Sources of variation in under-5 mortality across sub-Saharan Africa: a spatial analysis

Background Detailed spatial understanding of levels and trends in under-5 mortality is needed to improve the targeting of interventions to the areas of highest need, and to understand the sources of variation in mortality. To improve this understanding, we analysed local-level information on child mortality across sub-Saharan Africa between 1980–2010. Methods We used data from 82 Demographic and Health Surveys in 28 sub-Saharan African countries, including the location and timing of 3·24 million childbirths and 393 685 deaths, to develop high-resolution spatial maps of under-5 mortality in the 1980s, 1990s, and 2000s. These estimates were at a resolution of 0·1 degree latitude by 0·1 degree longitude (roughly 10 km × 10 km). We then analysed this spatial information to distinguish within-country versus between-country sources of variation in mortality, to examine the extent to which declines in mortality have been accompanied by convergence in the distribution of mortality, and to study localised drivers of mortality diff erences, including temperature, malaria burden, and confl ict. Findings In our sample of sub-Saharan African countries from the 1980s to the 2000s, within-country diff erences in under-5 mortality accounted for 74–78% of overall variation in under-5 mortality across space and over time. Mortality diff ered signifi cantly across only 8–15% of country borders, supporting the role of local, rather than national, factors in driving mortality patterns. We found that by the end of the study period, 23% of the eligible children in the study countries continue to live in mortality hotspots—areas where, if current trends continue, the Sustainable Developent Goals mortality targets will not be met. In multivariate analysis, within-country mortality levels at each pixel were signifi cantly related to local temperature, malaria burden, and recent history of confl ict. Interpretation Our fi ndings suggest that sub-national determinants explain a greater portion of under-5 mortality than do country-level characteristics. Sub-national measures of child mortality could provide a more accurate, and potentially more actionable, portrayal of where and why children are still dying than can national statistics

Comparative Analysis of Old-Age Mortality Estimations in Africa

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

AIDS and declining support for dependent elderly people in Africa: retrospective analysis using demographic and health surveys

Objectives To determine the relation between the HIV/AIDS epidemic and support for dependent elderly people in Africa

The relation of price of antiretroviral drugs and foreign assistance with coverage of HIV treatment in Africa: retrospective study

Objective To determine the association of reductions in price of antiretroviral drugs and foreign assistance for HIV with coverage of antiretroviral treatment

Mortality along the continuum of HIV care in Rwanda: a model-based analysis

HIV is the leading cause of death among adults in sub-Saharan Africa. However, mortality along the HIV care continuum is poorly described. We combine demographic, epidemiologic, and health services data to estimate where are people with HIV dying along Rwanda's care continuum.; We calibrated an age-structured HIV disease and transmission stochastic simulation model to the epidemic in Rwanda. We estimate mortality among HIV-infected individuals in the following states: untested, tested without establishing care in an antiretroviral therapy (ART) program (unlinked), in care before initiating ART (pre-ART), lost to follow-up (LTFU) following ART initiation, and retained in active ART care. We estimated mortality among people living with HIV in Rwanda through 2025 under current conditions, and with improvements to the HIV care continuum.; In 2014, the greatest portion of deaths occurred among those untested (35.4%), followed by those on ART (34.1%), reflecting the large increase in the population on ART. Deaths among those LTFU made up 11.8% of all deaths among HIV-infected individuals in 2014, and in the base case this portion increased to 18.8% in 2025, while the contribution to mortality declined among those untested, unlinked, and in pre-ART. In our model only combined improvements to multiple aspects of the HIV care continuum were projected to reduce the total number of deaths among those with HIV, estimated at 8177 in 2014, rising to 10,659 in the base case, and declining to 5,691 with combined improvements in 2025.; Mortality among those untested for HIV contributes a declining portion of deaths among HIV-infected individuals in Rwanda, but the portion of deaths among those LTFU is expected to increase the most over the next decade. Combined improvements to the HIV care continuum might be needed to reduce the number of deaths among those with HIV

Evaluation of a urine pooling strategy for the rapid and cost-efficient prevalence classification of schistosomiasis

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

Women and children living in areas of armed conflict in Africa: a geospatial analysis of mortality and orphanhood

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 (19286387 person-years), of which 103011 (6·3%) died (534·1 deaths per 100000 women-years), and 2 354 041 children younger than 15 years, of which 204276 (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 highintensity 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

State of deworming coverage and equity in low-income and middle-income countries using household health surveys: a spatiotemporal cross-sectional study

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.; 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.; 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.; 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.; Bill & Melinda Gates Foundation, Stanford University Medical Scientist Training Program