Emily Mosites

Technologies for Detecting Falsified and Substandard Drugs in Low and Middle-Income Countries

Falsified and substandard drugs are a global health problem, particularly in low- and middle-income countries (LMIC) that have weak pharmacovigilance and drug regulatory systems. Poor quality medicines have important health consequences, including the potential for treatment failure, development of antimicrobial resistance, and serious adverse drug reactions, increasing healthcare costs and undermining the publics confidence in healthcare systems. This article presents a review of the methods employed for the analysis of pharmaceutical formulations. Technologies for detecting substandard and falsified drugs were identified primarily through literature reviews. Key-informant interviews with experts augmented our methods when warranted. In order to aid comparisons, technologies were assigned a suitability score for use in LMIC ranging from 0–8. Scores measured the need for electricity, need for sample preparation, need for reagents, portability, level of training required, and speed of analysis. Technologies with higher scores were deemed the most feasible in LMICs. We categorized technologies that cost

Estimating the Burden of Paratyphoid A in Asia and Africa

10,000 USD or less as low cost,

Scaling up access to oral rehydration solution for diarrhea: Learning from historical experience in low- and high-performing countries

10,000–100,000 USD as medium cost and those greater than

The Relationship between Livestock Ownership and Child Stunting in Three Countries in Eastern Africa Using National Survey Data.

100,000 USD as high cost technologies (all prices are 2013 USD). This search strategy yielded information on 42 unique technologies. Five technologies were deemed both low cost and had feasibility scores between 6–8, and an additional four technologies had medium cost and high feasibility. Twelve technologies were deemed portable and therefore could be used in the field. Many technologies can aid in the detection of substandard and falsified drugs that vary from the simplest of checklists for packaging to the most complex mass spectrometry analyses. Although there is no single technology that can serve all the requirements of detecting falsified and substandard drugs, there is an opportunity to bifurcate the technologies into specific niches to address specific sections within the workflow process of detecting products.

Relations between Household Livestock Ownership, Livestock Disease, and Young Child Growth

Despite the increasing availability of typhoid vaccine in many regions, global estimates of mortality attributable to enteric fever appear stable. While both Salmonella enterica serovar Typhi (S. Typhi) and serovar Paratyphi (S. Paratyphi) cause enteric fever, limited data exist estimating the burden of S. Paratyphi, particularly in Asia and Africa. We performed a systematic review of both English and Chinese-language databases to estimate the regional burden of paratyphoid within Africa and Asia. Distinct from previous reviews of the topic, we have presented two separate measures of burden; both incidence and proportion of enteric fever attributable to paratyphoid. Included articles reported laboratory-confirmed Salmonella serovar classification, provided clear methods on sampling strategy, defined the age range of participants, and specified the time period of the study. A total of 64 full-text articles satisfied inclusion criteria and were included in the qualitative synthesis. Paratyphoid A was commonly identified as a cause of enteric fever throughout Asia. The highest incidence estimates in Asia came from China; four studies estimated incidence rates of over 150 cases/100,000 person-years. Paratyphoid A burden estimates from Africa were extremely limited and with the exception of Nigeria, few population or hospital-based studies from Africa reported significant Paratyphoid A burden. While significant gaps exist in the existing population-level estimates of paratyphoid burden in Asia and Africa, available data suggest that paratyphoid A is a significant cause of enteric fever in Asia. The high variability in documented incidence and proportion estimates of paratyphoid suggest considerable geospatial variability in the burden of paratyphoid fever. Additional efforts to monitor enteric fever at the population level will be necessary in order to accurately quantify the public health threat posed by S. Paratyphi A, and to improve the prevention and treatment of enteric fever.

Care-seeking and appropriate treatment for childhood acute respiratory illness: an analysis of Demographic and Health Survey and Multiple Indicators Cluster Survey datasets for high-mortality countries.

Aim This paper aims to identify factors that systematically predict why some countries that have tried to scale up oral rehydration solution (ORS) have succeeded, and others have not. Methods We examined ORS coverage over time, across countries, and through case studies. We conducted expert interviews and literature and data searches to better understand the history of ORS scale–up efforts and why they failed or succeeded in nine countries. We used qualitative, pairwise (or three–country) comparisons of geographically or otherwise similar countries that had different outcomes in terms of ORS scale–up. An algorithm was developed which scored country performance across key supply, demand and financing activities to quantitatively assess the scale–up efforts in each country. Results The vast majority of countries have neither particularly low nor encouragingly high ORS use rates. We observed three clearly identifiable contrasts between countries that achieved and sustained high ORS coverage and those that did not. Key partners across sectors have critical roles to play to effectively address supply– and demand–side barriers. Efforts must synchronize demand generation, private provider outreach and public sector work. Many donor funds are either suspended or redirected in the event of political instability, exacerbating the health challenges faced by countries in these contexts. We found little information on the cost of scale–up efforts. Conclusions We identified a number of characteristics of successful ORS scale–up programs, including involvement of a broad range of key players, addressing supply and demand generation together, and working with both public and private sectors. Dedicated efforts are needed to launch and sustain success, including monitoring and evaluation plans to track program costs and impacts. These case studies were designed to inform programmatic decision–making; thus, rigorous academic methods to qualitatively and quantitatively evaluate country ORS scale–up programs might yield additional, critical insights and confirm our conclusions.

Microbiome sharing between children, livestock and household surfaces in western Kenya

Livestock ownership has the potential to improve child nutrition through various mechanisms, although direct evaluations of household livestock and child stunting status are uncommon. We conducted an analysis of Demographic and Health Survey (DHS) datasets from Ethiopia (2011), Kenya (2008–2009), and Uganda (2010) among rural children under 5 years of age to compare stunting status across levels of livestock ownership. We classified livestock ownership by summing reported household numbers of goats, sheep, cattle and chickens, as well as calculating a weighted score to combine multiple species. The primary association was assessed separately by country using a log-binomial model adjusted for wealth and region, which was then stratified by child diarrheal illness, animal-source foods intake, sub-region, and wealth index. This analysis included n = 8079 children from Ethiopia, n = 3903 children from Kenya, and n = 1645 from Uganda. A ten-fold increase in household livestock ownership had significant association with lower stunting prevalence in Ethiopia (Prevalence Ratio [PR] 0.95, 95% CI 0.92–0.98) and Uganda (PR 0.87, 95% CI 0.79–0.97), but not Kenya (PR 1.01, 95% CI 0.96–1.07). The weighted livestock score was only marginally associated with stunting status. The findings varied slightly by region, but not by wealth, diarrheal disease, or animal-source food intake. This analysis suggested a slightly beneficial effect of household livestock ownership on child stunting prevalence. The small effect size observed may be related to limitations of the DHS dataset or the potentially complicated relationship between malnutrition and livestock ownership, including livestock health and productivity.

Community-based surveillance of zoonotic parasites in a ‘One Health’ world: A systematic review

BACKGROUND In resource-limited settings in which child malnutrition is prevalent, humans live in close proximity to household livestock. However, the relation between household livestock and child nutrition represents a considerable knowledge gap. OBJECTIVE We assessed whether household livestock ownership or livestock disease episodes were associated with growth in young children in western Kenya. METHODS We incorporated monthly anthropometric measurements for children <5 y of age into an ongoing linked human and animal surveillance cohort in rural western Kenya. Using linear mixed models adjusted for age, sex, and household wealth, we tested whether baseline household livestock ownership was related to baseline child height for age or prospective growth rate. We also evaluated whether livestock disease episodes were associated with child growth rate over 11 mo of follow-up. RESULTS We collected data on 925 children over the course of follow-up. Greater household livestock ownership at baseline was not related to baseline child height-for-age z score (adjusted β: 0.01 SD; 95% CI: -0.02, 0.04 SD) or child growth rate (adjusted β: 0.02 cm/y; 95% CI: -0.03, 0.07 cm/y). Livestock disease episodes were not significantly associated with child growth across the entire cohort (adjusted β: -0.007 cm/mo; 95% CI: -0.02, 0.006 cm/mo). However, children in households with livestock digestive disease between June and November gained less height than did children in households that did not report livestock disease (β: -0.063 cm/mo; 95% CI: -0.112, -0.016 cm/mo). Children <2 y of age in households with livestock digestive disease gained less weight than did those who did not report disease (β: -0.033 kg/mo; 95% CI: -0.063, -0.003 kg/mo). CONCLUSION In this cohort of young children in western Kenya, we did not find an association between ownership of livestock and child growth status. However, disease episodes in household livestock may be related to a lower child growth rate in some groups.

Piecing together the stunting puzzle: a framework for attributable factors of child stunting

BackgroundAcute lower respiratory illness (ALRI) is a major global cause of morbidity and mortality among children under 5. Antibiotic treatment for ALRI is inexpensive and decreases case fatality, but care-seeking patterns and appropriate treatment vary widely across countries. This study sought to examine patterns of appropriate treatment and estimate the burden of cases of untreated ALRI in high mortality countries.MethodsThis study used cross-sectional survey data from the Phase 5/Phase 6 DHS and MIC3/MICS4 for 39 countries. We analyzed care-seeking patterns and antibiotic treatment based on country-level trends, and estimated the burden of untreated cases using country-level predictors in a general linear model.ResultsAccording to this analysis, over 66 million children were not treated with antibiotics for ALRI in 2010. Overall, African countries had a lower proportion of mothers who sought care for a recent episode of ALRI (41% to 86%) relative to Asian countries (75% to 87%). Seeking any care for ALRI was inversely related to seeking public sector care. Treatment with antibiotics ranged from 8% in Nepal to 87% in Jordan, and was significantly associated with urban residence.ConclusionsUntreated ALRI remains a substantial problem in high mortality countries. In Asia, the large population numbers lead to a high burden of children with untreated ALRI. In Africa, care-seeking behaviors and access to care issues may lead to missed opportunities to treat children with antibiotics.

A comparison of an audiometric screening survey with an in-depth research questionnaire for hearing loss and hearing loss risk factors

The gut microbiome community structure and development are associated with several health outcomes in young children. To determine the household influences of gut microbiome structure, we assessed microbial sharing within households in western Kenya by sequencing 16S rRNA libraries of fecal samples from children and cattle, cloacal swabs from chickens, and swabs of household surfaces. Among the 156 households studied, children within the same household significantly shared their gut microbiome with each other, although we did not find significant sharing of gut microbiome across host species or household surfaces. Higher gut microbiome diversity among children was associated with lower wealth status and involvement in livestock feeding chores. Although more research is necessary to identify further drivers of microbiota development, these results suggest that the household should be considered as a unit. Livestock activities, health and microbiome perturbations among an individual child may have implications for other children in the household.