Diarrheal diseases (DD) are leading causes of disease burden, death, and disability, especially in children in low-income settings. DD can also impact a child's potential livelihood through stunted physical growth, cognitive impairment, and other sequelae. As part of the Global Burden of Disease Study, we estimated DD burden, and the burden attributable to specific risk factors and particular etiologies, in the Eastern Mediterranean Region (EMR) between 1990 and 2013. For both sexes and all ages, we calculated disability-adjusted life years (DALYs), which are the sum of years of life lost and years lived with disability. We estimate that over 125,000 deaths (3.6% of total deaths) were due to DD in the EMR in 2013, with a greater burden of DD in low- and middle-income countries. Diarrhea deaths per 100,000 children under 5 years of age ranged from one (95% uncertainty interval [UI] = 0-1) in Bahrain and Oman to 471 (95% UI = 245-763) in Somalia. The pattern for diarrhea DALYs among those under 5 years of age closely followed that for diarrheal deaths. DALYs per 100,000 ranged from 739 (95% UI = 520-989) in Syria to 40,869 (95% UI = 21,540-65,823) in Somalia. Our results highlighted a highly inequitable burden of DD in EMR, mainly driven by the lack of access to proper resources such as water and sanitation. Our findings will guide preventive and treatment interventions which are based on evidence and which follow the ultimate goal of reducing the DD burden.
Research shows that there is an increased risk of SARS-CoV-2 infection in migrants and ethnic minorities. However, increasing evidence indicates that socio-economic factors, such as employment, education and income, contribute to the association between migrant status and SARS-CoV-2 infection. This study aimed to examine the association between migrant status and the risk of SARS-CoV-2 infection in Germany and to discuss potential explanations for these associations.This was a cross-sectional study.Data from the German COVID-19 Snapshot Monitoring online survey were analysed, and hierarchical multiple linear regression models were used to calculate the probabilities of self-reported SARS-CoV-2 infection. Predictor variables were integrated in a stepwise method as follows: (1) migrant status (defined by own or parental country of birth other than Germany); (2) gender, age and education; (3) household size; (4) household language; and (5) occupation in the health sector, including an interaction term of migrant status (yes) and occupation in the health sector (yes).Of 45,858 participants, 3.5% reported a SARS-CoV-2 infection, and 16% were migrants. Migrants, participants in large households, those speaking a language other than German in their household and those working in the health sector were more likely to report SARS-CoV-2 infection. The probability of reporting SARS-CoV-2 infection was 3.95 percentage points higher for migrants than non-migrants; this probability decreased when integrating further predictor variables. The strongest association of reporting a SARS-CoV-2 infection was observed for migrants working in the health sector.Migrants and health sector employees, and especially migrant health workers, are at an increased risk of SARS-CoV-2 infection. The results show that the risk of SARS-CoV-2 infection is determined by living and working conditions rather than migrant status.
To propose health system strategies to meeting the World Health Organization (WHO) recommendations on HIV screening through antenatal care (ANC) services, we assessed predictors of HIV screening, and simulated the impact of changes in these predictors on the probability of HIV screening in Guatemala, Honduras, Mexico (State of Chiapas), Nicaragua, Panama, and El Salvador. We interviewed a representative sample of women of reproductive age from the poorest Mesoamerican areas on ANC services, including HIV screening. We used a multivariate logistic regression model to examine correlates of HIV screening. First differences in expected probabilities of HIV screening were simulated for health system correlates that were associated with HIV screening. Overall, 40.7% of women were screened for HIV during their last pregnancy through ANC. This rate was highest in El Salvador and lowest in Guatemala. The probability of HIV screening increased with education, household expenditure, the number of ANC visits, and the type of health care attendant of ANC visits. If all women were to be attended by a nurse, or a physician, and were to receive at least four ANC visits, the probability of HIV screening would increase by 12.5% to reach 45.8%. To meet WHO's recommendations for HIV screening, special attention should be given to the poorest and least educated women to ensure health equity and progress toward an HIV-free generation. In parallel, health systems should be strengthened in terms of testing and human resources to ensure that every pregnant woman gets screened for HIV. A 12.5% increase in HIV screening would require a minimum of four ANC visits and an appropriate professional attendance of these visits.
BackgroundThe Global Burden of Diseases, Injuries, and Risk Factors Study 2017 (GBD 2017) includes a comprehensive assessment of incidence, prevalence, and years lived with disability (YLDs) for 354 causes in 195 countries and territories from 1990 to 2017. Previous GBD studies have shown how the decline of mortality rates from 1990 to 2016 has led to an increase in life expectancy, an ageing global population, and an expansion of the non-fatal burden of disease and injury. These studies have also shown how a substantial portion of the world's population experiences non-fatal health loss with considerable heterogeneity among different causes, locations, ages, and sexes. Ongoing objectives of the GBD study include increasing the level of estimation detail, improving analytical strategies, and increasing the amount of high-quality data.MethodsWe estimated incidence and prevalence for 354 diseases and injuries and 3484 sequelae. We used an updated and extensive body of literature studies, survey data, surveillance data, inpatient admission records, outpatient visit records, and health insurance claims, and additionally used results from cause of death models to inform estimates using a total of 68 781 data sources. Newly available clinical data from India, Iran, Japan, Jordan, Nepal, China, Brazil, Norway, and Italy were incorporated, as well as updated claims data from the USA and new claims data from Taiwan (province of China) and Singapore. We used DisMod-MR 2.1, a Bayesian meta-regression tool, as the main method of estimation, ensuring consistency between rates of incidence, prevalence, remission, and cause of death for each condition. YLDs were estimated as the product of a prevalence estimate and a disability weight for health states of each mutually exclusive sequela, adjusted for comorbidity. We updated the Socio-demographic Index (SDI), a summary development indicator of income per capita, years of schooling, and total fertility rate. Additionally, we calculated differences between male and female YLDs to identify divergent trends across sexes. GBD 2017 complies with the Guidelines for Accurate and Transparent Health Estimates Reporting.FindingsGlobally, for females, the causes with the greatest age-standardised prevalence were oral disorders, headache disorders, and haemoglobinopathies and haemolytic anaemias in both 1990 and 2017. For males, the causes with the greatest age-standardised prevalence were oral disorders, headache disorders, and tuberculosis including latent tuberculosis infection in both 1990 and 2017. In terms of YLDs, low back pain, headache disorders, and dietary iron deficiency were the leading Level 3 causes of YLD counts in 1990, whereas low back pain, headache disorders, and depressive disorders were the leading causes in 2017 for both sexes combined. All-cause age-standardised YLD rates decreased by 3·9% (95% uncertainty interval [UI] 3·1–4·6) from 1990 to 2017; however, the all-age YLD rate increased by 7·2% (6·0–8·4) while the total sum of global YLDs increased from 562 million (421–723) to 853 million (642–1100). The increases for males and females were similar, with increases in all-age YLD rates of 7·9% (6·6–9·2) for males and 6·5% (5·4–7·7) for females. We found significant differences between males and females in terms of age-standardised prevalence estimates for multiple causes. The causes with the greatest relative differences between sexes in 2017 included substance use disorders (3018 cases [95% UI 2782–3252] per 100 000 in males vs s1400 [1279–1524] per 100 000 in females), transport injuries (3322 [3082–3583] vs 2336 [2154–2535]), and self-harm and interpersonal violence (3265 [2943–3630] vs 5643 [5057–6302]).InterpretationGlobal all-cause age-standardised YLD rates have improved only slightly over a period spanning nearly three decades. However, the magnitude of the non-fatal disease burden has expanded globally, with increasing numbers of people who have a wide spectrum of conditions. A subset of conditions has remained globally pervasive since 1990, whereas other conditions have displayed more dynamic trends, with different ages, sexes, and geographies across the globe experiencing varying burdens and trends of health loss. This study emphasises how global improvements in premature mortality for select conditions have led to older populations with complex and potentially expensive diseases, yet also highlights global achievements in certain domains of disease and injury.FundingBill & Melinda Gates Foundation.
Objectives The Salud Mesoamérica Initiative (SMI) is a three-operation strategy, and is a pioneer in the world of results-based aid (RBA) in terms of the success it has achieved in improving health system inputs following its initial operation. This success in meeting pre-defined targets is rare in the world of financial assistance for health. We investigated the influential aspects of SMI that could have contributed to its effectiveness in improving health systems, with the aim of providing international donors, bilateral organizations, philanthropies, and recipient countries with new perspectives that can help increase the effectiveness of future assistance for health, specifically in the arena of RBA. Methods Qualitative methods based on the criteria of relevance and effectiveness proposed by the Development Assistance Committee of the Organization for Economic Co-operation and Development. Our methods included document review, key informant interviews, a focus group discussion, and a partnership analysis. Participants A purposive sample of 113 key informants, comprising donors, representatives from the Inter-American Development Bank, ministries of health, technical assistance organizations, evaluation organizations, and health care providers. Results During May–October 2016, we interviewed regarding the relevance and effectiveness of SMI. Themes emerged relative to the topics we investigated, and covered the design and the drivers of success of the initiative. The success is due to 1) the initiative’s regional approach, which pressured recipient countries to compete toward meeting targets, 2) a robust and flexible design that incorporated the richness of input from stakeholders at all levels, 3) the design-embedded evaluation component that created a culture of accountability among recipient countries, and 4) the reflective knowledge environment that created a culture of evidence-based decision-making. Conclusions A regional approach involving all appropriate stakeholders, and based on knowledge sharing and embedded evaluation can help ensure the effectiveness of future results-based aid programs for health in global settings.
The Salud Mesoamérica Initiative is a public-private partnership aimed at reducing maternal and child morbidity and mortality for the poorest populations in Central America and the southernmost state of Mexico. Currently at the midpoint of implementation and with external funding expected to phase out by 2020, SMI’s sustainability warrants evaluation. In this study, we examine if the major SMI components fit into the Dynamic Sustainability Framework to predict whether SMI benefits could be sustainable beyond the external funding and to identify threats to sustainability. Through the 2016 Salud Mesoamérica Initiative Process Evaluation, we applied qualitative methods including document review, key informant interviews, focus group discussions, and a social network analysis to address our objective. SMI’s design continuously evolves and aligns with national needs and objectives. Partnerships, the regional approach, and the results-based aid model create a culture that prioritizes health care. SMI’s sector-wide approach and knowledge-sharing framework strengthen health systems. Evidence-based practice promotes policy dialogue and scale-up of interventions. Most SMI elements fit within the Dynamic Sustainability Framework, suggesting a likelihood of sustainability after external funding ceases, and subsequent application of lessons learned by the global community. This includes a flexible design, partnerships and a culture of prioritizing healthcare, health systems strengthening mechanisms, policy changes, and scale-ups of interventions. However, threats to sustainability, including possible transient culture of prioritizing health care, dissipation of reputational risk and financial partnerships, and personnel turnover, need to be addressed.
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