1
|
Caballero MT, Grigaites SD, De la Iglesia Niveyro PX, Esperante S, Bianchi AM, Nuño A, Valle S, Afarian G, Ferretti AJP, Baglivo SJ, De Luca J, Zea CM, Caporal P, Labanca MJ, Diamanti A, Alvarez-Paggi D, Bassat Q, Polack FP. Uncovering Causes of Childhood Death Using the Minimally Invasive Autopsy at the Community Level in an Urban Vulnerable Setting of Argentina: A Population-Based Study. Clin Infect Dis 2021; 73:S435-S441. [PMID: 34910178 PMCID: PMC8672764 DOI: 10.1093/cid/ciab838] [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] [Indexed: 11/30/2022] Open
Abstract
Background Precise determination of the causal chain that leads to community deaths in children in low- and middle-income countries is critical to estimating all causes of mortality accurately and to planning preemptive strategies for targeted allocation of resources to reduce this scourge. Methods An active surveillance population-based study that combined minimally invasive tissue sampling (MITS) and verbal autopsies (VA) among children under 5 was conducted in Buenos Aires, Argentina, from September 2018 to December 2020 to define the burden of all causes of community deaths. Results Among 90 cases enrolled (86% of parental acceptance), 81 had complete MITS, 15.6% were neonates, 65.6% were post-neonatal infants, and 18.9% were children aged 1–5 years. Lung infections were the most common cause of death (CoD) in all age groups (57.8%). Among all cases of lung infections, acute bronchiolitis was the most common CoD in infants aged <12 months (23 of 36, 63.9%), and bacterial pneumonia was the most common cause in children aged >12 months (8 of 11, 72.7%). The most common comorbid condition in all age groups was undernutrition in 18 of 90 (20%). It was possible to find an immediate CoD in 78 of 81 subjects where MITS could be done. With this combined approach, we were able to determine that sudden infant death syndrome was overestimated in state reports. Conclusions CoD determination by a combination of MITS and VA provides an accurate estimation of the chain of events that leads to death, emphasizing possible interventions to prevent mortality in children.
Collapse
Affiliation(s)
- Mauricio T Caballero
- Fundacion INFANT, Buenos Aires, Argentina.,Consejo Nacional de Investigaciones Científicas y Técnicas, Buenos Aires, Argentina
| | - Sebastian Diaz Grigaites
- Morgue Judicial del Instituto de Ciencias Forenses Conurbano Sur, Ministerio Público de la Provincia de Buenos Aires, Lomas de Zamora, Argentina
| | | | - Sebastian Esperante
- Fundacion INFANT, Buenos Aires, Argentina.,Consejo Nacional de Investigaciones Científicas y Técnicas, Buenos Aires, Argentina
| | | | | | | | - Gabriela Afarian
- Morgue Judicial del Instituto de Ciencias Forenses Conurbano Sur, Ministerio Público de la Provincia de Buenos Aires, Lomas de Zamora, Argentina
| | | | | | | | | | - Paula Caporal
- Hospital De Niños Sup. Sor Maria Ludovica, La Plata, Argentina
| | - Maria Jose Labanca
- Hospital Italiano de Buenos Aires, Servicio de Anatomía Patológica, Buenos Aires, Argentina
| | - Adriana Diamanti
- Morgue Judicial del Instituto de Ciencias Forenses Conurbano Sur, Ministerio Público de la Provincia de Buenos Aires, Lomas de Zamora, Argentina
| | - Damian Alvarez-Paggi
- Fundacion INFANT, Buenos Aires, Argentina.,Consejo Nacional de Investigaciones Científicas y Técnicas, Buenos Aires, Argentina
| | - Quique Bassat
- ISGlobal, Hospital Clínic-Universitat de Barcelona, Barcelona, Spain.,Centro de Investigação em Saúde de Manhiça, CP Maputo, Mozambique.,Institución Catalana de Investigación y Estudios Avanzados (ICREA), Pg. Lluís Companys, Barcelona, Spain.,Pediatric Infectious Diseases Unit, Pediatrics Department, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain.,Consorcio de Investigación Biomédica en Red de Epidemiología y Salud Pública, Madrid, Spain
| | | | | |
Collapse
|
2
|
Kufa T, Jassat W, Cohen C, Tempia S, Masha M, Wolter N, Walaza S, von Gottburg A, Govender NP, Hunt G, Shonhiwa AM, Ebonwu J, Ntshoe G, Maruma W, Bapela P, Ndhlovu N, Mathema H, Modise M, Shuping L, Manana PN, Moore D, Dangor Z, Verwey C, Madhi SA, Saloojee H, Zar HJ, Blumberg L. Epidemiology of SARS-CoV-2 infection and SARS-CoV-2 positive hospital admissions among children in South Africa. Influenza Other Respir Viruses 2021; 16:34-47. [PMID: 34796674 PMCID: PMC9664941 DOI: 10.1111/irv.12916] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 09/15/2021] [Indexed: 12/15/2022] Open
Abstract
Introduction We describe epidemiology and outcomes of confirmed SARS‐CoV‐2 infection and positive admissions among children <18 years in South Africa, an upper‐middle income setting with high inequality. Methods Laboratory and hospital COVID‐19 surveillance data, 28 January ‐ 19 September 2020 was used. Testing rates were calculated as number of tested for SARS‐CoV‐2 divided by population at risk; test positivity rates were calculated as positive tests divided by total number of tests. In‐hospital case fatality ratio (CFR) was calculated based on hospitalized positive admissions with outcome data who died in‐hospital and whose death was judged SARS‐CoV‐2 related by attending physician. Findings 315 570 children aged <18 years were tested for SARS‐CoV‐2; representing 8.9% of all 3 548 738 tests and 1.6% of all children in the country. Of children tested, 46 137 (14.6%) were positive. Children made up 2.9% (n = 2007) of all SARS‐CoV‐2 positive admissions to sentinel hospitals. Among children, 47 died (2.6% case‐fatality). In‐hospital deaths were associated with male sex [adjusted odds ratio (aOR) 2.18 (95% confidence intervals [CI] 1.08–4.40)] vs female; age <1 year [aOR 4.11 (95% CI 1.08–15.54)], age 10–14 years [aOR 4.20 (95% CI1.07–16.44)], age 15–17 years [aOR 4.86 (95% 1.28–18.51)] vs age 1–4 years; admission to a public hospital [aOR 5.07(95% 2.01–12.76)] vs private hospital and ≥1 underlying conditions [aOR 12.09 (95% CI 4.19–34.89)] vs none. Conclusions Children with underlying conditions were at greater risk of severe SARS‐CoV‐2 outcomes. Children > 10 years, those in certain provinces and those with underlying conditions should be considered for increased testing and vaccination.
Collapse
Affiliation(s)
- Tendesayi Kufa
- National Institute for Communicable DiseasesNational Health Laboratory ServicesJohannesburgSouth Africa
- School of Public HealthUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Waasila Jassat
- National Institute for Communicable DiseasesNational Health Laboratory ServicesJohannesburgSouth Africa
| | - Cheryl Cohen
- National Institute for Communicable DiseasesNational Health Laboratory ServicesJohannesburgSouth Africa
- School of Public HealthUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Stefano Tempia
- School of Public HealthUniversity of the WitwatersrandJohannesburgSouth Africa
- Influenza Division, National Center for Immunization and Respiratory DiseasesUS Centers for Disease Control and PreventionAtlantaGeorgiaUSA
- MassGenicsDuluthGeorgiaUSA
| | - Maureen Masha
- National Institute for Communicable DiseasesNational Health Laboratory ServicesJohannesburgSouth Africa
| | - Nicole Wolter
- National Institute for Communicable DiseasesNational Health Laboratory ServicesJohannesburgSouth Africa
- School of PathologyUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Sibongile Walaza
- National Institute for Communicable DiseasesNational Health Laboratory ServicesJohannesburgSouth Africa
| | - Anne von Gottburg
- National Institute for Communicable DiseasesNational Health Laboratory ServicesJohannesburgSouth Africa
- School of PathologyUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Nelesh P. Govender
- National Institute for Communicable DiseasesNational Health Laboratory ServicesJohannesburgSouth Africa
- School of PathologyUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Gillian Hunt
- National Institute for Communicable DiseasesNational Health Laboratory ServicesJohannesburgSouth Africa
- School of PathologyUniversity of the WitwatersrandJohannesburgSouth Africa
| | | | - Joy Ebonwu
- National Institute for Communicable DiseasesNational Health Laboratory ServicesJohannesburgSouth Africa
| | - Genevie Ntshoe
- National Institute for Communicable DiseasesNational Health Laboratory ServicesJohannesburgSouth Africa
- School of Health Systems and Public Health, Faculty of Health SciencesUniversity of PretoriaPretoriaSouth Africa
| | - Wellington Maruma
- National Institute for Communicable DiseasesNational Health Laboratory ServicesJohannesburgSouth Africa
| | - Poncho Bapela
- National Institute for Communicable DiseasesNational Health Laboratory ServicesJohannesburgSouth Africa
| | - Nomathamsanqa Ndhlovu
- National Institute for Communicable DiseasesNational Health Laboratory ServicesJohannesburgSouth Africa
| | - Hlengani Mathema
- National Institute for Communicable DiseasesNational Health Laboratory ServicesJohannesburgSouth Africa
| | - Motshabi Modise
- National Institute for Communicable DiseasesNational Health Laboratory ServicesJohannesburgSouth Africa
| | - Liliwe Shuping
- National Institute for Communicable DiseasesNational Health Laboratory ServicesJohannesburgSouth Africa
| | - Pinky N. Manana
- National Institute for Communicable DiseasesNational Health Laboratory ServicesJohannesburgSouth Africa
- School of PathologyUniversity of the WitwatersrandJohannesburgSouth Africa
| | - David Moore
- Department of Pediatrics and Child HealthUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Ziyaad Dangor
- Department of Pediatrics and Child HealthUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Charl Verwey
- Department of Pediatrics and Child HealthUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Shabir A. Madhi
- South African Medical Research Council: Vaccines and Infectious Diseases Analytical Research Unit (VIDA), Faculty of Health Science JohannesburgUniversity of the WitwatersrandJohannesburgSouth Africa
- Department of Science/National Research Foundation: Vaccine Preventable Diseases, Faculty of Health Science JohannesburgUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Haroon Saloojee
- Department of Pediatrics and Child HealthUniversity of the WitwatersrandJohannesburgSouth Africa
| | - Heather J. Zar
- Dept of Paediatrics and Child Health, Red Cross Children's Hospital, and SA‐MRC Unit on Child and Adolescent HealthUniversity of Cape TownCape TownSouth Africa
| | - Lucille Blumberg
- National Institute for Communicable DiseasesNational Health Laboratory ServicesJohannesburgSouth Africa
| |
Collapse
|
3
|
Herbst K, Juvekar S, Jasseh M, Berhane Y, Chuc NTK, Seeley J, Sankoh O, Clark SJ, Collinson MA. Health and demographic surveillance systems in low- and middle-income countries: history, state of the art and future prospects. Glob Health Action 2021; 14:1974676. [PMID: 35377288 PMCID: PMC8986235 DOI: 10.1080/16549716.2021.1974676] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 08/25/2021] [Indexed: 11/09/2022] Open
Abstract
Health and Demographic Surveillance Systems (HDSS) have been developed in several low- and middle-income countries (LMICs) in Africa and Asia. This paper reviews their history, state of the art and future potential and highlights substantial areas of contribution by the late Professor Peter Byass.Historically, HDSS appeared in the second half of the twentieth century, responding to a dearth of accurate population data in poorly resourced settings to contextualise the study of interventions to improve health and well-being. The progress of the development of this network is described starting with Pholela, and progressing through Gwembe, Balabgarh, Niakhar, Matlab, Navrongo, Agincourt, Farafenni, and Butajira, and the emergence of the INDEPTH Network in the early 1990'sThe paper describes the HDSS methodology, data, strengths, and limitations. The strengths are particularly their temporal coverage, detail, dense linkage, and the fact that they exist in chronically under-documented populations in LMICs where HDSS sites operate. The main limitations are generalisability to a national population and a potential Hawthorne effect, whereby the project itself may have changed characteristics of the population.The future will include advances in HDSS data harmonisation, accessibility, and protection. Key applications of the data are to validate and assess bias in other datasets. A strong collaboration between a national HDSS network and the national statistics office is modelled in South Africa and Sierra Leone, and it is possible that other low- to middle-income countries will see the benefit and take this approach.
Collapse
Affiliation(s)
- Kobus Herbst
- DSI-MRC South African Population Infrastructure Network, Durban, South Africa
- Population Science, Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa
| | - Sanjay Juvekar
- KEM Hospital Research Centre, Vadu Rural Health Program, Pune, India
| | - Momodou Jasseh
- Medical Research Council Unit, The Gambia at London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | - Yemane Berhane
- Addis Continental Institute of Public Health, Addis Ababa, Ethiopia
| | | | - Janet Seeley
- Population Science, Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Osman Sankoh
- Statistics Sierra Leone, Tower Hill, Freetown, Sierra Leone
- Njala University, University Secretariat, Njala, Sierra Leone
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Heidelberg Institute of Global Health, University of Heidelberg Medical School, Heidelberg, Germany
| | - Samuel J. Clark
- Department of Sociology, The Ohio State University, Columbus, Ohio, USA
| | - Mark A. Collinson
- DSI-MRC South African Population Infrastructure Network, Durban, South Africa
- SAMRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, South Africa
| |
Collapse
|
4
|
Price J, Willcox M, Dlamini V, Khosa A, Khanyile P, Seeley J, Harnden A, Kahn K, Hinton L. Care-seeking during fatal childhood illness in rural South Africa: a qualitative study. BMJ Open 2021; 11:e043652. [PMID: 33926978 PMCID: PMC8094335 DOI: 10.1136/bmjopen-2020-043652] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES This study aimed to better understand reasons why children in South Africa die at home, including caregivers' care-seeking experiences, decision-making, choice of treatment provider and barriers to accessing care during a child's final illness. DESIGN This qualitative study included semi-structured in-depth interviews and focus group discussions with caregivers of children who died below the age of 5 years. Data were thematically analysed, and key findings compared with the Pathways to Survival Framework-a model frequently used in the study of child mortality. An adapted model was developed. SETTING Two rural health and demographic surveillance system (HDSS) sites in South Africa-the Agincourt HDSS and the Africa Health Research Institute. PARTICIPANTS Thirty-eight caregivers of deceased children (29 participated in in-depth interviews and 9 were participants in two focus group discussions). Caregivers were purposively sampled to ensure maximum variation across place of death, child age at death, household socioeconomic status, maternal migration status and maternal HIV status. FINDINGS Although caregivers faced barriers in providing care to children (including insufficient knowledge and poor transport), almost all did seek care from the formal health system. Negative experiences in health facilities did not deter care-seeking, but most respondents still received poor quality care and were not given adequate safety-netting advice. Traditional healers were only consulted as a last resort when other approaches had failed. CONCLUSION Barriers to accessing healthcare disrupt the workings of previously accepted care-seeking models. The adapted model presented in this paper more realistically reflects care-seeking experiences and decision-making during severe childhood illness in rural South Africa and helps explain both the persistence of home deaths despite seeking healthcare, and the impact of a child's death on care-seeking in future childhood illness. This model can be used as the basis for developing interventions to reduce under-5 mortality.
Collapse
Affiliation(s)
- Jessica Price
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand Faculty of Health Sciences, Johannesburg, South Africa
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Merlin Willcox
- Primary Care Research Centre, University of Southampton, Southampton, UK
| | | | - Audrey Khosa
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand Faculty of Health Sciences, Johannesburg, South Africa
| | | | - Janet Seeley
- Africa Health Research Institute, Somkhele, South Africa
- Department of Global Health & Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Anthony Harnden
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Kathleen Kahn
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand Faculty of Health Sciences, Johannesburg, South Africa
| | - Lisa Hinton
- THIS Institute, University of Cambridge, Cambridge, UK
| |
Collapse
|
5
|
Berrueta M, Ciapponi A, Bardach A, Cairoli FR, Castellano FJ, Xiong X, Stergachis A, Zaraa S, Meulen AST, Buekens P. Maternal and neonatal data collection systems in low- and middle-income countries for maternal vaccines active safety surveillance systems: A scoping review. BMC Pregnancy Childbirth 2021; 21:217. [PMID: 33731029 PMCID: PMC7968860 DOI: 10.1186/s12884-021-03686-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 03/01/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Most post-licensure vaccine pharmacovigilance in low- and middle-income countries (LMICs) are passive reporting systems. These have limited utility for maternal immunization pharmacovigilance in LMIC settings and need to be supplemented with active surveillance. Our study's main objective was to identify existing perinatal data collection systems in LMICs that collect individual information on maternal and neonatal health outcomes and could be developed to inform active safety surveillance of novel vaccines for use during pregnancy. METHODS A scoping review was performed following the Arksey and O'Malley six-stage approach. We included studies describing electronic or mixed paper-electronic data collection systems in LMICs, including research networks, electronic medical records, and custom software platforms for health information systems. Medline PubMed, EMBASE, Global Health, Cochrane Library, LILACS, Bibliography of Asian Studies (BAS), and CINAHL were searched through August 2019. We also searched grey literature including through Google and websites of existing relevant perinatal data collection systems, as well as contacted authors of key studies and experts in the field to validate the information and identify additional sources of relevant unpublished information. RESULTS A total of 11,817 records were identified. The full texts of 264 records describing 96 data collection systems were assessed for eligibility. Eight perinatal data collection systems met our inclusion criteria: Global Network's Maternal Newborn Health Registry, International Network for the Demographic Evaluation of Populations and their Health; Perinatal Informatic System; Pregnancy Exposure Registry & Birth Defects Surveillance; SmartCare; Open Medical Record System; Open Smart Register Platform and District Health Information Software 2. These selected systems were qualitatively characterized according to seven different domains: governance; system design; system management; data management; data sources, outcomes and data quality. CONCLUSION This review provides a list of active maternal and neonatal data collection systems in LMICs and their characteristics as well as their outreach, strengths, and limitations. Findings could potentially help further understand where to obtain population-based high-quality information on outcomes to inform the conduct of maternal immunization active vaccine safety surveillance activities and research in LMICs.
Collapse
Affiliation(s)
- Mabel Berrueta
- Instituto de Efectividad Clínica y Sanitaria (IECS), Dr. Emilio Ravignani 2024 (C1014CPV), Buenos Aires, Argentina.
| | - Agustin Ciapponi
- Instituto de Efectividad Clínica y Sanitaria (IECS), Dr. Emilio Ravignani 2024 (C1014CPV), Buenos Aires, Argentina
| | - Ariel Bardach
- Instituto de Efectividad Clínica y Sanitaria (IECS), Dr. Emilio Ravignani 2024 (C1014CPV), Buenos Aires, Argentina
| | - Federico Rodriguez Cairoli
- Instituto de Efectividad Clínica y Sanitaria (IECS), Dr. Emilio Ravignani 2024 (C1014CPV), Buenos Aires, Argentina
| | - Fabricio J Castellano
- Instituto de Efectividad Clínica y Sanitaria (IECS), Dr. Emilio Ravignani 2024 (C1014CPV), Buenos Aires, Argentina
| | - Xu Xiong
- Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, 70112, USA
| | | | - Sabra Zaraa
- University of Washington, Seattle, WA, 98195-7631, USA
| | | | - Pierre Buekens
- Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, 70112, USA
| | | |
Collapse
|
6
|
Price J, Willcox M, Kabudula CW, Herbst K, Hinton L, Kahn K, Harnden A. Care pathways during a child's final illness in rural South Africa: Findings from a social autopsy study. PLoS One 2019; 14:e0224284. [PMID: 31639177 PMCID: PMC6804973 DOI: 10.1371/journal.pone.0224284] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 10/09/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Half of under-5 deaths in South Africa occur at home, however the reasons remain poorly described and data on the care pathways during fatal childhood illness is limited. This study aimed to better describe care-seeking behavior in fatal childhood illness and to assess barriers to healthcare and modifiable factors that contribute to under-5 deaths in rural South Africa. METHODS We conducted a social autopsy study on all under-5 deaths in two rural South African health and demographic surveillance system sites. Descriptive analyses based on the Pathways to Survival Framework were used to characterise how caregivers move through the stages of seeking and providing care for children during their final illness and to identify modifiable factors that contributed to death. FINDINGS Of 53 deaths, 40% occurred outside health facilities. Rates of antenatal and perinatal preventative care-seeking were high: over 70% of mothers had tested for HIV, 93% received professional assistance during delivery and 79% of children were reportedly immunised appropriately for age. Of the 48 deaths tracked through the stages of the Pathways to Survival Framework, 10% died suddenly without any care, 23% received home care of whom 80% had signs of severe or possibly severe illness, and 85% sought or attempted to seek formal care outside the home. Although half of all children left the first facility alive, only 27% were referred for further care. CONCLUSIONS Modifiable factors for preventing deaths during a child's final illness occur both inside and outside the home. The most important modifiable factors occurring inside the home relate to caregivers' recognition of illness and appreciation of urgency in response to the severity of the child's symptoms and signs. Outside the home, modifiable factors relate to inadequate referral and follow-up by health professionals. Further research should focus on identifying and overcoming barriers to referral.
Collapse
Affiliation(s)
- Jessica Price
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, England, United Kingdom
| | - Merlin Willcox
- Department of Primary Care and Population Sciences, University of Southampton, Southampton, England, United Kingdom
| | - Chodziwadziwa Whiteson Kabudula
- MRC-Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Kobus Herbst
- Africa Health Research Institute, KwaZulu-Natal, South Africa
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Lisa Hinton
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, England, United Kingdom
| | - Kathleen Kahn
- MRC-Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Anthony Harnden
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, England, United Kingdom
| |
Collapse
|