Children's speech, language and communication skills and parental knowledge in the growing up in New Zealand cohort.

INTRODUCTION: There is a substantial discrepancy between international and local prevalence rates for speech, language and communication needs (SLCN) amongst children in New Zealand. Reports of communication impairment are likely to be underestimates. Prevalence data can describe population characteristics and inform the scope and nature of services to adequately meet demand. Parents and other caregivers are central to the early identification of children with communication needs but they may not recognise their child's needs or act on their concerns. METHOD: Cross-sectional data were available for the Growing Up in New Zealand (GUiNZ) longitudinal study cohort at 24, 54 and 72 months of age, with 76% of whanau (families; n = 5241) completing three data waves. Descriptive and chi-square analyses were used to address: (1) What are the communication abilities of children in the first 5 years of life? (2) What do New Zealand parents understand of their children's communication? (3) Do New Zealand parents have concerns? (4) What are the trajectories of parental concern for children's communication in the first 6 years of life? RESULTS: At 24 months old, 16% of children had communication skills that were of concern to their parents. At 54 months, there were concerns for 12.6% of children. Although most parents were able to describe their child's expressive abilities, many parents remained unconcerned when their child demonstrated communication skills that did not met developmental expectations. CONCLUSION: Parents can offer valuable insights about their children, but in many cases their level of concern about SLCN did not align with a professional view which reflects a more nuanced understanding of children's speech and language and the impact on future communication skills and needs. Increased awareness through public health messaging specifically regarding lifelong influences of communication challenges will aid in prevention, early detection and intervention. WHAT THIS PAPER ADDS: What is already known on this subject Parent's expectations of child speech and language development will inform how responsive they are to difficulties in their child. Appropriate parental concern is key to recognition of children with speech, language and communication needs that warrant referral to a professional. What this paper adds to existing knowledge Parents are aware of expressive language skills that children acquire and can accurately identify their children's skills but have less knowledge of the ages of acquisition. Some parents are not concerned, do not seek support despite recognisable difficulties, and demonstrate limited understanding of the future consequences for children with communication needs that are unmet. What are the potential or actual clinical implications of this work? Public health messaging should include both skills and age ranges for speech and language acquisition. Additionally, educating the public of the impact of speech, language and communication skills on children's futures is needed.

The Burden of Hepatitis A Outbreaks in the United States: Health Outcomes, Economic Costs, and Management Strategies.

BACKGROUND: Hepatitis A (HepA) vaccines are recommended for United States (US) adults at risk of HepA. Ongoing US HepA outbreaks since 2016 have primarily spread person-to-person, especially among at-risk groups. We investigated the health outcomes, economic burden, and outbreak management considerations associated with HepA outbreaks from 2016 onwards. METHODS: A systematic literature review was conducted to assess HepA outbreak-associated health outcomes, healthcare resource utilization (HCRU), and economic burden. A targeted literature review evaluated HepA outbreak management considerations. RESULTS: Across 33 studies reporting on HepA outbreak-associated health outcomes/HCRU, frequently reported HepA-related morbidities included acute liver failure/injury (n=6 studies/33 studies) and liver transplantation (n=5/33); reported case fatality rates ranged from 0-10.8%. Hospitalization rates reported in studies investigating person-to-person outbreaks ranged from 41.6-84.8%. Ten studies reported on outbreak-associated economic burden, with a national study reporting an average cost of over $16,000 per hospitalization. Thirty-four studies reported on outbreak management; challenges included difficulty reaching at-risk groups and vaccination distrust. Successes included targeted interventions and increasing public awareness. CONCLUSIONS: This review indicates a considerable clinical and economic burden of ongoing US HepA outbreaks. Targeted prevention strategies and increased public awareness and vaccination coverage are needed to reduce HepA burden and prevent future outbreaks.

The Impact of Physical and Environment Factors on Parental Presence for Oral Feeding in New Zealand Neonatal Intensive Care Units.

AIM: To identify physical environmental factors influencing family involvement in feeding in New Zealand neonatal units. BACKGROUND: Infant oral feeding development is critical for both short-term feeding skills and longer term neurodevelopmental outcomes. The neonatal environment is well-known as challenging for neuroprotection due to negative sensory exposure. The impact of environmental factors on oral feeding in New Zealand (NZ) neonatal units is currently unexplored, and knowledge of this could allow for evidence-based unit design. METHODS: Focused ethnography at five neonatal units, a national survey of NZ neonatal professionals (n = 102), and five focus groups were carried out. Current oral feeding practice, and beliefs, experiences, and opinions of unit staff and family about these practices were explored. Data were analyzed using qualitative content analysis. RESULTS: Units were providing the best experience to families that they could with the resources they had available. Lack of physical space, lack of privacy, limited on-site accommodation for families, and lack of coordination between maternity and neonatal services were identified as impacting on family's comfort and sense of homeliness on the unit. Unit staff used furniture, screens, and external accommodation providers to support families where they could. CONCLUSIONS: The physical design of neonatal units in New Zealand provides barriers to family's spending time privately developing oral feeding. Solutions are proposed to increase the size of bedspaces, provide single-family rooms, create greater on-site family accommodation options, combine maternity and neonatal healthcare, and improve family comfort and therefore connection with their infant.

Epidemiology and burden of dengue fever in the United States: a systematic review.

BACKGROUND: Dengue is currently a global concern. The range of dengue vectors is expanding with climate change, yet United States of America (USA) studies on dengue epidemiology and burden are limited. This systematic review sought to characterize the epidemiology and disease burden of dengue within the USA. METHODS: Studies evaluating travel-related and endemic dengue in US states and territories were identified and qualitatively summarized. Commentaries and studies on ex-US cases were excluded. MEDLINE, Embase, Cochrane Library, Latin American and Caribbean Center of Health Sciences Information, Centre for Reviews and Dissemination and Clinicaltrials.gov were searched through January 2022. RESULTS: 116 studies were included. In US states, dengue incidence was generally low, with spikes occurring in recent years in 2013-16 (0.17-0.31 cases/100,000) and peaking in 2019 (0.35 cases/100,000). Most cases (94%, n = 7895, 2010-21) were travel related. Dengue was more common in Puerto Rico (cumulative average: 200 cases/100,000, 1980-2015); in 2010-21, 99.9% of cases were locally acquired. There were <50 severe cases in US states (2010-17); fatal cases were even rarer. Severe cases in Puerto Rico peaked in 1998 (n = 173) and 2021 (n = 76). Besides lower income, risk factors in US states included having birds in residence, suggesting unspecified environmental characteristics favourable to dengue vectors. Commonly reported symptoms included fever, headache and rash; median disease duration was 3.5-11 days. Hospitalization rates increased following 2009 World Health Organization disease classification changes (pre-2009: 0-54%; post-2009: 14-75%); median length of stay was 2.7-8 days (Puerto Rico) and 2-3 days (US states). Hospitalization costs/case (2010 USD) were$14 350 (US states),$1764-$5497 (Puerto Rico) and$4207 (US Virgin Islands). In Puerto Rico, average days missed were 0.2-5.3 (work) and 2.5 (school). CONCLUSIONS: Though dengue risk is ongoing, treatments are limited, and dengue's economic burden is high. There is an urgent need for additional preventive and therapeutic interventions.

Implementing an interprofessional palliative care education program to speech-language therapy and dietetic students.

Palliative care education for allied health professionals has received minimal research attention. This longitudinal study followed the development of an education program for speech-language therapy (SLT) and dietetic (DT) students. The project comprised three stages. In Stage I, consenting SLT and DT graduates (n = 9) were interviewed 6 months after graduation exploring preparedness for working in palliative care. Interviews were transcribed, and topics were extracted through content analysis. In Stage II, a new palliative care curriculum was developed using the extant literature and gaps reported in Stage I. In Stage III, we implemented and evaluated the new curriculum. Students were surveyed before (n = 68) and after (n = 42) the new program and at 6-month post-graduation (n = 15) to capture student-reported changes in knowledge and confidence in palliative care. In Stage I, 10 topics were developed covering knowledge, roles, team, family-focused care, and feelings. In Stage II, a hybrid program was developed including e-learning modules, didactic lectures, and a simulated learning experience. In Stage III, student feedback demonstrated positive shifts in knowledge and confidence ratings from medians 3-6 to 5-8 (1 = none; 10 = excellent) across all domains. Gains in knowledge and confidence were consistently higher at 6-month post-graduation for final survey respondents. Mixed modality interprofessional palliative care education for allied health professionals has merit in improving knowledge, confidence, and perceived preparedness for practice.

Prospective Comparative Effectiveness Trial of Multidisciplinary Lung Cancer Care Within a Community-Based Health Care System.

PURPOSE: Multidisciplinary lung cancer care is assumed to improve care delivery by increasing transparency, objectivity, and shared decision making; however, there is a lack of high-level evidence demonstrating its benefits, especially in community-based health care systems. We used implementation and team science principles to establish a colocated multidisciplinary lung cancer clinic in a large community-based health care system and evaluated patient experience and outcomes within and outside this clinic. METHODS: We conducted a prospective frequency-matched comparative effectiveness study (ClinicalTrials.gov identifier: NCT02123797) evaluating the thoroughness of lung cancer staging, receipt of stage-appropriate treatment, and survival between patients receiving care in the multidisciplinary clinic and those receiving usual serial care. Target enrollment was 150 patients on the multidisciplinary arm and 300 on the serial care arm. We frequency-matched patients by clinical stage, performance status, insurance type, race, and age. RESULTS: A total of 526 patients were enrolled: 178 on the multidisciplinary arm and 348 on the serial care arm. After adjusting for other factors, multidisciplinary patients had significantly higher odds (odds ratio [OR]: 2.3 [95% CI, 1.5 to 3.4]) of trimodality staging compared with serial care. Patients on the multidisciplinary arm also had higher odds of receiving invasive stage confirmation (OR: 2.0 [95% CI, 1.4 to 3.1]) and mediastinal stage confirmation (OR: 1.9 [95% CI, 1.3 to 2.8]). Additionally, patients receiving multidisciplinary care were significantly more likely to receive stage-appropriate treatment (OR: 1.8 [95% CI, 1.1 to 3.0]). We found no significant difference in overall or progression-free survival between study arms. CONCLUSION: The multidisciplinary clinic delivered significant improvements in evidence-based quality care on multiple levels. Even in the absence of a demonstrable survival benefit, these findings provide a strong rationale for recommending this model of care.

Multimorbidity patterns across race/ethnicity as stratified by age and obesity.

The objective of our study is to assess differences in prevalence of multimorbidity by race/ethnicity. We applied the FP-growth algorithm on middle-aged and elderly cohorts stratified by race/ethnicity, age, and obesity level. We used 2016-2017 data from the Cerner HealthFacts electronic health record data warehouse. We identified disease combinations that are shared by all races/ethnicities, those shared by some, and those that are unique to one group for each age/obesity level. Our findings demonstrate that even after stratifying by age and obesity, there are differences in multimorbidity prevalence across races/ethnicities. There are multimorbidity combinations distinct to some racial groups-many of which are understudied. Some multimorbidities are shared by some but not all races/ethnicities. African Americans presented with the most distinct multimorbidities at an earlier age. The identification of prevalent multimorbidity combinations amongst subpopulations provides information specific to their unique clinical needs.

Health professionals' perceptions of complex feeding decision-making in school-aged children.

AIM: Whilst prevalence of paediatric feeding disorders is high amongst children in specialist schools, there is little guidance for professionals supporting families with a child feeding orally with established risk of aspiration. We sought perceptions of the complex feeding decision-making process amongst health professionals supporting families in the specialist school setting in New Zealand. METHODS: An observational, cross-sectional, national online survey of speech-language therapists was followed by in-depth interviews with seven health professionals associated with one specialist school. RESULTS: Survey responses from 32 speech-language therapists showed inconsistency in assessment processes and how family, children and school staff are involved in feeding decisions, with 71% reporting a doctor had been involved. Respondents were not confident in their ability to predict aspiration risk, with 41% reporting that they could often determine risk, 41% sometimes and 16% never. Sixty-three percent of respondents indicated that level of risk was written in a report for a child and 50% reported that every child at high risk had a management plan. Speech-language therapists valued professional supervision, but it was not always available. Health professionals were broadly positive about the collaborative nature of decision-making in most but not all situations. They described communication, access/institutional and emotional barriers to timely, shared decision-making. CONCLUSION: These findings demonstrate variability in how families are supported to make complex feeding decisions. Health professionals identified a need for clearer processes and strengthened communication between family, school and health professionals. Trusting relationships are critical if all families are to be well-supported.

Projecting the Impact of Nutrition Policy to Improve Child Stunting: A Case Study in Guatemala Using the Lives Saved Tool.

BACKGROUND: Child stunting is a critical global health issue. Guatemala has one of the world's highest levels of stunting despite the sustained commitment to international nutrition policy best practices endorsed by the Scaling Up Nutrition (SUN) movement. Our objective was to use Guatemala as a case study to project the impact of a recently published national nutrition policy, the Great Crusade, that is consistent with SUN principles. METHODS: We used the Lives Saved Tool (LiST) to project the impact of scaling-up of nutrition interventions proposed in the Great Crusade and recommended by SUN. Our outcomes were changes in stunting prevalence, number of stunting cases averted, and number of cases averted by intervention in children under 5 years of age from 2020 to 2030. We considered 4 scenarios: (1) intervention coverage continues based on historical trends, (2) coverage targets in the Great Crusade are achieved, (3) coverage targets in the Great Crusade are achieved with reduced fertility risk, and (4) coverage reaches an aspirational level. RESULTS: All scenarios led to modest reductions in stunting prevalence. In 2024, stunting prevalence was estimated to change by -0.1% (95% confidence interval [CI]= 0.0%,-0.2%) if historical trends continue, -1.1% (95% CI=-0.8%,-1.5%) in the Great Crusade scenario, and -2.2% (95% CI=-1.6%,-3.0%) in the aspirational scenario. In 2030, we projected a stunting prevalence of -0.4% (95% CI=-0.2%,-0.8%) and -3.7% (95% CI=-2.8%,-5.1%) in the historical trends and aspirational scenario, respectively. Complementary feeding, sanitation, and breastfeeding were the highest-impact interventions across models. CONCLUSIONS: Targeted reductions in child stunting prevalence in Guatemala are unlikely to be achieved solely based on increases in intervention coverage. Our results show the limitations of current paradigms recommended by the international nutrition community. Policies and strategies are needed to address the broader structural drivers of stunting.

Oral-feeding guidelines for preterm neonates in the NICU: a scoping review.

OBJECTIVE: This scoping review describes the nature and evidence base of internationally available guidelines for the introduction of oral feeding for preterm infants in neonatal units. STUDY DESIGN: Thirty-nine current infant oral feeding introduction guidelines were obtained, and their recommendations contrasted with available scientific literature. RESULT: Documents were primarily from the USA, UK, Canada, and Australia, from hospitals, regional health authorities, and journal articles. Specifics of nonnutritive sucking, gestational age at first feed, exclusions to oral feeding, suggested interventions, and the definition of full oral feeding varied between documents. There was variable use of scientific evidence to back up recommendations. CONCLUSION: Guidelines for oral feeding, whether written by clinicians or researchers, vary greatly in their recommendations and details of interventions. Areas more widely researched were more commonly discussed. Recommendations varied more when evidence was not available or weak. Guideline developers need to synthesize evidence and local variability to create appropriate guidelines.

Becoming an expert: highly-experienced allied health professionals' relationships with their work.

PURPOSE: Highly-experienced allied health professionals have the opportunity to perform at the expert-level by sharing knowledge and skills with more junior staff, with the aim of upskilling the workforce. The study explored the current motivators, aspirations and the role of work in the life of highly-experienced practitioners, revealing factors that hinder or support them to further develop their own expertise and be inspiring role-models and mentors for less experienced staff. DESIGN/METHODOLOGY/APPROACH: Taking a grounded theoretical research design, we report on interviews with 45 allied health practitioners with at least seven years of professional experience from different professions and across organisational sectors. Transcripts were coded iteratively in conjunction with reviewing the literature, and cases were categorised to form a conceptual typology of work orientation. FINDINGS: Four work orientations are characterised capturing the diversity of the allied health workforce, particularly in relation to two dimensions of personal fulfilment and future ambition. The relationship between the types and expert-level performance is discussed, leading to recommendations for support that can be implemented to develop and sustain expert-level performance within a community. ORIGINALITY/VALUE: A new view of work orientation is introduced that relates expert-level performance with meaningful work. The findings highlight a diversity of work orientation for highly-experienced allied health professionals, that all require managerial awareness. Once recognised, the four types would benefit from different supports that could develop and maintain expert-level performance in those that seek it. Alternatives are also available for those that do not. Implications for workforce policy are discussed.

Early estimates of the indirect effects of the COVID-19 pandemic on maternal and child mortality in low-income and middle-income countries: a modelling study.

BACKGROUND: While the COVID-19 pandemic will increase mortality due to the virus, it is also likely to increase mortality indirectly. In this study, we estimate the additional maternal and under-5 child deaths resulting from the potential disruption of health systems and decreased access to food. METHODS: We modelled three scenarios in which the coverage of essential maternal and child health interventions is reduced by 9·8-51·9% and the prevalence of wasting is increased by 10-50%. Although our scenarios are hypothetical, we sought to reflect real-world possibilities, given emerging reports of the supply-side and demand-side effects of the pandemic. We used the Lives Saved Tool to estimate the additional maternal and under-5 child deaths under each scenario, in 118 low-income and middle-income countries. We estimated additional deaths for a single month and extrapolated for 3 months, 6 months, and 12 months. FINDINGS: Our least severe scenario (coverage reductions of 9·8-18·5% and wasting increase of 10%) over 6 months would result in 253 500 additional child deaths and 12 200 additional maternal deaths. Our most severe scenario (coverage reductions of 39·3-51·9% and wasting increase of 50%) over 6 months would result in 1 157 000 additional child deaths and 56 700 additional maternal deaths. These additional deaths would represent an increase of 9·8-44·7% in under-5 child deaths per month, and an 8·3-38·6% increase in maternal deaths per month, across the 118 countries. Across our three scenarios, the reduced coverage of four childbirth interventions (parenteral administration of uterotonics, antibiotics, and anticonvulsants, and clean birth environments) would account for approximately 60% of additional maternal deaths. The increase in wasting prevalence would account for 18-23% of additional child deaths and reduced coverage of antibiotics for pneumonia and neonatal sepsis and of oral rehydration solution for diarrhoea would together account for around 41% of additional child deaths. INTERPRETATION: Our estimates are based on tentative assumptions and represent a wide range of outcomes. Nonetheless, they show that, if routine health care is disrupted and access to food is decreased (as a result of unavoidable shocks, health system collapse, or intentional choices made in responding to the pandemic), the increase in child and maternal deaths will be devastating. We hope these numbers add context as policy makers establish guidelines and allocate resources in the days and months to come. FUNDING: Bill & Melinda Gates Foundation, Global Affairs Canada.

"All boats will rise": Physicians' perspectives on multidisciplinary lung cancer care in a community-based hospital setting.

PURPOSE: We explored the perceived strengths, barriers to implementation, and suggestions for sustainable implementation of a multidisciplinary model within a community-based hospital system from the physicians' perspectives. METHODS: We conducted 9 focus groups with 37 physicians involved in the care of lung cancer patients. Grounded theory methodology guided the identification of recurrent themes that emerged from the qualitative data analysis. RESULTS: The majority of study participants agreed that the multidisciplinary model could benefit patients by promoting high quality, efficient, and well-coordinated care. Co-location, financial disincentives, and time constraints were identified as major deterrents to full participation in a multidisciplinary clinic. Other perceived challenges were the integration of a multidisciplinary care model into the existing healthcare system, maintenance of referral streams, and designation of the physician primarily responsible for a patient's care. Educating physicians about the availability of a multidisciplinary clinic, establishing efficient processes for initial consultations, implementing technology for virtual participation, and using a nurse navigator with reliable closed-loop communication were suggested to improve the implementation of the multidisciplinary model. CONCLUSIONS: Physicians generally agreed that the multidisciplinary model could improve lung cancer care, but they perceived significant personal, institutional, and system-level barriers that need to be addressed for its successful implementation in a community healthcare setting.

Evaluation of a tracheostomy education programme for speech-language therapists.

BACKGROUND: Tracheostomy management is considered an area of advanced practice for speech-language therapists (SLTs) internationally. Infrequent exposure and limited access to specialist SLTs are barriers to competency development. AIMS: To evaluate the benefits of postgraduate tracheostomy education programme for SLTs working with children and adults. METHODS & PROCEDURES: A total of 35 SLTs participated in the programme, which included a 1-day tracheostomy simulation-based workshop. Before the workshop, SLTs took an online knowledge quiz and then completed a theory package. The workshop consisted of part-task skill learning and simulated scenarios. Scenarios were video recorded for delayed independent appraisal of participant performance. Manual skills were judged as (1) completed successfully, (2) completed inadequately/needed assistance or (3) lost opportunity. Core non-medical skills required when managing a crisis situation and overall performance were scored using an adapted Ottawa Global Rating Scale (GRS). Feedback from participants was collected and self-perceived confidence rated prior, immediately post and 4 months post-workshop. OUTCOMES & RESULTS: SLTs successfully performed 94% of manual tasks. Most SLTs (29 of 35) scored > 5 of 7 on all elements of the adapted Ottawa GRS. Workshop feedback was positive with significant increases in confidence ratings post-workshop and maintained at 4 months. CONCLUSIONS & IMPLICATIONS: Postgraduate tracheostomy education, using a flipped-classroom approach and low- and high-fidelity simulation, is an effective way to increase knowledge, confidence and manual skill performance in SLTs across patient populations. Simulation is a well-received method of learning.

Psychosocial interventions for informal caregivers of lung cancer patients: A systematic review.

OBJECTIVE: Caregivers of patients with lung cancer often face physical, emotional, and financial distress, which not only negatively affects the caregivers' mental health and quality of life but may also impact patients' well-being. The purpose of this systematic review is to examine the content, delivery, and efficacy of psychosocial interventions targeting caregivers of lung cancer patients. METHODS: Studies included in this systematic review assessed psychosocial interventions for caregivers of lung cancer patients that were published in English between January 2009 and December 2017. These interventions focused on burden, mental health, quality of life, self-efficacy, and/or coping as outcome measures. CINAHL, PubMed, PsycInfo, Science Direct, and Web of Science databases were searched using the terms (lung cancer OR lung neoplasms OR thoracic cancer) AND (caregiver OR caregiving) AND (intervention OR program) to systematically review the relevant literature on this topic. RESULTS: From the 22 studies included in this systematic review, interventions were classified into four categories: communication-based interventions, coping skills training interventions, multicomponent interventions, and stress reduction interventions. The majority of the interventions (especially communication-based and multicomponent) led to improvement, albeit not always statistically significant, in one or more outcomes; however, the most frequently reported improvements included, burden, distress, anxiety, depression, overall quality of life, self-efficacy, and coping abilities. CONCLUSIONS: The unmet needs of informal caregivers of lung cancer patients have a significant impact on their mental health and quality of life, but this burden can be alleviated by psychosocial interventions that offer appropriate support, education, and resources.

Educator-student talk during interprofessional simulation-based teaching.

Background: Simulated learning environments are increasingly common in interprofessional education (IPE). While reflection is key to simulated learning, little is known about the nature of these conversations during simulation. The aim of this exploratory paper was to quantify communicative features of conversations during interprofessional simulation scenarios between dietetics students, speech-language therapy students and their educators. Methods: Conversations between students and educators during the pauses between simulated scenario phases were recorded and transcribed. Student and educator utterances were quantitatively analysed for speech acts, question types and elements of IPE (clinical reasoning, roles and responsibilities, client and family centred care, interprofessional collaboration, clinical procedural tasks). Results: Across 1340 utterances from six scenarios, analyses of conversational speech acts and question types highlighted similar patterns of usage between two educators despite different clinical scenarios and professional backgrounds. Educators used a minimally higher proportion of open compared with closed questions, and higher-level problem-solving questions predominated in comparison to simple factual questioning. Educators used more requests for action and attention and students displayed more performative and responsive acts (p<0.05). Students were exposed to all elements of IPE through conversations in all scenarios. Conclusions: Conversations during pauses in immersive simulated scenarios between educators and students enable rich IPE opportunities and higher-level problem-solving. Educators encouraged students to problem solve within and across disciplines with open questions. Educators provided few factual responses to questions themselves rather diverting questions back to the students. This approach to the analysis of conversation can support educators to evaluate their own communication during interprofessional simulations.

Drivers of the reduction in childhood diarrhea mortality 1980-2015 and interventions to eliminate preventable diarrhea deaths by 2030.

BACKGROUND: Childhood diarrhea deaths have declined more than 80% from 1980 to 2015, in spite of an increase in the number of children in low- and middle-income countries (LMIC). Possible drivers of this remarkable accomplishment can guide the further reduction of the half million annual child deaths from diarrhea that still occur. METHODS: We used the Lives Saved Tool, which models effects on mortality due to changes in coverage of preventive or therapeutic interventions or risk factors, for 50 LMIC to determine the proximal drivers of the diarrhea mortality reduction. RESULTS: Diarrhea treatment (oral rehydration solution [ORS], zinc, antibiotics for dysentery and management of persistent diarrhea) and use of rotavirus vaccine accounted for 49.7% of the diarrhea mortality reduction from 1980 to 2015. Improvements in nutrition (stunting, wasting, breastfeeding practices, vitamin A) accounted for 38.8% and improvements in water, sanitation and handwashing for 11.5%. The contribution of ORS was greater from 1980 to 2000 (58.0% of the reduction) than from 2000 to 2015 (30.7%); coverage of ORS increased from zero in 1980 to 29.5% in 2000 and more slowly to 44.1% by 2015. To eliminate the remaining childhood diarrhea deaths globally, all these interventions will be needed. Scaling up diarrhea treatment and rotavirus vaccine, to 90% coverage could reduce global child diarrhea mortality by 74.1% from 2015 levels by 2030. Adding improved nutrition could increase that to 89.1%. Finally, adding increased use of improved water sources, sanitation and handwashing could result in a 92.8% reduction from the 2015 level. CONCLUSIONS: Employing the interventions that have resulted in such a large reduction in diarrhea mortality in the last 35 years can virtually eliminate remaining childhood diarrhea deaths by 2030.

Bangladesh: a success case in combating childhood diarrhoea.

BACKGROUND: Bangladesh had a large reduction in childhood deaths due to diarrhoeal disease in recent decades. This paper explores the preventive, promotive, curative and contextual drivers that helped Bangladesh achieve this exemplary success. METHODS: Primary and secondary data collection approaches were used to document trends in reduction of Diarrhoea Specific Mortality Rate (DSMR) between 1980 and 2015, understand what policies and programmes played key roles, and estimate the contribution of specific interventions that were implemented during the period. Data acquisition involved relevant document reviews and in-depth interviews with key stake-holders. A systematic search of literature was undertaken to explore socio-economic, aetiological, behavioural, and nutritional drivers of diarrhoeal disease reduction in Bangladesh. Finally, we used LiST (Lives Saved Tool) to model the contributions of the relevant interventions during three time periods (1980-2015, 1980-2000 and 2000-2015), and to project the number of lives saved in 2030 (compared to 2015) if these interventions were implemented at near universal coverage (90%). RESULTS: The factors which likely had the most impact on DSMR were the coordinated efforts of the Government of Bangladesh (GoB) with non-government organizations (NGOs) and the private sector that enabled swift implementation, at scale, of interventions like oral rehydration solution (ORS) and zinc, promotion of breastfeeding, handwashing and sanitary latrines (WASH), as well as improvements in female education and nutrition. Compared to 1980, we found ORS and reduction in stunting prevalence had the greatest impact on DSMR, saving roughly 70 000 lives combined in 2015. Until 2000, ORS had a higher contribution to DSMR reduction than reduction in stunting prevalence. This proportionate contribution was reversed during 2000-2015. At near universal coverage (90%) of combined direct diarrhoeal disease, nutrition and WASH interventions, we project that an additional 5356 deaths due to diarrhoea could be averted in 2030. CONCLUSION: Bangladesh's achievement in reduction of DSMR highlights the important role of an enabling policy environment that fostered coordinated efforts of the public and private sectors and NGOs for maximal impact. To maintain this momentum, evidence-based interventions should be scaled up at universal coverage.

Factors associated with the decline in under-five diarrhea mortality in India: a LiST analysis.

BACKGROUND: India has achieved 86% reduction in the number of under-five diarrheal deaths from 1980 to 2015. Nonetheless diarrhea is still among the leading causes of under-five deaths. The aim of this analysis was to study the contribution of factors that led to decline in diarrheal deaths in the country and the effect of scaling up of intervention packages to address the remaining diarrheal deaths. METHODS: We assessed the attribution of different factors and intervention packages such as direct diarrhea case management interventions, nutritional factors and WASH interventions which contributed to diarrhea specific under-five mortality reduction (DSMR) during 1980 to 2015 using the Lives Saved Tool (LiST). The potential impact of scaling up different packages of interventions to achieve universal coverage levels by year 2030 on reducing the number of remaining diarrheal deaths were estimated. RESULTS: The major factors associated with DSMR reduction in under-fives during 1980 to 2015, were increase in ORS use, reduction in stunting prevalence, improved sanitation, changes in age appropriate breastfeeding practices, increase in the vitamin-A supplementation and persistent diarrhea treatment. ORS use and reduction in stunting were the two key interventions, each accounting for around 32% of the lives saved during this period. Scaling up the direct diarrhea case management interventions from the current coverage levels in 2015 to achieve universal coverage levels by 2030 can save around 82 000 additional lives. If the universal targets for nutritional factors and WASH interventions can be achieved, an additional 23 675 lives can potentially be saved. CONCLUSIONS: While it is crucial to improve the coverage and equity in ORS use, an integrated approach to promote nutrition, WASH and direct diarrhea interventions is likely to yield the highest impact on reducing the remaining diarrheal deaths in under-five children.