Exploring preconception health in adolescents and young adults: Identifying risk factors and interventions to prevent adverse maternal, perinatal, and child health outcomes-A scoping review.

BACKGROUND: Preconception health provides an opportunity to examine a woman's health status and address modifiable risk factors that can impact both a woman's and her child's health once pregnant. In this review, we aimed to investigate the preconception risk factors and interventions of early pregnancy and its impact on adverse maternal, perinatal and child health outcomes. METHODS: We conducted a scoping review following the PRISMA-ScR guidelines to include relevant literature identified from electronic databases. We included reviews that studied preconception risk factors and interventions among adolescents and young adults, and their impact on maternal, perinatal, and child health outcomes. All identified studies were screened for eligibility, followed by data extraction, and descriptive and thematic analysis. FINDINGS: We identified a total of 10 reviews. The findings suggest an increase in odds of maternal anaemia and maternal deaths among young mothers (up to 17 years) and low birth weight (LBW), preterm birth, stillbirths, and neonatal and perinatal mortality among babies born to mothers up to 17 years compared to those aged 19-25 years in high-income countries. It also suggested an increase in the odds of congenital anomalies among children born to mothers aged 20-24 years. Furthermore, cancer treatment during childhood or young adulthood was associated with an increased risk of preterm birth, LBW, and stillbirths. Interventions such as youth-friendly family planning services showed a significant decrease in abortion rates. Micronutrient supplementation contributed to reducing anaemia among adolescent mothers; however, human papillomavirus (HPV) and herpes simplex virus (HSV) vaccination had little to no impact on stillbirths, ectopic pregnancies, and congenital anomalies. However, one review reported an increased risk of miscarriages among young adults associated with these vaccinations. CONCLUSION: The scoping review identified a scarcity of evidence on preconception risk factors and interventions among adolescents and young adults. This underscores the crucial need for additional research on the subject.

An evidence gap map of interventions for noncommunicable diseases and risk factors among children and adolescents.

Substance misuse, obesity, mental health conditions, type 1 diabetes, cancers, and cardiovascular and chronic respiratory diseases together account for 41% of disability-adjusted life years linked to noncommunicable diseases (NCDs) among children and adolescents worldwide. However, the evidence on risk factors and interventions for this age group is scarce. Here we searched four databases to generate an evidence gap map of existing interventions and research gaps for these risk factors and NCDs. We mapped 159 reviews with 2,611 primary studies; most (96.2%) were conducted in high-income countries, and only 100 studies (3.8%) were from low- and middle-income countries (LMICs). The efficacy of therapeutic interventions on biomarkers and adverse events for NCDs appears to be well evidenced. Interventions for mental health conditions appear to be moderately evidenced, while interventions for obesity and substance misuse appear to be moderate to very low evidenced. Priority areas for future research include evaluating digital health platforms to support primary NCD prevention and management, and evaluating the impact of policy changes on the prevalence of obesity and substance misuse. Our findings highlight the wide disparity of evidence between high-income countries and LMICs. There is an urgent need for increased, targeted financing to address the research gaps in LMICs.

Systematic Review of Management of Moderate Wasting in Children over 6 Months of Age.

The effective management of the 33 million children with moderate acute malnutrition (MAM) is key to reducing childhood morbidity and mortality. In this review, we aim to evaluate the effectiveness of specially formulated foods (SFFs) compared to non-food-based approaches to manage MAM in children >6 months old. We conducted a search on ten databases until 23 August 2021 and included five studies, covering 3387 participants. Meta-analysis of four studies comparing SFFs to counselling or standard of care showed that SFFs likely increase recovery rate, reduce non-response, and may improve weight-for-height z-score, weight-for-age z-score and time to recovery, but have little or no effect on MUAC gain. One study on a multicomponent intervention (SFFs, antibiotics and counselling provided to high-risk MAM) compared to counselling only was reported narratively. The intervention may increase weight gain after 24 weeks but may have little or no effect on weight gain after 12 weeks and on non-response and mortality after 12 and 24 weeks of enrollment. The effect of this intervention on recovery was uncertain. In conclusion, SFFs may be beneficial for children with moderate wasting in humanitarian contexts. Programmatic recommendations should consider context and cost-effectiveness.

Coverage survey of typhoid conjugate vaccine among children aged 6 months to 15 years in an urban slum settlement of Lyari Town Karachi, Pakistan.

OBJECTIVE: To estimate the coverage rate of typhoid conjugate vaccine (TCV) among children aged 6 months to 15 years in Lyari Town Karachi, Pakistan. METHODS: A cross-sectional survey was conducted to estimate the vaccine coverage of Typbar TCV in Lyari Town Karachi utilizing the World Health Organization (WHO) recommended rapid vaccine coverage assessment technique (30 clusters × 7 households). Sampling was powered at town level and multistage cluster sampling was used. Four union councils were randomly selected from a total of 11 and the survey was conducted in those union councils. After consent was obtained, parents of age-eligible children living in the selected union councils were invited to participate in the survey and information was collected on Typbar TCV vaccination status of children aged 6 months to 15 years. RESULTS: Overall, 2325 children were included in the survey. The mean age of the participants was 7.60 ± 3.84 years. The ratio of males to females was equal in the survey sample; 1163 (50.02%) were male. In the total target population, 82% children were found to be vaccinated; however, the vaccination status could be verified for 80%. The vaccine coverage of TCV was comparable among the four union councils and the overall coverage of TCV vaccine in Lyari Town was found to be 80%. The coverage was significantly lower in younger children, 5% and 17% among children aged 6 months to < 2 years and 2 years to < 5 years respectively and 78% among children aged 5 years to 15 years. CONCLUSION: The overall immunization coverage rate with TCV was found to be satisfactory. Immunization coverage was comparable among both sexes and the selected union councils but it was relatively low among children in younger age groups.

Health behaviors and care seeking practices for childhood diarrhea and pneumonia in a rural district of Pakistan: A qualitative study.

Diarrhea and pneumonia are the leading causes of morbidity and mortality in children under five, and Pakistan is amongst the countries with the highest burden and low rates of related treatment coverage. We conducted a qualitative study as part of the formative phase to inform the design of the Community Mobilization and Community Incentivization (CoMIC) cluster randomized control trial (NCT03594279) in a rural district of Pakistan. We conducted in-dept interviews and focused group discussions with key stakeholders using a semi-structured study guide. Data underwent rigorous thematic analysis and major themes identified included socio-cultural dynamics, community mobilization and incentives, behavioral patterns and care seeking practices for childhood diarrhea and pneumonia, infant and young child feeding practices (IYCF), immunization, water sanitation and hygiene (WASH) and access to healthcare. This study highlights shortcomings in knowledge, health practices and health systems. There was to a certain extent awareness of the importance of hygiene, immunization, nutrition, and care-seeking, but the practices were poor due to various reasons. Poverty and lifestyle were considered prime factors for poor health behaviors, while health system inefficiencies added to these as rural facilities lack equipment and supplies, resources, and funding. The community identified that intensive inclusive community engagement and demand creation strategies tied to conditioned short term tangible incentives could help foster behavior change.

Optimal timing of introduction of complementary feeding: a systematic review and meta-analysis.

CONTEXT: The timing of introducing complementary feeding (CF) is crucial because premature or delayed CF can be associated with adverse health outcomes in childhood and adulthood. OBJECTIVE: This systematic review aims to evaluate the impact of the timing of CF introduction on health, nutrition, and developmental outcomes among normal-term infants. DATA SOURCES: Electronic databases and trial registries were searched, along with the reference lists of the included studies and relevant systematic reviews. DATA EXTRACTION: Two investigators independently extracted data from the included studies on a standardized data-extraction form. DATA ANALYSIS: Data were meta-analyzed separately for randomized controlled trials (RCTs) and observational studies on the basis of early introduction of CF (< 3 months, < 4 months, < 6 months of age) or late introduction of CF (> 6 months, > 8 months of age). Evidence was summarized according to GRADE criteria. In total, 268 documents were included in the review, of which 7 were RCTs (from 24 articles) and 217 were observational studies (from 244 articles). Evidence from RCTs did not suggest an impact of early introduction, while low-certainty evidence from observational studies suggested that early introduction of CF (< 6 months) might increase body mass index (BMI) z score and overweight/obesity. Early introduction at < 3 months might increase BMI and odds of lower respiratory tract infection (LRTI), and early introduction at < 4 months might increase height, LRTI, and systolic and diastolic blood pressure (BP). For late introduction of CF, there was a lack of evidence from RCTs, but low-certainty evidence from observational studies suggests that late introduction of CF (> 6 months) might decrease height, BMI, and systolic and diastolic BP and might increase odds of intestinal helminth infection, while late introduction of CF (> 8 months) might increase height-for-age z score. CONCLUSION: Insufficient evidence does suggest increased adiposity with early introduction of CF. Hence, the current recommendation of introduction of CF should stand, though more robust studies, especially from low- and middle-income settings, are needed. SYSTEMATIC REVIEW REGISTRATION: PROSPERO registration number CRD42020218517.

Training health workers in clinical breast examination for early detection of breast cancer in low- and middle-income countries.

BACKGROUND: Most women living in low- and middle-income countries (LMICs) present with advanced-stage breast cancer. Limitations of poor serviceable health systems, restricted access to treatment facilities, and lack of breast cancer screening programmes all likely contribute to the late presentation of women with breast cancer living in these countries. Women are diagnosed with advanced disease and frequently do not complete their care due to a number of factors, including financial reasons as health expenditure is largely out of pocket resulting in financial toxicity; health system failures, such as missing services or health worker lack of awareness on common signs and symptoms of cancer; and sociocultural barriers, such as stigma and use of alternative therapies. Clinical breast examination (CBE) is an inexpensive early detection technique for breast cancer in women with palpable breast masses. Training health workers from LMICs to conduct CBE has the potential to improve the quality of the technique and the ability of health workers to detect breast cancers early. OBJECTIVES: To assess whether training in CBE affects the ability of health workers in LMICs to detect early breast cancer. SEARCH METHODS: We searched the Cochrane Breast Cancer Specialised Registry, CENTRAL, MEDLINE, Embase, the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) search portal, and ClinicalTrials.gov up to 17 July 2021. SELECTION CRITERIA: We included randomised controlled trials (RCTs) (including individual and cluster-RCTs), quasi-experimental studies and controlled before-and-after studies if they fulfilled the eligibility criteria. DATA COLLECTION AND ANALYSIS: Two review authors independently screened studies for inclusion, and extracted data, assessed risk of bias, and assessed the certainty of the evidence using the GRADE approach. We performed statistical analysis using Review Manager software and presented the main findings of the review in a summary of findings table. MAIN RESULTS: We included four RCTs that screened a total population of 947,190 women for breast cancer, out of which 593 breast cancers were diagnosed. All included studies were cluster-RCTs; two were conducted in India, one in the Philippines, and one in Rwanda. Health workers trained to perform CBE in the included studies were primary health workers, nurses, midwives, and community health workers. Three of the four included studies reported on the primary outcome (breast cancer stage at the time of presentation). Amongst secondary outcomes, included studies reported CBE coverage, follow-up, accuracy of health worker-performed CBE, and breast cancer mortality. None of the included studies reported knowledge attitude practice (KAP) outcomes and cost-effectiveness. Three studies reported diagnosis of breast cancer at early stage (at stage 0+I+II), suggesting that training health workers in CBE may increase the number of women detected with breast cancer at an early stage compared to the non-training group (45% detected versus 31% detected; risk ratio (RR) 1.44, 95% confidence interval (CI) 1.01 to 2.06; three studies; 593 participants; I2 = 0%; low-certainty evidence). Three studies reported diagnosis at late stage (III+IV) suggesting that training health workers in CBE may slightly reduce the number of women detected with breast cancer at late stage compared to the non-training group (13% detected versus 42%, RR 0.58, 95% CI 0.36 to 0.94; three studies; 593 participants; I2 = 52%; low-certainty evidence). Regarding secondary outcomes, two studies reported breast cancer mortality, implying that the evidence is uncertain for the impact on breast cancer mortality (RR 0.88, 95% CI 0.24 to 3.26; two studies; 355 participants; I2 = 68%; very low-certainty evidence). Due to the study heterogeneity, we could not conduct meta-analysis for accuracy of health worker-performed CBE, CBE coverage, and completion of follow-up, and therefore reported narratively using the 'Synthesis without meta-analysis' (SWiM) guideline. Sensitivity of health worker-performed CBE was reported to be 53.2% and 51.7%; while specificity was reported to be 100% and 94.3% respectively in two included studies (very low-certainty evidence). One trial reported CBE coverage with a mean adherence of 67.07% for the first four screening rounds (low-certainty evidence). One trial reported follow-up suggesting that compliance rates for diagnostic confirmation following a positive CBE were 68.29%, 71.20%, 78.84% and 79.98% during the respective first four rounds of screening in the intervention group compared to 90.88%, 82.96%, 79.56% and 80.39% during the respective four rounds of screening in the control group. AUTHORS' CONCLUSIONS: Our review findings suggest some benefit of training health workers from LMICs in CBE on early detection of breast cancer. However, the evidence regarding mortality, accuracy of health worker-performed CBE, and completion of follow up is uncertain and requires further evaluation.

A systematic review with evidence mapping of supportive care interventions for melanoma patients and caregivers.

AIM: We conducted a systematic review and evidence gap mapping to explore the existing supportive care interventions and their impact on well-being outcomes for melanoma patients and caregivers. METHODS: We searched MEDLINE, Embase, Web of Science Index Medicus, CINAHL, Lilacs, CENTRAL (Cochrane Library) and PsycINFO in December 2022, including interventional studies assessing the effectiveness of any supportive care intervention among melanoma patients and/or their caregivers. FINDINGS: Twenty studies were included in this review. These studies consisted of randomised controlled trials (n = 11, 55%), pre-post studies (n = 7, 35%) and quasi-experimental trials (n = 2, 10%). All studies originated from high-income countries and focused primarily on melanoma patients, with no studies identified that focused solely on caregivers. Educational interventions were the most common (n = 7, 35%), followed by psychoeducational interventions (n = 6, 30%) and psychotherapeutic interventions (n = 4, 20%). Nearly all included studies (n = 18, 90%) reported a positive effect of the intervention on the primary outcome of interest; however, most studies (n = 17, 85%) were judged to be at moderate or high risk of bias. Due to heterogeneity of study designs, intervention characteristics and outcome measures, meta-analysis was not conducted. IMPLICATIONS: Supportive care interventions have positive impacts on melanoma patient well-being outcomes, while being acceptable and feasible to conduct. More research is needed regarding supportive care interventions for melanoma caregivers. Future research should focus on eliminating sources of bias through rigorous methodology, with the development of standardised outcome measures for psychosocial outcomes to facilitate future meta-analyses.

Effectiveness of Dietary Management for Moderate Wasting among Children > 6 Months of Age-A Systematic Review and Meta-Analysis Exploring Different Types, Quantities, and Durations.

Currently, no World Health Organization guidelines exist for the management of approximately 31.8 million moderately wasted children globally. The objective of this review was to synthesise evidence on the optimal type, quantity, and duration of dietary treatment for moderate wasting. Ten electronic databases were searched until the 23rd of August 2021. Experimental studies comparing interventions for the dietary management of moderate wasting were included. Meta-analyses were conducted and results were presented as risk ratios or mean differences with 95% confidence intervals. Seventeen studies comparing specially formulated foods were included involving 23,005 participants. Findings suggest little or no difference in recovery between Fortified Blended Foods (FBFs) with improved micronutrient and/or milk content (enhanced FBFs) and lipid-based nutrient supplements (LNS), whereas children treated with non-enhanced FBFs (locally produced FBFs or standard corn-soy blend) may have lower recovery rates than those treated with LNS. There was no difference in recovery when ready-to-use therapeutic and ready-to-use supplementary food were compared. Other outcomes mostly aligned with results for recovery. In conclusion, LNSs improve recovery compared to non-enhanced FBFs, but are comparable to enhanced FBFs. Programmatic choice of supplement should consider factors such as cost, cost-effectiveness, and acceptability. Further research is required to determine optimal dosing and duration of supplementation.

Community Mobilization and Community Incentivization (CoMIC) Strategy for Child Health in a Rural Setting of Pakistan: Study Protocol for a Randomized Controlled Trial.

Despite the decline in under-five mortality by over 60% in the last three decades, majority of child mortality is still attributable to communicable and infectious diseases that are not only preventable, but they are also treatable. We evaluated the potential impact of a participatory community engagement and innovative community incentivization (C3I) strategy for improving the coverage of child health interventions in a rural setting in Pakistan. We first undertook formative research to assess community knowledge and the likelihood of collective community strategy and conditional incentives for improving existing preventive and care-seeking practices for childhood diarrhea and pneumonia. We developed options for community incentivization and improving group practices, taking local norms and customs into account in the design of the community mobilization strategies and messages. These interventions were then formally evaluated prospectively in a three-arm cluster randomized controlled trial. Clusters were randomly assigned by a computer algorithm using restricted randomization by an external statistician (1:1:1) into three groups: community mobilization and incentivization (CMI); community mobilization only using an enhanced communication package (CM); and control group. The C3I was an innovative strategy as it involved serial incremental targets of collective improvement in community behavior related to improvement in the coverage of a composite indicator of fully immunized children (FIC), oral rehydration salt (ORS), and the sanitation index (SI). The evaluation was done by an independent data collection and analysis team at baseline and end line (after 24 months).

Interventions for Health and Well-Being in School-Aged Children and Adolescents: A Way Forward.

The health and well-being of school-aged children has received little attention compared with younger children aged < 5 years and adolescents. In this final article in a supplement of reviews that have assessed the effectiveness of interventions for school-aged children across a variety of health-related domains (including infectious diseases, noncommunicable diseases, healthy lifestyle, mental health, unintentional injuries, and sexual and reproductive health), we summarize the main findings and offer a way forward for future research, policy, and implementation. We complement this evidence base on interventions with a summary of the literature related to enabling policies and intersectoral actions supporting school-aged child health. The school represents an important platform for both the delivery of preventive interventions and the collection of data related to child health and academic achievement, and several frameworks exist that help to facilitate the creation of a health-promoting environment at school.

Interventions for High-Burden Infectious Diseases in Children and Adolescents: A Meta-analysis.

BACKGROUND: Approximately 2.2 million deaths were reported among school-age children and young people in 2019, and infectious diseases remain the leading causes of morbidity and mortality, especially in low and middle-income countries. We aim to synthesize evidence on interventions for high-burden infectious diseases among children and adolescents aged 5 to 19 years. METHODS: We conducted a comprehensive literature search until December 31, 2020. Two review authors independently screened studies for relevance, extracted data, and assessed risk of bias. RESULTS: We included a total of 31 studies, including 81 596 participants. Sixteen studies focused on diarrhea; 6 on tuberculosis; 2 on human immunodeficiency virus; 2 on measles; 1 study each on acute respiratory infections, malaria, and urinary tract infections; and 2 studies targeted multiple diseases. We did not find any study on other high burden infectious diseases among this age group. We could not perform meta-analysis for most outcomes because of variances in interventions and outcomes. Findings suggests that for diarrhea, water treatment, water filtration, and zinc supplementation have some protective effect. For tuberculosis, peer counseling, contingency contract, and training of health care workers led to improvements in tuberculosis detection and treatment completion. Continuation of cotrimoxazole therapy reduced the risk of tuberculosis and hospitalizations among human immunodeficiency virus-infected children and reduced measles complications and pneumonia cases among measles-infected children. Zinc supplementation led to a faster recovery in urinary tract infections with a positive effect in reducing symptoms. CONCLUSIONS: There is scarcity of data on the effectiveness of interventions for high-burden infectious diseases among school-aged children and adolescents.

Interventions for Neglected Tropical Diseases Among Children and Adolescents: A Meta-analysis.

BACKGROUND: Neglected tropical diseases (NTDs) are a group of communicable diseases affecting the poorest populations around the world. OBJECTIVE: To assess the effectiveness of interventions, including mass drug administration (MDA), water, sanitation, and hygiene (WASH), vector control, health education, and micronutrients supplementation, for NTDs among children and adolescents. METHODS: We conducted a literature search on the Cochrane Controlled Trials Register, Medline, and other databases until December 2020. We included randomized controlled trials and quasi-experimental studies conducted among children and adolescents. Two authors independently screened studies for relevance. Two authors independently extracted data, assessed the risk of bias, performed metaanalysis, and rated the quality of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation. RESULTS: We included 155 studies (231 articles) involving 262 299 participants. For soil-transmitted helminthiasis, MDA may reduce the prevalence of Ascaris, Trichuris, and hookworm by 58%, 36%, and 57%, respectively. We are uncertain of the effect of health education, WASH, and iron supplementation on soil-transmitted helminthiasis prevalence. For Schistosomiasis, health education probably reduces the intensity and prevalence of S. mansoni, whereas micronutrient supplementation may reduce anemia prevalence and the infection intensity of S. hematobium compared with no supplementation. We are uncertain of the effect of MDA and vector control on Schistosomiasis outcomes. For trachoma, health education probably reduces the prevalence of active Trachoma, whereas we are uncertain of the effect of MDA, WASH, and vector control on Trachoma outcomes. There is limited data on the effectiveness of interventions for NTDs targeting children and adolescents. CONCLUSION: Future studies are needed to evaluate the relative effectiveness and cost-effectiveness of various interventions specifically targeting children and adolescents.

Interventions to Improve Immunization Coverage Among Children and Adolescents: A Meta-analysis.

BACKGROUND AND OBJECTIVES: Vaccinations are recognized as a feasible, cost-effective public health intervention for reducing the burden and associated mortality of many infectious diseases. The purpose of this study was to evaluate the effectiveness of potential interventions to improve the uptake of vaccines among children and adolescents. METHODS: We performed a literature search until December 2020. Eligible studies were identified using Cochrane Central Register of Controlled Trials, MEDLINE, PubMed, and other sources. We included studies conducted on children and adolescents aged 5 to 19 years. Studies comprised of hospitalized children and those with comorbid conditions were excluded. Two authors independently performed the meta-analysis. RESULTS: Findings from 120 studies (123 articles), of which 95 were meta-analyzed, reveal that vaccination education may increase overall vaccination coverage by 19% (risk ratio [RR], 1.19; 95% confidence interval [CI], 1.12-1.26), reminders by 15% (RR, 1.15; 95% CI, 1.11-1.18), interventions for providers by 13% (RR, 1.13; 95% CI, 1.07-1.19), financial incentives by 67% (RR, 1.67; 95% CI, 1.40-1.99), and multilevel interventions by 25% (RR, 1.25; 95% CI, 1.10-1.41). The impact of school-based clinics and policy and legislation on overall vaccination coverage is still uncertain, and no impact of a multicomponent intervention on overall vaccination coverage was found. CONCLUSIONS: Educational interventions, reminders, provider-directed interventions, financial incentives, and multilevel interventions may improve vaccination coverage among school-aged children and adolescents.

What can work and how? An overview of evidence-based interventions and delivery strategies to support health and human development from before conception to 20 years.

Progress has been made globally in improving the coverage of key maternal, newborn, and early childhood interventions in low-income and middle-income countries, which has contributed to a decrease in child mortality and morbidity. However, inequities remain, and many children and adolescents are still not covered by life-saving and nurturing care interventions, despite their relatively low costs and high cost-effectiveness. This Series paper builds on a large body of work from the past two decades on evidence-based interventions and packages of care for survival, strategies for delivery, and platforms to reach the most vulnerable. We review the current evidence base on the effectiveness of a variety of essential and emerging interventions that can be delivered from before conception until age 20 years to help children and adolescents not only survive into adulthood, but also to grow and develop optimally, support their wellbeing, and help them reach their full developmental potential. Although scaling up evidence-based interventions in children younger than 5 years might have the greatest effect on reducing child mortality rates, we highlight interventions and evidence gaps for school-age children (5-9 years) and the transition from childhood to adolescence (10-19 years), including interventions to support mental health and positive development, and address unintentional injuries, neglected tropical diseases, and non-communicable diseases.

Differences in pregnancy and perinatal outcomes among symptomatic versus asymptomatic COVID-19-infected pregnant women: a systematic review and meta-analysis.

BACKGROUND: There is dearth of information on COVID-19's impact on pregnant women. However, literature reported trends of COVID-19 differ, depending on the presence of clinical features upon presentation. OBJECTIVE: This systematic review aimed to assess differences in risk factors, management, complications, and pregnancy and perinatal outcomes in symptomatic vs. asymptomatic pregnant women with confirmed SARS-CoV-2 infection. METHODS: A search was run on electronic databases to identify studies reporting COVID-19 in pregnancy. Meta-analysis was performed and odds ratios and mean difference with 95% confidence intervals were calculated using Review Manager 5.4. Review Prospero registration number CRD42020204662. RESULTS: We included ten articles reporting data from 3158 pregnancies; with 1900 symptomatic and 1258 asymptomatic pregnant women. There was no significant difference in the mean age, gestational age, and body mass index between the two groups. The meta-analysis suggested that pregnant women who were obese (OR:1.37;95%CI:1.15 to 1.62), hypertensive (OR:2.07;95%CI:1.38 to 3.10) or had a respiratory disorder (OR:1.64;95%CI:1.25 to 2.16), were more likely to be symptomatic when infected with SARS-CoV-2. Pregnant women with Black (OR:1.48;95%CI:1.19 to 1.85) or Asian (OR:1.64;95%CI:1.23 to 2.18) ethnicity were more likely to be symptomatic while those with White ethnicity (OR:0.63;95%CI:0.52 to 0.76) were more likely to be asymptomatic. Cesarean-section delivery (OR:1.40;95%CI:1.17 to 1.67) was more likely amongst symptomatic pregnant women. The mean birthweight(g) (MD:240.51;95%CI:188.42 to 293.51), was significantly lower, while the odds of low birthweight (OR:1.85;95%CI:1.06 to 3.24) and preterm birth (< 37 weeks) (OR:2.10;95%CI:1.04 to 4.23) was higher amongst symptomatic pregnant women. Symptomatic pregnant women had a greater requirement for maternal ICU admission (OR:13.25;95%CI:5.60 to 31.34) and mechanical ventilation (OR:15.56;95%CI:2.96 to 81.70) while their neonates had a higher likelihood for Neonatal Intensive Care Unit admission (OR:1.96;95%CI:1.59 to 2.43). The management strategies in the included studies were poorly discussed, hence could not be analyzed. CONCLUSION: The evidence suggests that the presence of risk factors (co-morbidities and ethnicity) increased the likelihood of pregnant women being symptomatic. Higher odds of complications were also observed amongst symptomatic pregnant women. However, more adequately conducted studies with adjusted analysis and parallel comparison groups are required to reach conclusive findings.

A century past the discovery of insulin: global progress and challenges for type 1 diabetes among children and adolescents in low-income and middle-income countries.

Type 1 diabetes is on the rise globally; however, the burden of mortality remains disproportionate in low-income and middle-income countries (LMICs). As 2021 marks 100 years since the discovery of insulin, we revisit progress, global burden of type 1 diabetes trends, and understanding of the pathogenesis and management practices related to the disease. Despite much progress, inequities in access and availability of insulin formulations persist and are reflected in differences in survival and morbidity patterns related to the disease. Some of these inequities have also been exacerbated by health-system challenges during the COVID-19 pandemic. There is a clear opportunity to improve access to insulin and related essential technologies for improved management of type 1 diabetes in LMICs, especially as a part of universal health coverage. These improvements will require concerted action and investments in human resources, community engagement, and education for the timely diagnosis and management of type 1 diabetes, as well as adequate health-care financing. Further research in LMICs, especially those in Africa, is needed to improve our understanding of the burden, risk factors, and implementation strategies for managing type 1 diabetes.

Vitamin C supplementation for prevention and treatment of pneumonia.

BACKGROUND: According to the Global Burden of Disease Study 2015, lower respiratory tract infection is the leading cause of infectious disease death, and the fifth most common cause of death overall. Vitamin C has a role in modulating resistance to infectious agents, therefore vitamin C supplementation may be important in preventing and treating pneumonia. OBJECTIVES: To assess the impact of vitamin C supplementation to prevent and treat pneumonia in children and adults. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, PubMed, CINAHL, LILACS, Web of Science, and two trials registers to 4 March 2020. We also checked references to identify additional studies. We did not apply any publication status or language filters. SELECTION CRITERIA: We included randomised controlled trials (RCTs) and quasi-RCTs (studies using allocation methods that are not random, e.g. date of birth, medical record number) assessing the role of vitamin C supplementation in the prevention and treatment of pneumonia in children and adults compared to control or placebo. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. MAIN RESULTS: We included five studies in the review and identified two ongoing studies. The five included studies involved a total of 2655 participants; two studies were RCTs and three were quasi-RCTs. The included studies were conducted in one high-income country (USA) and three lower-middle-income countries (Bangladesh and Pakistan). Three studies were conducted in hospital inpatient settings, one in school, and one in a military training centre. Three studies included children under five years of age, one study included school-aged children, and one study included adult participants. Two studies assessed the effect of vitamin C supplementation for pneumonia prevention; and three studies assessed the effect of vitamin C supplementation as an adjunct to pneumonia treatment. For pneumonia prevention, the included studies provided supplementation in doses of 1 g daily for 14 weeks, 2 g daily for 8 weeks, and 2 g daily for 14 weeks. For pneumonia treatment, the included studies provided vitamin C supplementation in doses of 125 mg daily and 200 mg daily until the symptoms resolved or discharge, as an adjunct to the pneumonia treatment. Overall, the included studies were judged to be at either high or unclear risk of bias for random sequence generation, allocation concealment, and blinding; and the evidence certainty was very low. Two studies assessed the effect of vitamin C supplementation for pneumonia prevention; we judged the certainty of the evidence as very low. We are uncertain about the effect of vitamin C supplementation on pneumonia incidence and adverse events (urticaria). None of the included studies reported other primary outcomes (pneumonia prevalence and mortality) or any of the secondary outcomes. Three studies assessed the effect of vitamin C supplementation as an adjunct to pneumonia treatment; we judged the certainty of the evidence as very low. We are uncertain of the effect of vitamin C supplementation on duration of illness and hospitalisation. None of the included studies reported other primary or secondary outcomes. AUTHORS' CONCLUSIONS: Due to the small number of included studies and very low certainty of the existing evidence, we are uncertain of the effect of vitamin C supplementation for the prevention and treatment of pneumonia. Further good-quality studies are required to assess the role of vitamin C supplementation in the prevention and treatment of pneumonia.

A systematic review and meta-analysis of data on pregnant women with confirmed COVID-19: Clinical presentation, and pregnancy and perinatal outcomes based on COVID-19 severity.

BACKGROUND: We determined the clinical presentation, risk factors, and pregnancy and perinatal outcomes in pregnant women with confirmed COVID-19 and identified if these are different based on COVID-19 severity. METHODS: We included all observational studies on pregnant women with confirmed COVID-19 reporting clinical presentation, risk factors, and pregnancy and perinatal outcomes. We included all studies published between Dec/2019-Feb/2021 in Medline, Embase, the WHO COVID-19 databases, and clinicaltrials.gov. The methodological quality of cohort and case-series was assessed using NHLBI criteria. RESULTS: 31 016 pregnant women from 62 studies were included. Women were an average of 30.9 years of age, most (77.7%) were in the third trimester, and 16.4% developed severe COVID-19. Nearly half were asymptomatic, while the most commonly reported symptoms were cough, fever, fatigue, and anosmia/ageusia. About 7% were admitted to the intensive care unit (ICU), 8% required mechanical ventilation, and 2% of the women died. Almost 80% of women delivered; 48.4% had cesarean births. Among newborns, 23.4% were preterm (<37 weeks), 16.6% were low birth weight, and 23.7% were admitted to neonatal ICU. A total of 21 stillbirths (1.6%) and 24 neonatal deaths (1.6%) were recorded, while 50 babies (3.5%) were COVID-19 positive. Studies comparing pregnant women with severe and non-severe COVID-19 showed that women with severe COVID-19 were 3.7 years older and the risk of severe COVID-19 was 1.5 times higher among women >35 years. The risk of severe COVID-19 was significantly higher among women who were obese, had smoked, diabetic, and had pre-eclampsia. The risk of preterm birth was almost 2.4 folds among women with severe COVID-19. CONCLUSIONS: Our review suggests a heightened risk of COVID-19 severity and adverse pregnancy and perinatal outcomes among women with certain demographic and health profiles. These findings can inform the formation of current guidelines; however, these should be constantly updated as the global COVID-19 scenario unfolds. REGISTRATION: PROSPERO: CRD42020182048.

The Differences in Clinical Presentation, Management, and Prognosis of Laboratory-Confirmed COVID-19 between Pregnant and Non-Pregnant Women: A Systematic Review and Meta-Analysis.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has affected millions of people across the globe. Previous coronavirus outbreaks led to worsened symptoms amongst pregnant women, suggesting that pregnant women are at greater risk. OBJECTIVES: Our aim is to investigate the differences in clinical presentation, management, and prognosis of COVID-19 infection in pregnant and non-pregnant women. METHODS: We ran a search on electronic databases and analysis of the relevant articles was done using Revie Manager 5.4. RESULTS: The review consists of nine studies comprising 591,058 women (28,797 pregnant and 562,261 non-pregnant), with most of the data derived from two large studies. The risk of experiencing fever (RR: 0.74; 95% CI: 0.64-0.85), headache (RR: 0.77; 95% CI: 0.74-0.79), myalgia (RR: 0.92; 95% CI: 0.89-0.95), diarrhea (RR: 0.40, 95% CI: 0.39-0.43), chest tightness (RR: 0.86; 95% CI: 0.77-0.95), and expectoration (RR: 0.45; 95% CI: 0.21-0.97) were greater amongst non-pregnant COVID-19-infected women. Pregnant women with COVID-19 were less likely to be obese (RR: 0.68; 95% CI: 0.63-0.73) or have a smoking history (RR: 0.32; 95% CI: 0.26-0.39). COVID-19-infected non-pregnant women had a higher frequency of comorbidity such as chronic cardiac disease (RR: 0.58; 95% CI: 0.44-0.77), renal disease (RR: 0.45; 95% CI: 0.29-0.71), and malignancy (RR: 0.82; 95% CI: 0.68-0.98), compared to COVID-19-infected pregnant women. The risk of ICU admission (RR: 2.26; 95% CI: 1.68-3.05) and requirement of invasive mechanical ventilation (RR: 2.68; 95% CI: 2.07-3.47) were significantly higher amongst pregnant women. CONCLUSIONS: Although the frequency of risk factors and the risk of experiencing clinical symptoms of COVID-19 were higher among non-pregnant women, COVID-19-infected pregnant women had a higher requirement of ICU admission and invasive mechanical ventilation compared to non-pregnant COVID-19-infected women. More well-conducted studies from varying contexts are needed to draw conclusions. Prospero registration: CRD42020204638.