Last data update: May 06, 2024. (Total: 46732 publications since 2009)
Records 1-27 (of 27 Records) |
Query Trace: Raghunathan PL[original query] |
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A United Response to COVID-19—an Artist’s Perspective
Breedlove B , Cassell CH , Raghunathan PL . Emerg Infect Dis 2022 28 S302-3 During mid-March 2020, the World Health Organization (WHO) declared that the spread of COVID-19, the respiratory illness caused by SARS-CoV-2, was a pandemic. This novel emerging infectious disease spread insidiously and swiftly around the globe, undeterred by geographic borders. Countries reacted to COVID-19 with attempts to control transmission, including isolation and quarantine orders, social distancing recommendations, and mask requirements. Responses at the local, national, regional, and international levels involved public health experts, field epidemiologists (disease detectives), clinicians, researchers, policy makers, political leaders, and civil authorities. | | Artists from across the globe also responded to the effects of COVID-19 in myriad ways, communicating a wide range of perspectives and experiences about the pandemic through imagery, music, dance, and writing. Efforts to collect and share some of this artistic output via online platforms helped connect artists and audiences to a greater degree than would otherwise have been possible during the pandemic. For example, in spring 2020 the Washington Post invited readers to submit artwork created during the early months of the COVID-19 outbreak. The paper featured 20 works, selected from more than 650 submissions, in the article “The Best Art Created by Washington Post Readers during the Pandemic.” Michael Cavna, a writer-artist-cartoonist who penned the story, explained, “The Post considered not only the quality and creativity of the art, but also the fascinating accompanying backstories. Enduring quarantines, some artists rendered what isolation and loneliness felt like, while others depicted longed-for social scenes from a pre-pandemic time.” |
Principles of health equity science for public health action
Burton DC , Kelly A , Cardo D , Daskalakis D , Huang DT , Penman-Aguilar A , Raghunathan PL , Zhu BP , Bunnell R . Public Health Rep 2023 333549231213162 Health equity is the state in which everyone has a fair and just opportunity to attain their highest level of health, and no one is disadvantaged from achieving this potential because of social position or other socially determined circumstances.1 Science is a cornerstone of public health and central to efforts to achieve health equity. Science designed to generate knowledge to advance equity can improve population health and promote health for all members of society.2 In contrast, science and interventions not designed and implemented with equity in mind may inadvertently perpetuate or widen disparities, even while fostering overall improvements in population health.3 | Health equity science provides a conceptual framework for scientific endeavors that are designed and conducted to advance health equity.4 Health equity science investigates patterns and underlying contributors to health inequities and builds an evidence base that can guide action across the domains of the public health program, surveillance, policy, communication, and scientific inquiry to move toward eliminating, rather than simply documenting, inequities. | Building on extensive work in developing the importance and application of equity concepts in public health practice,5-7 we describe an equity-focused scientific framework and set of principles to guide public health efforts to fulfill the health equity mission of the Centers for Disease Control and Prevention (CDC).8 |
Global responses to the COVID-19 pandemic
Cassell CH , Raghunathan PL , Henao O , Pappas-DeLuca KA , Rémy WL , Dokubo EK , Merrill RD , Marston BJ . Emerg Infect Dis 2022 28 (13) S4-s7 Confronted with a novel coronavirus, countries worldwide were forced to rapidly adjust their public health systems, platforms, and tools to respond to COVID-19. The US Centers for Disease Control and Prevention (CDC) and its global partners adapted health systems and programs originally developed for other purposes, such as controlling the HIV/AIDS pandemic through the US President’s Emergency Plan for AIDS Relief (PEPFAR), Global Health Security Agenda implementation, influenza surveillance, and vaccine-preventable disease elimination and eradication. This special supplement of Emerging Infectious Diseases highlights responses to the early phases of the COVID-19 pandemic from >80 countries, spanning 6 continents and representing >130 organizations. This article summarizes global adaptations of core public health functions during COVID-19: surveillance, information, and laboratory systems; workforce, institutional, and public health capacity; and clinical and health services delivery. |
Investing in global measles and rubella elimination is needed to avert deaths and advance health equity
Raghunathan PL , Orenstein W . Lancet Glob Health 2022 10 (10) e1363-e1364 Is it feasible to eradicate measles and rubella globally? In response to a request from the 70th World Health Assembly in 2017, a group of experts concluded in 2020 that global eradication was technically feasible with sustained high coverage of two doses of measles- and rubella-containing vaccine, but the more realistic course was to accelerate regional progress towards measles and rubella elimination.1 Advances have been hard-fought and occasionally reversed in the six WHO regions that have established measles elimination goals and the four regions with rubella elimination goals. Measles and rubella have been verified as eliminated in 81 and 93 countries, respectively, as of 2020.2, 3 |
Effect of Delays in Maternal Access to Healthcare on Neonatal Mortality in Sierra Leone: A Social Autopsy Case-Control Study at a Child Health and Mortality Prevention Surveillance (CHAMPS) Site
Preslar JP , Worrell MC , Kaiser R , Cain CJ , Samura S , Jambai A , Raghunathan PL , Clarke K , Goodman D , Christiansen-Lindquist L , Webb-Girard A , Kramer M , Breiman R . Matern Child Health J 2021 25 (8) 1326-1335 INTRODUCTION: In low-resource settings, a social autopsy tool has been proposed to measure the effect of delays in access to healthcare on deaths, complementing verbal autopsy questionnaires routinely used to determine cause of death. This study estimates the contribution of various delays in maternal healthcare to subsequent neonatal mortality using a social autopsy case-control design. METHODS: This study was conducted at the Child Health and Mortality Prevention Surveillance (CHAMPS) Sierra Leone site (Makeni City and surrounding rural areas). Cases were neonatal deaths in the catchment area, and controls were sex- and area-matched living neonates. Odds ratios for maternal barriers to care and neonatal death were estimated, and stratified models examined this association by neonatal age and medical complications. RESULTS: Of 53 neonatal deaths, 26.4% of mothers experienced at least one delay during pregnancy or delivery compared to 46.9% of mothers of stillbirths and 18.6% of control mothers. The most commonly reported delay among neonatal deaths was receiving care at the facility (18.9%). Experiencing any barrier was weakly associated (OR 1.68, CI 0.77, 3.67) and a delay in receiving care at the facility was strongly associated (OR 19.15, CI 3.90, 94.19) with neonatal death. DISCUSSION: Delays in healthcare are associated with neonatal death, particularly delays experienced at the healthcare facility. Heterogeneity exists in the prevalence of specific delays, which has implications for local public health policy. The findings and conclusions in this report are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention. |
Initial findings from a novel population-based child mortality surveillance approach: a descriptive study
Taylor AW , Blau DM , Bassat Q , Onyango D , Kotloff KL , Arifeen SE , Mandomando I , Chawana R , Baillie VL , Akelo V , Tapia MD , Salzberg NT , Keita AM , Morris T , Nair S , Assefa N , Seale AC , Scott JAG , Kaiser R , Jambai A , Barr BAT , Gurley ES , Ordi J , Zaki SR , Sow SO , Islam F , Rahman A , Dowell SF , Koplan JP , Raghunathan PL , Madhi SA , Breiman RF . Lancet Glob Health 2020 8 (7) e909-e919 BACKGROUND: Sub-Saharan Africa and south Asia contributed 81% of 5.9 million under-5 deaths and 77% of 2.6 million stillbirths worldwide in 2015. Vital registration and verbal autopsy data are mainstays for the estimation of leading causes of death, but both are non-specific and focus on a single underlying cause. We aimed to provide granular data on the contributory causes of death in stillborn fetuses and in deceased neonates and children younger than 5 years, to inform child mortality prevention efforts. METHODS: The Child Health and Mortality Prevention Surveillance (CHAMPS) Network was established at sites in seven countries (Baliakandi, Bangladesh; Harar and Kersa, Ethiopia; Siaya and Kisumu, Kenya; Bamako, Mali; Manhica, Mozambique; Bombali, Sierra Leone; and Soweto, South Africa) to collect standardised, population-based, longitudinal data on under-5 mortality and stillbirths in sub-Saharan Africa and south Asia, to improve the accuracy of determining causes of death. Here, we analysed data obtained in the first 2 years after the implementation of CHAMPS at the first five operational sites, during which surveillance and post-mortem diagnostics, including minimally invasive tissue sampling (MITS), were used. Data were abstracted from all available clinical records of deceased children, and relevant maternal health records were also extracted for stillbirths and neonatal deaths, to incorporate reported pregnancy or delivery complications. Expert panels followed standardised procedures to characterise causal chains leading to death, including underlying, intermediate (comorbid or antecedent causes), and immediate causes of death for stillbirths, neonatal deaths, and child (age 1-59 months) deaths. FINDINGS: Between Dec 10, 2016, and Dec 31, 2018, MITS procedures were implemented at five sites in Mozambique, South Africa, Kenya, Mali, and Bangladesh. We screened 2385 death notifications for inclusion eligibility, following which 1295 families were approached for consent; consent was provided for MITS by 963 (74%) of 1295 eligible cases approached. At least one cause of death was identified in 912 (98%) of 933 cases (180 stillbirths, 449 neonatal deaths, and 304 child deaths); two or more conditions were identified in the causal chain for 585 (63%) of 933 cases. The most common underlying causes of stillbirth were perinatal asphyxia or hypoxia (130 [72%] of 180 stillbirths) and congenital infection or sepsis (27 [15%]). The most common underlying causes of neonatal death were preterm birth complications (187 [42%] of 449 neonatal deaths), perinatal asphyxia or hypoxia (98 [22%]), and neonatal sepsis (50 [11%]). The most common underlying causes of child deaths were congenital birth defects (39 [13%] of 304 deaths), lower respiratory infection (37 [12%]), and HIV (35 [12%]). In 503 (54%) of 933 cases, at least one contributory pathogen was identified. Cytomegalovirus, Escherichia coli, group B Streptococcus, and other infections contributed to 30 (17%) of 180 stillbirths. Among neonatal deaths with underlying prematurity, 60% were precipitated by other infectious causes. Of the 275 child deaths with infectious causes, the most common contributory pathogens were Klebsiella pneumoniae (86 [31%]), Streptococcus pneumoniae (54 [20%]), HIV (40 [15%]), and cytomegalovirus (34 [12%]), and multiple infections were common. Lower respiratory tract infection contributed to 174 (57%) of 304 child deaths. INTERPRETATION: Cause of death determination using MITS enabled detailed characterisation of contributing conditions. Global estimates of child mortality aetiologies, which are currently based on a single syndromic cause for each death, will be strengthened by findings from CHAMPS. This approach adds specificity and provides a more complete overview of the chain of events leading to death, highlighting multiple potential interventions to prevent under-5 mortality and stillbirths. FUNDING: Bill & Melinda Gates Foundation. |
Case definitions used during the first 6 months of the 10th Ebola virus disease outbreak in the Democratic Republic of the Congo - four neighboring countries, August 2018-February 2019
Medley AM , Mavila O , Makumbi I , Nizeyemana F , Umutoni A , Balisanga H , Manoah YK , Geissler A , Bunga S , MacDonald G , Homsy J , Ojwang J , Ewetola R , Raghunathan PL , MacGurn A , Singler K , Ward S , Roohi S , Brown V , Shoemaker T , Lako R , Kabeja A , Muruta A , Lubula L , Merrill R . MMWR Morb Mortal Wkly Rep 2020 69 (1) 14-19 On August 1, 2018, the Democratic Republic of the Congo (DRC) declared its 10th Ebola virus disease (Ebola) outbreak in an area with a high volume of cross-border population movement to and from neighboring countries. The World Health Organization (WHO) designated Rwanda, South Sudan, and Uganda as the highest priority countries for Ebola preparedness because of the high risk for cross-border spread from DRC (1). Countries might base their disease case definitions on global standards; however, historical context and perceived risk often affect why countries modify and adapt definitions over time, moving toward or away from regional harmonization. Discordance in case definitions among countries might reduce the effectiveness of cross-border initiatives during outbreaks with high risk for regional spread. CDC worked with the ministries of health (MOHs) in DRC, Rwanda, South Sudan, and Uganda to collect MOH-approved Ebola case definitions used during the first 6 months of the outbreak to assess concordance (i.e., commonality in category case definitions) among countries. Changes in MOH-approved Ebola case definitions were analyzed, referencing the WHO standard case definition, and concordance among the four countries for Ebola case categories (i.e., community alert, suspected, probable, confirmed, and case contact) was assessed at three dates (2). The number of country-level revisions ranged from two to four, with all countries revising Ebola definitions by February 2019 after a December 2018 peak in incidence in DRC. Case definition complexity increased over time; all countries included more criteria per category than the WHO standard definition did, except for the "case contact" and "confirmed" categories. Low case definition concordance and lack of awareness of regional differences by national-level health officials could reduce effectiveness of cross-border communication and collaboration. Working toward regional harmonization or considering systematic approaches to addressing country-level differences might increase efficiency in cross-border information sharing. |
Development and Implementation of Multiplex TaqMan Array Cards for Specimen Testing at Child Health and Mortality Prevention Surveillance Site Laboratories.
Diaz MH , Waller JL , Theodore MJ , Patel N , Wolff BJ , Benitez AJ , Morris T , Raghunathan PL , Breiman RF , Whitney CG , Blau DM , Winchell JM . Clin Infect Dis 2019 69 S311-s321 Child Health and Mortality Prevention Surveillance (CHAMPS) laboratories are employing a variety of laboratory methods to identify infectious agents contributing to deaths of children <5 years old and stillbirths in sub-Saharan Africa and South Asia. In support of this long-term objective, our team developed TaqMan Array Cards (TACs) for testing postmortem specimens (blood, cerebrospinal fluid, lung tissue, respiratory tract swabs, and rectal swabs) for >100 real-time polymerase chain reaction (PCR) targets in total (30-45 per card depending on configuration). Multipathogen panels were configured by syndrome and customized to include pathogens of significance in young children within the regions where CHAMPS is conducted, including bacteria (57 targets covering 30 genera), viruses (48 targets covering 40 viruses), parasites (8 targets covering 8 organisms), and fungi (3 targets covering 3 organisms). The development and application of multiplex real-time PCR reactions to the TAC microfluidic platform increased the number of targets in each panel while maintaining assay efficiency and replicates for heightened sensitivity. These advances represent a substantial improvement in the utility of this technology for infectious disease diagnostics and surveillance. We optimized all aspects of the CHAMPS molecular laboratory testing workflow including nucleic acid extraction, quality assurance, and data management to ensure comprehensive molecular testing of specimens and high-quality data. Here we describe the development and implementation of multiplex TACs and associated laboratory protocols for specimen processing, testing, and data management at CHAMPS site laboratories. |
Overview and development of the Child Health and Mortality Prevention Surveillance Determination of Cause of Death (DeCoDe) Process and DeCoDe Diagnosis Standards
Blau DM , Caneer JP , Philipsborn RP , Madhi SA , Bassat Q , Varo R , Mandomando I , Igunza KA , Kotloff KL , Tapia MD , Johnstone S , Chawana R , Rahman A , El Arifeen S , Onyango D , Kaiser R , Seale AC , Assefa N , Morris T , Raghunathan PL , Breiman RF . Clin Infect Dis 2019 69 S333-s341 Mortality surveillance and cause of death data are instrumental in improving health, identifying diseases and conditions that cause a high burden of preventable deaths, and allocating resources to prevent these deaths. The Child Health and Mortality Prevention Surveillance (CHAMPS) network uses a standardized process to define, assign, and code causes of stillbirth and child death (<5 years of age) across the CHAMPS network. A Determination of Cause of Death (DeCoDe) panel composed of experts from a local CHAMPS site analyzes all available individual information, including laboratory, histopathology, abstracted clinical records, and verbal autopsy findings for each case and, if applicable, also for the mother. Using this information, the site panel ascertains the underlying cause (event that precipitated the fatal sequence of events) and other antecedent, immediate, and maternal causes of death in accordance with the International Classification of Diseases, Tenth Revision and the World Health Organization death certificate. Development and use of the CHAMPS diagnosis standards-a framework of required evidence to support cause of death determination-assures a homogenized procedure leading to a more consistent interpretation of complex data across the CHAMPS network. This and other standardizations ensures future comparability with other sources of mortality data produced externally to this project. Early lessons learned from implementation of DeCoDe in 5 CHAMPS sites in sub-Saharan Africa and Bangladesh have been incorporated into the DeCoDe process, and the implementation of DeCoDe has the potential to spur health systems improvements and local public health action. |
Using participatory workshops to assess alignment or tension in the Community for Minimally Invasive Tissue Sampling Prior to Start of Child Mortality Surveillance: Lessons from 5 sites across the CHAMPS Network
Blevins J , O'Mara Sage E , Kone A , Maixenchs M , Raghunathan PL , Guilaze RA , Cossa S , Girma Z , Zegeye Y , Ackley C , Hussain F , Islam S , Myburgh N , Ngwenya N , Madhi SA , Otieno P , Ochola K , Munguambe K , Breiman RF . Clin Infect Dis 2019 69 S280-s290 The Child Health and Mortality Prevention Surveillance (CHAMPS) program is a 7-country network (as of December 2018) established by the Bill & Melinda Gates Foundation to identify the causes of death in children in communities with high rates of under-5 mortality. The program carries out both mortality and pregnancy surveillance, and mortality surveillance employs minimally invasive tissue sampling (MITS) to gather small samples of body fluids and tissue from the bodies of children who have died. While this method will lead to greater knowledge of the specific causes of childhood mortality, the procedure is in tension with cultural and religious norms in many of the countries where CHAMPS works-Bangladesh, Ethiopia, Kenya, Mali, Mozambique, Sierra Leone, and South Africa. Participatory Inquiry Into Community Knowledge of Child Health and Mortality Prevention (PICK-CHAMP) is a community entry activity designed to introduce CHAMPS to communities and gather initial perspectives on alignments and tensions between CHAMPS activities and community perceptions and priorities. Participants' responses revealed medium levels of overall alignment in all sites (with the exception of South Africa, where alignment was high) and medium levels of tension (with the exception of Ethiopia, where tension was high). Alignment was high and tension was low for pregnancy surveillance across all sites, whereas Ethiopia reflected low alignment and high tension for MITS. Participants across all sites indicated that support for MITS was possible only if the procedure did not interfere with burial practices and rituals. |
Potential of minimally invasive tissue sampling for attributing specific causes of childhood deaths in South Africa: A pilot, epidemiological study
Chawana R , Baillie V , Izu A , Solomon F , Bassat Q , Blau DM , Breiman RF , Hale M , Houpt ER , Lala SG , Martines RB , Mathunjwa A , Nzenze S , Pathirana J , Petersen KL , Raghunathan PL , Ritter JM , Wadula J , Zaki SR , Madhi SA . Clin Infect Dis 2019 69 S361-s373 BACKGROUND: Current estimates for causes of childhood deaths are mainly premised on modeling of vital registration and limited verbal autopsy data and generally only characterize the underlying cause of death (CoD). We investigated the potential of minimally invasive tissue sampling (MITS) for ascertaining the underlying and immediate CoD in children 1 month to 14 years of age. METHODS: MITS included postmortem tissue biopsies of brain, liver, and lung for histopathology examination; microbial culture of blood, cerebrospinal fluid (CSF), liver, and lung samples; and molecular microbial testing on blood, CSF, lung, and rectal swabs. Each case was individually adjudicated for underlying, antecedent, and immediate CoD by an international multidisciplinary team of medical experts and coded using the International Classification of Diseases, Tenth Revision (ICD-10). RESULTS: An underlying CoD was determined for 99% of 127 cases, leading causes being congenital malformations (18.9%), complications of prematurity (14.2%), human immunodeficiency virus/AIDS (12.6%), diarrheal disease (8.7%), acute respiratory infections (7.9%), injuries (7.9%), and malignancies (7.1%). The main immediate CoD was pneumonia, sepsis, and diarrhea in 33.9%, 19.7%, and 10.2% of cases, respectively. Infection-related deaths were either an underlying or immediate CoD in 78.0% of cases. Community-acquired pneumonia deaths (n = 32) were attributed to respiratory syncytial virus (21.9%), Pneumocystis jirovecii (18.8%), cytomegalovirus (15.6%), Klebsiella pneumoniae (15.6%), and Streptococcus pneumoniae (12.5%). Seventy-one percent of 24 sepsis deaths were hospital-acquired, mainly due to Acinetobacter baumannii (47.1%) and K. pneumoniae (35.3%). Sixty-two percent of cases were malnourished. CONCLUSIONS: MITS, coupled with antemortem clinical information, provides detailed insight into causes of childhood deaths that could be informative for prioritization of strategies aimed at reducing under-5 mortality. |
Health and demographic surveillance systems within the Child Health and Mortality Prevention Surveillance Network
Cunningham SA , Shaikh NI , Nhacolo A , Raghunathan PL , Kotloff K , Naser AM , Mengesha MM , Adedini SA , Misore T , Onuwchekwa UU , Worrell MC , El Arifeen S , Assefa N , Chowdhury AI , Kaiser R , Madhi SA , Mehta A , Obor D , Sacoor C , Sow SO , Tapia MD , Wilkinson AL , Breiman RF . Clin Infect Dis 2019 69 S274-s279 Health and demographic surveillance systems (HDSSs) provide a foundation for characterizing and defining priorities and strategies for improving population health. The Child Health and Mortality Prevention Surveillance (CHAMPS) project aims to inform policy to prevent child deaths through generating causes of death from surveillance data combined with innovative diagnostic and laboratory methods. Six of the 7 sites that constitute the CHAMPS network have active HDSSs: Mozambique, Mali, Ethiopia, Kenya, Bangladesh, and South Africa; the seventh, in Sierra Leone, is in the early planning stages. This article describes the network of CHAMPS HDSSs and their role in the CHAMPS project. To generate actionable health and demographic data to prevent child deaths, the network depends on reliable demographic surveillance, and the HDSSs play this crucial role. |
An observational pilot study evaluating the utility of minimally invasive tissue sampling to determine the cause of stillbirths in South African women
Madhi SA , Pathirana J , Baillie V , Cutland C , Adam Y , Izu A , Bassat Q , Blau DM , Breiman RF , Hale M , Johnstone S , Martines RB , Mathunjwa A , Nzenze S , Ordi J , Raghunathan PL , Ritter JM , Solomon F , Wadula J , Zaki SR , Chawana R . Clin Infect Dis 2019 69 S342-s350 BACKGROUND: Despite approximately 2.6 million stillbirths occurring annually, there is a paucity of systematic biological investigation and consequently knowledge on the causes of these deaths in low- and middle-income countries (LMICs). We investigated the utility of minimally invasive tissue sampling (MITS), placental examination, and clinical history, in attributing the causes of stillbirth in a South African LMIC setting. METHODS: This prospective, observational pilot study undertook sampling of brain, lung, and liver tissue using core biopsy needles, blood and cerebrospinal fluid collection, and placental examination. Testing included microbial culture and/or molecular testing and tissue histological examination. The cause of death was determined for each case by an international panel of medical specialists and categorized using the World Health Organization's International Classification of Diseases, Tenth Revision application to perinatal deaths. RESULTS: A cause of stillbirth was identifiable for 117 of 129 (90.7%) stillbirths, including an underlying maternal cause in 63.4% (n = 83) and an immediate fetal cause in 79.1% (n = 102) of cases. The leading underlying causes of stillbirth were maternal hypertensive disorders (16.3%), placental separation and hemorrhage (14.0%), and chorioamnionitis (10.9%). The leading immediate causes of fetal death were antepartum hypoxia (35.7%) and fetal infection (37.2%), including due to Escherichia coli (16.3%), Enterococcus species (3.9%), and group B Streptococcus (3.1%). CONCLUSIONS: In this pilot, proof-of-concept study, focused investigation of stillbirth provided granular detail on the causes thereof in an LMIC setting, including provisionally highlighting the largely underrecognized role of fetal sepsis as a dominant cause. |
Unraveling specific causes of neonatal mortality using minimally invasive tissue sampling: An observational study
Madhi SA , Pathirana J , Baillie V , Izu A , Bassat Q , Blau DM , Breiman RF , Hale M , Mathunjwa A , Martines RB , Nakwa FL , Nzenze S , Ordi J , Raghunathan PL , Ritter JM , Solomon F , Velaphi S , Wadula J , Zaki SR , Chawana R . Clin Infect Dis 2019 69 S351-s360 BACKGROUND: Postmortem minimally invasive tissue sampling (MITS) is a potential alternative to the gold standard complete diagnostic autopsy for identifying specific causes of childhood deaths. We investigated the utility of MITS, interpreted with available clinical data, for attributing underlying and immediate causes of neonatal deaths. METHODS: This prospective, observational pilot study enrolled neonatal deaths at Chris Hani Baragwanath Academic Hospital in Soweto, South Africa. The MITS included needle core-biopsy sampling for histopathology of brain, lung, and liver tissue. Microbiological culture and/or molecular tests were performed on lung, liver, blood, cerebrospinal fluid, and stool samples. The "underlying" and "immediate" causes of death (CoD) were determined for each case by an international panel of 12-15 medical specialists. RESULTS: We enrolled 153 neonatal deaths, 106 aged 3-28 days. Leading underlying CoD included "complications of prematurity" (52.9%), "complications of intrapartum events" (15.0%), "congenital malformations" (13.1%), and "infection related" (9.8%). Overall, infections were the immediate or underlying CoD in 57.5% (n = 88) of all neonatal deaths, including the immediate CoD in 70.4% (58/81) of neonates with "complications of prematurity" as the underlying cause. Overall, 74.4% of 90 infection-related deaths were hospital acquired, mainly due to multidrug-resistant Acinetobacter baumannii (52.2%), Klebsiella pneumoniae (22.4%), and Staphylococcus aureus (20.9%). Streptococcus agalactiae was the most common pathogen (5/15 [33.3%]) among deaths with "infections" as the underlying cause. CONCLUSIONS: MITS has potential to address the knowledge gap on specific causes of neonatal mortality. In our setting, this included the hitherto underrecognized dominant role of hospital-acquired multidrug-resistant bacterial infections as the leading immediate cause of neonatal deaths. |
Investigating the feasibility of child mortality surveillance with postmortem tissue sampling: Generating constructs and variables to strengthen validity and reliability in qualitative research
O'Mara Sage E , Munguambe KR , Blevins J , Guilaze R , Kosia B , Maixenchs M , Bassat Q , Mandomando I , Kaiser R , Kone A , Jambai A , Myburgh ND , Ngwenya N , Madhi SA , Degefa K , Ackley C , Breiman RF , Raghunathan PL . Clin Infect Dis 2019 69 S291-s301 BACKGROUND: The Child Health and Mortality Prevention Surveillance (CHAMPS) network aims to generate reliable data on the causes of death among children aged <5 years using all available information, including minimally invasive tissue sampling (MITS). The sensitive nature of MITS inevitably evokes religious, cultural, and ethical questions influencing the feasibility and sustainability of CHAMPS. METHODS: Due to limited behavioral studies related to child MITS, we developed an innovative qualitative methodology to determine the barriers, facilitators, and other factors that affect the implementation and sustainability of CHAMPS surveillance across 7 diverse locations in sub-Saharan Africa and South Asia. We employed a multimethod grounded theory approach and analytical structure based on culturally specific conceptual frameworks. The methodology guided data interpretation and collective analyses confirming how to define dimensions of CHAMPS feasibility within the cultural context of each site while reducing subjectivity and bias in the process of interpretation and reporting. RESULTS: Findings showed that the approach to gain consent to conduct the MITS procedure involves religious factors associated with timing of burial, use of certain terminology, and methods of transporting the body. Community misperceptions and uncertainties resulted in rumor surveillance and consistency in information sharing. Religious pronouncements, recognition of health priorities, attention to pregnancy, and advancement of child health facilitated community acceptability. CONCLUSIONS: These findings helped formulate program priorities, guided site-specific adaptations in surveillance procedures, and verified inferences drawn from CHAMPS epidemiological and formative research data. Results informed appropriate community sensitization and engagement activities for introducing and sustaining mortality surveillance, including MITS. |
Illuminating child mortality: Discovering why children die
Raghunathan PL , Madhi SA , Breiman RF . Clin Infect Dis 2019 69 S257-s259 Current understanding of the causes of under-5 childhood deaths in low- and middle-income countries relies heavily on country-level vital registration data and verbal autopsies. Reliable data on specific causes of deaths are crucial to target interventions more effectively and achieve rapid reductions in under-5 mortality. The Child Health and Mortality Prevention Surveillance (CHAMPS) network aims to systematically describe causes of child death and stillbirth in low- and middle-income countries using minimally invasive tissue sampling. The articles in this supplement introduce the set of foundational epidemiologic, demographic surveillance, social behavioral science, and laboratory methods. Undergirding the CHAMPS surveillance system designed to determine causes of child mortality. |
Mortality surveillance methods to identify and characterize deaths in Child Health and Mortality Prevention Surveillance Network sites
Salzberg NT , Sivalogan K , Bassat Q , Taylor AW , Adedini S , El Arifeen S , Assefa N , Blau DM , Chawana R , Cain CJ , Cain KP , Caneer JP , Garel M , Gurley ES , Kaiser R , Kotloff KL , Mandomando I , Morris T , Nyamthimba Onyango P , Sazzad HMS , Scott JAG , Seale AC , Sitoe A , Sow SO , Tapia MD , Whitney EA , Worrell MC , Zielinski-Gutierrez E , Madhi SA , Raghunathan PL , Koplan JP , Breiman RF . Clin Infect Dis 2019 69 S262-s273 Despite reductions over the past 2 decades, childhood mortality remains high in low- and middle-income countries in sub-Saharan Africa and South Asia. In these settings, children often die at home, without contact with the health system, and are neither accounted for, nor attributed with a cause of death. In addition, when cause of death determinations occur, they often use nonspecific methods. Consequently, findings from models currently utilized to build national and global estimates of causes of death are associated with substantial uncertainty. Higher-quality data would enable stakeholders to effectively target interventions for the leading causes of childhood mortality, a critical component to achieving the Sustainable Development Goals by eliminating preventable perinatal and childhood deaths. The Child Health and Mortality Prevention Surveillance (CHAMPS) Network tracks the causes of under-5 mortality and stillbirths at sites in sub-Saharan Africa and South Asia through comprehensive mortality surveillance, utilizing minimally invasive tissue sampling (MITS), postmortem laboratory and pathology testing, verbal autopsy, and clinical and demographic data. CHAMPS sites have established facility- and community-based mortality notification systems, which aim to report potentially eligible deaths, defined as under-5 deaths and stillbirths within a defined catchment area, within 24-36 hours so that MITS can be conducted quickly after death. Where MITS has been conducted, a final cause of death is determined by an expert review panel. Data on cause of death will be provided to local, national, and global stakeholders to inform strategies to reduce perinatal and childhood mortality in sub-Saharan Africa and South Asia. |
Reporting deaths among children aged <5 years after the Ebola virus disease epidemic - Bombali District, Sierra Leone, 2015-2016
Wilkinson AL , Kaiser R , Jalloh MF , Kamara M , Blau DM , Raghunathan PL , Kamara A , Kamara U , Houston-Suluku N , Clarke K , Jambai A , Redd JT , Hersey S , Osaio-Kamara B . MMWR Morb Mortal Wkly Rep 2017 66 (41) 1116-1118 Mortality surveillance and vital registration are limited in Sierra Leone, a country with one of the highest mortality rates among children aged <5 years worldwide, approximately 120 deaths per 1,000 live births (1,2). To inform efforts to strengthen surveillance, stillbirths and deaths in children aged <5 years from multiple surveillance streams in Bombali Sebora chiefdom were retrospectively reviewed. In total, during January 2015-November 2016, 930 deaths in children aged <5 years were identified, representing 73.3% of the 1,269 deaths that were expected based on modeled estimates. The "117" telephone alert system established during the Ebola virus disease (Ebola) epidemic captured 683 (73.4%) of all reported deaths in children aged <5 years, and was the predominant reporting source for stillbirths (n = 172). In the absence of complete vital events registration, 117 call alerts markedly improved the completeness of reporting of stillbirths and deaths in children aged <5 years. |
Knowledge, attitudes, and practices related to Ebola virus disease at the end of a national epidemic - Guinea, August 2015
Jalloh MF , Robinson SJ , Corker J , Li W , Irwin K , Barry AM , Ntuba PN , Diallo AA , Jalloh MB , Nyuma J , Sellu M , VanSteelandt A , Ramsden M , Tracy L , Raghunathan PL , Redd JT , Martel L , Marston B , Bunnell R . MMWR Morb Mortal Wkly Rep 2017 66 (41) 1109-1115 Health communication and social mobilization efforts to improve the public's knowledge, attitudes, and practices (KAP) regarding Ebola virus disease (Ebola) were important in controlling the 2014-2016 Ebola epidemic in Guinea (1), which resulted in 3,814 reported Ebola cases and 2,544 deaths.* Most Ebola cases in Guinea resulted from the washing and touching of persons and corpses infected with Ebola without adequate infection control precautions at home, at funerals, and in health facilities (2,3). As the 18-month epidemic waned in August 2015, Ebola KAP were assessed in a survey among residents of Guinea recruited through multistage cluster sampling procedures in the nation's eight administrative regions (Boke, Conakry, Faranah, Kankan, Kindia, Labe, Mamou, and Nzerekore). Nearly all participants (92%) were aware of Ebola prevention measures, but 27% believed that Ebola could be transmitted by ambient air, and 49% believed they could protect themselves from Ebola by avoiding mosquito bites. Of the participants, 95% reported taking actions to avoid getting Ebola, especially more frequent handwashing (93%). Nearly all participants (91%) indicated they would send relatives with suspected Ebola to Ebola treatment centers, and 89% said they would engage special Ebola burial teams to remove corpses with suspected Ebola from homes. Of the participants, 66% said they would prefer to observe an Ebola-affected corpse from a safe distance at burials rather than practice traditional funeral rites involving corpse contact. The findings were used to guide the ongoing epidemic response and recovery efforts, including health communication, social mobilization, and planning, to prevent and respond to future outbreaks or sporadic cases of Ebola. |
Attitudes about vaccines to prevent Ebola virus disease in Guinea at the end of a large Ebola epidemic: Results of a national household survey
Irwin KL , Jalloh MF , Corker J , Alpha Mahmoud B , Robinson SJ , Li W , James NE , Sellu M , Jalloh MB , Diallo AA , Tracy L , Hajjeh R , VanSteelandt A , Bunnell R , Martel L , Raghunathan PL , Marston B . Vaccine 2017 35 6915-6923 INTRODUCTION: In 2014-2016, an Ebola epidemic devastated Guinea; more than 3800 cases and 2500 deaths were reported to the World Health Organization. In August 2015, as the epidemic waned and clinical trials of an experimental, Ebola vaccine continued in Guinea and neighboring Sierra Leone, we conducted a national household survey about Ebola-related knowledge, attitudes, and practices (KAP) and opinions about "hypothetical" Ebola vaccines. METHODS: Using cluster-randomized sampling, we selected participants aged 15+ years old in Guinea's 8 administrative regions, which had varied cumulative case counts. The questionnaire assessed socio-demographic characteristics, experiences during the epidemic, Ebola-related KAP, and Ebola vaccine attitudes. To assess the potential for Ebola vaccine introduction in Guinea, we examined the association between vaccine attitudes and participants' characteristics using categorical and multivariable analyses. RESULTS: Of 6699 persons invited to participate, 94% responded to at least 1 Ebola vaccine question. Most agreed that vaccines were needed to fight the epidemic (85.8%) and that their family would accept safe, effective Ebola vaccines if they became available in Guinea (84.2%). These measures of interest and acceptability were significantly more common among participants who were male, wealthier, more educated, and lived with young children who had received routine vaccines. Interest and acceptability were also significantly higher among participants who understood Ebola transmission modes, had witnessed Ebola response teams, knew Ebola-affected persons, believed Ebola was not always fatal, and would access Ebola treatment centers. In multivariable analyses of the majority of participants living with young children, interest and acceptability were significantly higher among those living with vaccinated children than among those living with unvaccinated children. DISCUSSION: The high acceptability of hypothetical vaccines indicates strong potential for introducing Ebola vaccines across Guinea. Strategies to build public confidence in use of Ebola vaccines should highlight any similarities with safe, effective vaccines routinely used in Guinea. |
Transitioning to country ownership of HIV programs in Rwanda
Binagwaho A , Kankindi I , Kayirangwa E , Nyemazi JP , Nsanzimana S , Morales F , Kadende-Kaiser R , Scott KW , Mugisha V , Sahabo R , Baribwira C , Isanhart L , Asiimwe A , El-Sadr WM , Raghunathan PL . PLoS Med 2016 13 (8) e1002075 Agnes Binagwaho and colleagues describe how Rwanda achieved country ownership of its HIV programs. |
Evolution of couples' voluntary counseling and testing for HIV in Rwanda: from research to public health practice
Karita E , Nsanzimana S , Ndagije F , Wall KM , Mukamuyango J , Mugwaneza P , Remera E , Raghunathan PL , Bayingana R , Kayitenkore K , Bekan-Homawoo B , Tichacek A , Allen S . J Acquir Immune Defic Syndr 2016 73 (3) e51-e58 BACKGROUND: Couples' Voluntary HIV Counseling and Testing (CVCT) is a WHO-recommended intervention for prevention of heterosexual HIV transmission which very few African couples have received. We report the successful nationwide implementation of CVCT in Rwanda. METHODS: From 1988-1994, pregnant and post-partum women were tested for HIV and requested testing for their husbands. Partner testing was associated with more condom use and lower HIV and STI rates, particularly among HIV discordant couples. After the 1994 genocide, the research team continued to refine CVCT procedures in Zambia. These were re-introduced to Rwanda in 2001 and continually tested and improved. In 2003, the Government of Rwanda (GoR) established targets for partner testing among pregnant women, with the proportion rising from 16% in 2003 to 84% in 2008 as the PMTCT program expanded to >400 clinics. In 2009 the GoR adopted joint post-test counseling procedures, and in 2010 a quarterly follow-up program was established in government clinics with training and technical assistance. An estimated 80-90% of Rwandan couples have now been jointly counseled and tested resulting in prevention of >70% of new HIV infections. CONCLUSION: Rwanda is the first African country to have established CVCT as standard of care in ANC. More than 20 countries have sent providers to Rwanda for CVCT training. To duplicate Rwanda's success, training and technical assistance must be part of a coordinated effort to set national targets, timelines, indicators and budgets. Governments, bilateral and multilateral funding agencies must jointly prioritize CVCT for prevention of new HIV infections. |
CDC's response to the 2014-2016 Ebola epidemic - Guinea, Liberia, and Sierra Leone
Dahl BA , Kinzer MH , Raghunathan PL , Christie A , De Cock KM , Mahoney F , Bennett SD , Hersey S , Morgan OW . MMWR Suppl 2016 65 (3) 12-20 CDC's response to the 2014-2016 Ebola virus disease (Ebola) epidemic in West Africa was the largest in the agency's history and occurred in a geographic area where CDC had little operational presence. Approximately 1,450 CDC responders were deployed to Guinea, Liberia, and Sierra Leone since the start of the response in July 2014 to the end of the response at the end of March 2016, including 455 persons with repeat deployments. The responses undertaken in each country shared some similarities but also required unique strategies specific to individual country needs. The size and duration of the response challenged CDC in several ways, particularly with regard to staffing. The lessons learned from this epidemic will strengthen CDC's ability to respond to future public health emergencies. These lessons include the importance of ongoing partnerships with ministries of health in resource-limited countries and regions, a cadre of trained CDC staff who are ready to be deployed, and development of ongoing working relationships with U.S. government agencies and other multilateral and nongovernment organizations that deploy for international public health emergencies. CDC's establishment of a Global Rapid Response Team in June 2015 is anticipated to meet some of these challenges. The activities summarized in this report would not have been possible without collaboration with many U.S. and international partners (http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/partners.html). |
A mixed outbreak of epidemic typhus fever and trench fever in a youth rehabilitation center: Risk factors for illness from a case-control study, Rwanda, 2012
Umulisa I , Omolo J , Muldoon KA , Condo J , Habiyaremye F , Uwimana JM , Muhimpundu MA , Galgalo T , Rwunganira S , Dahourou AG , Tongren E , Koama JB , McQuiston J , Raghunathan PL , Massung R , Gatei W , Boer K , Nyatanyi T , Mills EJ , Binagwaho A . Am J Trop Med Hyg 2016 95 (2) 452-6 In August 2012, laboratory tests confirmed a mixed outbreak of epidemic typhus fever and trench fever in a male youth rehabilitation center in western Rwanda. Seventy-six suspected cases and 118 controls were enrolled into an unmatched case-control study to identify risk factors for symptomatic illness during the outbreak. A suspected case was fever or history of fever, from April 2012, in a resident of the rehabilitation center. In total, 199 suspected cases from a population of 1,910 male youth (attack rate = 10.4%) with seven deaths (case fatality rate = 3.5%) were reported. After multivariate analysis, history of seeing lice in clothing (adjusted odds ratio [aOR] = 2.6, 95% confidence interval [CI] = 1.1-5.8), delayed (≥ 2 days) washing of clothing (aOR = 4.0, 95% CI = 1.6-9.6), and delayed (≥ 1 month) washing of beddings (aOR = 4.6, 95% CI = 2.0-11) were associated with illness, whereas having stayed in the rehabilitation camp for ≥ 6 months was protective (aOR = 0.20, 95% CI = 0.10-0.40). Stronger surveillance and improvements in hygiene could prevent future outbreaks. |
"Research participants want to feel they are better off than they were before research was introduced to them": engaging Cameroonian rural plantation populations in HIV research
Kiawi E , McLellan-Lemal E , Mosoko J , Chillag K , Raghunathan PL . BMC Int Health Hum Rights 2012 12 8 BACKGROUND: During a period of evolving international consensus on how to engage communities in research, facilitators and barriers to participation in HIV prevention research were explored in a rural plantation community in the coastal region of Cameroon. METHODS: A formative rapid assessment using structured observations, focus group discussions (FGD), and key informant interviews (KIIs) was conducted with a purposive non-probabilistic sample of plantation workers and their household members. Eligibility criteria included living or working >1 year within the plantation community and age >18 years. Both rapid and in-depth techniques were used to complete thematic analysis. RESULTS: Sixty-five persons participated in the study (6 FGDs and 12 KIIs). Participants viewed malaria and gastrointestinal conditions as more common health concerns than HIV. They identified three factors as contributing to HIV risk: concurrent sexual relationships, sex work, and infrequent condom use. Interviewees perceived that the community would participate in HIV research if it is designed to: (1) improve community welfare, (2) provide comprehensive health services and treatment for illnesses, (3) protect the personal information of participants, especially those who test positive for HIV, (4) provide participant incentives, (5) incorporate community input, and (6) minimize disruptions to "everyday life". Barriers to participation included: (1) fear of HIV testing, (2) mistrust of researchers given possible disrespect or intolerance of plantation community life and lack of concern for communication, (3) time commitment demands, (3) medical care and treatment that would be difficult or costly to access, and (4) life disruptions along with potential requirements for changes in behaviour (i.e., engage in or abstain from alcohol use and sex activities). CONCLUSIONS: Consistent with UNAIDS guidelines for good participatory practice in HIV prevention research, study participants placed a high premium on researchers' politeness, trust, respect, communication, tolerance and empathy towards their community. Plantation community members viewed provision of comprehensive health services as an important community benefit likely to enhance HIV research participation. |
Cell phone- and internet-based monitoring and evaluation of the national antiretroviral treatment program during rapid scale-up in Rwanda: TRACnet, 2004--2010
Nsanzimana S , Ruton H , Lowrance DW , Cishahayo S , Nyemazi JP , Muhayimpundu R , Karema C , Raghunathan PL , Binagwaho A , Riedel DJ . J Acquir Immune Defic Syndr 2011 59 (2) e17-23 BACKGROUND: Monitoring and evaluation of antiretroviral treatment (ART) scale-up has been challenging in resource-limited settings. We describe an innovative cell-phone and internet-based reporting system (TRACnet) utilized in Rwanda. METHODS: From January 2004 to June 30, 2010, all health facilities with ART services submitted standardized monthly aggregate reports of key indicators. National cohort data were analyzed to examine trends in characteristics of patients initiating ART and cumulative cohort outcomes. Estimates of HIV-infected patients eligible for ART were obtained from UNAIDS (EPP-Spectrum, 2010). RESULTS: By June 30, 2010, 295 (65%) of 451 health centers, District and referral hospitals provided ART services; of these, 255 (86%) were located outside Kigali, the capital. Cell-phone- and internet-based reporting was used by 253 (86%) and 42 (14%), respectively. As of June 30, 2010, 83,041 patients were alive on ART, 6,171 (6%) had died, and 9,621 (10%) were lost-to-follow-up. Of those alive on ART, 7,111 (8.6%) were children, 50,971 (61.4%) were female, and 1,823 (2.2%) were on a second-line regimen. The proportion of all patients initiating ART at WHO clinical stages 3 and 4 declined from 65% in 2005 to 27% in 2010. National ART coverage of eligible patients increased from 13% in 2005 to 79% in 2010. CONCLUSIONS: Rwanda has successfully expanded ART access and achieved high national ART coverage among eligible patients. TRACnet captured essential data about the ART program during rapid scale-up. Cell-phone and internet-based reporting may be useful for monitoring and evaluation of similar public health initiatives in other resource-limited settings. |
Retention in an antiretroviral therapy programme during an era of decreasing drug cost in Limbe, Cameroon
Mosoko JJ , Akam W , Weidle PJ , Brooks JT , Aweh AJ , Kinge TN , Pals S , Raghunathan PL . J Int AIDS Soc 2011 14 32 BACKGROUND: In 2002, Cameroon initiated scale up of antiretroviral therapy (ART); on 1 October 2004, a substantial reduction in ART cost occurred. We assessed the impact of this event and other factors on enrolment and retention in care among HIV-infected patients initiating ART from February 2002 to December 2005 at the single ART clinic serving the Southwest Region in Limbe, Cameroon. METHODS: We retrospectively analyzed clinical and pharmacy payment records of HIV-infected patients initiating ART according to national guidelines. We compared two cohorts of patients, enrolled before and after 1 October 2004, to determine if price reduction was associated with enhanced enrolment. We assessed factors associated with retention and survival by Cox proportional hazards models. Retention in care implied patients who had contact with the healthcare system as of 31 December 2005 (including those who were transferred to continue care in other ART centres), although these patients may have interrupted therapy at some time. A patient who was not retained in care may have dropped out (lost to follow up) or died. RESULTS: Mean enrolment rates for 2920 patients who initiated ART before and after the price reduction were 46.5 and 95.5 persons/month, respectively (p < 0.001). The probabilities of remaining alive and in care were 0.66 (95% CI 0.64-0.68) at six months, 0.58 (95% CI 0.56-0.60) at one year, 0.47 (95% CI 0.45-0.49) at two years and 0.35 (95% CI 0.32-0.38) at three years; they were not significantly different between the two cohorts of patients enrolled before and after the price reduction over the first 15 months of comparable follow up (hazard ratio 1.1; 95% CI 0.9-1.2, p = 0.27). In multivariable analysis using multiple imputations to compensate for missing values, factors associated with dropping out of care or dying were male gender (HR 1.33 [1.18-1.50], p = 0.003), treatment paid by self, family or partly by other (HR 3.05 [1.99-4.67], p < 0.001), and, compared with residents of Limbe, living more than 150 km from Limbe (HR 1.41 [1.18-1.69], p < 0.001), or being residents of Douala (HR 1.51 [1.16-1.98], p < 0.001). CONCLUSIONS: Reducing the cost of ART increased enrolment of clients in the programme, but did not change retention in care. In a system where most clients pay for ART, an accessible clinic location may be more important than the cost of medication for retention in care. Decentralizing ART clinics might improve retention and survival among patients on ART. |
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