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

Objective To assess the effectiveness of care provided by mid-level health workers. Methods Experimental and observational studies comparing mid-level health workers and higher level health workers were identified by a systematic review of the scientific literature. The quality of the evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation criteria and data were analysed using Review Manager. Findings Fifty-three studies, mostly from high-income countries and conducted at tertiary care facilities, were identified. In general, there was no difference between the effectiveness of care provided by mid-level health workers in the areas of maternal and child health and communicable and noncommunicable diseases and that provided by higher level health workers. However, the rates of episiotomy and analgesia use were significantly lower in women giving birth who received care from midwives alone than in those who received care from doctors working in teams with midwives, and women were significantly more satisfied with care from midwives. Overall, the quality of the evidence was low or very low. The search also identified six observational studies, all from Africa, that compared care from clinical officers, surgical technicians or non-physician clinicians with care from doctors. Outcomes were generally similar. Conclusion No difference between the effectiveness of care provided by mid-level health workers and that provided by higher level health workers was found. However, the quality of the evidence was low. There is a need for studies with a high methodological quality, particularly in Africa--the region with the greatest shortage of health workers. [TEXT NOT REPRODUCIBLE IN ASCII] [TEXT NOT REPRODUCIBLE IN ASCII] Objectif Evaluer l'efficacite des soins fournis par les agents de sante de niveau intermediaire. Methodes Des etudes experimentales et observationnelles comparant des agents de sante de niveaux intermediaire et de nivea u superieur ont ete identifiees a l'aide d'une revue systematique de la documentation scientifique. La qualite des elements de preuve a ete evaluee a l'aide des criteres GRADE (Grading of Recommendations Assissment, Development and Evaluation--Methode d'evaluation des recommandations, de determination, d'elaboration et d'evaluation), et les donnees ont ete analysees a l'aide d'un gestionnaire d'examen. Resultats Cinquante-trois etudes ont ete identifiees, la plupart provenant de pays a revenu eleve, et menees dans des etablissements de soins tertiaires. En general, il n'y avait pas de difference entre l'efficacite des soins prodigues par des agents de sante de niveau intermediaire dans les domaines de la sante matemelle et infantile et des maladies contagieuses et non contagieuses et ceux prodigues par des agents de sante de niveau superieur. Cependant, les taux de recours a l'episiotomie et aux analgesiques etaient significativement moins eleves chez les femmes accouchant avec la seule aide d'une sage-femme que chez les femmes prises en charge par des docteurs secondes par des sagesfemmes, et les femmes etaient significativement plus satisfaites des soins prodigues par les sages-femmes. Dans l'ensemble, la qualite des elements de preuve etait basse, voire tres basse. La recherche a egalement identifie six etudes observationnelles, provenant toutes d'Afrique, qui comparaient les soins de praticiens cliniques, de techniciens chirurgicaux ou de cliniciens non-medecins avec les soins prodigues par des medecins. Les resultats etaient generalement similaires. Conclusion Aucune difference n'a ete constatee entre l'efficacite des soins prodigues par des agents de sante de niveau intermediaire et ceux fournis par des agents de sante de niveau superieur. Cependant, la qualite des elements de preuve etait basse. Il est necessaire d'effectuer des etudes basees sur une methodologie de haute qualite, en particulier en Afrique, la region qui manque le plus d'agents de sante. [TEXT NOT REPRODUCIBLE IN ASCII] Objetivo Evaluar la eficacia de la atencion proporcionada por los trabajadores sanitarios de nivel intermedio. Metodos A traves de un examen sistematico de la literatura cientifica se identificaron diversos estudios experimentales y observacionales que comparaban a los trabajadores sanitarios de nivel intermedio con los de nivel superior. Se evaluo la calidad de las pruebas cientificas con ayuda de los criterios GRADE y se empleo el programa Review Manager para el analisis de los datos. Resultados Se identificaron 53 estudios, la mayoria de ellos de paises de ingresos elevados y que se habian efectuado en centros de atencion sanitaria terciaria. En general, no se observaron diferencias entre la eficacia de la atencion prestada por los trabajadores de salud de nivel intermedio y la proporcionada por los trabajadores de salud de nivel superior en las areas de salud materno-infantil y en relacion a las enfermedades transmisibles y no transmisibles. Sin embargo, los indices de episiotomia y el uso de analgesicos fueron significativa mente inferiores en las mujeres que dieron a luz unicamente con la ayuda de una matrona en comparacion con aquellas cuya atencion corrio a cargo de medicos que trabajaron conjuntamente con matronas. Las mujeres estuvieron mucho mas satisfechas con el trabajo de las matronas. En general, la calidad de las pruebas cientificas fue baja o muy baja. La busqueda tambien identifico seis estudios observacionales, todos ellos realizados en Africa, que comparaban la atencion de los encargados clinicos y la de los instrumentadores quirurgicos o clinicos sin licencia para practicar medicina con la de los medicos. Los resultados fueron, en su mayoria, similares. Conclusion No se encontro diferencia alguna entre la eficacia de la atencion proporcionada por trabajadores sanitarios de nivel intermedio o de nivel superior. No obstante, la calidad de las pruebas cientificas era baja. Es necesario realizar estudios con una calidad metodologica alta, especialmente en Africa, la region con la mayor escasez de personal sanitario., Introduction In 2000, 189 countries adopted the United Nation's Millennium Declaration and its eight Millennium Development Goals, including Goals 4, 5 and 6, which are directly related to health. However, [...]

Many countries have developed strategies to attract and retain qualified health workers in underserved areas, but there is only scarce and weak evidence on their successes or failures. It is difficult to compare lessons and measure results from the few evaluations that are available. Evaluation faces several challenges, including the heterogeneity of the terminology, the complexity of the interventions, the difficulty of assessing the influence of contextual factors, the lack of baseline information, and the need for multimethod and multi-disciplinary approaches for monitoring and evaluation. Moreover, the social, political and economic context in which interventions are designed and implemented is rarely considered in monitoring and evaluating interventions for human resources for health. This paper proposes a conceptual framework that offers a model for monitoring and evaluation of retention interventions taking into account such challenges. The conceptual framework is based on a systems approach and aims to guide the thinking in evaluating an intervention to increase access to health workers in underserved areas, from its design phase through to its results. It also aims to guide the monitoring of interventions through the routine collection of a set of indicators, applicable to the specific context. It suggests that a comprehensive approach needs to be used for the design, implementation, monitoring, evaluation and review of the interventions. The framework is not intended to be prescriptive and can be applied flexibly to each country context. It promotes the use of a common understanding on how attraction and retention interventions work, using a systems perspective. De nombreux pays ont mis au point des strategies pour attirer et retenir le personnel medical qualifie dans les zones mal desservies, mais les preuves du succes ou de l'echec de ces strategies sont rares et faibles. Il est difficile de comparer les en seignements tires et de mesurer les resultats a partir des quelques evaluations disponibles. L'evaluation de ces strategies se heurte en effet a plusieurs difficultes, dont l'heterogeneite de la terminologie, la complexite des interventions, la difficulte d'evaluer l'influence des facteurs contextuels, le manque de donnees de reference et la necessite de demarches empruntant a plusieurs methodologies et a plusieurs disciplines pour le suivi et l'evaluation. En outre, le contexte social, politique et economique dans lequel les interventions sont concues et mises en oeuvre est rarement pris en compte dans le suivi et l'evaluation des interventions en faveur des ressources humaines pour la sante. Le present article presente un cadre conceptuel proposant un modele pour le suivi et l'evaluation des interventions visant a retenir la main d'oeuvre qui tient compte de ces difficultes. Ce cadre conceptuel repose sur une demarche systematique et a pour objectif de guider la reflexion dans l'evaluation d'une intervention pour ameliorer l'acces au personnel de sante dans des zones mal desservies, depuis sa phase de conception jusqu'a ses resultats. Il vise aussi a guider le suivi des interventions par le recueil systematique d'une serie d'indicateurs, applicable au contexte considere. Il introduit l'idee qu'une approche globale est necessaire pour la conception, la mise en oeuvre, le suivi, l'evaluation et le bilan des interventions. Il n'est pas destine a etre prescriptif et s'applique de maniere flexible a chaque contexte national. Il favorise l'utilisation d'une interpretation commune des modalites d'action des interventions pour attirer et retenir la main-d'oeuvre, en recourant a une perspective systematique. Muchos paises han desarrollado estrategias para atraer y conservar a personal sanitario cualificado en zonas insuficientemente atendidas, pero la evidencia sobre el exito o fracaso de esas iniciativas es escasa y poco robusta. Es dificil comparar las ensenanzas extraidas y cuantificar los resultados de las escasas evaluaciones disponibles. Las medidas de evaluacion tropiezan con varios problemas, en particular la heterogeneidad de la terminologia, la complejidad de las intervenciones, las dificultades para evaluar la influencia de factores contextuales, la falta de informacion basal, y la necesidad de aplicar enfoques multimetodicos y multidisciplinarios en la vigilancia y la evaluacion. Por otra parte, en la vigilancia y evaluacion de las intervenciones relacionadas con los recursos humanos para la salud rara vez se tiene en cuenta el contexto social, politico y economico en el que se disenan y aplican esas intervenciones. En este articulo se propone un marco conceptual que brinda un modelo de vigilancia y evaluacion de las intervenciones de promocion de la permanencia que si tiene en cuenta esos factores. Dicho marco esta basado en un enfoque sistemico y pretende servir de orientacion a la hora de evaluar una intervencion de ampliacion del acceso al personal sanitario en las zonas subatendidas, desde su fase de diseno hasta sus resultados. Tambien tiene por objeto orientar la vigilancia de las intervenciones mediante la recopilacion sistematica de un conjunto de indicadores, aplicables al contexto especifico. Se sugiere que es necesario aplicar un enfoque omnicomprensivo al diseno, ejecucion, vigilancia, evaluacion y examen de las intervenciones. El marco no pretende ser prescriptivo y se puede aplicar con flexibilidad en el contexto de cada pais. Promueve el uso de una perspectiva comun sobre el funcionamiento de las intervenciones de fomento de la captacion y la permanencia, aplicando un enfoque sistemico., Introduction Health workers' willingness to practise in underserved areas, 'such as rural, remote or poor areas, is a recognized challenge in achieving equitable access to health services. Many countries have [...]

Electrocardiographic studies have reported persistent right ventricle predominance in high altitude children as an adaptive response. No information was provided on ethnicity and environmental factors in those studies. We assessed the electrocardiographic characteristics in healthy high altitude children with mixed ancestry and relatively high mobility to lower altitudes. A cross-sectional study of 321 children aged 2 months through 19 years old and living at high altitude (Tintaya, Peru, 4,100 m) was conducted. Standard 12-lead electrocardiography was performed. Information was obtained on ethnicity, medical history, place and altitude of pregnancy and birth, mobility of children and their parents and grandparents to lower altitudes, and housing conditions. A medical examination, echocardiography, hemoglobin, oxygen saturation, and anthropometric measurements were performed. Means between sexes were compared through Mann-Whitney test for independent samples not normally distributed. Potentially influential variables on electrocardiographic values were controlled through a general linear model. Electrocardiographic parameters including QRS axis, RV1, RSV1, RV1SV5, RSV5, RSV6, and SV1RV5 did not show a right predominance pattern at any age. Values were within sea level norms. None of the genetic or environmental factors controlled showed a consistent influence on the electrocardiographic variables. Our study showed an electrocardiographic pattern similar to that of sea level in high altitude children with some degree of high-altirude ancestry, comparatively well-nourished and with relatively high mobility to low altitudes. Am J Phys Anthropol 133:879-886, 2007. KEY WORDS electrocardiography; pediatrics; altitude hypoxia; adaptation

Assessment of cardiovascular developmental characteristics of healthy children living at high altitudes through the performance of echocardiographic measurements is carried out. The result shows that the pattern of cardiovascular development at high altitude in children with some degree of high-altitude genetic background and living in comparatively good nutritional and socioeconomic conditions is similar to that reported for sea-level children.

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This article discusses the growth of children in southern Peru's high-altitude copper mining region, examining subjects enjoying good and health and nutrition in the economically favorable mining communities with those in poorer communities. Results show significant differences in weight, height and body fat, with children from the mining communities exhibiting higher porportions than the other children, and both groups being taller and heavier than samples from the 1960s.

Abstract Background Evaluation of interventions on road traffic injuries (RTI) going beyond the assessment of impact to include factors underlying success or failure is an important complement to standard impact evaluations. We report here how we used a qualitative approach to assess current interventions implemented to reduce RTIs in Peru. Methods We performed in-depth interviews with policymakers and technical officers involved in the implementation of RTI interventions to get their insight on design, implementation and evaluation aspects. We then conducted a workshop with key stakeholders to analyze the results of in-depth interviews, and to further discuss and identify key programmatic considerations when designing and implementing RTI interventions. We finally performed brainstorming sessions to assess potential system-wide effects of a selected intervention (Zero Tolerance), and to identify adaptation and redesign needs for this intervention. Results Key programmatic components were consistently identified that should be considered when designing and implementing RTI interventions. They include effective and sustained political commitment and planning; sufficient and sustained budget allocation; training, supervision, monitoring and evaluation of implemented policies; multisectoral participation; and strong governance and accountability. Brainstorming sessions revealed major negative effects of the selected intervention on various system building blocks. Conclusions Our approach revealed substantial caveats in current RTI interventions in Peru, and fundamental negative effects on several components of the sectors and systems involved. It also highlighted programmatic issues that should be applied to guarantee an effective implementation and evaluation of these policies. The findings from this study were discussed with key stakeholders for consideration in further designing and planning RTI control interventions in Peru.

Abstract Background Sub-national analyses of causes of death and time-trends help to define public health policy priorities. They are particularly important in countries undergoing epidemiological transition like Peru. There are no studies exploring Peruvian national and regional characteristics of such epidemiological transition. We aimed to describe Peru's national and regional mortality profiles between 1996 and 2000. Methods Registered mortality data for the study period were corrected for under-registration following standardized methods. Main causes of death by age group and by geographical region were determined. Departmental mortality profiles were constructed to evaluate mortality transition, using 1996 data as baseline. Annual cumulative slopes for the period 1996–2000 were estimated for each department and region. Results For the study period non-communicable diseases explained more than half of all causes of death, communicable diseases more than one third, and injuries 10.8% of all deaths. Lima accounted for 32% of total population and 20% of total deaths. The Andean region, with 38% of Peru's population, accounted for half of all country deaths. Departmental mortality predominance shifted from communicable diseases in 1996 towards non-communicable diseases and injuries in 2000. Maternal and perinatal conditions, and nutritional deficiencies and nutritional anaemia declined markedly in all departments and regions. Infectious diseases decreased in all regions except Lima. In all regions acute respiratory infections are a leading cause of death, but their proportion ranged from 9.3% in Lima and Callao to 15.3% in the Andean region. Tuberculosis and injuries ranked high in Lima and the Andean region. Conclusion Peruvian mortality shows a double burden of communicable and non-communicable, with increasing importance of non-communicable diseases and injuries. This challenges national and sub-national health system performance and policy making.

Abstract Background Life at altitude depends on adaptation to ambient hypoxia. In the Andes, susceptibility to chronic mountain sickness (CMS), a clinical condition that occurs to native highlanders or to sea level natives with prolonged residence at high altitude, remains poorly understood. We hypothesized that hypoxia-associated gene expression in children of men with CMS might identify markers that predict the development of CMS in adults. We assessed distinct patterns of gene expression of hypoxia-responsive genes in children of highland Andean men, with and without CMS. Methods We compared molecular signatures in children of highland (HA) men with CMS (n = 10), without CMS (n = 10) and in sea level (SL) children (n = 20). Haemoglobin, haematocrit, and oxygen saturation were measured. Gene expression in white cells was assessed at HA and then, in the same subjects, within one hour of arrival at sea level. Results HA children showed higher expression levels of genes regulated by HIF (hypoxia inducible factor) and lower levels of those involved in glycolysis and in the tricarboxilic acid (TCA) cycle. Pyruvate dehydrogenase kinase 1(PDK1) and HIF prolyl hydroxylase 3 (HPH3) mRNA expressions were lowest in children of CMS fathers at altitude. At sea level the pattern of gene expression in the 3 children's groups was indistinguishable. Conclusion The molecular signatures of children of CMS patients show impaired adaptation to hypoxia. At altitude children of CMS fathers had defective coupling between glycolysis and mitochondria TCA cycle, which may be a key mechanism/biomarker for adult CMS. Early biologic markers of disease susceptibility in Andeans might impact health services and social planning.

Abstract Background Information on profiles for under-five causes of death is important to guide choice of child-survival interventions. Global level data have been published, but information at country level is scarce. We aimed at defining national and departmental trends and profiles of under-five mortality in Peru from 1996 through 2000. Methods We used the Ministry of Health registered under-five mortality data. For correction of under-registration, a model life-table that fitted the age distribution of the population and of registered deaths was identified for each year. The mortality rates corresponding to these model life-tables were then assigned to each department in each particular year. Cumulative reduction in under-five mortality rate in the 1996–2000 period was estimated calculating the annual reduction slope for each department. Departmental level mortality profiles were constructed. Differences in mortality profiles and in mortality reduction between coastal, andean and jungle regions were also assessed. Results At country level, only 4 causes (pneumonia, diarrhoea, neonatal diseases and injuries) accounted for 68% of all deaths in 1996, and for 62% in 2000. There was 32.7% of under-five death reduction from 1996 to 2000. Diarrhoea and pneumonia deaths decreased by 84.5% and 41.8%, respectively, mainly in the andean region, whereas deaths due to neonatal causes and injuries decreased by 37.2% and 21.7%. For 1996–2000 period, the andean, coast and jungle regions accounted for 52.4%, 33.1% and 14.4% of deaths, respectively. These regions represent 41.0%, 46.4% and 12.6% of under-five population. Both diarrhoea and pneumonia constitute 30.6% of under-five deaths in the andean region. As a proportion, neonatal deaths remained stable in the country from 1996 to 2000, accounting for about 30% of under-five deaths, whereas injuries and "other" causes, including congenital anomalies, increased by about 5%. Conclusion Under-five mortality declined substantially in all departments from 1996 to 2000, which is explained mostly by reduction in diarrhoea and pneumonia deaths, particularly in the andean region. There is the need to emphasize interventions to reduce neonatal deaths and emerging causes of death such as injuries and congenital anomalies.

Abstract Background Anaemia is highly prevalent in children of developing countries. It is associated with impaired physical growth and mental development. Palmar pallor is recommended at primary level for diagnosing it, on the basis of few studies. The objective of the study was to systematically assess the accuracy of clinical signs in the diagnosis of anaemia in children. Methods A systematic review on the accuracy of clinical signs of anaemia in children. We performed an Internet search in various databases and an additional reference tracking. Studies had to be on performance of clinical signs in the diagnosis of anaemia, using haemoglobin as the gold standard. We calculated pooled diagnostic likelihood ratios (LR's) and odds ratios (DOR's) for each clinical sign at different haemoglobin thresholds. Results Eleven articles met the inclusion criteria. Most studies were performed in Africa, in children underfive. Chi-square test for proportions and Cochran Q for DOR's and for LR's showed heterogeneity. Type of observer and haemoglobin technique influenced the results. Pooling was done using the random effects model. Pooled DOR at haemoglobin Conclusion This meta-analysis did not document a highly accurate clinical sign of anaemia. In view of poor performance of clinical signs, universal iron supplementation may be an adequate control strategy in high prevalence areas. Further well-designed studies are needed in settings other than Africa. They should assess inter-observer variation, performance of combined clinical signs, phenotypic differences, and different degrees of anaemia.

Abstract Background The evidence base of clinical interventions in paediatric hospitals of developing countries has not been formally assessed. We performed this study to determine the proportion of evidence-based therapeutic interventions in a paediatric referral hospital of a developing country Methods The medical records of 167 patients admitted in one-month period were revised. Primary diagnosis and primary therapeutic interventions were determined for each patient. A systematic search was performed to assess the level of evidence for each intervention. Therapeutic interventions were classified using the Ellis score and the Oxford Centre for Evidence Based Medicine Levels of Evidence Results Any dehydration due to diarrhoea (59 cases) and pneumonia (42 cases) were the most frequent diagnoses. Based on Ellis score, level I evidence supported the primary therapeutic intervention in 21%, level II in 73% and level III in 6% cases. Using the Oxford classification 16%, 8%, 1% and 75% therapeutic interventions corresponded to grades A, B, C, and D recommendations, respectively. Overall, according to Ellis score, 94% interventions were evidence based. However, out of the total, 75% interventions were based on expert opinion or basic sciences. Most children with mild to moderate dehydration (52 cases) were inappropriately treated with slow intravenous fluids, and most children with non-complicated community acquired pneumonia (42 cases) received intravenous antibiotics Conclusions Most interventions were inappropriate, despite the availability of effective therapy for several of them. Diarrhoeal dehydration and community acquired pneumonia were the most common diagnoses and were inappropriately managed. Existing effective interventions for dehydration and pneumonia need to be put into practice at referral hospitals of developing countries. For the remaining problems, there is the need to conduct appropriate clinical studies. Caution must be taken when assigning the level of evidence supporting therapeutic interventions, as commonly used classifications may be misleading

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

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