Auditing causality of the multiple-burden of malnutrition in India and South Africa: A critical need for directions

Developing economies are shaped by the current predicament of urbanization and its impact on health is inevitable. In the post-pandemic times, India and South Africa witnessed a GDP growth rate of about 1.7% and 1.9% respectively, while the developed economies like Europe and the United States have bounced back with more than 2% GDP. The similarities and differences between India and South Africa provide potential candidates to study nutrition transition with the elements of urbanization. In both countries increased access to convenience foods is a consequence of the rapid expansion of small and medium enterprises (SMEs), open international markets, and expanding food supply chains. Also, there has been significant acculturation and people have moved away from traditional diets in these two countries. A spate of similar changes in the food environment is a telling sign of serious ill-health consequences in both countries. Generating evidence on causality is fundamental to informing policy. India and South Africa qualify as potential candidates to study the multiple burdens of malnutrition. Collaborating with different disciplines such as data sciences, and capacitating analytic skills is key to progress in this direction

Antimicrobial resistance among migrants in Europe: a systematic review and meta-analysis

BACKGROUND: Rates of antimicrobial resistance (AMR) are rising globally and there is concern that increased migration is contributing to the burden of antibiotic resistance in Europe. However, the effect of migration on the burden of AMR in Europe has not yet been comprehensively examined. Therefore, we did a systematic review and meta-analysis to identify and synthesise data for AMR carriage or infection in migrants to Europe to examine differences in patterns of AMR across migrant groups and in different settings. METHODS: For this systematic review and meta-analysis, we searched MEDLINE, Embase, PubMed, and Scopus with no language restrictions from Jan 1, 2000, to Jan 18, 2017, for primary data from observational studies reporting antibacterial resistance in common bacterial pathogens among migrants to 21 European Union-15 and European Economic Area countries. To be eligible for inclusion, studies had to report data on carriage or infection with laboratory-confirmed antibiotic-resistant organisms in migrant populations. We extracted data from eligible studies and assessed quality using piloted, standardised forms. We did not examine drug resistance in tuberculosis and excluded articles solely reporting on this parameter. We also excluded articles in which migrant status was determined by ethnicity, country of birth of participants' parents, or was not defined, and articles in which data were not disaggregated by migrant status. Outcomes were carriage of or infection with antibiotic-resistant organisms. We used random-effects models to calculate the pooled prevalence of each outcome. The study protocol is registered with PROSPERO, number CRD42016043681. FINDINGS: We identified 2274 articles, of which 23 observational studies reporting on antibiotic resistance in 2319 migrants were included. The pooled prevalence of any AMR carriage or AMR infection in migrants was 25·4% (95% CI 19·1-31·8; I2 =98%), including meticillin-resistant Staphylococcus aureus (7·8%, 4·8-10·7; I2 =92%) and antibiotic-resistant Gram-negative bacteria (27·2%, 17·6-36·8; I2 =94%). The pooled prevalence of any AMR carriage or infection was higher in refugees and asylum seekers (33·0%, 18·3-47·6; I2 =98%) than in other migrant groups (6·6%, 1·8-11·3; I2 =92%). The pooled prevalence of antibiotic-resistant organisms was slightly higher in high-migrant community settings (33·1%, 11·1-55·1; I2 =96%) than in migrants in hospitals (24·3%, 16·1-32·6; I2 =98%). We did not find evidence of high rates of transmission of AMR from migrant to host populations. INTERPRETATION: Migrants are exposed to conditions favouring the emergence of drug resistance during transit and in host countries in Europe. Increased antibiotic resistance among refugees and asylum seekers and in high-migrant community settings (such as refugee camps and detention facilities) highlights the need for improved living conditions, access to health care, and initiatives to facilitate detection of and appropriate high-quality treatment for antibiotic-resistant infections during transit and in host countries. Protocols for the prevention and control of infection and for antibiotic surveillance need to be integrated in all aspects of health care, which should be accessible for all migrant groups, and should target determinants of AMR before, during, and after migration. FUNDING: UK National Institute for Health Research Imperial Biomedical Research Centre, Imperial College Healthcare Charity, the Wellcome Trust, and UK National Institute for Health Research Health Protection Research Unit in Healthcare-associated Infections and Antimictobial Resistance at Imperial College London

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

Background: Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. Methods: This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. Findings: Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p < 0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p < 0·001). Interpretation: Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication

Determinants of early initiation of breastfeeding in The Gambia: a population-based study using the 2019–2020 demographic and health survey data

Abstract Background Early initiation of breastfeeding within the first hour of life prevents neonatal and infant mortality. Sustainable Development Goals (SDGs) Target 3.2 aims to reduce neonatal mortality and under 5 mortality globally. The decline in the early initiation of breastfeeding in The Gambia coincides with deviations from the SDGs, due to poor indicators of child survival. Our work studied the determinants of early initiation of breastfeeding in The Gambia. Methods We used the 2019–2020 Gambia Demographic Health Survey (GDHS) conducted across all regions of the country. Since our population of interest was children born two years preceding the study, we only included children less than 24 months of age, living with an eligible respondent. Thus, a weighted sample of 5691 mother-child pairs was applied in the analysis. We reported summary statistics of individuals’ sociodemographic, obstetrics and antenatal, household, and community-level factors. A logistic regression model was used to determine associations between early initiation of breastfeeding and covariates. Results The prevalence of early initiation of breastfeeding was 64.3% (n = 3659). Mothers who had secondary education or higher educational level had higher odds of early initiation of breastfeeding (AOR 1.22; 95% CI 1.07, 1.40). Regions with rural population notably Lower and Central and Upper River Region had lower odds of early initiation of breastfeeding [Mansakonko (AOR 0.37; 95% CI 0.26, 0.15), Kerewan (AOR 0.26; 95% CI 0.19, 0.36), Kuntaur (AOR 0.39; 95% CI 0.28, 0.54), Janjanbureh (AOR 0.48; 95% CI 0.35, 0.66) and Basse (AOR 0.64; 95%CI 0.49, 0.85)]. Also, women in the high quintile of the wealth index were more likely to initiate breastfeeding early (AOR 1.29; 95% CI 1.06, 1.57). Four or more antenatal care visits did not increase early initiation of breastfeeding. Conclusions The results of the analyses demand affirmative action to improve maternal education, reduce poverty and inequality and empower rural communities in The Gambia. The IYCF component in antenatal care needs to be strengthened. Programs and policies on IYCF must resonate to address determinants of timely breastfeeding initiation to chart progress towards the SDG

Determinants of complementary feeding practices among children aged 6–24 months in urban slums of Pune, Maharashtra, in India

Abstract Background Inequalities in child feeding practices are evident in urban slums in developing nations. Our study identified the determinants of complementary feeding (CF) practices in the informal settings of Pune, India, a district close to the business capital of India. Methods Employing a cross-sectional study design, 1066 mother–children dyads were surveyed. Five indicators defined by the WHO were used to study complementary feeding practices. Determinants of complementary feeding practices were identified using multivariate analyses. Results Timely initiation of CF was reported by 42%. Minimum acceptable diet (MAD), minimum meal frequency (MMF), and Diet Diversity Score > 4 were achieved by 14.9%, 76.5%, and 16.4%, respectively. Continued breastfeeding (CBF) at 2 years, and feeding processed foods were practiced by 94% and 50%, respectively. Among the maternal characteristics, a mother’s age > 30 years at pregnancy was less likely to achieve DD [AOR: 0.195 (CI 0.047–0.809)] and MAD [AOR: 0.231 (CI 0.056–0.960)]. Mothers with lower education were less likely to meet MMF [AOR: 0.302 (0.113–0.807)], MAD [AOR: 0.505 (CI 0.295–0.867)] and to introduce formula feeds (FF) [AOR: 0.417 (0.193- 0.899)]. Among obstetric characteristics, birth spacing < 33 months was less likely to achieve DD [AOR: 0.594 (CI 0.365–0.965)] and CBF [AOR: 0.562 (CI: 0.322–0.982)]. Receiving IYCF counseling only during postnatal care hindered the timely initiation of CF [AOR: 0.638 (0.415–0.981)]. Very Low Birth Weight increased the odds of achieving DD [AOR: 2.384 (1.007–5.644)] and MAD [AOR: 2.588(CI: 1.054–6.352)], while low birth weight increased the odds of children being introduced to processed foods [AOR: 1.370 (CI: 1.056–1.776)]. Concerning socio-economic status, being above the poverty line increased the odds of achieving MMF, [AOR: 1.851 (1.005–3.407)]. Other backward castes showed higher odds of achieving MAD [AOR: 2.191 (1.208–3.973)] and undisclosed caste in our study setting decreased the odds of FF [AOR: 0.339 (0.170–0.677)]. Bottle feeding interfered with MMF [AOR: 0.440 (0.317–0.611)] and CBF [AOR: 0.153 (0.105–0.224)]. Conclusion Investing in maternal education and IYCF counseling during both ANC and PNC to provide nutritious complementary foods alongside addressing poverty should be a national priority to prevent the double burden of undernutrition at an early age in informal settings

Surgical site infection after gastrointestinal surgery in children : an international, multicentre, prospective cohort study

Introduction Surgical site infection (SSI) is one of the most common healthcare-associated infections (HAIs). However, there is a lack of data available about SSI in children worldwide, especially from low-income and middle-income countries. This study aimed to estimate the incidence of SSI in children and associations between SSI and morbidity across human development settings. Methods A multicentre, international, prospective, validated cohort study of children aged under 16 years undergoing clean-contaminated, contaminated or dirty gastrointestinal surgery. Any hospital in the world providing paediatric surgery was eligible to contribute data between January and July 2016. The primary outcome was the incidence of SSI by 30 days. Relationships between explanatory variables and SSI were examined using multilevel logistic regression. Countries were stratified into high development, middle development and low development groups using the United Nations Human Development Index (HDI). Results Of 1159 children across 181 hospitals in 51 countries, 523 (45 center dot 1%) children were from high HDI, 397 (34 center dot 2%) from middle HDI and 239 (20 center dot 6%) from low HDI countries. The 30-day SSI rate was 6.3% (33/523) in high HDI, 12 center dot 8% (51/397) in middle HDI and 24 center dot 7% (59/239) in low HDI countries. SSI was associated with higher incidence of 30-day mortality, intervention, organ-space infection and other HAIs, with the highest rates seen in low HDI countries. Median length of stay in patients who had an SSI was longer (7.0 days), compared with 3.0 days in patients who did not have an SSI. Use of laparoscopy was associated with significantly lower SSI rates, even after accounting for HDI. Conclusion The odds of SSI in children is nearly four times greater in low HDI compared with high HDI countries. Policies to reduce SSI should be prioritised as part of the wider global agenda.Peer reviewe

Prevalence, years lived with disability, and trends in anaemia burden by severity and cause, 1990–2021: findings from the Global Burden of Disease Study 2021

Background: Anaemia is a major health problem worldwide. Global estimates of anaemia burden are crucial for developing appropriate interventions to meet current international targets for disease mitigation. We describe the prevalence, years lived with disability, and trends of anaemia and its underlying causes in 204 countries and territories. Methods: We estimated population-level distributions of haemoglobin concentration by age and sex for each location from 1990 to 2021. We then calculated anaemia burden by severity and associated years lived with disability (YLDs). With data on prevalence of the causes of anaemia and associated cause-specific shifts in haemoglobin concentrations, we modelled the proportion of anaemia attributed to 37 underlying causes for all locations, years, and demographics in the Global Burden of Disease Study 2021. Findings: In 2021, the global prevalence of anaemia across all ages was 24·3% (95% uncertainty interval [UI] 23·9–24·7), corresponding to 1·92 billion (1·89–1·95) prevalent cases, compared with a prevalence of 28·2% (27·8–28·5) and 1·50 billion (1·48–1·52) prevalent cases in 1990. Large variations were observed in anaemia burden by age, sex, and geography, with children younger than 5 years, women, and countries in sub-Saharan Africa and south Asia being particularly affected. Anaemia caused 52·0 million (35·1–75·1) YLDs in 2021, and the YLD rate due to anaemia declined with increasing Socio-demographic Index. The most common causes of anaemia YLDs in 2021 were dietary iron deficiency (cause-specific anaemia YLD rate per 100 000 population: 422·4 [95% UI 286·1–612·9]), haemoglobinopathies and haemolytic anaemias (89·0 [58·2–123·7]), and other neglected tropical diseases (36·3 [24·4–52·8]), collectively accounting for 84·7% (84·1–85·2) of anaemia YLDs. Interpretation: Anaemia remains a substantial global health challenge, with persistent disparities according to age, sex, and geography. Estimates of cause-specific anaemia burden can be used to design locally relevant health interventions aimed at improving anaemia management and prevention. Funding: Bill & Melinda Gates Foundation