Assessing the impact of COVID-19 on self-reported levels of depression during the pandemic relative to pre-pandemic among Canadian adults

OBJECTIVES

This study aims to assess the impact of COVID-19 related risk factors on self-reported increases in depression among Canadian adults during the pandemic compared to pre-pandemic levels. We aim to investigate the interactive effects of stressors, including social isolation, financial stress, and fear of catching COVID-19, on mental health outcomes. Our study aims to provide insights for the development of prevention and intervention strategies to address the mental health effects of the pandemic by examining the psychological changes attributable to the pandemic and its impact.

METHODS

This study used data collected from the Mental Health Research Canada online survey during the third wave of COVID-19 (April 20-28, 2021). The study examined the impact of COVID-19 related factors, including social isolation, financial concerns, fear of catching COVID-19, and concerns about paying bills, on self-reported increases in depression. Multivariable logistic regression models were utilized to examine these associations, with adjustments made for potential confounding variables. All statistical analysis was performed using SAS V9.4 (SAS Institute Inc., Cary, NC, USA).

RESULTS

Participants reporting social isolation, financial concerns, and fear of catching COVID-19 were more likely to report increased depression. An interaction was observed between concerns for paying bills and catching COVID-19 in relation to depression (p = 0.0085). In other words, the effect of concerns about paying bills on depression was stronger for individuals who also had a fear of catching COVID-19, and vice versa. Young adults, females, patients with pre-existing depression, and residents of certain provinces reported higher levels of depression during COVID-19.

CONCLUSION

Our study underscores the significant impact of the COVID-19 pandemic on mental health, particularly among certain demographic groups. It emphasizes the need for depression screening and increased support for mental health during the pandemic, with a focus on mitigating financial burdens and reducing negative psychological impacts of social isolation. Our findings highlight the complex interplay between different stressors and the need to consider this when designing interventions to support mental health during times of crisis.

Understanding inequities in child mortality in Egypt: Socioeconomic and proximate factors

While there have been notable advancements in child health in Egypt, disparities in child mortality still exist. Understanding these disparities is crucial to addressing them. The objective of this study is to explore the factors linked to child mortality in Egypt, providing a comprehensive understanding of the disparities in child mortality rates. The study utilises cross-sectional data from Egypt's Demographic and Health Survey (EDHS) in 2014 to examine child mortality. The dataset consists of 15,848 observations from mothers with children born within five years prior to the survey. The choice of explanatory variables was guided by the Mosely and Chen Framework and logistic multivariate regression was used to conduct the analyses. The study finds lower education, early childbearing, insufficient birth spacing, lack of breastfeeding, and absence of improved toilet facilities (proxy for living conditions) were all significantly linked to an increased likelihood of child loss. Additionally, poorer people in rural settings experienced the worst child mortality. The findings align with the World Health Organization's Conceptual Framework for Action on the Social Determinants of Health (CSDH). Recommended policy interventions include targeting women in rural areas, improving living conditions and removing financial/other barriers to accessing care.

Relationship between coronary stenosis severity and high shear thrombosis assessment in vitro

Funding Acknowledgements

Type of funding sources: None.

Among stable outpatients presenting with suspected coronary artery disease, the presence and extent of coronary artery calcification (CAC) and the severity of disease on CT coronary angiography (CTCA) has been shown to be predictive of future major adverse cardiovascular events (MACE) including myocardial infarction (MI). In stable patients, high on-treatment platelet reactivity has also been shown to relate to an increased risk of MACE including MI. The relationship between thrombotic markers in peripheral blood and the extent of CAC and coronary disease severity, is unknown.

It was the aim of this pilot study to assess the relationship between thrombotic status and the extent of CAC and severity of coronary stenosis on CT.

Subjects with suspected coronary disease undergoing CTCA and CAC were invited to participate in this observational study. Venous blood was obtained to assess platelet reactivity to high shear (occlusion time, OT) and endogenous fibrinolysis (lysis time, LT) using the Global Thrombosis Test, and related to CAC and to maximum stenosis in any main coronary artery on CTCA.

Eighty patients were recruited, specifically 20 patients from each CAC quartile (adjusted for age, gender and ethnicity), 58% were male, aged 61±10 y. Groups were matched for age, sex, diabetes, and hs-CRP. The median Agatson CAC score was 27 [interquartile range (IQR) 0.5-125.5] and in each quartile (Q) as follows: Q1 0[0-0]; Q2 17[6-51.5]; Q3 70.25[26-111.5] and Q4 192.6[70.5-413.5].

Patients were divided into 4 groups according to maximal severity of coronary stenosis on CTCA (0%, 1-49%, 50-69%, >70%). With increasing stenosis severity, we found patients exhibited less efficient endogenous fibrinolysis (longer LT) (LT 1728s[1512-2102] vs. 2028s[1687-2288] vs. 1728s[1634-1927] vs. 2524s[2425-2623] respectively, p=0.040) whilst platelet reactivity appeared unrelated to severity of coronary stenosis (438s[341-479] vs. 415s[357-484] vs. 444s[384-504] vs. 391s[357-425], p=0.907).

Platelet reactivity (OT 430s[339-477] vs. 458s[391-499] vs. 409s[351-488] vs. 413s[354-496], p=0.76) and spontaneous fibrinolysis (LT 1754s[1548-2162] vs. 1809s[1635-2291] vs. 2111s[1838-2312] vs. 1846s[1666-2090], p=0.253) were similar between the quartiles. Furthermore, there was no difference in platelet reactivity (430s[339-477] vs. 413s[354-496], p=0.830) or spontaneous fibrinolysis (1754s[1548-2162] vs. 1846s[1666-2090], p=0.561) when comparing patients within the lowest and the highest quartiles of CAC.

The severity of maximal coronary stenosis, but not the extent of CAC, is related to the effectiveness of spontaneous fibrinolysis at high shear in vitro, with patients with more severe stenoses exhibiting less efficient fibrinolysis. Further studies are required to investigate whether the extent of in vivo coronary shear (related to plaque morphology) can be reflected by the assessment of thrombosis and fibrinolysis in response to high shear in vitro.

Diurnal Variation in thrombolytic status in patients presenting with STEMI

Funding Acknowledgements

Type of funding sources: None.

Background

Prior studies mainly in healthy volunteers and patients with stable coronary artery disease (CAD) indicate circadian variation in spontaneous fibrinolytic activity. This is predominantly attributable to changes plasminogen activator inhibitor-1 (PAI-1) levels peaking between midnight and 06:00 hr, with a nadir at 18:00 hr. Whether circadian variation in spontaneous fibrinolysis exists amongst patients with ST-elevation myocardial infarction (STEMI) is unknown.

Purpose

It was our aim to assess circadian variation in fibrinolytic status in the acute setting in patients presenting with STEMI.

Methods

A prospective, observational study was conducted in patients presenting with STEMI for primary percutaneous coronary intervention (PPCI). Blood was tested on arrival pre-PPCI, after aspirin and P2Y12 inhibitor administration, but before any anticoagulant or antithrombotic agent administration in the cardiac cath lab. Venous blood was assessed to determine endogenous fibrinolysis using the Global Thrombosis Test, which utilises non-anticoagulated blood to assess the formation of an occlusive thrombus under high shear and the time taken for spontaneous restart of flow as a measure of endogenous fibrinolysis (lysis time, LT).

Results

A total of 527 patients were included, aged 64±13 years and 78% were male. 304 (58%) patients presented within working hours (08:00-17:00) with peak presentation between 11:00-12:00 and trough between 03:00 to 05:00 hrs.

Lysis time was not related to time of presentation. Time of presentation was divided into 4 groups (A 00:00-05:59, B 06:00-11:59, C 12:00-17:59, D 18:00-23:59 hrs). There was no significant difference in LT between patients presenting at the 4 timepoints (median 1362s [interquartile range IQR 1077-1808] vs 1503s [1182-2056] vs 1440s [1164-1998] vs. 1420s [1125-1820], respectively, p=0.340). When comparing Group A to C, the LT was not significantly different (1362s [1077-1808] vs. 1440 [1164-1998], p=0.413). The presentation time of patients with impaired endogenous fibrinolysis (LT>3000 sec) did not differ significantly from patients with normal endogenous fibrinolysis. The hourly variation was similar in diabetics and non-diabetics, but the variation in lysis time appeared blunted in patients taking long term aspirin prior to presentation compared to non-aspirin takers.

Conclusion

In contrast to the known circadian variation in fibrinolysis in normal volunteers, and stable CAD, in our large cohort of STEMI patients, there appears to be no relationship between time of presentation/onset of STEMI and the effectiveness spontaneous fibrinolysis. This is reflected in our observation, supported by most contemporary studies, that peak time of STEMI presentation is during the late morning, and this does not relate to known circadian variation in fibrinolysis markers in CAD.

Intraventricular hemorrhage prediction in premature neonates in the era of hemodynamics monitoring:a prospective cohort study.. [DOI: 10.21203/rs.3.rs-1475610/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Purpose Unstable hemodynamics and prematurity are the main players in IVH development. Our objective was the use of SVCF, LVO and RVO, and ACA Doppler measures in prediction of IVH in the first week of life in preterm infant ≤ 32 weeks.Method Prospective cohort Study in NICU of the Maternity university hospital is presented. Of 147 patients, 132 infants born ≤32 weeks GA were enrolled in the study. 127 completed the study till 7th day of life. Infants were scanned for ACA-RI using transfontanellar ultrasound, and SVC flow, LVO, and RVO using FE in the first 24 hours after birth. Patients had another two scans on DOL3 and7 to detect IVH development. Results Low SVCF and high ACA-RI significantly increased the risk of IVH using logistic regression models with (OR, 3.16; 95%Cl, 1.19 – 8.39; P0.02) and (OR, 1.64; 95%Cl, 1.10 – 2.44;P0.02),respectively. Low SVCF and high ACA-RI significantly increased risk of catastrophic IVH P 0.025 and 0.023, respectively. Combined use Low SVCF < 55 ml/kg/min and ACA-RI > 0.75 is predictor of IVH with sensitivity 40.8% and 82.1% specificity. This work was registered in clinical trial.gv no NCT05050032ConclusionsThere are strong relations between both low SVC flow and high ACA-RI and IVH development in premature neonates ≤32 weeks, with more significance towards catastrophic IVH. Admission RSS and LVO are the strongest factors affecting SVC flow. PDA size (mm/kg) and CRT were significantly associated with high ACA-RI. Theses finding helps in more understanding of pathophysiological factors affecting central perfusion that might affect the longer term neurodeveopmental outcome.

Behavioral factors are perhaps more important than income in determining diet quality in Canada

This study examines the importance of income in determining the diet quality of Canadian adults measured based on Nutrient Rich Food Index version 9.3. We used the latest available data on Canadians' consumption of foods and nutrients from the Canadian Community Health Survey-Nutrition 2015. The Canada' Food Guide classification was used for categorizing food groups based on types of food and their healthiness. Unsupervised and supervised machine learning models were employed in order to examine the links between income and the choice of foods. We first employed cluster analysis to identify the dietary patterns among individuals included in the sample and then we examined whether the intakes of various food groups across the identified clusters vary by income levels. Further, we evaluated the association between diet quality and income using Lasso Regression to determine the most important predictors of diet quality among adults in Canada. The results of both cluster analysis and regularized regression model suggested that behavioral factors and cultural backgrounds are more important determinants of diet quality among adults in Canada.

Socio-demographic and environmental risk factors associated with multiple under-five child loss among mothers in Bangladesh

Background

Despite the substantial decline in child mortality globally over the last decade, reducing neonatal and under-five mortality in Bangladesh remains a challenge. Mothers who experienced multiple child losses could have substantial adverse personal and public health consequences. Hence, prevention of child loss would be extremely desirable during women’s reproductive years. The main objective of this study was to determine the risk factors associated with multiple under-five child loss from the same mother in Bangladesh.

Methods

In this study, a total of 15,877 eligible women who had given birth at least once were identified from the 2014 Bangladesh Demographic and Health Survey. A variety of count regression models were considered for identifying socio-demographic and environmental factors associated with multiple child loss measured as the number of lifetime under-five child mortality (U5M) experienced per woman.

Results

Of the total sample, approximately one-fifth (18.9%, n = 3003) of mothers experienced at least one child’s death during their reproductive period. The regression analysis results revealed that women in non-Muslim families, with smaller household sizes, with lower education, who were more advanced in their childbearing years, and from an unhygienic environment were at significantly higher risk of experiencing offspring mortality. This study also identified the J-shaped effect of age at first birth on the risk of U5M.

Conclusions

This study documented that low education, poor socio-economic status, extremely young or old age at first birth, and an unhygienic environment significantly contributed to U5M per mother. Therefore, improving women’s educational attainment and socio-economic status, prompting appropriate timing of pregnancy during reproductive life span, and increasing access to healthy sanitation are recommended as possible interventions for reducing under-five child mortality from a mother. Our findings point to the need for health policy decision-makers to target interventions for socio-economically vulnerable women in Bangladesh.

Optimizing immunization schedules in endemic cholera regions: cost-effectiveness assessment of vaccination strategies for cholera control in Bangladesh

This study is to examine the cost-effectiveness of deployment strategies of oral cholera vaccines (OCVs) in controlling cholera in Bangladesh. We developed a dynamic compartment model to simulate costs and health outcomes for 12 years for four OCVs deployment scenarios: (1) vaccination of children aged one and above with two doses of OCVs, (2) vaccination of population aged 5 and above with a single dose of OCVs, (3) vaccination of children aged 1-4 with two doses of OCVs; and (4) combined strategy of (2) and (3). We obtained all parameters from the literature and performed a cost-effectiveness analysis from both health systems and societal perspectives, in comparison with the base scenario of no vaccination.The incremental cost-effectiveness ratios (ICERs) for the four strategies from the societal perspective were $2,236, $2,250, $1,109, and $2,112 per DALY averted, respectively, with herd immunity being considered. Without herd immunity, the ICERs increased substantially for all four scenarios except for the scenario that vaccinates children aged 1-4 only. The major determinants of ICERs were the case fatality rate and the incidence of cholera, as well as the efficacy of OCVs. The projection period and frequency of administering OCVs would also affect the cost-effectiveness of OCVs. With the cut-off of 1.5 times gross domestic product per capita, the four OCVs deployment strategies are cost-effective. The combined strategy is more efficient than the strategy of vaccinating the population aged one and above with two doses of OCVs and could be considered in the resource-limited settings.

In-hospital clinical outcomes of percutaneous coronary intervention for patients deemed ineligible for surgical revascularization

Background

Ineligibility for surgical revascularization remains subjective with limited data. Coronary artery bypass graft surgery (CABG)-ineligible patients usually have a high prevalence of risk factors and complex coronary disease, which lead to worse clinical outcomes.

Aim

We aimed to evaluate CABG surgical ineligibility reasons and in-hospital percutaneous coronary intervention (PCI) outcomes at a large tertiary centre.

Methods

Anonymized, prospectively collected data from the institutional electronic records between April 2013 and November 2020 were analysed retrospectively. All patients who were formally turned down for CABG and had PCI were included.

Results

There were 473 patients in total. Perceived frailty of the patient with associated comorbidities and/or the quality of distal coronary arteries were the main documented reasons for surgical ineligibility in 52.4% of patients. Mean age was 72±11 years, mean body mass index was 29±6 kg/m2 and 69.8% were male. Stable angina constituted 216 patients (45.7%) and 257 patients (54.3%) had acute coronary syndromes. Mean hospital stay was 4±5 days. Procedural success was documented in 457 out of 473 patients (96.6%). PCI adjunctive tools included coronary imaging in 97 patients (20.5%), rotational atherectomy in 96 patients (20.3%), laser atherectomy in 12 patients (2.5%), lithotripsy in 3 patients (0.6%) and physiological assessments in 34 patients (7.2%). In-hospital major adverse cardiac events were experienced in 32 patients (6.8%), death in 12 patients (2.5%), myocardial infarction in 21 patients (4.4%), ischaemic stroke in 1 patient (0.2%), coronary perforation in 7 patients (1.5%), repeat target vessel revascularization in 6 patients (1.3%), major access-site bleeding in 2 patients (0.4%), aortic dissection in 1 patient (0.2%) and new acute kidney injury requiring dialysis in 1 patient (0.2%).

Conclusions

PCI in surgically ineligible patients is generally safe and effective. The process of determining suitability for surgical revascularization remains complex in the real-world.

Funding Acknowledgement

Type of funding sources: None.

Positive predictive value of CT coronary angiography vs. CT fractional flow reserve in a real-world population

Background

Computerised tomography coronary angiography and fractional flow reserve (CTCA and CT-FFR) are non-invasive diagnostic tools for the detection of flow limiting coronary artery stenoses. Although their negative predictive values are well established, there is a concern that the high sensitivity of these tests may lead to overestimation of coronary artery disease (CAD) and unnecessary invasive coronary angiography (ICA). We compared the positive predictive value (PPV) of CT-FFR with computerised tomography coronary angiography (CTCA) against the gold standard of ICA in different real-world patient groups.

Methods

We conducted a retrospective study of 477 patients referred for CTCA or CT-FFR for investigation of possible coronary ischaemia. Patients were excluded if the image quality was poor or inconclusive. Patient-based PPV was calculated to detect or rule out significant CAD, defined as more than 70% stenosis on ICA. A sub-analysis of PPV by indication for scan was also performed. Patients that underwent invasive non-hyperaemic pressure wire measurements had their iFR or RFR compared with their CT-FFR values.

Results

In a patient-based analysis, the overall PPV was 59.3% for CTCA and 76.2% for CT-FFR. This increased to 81.0% and 86.7% respectively for patients with stable angina symptoms. In patients with atypical angina symptoms, CT-FFR considerably outperformed CTCA with a PPV of 61.3% vs. 37.5%. There was not a linear relationship between invasive pressure wire measurement and CT-FFR value (r=0.23, p=0.265).

Conclusion

The PPV of CTCA and CT-FFR is lower in the real-world than in previously published trials, partly due to the heterogeneity of indication for the scan. However, in patients with typical angina symptoms, both are reliable diagnostic tools to determine the presence of clinically significant coronary stenoses. CT-FFR significantly outperforms CTCA in patients with more atypical symptoms and the targeted use of CT-FFR in this group may help to avoid unnecessary invasive procedures.

Funding Acknowledgement

Type of funding sources: None.

Assessing the contextual effect of community in the utilization of postnatal care services in Ghana

BACKGROUND

Inequalities in the use of postnatal care services (PNC) in Ghana have been linked to poor maternal and neonatal health outcomes. This has ignited a genuine concern that PNC interventions with a focus on influencing solely individual-level risk factors do not achieve the desired results. This study aimed to examine the community-level effect on the utilization of postnatal care services. Specifically, the research explored clusters of non-utilization of PNC services as well as the effect of community-level factors on the utilization of PNC services, with the aim of informing equity-oriented policies and initiatives.

METHODS

The 2014 Ghana Demographic and Health Survey GDHS dataset was used in this study. Two statistical methods were used to analyze the data; spatial scan statistics were used to identify hotspots of non-use of PNC services and second two-level mixed logistic regression modeling was used to determine community-level factors associated with PNC services usage.

RESULTS

This study found non-use of PNC services to be especially concentrated among communities in the Northern region of Ghana. Also, the analyses revealed that community poverty level, as well as community secondary or higher education level, were significantly associated with the utilization of PNC services, independent of individual-level factors. In fact, this study identified that a woman dwelling in a community with a higher concentration of poor women is less likely to utilize of PNC services than those living in communities with a lower concentration of poor women (Adjusted odds ratio (AOR) = 0.60, 95%CI: 0.44-0.81). Finally, 24.0% of the heterogeneity in PNC services utilization was attributable to unobserved community variability.

CONCLUSION

The findings of this study indicate that community-level factors have an influence on women's health-seeking behavior. Community-level factors should be taken into consideration for planning and resource allocation purposes to reduce maternal health inequities. Also, high-risk communities of non-use of obstetric services were identified in this study which highlights the need to formulate community-specific strategies that can substantially shift post-natal use in a direction leading to universal coverage.

Protective and Risk Factors Associated With Youth Attitudes Toward Violence in Canada

Adolescents and young adults are the main perpetrators and victims of violence in almost all parts of the world. Theories of human behavior predict that the intention to behave violently is formed in part by the individual's attitude toward violent behavior. The purpose of this study was thus to investigate factors which both promote and protect against violent youth attitudes in Toronto, Canada's largest urban center. Multinomial logit models were fit separately for males and females in Grades 7 to 9 using cross-sectional data from the 2006 International Youth Survey. Odds ratios were estimated for the associations between levels of attitude toward violence and select factors in each of the biological, familial, peer-related, school and community domains. A graded effect of school attachment on violent attitude was observed for both sexes; male and female students who do not like school at all are 9.89 (3.15-31.0) and 6.49 (2.19-19.2) times as likely as those who like school a lot to have the "most" versus "least" violent attitude, respectively. For every one-unit increase in (negative) perception of neighborhood score, male and female students are 1.15 (1.07-1.23) and 1.20 (1.12-1.28) times as likely to have the "most" versus "least" violent attitude. The number of victimization events was associated with attitude toward violence in males but not females, while the reverse was true for academic performance and exposure to prejudice. Our findings highlight the important relationships between connections to social environments and youth attitudes toward violence, and identify modifiable factors which may be amenable to intervention. Sex-specific differences in the predictors of violent youth attitudes warrant additional investigation and have implications for policy design.

What We Know Now: An Economic Evaluation of Chickenpox Vaccination and Dose Timing Using an Agent-Based Model

OBJECTIVES

The value of chickenpox vaccination is still debated in the literature and by jurisdictions worldwide. This uncertainty is reflected in the inconsistent uptake of the vaccine, where some countries offer routine childhood immunization programs, others have targeted programs, and in many the vaccine is only privately available. Even across the countries that have universal funding for the vaccine, there is a diversity of schedules and dosing intervals. Using an agent-based model of chickenpox and shingles, we conducted an economic evaluation of chickenpox vaccination in Alberta, Canada.

METHODS

We compared the cost-effectiveness of 2 common chickenpox vaccination schedules, specifically a long dosing interval (first dose: 12 months; second dose: 4-6 years) and a short dosing interval (first dose: 12 months; second dose: 18 months).

RESULTS

The economic evaluation demonstrated a shorter dosing interval may be marginally preferred, although it consistently led to higher costs from both the societal and healthcare perspectives. We found that chickenpox vaccination would be cost-saving and highly cost-effective from the societal and healthcare perspective, assuming there was no impact on shingles.

CONCLUSION

Chickenpox vaccine was cost-effective when not considering shingles and remained so even if there was a minor increase in shingles following vaccination. However, if chickenpox vaccination did lead to a substantial increase in shingles, then chickenpox vaccination was not cost-effective from the healthcare perspective.

Exploring food security among recently resettled Syrian refugees: results from a qualitative study in two Canadian cities

Purpose

This study aims to provide a qualitative in-depth account of the status and experience of food insecurity for Syrian refugee households in Toronto and Saskatoon, Canada. The study considers the range of geographic, socio-economic, cultural and gendered components shaping and determining the barriers and management of food insecurity.

Design/methodology/approach

The study included 54 semi-structured interviews with refugee families in Toronto and Saskatoon who resettled in Canada after November 2015. In addition, 15 semi-structured in-person or telephone interviews were conducted with settlement and support agencies to measure their capacity to respond to issues of food insecurity for Syrian refugees.

Findings

Syrian refugees reported experiencing food insecurity as part of the broader resettlement journey, including in the transitional phase of refuge and in each settlement context in Canada. Income status in Canada was reported as a key barrier to food security. Low-income barriers to food security were experienced and shaped by factors including food affordability, physical access and availability and the extent of familial or other support networks including sponsorship relationships. Participants also reported how managing food insecurity contributed to the intensification of gender expectations.

Originality/value

The analysis reveals food insecurity as both an income and non-income based concern for refugees during the process of resettlement. The study also highlights the importance of considering variations between primary barriers to food security identified by Syrian families and key informants as critical to the development of strategies designed to mitigate the impacts of resettlement on food security.

Correlation between plasma clot properties, thrombin generation and whole blood fibrinolytic assays in patients presenting with STEMI

Background

Impaired endogenous fibrinolysis is a novel risk factor for recurrent adverse cardiovascular events in acute coronary syndrome (ACS) patients. This is independent of conventional cardiovascular risk factors and unaffected by dual antiplatelet therapy (DAPT). The mechanism underlying impaired endogenous fibrinolysis in ACS patients is currently unclear.

Aim

To identify the relationship between whole blood fibrinolysis, plasma fibrinolysis and thrombin generation in samples from STEMI patients.

Methods

In a large, prospective, observational study of 500 patients presenting with ST-segment elevation myocardial infarction (STEMI), blood samples were taken on arrival, after DAPT loading, and before administration of heparin or PPCI. Non-anticoagulated venous whole blood was analysed using the point-of-care Global Thrombosis Test, which assesses the time taken for occlusive thrombus formation under high shear (occlusion time, OT) and time required for spontaneous restart of flow as a measure of endogenous fibrinolysis (lysis time, LT). Patients were divided into 4 groups based on quartiles (Q) of whole blood LT (Q1: LT&lt;1500s, Q2:1501–3000s, Q3:3001–4500s, Q4:&gt;4500s). Plasma samples (20 per quartile) were examined in a thrombin generation assay using 1pM tissue factor to initiate and using a turbidity assay to determine the plasma clot lysis time (CLT).

Results

Clinical characteristics of patients were similar in the four groups. The whole blood LT in the 4 groups were Q1: 1194 (1125–1329) s, Q2: 1859 (1634–2157) s, Q3: 3638 (3252–3962) s, Q4: 6000 (5523–6000) s. As LT increased, there was a trend towards longer plasma CLT (50% CLT Q2: 88.5 [73.5–102] vs. Q4: 100 [85–128.5] min, p=0.088). As a continuous variable, there was no significant relationship between whole blood LT and plasma CLT, or between endogenous thrombin potential (ETP) and either whole blood LT or plasma CLT. There was a significant negative correlation between OT and velocity index (r=−0.425, p=0.0138), ETP (r=−0.519, p=0.002), peak thrombin generation (r=−0.390, p=0.0247) and a positive correlation with lag-time (r=0.427, p=0.013). There was positive correlation between CLT and white cell count (WCC, r=0.388, p=0.026), C-reactive protein (CRP, r=0.477, p=0.005) and maximum absorbance (MA, r=0.530, p=0.002). MA correlated with WCC (r=0.436, p=0.011) and platelet count (r=0.357, p=0.042). There was a negative correlation between OT and WCC (r=−0.537, p=0.001) and CRP (r=−0.381, p=0.029).

Conclusion

In patients with STEMI, increased platelet reactivity (shorter OT) correlated with increased thrombin generation (higher ETP, peak thrombin generation, velocity index and reduced lag time), demonstrating the key role of thrombin in occlusive thrombus formation. Fibrinolysis in whole blood was poorly related to plasma CLT or thrombin generation, suggesting that cellular components such as platelets, erythrocytes and neutrophil extracellular traps may significantly influence endogenous fibrinolysis.

Funding Acknowledgement

Type of funding source: None

Prostate-specific antigen (PSA) screening rates and factors associated with screening in Eastern Canadian men: Findings from cross-sectional survey data

INTRODUCTION

The prostate-specific antigen (PSA) test is used in Canada to detect prostate cancer (PCa) despite mixed recommendations. Complications arising from false-positives are common, posing as a cancer-screening concern. This work estimates some Canadian rates of PSA screening and identifies men at increased odds for PSA screening.

METHODS

The Canadian Community Health Survey (CCHS) from 2009/10 (Atlantic Canada; ATL), 2011/2012 (Ontario; ON), and 2013/2014 (Quebec; QC) were used. Lifetime and recent PSA screening with confidence intervals were constructed to estimate PSA screening in ATL, ON, and QC. Two logistic regression models (for men <50 and ≥50 years of age) were used to determine associations between factors and lifetime PSA screening.

RESULTS

PSA screening rates have increased in most age groups for ATL, ON, and QC since 2000/2001. Factors positively associated with lifetime PSA screening in men of all ages were: having a digital rectal exam, having a regular doctor, and having a colorectal exam. Fruit and vegetables consumption and non-smoking status were positively associated with lifetime PSA screening in men <50 years of age. High income and the presence of chronic health conditions were positively associated with lifetime PSA screening in men ≥50 years of age.

CONCLUSIONS

PSA screening rates have generally increased since 2000/2001 in Canada. Physician-related factors play a role in men at all ages, while different factors are associated in men <50 years of age and men ≥50 years of age. Limitations include the generalizability to all of Canada and the potential for recall bias.

Socioeconomic inequalities in the use of caesarean section delivery in Ghana: a cross-sectional study using nationally representative data

Background

Inappropriate use of Caesarean Section (CS) delivery is partly to blame for Ghana’s high maternal mortality rate. However, previous research offered mixed findings about factors associated with CS use. The goal of this study is to examine use of CS in Ghana and the socioeconomic factors associated with it.

Methods

Data from the nationally representative 2014 Ghana Demographic and Health Survey (GDHS) was used after permission from the Monitoring and Evaluation to Assess and Use Results (MEASURE) Demographic and Health Survey (DHS) program. Univariable and multivariable logistic regression models were fitted to examine the socioeconomic inequalities in CS use. The independent variables included maternal age, marital status, religion, ethnicity, education, place of residence, wealth quintile, and working status. Concentration index (CI) and rate-ratios were computed to ascertain the level of CS inequalities.

Results

Out of the 4294 women, 11.4% had CS delivery. However, the percentage of CS delivery ranged from 5% of women in the poorest quintile to 27.5% of women in the richest qunitle. Significant associations were detected between CS delivery and maternal age, parity, education, and wealth quintile .

Conclusions

This study revealed that first, even though Ghana has achieved an aggregate CS rate consistent with WHO recommendations, it still suffers from inequities in the use of CS. Second, both underuse of CS among poorer women in Ghana and overuse among rich and educated women are public health concerns that need to be addressed. Third, the results show in spite of Ghana’s free maternal care services policies, wealth status of women continues to be strongly and signtificantly associated with CS delivery, indicating that there are indirect health care costs and other reasons preventing poorer women from having access to CS which should be understood better and addressed with appropriate policies.

P327Predictive value of platelet reactivity, neutrophil to lymphocyte ratio, and hs-CRP at presentation in patients with ST-elevation myocardial infarction treated with percutaneous coronary intervention

Background

Patients with ST-elevation myocardial infarction (STEMI) exhibit enhanced platelet reactivity and a rise in inflammatory biomarkers such as neutrophil to lymphocyte ratio (NLR) and high-sensitivity C-reactive protein (hs-CRP). The extent of the prothrombotic and inflammatory state are predictive of adverse outcomes in patients with acute coronary syndromes. The relationship of these markers of inflammation and thrombosis in the hyperacute phase of STEMI and, whether together, they improve cardiovascular outcome prediction, is not known.

Purpose

The aim of this study was to assess the individual and combined predictive values of NLR, hs-CRP, and platelet reactivity for clinical outcomes in patients with STEMI.

Method

In a prospective study of 541 patients presenting with STEMI, acute admission bloods taken prior to emergency percutaneous coronary intervention, were analysed for NLR and hs-CRP. Platelet reactivity was measured using the point-of-care Global Thrombosis Test, which assesses platelet reactivity in native whole blood under high shear, and measures the occlusion time (OT, sec). Shorter occlusion time represents higher platelet reactivity. The study endpoint was occurrence of major adverse cardiovascular events (MACE, defined as composite of cardiovascular death [CVD], myocardial infarction [MI] or stroke [CVA]) at 30 days and 12 months.

Results

There was a weak, but significant, correlation between hs-CRP and NLR (r=0.25, p<0.001), and hs-CRP and platelet reactivity (r=0.14, p=0.003) on admission. There was no correlation between platelet reactivity and NLR. Amongst 541 patients, 42 patients experienced a MACE within the first 30 days, and 50 within 12 months. Cut-values associated with the highest specificity and sensitivity for 12-month MACE were NLR 5.6, hs-CRP 8 mg/L and OT 302 sec. Platelet reactivity and hs-CRP were each only weakly predictive of MACE at 30 days (platelet reactivity: hazard ratio [HR] 1.004 [95% confidence interval (CI) 1.002–1.006,] p<0.001; hs-CRP: HR 1.005 [95% CI 1.0009–1.009], p=0.016) and 12 months (platelet reactivity HR 1.004 (95% CI 1.002–1.006), p<0.001; hs-CRP HR 1.005 (95% CI 1.001–1.01), p=0.014). NLR was not predictive of MACE at either 30 days or 12 months (p=NS). When patients were divided into quartiles based on hs-CRP and platelet reactivity, patients in the highest quartile for both hs-CRP and platelet reactivity had an HR 3.46 (95% CI 1.81–6.63), p<0.001 compared to those in the lowest quartile for both (HR 0.04 (95% CI 0.005–0.27), p=0.001). The combination of enhanced platelet reactivity and raised hs-CRP was the strongest predictor of MACE at 30 days (HR 2.32 [95% CI 1.71–3.13], p<0.001) and 12 months (HR 2.31 [95% CI 1.71–3.11], p<0.001).

Conclusion

Both hs-CRP and platelet reactivity are very weakly predictive of MACE, but in combination provide a strong predictor of adverse outcome in STEMI.

Prevalence of Type 1 and Type 2 Diabetes-Related Complications and Their Association With Determinants Identified in Canada's Survey on Living With Chronic Diseases-Diabetes Component

OBJECTIVES

In this study, we estimated the prevalence of diabetes-related complications and the factors associated with them in Canadian patients with diabetes.

METHODS

Data from the 2011 Survey on Living with Chronic Diseases in Canada---Diabetes Component (SLCDC-DM-2011) were used to calculate the weighted prevalence of 16 diabetes-related complications. A multivariable, sex-stratified logistic regression model was used to examine the association between each diabetes-related complication and select determinants.

RESULTS

Among Canadian patients who self-reported having diabetes, 80.26% reported having at least 1 type of diabetes-related complication. The most frequently reported complications were high blood pressure (54.65%), cataracts (29.52%) and poor circulation (21.68%). Male patients were more associated to have at least 1 complication if they had an inappropriate body mass index (odds ratio [OR], 2.94; 95% confidence interval [CI], 1.39 to 6.23) and had a high level of glycated hemoglobin (OR, 2.32; 95% CI, 1.05 to 5.13), were older (OR, 6.92; 95% CI, 1.82 to 24.74) and had diabetes for a longer period of time (OR, 3.42; 95% CI, 1.71 to 6.85). Among the female patients, a longer duration diabetes was found to have a significant association with complications (OR, 2.00; 95% CI, 1.05 to 3.81).

CONCLUSIONS

Our findings suggest that socioeconomic factors, including marital status, income and education, have a significant association with most types of complications. Our findings also confirm that low levels of physical activity and high levels of glycated hemoglobin were major determinants in many diabetes-related complications.

The social determinants of health facility delivery in Ghana

Background

Many women still deliver outside a health facility in Ghana, often under unhygienic conditions and without skilled birth attendants. This study aims to examine the social determinants influencing the use of health facility delivery among reproductive-aged women in Ghana.

Methods

Nationally representative data from the 2014 Ghana Demographic and Health Survey was used to fit univariable and multivariable logistic regression models to estimate the influence of the social determinants on health facility delivery. Andresen’s health care utilization model was used as the conceptual framework guiding this study..

Results

Only 72% of deliveries take place at a health facility in Ghana. The results of the adjusted model indicate that place of residence, financial status, education, religion, parity and perceived need were significantly associated with health facility delivery. First, urban women had a higher likelihood of health facility delivery than rural women (Adjusted Odds ratio [AOR] =2.21; 95% Confidence interval [CI] = 1.53–3.19). Second, middle-class and rich women were 1.57 (95%CI = 1.18–2.08) times and 6.91 (95%CI = 4.12–11.59) times, respectively more likely to deliver at health facility compared to the poor. Third, women with either at least secondary education (AOR = 2.04; 95%CI = 1.57–2.64) or primary education (AOR = 1.39, 95%CI = 1.02–1.92) were more likely to deliver at health facility than women with no education. In terms of parity, first time mothers were 1.58 (95% CI = 1.18–2.12) times more likely to deliver at health facility than those who had given birth three or more times before. Finally, regarding perceived need, women who were aware of pregnancy complications were 1.32 (95%CI = 1.02–1.70) times more likely to use health facility delivery than those who were not informed about pregnancy complications.

Conclusions

First, in spite of Ghana’s free maternal health services policy, poorer women were much less likely to have a health facility delivery, which points to the need to understand the indirect costs and other financial barriers preventing women from delivering at a health facility. Second, many of the identified variables influence the demand and not just the supply for health care services, and highlight the importance of the social determinants of health and investments in interventions that extend beyond improving physical access.

Facilitators and Barriers toward Food Security of Afghan Refugees Residing in Karachi, Pakistan

The present study comparatively assesses how Afghan refugees in Pakistan understand both the factors and barriers affecting their food security status before and after refuge. Through qualitative in-depth interviews with 25 Afghan refugee families, we assess how quality of life, together with perceptions of a balanced meal, food environments both pre- and post-migration and push and pull factors of migration, impact food security and food choices for refugee families. Furthermore, our results reveal that regardless of the length of protracted status for Afghan refugees, food insecurity remains as a consistent condition for refugee families.

The relationship between sociodemographic factors and reporting having terminated a pregnancy among Ghanaian women: a population-based study

Background

Pregnancy termination is an illegal medical procedure in Ghana and 88% of induced abortions are performed in unsafe conditions, thus recipients face an elevated risk of abortion-related complications. This study aims to explore the associations between sociodemographic factors and reporting having terminated a pregnancy among Ghanaian women.

Methods

Logistic regression models were estimated using data from the 2014 Ghana Demographic and Health Survey (n=9396). ORs were computed for the associations between reporting pregnancy termination and select demographic and socio-economic factors.

Results

Education level, employment status, financial status and marital status of women are significantly associated with reporting having terminated a pregnancy.

Conclusions

Women who are employed, cohabit with a partner and are considered middle class or wealthy are more likely than their counterparts to report having terminated a pregnancy. Ghanaian women with intermediate levels of education are more likely than both their more- and less-educated counterparts to report having terminated a pregnancy. These findings highlight the need for the development of policies aimed at reducing unsafe abortions associated with unintended pregnancies. Specific recommendations include providing family planning education and outreach to high-risk groups to reduce unintended pregnancies and improving working conditions for expectant mothers, including provisions for paid maternity leave and job protection.

Correction to: Response to: Costs and savings associated with a pharmacists prescribing for minor ailments program in Saskatchewan

[This corrects the article DOI: 10.1186/s12962-018-0159-y.].

Chronic health disparities among refugee and immigrant children in Canada

There are knowledge gaps in our understanding of the development of chronic disease risks in children, especially with regard to the risk differentials experienced by immigrants and refugees. The Healthy Immigrant Children study employed a mixed-methods cross-sectional study design to characterize the health and nutritional status of 300 immigrant and refugee children aged 3-13 years who had been in Canada for less than 5 years. Quantitative data regarding socioeconomic status, food security, physical activity, diet, and bone and body composition and anthropometric measurements were collected. Qualitative data regarding their experiences with accessing health care and their family lifestyle habits were gathered through in-depth interviews with the parents of newcomer children. Many newcomers spoke about their struggles to attain their desired standard of living. Regarding health outcomes, significantly more refugees (23%) had stunted growth when compared with immigrants (5%). Older children, those with better-educated parents, and those who consumed a poorer-quality diet were at a higher risk of being overweight or obese. Sixty percent of refugees and 42% of immigrants had high blood cholesterol. Significant health concerns for refugee children include stunting and high blood cholesterol levels, and emerging trends indicate that older immigrant children from privileged backgrounds in low-income countries may be more at risk of overweight and obesity. A variety of pathways related to their families' conceptualization of life in Canada and the social structures that limit progress to meeting their goals likely influence the development of health inequity among refugee and immigrant children. Public health initiatives should address these health inequities among newcomer families.

Mode of presentation and mortality amongst patients hospitalized with heart failure? A report from the First Euro Heart Failure Survey

BACKGROUND

Heart failure is heterogeneous in aetiology, pathophysiology, and presentation. Despite this diversity, clinical trials of patients hospitalized for HF deal with this problem as a single entity, which may be one reason for repeated failures.

METHODS

The first EuroHeart Failure Survey screened consecutive deaths and discharges of patients with suspected heart failure during 2000-2001. Patients were sorted into seven mutually exclusive hierarchical presentations: (1) with cardiac arrest/ventricular arrhythmia; (2) with acute coronary syndrome; (3) with rapid atrial fibrillation; (4) with acute breathlessness; (5) with other symptoms/signs such as peripheral oedema; (6) with stable symptoms; and (7) others in whom the contribution of HF to admission was not clear.

RESULTS

The 10,701 patients enrolled were classified into the above seven presentations as follows: 260 (2%), 560 (5%), 799 (8%), 2479 (24%), 1040 (10%), 703 (7%), and 4691 (45%) for which index-admission mortality was 26%, 20%, 10%, 8%, 6%, 6%, and 4%, respectively. Compared to those in group 7, the hazard ratios for death during the index admission were 4.9 (p ≤ 0.001), 4.0 (p < 0.001), 2.2 (p < 0.001), 2.1 (p < 0.001), 1.4 (p < 0.04) and 1.4 (p = 0.04), respectively. These differences were no longer statistically significant by 12 weeks.

CONCLUSION

There is great diversity in the presentation of heart failure that is associated with very different short-term outcomes. Only a minority of hospitalizations associated with suspected heart failure are associated with acute breathlessness. This should be taken into account in the design of future clinical trials.

Just Enough Cooks in the Kitchen: Key Ingredients for International Collaboration

Research approaches that cross disciplinary silos, industry sectors, and political borders are now increasingly prioritized for tackling issues of global concern. Nevertheless, team science can be challenging. The goal of this article is to help researchers proactively consider factors influencing conflicts and successes with an emphasis on the health sciences.

Role of plasma asymmetric dimethyl-L-arginine levels in detection of pulmonary hypertension in children with CHD

OBJECTIVES

The objectives of this study were to evaluate the plasma levels of asymmetric dimethyl-L-arginine in children with pulmonary hypertension due to CHD before and after treatment with sildenafil and to evaluate its diagnostic and prognostic value as a biomarker in such children.

METHODS

A total of 60 children with CHD and 30 healthy control children matched for age and sex were recruited. Children with CHD were divided into two equal groups: the normal pulmonary pressure group (n=30) and the pulmonary hypertension group (n=30). Children with pulmonary hypertension were treated with sildenafil and were followed up for 6 months. Clinical data, haemodynamic parameters, echocardiographic examination, and asymmetric dimethyl-L-arginine levels were evaluated before and after treatment.

RESULTS

Asymmetric dimethyl-L-arginine levels were significantly higher in patients with pulmonary hypertension than in those with CHD-only or the control group, and this increase was positively correlated with increased severity of pulmonary hypertension. Asymmetric dimethyl-L-arginine levels, mean pulmonary artery pressure, and pulmonary vascular resistance were significantly decreased after treatment with sildenafil. Moreover, asymmetric dimethyl-L-arginine level was significantly lower in patients who responded to sildenafil treatment compared with those who did not. At a cut-off point of more than 0.85 nmol/ml, asymmetric dimethyl-L-arginine has a sensitivity of 83% and a specificity of 80% to diagnose pulmonary hypertension-CHD. Asymmetric dimethyl-L-arginine has a sensitivity of 100% and a specificity of 94% to predict poor prognosis in pulmonary hypertension-CHD children at a cut-off point of 1.3 nmol/ml.

CONCLUSION

Asymmetric dimethyl-L-arginine level has a good diagnostic and prognostic value as a biomarker in children with pulmonary hypertension-CHD and can be used for following up patients with pulmonary hypertension and predicting response to treatment.

Sleep duration and sleep disturbances in association with falls among the middle-aged and older adults in China: a population-based nationwide study

BACKGROUND

Falls pose major health problems to the middle-aged and older adults and may potentially lead to various levels of injuries. Sleep duration and disturbances have been shown to be associated with falls in literature; however, studies of the joint and distinct effects of those sleep problems are still sparse. To fill this gap, we aimed to determine the association between sleep duration, sleep disturbances and falls among middle-aged and older adults in China controlling for psychosocial, lifestyle, socio-demographical factors and comorbidity.

METHODS

Data were derived from the China Health and Retirement Longitudinal Study (CHARLS) based on multi-stage sampling designs, with respondents aged 50 and older. Associations were evaluated by using multiple logistic regression adjusting for confounders and complex survey design. To further determine if the association of sleep duration/disturbance and falls depends on age groups, the study data were divided into two samples (age 50-64 vs. age 65+) and comparison was made between the two age groups.

RESULTS

Of the 12,759 respondents, 2172 (17%) had falls within the last 2 years. Our findings indicated that the participants who had nighttime sleep duration ≤5 were more likely to report falls than those who had nighttime sleep duration ≥6 h; whereas no association between nighttime sleep duration > 8 h and falls. Participants having sleep disturbances 1-2 days, or 3-4 days, and 5-7 days per week were also more likely to report falls than those who had no sleep disturbance. The nap sleep duration was not significantly associated with falls. Although the combined sample found both sleep duration and sleep disturbance to be strongly associated with falls after adjusting for various confounders, sleep disturbance was not significantly related to falls among participants aged 65 + .

CONCLUSIONS

Our study suggested that there is an independent association between falls and short sleep duration and disturbed sleep among middle-aged and older adults in China. Findings underscore the need for evidence-based prevention and interventions targeting sleep duration and disturbance among this study population.

Effects of Pharmacy-Based Interventions on the Control and Management of Diabetes in Adults: A Systematic Review and Meta-Analysis

OBJECTIVES

The aim of this systematic review and meta-analysis was to evaluate the effects of pharmacy-based interventions on clinical outcomes associated with diabetes-related complications as well as on nonclinical outcomes in people with diabetes.

METHODS

We searched 4 main databases (MEDLINE, EMBASE, CINAHL and Cochrane Central Register of Controlled Trials) for studies that considered clinical and nonclinical outcomes of pharmacy-based interventions among people with diabetes. Clinical outcomes included patients' mean reductions of glycated hemoglobin (A1C) levels and body mass indexes (BMIs). Nonclinical outcomes included patients' healthcare utilization and quality of life. A meta-analysis was conducted to estimate the pooled net mean difference in clinical outcomes between the pharmacy-intervention and the control groups.

RESULTS

Of the 44 studies included in the systematic review, 32 studies reported results from randomized controlled trials measuring reductions of A1C levels in 4,132 patients. Meta-analysis revealed that the standardized absolute mean difference in reduction of A1C levels from baseline to the time of the last follow up significantly favoured the pharmacy intervention versus the control group (0.96%; 95% CI 0.71 to 1.22; p<0.001). Of the studies, 13 reported BMI kg/m² in 1,827 patients. The estimation of standardized absolute mean difference in reduction of BMI unit calculated through meta-analysis was 0.61 (95% CI 0.20 to 1.03; p=0.000) in favour of the pharmacy-intervention group.

CONCLUSIONS

Pharmacy-based interventions have significant positive effects on controlling 2 major risks factors associated with diabetes-related complications: A1C levels and BMI. However, there is a dearth of evidence about the effects of pharmacy-based intervention on nonclinical outcomes, including healthcare utilization and quality of life.

Social determinants of self-reported health for Canada's indigenous peoples: a public health approach

OBJECTIVE

In Canada, indigenous peoples suffer from a multitude of health disparities. To better understand these disparities, this study aims to examine the social determinants of self-reported health for indigenous peoples in Canada.

STUDY DESIGN

This study uses data from Statistics Canada's Aboriginal Peoples Survey 2012.

METHODS

Multinomial logistic regression models were used to examine how selected social determinants of health are associated with self-reported health among off-reserve First Nations and Métis peoples in Canada.

RESULTS

Our analysis shows that being older, female, and living in urban settings were significantly associated with negative ratings of self-reported health status among the indigenous respondents. Additionally, we found that higher income and levels of education were strongly and significantly associated with positive ratings of self-reported health status. Compared with indigenous peoples with an education level of grade 8 or lower, respondents with higher education were 10 times (5.35-22.48) more likely to report 'excellent' and 'very good' health. Respondents who earned more than $40,000 annually were three times (2.17-4.72) more likely to report 'excellent' and 'very good' health compared with those who earned less than $20,000 annually. When interacted with income, we also found that volunteering in the community is associated with better self-reported health.

CONCLUSIONS

There are known protective determinants (income and education) and risk determinants (location of residence, gender, and age) which are associated with self-reported health status among off-reserve First Nations and Métis peoples. For indigenous-specific determinants, volunteering in the community appears to be associated with self-perceived health status. Thus, addressing these determinants will be necessary to achieve better health outcomes for indigenous peoples in Canada. Next steps include developing indigenous-specific social determinants of health indicators that adequately measure culture, connection, and community.

Pediatric cryptosporidiosis: An evaluation of health care and societal costs in Peru, Bangladesh and Kenya

Cryptosporidium is a leading cause of pediatric diarrhea in resource-limited settings; yet, few studies report the health care costs or societal impacts of this protozoan parasite. Our study examined direct and indirect costs associated with symptomatic cryptosporidiosis in infants younger than 12 months in Kenya, Peru and Bangladesh. Inputs to the economic burden model, such as disease incidence, population size, health care seeking behaviour, hospital costs, travel costs, were extracted from peer-reviewed literature, government documents, and internationally validated statistical tools for each country. Indirect losses (i.e. caregiver income loss, mortality, and growth faltering) were also estimated. Our findings suggest that direct treatment costs per symptomatic cryptosporidiosis episode were highest in Kenya ($59.01), followed by Peru ($23.32), and Bangladesh ($7.62). The total annual economic impacts for the 0-11 month cohorts were highest in Peru ($41.5M; range $0.88-$599.3M), followed by Kenya ($37.4M; range $1.6-$804.5M) and Bangladesh ($9.6M, range $0.28-$91.5M). For all scenarios, indirect societal costs far outweighed direct treatment costs. These results highlight the critical need for innovative improvements to current prevention, diagnostic and treatment strategies available in resource poor settings, as well as the need for solutions that span multiple disciplines including food and water safety, sanitation and livestock production.