Association between concurrence of multiple risk factors and under-5 mortality: a pooled analysis of data from Demographic and Health Survey in 61 low-and-middle-income countries.

Background: Exposure to multiple risk factors is prevalent in low-and middle-income countries (LMICs), challenging one-directional strategies to address preventable under-5 mortality (U5M). This study aims to assess the associations between concurrence of multiple risk factors and U5M in LMICs. Methods: We extracted data from the Demographic and Health Surveys conducted between 2010 and 2021 across 61 LMICs. Our primary outcome was U5M, defined as deaths from birth to 59 months. Binary logistic regression model was applied to ascertain the association between U5M and a total of 20 critical risk factors. Upon identifying the risk factors demonstrating the strongest associations, we investigated the simultaneous presence of multiple risk factors in each individual and assessed their combined effects on U5M with logistic regression models. Findings: Of the 604,372 under-5 children, 18,166 (3.0%) died at the time of the survey. Unsatisfied family planning needs was the strongest risk factor for U5M (odds ratio [OR]: 2.0, 95% confidence interval [CI]: 1.9-2.1), followed by short birth interval (<18 months; OR: 2.0, 95% CI: 1.9-2.1), small birth size (OR: 2.0, 95% CI: 1.8-2.1), never breastfed or delayed breastfeeding (OR: 2.0, 95% CI: 1.9-2.0), and low maternal education (OR: 1.6, 95% CI: 1.4-1.8). 66.7% (66.6%-66.8%) of the children had 2 or more leading risk factors simultaneously. Simultaneous presence of multiple leading risk factors was significantly associated with elevated risk of U5M and children presenting with all 5 leading risk factors exhibited an exceedingly high risk of U5M (OR: 5.2, 95% CI: 4.3-6.3); a dose-response relationship between the number of risk factors and U5M was also observed-with the increment of numbers of leading risk factors, the U5M showed an increasing trend (p-trend < 0.001). Interpretation: Exposure to multiple risk factors is very common in LMICs and underscores the necessity of developing multisectoral and integrated approaches to accelerate progress in reducing U5M in line with the SDG 3.2. Funding: This research is funded by Research Fund, Vanke School of Public Health, Tsinghua University.

Spatial distribution and characteristics of HIV clusters in Ethiopia.

OBJECTIVES: Ethiopia's HIV prevalence has decreased by 75% in the past 20 years with the implementation of antiretroviral therapy, but HIV transmission continues in high-risk clusters. Identifying the spatial and temporal trends, and epidemiologic correlates, of these clusters can lead to targeted interventions. METHODS: We used biomarker and survey data from the 2005, 2011 and 2016 Ethiopia Demographic and Health Surveys (DHS). The spatial-temporal distribution of HIV was estimated using the Kulldorff spatial scan statistic, a likelihood-based method for determining clustering. Significant clusters (P < 0.05) were identified and compared based on HIV risk factors to non-cluster areas. RESULTS: In 2005, 2011 and 2016, respectively, 219, 568 and 408 individuals tested positive for HIV. Four HIV clusters were identified, representing 17% of the total population and 43% of all HIV cases. The clusters were centred around Addis Ababa (1), Afar (2), Dire Dawa (3) and Gambella (4). Cluster 1 had higher rates of unsafe injections (4.9% vs. 2.2%, P < 0.001) and transactional sex (6.0% vs. 1.6%, P < 0.001) than non-cluster regions, but more male circumcision (98.5% vs. 91.3%, P < 0.001). Cluster 2 had higher levels of transactional sex (4.9% vs. 1.6%, P < 0.01), but lower levels of unsafe injections (0.8% vs. 2.2%, P < 0.01). Cluster 3 had fewer individuals with> 1 sexual partner (0% vs. 1.7%, P < 0.001) and more male circumcision (100% vs. 91.3%, P < 0.001). Cluster 4 had less male circumcision (59.1% vs. 91.3%, P < 0.01). CONCLUSIONS: In Ethiopia, geographic HIV clusters are driven by different risk factors. Decreasing the HIV burden requires targeted interventions.

OBJECTIFS: La prévalence du VIH en Ethiopie a diminué de 75% au cours des 20 dernières années avec l'implémentation du traitement antirétroviral, mais la transmission du VIH se poursuit dans les grappes à haut risque. L'identification des tendances spatiales et temporelles et des corrélations épidémiologiques de ces grappes peut mener à des interventions ciblées. MÉTHODES: Nous avons utilisé des biomarqueurs et des données d'enquête provenant des Surveillances Démographiques et de Santé (SDS) en Ethiopie de 2005, 2011 et 2016. La distribution spatiotemporelle du VIH a été estimée à l'aide de la statistique de balayage spatial de Kulldorff, une méthode basée sur la probabilité de déterminer des regroupements. Des grappes significatives (P < 0.05) ont été identifiées et comparées sur base des facteurs de risque du VIH dans les zones sans regroupements. RÉSULTATS: En 2005, 2011 et 2016, respectivement, 219, 568 et 408 personnes ont été testées positives pour le VIH. Quatre grappes de VIH ont été identifiées, représentant 17% de la population totale et 43% de tous les cas de VIH. Les grappes étaient centrées sur Addis-Abeba (1), Afar (2), Dire Dawa (3) et Gambella(4). La grappe 1 avait des taux plus élevés d'injections à risque (4,9% contre 2,2%, P < 0.001) et de rapports sexuels transactionnels (6,0% contre 1,6%, P < 0.001) que les régions sans regroupement, mais plus de circoncisions masculines (98,5% contre 91,3%, p <0,001). La grappe 2 avait des taux plus élevés de rapports sexuels transactionnels (4,9% contre 1,6%, P < 0.01), mais des taux inférieurs d'injections à risque (0,8% contre 2,2%, P < 0.01). La grappe 3 avait moins d'individus avec >1 partenaire sexuel (0% contre 1,7%, P < 0.001) et plus de circoncisions masculines (100% contre 91,3%, P < 0.001). La grappe 4 avait moins de circoncisions masculines (59,1% contre 91,3%, P < 0.01). CONCLUSIONS: En Ethiopie, les grappes géographiques du VIH sont guidées par différents facteurs de risque. La réduction de la charge du VIH nécessite des interventions ciblées.

Ethiopia's experience on scaling up latent TB infection management for people living with HIV and under-five child household contacts of index TB patients.

Management of latent tuberculosis infection (LTBI) is one of the globally recommended key strategies to end tuberculosis. However, there is limited experience with translation of global recommendations into action at country levels. We present Ethiopia's experience in implementing LTBI management. Our objective is to share promising practices, existing opportunities and to suggest specific steps required for further scale up of the services. Our report is based on synthesis of data from secondary sources including official routine reports of Ministry of Health, materials presented at review meetings, and findings from supervisory visits to districts and health facilities. Our results suggest that Ethiopia has made significant strides toward strengthening LTBI management in people living with HIV and among under-five-year-old household contacts of TB patients. The use of contact investigation as entry point for LTBI management could be taken as best practice. More effort is needed to further strengthen implementation of LTBI management, and it should be supported through context-specific implementation and operational research activities.

Increasing Access to Tuberculosis Services in Ethiopia: Findings From a Patient-Pathway Analysis.

Background: In Ethiopia, extensive scale-up of the availability of health extension workers (HEWs) at the community level has been credited with increased identification and referral of patients with presumptive tuberculosis, which has contributed to increased tuberculosis case notification and better treatment outcomes. However, nearly 30% of Ethiopia's estimated 191000 patients with tuberculosis remained unnotified in 2015. A better understanding of patient care-seeking practices may inform future government action to reach all patients with tuberculosis. Methods: A patient-pathway analysis was completed to assess the alignment between patient care initiation and the availability of diagnostic and treatment services at the national level. Results: More than one third of patients initiated care with HEWs, who refer patients to health centers for diagnosis. An additional one third of patients initiated care at health centers. Of those health centers, >80% had microscopy services, but few had access to Xpert. Despite an extensive microscopy and radiography network at middle levels of the health system, a quarter of all notified patients with tuberculosis had no bacteriological confirmation of disease. While 30% of patients reported receiving some form of care from the private sector, private-sector facilities, especially pharmacies, were not widely accessed for tuberculosis diagnosis. Discussion: The availability of HEWs can increase access to tuberculosis diagnostic and treatment support services, particularly for rural populations. Continued strengthening of referral systems from HEWs and health posts are needed to enable consistent and timely access to Xpert as an initial diagnostic test and to drug resistance screening.