Geographical variation and temporal trend in anemia among children aged 6-59 months in low- and middle-income countries during 2000-2018: forecasting the 2030 SDG target.

OBJECTIVE: To examine geographical variations, trends and projections in the prevalence of childhood anemia at national and subpopulation levels. DESIGN: Repeated cross-sectional Demographic and Health Survey (DHS) conducted during 2000-2018. SETTING: Fifty-three low- and middle-income countries (LMIC). PARTICIPANTS: Totally, 776 689 children aged 6-59 months. RESULTS: During the latest DHS rounds between 2005 and 2018, the prevalence of child anemia was > 20 % in fifty-two out of fifty-three countries and ranged from 15·9 % in Armenia in 2016 to 87·8 % in Burkina Faso in 2010. Out of thirty-six countries with at least two surveys during 2000-2018, the prevalence of child anemia decreased in twenty-two countries, highest in Zimbabwe (-4·2 %) and increased in fourteen countries, highest in Burundi (5·0 %). Based on the trend, eleven and twenty-two out of thirty-six countries are projected to experience, respectively, moderate and severe public health problem according to the WHO criteria (moderate problem: 20-39·9 % and severe problem: ≥ 40 %) due to child anemia in 2030, with the highest prevalence in Liberia (87·5 %, 95 % credible interval 52·0-98·8 %). The prevalence of child anemia varied across the mother's education and age, child sex, wealth quintiles, and place of residence, with the highest rate of child anemia among the poorest, rural and low-educated mothers. These scenarios are projected to continue. The probability of reducing child anemia at < 0·5 % by 2030 is 0 % for all study countries. CONCLUSIONS: The prevalence of child anemia varied between and within countries. None of the thirty-six LMIC is likely to eradicate child anemia by 2030.

Elective Caesarean Delivery Associated with Infant Hospitalisation for Intestinal But Not Respiratory Infection.

OBJECTIVES: We assessed the impact of caesarean delivery on offspring respiratory and intestinal infection. METHODS: Data were extracted from all live births (n = 429,058) occurring in the Australian state of Queensland between January 2009 and December 2015, and followed for 12 months. Births were categorised as either non-medically indicated caesarean or vaginal delivery and each offspring had a record (present/absent) of respiratory and intestinal infection hospitalisation for each month from birth to 12 months. RESULTS: Infants delivered by non-medically indicated caesarean were more likely to experience respiratory infection [OR = 1.51 (1.15, 1.99)] and intestinal infection [OR = 1.74 (1.19, 2.55)] than those born by vaginal delivery. In the propensity score weighted analyses the estimate for respiratory infection was similar but non-significant [OR = 1.52 (0.99, 2.31)], while the association with intestinal infection strengthened [OR = 2.21 (1.25, 3.89)]. CONCLUSIONS FOR PRATICE: Our findings provide strong evidence for a specific and clinically meaningful link between non-medically indicated caesarean delivery and infant intestinal infection.

Seroprevalence of and risk factors for Q fever in dairy and slaughterhouse cattle of Jimma town, South Western Ethiopia.

BACKGROUND: Q fever is a zoonotic disease, caused by Gram negative bacterium C. burnetii, which imparts significant socio-economic burden due to production and reproductive loss (abortion, stillbirth, and infertility) in ruminants and debilitating clinical disease in human populations. While sheep and goats are considered the primary reservoirs of infection to humans, infection can also result from exposure to cattle. Recent studies indicate that in Ethiopia Q fever is a disease of growing public health interest. The top cattle producing region in Ethiopia is the Oromia region and Jimma is the zone that ranks first in the population of cattle within Oromia. While in Jimma zone livestock production plays an important role in people's livelihoods and nutrition, to date, there is no available report on seroprevalence of Q fever in cattle. This is particularly important due to the low dairy farm biosecurity in Jimma town. This study aimed to evaluate the potential risk for public health from cattle production; a specific objective of this study included the estimation of the seroprevalence of C. burnetii infection and its potential risk factors in dairy cattle and cattle for slaughter in Jimma Town. RESULTS: The seroprevalence of C. burnetii in cattle present at dairy farms was significantly lower compared to cattle presented at slaughterhouse [6.17% (95% CI: 3.41-10.13) and 11.79% (95% CI: 7.63-17.17), respectively; (P = 0.04)]. As the age of dairy cattle increase by 1 year, they were 1.51 more likely to be positive of C. burnetii [OR = 1.51 (95%CI: 1.30-1.75; (P = 0.000)]. Cattle managed in semi-intensive production systems were 8.08 more likely to be C. burnetii seropositive compared to intensively managed dairy cattle [OR = 8.08 (95%CI: 1.03-63.68); P = 0.047]. Dairy cattle with access to nuisance animals like dogs, cats and mice were 5.65 more likely to be C. burnetii seropositive compared to dairy cattle without access to these animals. On the other hand, dairy cattle that have no tick infestation are 93% less likely to be seropositive for C. burnetii [OR = 0.07 (95%CI: 0.01-0.74); P = 0.027]. Concerning farm-level data, farms of larger herd sizes were 1.03 more likely to be C. burnetii seropositive than small herd farms [OR = 1.03 (95%CI: 0.99-1.06)]. The result from slaughterhouse indicates that as the age of cattle increase by 1 year their chance of being C. burnetii seropositive increases by 2.27 [OR = 2.27 (95%CI: 1.93-2.68); p = 0.000]. CONCLUSION: Considering its zoonotic and economic burden the seroprevalence of Q fever recorded in this study is of eminent public health concern with a farm-level and slaughterhouse seroprevalence of 6.17 and 11.79% respectively. Based on modifiable risk factors identified in this study, Q fever management plans better be focused on health education and awareness campaigns for abattoir workers and dairy farm workers. Dairy farm Q fever management plans should contemplate improved dairy herd biosecurity with regards to cattle tick infestation, keeping different livestock species segregated and avoiding mixing of herd with others with unknown health status.

Comparison of influenza disease burden in older populations of Hong Kong and Brisbane: the impact of influenza and pneumococcal vaccination.

BACKGROUND: Influenza and pneumococcal vaccine uptake in the older population aged 65 years or over of Hong Kong dramatically increased since the 2003 SARS outbreak. This study is aimed to evaluate the impact of increased coverage of influenza and pneumococcal vaccines by comparing the change of disease burden in the older population of Hong Kong, with the burden in the older population of Brisbane with relatively high vaccine coverage in the past fifteen years. METHODS: Time series segmented regression models were applied to weekly numbers of cause-specific mortality or hospitalization of Hong Kong and Brisbane. Annual excess rates of mortality or hospitalization associated with influenza in the older population were estimated for the pre-SARS (reference period), post-SARS and post-pandemic period, respectively. The rate ratios (RRs) between these periods were also calculated to assess the relative change of disease burden. RESULTS: Compared to the pre-SARS period, excess rates of mortality associated with influenza during the post-SARS period in Hong Kong decreased for cardiorespiratory diseases (RR = 0.90, 95% CI 0.80, 1.01), stroke (RR = 0.74, 95% CI 0.50, 1.09), and ischemic heart diseases (RR = 0.45, 95% CI 0.34, 0.58). The corresponding RRs in Brisbane were 0.79 (95% CI 0.54, 1.15), 0.33 (0.13, 0.80), and 1.09 (0.62, 1.90), respectively. Only the mortality of ischemic heart diseases showed a greater reduction in Hong Kong than in Brisbane. During the post-pandemic period, excess rates of all-cause mortality increased in Hong Kong, but to a lesser extent than in Brisbane (RR = 1.41 vs 2.39). CONCLUSION: A relative decrease (or less of an increase) of influenza disease burden was observed in the older population of Hong Kong after increased coverage of influenza and pneumococcal vaccines in this population, as compared to those of Brisbane where vaccination rates remained stable. The lack of significant findings in some disease categories highlights the challenges of evaluating the benefits of vaccination at the population level.

Prevalence and risk factors of vitamin D insufficiency and deficiency among 6-24-month-old underweight and normal-weight children living in an urban slum of Bangladesh.

OBJECTIVE: We quantified the prevalence of vitamin D status in 6-24-month-old underweight and normal-weight children and identified the socio-economic and dietary predictors for status. DESIGN: Cross-sectional, baseline data from a nutritional intervention study were analysed. Multinomial logistic regression was used to estimate the odds of being vitamin D deficient or insufficient with the reference being vitamin D sufficient. SETTING: Urban slum area of Mirpur field site, Dhaka, Bangladesh. SUBJECTS: Underweight (weight-for-age Z-score <-2·00) and normal-weight (weight-for-age Z-score ≥-1·00) children aged 6-24 months. RESULTS: Among 468 underweight children, 23·1 % were sufficient, 42·3 % insufficient, 31·2 % deficient and 3·4 % severely vitamin D deficient. Among 445 normal-weight children, 14·8 % were sufficient, 39·6 % insufficient and 40·0 % deficient and 5·6 % severely deficient. With adjusted multinominal regression analysis, risk factors (OR (95 % CI)) for vitamin D deficiency in underweight children were: older age group (18-24 months old; 2·9 (1·5-5·7)); measurement of vitamin D status during winter (3·0 (1·4-6·4)) and spring (6·9 (3·0-16·1)); and maternal education (≥6 years of institutional education; 2·2 (1·0-4·9)). In normal-weight children, older age group (3·6 (1·2-10·6)) and living in the richest quintile (3·7 (1·1-12·5)) were found to be significantly associated with vitamin D insufficiency. CONCLUSIONS: The study demonstrates a significant burden of vitamin D insufficiency and deficiency in both underweight and normal-weight children <2 years of age from an urban slum of Bangladesh. Identification of risk factors may help in mitigating the important burden in such children.

Heterogeneous and Dynamic Prevalence of Asymptomatic Influenza Virus Infections.

Influenza infection manifests in a wide spectrum of severity, including symptomless pathogen carriers. We conducted a systematic review and meta-analysis of 55 studies to elucidate the proportional representation of these asymptomatic infected persons. We observed extensive heterogeneity among these studies. The prevalence of asymptomatic carriage (total absence of symptoms) ranged from 5.2% to 35.5% and subclinical cases (illness that did not meet the criteria for acute respiratory or influenza-like illness) from 25.4% to 61.8%. Statistical analysis showed that the heterogeneity could not be explained by the type of influenza, the laboratory tests used to detect the virus, the year of the study, or the location of the study. Projections of infection spread and strategies for disease control require that we identify the proportional representation of these insidious spreaders early on in the emergence of new influenza subtypes or strains and track how this rate evolves over time and space.

Community-based interventions to enhance knowledge, protective attitudes and behaviors towards canine rabies: results from a health communication intervention study in Guangxi, China.

BACKGROUND: In China canine rabies poses a serious public health problem in that human mortality ranks the second highest globally. While rabies health education interventions are advocated by WHO to be critical components of modern rabies control and prevention programs, available studies have not adequately investigated the relative efficacy of their implementation in at-risk populations. This study aims to measure and compare the effect on knowledge and protective behavior towards rabies of health education interventions that include a novel Short Messaging Service via cell phone (SMS) and rabies health information sessions (IS). METHODS: The study used a between-subject design involving repeated measures of rabies-related KAP (knowledge, attitude and practice). A total of 350 randomly selected villagers were randomly allocated into three intervention (SMS, IS and SMS + IS) and one control group. The content of SMS and IS covered topics about rabies prevention and route of transmission. The SMS intervention consisted of ten separate messages delivered three times two weeks after the pretest; the IS intervention was conducted once immediately after the pretest. A validated questionnaire was used to capture demographic information and KAP information. Ordinary Least Squares regression was used to contrast the effects of interventions. RESULTS: Our results indicate that overall SMS outperforms IS at improving knowledge and protective behavior against rabies. Our results suggest that a combined intervention of SMS and IS can result in higher scores than any of the two in isolation. The impact of SMS, IS and SMS + IS is greatest on knowledge, followed by attitude and practice scores. CONCLUSION: This study demonstrated that health communication modes based on SMS, IS and a combination of the two are all effective to improve rabies-related KAP in the short term. These findings highlight the potential usefulness of SMS as an additional tool for public health communication and promotion; further studies are needed to investigate the long term benefits of these interventions on the reduction of dog bites and resulting human rabies incidence.

Nasal microbiota profiles in shelter dogs with dermatological conditions carrying methicillin-resistant and methicillin-sensitive Staphylococcus species.

Dermatological conditions may be complicated by Staphylococcus spp. infections influencing skin and nasal microbiota. We investigated the associations between the resident nasal microbiota of shelter dogs with and without dermatological conditions carrying methicillin-resistant and -sensitive Staphylococcus spp. Nasal sampling of 16 dogs with and 52 without dermatological conditions were performed upon shelter admission (baseline), and then bi-weekly until discharge (follow-up). All samples were cultured for Staphylococcus spp., while 52 samples underwent microbiota analysis. Two elastic net logistic regression (ENR) models (Model 1-baseline samples; Model 2-follow-up samples) were developed to identify predictive associations between dermatological conditions and the variables: signalment, antimicrobial treatment, and nasal microbial genera. Follow-up nasal samples of dogs with dermatological conditions had decreased microbiota diversity and abundance compared to dogs without dermatological conditions. Our ENR models identified predictive differences in signalment and nasal microbial genera between baseline and follow-up samples. Co-occurrence networks showed nasal microbial genera were more dissimilar when comparing dogs with and without dermatological conditions at follow-up. Overall, this study is the first to investigate Staphylococcus spp. carriage effects on nasal microbial genera in a canine animal shelter population, and ultimately reveals the importance of investigating decolonisation and probiotic therapies for restoring nasal microbiota.

Finding malaria hot-spots in northern Angola: the role of individual, household and environmental factors within a meso-endemic area.

BACKGROUND: Identifying and targeting hyper-endemic communities within meso-endemic areas constitutes an important challenge in malaria control in endemic countries such like Angola. Recent national and global predictive maps of malaria allow the identification and quantification of the population at risk of malaria infection in Angola, but their small-scale accuracy is surrounded by large uncertainties. To observe the need to develop higher resolution malaria endemicity maps a predictive risk map of malaria infection for the municipality of Dande (a malaria endemic area in Northern Angola) was developed and compared to existing national and global maps, the role of individual, household and environmental risk factors for malaria endemicity was quantified and the spatial variation in the number of children at-risk of malaria was estimated. METHODS: Bayesian geostatistical models were developed to predict small-scale spatial variation using data collected during a parasitological survey conducted from May to August 2010. Maps of the posterior distributions of predicted prevalence were constructed in a geographical information system. RESULTS: Malaria infection was significantly associated with maternal malaria awareness, households with canvas roofing, distance to health care centre and distance to rivers. The predictive map showed remarkable spatial heterogeneity in malaria risk across the Dande municipality in contrast to previous national and global spatial risk models; large high-risk areas of malaria infection (prevalence >50%) were found in the northern and most eastern areas of the municipality, in line with the observed prevalence. CONCLUSIONS: There is remarkable spatial heterogeneity of malaria burden which previous national and global spatial modelling studies failed to identify suggesting that the identification of malaria hot-spots within seemingly mesoendemic areas may require the generation of high resolution malaria maps. Individual, household and hydrological factors play an important role in the small-scale geographical variation of malaria risk in northern Angola. The results presented in this study can be used by provincial malaria control programme managers to help target the delivery of malaria control resources to priority areas in the Dande municipality.

Research and Innovation Opportunities to Improve Epidemiological Knowledge and Control of Environmentally Driven Zoonoses.

While zoonotic diseases are defined by transmission processes between animals and humans, for many of these diseases the presence of a contaminated environmental source is the cause of transmission. Most zoonoses depend on complex environmentally driven interactions between humans and animals, which occur along an occupational and recreational environmental continuum, including farming and animal marketing systems, environmental management systems, and community leisure environments. Environmentally driven zoonoses (EDZs) are particularly challenging to diagnose and control as their reservoirs are in the natural environment and thus often escape conventional surveillance systems that rely on host monitoring. Changes in the environment as a result of climate change [1], human population density [2], and intensification of agriculture [3] have been linked to increasing transmission events for this group of infections. As such, there is a recognised need to be able to detect the presence of EDZs in the environment as a means to better anticipate transmission events and improve source attribution investigations. Finally, the recognition that a One Health approach is needed to combat these infections is signalling to governments the need to develop policy that optimises trade-offs across human, animal, and environmental health sectors. In this review, we discuss and critically appraise the main challenges relating to the epidemiology, diagnosis, and control of environmental zoonotic disease. Using a set of exemplar diseases, including avian influenza and antimicrobial resistant pathogens, we explore the epidemiological contexts (risk factors) within which these infections not only impact human health but also contribute to animal health and environmental impacts. We then critically appraise the surveillance challenges of monitoring these infections in the environment and examine the policy trade-offs for a more integrated approach to mitigating their impacts.

Impact of a 5-Year Mass Drug Administration Programme for Soil-Transmitted Helminthiases on the Spatial Distribution of Childhood Anaemia in Burundi from 2007 to 2011.

Background: Childhood anaemia affects 1.8 billion people globally. Little is known about the long-term impact of mass drug administration (MDA) for the control of soil-transmitted helminthiases (STH) on the spatiotemporal variation of anaemia prevalence and severity. We describe the long-term spatiotemporal impact of a 5-year STH MDA programme (2007−2011) on the prevalence of anaemia and anaemia severity in school-aged children (SAC) in Burundi. Methodology/Principal Findings: We used annual haemoglobin concentration and STH data collected during 2007−2011 in 31 schools in Burundi. Spatial dependence in prevalence and severity of anaemia was assessed using semivariograms. Bayesian geostatistical models were developed to (a) quantify the role of STH (adjusted for other anaemia determinants) in the spatiotemporal distribution of anaemia prevalence/severity, and (b) predict the geographical variation of both outcomes across Burundi. Adjusted population data were used to estimate the geographical distribution of the number of SAC at risk of anaemia and with low and moderate/severe anaemia. Infections with Ascaris lumbricoides and Trichuris trichiura were positively and significantly associated with childhood anaemia; hookworm infections were not. A significant decrease in anaemia prevalence, from 40−50% (2008) to 10−20% (2011) was predicted in western areas. The predicted prevalence of low-severity anaemia decreased from 40−50% (2008) to <20% (2011) in southern and eastern areas. Moderate/high-severity anaemia was concentrated in western regions of Burundi, with pockets of moderate/high-severity anaemia in central and northern regions in 2008. The overall number of predicted anaemic children decreased from 443,657 (2008) to 232,304 (2011), with a resurgence after MDA disruption in 2010 (to 480,605). Prevalence of low- and moderate-severity anaemia was higher in boys than in girls. Conclusions/Significance: Despite ongoing MDA, the prevalence of anaemia in SAC remained high and increased in certain parts of the country. It is recommended that MDA programmes targeting STH are complemented with specific anaemia interventions.

Knowledge, Attitudes, and Common Practices of Livestock and Poultry Veterinary Practitioners Regarding the AMU and AMR in Bangladesh.

Current evidence indicates that more than half of all antimicrobials are used in the animal food-producing sector, which is considered a significant risk factor for the development, spread, and existence of antimicrobial resistance (AMR) pathogens in animals, humans, and the environment. Among other factors, clinical etiology and the level of knowledge, attitudes, and practices (KAP) of veterinarians are thought to be responsible for inappropriate prescriptions in the animal-source protein production sector in lower-resource settings like Bangladesh. We performed this cross-sectional study to assess factors associated with veterinarians' antimicrobial prescription behavior and their KAP on antimicrobial use (AMU) and AMR in Bangladesh. Exploratory and multivariate logistic models were used to describe an association between knowledge, attitudes, and practices of AMU and AMR and demographic characteristics of veterinarians. The results demonstrated that when selecting an antimicrobial, there was no to minimal influence of culture and susceptibility tests and patients' AMU history but moderate to high influence of the farmer's economic condition and drug instructions among the veterinarians. The results also demonstrated that more than half of the veterinarians had correct KAP regarding AMU and AMR, while the rest had moderate or lower levels of KAP. The factor score analysis revealed that age, level of education, years of experience, gender, and previous training on AMU and AMR were the key influencing factors in their level of KAP. Adjusted logistic regression analysis showed that respondents' age, current workplace, and previous training on AMU and AMR had a positive association with increased KAP. Considering the results, it is imperative to include AMR issues on vet curricula, and to provide post-education training, awareness campaigns, easy access to, and dissemination of AMR resources. Increasing the veterinary services to the outreach areas of the country and motivating veterinarians to follow the national AMR guidelines could be some other potential solutions to tackle the over-prescriptions of antimicrobials.

Exploring the determinants of influenza A/H7N9 control intervention efficacy in China: Disentangling the effect of the '1110' policy and poultry vaccination.

The influenza A virus of the H7N9 subtype (FLUAV H7N9) emerged in Eastern China provinces in 2013 causing illness in both poultry and humans. Most reported FLUAV H7N9 human cases were related to those associated with the live poultry market chain. From 2013 to 2017, there were five epidemic waves of human infections, and from the end of 2016, the number of human cases increased sharply. To control FLUAV H7N9 in the market chain, the so-called '1110' policy at live poultry markets and a national vaccination programme were implemented. The relative efficacy of these two measures on the number of poultry and human infections has not been quantified and compared. To explore their efficacy, a cross-sectional study was conducted in six provinces of China, and the vaccination and surveillance data of H7N9 were analysed. Our survey data showed that poultry vendors were not widely aware of and did not accept the '1110' policy. For subjective and objective factors, some measures of the '1110' policy were not implemented in live bird markets (LBMs). However, the national vaccination programme achieved good immune effects and sharply decreased poultry FLUAV H7N9 infections. The detection rates of FLUAV H7N9 in LBMs and farms gradually decreased since the vaccination programme was implemented. Our analysis also indicated that human infections were closely related to poultry virus carriage rates; therefore, controlling FLUAV H7N9 circulation in poultry was an effective measure to control FLUAV H7N9 infections in humans. Although LBMs play a significant role in human infections, the management measures may not be implemented efficiently; hence, we need to conduct more investigations before developing related policies.

Epidemiological characteristics and spatiotemporal patterns of scrub typhus in Fujian province during 2012-2020.

BACKGROUND: Scrub typhus has become a serious public health concern in the Asia-Pacific region including China. There were new natural foci continuously recognized and dramatically increased reported cases in mainland China. However, the epidemiological characteristics and spatiotemporal patterns of scrub typhus in Fujian province have yet to be investigated. OBJECTIVE: This study proposes to explore demographic characteristics and spatiotemporal dynamics of scrub typhus cases in Fujian province, and to detect high-risk regions between January 2012 and December 2020 at county/district scale and thereby help in devising public health strategies to improve scrub typhus prevention and control measures. METHOD: Monthly cases of scrub typhus reported at the county level in Fujian province during 2012-2020 were collected from the National Notifiable Disease Surveillance System. Time-series analyses, spatial autocorrelation analyses and space-time scan statistics were applied to identify and visualize the spatiotemporal patterns of scrub typhus cases in Fujian province. The demographic differences of scrub typhus cases from high-risk and low-risk counties in Fujian province were also compared. RESULTS: A total of 11,859 scrub typhus cases reported in 87 counties from Fujian province were analyzed and the incidence showed an increasing trend from 2012 (2.31 per 100,000) to 2020 (3.20 per 100,000) with a peak in 2018 (4.59 per 100,000). There existed two seasonal peaks in June-July and September-October every year in Fujian province. A significant positive spatial autocorrelation of scrub typhus incidence in Fujian province was observed with Moran's I values ranging from 0.258 to 0.471 (P<0.001). Several distinct spatiotemporal clusters mainly concentrated in north and southern parts of Fujian province. Compared to low-risk regions, a greater proportion of cases were female, farmer, and older residents in high-risk counties. CONCLUSIONS: These results demonstrate a clear spatiotemporal heterogeneity of scrub typhus cases in Fujian province, and provide the evidence in directing future researches on risk factors and effectively assist local health authorities in the refinement of public health interventions against scrub typhus transmission in the high risk regions.

Toxoplasma gondii Infection Is Associated with Low Birth Weight: Findings from an Observational Study among Rural Bangladeshi Women.

Gestational Toxoplasma gondii (T. gondii) infection may cause substantial adverse effects on developing fetuses, newborns and also mothers. This study aims to estimate the seroprevalence of T. gondii among rural Bangladeshi pregnant women and determine the risk of a low birth weight (LBW). We followed a longitudinal design where 208 pregnant women were followed until the birth of their infants. Levels of IgG and IgM of T. gondii were assessed using chemiluminescent immunoassay. Modified Poisson regression was used to estimate crude and adjusted associations and multiple regression analysis was performed to understand the confounding and modifying effects of the variables. Thirty-nine (19%) children were born with LBW, among whom 15 (39%) mothers were positive for T. gondii IgG during pregnancy. After adjusting for several confounders and modifiers, pregnant women with T. gondii IgG or IgM seropositivity were significantly associated with LBW of infants (aRR: 2.00, 95% CI: 1.17-3.42). The strength of this association increased after adjusting for maternal education (aRR: 4.88, 95% CI: 1.74-13.69). The final model had an AROC of 0.84 with a sensitivity of 36% and specificity of 97%. Although causality is yet to be established, the study observed an association between T. gondii infection during pregnancy among rural Bangladeshi women and LBW of newborns.

Mapping the risk of anaemia in preschool-age children: the contribution of malnutrition, malaria, and helminth infections in West Africa.

BACKGROUND: Childhood anaemia is considered a severe public health problem in most countries of sub-Saharan Africa. We investigated the geographical distribution of prevalence of anaemia and mean haemoglobin concentration (Hb) in children aged 1-4 y (preschool children) in West Africa. The aim was to estimate the geographical risk profile of anaemia accounting for malnutrition, malaria, and helminth infections, the risk of anaemia attributable to these factors, and the number of anaemia cases in preschool children for 2011. METHODS AND FINDINGS: National cross-sectional household-based demographic health surveys were conducted in 7,147 children aged 1-4 y in Burkina Faso, Ghana, and Mali in 2003-2006. Bayesian geostatistical models were developed to predict the geographical distribution of mean Hb and anaemia risk, adjusting for the nutritional status of preschool children, the location of their residence, predicted Plasmodium falciparum parasite rate in the 2- to 10-y age group (Pf PR(2-10)), and predicted prevalence of Schistosoma haematobium and hookworm infections. In the four countries, prevalence of mild, moderate, and severe anaemia was 21%, 66%, and 13% in Burkina Faso; 28%, 65%, and 7% in Ghana, and 26%, 62%, and 12% in Mali. The mean Hb was lowest in Burkina Faso (89 g/l), in males (93 g/l), and for children 1-2 y (88 g/l). In West Africa, severe malnutrition, Pf PR(2-10), and biological synergisms between S. haematobium and hookworm infections were significantly associated with anaemia risk; an estimated 36.8%, 14.9%, 3.7%, 4.2%, and 0.9% of anaemia cases could be averted by treating malnutrition, malaria, S. haematobium infections, hookworm infections, and S. haematobium/hookworm coinfections, respectively. A large spatial cluster of low mean Hb (<80 g/l) and maximal risk of anaemia (>95%) was predicted for an area shared by Burkina Faso and Mali. We estimate that in 2011, approximately 6.7 million children aged 1-4 y are anaemic in the three study countries. CONCLUSIONS: By mapping the distribution of anaemia risk in preschool children adjusted for malnutrition and parasitic infections, we provide a means to identify the geographical limits of anaemia burden and the contribution that malnutrition and parasites make to anaemia. Spatial targeting of ancillary micronutrient supplementation and control of other anaemia causes, such as malaria and helminth infection, can contribute to efficiently reducing the burden of anaemia in preschool children in Africa.

Distribution of complementary and alternative medicine (CAM) providers in rural New South Wales, Australia: a step towards explaining high CAM use in rural health?

OBJECTIVE: Complementary and alternative medicine (CAM) use is high in rural health and an agenda for research in the geography of CAM has been outlined. Unfortunately, no studies to date have mapped the geographic distribution of CAM practitioners in rural areas. For the first time we investigate CAM practitioner distributions across a large district/region in rural Australia. SETTING AND DESIGN: A CAM infrastructure audit of practitioners was performed in rural Divisions of General Practice in New South Wales, Australia. RESULTS: CAM providers form a significant part of the health care system in rural New South Wales with substantial representation across all degrees of rurality and in both under-serviced and well-serviced areas. CAM practitioners outnumbered GPs in four NSW Divisions of General Practice and in no Division numbered less than half of the total number of GPs. CONCLUSIONS: Given the challenges of access to and recruitment and retention of conventional health care providers in rural settings and the significant presence of CAM practitioners, it is possible to consider such practitioners as an untapped resource in rural health care delivery. Assuming appropriate regulatory and quality standards are in place this resource should attract careful attention as part of future rural health policy and planning. The significant presence and high prevalence of use of CAM practitioners should also serve as an impetus to reform CAM service delivery in Australia.

What drives small-scale farmers to vaccinate their multiple livestock species animals against common infectious diseases in Myanmar?

Livestock rearing is an important income source for small-scale farmers in Myanmar, but Foot and Mouth Disease (FMD) and Newcastle disease (ND) are major constraints to livestock production. A study was conducted to identify perceptions of farmers about FMD and ND disease risks and perceptions about vaccination practices by using the modified health belief model. The majority of livestock farmers (>70%) reported that they were aware of the risk and impact of FMD and ND and were willing to vaccinate their livestock (>60%). Focusing on three main livestock farmer groups, about 17.0% of cattle, 15.4% of village chicken, but only 2.3% of small ruminant owners, indicated that the non-availability of vaccinations in the villages was the major constraint to vaccinations (p<0.001), while in contrast twice as many small ruminant farmers compared to cattle and village chicken farmers indicated they had no knowledge about vaccinations and no funds to conduct vaccinations. Limited accessibility to vaccines and vaccinators was related to size of villages (p = 0.001 for cattle; p = 0.027 for small ruminants; p = 0.005 for village chicken). Willingness to vaccinate small ruminants against FMD was associated with the perceived impact of the disease on sales and accessibility of information about vaccination. Accessibility to information about ND vaccination influenced the willingness of village chicken farmers to conduct vaccinations. In addition, beliefs in the effectiveness of vaccinations played a major role in the willingness to carry out vaccinations on both, cattle (ß = 0.3, p = 0.018) and village chicken farms (ß = 0.5, p<0.001). Our study highlights that policies that increase the accessibility of vaccines and the dissemination of information about disease prevention and vaccination practices in villages of all sizes, have the potential to increase FMD and ND vaccination rates and thereby reduce outbreak occurrence in Myanmar. On the other hand, indirect factors, such as village size strongly influenced the availability of vaccinations.

Levels, Trends, and Inequalities in Using Institutional Delivery Services in Low- and Middle-Income Countries: A Stratified Analysis by Facility Type.

INTRODUCTION: To ensure equitable and accessible services and improved utilization of institutional delivery it is important to identify what progress has been achieved, whether there are vulnerable and disadvantaged groups that need specific attention and what are the key factors affecting the utilization of institutional delivery services. In this study, we examined levels, trends, and inequalities in the utilization of institutional delivery services in low- and middle-income countries. METHODS: We used nationally representative cross-sectional data from Demographic and Health Surveys (DHS) conducted during 1990-2018. Bayesian linear regression analysis was performed. RESULTS: Among 74 countries, the utilization of institutional delivery services ranged from 23.7% in Chad to 100% in Ukraine and Armenia (with >90% in 19 countries and <50% in 13 countries) during the latest DHS rounds. Trend analysis in 63 countries with at least 2 surveys showed that the utilization of institutional delivery services increased in 60 countries during 1990-2018, with the highest increase being in Cambodia (18.3%). During this period, the utilization of institutional delivery services increased in 90.3% of countries among the richest, 95.2% of countries in urban, and 84.1% of countries among secondary+ educated women. The utilization of institutional delivery services was higher among wealthiest, urban, and secondary+ educated women compared to their counterparts. Greater utilization of private facilities for delivery was observed in women from the highest income group and urban communities, whereas highest utilization of public facilities was observed for women from the lowest income group and rural communities. CONCLUSIONS: The utilization of institutional delivery services varied substantially between and within countries over time. Significant disparities in service utilization identified in this study highlight the need for tailored support for women from disadvantaged and vulnerable groups.