Vulnerable newborn phenotypes in Peru: a population-based study of 3,841,531 births at national and subnational levels from 2012 to 2021.

Background: We aimed to examine the national and subnational prevalence of vulnerable newborn phenotypes in Peru, 2012-2021. Methods: Newborn phenotypes were defined using gestational age (preterm [PT], term [T]), birthweight for gestational age using INTERGROWTH-21st standards (small for gestational age [SGA], appropriate for gestational age [AGA] or large for gestational age [LGA]), and birthweight (low birthweight [LBW], non-LBW) using the Peruvian National Birth Registry as six (by excluding birthweight) and ten newborn phenotypes (using all three outcomes). Small phenotypes (with at least one classification of PT, SGA, or LBW) were further considered. Using individual-level data, we stratified the phenotypes by maternal educational level, maternal age, healthcare insurance, altitude of residence, and geographic region (Coast, Andes, and Amazon). Findings: The prevalence of the five vulnerable newborn phenotypes for the study period was LGA+T (15.2%), AGA+PT (5.2%), SGA+T (4.6%), LGA+PT (0.8%), and SGA+PT (0.7%). The Coast had a higher prevalence of newborns with large phenotypes (19.4%) and the Highlands a higher prevalence of newborns with small phenotypes (12.5%). Mothers with poor socioeconomic status, extreme ages and living at high altitude had a higher prevalence of newborns with small phenotypes, and mothers who were wealthier, more educated, and older had a higher prevalence of infants with large phenotypes. Interpretation: Our findings cautiously suggest that socioeconomic and geographic disparities may play a crucial role in shaping vulnerable newborn phenotypes at national and subnational level in Peru. Further studies using longitudinal data are needed to corroborate our findings and to identify individual-level risk factors. Funding: Ter Meulen Grant from the KNAW Medical Sciences Fund of the Royal Netherlands Academy of Arts and Sciences (KNAWWF/1085/TMB406, KNAWWF/1327/TMB202116), Fogarty Program (D43TW011502).

Comprehensive Health Insurance and access to maternal healthcare services among Peruvian women: a cross-sectional study using the 2021 national demographic survey.

BACKGROUND: The government-subsidized health insurance scheme Seguro Integral de Salud ("SIS") was introduced in Peru initially to provide coverage to uninsured and poor pregnant women and children under five years old and was later extended to cover all uninsured members of the population following the Peruvian Plan Esencial de Aseguramiento Universal - "PEAS" (Essential UHC Package). Our study aimed to analyze the extent to which the introduction of SIS has increased equity in access and quality by comparing the utilization of maternal healthcare services among women with different insurance coverages. METHODS: Relying on the 2021 round of the nationally-representative survey "ENDES" (Encuesta Nacional Demográfica y de Salud Familiar), we analyzed data for 19,181 women aged 15-49 with a history of pregnancy in the five years preceding the survey date. We used a series of logistic regressions to explore the association between health insurance coverage (defined as No Insurance, SIS, or Standard Insurance) and a series of outcome variables measuring access to and quality of all services along the available maternal healthcare continuum. RESULTS: Only 46.5% of women across all insurance schemes reported having accessed effective ANC prevention. Findings from the adjusted logistic regression confirmed that insured women were more likely to have accessed ANC services compared with uninsured women. Our findings indicate that women in the "SIS" group were more likely to have accessed six ANC visits (aOR = 1.40; 95% CI 1.14-1.73) as well as effective ANC prevention (aOR = 1.32; 95% CI 1.17-1.48), ANC education (aOR = 1.59; 95% CI 1.41-1.80) and ANC screening (aOR = 1.46; 95% CI 1.27-1.69) during pregnancy, compared with women in the "Standard Insurance" group [aOR = 1.35 (95% CI 1.13-1.62), 1.22 (95% CI 1.04-1.42), 1.34 (95% CI 1.18-1.51) and 1.31(95% CI 1.15-1.49)] respectively. In addition, women in the "Standard Insurance" group were more likely to have received skilled attendance at birth (aOR = 2.17, 95% CI 1.33-3.55) compared with the women in the "SIS" insurance group (aOR = 2.12; 95% CI 1.41-3.17). CONCLUSIONS: Our findings indicate the persistence of inequities in access to maternal healthcare services that manifest themselves not only in the reduced utilization among the uninsured, but also in the lower quality of service coverage that uninsured women received compared with women insured under "Standard Insurance" or "SIS". Further policy reforms are needed both to expand insurance coverage and to ensure that all women receive the same access to care irrespective of their specific insurance coverage.

The impact of the COVID-19 pandemic on trends in stillbirths, under-5 and maternal mortality in Brazil: Excess deaths and regional inequalities.

Background: Despite the proliferation of studies on the impact of the coronavirus disease 2019 (COVID-19) pandemic, there is less evidence on the indirect death toll compared to the health system and service provision disruptions. We assessed the impact of the COVID-19 pandemic on national and regional trends and differences in stillbirths, under-5 and maternal deaths in Brazil. Methods: We used the nationwide routine health information system data from January 2017 to December 2021, to which we applied descriptive and advanced mixed effects ordinary least squared regression models to measure the percent change in mortality levels during the COVID-19 pandemic (March 2020 to December 2021). We carried out counterfactual analyses comparing the observed and expected mortality levels for each type of mortality at national and regional levels. Results: Stillbirths increased 4.8% (3.1% in 2020 and 6.2% in 2021) and most noticeably maternal deaths increased 71.6% (35.3% in 2020 and 103.3% in 2021) over the COVID-19 period. An opposite pattern was observed in under-5 mortality, which dropped -10.2% (-12.5% in 2020 and -8.1% in 2021). We identified regional disparities, with a higher percent increase in stillbirths observed in the Central-West region and in maternal deaths in the South region. Discussion: Based on pre-pandemic trends and expected number of deaths in the absence of the COVID-19, we observed increases in stillbirths and maternal deaths and reductions in under-5 deaths during the pandemic. The months with the highest number of deaths (stillbirths and maternal deaths) coincided with the months with the highest mortality from COVID-19. The increase in deaths may also have resulted from indirect effects of the pandemic, such as unavailability of health services or even reluctance to go to the hospital when necessary due to fear of contagion. Conclusions: In Brazil, the COVID-19 outbreak and subsequent restrictions had a detrimental impact on stillbirths and maternal deaths. Even before the pandemic, mortality trends highlighted pre-existing regional inequalities in the country's health care system. Although there were some variations, increases were observed in all regions, indicating potential weaknesses in the health system and inadequate management during the pandemic, particularly concerning pregnant and postpartum women.

Vulnerable newborn types: Analysis of population-based registries for 165 million births in 23 countries, 2000-2021.

OBJECTIVE: To examine the prevalence of novel newborn types among 165 million live births in 23 countries from 2000 to 2021. DESIGN: Population-based, multi-country analysis. SETTING: National data systems in 23 middle- and high-income countries. POPULATION: Liveborn infants. METHODS: Country teams with high-quality data were invited to be part of the Vulnerable Newborn Measurement Collaboration. We classified live births by six newborn types based on gestational age information (preterm <37 weeks versus term ≥37 weeks) and size for gestational age defined as small (SGA, <10th centile), appropriate (10th-90th centiles), or large (LGA, >90th centile) for gestational age, according to INTERGROWTH-21st standards. We considered small newborn types of any combination of preterm or SGA, and term + LGA was considered large. Time trends were analysed using 3-year moving averages for small and large types. MAIN OUTCOME MEASURES: Prevalence of six newborn types. RESULTS: We analysed 165 017 419 live births and the median prevalence of small types was 11.7% - highest in Malaysia (26%) and Qatar (15.7%). Overall, 18.1% of newborns were large (term + LGA) and was highest in Estonia 28.8% and Denmark 25.9%. Time trends of small and large infants were relatively stable in most countries. CONCLUSIONS: The distribution of newborn types varies across the 23 middle- and high-income countries. Small newborn types were highest in west Asian countries and large types were highest in Europe. To better understand the global patterns of these novel newborn types, more information is needed, especially from low- and middle-income countries.

A comprehensive analysis of cardiovascular mortality trends in Peru from 2017 to 2022: Insights from 183,386 deaths of the national death registry.

Background/objectives: Cardiovascular diseases are the leading cause of global mortality. Systematic studies on cardiovascular-related mortality at national and subnational levels in Peru are lacking. We aimed to describe the trends in cardiovascular-related mortality between 2017 and 2022 in Peru at national and subnational levels and by socioeconomic indicators. Subjects/methods: We used data from the Peruvian death registry 2017-2022. Using ICD-10 codes, mortality was categorized into: hypertensive-, coronary-, and cerebrovascular- related deaths. We estimated age-standardized cardiovascular-related mortality rates by sex at national and regional levels, and by natural regions (Coast, Highlands, Amazon). We estimated the change in mortality rates between 2017-2019 and 2020-2022 and explored factors that contributed to such a change. We explored ecological relationships between mortality rates and socioeconomic indicators. Findings: Overall 183,386 cardiovascular-related deaths were identified. Coronary-related deaths (37.2 %) were followed by hypertensive-related (25.1 %) and cerebrovascular-related deaths (22.6 %). Peru showed a marked increasing trend in cardiovascular-related mortality in 2020-2022 (77.8 %). The increase clustered in the Coast and Highlands, with the highest change observed in Lima (132.1 %). Mortality was highest in subjects with lower education and subjects with public health insurance. Gini coefficient was associated with lower mortality rates while unemployment was associated with higher mortality rates. Interpretation: There was a notable rise in cardiovascular-related mortality in Peru, particularly during the Covid-19 pandemic with a slight decrease in 2022. Gaining a comprehensive understanding of the factors that contribute to the increase in cardiovascular deaths in Peru will facilitate the development of precise interventions at both the national and regional levels.

COVID-19 and drivers of excess death rate in Peru: A longitudinal ecological study.

Background: Peru has experienced unprecedented mortality and economic toll due to the COVID-19 (Coronavirus disease 2019) pandemic in 2020. We aimed to assess the association between socioeconomic factors and excess death rate, and to explore the relative contribution of these factors to the differences in excess death rate during January-December 2020. Methods: Different national secondary data sources were used to describe excess death rates and different determinants, from distal to proximal. A confounding-adjusted multilevel mixed-effects linear regression was used to assess the association between these variables and excess death rates. Their relative contributions to the differences in excess death rate between the periods with the highest and lowest excess death rates were analyzed through regression-based Oaxaca-Blinder decomposition methods. Findings: The excess death rate showed an increasing trend in all regions, with different slopes. The confounding-adjusted multilevel analysis showed that higher healthcare access was associated with lower excess death rates (difference (95%CI) -0.004 (-0.005, -0.002)), whereas COVID-19 incidence was associated with higher excess death rates (difference (95%CI) 0.052 (0.042, 0.063)). The decomposition analysis showed COVID-19 incidence (41.9%), per capita income (19.4%) and unemployment rate (14.6%) as the main risk factors, while the main protective factors included per capita health expenditure (44.7%), healthcare access (33.2%) and health insurance (12.1%). Interpretation: Our study suggests that the excess death rate during the COVID-19 pandemic in Peru may have been influenced by other factors besides COVID-19 incidence, from distal to proximal drivers, including socioeconomic determinants, factors outside and within the health sector, and susceptibility factors. Further studies at individual level are needed to corroborate our findings.

Geographic inequalities in health intervention coverage - mapping the composite coverage index in Peru using geospatial modelling.

BACKGROUND: The composite coverage index (CCI) provides an integrated perspective towards universal health coverage in the context of reproductive, maternal, newborn and child health. Given the sample design of most household surveys does not provide coverage estimates below the first administrative level, approaches for achieving more granular estimates are needed. We used a model-based geostatistical approach to estimate the CCI at multiple resolutions in Peru. METHODS: We generated estimates for the eight indicators on which the CCI is based for the departments, provinces, and areas of 5 × 5 km of Peru using data from two national household surveys carried out in 2018 and 2019 plus geospatial covariates. Bayesian geostatistical models were fit using the INLA-SPDE approach. We assessed model fit using cross-validation at the survey cluster level and by comparing modelled and direct survey estimates at the department-level. RESULTS: CCI coverage in the provinces along the coast was consistently higher than in the remainder of the country. Jungle areas in the north and east presented the lowest coverage levels and the largest gaps between and within provinces. The greatest inequalities were found, unsurprisingly, in the largest provinces where populations are scattered in jungle territory and are difficult to reach. CONCLUSIONS: Our study highlighted provinces with high levels of inequality in CCI coverage indicating areas, mostly low-populated jungle areas, where more attention is needed. We also uncovered other areas, such as the border with Bolivia, where coverage is lower than the coastal provinces and should receive increased efforts. More generally, our results make the case for high-resolution estimates to unveil geographic inequities otherwise hidden by the usual levels of survey representativeness.

Flat trend of high caesarean section rates in Peru: A pooled analysis of 3,376,062 births from the national birth registry, 2012 to 2020.

Background: National and subnational C-section rates are seldom available in low- and middle-income countries to guide policies and interventions. We aimed to describe the C-section rates at the national and subnational levels in Peru (2012-2020). Methods: Based on the Peruvian national birth registry, we quantified C-section rates at the national, regional and province levels; also, by natural regions (Coast, Highlands, and Amazon). Using individual-level data from the mother, we stratified the C-section rates by educational level, healthcare insurance and provider. Ecologically, we studied the correlations between C-section rates and human development index (HDI), altitude above sea level, proportion of the population living in poverty and proportion of rural population. Findings: C-section rate in Peru decreased slightly from 2012 (39·7%) to 2020 (38·0%). A widening gap of C-section rates was observed through the study years among the Coast that showed higher rates and the other natural regions that showed lower rates. The rates in most of the 25 regions showed a flat trend, particularly in the last four years and some provinces showed a very low rate. The rates were highest in mothers with higher education and in users of private health insurance. Higher HDI, health facility located at lower altitude, lower poverty and urbanization were positively correlated with higher C-section rates. Interpretation: C-section rates in Peru are above the international recommendations. Large differences by natural region, provinces and women socioeconomic status were found. Further efforts are needed to achieve the recommended C-section rates. Funding: Academy Ter Meulen grant of the Academy Medical Sciences Fund of the Royal Netherlands Academy of Arts & Sciences (KNAWWF/1327/TMB202116), Wellcome Trust (214185/Z/18/Z), Fogarty (D43TW011502).

Validación de un método mul-tirresiduo para la determinación de medicamentos veterinarios en trucha y langostino

Este estudio se realizó con el objetivo de desarrollar y validar un método para la determinación de 30 medicamentos veterinarios en muestras de trucha y langostino. El método utiliza extracción en fase sólida dispersiva (dSPE) con C18 y detección por cromatografía líquida acoplada a espectrometría de masas. Se determinó linealidad, veracidad (porcentaje de recuperación), repetitividad y reproducibilidad intralaboratorio (porcentaje de desviación estándar relativa (% RSD)), límites de detección (LoD), límites de cuantificación (LoQ), selectividad e incertidumbre. La recuperación varió de 70 a 120% y la repetibilidad y la reproducibilidad fueron menores de 20% de la desviación estándar relativa. La selectividad fue adecuada, sin picos interferentes. Las relaciones iónicas cumplieron con los criterios de confirmación. Los coeficientes de determinación (R2) fueron mayores de 0,99, con excepción de la sulfaquinoxalina en langostino (R2 = 0,97). Los LoD y los LoQ variaron entre 0,6 µg/kg y 12,8 µg /kg y los valores de incertidumbre entre 6 µg/kg y 49 µg/ kg. Se analizaron adicionalmente 6 muestras de diferentes mercados de Lima y se detectaron trazas de algunos medicamentos incluidos en el ensayo. El método es adecuado para el análisis de residuos de medicamentos veterinarios y se recomienda su aplicación en los programas nacionales de monitoreo de la inocuidad de truchas y langostinos provenientes de acuicultura.

The study was aimed at developing and validate an analysis method to determine residues of 30 veterinary drugs in rainbow trout and shrimp specimens. The method involves extraction in dispersive solid phase with C18 and the subsequent detection through liquid chromatography coupled to mass spectrometry. Validation was done through determination of linearity, trueness (% of recovery), repeatability and intralaboratory reproducibility, limits of detection (LoD), limits of quantification (LoQ) selectivity and uncertainty. Recovery ranged from 70 to 120% and repeatability and intralaboratory reproducibility were lower than 20%. Selectivity was adequate, without interference peaks. Likewise, the ionic relationships met the confirmation criteria. The linearity was adequate, with determination coefficients (R2) above 0.99, except for sulfaquinolaxin in shrimp specimens (R2 = 0,97). LoD and LoQ varied from 0,6 µg /kg to 12,8 µg / kg. Limits of uncertainty ranged from 6 µg /kg to 49 µg /kg. The method was used to analyze 6 samples from different markets in Lima (Peru), identifying traces of some drugs included in the study. Our results show that the method is adequate for the analysis of veterinary drug residues and allow us to recommend its application in national monitoring programs, to assess the safety of rainbow trout and shrimp specimens from aquaculture.

O estudo foi realizado com o objetivo de desenvolver e validar um método para a determinação de 30 medicamentos veterinários, em amostras de truta e camarão. O método utiliza extração dispersiva em fase sólida com C18 e detecção por cromatografia líquida acoplada à espectrometria de massas. Foram determinados a linearidade, a veracidade (recuperação percentual), a repetibilidade, a reprodutibilidade intra-laboratorial, os limites de detecção (LoD) e de quantificação (LoQ), a linearidade, a selectividade e a incerteza. A recuperação variou de 70 a 120%, a repetibilidade e reprodutibilidade estiveram abaixo do 20% do desvio padrão relativo. A selectividade fio adequada, sem picos de interferentes. As proporções de íons atenderam aos critérios de confirmação. Os coeficientes de determinação (R2) foram superiores a 0,99, com excepção da sulfanoxalina em camarão (R2 = 0,97). LoD e LoQ variavam entre 0,6 µg /kg e 12,8 µg /kg e valores de incerteza entre 6 µg /kg e 49 µg / kg. Seis amostras de mercados do Lima foram adicionalmente analisadas e foram detectados vestígios de alguns medicamentos incluídos no estudo. O método é adequado para o análise de resíduos de medicamentos veterinários e sua aplicação é recomendada em programas nacionais de controlo da segurança da truta e do camarão provenientes da aquicultura.

National and subnational trends of birthweight in Peru: Pooled analysis of 2,927,761 births between 2012 and 2019 from the national birth registry.

BACKGROUND: National and subnational characterization of birthweight profiles lacks in low- and middle-income countries, yet these are needed for monitoring the progress of national and global nutritional targets. We aimed to describe birthweight indicators at the national and subnational levels in Peru (2012-2019), and by selected correlates. METHODS: We studied mean birthweight (g), low birthweight (<2,500 g) and small for gestational age (according to international growth curves) prevalences. We analysed the national birth registry and summarized the three birthweight indicators at the national, regional, and province level, also by geographic area (Coast, Highlands, and Amazon). With individual-level data from the mother, we described the birthweight indicators by age, educational level and healthcare provider. Following an ecological approach (province level), we described the birthweight indicators by human development index (HDI), altitude above sea level, proportion of the population living in poverty and proportion of rural population. FINDINGS: Mean birthweight was always the lowest in the Highlands (2,954 g in 2019) yet the highest in the Coast (3,516 g in 2019). The same was observed for low birthweight and small for gestational age. In regions with Coast and Highlands, the birthweight indicators worsen from the Coast to the Highlands; the largest absolute difference in mean birthweight between Coast and Highlands in the same region was 367 g. All birthweight indicators were the worst in mothers with none/initial education, while they improved with higher HDI. INTERPRETATION: This analysis suggests that interventions are needed at the province level, given the large differences observed between Coast and Highlands even in the same region. FUNDING: Wellcome Trust (214185/Z/18/Z).

Indigenous communities' responses to the COVID-19 pandemic and consequences for maternal and neonatal health in remote Peruvian Amazon: a qualitative study based on routine programme supervision.

AIM: To explore indigenous communities' responses to the COVID-19 pandemic and its consequences for maternal and neonatal health (MNH) care in the Peruvian Amazon. METHODS: Mamás del Río is a community-based, MNH programme with comprehensive supervision covering monthly meetings with community health workers (CHW), community leaders and health facilities. With the onset of the lockdown, supervisors made telephone calls to discuss measures against COVID-19, governmental support, CHW activities in communities and provision of MNH care and COVID-19 preparedness at facilities. As part of the programme's ongoing mixed methods evaluation, we analysed written summaries of supervisor calls collected during the first 2 months of Peru's lockdown. RESULTS: Between March and May 2020, supervisors held two rounds of calls with CHWs and leaders of 68 communities and staff from 17 facilities. Most communities banned entry of foreigners, but about half tolerated residents travelling to regional towns for trade and social support. While social events were forbidden, strict home isolation was only practised in a third of communities as conflicting with daily routine. By the end of April, first clusters of suspected cases were reported in communities. COVID-19 test kits, training and medical face masks were not available in most rural facilities. Six out of seven facilities suspended routine antenatal and postnatal consultations while two-thirds of CHWs resumed home visits to pregnant women and newborns. CONCLUSIONS: Home isolation was hardly feasible in the rural Amazon context and community isolation was undermined by lack of external supplies and social support. With sustained community transmission, promotion of basic hygiene and mask use becomes essential. To avoid devastating effects on MNH, routine services at facilities need to be urgently re-established alongside COVID-19 preparedness plans. Community-based MNH programmes could offset detrimental indirect effects of the pandemic and provide an opportunity for local COVID-19 prevention and containment.

Drivers of stunting reduction in Peru: a country case study.

BACKGROUND: Peru reduced its under-5 child stunting prevalence notably from 31.3% in 2000 to 13.1% in 2016. OBJECTIVES: We aimed to study factors and key enablers of child stunting reduction in Peru from 2000-2016. METHODS: Demographic and Health Surveys were used to conduct descriptive analyses [height-for-age z scores (HAZ) means and distributions, equity analysis, predicted child growth curves through polynomial regressions] and advanced regression analyses. An ecological (at department level) multilevel regression analysis was conducted to identify the major predictors of stunting decline from 2000 to 2016, and Oaxaca-Blinder decomposition was conducted to identify the relative contribution of each factor to child HAZ change. A systematic literature review, policy and program analysis, and interviews with relevant stakeholders were conducted to understand key drivers of stunting decline in Peru. RESULTS: The distribution of HAZ scores showed a slight rightward shift from 2000 to 2007/2008, and a greater shift from 2007/2008 to 2016. Stunting reduction was higher in the lowest wealth quintile, in rural areas, and among children with the least educated mothers. Decomposing predicted changes showed that the most important factors were increased maternal BMI and maternal height, improved maternal and newborn health care, increased parental education, migration to urban areas, and reduced fertility. Key drivers included the advocacy role of civil society and political leadership around poverty and stunting reduction since the early 2000s. Key enablers included the economic growth and the consolidation of democracy since the early 2000s, and the acknowledgement that stunting reduction needs much more than food supplementation. CONCLUSIONS: Peru reduced child stunting owing to improved socioeconomic determinants, sustained implementation of out-of-health-sector and within-health-sector changes, and implementation of health interventions. These efforts were driven through a multisectoral approach, strong civil society advocacy, and keen political leadership. Peru's experience offers useful lessons on how to tackle the problem of stunting under differing scenarios, with the participation of multiple sectors.

Drivers of the progress achieved by Peru in reducing childhood diarrhoea mortality: a country case study.

BACKGROUND: Childhood diarrhoea mortality has declined substantially in Peru in recent decades. We documented trends in childhood diarrhoea mortality from 1980 to 2015, along with trends in coverage of diarrhoea-related interventions and risk factors, to identify the main drivers of mortality reduction. METHODS: We conducted desk reviews on social determinants, policies and programmes, and diarrhoea-related interventions implemented during the study period. We reviewed different datasets on child mortality, and on coverage of diarrhoea-related interventions. We received input from individuals familiar with implementation of diarrhoea-related policies and programmes. We used the Lives Saved Tool (LiST) to help explain the reasons for the decline in diarrhoea mortality from 1980 to 2015 and to predict additional reduction with further scale up of diarrhoea-related interventions by 2030. RESULTS: In Peru under-five diarrhoea mortality declined from 23.3 in 1980 to 0.8 per 1000 livebirths in 2015. The percentage of under-five diarrhoea deaths as related to total under-five deaths was reduced from 17.8% in 1980 to 4.9% in 2015. Gross domestic product increased and poverty declined from 1990 to 2015. Access to improved water increased from 56% in 1986 to 79.3% in 2015. Oral rehydrating salts (ORS) use during an episode of diarrhoea increased from 3.6% in 1986 to 32% in 2015. Vertical programmes focused on diarrhoea management with ORS were implemented successfully in the 1980s and 1990s, and were replaced by integrated crosscutting interventions since the early 2000s. LiST analyses showed that about half (53.9%) of the reduction in diarrhoea mortality could be attributed to improved water, sanitation and hygiene, 25.0% to direct diarrhoea interventions and 21.1% to nutrition. The remaining mortality could be reduced by three-quarters by 2030 with improved diarrhoea treatment and further with enhanced breastfeeding practices and reduction in stunting. LiST does not take into account the role of social determinants. CONCLUSIONS: The reduction of diarrhoeal under-five mortality in Peru can be explained by a combination of factors, including improvement of social determinants, child nutrition, diarrhoea treatment with ORS and prevention with rotavirus vaccine and increased access to water and sanitation. The already low rate of diarrhoea mortality could be further reduced by a number of interventions, especially additional use of ORS and zinc for diarrhoea treatment. Peru is a remarkable example of a country that was able to reduce childhood diarrhoea mortality by implementing interventions through vertical programmes initially, and afterwards through implementation of integrated multisectoral packages targeting prevalent illnesses and multi-causal problems like stunting.

Non-clinical performance and acceptability of a small portable respiratory stimulator device for basic neonatal resuscitation, tested by health personnel / Desempeño no clínico y aceptabilidad de un estimulador respiratorio portátil para reanimación neonatal básica, evaluado en personal de salud

Introducción: La reanimación neonatal demanda dispositivos para apoyo respiratorio que no siempre se encuentran en áreas rurales. Se requieren dispositivos innovadores y el prototipado rápido permite generarlos usando diseños e impresoras tridimensionales (3D). Objetivo: Evaluar el desempeño no clínico y la aceptabilidad por el personal de salud de un dispositivo respiratorio neonatal producido mediante prototipado rápido. Métodos: Estudio observacional, descriptivo, de prueba de concepto desarrollado en dos etapas. Etapa 1: Fabricación del dispositivo con prototipado rápido en impresoras y escáneres tridimensionales (3D). Etapa 2: Demostración del dispositivo durante programas de capacitación en reanimación neonatal para personal de salud en tres regiones del Perú (Tarapoto, Huánuco y Ayacucho). En ambas etapas se evaluó el desempeño del dispositivo conectado a un analizador de flujo de gases. Se administró una encuesta a los trabajadores de salud de Tarapoto y Ayacucho para conocer su aceptabilidad. Resultados: El prototipo desarrollado tiene forma de T con dos fuelles laterales que al presionarse con una sola mano, proyectan aire por el centro hacia un adaptador facial. El uso del prototipo en laboratorio generó un flujo de aire promedio de 4,8 Lt/min (DE ± 1,7) y una presión promedio de 5,9 cm H2O (DE ± 1,4). Este dispositivo fue considerado como "de uso muy simple" en una encuesta de aceptabilidad donde participaron 39 enfermeras y 11 médicos en zonas alejadas de la capital del Perú. Conclusiones: El prototipo evaluado fue aceptado por el personal y tuvo un desempeño capaz de generar un estímulo de la respiración espontánea al nacer.

Introduction: Neonatal resuscitation demands equipment for respiratory support not always available in rural areas. Innovative devices are required, and rapid prototyping allows to generate them using three-dimensional (3D) designs and printers. Objective: To evaluate the non-clinical performance and the acceptability by health personnel of a neonatal respiratory device produced by rapid prototyping. Methods: Observational study, descriptive, of proof of concept developed in two steps. Step 1: Manufacture of the device with rapid prototyping in three-dimensional (3D) scanners and printers. Step 2: Demonstration of the invention during training programs in neonatal resuscitation for health personnel in three regions of Peru (Tarapoto, Huánuco and Ayacucho). In both steps, we evaluated the performance of the device connected to a gas flow analyser. A survey was administered to the health workers of Tarapoto and Ayacucho to know their acceptability. Results: The developed prototype is T-shaped with two side bellows that, when pressed with one hand, project air through the centre towards a facial adapter. The use of the prototype in the laboratory generated an average air flow of 4.8 Lt /min (SD ± 1.7) and an average pressure of 5.9 cm H2O (SD ± 1.4). This device was considered to be "very simple to use" in an acceptability survey involving 39 nurses and 11 doctors in remote areas of the capital of Peru. Conclusions: The evaluated prototype is acceptable by the staff and has a performance capable of generating spontaneous breathing at birth.

Understanding drivers of domestic public expenditure on reproductive, maternal, neonatal and child health in Peru at district level: an ecological study.

BACKGROUND: Peru has increased substantially its domestic public expenditure in maternal and child health. Peruvian departments are heterogeneous in contextual and geographic factors, underlining the importance of disaggregated expenditure analysis up to the district level. We aimed to assess possible district level factors influencing public expenditure on reproductive, maternal, neonatal and child health (RMNCH) in Peru. METHODS: We performed an ecological study in 24 departments, with specific RMNCH expenditure indicators as outcomes, and covariates of different hierarchical dimensions as predictors. To account for the influence of variables included in the different dimensions over time and across departments, we chose a stepwise multilevel mixed-effects regression model, with department-year as the unit of analysis. RESULTS: Public expenditure increased in all departments, particularly for maternal-neonatal and child health activities, with a different pace across departments. The multilevel analysis did not reveal consistently influential factors, except for previous year expenditure on reproductive and maternal-neonatal health. Our findings may be explained by a combination of inertial expenditure, a results-based budgeting approach to increase expenditure efficiency and effectiveness, and by a mixed-effects decentralization process. Sample size, interactions and collinearity cannot be ruled out completely. CONCLUSIONS: Public district-level RMNCH expenditure has increased remarkably in Peru. Evidence on underlying factors influencing such trends warrants further research, most likely through a combination of quantitative and qualitative approaches.

Enabling reproductive, maternal, neonatal and child health interventions: Time trends and driving factors of health expenditure in the successful story of Peru.

We compared expenditure trends for reproductive, maternal, neonatal and child health (RMNCH) with trends in RMNCH service coverage in Peru. We used National Health Accounts data to report on total health expenditure by source; the Countdown database for trends in external funding to RMNCH, and Ministry of Finance data for trends in domestic funding to RMNCH. We undertook over 170 interviews and group discussions to explore factors explaining expenditure trends. We describe trends in total health expenditure and RMNCH expenditure in constant 2012 US$ between 1995 and 2012. We estimated expenditure to coverage ratios. There was a substantial increase in domestic health expenditure over the period. However, domestic health expenditure as share of total government spending and GDP remained stable. Out-of-pocket health spending (OOPS) as a share of total health expenditure remained above 35%, and increased in real terms. Expenditure on reproductive health per woman of reproductive age varied from US$ 1.0 in 2002 to US$ 6.3 in 2012. Expenditure on maternal and neonatal health per pregnant woman increased from US$ 34 in 2000 to US$ 512 in 2012, and per capita expenditure on under-five children increased from US$ 5.6 in 2000 to US$ 148.6 in 2012. Increased expenditure on RMNCH reflects a greater political support for RMNCH, along with greater emphasis on social assistance, family planning, and health reforms targeting poor areas, and a recent emphasis on antipoverty and crosscutting equitable policies and programmes focused on nutrition and maternal and neonatal mortality. Increasing domestic RMNCH expenditure likely enabled Peru to achieve substantial health gains. Peru can provide useful lessons to other countries struggling to achieve sustained gains in RMNCH by relying on their own health financing.

[Pott's Disease in Upper Thoracic Vertebrae in a Two-Year-Old Boy: Case Report]. / Reporte de caso de enfermedad de Pott en vértebras torácicas altas en un niño de dos años.

Pott's disease is a health problem in developing countries and its diagnosis in children is a challenge. Here we present the case of a two-year-old boy with Pott's disease involving T1 to T3 thoracic vertebrae. The clinical presentation was characterized by difficulty walking, fever, cough, and dyspnea. At physical examination, kyphosis and bony prominence were observed in the cervicodorsal area. A positive tuberculin test was obtained, and Mycobacterium tuberculosis was isolated via culture of the gastric aspiration sample. The spine MRI showed a chronic abscess, destruction of two vertebrae, and bone marrow compression. The patient experienced some improvement with anti-TB therapy. Here, we emphasize the importance of giving consideration to the clinical suspicion for the early detection of this condition, as well as a quick TB-treatment start so as to avoid the disability and mortality associated to this disease.

La enfermedad de Pott es un problema de salud en países en desarrollo y su diagnóstico en niños es un desafío. Presentamos el caso de un niño de dos años de edad, con enfermedad de Pott que compromete vértebras torácicas de T1 a T3. El cuadro clínico se caracterizó por dificultad para caminar, fiebre, tos y disnea. Al examen físico, se evidenció cifosis y prominencia ósea en la región cervicodorsal. Se obtuvo una prueba de tuberculina positiva y se aisló Mycobacterium tuberculosis en el cultivo del aspirado gástrico. La resonancia de columna vertebral mostró un absceso frio, destrucción de dos vértebras y compresión de la médula espinal. El paciente presentó mejoría con la terapia antituberculosa. Resaltamos la importancia de tener en cuenta la sospecha clínica para la detección temprana de esta condición, así como un inicio rápido del tratamiento antituberculoso, para evitar la discapacidad y mortalidad asociada a esta enfermedad.

Emergency department risk factors for serious clinical deterioration in a paediatric hospital in Peru.

AIM: Identification of critically ill children upon presentation to the emergency department (ED) is challenging, especially when resources are limited. The objective of this study was to identify ED risk factors associated with serious clinical deterioration (SCD) during hospitalisation in a resource-limited setting. METHODS: A retrospective case-control study of children less than 18 years of age presenting to the ED in a large, freestanding children's hospital in Peru was performed. Cases had SCD during the first 7 days of hospitalisation whereas controls did not. Information collected during initial ED evaluation was used to identify risk factors for SCD. RESULTS: A total of 120 cases and 974 controls were included. In univariate analysis, young age, residence outside Lima, evaluation at another facility prior to ED presentation, congenital malformations, abnormal neurologic baseline, co-morbidities and a prior paediatric intensive care unit admission were associated with SCD. In multivariate analysis, age < 12 months, residence outside Lima and evaluation at another facility prior to ED presentation remained associated with SCD. In addition, comatose neurological status, hypoxaemia, tachycardia, tachypnoea and temperature were also associated with SCD. CONCLUSIONS: Many risk factors for SCD during hospitalisation can be identified upon presentation to the ED. Using these factors to adjust monitoring during and after the ED stay has the potential to decrease SCD events. Further studies are needed to determine whether this holds true in other resource-limited settings.

Reporte de caso de enfermedad de Pott en vértebras torácicas altas en un niño de dos años / Pott's Disease in Upper Thoracic Vertebrae in a Two-Year-Old Boy: Case Report

RESUMEN La enfermedad de Pott es un problema de salud en países en desarrollo y su diagnóstico en niños es un desafío. Presentamos el caso de un niño de dos años de edad, con enfermedad de Pott que compromete vértebras torácicas de T1 a T3. El cuadro clínico se caracterizó por dificultad para caminar, fiebre, tos y disnea. Al examen físico, se evidenció cifosis y prominencia ósea en la región cervicodorsal. Se obtuvo una prueba de tuberculina positiva y se aisló Mycobacterium tuberculosis en el cultivo del aspirado gástrico. La resonancia de columna vertebral mostró un absceso frio, destrucción de dos vértebras y compresión de la médula espinal. El paciente presentó mejoría con la terapia antituberculosa. Resaltamos la importancia de tener en cuenta la sospecha clínica para la detección temprana de esta condición, así como un inicio rápido del tratamiento antituberculoso, para evitar la discapacidad y mortalidad asociada a esta enfermedad.

ABSTRACT Pott's disease is a health problem in developing countries and its diagnosis in children is a challenge. Here we present the case of a two-year-old boy with Pott's disease involving T1 to T3 thoracic vertebrae. The clinical presentation was characterized by difficulty walking, fever, cough, and dyspnea. At physical examination, kyphosis and bony prominence were observed in the cervicodorsal area. A positive tuberculin test was obtained, and Mycobacterium tuberculosis was isolated via culture of the gastric aspiration sample. The spine MRI showed a chronic abscess, destruction of two vertebrae, and bone marrow compression. The patient experienced some improvement with anti-TB therapy. Here, we emphasize the importance of giving consideration to the clinical suspicion for the early detection of this condition, as well as a quick TB-treatment start so as to avoid the disability and mortality associated to this disease.