Asthma exacerbations are associated with a decline in lung function: a longitudinal population-based study.

RATIONALE: Progressive lung function (LF) decline in patients with asthma contributes to worse outcomes. Asthma exacerbations are thought to contribute to this decline; however, evidence is limited with mixed results. METHODS: This historical cohort study of a broad asthma patient population in the Optimum Patient Care Research Database, examined asthma patients with 3+eligible post-18th birthday peak expiratory flow rate (PEF) records (primary analysis) or records of forced expiratory flow in 1 s (FEV1) (sensitivity analysis). Adjusted linear growth models tested the association between mean annual exacerbation rate (AER) and LF trajectory. RESULTS: We studied 1 09 182 patients with follow-up ranging from 5 to 50 years, of which 75 280 had data for all variables included in the adjusted analyses. For each additional exacerbation, an estimated additional -1.34 L/min PEF per year (95% CI -1.23 to -1.50) were lost. Patients with AERs >2/year and aged 18-24 years at baseline lost an additional -5.95 L/min PEF/year (95% CI -8.63 to -3.28) compared with those with AER 0. These differences in the rate of LF decline between AER groups became progressively smaller as age at baseline increased. The results using FEV1 were consistent with the above. CONCLUSION: To our knowledge, this study is the largest nationwide cohort of its kind and demonstrates that asthma exacerbations are associated with faster LF decline. This was more prominent in younger patients but was evident in older patients when it was related to lower starting LF, suggesting a persistent deteriorating phenotype that develops in adulthood over time. Earlier intervention with appropriate management in younger patients with asthma could be of value to prevent excessive LF decline.

Assessing the impact of the "malaria supporters project" intervention to malaria control in the Brazilian Amazon: an interrupted time-series analysis.

BACKGROUND: In 2021, Brazil was responsible for more than 25% of malaria cases in the Americas. Although the country has shown a reduction of cases in the last decades, in 2021 it reported over 139,000 malaria cases. One major malaria control strategy implemented in Brazil is the "Malaria Supporters Project", which has been active since 2012 and is directed to municipalities responsible for most Brazil's cases. The objective of this study is to analyse the intervention effect on the selected municipalities. METHODS: An ecological time-series analysis was conducted to assess the "Malaria Supporters Project" effect. The study used data on Annual Parasitic Incidence (API) spanning the period from 2003 to 2020 across 48 intervention municipalities and 88 control municipalities. To evaluate the intervention effect a Prais-Winsten segmented regression model was fitted to the difference in malaria Annual Parasitic Incidence (API) between control and intervention areas. RESULTS: The intervention group registered 1,104,430 cases between 2012 and 2020, a 50.6% reduction compared to total cases between 2003 and 2011. In 2020 there were 95,621 cases, 50.4% fewer than in 2011. The number of high-risk municipalities (API > 50 cases/1000) reduced from 31 to 2011 to 17 in 2020. The segmented regression showed a significant 42.0 cases/1000 residents annual decrease in API compared to control group. CONCLUSIONS: The intervention is not a silver bullet to control malaria, but it has reduced API in locations with high malaria endemicity. Furthermore, the model has the potential to be replicated in other countries with similar epidemiological scenarios.

Population cause of death estimation using verbal autopsy methods in large-scale field trials of maternal and child health: lessons learned from a 20-year research collaboration in Central Ghana.

Low and middle-income countries continue to use Verbal autopsies (VAs) as a World Health Organisation-recommended method to ascertain causes of death in settings where coverage of vital registration systems is not yet comprehensive. Whilst the adoption of VA has resulted in major improvements in estimating cause-specific mortality in many settings, well documented limitations have been identified relating to the standardisation of the processes involved. The WHO has invested significant resources into addressing concerns in some of these areas; there however remains enduring challenges particularly in operationalising VA surveys for deaths amongst women and children, challenges which have measurable impacts on the quality of data collected and on the accuracy of determining the final cause of death. In this paper we describe some of our key experiences and recommendations in conducting VAs from over two decades of evaluating seminal trials of maternal and child health interventions in rural Ghana. We focus on challenges along the entire VA pathway that can impact on the success rates of ascertaining the final cause of death, and lessons we have learned to optimise the procedures. We highlight our experiences of the value of the open history narratives in VAs and the training and skills required to optimise the quality of the information collected. We describe key issues in methods for ascertaining cause of death and argue that both automated and physician-based methods can be valid depending on the setting. We further summarise how increasingly popular information technology methods may be used to facilitate the processes described. Verbal autopsy is a vital means of increasing the coverage of accurate mortality statistics in low- and middle-income settings, however operationalisation remains problematic. The lessons we share here in conducting VAs within a long-term surveillance system in Ghana will be applicable to researchers and policymakers in many similar settings.

Costs of treating childhood malaria, diarrhoea and pneumonia in rural Mozambique and Uganda.

BACKGROUND: Globally, nearly half of all deaths among children under the age of 5 years can be attributed to malaria, diarrhoea, and pneumonia. A significant proportion of these deaths occur in sub-Saharan Africa. Despite several programmes implemented in sub-Saharan Africa, the burden of these illnesses remains persistently high. To mobilise resources for such programmes it is necessary to evaluate their costs, costs-effectiveness, and affordability. This study aimed to estimate the provider costs of treating malaria, diarrhoea, and pneumonia among children under the age of 5 years in routine settings at the health facility level in rural Uganda and Mozambique. METHODS: Service and cost data was collected from health facilities in midwestern Uganda and Inhambane province, Mozambique from private and public health facilities. Financial and economic costs of providing care for childhood illnesses were investigated from the provider perspective by combining a top-down and bottom-up approach to estimate unit costs and annual total costs for different types of visits for these illnesses. All costs were collected in Ugandan shillings and Mozambican meticais. Costs are presented in 2021 US dollars. RESULTS: In Uganda, the highest number of outpatient visits were for children with uncomplicated malaria and of inpatient admissions were for respiratory infections, including pneumonia. The highest unit cost for outpatient visits was for pneumonia (and other respiratory infections) and ranged from $0.5 to 2.3, while the highest unit cost for inpatient admissions was for malaria ($19.6). In Mozambique, the highest numbers of outpatient and inpatient admissions visits were for malaria. The highest unit costs were for malaria too, ranging from $2.5 to 4.2 for outpatient visits and $3.8 for inpatient admissions. The greatest contributors to costs in both countries were drugs and diagnostics, followed by staff. CONCLUSIONS: The findings highlighted the intensive resource use in the treatment of malaria and pneumonia for outpatient and inpatient cases, particularly at higher level health facilities. Timely treatment to prevent severe complications associated with these illnesses can also avoid high costs to health providers, and households. TRIAL REGISTRATION: ClinicalTrials.gov, identifier: NCT01972321.

Implementing effective community-based surveillance in research studies of maternal, newborn and infant outcomes in low resource settings.

BACKGROUND: Globally adopted health and development milestones have not only encouraged improvements in the health and wellbeing of women and infants worldwide, but also a better understanding of the epidemiology of key outcomes and the development of effective interventions in these vulnerable groups. Monitoring of maternal and child health outcomes for milestone tracking requires the collection of good quality data over the long term, which can be particularly challenging in poorly-resourced settings. Despite the wealth of general advice on conducting field trials, there is a lack of specific guidance on designing and implementing studies on mothers and infants. Additional considerations are required when establishing surveillance systems to capture real-time information at scale on pregnancies, pregnancy outcomes, and maternal and infant health outcomes. MAIN BODY: Based on two decades of collaborative research experience between the Kintampo Health Research Centre in Ghana and the London School of Hygiene and Tropical Medicine, we propose a checklist of key items to consider when designing and implementing systems for pregnancy surveillance and the identification and classification of maternal and infant outcomes in research studies. These are summarised under four key headings: understanding your population; planning data collection cycles; enhancing routine surveillance with additional data collection methods; and designing data collection and management systems that are adaptable in real-time. CONCLUSION: High-quality population-based research studies in low resource communities are essential to ensure continued improvement in health metrics and a reduction in inequalities in maternal and infant outcomes. We hope that the lessons learnt described in this paper will help researchers when planning and implementing their studies.

Maximizing community participation and engagement: lessons learned over 2 decades of field trials in rural Ghana.

BACKGROUND: Successful implementation of community-based research is dominantly influenced by participation and engagement from the local community without which community members will not want to participate in research and important knowledge and potential health benefits will be missed. Therefore, maximising community participation and engagement is key for the effective conduct of community-based research. In this paper, we present lessons learnt over two decades of conducting research in 7 rural districts in the Brong Ahafo region of Ghana with an estimated population of around 600,000. The trials which were mainly in the area of Maternal, Neonatal and Child Health were conducted by the Kintampo Health Research Centre (KHRC) in collaboration with the London School of Hygiene and Tropical Medicine (LSHTM). METHODS: The four core strategies which were used were formative research methods, the formation of the Information, Education and Communication (IEC) team to serve as the main link between the research team and the community, recruitment of field workers from the communities within which they lived, and close collaboration with national and regional stakeholders. RESULTS: These measures allowed trust to be built between the community members and the research team and ensured that potential misconceptions which came up in the communities were promptly dealt with through the IEC team. The decision to place field workers in the communities from which they came and their knowledge of the local language created trust between the research team and the community. The close working relationship between the District health authorities and the Kintampo Health Research Centre supported the acceptance of the research in the communities as the District Health Authorities were respected and trusted. CONCLUSION: The successes achieved during the past 2 decades of collaboration between LSHTM and KHRC in conducting community-based field trials were based on involving the community in research projects. Community participation and engagement helped not only to identify the pertinent issues, but also enabled the communities and research team to contribute towards efforts to address challenges.

Missed treatment opportunities and barriers to comprehensive treatment for sexual violence survivors in Kenya: a mixed methods study.

BACKGROUND: In Kenya, most sexual violence survivors either do not access healthcare, access healthcare late or do not complete treatment. To design interventions that ensure optimal healthcare for survivors, it is important to understand the characteristics of those who do and do not access healthcare. In this paper, we aim to: compare the characteristics of survivors who present for healthcare to those of survivors reporting violence on national surveys; understand the healthcare services provided to survivors; and, identify barriers to treatment. METHODS: A mixed methods approach was used. Hospital records for survivors from two referral hospitals were compared with national-level data from the Kenya Demographic and Health Survey 2014, and the Violence Against Children Survey 2010. Descriptive summaries were calculated and differences in characteristics of the survivors assessed using chi-square tests. Qualitative data from six in-depth interviews with healthcare providers were analysed thematically. RESULTS: Among the 543 hospital respondents, 93.2% were female; 69.5% single; 71.9% knew the perpetrator; and 69.2% were children below 18 years. Compared to respondents disclosing sexual violence in nationally representative datasets, those who presented at hospital were less likely to be partnered, male, or assaulted by an intimate partner. Data suggest missed opportunities for treatment among those who did present to hospital: HIV PEP and other STI prophylaxis was not given to 30 and 16% of survivors respectively; 43% of eligible women did not receive emergency contraceptive; and, laboratory results were missing in more than 40% of the records. Those aged 18 years or below and those assaulted by known perpetrators were more likely to miss being put on HIV PEP. Qualitative data highlighted challenges in accessing and providing healthcare that included stigma, lack of staff training, missing equipment and poor coordination of services. CONCLUSIONS: Nationally, survivors at higher risk of not accessing healthcare include older survivors; partnered or ever partnered survivors; survivors experiencing sexual violence from intimate partners; children experiencing violence in schools; and men. Interventions at the community level should target survivors who are unlikely to access healthcare and address barriers to early access to care. Staff training and specific clinical guidelines/protocols for treating children are urgently needed.

Neonatal mortality within 24 hours of birth in six low- and lower-middle-income countries.

OBJECTIVE: To estimate neonatal mortality, particularly within 24 hours of birth, in six low- and lower-middle-income countries. METHODS: We analysed epidemiological data on a total of 149 570 live births collected between 2007 and 2013 in six prospective randomized trials and a cohort study from predominantly rural areas of Bangladesh, Ghana, India, Pakistan, the United Republic of Tanzania and Zambia. The neonatal mortality rate and mortality within 24 hours of birth were estimated for all countries and mortality within 6 hours was estimated for four countries with available data. The findings were compared with published model-based estimates of neonatal mortality. FINDINGS: Overall, the neonatal mortality rate observed at study sites in the six countries was 30.5 per 1000 live births (range: 13.6 in Zambia to 47.4 in Pakistan). Mortality within 24 hours was 14.1 per 1000 live births overall (range: 5.1 in Zambia to 20.1 in India) and 46.3% of all neonatal deaths occurred within 24 hours (range: 36.2% in Pakistan to 65.5% in the United Republic of Tanzania). Mortality in the first 6 hours was 8.3 per 1000 live births, i.e. 31.9% of neonatal mortality. CONCLUSION: Neonatal mortality within 24 hours of birth in predominantly rural areas of six low- and lower-middle-income countries was higher than model-based estimates for these countries. A little under half of all neonatal deaths occurred within 24 hours of birth and around one third occurred within 6 hours. Implementation of high-quality, effective obstetric and early newborn care should be a priority in these settings.

Effectiveness of a Home-Based Counselling Strategy on Neonatal Care and Survival: A Cluster-Randomised Trial in Six Districts of Rural Southern Tanzania.

BACKGROUND: We report a cluster-randomised trial of a home-based counselling strategy, designed for large-scale implementation, in a population of 1.2 million people in rural southern Tanzania. We hypothesised that the strategy would improve neonatal survival by around 15%. METHODS AND FINDINGS: In 2010 we trained 824 female volunteers to make three home visits to women and their families during pregnancy and two visits to them in the first few days of the infant's life in 65 wards, selected randomly from all 132 wards in six districts in Mtwara and Lindi regions, constituting typical rural areas in Southern Tanzania. The remaining wards were comparison areas. Participants were not blinded to the intervention. The primary analysis was an intention-to-treat analysis comparing the neonatal mortality (day 0-27) per 1,000 live births in intervention and comparison wards based on a representative survey in 185,000 households in 2013 with a response rate of 90%. We included 24,381 and 23,307 live births between July 2010 and June 2013 and 7,823 and 7,555 live births in the last year in intervention and comparison wards, respectively. We also compared changes in neonatal mortality and newborn care practices in intervention and comparison wards using baseline census data from 2007 including 225,000 households and 22,243 births in five of the six intervention districts. Amongst the 7,823 women with a live birth in the year prior to survey in intervention wards, 59% and 41% received at least one volunteer visit during pregnancy and postpartum, respectively. Neonatal mortality reduced from 35.0 to 30.5 deaths per 1,000 live births between 2007 and 2013 in the five districts, respectively. There was no evidence of an impact of the intervention on neonatal survival (odds ratio [OR] 1.1, 95% confidence interval [CI] 0.9-1.2, p = 0.339). Newborn care practices reported by mothers were better in intervention than in comparison wards, including immediate breastfeeding (42% of 7,287 versus 35% of 7,008, OR 1.4, CI 1.3-1.6, p < 0.001), feeding only breast milk for the first 3 d (90% of 7,557 versus 79% of 7,307, OR 2.2, 95% CI 1.8-2.7, p < 0.001), and clean hands for home delivery (92% of 1,351 versus 88% of 1,799, OR 1.5, 95% CI 1.0-2.3, p = 0.033). Facility delivery improved dramatically in both groups from 41% of 22,243 in 2007 and was 82% of 7,820 versus 75% of 7,553 (OR 1.5, 95% CI 1.2-2.0, p = 0.002) in intervention and comparison wards in 2013. Methodological limitations include our inability to rule out some degree of leakage of the intervention into the comparison areas and response bias for newborn care behaviours. CONCLUSION: Neonatal mortality remained high despite better care practices and childbirth in facilities becoming common. Public health action to improve neonatal survival in this setting should include a focus on improving the quality of facility-based childbirth care. TRIAL REGISTRATION: ClinicalTrials.gov NCT01022788.

Efficacy and safety of artemether-lumefantrine for the treatment of uncomplicated malaria in the setting of three different chemopreventive regimens.

BACKGROUND: The burden of malaria remains high for children in parts of Africa despite the use of insecticide-treated bed nets (ITNs). Chemoprevention has the potential of reducing the malaria burden; however, limited data exist on the efficacy and safety of anti-malarial therapy in the setting of chemoprevention. METHODS: 600 children 4-5 months of age were enrolled in Tororo, Uganda, an area of high transmission intensity. Participants were given ITNs, and caregivers instructed to bring their child to a study clinic whenever they were ill. Starting at six months of age, 579 were randomized to no chemoprevention, monthly sulphadoxine-pyrimethamine (SP), daily trimethoprim-sulphamethoxazole (TS), or monthly dihydroartemisinin-piperaquine (DP). Study drugs were administered unsupervised at home until 24 months of age. Episodes of uncomplicated malaria were treated with artemether-lumefantrine (AL) with active follow-up for 28 days. The cumulative risk of recurrent malaria within 84 days and the risk of adverse events within 28 days were compared across study arms using a Cox proportional hazards model and generalized estimating equations, respectively. RESULTS: A total of 1007, 919, 736, and 451 episodes of malaria were treated in the no chemoprevention, SP, TS, and DP arms, respectively. Only 19 (0.6%) treatments were for severe malaria. Early response to therapy with AL was excellent with 96.5% fever clearance and 99.4% parasite clearance by day 3. However, over 50% of AL treatments were followed by recurrent parasitaemia within 28 days. Compared to the no chemoprevention arm, the cumulative risk of recurrent malaria within 84 days following treatment of uncomplicated malaria with AL was significantly lower in the DP arm (HR = 0.77, 95% CI 0.63-0.95, p = 0.01) but not the SP or TS arms. Compared to the no chemoprevention arm, none of the chemopreventive regimens were associated with an increased risk of adverse events following treatment of malaria with AL. CONCLUSIONS: The risk of severe malaria was very low in this cohort of young children living in a high transmission setting. In the setting of chemoprevention, treatment of uncomplicated malaria with AL was safe and efficacious, with moderate protection against recurrent malaria among children assigned monthly DP. TRIAL REGISTRATION: ClinicalTrials.gov NCT00948896 .

Determinants of postnatal depression in rural ghana: findings from the don population based cohort study.

BACKGROUND: Risk factors for postnatal depression (PND), one of the most pervasive complications of child bearing, are poorly understood in Africa. A recent systematic review of 31 studies found that the strongest predictors are social and economic disadvantage and gender-based factors; only six of these studies were community based, and almost all were in South Asia. METHODS: Cohort study nested within 4 weekly surveillance of all women of reproductive age to identify pregnancies and collect data on births and deaths in the Kintampo Health Research Centre study area of Ghana. Women were screened for depression during pregnancy and after birth using the Patient Health Questionnaire to ascertain DSM-IV major or minor depression. Information was collected on determinants relating to the mother, birth, and baby, which were examined using logistic regression; effect sizes reported as relative risks with 95% confidence intervals. RESULTS: Thirteen thousand nine hundred and twenty nine women were screened both during pregnancy and after birth, of whom 13,360 (95.9%) had complete data on potential determinants. Two hundred and fifty five (3.8%, 95% CI: 3.5%, 4.1%) had PND. Antenatal depression (AND) was the strongest determinant accounting for 34.4% of PND cases. Other determinants were season of delivery, peripartum/postpartum complications, newborn ill health, still birth, or neonatal death. Common determinants were observed for onset and persistent depression. CONCLUSIONS: Although most AND resolves in this setting, more than a third of women with PND also had AND. Adverse birth- and baby-related outcomes are the other main determinants. We recommend that programs detect and treat depression during pregnancy and provide support to women with adverse birth outcomes.

Effect of the Newhints home-visits intervention on neonatal mortality rate and care practices in Ghana: a cluster randomised controlled trial.

BACKGROUND: In 2009, on the basis of promising evidence from trials in south Asia, WHO and UNICEF issued a joint statement about home visits as a strategy to improve newborn survival. In the Newhints trial, we aimed to test this home-visits strategy in sub-Saharan Africa by assessing the effect on all-cause neonatal mortality rate (NMR) and essential newborn-care practices. METHODS: The Newhints cluster randomised trial was undertaken in 98 zones in seven districts in the Brong Ahafo Region, Ghana. 49 zones were randomly assigned to the Newhints intervention and 49 to the control intervention by use of restricted randomisation with stratification to ensure comparability between interventions. Community-based surveillance volunteers (CBSVs) in Newhints zones were trained to identify pregnant women in their community and to make two home visits during pregnancy and three in the first week of life to promote essential newborn-care practices, weigh and assess babies for danger signs, and refer as necessary. Primary outcomes were NMR and coverage of key essential newborn-care practices. Analyses were by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00623337. FINDINGS: 16,168 (99%) of 16,329 deliveries between November, 2008, and December, 2009, were livebirths; the status at 1 month was known for 15,619 (97%) livebirths. 482 neonatal deaths were recorded. Coverage data were available from 6029 women in Newhints zones; of these 4358 (72%) reported having CBSV visits during pregnancy and 3815 (63%) reported having postnatal visits. This coverage increased substantially from June, 2009, after the introduction of new implementation strategies and reached almost 90% for pregnancy visits by the end of the trial and 75% for postnatal visits. The Newhints intervention significantly increased coverage of key essential newborn-care behaviours, except for four or more antenatal-care visits (5975 [76%] of 7859 vs 5988 [74%] of 8121, respectively; relative risk 1·02, 95% CI 0·96-1·09; p=0·52) and baby delivered in a facility (5373 [68%] vs 5539 [68%], respectively; 0·97, 0·81-1·14; p=0·69). The largest increase was for care-seeking, with 102 (77%) of 132 sick babies in Newhints zones taken to a hospital or clinic compared with 77 (55%) of 139 in control zones (1·43, 1·17-1·76; p=0·001). Increases were also noted in bednet use during pregnancy (5398 [69%] of 7859 vs 5135 [63%] of 8121, respectively; 1·12, 1·03-1·21; p=0·005), money saved for delivery or emergency (5730 [86%] of 6681 vs 5525 [80%] of 6941, respectively; 1·09, 1·05-1·12; p<0·0001), transport arranged in advance for facility (2496 [37%] vs 2061 [30%], respectively; 1·30, 1·12-1·49; p=0·0004), birth assistant for home delivery washed hands with soap (1853 [93%] of 1992 vs 1817 [87%] of 2091, respectively; 1·05, 1·02-1·09; p=0·001), initiation of breastfeeding in less than 1 h of birth (3743 [49%] of 7673 vs 3280 [41%] of 7921, respectively; 1·22, 1·07-1·40; p=0·004), skin to skin contact (3355 [44%] vs 1931 [24%], respectively; 2·30, 1·85-2·87; p=0·0002), first bath delayed for longer than 6 h (3131 [41%] vs 2269 [29%], respectively; 1·65, 1·27-2·13; p<0·0001), exclusive breastfeeding for 26-32 days (1217 [86%] of 1414 vs 1091 [80%] of 1371; 1·10, 1·04-1·16; p=0·001), and baby sleeping under bednet for 8-56 days (4548 [79%] of 5756 vs 4291 [73%] of 5846; 1·09, 1·03-1·15; p=0·002). There were 230 neonatal deaths in the Newhints zones compared with 252 in the control zones. The overall NMRs per 1000 livebirths were 29·8 and 31·9, respectively (0·92, 0·75-1·12; p=0·405). INTERPRETATION: The reduction in NMR with Newhints is consistent with the reductions achieved in three trials undertaken in programme settings in south Asia. Because there is no suggestion of any heterogeneity (p=0·850) between these trials and Newhints, the meta-analysis summary estimate of a reduction of 12% (95% CI 5-18) provides the best evidence for the likely effect of the home-visits strategy delivered within programmes in sub-Saharan Africa and in south Asia. Improvements in the quality of delivery and neonatal care in health facilities and development of innovative, effective strategies to increase coverage of home visits on the day of birth could lead to the achievement of more substantial reductions. FUNDING: WHO, Bill & Melinda Gates Foundation, and UK Department for International Development.

Socio-economic determinants and inequities in coverage and timeliness of early childhood immunisation in rural Ghana.

OBJECTIVES: To assess the extent of socio-economic inequity in coverage and timeliness of key childhood immunisations in Ghana. METHODS: Secondary analysis of vaccination card data collected from babies born between January 2008 and January 2010 who were registered in the surveillance system supporting the ObaapaVita and Newhints Trials was carried out. 20 251 babies had 6 weeks' follow-up, 16 652 had 26 weeks' follow-up, and 5568 had 1 year's follow-up. We performed a descriptive analysis of coverage and timeliness of vaccinations by indicators for urban/rural status, wealth and educational attainment. The association of coverage with socio-economic indicators was tested using a chi-square-test and the association with timeliness using Cox regression. RESULTS: Overall coverage at 1 year of age was high (>95%) for Bacillus Calmette-Guérin (BCG), all three pentavalent diphtheria-pertussis-tetanus-haemophilus influenzae B-hepatitis B (DPTHH) doses and all polio doses except polio at birth (63%). Coverage against measles and yellow fever was 85%. Median delay for BCG was 1.7 weeks. For polio at birth, the median delay was 5 days; all other vaccine doses had median delays of 2-4 weeks. We found substantial health inequity across all socio-economic indicators for all vaccines in terms of timeliness, but not coverage at 1 year. For example, for the last DPTHH dose, the proportion of children delayed more than 8 weeks were 27% for urban children and 31% for rural children (P < 0.001), 21% in the wealthiest quintile and 41% in the poorest quintile (P < 0.001), and 9% in the most educated group and 39% in the least educated group (P < 0.001). However, 1-year coverage of the same dose remained above 90% for all levels of all socio-economic indicators. CONCLUSIONS: Ghana has substantial health inequity across urban/rural, socio-economic and educational divides. While overall coverage was high, most vaccines suffered from poor timeliness. We suggest that countries achieving high coverage should include timeliness indicators in their surveillance systems.

Methods to measure potential spatial access to delivery care in low- and middle-income countries: a case study in rural Ghana.

BACKGROUND: Access to skilled attendance at childbirth is crucial to reduce maternal and newborn mortality. Several different measures of geographic access are used concurrently in public health research, with the assumption that sophisticated methods are generally better. Most of the evidence for this assumption comes from methodological comparisons in high-income countries. We compare different measures of travel impedance in a case study in Ghana's Brong Ahafo region to determine if straight-line distance can be an adequate proxy for access to delivery care in certain low- and middle-income country (LMIC) settings. METHODS: We created a geospatial database, mapping population location in both compounds and village centroids, service locations for all health facilities offering delivery care, land-cover and a detailed road network. Six different measures were used to calculate travel impedance to health facilities (straight-line distance, network distance, network travel time and raster travel time, the latter two both mechanized and non-mechanized). The measures were compared using Spearman rank correlation coefficients, absolute differences, and the percentage of the same facilities identified as closest. We used logistic regression with robust standard errors to model the association of the different measures with health facility use for delivery in 9,306 births. RESULTS: Non-mechanized measures were highly correlated with each other, and identified the same facilities as closest for approximately 80% of villages. Measures calculated from compounds identified the same closest facility as measures from village centroids for over 85% of births. For 90% of births, the aggregation error from using village centroids instead of compound locations was less than 35 minutes and less than 1.12 km. All non-mechanized measures showed an inverse association with facility use of similar magnitude, an approximately 67% reduction in odds of facility delivery per standard deviation increase in each measure (OR = 0.33). CONCLUSION: Different data models and population locations produced comparable results in our case study, thus demonstrating that straight-line distance can be reasonably used as a proxy for potential spatial access in certain LMIC settings. The cost of obtaining individually geocoded population location and sophisticated measures of travel impedance should be weighed against the gain in accuracy.

Is Brazil reaching malaria elimination? A time series analysis of malaria cases from 2011 to 2023.

In Brazil, 99% of malaria cases occur in the Amazon region, mainly caused by Plasmodium vivax (~83%) and Plasmodium falciparum (Pf) species. Aligned with the Sustainable Development Goals, Brazil aims to eliminate autochthonous malaria by 2035. This study aims to analyse epidemiological patterns of malaria in Brazil to discuss if Brazil is on track to meet malaria control targets. A time-series study was conducted analysing autochthonous malaria new infections notifications in the Brazilian Amazon region from 2011 until June 2023. Descriptive analyses were conducted, along with joinpoint regression and forecast models to verify trend and future behaviour. A total of 2,067,030 malaria cases were reported in the period. Trend analysis indicated a decreasing trend in all malaria infections since late 2017 (monthly reduction = 0.81%, p-value <0.05), while Pf infections have increased progressively since 2015 (monthly increase = 0.46%, p-value <0.05). Forecast models predict over 124,000 malaria cases in 2023 and over 96,000 cases in 2024. Predictions for Pf infections are around 23,900 cases in 2023 and 22,300 in 2024. Cases in indigenous population villages are predicted to reach 48,000 cases in 2023 and over 51,000 in 2024. In gold mining areas it is expected over 21,000 cases in 2023 and over 20.000 in 2024. Malaria elimination in Brazil has advanced over the last decade, but its speed has slowed. The country exhibits noteworthy advancements in the reduction of overall malaria cases. It is imperative, however, to proactively target specific issues such as the incidence raise among indigenous populations and in gold mining areas. Pf infections remain a persistent challenge to control in the country and may require novel measures for containment. Current government supporting actions towards combating illegal goldmining activities and protecting indigenous populations may help malaria control indicators for the following years.

Household-level effects of seasonal malaria chemoprevention in the Gambia.

BACKGROUND: In 2022 the WHO recommended the discretionary expansion of the eligible age range for seasonal malaria chemoprevention (SMC) to children older than 4 years. Older children are at lower risk of clinical disease and severe malaria so there has been uncertainty about the cost-benefit for national control programmes. However, emerging evidence from laboratory studies suggests protecting school-age children reduces the infectious reservoir for malaria and may significantly impact on transmission. This study aimed to assess whether these effects were detectable in the context of a routinely delivered SMC programme. METHODS: In 2021 the Gambia extended the maximum eligible age for SMC from 4 to 9 years. We conducted a prospective population cohort study over the 2021 malaria transmission season covering 2210 inhabitants of 10 communities in the Upper River Region, and used a household-level mixed modelling approach to quantify impacts of SMC on malaria transmission. RESULTS: We demonstrate that the hazard of clinical malaria in older participants aged 10+ years ineligible for SMC decreases by 20% for each additional SMC round per child 0-9 years in the same household. Older inhabitants also benefit from reduced risk of asymptomatic infections in high SMC coverage households. Spatial autoregression tests show impacts are highly localised, with no detectable spillover from nearby households. CONCLUSIONS: Evidence for the transmission-reducing effects of extended-age SMC from routine programmes implemented at scale has been previously limited. Here we demonstrate benefits to the entire household, indicating such programmes may be more cost-effective than previously estimated.

Seasonal malaria chemoprevention (SMC) is the provision of monthly, preventative, anti-malaria medication to young children at times when they are most at risk of severe disease. Recently the World Health Organisation recommended expanding SMC to children older than 4 years. Older children with malaria typically remain symptomless so the advantages were unclear. However, laboratory evidence suggests this group continues to transmit malaria to others. We conducted a population study in 2021 in 10 communities in the Gambia where SMC was extended to all children up to 9 years of age for the first time. We found household members aged over 9 years were less likely to get clinical disease when most young children in the same household did receive SMC. This suggests an added protection of SMC for those who do not receive it, potentially increasing cost-effectiveness.

Understanding and maximising the community impact of seasonal malaria chemoprevention in Burkina Faso (INDIE-SMC): study protocol for a cluster randomised evaluation trial.

INTRODUCTION: Seasonal malaria chemoprevention (SMC) involves repeated administrations of sulfadoxine-pyrimethamine plus amodiaquine to children below the age of 5 years during the peak transmission season in areas of seasonal malaria transmission. While highly impactful in reducing Plasmodium falciparum malaria burden in controlled research settings, the impact of SMC on infection prevalence is moderate in real-life settings. It remains unclear what drives this efficacy decay. Recently, the WHO widened the scope for SMC to target all vulnerable populations. The Ministry of Health (MoH) in Burkina Faso is considering extending SMC to children below 10 years old. We aim to assess the impact of SMC on clinical incidence and parasite prevalence and quantify the human infectious reservoir for malaria in this population. METHODS AND ANALYSIS: We will perform a cluster randomised trial in Saponé Health District, Burkina Faso, with three study arms comprising 62 clusters of three compounds: arm 1 (control): SMC in under 5-year-old children, implemented by the MoH without directly observed treatment (DOT) for the full course of SMC; arm 2 (intervention): SMC in under 5-year-old children, with DOT for the full course of SMC; arm 3 (intervention): SMC in under 10-year-old children, with DOT for the full course of SMC. The primary endpoint is parasite prevalence at the end of the malaria transmission season. Secondary endpoints include the impact of SMC on clinical incidence. Factors affecting SMC uptake, treatment adherence, drug concentrations, parasite resistance markers and transmission of parasites will be determined. ETHICS AND DISSEMINATION: The London School of Hygiene & Tropical Medicine's Ethics Committee (29193) and the Burkina Faso National Medical Ethics Committee (Deliberation No 2023-05-104) approved this study. The findings will be presented to the community; disease occurrence data and study outcomes will also be shared with the Burkina Faso MoH. Findings will be published irrespective of their results. TRIAL REGISTRATION NUMBER: NCT05878366.

Promoting skin-to-skin care for low birthweight babies: findings from the Ghana Newhints cluster-randomised trial.

OBJECTIVE: To evaluate whether the Newhints home visits intervention increased the adoption of skin-to-skin care (SSC), in particular, among low birthweight (LBW) (<2.5 kg) babies. METHODS: A cluster-randomised trial, with 49 Newhints zones and 49 control zones, was conducted in seven districts in the Brong Ahafo Region, Ghana. It included all live births between November 2008 and December 2009. In Newhints zones, existing community-based surveillance volunteers were trained to conduct home visits during which they weighed babies and counselled mothers of LBW babies on SSC. Performance of any SSC and SSC for more than 2 h was evaluated. RESULTS: Of 15,615 live births, 68.5% had recorded birthweights; 10.1% were LBW. Any SSC was 19.4% higher among babies in Newhints vs. control zones (risk ratio, RR: 1.81; 95% confidence interval, CI: 1.40-2.35). Performance of SSC for more than 2 h was, however, low, at only 7.5%, although more than double compared with control zones (RR: 2.72; 95% CI: 1.80-4.10). LBW babies visited and weighed by a volunteer were more likely to receive SSC (PA ny  = 0.005; P >  2 h  = 0.021), greater for LBW babies, particularly for more than 2 h of SSC (Pinteraction  = 0.050). CONCLUSION: Newhints successfully promoted the uptake of SSC in rural Ghana. Although findings are encouraging, promotion in rural community settings in sub-Saharan Africa is challenging. Lessons learned can help shape SSC promotion in efforts to increase adoption and save newborn lives.

Record Linkage for Malaria Deaths Data Recovery and Surveillance in Brazil.

OBJECTIVE: The objective is to describe the results and the methodological processes of record linkage for matching deaths and malaria cases. METHODS: A descriptive cross-sectional study was conducted with probabilistic record linkage of death and malaria cases data in Brazil from 2011 to 2020 using death records from the Mortality Information System (SIM) and epidemiological data from the Notifiable Diseases Information System (Sinan) and Epidemiological Surveillance Information Systems for malaria (Sivep-Malaria). Three matching keys were used: patient's name, date of birth, and mother's name, with an analysis of cosine and Levenshtein dissimilarity measures. RESULTS: A total of 490 malaria deaths were recorded in Brazil between 2011 and 2020. The record linkage resulted in the pairing of 216 deaths (44.0%). Pairings where all three matching keys were identical accounted for 30.1% of the total matched deaths, 39.4% of the matched deaths had two identical variables, and 30.5% had only one of the three key variables identical. The distribution of the variables of the matched deaths (216) was similar to the distribution of all recorded deaths (490). Out of the 216 matched deaths, 80 (37.0%) had poorly specified causes of death in the SIM. CONCLUSIONS: The record linkage allowed for the detailing of the data with additional information from other epidemiological systems. Record linkage enables data linkage between information systems that lack interoperability and is an extremely useful tool for refining health situation analyses and improving malaria death surveillance in Brazil.

Maternal time investment in caregiving activities to promote early childhood development: evidence from rural India.

Introduction: Intervention strategies that seek to improve early childhood development outcomes are often targeted at the primary caregivers of children, usually mothers. The interventions require mothers to assimilate new information and then act upon it by allocating sufficient physical resources and time to adopt and perform development promoting behaviours. However, women face many competing demands on their resources and time, returning to familiar habits and behaviours. In this study, we explore mothers' allocation of time for caregiving activities for children under the age of 2, nested within a cluster randomised controlled trial of a nutrition and care for development intervention in rural Haryana, India. Methods: We collected quantitative maternal time use data at two time points in rural Haryana, India, using a bespoke survey instrument. Data were collected from 704 mothers when their child was 12 months old, and 603 mothers when their child was 18 months old. We tested for significant differences in time spent by mothers on different activities when children are 12 months of age vs. 18 months of age between arms as well as over time, using linear regression. As these data were collected within a randomised controlled trial, we adjusted for clusters using random effects when testing for significant differences between the two time points. Results: At both time points, no statistically significant difference in maternal time use was found between arms. On average, mothers spent most of their waking time on household chores (over 6 h and 30 min) at both time points. When children were aged 12 months, approximately three and a half hours were spent on childcare activities for children under the age of 2 years. When children were 18 months old, mothers spent more time on income generating activities (30 min) than when the children were 12 years old, and on leisure (approximately 4 h and 30 min). When children were 18 months old, less time was spent on feeding/breastfeeding children (30 min less) and playing with children (15 min). However, mothers spent more time talking or reading to children at 18 months than at 12 months. Conclusion: We find that within a relatively short period of time in early childhood, maternal (or caregiver) time use can change, with time allocation being diverted away from childcare activities to others. This suggests that changing maternal time allocation in resource poor households may be quite challenging, and not allow the uptake of new and/or optimal behaviours.