlottesville, Virginia, USA
| | - Joann M McDermid
- Department of Medicine, University of Virginia, Charlottesville, Virginia, USA
| | - Anne W Wanjuhi
- Department of Pediatrics, University of Virginia, Charlottesville, Virginia, USA
| | - Jean Gratz
- Department of Medicine, University of Virginia, Charlottesville, Virginia, USA
| | - Erling Svensen
- Department of Global Health and Primary Care, University of Bergen, Bergen, Norway
| | - Jon R Swann
- Department of Surgery & Cancer, Imperial College of London, London, UK
| | - Jeffrey R Donowitz
- Division of Infectious Disease, Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, Virginia, USA
| | - Samwel Jatosh
- Haydom Global Health Research Centre, Haydom Lutheran Hospital, Haydom, Tanzania
| | - Eric R Houpt
- Department of Medicine, University of Virginia, Charlottesville, Virginia, USA
| | - Estomih Mduma
- Haydom Global Health Research Centre, Haydom Lutheran Hospital, Haydom, Tanzania
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Chen C, Mitchell NJ, Gratz J, Houpt ER, Gong Y, Egner PA, Groopman JD, Riley RT, Showker JL, Svensen E, Mduma ER, Patil CL, Wu F. Exposure to aflatoxin and fumonisin in children at risk for growth impairment in rural Tanzania. ENVIRONMENT INTERNATIONAL 2018; 115:29-37. [PMID: 29544138 PMCID: PMC5989662 DOI: 10.1016/j.envint.2018.03.001] [Citation(s) in RCA: 98] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 03/01/2018] [Accepted: 03/01/2018] [Indexed: 05/11/2023]
Abstract
Growth impairment is a major public health issue for children in Tanzania. The question remains as to whether dietary mycotoxins play a role in compromising children's growth. We examined children's exposures to dietary aflatoxin and fumonisin and potential impacts on growth in 114 children under 36 months of age in Haydom, Tanzania. Plasma samples collected from the children at 24 months of age (N = 60) were analyzed for aflatoxin B1-lysine (AFB1-lys) adducts, and urine samples collected between 24 and 36 months of age (N = 94) were analyzed for urinary fumonisin B1 (UFB1). Anthropometric, socioeconomic, and nutritional parameters were measured and growth parameter z-scores were calculated for each child. Seventy-two percent of the children had detectable levels of AFB1-lys, with a mean level of 5.1 (95% CI: 3.5, 6.6) pg/mg albumin; and 80% had detectable levels of UFB1, with a mean of 1.3 (95% CI: 0.8, 1.8) ng/ml. This cohort had a 75% stunting rate [height-for-age z-scores (HAZ) < -2] for children at 36 months. No associations were found between aflatoxin exposures and growth impairment as measured by stunting, underweight [weight-for-age z-scores (WAZ) < -2], or wasting [weight-for-height z-scores (WHZ) < -2]. However, fumonisin exposure was negatively associated with underweight (with non-detectable samples included, p = 0.0285; non-detectable samples excluded, p = 0.005) in this cohort of children. Relatively low aflatoxin exposure at 24 months was not linked with growth impairment, while fumonisin exposure at 24-36 months based on the UFB1 biomarkers may contribute to the high growth impairment rate among children of Haydom, Tanzania; which may be associated with their breast feeding and weaning practices.
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Affiliation(s)
- Chen Chen
- Department of Food Science and Human Nutrition, Michigan State University, East Lansing, MI, USA
| | - Nicole J Mitchell
- Department of Food Science and Human Nutrition, Michigan State University, East Lansing, MI, USA; Uckele Health and Nutrition, Blissfield, MI, USA
| | - Jean Gratz
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA, USA
| | - Eric R Houpt
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA, USA
| | - Yunyun Gong
- School of Food Science and Nutrition, University of Leeds, UK
| | - Patricia A Egner
- Department of Environmental Health Sciences, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD, USA
| | - John D Groopman
- Department of Environmental Health Sciences, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD, USA
| | - Ronald T Riley
- Toxicology and Mycotoxin Research Unit, National Poultry Disease Research Center, R.B. Russell Research Center, USDA-ARS, Athens, GA, USA
| | - Jency L Showker
- Toxicology and Mycotoxin Research Unit, National Poultry Disease Research Center, R.B. Russell Research Center, USDA-ARS, Athens, GA, USA
| | - Erling Svensen
- Haukeland University Hospital, Bergen, Norway; Haydom Lutheran Hospital, Manyara Region, Tanzania; University of Bergen, Norway
| | | | - Crystal L Patil
- Department of Women, Children and Family Health Science, University of Illinois at Chicago, College of Nursing, Chicago, IL, USA
| | - Felicia Wu
- Department of Food Science and Human Nutrition, Michigan State University, East Lansing, MI, USA.
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Ribe IG, Svensen E, Lyngmo BA, Mduma E, Hinderaker SG. Determinants of early child development in rural Tanzania. Child Adolesc Psychiatry Ment Health 2018; 12:18. [PMID: 29568326 PMCID: PMC5859781 DOI: 10.1186/s13034-018-0224-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 02/27/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND It has been estimated that more than 200 million children under the age of five do not reach their full potential in cognitive development. Much of what we know about brain development is based on research from high-income countries. There is limited evidence on the determinants of early child development in low-income countries, especially rural sub-Saharan Africa. The present study aimed to identify the determinants of cognitive development in children living in villages surrounding Haydom, a rural area in north-central Tanzania. METHODS This cohort study is part of the MAL-ED (The Interactions of Malnutrition & Enteric Infections: Consequences for Child Health and Development) multi-country consortium studying risk factors for ill health and poor development in children. Descriptive analysis and linear regression analyses were performed. Associations between nutritional status, socio-economic status, and home environment at 6 months of age and cognitive outcomes at 15 months of age were studied. The third edition of the Bayley Scales for Infant and Toddler Development was used to assess cognitive, language and motor development. RESULTS There were 262 children enrolled into the study, and this present analysis included the 137 children with data for 15-month Bayley scores. Univariate regression analysis, weight-for-age and weight-for-length z-scores at 6 months were significantly associated with 15-month Bayley gross motor score, but not with other 15-month Bayley scores. Length-for-age z-scores at 6 months were not significantly associated with 15-month Bayley scores. The socio-economic status, measured by a set of assets and monthly income was significantly associated with 15-month Bayley cognitive score, but not with language, motor, nor total 15-month Bayley scores. Other socio-economic variables were not significantly associated with 15-month Bayley scores. No significant associations were found between the home environment and 15-month Bayley scores. In multivariate regression analyses we found higher Bayley scores for girls and higher Bayley scores in families with more assets. Adjusted R-squared of this model was 8%. CONCLUSION We conclude that poverty is associated with a slower cognitive development in children and malnutrition is associated with slower gross motor development. This information should encourage authorities and other stakeholders to invest in improved welfare and nutrition programmes for children from early infancy.
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Affiliation(s)
- Ingeborg G. Ribe
- 0000 0004 1936 7443grid.7914.bUniversity of Bergen, Bergen, Norway
| | - Erling Svensen
- 0000 0004 1936 7443grid.7914.bUniversity of Bergen, Bergen, Norway ,0000 0004 1797 1065grid.461293.bHaydom Lutheran Hospital, Haydom, Mbulu District, Tanzania
| | - Britt A. Lyngmo
- 0000 0004 1936 7443grid.7914.bUniversity of Bergen, Bergen, Norway
| | - Estomih Mduma
- 0000 0004 1797 1065grid.461293.bHaydom Lutheran Hospital, Haydom, Mbulu District, Tanzania
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Enteroaggregative Escherichia coli Subclinical Infection and Coinfections and Impaired Child Growth in the MAL-ED Cohort Study. J Pediatr Gastroenterol Nutr 2018; 66:325-333. [PMID: 29356769 DOI: 10.1097/mpg.0000000000001717] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVE We evaluated the impact of subclinical enteroaggregative Escherichia coli (EAEC) infection alone and in combination with other pathogens in the first 6 months of life on child growth. METHODS Nondiarrheal samples from 1684 children across 8 Multisite Birth Cohort Study, Malnutrition and Enteric Diseases (MAL-ED) sites in Asia, Africa, and Latin America were tested monthly; more than 90% of children were followed-up twice weekly for the first 6 months of life. RESULTS Children with subclinical EAEC infection did not show altered growth between enrollment and 6 months. Conversely, EAEC coinfection with any other pathogen was negatively associated with delta weight-for-length (P < 0.05) and weight-for-age (P > 0.05) z scores between 0 and 6 months. The presence of 2 or more pathogens without EAEC was not significantly associated with delta weight-for-length and weight-for-age. The most frequent EAEC coinfections included Campylobacter spp, heat-labile toxin-producing enterotoxigenic E coli, Cryptosporidium spp, and atypical enteropathogenic E coli. Myeloperoxidase levels were increased with EAEC coinfection (P < 0.05). EAEC pathogen codetection was associated with lower neopterin levels compared to those of no-pathogen control children (P < 0.05). Mothers of children with EAEC coinfections had lower levels of education, poorer hygiene and sanitation, lower socioeconomic status, and lower breast-feeding rates compared to mothers of children in whom no pathogen was detected (P < 0.05). CONCLUSIONS These data emphasize the public health importance of subclinical EAEC infection in early infancy in association with other pathogens and the need for improved maternal and child care, hygiene, sanitation, and socioeconomic factors.
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Hanselman B, Ambikapathi R, Mduma E, Svensen E, Caulfield LE, Patil CL. Associations of land, cattle and food security with infant feeding practices among a rural population living in Manyara, Tanzania. BMC Public Health 2018; 18:159. [PMID: 29351750 PMCID: PMC5775554 DOI: 10.1186/s12889-018-5074-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 01/11/2018] [Indexed: 11/29/2022] Open
Abstract
Background Livelihoods strategies and food security experiences can positively and negatively affect infant and young child feeding (IYCF) practices. This study contributes to this literature by exploring how variation in household economics among rural farmers in Tanzania relates to IYCF patterns over the first 8 months of an infant’s life. Methods These data were produced from a longitudinal study in which a cohort of mother-infant dyads was followed from birth to 24 months. In addition to baseline maternal, infant, and household characteristics, mothers were queried twice weekly and monthly about infant feeding practices and diet. Weekly and monthly datasets were merged and analyzed to assess infant feeding patterns through the first 8 months. Standard statistical methods including survival and logistic regression analyses were used. Results Aside from breastfeeding initiation, all other IYCF practices were suboptimal in this cohort. Land and cattle ownership were associated with the early introduction of non-breastmilk food items. Food insecurity also played a role in patterning and inadequate complementary feeding was commonplace. Conclusions Health promotion programs are needed to delay the introduction of animal milks and grain-based porridge, and to achieve a minimum acceptable diet after 6 months of age among smallholder farmers in rural Tanzania. Results highlight that livelihoods-based health promotion interventions, built from a flexible and integrated design, may be an important strategy to address community-level variation in infant feeding practices and promote optimal IYCF practices.
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Affiliation(s)
- Bailey Hanselman
- Department of Women, Children and Family Health Science, University of Illinois at Chicago, College of Nursing, Chicago, IL, 60612, USA
| | - Ramya Ambikapathi
- Fogarty International Center, National Institutes of Health, Bethesda, MD, USA.,Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Estomih Mduma
- Haydom Global Health Research Centre, Haydom, Tanzania
| | | | - Laura E Caulfield
- Department of International Health, The Johns Hopkins Bloomberg School of Public Health & Fogarty International Center, National Institutes of Health, Bethesda, MD, USA
| | - Crystal L Patil
- Department of Women, Children and Family Health Science, University of Illinois at Chicago, College of Nursing, Chicago, IL, 60612, USA.
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Jones PC, Pendergast LL, Schaefer BA, Rasheed M, Svensen E, Scharf R, Shrestha R, Maphula A, Roshan R, Rasmussen Z, Seidman JC, Murray-Kolb LE. Measuring home environments across cultures: Invariance of the HOME scale across eight international sites from the MAL-ED study. J Sch Psychol 2017; 64:109-127. [PMID: 28735604 PMCID: PMC5540057 DOI: 10.1016/j.jsp.2017.06.001] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Revised: 04/18/2017] [Accepted: 06/14/2017] [Indexed: 12/03/2022]
Abstract
The home environment provides the context for much of a child's early development. Examples of important aspects of the home environment include safety, cleanliness, and opportunities for cognitive stimulation. This study sought to examine the psychometric properties of an adapted form of the Home Observation for the Measurement of the Environment (HOME; Caldwell & Bradley, 1984, 2003) across the eight international sites of the MAL-ED project (Dhaka, Bangladesh; Vellore, India; Bhakatapur, Nepal; Naushahro Feroze, Pakistan; Fortaleza, Brazil; Loreto, Peru; Venda, South Africa; Haydom, Tanzania), to identify a factor structure that fit the data at all sites, and to derive a subset of items that could be used to examine home environmental characteristics across sites. A three-factor structure (i.e., Emotional and Verbal Responsivity; Clean and Safe Environment; Child Cleanliness) was identified, and partial measurement equivalence/invariance across sites was supported. Overall, these findings lend support for the use of portions of this abbreviated and adapted version of the HOME for use among heterogeneous, cross-cultural groups in low- and middle-income nations.
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Affiliation(s)
| | | | | | | | - Erling Svensen
- University of Bergen, Norway; Haydom Lutheran Hospital, Tanzania
| | | | - Rita Shrestha
- Institute of Medicine, Tribuhvan University, Kathmandu, Nepal
| | | | | | - Zeba Rasmussen
- Fogarty International Center/National Institutes of Health, Bethesda, MD, USA
| | - Jessica C Seidman
- Fogarty International Center/National Institutes of Health, Bethesda, MD, USA
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Mohan VR, Karthikeyan R, Babji S, McGrath M, Shrestha S, Shrestha J, Mdumah E, Amour C, Samie A, Nyathi E, Haque R, Qureshi S, Yori PP, Lima AAM, Bodhidatta L, Svensen E, Bessong P, Ahmed T, Seidman JC, Zaidi AKM, Kosek MN, Guerrant RL, Gratz J, Platts-Mills JA, Lang DR, Gottlieb M, Houpt ER, Kang G. Rotavirus Infection and Disease in a Multisite Birth Cohort: Results From the MAL-ED Study. J Infect Dis 2017; 216:305-316. [PMID: 28472348 DOI: 10.1093/infdis/jix199] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2017] [Accepted: 04/27/2017] [Indexed: 12/14/2022] Open
Abstract
Background In a multicountry birth cohort study, we describe rotavirus infection in the first 2 years of life in sites with and without rotavirus vaccination programs. Methods Children were recruited by 17 days of age and followed to 24 months with collection of monthly surveillance and diarrheal stools. Data on sociodemographics, feeding, and illness were collected at defined intervals. Stools were tested for rotavirus and sera for antirotavirus immunoglobulins by enzyme immunoassays. Results A total of 1737 children contributed 22646 surveillance and 7440 diarrheal specimens. Overall, rotavirus was detected in 5.5% (408/7440) of diarrheal stools, and 344 (19.8%) children ever had rotavirus gastroenteritis. Household overcrowding and a high pathogen load were consistent risk factors for infection and disease. Three prior infections conferred 74% (P < .001) protection against subsequent infection in sites not using vaccine. In Peru, incidence of rotavirus disease was relatively higher during the second year of life despite high vaccination coverage. Conclusions Rotavirus infection and disease were common, but with significant heterogeneity by site. Protection by vaccination may not be sustained in the second year of life in settings with high burdens of transmission and poor response to oral vaccines.
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Affiliation(s)
| | | | - Sudhir Babji
- Division of Gastrointestinal Sciences, Christian Medical College, Vellore, India
| | - Monica McGrath
- Fogarty International Center, National Institutes of Health, Bethesda, Maryland
| | - Sanjaya Shrestha
- Walter Reed/Armed Forces Research Institute of Medical Sciences (AFRIMS) Research Unit Nepal.,Centre for International Health, University of Bergen, Norway
| | - Jasmin Shrestha
- Walter Reed/Armed Forces Research Institute of Medical Sciences (AFRIMS) Research Unit Nepal.,Centre for International Health, University of Bergen, Norway
| | | | | | | | | | - Rashidul Haque
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | | | - Pablo Peñataro Yori
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.,Asociación Benéfica PRISMA, Iquitos, Peru
| | - Aldo A M Lima
- Clinical Research Unit and Institute of Biomedicine, Federal University of Ceara, Fortaleza, Brazil
| | - Ladaporn Bodhidatta
- Walter Reed/Armed Forces Research Institute of Medical Sciences (AFRIMS) Research Unit Nepal.,Centre for International Health, University of Bergen, Norway
| | | | | | - Tahmeed Ahmed
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Jessica C Seidman
- Fogarty International Center, National Institutes of Health, Bethesda, Maryland
| | | | - Margaret N Kosek
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.,Asociación Benéfica PRISMA, Iquitos, Peru
| | - Richard L Guerrant
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville
| | - Jean Gratz
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville
| | - James A Platts-Mills
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville
| | - Dennis R Lang
- Foundation for the National Institutes of Health, Bethesda, Maryland
| | - Michael Gottlieb
- Foundation for the National Institutes of Health, Bethesda, Maryland
| | - Eric R Houpt
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville
| | - Gagandeep Kang
- Division of Gastrointestinal Sciences, Christian Medical College, Vellore, India
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Age and Sex Normalization of Intestinal Permeability Measures for the Improved Assessment of Enteropathy in Infancy and Early Childhood: Results From the MAL-ED Study. J Pediatr Gastroenterol Nutr 2017. [PMID: 28644347 DOI: 10.1097/mpg.0000000000001610] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES The aim of the study was to describe changes in intestinal permeability in early childhood in diverse epidemiologic settings. METHODS In a birth cohort study, the lactulose:mannitol (L:M) test was administered to 1980 children at 4 time points in the first 24 months of life in 8 countries. Data from the Brazil site with an incidence of diarrhea similar to that seen in the United States and no growth faltering was used as an internal study reference to derive age- and sex-specific z scores for mannitol and lactulose recoveries and the L:M ratio. RESULTS A total of 6602 tests demonstrated mannitol recovery, lactulose recovery, and the L:M ratio were associated with country, sex, and age. There was heterogeneity in the recovery of both probes between sites with mean mannitol recovery ranging for 1.34% to 5.88%, lactulose recovery of 0.19% to 0.58%, and L:M ratios 0.10 to 0.17 in boys of 3 months of age across different sites. We observed strong sex-specific differences in both mannitol and lactulose recovery, with boys having higher recovery of both probes. Alterations in intestinal barrier function increased in most sites from 3 to 9 months of age and plateaued or diminished from 9 to 15 months of age. CONCLUSIONS Alterations in recovery of the probes differ markedly in different epidemiologic contexts in children living in the developing world. The rate of change in the L:M-z ratio was most rapid and consistently disparate from the reference standard in the period between 6 and 9 months of age, suggesting that this is a critical period of physiologic impact of enteropathy in these populations.
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Anthropometry and Nutritional Status of Primary School Children in a Sub-urban Region in Tanzania. INTERNATIONAL JOURNAL OF SCHOOL HEALTH 2017. [DOI: 10.5812/intjsh.46079] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Protein Malnutrition Modifies Innate Immunity and Gene Expression by Intestinal Epithelial Cells and Human Rotavirus Infection in Neonatal Gnotobiotic Pigs. mSphere 2017; 2:mSphere00046-17. [PMID: 28261667 PMCID: PMC5332602 DOI: 10.1128/msphere.00046-17] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Accepted: 02/06/2017] [Indexed: 12/11/2022] Open
Abstract
Malnutrition and rotavirus infection, prevalent in developing countries, individually and in combination, affect the health of millions of children, compromising their immunity and increasing the rates of death from infectious diseases. However, the interactions between the two and their combined effects on immune and intestinal functions are poorly understood. We have established the first human infant microbiota-transplanted neonatal pig model of childhood malnutrition that reproduced the impaired immune, intestinal, and other physiological functions seen in malnourished children. This model can be used to evaluate relevant dietary and other health-promoting interventions. Our findings provide an explanation of why adequate nutrition alone may lack efficacy in malnourished children. Malnutrition affects millions of children in developing countries, compromising immunity and contributing to increased rates of death from infectious diseases. Rotavirus is a major etiological agent of childhood diarrhea in developing countries, where malnutrition is prevalent. However, the interactions between the two and their combined effects on immune and intestinal functions are poorly understood. In this study, we used neonatal gnotobiotic (Gn) pigs transplanted with the fecal microbiota of a healthy 2-month-old infant (HIFM) and fed protein-deficient or -sufficient bovine milk diets. Protein deficiency induced hypoproteinemia, hypoalbuminemia, hypoglycemia, stunting, and generalized edema in Gn pigs, as observed in protein-malnourished children. Irrespective of the diet, human rotavirus (HRV) infection early, at HIFM posttransplantation day 3 (PTD3), resulted in adverse health effects and higher mortality rates (45 to 75%) than later HRV infection (PTD10). Protein malnutrition exacerbated HRV infection and affected the morphology and function of the small intestinal epithelial barrier. In pigs infected with HRV at PTD10, there was a uniform decrease in the function and/or frequencies of natural killer cells, plasmacytoid dendritic cells, and CD103+ and apoptotic mononuclear cells and altered gene expression profiles of intestinal epithelial cells (chromogranin A, mucin 2, proliferating cell nuclear antigen, SRY-Box 9, and villin). Thus, we have established the first HIFM-transplanted neonatal pig model that recapitulates major aspects of protein malnutrition in children and can be used to evaluate physiologically relevant interventions. Our findings provide an explanation of why nutrient-rich diets alone may lack efficacy in malnourished children. IMPORTANCE Malnutrition and rotavirus infection, prevalent in developing countries, individually and in combination, affect the health of millions of children, compromising their immunity and increasing the rates of death from infectious diseases. However, the interactions between the two and their combined effects on immune and intestinal functions are poorly understood. We have established the first human infant microbiota-transplanted neonatal pig model of childhood malnutrition that reproduced the impaired immune, intestinal, and other physiological functions seen in malnourished children. This model can be used to evaluate relevant dietary and other health-promoting interventions. Our findings provide an explanation of why adequate nutrition alone may lack efficacy in malnourished children.
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Hoest C, Seidman JC, Lee G, Platts-Mills JA, Ali A, Olortegui MP, Bessong P, Chandyo R, Babji S, Mohan VR, Mondal D, Mahfuz M, Mduma ER, Nyathi E, Abreu C, Miller MA, Pan W, Mason CJ, Knobler SL. Vaccine coverage and adherence to EPI schedules in eight resource poor settings in the MAL-ED cohort study. Vaccine 2017; 35:443-451. [PMID: 27998640 PMCID: PMC5244255 DOI: 10.1016/j.vaccine.2016.11.075] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Revised: 11/17/2016] [Accepted: 11/18/2016] [Indexed: 11/21/2022]
Abstract
BACKGROUND Launched in 1974, the Expanded Program on Immunization (EPI) is estimated to prevent two-three million deaths annually from polio, diphtheria, tuberculosis, pertussis, measles, and tetanus. Additional lives could be saved through better understanding what influences adherence to the EPI schedule in specific settings. METHODS The Etiology, Risk Factors and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health and Development (MAL-ED) study followed cohorts in eight sites in South Asia, Africa, and South America and monitored vaccine receipt over the first two years of life for the children enrolled in the study. Vaccination histories were obtained monthly from vaccination cards, local clinic records and/or caregiver reports. Vaccination histories were compared against the prescribed EPI schedules for each country, and coverage rates were examined in relation to the timing of vaccination. The influence of socioeconomic factors on vaccine timing and coverage was also considered. RESULTS Coverage rates for EPI vaccines varied between sites and by type of vaccine; overall, coverage was highest in the Nepal and Bangladesh sites and lowest in the Tanzania and Brazil sites. Bacillus Calmette-Guérin coverage was high across all sites, 87-100%, whereas measles vaccination rates ranged widely, 73-100%. Significant delays between the scheduled administration age and actual vaccination date were present in all sites, especially for measles vaccine where less than 40% were administered on schedule. A range of socioeconomic factors were significantly associated with vaccination status in study children but these results were largely site-specific. CONCLUSIONS Our findings highlight the need to improve measles vaccination rates and reduce delayed vaccination to achieve EPI targets related to the establishment of herd immunity and reduction in disease transmission.
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Affiliation(s)
- Christel Hoest
- Division of International Epidemiology and Population Studies of Fogarty International Center, National Institutes of Health, 16 Center Drive, Bethesda, MD 20892, USA.
| | - Jessica C Seidman
- Division of International Epidemiology and Population Studies of Fogarty International Center, National Institutes of Health, 16 Center Drive, Bethesda, MD 20892, USA
| | - Gwenyth Lee
- Department of International Health, Johns Hopkins University, Baltimore, MD, 21205, USA
| | - James A Platts-Mills
- Division of Infectious Diseases and International Health, University of Virginia, P.O. Box 801340, 345 Crispell Drive, Carter Harrison Building, Charlottesville, VA 22908, USA
| | - Asad Ali
- Aga Khan University, Department of Pediatrics and Child Health, Stadium Road, Karachi, Pakistan
| | - Maribel Paredes Olortegui
- Asociaciόn Benéfica Proyectos de Informática, Salud, Medicina, y Agricultura (A.B. PRISMA), Ramirez Hurtado 622, Iquitos, Peru
| | - Pascal Bessong
- HIV/AIDS and Global Health Research Programme, University of Venda, Thohoyandou 0950, South Africa
| | - Ram Chandyo
- Department of Child Health, Institute of Medicine, Tribhuvan University, Katmandu, Nepal; Centre for International Health, University of Bergen, P.O. Box 7800, 5020 Bergen, Norway
| | - Sudhir Babji
- Department of Gastrointestinal Sciences/Department of Community Health, Christian Medical College, Vellore, Tamil Nadu 632004, India
| | - Venkata Raghava Mohan
- Department of Gastrointestinal Sciences/Department of Community Health, Christian Medical College, Vellore, Tamil Nadu 632004, India
| | - Dinesh Mondal
- Nutrition and Clinical Services Division, International Centre For Diarrhoeal Disease Research, Bangladesh (icddr,b), 68 Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka 1212, Bangladesh
| | - Mustafa Mahfuz
- Nutrition and Clinical Services Division, International Centre For Diarrhoeal Disease Research, Bangladesh (icddr,b), 68 Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka 1212, Bangladesh
| | - Estomih R Mduma
- Haydom Lutheran Hospital, POB 9041, Haydom, Manyara Region, Tanzania
| | - Emanuel Nyathi
- HIV/AIDS and Global Health Research Programme, University of Venda, Thohoyandou 0950, South Africa
| | - Claudia Abreu
- Instituto de Biomedicina, Departamento de Fisiologia e Farmacologia, Faculdade de Medicina Federal University of Ceara, Rua Coronel Nunes de Melo, 1315, CEP: 60.430-270 - C.P. 3229 - Porangabussu, Fortaleza Ceará, Brazil
| | - Mark A Miller
- Division of International Epidemiology and Population Studies of Fogarty International Center, National Institutes of Health, 16 Center Drive, Bethesda, MD 20892, USA
| | - William Pan
- Department of Environmental Science and Policy and the Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Carl J Mason
- Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | - Stacey L Knobler
- Division of International Epidemiology and Population Studies of Fogarty International Center, National Institutes of Health, 16 Center Drive, Bethesda, MD 20892, USA
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Kosek MN, Mduma E, Kosek PS, Lee GO, Svensen E, Pan WKY, Olortegui MP, Bream JH, Patil C, Asayag CR, Sanchez GM, Caulfield LE, Gratz J, Yori PP. Plasma Tryptophan and the Kynurenine-Tryptophan Ratio are Associated with the Acquisition of Statural Growth Deficits and Oral Vaccine Underperformance in Populations with Environmental Enteropathy. Am J Trop Med Hyg 2016; 95:928-937. [PMID: 27503512 PMCID: PMC5062803 DOI: 10.4269/ajtmh.16-0037] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Accepted: 06/14/2016] [Indexed: 01/22/2023] Open
Abstract
Early childhood enteric infections have adverse impacts on child growth and can inhibit normal mucosal responses to oral vaccines, two critical components of environmental enteropathy. To evaluate the role of indoleamine 2,3-dioxygenase 1 (IDO1) activity and its relationship with these outcomes, we measured tryptophan and the kynurenine–tryptophan ratio (KTR) in two longitudinal birth cohorts with a high prevalence of stunting. Children in rural Peru and Tanzania (N = 494) contributed 1,251 plasma samples at 3, 7, 15, and 24 months of age and monthly anthropometrics from 0 to 36 months of age. Tryptophan concentrations were directly associated with linear growth from 1 to 8 months after biomarker assessment. A 1-SD increase in tryptophan concentration was associated with a gain in length-for-age Z-score (LAZ) of 0.17 over the next 6 months in Peru (95% confidence interval [CI] = 0.11–0.23, P < 0.001) and a gain in LAZ of 0.13 Z-scores in Tanzania (95% CI = 0.03–0.22, P = 0.009). Vaccine responsiveness data were available for Peru only. An increase in kynurenine by 1 μM was associated with a 1.63 (95% CI = 1.13–2.34) increase in the odds of failure to poliovirus type 1, but there was no association with tetanus vaccine response. A KTR of 52 was 76% sensitive and 50% specific in predicting failure of response to serotype 1 of the oral polio vaccine. KTR was associated with systemic markers of inflammation, but also interleukin-10, supporting the association between IDO1 activity and immunotolerance. These results strongly suggest that the activity of IDO1 is implicated in the pathophysiology of environmental enteropathy, and demonstrates the utility of tryptophan and kynurenine as biomarkers for this syndrome, particularly in identifying those at risk for hyporesponsivity to oral vaccines.
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Affiliation(s)
- Margaret N Kosek
- Department of International Health, Johns Hopkins School of Public Health, Baltimore, Maryland
| | - Estomih Mduma
- Global Health Research Center, Haydom Lutheran Hospital, Manyara, Tanzania
| | | | - Gwenyth O Lee
- Department of Global Community Health and Behavioral Sciences, Tulane University, New Orleans, Louisiana
| | | | - William K Y Pan
- Duke Global Health Institute, Nicholas School of Environment, Duke University, Durham, North Carolina
| | - Maribel Paredes Olortegui
- Asociacion Benefica Proyectos de Informática, Salud, Medicina, y Agricultura (PRISMA), Iquitos, Peru
| | - Jay H Bream
- Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Crystal Patil
- Department of Women, Children, and Family Health Science, University of Illinois at Chicago College of Nursing, Chicago, Illinois
| | | | | | - Laura E Caulfield
- Department of International Health, Johns Hopkins School of Public Health, Baltimore, Maryland
| | - Jean Gratz
- Center for Global Health, University of Virginia, Charlottesville, Virginia
| | - Pablo Peñataro Yori
- Department of International Health, Johns Hopkins School of Public Health, Baltimore, Maryland
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Ambikapathi R, Kosek MN, Lee GO, Mahopo C, Patil CL, Maciel BL, Turab A, Islam MM, Ulak M, Bose A, Paredes Olortegui M, Pendergast LL, Murray-Kolb LE, Lang D, McCormick BJJ, Caulfield LE. How multiple episodes of exclusive breastfeeding impact estimates of exclusive breastfeeding duration: report from the eight-site MAL-ED birth cohort study. MATERNAL AND CHILD NUTRITION 2016; 12:740-56. [PMID: 27500709 PMCID: PMC5095788 DOI: 10.1111/mcn.12352] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Revised: 06/02/2016] [Accepted: 06/07/2016] [Indexed: 11/28/2022]
Abstract
The duration of exclusive breastfeeding (EBF) is often defined as the time from birth to the first non‐breast milk food/liquid fed (EBFLONG), or it is estimated by calculating the proportion of women at a given infant age who EBF in the previous 24 h (EBFDHS). Others have measured the total days or personal prevalence of EBF (EBFPREV), recognizing that although non‐EBF days may occur, EBF can be re‐initiated for extended periods. We compared breastfeeding metrics in the MAL‐ED study; infants' breastfeeding trajectories were characterized from enrollment (median 7 days, IQR: 4, 12) to 180 days at eight sites. During twice‐weekly surveillance, caretakers were queried about infant feeding the prior day. Overall, 101 833 visits and 356 764 child days of data were collected from 1957 infants. Median duration of EBFLONG was 33 days (95% CI: 32–36), compared to 49 days based on the EBFDHS. Median EBFPREV was 66 days (95% CI: 62–70). Differences were because of the return to EBF after a non‐EBF period. The median number of returns to EBF was 2 (IQR: 1, 3). When mothers re‐initiated EBF (second episode), infants gained an additional 18.8 days (SD: 25.1) of EBF, and gained 13.7 days (SD: 18.1) (third episode). In settings where women report short gaps in EBF, programmes should work with women to return to EBF. Interventions could positively influence the duration of these additional periods of EBF and their quantification should be considered in impact evaluation studies. © 2016 John Wiley & Sons Ltd
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Affiliation(s)
- Ramya Ambikapathi
- Fogarty International Center, National Institutes of Health, Bethesda, Maryland, USA.,Center for Human Nutrition, Department of International Health, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Margaret N Kosek
- Center for Human Nutrition, Department of International Health, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Gwenyth O Lee
- Center for Human Nutrition, Department of International Health, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Cloupas Mahopo
- Department of Nutrition, School of Health Sciences, University of Venda, Thohoyandou, Limpopo Province, South Africa
| | - Crystal L Patil
- Department of Women, Children and Family Health Science, College of Nursing, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Bruna L Maciel
- Department of Nutrition, State University of Ceará, Fortaleza, Ceará, Brazil
| | - Ali Turab
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | - M Munirul Islam
- Centre for Nutrition and Food Security, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Manjeswori Ulak
- Department of Child Health and Institute of Medicine, Tribhuvan University, Kathmandu, Nepal
| | | | | | - Laura L Pendergast
- School Psychology Program, Temple University, Philadelphia, Pennsylvania, USA
| | - Laura E Murray-Kolb
- Department of Nutritional Sciences, The Pennsylvania State University, State College, Pennsylvania, USA
| | - Dennis Lang
- Fogarty International Center, National Institutes of Health, Bethesda, Maryland, USA
| | | | - Laura E Caulfield
- Center for Human Nutrition, Department of International Health, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.
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Mapesa JO, Maxwell AL, Ryan EP. An Exposome Perspective on Environmental Enteric Dysfunction. ENVIRONMENTAL HEALTH PERSPECTIVES 2016; 124:1121-6. [PMID: 26713888 PMCID: PMC4977058 DOI: 10.1289/ehp.1510459] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Accepted: 12/18/2015] [Indexed: 05/26/2023]
Abstract
BACKGROUND Environmental exposures to chemicals have been shown to influence gastrointestinal function, yet little is known regarding whether chemical mixtures may be involved in the development of a subclinical enteric dysfunction found in infants and children born into poor hygiene and sanitation. Advances in gastrointestinal and immunotoxicology fields merit inclusion in complex discussions of environmental enteric dysfunction (EED) that severely affects children in developing countries. OBJECTIVE We aimed to highlight exposome approaches for investigating the potential influence of environmental chemical exposures on EED development, including a role for toxicant modulation of gut immune system and microbiome function. DISCUSSION A major focus on fecal-oral contamination in impoverished living conditions already exists for EED, and should now expand to include environmental chemicals such as pesticides and heavy metals that may be anthropogenic or dietary or from microbial sources. A comprehensive characterization of environmental chemical exposures prenatally and occurring in infants and young children will enhance our knowledge of any associated risks for EED and stunting. CONCLUSIONS Integrating EED, chemical exposure, and stunting at various ages during childhood will enhance our apparent limited view when evaluating EED. Etiology and intervention studies should evaluate the suite of environmental chemical exposures as candidates in the composite of EED biomarkers. CITATION Mapesa JO, Maxwell AL, Ryan EP. 2016. An exposome perspective on environmental enteric dysfunction. Environ Health Perspect 124:1121-1126; http://dx.doi.org/10.1289/ehp.1510459.
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Affiliation(s)
- Job O. Mapesa
- Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, Colorado, USA
- Department of Public Health and Human Nutrition and Dietetics, Kenya Methodist University, Nairobi, Kenya
| | - Amy L. Maxwell
- Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, Colorado, USA
- Department of Health Sciences, University of Alaska Anchorage, Anchorage, Alaska, USA
| | - Elizabeth P. Ryan
- Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, Colorado, USA
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Abstract
PURPOSE OF REVIEW We highlight recent advances relevant to understanding norovirus infections in the tropics, both in populations living in developing settings and travelers to these regions. RECENT FINDINGS Because of the decrease in diarrheal disease associated with the global rollout of vaccines against rotavirus, norovirus is emerging as the predominant cause of diarrhea morbidity among children in the tropics, and evidence suggests that it contributes to adult disease in endemic populations and travelers. In addition to identifying potential target populations for preventive measures, we provide an update on norovirus vaccine development and concepts related to their implementation in low-income and middle-income countries. SUMMARY These current concepts related to norovirus-attributable disease burden, clinical significance, and economic impact can potentially be applied to tailoring efforts to prevent and mitigate the effects of this important enteropathogen.
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Platts-Mills JA, Babji S, Bodhidatta L, Gratz J, Haque R, Havt A, McCormick BJ, McGrath M, Olortegui MP, Samie A, Shakoor S, Mondal D, Lima IF, Hariraju D, Rayamajhi BB, Qureshi S, Kabir F, Yori PP, Mufamadi B, Amour C, Carreon JD, Richard SA, Lang D, Bessong P, Mduma E, Ahmed T, Lima AA, Mason CJ, Zaidi AK, Bhutta ZA, Kosek M, Guerrant RL, Gottlieb M, Miller M, Kang G, Houpt ER. Pathogen-specific burdens of community diarrhoea in developing countries: a multisite birth cohort study (MAL-ED). LANCET GLOBAL HEALTH 2015. [PMID: 26202075 DOI: 10.1016/s2214-109x(15)00151-5] [Citation(s) in RCA: 616] [Impact Index Per Article: 68.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Most studies of the causes of diarrhoea in low-income and middle-income countries have looked at severe disease in people presenting for care, and there are few estimates of pathogen-specific diarrhoea burdens in the community. METHODS We undertook a birth cohort study with not only intensive community surveillance for diarrhoea but also routine collection of non-diarrhoeal stools from eight sites in South America, Africa, and Asia. We enrolled children within 17 days of birth, and diarrhoeal episodes (defined as maternal report of three or more loose stools in 24 h, or one loose stool with visible blood) were identified through twice-weekly home visits by fieldworkers over a follow-up period of 24 months. Non-diarrhoeal stool specimens were also collected for surveillance for months 1-12, 15, 18, 21, and 24. Stools were analysed for a broad range of enteropathogens using culture, enzyme immunoassay, and PCR. We used the adjusted attributable fraction (AF) to estimate pathogen-specific burdens of diarrhoea. FINDINGS Between November 26, 2009, and February 25, 2014, we tested 7318 diarrhoeal and 24 310 non-diarrhoeal stools collected from 2145 children aged 0-24 months. Pathogen detection was common in non-diarrhoeal stools but was higher with diarrhoea. Norovirus GII (AF 5·2%, 95% CI 3·0-7·1), rotavirus (4·8%, 4·5-5·0), Campylobacter spp (3·5%, 0·4-6·3), astrovirus (2·7%, 2·2-3·1), and Cryptosporidium spp (2·0%, 1·3-2·6) exhibited the highest attributable burdens of diarrhoea in the first year of life. The major pathogens associated with diarrhoea in the second year of life were Campylobacter spp (7·9%, 3·1-12·1), norovirus GII (5·4%, 2·1-7·8), rotavirus (4·9%, 4·4-5·2), astrovirus (4·2%, 3·5-4·7), and Shigella spp (4·0%, 3·6-4·3). Rotavirus had the highest AF for sites without rotavirus vaccination and the fifth highest AF for sites with the vaccination. There was substantial variation in pathogens according to geography, diarrhoea severity, and season. Bloody diarrhoea was primarily associated with Campylobacter spp and Shigella spp, fever and vomiting with rotavirus, and vomiting with norovirus GII. INTERPRETATION There was substantial heterogeneity in pathogen-specific burdens of diarrhoea, with important determinants including age, geography, season, rotavirus vaccine usage, and symptoms. These findings suggest that although single-pathogen strategies have an important role in the reduction of the burden of severe diarrhoeal disease, the effect of such interventions on total diarrhoeal incidence at the community level might be limited.
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Affiliation(s)
- James A Platts-Mills
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA, USA
| | | | | | - Jean Gratz
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA, USA; Haydom Lutheran Hospital, Haydom, Tanzania
| | - Rashidul Haque
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Alexandre Havt
- Clinical Research Unit and Institute of Biomedicine, Federal University of Ceara, Fortaleza, Brazil
| | | | - Monica McGrath
- Fogarty International Center, National Institutes of Health, Bethesda, MD, USA
| | | | | | | | - Dinesh Mondal
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Ila Fn Lima
- Clinical Research Unit and Institute of Biomedicine, Federal University of Ceara, Fortaleza, Brazil
| | | | | | | | | | | | | | | | - J Daniel Carreon
- Fogarty International Center, National Institutes of Health, Bethesda, MD, USA
| | - Stephanie A Richard
- Fogarty International Center, National Institutes of Health, Bethesda, MD, USA
| | - Dennis Lang
- Foundation for the National Institutes of Health, Bethesda, MD, USA
| | | | - Esto Mduma
- Haydom Lutheran Hospital, Haydom, Tanzania
| | - Tahmeed Ahmed
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Aldo Aam Lima
- Clinical Research Unit and Institute of Biomedicine, Federal University of Ceara, Fortaleza, Brazil
| | - Carl J Mason
- Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | | | | | - Margaret Kosek
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA; Asociación Benéfica PRISMA, Iquitos, Peru
| | - Richard L Guerrant
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA, USA
| | - Michael Gottlieb
- Foundation for the National Institutes of Health, Bethesda, MD, USA
| | - Mark Miller
- Fogarty International Center, National Institutes of Health, Bethesda, MD, USA
| | | | - Eric R Houpt
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, VA, USA.
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Patil CL, Turab A, Ambikapathi R, Nesamvuni C, Chandyo RK, Bose A, Islam MM, Ahmed AMS, Olortegui MP, de Moraes ML, Caulfield LE. Early interruption of exclusive breastfeeding: results from the eight-country MAL-ED study. JOURNAL OF HEALTH, POPULATION, AND NUTRITION 2015; 34:10. [PMID: 26825923 PMCID: PMC5025973 DOI: 10.1186/s41043-015-0004-2] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/11/2013] [Accepted: 02/24/2015] [Indexed: 05/25/2023]
Abstract
We report the infant feeding experiences in the first month of life for 2,053 infants participating in "Malnutrition and Enteric Infections: Consequences for Child Health and Development" (MAL-ED). Eight sites (in Bangladesh, India, Nepal, Pakistan, Brazil, Peru, South Africa, Tanzania), each followed a cohort of children from birth (by day 17), collecting detailed information on infant feeding practices, diet and illness episodes. Mothers were queried twice weekly regarding health status, breastfeeding and the introduction (or no) of non-breast milk liquids and foods. Here, our goal is to describe the early infant feeding practices in the cohort and evaluate factors associated with termination of exclusive breastfeeding in the first month of life. With data from enrollment to a visit at 28-33 days of life, we characterized exclusive, predominant or partial breastfeeding (using a median of 6-9 visits per child across the sites). Only 6 of 2,053 infants were never breastfed. By one month, the prevalences of exclusive breastfeeding were < 60% in 6 of 8 sites, and of partial breastfeeding (or no) were > 20% in 6 of 8 sites. Logistic regression revealed that prelacteal feeding (given to 4-63% of infants) increased the likelihood of partial breastfeeding (Odds Ratio (OR): 1.48 (95% confidence interval (CI): 1.04, 2.10), as did the withholding of colostrum (2-16% of infants) (OR: 1.63:1.01, 2.62), and being a first-time mother (OR: 1.38:1.10, 1.75). Our results reveal diversity across these sites, but an overall trend of early transition away from exclusive breastfeeding in the first month of life. Interventions which introduce or reinforce the WHO/UNICEF Ten Steps for Successful Breastfeeding are needed in these sites to improve breastfeeding initiation, to reinforce exclusive breastfeeding and delay introduction of non-breast milk foods and/or liquids.
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Affiliation(s)
- Crystal L Patil
- Department of Women, Children and Family Health Science, College of Nursing, University of Illinois at Chicago, Chicago, IL, USA.
| | - Ali Turab
- Department of Pediatrics and Child Health, Aga Khan University, Karachi, Pakistan.
| | - Ramya Ambikapathi
- Fogarty International Center, National Institutes of Health, Bethesda, MD, USA.
| | - Cebisa Nesamvuni
- Department of Nutrition, School of Health Sciences, University of Venda, Thohoyandou, Limpopo Province, South Africa.
| | - Ram Krishna Chandyo
- Centre for International Health, University of Bergen, Norway and Department of Child Health and Institute of Medicine, Tribhuvan University, Kathmandu, Nepal.
| | | | - M Munirul Islam
- Centre for Nutrition and Food Security, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh.
| | | | | | - Milena Lima de Moraes
- The Johns Hopkins Bloomberg School of Public Health, Department of International Health, 615 North Wolfe Street, W2041, Baltimore, MD, USA, 21205.
| | - Laura E Caulfield
- The Johns Hopkins Bloomberg School of Public Health, Department of International Health, 615 North Wolfe Street, W2041, Baltimore, MD, USA, 21205.
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47
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Hoest C, Seidman JC, Pan W, Ambikapathi R, Kang G, Kosek M, Knobler S, Mason CJ, Miller M. Evaluating associations between vaccine response and malnutrition, gut function, and enteric infections in the MAL-ED cohort study: methods and challenges. Clin Infect Dis 2015; 59 Suppl 4:S273-9. [PMID: 25305297 DOI: 10.1093/cid/ciu611] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Most vaccine assessments have occurred in well-nourished populations of higher socioeconomic status. However, vaccines are often used in populations with high incidences of malnutrition and infections, in whom the effectiveness of some vaccines is inferior for unknown reasons. The degree and extent of vaccine underperformance have not been systematically studied for most vaccines across differing epidemiologic settings. This paper outlines the methods used and challenges associated with measuring immunological responses to oral vaccines against poliovirus and rotavirus, and parenteral vaccines against pertussis, tetanus, and measles in an observational study that monitored daily illness, monthly growth, intestinal inflammation and permeability, pathogen burden, dietary intake, and micronutrient status in children in 8 countries. This evaluation of vaccine response in the context of low- and middle-income countries is intended to address the gaps in knowledge of the heterogeneity in vaccine response in diverse epidemiological settings and the interplay between infections, nutrition, and immune response.
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Affiliation(s)
- Christel Hoest
- Division of International Epidemiology and Population Studies, Fogarty International Center, National Institutes of Health, Bethesda, Maryland
| | - Jessica C Seidman
- Division of International Epidemiology and Population Studies, Fogarty International Center, National Institutes of Health, Bethesda, Maryland
| | - William Pan
- Department of Environmental Science and Policy and the Duke Global Health Institute, Duke University, Durham, North Carolina
| | - Ramya Ambikapathi
- Division of International Epidemiology and Population Studies, Fogarty International Center, National Institutes of Health, Bethesda, Maryland
| | | | - Margaret Kosek
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Stacey Knobler
- Division of International Epidemiology and Population Studies, Fogarty International Center, National Institutes of Health, Bethesda, Maryland
| | - Carl J Mason
- Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | - Mark Miller
- Division of International Epidemiology and Population Studies, Fogarty International Center, National Institutes of Health, Bethesda, Maryland
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48
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Richard SA, Barrett LJ, Guerrant RL, Checkley W, Miller MA. Disease surveillance methods used in the 8-site MAL-ED cohort study. Clin Infect Dis 2015; 59 Suppl 4:S220-4. [PMID: 25305290 DOI: 10.1093/cid/ciu435] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Describing the early life associations between infectious disease episodes and growth, cognitive development, and vaccine response in the first 2 years of life is one of the primary goals of the Etiology, Risk Factors and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health and Development (MAL-ED) cohort study. To collect high-resolution data during a critical early period of development, field staff visit each study participant at their house twice weekly from birth to 2 years of age to collect daily reported illness and treatment data from caregivers. Detailed infectious disease histories will not only allow us to relate the overall burden of infectious disease with the primary outcomes of the study, but will also allow us to describe the ages at which infectious diseases have the greatest effect on child health. In addition, twice-weekly visits allow for sample collection when diarrhea episodes are identified. This article describes the methods used to collect illness and treatment history data and discusses the a priori definitions of diarrhea and acute lower respiratory illness episodes.
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Affiliation(s)
- Stephanie A Richard
- Fogarty International Center, National Institutes of Health, Bethesda, Maryland
| | - Leah J Barrett
- Center for Global Health, University of Virginia School of Medicine, Charlottesville
| | - Richard L Guerrant
- Center for Global Health, University of Virginia School of Medicine, Charlottesville
| | - William Checkley
- Fogarty International Center, National Institutes of Health, Bethesda, Maryland Program in Global Disease Epidemiology and Control, Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Mark A Miller
- Fogarty International Center, National Institutes of Health, Bethesda, Maryland
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49
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The MAL-ED study: a multinational and multidisciplinary approach to understand the relationship between enteric pathogens, malnutrition, gut physiology, physical growth, cognitive development, and immune responses in infants and children up to 2 years of age in resource-poor environments. Clin Infect Dis 2015; 59 Suppl 4:S193-206. [PMID: 25305287 DOI: 10.1093/cid/ciu653] [Citation(s) in RCA: 261] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Highly prevalent conditions with multiple and complex underlying etiologies are a challenge to public health. Undernutrition, for example, affects 20% of children in the developing world. The cause and consequence of poor nutrition are multifaceted. Undernutrition has been associated with half of all deaths worldwide in children aged <5 years; in addition, its pernicious long-term effects in early childhood have been associated with cognitive and physical growth deficits across multiple generations and have been thought to suppress immunity to further infections and to reduce the efficacy of childhood vaccines. The Etiology, Risk Factors, and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health (MAL-ED) Study, led by the Fogarty International Center of the National Institutes of Health and the Foundation for the National Institutes of Health, has been established at sites in 8 countries with historically high incidence of diarrheal disease and undernutrition. Central to the study is the hypothesis that enteropathogen infection contributes to undernutrition by causing intestinal inflammation and/or by altering intestinal barrier and absorptive function. It is further postulated that this leads to growth faltering and deficits in cognitive development. The effects of repeated enteric infection and undernutrition on the immune response to childhood vaccines is also being examined in the study. MAL-ED uses a prospective longitudinal design that offers a unique opportunity to directly address a complex system of exposures and health outcomes in the community-rather than the relatively rarer circumstances that lead to hospitalization-during the critical period of development of the first 2 years of life. Among the factors being evaluated are enteric infections (with or without diarrhea) and other illness indicators, micronutrient levels, diet, socioeconomic status, gut function, and the environment. MAL-ED aims to describe these factors, their interrelationships, and their overall impact on health outcomes in unprecedented detail, and to make individual, site-specific, and generalized recommendations regarding the nature and timing of possible interventions aimed at improving child health and development in these resource-poor settings.
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