Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Background: Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. // Methods: We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung's disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. // Findings: We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung's disease) from 264 hospitals (89 in high-income countries, 166 in middle-income countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in low-income countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. // Interpretation: Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between low-income, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030

The burden of bacterial antimicrobial resistance in the WHO African region in 2019: a cross-country systematic analysis

Background A critical and persistent challenge to global health and modern health care is the threat of antimicrobial resistance (AMR). Previous studies have reported a disproportionate burden of AMR in low-income and middle-income countries, but there remains an urgent need for more in-depth analyses across Africa. This study presents one of the most comprehensive sets of regional and country-level estimates of bacterial AMR burden in the WHO African region to date. Methods We estimated deaths and disability-adjusted life-years (DALYs) attributable to and associated with AMR for 23 bacterial pathogens and 88 pathogen–drug combinations for countries in the WHO African region in 2019. Our methodological approach consisted of five broad components: the number of deaths in which infection had a role, the proportion of infectious deaths attributable to a given infectious syndrome, the proportion of infectious syndrome deaths attributable to a given pathogen, the percentage of a given pathogen resistant to an antimicrobial drug of interest, and the excess risk of mortality (or duration of an infection) associated with this resistance. These components were then used to estimate the disease burden by using two counterfactual scenarios: deaths attributable to AMR (considering an alternative scenario where infections with resistant pathogens are replaced with susceptible ones) and deaths associated with AMR (considering an alternative scenario where drug-resistant infections would not occur at all). We obtained data from research hospitals, surveillance networks, and infection databases maintained by private laboratories and medical technology companies. We generated 95% uncertainty intervals (UIs) for final estimates as the 25th and 975th ordered values across 1000 posterior draws, and models were cross-validated for out-of-sample predictive validity. Findings In the WHO African region in 2019, there were an estimated 1·05 million deaths (95% UI 829 000–1 316 000) associated with bacterial AMR and 250 000 deaths (192 000–325 000) attributable to bacterial AMR. The largest fatal AMR burden was attributed to lower respiratory and thorax infections (119 000 deaths [92 000–151 000], or 48% of all estimated bacterial pathogen AMR deaths), bloodstream infections (56 000 deaths [37 000–82 000], or 22%), intra-abdominal infections (26 000 deaths [17 000–39 000], or 10%), and tuberculosis (18 000 deaths [3850–39 000], or 7%). Seven leading pathogens were collectively responsible for 821 000 deaths (636 000–1 051 000) associated with resistance in this region, with four pathogens exceeding 100 000 deaths each: Streptococcus pneumoniae, Klebsiella pneumoniae, Escherichia coli, and Staphylococcus aureus. Third-generation cephalosporin-resistant K pneumoniae and meticillin-resistant S aureus were shown to be the leading pathogen–drug combinations in 25 and 16 countries, respectively (53% and 34% of the whole region, comprising 47 countries) for deaths attributable to AMR. Interpretation This study reveals a high level of AMR burden for several bacterial pathogens and pathogen–drug combinations in the WHO African region. The high mortality rates associated with these pathogens demonstrate an urgent need to address the burden of AMR in Africa. These estimates also show that quality and access to health care and safe water and sanitation are correlated with AMR mortality, with a higher fatal burden found in lower resource settings. Our cross-country analyses within this region can help local governments to leverage domestic and global funding to create stewardship policies that target the leading pathogen–drug combinations. Funding Bill & Melinda Gates Foundation, Wellcome Trust, and Department of Health and Social Care using UK aid funding managed by the Fleming Fund

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Summary Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. Methods We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung’s disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. Findings We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung’s disease) from 264 hospitals (89 in high-income countries, 166 in middleincome countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in lowincome countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. Interpretation Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between lowincome, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030

Livelihoods from predators: Shark fisheries in Eastern Indonesia

Remote rural fishing communities in Eastern Indonesia are in danger of suffering livelihood loss as a result of declining marine resources and increasing social and economic pressures, but also through management decisions which are often based solely on biological data and do not take into account the needs of local fishers. We present preliminary data from an interdisciplinary investigation of East Indonesian shark fisheries and their significance to fishing communities. Using methodologies from the natural and social sciences, we aim to identify options for shark management in the Arafura, Halmahera and Seram Seas, where shark fisheries are presumably extensive but remain largely unregulated and unreported. Through DNA barcoding of dried fin samples and by engaging shark fishers in the collection of biological data from captured sharks, we obtain vital baseline data on shark populations in fishing grounds around Halmahera in Northern Maluku and Raja Ampat, a shark and ray sanctuary in West Papua Province. Through participant observation, focus group discussions and semi-structured interviews we assess ecosystem awareness, shark fishing traditions, local knowledge and livelihood requirements in three fishing communities exploiting those fishing grounds. This study identifies the challenges of shark management in Eastern Indonesia, where current conservation initiatives threaten to displace fishing effort and negatively impact on the livelihood security of remote fishing communities. We address the contribution of this interdisciplinary, longitudinal approach to shark management in light of the biological, economic and social factors affecting a fishery that provides an important source of income but is increasingly contested globally

What’s the catch? Shark fisheries in Eastern Indonesia

Indonesia has the world’s largest shark fishery, but very little locally relevant information is available on catch statistics or life history characteristics of targeted species. This poses major challenges for fisheries management and shark conservation in the region, particularly in the more remote coastal communities of Eastern Indonesia. Shark fishers from three coastal communities were interviewed and trained in data collection in their fishing grounds in the Seram, Aru-Arafura and Timor Seas. Of the over 30 species recorded by the fishers, we assessed ten species based on criteria including proportion of total catch, high intrinsic vulnerability to fishing pressure, and market and conservation value. Using a combination of fishers’ data and published life history characteristics, we estimated the intrinsic rate of population growth to evaluate the relative vulnerability of each species, and compared the observed size structure with established fisheries reference points. The interviews revealed that the fishers generally perceived sharks in their fishing grounds to be declining in numbers and size. Our study found that the fishery is catching several high risk species, such as hammerheads and guitarfish, with catches predominantly comprised of immature individuals and a high level of fishing mortality. Involving fishers in data collection and interpretation provided data and information in regions with low management and research capacity. Additionally, close collaboration with the fishers provided fundamental insights into the circumstances that shape fishers’ decision-making and the ecological and socio-economic requirements that must be addressed for management initiatives to be effective

Arresting shark declines: who’s being killed (and where)?

Shark populations have experienced a dramatic worldwide decline due to overfishing, largely because they are targeted for their highly priced fins. Indonesia is the world’s highest harvester of shark fins, and the Arafura Sea particularly is a region of intensive shark fishing activity. Recent population genetic studies found high connectivity among Indonesian and Australian shark populations. Furthermore, Indonesian fishermen often venture into protected areas within Australian waters. This has resulted in conflicts over shared marine resources. Little is known about catch composition of the Indonesian shark fisheries, particularly in the Arafura Sea, and whether sharks are systematically poached in Australian waters. During my PhD I am planning to address these knowledge gaps by: -Determining the catch composition of Indonesian shark fisheries in the Arafura Sea. This will be achieved by DNA barcoding samples of dried shark fins collected from GPS tracked fishing vessels, as well as local fish markets. - Investigating fine-scale population genetic structure in Western Australia, Northern Australia and Indonesia for one of the main coral-reef associated target species: the grey reef shark (C. amblyrhynchos), identifying possible conflicts among the two nations over shared marine resources. - Determining provenance (region, country) of grey reef shark fins sold in local Indonesian fish markets via genetic assignment tests, providing insight as to whether poaching in Australian waters is a common practice. This project will increase our knowledge of these ecological important apex predators, and further develop the application of molecular genetics to monitor fin trade

Sub-surface behaviour of bottlenose dolphins (Tursiops truncatus) interacting with fish trawl nets in north-western Australia

Most studies on the interactions between dolphins and trawl fisheries have focused on the opportunistic feeding of dolphins on discards at the surface. Little is known about sub-surface associations between dolphins and actively fishing trawl nets. Using underwater video footage recorded inside trawl nets, we evaluated behavioural aspects of interactions between common bottlenose dolphins (Tursiops truncatus) and trawl nets in the Pilbara trawl fishery. The interaction rates were very high; in 85 hours of footage collected from 36 trawls, dolphins were recorded inside trawl nets during 29 (81%) trawls and outside trawl nets in 34 (94%) trawls, and for up to 98% and 99% of the trawl duration, respectively. The proportion of foraging behaviours was significantly higher for dolphins inside the net (54%) than those outside the net (31%), indicating that dolphins were presented with a concentrated food source inside the net. Dolphins observed outside the net spent time ‘trampolining’ and socialising, indicating that they were motivated by several factors to approach and interact with trawl nets. Twenty-nine individuals were identified inside the net, some returning to the net numerous times within each trawl and between different trawls and fishing trips. Our results suggest that these dolphins are highly motivated to interact with trawl nets and that entering nets may be a specialised behaviour exhibited only by a subset of trawler-associated dolphins. We conclude that gear modifications, not spatial or temporal adjustments to fishing effort, have the greatest potential to reduce dolphin bycatch in this fishery

Incidental dolphin capture in a Western Australian trawl fishery: Bycatch reduction devices no silver bullet

An estimated 350 dolphins were incidentally caught between late 2003 and 2009 in the Pilbara trawl fishery, north-western Australia. Data from skipper logbooks and independent observers were used to assess spatial and temporal patterns of dolphin bycatch in this fishery. Both datasets indicated that dolphins were caught throughout all four of the fishery management areas (total area ca. 13,000 km2), across all depths, and all year-round. However, based on a smaller number of trawls, independent observer records better explained the variation in dolphin bycatch than did the skipper logbooks. The most significant predictors of dolphin bycatch were: (1) which vessel was fishing, with one of the four vessels catching the greatest proportion of dolphins; (2) the time of day of fishing activity (corrected for effort, the lowest dolphin capture rate occurred between 00:00 and 05:59 when the least fishing occurred); and (3) whether nets included bycatch reduction devices (BRDs) (there was a 50% reduction in dolphin bycatch after the introduction of BRDs). Nevertheless, concurrent research using underwater video footage collected within actively fishing trawl nets indicated that BRDs with bottom-opening escape hatches lead to the under-estimation of bycatch as some dead dolphins fall out during the trawl and are thus not recorded on deck. These results suggest that spatial or seasonal adjustments to trawling effort, other than an overall reduction in fishing across the fishery, would be unlikely to reduce dolphin bycatch rates. Trials of BRDs with top-opening escape hatches, from which air-breathing megafauna might escape, have been recommended, with both observers and underwater video camera deployments to validate the design’s efficacy. The vulnerability of this dolphin population to the current level of trawling remains unknown without information on dolphin abundance and the genetic connectivity of this population with adjacent populations

Incidental dolphin capture and bycatch mitigation in a Western Australian trawl fishery

The incidental capture of common bottlenose dolphins (Tursiops truncatus) is an ongoing protected species management problem in the Pilbara Fish Trawl Interim Managed Fishery, Western Australia. We investigated this issue using four approaches: the analysis of skippers’ logbook and independent observer data on bycatch; underwater video of dolphins interacting with trawl gear; genetic methods to estimate population structure and connectivity; and a photo-identification study to estimate trawler-associated dolphin community size. Logbooks and observer records were used to assess dolphin bycatch patterns from 2003 to 2009. During this six year period, between 172 and 366 dolphins were reported caught across all management areas, depths and seasons. Dolphin capture rates reported by independent observers varied between 1.6 and 3.8 times higher than those reported by skippers, with observer records also better explaining the variation in dolphin bycatch. Significant predictors of dolphin bycatch were fishing vessels; time of day; and whether nets included bycatch reduction devices. Underwater video footage taken inside trawl nets indicated that even the observer records underestimated bycatch, as some dead dolphins fell out of bottom-opening escape hatches during trawls and were not landed on deck. Genetic evidence suggested one panmictic population, but no connectivity between trawler-associated and adjacent coastal dolphins. Mark-recapture analysis of photoidentified dolphins around one of three trawlers over two oneweek fishing trips yielded a global mean estimate (± 1 SE) of just 183 ± 11 dolphins. These data indicate that a relatively small dolphin community shows fidelity to foraging around trawlers over periods ranging from weeks to years. Potentially, an overall reduction in fishing effort and improved bycatch reduction devices (with top-opening escape hatches from which air-breathing animals might escape) would reduce bycatch. The vulnerability of this dolphin population to depletion from the current and ongoing level of trawling is likely, but currently remains unknown