Ending preventable child deaths from pneumonia and diarrhoea by 2025. Development of the integrated Global Action Plan for the Prevention and Control of Pneumonia and Diarrhoea

Nutritional supplementation in children with severe pneumonia in Uganda and Kenya (COAST-Nutrition): a phase 2 randomised controlled trial

Background

Severe pneumonia in African children results in poor long-term outcomes (deaths/readmissions) with undernutrition as a key risk factor. We hypothesised additional energy/protein-rich Ready-to-Use Therapeutic Foods (RUTF) would meet additional nutritional requirements and improve outcomes.

Methods

COAST-Nutrition was an open-label Phase 2 randomised controlled trial in children (aged 6 months-12 years) hospitalised with severe pneumonia (and hypoxaemia, SpO2 <92%) in Mbale, Soroti, Jinja, Masaka Regional Referral Hospitals, Uganda and Kilifi County Hospital, Kenya (ISRCTN10829073 (registered 6th June 2018) PACTR202106635355751 (registered 2nd June 2021)). Children were randomised (ratio 1:1) to enhanced nutritional supplementation with RUTF (plus usual diet) for 56 days vs usual diet (control). The primary outcome was change in mid-upper arm circumference (MUAC) at 90 days as a composite with mortality. Secondary outcomes include anthropometric status, mortality, and readmissions at Days 28, 90 and 180.

Findings

Between 12 August 2018 and 22 April 2022, 846 eligible children were randomised, 424 to RUTF and 422 to usual diet, and followed for 180-days [12 (1%) lost-to-follow-up]. RUTF supplement was initiated in 417/419 (>99%). By Day 90, there was no significant difference in the composite endpoint (probabilistic index 0.49, 95% CI 0.45-0.53, p = 0.74). Respective 90-day mortality (13/420 3.1% vs 14/421 3.3%) and MUAC increment (0.54 (SD 0.85) vs 0.55 (SD 0.81)) were similar between arms. There was no difference in any anthropometric secondary endpoints to Day 28, 90 or 180 except skinfold thickness at Day 28 and Day 90 was greater in the RUTF arm. Serious adverse events were higher in the RUTF arm (n = 164 vs 108), mainly due to hospital readmission for acute illness (54/387 (14%) vs 37/375 (10%).

Interpretation

Our study suggested that nutritional supplementation with RUTF did not improve outcomes to 180 days in children with severe pneumonia.

Funding

This trial is part of the EDCTP2 programme (grant number RIA-2016S-1636-COAST-Nutrition) supported by the European Union, and UK Joint Global Health Trials scheme: Medical Research Council, Department for International Development, Wellcome Trust (grant number MR/L004364/1, UK).

Assessing safety and efficacy of a novel glucose-free amino acid oral rehydration solution for watery diarrhea management in children: a randomized, controlled, phase III trial

Background

Diarrhoeal disease poses a significant global health challenge, especially in children under three years old. Despite the effectiveness of oral rehydration therapy (ORT), its adoption remains low. Glucose-based ORS (GORS) is the standard, but novel formulations like glucose-free amino acid-based VS002A have emerged as potential alternatives. This study aimed to compare the safety and efficacy of VS002A against the standard WHO-ORS in treating non-cholera acute watery diarrhoea in children.

Methods

A triple-blind, randomized trial enrolled 310 male infants and children aged 6-36 months, who were assigned to receive WHO-ORS or VS002A over a 16-month period, from June 2021 to September 2022. Both groups received standard of care, including zinc supplementation. The Primary study outcome measured was the duration of diarrhoea. Secondary outcomes included stool output, treatment failure and adverse events. Exploratory endpoints included urinary output, body weight changes, blood biochemistry, stool microbiology and gut health biomarkers.

Findings

Both VS002A and WHO-ORS were well-tolerated with a low adverse event rate. While not different statistically (p = 0.10), duration of diarrhoea was shorter in children treated with VS002A vs. WHO-ORS (65.4 h vs. 72.6 h). Similarly, stool output was also lower vs. WHO-ORS in children treated with VS002A, though not statistically different (p = 0.40). Serum citrulline levels, an indicator of gut health, were higher in the VS002A group at 24 h suggesting a potential protective effect (p = 0.06).

Interpretation

The findings of this study support the non-inferiority of VS002A, a glucose-free amino acid-based ORS compared to the WHO-ORS standard of care. VS002A was shown to be safe and effective in treating non-cholera acute watery diarrhoea in young children. VS002A may offer advantages in pathogen-driven diarrhoea, supported by trends toward a lower duration of diarrhoea and stool output within the per protocol group. Furthermore, individuals with prolonged diarrhoea, severe malnutrition, environmental enteric dysfunction or have issues with obesity or insulin resistance, could benefit from a glucose-free ORS. This research contributes to addressing the persistent challenge of childhood diarrhoea by presenting an alternative glucose-free ORS formulation with potential advantages in select scenarios, offering a promising avenue for improving paediatric diarrhoea management worldwide.

Funding

The study was funded by Entrinsic Bioscience, LLC., Norwood, MA, USA.

Multilevel analysis of early initiation of breastfeeding in Ethiopia

Introduction

Breast milk is the ideal food for the infant and is associated with various public health benefits for both the infant and the mother. The recommended time for early initiation of breastfeeding is within one hour after birth. The prevalence of early initiation of breastfeeding was lower than the plan of the Ethiopian Ministry of Health Sector Development program. Thus, the main objective of this study was to identify individual and group-level factors associated with the early initiation of breastfeeding in Ethiopia.

Methods

Secondary data on children was obtained from the 2019 Ethiopia mini-demographic and health survey. The survey was a population-based cross-sectional study and was downloaded from the Measure Demographic and Health Survey website (http://www.measuredhs.com). The study included a random sample of 2,125 last-born infants who were born within 24 months before the survey. A multilevel binary logistic regression analysis was employed to identify the factors associated with the early initiation of breastfeeding in Ethiopia. Statistical data was analyzed using the Statistical Analysis System (SAS 9.4).

Results

The prevalence of early breastfeeding initiation was 72%. The higher preceding birth interval (AOR = 1.18, 95% CI: 1.1076, 1.5451), the higher gestational age of infants (AOR = 1.38, 95% CI: 1.2796, 1.4782), the higher number of antenatal care visits (AOR = 1.26, 95% CI: 1.2340, 1.2934), delivery at a health facility (AOR = 1.60, 95% CI: 1.4585, 1.7515), vaginal delivery (AOR = 1.11, 95% CI: 1.1019, 1.1123), mothers with primary education (AOR = 1.14, 95% CI: 1.0204, 1.2738), mothers with secondary education (AOR = 1.54, 95% CI: 1.4678, 1.6190), and mothers with higher education (AOR = 2.62, 95% CI: 2.2574, 3.0526) were associated with higher odds of early initiation of breastfeeding. Being a rural dweller (AOR = 0.63, 95% CI: 0.5684, 0.7038) and the age of mothers (AOR = 0.44, 95% CI: 0.3921, 0.4894) were associated with lower odds of early initiation of breastfeeding.

Conclusion

Since the prevalence of early initiation of breastfeeding was minimal among rural mothers who delivered their child by caesarean section, this study strongly suggests special supportive care for these mothers.

Contextual factors associated with diarrhea among under-five children in the Gambia: a multi-level analysis of population-based data

BACKGROUND

Diarrhea poses a significant threat to the lives of children in The Gambia, accounting for approximately 9% of all deaths among children under the age of five. Addressing and reducing child mortality from diarrhea diseases is crucial for achieving the Sustainable Development Goal (SDG) 3, specifically target 3.2, which aims to eliminate preventable deaths in newborns and children under the age of five by 2030. Thus, this research aims to assess the prevalence and contextual factors associated with diarrhea among under-five children in The Gambia.

METHODS

This research employed secondary data from the 2019/20 Gambia Demographic Health Survey (GDHS). The study initially involved 8,362 women aged between 15 and 49 years. Of these, 6,929 women with children under five were included in this analysis. Data were analyzed using STATA with cross-tabulation and model fitting. Multilevel logistic regression was applied to accommodate the hierarchical structure of the demographic health survey data. The model comparison parameters were BIC, AIC, deviance, and LLR. Variables with a p-value less than 0.05 were selected for multivariable analysis. The statistical significance of the factors was determined using an adjusted odds ratio with a 95% confidence interval (CI) and a p-value of less than 0.05.

RESULTS

The prevalence of diarrhea in under-five children was 53.2% in males and 46.8% in females. In the final model, Kerewan (aOR = 0.58; 95% CI = 0.33-0.98) and Basse (aOR = 0.59; 95% CI = 0.35-0.98) have significantly lower odds of childhood diarrhea compared to Banjul, female children show slightly lower, yet significant, odds of diarrhea compared to males (aOR = 0.96; 95% CI = 0.86-0.98), deliveries at government health centers are associated with higher odds of childhood diarrhea compared to home births (aOR = 1.24; 95% CI = 1.01-1.52). Mothers with post-secondary education had significantly lower odds of having children with diarrhea than those without any education (aOR = 0.50; 95% CI = 0.26-0.99) after controlling for confounders.

CONCLUSION

The study findings indicate that several factors significantly impact the risk of childhood diarrhea in The Gambia. These factors include region of residence, sex of the child, place of delivery, and education level of the mother. The study suggests that existing interventions aimed at improving child health outcomes in the country should take into consideration these influential factors. Addressing these modifiable factors can enhance the effectiveness of interventions and promote better health outcomes for children in Gambia.

Effect of housing construction material on childhood acute respiratory infection: a hospital based case control study in Bangladesh

Despite several studies conducted to investigate housing factors, the effects of housing construction materials on childhood ARI symptoms in Bangladesh remain unclear. Hence, the study aimed to measure such a correlation among children under the age of five. A hospital-based case-control study was conducted, involving 221 cases and 221 controls from January to April 2023. Bivariate and multivariate binary logistic regression was performed to measure the degree of correlation between housing construction materials and childhood ARI symptoms. Households composed of natural floor materials had 2.7 times (95% confidence interval 1.27-5.57) and households composed of natural roof materials had 1.8 times (95% confidence interval 1.01-3.11) higher adjusted odds of having under-five children with ARI symptoms than household composed of the finished floor and finished roof materials respectively. Households with natural wall type were found protective against ARI symptoms with adjusted indoor air pollution determinants. The study indicates that poor housing construction materials are associated with an increased risk of developing ARI symptoms among under-five children in Bangladesh. National policy regarding replacing poor housing materials with concrete, increasing livelihood opportunities, and behavioral strategies programs encouraging to choice of quality housing construction materials could eliminate a fraction of the ARI burden.

Mortality among non-severely under nourished children with pneumonia globally: protocol for a systematic review and meta-analysis

Background

Pneumonia remains the commonest cause of ill health and mortality among children worldwide. Severe undernutrition increases the mortality risk among children with pneumonia. While children with pneumonia are at increased risk of developing malnutrition, the impact of pneumonia on mortality and nutritional status of non-severely undernourished children is not well described. The impact of nutritional supplementation on mortality and nutritional status in this population is not well understood. This review will collate available evidence on the all-cause mortality and anthropometric indices outcomes following pneumonia, as well as the impact of nutritional supplementation on mortality and anthropometry among non-severely malnourished children with pneumonia.

Methods

The review will be done using a priori criteria developed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. Data will be obtained from data bases, grey literature, and bibliographies. An experienced librarian will conduct article search in PUBMED, MEDLINE, EMBASE, Web of Science, Google scholar, and Scopus. Retrieved articles will be entered in Endnote ver 9.0, duplicates removed, and transferred to Epi-reviewer for screening and data abstraction. Risk of bias in the included articles will be assessed using standard criteria. Heterogeneity will be assessed using I 2-statistic and sub-group analysis will be done. Data will be analysed using both narrative and quantitative synthesis. Quantitative synthesis will be done using DeSimonian and Laird Random-effects model in STATA ver 15.0.

Conclusions

The results will provide baseline information about the mortality and anthropometric outcomes of pneumonia among non-severely malnourished children as well as the potential effect of nutritional supplementation on these outcomes. This will provide a basis to explore the potential for nutritional supplementation improving clinical outcomes like mortality and occurrence of severe acute malnutrition among children with severe pneumonia worldwide.

Registration

The review has been registered in PROSPERO (CRD42021257272; 15 July 2021).

Effective coverage of curative child health services in Ethiopia: analysis of the Demographic and Health Survey and Service Provision Assessment survey

OBJECTIVES

Despite a remarkable decline, childhood morbidity and mortality in Ethiopia remain high and inequitable. Thus, we estimated the effective coverage of curative child health services in Ethiopia.

DESIGN

We conducted a cross-sectional analysis of data from the 2016 Ethiopia Demographic and Health Survey (DHS) and the 2014 Ethiopia Service Provision Assessment Plus (SPA+) survey.

SETTING

Nationally representative household and facility surveys.

PARTICIPANTS AND OUTCOMES

We included a sample of 2096 children under 5 years old (from DHS) who had symptoms of one or more common childhood illnesses (diarrhoea, fever and acute respiratory infection) and estimated the percentage of sick children who were taken to a health facility (crude coverage). To construct a quality index of child health services, we used the SPA+ survey, which was conducted in 1076 health facilities and included observations of care for 1980 sick children and surveys of 1908 mothers/caregivers and 5328 health providers. We applied the Donabedian quality of care framework to identify 58 quality parameters (structure, 31; process, 16; and outcome, 11) and used the weighted additive method to estimate the overall quality of care index. Finally, we multiplied the crude coverage by the quality of care index to estimate the effective coverage of curative child health services, nationally and by region.

RESULTS

Among the 2096 sick children, only 38.4% (95% CI: 36.5 to 40.4) of them were taken to a health facility. The overall quality of care was 54.4%, weighted from structure (30.0%), process (9.2%) and outcome (15.2%). The effective coverage of curative child health services was estimated at 20.9% (95%CI: 19.9 to 22.0) nationally, ranging from 16.9% in Somali to 34.6% in Dire Dawa regions.

CONCLUSIONS

System-wide interventions are required to address both demand-side and supply-side bottlenecks in the provision of child health services if child health-related targets are to be achieved in Ethiopia.

Rotavirus and adenovirus infections in children with acute gastroenteritis after introducing the Rotasiil® vaccine in Kisangani, Democratic Republic of the Congo

BACKGROUND

Although rotavirus vaccination has reduced the global burden of the virus, morbidity and mortality from rotavirus infection remain high in Sub-Saharan Africa. This study aimed to determine the prevalence of rotavirus and adenovirus infections in children under five years with acute gastroenteritis and to identify factors associated with rotavirus infection after the introduction of the Rotasiil® vaccine in 2019 in Kisangani, Democratic Republic of the Congo (DRC).

METHODS

This study consisted of a cross-sectional hospital-based survey conducted from May 2022 to April 2023 in four health facilities in Kisangani, using a fecal-based test (rapid antigenic immuno-chromatographic diagnostic test, BYOSYNEX adenovirus/rotavirus BSS, Biosynex SA, Illkirch-Graffenstaden, France) of rotavirus and adenovirus infections among children under five years of age with acute gastroenteritis.

RESULTS

A total of 320 children under five years of age with acute gastroenteritis were included. The prevalence of rotavirus infection was 34.4%, that of adenovirus was 6.3%, and that of both rotavirus and adenovirus coinfection was 1.3%. The prevalence of rotavirus was significantly higher in unvaccinated children than in vaccinated children (55.4% versus 23.1%; P < 0.001). This difference was observed only in children who received all three vaccine doses. Multivariate logistic regression analysis shows that the rate of rotavirus infection was significantly reduced in vaccinated children (adjusted OR: 0.31 [95% confidence intervals (CI): 0.19-0.56]; P < 0.001) and those whose mothers had an average (adjusted OR: 0.51 [95% CI: 0.25-0.91]; P = 0.018) or high level (adjusted OR: 0.34 [95% CI: 0.20-0.64]; P < 0.001) of knowledge about the rotavirus vaccine.

CONCLUSIONS

The prevalence of rotavirus infection remains high in Kisangani despite vaccination. However, the prevalence of adenovirus infections was low in our series. Complete vaccination with three doses and mothers' average and high level of knowledge about the rotavirus vaccine significantly reduces the rate of rotavirus infection. It is, therefore, essential to strengthen the mothers' health education, continue with the Rotasiil® vaccine, and ensure epidemiological surveillance of rotavirus infection.

Trends of Incidence, Mortality, and Risk Factors for Lower Respiratory Infections among Children under 5 Years in China from 2000 to 2019

BACKGROUND

Understanding the temporal trends in the burden of lower respiratory tract infections (LRI) and their attributable risk factors in children under 5 years is important for effective prevention strategies.

METHODS

We used incidence, mortality, and attributable risk factors of LRI among children under 5 years from the Global Burden of Diseases database to analyze health patterns in 33 provincial administrative units in China from 2000 to 2019. Trends were examined using the annual average percentage change (AAPC) by the joinpoint regression method.

RESULTS

The rates of incidence and mortality for under-5 LRI in China were 18.1 and 4134.3 per 100,000 children in 2019, with an AAPC decrease of 4.1% and 11.0% from 2000, respectively. In recent years, the under-5 LRI incidence rate has decreased significantly in 11 provinces (Guangdong, Guangxi, Guizhou, Hainan, Heilongjiang, Jiangxi, Qinghai, Sichuan, Xinjiang, Xizang, and Zhejiang) and remained stable in the other 22 provinces. The case fatality ratio was associated with the Human Development Index and the Health Resource Density Index. The largest decline in risk factors of deaths was household air pollution from solid fuels.

CONCLUSIONS

The burden of under-5 LRI in China and the provinces has declined significantly, with variation across provinces. Further efforts are needed to promote child health through the development of measures to control major risk factors.

Quality of sick child management by health extension workers: role of a complex improvement intervention

BACKGROUND

Despite the expansion of the Integrated Community Case Management services for childhood illness, quality and utilization of services have remained low. To address the problem, the Government of Ethiopia introduced a complex intervention that included community engagement, capacity building of health workers and enhanced district-level ownership of sick child management. We examined whether this complex intervention was associated with improved management of sick children by health extension workers.

METHODS

The study was conducted in four Ethiopian regions. A baseline survey was conducted in 26 intervention and 26 comparison districts from December 2016 to February 2017, followed by an end-line survey 24 months later. We observed health extension workers' consultations of sick 2-59 months old children. The analysis has evaluated if children with pneumonia, diarrhoea and malnutrition were assessed, classified and treated according to guidelines, and included difference-in-difference analyses.

RESULTS

We observed 1325 consultations of sick children. At baseline, 86% of the sick children with cough in the intervention areas and 85% in comparison areas were assessed according to the guidelines, without any change at end-line associated with the intervention (difference-in-difference = -21%, p = 0.55). Sixty-two percent of children were assessed for dehydration at baseline in intervention and 47% in comparison areas, with no improvement associated with the intervention. Similarly, 87% of sick children in intervention and 91% in comparison areas were assessed for malnutrition, with no change over time associated with the intervention (difference-in-difference = 5%, p = 0.16). Appropriate pneumonia treatment with antibiotics declined and diarrhea treatment increased in both areas. Half of the malnourished children received ready-to-use therapeutic foods without any improvement associated with the intervention.

CONCLUSION

The intervention was not associated with improved quality of the health extension workers' management of sick children. The lack of association may be linked to low fidelity in the implementation of the intervention. Our findings suggest that training healthcare providers without continued clinical mentoring and support does not improve the quality of care. Community-based programs can be strengthened by ensuring high coverage and continued clinical mentorships, supportive supervision, and supply of medicines and other essential commodities.

TRIAL REGISTRATION NUMBER

ISRCTN12040912, retrospectively registered on 19/12/ 2017.

Validation of risk prediction for outcomes of severe community-acquired pneumonia among under-five children in Amhara region, Northwest Ethiopia

BACKGROUND

Globally there are over 1,400 cases of pneumonia per 100,000 children every year, where children in South Asia and Sub-Saharan Africa are disproportionately affected. Some of the cases develop poor treatment outcome (treatment failure or antibiotic change or staying longer in the hospital or death), while others develop good outcome during interventions. Although clinical decision-making is a key aspect of the interventions, there are limited tools such as risk scores to assist the clinical judgment in low-income settings. This study aimed to validate a prediction model and develop risk scores for poor outcomes of severe community-acquired pneumonia (SCAP).

METHODS

A cohort study was conducted among 539 under-five children hospitalized with SCAP. Data analysis was done using R version 4.0.5 software. A multivariable analysis was done. We developed a simplified risk score to facilitate clinical utility. Model performance was evaluated using the area under the receiver operating characteristic curve (AUC) and calibration plot. Bootstrapping was used to validate all accuracy measures. A decision curve analysis was used to evaluate the clinical and public health utility of our model.

RESULTS

The incidence of poor outcomes of pneumonia was 151(28%) (95%CI: 24.2%-31.8%). Vaccination status, fever, pallor, unable to breastfeed, impaired consciousness, CBC abnormal, entered ICU, and vomiting remained in the reduced model. The AUC of the original model was 0.927, 95% (CI (0.90, 0.96), whereas the risk score model produced prediction accuracy of an AUC of 0.89 (95%CI: 0.853-0.922. Our decision curve analysis for the model provides a higher net benefit across ranges of threshold probabilities.

CONCLUSIONS

Our model has excellent discrimination and calibration performance. Similarly, the risk score model has excellent discrimination and calibration ability with an insignificant loss of accuracy from the original. The models can have the potential to improve care and treatment outcomes in the clinical settings.

Assembling a global database of child pneumonia studies to inform WHO pneumonia management algorithm: Methodology and applications

Background

The existing World Health Organization (WHO) pneumonia case management guidelines rely on clinical symptoms and signs for identifying, classifying, and treating pneumonia in children up to 5 years old. We aimed to collate an individual patient-level data set from large, high-quality pre-existing studies on pneumonia in children to identify a set of signs and symptoms with greater validity in the diagnosis, prognosis, and possible treatment of childhood pneumonia for the improvement of current pneumonia case management guidelines.

Methods

Using data from a published systematic review and expert knowledge, we identified studies meeting our eligibility criteria and invited investigators to share individual-level patient data. We collected data on demographic information, general medical history, and current illness episode, including history, clinical presentation, chest radiograph findings when available, treatment, and outcome. Data were gathered separately from hospital-based and community-based cases. We performed a narrative synthesis to describe the final data set.

Results

Forty-one separate data sets were included in the Pneumonia Research Partnership to Assess WHO Recommendations (PREPARE) database, 26 of which were hospital-based and 15 were community-based. The PREPARE database includes 285 839 children with pneumonia (244 323 in the hospital and 41 516 in the community), with detailed descriptions of clinical presentation, clinical progression, and outcome. Of 9185 pneumonia-related deaths, 6836 (74%) occurred in children <1 year of age and 1317 (14%) in children aged 1-2 years. Of the 285 839 episodes, 280 998 occurred in children 0-59 months old, of which 129 584 (46%) were 2-11 months of age and 152 730 (54%) were males.

Conclusions

This data set could identify an improved specific, sensitive set of criteria for diagnosing clinical pneumonia and help identify sick children in need of referral to a higher level of care or a change of therapy. Field studies could be designed based on insights from PREPARE analyses to validate a potential revised pneumonia algorithm. The PREPARE methodology can also act as a model for disease database assembly.

Joint modeling of longitudinal measures of pneumonia and time to convalescence among pneumonia patients: a comparison of separate and joint models

BACKGROUND

Globally, pneumonia is the leading cause of children under age five morbidity and mortality with 98% of deaths in developing countries.

OBJECTIVE

This study aimed to identify the determinants of longitudinal measures of pneumonia and time to convalescence or recovery of under five admitted pneumonia patients at Felege Hiwot Referral Hospital, Bahir Dar, Ethiopia.

METHODS

A prospective cohort study was conducted among a randomly selected sample of 101 pneumonia patients using simple random sampling who were on follow up from December 2019 to February 2020. A Linear mixed effect model were used for the longitudinal outcomes and joint model for modeling both longitudinal and time to event outcomes jointly respectively.

RESULTS

The significant values of shared parameters in the survival sub model shows that the use of joint modeling of multivariate longitudinal outcomes with the time to event outcome is the best model compared to separate models. The estimated values of the association parameters: - 0.297(p-value = 0.0021), - 0.121) (p-value = < 0.001) and 0.5452 (p-value = 0.006) indicates association of respiratory rate, pulse rate and oxygen saturation respectively with time to recovery. The significant values show that there is an evidence to say that there is a negative relationship between longitudinal measures of respiratory rate and pulse rate with time to recovery and there is positive relationship between longitudinal measures of oxygen saturation with time to recovery. Variables age, birth order, dangerous signs, severity and visit time were significant factors on the longitudinal measure of pulse rate. The significant factors related to longitudinal measures of oxygen saturation were birth order, severity and visit. From this we can conclude that birth order, severity and visit were significant variables that simultaneously affect the longitudinal measures of respiratory rate, pulse rate and oxygen saturation of patients at 5% level of significance.

CONCLUSION

Results of multivariate joint analysis shows that severity was significant variable that jointly affects the three longitudinal measures and time to recovery of pneumonia patients and we can conclude that patients with severe pneumonia have high values of respiratory rate and pulse rate as well as less amount of oxygen saturation and they need longer time to recover from the disease.

Global burden and trends of rotavirus infection-associated deaths from 1990 to 2019: an observational trend study

Background

Rotavirus is the leading global pathogen of diarrhea-associated mortality and poses a great threat to public health in all age groups. This study aimed to explore the global burden and 30-year change patterns of rotavirus infection-associated deaths.

Methods

Based on the Global Burden of Disease 2019 Study (GBD 2019), we analyzed the age-standardized death rate (ASDR) of rotavirus infection by sex, geographical region, and sociodemographic index (SDI) from 1990 to 2019. A Joinpoint regression model was used to analyze the global trends in rotavirus infection over the 30 years, SaTScan software was used to detect the spatial and temporal aggregations, and a generalized linear model to explore the relationship between sociodemographic factors and death rates of rotavirus infection.

Results

Globally, rotavirus infection was the leading cause of diarrheal deaths, accounting for 19.11% of deaths from diarrhea in 2019. Rotavirus caused a higher death burden in African, Oceanian, and South Asian countries in the past three decades. The ASDR of rotavirus declined from 11.39 (95% uncertainty interval [95% UI] 5.46–19.48) per 100,000 people in 1990 to 3.41 (95% UI 1.60–6.01) per 100,000 people in 2019, with an average annual percentage change (AAPC) (− 4.07%, P < 0.05). However, a significant uptrend was found in high-income North America (AAPC = 1.79%, P < 0.05). The death rate was the highest among children under 5 years worldwide. However, the death rates of elderly individuals over 70 years were higher than those of children under 5 years in 2019 among high, high-middle, middle, and low-middle SDI regions. Current health expenditure, gross domestic product per capita, and the number of physicians per 1000 people were significantly negatively correlated with death rates of rotavirus.

Conclusions

Although the global trends in the rotavirus burden have decreased substantially over the past three decades, the burden of rotavirus remained high in Africa, Oceania, and South Asia. Children under 5 years and elderly individuals over 70 years were the populations most at risk for rotavirus infection-associated deaths, especially elderly individuals over 70 years in relatively high SDI regions. More attention should be paid to these areas and populations, and effective public health policies should be implemented in the future.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12985-022-01898-9.

Does Poor Mental Health Impair the Effectiveness of Complementary Food Hygiene Behavior Change Intervention in Rural Malawi?

Mental disorders have the potential to affect an individual's capacity to perform household daily activities such as water, sanitation, and hygiene (food hygiene inclusive) that require effort, time, and strong internal motivation. However, there is limited detailed assessment about the influence of mental health on food hygiene behaviors at household level. We conducted a follow-up study to detect the effects of mental health on food hygiene behaviors after food hygiene intervention delivery to child caregivers in rural Malawi. Face-to-face interviews, based on the Risk, Attitude, Norms, Ability, and Self-regulations (RANAS) model, were conducted with 819 participants (control and intervention group) to assess their handwashing and food hygiene-related behaviors. Mental health was assessed using the validated Self-Reporting Questionnaire. Study results showed a significant negative relationship between mental health and handwashing with soap behavior (r = -0.135) and keeping utensils in an elevated place (r = -0.093). Further, a significant difference was found between people with good versus poor mental health on handwashing with soap behavior (p = 0.050) among the intervention group. The results showed that the influence of the intervention on handwashing with soap behavior was mediated by mental health. Thus, integration of mental health in food hygiene interventions can result in improved outcomes for caregivers with poor mental health.

El Niño Southern Oscillation, monsoon anomaly, and childhood diarrheal disease morbidity in Nepal

Climate change is adversely impacting the burden of diarrheal diseases. Despite significant reduction in global prevalence, diarrheal disease remains a leading cause of morbidity and mortality among young children in low- and middle-income countries. Previous studies have shown that diarrheal disease is associated with meteorological conditions but the role of large-scale climate phenomena such as El Niño-Southern Oscillation (ENSO) and monsoon anomaly is less understood. We obtained 13 years (2002-2014) of diarrheal disease data from Nepal and investigated how the disease rate is associated with phases of ENSO (El Niño, La Niña, vs. ENSO neutral) monsoon rainfall anomaly (below normal, above normal, vs. normal), and changes in timing of monsoon onset, and withdrawal (early, late, vs. normal). Monsoon season was associated with a 21% increase in diarrheal disease rates (Incident Rate Ratios [IRR]: 1.21; 95% CI: 1.16-1.27). El Niño was associated with an 8% reduction in risk while the La Niña was associated with a 32% increase in under-5 diarrheal disease rates. Likewise, higher-than-normal monsoon rainfall was associated with increased rates of diarrheal disease, with considerably higher rates observed in the mountain region (IRR 1.51, 95% CI: 1.19-1.92). Our findings suggest that under-5 diarrheal disease burden in Nepal is significantly influenced by ENSO and changes in seasonal monsoon dynamics. Since both ENSO phases and monsoon can be predicted with considerably longer lead time compared to weather, our findings will pave the way for the development of more effective early warning systems for climate sensitive infectious diseases.

The Use of Portable Oxygen Concentrators in Low-Resource Settings: A Systematic Review

INTRODUCTION

Portable oxygen concentrators (POCs) are medical devices that use physical means to separate oxygen from the atmosphere to produce concentrated, medical-grade gas. Providing oxygen to low-resources environments, such as austere locations, military combat zones, rural Emergency Medical Services (EMS), and during disasters, becomes expensive and logistically intensive. Recent advances in separation technology have promoted the development of POC systems ruggedized for austere use. This review provides a comprehensive summary of the available data regarding POCs in these challenge environments.

METHODS

PubMed, Google Scholar, and the Defense Technical Information Center were searched from inception to November 2021. Articles addressing the use of POCs in low-resource settings were selected. Three authors were independently involved in the search, review, and synthesis of the articles. Evidence was graded using Oxford Centre for Evidence-Based Medicine guidelines.

RESULTS

The initial search identified 349 articles, of which 40 articles were included in the review. A total of 724 study subjects were associated with the included articles. There were no Level I systematic reviews or randomized controlled trials.

DISCUSSION

Generally, POCs are a low-cost, light-weight tool that may fill gaps in austere, military, veterinary, EMS, and disaster medicine. They are cost-effective in low-resource areas, such as rural and high-altitude hospitals in developing nations, despite relatively high capital costs associated with initial equipment purchase. Implementation of POC in low-resource locations is limited primarily on access to electricity but can otherwise operate for thousands of hours without maintenance. They provide a unique advantage in combat operations as there is no risk of explosive if oxygen tanks are struck by high-velocity projectiles. Despite their deployment throughout the battlespace, there were no manuscripts identified during the review involving the efficacy of POCs for combat casualties or clinical outcomes in combat. Veterinary medicine and animal studies have provided the most robust data on the physiological effectiveness of POCs. The success of POCs during the coronavirus disease 2019 (COVID-19) pandemic highlights the potential for POCs during future mass-casualty events. There is emerging technology available that combines a larger oxygen concentrator with a compressor system capable of refilling small oxygen cylinders, which could transform the delivery of oxygen in austere environments if ruggedized and miniaturized. Future clinical research is needed to quantify the clinical efficacy of POCs in low-resource settings.

Association between Attitude towards Wife Beating and Childhood Diarrhea: A Demographic and Health Survey-Based Study in 25 Sub-Saharan African Countries

Background

Childhood diarrhea remains a major public health problem in sub-Saharan Africa (SSA). Women empowerment reduces child mortality, and wife beating attitude is one of the indicators of women empowerment. There is a dearth of evidence about wife beating attitudes and childhood diarrhea in SSA. Therefore, the present study aimed to examine the association between attitude towards wife beating and diarrhea among under-five children.

Methods

We used Demographic and Health Surveys from 25 countries in SSA that were conducted between 2010 and 2020. Using Stata version 14 software, we carried out the analysis on 153,864 children under five. Bivariate and multivariate logistic regression analyses were applied, and the results were presented using adjusted odd ratios (aOR) at 95% confidence interval (CI).

Results

The pooled results show that 71.4% of married women disagreed with wife beating. About 20.5% of under-five children of married women had diarrhea. Childhood diarrhea varied from highest prevalence in Chad (27.9%) to the lowest prevalence in Sierra-Leone (8.5%). The study showed lower odds of diarrhea among children of married women who disagreed with wife beating (aOR = 0.66 95% CI; 0.54-0.80) compared to children of married women who agreed with wife beating. Moreover, the study results show that women's age (35-39 years-aOR = 0.48, 95% CI; 0.31-0.74, 40-44 years-aOR = 0.57, 95% CI; 0.35-0.93, 45-49 years-aOR = 0.35, 95% CI; 0.16-0.79) was negatively associated with childhood diarrhea, while husband's education (primary school-aOR = 1.36, 95% CI; 1.05-1.77), parity (ever born 3-4 children-aOR = 1.36, 95% CI; 1.09-1.70, and 5+ children-aOR = 1.56, 95% CI; 1.14-2.12), and religion (Muslim-aOR = 3.56, 95% CI; 1.44-8.83) were positively associated with diarrhea among under-five children.

Conclusions

The study shows association between women attitude towards wife beating and childhood diarrhea. Therefore, empowering women, especially young women by increasing awareness about domestic violence, their rights, and empowering them through education and economic advancement need to be considered in order to reduce childhood diarrhea. Moreover, fertility control or birth spacing and working closely with religious leaders are important factors to consider in reducing childhood diarrhea.

Incidence and disease burden of community-acquired pneumonia in southeastern China: data from integrated medical resources

Community-acquired pneumonia (CAP) is a lower respiratory tract infection. It is one of the commonest infectious diseases and the third leading cause of death worldwide. However, the epidemiological profiles of CAP in southeastern China are unknown. Data of inpatients and outpatients diagnosed with CAP from January 1, 2015 to December 31, 2020 were obtained from the National Healthcare Big Data in Fuzhou (Fuzhou Database). This database covers medical data from 37 hospitals and 159 community health service stations. The incidence rate, treatment pattern, and direct medical costs of CAP were assessed using clinical data. A total of 8,156,237 patients were enrolled, with a mean age of 33.72 ± 20.88 years. The overall incidence rate of CAP was 3.13 (95% confidence interval [CI]: 3.11-3.15) per 1000 person-years (PY), with 15.97 (95% CI: 15.85-16.08) per 1000 PY in children below 5 years old and 2.62 (95% CI: 2.57-2.66) per 1000 PY in the elderly ≥60 years. The cost per outpatient was $242.83 ± 341.62, and the cost per inpatient was $4,530.4 ± 9,151.68. The three most used therapeutic drugs in patients with CAP are cefotaxime, moxifloxacin, and azithromycin. In addition, despite the ability of both imported and domestic pneumococcal conjugate vaccines to reduce the incidence rate of CAP, the current vaccination coverage rates were relatively low. We suggest that more attention should be paid to the disease burden of CAP, especially due to its great economic burden in China.

Children's Oxygen Administration Strategies And Nutrition Trial (COAST-Nutrition): a protocol for a phase II randomised controlled trial

Background: To prevent poor long-term outcomes (deaths and readmissions) the integrated global action plan for pneumonia and diarrhoea recommends under the 'Treat' element of Protect, Prevent and Treat interventions the importance of continued feeding but gives no specific recommendations for nutritional support. Early nutritional support has been practiced in a wide variety of critically ill patients to provide vital cell substrates, antioxidants, vitamins, and minerals essential for normal cell function and decreasing hypermetabolism. We hypothesise that the excess post-discharge mortality associated with pneumonia may relate to the catabolic response and muscle wasting induced by severe infection and inadequacy of the diet to aid recovery. We suggest that providing additional energy-rich, protein, fat and micronutrient ready-to-use therapeutic feeds (RUTF) to help meet additional nutritional requirements may improve outcome. Methods: COAST-Nutrition is an open, multicentre, Phase II randomised controlled trial in children aged 6 months to 12 years hospitalised with suspected severe pneumonia (and hypoxaemia, SpO 2 <92%) to establish whether supplementary feeds with RUTF given in addition to usual diet for 56-days (experimental) improves outcomes at 90-days compared to usual diet alone (control). Primary endpoint is change in mid-upper arm circumference (MUAC) at 90 days and/or as a composite with 90-day mortality. Secondary outcomes include anthropometric status, mortality, readmission at days 28 and 180. The trial will be conducted in four sites in two countries (Uganda and Kenya) enrolling 840 children followed up to 180 days. Ancillary studies include cost-economic analysis, molecular characterisation of bacterial and viral pathogens, evaluation of putative biomarkers of pneumonia, assessment of muscle and fat mass and host genetic studies.   Discussion: This study is the first step in providing an option for nutritional support following severe pneumonia and will help in the design of a large Phase III trial. Registration: ISRCTN10829073 (6 th June 2018) PACTR202106635355751 (2 nd June 2021).

We refuse to die - T cells causing havoc

This issue of the Biomedical Journal offers insights into the origin and consequences of different lymphoproliferative disorders and autoimmunity. Furthermore we learn about RASopathies, a group of congenital disorders that occur rather frequently. Then the current ELISA assays for measuring antibody avidity are critically examined, the relationship between female sex steroid hormones and cardiovascular disease is explored, and an assessment of persistent diarrhea as a leading cause of child death in India is performed. Additionally, there are several articles about COVID-19, presenting its connection to neutrophil recruitment and acute respiratory distress syndrome, as well as its relation to changes in the vascular glycocalyx. A COVID-19 case study from the emergency room is presented. We are also introduced to novel treatment approaches against COVID-19 like the construction of peptide-based vaccines, or targeting the respiratory tract microbiome. Finally, there is an assessment about how prepared medical students at a Taiwan University feel for independent practice, and another article about the treatment of intravascular large B cell lymphoma in a Taiwanese institution. Lastly, we discover possible surgery techniques in the case of external auditory canal osteoma.

Community-acquired pneumonia: Trends in and research on drug resistance and advances in new antibiotics

Community-acquired pneumonia (CAP) refers to infectious inflammation of the lung parenchyma developing outside of a hospital. CAP has quite a high mortality and morbidity rate worldwide, and especially among elderly patients. The increasing burden of CAP is due to antibiotic resistance, the growth of the elderly population, and underlying comorbidities. Streptococcus pneumoniae remains the most common bacterial pathogen causing CAP, but multi-drug resistance bacteria and potential pathogens have increased the difficulty and challenges of managing CAP. Although preventive measures, diagnostic techniques, and treatment strategies are constantly advancing and improving, the susceptibility of multi-drug resistant pathogens, such as including Methicillin-Resistant Staphylococcus aureus (MRSA), Klebsiella pneumoniae, and Pseudomonas aeruginosa, has not improved significantly in recent decades, thus highlighting the importance and necessity of developing new antibiotics for the treatment of CAP. New antimicrobials have been approved over the past few years that will expand treatment options for CAP, and especially for patients with potential comorbidities. This situation also offers the chance to reduce the abuse of antibiotics, their toxicities, and their adverse reactions and to provide effective personalized antibiotic treatment.

Children's Oxygen Administration Strategies And Nutrition Trial (COAST-Nutrition): a protocol for a phase II randomised controlled trial

Background: To prevent poor long-term outcomes (deaths and readmissions) the integrated global action plan for pneumonia and diarrhoea recommends under the 'Treat' element of Protect, Prevent and Treat interventions the importance of continued feeding but gives no specific recommendations for nutritional support. Early nutritional support has been practiced in a wide variety of critically ill patients to provide vital cell substrates, antioxidants, vitamins, and minerals essential for normal cell function and decreasing hypermetabolism. We hypothesise that the excess post-discharge mortality associated with pneumonia may relate to the catabolic response and muscle wasting induced by severe infection and inadequacy of the diet to aid recovery. We suggest that providing additional energy-rich, protein, fat and micronutrient ready-to-use therapeutic feeds (RUTF) to help meet additional nutritional requirements may improve outcome. Methods: COAST-Nutrition is an open, multicentre, Phase II randomised controlled trial in children aged 6 months to 12 years hospitalised with suspected severe pneumonia (and hypoxaemia, SpO 2 <92%) to establish whether supplementary feeds with RUTF given in addition to usual diet for 56-days (experimental) improves outcomes at 90-days compared to usual diet alone (control). Primary endpoint is change in mid-upper arm circumference (MUAC) at 90 days and/or as a composite with 90-day mortality. Secondary outcomes include anthropometric status, mortality, readmission at days 28 and 180. The trial will be conducted in four sites in two countries (Uganda and Kenya) enrolling 840 children followed up to 180 days. Ancillary studies include cost-economic analysis, molecular characterisation of bacterial and viral pathogens, evaluation of putative biomarkers of pneumonia, assessment of muscle and fat mass and host genetic studies.   Discussion: This study is the first step in providing an option for nutritional support following severe pneumonia and will help in the design of a large Phase III trial. Registration: ISRCTN10829073 (6 th June 2018) PACTR202106635355751 (2 nd June 2021).

Availability and Utilization of World Health Organization Recommended Priority Life-Saving Medicines for Under Five-Year-Old Children in Gondar Town, Ethiopia: A Cross-Sectional Study

BACKGROUND

Globally, more than eight million under-five children die every year because of diseases that could be treated or prevented with drug therapy. Thus, this study aimed to evaluate the utilization and availability of the World Health Organization (WHO) suggested priority life-saving medicines for under-five-year-old children in Gondar town.

METHODS

Institutional-based cross-sectional survey was conducted from March 2020 to May 2020 in public health centers of Gondar town. Data entry and validation were performed in EpiData 3.1 and exported to SPSS version 20 for descriptive analysis like frequency, percentage, mean, standard deviation, and median.

RESULTS

The availability of zinc phosphate and oral rehydration salt for the diarrheal cases was 57.14% and 85.71%, respectively. The availabilities of amoxicillin dispersible tablet and gentamicin injection for the treatments of pneumonia cases were 71.43% and 42.85%, respectively, and the availability of paracetamol tablet was high (85.71%). The availabilities of artemether/lumefantrine tablet and artesunate rectal were ranged between fairly high (57.1%) to very low (28.5%), respectively, and the availabilities of zidovudine/lamivudine/nevirapine-based antiretroviral regimen was 100%, a utilization for this regimen was high (96.29%). Two (3.70%) of the surveyed cases were utilized lopinavir/ritonavir-based regimen. The utilization of priority medicines was low for pain management and pneumonia which was 18.5% and 48.18%, respectively.

CONCLUSION

The study concluded that medicine was not consistently available throughout public health centers in Gondar town. Thus, this finding suggests the integration of WHO-recommended life-saving priority medicines into the essential drug management systems and health unit logistics to raise their utilization and availability.

Disease burden and attributable risk factors of respiratory infections in China from 1990 to 2019

BACKGROUND

There was lack of data on the burdens and trends of upper and lower respiratory infections (URIs and LRIs) over the past three decades in China.

METHODS

We estimated the incidence, mortality, and disability-adjusted life years (DALYs) due to upper and lower respiratory infections (URIs and LRIs) and attributable risk factors in China by a systematic analysis of the Global Burden of Disease 2019 study. Incidence, mortality, and DALYs were stratified by sex, age, and province. Risk factors for respiratory infections were analyzed from exposure data.

FINDINGS

The age-standardized incidence rates of URIs and LRIs were 179,077 and 3926 per 100,000 persons in 2019, with a 7•52% and 35•07% decrease from 1990, respectively. Moreover, 2801 and 185,264 persons died of URIs and LRIs in 2019, respectively. DALYs for URIs and LRIs also decreased from 1,516,727 in 1990 to 928,617 in 2019 and from 38,278,504 in 1990 to 4,020,676 in 2019. The burden of URIs and LRIs were generally similar in males and females, but relatively higher in the new-borns and the elderly. Child malnutrition and low birth weight were the most important cause of age-standardized DALYs of LRIs and URIs, respectively.

INTERPRETATION

Future URI and LRI prevention strategies should focus on the maternal and child health, air pollution, and tobacco control, especially in young children and the elderly population.

FUNDING

National Key R&D Program of China (2018YFA0606200); National Natural Science Foundation of China (82041021); Fundamental Research Funds for the Central Universities (20ykpy86) and Guangdong Basic and Applied Basic Research Foundation (2019A1515110003); Bill & Melinda Gates Foundation (No.: INV-006371).

Burden and etiology of moderate and severe diarrhea in children less than 5 years of age living in north and south of China: Prospective, population-based surveillance

Background

Diarrhea remains the leading cause of childhood illness in China. Better understanding of burden and etiology of diarrheal diseases is important for development of effective prevention measures.

Methods

Population-based diarrhea surveillance was conducted in Sanjiang (southern China) year-round and Zhengding (northern China) in autumn/winter. Stool specimens were collected from children < 5 years of age experiencing diarrhea. The TaqMan Array Card (TAC), based on multiplex real-time PCR, was applied to detect multiple enteric microbial agents simultaneously. Results using these methods were compared to those derived from conventional PCR assays.

Results

During the study period, 6,380 children in Zhengding and 3,581 children in Sanjiang < 5 years of age participated. Three hundred and forty (31.2%) and 279 (22.9%) diarrhea episodes were identified as moderate-to-severe in the two counties, with incidence of 60.4 and 88.3 cases per 1,000 child-years in Zhengding and Sanjiang, respectively. The five most frequently detected bacterial and viral agents in Sanjiang were adenovirus, enterovirus, enteroaggregative Escherichia coli (EAEC), rotavirus, and sapovirus all the year round, while the most common viral agents in Zhengding were rotavirus, followed by astrovirus and adenovirus during the cool season. Compared to conventional PCR assay, the average incremental detection via the TAC method was twofold.

Conclusion

Our study demonstrated high diversity and prevalence of multiple major bacterial and viral agents, including rotavirus and calicivirus, among children in China. Further studies are needed to define the public health significance of neglected but frequently detected pathogens such as EAEC, enterotoxigenic E. coli, Campylobacter, adenovirus, and enterovirus.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13099-021-00428-2.

Currently bacterial and viral agents in the gastrointestinal tract are under-detected and poorly defined in developing countries. A new sensitive TAC assay provided comprehensive identification of microorganisms, including neglected pathogens, in Chinese children with moderate and severe diarrhea.

Nasal high flow therapy introduction lowers reintubation risk in a Peruvian paediatric intensive care unit

AIM

We examined the impact of introducing high-flow nasal oxygen therapy (HFNT) on children under five with post-extubation respiratory failure in a paediatric intensive care unit (PICU) in Peru.

METHODS

This quasi-experimental study compared clinical outcomes before and after initial HFNT deployment in the PICU at Instituto Nacional de Salud del Niño in Lima in June 2016. We compared three groups: 29 received post-extubation HFNT and 17 received continuous positive airway pressure (CPAP) from 2016-17 and 12 historical controls received CPAP from 2012-16. The primary outcome was the need for mechanical ventilation. Adjusted hazard ratios (aHR) and 95% confidence intervals (95% CI) were calculated via survival analysis.

RESULTS

High-flow nasal oxygen therapy and CPAP did not alter the need for mechanical ventilation after extubation (aHR 0.47, 95% CI 0.15-1.48 and 0.96, 95% CI 0.35-2.62, respectively) but did reduce the risk of reintubation (aHR 0.18, 95% CI 0.06-0.57 and 0.14, 95% CI 0.03-0.72, respectively). PICU length of stay was 11, 18 and 37 days for CPAP, HFNT and historical CPAP and mortality was 12%, 7% and 27%, respectively. There was no effect on the duration of sedative infusions.

CONCLUSION

High-flow nasal oxygen therapy provided effective support for some children, but larger studies in resource-constrained settings are needed.

Incidence of community-acquired pneumonia in urban China: A national population-based study

BACKGROUND

Community-acquired pneumonia (CAP) is one of the major global health problems worldwide. However, the epidemiological information of CAP is limited in China. This study aimed to estimate the incidence rate of CAP and describe the epidemiologic characteristics among the Chinese population.

METHODS

We conducted a retrospective analysis of CAP incidence using the Chinese Urban Basic Medical Insurance database of 23 provinces in 2016, which covered 427.52 million urban beneficiaries of all age groups in Mainland China. CAP episodes were identified using a diagnosis-term-derived algorithm, and multiple CAP records of one single person within 90 continuous days were considered as one single episode. The incidence rates were calculated and described by sex, age, region, and season.

RESULTS

A total of 1.42 million patients were identified as having one or more CAP episodes, and finally a sum of 1.48 million CAP episodes were counted. The overall incidence of CAP was 7.13 (95% CI: 6.11-8.15) per 1000 person-years, in males 7.32 (95% CI: 6.28-8.35) and females 6.93 (95% CI: 5.92-7.94) per 1000 person-years, respectively. The incidence varied by age with a U-shaped curve peaking in children aged < 5 years old [65.80 (95% CI: 62.52-69.08)] and elderly population aged ≥ 80 years old [14.98 (95% CI: 13.63-16.34)]. The incidence varied markedly by regions. Furthermore, the rate showed a clear seasonal trend, which peaked in spring, decreased in summer and autumn, and re-ascended in winter.

CONCLUSION

This study reveals a relatively high level of CAP incidence in China. These findings provide baseline data for establishing effective prevention strategies, targeted at susceptible populations, regions, and seasons in China.

Detection and identification of enteroviruses circulating in children with acute gastroenteritis in Pará State, Northern Brazil (2010-2011)

Although acute gastroenteritis (AGE) has been reported as a common infectious disease in children, there is scarce information about enterovirus (EV) circulating associated with AGE cases in Brazil. The purpose of the present study was to identify and characterize the enteroviruses associated with AGE in children in Belém, Brazil. A total of 175 stool samples were obtained from children hospitalized revealing the presence of EV in 26.3% (46/175) of infections. EV type was identified in 78.3% (36/46) and EV-B species (61.1%; 22/36) was the most prevalent EV-detected followed by EV-C (25%; 9/36) and EV-A (13.9%; 5/36). This study has provided important information about the enterovirus circulation in Pará state, Northern Brazil.

Effect of pneumococcal conjugate vaccine introduction on childhood pneumonia mortality in Brazil: a retrospective observational study

Background

Understanding the real-world effect of pneumococcal conjugate vaccines (PCVs) on pneumonia mortality is crucial because of the expectation that increased PCV use will substantially reduce the burden of pneumonia deaths in children younger than 5 years. However, few post-vaccine introduction studies have estimated the benefits of PCV use on childhood mortality and results have been inconsistent. Therefore, we set out to assess the effect of introduction of ten-valent pneumococcal conjugate vaccine (PCV10) on pneumonia mortality in children in Brazil.

Methods

In this retrospective observational study, we used publicly available mortality data of children aged 3–59 months in Brazil. We separated data by age group (3–11 months, 3–23 months, and 3–59 months) and stratified data by three different socioeconomic factors of Brazilian municipalities (in 2010): Human Development Index, proportion of children living in extreme poverty, and proportion of mothers with no primary education. We first examined long-term trends in childhood pneumonia mortality in Brazil (from 1980 to 2014). We then assessed the effect of PCV10—introduced in Brazil in 2010—both nationally and in municipalities stratified by socioeconomic status, with a synthetic control approach as our primary analytical method.

Findings

Between 1980 and 2010, a period during which Brazil's Human Development Index rose substantially, national pneumonia mortality in children younger than 5 years decreased from about 150 to 15 deaths per 100 000 children younger than 5 years. Despite rapid uptake of PCV10 after its introduction in 2010, we observed a further vaccine-associated decline of about 10% in national childhood pneumonia mortality with our primary analytical method, with a high degree of uncertainty in the estimates. We observed larger reductions in municipal childhood pneumonia mortality in all three age groups (3–11 months, 3–23 months, and 3–59 months) in municipalities with a high percentage of extreme childhood poverty and mothers with no primary education, with the largest decrease observed in children aged 3–23 months in municipalities with low maternal education (24%, 95% credible interval 7–35).

Interpretation

The large reduction observed from 1980 to 2010 in national pneumonia mortality in children younger than 5 years underscores that improvements in nutrition, hygiene, education, and health care have an important role in reducing pneumonia mortality. Although the PCV-associated reduction in childhood pneumonia mortality at the national level was modest, we found that PCV led to larger reductions in low-income municipalities. Similarly, large benefits might occur when PCVs are introduced in other low-income settings.

Funding

Bill & Melinda Gates Foundation and National Institute of Allergy and Infectious Diseases.

The impact of daily soap use in rural areas of Senegal on respiratory infectious diseases, fevers and skin microbiota

OBJECTIVES

Children aged <5 years are the group most affected by infectious diseases, more specifically in underdeveloped countries. A study was performed to assess the effects of daily soap use on the incidence of diarrhoea, fever, respiratory infection, and the prevalence of pathogenic bacteria on the skin.

METHODS

Soap was distributed to the population of the village of Ndiop (test) for use in their daily hygiene but not to the population of the village of Dielmo (control). Fieldworkers daily recorded the clinical events in the two villages and encouraged the use of soap in Ndiop.

RESULTS

A total of 638 people participated in the study. The incidence rates of cough, runny nose and fever significantly decreased in 2016 compared with 2015, unlike that of diarrhoea. In 2016, significant reductions in the incidence rates of cough, runny nose and fever were observed in children aged <15 years in Ndiop. The prevalence of Streptococcus pneumoniae, Staphylococcus aureus and Streptococcus pyogenes in the palms of the hands significantly dropped in Ndiop.

CONCLUSION

Using soap reduces the incidence of respiratory infections, fevers and the prevalence of pathogenic bacteria on the skin. However, for diarrhoea, additional strategies are needed to improve outcomes.

IgY - turning the page toward passive immunization in COVID-19 infection (Review)

The world is facing one of the major outbreaks of viral infection of the modern history, however, as vaccine development workflow is still tedious and can not control the infection spreading, researchers are turning to passive immunization as a good and quick alternative to treat and contain the spreading. Within passive immunization domain, raising specific immunoglobulin (Ig)Y against acute respiratory tract infection has been developing for more than 20 years. Far from being an obsolete chapter we will revise the IgY-technology as a new frontier for research and clinic. A wide range of IgY applications has been effectively confirmed in both human and animal health. The molecular particularities of IgY give them functional advantages recommending them as good candidates in this endeavor. Obtaining specific IgY is sustained by reliable and nature friendly methodology as an alternative for mammalian antibodies. The aria of application is continuously enlarging from bacterial and viral infections to tumor biology. Specific anti-viral IgY were previously tested in several designs, thus its worth pointing out that in the actual COVID-19 pandemic context, respiratory infections need an enlarged arsenal of therapeutic approaches and clearly the roles of IgY should be exploited in depth.

Chitotriosidase: a marker and modulator of lung disease

Chitotriosidase (CHIT1) is a highly conserved and regulated chitinase secreted by activated macrophages; it is a member of the 18-glycosylase family (GH18). CHIT1 is the most prominent chitinase in humans, can cleave chitin and participates in the body's immune response and is associated with inflammation, infection, tissue damage and remodelling processes. Recently, CHIT1 has been reported to be involved in the molecular pathogenesis of pulmonary fibrosis, bronchial asthma, COPD and pulmonary infections, shedding new light on the role of these proteins in lung pathophysiology. The potential roles of CHIT1 in lung diseases are reviewed in this article.

This is the first review of chitotriosidase in lung diseasehttp://bit.ly/2LpZUQI

Does Chest Attachment of an Automated Respiratory Rate Monitor Influence the Actual Respiratory Rate in Children Under Five?

Pneumonia is one of the leading causes of death in children under 5 years worldwide. In resource-limited settings, WHO recommendations state that pneumonia can be presumptively diagnosed through the presence of cough and/or difficult breathing and a respiratory rate (RR) that is higher than age-specific cutoffs. As a new diagnostic aid the children's automated respiration monitor (ChARM) can automatically measure and classify RR in children under 5 years, but the effect of its chest attachment on the RR has not been studied. The aim of this study was to understand if misclassification of the true RR occurred by ChARM attachment. Two hundred eighty-seven children at a health center in South Ethiopia were screened for eligibility, with 188 children aged 2-59 months enrolled in the study. The RR was measured manually before and 1, 3, and 5 minutes after ChARM attachment. The proportion of children with fast or normal RR classification at baseline and the change between RR classifications over time were analyzed. Eight (4.9%; 95% CI 2.1, 9.4) of 163 children changed RR classification from normal to fast between the baseline RR count and the 1 minute RR count. Results from this study suggest that ChARM has a minor influence on the RR of children immediately after attachment, in most cases without clinical importance.

Pneumonia a neglected disease: A mixed-method study on the case-finding program in Indonesia

Pneumonia eradication program has been implemented, but the incidence rate remains high. This research aims to evaluate the Pneumonia finding program in Sleman district of Indonesia. A mixed-method using sequential explanatory design was conducted during July–August 2019. Input, Process and Output were used as the evaluated methods. Input component were human resource quality, facilities, infrastructure and funding. Process aspect was planning, implementation, monitoring and evaluation. Output was the Pneumonia finding coverage. The quantitative study that employed a survey was done among the Pneumonia officer in 25 primary health centres in the research area. Qualitative study used a semi-structured interview to explore the Pneumonia officer's opinion about the case finding program. Analysis was performed in two stages: 1) Quantitative analysis was started with input data to the spreadsheet, clean the data, and classify into the cut-off. 2) Qualitative analysis was done using a content analysis approach. Input and process found sufficient. But we found poor in the output (Pneumonia finding coverage). Pneumonia finding program has not executed as the expected. The coverage was inadequate since only one out 25 reaches the target of Pneumonia finding coverage. Pneumonia is considered not severe disease become a reason for the inadequate coverage.

High frequency of Chlamydia pneumoniae and risk factors in children with acute respiratory infection

This study was performed as a contribution for a better understanding of Chlamydia pneumoniae frequency in children with respiratory infections. A total of 416 children were recruited from two clinical centers in Sao Luis, Brazil. Of these patients, 165 children had upper respiratory tract infections (URTI), 150 had community-acquired pneumonia (CAP), and 101 were asymptomatic volunteer children. Clinical and epidemiological data from the participants were recorded. Nasopharyngeal swab samples were collected to extract DNA. C. pneumoniae DNA positivity and copy numbers were obtained by an absolute quantitative real-time PCR method. RESULTS: Positivity for C. pneumoniae DNA was higher in samples from URTI children (38.2%) and from CAP children (18.0%) than in those from the control group (7.9%; p < 0.001). Moreover, C. pneumoniae DNA was denser in children with URTI than in asymptomatic children. Considering the cutoff, the highest value of C. pneumoniae DNA found in asymptomatic children of the 3.98 log10 copies/mL, 8.5% (14/165) of the children with URTI, and 3.3% (5/150) with CAP presented high copy numbers of C. pneumoniae DNA. CONCLUSION: Taken together, these results revealed a high frequency of C. pneumoniae in both children with URTI and CAP.

Development of a low-cost, portable, pediatric infection screening system using simultaneous measurement of multiple vital signs

The primary cause of death among children under age 5 years is acute respiratory infection, such as pneumonia. Detection of infection at the earliest point of contagion is necessary, to reduce morbidity and prevent infectious disease epidemics; therefore, identifying abnormal vital signs is essential. For early detection of pediatric infections, we developed a low-cost, portable, rapid screening system of pediatric infection. The system simultaneously measures three vital signs: heart rate (HR), respiration rate (RR), and body temperature (Temp) within 10 seconds using a pulse sensor, Doppler radar, and an infrared thermopile. Vital sign signal processing and computation are conducted using an Arduino Nano microprocessor, enabling the small, lightweight, and portable design of this system. Moreover, the cost-effectiveness of the system facilitates system applications in developing countries, which have the highest levels of pediatric mortality. We conducted trial measurement in Bayangol Health Center, Ulaanbaatar, Mongolia in 2019. A total of 50 children (age 1-14 years, 26 boys/24 girls) were enrolled in this study. Bland-Altman plot and Pearson correlation methods were used to evaluate the accuracy of the proposed system. The correlation coefficients were calculated as HR: r=0.92, RR: r=0.8, and Temp: r=0.82, with p<; 0.01. The system appears promising for rapid and convenient detection of infection in children.

New immunization strategies: adapting to global challenges

Immunization has made an enormous contribution to global health. Global vaccination coverage has dramatically improved and mortality rates among children due to vaccine-preventable diseases have been significantly reduced since the creation of the Expanded Programme of Immunization in 1974, the formation of Gavi, the Vaccine Alliance, in 2000, and the development of the Global Vaccine Action Plan in 2012. However, challenges remain and persisting inequities in vaccine uptake contribute to the continued occurrence and outbreaks of vaccine-preventable diseases. Inequalities in immunization coverage by geography, urban-rural, and socio-economic status jeopardize the achievement of global immunization goals and call for renewed immunization strategies. These should take into account emerging opportunities for building better immunization systems and services, as well as the development of new vaccine products and delivery technologies. Such strategies need to achieve equity in vaccination coverage across and within countries. This will require the participation of communities, a better understanding of vaccine acceptance and hesitancy, the expansion of vaccination across the life course, approaches to improve immunization in middle-income countries, enhanced use of data and possible financial and non-financial incentives. Vaccines also have an important role to play in comprehensive disease control, including the fight against antimicrobial resistance. Lessons learned from disease eradication and elimination efforts of polio, measles and maternal and neonatal tetanus are instrumental in further enhancing global immunization strategies in line with the revised goals and targets of the new Immunization Agenda 2030, which is currently being developed.

Knowledge acquisition and retention following Saving Children's Lives course for healthcare providers in Botswana: a longitudinal cohort study

OBJECTIVES

Millions of children die every year from serious childhood illnesses. Most deaths are avertable with access to quality care. Saving Children's Lives (SCL) includes an abbreviated high-intensity training (SCL-aHIT) for providers who treat serious childhood illnesses. The objective of this study was to examine the impact of SCL-aHIT on knowledge acquisition and retention of providers.

SETTING

76 participating centres who provide primary and secondary care in Kweneng District, Botswana.

PARTICIPANTS

Doctors and nurses expected by the District Health Management Team to provide initial care to seriously ill children, completed SCL-aHIT between January 2014 and December 2016, submitted demographic data, course characteristics and at least one knowledge assessment.

METHODS

Retrospective, cohort study. Planned and actual primary outcome was adjusted acquisition (change in total knowledge score immediately after training) and retention (change in score at 1, 3 and 6 months), secondary outcomes were pneumonia and dehydration subscores. Descriptive statistics and linear mixed models with random intercept and slope were conducted. Relevant institutional review boards approved this study.

RESULTS

211 providers had data for analysis. Cohort was 91% nurses, 61% clinic/health postbased and 45% pretrained in Integrated Management of Childhood Illness (IMCI). A strong effect of SCL-aHIT was seen with knowledge acquisition (+24.56±1.94, p<0.0001), and loss of retention was observed (-1.60±0.67/month, p=0.018). IMCI training demonstrated no significant effect on acquisition (+3.58±2.84, p=0.211 or retention (+0.20±0.91/month, p=0.824) of knowledge. On average, nurses scored lower than physicians (-19.39±3.30, p<0.0001). Lost to follow-up had a significant impact on knowledge retention (-3.03±0.88/month, p=0.0007).

CONCLUSIONS

aHIT for care of the seriously ill child significantly increased provider knowledge and loss of knowledge occurred over time. IMCI training did not significantly impact overall knowledge acquisition nor retention, while professional status impacted overall score and lost to follow-up impacted retention.

Immunoglobulin M profile of viral and atypical pathogens among children with community acquired lower respiratory tract infections in Luzhou, China

Background

Community-acquired lower respiratory tract infections (CA-LRTIs) are the primary cause of hospitalization among children globally. A better understanding of the role of atypical pathogen infections in native conditions is essential to improve clinical management and preventive measures. The main objective of this study was to detect the presence of 7 respiratory viruses and 2 atypical pathogens among hospitalized infants and children with community-acquired lower respiratory tract infections in Luzhou via an IgM test.

Methods

Overall, 6623 cases of local hospitalized children with 9 pathogen-IgM results from 1st July 2013 to 31st Dec 2016 were included; multidimensional analysis was performed.

Results

1) Out of 19,467 hospitalized children with lower respiratory tract infections, 6623 samples were collected, for a submission ratio of 33.96% (6623 /19467). Of the total 6623 serum samples tested, 5784 IgM stains were positive, for a ratio of 87.33% (5784 /6623). Mycoplasma pneumoniae (MP) was the dominant pathogen (2548 /6623, 38.47%), with influenza B (INFB) (1606 /6623, 24.25%), Legionella pneumophila serogroup 1 (LP1) (485 /6623, 7.32%) and parainfluenza 1, 2 and 3(PIVs) (416 /6623, 6.28%) ranking second, third and fourth, respectively.

2) The distribution of various pathogen-IgM by age group was significantly different (χ² = 455.039, P < 0.05).

3) Some pathogens were found to be associated with a certain age of children and seasons statistically.

Conclusions

The dominant positive IgM in the area was MP, followed by INFB, either of which prefers to infect children between 2 years and 5 years in autumn. The presence of atypical pathogens should not be underestimated clinically as they were common infections in the respiratory tract of children in the hospital.

Determinants of pneumonia among 2-59 months old children at Debre Markos referral hospital, Northwest Ethiopia: a case-control study

BACKGROUND

Pneumonia is a significant public health problem globally. The early identification and management of the determinants of pneumonia demands clear evidence. But, there is a limited data on this issue in the current study area. Thus, this study aimed to identify the determinants of pneumonia among 2-59 months old children at Debre Markos Referral Hospital, Northwest Ethiopia.

METHODS

A Hospital based unmatched case-control study was conducted among 334 (167 Cases and 167 Controls) children at Debre Markos Referral Hospital from February 1 to March 30, 2018. Consecutive sampling technique was employed and data were collected with a pre-tested interviewer administered questionnaire. Data were entered into Epi-Data version 4.2, and analyzed using SPSS version 25 software. Bi-variable and multi-variable logistic regression analyses were fitted. Variables having p-value < 0.05 were considered as statistically significant.

RESULTS

A total of 328(164 cases and 164 controls) 2-59 months old children were included in this study. Not opening windows daily [AOR:6.15(2.55,14.83)], household near to the street [AOR:4.23(1.56,11.44)], child care by the house workers and relatives [AOR:2.97 (1.11,7.93)], using only water for hand washing before child feeding [AOR:3.81 (1.51, 9.66)], mixed feeding practice from birth to six months [AOR: 7.62 (2.97, 19.55)], having upper respiratory tract infection in the last 2 weeks for the child [AOR: 5.33 (2.16, 13.19)] and children with history of co- residence with URTI family [AOR: 6.17 (2.36,16.15)] were found to be determinants of pneumonia.

CONCLUSIONS

The main contributing factors for pneumonia in this study are preventable with no or minimal cost. Therefore, we recommend appropriate and adequate health education regarding pneumonia prevention and control.

Healthcare-provider perceptions of barriers to oxygen therapy for paediatric patients in three government-funded eastern Ugandan hospitals; a qualitative study

Background

This study aimed to assess on-the-ground barriers to the provision of oxygen therapy for paediatric patients in three government-funded Eastern Ugandan district general hospitals (DGHs).

Methods

Site visits to DGHs during March 2017 involved semi-structured interviews with medical officers, clinical officers, paediatric nurses and non-clinical staff (n = 29). MAXQDA qualitative data software was used to assist with response analysis.

Results

The healthcare professionals reported that erratic electricity supplies, few and/or malfunctioning oxygen cylinders and concentrators, limited or no access to pulse oximetry, inadequate staffing and lack of continued professional training were key barriers to the delivery of oxygen therapy. Local populations were reportedly fearful of oxygen therapy and reluctant to consent for oxygen therapy to be administered to their children.

Conclusion

According to healthcare providers in three Eastern Ugandan DGHs, numerous barriers exist to oxygen therapy for paediatric patients. Healthcare professionals reported lack of facilities and training to effectively deliver oxygen therapy. Quality improvement work prioritising oxygen therapy in government-funded district general hospitals should focus on oxygen supply and delivery issues on a site-specific level and sensitizing communities to the potential benefits of oxygen.

Exclusive Breastfeeding Associated with the Reduction of Acute Respiratory Tract Infections in Toddlers with High-Risk Factors

Introduction: Acute respiratory tract infections (ARI) is a disease that is the primary cause of death, especially in children. Toddlers can be prevented from developing ARI with increased immunity. Giving breast milk can increase children's immunity, but there are still children who experience ARI. This study aimed to explain the differences in Acute Respiratory Tract Infections (ARI) events in toddlers who are exclusively and non-exclusively breastfed.Methods: The research design used was descriptive-comparative with a retrospective design. The population in this study were all children one to three years of age. A sample of 158 toddlers was recruited by a purposive sampling technique. Data retrieval was done with the criteria that the child had visited a public health centre (puskesmas) or integrated health care service post (posyandu), and does not suffer from a disease such as asthma or have any allergies. The variables were measured using a questionnaire and observation sheet. Data analysis was done by a chi-square test and binary logistic regression.Results: The results showed that there were differences in ARI incidence in toddlers (one to three years) who were exclusively and non-exclusively breastfed with a value of p = 0.003. The air pollution factor proved to be significant, dominantly affecting the incidence of ARI.Conclusion: Differences in ARI incidence in toddlers who are exclusively and non-exclusively breastfed is possible due to air pollution factors. Key implications for nursing practice from this research are improving services, and prevent the occurrence of ARI.

Understanding the effect of indoor air pollution on pneumonia in children under 5 in low- and middle-income countries: a systematic review of evidence

Exposure to indoor air pollution increases the risk of pneumonia in children, accounting for about a million deaths globally. This study investigates the individual effect of solid fuel, carbon monoxide (CO), black carbon (BC) and particulate matter (PM)2.5 on pneumonia in children under 5 in low- and middle-income countries. A systematic review was conducted to identify peer-reviewed and grey full-text documents without restrictions to study design, language or year of publication using nine databases (Embase, PubMed, EBSCO/CINAHL, Scopus, Web of Knowledge, WHO Library Database (WHOLIS), Integrated Regional Information Networks (IRIN), the World Meteorological Organization (WMO)-WHO and Intergovernmental Panel on Climate Change (IPCC). Exposure to solid fuel use showed a significant association to childhood pneumonia. Exposure to CO showed no association to childhood pneumonia. PM2.5 did not show any association when physically measured, whilst eight studies that used solid fuel as a proxy for PM2.5 all reported significant associations. This review highlights the need to standardise measurement of exposure and outcome variables when investigating the effect of air pollution on pneumonia in children under 5. Future studies should account for BC, PM1 and the interaction between indoor and outdoor pollution and its cumulative impact on childhood pneumonia.

IgY antibodies for the immunoprophylaxis and therapy of respiratory infections

Emergence of drug resistance among the causative organisms for respiratory tract infections represents a critical challenge to the global health care community. Further, although vaccination can prevent disease, vaccine development is impeded by several factors. Therefore, novel approaches to treat and manage respiratory infections are urgently needed. Passive immunization represents a possible alternative to meet this need. Immunoglobulin Y antibodies (IgYs) from the yolk of chicken eggs have previously been used against bacterial and viral infections in human and animals. Their advantages include lack of reaction with mammalian Fc receptors, low production cost, and ease of extraction. Compared to mammalian IgGs, they have higher target specificity and greater binding avidity. They also possess remarkable pathogen-neutralizing activity in the respiratory tract and lungs. In this review, we provide an overview of avian IgYs and describe their potential therapeutic applications for the prevention and treatment of respiratory infections.

Reported incidence and risk factors of childhood pneumonia in India: a community-based cross-sectional study

Background

Pneumonia is responsible for high morbidity and mortality amongst children under five year of age. India accounts for one-third of the total WHO South East Asia burden of under-five mortality. There is a paucity of epidemiological studies indicating the true burden of pneumonia. Identification of the risk factors associated with pneumonia will help to effectively plan and implement the preventive measures for its reduction.

Methods

It was a descriptive cross-sectional study conducted in 16 randomly selected clusters in two districts of Maharashtra state, India. All mothers of under-five children in the selected clusters were included. A validated pretested interview schedule was filled by trained field supervisors through the house to house visits.WHO definition was used to define and classify clinical pneumonia. Height and weight of children were taken as per standard guidelines. Quality checks for data collection were done by the site investigators and critical and noncritical fields in the questionnaire were monitored during data entry. For continuous variables mean and SD were calculated. Chi-square test was applied to determine the association between the variables. Level of significance was considered at 0.05.

Results

There were 3671 under five-year children, 2929 mothers in 10,929 households.Unclean fuel usage was found in 15.1% of households. Mean birth weight was 2.6 kg (SD;0.61). Exclusive breastfeeding till 6 months of age was practiced by 46% of mothers. Reported incidence of ARI was 0.49 per child per month and the reported incidence of pneumonia was 0.075 per child per year. It was not associated with any of the housing environment factors (p > 0.05) but was found to be associated with partial immunization (p < 0.05). Poor practices related to child feeding, hand hygiene and poor knowledge related to signs and symptoms of pneumonia amongst mother were found.

Conclusions

Very low incidence of pneumonia was observed in Pune and Sangli districts of Maharashtra. Partial immunization emerged as a most important risk factor. Reasons for low incidence and lack of association of pneumonia with known risk factors may be a better literacy rate among mothers and better immunization coverage.

Trial registration

Registration number of the trial- CTRI/2017/12/010881; date of registration-14/12/2017.