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Abstract Synthetic downscaling of tropical cyclones (TCs) is critically important to estimate the long‐term hazard of rare high‐impact storm events. Existing downscaling approaches rely on statistical or statistical‐deterministic models that are capable of generating large samples of synthetic storms with characteristics similar to observed storms. However, these models do not capture the complex two‐way interactions between a storm and its environment. In addition, these approaches either necessitate a separate TC size model to simulate storm size or involve post‐processing to capture the asymmetries in the simulated surface wind. In this study, we present an innovative data‐driven approach for TC synthetic downscaling. Using a machine learning‐based high‐resolution global weather model (ML‐GWM), our approach can simulate the full life cycle of a storm with asymmetric surface wind that accounts for the two‐way interactions between the storm and its environment. This approach consists of multiple components: a data‐driven model for generating synthetic TC seeds, a blending method that seamlessly integrates storm seeds into the surrounding while maintaining the seed structure, and a model based on a recurrent neural network to correct for biases in storm intensity. Compared to observations and synthetic storms simulated using existing statistical‐deterministic and statistical downscaling approaches, our method shows the ability to effectively capture many aspects of TC statistics, including track density, landfall frequency, landfall intensity, and outermost wind extent. Leveraging the computational efficiency of ML‐GWM, our approach shows substantial potential for TC regional hazard and risk assessment.

Patel et al. perform a comprehensive analysis of factors associated with HIV positivity across 29 sub-Saharan African countries from 2003 to 2017. They identify over 300 factors associated with HIV positivity in each sex, some of them under-recognized but consistent across countries and sex.

Objective To better understand diverse experts’ views about the ethical implications of ongoing research funded by the National Institutes of Health that uses machine learning to predict HIV/AIDS risk in sub-Saharan Africa (SSA) based on publicly available Demographic and Health Surveys data.Design Three rounds of semi-structured surveys in an online expert panel using a modified Delphi approach.Participants Experts in informatics, African public health and HIV/AIDS and bioethics were invited to participate.Measures Perceived importance of or agreement about relevance of ethical issues on 5-point unipolar Likert scales. Qualitative data analysis identified emergent themes related to ethical issues and development of an ethical framework and recommendations for open-ended questions.Results Of the 35 invited experts, 22 participated in the online expert panel (63%). Emergent themes were the inclusion of African researchers in all aspects of study design, analysis and dissemination to identify and address local contextual issues, as well as engagement of communities. Experts focused on engagement with health and science professionals to address risks, benefits and communication of findings. Respondents prioritised the mitigation of stigma to research participants but recognised trade-offs between privacy and the need to disseminate findings to realise public health benefits. Strategies for responsible communication of results were suggested, including careful word choice in presentation of results and limited dissemination to need-to-know stakeholders such as public health planners.Conclusion Experts identified ethical issues specific to the African context and to research on sensitive, publicly available data and strategies for addressing these issues. These findings can be used to inform an ethical implementation framework with research stage-specific recommendations on how to use publicly available data for machine learning-based predictive analytics to predict HIV/AIDS risk in SSA.

Background: An estimated 166,155 individuals in the United States have undiagnosed HIV infection. We modeled the numbers of HIV-infected individuals who could be diagnosed in clinical and community settings by broadly implementing HIV screening guidelines. Setting: United States. Methods: We modeled testing for general population (once lifetime) and high-risk populations (annual): men who have sex with men, people who inject drugs, and high-risk heterosexuals. We used published data on HIV infections, HIV testing, engagement in clinical care, and risk status disclosure. Results: In clinical settings, about 76 million never-tested low-risk and 2.6 million high-risk individuals would be tested, yielding 36,000 and 55,000 HIV diagnoses, respectively. In community settings, 30 million low-risk and 4.4 million high-risk individuals would be tested, yielding 75,000 HIV diagnoses. Conclusion: HIV testing in clinical and community settings diagnoses similar numbers of individuals. Lifetime and risk-based testing are both needed to substantially reduce undiagnosed HIV.

BackgroundThe key metric for monitoring the progress of deworming programs in controlling soil-transmitted helminthiasis (STH) is national drug coverage reported to the World Health Organization (WHO). There is increased interest in utilizing geographically-disaggregated data to estimate sub-national deworming coverage and equity, as well as gender parity. The Demographic and Health Surveys (DHS) offer a potential source of sub-national data. This study aimed to compare deworming coverage routinely reported to WHO and estimated by DHS in pre-school aged children to inform global STH measurement and evaluation.MethodologyWe compared sub-national deworming coverage in pre-school aged children reported to WHO and estimated by DHS aligned geospatially and temporally. We included data from Burundi (2016-2017), Myanmar (2015-2016), and the Philippines (2017) based on data availability. WHO provided data on the date and sub-national coverage per mass drug administration reported by Ministries of Health. DHS included maternally-reported deworming status within the past 6 months for each child surveyed. We estimated differences in sub-national deworming coverage using WHO and DHS data, and performed sensitivity analyses.Principal findingsWe compared data on pre-school aged children from 13 of 18 districts in Burundi (N = 6,835 in DHS), 11 of 15 districts in Myanmar (N = 1,462 in DHS) and 16 of 17 districts in the Philippines (N = 7,594 in DHS) following data exclusion. The national deworming coverages estimated by DHS in Burundi, Myanmar, and the Philippines were 75.5% (95% CI: 73.7%-77.7%), 47.0% (95% CI: 42.7%-51.3%), and 48.0% (95% CI: 46.0%-50.0%), respectively. The national deworming coverages reported by WHO in Burundi, Myanmar, and the Philippines were 80.1%, 93.6% and 75.7%, respectively. The mean absolute differences in district-level coverage reported to WHO and estimated by DHS in Burundi, Myanmar, and the Philippines were 9.5%, 41.5%, and 24.6%, respectively. Across countries, coverage reported to WHO was frequently higher than DHS estimates (32 of 40 districts). National deworming coverage from DHS estimates were similar by gender within countries.Conclusions and significanceAgreement of deworming coverage reported to WHO and estimated by DHS data was heterogeneous across countries, varying from broadly compatible in Burundi to largely discrepant in Myanmar. DHS data could complement deworming data reported to WHO to improve data monitoring practices and serve as an independent sub-national source of coverage data.

Background: The prevalence of pre-treatment drug resistance (PDR) to non-nucleoside reverse-transcriptase inhibitor (NNRTI) agents is increasing in sub-Saharan Africa, which may decrease the effectiveness of efavirenz-based antiretroviral therapy (ART) programs. However, due to recent safety concerns, there has been hesitancy to replace efavirenz-based ART with dolutegravir in women of reproductive potential. Our objective was to evaluate whether PDR testing for women not initiating dolutegravir-based ART would be a cost-effective strategy to address the challenges posed by PDR. Methods: We developed an HIV drug resistance model that simulates the emergence and transmission of resistance mutations, calibrated to the Kenyan epidemic. We modeled three care strategies for PDR testing among women not initiating dolutegravir-based ART: no PDR testing, PDR testing with a low-cost point mutation assay, known as oligonucleotide ligation assay (OLA), and PDR testing with consensus sequencing. Using a health sector perspective, this model was used to evaluate the health outcomes, lifetime costs, and cost-effectiveness under each strategy over a 15-year time horizon starting in 2019. Findings: OLA and CS PDR testing were projected to have incremental cost-effectiveness ratios (ICER) of $10,741/QALY gained and $134,396/QALY gained, respectively, which are not cost-effective by national income standards. Viral suppression rates among women at 12 months after ART initiation were 87·8%, 89·0%, and 89·3% with no testing, OLA testing, and CS testing, respectively. PDR testing with OLA and CS were associated with a 0.5% and 0.6% reduction in incidence rate compared to no PDR testing. Initial PDR prevalence among women was 13.1% in 2019. By 2034, this prevalence was 17·6%, 17·4%, and 17·3% with no testing, OLA testing, and CS testing, respectively. Interpretation: PDR testing for women is unlikely to be cost-effective in Kenya whether one uses a low-cost assay, such as OLA, or consensus sequencing. Funding: National Institutes of Health, Gilead Sciences.

BackgroundDrought has many known deleterious impacts on human health, but little is known about the relationship between drought and intimate partner violence (IPV). We aimed to evaluate this relationship and to assess effect heterogeneity between population subgroups among women in 19 sub-Saharan African countries.Methods and findingsWe used data from 19 Demographic and Health Surveys from 2011 to 2018 including 83,990 partnered women aged 15-49 years. Deviations in rainfall in the year before the survey date were measured relative to the 29 previous years using Climate Hazards Group InfraRed Precipitation with Station data, with recent drought classified as ordinal categorical variable (severe: ≤10th percentile; mild/moderate: >10th percentile to ≤30th percentile; none: >30th percentile). We considered 4 IPV-related outcomes: reporting a controlling partner (a risk factor for IPV) and experiencing emotional violence, physical violence, or sexual violence in the 12 months prior to survey. Logistic regression was used to estimate marginal risk differences (RDs). We evaluated the presence of effect heterogeneity by age group and employment status. Of the 83,990 women included in the analytic sample, 10.7% (9,019) experienced severe drought and 23.4% (19,639) experienced mild/moderate drought in the year prior to the survey, with substantial heterogeneity across countries. The mean age of respondents was 30.8 years (standard deviation 8.2). The majority of women lived in rural areas (66.3%) and were married (73.3%), while less than half (42.6%) were literate. Women living in severe drought had higher risk of reporting a controlling partner (marginal RD in percentage points = 3.0, 95% CI 1.3, 4.6; p < 0.001), experiencing physical violence (marginal RD = 0.8, 95% CI 0.1, 1.5; p = 0.019), and experiencing sexual violence (marginal RD = 1.2, 95% CI 0.4, 2.0; p = 0.001) compared with women not experiencing drought. Women living in mild/moderate drought had higher risk of reporting physical (marginal RD = 0.7, 95% CI 0.2, 1.1; p = 0.003) and sexual violence (marginal RD = 0.7, 95% CI 0.3, 1.2; p = 0.001) compared with those not living in drought. We did not find evidence for an association between drought and emotional violence. In analyses stratified by country, we found 3 settings where drought was protective for at least 1 measure of IPV: Namibia, Tanzania, and Uganda. We found evidence for effect heterogeneity (additive interaction) for the association between drought and younger age and between drought and employment status, with stronger associations between drought and IPV among adolescent girls and unemployed women. This study is limited by its lack of measured hypothesized mediating variables linking drought and IPV, prohibiting a formal mediation analysis. Additional limitations include the potential for bias due to residual confounding and potential non-differential misclassification of the outcome measures leading to an attenuation of observed associations.ConclusionsOur findings indicate that drought was associated with measures of IPV towards women, with larger positive associations among adolescent girls and unemployed women. There was heterogeneity in these associations across countries. Weather shocks may exacerbate vulnerabilities among women in sub-Saharan Africa. Future work should further evaluate potential mechanisms driving these relationships.

Introduction Conflict adversely impacts health and health systems, yet its effect on health inequalities, particularly for women and children, has not been systematically studied. We examined wealth, education and urban/rural residence inequalities for child mortality and essential reproductive, maternal, newborn and child health interventions between conflict and non-conflict low-income and middle-income countries (LMICs).Methods We carried out a time-series multicountry ecological study using data for 137 LMICs between 1990 and 2017, as defined by the 2019 World Bank classification. The data set covers approximately 3.8 million surveyed mothers (15–49 years) and 1.1 million children under 5 years including newborns (

BackgroundVaccine hesitancy, the reluctance or refusal to receive vaccination, is a growing public health problem in the United States and globally. State policies that eliminate nonmedical ("personal belief") exemptions to childhood vaccination requirements are controversial, and their effectiveness to improve vaccination coverage remains unclear given limited rigorous policy analysis. In 2016, a California policy (Senate Bill 277) eliminated nonmedical exemptions from school entry requirements. The objective of this study was to estimate the association between California's 2016 policy and changes in vaccine coverage.Methods and findingsWe used a quasi-experimental state-level synthetic control analysis and a county-level difference-in-differences analysis to estimate the impact of the 2016 California policy on vaccination coverage and prevalence of exemptions to vaccine requirements (nonmedical and medical). We used publicly available state-level data from the US Centers for Disease Control and Prevention on coverage of measles, mumps, and rubella (MMR) vaccination, nonmedical exemption, and medical exemption in children entering kindergarten. We used county-level data individually requested from state departments of public health on overall vaccine coverage and exemptions. Based on data availability, we included state-level data for 45 states, including California, from 2011 to 2017 and county-level data for 17 states from 2010 to 2017. The prespecified primary study outcome was MMR vaccination in the state analysis and overall vaccine coverage in the county analysis. In the state-level synthetic control analysis, MMR coverage in California increased by 3.3% relative to its synthetic control in the postpolicy period (top 2 of 43 states evaluated in the placebo tests, top 5%), nonmedical exemptions decreased by 2.4% (top 2 of 43 states evaluated in the placebo tests, top 5%), and medical exemptions increased by 0.4% (top 1 of 44 states evaluated in the placebo tests, top 2%). In the county-level analysis, overall vaccination coverage increased by 4.3% (95% confidence interval [CI] 2.9%-5.8%, p < 0.001), nonmedical exemptions decreased by 3.9% (95% CI 2.4%-5.4%, p < 0.001), and medical exemptions increased by 2.4% (95% CI 2.0%-2.9%, p < 0.001). Changes in vaccination coverage across counties after the policy implementation from 2015 to 2017 ranged from -6% to 26%, with larger increases in coverage in counties with lower prepolicy vaccine coverage. Results were robust to alternative model specifications. The limitations of the study were the exclusion of a subset of US states from the analysis and the use of only 2 years of postpolicy data based on data availability.ConclusionsIn this study, implementation of the California policy that eliminated nonmedical childhood vaccine exemptions was associated with an estimated increase in vaccination coverage and a reduction in nonmedical exemptions at state and county levels. The observed increase in medical exemptions was offset by the larger reduction in nonmedical exemptions. The largest increases in vaccine coverage were observed in the most "high-risk" counties, meaning those with the lowest prepolicy vaccine coverage. Our findings suggest that government policies removing nonmedical exemptions can be effective at increasing vaccination coverage.

Summary: Background: The population effects of armed conflict on non-combatant vulnerable populations are incompletely understood. We aimed to study the effects of conflict on mortality among women of childbearing age (15–49 years) and on orphanhood among children younger than 15 years in Africa. Methods: We tested the extent to which mortality among women aged 15–49 years, and orphanhood among children younger than 15 years, increased in response to nearby armed conflict in Africa. Data on location, timing, and intensity of armed conflicts were obtained from the Uppsala Conflict Data Program, and data on the location, timing, and outcomes of women and children from Demographic and Health Surveys done in 35 African countries from 1990 to 2016. Mortality among women was obtained from sibling survival data. We used cluster-area fixed-effects regression models to compare survival of women during periods of nearby conflict (within 50 km) to survival of women in the same area during times without conflict. We used similar methods to examine the extent to which children living near armed conflicts are at increased risk of becoming orphans. We examined the effects of varying conflict intensity using number of direct battle deaths and duration of consecutive conflict exposure. Findings: We analysed data on 1 629 352 women (19 286 387 person-years), of which 103 011 (6·3%) died (534·1 deaths per 100 000 women-years), and 2 354 041 children younger than 15 years, of which 204 276 (8·7%) had lost a parent. On average, conflict within 50 km increased women's mortality by 112 deaths per 100 000 person-years (95% CI 97–128; a 21% increase above baseline), and the probability that a child has lost at least one parent by 6·0% (95% CI 3–8). This effect was driven by high-intensity conflicts: exposure to the highest (tenth) decile conflict in terms of conflict-related deaths increased the probability of female mortality by 202% (187–218) and increased the likelihood of orphanhood by 42% compared with a conflict-free period. Among the conflict-attributed deaths, 10% were due to maternal mortality. Interpretation: African women of childbearing age are at a substantially increased risk of death from nearby high-intensity armed conflicts. Children exposed to conflict are analogously at increased risk of becoming orphans. This work fills gaps in literature on the harmful effects of armed conflict on non-combatants and highlights the need for humanitarian interventions to protect vulnerable populations. Funding: Bill & Melinda Gates Foundation to the BRANCH Consortium.

Abstract Background Malaria is a leading cause of morbidity and mortality among HIV-infected pregnant women in sub-Saharan Africa: at least 1 million pregnancies among HIV-infected women are complicated by co-infection with malaria annually, leading to increased risk of premature delivery, severe anaemia, delivery of low birth weight infants, and maternal death. Current guidelines recommend either daily cotrimoxazole (CTX) or intermittent preventive treatment with sulfadoxine–pyrimethamine (IPTp-SP) for HIV-infected pregnant women to prevent malaria and its complications. The cost-effectiveness of CTX compared to IPTp-SP among HIV-infected pregnant women was assessed. Methods A microsimulation model of malaria and HIV among pregnant women in five malaria-endemic countries in sub-Saharan Africa was constructed. Four strategies were compared: (1) 2-dose IPTp-SP at current IPTp-SP coverage of the country (“2-IPT Low”); (2) 3-dose IPTp-SP at current coverage (“3-IPT Low”); (3) 3-dose IPTp-SP at the same coverage as antiretroviral therapy (ART) in the country (“3-IPT High”); and (4) daily CTX at ART coverage. Outcomes measured include maternal malaria, anaemia, low birth weight (LBW), and disability-adjusted life years (DALYs). Sensitivity analyses assessed the effect of adherence to CTX. Results Compared with the 2-IPT Low Strategy, women receiving CTX had 22.5% fewer LBW infants (95% CI 22.3–22.7), 13.5% fewer anaemia cases (95% CI 13.4–13.5), and 13.6% fewer maternal malaria cases (95% CI 13.6–13.7). In all simulated countries, CTX was the preferred strategy, with incremental cost-effectiveness ratios ranging from cost-saving to $3.9 per DALY averted from a societal perspective. CTX was less effective than the 3-IPT High Strategy when more than 18% of women stopped taking CTX during the pregnancy. Conclusion In malarious regions of sub-Saharan Africa, daily CTX for HIV-infected pregnant women regardless of CD4 cell count is cost-effective compared with 3-dose IPTp-SP as long as more than 82% of women adhere to daily dosing.

Abstract Background We sought to examine the relationship between child specific health aid (CHA) and burden of disease. Based on existing evidence, we hypothesized that foreign aid for child health would not be proportional to burden of disease. Methods In order to examine CHA and burden of disease, we obtained estimates of these parameters from established sources. Estimates of disability adjusted life years (DALYs) in children (0–5 years) were obtained from the World Health Organization for 2000 and 2012. The 10 most burdensome disease categories in each continent, excluding high-income countries, were identified for study. Descriptions of all foreign aid commitments between 1996 and 2009 were obtained from AidData, and an algorithm to designate the target diseases of the commitments was constructed. Data were examined in scatterplots for trends. Results The most burdensome childhood diseases varied by continent. In all continents, newborn diseases, vaccine-preventable diseases (lower respiratory diseases, measles, meningitis, tetanus, and pertussis), and diarrheal diseases ranked within the four most burdensome diseases. Infectious diseases such as malaria, tuberculosis, and HIV were also among the ten most burdensome diseases in sub-Saharan Africa, and non-communicable diseases were associated with much of the burden in the other continents. CHA grew from $7.4 billion in 1996 to $17.7 billion in 2009 for our study diseases. Diarrheal diseases and malnutrition received the most CHA as well as the most CHA per DALY. CHA directed at HIV increased dramatically over our study period, from $227,000 in 1996 to $3.4 billion in 2008. Little aid was directed at injuries such as drowning, car accidents, and fires, as well as complex medical diseases such as leukemia and endocrine disorders. Conclusion CHA has grown significantly over the last two decades. There is no clear relationship between CHA and burden of disease. This report provides a description of foreign aid for child health, and hopes to inform policy and decision-making regarding foreign aid.

BACKGROUND:In high-income countries, obesity prevalence (body mass index greater than or equal to 30 kg/m2) is highest among the poor, while overweight (body mass index greater than or equal to 25 kg/m2) is prevalent across all wealth groups. In contrast, in low-income countries, the prevalence of overweight and obesity is higher among wealthier individuals than among poorer individuals. We characterize the transition of overweight and obesity from wealthier to poorer populations as countries develop, and project the burden of overweight and obesity among the poor for 103 countries. METHODS AND FINDINGS:Our sample used 182 Demographic and Health Surveys and World Health Surveys (n = 2.24 million respondents) from 1995 to 2016. We created a standard wealth index using household assets common among all surveys and linked national wealth by country and year identifiers. We then estimated the changing probability of overweight and obesity across every wealth decile as countries' per capita gross domestic product (GDP) rises using logistic and linear fixed-effect regression models. We found that obesity rates among the wealthiest decile were relatively stable with increasing national wealth, and the changing gradient was largely due to increasing obesity prevalence among poorer populations (3.5% [95% uncertainty interval: 0.0%-8.3%] to 14.3% [9.7%-19.0%]). Overweight prevalence among the richest (45.0% [35.6%-54.4%]) and the poorest (45.5% [35.9%-55.0%]) were roughly equal in high-income settings. At $8,000 GDP per capita, the adjusted probability of being obese was no longer highest in the richest decile, and the same was true of overweight at $10,000. Above $25,000, individuals in the richest decile were less likely than those in the poorest decile to be obese, and the same was true of overweight at $50,000. We then projected overweight and obesity rates by wealth decile to 2040 for all countries to quantify the expected rise in prevalence in the relatively poor. Our projections indicated that, if past trends continued, the number of people who are poor and overweight will increase in our study countries by a median 84.4% (range 3.54%-383.4%), most prominently in low-income countries. The main limitations of this study included the inclusion of cross-sectional, self-reported data, possible reverse causality of overweight and obesity on wealth, and the lack of physical activity and food price data. CONCLUSIONS:Our findings indicate that as countries develop economically, overweight prevalence increased substantially among the poorest and stayed mostly unchanged among the wealthiest. The relative poor in upper- and lower-middle income countries may have the greatest burden, indicating important planning and targeting needs for national health programs.

Summary: Background: Mass deworming against soil-transmitted helminthiasis, which affects 1 billion of the poorest people globally, is one of the largest public health programmes for neglected tropical diseases, and is intended to be equitable. However, the extent to which treatment programmes for deworming achieve equitable coverage across wealth class and sex is unclear and the public health metric of national deworming coverage does not include representation of equity. This study aims to measure both coverage and equity in global, national, and subnational deworming to guide future programmatic evaluation, investment, and metric design. Methods: We used nationally representative, geospatial, household data from Demographic and Health Surveys that measured mother-reported deworming in children of preschool age (12–59 months). Deworming was defined as children having received drugs for intestinal parasites in the previous 6 months before the survey. We estimated deworming coverage disaggregated by geography, wealth quintile, and sex, and computed an equity index. We examined trends in coverage and equity index across countries, within countries, and over time. We used a regression model to compute the household correlates of deworming and ecological correlates of equitable deworming. Findings: Our study included 820 883 children living in 50 countries from Africa, the Americas, Asia, and Europe that are endemic for soil-transmitted helminthiasis using 77 Demographic and Health Surveys from December, 2003, to October, 2017. In these countries, the mean deworming coverage in preschool children was estimated at 33·0% (95% CI 32·9–33·1). The subnational coverage ranged from 0·5% to 87·5%, and within-country variation was greater than between-country variation. Of the 31 countries reporting that they reached the WHO goal of more than 75% national coverage, 30 had inequity in deworming, with treatment concentrated in wealthier populations. We did not detect systematic differences in deworming equity by sex. Interpretation: Substantial inequities in mass deworming programmes are common as wealthier populations have consistently higher coverage than that of the poor, including in countries reporting to have reached the WHO goal of more than 75% national coverage. These inequities seem to be geographically heterogeneous, modestly improving over time, with no evidence of sex differences in inequity. Future reporting of deworming coverage should consider disaggregation by geography, wealth, and sex with incorporation of an equity index to complement the conventional public health metric of national deworming coverage. Funding: Bill & Melinda Gates Foundation, Stanford University Medical Scientist Training Program.

Summary: Background: The Mexico City Policy, first announced by US President Ronald Reagan and since lifted and reinstated by presidents along partisan lines, prohibits US foreign assistance to any organisation that performs or provides counselling on abortion. Many organisations affected by this policy are also providers of modern contraception. If the policy reduces these organisations' ability to supply modern contraceptives, it could have the unintended consequence of increasing abortion rates. Methods: We empirically examined patterns of modern contraception use, pregnancies, and abortion among women in 26 countries in sub-Saharan Africa in response to the reinstatement and subsequent repeal of the Mexico City Policy across three presidential administrations (William Clinton, George W Bush, and Barack Obama). We combine individual-level data on pregnancies and abortions from 743 691 women, country-year data on modern contraception use, and annual data on development assistance for family planning and reproductive health in a difference-in-difference framework to examine relative changes in use of modern contraception, pregnancy, and abortion in response to the policy. Findings: We found that when the Mexico City Policy was in effect (2001–08), abortion rates rose among women in countries highly exposed to the policy by 4·8 abortions per 10 000 woman-years (95% CI 1·5 to 8·1, p=0·0041) relative to women in low-exposure countries and relative to periods when the policy was rescinded in 1995–2000 and 2009–14, a rise of approximately 40%. We found a symmetric reduction in use of modern contraception by 3·15 percentage points (relative decrease of 13·5%; 95% CI −4·9 to −1·4; p=0·0006) and increase in pregnancies by 3·2 percentage points (relative increase of 12%; 95% CI 1·6 to 4·8; p

BackgroundDespite the sharp decline in global under-5 deaths since 1990, uneven progress has been achieved across and within countries. In sub-Saharan Africa (SSA), the Millennium Development Goals (MDGs) for child mortality were met only by a few countries. Valid concerns exist as to whether the region would meet new Sustainable Development Goals (SDGs) for under-5 mortality. We therefore examine further sources of variation by assessing age patterns, trends, and forecasts of mortality rates.Methods and findingsData came from 106 nationally representative Demographic and Health Surveys (DHSs) with full birth histories from 31 SSA countries from 1990 to 2017 (a total of 524 country-years of data). We assessed the distribution of age at death through the following new demographic analyses. First, we used a direct method and full birth histories to estimate under-5 mortality rates (U5MRs) on a monthly basis. Second, we smoothed raw estimates of death rates by age and time by using a two-dimensional P-Spline approach. Third, a variant of the Lee-Carter (LC) model, designed for populations with limited data, was used to fit and forecast age profiles of mortality. We used mortality estimates from the United Nations Inter-agency Group for Child Mortality Estimation (UN IGME) to adjust, validate, and minimize the risk of bias in survival, truncation, and recall in mortality estimation. Our mortality model revealed substantive declines of death rates at every age in most countries but with notable differences in the age patterns over time. U5MRs declined from 3.3% (annual rate of reduction [ARR] 0.1%) in Lesotho to 76.4% (ARR 5.2%) in Malawi, and the pace of decline was faster on average (ARR 3.2%) than that observed for infant (IMRs) (ARR 2.7%) and neonatal (NMRs) (ARR 2.0%) mortality rates. We predict that 5 countries (Kenya, Rwanda, Senegal, Tanzania, and Uganda) are on track to achieve the under-5 sustainable development target by 2030 (25 deaths per 1,000 live births), but only Rwanda and Tanzania would meet both the neonatal (12 deaths per 1,000 live births) and under-5 targets simultaneously. Our predicted NMRs and U5MRs were in line with those estimated by the UN IGME by 2030 and 2050 (they overlapped in 27/31 countries for NMRs and 22 for U5MRs) and by the Institute for Health Metrics and Evaluation (IHME) by 2030 (26/31 and 23/31, respectively). This study has a number of limitations, including poor data quality issues that reflected bias in the report of births and deaths, preventing reliable estimates and predictions from a few countries.ConclusionsTo our knowledge, this study is the first to combine full birth histories and mortality estimates from external reliable sources to model age patterns of under-5 mortality across time in SSA. We demonstrate that countries with a rapid pace of mortality reduction (ARR ≥ 3.2%) across ages would be more likely to achieve the SDG mortality targets. However, the lower pace of neonatal mortality reduction would prevent most countries from achieving those targets: 2 countries would reach them by 2030, 13 between 2030 and 2050, and 13 after 2050.

BackgroundRising atmospheric carbon dioxide concentrations are anticipated to decrease the zinc and iron concentrations of crops. The associated disease burden and optimal mitigation strategies remain unknown. We sought to understand where and to what extent increasing carbon dioxide concentrations may increase the global burden of nutritional deficiencies through changes in crop nutrient concentrations, and the effects of potential mitigation strategies.Methods and findingsFor each of 137 countries, we incorporated estimates of climate change, crop nutrient concentrations, dietary patterns, and disease risk into a microsimulation model of zinc and iron deficiency. These estimates were obtained from the Intergovernmental Panel on Climate Change, US Department of Agriculture, Statistics Division of the Food and Agriculture Organization of the United Nations, and Global Burden of Disease Project, respectively. In the absence of increasing carbon dioxide concentrations, we estimated that zinc and iron deficiencies would induce 1,072.9 million disability-adjusted life years (DALYs) globally over the period 2015 to 2050 (95% credible interval [CrI]: 971.1-1,167.7). In the presence of increasing carbon dioxide concentrations, we estimated that decreasing zinc and iron concentrations of crops would induce an additional 125.8 million DALYs globally over the same period (95% CrI: 113.6-138.9). This carbon-dioxide-induced disease burden is projected to disproportionately affect nations in the World Health Organization's South-East Asia and African Regions (44.0 and 28.5 million DALYs, respectively), which already have high existing disease burdens from zinc and iron deficiencies (364.3 and 299.5 million DALYs, respectively), increasing global nutritional inequalities. A climate mitigation strategy such as the Paris Agreement (an international agreement to keep global temperatures within 2°C of pre-industrial levels) would be expected to avert 48.2% of this burden (95% CrI: 47.8%-48.5%), while traditional public health interventions including nutrient supplementation and disease control programs would be expected to avert 26.6% of the burden (95% CrI: 23.8%-29.6%). Of the traditional public health interventions, zinc supplementation would be expected to avert 5.5%, iron supplementation 15.7%, malaria mitigation 3.2%, pneumonia mitigation 1.6%, and diarrhea mitigation 0.5%. The primary limitations of the analysis include uncertainty regarding how food consumption patterns may change with climate, how disease mortality rates will change over time, and how crop zinc and iron concentrations will decline from those at present to those in 2050.ConclusionsEffects of increased carbon dioxide on crop nutrient concentrations are anticipated to exacerbate inequalities in zinc and iron deficiencies by 2050. Proposed Paris Agreement strategies are expected to be more effective than traditional public health measures to avert the increased inequality.

There is debate over the effectiveness of deworming children against soil-transmitted helminthiasis (STH) to improve health outcomes, and current evidence may be limited in study design and generalizability. However, programmatic deworming continues throughout low and middle-income countries.We performed an empirical evaluation of the relationship between deworming in pre-school age children (ages 1-4 years) within the previous 6 months, as proxy-reported by the mother, and health outcomes of weight, height, and hemoglobin. We used nationally representative cross-sectional data from 45 countries using the Demographic and Health Surveys (DHS) during the period 2005-2016. We used logistic regression with coarsened exact matching, fixed effects for survey and year, and person-level covariates. We included data on 325,115 children in 45 STH-endemic countries from 66 DHS surveys. Globally in STH-endemic countries, children who received deworming treatment were less likely to be stunted (1.2 percentage point decline from mean of 36%; 95% CI [-1.9, -0.5%]; p

INTRODUCTION:Early diagnosis of cutaneous melanoma is critical in preventing melanoma-associated deaths, but the role of primary care providers (PCPs) in diagnosing melanoma is underexplored. We aimed to explore the association of PCP density with melanoma incidence and mortality. METHODS:All cases of cutaneous melanoma diagnosed in the United States from 2008-2012 and reported in the Surveillance, Epidemiology, and End Results (SEER) database were analyzed in 2016. County-level primary care physician density was obtained from the Area Health Resources File (AHRF). We conducted multivariate linear regression using 1) average annual melanoma incidence or 2) average annual melanoma mortality by county as primary outcomes, adjusting for demographic confounders and dermatologist density. Cox proportional hazard regression was conducted using individual outcome data from SEER with the same covariates. RESULTS:Across 611 counties, 167,305 cases of melanoma were analyzed. Per 100,000 people, an additional 10 PCPs per county was associated with 1.62 additional cases of melanoma per year (95% CI 1.06-2.18, p

In this Perspective, Eran Bendavid discusses the broader political and health consequences of US foreign aid in light of the study by Aleksandra Jakubowski and colleagues of the President's Malaria Initiative in sub-Saharan Africa.

There are large differences in the burden and health implications of obesity by race and gender in the US. It is unclear to what extent policies modifying caloric consumption change the distribution of the burden of obesity and related health outcomes. Meat is a large component of the American diet. We investigate how changing meat prices (that may result from policies or from exogenous factors that reduce supply) might impact the burden of obesity by race and gender.We construct a microsimulation model that evaluates the 15-year body-mass index (BMI) and mortality impact of changes in meat price (5, 10, 25, and 50% increase) in the US adult population stratified by age, gender, race, and BMI.Under each price change evaluated, relative to the status quo, white males, black males, and black females are expected to realize more dramatic reduction in 2030 obesity prevalence than white females. Life expectancy gains are also projected to differ by subpopulation, with black males far less likely to benefit from an increase in meat prices than other groups.Changing meat prices has considerable potential to affect population health differently by race and gender. In designing interventions that alter the price of foods to consumers, it is not sufficient to assess health effects based solely on the population as a whole, since differential effects across subpopulations may be substantial.

Background: The post-2015 End TB Strategy proposes targets of 50% reduction in tuberculosis incidence and 75% reduction in mortality from tuberculosis by 2025. We aimed to assess whether these targets are feasible in three high-burden countries with contrasting epidemiology and previous programmatic achievements. Methods: 11 independently developed mathematical models of tuberculosis transmission projected the epidemiological impact of currently available tuberculosis interventions for prevention, diagnosis, and treatment in China, India, and South Africa. Models were calibrated with data on tuberculosis incidence and mortality in 2012. Representatives from national tuberculosis programmes and the advocacy community provided distinct country-specific intervention scenarios, which included screening for symptoms, active case finding, and preventive therapy. Findings: Aggressive scale-up of any single intervention scenario could not achieve the post-2015 End TB Strategy targets in any country. However, the models projected that, in the South Africa national tuberculosis programme scenario, a combination of continuous isoniazid preventive therapy for individuals on antiretroviral therapy, expanded facility-based screening for symptoms of tuberculosis at health centres, and improved tuberculosis care could achieve a 55% reduction in incidence (range 31–62%) and a 72% reduction in mortality (range 64–82%) compared with 2015 levels. For India, and particularly for China, full scale-up of all interventions in tuberculosis-programme performance fell short of the 2025 targets, despite preventing a cumulative 3·4 million cases. The advocacy scenarios illustrated the high impact of detecting and treating latent tuberculosis. Interpretation: Major reductions in tuberculosis burden seem possible with current interventions. However, additional interventions, adapted to country-specific tuberculosis epidemiology and health systems, are needed to reach the post-2015 End TB Strategy targets at country level. Funding: Bill and Melinda Gates Foundation

Background: The post-2015 End TB Strategy sets global targets of reducing tuberculosis incidence by 50% and mortality by 75% by 2025. We aimed to assess resource requirements and cost-effectiveness of strategies to achieve these targets in China, India, and South Africa. Methods: We examined intervention scenarios developed in consultation with country stakeholders, which scaled up existing interventions to high but feasible coverage by 2025. Nine independent modelling groups collaborated to estimate policy outcomes, and we estimated the cost of each scenario by synthesising service use estimates, empirical cost data, and expert opinion on implementation strategies. We estimated health effects (ie, disability-adjusted life-years averted) and resource implications for 2016–35, including patient-incurred costs. To assess resource requirements and cost-effectiveness, we compared scenarios with a base case representing continued current practice. Findings: Incremental tuberculosis service costs differed by scenario and country, and in some cases they more than doubled existing funding needs. In general, expansion of tuberculosis services substantially reduced patient-incurred costs and, in India and China, produced net cost savings for most interventions under a societal perspective. In all three countries, expansion of access to care produced substantial health gains. Compared with current practice and conventional cost-effectiveness thresholds, most intervention approaches seemed highly cost-effective. Interpretation: Expansion of tuberculosis services seems cost-effective for high-burden countries and could generate substantial health and economic benefits for patients, although substantial new funding would be required. Further work to determine the optimal intervention mix for each country is necessary. Funding: Bill & Melinda Gates Foundation.

A key epidemiologic feature of schistosomiasis is its focal distribution, which has important implications for the spatial targeting of preventive chemotherapy programs. We evaluated the diagnostic accuracy of a urine pooling strategy using a point-of-care circulating cathodic antigen (POC-CCA) cassette test for detection of Schistosoma mansoni, and employed simulation modeling to test the classification accuracy and efficiency of this strategy in determining where preventive chemotherapy is needed in low-endemicity settings.We performed a cross-sectional study involving 114 children aged 6-15 years in six neighborhoods in Azaguié Ahoua, south Côte d'Ivoire to characterize the sensitivity and specificity of the POC-CCA cassette test with urine samples that were tested individually and in pools of 4, 8, and 12. We used a Bayesian latent class model to estimate test characteristics for individual POC-CCA and quadruplicate Kato-Katz thick smears on stool samples. We then developed a microsimulation model and used lot quality assurance sampling to test the performance, number of tests, and total cost per school for each pooled testing strategy to predict the binary need for school-based preventive chemotherapy using a 10% prevalence threshold for treatment.The sensitivity of the urine pooling strategy for S. mansoni diagnosis using pool sizes of 4, 8, and 12 was 85.9%, 79.5%, and 65.4%, respectively, when POC-CCA trace results were considered positive, and 61.5%, 47.4%, and 30.8% when POC-CCA trace results were considered negative. The modeled specificity ranged from 94.0-97.7% for the urine pooling strategies (when POC-CCA trace results were considered negative). The urine pooling strategy, regardless of the pool size, gave comparable and often superior classification performance to stool microscopy for the same number of tests. The urine pooling strategy with a pool size of 4 reduced the number of tests and total cost compared to classical stool microscopy.This study introduces a method for rapid and efficient S. mansoni prevalence estimation through examining pooled urine samples with POC-CCA as an alternative to widely used stool microscopy.

Antiretroviral therapy (ART) reduces mortality in patients with active tuberculosis (TB), but the population-level relationship between ART coverage and TB mortality is untested. We estimated the reduction in population-level TB mortality that can be attributed to increasing ART coverage across 41 high HIV-TB burden countries.We compiled TB mortality trends between 1996 and 2011 from two sources: (1) national program-reported TB death notifications, adjusted for annual TB case detection rates, and (2) WHO TB mortality estimates. National coverage with ART, as proportion of HIV-infected people in need, was obtained from UNAIDS. We applied panel linear regressions controlling for HIV prevalence (5-year lagged), coverage of TB interventions (estimated by WHO and UNAIDS), gross domestic product per capita, health spending from domestic sources, urbanization, and country fixed effects.Models suggest that that increasing ART coverage was followed by reduced TB mortality, across multiple specifications. For death notifications at 2 to 5 years following a given ART scale-up, a 1% increase in ART coverage predicted 0.95% faster mortality rate decline (p = 0.002); resulting in 27% fewer TB deaths in 2011 alone than would have occurred without ART. Based on WHO death estimates, a 1% increase in ART predicted a 1.0% reduced TB death rate (p

Background: Foreign aid for health has increased substantially in the past two decades. However, there is limited information on the relation between the distribution of foreign aid for health and the actual burden of disease in different diseases and age groups, particularly children. We examined the association between disease-specific foreign aid for children (FACH) and burden of disease. Methods: Burden of disease data including estimates of disability adjusted life years (DALYs) were derived from the WHO Global Health Estimates resource for 2000–11. Children 0–5 years of age in sub-Saharan African countries were examined and the number of DALYs lost for the top 15 diseases calculated. Data for foreign aid were derived from the AidData dataset, which includes descriptions of all foreign aid donations. We constructed an instrument that searched the text of each description for words indicative of a certain disease, such as “malaria” or “bed-net”, and designated child or infant in the age category. Findings: Overall, the amount of FACH increased substantially during the period 1996–2009, from US$3·5 billion in 1996 to US$13·5 billion in 2009. The relation between the burden of disease and the amount of disease-specific FACH was mixed. For example, diarrhoeal diseases were responsible for 19% of DALYs lost in 2009, and were targeted with 21% of FACH. By contrast, the amount of FACH targeted towards HIV in 2009 (5·5%) was much more than the that of lost DALYs caused by HIV (23%). Pneumonia, however, was responsible for the most DALYs lost in 2009 (29%) yet received only 0·6% of all FACH. Interpretation: Our findings suggest that the relation between the distribution of foreign aid for child health and burden of disease in sub-Saharan African countries is mixed. Further work is needed to analyse present distribution patterns of foreign aid for child health and to advise future distribution Funding: None.

ObjectiveTo determine the extent to which the narrowing of child mortality across wealth gradients has been related to foreign aid to the health sector in low- and middle-income countries.MethodsMortality and wealth data on 989,901 under-5 children from 957,674 households in 49 aid recipient countries in Africa, Asia, South America, and the Caribbean between 1993 and 2012 were used in the analysis. Declines in under-5 mortality in the four poorest wealth quantiles were compared to the decline among the wealthiest at varying levels of health aid per capita using fixed effects multivariable regression models and controlling for maternal education, urbanization, and domestic spending on health among recipient countries.ResultsEach additional dollar in total health aid per capita was associated with 5.7 fewer deaths per 10,000 child-years among children in the poorest relative to the wealthiest households (pConclusionsForeign aid to the health sector is preferentially related to reductions in under-5 mortality among the poorest compared with the wealthiest. Health aid addressing malaria, which imposes a disproportionate burden among the poor, may explain the observed effect.

Multi-drug resistant tuberculosis (MDR TB) is a major health challenge in India that is gaining increasing public attention, but the implications of India's evolving MDR TB epidemic are poorly understood. As India's MDR TB epidemic is transitioning from a treatment-generated to transmission-generated epidemic, we sought to evaluate the potential effectiveness of the following two disease control strategies on reducing the prevalence of MDR TB: a) improving treatment of non-MDR TB; b) shortening the infectious period between the activation of MDR TB and initiation of effective MDR treatment.We developed a dynamic transmission microsimulation model of TB in India. The model followed individuals by age, sex, TB status, drug resistance status, and treatment status and was calibrated to Indian demographic and epidemiologic TB time trends. The main effectiveness measure was reduction in the average prevalence reduction of MDR TB over the ten years after control strategy implementation. We find that improving non-MDR cure rates to avoid generating new MDR cases will provide substantial non-MDR TB benefits but will become less effective in reducing MDR TB prevalence over time because more cases will occur from direct transmission--by 2015, the model estimates 42% of new MDR cases are transmission-generated and this proportion continues to rise over time, assuming equal transmissibility of MDR and drug-susceptible TB. Strategies that disrupt MDR transmission by shortening the time between MDR activation and treatment are projected to provide greater reductions in MDR prevalence compared with improving non-MDR treatment quality: implementing MDR diagnostic improvements in 2017 is expected to reduce MDR prevalence by 39%, compared with 11% reduction from improving non-MDR treatment quality.As transmission-generated MDR TB becomes a larger driver of the MDR TB epidemic in India, rapid and accurate MDR TB diagnosis and treatment will become increasingly effective in reducing MDR TB cases compared to non-MDR TB treatment improvements.

Recent studies suggest certain antiretroviral therapy (ART) drugs are associated with increases in cardiovascular disease.We performed a systematic review and meta-analysis to summarize the available evidence, with the goal of elucidating whether specific ART drugs are associated with an increased risk of myocardial infarction (MI).We searched Medline, Web of Science, the Cochrane Library, and abstract archives from the Conference on Retroviruses and Opportunistic Infections and International AIDS Society up to June 2011 to identify published articles and abstracts.Eligible studies were comparative and included MI, strokes, or other cardiovascular events as outcomes.Eligibility screening, data extraction, and quality assessment were performed independently by two investigators.Random effects methods and Fisher's combined probability test were used to summarize evidence.Twenty-seven studies met inclusion criteria, with 8 contributing to a formal meta-analysis. Findings based on two observational studies indicated an increase in risk of MI for patients recently exposed (usually defined as within last 6 months) to abacavir (RR 1.92, 95% CI 1.51-2.42) and protease inhibitors (PI) (RR 2.13, 95% CI 1.06-4.28). Our analysis also suggested an increased risk associated with each additional year of exposure to indinavir (RR 1.11, 95% CI 1.05-1.17) and lopinavir (RR 1.22, 95% CI 1.01-1.47). Our findings of increased cardiovascular risk from abacavir and PIs were in contrast to four published meta-analyses based on secondary analyses of randomized controlled trials, which found no increased risk from cardiovascular disease.Although observational studies implicated specific drugs, the evidence is mixed. Further, meta-analyses of randomized trials did not find increased risk from abacavir and PIs. Our findings that implicate specific ARTs in the observational setting provide sufficient evidence to warrant further investigation of this relationship in studies designed for that purpose.

ObjectiveTo estimate the cost, effectiveness, and cost effectiveness of HIV and HCV screening of injection drug users (IDUs) in opioid replacement therapy (ORT).DesignDynamic compartmental model of HIV and HCV in a population of IDUs and non-IDUs for a representative U.S. urban center with 2.5 million adults (age 15-59).MethodsWe considered strategies of screening individuals in ORT for HIV, HCV, or both infections by antibody or antibody and viral RNA testing. We evaluated one-time and repeat screening at intervals from annually to once every 3 months. We calculated the number of HIV and HCV infections, quality-adjusted life years (QALYs), costs, and incremental cost-effectiveness ratios (ICERs).ResultsAdding HIV and HCV viral RNA testing to antibody testing averts 14.8-30.3 HIV and 3.7-7.7 HCV infections in a screened population of 26,100 IDUs entering ORT over 20 years, depending on screening frequency. Screening for HIV antibodies every 6 months costs $30,700/QALY gained. Screening for HIV antibodies and viral RNA every 6 months has an ICER of $65,900/QALY gained. Strategies including HCV testing have ICERs exceeding $100,000/QALY gained unless awareness of HCV-infection status results in a substantial reduction in needle-sharing behavior.DiscussionAlthough annual screening for antibodies to HIV and HCV is modestly cost effective compared to no screening, more frequent screening for HIV provides additional benefit at less cost. Screening individuals in ORT every 3-6 months for HIV infection using both antibody and viral RNA technologies and initiating ART for acute HIV infection appears cost effective.

Many mathematical models have investigated the impact of expanding access to antiretroviral therapy (ART) on new HIV infections. Comparing results and conclusions across models is challenging because models have addressed slightly different questions and have reported different outcome metrics. This study compares the predictions of several mathematical models simulating the same ART intervention programmes to determine the extent to which models agree about the epidemiological impact of expanded ART.Twelve independent mathematical models evaluated a set of standardised ART intervention scenarios in South Africa and reported a common set of outputs. Intervention scenarios systematically varied the CD4 count threshold for treatment eligibility, access to treatment, and programme retention. For a scenario in which 80% of HIV-infected individuals start treatment on average 1 y after their CD4 count drops below 350 cells/µl and 85% remain on treatment after 3 y, the models projected that HIV incidence would be 35% to 54% lower 8 y after the introduction of ART, compared to a counterfactual scenario in which there is no ART. More variation existed in the estimated long-term (38 y) reductions in incidence. The impact of optimistic interventions including immediate ART initiation varied widely across models, maintaining substantial uncertainty about the theoretical prospect for elimination of HIV from the population using ART alone over the next four decades. The number of person-years of ART per infection averted over 8 y ranged between 5.8 and 18.7. Considering the actual scale-up of ART in South Africa, seven models estimated that current HIV incidence is 17% to 32% lower than it would have been in the absence of ART. Differences between model assumptions about CD4 decline and HIV transmissibility over the course of infection explained only a modest amount of the variation in model results.Mathematical models evaluating the impact of ART vary substantially in structure, complexity, and parameter choices, but all suggest that ART, at high levels of access and with high adherence, has the potential to substantially reduce new HIV infections. There was broad agreement regarding the short-term epidemiologic impact of ambitious treatment scale-up, but more variation in longer term projections and in the efficiency with which treatment can reduce new infections. Differences between model predictions could not be explained by differences in model structure or parameterization that were hypothesized to affect intervention impact.

OBJECTIVE: To determine whether the Mexico City Policy, a United States government policy that prohibits funding to nongovernmental organizations performing or promoting abortion, was associated with the induced abortion rate in sub-Saharan Africa. METHODS: Women in 20 African countries who had induced abortions between 1994 and 2008 were identified in Demographic and Health Surveys. A country's exposure to the Mexico City Policy was considered high (or low) if its per capita assistance from the United States for family planning and reproductive health was above (or below) the median among study countries before the policy's reinstatement in 2001. Using logistic regression and a difference-in-difference design, the authors estimated the differential change in the odds of having an induced abortion among women in high exposure countries relative to low exposure countries when the policy was reinstated. FINDINGS: The study included 261 116 women aged 15 to 44 years. A comparison of 1994-2000 with 2001-2008 revealed an adjusted odds ratio for induced abortion of 2.55 for high-exposure countries versus low-exposure countries under the policy (95% confidence interval, CI: 1.76-3.71). There was a relative decline in the use of modern contraceptives in the high-exposure countries over the same time period. CONCLUSION: The induced abortion rate in sub-Saharan Africa rose in high-exposure countries relative to low-exposure countries when the Mexico City Policy was reintroduced. Reduced financial support for family planning may have led women to substitute abortion for contraception. Regardless of one's views about abortion, the findings may have important implications for public policies governing abortion.

Survival to old ages is increasing in many African countries. While demographic tools for estimating mortality up to age 60 have improved greatly, mortality patterns above age 60 rely on models based on little or no demographic data. These estimates are important for social planning and demographic projections. We provide direct estimations of older-age mortality using survey data.Since 2005, nationally representative household surveys in ten sub-Saharan countries record counts of living and recently deceased household members: Burkina Faso, Côte d'Ivoire, Ethiopia, Namibia, Nigeria, Swaziland, Tanzania, Uganda, Zambia, and Zimbabwe. After accounting for age heaping using multiple imputation, we use this information to estimate probability of death in 5-year intervals ((5)q(x)). We then compare our (5)q(x) estimates to those provided by the World Health Organization (WHO) and the United Nations Population Division (UNPD) to estimate the differences in mortality estimates, especially among individuals older than 60 years old.We obtained information on 505,827 individuals (18.4% over age 60, 1.64% deceased). WHO and UNPD mortality models match our estimates closely up to age 60 (mean difference in probability of death -1.1%). However, mortality probabilities above age 60 are lower using our estimations than either WHO or UNPD. The mean difference between our sample and the WHO is 5.9% (95% CI 3.8-7.9%) and between our sample is UNPD is 13.5% (95% CI 11.6-15.5%). Regardless of the comparator, the difference in mortality estimations rises monotonically above age 60.Mortality estimations above age 60 in ten African countries exhibit large variations depending on the method of estimation. The observed patterns suggest the possibility that survival in some African countries among adults older than age 60 is better than previously thought. Improving the quality and coverage of vital information in developing countries will become increasingly important with future reductions in mortality.