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Background: Antibiotic use during early infancy has been linked to childhood obesity in high-income countries. We evaluated whether a single oral dose of azithromycin administered during infant-well visits led to changes in infant growth outcomes at 6 months of age in a setting with a high prevalence of undernutrition in rural Burkina Faso. Methods and findings: Infants were enrolled from September 25, 2019, until October 22, 2022, in a randomized controlled trial designed to evaluate the efficacy of a single oral dose of azithromycin (20 mg/kg) compared to placebo when administered during well-child visits for prevention of infant mortality. The trial found no evidence of a difference in the primary endpoint. This paper presents prespecified secondary anthropometric endpoints including weight gain (g/day), height change (mm/day), weight-for-age Z-score (WAZ), weight-for-length Z-score (WLZ), length-for-age Z-score (LAZ), and mid-upper arm circumference (MUAC). Infants were eligible for the trial if they were between 5 and 12 weeks of age, able to orally feed, and their families were planning to remain in the study area for the duration of the study. Anthropometric measurements were collected at enrollment (5 to 12 weeks of age) and 6 months of age. Among 32,877 infants enrolled in the trial, 27,298 (83%) were followed and had valid anthropometric measurements at 6 months of age. We found no evidence of a difference in weight gain (mean difference 0.03 g/day, 95% confidence interval (CI) −0.12 to 0.18), height change (mean difference 0.004 mm/day, 95% CI −0.05 to 0.06), WAZ (mean difference −0.004 SD, 95% CI −0.03 to 0.02), WLZ (mean difference 0.001 SD, 95% CI −0.03 to 0.03), LAZ (mean difference −0.005 SD, 95% CI −0.03 to 0.02), or MUAC (mean difference 0.01 cm, 95% CI −0.01 to 0.04). The primary limitation of the trial was that measurements were only collected at enrollment and 6 months of age, precluding assessment of shorter-term or long-term changes in growth. Conclusions: Single-dose azithromycin does not appear to affect weight and height outcomes when administered during early infancy. Trial registration: ClinicalTrials.govNCT03676764 Ali Sié and colleagues present pre-specified anthropometric outcomes from a randomized controlled trial that assessed the impact of a single-dose of oral azithromycin on infant mortality in Burkina Faso. Author summary: Why was this study done?: Antibiotics have been linked to obesity in children in nonrandomized studies in high-income settings. In low-income settings, malnutrition is a strong risk factor for child mortality, and interventions that increase weight gain may be beneficial. Single-dose azithromycin has previously been shown to reduce child mortality in sub-Saharan Africa, and it is possible that some of this effect is via weight gain. Why did the researchers do and find?: We conducted a randomized controlled trial in which infants aged 5 to 12 weeks were randomly assigned to a single dose of azithromycin or a matching placebo. The primary outcome of the parent trial was all-cause mortality, and the trial found no evidence of a benefit of azithromycin for prevention of mortality. Infants were followed until 6 months of age and had anthropometric measurements, including height, weight, and mid-upper arm circumference, collected. We found no evidence of a difference in any anthropometric endpoint in infants randomized to azithromycin compared to placebo. What do these findings mean?: Single-dose azithromycin does not appear to affect growth when administered to healthy infants who are 5 to 12 weeks of age. Growth outcomes were only measured at 6 months of age, and thus, any shorter or longer-term effects of azithromycin would not be detected by this study. This study only considered a single dose of azithromycin, as is used for prevention of child mortality and trachoma, and thus, it is possible that higher doses or longer duration of antibiotics could have a different effects on child growth. [ABSTRACT FROM AUTHOR]

Children's time allocation plays an important role in their well-being, education and future chances in life. This paper examines children's time use in rural Sierra Leone in the context of dynamics of power. It analyses the ways in which children co-construct their patterns of time use and create their own temporal spaces within the boundaries of existing expectations and norms. Drawing on rich qualitative data we argue that children's routines are shaped by an interplay of various dimensions and expressions of power that create and re-create gender, generation and other social orders in a particular society. This power interplay creates polyphonic temporal spaces where school, work and play time overlap each other.The analysis of this polyphony of time use has demonstrated that children's time allocation goes beyond simple one dimensional task distribution and includes a complex network of activities that may take place simultaneously. [ABSTRACT FROM AUTHOR]

Background: The COVID-19 virus pandemic has caused a significant number of deaths worldwide. If the prevalence of the infection continues to grow, this could impact life expectancy. This paper provides first estimates of the potential direct impact of the COVID-19 pandemic on period life expectancy. Methods: From the estimates of bias-adjusted age-specific infection fatality rates in Hubei (China) and a range of six prevalence rate assumptions ranging from 1% to 70%, we built a discrete-time microsimulation model that simulates the number of people infected by COVID-19, the number dying from it, and the number of deaths from all causes week by week for a period of one year. We applied our simulation to four broad regions: North America and Europe; Latin America and the Caribbean; Southeastern Asia; and sub-Saharan African. For each region, 100,000 individuals per each 5-year age group are simulated. Results: At a 10% COVID-19 prevalence rate, the loss in life expectancy at birth is likely above 1 year in North America and Europe and in Latin America and the Caribbean. In Southeastern Asia and sub-Saharan Africa, one year lost in life expectancy corresponds to an infection prevalence of about 15% and 25%, respectively. Given the uncertainty in fatality rates, with a 50% prevalence of COVID-19 infections under 95% prediction intervals, life expectancy would drop by 3 to 9 years in North America and Europe, by 3 to 8 years in Latin America and the Caribbean, by 2 to 7 years in Southeastern Asia, and by 1 to 4 years in sub-Saharan Africa. In all prevalence scenarios, as long as the COVID-19 infection prevalence rate remains below 1 or 2%, COVID-19 would not affect life expectancy in a substantial manner. Interpretation: In regions with relatively high life expectancy, if the infection prevalence threshold exceeds 1 or 2%, the COVID-19 pandemic will break the secular trend of increasing life expectancy, resulting in a decline in period life expectancy. With life expectancy being a key indicator of human development, mortality increase, especially among the vulnerable subgroups of populations, would set a country back on its path of human development. [ABSTRACT FROM AUTHOR]

Objective: To examine whether childbearing before age 18 in Sub-Saharan Africa is associated with increased risk of maternal and child complications through a systematic literature review and meta-analysis. Methods: The literature on adolescent pregnancy and associated complications in Sub-Saharan Africa was reviewed. A systematic electronic database search in Medline and Embase identified relevant papers. Studies were eligible for inclusion if they had numeric data on maternal mortality, pre-eclampsia, eclampsia, preterm birth, low birth weight, small for gestational age, stillbirth, neonatal death or perinatal death. We included studies on adolescents aged 17 years or younger, and with a comparison group of adult women aged between 20 and 35 years. The quality of the articles was assessed. Meta-analyses were conducted when there were at least three included studies with minor clinical heterogeneity in population and outcome measures. Results: Eighteen studies met our inclusion criteria. There were many studies from Sub-Saharan Africa with data on the age group 15–19 years old, but few studies had separate data on adolescents <18 years old. All included studies were of either moderate or low quality. Adolescents had an increased risk of low birth weight, pre-eclampsia/eclampsia, preterm birth and maternal and perinatal mortality. We found a lower, nonsignificant risk of stillbirth and for small for gestational age babies among the young mothers. Conclusion: In this systematic review, the findings indicate that young maternal age is associated with some unfavorable outcomes in Sub-Saharan Africa. High quality observational studies that adjust for sociodemographic factors are lacking. [ABSTRACT FROM AUTHOR]

• Morbidity and mortality in children due to COVID-19 remained low • Adolescents had higher reported cases than younger children • Reported cases were lower in pediatric population than adult population • Testing protocols vary between countries; reflects bias in reported cases Few data on the COVID-19 epidemiological characteristics among the pediatric population in Africa exists. This paper examines the age and sex distribution of the morbidity and mortality rate in children with COVID-19 and compares it to the adult population in 15 Sub-Saharan African countries. A merge line listing dataset shared by countries within the Regional Office for Africa was analyzed. Patients diagnosed within 1 March and 1 September 2020 with a confirmed positive RT-PCR test for SARS-CoV-2 were analyzed. Children's data were stratified into three age groups: 0-4 years, 5-11 years, and 12-17 years, while adults were combined. The cumulative incidence of cases, its medians, and 95% confidence intervals were calculated. 9% of the total confirmed cases and 2.4% of the reported deaths were pediatric cases. The 12-17 age group in all 15 countries showed the highest cumulative incidence proportion in children. Adults had a higher case incidence per 100,000 people than children. The cases and deaths within the children's population were smaller than the adult population. These differences may reflect biases in COVID-19 testing protocols and reporting implemented by countries, highlighting the need for more extensive investigation and focus on the effects of COVID-19 in children. [ABSTRACT FROM AUTHOR]

Purpose: Knowledge, positive attitude and good preventive practices are keys to successful myopia control, but information on these is lacking in Africa. This study determined the KAP on myopia in Ghana. Methods: This was a population-based cross-sectional survey conducted among adults (aged 18 years and older) living across 16 regions of Ghana between May and October 2021. Data on socio-demographic factors (sex, age, gender, level of education, working status, type of employment, monthly income, and region of residence), respondents' awareness, and knowledge, attitude and preventive practices (KAP) about myopia were collected. Composite and mean scores were calculated from eleven knowledge (total score = 61), eight attitude (48), and nine preventive practice items (33). Differences in mean scores were assessed using one-way analysis of variance (ANOVA) and standardized coefficients (β) with 95% confidence intervals (CI), using multiple linear regression to determine the associations between the dependent (KAP) and demographic variables. Results: Of the 1,919 participants, mean age was 37.4 ± 13.4 years, 42.3% were aged 18–30 years, 52.6% were men, 55.8% had completed tertiary education, and 49.2% had either heard about myopia, or accurately defined myopia as short sightedness. The mean KAP scores were 22.9 ± 23.7, 33.9 ± 5.4, and 22.3 ± 2.8, respectively and varied significantly with many of the demographic variables particularly with age group, region, marital status, and type of employment. Multiple linear regression analyses revealed significant associations between region of residence and knowledge (β =—0.54, 95%CI:-0.87, -0.23, p < 0.001), attitude (β =—0.24, 95%CI:-0.35,-0.14, p < 0.001) and preventive practices (β = 0.07, 95%CI: 0.01, 0.12, p = 0.015). Preventive practices were also associated with type of employment (self-employed vs employee: β = 0.25, 95%CI: 0.15, 4.91, p < 0.05). Knowledge scores were significantly higher in those who lived in the Greater Accra (39.5 ± 18.5) and Eastern regions (39.1 ± 17.5) and lower among those who lived in the Upper West region (6.4 ± 15.6). Government employees and those with tertiary education had significantly higher mean knowledge scores compared with non-government employees (β = 4.56, 95%CI 1.22, 7.89, p = 0.007), and those with primary/no education (β = 18.35, 95%CI: 14.42, 22.27, p < 0.001). Conclusion: Ghanaian participants had adequate knowledge of myopia but showed poor attitude and low preventive practices, which varied significantly between regions and were modified by socio-demographic factors. Further research into how education can be used to stimulate Ghanaians' engagement in preventive practices is needed. [ABSTRACT FROM AUTHOR]

This study explores the role of political information seeking on social media and perceived exposure to misinformation in influencing online political engagement. A survey investigation of three Sub-Saharan African countries (Kenya, Nigeria, and South Africa) suggests that both information seeking and perceived exposure to misinformation are positively associated with online political engagement. We find that younger citizens are more actively engaged in online political activities. However, we also find that perceived exposure to misinformation has varying effects on political engagement across age groups. More frequent perceived exposure to misinformation is found to be a mobilizer for online political engagement for the older population. We conclude with a discussion of how social media may facilitate greater engagement for the older population. Still, the mobilizing role of misinformation exposure raises concerns about the consequences of such political engagement. Theoretical implications for political engagement research, in general and in the countries under study, are discussed. [ABSTRACT FROM AUTHOR]

Background: Rheumatic Heart Disease (RHD) continues to cause suffering and premature deaths in many sub-Saharan Africa (SSA) countries, where the disease is still endemic. RHD is largely preventable and determining its community burden is an important critical step in any RHD prevention program. Methods: We conducted a cross-sectional study of 5–16 years old pupils from 11 primary schools participating in an RHD prevention program in 4 districts in Tanzania, between 2018 and 2019. At the school, all children were invited to participate after receiving consent from their parents/guardians. Participating children filled a questionnaire and were auscultated for cardiac murmurs. Echocardiographic screening was done by two experienced cardiologists, using a hand-held machine (V-Scan, GE®). All positive screening tests were stored for further examination by the same two cardiologists to reach to a consensus of definite, borderline or no RHD, using a modified World Heart Federation (WHF) criterion. Results: Of the 6895 children invited, 4738 (68.7%) were screened and 4436 (64.3%) had complete data. The mean (SD) age was 10.04 (2.43) years, and 2422 (54.6%) were girls. Fifty three (1.2%) children were found to have a murmur. The proportion of children with trace or mild valvular regurgitation, sub-valvular/chordal thickening and valvular thickening/deformity were 8.3%, 1.3%, and 1.0%, respectively. Sub-clinical RHD was found in 95 children (59 definite and 36 borderline), giving a prevalence of 2.1%, [95% CI 1.7% – 2.6%]. Sub-clinical RHD was independently associated with female sex (aOR 1.83, 95% CI 1.18–2.85, p = 0.007), older age groups (aOR 1.73, 95% CI 1.10–2.72, p = 0.018 for age group 11–14 years; and aOR 3.02 95% CI 1.01–9.05, p = 0.048 for age group 15–16 years), as well as presence of a cardiac murmur, aOR 5.63 95% CI 2.31–13.69, p < 0.0001. None of the studied socio- or economic factors was associated with the presence of sub-clinical RHD in this study. Conclusion: The prevalence of sub-clinical RHD among primary school children in Tanzania is 2.1%, similar to previous reports in SSA. Efforts to prevent and control RHD in our communities are highly warranted. [ABSTRACT FROM AUTHOR]

Introduction: Pediatric hydrocephalus is a common disease in sub-Saharan Africa. In Mali, 350–400 new cases are diagnosed in our center yearly. With a total land mass of 1,241,000 km2, patients in remote areas must travel up to 1,500 km to access neurosurgical care. Hence, treatment and follow-ups of "shunted" patients are difficult. In this context, endoscopic third ventriculostomy with choroid plexus cauterization (ETV/CPC) provides an opportunity for an affordable and less constraining treatment for hydrocephalus children under 12 months of age. Methods: We performed a retrospective analysis of ETV/CPC performed on infants from July 2013 to January 2015. Patients were followed postoperatively on day 15, month 6, and month 12. Statistical analysis was conducted using Prism 9 GraphPad software. ETV successes were categorized according to the patient's age into 3 groups: ≤3 months, 3–6 months, and 6–12 months. Statistical significance was defined at p < 0.05. Results: During the study period, 199 patients were included with 40% of patients aged between 0 and 6 months. The head circumference ranged from 35 cm to 79 cm. The etiology was congenital malformation in 55%. ETV/CPC was a success in 69% of 6- to 12-month-old patients, 54% in the 3- to 6-month-old patients, and 29% in ≤3-month-old patients. Overall, 94 (47%) patients were successfully treated without a shunt. The postoperative infection rate was 1% and mortality at 12 months was 8%. Conclusion: In a low-income environment such as Mali, ETV/CPC stands as a viable and alternative treatment option for pediatric hydrocephalus patients; our findings suggest that age is an important factor in predicting ETV success. [ABSTRACT FROM AUTHOR]

Background: Approximately 80% of the population residing in sub-Saharan Africa relies on Traditional Medicine (TM). However, literature on factors motivating the use of TM for children under the age of five in these settings is limited. Such information can guide policy formulation for integration of TM into mainstream health care services. This study aimed to describe the motivation on use of TM among caregivers of children residing in rural and urban communities in western Kenya. Methods: The socio-behavioral sciences (SBS) arm of the Child Health and Mortality Prevention Surveillance (CHAMPS) program in western Kenya, conducted a cross-sectional qualitative study in Manyatta—an urban informal settlement located in Kisumu town and Karemo—a rural setting in Siaya County. We performed 29 in-depth interviews, 5 focus group discussions and 11 semi-structured interviews with community representatives (n = 53), health workers (n = 17), and community leaders (n = 18). All the participants were purposively sampled. We performed thematic analysis using both inductive and deductive approaches. Data management was completed on Nvivo 11.0 software (QSR International, Melbourne, Australia). Results: Our findings reveal that some caregivers prefer TM to treat some childhood diseases. Use of TM was informed by illness beliefs about etiology of disease. We observed an appreciation from the study participants that malaria can effectively be treated by Conventional Medicine (CM) while TM was preferred to treat measles and diseases believed to be associated with supernatural etiology such as witchcraft, evil spirit or breaching cultural taboos. TM was also used in instances where CM failed to provide a diagnosis or when CM was 'slow'. TM in such cases was used as a last resort. Conclusion: We observed varied beliefs that motivate caregivers' choice of TM use among children in western Kenya. It is therefore crucial to consider perceptions and socio-cultural beliefs about illnesses when formulating interventions that are geared towards child health. [ABSTRACT FROM AUTHOR]

Cross-national studies of age patterns among couples have tended to compare the ages at which men and women first marry, but few have analysed age differences between current spouses or cohabiting partners (i.e. partner age gaps). We address this gap in the literature by using recent census and survey data to analyse age differences between current partners in 130 countries. Worldwide, men are an average of 4.2 years older than their wives or cohabiting partners. However, age gaps vary by region, ranging from 8.6 years in sub-Saharan Africa to 2.2 years in North America. The religious group with the largest age gap is Muslims (6.6 years), while the smallest age gap is seen among Jews (2.2 years). Differences between Muslims and non-Muslims remain even after controlling for country-level gender inequality and per-capita GDP. Supplementary material is available for this article at: [ABSTRACT FROM AUTHOR]

Background: Wasting and stunting commonly coexist, supposedly due to biological and social mechanisms. In under-five children, low-ponderosity is defined as <—2SD of WHO standards for either weight for height (wasted) or body mass index for age (thin) metrics. Unlike body mass index for age, weight for height ignores physiological changes in ponderosity with age, resulting in overestimation of wasting in comparison to thinness in under-5 populations with high stunting prevalence. This suggests a plausible statistical explanation for the wasting-stunting association. Aim: To test the null hypothesis that wasting-stunting (WaSt) and thinness-stunting (ThSt) associations are similar. Methods: Demographic Health Survey datasets (2010–2020) from South and South-East Asia (7 countries) and Sub-Saharan Africa (13 countries) were evaluated. WaSt and ThSt associations were estimated as odds ratio (OR) for individual datasets, which was pooled (random-effects meta-analysis). Stratified analyses were done for sex, age and region. Results: Young infants (0–6 months) comprised 8–14% of under-five children, with equal representation of boys and girls. Participants, especially Asians, were mostly shorter with lower ponderosity than WHO standards. WaSt prevalence was higher than ThSt in the 6–59 months age group, but lower in young infants. Pooled WaSt estimates were not significant: Asia (OR 0.95; 95% CI 0.75–1.14), Africa (1.17; 0.95–1.40), and combined (1.09; 0.93–1.24). In contrast, pooled ThSt associations were significantly negative: Asia (0.63; 0.50–0.76), Africa (0.82; 0.68–0.96), and combined (0.75; 0.65–0.85). In girls, these associations were attenuated for WaSt (0.96; 0.8–1.1), but enhanced for ThSt (0.6; 0.5–0.7). Conclusion: WaSt and ThSt associations are dissimilar. This suggests a primary statistical explanation for the reported wasting-stunting association, originating from ignoring physiological changes with age. [ABSTRACT FROM AUTHOR]

As Andrews et al. (2012) make clear, these emerging 21 SP st sp -century health issues - an aging population, health system strains, resource limitations, and widening health inequalities - are underexamined, yet demand critical sub-disciplinary consideration and translational engagement. Despite the potential of iKT to actually I do i something about health inequalities, health geography iKT uptake is rare. Building on these insights underscores why future iKT work must ensure "all people (individuals, groups and communities) have a fair chance to reach their full health potential and are not disadvantaged by social, economic and environmental conditions", that is, a fair chance to attain health equity (National Collaborating Centre for Determinants of Health 2015). Walking the health geographers' talk: Aging and health inequalities in sub-Saharan Africa Keywords: health geography; inequality; aging; integrated knowledge translation; sub-Saharan Africa; géographie de la santé; inégalités; vieillissement; application des connaissances intégrées; Afrique subsaharienne EN health geography inequality aging integrated knowledge translation sub-Saharan Africa FR géographie de la santé inégalités vieillissement application des connaissances intégrées Afrique subsaharienne 497 511 15 09/12/22 20220901 NES 220901 Introduction Inequalities in the production, distribution, and determinants of health and well-being are a central focus in health geography and geography writ large (see Andrews et al. 2012; Brown and Moon 2012; Hopkins 2021). [Extracted from the article]

Background: The introduction in many countries of conjugate vaccines against Haemophilus influenzae type b, Streptococcus pneumoniae, and Neisseria meningitidis has led to significant reductions in acute bacterial meningitis (ABM) in children. However, recent population-based data on ABM in sub-Saharan Africa are limited. Methods: Population-based surveillance for meningitis was carried out in a rural area of The Gambia under demographic surveillance from 2008 to 2017, using standardised criteria for referral, diagnosis and investigation. We calculated incidence using population denominators. Results: We diagnosed 1,666 patients with suspected meningitis and collected cerebrospinal fluid (n = 1,121) and/or blood (n = 1,070) from 1,427 (88%) of cases. We identified 169 cases of ABM, 209 cases of suspected non-bacterial meningitis (SNBM) and 1,049 cases of clinically suspected meningitis (CSM). The estimated average annual incidence of ABM was high at 145 per 100,000 population in the <2-month age group, 56 per 100,000 in the 2–23-month age group, but lower at 5 per 100,000 in the 5–14-year age group. The most common causes of ABM were Streptococcus pneumoniae (n = 44), Neisseria meningitidis (n = 42), and Gram-negative coliform bacteria (n = 26). Eighteen of 22 cases caused by pneumococcal serotypes included in PCV13 occurred prior to vaccine introduction and four afterwards. The overall case fatality ratio for ABM was 29% (49/169) and was highest in the <2-month age group 37% (10/27). The case fatality ratio was 8.6% (18/209) for suspected non-bacterial meningitis and 12.8% (134/1049) for clinically suspected meningitis cases. Conclusions: Gambian children continue to experience substantial morbidity and mortality associated with suspected meningitis, especially acute bacterial meningitis. Such severely ill children in sub-Saharan Africa require improved diagnostics and clinical care. [ABSTRACT FROM AUTHOR]

Background: World Health Organization announced its goal of ending sexually transmitted infection (STI) epidemics by 2030. To provide a reference for tailored prevention strategies, we analyzed trends and differences in STIs by geographical regions and age groups from 1990 to 2019. Methods: Annual number of new infections and age-standardized incidence rates (ASRs) of syphilis, chlamydia, gonorrhea, trichomoniasis, and genital herpes were recorded from the 2019 Global Burden of Disease study. We quantified the temporal trends of STIs by calculating changes in new infections and estimated annual percentage changes (EAPCs) of ASR. Results: The ASRs of syphilis, chlamydia, trichomoniasis, and genital herpes increased by 1.70% (95% confidence interval [CI], 1.62–1.78%), 0.29% (95% CI 0.04–0.54%), 0.27% (95% CI 0.03–0.52%), and 0.40% (95% CI 0.36–0.44%) per year from 2010 to 2019 worldwide, respectively, while that of gonorrhea did not. The American regions had the greatest increase in ASR for syphilis (tropical Latin America: EAPC, 5.72; 95% CI 5.11–6.33), chlamydia (high-income North America: EAPC, 1.23; 95% CI 0.73–1.73), and gonorrhea (high-income North America: EAPC, 0.77; 95% CI 0.12–1.41). Additionally, southern sub-Saharan Africa and East Asia had the greatest increase in ASR for trichomoniasis (EAPC, 0.88; 95% CI 0.57–1.20) and genital herpes (EAPC, 1.44; 95% CI 0.83–2.06), respectively. In the most recent years, the population with the greatest incidence of syphilis tended to be younger globally (25–29 years in 2010 vs. 20–24 years in 2019) but older in North Africa and Middle East (20–24 year vs. 25–29 years); with chlamydia tended to be older in southern sub-Saharan Africa (25–29 years vs. 30–34 years) but younger in Australasia (40–44 years vs. 25–29 years); with genital herpes tended to be older in high-income North America (20–24 years vs. 25–29 years) and South Asia (25–29 years vs. 30–34 years). Conclusions: Syphilis, chlamydia, trichomoniasis, and genital herpes showed a trend of increasing ASR from 2010 to 2019. The differences in trends by geographical regions and age groups point to the need for more targeted prevention strategies in key regions and populations. [ABSTRACT FROM AUTHOR]

Voluntary medical male circumcision is a crucial HIV prevention program for men in sub-Saharan Africa. Kenya is one of the first countries to achieve high population coverage and seek to transition the program to a more sustainable structure designed to maintain coverage while making all aspects of service provision domestically owned and implemented. Using pre-defined metrics, we created and evaluated three models of circumcision service delivery (static, mobile and mixed) to identify which had potential for sustaining high circumcision coverage among 10-14-year-olds group, a historically high-demand and accessible age group, at the lowest possible cost. We implemented each model in two distinct geographic areas, one in Siaya and the other in Migori county, and assessed multiple aspects of each model's sustainability. These included numerical achievements against targets designed to reach 80% coverage over two years; quantitative expenditure outcomes including unit expenditure plus its primary drivers; and qualitative community perception of program quality and sustainability based on Likert scale. Outcome values at baseline were compared with those for year one of model implementation using bivariate linear regression, unpaired t-tests and Wilcoxon rank tests as appropriate. Across models, numerical target achievement ranged from 45–140%, with the mixed models performing best in both counties. Unit expenditures varied from approximately $57 in both countries at baseline to $44-$124 in year 1, with the lowest values in the mixed and static models. Mean key informant perception scores generally rose significantly from baseline to year 1, with a notable drop in the area of community engagement. Consistently low scores were in the aspects of domestic financing for service provision. Sustainability-focused circumcision service delivery models can successfully achieve target volumes at lower unit expenditures than existing models, but strategies for domestic financing remain a crucial challenge to address for long-term maintenance of the program. [ABSTRACT FROM AUTHOR]

Purpose: The metabolic syndrome (MetS) is on the rise in Sub-Saharan Africa, attributed to increased and uncontrollable urbanization accompanied by its lifestyle changes. Non-communicable diseases, such as hypertension, diabetes, and obesity, which are components of the (MetS) are also on the increase in Botswana. To date, no study has determined the prevalence of the MetS in the apparently healthy Batswana adults. The objective of the study was to determine the prevalence of the MetS among the 25– 65-year-old Batswana residing in urban and neighboring semi-urban areas of Gaborone. Participants and Methods: A cross-sectional study was used to collect data from N=794 participants, n=383 men and n=411 women, residing in Gaborone and two surrounding semi-urban areas. Data collected included demographic, anthropometric measurements, blood pressure (BP), blood glucose, triglycerides, high-density lipoprotein cholesterol (HDL-C) and total cholesterol. Results: A high prevalence of 26.8% was reported, with women mostly afflicted (35.0% vs 18.0%). The MetS risk factors found to be common in women were low HDL-C at (50% vs 48.7%) compared to men, while proportions with elevated BP (50.3% vs 39.4%) were prominent in men. The prevalence increased with age, with the oldest age group showing a higher prevalence in both women and men, respectively (55– 65 years; 38.5% vs 41.2%). Conclusion: An unprecedented high MetS prevalence was revealed among perceived to be healthy Batswana adults, with women at a higher risk. This public health concern creates an opportunity to establish evidence of risk factors, develop guidelines and strategies with appropriate public health measures to prevent and control the MetS. [ABSTRACT FROM AUTHOR]

Background: Progress towards viral hepatitis elimination goals relies on accurate estimates of chronic hepatitis B virus (HBV)-infection prevalence. We compared existing sources of country-level estimates from 2013 to 2017 to investigate the extent and underlying drivers of differences between them.Methods: The four commonly cited sources of global-prevalence estimates, i.e. the Institute for Health Metrics and Evaluation, Schweitzer et al., the World Health Organization (WHO) and the CDA Foundation, were compared by calculating pairwise differences between sets of estimates and assessing their within-country variation. Differences in underlying empirical data and modelling methods were investigated as contributors to differences in sub-Saharan African estimates.Results: The four sets of estimates across all ages were comparable overall and agreed on the global distribution of HBV burden. The WHO and the CDA produced the most similar estimates, differing by a median of 0.8 percentage points. Larger discrepancies were seen in estimates of prevalence in children under 5 years of age and in sub-Saharan African countries, where the median pairwise differences were 2.7 percentage and 2.4 percentage points for all-age prevalence and in children, respectively. Recency and representativeness of included data, and different modelling assumptions of the age distribution of HBV burden, seemed to contribute to these differences.Conclusion: Current prevalence estimates, particularly those from the WHO and the CDA based on more recent empirical data, provide a useful resource to assess the population-level burden of chronic HBV-infection. However, further seroprevalence data in young children are needed particularly in sub-Saharan Africa. This is a priority, as monitoring progress towards elimination depends on improved knowledge of prevalence in this age group. [ABSTRACT FROM AUTHOR]

Background: Voluntary counseling and testing (VCT) is a vital response to human immunodeficiency virus (HIV) infection among adolescents in sub-Saharan Africa. Determining the status of VCT services is important to link HIV care and antiretroviral therapy. Methods: An institutional cross-sectional study design was conducted among 841 young students at Gondar College of Teachers' Education. A self-administered questionnaire was used to gather the data. Descriptive statistics were performed. Bivariate and multivariable binary logistic regressions were used to identify factors associated with the use of VCTs. The adjusted odds ratio (AOR) with 95% confidence was used to report statistical significance. Results: The majority (71%) were aware of VCT services. More than one-third (37.8%, 95% CI: 34.6– 41.2) participants had used VCT services. Having peer groups used VCT (AOR=2.04, 95% CI: 1.31– 3.20), having partner (AOR: =1.6, 95% CI: 1.04– 2.45), desiring to have VCT in the future (AOR=3.58, 95% CI: 1.98– 6.50), being aware of VCT (AOR= 1.98, 95% CI: 1.20– 3.34), knew infected/dead individuals with HIV/AIDS (AOR=1.67, 95% CI: 1.07– 2.61), know test sites (AOR=2.01, 95% CI: 1.29– 3.13) were positively associated, whereas being married (AOR=0.36, 95% CI: 0.20– 0.63) and fear of confidentiality (AOR=0.23, 95% CI: 0.10– 0.52) were major barriers to use. Conclusion: Low use of VCTs, which was far away from the 90:90:90 WHO goal, has been noted. The use of VCT services was associated with having peer groups that used VCT, having a partner, wanting to have VCT in the future, knowing the infected/dead individual with HIV/AIDS, fear of confidentiality of results, knowing the test sites, and having awareness of VCT. Efforts are needed to strengthen the health system that also needs to pay attention to education about HIV and VCT. [ABSTRACT FROM AUTHOR]

Objective: The ongoing demographic, nutritional and epidemiological transitions in sub-Saharan Africa highlight the importance of monitoring overweight and obesity. We aimed to assess the prevalence of overweight and obesity in Mozambique in 2014/2015 and compare the estimates with those obtained in 2005.Design: Cross-sectional study conducted in 2014/2015, following the WHO Stepwise Approach to Chronic Disease Risk Factor Surveillance (STEPS). Prevalence estimates with 95 % CI were computed for different categories of BMI and abdominal obesity, along with age-, education- and income-adjusted OR. The age-standardized prevalence in the age group 25-64 years was compared with results from a STEPS survey conducted in 2005.Setting: Mozambique.Participants: Representative sample of the population aged 18-64 years (n 2595).Results: Between 2005 and 2014/2015, the prevalence of overweight and obesity increased from 18·3 to 30·5 % (P < 0·001) in women and from 11·7 to 18·2 % (P < 0·001) in men. Abdominal obesity increased among women (from 9·4 to 20·4 %, P < 0·001), but there was no significant difference among men (1·5 v. 2·1 %, P = 0·395). In 2014/2015, the prevalence of overweight and obesity was more than twofold higher in urban areas and in women; in the age group 18-24 years, it was highest in urban women and lowest in rural men.Conclusions: In Mozambique, there was a steep increase in the prevalence of overweight and obesity among adults between 2005 and 2014/2015. Overweight and obesity are more prevalent in urban areas and among women, already affecting one in five urban women aged 18-24 years. [ABSTRACT FROM AUTHOR]

The study of regional trends in the rural-urban fertility gradient helps us to understand the pace of completion of the fertility transition and the geography of urban growth in the global South. We question whether the hypothesized inverted U-shaped evolution in rural excess fertility is confirmed in four developing regions, and investigate the underlying fertility dynamics by place of residence. Using multiple surveys for 60 developing countries, we analyze long-term rural and urban trends in cohort fertility. The regional comparison is controlled for the international heterogeneity in the stages attained in the fertility transition and the context of urbanization. We found a clearly inverted U-shaped trend in the rural-urban fertility gradient in Latin America, the Middle East and Northern Africa. In Asia, rural excess fertility remained limited. In sub-Saharan Africa it increased monotonically until the most recent cohorts. These differences stem from variations in the urban-to-rural diffusion of the onset of fertility transition and, in sub-Saharan Africa, from a slower pace of decline in rural areas. [ABSTRACT FROM AUTHOR]

Lead and malaria both present significant health risks to children in Sub-Saharan Africa. Previous studies have shown that high blood lead levels in children act as a protective factor against subsequent malaria incidence. The main objective of this study was to investigate associations between blood lead level and malaria outcomes prospectively in Beninese children from 12 to 24 months of age. Two-hundred and four children were assessed for lead at 12 months and closely followed until 24 months for malaria; when symptoms and parasite density were also recorded. Univariate and multivariate negative binomial and linear regression models tested associations between blood lead level quartile and total episodes of malaria (total symptomatic and asymptomatic episodes) and parasite density, respectively. Median blood lead level among children measured at 12 months was 56.50 (4.81–578) μg/L. During the 12-month follow-up, 172 (84.31%) children had at least one malaria episode. Univariate and multivariate negative binomial and linear regressions did not reveal significant associations between blood lead level quartile and malaria outcomes. Iron deficiency was not found to be an effect modifier. Results from this prospective child-cohort study investigating associations between blood lead level and malaria did not confirm results from previous cross-sectional studies. Further research is needed to further explore this relationship and other co-morbidities due to malaria and lead. [ABSTRACT FROM AUTHOR]

Background: The gap between fertility outcomes and fertility ideals is notably higher in sub-Saharan Africa (SSA) than elsewhere, relating to both under- and overachievement of fertility ideals. We consider the extent to which the relationship between fertility ideals and fertility outcomes is related to educational achievement. Further, we consider if these educational differentials are the same or different in SSA, and thereby consider the extent to which increasing levels of education in SSA may decrease fertility. Data and methods: We use 227 Demographic and Health Surveys (DHSs) from 58 countries worldwide to look at population- level measures of the mismatch between fertility ideals and fertility outcomes. Population level measures are used to assess whether the correspondence between fertility intentions and achievements differ by level of education. We then look at the individual-level determinants of both under- and overachieving fertility intentions. Data from the most recent DHS in 54 of the original countries is used for the individual level analysis, with five countries excluded due to the most recent available survey being out of date. Results: An average of 40% of women in SSA underachieve their stated fertility intentions compared to 26% in non-SSA countries. Furthermore, compared to other LMICs, higher levels of education are not related to better correspondence between fertility intentions and outcomes in SSA. In Middle/Western Africa countries, on average, 48% of women with secondary or higher education have fewer children than their ideal, compared to just 24% who have more children than their ideal. Conclusion: We argue that the phenomenon of underachieving fertility ideals (or unrealized fertility) may be of particular importance for the ongoing fertility transition throughout SSA, especially as more highly educated groups do not appear to be following the patterns observed elsewhere. [ABSTRACT FROM AUTHOR]

Background: Despite Taenia solium taeniosis/cysticercosis (TSTC) having been put high on the global agenda of neglected tropical diseases (NTDs), which over the last years has received a lot of attention, there has been no control programmes in place in sub-Saharan Africa, a highly endemic region. This could be attributed to lack of awareness of many stakeholders on the burden and impact of T. solium. This information is essential in guiding TSTC policies, practices and research agendas as well as encouraging cross-sectoral collaboration in the control of this important zoonotic parasite using a One Health approach. National elimination of the parasite is the foundation for global eradication. This will require that substantial country-level information is provided to all key stakeholders. We have mapped out TSTC research evidence in Tanzania to inform on disease burden and potential for integrated control measures. Methodology/Principal findings: A scoping review of all TSTC studies undertaken in Tanzania and published up to December 2018 was conducted. The articles were searched from PUBMED, AJOL, Google Scholar and Google in general. Fifty-one (51) articles met the inclusion criteria and were reviewed. Prevalence of taeniosis of 2.3% - 5.2% was estimated based on copro-antigen ELISA while human cysticercosis of >16% was estimated based on serum antigen ELISA (Ag-ELISA) or IgG Western Blot. Neurocysticercosis (NCC) contributed significantly to epilepsy in adults. Farm prevalence of porcine cysticercosis were 6.0% - 17.4% (lingual examination) and 1.5% - 33.3% (Ag-ELISA). Slaughter-slab prevalence were 0% - 18.2% (routine meat inspection). Lacking latrines, watering pigs with river or pond water, and feeding pigs with potato peels were associated with porcine cysticercosis prevalence. Washing hands by dipping method increased the risk of human cysticercosis. In 2012, the number of DALYs/1000 person-years for NCC-associated epilepsy was 0.7 (95% UI, 0.2–1.6), around 5 million USD (95% UI, 797,535–16,933,477) were spent due to NCC-associated epilepsy and nearly 3 million USD (95% UI, 1,095,960–5,366,038) were potentially lost due to porcine cysticercosis. Three rounds of annual treatment of school-age children with praziquantel significantly reduced prevalence of taeniosis and porcine cysticercosis. Health education was efficacious in improving knowledge and attitudes favourable for control of TSTC while a single dose of oxfendazole 30 mg/kg body weight was efficacious in eliminating T. solium cysticerci from pig musculature. Conclusions/Significance: The observed high burden of TSTC and the significant contribution of NCC to epilepsy in Tanzania warrant urgent interventions. Evaluation of best control options should make use of disease transmission dynamics models such as cystiSim, taking into account findings from the field based intervention studies. In addition, locally adapted management guidelines for people suffering from NCC are urgently needed. [ABSTRACT FROM AUTHOR]

Several studies have focused on the risk factors associated with adolescent developmental outcomes, but the literature on the role of protective factors at the family and community level for positive adolescent development is scarce, especially in sub-Saharan Africa (SSA). We hypothesize that ensuring a supportive environment for adolescents may result in delayed sexual debut for adolescents in SSA. The relationship between family structure and positive adolescent sexual behaviour, measured as delay in sexual debut, was examined using the bioecological theory framed by a risk and resilience perspective. We used nationally representative data on female and male adolescents (aged 15–17 years) from 12 countries in SSA. We modelled logistic regressions to test for associations between family structure and delayed sexual debut while controlling for other covariates in SSA. The majority (90%) of the young adults delayed sexual debut, and this delay varied by family structure. After controlling for other covariates, adolescents living with neither parent had lower odds of delaying sexual debut although results were only significant for males. Interaction terms with community socio-economic status showed an interaction between community education and males living with neither parent. Future studies must investigate the gender differentials in the relationship between family structure and delayed sexual debut among adolescents in SSA. [ABSTRACT FROM AUTHOR]

Background: Under-5 mortality rate in the sub-Saharan region has remained unabated. Worse still, information on the regional trend and associated determinants are not readily available. Knowledge of the trend and determinants of under-5 mortality are essential for effective design of intervention programmes that will enhance their survival. We aimed to examine the mortality patterns in under-5 children and maternal factors associated with under-5 deaths. Methods: Demographic and Health Survey (DHS) data from five sub-Sahara Africa countries; Chad, Democratic Republic of Congo, Mali, Niger and Zimbabwe were used in this study. The sample size consisted of 68,085 women aged 15–49 years with at least one history of childbirth. The outcome variable was under-five mortality rate. Relevant information on maternal factors were extracted for analysis. Multivariable Cox proportional hazards regression was used to model maternal factors associated with under-five mortality. Results: The current under-5 mortality rate (per 1,000 live births) was; 133 in Republic of Chad, 104 in Democratic Republic of Congo, 95 in Mali, 127 in Niger, and 69 in Zimbabwe. Several maternal and child level factors were found to be significantly associated with under-five mortality. Lack of spousal support (not currently married) resulted to increase in under-five mortality (Chad- Hazard Ratio [HR] = 1.11, 95%CI = 0.97–1.25; DR Congo- HR = 1.24, 95%CI = 1.11–1.40; Mali- HR = 2.43, 95%CI = 1.63–3.64; Niger- HR = 1.59, 95%CI = 1.24–2.03; Zimbabwe- HR = 1.33, 95%CI = 1.06–1.67). Delivery by caesarean section was significantly associated with under-five mortality (Chad- HR = 1.32, 95%CI = 1.00–1.77; DR Congo- HR = 1.20, 95%CI = 1.01–1.43; Mali- HR = 1.42, 95%CI = 1.08–1.85; Niger- HR = 1.43, 95%CI = 1.06–1.92; Zimbabwe- HR = 1.49, 95%CI = 1.03–2.15). Conclusion: Despite concerted effort by government and several stakeholders in health to improve childhood survival, the rate of under-5 mortality is still high. Our findings provided evidence on the contribution of maternal age, place of residence, household wealth index, level of education, employment, marital status, religious background, birth type, birth order and interval, sex and size of child, place and mode of delivery, to Under-5 mortality rate in SSA. The position of prominent risk factors for under-five mortality should be addressed through effective design of timely and efficient intervention aimed at reducing childhood mortality. [ABSTRACT FROM AUTHOR]

Background: Estimates of sexually transmitted infection (STI) prevalence are essential for efforts to prevent and control STIs. Few large STI prevalence studies exist, especially for low- and middle-income countries (LMICs). Our primary objective was to estimate the prevalence of chlamydia, gonorrhea, trichomoniasis, syphilis, herpes simplex virus type 2 (HSV-2), and bacterial vaginosis (BV) among women in sub-Saharan Africa by age, region, and population type.Methods and Findings: We analyzed individual-level data from 18 HIV prevention studies (cohort studies and randomized controlled trials; conducted during 1993-2011), representing >37,000 women, that tested participants for ≥1 selected STIs or BV at baseline. We used a 2-stage meta-analysis to combine data. After calculating the proportion of participants with each infection and standard error by study, we used a random-effects model to obtain a summary mean prevalence of each infection and 95% confidence interval (CI) across ages, regions, and population types. Despite substantial study heterogeneity for some STIs/populations, several patterns emerged. Across the three primary region/population groups (South Africa community-based, Southern/Eastern Africa community-based, and Eastern Africa higher-risk), prevalence was higher among 15-24-year-old than 25-49-year-old women for all STIs except HSV-2. In general, higher-risk populations had greater prevalence of gonorrhea and syphilis than clinic/community-based populations. For chlamydia, prevalence among 15-24-year-olds was 10.3% (95% CI: 7.4%, 14.1%; I2 = 75.7%) among women specifically recruited from higher-risk settings for HIV in Eastern Africa and was 15.1% (95% CI: 12.7%, 17.8%; I2 = 82.3%) in South African clinic/community-based populations. Among clinic/community-based populations, prevalence was generally greater in South Africa than in Southern/Eastern Africa for most STIs; for gonorrhea, prevalence among 15-24-year-olds was 4.6% (95% CI: 3.3%, 6.4%; I2 = 82.8%) in South Africa and was 1.7% (95% CI: 1.2%, 2.6%; I2 = 55.2%) in Southern/Eastern Africa. Across the three primary region/population groups, HSV-2 and BV prevalence was high among 25-49-year-olds (ranging from 70% to 83% and 33% to 44%, respectively). The main study limitation is that the data are not from random samples of the target populations.Conclusions: Combining data from 18 HIV prevention studies, our findings highlight important features of STI/BV epidemiology among sub-Saharan African women. This methodology can be used where routine STI surveillance is limited and offers a new approach to obtaining critical information on STI and BV prevalence in LMICs. [ABSTRACT FROM AUTHOR]

Background: Orphaned and vulnerable adolescents (OVA) in sub-Saharan Africa are at greater risk for adverse psychological outcomes compared with their non-OVA counterparts. Social interventions that provide cash transfers (CTs) have been shown to improve health outcomes among young people, but little is known about their impact on the psychological wellbeing of OVA. Objective: Among OVA in western Kenya, we assessed the association between living in a household that received monthly unconditional government CTs and psychological wellbeing. Methods: We examined the likelihood of depression, anxiety, post-traumatic stress symptoms (PTSS) and positive future outlook among 655 OVA aged between 10 and 18 years who lived in 300 randomly selected households in western Kenya that either received or did not receive unconditional monthly CTs. Results: The mean age was 14.0 (SD 2.4) years and 329 (50.2%) of the participants were female while 190 (29.0%) were double orphans whose biological parents were both deceased. After adjusting for socio-demographic, caregiver, and household characteristics and accounting for potential effects of participant clustering by sub-location of residence, OVA living in CT households were more likely to have a positive future outlook (odds ratio [OR] 1.47, 95% confidence interval [CI] 1.08, 1.99), less likely to be anxious (OR 0.57, 95% CI 0.42, 0.78), and less likely to have symptoms of post-traumatic stress (OR 0.50, 95% CI 0.29, 0.89). We did not find statistically significant differences in odds of depression by CT group. Conclusion: OVA in CT households reported better psychological wellbeing compared to those in households not receiving CTs. CT interventions may be effective for improving psychological wellbeing among vulnerable adolescents in socioeconomically deprived households. [ABSTRACT FROM AUTHOR]

Over 11 million voluntary medical male circumcisions (VMMC) have been performed of the projected 20.3 million needed to reach 80% adult male circumcision prevalence in priority sub-Saharan African countries. Striking numbers of adolescent males, outside the 15-49-year-old age target, have been accessing VMMC services. What are the implications of overall progress in scale-up to date? Can mathematical modeling provide further insights on how to efficiently reach the male circumcision coverage levels needed to create and sustain further reductions in HIV incidence to make AIDS no longer a public health threat by 2030? Considering ease of implementation and cultural acceptability, decision makers may also value the estimates that mathematical models can generate of immediacy of impact, cost-effectiveness, and magnitude of impact resulting from different policy choices. This supplement presents the results of mathematical modeling using the Decision Makers’ Program Planning Tool Version 2.0 (DMPPT 2.0), the Actuarial Society of South Africa (ASSA2008) model, and the age structured mathematical (ASM) model. These models are helping countries examine the potential effects on program impact and cost-effectiveness of prioritizing specific subpopulations for VMMC services, for example, by client age, HIV-positive status, risk group, and geographical location. The modeling also examines long-term sustainability strategies, such as adolescent and/or early infant male circumcision, to preserve VMMC coverage gains achieved during rapid scale-up. The 2016–2021 UNAIDS strategy target for VMMC is an additional 27 million VMMC in high HIV-prevalence settings by 2020, as part of access to integrated sexual and reproductive health services for men. To achieve further scale-up, a combination of evidence, analysis, and impact estimates can usefully guide strategic planning and funding of VMMC services and related demand-creation strategies in priority countries. Mid-course corrections now can improve cost-effectiveness and scale to achieve the impact needed to help turn the HIV pandemic on its head within 15 years. [ABSTRACT FROM AUTHOR]

Objective: The literature on the impact of internal migration on under-five mortality in sub-Saharan Africa has been limited. This study examined the impact of internal migration on under-five mortality rate in 27 sub-Saharan African countries. Design: The analysis used cross-sectional data from the most recent Demographic and Health Surveys of 27 sub-Saharan African countries. Information on the number of live births and the number of under-five deaths in the five years preceding the surveys in these countries was examined. Using variables from which migration data were generated, four migration statuses were computed, and the impact of each migration status on under-five mortality was analysed by using multivariate Cox proportional hazards regression models. Results: Of the 96333 live births, 7036 deaths were reported. Adjusting for internal migration status revealed a 20% increase in under-five mortality rate among urban-rural migrant mothers [HR = 1.20; 95% confidence interval (CI): (1.06–1.35)], a 40% increase in under-five mortality rates among rural non-migrant mothers, [HR = 1.40; 95% CI: (1.29–1.53)] and a 43% increase in under-five deaths among rural-urban migrant mothers [HR = 1.43; 95% CI: (1.30–1.58)]. Whilst under-five mortality rate did not change considerably when we adjusted for country and demographic variables, there were significant decreases among rural non-migrant and rural-urban migrant mothers when health care service utilization factors were adjusted for [HR = 1.20; 95% CI: (1.07–1.33) and [HR = 1.29; 95% CI: (1.14–1.45)]. The decreased risk of under-five deaths was not significant among rural non-migrant and rural-urban migrant mothers when socio-economic factors were adjusted for. Other factors for which there were significant risks of under-five deaths included household poverty, lack of health care services Conclusion: Although under-five child mortality rate declined by 52% between 1990 and 2015 (from 179 to 86 per1000 live births) in sub-Saharan Africa, the continent still has the highest rate in the world. This finding highlights the need to consider providing education and health care services in rural areas, when implementing interventions meant to reduce under-five mortality rates among internal migrant mothers. [ABSTRACT FROM AUTHOR]

Background: It is estimated that more than two-thirds of the population in sub-Saharan Africa (SSA) must leave their home to collect water, putting them at risk for a variety of negative health outcomes. There is little research, however, quantifying who is most affected by long water collection times. Objectives: This study aims to a) describe gender differences in water collection labor among both adults and children (< 15 years of age) in the households (HHs) that report spending more than 30 minutes collecting water, disaggregated by urban and rural residence; and b) estimate the absolute number of adults and children affected by water collection times greater than 30 minutes in 24 SSA countries. Methods: We analyzed data from the Demographic Health Survey (DHS) and the Multiple Indicator Cluster Survey (MICS) (2005–2012) to describe water collection labor in 24 SSA countries. Results: Among households spending more than 30 minutes collecting water, adult females were the primary collectors of water across all 24 countries, ranging from 46% in Liberia (17,412 HHs) to 90% in Cote d’Ivoire (224,808 HHs). Across all countries, female children were more likely to be responsible for water collection than male children (62% vs. 38%, respectively). Six countries had more than 100,000 households (HHs) where children were reported to be responsible for water collection (greater than 30 minutes): Burundi (181,702 HHs), Cameroon (154,453 HHs), Ethiopia (1,321,424 HHs), Mozambique (129,544 HHs), Niger (171,305 HHs), and Nigeria (1,045,647 HHs). Conclusion: In the 24 SSA countries studied, an estimated 3.36 million children and 13.54 million adult females were responsible for water collection in households with collection times greater than 30 minutes. We suggest that accessibility to water, water collection by children, and gender ratios for water collection, especially when collection times are great, should be considered as key indicators for measuring progress in the water, sanitation and hygiene sector. [ABSTRACT FROM AUTHOR]

Major efforts for malaria prevention programs have gone into scaling up ownership and use of insecticidal mosquito nets, particularly in sub-Saharan Africa where the malaria burden is high. Socioeconomic inequities in access to long lasting insecticidal nets (LLINs) are reduced with free distributions of nets. However, the relationship between social factors and retention of nets after a free distribution has been less studied, particularly using a longitudinal approach. Our research aimed to estimate the ownership and use of LLINs, and examine the determinants of LLIN retention, within an Indigenous Batwa population after a free LLIN distribution. Two LLINs were given free of charge to each Batwa household in Kanungu District, Uganda in November 2012. Surveyors collected data on LLIN ownership and use through six cross-sectional surveys pre- and post-distribution. Household retention, within household access, and individual use of LLINs were assessed over an 18-month period. Socioeconomic determinants of household retention of LLINs post-distribution were modelled longitudinally using logistic regression with random effects. Direct house-to-house distribution of free LLINs did not result in sustainable increases in the ownership and use of LLINs. Three months post-distribution, only 73% of households owned at least one LLIN and this period also saw the greatest reduction in ownership compared to other study periods. Eighteen-months post distribution, only a third of households still owned a LLIN. Self-reported age-specific use of LLINs was generally higher for children under five, declined for children aged 6–12, and was highest for older adults aged over 35. In the model, household wealth was a significant predictor of LLIN retention, controlling for time and other variables. This research highlights on-going socioeconomic inequities in access to malaria prevention measures among the Batwa in southwestern Uganda, even after free distribution of LLINs, and provides critical information to inform local malaria programs on possible intervention entry-points to increase access and use among this marginalized population. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to examine changes over time in the female: male HIV prevalence ratio in 18 countries in Sub-Saharan Africa, overall and when stratified by area of residence, educational attainment and marital status. Methodology: We used data from the Demographic and Health Surveys, which are nationally representative household surveys. By using data from 18 countries with at least two survey rounds with HIV testing, and dividing the countries into three regions (Western/Central, Eastern and Southern) we were able to examine cross-country and regional changes in the female: male HIV prevalence ratio over time. Logistic regression was used to estimate female: male HIV prevalence ratios in urban versus rural areas and for different categories of education and marital status. To assess changes over time, we compared the confidence intervals of the prevalence ratios. Results: The female: male HIV prevalence ratio was above one in all countries in at least one survey round for both ages 15–24 years and 25–49 years. In 13 out of 18 countries the prevalence ratio was higher for the younger age group compared to the age group 25–49 years (3 significant) and this difference in prevalence ratios between the age groups did not change over time. Overall, there was a higher frequency of increasing than decreasing prevalence ratios. The gender disparity was greater among those who were married/living together than among the never-married, and over time, the ratio was more stable among the married/living together. The study found no clear differential changes by education. Conclusion: Women continue to carry the greater burden of HIV in Sub-Saharan Africa and there is no clear pattern of change in the gap between men and women as the direction and magnitude of change in the prevalence ratios varied greatly. [ABSTRACT FROM AUTHOR]

Background: Several infectious diseases and therapeutic interventions cause gut microbe dysbiosis and associated pathology. We characterised the gut microbiome of children exposed to the helminth Schistosoma haematobium pre- and post-treatment with the drug praziquantel (PZQ), with the aim to compare the gut microbiome structure (abundance and diversity) in schistosome infected vs. uninfected children. Methods: Stool DNA from 139 children aged six months to 13 years old; with S. haematobium infection prevalence of 27.34% was extracted at baseline. 12 weeks following antihelminthic treatment with praziqunatel, stool DNA was collected from 62 of the 139 children. The 16S rRNA genes were sequenced from the baseline and post-treatment samples and the sequence data, clustered into operational taxonomic units (OTUs). The OTU data were analysed using multivariate analyses and paired T- test. Results: Pre-treatment, the most abundant phyla were Bacteroidetes, followed by Firmicutes and Proteobacteria respectively. The relative abundance of taxa among bacterial classes showed limited variation by age group or sex and the bacterial communities had similar overall compositions. Although there were no overall differences in the microbiome structure across the whole age range, the abundance of 21 OTUs varied significantly with age (FDR<0.05). Some OTUs including Veillonella, Streptococcus, Bacteroides and Helicobacter were more abundant in children ≤ 1 year old compared to older children. Furthermore, the gut microbiome differed in schistosome infected vs. uninfected children with 27 OTU occurring in infected but not uninfected children, for 5 of these all Prevotella, the difference was statistically significant (p <0.05) with FDR <0.05. PZQ treatment did not alter the microbiome structure in infected or uninfected children from that observed at baseline. Conclusions: There are significant differences in the gut microbiome structure of infected vs. uninfected children and the differences were refractory to PZQ treatment. Author Summary: The role of the gut microbiome in host health is becoming clearer with better characterisation of the nutritional, biochemical and immunological function of the microbes. However, to date, there is a paucity of studies describing/ investigating the role of the gut microbiome in infection, pathology and acquired immunity in children exposed to helminths, in sub-Saharan Africa. We determined how the diversity and abundance of different gut bacteria taxonomic groups differ with age, sex and infection with the helminths parasites causing bilharzia/schistosomiasis in children aged 6 months -13 years. The parasites are controlled by treatment with the antihelminthic praziquantel (PZQ), which is associated with diarrhoea within the first 24 hours of treatment in some children. We therefore also investigated the effects of PZQ treatment on the gut microbiome of the children 12 weeks post-PZQ treatment. The composition of the gut microbiome changed with age within the 0–3 year age range and also differed significantly in abundance of the different taxonomic groups between infected and uninfected children prior to treatment with PZQ. However, the pre-treatment microbiome structure was not altered by antihelminthic treatment of infected or uninfected children. Further studies are required to investigate causality and mechanisms of interaction. [ABSTRACT FROM AUTHOR]

Background: Limited information exists on adults ≥50 years receiving HIV care in sub-Saharan Africa. Methodology: Using routinely-collected longitudinal patient-level data among 391,111 adults ≥15 years enrolling in HIV care from January 2005–December 2010 and 184,689 initiating ART, we compared characteristics and outcomes between older (≥50 years) and younger adults at 199 clinics in Kenya, Mozambique, Rwanda, and Tanzania. We calculated proportions over time of newly enrolled and active adults receiving HIV care and initiating ART who were ≥50 years; cumulative incidence of loss to follow-up (LTF) and recorded death one year after enrollment and ART initiation, and CD4+ response following ART initiation. Findings: From 2005–2010, the percentage of adults ≥50 years newly enrolled in HIV care remained stable at 10%, while the percentage of adults ≥50 years newly initiating ART (10% [2005]-12% [2010]), active in follow-up (10% [2005]-14% (2010]), and active on ART (10% [2005]-16% [2010]) significantly increased. One year after enrollment, older patients had significantly lower incidence of LTF (33.1% vs. 32.6%[40–49 years], 40.5%[25–39 years], and 56.3%[15–24 years]; p-value<0.0001), but significantly higher incidence of recorded death (6.0% vs. 5.0% [40–49 years], 4.1% [25–39 years], and 2.8% [15–24 years]; p-valve<0.0001). LTF was lower after vs. before ART initiation for all ages, with older adults experiencing less LTF than younger adults. Among 85,763 ART patients with baseline and follow-up CD4+ counts, adjusted average 12-month CD4+ response for older adults was 20.6 cells/mm3 lower than for adults 25–39 years of age (95% CI: 17.1–24.1). Conclusions: The proportion of patients who are ≥50 years has increased over time and been driven by aging of the existing patient population. Older patients experienced less LTF, higher recorded mortality and less robust CD4+ response after ART initiation. Increased programmatic attention on older adults receiving HIV care in sub-Saharan Africa is warranted. [ABSTRACT FROM AUTHOR]

Background: The rapid and often uncontrolled rural–urban migration in Sub-Saharan Africa is transforming urban landscapes expected to provide shelter for more than 50% of Africa's population by 2030. Consequently, the burden of malaria is increasingly affecting the urban population, while socio-economic inequalities within the urban settings are intensified. Few studies, relying mostly on moderate to high resolution datasets and standard predictive variables such as building and vegetation density, have tackled the topic of modeling intra-urban malaria at the city extent. In this research, we investigate the contribution of very-high-resolution satellite-derived land-use, land-cover and population information for modeling the spatial distribution of urban malaria prevalence across large spatial extents. As case studies, we apply our methods to two Sub-Saharan African cities, Kampala and Dar es Salaam. Methods: Openly accessible land-cover, land-use, population and OpenStreetMap data were employed to spatially model Plasmodium falciparum parasite rate standardized to the age group 2–10 years (PfPR2–10) in the two cities through the use of a Random Forest (RF) regressor. The RF models integrated physical and socio-economic information to predict PfPR2–10 across the urban landscape. Intra-urban population distribution maps were used to adjust the estimates according to the underlying population. Results: The results suggest that the spatial distribution of PfPR2–10 in both cities is diverse and highly variable across the urban fabric. Dense informal settlements exhibit a positive relationship with PfPR2–10 and hotspots of malaria prevalence were found near suitable vector breeding sites such as wetlands, marshes and riparian vegetation. In both cities, there is a clear separation of higher risk in informal settlements and lower risk in the more affluent neighborhoods. Additionally, areas associated with urban agriculture exhibit higher malaria prevalence values. Conclusions: The outcome of this research highlights that populations living in informal settlements show higher malaria prevalence compared to those in planned residential neighborhoods. This is due to (i) increased human exposure to vectors, (ii) increased vector density and (iii) a reduced capacity to cope with malaria burden. Since informal settlements are rapidly expanding every year and often house large parts of the urban population, this emphasizes the need for systematic and consistent malaria surveys in such areas. Finally, this study demonstrates the importance of remote sensing as an epidemiological tool for mapping urban malaria variations at large spatial extents, and for promoting evidence-based policy making and control efforts. [ABSTRACT FROM AUTHOR]

Background: Biannual, mass azithromycin distribution has previously been shown to reduce all-cause child mortality in sub-Saharan Africa. Subgroup analysis suggested that the strongest effects were in the youngest children, leading to the hypothesis that targeting younger age groups might be an effective strategy to prevent mortality. We present the methods of two randomized controlled trials designed to evaluate mass and targeted azithromycin distribution for the prevention of child mortality in Burkina Faso, West Africa.Methods/design: The Child Health with Azithromycin Treatment (CHAT) study consists of two nested, randomized controlled trials. In the first, communities are randomized in a 1:1 fashion to biannual, mass azithromycin distribution or placebo. The primary outcome is under-5 all-cause mortality measured at the community level. In the second, children attending primary healthcare facilities during the first 5-12 weeks of life for a healthy child visit (e.g., for vaccination) are randomized in a 1:1 fashion to a single orally administered dose of azithromycin or placebo. The primary outcome is all-cause mortality measured at 6 months of age. The trial commenced enrollment in August 2019.Discussion: This study is expected to provide evidence on two health systems delivery approaches (mass and targeted treatment) for azithromycin to prevent all-cause child mortality. The results will inform global and national policies related to azithromycin for the prevention of child mortality.Trial Registration: ClinicalTrials.gov, ID: NCT03676764. Registered on 19 September 2018; prospectively registered pre results. [ABSTRACT FROM AUTHOR]

Background: Soil-transmitted helminth (STH) infections affect predominantly socio-economically disadvantaged populations in sub-Saharan Africa, East Asia and the Americas. Previous mathematical modelling studies have evaluated optimal intervention strategies to break STH transmission in clusters of villages. These studies assumed that villages are closed independent units with no movement of people in or out of communities. Here we examine how human population movement, for example, of seasonal migrant labourers, affect the outcome of mass drug administration (MDA) programmes. Results: We used a stochastic individual-based metapopulation model to analyse the impact of human population movement at varying rates on STH elimination efforts. Specifically, we looked at seasonal clumped movement events of infected individuals into a village. We showed that even if on average 75% of the entire resident population within a village are treated, an annual rate of 2–3% of the population arriving from an untreated source village can reduce the probability of STH elimination to less than 50% in high-prevalence settings. If a village is infection-free, an annual movement rate of 2–3% from an infected source village imposes a risk of re-introduction of STH of 75% or higher, unless the prevalence in the source village is less than 20%. Even a single arrival of 2–3% of the population can impose a risk of re-introducing STH of 50% or greater depending on the prevalence in the source village. The risk of re-introduction also depends on both the age group of moving individuals and STH species, since the pattern of cross-sectional age-prevalence and age-intensity profiles of infection in the human host are species-specific. Conclusions: Planning for STH elimination programmes should account for human mobility patterns in defined regions. We recommend that individuals arriving from areas with ongoing STH transmission should receive preventive chemotherapy for STHs. This can most easily be implemented if migration is seasonal and overlaps with treatment rounds, e.g. seasonal migrant labour. Moreover, transmission hotspots in or near treatment clusters should be eliminated, for example, by implementing appropriate water, sanitation and hygiene (WASH) measures and targeting treatment to individuals living in hotspots. [ABSTRACT FROM AUTHOR]