Exploring a Preliminary Set of Indicators to Measure Adolescent Health: Results From a 12-Country Feasibility Study

PURPOSE

To explore data availability, perceived relevance, acceptability and feasibility of implementing 52 draft indicators for adolescent health measurement in different countries globally.

METHODS

A mixed-methods, sequential explanatory study was conducted in 12 countries. An online spreadsheet was used to assess data availability and a stakeholder survey to assess perceived relevance, acceptability, and feasibility of implementing each draft indicator proposed by the Global Action for Measurement of Adolescent health (GAMA). The assessments were discussed in virtual meetings with all countries and in deep dives with three countries. Findings were synthesized using descriptive statistics and qualitative thematic analysis.

RESULTS

Data availability varied across the 52 draft GAMA indicators and across countries. Nine countries reported measuring over half of the indicators. Most indicators were rated relevant by stakeholders, while some were considered less acceptable and feasible. The ten lowest-ranking indicators were related to mental health, sexual health and substance use; the highest-ranking indicators centered on broader adolescent health issues, like use of health services. Indicators with higher data availability and alignment with national priorities were generally considered most relevant, acceptable and feasible. Barriers to measurement included legal, ethical and sensitivity issues, challenges with multi-sectoral coordination and data systems flexibility.

DISCUSSION

Most of the draft GAMA indicators were deemed relevant and feasible, but contextual priorities and perceived acceptability influenced their implementation in countries. To increase their use for a more comprehensive understanding of adolescent health, better multi-sectoral coordination and tailored capacity building to accommodate the diverse data systems in countries will be required.

Respectful Abortion Care initiative: How a large-scale virtual training for providers in India increased knowledge of the new 2021 Medical Termination of Pregnancy Act

BACKGROUND

In a historic move to ensure comprehensive abortion care, India amended the 1971 Medical Termination of Pregnancy (MTP) Act in 2021, creating an unprecedented opportunity for accelerating safe, respectful, and rights-based abortion services. The Federation of Obstetric and Gynecological Societies of India (FOGSI), together with World Health Organization (WHO) India and the Ministry of Health and Family Welfare, set up a flagship initiative "Respectful Abortion Care" (RAC) to provide training to obstetricians and gynecologists on the new Act, and also address their values and biases.

METHODS

Virtual training sessions were organized during the COVID-19 pandemic to disseminate the amendments made under the MTP Act and address provider values and biases. The primary focus was on private providers as they account for more than half of all abortion services in India (52.9%). The RAC modules were systematically designed and delivered by 690 Master Trainers, trained by FOGSI and WHO.

RESULTS

A total of 9051 FOGSI members (22%, with 50% from private clinics) completed the RAC trainings. Pretests and post-tests were conducted for impact assessment. Significant improvement was seen on knowledge of criteria for termination of pregnancy for significant birth defects (52%-83%). The post-training survey showed a high level of commitment to promote RAC: >95% were strongly motivated to perform or assist in abortion; 89% reported that the WHO value clarification exercises were helpful in facilitating open discussions on sensitive topics in a comfortable manner; 96% expressed a strong commitment to addressing the issue of respect and confidentiality in abortion care.

CONCLUSION

RAC was a unique initiative around the MTP Act amendment 2021 in India, which demonstrated that collaboration and leadership by professional associations can help motivate providers and lead to improved knowledge and commitment from public and private sector providers.

Effectiveness of a participatory approach to develop school health interventions in four low resource cities: study protocol of the 'empowering adolescents to lead change using health data' cluster randomised controlled trial

INTRODUCTION

Comprehensive local data on adolescent health are often lacking, particularly in lower resource settings. Furthermore, there are knowledge gaps around which interventions are effective to support healthy behaviours. This study generates health information for students from cities in four middle-income countries to plan, implement and subsequently evaluate a package of interventions to improve health outcomes.

METHODS AND ANALYSIS

We will conduct a cluster randomised controlled trial in schools in Fez, Morocco; Jaipur, India; Saint Catherine Parish, Jamaica; and Sekondi-Takoradi, Ghana. In each city, approximately 30 schools will be randomly selected and assigned to the control or intervention arm. Baseline data collection includes three components. First, a Global School Health Policies and Practices Survey (G-SHPPS) to be completed by principals of all selected schools. Second, a Global School-based Student Health Survey (GSHS) to be administered to a target sample of n=3153 13-17 years old students of randomly selected classes of these schools, including questions on alcohol, tobacco and drug use, diet, hygiene, mental health, physical activity, protective factors, sexual behaviours, violence and injury. Third, a study validating the GSHS physical activity questions against wrist-worn accelerometry in one randomly selected class in each control school (n approximately 300 students per city). Intervention schools will develop a suite of interventions using a participatory approach driven by students and involving parents/guardians, teachers and community stakeholders. Interventions will aim to change existing structures and policies at schools to positively influence students' behaviour, using the collected data and guided by the framework for Making Every School a Health Promoting School. Outcomes will be assessed for differential change after a 2-year follow-up.

ETHICS AND DISSEMINATION

The study was approved by WHO's Research Ethics Review Committee; by the Jodhpur School of Public Health's Institutional Review Board for Jaipur, India; by the Noguchi Memorial Institute for Medical Research Institutional Review Board for Sekondi-Takoradi, Ghana; by the Ministry of Health and Wellness' Advisory Panel on Ethics and Medico-Legal Affairs for St Catherine Parish, Jamaica, and by the Comité d'éthique pour la recherche biomédicale of the Université Mohammed V of Rabat for Fez, Morocco. Findings will be shared through open access publications and conferences.

TRIAL REGISTRATION NUMBER

NCT04963426.

SCOPE: Surveillance of COVID-19 in pregnancy- results of a multicentric ambispective case-control study on clinical presentation and maternal outcomes in India between April to November 2020

OBJECTIVE

To determine the clinical manifestations, risk factors, treatment modalities and maternal outcomes in pregnant women with lab-confirmed COVID-19 and compare it with COVID-19 negative pregnant women in same age group.

DESIGN

Multicentric case-control study.

DATA SOURCES

Ambispective primary data collection through paper-based forms from 20 tertiary care centres across India between April and November 2020.

STUDY POPULATION

All pregnant women reporting to the centres with a lab-confirmed COVID-19 positive result matched with controls.

DATA QUALITY

Dedicated research officers extracted hospital records, using modified WHO Case Record Forms (CRF) and verified for completeness and accuracy.

STATISTICAL ANALYSIS

Data converted to excel files and statistical analyses done using STATA 16 (StataCorp, TX, USA). Odds ratios (ORs) with 95% confidence intervals (CI) estimated using unconditional logistic regression.

RESULTS

A total of 76,264 women delivered across 20 centres during the study period. Data of 3723 COVID positive pregnant women and 3744 age-matched controls was analyzed. Of the positive cases 56·9% were asymptomatic. Antenatal complications like preeclampsia and abruptio placentae were seen more among the cases. Induction and caesarean delivery rates were also higher among Covid positive women. Pre-existing maternal co-morbidities increased need for supportive care. There were 34 maternal deaths out of the 3723(0.9%) positive mothers, while covid negative deaths reported from all the centres were 449 of 72,541 (0·6%).

CONCLUSION

Covid-19 infection predisposed to adverse maternal outcomes in a large cohort of Covid positive pregnant women as compared to the negative controls.

Increasing Use of Postpartum Family Planning and the Postpartum IUD: Early Experiences in West and Central Africa

A global resurgence of interest in the intrauterine device (IUD) as an effective long-acting reversible contraceptive and in improving access to a wide range of contraceptive methods, as well as an emphasis on encouraging women to give birth in health care facilities, has led programs to introduce postpartum IUD (PPIUD) services into postpartum family planning (PPFP) programs. We describe strategic, organizational, and technical elements that contributed to early successes of a regional initiative in West and Central Africa to train antenatal, maternity, and postnatal care providers in PPFP counseling for the full range of available methods and in PPIUD service delivery. In November 2013, the initiative provided competency-based training in Guinea for providers from the main public teaching hospital in 5 selected countries (Benin, Chad, Côte d'Ivoire, Niger, and Senegal) with no prior PPFP counseling or PPIUD capacity. The training was followed by a transfer-of-learning visit and monitoring to support the trained providers. One additional country, Togo, replicated the initiative's model in 2014. Although nascent, this initiative has introduced high-quality PPFP and PPIUD services to the region, where less than 1% of married women of reproductive age use the IUD. In total, 21 providers were trained in PPFP counseling, 18 of whom were also trained in PPIUD insertion. From 2014 to 2015, more than 15,000 women were counseled about PPFP, and 2,269 women chose and received the PPIUD in Benin, Côte d'Ivoire, Niger, Senegal, and Togo. (Introduction of PPIUD services in Chad has been delayed.) South-South collaboration has been central to the initiative's accomplishments: Guinea's clinical centers of excellence and qualified trainers provided a culturally resonant example of a PPFP/PPIUD program, and trainings are creating a network of regional trainers to facilitate expansion. Two of the selected countries (Benin and Niger) have expanded their PPFP/PPUID training programs to additional sites. Inspired after learning about the initiative at a regional meeting, Togo has outperformed the original countries involved in the initiative by training more providers than the other countries. Challenges to scale-up include a lack of formal channels for reporting PPFP and PPIUD service delivery outcomes, inconsistent coordination of services across the reproductive health continuum of care, and slow uptake in some countries. Continued success will rely on careful recordkeeping, regular monitoring and feedback, and strategic data use to advocate scale-up.

Targeted delivery of siRNA-generating DNA nanocassettes using multifunctional nanoparticles

Molecular therapy using a small interfering RNA (siRNA) has shown promise in the development of novel therapeutics. Various formulations have been used for in vivo delivery of siRNAs. However, the stability of short double-stranded RNA molecules in the blood and efficiency of siRNA delivery into target organs or tissues following systemic administration have been the major issues that limit applications of siRNA in human patients. In this study, multifunctional siRNA delivery nanoparticles are developed that combine imaging capability of nanoparticles with urokinase plasminogen activator receptor-targeted delivery of siRNA expressing DNA nanocassettes. This theranostic nanoparticle platform consists of a nanoparticle conjugated with targeting ligands and double-stranded DNA nanocassettes containing a U6 promoter and a shRNA gene for in vivo siRNA expression. Targeted delivery and gene silencing efficiency of firefly luciferase siRNA nanogenerators are demonstrated in tumor cells and in animal tumor models. Delivery of survivin siRNA expressing nanocassettes into tumor cells induces apoptotic cell death and sensitizes cells to chemotherapy drugs. The ability of expression of siRNAs from multiple nanocassettes conjugated to a single nanoparticle following receptor-mediated internalization should enhance the therapeutic effect of the siRNA-mediated cancer therapy.

Passive transfer of hepatitis antibodies during intravenous administration of immune globulin

We studied the effect of intravenous immune globulin (IVIG) infusion on the levels of hepatitis B and C antibodies in 10 premature babies. All four tested lots of a commercially purchased IVIG preparation were found to contain substantial amounts of hepatitis B core and hepatitis C antibodies. Our results show that passive transfer of hepatitis B and C virus antibodies occurred after IVIG infusion, and that the levels were dependent on the quantity of IVIG given. When assessing neonates for hepatitis, the factor of receipt of blood products, including IVIG, needs to be considered to interpret laboratory results.

Diphallus and associated anomalies with balanced autosomal chromosomal translocation

We report a sporadic case of complete diphallus with multiple other anomalies in a premature newborn. Chromosomal analysis at the 500 band level showed an apparently balanced reciprocal translocation 46,XY, t(1;14)(p36.3;q24.3). The mother has a normal karyotype, but the father was not available for chromosomal analysis. The significance of this balanced chromosomal rearrangement and the possibility that the chromosomal breakpoints contribute to deregulation of mesodermal development is discussed.

Population pharmacokinetics of ceftizoxime in premature newborns

The population pharmacokinetic parameters of ceftizoxime were determined in 50 premature newborns less than 1 week of age (birth weight = 1.8 +/- 0.6 kg) with a clinical diagnosis of suspected sepsis. Each infant received ceftizoxime 25 mg/kg every 12 h intravenously over 30 min for a total of 6 doses. Serum concentrations of ceftizoxime were assayed by HPLC at 0.5, 1, 2.5 and 11.5 h or at 0.5, 1.5, 4.5 and 11.5 h after the first and the sixth dose. A total of 184 serum concentrations following the first dose and 160 following the sixth dose were fit separately and then collectively to a one-compartment model using NONMEM. The separately estimated parameters were not significantly different between the first and the sixth dose. The final parameter estimates were 27.1 ml/h/kg, 333 ml/kg and 8.5 h for clearance, volume of distribution and half-life, respectively. Other factors including gestational and postnatal age were not associated with alterations in ceftizoxime clearance. That the large variability in clearance was decreased from a coefficient of variation of 80 to 50% warrants dosing premature infants on the basis of body weight. The results of this study suggest that 25 mg/kg ceftizoxime every 12 h appears to be an appropriate dosing regimen for premature neonates.

Developmental follow-up of very low birthweight premature infants with low free thyroxine

If a low level of free thyroxine (T4) is predictive of the true hypothyroidism in sick premature infants, long-term developmental follow-up of these infants should reveal a direct correlation between the free thyroxine level early in life and developmental disability in later years. Half of the 16 infants who were followed had normal free T4 (0.8 ng/dl or higher) and the remaining 8 infants had a low free T4 (0.38 +/- 0.15 ng/dl) during the first 2 weeks of life. Infants with low free T4 were followed sequentially during their stay in the neonatal intensive care unit and all eight showed free T4 levels more than 0.8 ng/dl by 36 to 44 weeks postconceptional age without any thyroid replacement. At follow-up, all 16 infants were functioning within normal range by Stanford-Binet testing at mean age of 4.6 years. There was no significant difference between the two groups in their motor development, hearing, language, or physical growth. Despite the small sample size, it appears there is no correlation between the free T4 levels during the first 2 weeks of life in infants 33 weeks' or less gestation and their developmental outcome at mean age of 4.6 years.

Effect of fluids on life span of peripheral arterial lines

This study examines the effect of two different fluids to maintain peripheral arterial line patency at 1 to 2 ml/hr in a randomized controlled trial. Sixty sick newborn infants requiring ventilatory support and frequent blood gas monitoring were randomly assigned to receive either heparinized normal saline (HNS) or heparinized 5% dextrose water (HD5W) to maintain peripheral arterial line patency. One unit of heparin was added to each mililiter of both solutions. The duration of functional arterial lines, sodium balance, and number of peripheral punctures for blood glucose monitoring were compared using Student's t test for independent samples. HNS peripheral arterial catheters functioned significantly longer than HD5W without increased risk of hypernatremia. We conclude that HNS in arterial catheters is safe, lasts longer, and saves the infant (1500 gm or more) from the unnecessary stress of multiple peripheral punctures for blood glucose measurements, which can be obtained from the arterial catheter if glucose is not part of the infusate.

Intermamillary indices in premature infants

The internipple distance and its relationship to gestational age has not been studied in infants born in the United States. One hundred and thirty-three newborns between 25 and 40 weeks gestation showed progressive increase in the internipple distance with increasing gestational age. The internipple index stays constant during various gestational ages. The internipple index greater than 28% (greater than 2 SD) at any gestational age or during immediate postnatal age should be flagged to look into widely spaced nipples. Extrauterine growth of internipple distance is similar to that of intrauterine growth.

Amino acid mixture designed to maintain normal plasma amino acid patterns in infants and children requiring parenteral nutrition

A mixture of amino acids designed to maintain normal plasma amino acid concentrations of infants and children requiring parenteral nutrition was evaluated in 40 infants and children receiving only parenteral nutrients (2.39 +/- 0.26 g/kg/d of amino acids and 110.3 +/- 10.4 kcal/kg/d) for five to 21 days. The children ranged in weight from 2.0 to 12.6 kg (median weight, 3.83 kg; fifth to 95th percentile, 2.06 to 11.1 kg) and in age from 1 week to 43.6 months (median age, 2.7 months; fifth to 95th percentile, 0.2 to 25.3 months). Mean weight gain was 11.0 +/- 5.0 g/kg/d; mean nitrogen balance was 242 +/- 70 mg/kg/d. Plasma concentrations of all amino acids except tyrosine were within the normal range (ie, within the 95% confidence limits of the two-hour postprandial plasma concentrations observed in 30-day-old, healthy, normally growing, breast-fed, term infants) throughout the period of study. Mean prestudy and poststudy serum total protein, albumin, and transthyretin (prealbumin) concentrations were not significantly different. However, plasma transthyretin concentration increased in all children with low prestudy concentrations. Mean poststudy serum total bilirubin concentration of the total population was not different from the mean prestudy concentration. This was true also for the 31 children who received the parenteral amino acid mixture for more than ten days. In contrast to the expected 30% to 50% incidence of cholestasis, only one of these 31 experienced an unexplained increase in serum total bilirubin concentration during study, suggesting that normalizing plasma amino acid concentrations and/or providing taurine during parenteral nutrition may decrease the incidence of cholestasis associated with this therapy.

Comparison of the effect of asphyxia, hypoxia, and acidosis on intestinal blood flow and O2 uptake in newborn piglets

The aim of our study was to compare the effects of asphyxia and the two components of asphyxia, i.e. hypoxia and acidosis, on intestinal blood flow and oxygen consumption in anesthetized newborn piglets less than 3 days old. The first series of experiments, consisting of four groups of piglets, showed that blood flow to the proximal and distal small intestine and colon (as determined by the microsphere technique) significantly decreased after piglets were subjected to a sustained hypoxic hypoxemia (PaO2 50% of control) or asphyxia (acidosis plus hypoxia) for 90 min. A sustained acidosis (arterial pH = 7.0-7.15 for 90 min), however, decreased blood flow only to the proximal small intestine, and sham operation did not significantly alter any intestinal blood flow. All animals subjected to asphyxia and two of five of the animals subjected to hypoxia alone in this series, produced gross and microscopic intestinal lesions similar to those seen in human newborn with necrotizing enterocolitis. Acidosis alone, however, did not produce any pathologic lesions. The second series of experiments showed that the 90-min hypoxic hypoxemia decreased blood flow to both the mucosa and muscularis layers of the small intestine. The third series of experiments, consisting of four groups of piglets, determined the effects of 60-min acidosis, hypoxic hypoxemia, asphyxia, or sham operation on venous outflow and oxygen consumption of the isolated in situ terminal ileum. Acidosis or sham operation altered neither ileal blood flow nor oxygen consumption. Hypoxia or asphyxia, however, decreased ileal oxygen consumption without significantly decreasing blood flow.(ABSTRACT TRUNCATED AT 250 WORDS)

Monitoring critically ill newborn infants with digital capillary blood samples: an alternative

Capillary blood samples obtained from a warmed distal phalanx of the right hand were compared with either temporal or right radial arterial blood samples for PO2, PCO2, and pH in 33 critically ill newborn infants. The blood pressure and skin temperatures of each infant and the ambient oxygen concentration were recorded at the time the blood was sampled. Sixty-eight paired PO2 analyses yielded a regression line close to the line of identity. The mean difference between digital capillary and arterial PO2 was 11.3 +/- 1.4 mm Hg (r = 0.92). The results were similar for the paired PCO2 analyses (r = 0.84) and for the paired pH analyses (r = 0.94). The correlation between arterial PO2 and digital capillary PO2 deteriorated when the systolic blood pressure of the patient was below 35 mm Hg. There was no correlation between skin temperature and capillary-arterial PO2 differences. The frequency of retrolental fibroplasia leading to blindness was not different from that in nurseries that sample umbilical arterial blood routinely.