Temporal trends analysis of emergency obstetric and newborn care availability and readiness index of healthcare facilities in Burkina Faso.

BACKGROUND: Ensuring healthcare services are equipped to offer; emergency obstetric and newborn care (EmONC) is crucial for improving the quality of maternal and newborn care in low- and middle-income countries. We assessed the temporal trends of the availability and readiness of the healthcare system to provide EmONC in Burkina Faso. METHODS: We analyzed the data from three national health facilities surveys, conducted in 2014, 2016 and 2018, using the WHO Service Availability and Readiness Assessment tool. We performed multivariable linear regression models to examine the trends. RESULTS: Between 2014 and 2018, the percentage of healthcare facilities providing delivery service and blood transfusion significantly decreased (88.1% to 75.4% for delivery services and 67.3% to 50.2% for blood transfusion, p < 0.001). The readiness index of healthcare facilities to provide basic EmONC showed a negative trend according to public healthcare, primary healthcare, and Centre-Nord, Centre-sud, Hauts-Bassins, Nord, Plateau Central and Sud-ouest health regions. CONCLUSIONS: We observed multiple indications of a decline in the readiness of healthcare services to offer EmONC in Burkina Faso from 2014 to 2018. As such, bolstering the capabilities of health facilities to deliver EmONC is essential for hastening the decrease in maternal mortality.

Trends in and Correlates of Short-Acting Contraceptive Stock-Outs: Multicountry Analysis of Performance Monitoring for Action Agile Platform Data.

Understanding trends in contraceptive stock-outs, as well as their structural and demand-side correlates, is critical for policymakers and program managers to identify strategies to further anticipate, reduce, and prevent stock-outs. We analyzed trends as well as supply- and demand-side correlates of short-acting contraceptive method stock-outs by using data from multiple rounds of Performance Monitoring for Action Agile surveys. These data longitudinally measured contraceptive availability over 2 years (between November 2017 and January 2020) across 2,134 public and private service delivery points (SDPs) from urban areas of 5 countries (Burkina Faso, Democratic Republic of the Congo [DRC], India, Kenya, and Nigeria). For each country, we analyzed the trends and used multilevel mixed-effect logistic regression to model the odds of short-acting contraceptive stock-outs, adjusting for key structural and demand-side factors of the SDPs. Stock-outs in short-acting contraceptive methods were common in health facilities and varied markedly, ranging from as low as 2.9% (95% confidence interval [CI]=1.7%, 5.1%) in India to 51.0% (95% CIs=46.8%, 56.0%) in Kenya. During the observation period, stock-out rates decreased by 28% in the SDP samples in India (aOR=0.72, P<.001) and 8% in Nigeria (aOR=0.92, P<.001) but increased by 15% in DRC (aOR=1.15; P=036) and 5% in Kenya (aOR=1.05, P=003) with each round of data collection. Correlates of stock-out rates included the facility managerial authority (private versus public), whether the facility was rated high quality, whether the facility was at an advanced tier, and whether there was high demand for short-acting contraceptives. In conclusion, stock-outs of short-acting contraceptives are still common in many settings. Measuring and monitoring contraceptive stock-outs is crucial for identifying and addressing issues related to the availability and supply of short-acting contraceptives.

Delays in accessing high-quality care for newborns in East Africa: An analysis of survey data in Malawi, Mozambique, and Tanzania.

Background: Despite the existence of evidence-based interventions, substantial progress in reducing neonatal mortality is lagging, indicating that small and sick newborns (SSNs) are likely not receiving the care they require to survive and thrive. The 'three delays model' provides a framework for understanding the challenges in accessing care for SSNs. However, the extent to which each delay impacts access to care for SSNs is not well understood. To fill this evidence gap, we explored the impact of each of the three delays on access to care for SSNs in Malawi, Mozambique, and Tanzania. Methods: Secondary analyses of data from three different surveys served as the foundation of this study. To understand the impact of delays in the decision to seek care (delay 1) and the ability to reach an appropriate point of care (delay 2), we investigated time trends in place of birth disaggregated by facility type. We also explored care-seeking behaviours for newborns who died. To understand the impact of delays in accessing high-quality care after reaching a facility (delay 3), we measured facility readiness to manage care for SSNs. We used this measure to adjust institutional delivery coverage for SSN care readiness. Results: Coverage of institutional deliveries was substantially lower after adjusting for facility readiness to manage SSN care, with decreases of 30 percentage points (pp) in Malawi, 14 pp in Mozambique, and 24 pp in Tanzania. While trends suggest more SSNs are born in facilities, substantial gaps remain in facilities' capacities to provide lifesaving interventions. In addition, exploration of care-seeking pathways revealed that a substantial proportion of newborn deaths occurred outside of health facilities, indicating barriers in the decision to seek care or the ability to reach an appropriate source of care may also prevent SSNs from receiving these interventions. Conclusions: Investments are needed to overcome delays in accessing high-quality care for the most vulnerable newborns, those who are born small or sick. As more mothers and newborns access health services in low- and middle-income countries, ensuring that life-saving interventions for SSNs are available at the locations where newborns are born and seek care after birth is critical.

Maternal interventions to decrease stillbirths and neonatal mortality in Tanzania: evidence from the 2017-18 cross-sectional Tanzania verbal and social autopsy study.

BACKGROUND: Reduction of Tanzania's neonatal mortality rate has lagged behind that for all under-fives, and perinatal mortality has remained stagnant over the past two decades. We conducted a national verbal and social autopsy (VASA) study to estimate the causes and social determinants of stillbirths and neonatal deaths with the aim of identifying relevant health care and social interventions. METHODS: A VASA interview was conducted of all stillbirths and neonatal deaths in the prior 5 years identified by the 2015-16 Tanzania Demographic and Health Survey. We evaluated associations of maternal complications with antepartum and intrapartum stillbirth and leading causes of neonatal death; conducted descriptive analyses of antenatal (ANC) and delivery care and mothers' careseeking for complications; and developed logistic regression models to examine factors associated with delivery place and mode. RESULTS: There were 204 stillbirths, with 185 able to be classified as antepartum (88 [47.5%]) or intrapartum (97 [52.5%]), and 228 neonatal deaths. Women with an intrapartum stillbirth were 6.5% (adjusted odds ratio (aOR) = 1.065, 95% confidence interval (CI) 1.002, 1.132) more likely to have a C-section for every additional hour before delivery after reaching the birth attendant. Antepartum hemorrhage (APH), maternal anemia, and premature rupture of membranes (PROM) were significantly positively associated with early neonatal mortality due to preterm delivery, intrapartum-related events and serious infection, respectively. While half to two-thirds of mothers made four or more ANC visits (ANC4+), a third or fewer received quality ANC (Q-ANC). Women with a complication were more likely to deliver at hospital only if they received Q-ANC (neonates: aOR = 4.5, 95% CI 1.6, 12.3) or ANC4+ (stillbirths: aOR = 11.8, 95% CI 3.6, 38.0). Nevertheless, urban residence was the strongest predictor of hospital delivery. CONCLUSIONS: While Q-ANC and ANC4 + boosted hospital delivery among women with a complication, attendance was low and the quality of care is critical. Quality improvement efforts in urban and rural areas should focus on early detection and management of APH, maternal anemia, PROM, and prolonged labor, and on newborn resuscitation.

Tsetse fly ecology and risk of transmission of African trypanosomes related to a protected forest area at a military base in the city of Abidjan, Côte d'Ivoire.

African trypanosomoses, whose pathogens are transmitted by tsetse flies, are a threat to animal and human health. Tsetse flies observed at the military base of the French Forces in Côte d'Ivoire (FFCI base) were probably involved in the infection and death of military working dogs. Entomological and parasitological surveys were carried out during the rainy and dry seasons using "Vavoua" traps to identify tsetse fly species, their distribution, favorable biotopes and food sources, as well as the trypanosomes they harbor. A total of 1185 Glossina palpalis palpalis tsetse flies were caught, corresponding to a high average apparent density of 2.26 tsetse/trap/day. The results showed a heterogeneous distribution of tsetse at the FFCI base, linked to more or less favorable biotopes. No significant variation in tsetse densities was observed according to the season. The overall trypanosomes infection rate according to microscopic observation was 13.5%. Polymerase chain reaction (PCR) analyses confirmed the presence of Trypanosoma vivax and T. congolense forest type, responsible for African animal trypanosomosis. Our findings suggest that there is a risk of introduction and transmission of T. brucei gambiense, responsible for human African trypanosomiasis, on the study site. This risk of transmission of African trypanosomes concerns not only the FFCI base, but also inhabited peripheral areas. Our study confirmed the need for vector control adapted to the eco-epidemiological context of the FFCI base.

Title: Écologie des mouches tsé-tsé et risque de transmission des trypanosomes africains lié à une zone forestière protégée dans une base militaire de la ville d'Abidjan, Côte d'Ivoire. Abstract: Les trypanosomoses africaines, dont les agents pathogènes sont transmis par les mouches tsé-tsé, constituent une contrainte pour la santé animale et humaine. Des mouches tsé-tsé observées dans la base militaire des Forces françaises en Côte d'Ivoire (base FFCI) ont probablement été impliquées dans l'infection et la mort de chiens militaires. Des enquêtes entomologiques et parasitologiques ont été menées pendant la saison pluvieuse et la saison sèche à l'aide de pièges "Vavoua" afin d'identifier les espèces de mouches tsé-tsé, leur distribution, les biotopes favorables et leur source de nourriture ainsi que les trypanosomes qu'elles hébergent. Au total 1185 mouches tsé-tsé de l'espèce Glossina palpalis palpalis ont été capturées, ce qui correspond à une densité apparente moyenne élevée de 2,26 tsé-tsé/piège/jour. Les résultats ont montré une distribution hétérogène des tsé-tsé dans la base FFCI en lien avec des biotopes plus ou moins favorables. Aucune variation significative des densités de tsé-tsé n'a été observée en fonction de la saison. Le taux d'infection global par les trypanosomes était de 13,5 % selon l'observation microscopique. Les analyses PCR ont confirmé la présence de Trypanosoma vivax et T. congolense type forêt, responsable de la trypanosomose animale africaine. Nos résultats suggèrent qu'il existe un risque potentiel d'introduction et de transmission de T. brucei gambiense responsable de la trypanosomiase humaine africaine dans la zone d'étude. Ce risque de transmission des trypanosomes africains concerne non seulement l'intérieur de la base FFCI, mais aussi les espaces périphériques habités. Notre étude a confirmé la nécessité de mener une lutte antivectorielle adaptée au contexte éco-épidémiologique de la base FFCI.

Countrywide Mortality Surveillance for Action in Mozambique: Results from a National Sample-Based Vital Statistics System for Mortality and Cause of Death.

Sub-Saharan Africa lacks timely, reliable, and accurate national data on mortality and causes of death (CODs). In 2018 Mozambique launched a sample registration system (Countrywide Mortality Surveillance for Action [COMSA]-Mozambique), which collects continuous birth, death, and COD data from 700 randomly selected clusters, a nationally representative population of 828,663 persons. Verbal and social autopsy interviews are conducted for COD determination. We analyzed data collected in 2019-2020 to report mortality rates and cause-specific fractions. Cause-specific results were generated using computer-coded verbal autopsy (CCVA) algorithms for deaths among those age 5 years and older. For under-five deaths, the accuracy of CCVA results was increased through calibration with data from minimally invasive tissue sampling. Neonatal and under-five mortality rates were, respectively, 23 (95% CI: 18-28) and 80 (95% CI: 69-91) deaths per 1,000 live births. Mortality rates per 1,000 were 18 (95% CI: 14-21) among age 5-14 years, 26 (95% CI: 20-31) among age 15-24 years, 258 (95% CI: 230-287) among age 25-59 years, and 531 (95% CI: 490-572) among age 60+ years. Urban areas had lower mortality rates than rural areas among children under 15 but not among adults. Deaths due to infections were substantial across all ages. Other predominant causes by age group were prematurity and intrapartum-related events among neonates; diarrhea, malaria, and lower respiratory infections among children 1-59 months; injury, malaria, and diarrhea among children 5-14 years; HIV, injury, and cancer among those age 15-59 years; and cancer and cardiovascular disease at age 60+ years. The COMSA-Mozambique platform offers a rich and unique system for mortality and COD determination and monitoring and an opportunity to build a comprehensive surveillance system.

[Prevalence of hepatitis B infection and factors associated in children of Ivorian HBsAg carrier subjects]. / Prevalence de l'infection par l'hepatite virale B et facteurs associes chez les enfants des sujets Ivoiriens porteurs de L'AgHBs.

OBJECTIVES: To determine the prevalence of hepatitis B virus (HBV) infection in children (contact subjects) of chronic HBsAg (index subjects) and to investigate the factors associated with this infection in these children. PATIENTS AND METHODS: this was a retrospective cross-sectional study of HBsAg positive patients (index subjects), whose families (contact subjects: spouses and children) were routinely screened for HBV infection. RESULTS: The median age of our 44 subjects was 43.1 ± 7.49 years. The average number of children per index subject was 2.3 ± 1.1. The median age of the 92 children was 9.3± 4.55 (1 to 15 years) and 43 (44.8%) were vaccinated against HBV. The prevalence of HBV infection was 24%. The independent factors associated with HBV infection in children were HBV DNA for index subjects> 2000 IU/ml (OR = 11.5; p = 0.001), the existence of HBV in both parents (OR = 7.9; p = 0.03) and no HBV vaccination in children (OR = 30.9; p = 0.003). CONCLUSION: Immunization coverage of children of index subjects was insufficient. In addition to vertical transmission, the risk of intrafamilial transmission was high in the presence of at least one of the three associated factors.

OBJECTIFS: Déterminer la prévalence de l'infection par le virus de l'hépatite B (VHB) chez les enfants (sujets contact) des sujets porteurs chroniques de l'Ag HBs (sujets index) et rechercher les facteurs associés à cette infection chez ces enfants. PATIENTS ET MÉTHODES: il s'est agi d'étude rétrospective transversale portant sur les patients positifs pour l'Ag HBs (sujets index), dont la famille (sujets contact: conjoints et enfants) a été soumise à un dépistage systématique de l'infection par le VHB. RÉSULTATS: L'âge médian de nos 44 sujets était de 43,1 ± 7,49 ans. Le nombre moyen d'enfants par sujet index était de 2,3 ± 1,1. L'âge médian des 92 enfants était de 9,3 ± 4,55 (de 1 à 15 ans) et 43 (44,8%) étaient vaccinés contre le VHB. La fréquence de l'infection par le VHB était de 24%. Les facteurs indépendants associés à l'infection par le VHB chez les enfants étaient l'ADN du VHB pour les sujets index> 2000 UI/ml (OR = 11,5; p = 0,001), l'existence du VHB chez les deux parents (OR = 7,9; p = 0,03) et l'absence de vaccination contre le VHB chez les enfants (OR = 30,9; p = 0,003). CONCLUSION: La couverture vaccinale des enfants des sujets index était insuffisante. Outre la transmission verticale, le risque de transmission intrafamiliale était élevé en présence d'au moins un des trois facteurs associés.

Gendered power dynamics and threats to sexual and reproductive autonomy among adolescent girls and young adult women: A cross-sectional survey in three urban settings.

BACKGROUND: Gendered economic and social systems can enable relational power disparities for adolescent girls and young women (AGYW), and undercut autonomy to negotiate sex and contraceptive use. Less is known about their accumulation and interplay. This study characterizes relationship power imbalances (age disparity, intimate partner violence [IPV], partner-related fear, transactional sex, and transactional partnerships), and evaluates associations with modern contraceptive use, and sexual/reproductive autonomy threats (condom removal/"stealthing", reproductive coercion, ability to refuse sex, and contraceptive confidence). METHODS: Cross-sectional surveys were conducted with unmarried, currently-partnered AGYW aged 15-24 recruited via respondent-driven sampling in Abidjan, Côte d'Ivoire (n = 555; 2018-19), Nairobi, Kenya (n = 332; 2019), and Lagos, Nigeria (n = 179; 2020). Descriptive statistics, Venn diagrams, and multivariate regression models characterized relationship power imbalances, and associations with reproductive autonomy threats and contraceptive use. FINDINGS: Relationship power imbalances were complex and concurrent. In current partnerships, partner-related fears were common (50.4%Nairobi; 54.5%Abidjan; 55.7%Lagos) and physical IPV varied (14.5%Nairobi; 22.1%Abidjan; 9.6%Lagos). IPV was associated with reproductive coercion in Nairobi and Abidjan. Age disparate relationships undermined confidence in contraception in Nairobi. In Nairobi and Lagos, transactional sex outside the relationship was associated with condom stealthing. INTERPRETATION: AGYW face simultaneous gendered power differentials, against the backdrop of gendered social and economic systems. Power imbalances were linked with coercive sexual/reproductive health experiences which are often underrecognized yet represent a potent link between gendered social systems and poor health. Pregnancy prevention efforts for AGYW must address reproductive autonomy threats, and the relational power imbalances and broader gendered systems that enable them.

Impact of national introduction of ten-valent pneumococcal conjugate vaccine on invasive pneumococcal disease in Bangladesh: Case-control and time-trend studies.

BACKGROUND: Bangladesh introduced the ten-valent pneumococcal conjugate vaccine (PCV10) into its national immunization program in March 2015 creating an opportunity to assess the real-world impact of PCV on invasive pneumococcal disease (IPD). METHODS: Between January 2014 and June 2018, children aged 3-35 months in three rural sub-districts of Sylhet district of Bangladesh were visited every two months to collect morbidity and care-seeking data. Children attending sub-district hospitals with pneumonia, meningitis, or sepsis were assessed for IPD after obtaining informed consent. Blood and cerebrospinal fluid were collected from enrolled children to isolate pneumococcus using culture and molecular test. Children who were age-eligible to receive the PCV and had pneumococcus isolated were enrolled as cases. Four age and sex-matched clinic and community controls were selected for each case within one to two weeks of case identification. Data on immunization status and confounders were collected. PCV coverage was estimated using vaccine coverage surveys. Case-control and incidence trend analyses were conducted to assess the impact of PCV on IPD. RESULTS: The community cohort yielded 217,605 child years of observations and 154,773 sick child-visits to study hospitals. Pneumococcus was isolated from 44 children who were age-eligible to receive PCV; these children were enrolled as cases. The cases were matched with 166 community- and 150 clinic-controls. The matched case-control analyses using community-controls showed 83% effectiveness (95% CI: 1.57-97.1%) and clinic controls showed 90% effectiveness (95% CI: -26.0% to 99.1%) of PCV in preventing IPD. Incidence trend analysis estimated vaccine effectiveness at 80.1% (95% CI: 38.4, 93.6). CONCLUSION: PCV in this pediatric population in Bangladesh was highly effective in preventing IPD.

Use of vector control to protect people from sleeping sickness in the focus of Bonon (Côte d'Ivoire).

BACKGROUND: Gambian human African trypanosomiasis (gHAT) is a neglected tropical disease caused by Trypanosoma brucei gambiense transmitted by tsetse flies (Glossina). In Côte d'Ivoire, Bonon is the most important focus of gHAT, with 325 cases diagnosed from 2000 to 2015 and efforts against gHAT have relied largely on mass screening and treatment of human cases. We assessed whether the addition of tsetse control by deploying Tiny Targets offers benefit to sole reliance on the screen-and-treat strategy. METHODOLOGY AND PRINCIPAL FINDINGS: In 2015, we performed a census of the human population of the Bonon focus, followed by an exhaustive entomological survey at 278 sites. After a public sensitization campaign, ~2000 Tiny Targets were deployed across an area of 130 km2 in February of 2016, deployment was repeated annually in the same month of 2017 and 2018. The intervention's impact on tsetse was evaluated using a network of 30 traps which were operated for 48 hours at three-month intervals from March 2016 to December 2018. A second comprehensive entomological survey was performed in December 2018 with traps deployed at 274 of the sites used in 2015. Sub-samples of tsetse were dissected and examined microscopically for presence of trypanosomes. The census recorded 26,697 inhabitants residing in 331 settlements. Prior to the deployment of targets, the mean catch of tsetse from the 30 monitoring traps was 12.75 tsetse/trap (5.047-32.203, 95%CI), i.e. 6.4 tsetse/trap/day. Following the deployment of Tiny Targets, mean catches ranged between 0.06 (0.016-0.260, 95%CI) and 0.55 (0.166-1.794, 95%CI) tsetse/trap, i.e. 0.03-0.28 tsetse/trap/day. During the final extensive survey performed in December 2018, 52 tsetse were caught compared to 1,909 in 2015, with 11.6% (5/43) and 23.1% (101/437) infected with Trypanosoma respectively. CONCLUSIONS: The annual deployment of Tiny Targets in the gHAT focus of Bonon reduced the density of Glossina palpalis palpalis by >95%. Tiny Targets offer a powerful addition to current strategies towards eliminating gHAT from Côte d'Ivoire.

Investigation of tautomerism of 1,3,5-triazine derivative, stability, and acidity of its tautomers from density functional theory.

Recent studies have identified N2,N4-bis(4-fluorophenethyl)-N6-(3-(dimethylamino)propyl)-1,3,5-triazine-2,4,6-triamine (1TZ(7,8,9)) as a potent, pure antagonist that inhibits thermosensory transient receptor potential vanilloid 1 channel (TRPV1) channel activity. This study provides theoretical data on the stability and acidity of the tautomers of this molecule. We show that this triazine can exist as three predominant tautomers (2TZ(5,7,8), 4TZ(3,7,9), 7TZ(1,8,9)). In the aqueous phase, equilibrium constants calculations show that only the tautomeric equilibria between 1TZ(7,8,9) and the three most stable triazines can be present which suggests that these three tautomeric equilibria would be the basis of 1TZ(7,8,9)'s biological activity.

Modern contraceptive availability and stockouts: a multi-country analysis of trends in supply and consumption.

Approximately 214 million women of reproductive age lack adequate access to contraception for their family planning needs, yet patterns of contraceptive availability have seldom been examined. With growing demand for contraceptives in some areas, low contraceptive method availability and stockouts are thought to be major drivers of unmet need among women of reproductive age, though evidence for this is limited. In this research, we examined trends in stockouts, method availability and consumption of specific contraceptive methods in urban areas of four sub-Saharan African countries (Burkina Faso, Democratic Republic of Congo, Kenya and Nigeria) and India. We used representative survey data from the Performance Monitoring for Action Agile Project that were collected in quarterly intervals at service delivery points (SDP) stratified by sector (public vs private), with all countries having five to six quarters of surveys between 2017 and 2019. Among SDPs that offer family planning, we calculated the percentage offering at least one type of modern contraceptive method (MCM) for each country and quarter, and by sector. We examined trends in the percentage of SDPs with stockouts and which currently offer condoms, emergency contraception, oral pills, injectables, intrauterine devices and implants. We also examined trends of client visits for specific methods and the resulting estimated protection from pregnancy by quarter and country. Across all countries, the vast majority of SDPs had at least one type of MCM in-stock during the study period. We find that the frequency of stockouts varies by method and sector and is much more dynamic than previously thought. While the availability and distribution of long-acting reversible contraceptives (LARCs) were limited compared to other methods across countries, LARCs nonetheless consistently accounted for a larger portion of couple years of protection. We discuss findings that show the importance of engaging the private sector towards achieving global and national family planning goals.

Verbal/social autopsy analysis of causes and determinants of under-5 mortality in Tanzania from 2010 to 2016.

BACKGROUND: Tanzania has decreased its child mortality rate by more than 70 percent in the last three decades and is striving to develop a nationally-representative sample registration system with verbal autopsy to help focus health policies and programs toward further reduction. As an interim measure, a verbal and social autopsy study was conducted to provide vital information on the causes and social determinants of neonatal and child deaths. METHODS: Causes of neonatal and 1-59 month-old deaths identified by the 2015-16 Tanzania Demographic and Health Survey were assessed using the expert algorithm verbal autopsy method. The social autopsy examined prevalence of key household, community and health system indicators of preventive and curative care provided along the continuum of care and Pathway to Survival models. Careseeking for neonates and 1-59 month-olds was compared, and tests of associations of age and cause of death to careseeking indicators and place of death were conducted. RESULTS: The most common causes of death of 228 neonates and 351 1-59 month-olds, respectively, were severe infection, intrapartum related events and preterm delivery, and pneumonia, diarrhea and malaria. Coverage of early initiation of breastfeeding (24%), hygienic cord care (29%), and full immunization of 12-59 month-olds (33%) was problematic. Most (88.8%) neonates died in the first week, including 44.3% in their birth facility before leaving. Formal care was sought for just 41.9% of newborns whose illness started at home and was delayed by 5.3 days for 1-59 month-olds who sought informal care. Care was less likely to be sought for the youngest neonates and infants and severely ill children. Although 70.3% of 233 under-5 year-olds were moderately or severely ill on discharge from their first provider, only 29.0%-31.2% were referred. CONCLUSIONS: The study highlights needed actions to complete Tanzania's child survival agenda. Low levels of some preventive interventions need to be addressed. The high rate of facility births and neonatal deaths requires strengthening of institutionally-based interventions targeting maternal labor and delivery complications and neonatal causes of death. Scale-up of Integrated Community Case Management should be considered to strengthen careseeking for the youngest newborns, infants and severely ill children and referral practices at first level facilities.

Performance monitoring and accountability: The Agile Project's protocol, record and experience.

The Performance Monitoring and Accountability 2020 (PMA2020) project implemented a multi-country sub-project called PMA Agile, a system of continuous data collection for a probability sample of urban public and private health facilities and their clients that began November 2017 and concluded December 2019.  The objective was to monitor the supply, quality and consumption of family planning services.  In total, across 14 urban settings, nearly 2300 health facilities were surveyed three to six times in two years and a total sample of 48,610 female and male clients of childbearing age were interviewed in Burkina Faso, Democratic Republic of Congo, India, Kenya, Niger and Nigeria.  Consenting female clients with access to a cellphone were re-interviewed by telephone after four months; two rounds of the client exit, and follow-up interviews were conducted in nearly all settings.  This paper reports on the PMA Agile data system protocols, coverage and early experiences.  An online dashboard is publicly accessible, analyses of measured trends are underway, and the data are publicly available.

Using propensity scores to estimate the effectiveness of maternal and newborn interventions to reduce neonatal mortality in Nigeria.

BACKGROUND: Nigeria is the largest country in sub-Saharan Africa, with one of the highest neonatal mortality rates and the second highest number of neonatal deaths in the world. There is broad international consensus on which interventions can most effectively reduce neonatal mortality, however, there is little direct evidence on what interventions are effective in the Nigerian setting. METHODS: We used the 2013 Nigeria Demographic and Health Survey (NDHS) and the follow-up 2014 Verbal and Social Autopsy study of neonatal deaths to estimate the association between neonatal survival and mothers' and neonates' receipt of 18 resources and interventions along the continuum of care with information available in the NDHS. We formed propensity scores to predict the probability of receiving the intervention or resource and then weighted the observations by the inverse of the propensity score to estimate the association with mortality. We examined all-cause mortality as well as mortality due to infectious causes and intrapartum related events. RESULTS: Among 19,685 livebirths and 538 neonatal deaths, we achieved adequate balance for population characteristics and maternal and neonatal health care received for 10 of 18 resources and interventions, although inference for most antenatal interventions was not possible. Of ten resources and interventions that met our criteria for balance of potential confounders, only early breastfeeding was related to decreased all-cause neonatal mortality (relative risk 0.42, 95% CI 0.32-0.52, p <  0.001). Maternal decision making and postnatal health care reduced mortality due to infectious causes, with relative risks of 0.29 (95% CI 0.09-0.88; 0.030) and 0.46 (0.22-0.95; 0.037), respectively. Early breastfeeding and delayed bathing were related to decreased mortality due to intrapartum events, although these are not likely to be causal associations. CONCLUSION: Access to immediate postnatal care and women's autonomous decision-making have been among the most effective interventions for reducing neonatal mortality in Nigeria. As neonatal mortality increases relative to overall child mortality, accessible interventions are necessary to make further progress for neonatal survival in Nigeria and other low resource settings.

Population-based incidence and serotype distribution of invasive pneumococcal disease prior to introduction of conjugate pneumococcal vaccine in Bangladesh.

BACKGROUND: Bangladesh introduced the 10-valent pneumococcal conjugate vaccine (PCV-10) in 2015. We measured population-based incidence of invasive pneumococcal disease (IPD) prior to introduction of PCV-10 to provide a benchmark against which the impact of PCV-10 can be assessed. METHODS: We conducted population, facility and laboratory-based surveillance in children 0-59 months of age in three rural sub-districts of Sylhet district of Bangladesh from January 2014 to June 2015. All children received two-monthly home visits with one week recall for morbidity and care seeking. Children attending the three Upazilla Health Complexes (UHC, sub-district hospitals) in the surveillance area were screened for suspected IPD. Blood samples were collected from suspected IPD cases for culture and additionally, cerebrospinal fluid (CSF) was collected from suspected meningitis cases for culture and molecular testing. Pneumococcal isolates were serotyped by Quellung. Serotyping of cases detected by molecular testing was done by sequential multiplex polymerase chain reaction. RESULTS: Children under surveillance contributed to 126,657 child years of observations. Sixty-three thousand three hundred eighty-four illness episodes were assessed in the UHCs. Blood specimens were collected from 8,668 suspected IPD cases and CSF from 177 suspected meningitis cases. Streptococcus pneumoniae was isolated from 46 cases; 32 (70%) were vaccine serotype. The population-based incidence of IPD was 36.3/100,000 child years of observations. About 80% of the cases occurred in children below two years of age. DISCUSSION: IPD was common in rural Bangladesh suggesting the potential benefit of an effective vaccine. Measurement of the burden of IPD requires multiple surveillance modalities.

How fast did newborns die in Nigeria from 2009-2013: a time-to-death analysis using Verbal /Social Autopsy data.

BACKGROUND: The slow decline in neonatal mortality as compared to post-neonatal mortality in Nigeria calls for attention and efforts to reverse this trend. This paper examines how socioeconomic, cultural, behavioral, and contextual factors interact to influence survival time among deceased newborns in Nigeria. METHODS: Using the neonatal deaths data from the 2014 Nigeria Verbal/ Social Autopsy survey, we examined the temporal distribution of overall and cause-specific mortality of a sample of 723 neonatal deaths. We fitted an extended Cox regression model that also allowed a time-dependent set of risk factors on time-to-neonatal death from all causes, and then separately, from birth injury/birth asphyxia (BIBA) and neonatal infections, while adjusting for possible confounding variables. RESULTS: Approximately 26% of all neonatal deaths occurred during the first day, 52.8% during the first three days, and 73.9% during the first week of life. Almost all deaths (94.4%) due to BIBA and about 64% from neonatal infections occurred in the first week of life. The expected all-cause mortality hazard was 6.23 times higher on any particular illness day for the deceased newborns who had a severe illness at onset compared to those who did not. While the all-cause mortality hazard ratio of poor vs wealthier households was 0.77 (95% confidence interval (CI) = 0.648-0.922), the BIBA mortality hazard ratio of households with no electricity was 1.79 times higher compared to households with electricity (95% CI = 1.180-2.715). CONCLUSIONS: The findings suggest the need for continued improvement of the coverage and quality of maternal and neonatal health interventions at birth and in the immediate postnatal period. They may also require confirmation in real-world cohorts with detailed, time-varying information on neonatal mortality.

Engaging communities in collecting and using results from verbal autopsies for child deaths: an example from urban slums in Freetown, Sierra Leone.

BACKGROUND: Verbal autopsies (VAs) can provide important epidemiological information about the causes of child deaths. Though studies have been conducted to assess the validity of various types of VAs, the programmatic experience of engaging local communities in collecting and using VA has received little attention in the published literature. Concern Worldwide, an international non-governmental organization (NGO), in collaboration with the Ministry of Health and Sanitation (MOHS), has implemented a VA protocol in five urban slums of Freetown, Sierra Leone. This paper provides VA results and describes lessons learned from the VA process. METHODS: Under-five child deaths were registered by Community Health Workers (CHWs) in five urban slums between 2014 and 2017, and a specially trained local clinician used a VA protocol to interview caretakers. Symptoms were analysed using InterVA-4 computerized algorithm, a probabilistic expert-driven model to determine the most likely cause of death. Themes in care-seeking were extracted from multiple-choice and open-ended questions. VAs were implemented in collaboration with the community and the results were shared with community stakeholders in participatory review meetings. RESULTS: Main challenges included limitations in death notification and capacity to conduct VA for all notified deaths. A total of 215 VA were available for analysis. Among 79 neonatal deaths aged 0-27 days, the most common cause of death was neonatal pneumonia (55%); among 136 children deaths aged 1-4 years, the most common causes were malaria (56%) and pneumonia (41%). Key themes in care-seeking identified included use of traditional medicine (14% of deaths), absence of care-seeking (23% of deaths), and difficultly reaching the health facility (8% of deaths that occurred at home) during fatal illness. CONCLUSIONS: Conducting VAs as a collaborative process with communities is challenging but can provide valuable data that can be used for local-level decision-making. The findings have practical implications for engaging the community and CHWs in reducing the number of these preventable deaths through expanded efforts at prevention, early and appropriate treatment, and reduction of barriers to care-seeking. A functional end-to-end VA system can enhance meaningful routine vital events monitoring by community, national, and international stakeholders.

Prevalence of and risk factors for abnormal vaginal flora and its association with adverse pregnancy outcomes in a rural district in north-east Bangladesh.

INTRODUCTION: The role of screening and treatment for abnormal vaginal flora (AVF) on adverse pregnancy outcomes remains unclear. Using data from women who participated in a population-based cluster randomized trial who were screened and treated for AVF, we report risk factors for AVF and association of persistent AVF with adverse perinatal outcomes. MATERIAL AND METHODS: Pregnant women (n = 4221) <19 weeks of gestation provided self-administered mid-vaginal swabs; smears were Nugent-scored. AVF was treated with oral clindamycin; if AVF was present 3 weeks after treatment, persistent AVF was re-treated. We examined risk factors for AVF and the association of persistent AVF with adverse pregnancy outcomes. RESULTS: The prevalence of AVF was 16.5%: 9.8% of women had bacterial vaginosis and 6.8% had intermediate flora. Lower economic and educational status of women were associated with increased risk of AVF. One-third of women with AVF had persistent abnormal flora; these women had a higher risk of a composite measure of adverse pregnancy outcomes from 20 to <37 weeks (preterm live birth, preterm still birth, late miscarriage) (relative risk [RR] 1.33, 95% confidence interval [CI] 1.07-1.65) and of late miscarriage alone (RR 4.15, 95% CI 2.12-8.12) compared to women without AVF. CONCLUSIONS: In this study in Sylhet District, Bangladesh, rates of AVF and persistent AVF were high and persistent AVF was associated with adverse pregnancy outcomes, with an especially high associated risk for late miscarriage. Further characterization of the microbiome and relative bacterial species density associated with persistent AVF is needed.

Urinary tract infections in pregnancy in a rural population of Bangladesh: population-based prevalence, risk factors, etiology, and antibiotic resistance.

BACKGROUND: Urinary tract infection (UTI) in pregnancy, including asymptomatic bacteriuria, is associated with maternal morbidity and adverse pregnancy outcomes, including preterm birth and low birthweight. In low-middle income countries (LMICs), the capacity for screening and treatment of UTIs is limited. The objective of this study was to describe the population-based prevalence, risk factors, etiology and antimicrobial resistance patterns of UTIs in pregnancy in Bangladesh. METHODS: In a community-based cohort in Sylhet district, Bangladesh, urine specimens were collected at the household level in 4242 pregnant women (< 20 weeks gestation) for culture and antibiotic susceptibility testing. Basic descriptive analysis was performed, as well as logistic regression to calculate adjusted odds ratios (aOR) for UTI risk factors. RESULTS: The prevalence of UTI was 8.9% (4.4% symptomatic UTI, 4.5% asymptomatic bacteriuria). Risk factors for UTI in this population included maternal undernutrition (mid-upper arm circumference <23 cm: aOR= 1.29, 95% CI: 1.03-1.61), primiparity (aOR= 1.45, 95% CI: 1.15-1.84), and low paternal education (no education: aOR= 1.56, 95% CI: 1.09-2.22). The predominant uro-pathogens were E. coli (38% of isolates), Klebsiella (12%), and staphyloccocal species (23%). Group B streptococcus accounted for 5.3% of uro-pathogens. Rates of antibiotic resistance were high, with only two-thirds of E. coli susceptible to 3rd generation cephalosporins. CONCLUSIONS: In Sylhet, Bangladesh, one in 11 women had a UTI in pregnancy, and approximately half of cases were asymptomatic. There is a need for low-cost and accurate methods for UTI screening in pregnancy and efforts to address increasing rates of antibiotic resistance in LMIC.