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Summary: Background: Identification of unvaccinated children is important for preventing deaths due to infections. Number of siblings and birth order have been postulated as risk factors for zero-dose prevalence. Methods: We analysed nationally representative cross-sectional surveys from 85 low and middle-income countries (2010–2020) with information on immunisation status of children aged 12–35 months. Zero-dose prevalence was defined as the failure to receive any doses of DPT (diphtheria-pertussis-tetanus) vaccine. We examined associations with birth order and the number of siblings, adjusting for child's sex, maternal age and education, household wealth quintiles and place of residence. Poisson regression was used to calculate zero-dose prevalence ratios. Findings: We studied 375,548 children, of whom 13.7% (n = 51,450) were classified as zero-dose. Prevalence increased monotonically with birth order and with the number of siblings, with prevalence increasing from 11.0% for firstborn children to 17.1% for birth order 5 or higher, and from 10.5% for children with no siblings to 17.2% for those with four or more siblings. Adjustment for confounders attenuated but did not eliminate these associations. The number of siblings remained as a strong risk factor when adjusted for confounders and birth order, but the reverse was not observed. Among children with the same number of siblings, there was no clear pattern in zero-dose prevalence by birth order; for instance, among children with two siblings, the prevalence was 13.0%, 14.7%, and 13.3% for firstborn, second, and third-born, respectively. Similar results were observed for girls and boys. 9513 families had two children aged 12–35 months. When the younger sibling was unvaccinated, 61.9% of the older siblings were also unvaccinated. On the other hand, when the younger sibling was vaccinated, only 5.9% of the older siblings were unvaccinated. Interpretation: The number of siblings is a better predictor than birth order in identifying children to be targeted by immunization campaigns. Zero-dose children tend to be clustered within families. Funding: Gavi, the Vaccine Alliance.

Summary: Background: Afrodescendants are systematically affected by discrimination in the Americas and few multi-country studies addressed ethnic inequalities in health and wellbeing in the region. We aimed to investigate gaps in coverage of key health outcomes and socioeconomic inequalities between Afrodescendants and non-Afrodescendants populations in Latin American and Caribbean countries. Methods: Using national household surveys (2011–2019) from ten countries, we analyzed absolute inequalities between Afrodescendants and a comparison group that includes non-Afrodescendants and non-Indigenous individuals (henceforth non-Afrodescendants) across 17 indicators in the continuum of reproductive, maternal, newborn, child, and adolescent health. These include indicators of family planning, antenatal care, delivery assistance, child nutrition, immunization coverage, child protection, access to improved water, sanitation and hygiene, adolescent fertility, and early childhood mortality. Inequalities between country-specific subgroups of Afrodescendants were also explored. The slope index of inequality was used to assess wealth-based inequalities within each ethnic group. Findings: Afrodescendants represented from 2·8% (Honduras) to 59·1% (Brazil) of the national samples. Of the 128 combinations of country and indicators with data, Afrodescendants fared worse in 78 (of which 33 were significant) and performed better in 50 (15 significant). More systematic disadvantages for Afrodescendants were found for demand for family planning satisfied, early marriage, and household handwashing and sanitation facilities. In contrast, Afrodescendants tended to present lower c-section rates and lower stunting prevalence. Honduras was the only country where Afrodescendants performed better than non-Afrodescendants in several indicators. Wealth gaps among Afrodescendants were wider than those observed for non-Afrodescendants for most indicators and across all countries. Interpretation: Gaps in health outcomes between Afrodescendants and non-Afrodescendants were observed in most countries, with more frequent disadvantages for the former although, in many cases, the gaps were reversed. Wealth inequalities within Afrodescendants tended to be wider than for non-Afrodescendants. Funding: Pan American Health Organization, Bill and Melinda Gates Foundation, and the Wellcome Trust.

Background: Using data from Mexico, the country with the largest indigenous population in Latin America, we describe ethnic inequalities in coverage with women's health interventions at individual and municipal levels. Methods: Cross-sectional study using data from the National Health and Nutrition Survey 2018 and the Mexican Intercensal Survey 2015. We selected five outcomes: modern contraceptive use, content-qualified antenatal care (ANCq), and skilled birth attendant (SBA) for women aged 15–49 years; Pap smear test and mammogram among women aged 25-64 and 40-69 years respectively. Municipalities were classified into three groups by the percentage of indigenous population:

Background: Large-scale epidemiological studies of seroprevalence of antibodies against SARS-CoV-2 often rely on point-of-care tests that provide immediate results to participants. Yet, little is known on how long rapid tests remain positive after the COVID-19 episode, or how much variability exists across different brands and even among batches of the same test. Methods: In November 2020, we assessed the sensitivity of three tests applied to 133 individuals with a previous positive PCR result between April and October. All subjects provided finger prick blood samples for two batches (A and B) of the Wondfo lateral-flow IgG/IgM test, and dried blood spot samples for the S-UFRJ ELISA test. Results: Overall sensitivity levels were 92.5% (95% CI 86.6–96.3), 63.2% (95% CI 54.4–71.4) and 33.8% (95% CI 25.9–42.5) for the S-UFRJ test, Wondfo A and Wondfo B tests, respectively. There was no evidence of a decline in the positivity of S-UFRJ with time since the diagnosis, but the two Wondfo batches showed sharp reductions to as low as 41.9% and 19.4%, respectively, for subjects with a positive PCR in June or earlier. Positive results for batch B of the rapid test were 35% to 54% lower than for batch A at any given month of diagnosis. Interpretation: Whereas the ELISA test showed high sensitivity and stability of results over the five months of the study, both batches of the rapid test showed substantial declines, with one of the batches consistently showing lower sensitivity levels than the other. ELISA tests based on dried-blood spots are an inexpensive alternative to rapid lateral-flow tests in large-scale epidemiological studies. Funding: The study was funded by the “Todos Pela Saúde” initiative, Instituto Serrapilheira, Brazilian Ministry of Health, Brazilian Collective Health Association (ABRASCO) and the JBS S.A. initiative ‘Fazer o Bem Faz Bem’.

Summary: Background: The UN Sustainable Development Goals (SDGs) call for stratification of social indicators by ethnic groups; however, no recent multicountry analyses on ethnicity and child survival have been done in low-income and middle-income countries (LMICs). Methods: We used data from Demographic and Health Surveys and Multiple Indicator Cluster Surveys collected between 2010 and 2016, from LMICs that provided birth histories and information on ethnicity or a proxy variable. We calculated neonatal (age 0–27 days), post-neonatal (age 28–364 days), child (age 1–4 years), and under-5 mortality rates (U5MRs) for each ethnic group within each country. We assessed differences in mortality between ethnic groups using a likelihood ratio test, Theil's index, and between-group variance. We used multivariable analyses of U5MR by ethnicity to adjust for household wealth, maternal education, and urban–rural residence. Findings: We included data from 36 LMICs, which included 2 812 381 livebirths among 415 ethnic groups. In 25 countries, significant differences in U5MR by ethnic group were identified (all p

Summary: Background: Latin American and Caribbean populations include three main ethnic groups: indigenous people, people of African descent, and people of European descent. We investigated ethnic inequalities among these groups in population coverage with reproductive, maternal, newborn, and child health interventions. Methods: We analysed 16 standardised, nationally representative surveys carried out from 2004 to 2015 in Latin America and the Caribbean that provided information on ethnicity or a proxy indicator (household language or skin colour) and on coverage of reproductive, maternal, newborn, and child health interventions. We selected four outcomes: coverage with modern contraception, antenatal care coverage (defined as four or more antenatal visits), and skilled attendants at birth for women aged 15–49 years; and coverage with three doses of diphtheria-pertussis-tetanus (DPT3) vaccine among children aged 12–23 months. We classified women and children as indigenous, of African descent, or other ancestry (reference group) on the basis of their self-reported ethnicity or language. Mediating variables included wealth quintiles (based on household asset indices), woman's education, and urban-rural residence. We calculated crude and adjusted coverage ratios using Poisson regression. Findings: Ethnic gaps in coverage varied substantially from country to country. In most countries, coverage with modern contraception (median coverage ratio 0·82, IQR 0·66–0·92), antenatal care (0·86, 0·75–0·94), and skilled birth attendants (0·75, 0·68–0·92) was lower among indigenous women than in the reference group. Only three countries (Nicaragua, Panama, and Paraguay) showed significant gaps in DPT3 coverage between the indigenous and the reference groups. The differences were attenuated but persisted after adjustment for wealth, education, and residence. Women and children of African descent showed similar coverage to the reference group in most countries. Interpretation: The lower coverage levels for indigenous women are pervasive, and cannot be explained solely by differences in wealth, education, or residence. Interventions delivered at community level—such as vaccines—show less inequality than those requiring access to services, such as birth attendance. Regular monitoring of ethnic inequalities is essential to evaluate existing initiatives aimed at the inclusion of minorities and to plan effective multisectoral policies and programmes. Funding: The Bill & Melinda Gates Foundation (through the Countdown to 2030 initiative) and the Wellcome Trust.

Background: The Sustainable Development Goals strongly focus on equity. Goal 5 explicitly aims to empower all women and girls, reinforcing the need to have a reliable indicator to track progress. Our objective was to develop a novel women's empowerment indicator from widely available data sources, broadening opportunities for monitoring and research on women's empowerment. Methods: We used Demographic and Health Survey data from 34 African countries, targeting currently partnered women. We identified items related to women's empowerment present in most surveys, and used principal component analysis to extract the components. We carried out a convergent validation process using coverage of three health interventions as outcomes; and an external validation process by analysing correlations with the Gender Development Index. Findings: 15 items related to women's empowerment were selected. We retained three components (50% of total variation) which, after rotation, were identified as three dimensions of empowerment: attitude to violence, social independence, and decision making. All dimensions had moderate to high correlation with the Gender Development Index. Social independence was associated with higher coverage of maternal and child interventions; attitude to violence and decision making were more consistently associated with the use of modern contraception. Interpretation: The index, named Survey-based Women's emPowERment index (SWPER), has potential to widen the research on women's empowerment and to give a better estimate of its effect on health interventions and outcomes. It allows within-country and between-country comparison, as well as time trend analysis, which no other survey-based index provides. Funding: Bill & Melinda Gates Foundation.

Summary: Background: Coverage levels for essential interventions aimed at reducing deaths of mothers and children are increasing steadily in most low-income and middle-income countries. We assessed how much poor and rural populations in these countries are benefiting from national-level progress. Methods: We analysed trends in a composite coverage indicator (CCI) based on eight reproductive, maternal, newborn, and child health interventions in 209 national surveys in 64 countries, from Jan 1, 1994, to Dec 31, 2014. Trends by wealth quintile and urban or rural residence were fitted with multilevel modelling. We used an approach akin to the calculation of population attributable risk to quantify the contribution of poor and rural populations to national trends. Findings: From 1994 to 2014, the CCI increased by 0·82 percent points a year across all countries; households in the two poorest quintiles had an increase of 0·99 percent points a year, which was faster than that for the three wealthiest quintiles (0·68 percent points). Gains among poor populations were faster in lower-middle-income and upper-middle-income countries than in low-income countries. Globally, national level increases in CCI were 17·5% faster than they would have been without the contribution of the two poorest quintiles. Coverage increased more rapidly annually in rural (0·93 percent points) than urban (0·52 percent points) areas. Interpretation: National coverage gains were accelerated by important increases among poor and rural mothers and children. Despite progress, important inequalities persist, and need to be addressed to achieve the Sustainable Development Goals. Funding: UNICEF, Wellcome Trust.

OBJETIVO: Avaliar a influência do apoio à amamentação sobre as taxas de aleitamento materno no município de Pelotas (RS). MÉTODOS: Foram comparadas as prevalências de aleitamento materno de quatro coortes de crianças, nascidas em 1982, 1993, 1997-1998 e 2004. Participaram crianças que preenchiam os critérios de inclusão do Estudo Multicêntrico de Curvas de Crescimento da Organização Mundial da Saúde, já que este originou a coorte de 1997-1998, na qual houve apoio sistematizado à amamentação. RESULTADOS: Houve aumento nas taxas de aleitamento materno exclusivo: com 1 mês de vida, de 26% em 1993 para 77% em 2004, e, aos 3 meses, de 16 para 46%, respectivamente. As taxas de aleitamento materno mostraram ascendência, porém menos significativa: aos 12 meses de 15% em 1982 para 34% em 2004 e, aos 24 meses, de 6 para 14%, respectivamente. CONCLUSÕES: O apoio à amamentação contribuiu na tendência ascendente das taxas de aleitamento materno.OBJECTIVE: To evaluate the influence of breastfeeding support on breastfeeding rates in the city of Pelotas (RS), Brazil. METHODS: The prevalence rates of exclusive breastfeeding and of overall breastfeeding were compared in four cohorts of children, born in 1982, 1993, 1997-1998 and 2004. The children selected for this study fulfilled the inclusion criteria for the WHO Multicenter Growth Reference Study, in order to afford comparison with the 1997-1998 cohort, which was made up of children selected for that study. The 1997-1998 cohort received systematic breastfeeding support. RESULTS: There was an increase in the rates of exclusive breastfeeding: from 26% at 1 month of age in 1993 to 77% at the same age in 2004, and from 16% at 3 months to 46% for the same dates, respectively. Breastfeeding rates at later ages exhibited a tendency to increase, although with less significance: from 15% in 1982 at 12 months to 34% in 2004 at the same age and from 6% at 24 months to 14% for the same dates, respectively. CONCLUSIONS: Breastfeeding support has contributed to a tendency for breastfeeding rates to increase.

Background: Breastfeeding has clear short-term benefits, but its long-term consequences on human capital are yet to be established. We aimed to assess whether breastfeeding duration was associated with intelligence quotient (IQ), years of schooling, and income at the age of 30 years, in a setting where no strong social patterning of breastfeeding exists. Methods: A prospective, population-based birth cohort study of neonates was launched in 1982 in Pelotas, Brazil. Information about breastfeeding was recorded in early childhood. At 30 years of age, we studied the IQ (Wechsler Adult Intelligence Scale, 3rd version), educational attainment, and income of the participants. For the analyses, we used multiple linear regression with adjustment for ten confounding variables and the G-formula. Findings: From June 4, 2012, to Feb 28, 2013, of the 5914 neonates enrolled, information about IQ and breastfeeding duration was available for 3493 participants. In the crude and adjusted analyses, the durations of total breastfeeding and predominant breastfeeding (breastfeeding as the main form of nutrition with some other foods) were positively associated with IQ, educational attainment, and income. We identified dose-response associations with breastfeeding duration for IQ and educational attainment. In the confounder-adjusted analysis, participants who were breastfed for 12 months or more had higher IQ scores (difference of 3·76 points, 95% CI 2·20–5·33), more years of education (0·91 years, 0·42–1·40), and higher monthly incomes (341·0 Brazilian reals, 93·8–588·3) than did those who were breastfed for less than 1 month. The results of our mediation analysis suggested that IQ was responsible for 72% of the effect on income. Interpretation: Breastfeeding is associated with improved performance in intelligence tests 30 years later, and might have an important effect in real life, by increasing educational attainment and income in adulthood. Funding: Wellcome Trust, International Development Research Center (Canada), CNPq, FAPERGS, and the Brazilian Ministry of Health.

OBJETIVO: Descrever os hábitos miccionais e suas disfunções em uma amostra populacional de crianças de 3 a 9 anos. MÉTODOS: Delineamento transversal, incluindo 580 crianças. Uma amostra probabilística de domicílios da zona urbana da cidade de Pelotas (RS) foi selecionada em múltiplos estágios. Os hábitos miccionais e fecais foram avaliados com o escore de disfunção miccional proposto por Farhat et al. e modificado pela equipe de pesquisa com acréscimo do sintoma freqüência urinária superior a oito vezes ao dia. Os meninos com pontuação maior que oito e as meninas com pontuação maior que cinco foram reavaliados clinicamente, assim como uma subamostra dos demais. RESULTADOS: Os sintomas miccionais mais freqüentes foram noctúria (60,4%), urgência miccional (49,7%) e manobras de contenção (42,1%). A prevalência de enurese foi de 20,1% em meninos e 15,1% em meninas. A prevalência de disfunção miccional pelo escore Farhat et al. foi de 24,2%. A maioria dos sintomas foi mais freqüente entre as meninas e entre crianças mais jovens. As meninas de nível econômico baixo apresentaram maior freqüência de enurese e força para urinar, enquanto que, entre os meninos, a urgência miccional foi mais comum entre os mais pobres. Apenas 10,5% dos pais de crianças com disfunção haviam levado seu filho ao médico por causa dos sintomas. CONCLUSÕES: Os sintomas miccionais apresentam prevalências altas e devem ser investigados ativamente nas consultas de rotina, com perguntas diretas sobre cada sintoma isoladamente, objetivando o diagnóstico de disfunção miccional.OBJECTIVE: To describe voiding patterns and related dysfunctions in a population-based sample of children aged 3 to 9 years. METHODS: A cross-sectional population-based survey including 580 children. A probabilistic sample of households in the urban area of Pelotas in southern Brazil was selected following a multiple-stage protocol. Voiding and fecal patterns were investigated using the dysfunction score created by Farhat et al. and modified by the addition of high urinary frequency (more than eight times a day). Boys with scores above eight and girls above five were clinically investigated, as well as a sub-sample of the remaining children. RESULTS: Nocturia (60.4%), urinary urgency (49.7%) and holding maneuvers (42.1%) were the most frequently reported symptoms. The prevalence of enuresis was 20.1% in boys and 15.1% in girls. The prevalence of urinary dysfunction was 22.8%. Most symptoms were more frequently reported by girls and younger children. Among girls, low socioeconomic level was related to an increased prevalence of enuresis and straining to urinate, while among boys urgency was more common among the poor. Only 10.5% of the parents of the children with voiding dysfunction consulted a doctor because of their problems. CONCLUSIONS: The voiding symptoms studied presented high prevalence rates, and therefore should be investigated in clinical practice, with direct questions about each symptom, aiming to diagnose voiding dysfunction.

Objetivo: medir os principais fatores de risco relacionados à ocorrência de injúrias acidentais, na faixa etária entre quatro e cinco anos de idade.Métodos: foi estudada uma coorte prospectiva de 620 crianças, na qual a ocorrência de acidentes e injúrias foi registrada em um diário, durante um período de um mês. Esta foi uma subamostra sistemática, proveniente da coorte de nascimentos de 1993, que ainda residiam na área urbana de Pelotas, RS. O desfecho em estudo foi o número de injúrias acidentais relatadas por criança-mês. A análise multivariada, utilizando Regressão de Poisson, foi usada para controlar fatores de confusão.Resultados: a incidência mensal de acidentes foi de 53,8%, e 48,4% das crianças sofreram pelo menos uma injúria acidental. As crianças do sexo masculino tiveram 30% mais de chances de se lesionarem do que aquelas do sexo feminino, e as crianças brancas tiveram um risco 70% maior do que as crianças não-brancas. Renda familiar, escolaridade dos pais e trabalho materno não se associaram à ocorrência de injúrias. Após ajuste para variáveis socioeconômicas e ambientais, as crianças que possuíam um ou mais irmãos menores apresentavam taxa 30% maior de injúrias acidentais. Crianças residentes em casa de tijolo apresentaram uma incidência de injúrias cerca de 40%superior. Conclusões: poucos fatores de risco modificáveis foram associados a um aumento na freqüência de injúrias acidentais. Destes fatores, a presença de crianças mais jovens em casa merece especial atenção, sendo necessário instruir os pais sobre o aumento no risco observado por ocasião do nascimento de um irmão menor.Objective: to measure the main risk factors associated with the occurrence of accidental injuries in children aged 4-5 years.Methods: the study included a prospective cohort of children whose parents filled in a diary recording accidents and injuries during a period of one-month. The children represented a systematic subsample from a population-based birth cohort in southern Brazil. The outcome was the number of reported injuries per child during one month. Multivariate analysis (Poisson regression) was used to assess confounding factors.Results: the monthly frequency of accidents was 53.8%, and 48.4% of the children suffered at least one injury. Boys had 30% more injuries than girls, and white children had 70% higher incidence than non-white. Family income, parental education and maternal employment were not associated with the frequency of injuries. After adjustment of socioeconomic and environmental factors, having younger siblings was associated with a 30% higher injury rate, and living in a home made of bricks was associated with a 35% increase. The incidence of injuries appeared to be higher among children attending day-care centers and those living in periurban areas.Conclusions: few risk factors were associated with an increased frequency of injuries. Among them, the most amenable to intervention seems to be the presence of younger siblings. Parents should become aware of children’s needs for increased attention when a younger sibling is born.