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Wirth J.P.,GroundWork | Petry N.,GroundWork | Tanumihardjo S.A.,University of Wisconsin - Madison | Rogers L.M.,World Health Organization | And 5 more authors.
Nutrients | Year: 2017

Vitamin A supplementation (VAS) programs targeted at children aged 6–59 months are implemented in many countries. By improving immune function, vitamin A (VA) reduces mortality associated with measles, diarrhea, and other illnesses. There is currently a debate regarding the relevance of VAS, but amidst the debate, researchers acknowledge that the majority of nationally-representative data on VA status is outdated. To address this data gap and contribute to the debate, we examined data from 82 countries implementing VAS programs, identified other VA programs, and assessed the recentness of national VA deficiency (VAD) data. We found that two-thirds of the countries explored either have no VAD data or data that were >10 years old (i.e., measured before 2006), which included twenty countries with VAS coverage ≥70%. Fifty-one VAS programs were implemented in parallel with at least one other VA intervention, and of these, 27 countries either had no VAD data or data collected in 2005 or earlier. To fill these gaps in VAD data, countries implementing VAS and other VA interventions should measure VA status in children at least every 10 years. At the same time, the coverage of VA interventions can also be measured. We identified three countries that have scaled down VAS, but given the lack of VA deficiency data, this would be a premature undertaking in most countries without appropriate status assessment. While the global debate about VAS is important, more attention should be directed towards individual countries where programmatic decisions are made. © 2017 by the authors. Licensee MDPI, Basel, Switzerland.


Moxon S.G.,London School of Hygiene and Tropical Medicine | Lawn J.E.,London School of Hygiene and Tropical Medicine | Dickson K.E.,UNICEF Headquarters | Simen-Kapeu A.,UNICEF Headquarters | And 8 more authors.
BMC Pregnancy and Childbirth | Year: 2015

Background: Preterm birth is the leading cause of child death worldwide. Small and sick newborns require timely, high-quality inpatient care to survive. This includes provision of warmth, feeding support, safe oxygen therapy and effective phototherapy with prevention and treatment of infections. Inpatient care for newborns requires dedicated ward space, staffed by health workers with specialist training and skills. Many of the estimated 2.8 million newborns that die every year do not have access to such specialised care. Methods: The bottleneck analysis tool was applied in 12 countries in Africa and Asia as part of the Every Newborn Action Plan process. Country workshops involved technical experts to complete the survey tool, which is designed to synthesise and grade health system "bottlenecks" (or factors that hinder the scale up) of maternal-newborn intervention packages. For this paper, we used quantitative and qualitative methods to analyse the bottleneck data, and combined these with literature review, to present priority bottlenecks and actions relevant to different health system building blocks for inpatient care of small and sick newborns. Results: Inpatient care of small and sick newborns is an intervention package highlighted by all country workshop participants as having critical health system challenges. Health system building blocks with the highest graded (significant or major) bottlenecks were health workforce (10 out of 12 countries) and health financing (10 out of 12 countries), followed by community ownership and partnership (9 out of 12 countries). Priority actions based on solution themes for these bottlenecks are discussed. Conclusions: Whilst major bottlenecks to the scale-up of quality inpatient newborn care are present, effective solutions exist. For all countries included, there is a critical need for a neonatal nursing cadre. Small and sick newborns require increased, sustained funding with specific insurance schemes to cover inpatient care and avoid catastrophic out-of-pocket payments. Core competencies, by level of care, should be defined for monitoring of newborn inpatient care, as with emergency obstetric care. Rather than fatalism that small and sick newborns will die, community interventions need to create demand for accessible, high-quality, family-centred inpatient care, including kangaroo mother care, so that every newborn can survive and thrive. © 2015 Moxon et al.


PubMed | Biostatistics., Boston Childrens Hospital, Muhimbili University of Health and Allied Sciences, Epidemiology and Global Health and Population and UNICEF Headquarters
Type: Journal Article | Journal: The American journal of clinical nutrition | Year: 2016

Poor child growth increases risks of mortality and morbidity. Micronutrient supplements have the potential to improve child growth.We assessed the effect of daily zinc, multivitamin (vitamins C, E, and B-complex), and zinc and multivitamin (Zn+MV) supplementation on growth in infants in Tanzania.In this randomized, 2 2 factorial, double-blind trial, 2400 infants were randomly assigned to receive zinc, multivitamins, Zn+MVs, or a placebo at 6 wk of age and were followed up for 18 mo with monthly growth measurements. Mixed-effects models with restricted cubic splines for the mean change in anthropometric z scores were fit for each group. Likelihood ratio tests were used to compare the effect of supplements on growth trajectories. Cox proportional hazards models were used to compare incidences of stunting, wasting, and underweight.Children in all groups experienced growth faltering. At 19 mo of age, prevalences of stunting, wasting, and underweight were 19.8%, 6.0%, and 10.8%, respectively. Changes in weight-for-age z scores (WAZs) and weight-for-height z scores (WHZs) were significantly different across the 4 groups (P < 0.001 for both). The mean SE decline in the WAZ from baseline to the end of follow-up in the Zn+MV group was significantly less than in the placebo group (-0.36 0.04 compared with -0.50 0.04; P = 0.020), whereas the decline in the WHZ was significantly greater in the zinc-only group than in the placebo group (-0.57 0.07 compared with -0.35 0.07; P = 0.021). Supplements did not have a significant effect on mean change in the height-for-age z score or on rates of stunting, wasting, or underweight.Although there were small but significant improvements in the WAZ in the Zn+MV group, daily zinc supplementation alone, multivitamin supplementation alone, and the combined Zn+MV did not reduce the incidences of underweight, stunting, or wasting in Tanzanian infants. Alternative approaches to prevent growth faltering should be pursued. This trial was registered at clinicaltrials.gov as NCT00421668.


PubMed | Helen Keller International Headquarters, Bill and Melinda Gates Foundation, UNICEF Headquarters, Helen Keller International Africa Regional Office and 2 more.
Type: | Journal: Food and nutrition bulletin | Year: 2016

Vitamin A supplementation (VAS) among children 6 to 59 months of age reduces vitamin A deficiency (VAD)-related mortality. Child health days (CHDs) only reach an estimated 16.7% of children at exactly 6 months, leaving uncovered children at risk of VAD-related mortality; similarly, VAS provided at 9 months of age with measles-containing vaccine leaves infants unprotected for 3 months.Using data from sub-Saharan Africa, we estimated the mortality benefits and safety of providing VAS at age 6 months, compared to delivery through CHDs and at 9 months.We modeled VAS-preventable mortality benefits at 6 months as a function of published VAS effect sizes, intervention coverage, and proportion of infant deaths occurring between 6 and 11 months. To evaluate safety, we modeled the effect of different VAS coverage scenarios on maximum hepatic vitamin A concentrations (HVACs).VAS linked to a 6-month visit could reduce infant mortality by an additional 1.95 (95% confidence interval [CI]: 1.38-2.52) and 1.63 (95% CI: 1.15-2.11) percentage points compared to VAS through CHDs and at 9 months, respectively. The HVAC models indicate that VAS at 6 months is safe even in the presence of a second VAS dose 1 month later and other food-based vitamin A control strategies.Advancing the first VAS dose to 6 months should be considered in settings where VAS is currently given first at 9 months. A 6-month VAS dose should also be considered in settings where VAS is delivered through CHDs. VAS delivery at 6 months could also serve as a platform to deliver other high-impact interventions.


PubMed | UNICEF China Country Office, U.S. Center for Disease Control and Prevention, Peking University and UNICEF Headquarters
Type: Journal Article | Journal: BMJ open | Year: 2016

To evaluate interventions to improve routine vaccination coverage and caregiver knowledge in Chinas remote west, where routine immunisation is relatively weak.Prospective pre-post (2006-2010) evaluation in project counties; retrospective comparison based on 2004 administrative data at baseline and surveyed post-intervention (2010) data in selected non-project counties.Four project counties and one non-project county in each of four provinces.3390 children in project counties at baseline, and 3299 in project and 830 in non-project counties post-intervention; and 3279 caregivers at baseline, and 3389 in project and 830 in non-project counties post-intervention.Multicomponent inexpensive knowledge-strengthening and service-strengthening and innovative, multisectoral engagement.Standard 30-cluster household surveys of vaccine coverage and caregiver interviews pre-intervention and post-intervention in each project county. Similar surveys in one non-project county selected by local authorities in each province post-intervention. Administrative data on vaccination coverage in non-project counties at baseline.Changes in vaccine coverage between baseline and project completion (2010); comparative caregiver knowledge in all counties in 2010.Crude ((2)) analysis of changes and differences in vaccination coverage and related knowledge. Multiple logistic regression to assess associations with timely coverage.Timely coverage of four routine vaccines increased by 21% (p<0.001) and hepatitis B (HepB) birth dose by 35% (p<0.001) over baseline in project counties. Comparison with non-project counties revealed secular improvement in most provinces, except new vaccine coverage was mostly higher in project counties. Ethnicity, province, birthplace, vaccination site, dual-parental out-migration and parental knowledge had significant associations with coverage. Knowledge increased for all variables but one in project counties (highest p<0.05) and was substantially higher than in non-project counties (p<0.01).Comprehensive but inexpensive strategies improved vaccination coverage and caretaker knowledge in western China. Establishing multisectoral leadership, involving the education sector and including immunisation in public-sector performance standards, are affordable and effective interventions.


PubMed | London School of Hygiene and Tropical Medicine, World Health Organization, Womens Health and Development, EnCompass LLC and 10 more.
Type: Journal Article | Journal: Lancet (London, England) | Year: 2016

Efforts to achieve the new worldwide goals for maternal and child survival will also prevent stillbirth and improve health and developmental outcomes. However, the number of annual stillbirths remains unchanged since 2011 and is unacceptably high: an estimated 2.6 million in 2015. Failure to consistently include global targets or indicators for stillbirth in post-2015 initiatives shows that stillbirths are hidden in the worldwide agenda. This Series paper summarises findings from previous papers in this Series, presents new analyses, and proposes specific criteria for successful integration of stillbirths into post-2015 initiatives for womens and childrens health. Five priority areas to change the stillbirth trend include intentional leadership; increased voice, especially of women; implementation of integrated interventions with commensurate investment; indicators to measure effect of interventions and especially to monitor progress; and investigation into crucial knowledge gaps. The post-2015 agenda represents opportunities for all stakeholders to act together to end all preventable deaths, including stillbirths.


Zimmermann M.B.,ETH Zurich | Aeberli I.,ETH Zurich | Andersson M.,ETH Zurich | Assey V.,Tanzanian Food and Nutrition Center | And 9 more authors.
Journal of Clinical Endocrinology and Metabolism | Year: 2013

Context: The median urinary iodine concentration (UIC) is a biomarker of iodine intake. According to the World Health Organization, a median UIC in the range 100-199 μg/L indicates adequate and 200-299 μg/L more than adequate intake. Thyroglobulin (Tg) may be a promising functional biomarker of both iodine deficiency and excess. Objectives: Using a standardized dried blood spots-Tg assay in children, we evaluated the Tg response to bothlow-and high-iodine intake and estimated the population cut off point for iodine deficiency or excess. Also, we compared thyroid functions within the UIC ranges of 100-199 vs 200-299 μg/L. Design and Setting: We conducted a cross-sectional study in primary schools in 12 countries. Subjects: Subjects were 6 to 12 years old (n = 2512). Main Outcome Measures: We measured UIC, TSH, total T4, Tg, and thyroid antibodies. Results: Over a range of iodine intakes from severely deficient to excessive, Tg concentrations showed a clear U-shaped curve. Compared with iodine-sufficient children, there was a significantly higher prevalence of elevated Tg values in children with iodine deficiency (UIC<100 μg/L) and iodine excess (UIC>300 μg/L). There was no significant change in the prevalence of elevated Tg, TSH, T4, or thyroid antibodies comparing children within the UIC ranges of 100-199 vs 200-299 μg/L. Conclusions: In school-aged children, 1) Tg is a sensitive indicator of both low and excess iodine intake; 2) a median Tg of <13 μg/L and/or <3% of Tg values >40 μg/L indicates iodine sufficiency in the population; 3) the acceptable range of median UIC in monitoring iodized salt programs could be widened to a single category of sufficient iodine intake from 100 to 299 μg/L. Copyright © 2013 by The Endocrine Society.


Sharma G.,London School of Hygiene and Tropical Medicine | Mathai M.,World Health Organization | Dickson K.E.,UNICEF Headquarters | Weeks A.,University of Liverpool | And 7 more authors.
BMC Pregnancy and Childbirth | Year: 2015

Background: Good outcomes during pregnancy and childbirth are related to availability, utilisation and effective implementation of essential interventions for labour and childbirth. The majority of the estimated 289,000 maternal deaths, 2.8 million neonatal deaths and 2.6 million stillbirths every year could be prevented by improving access to and scaling up quality care during labour and birth. Methods: The bottleneck analysis tool was applied in 12 countries in Africa and Asia as part of the Every Newborn Action Plan process. Country workshops engaged technical experts to complete the survey tool, which is designed to synthesise and grade health system "bottlenecks", factors that hinder the scale up, of maternal-newborn intervention packages. We used quantitative and qualitative methods to analyse the bottleneck data, combined with literature review, to present priority bottlenecks and actions relevant to different health system building blocks for skilled birth attendance and basic and comprehensive emergency obstetric care. Results: Across 12 countries the most critical bottlenecks identified by workshop participants for skilled birth attendance were health financing (10 out of 12 countries) and health workforce (9 out of 12 countries). Health service delivery bottlenecks were found to be the most critical for both basic and comprehensive emergency obstetric care (9 out of 12 countries); health financing was identified as having critical bottlenecks for comprehensive emergency obstetric care (9 out of 12 countries). Solutions to address health financing bottlenecks included strengthening national financing mechanisms and removing financial barriers to care seeking. For addressing health workforce bottlenecks, improved human resource planning is needed, including task shifting and improving training quality. For health service delivery, proposed solutions included improving quality of care and establishing public private partnerships. Conclusions: Progress towards the 2030 targets for ending preventable maternal and newborn deaths is dependent on improving quality of care during birth and the immediate postnatal period. Strengthening national health systems to improve maternal and newborn health, as a cornerstone of universal health coverage, will only be possible by addressing specific health system bottlenecks during labour and birth, including those within health workforce, health financing and health service delivery. © 2015 Sharma et al.


Van Der Haar F.,Emory University | Gerasimov G.,UNICEF Office in Moscow | Tyler V.Q.,UNICEF Regional Office of Central and Eastern Europe | Timmer A.,UNICEF Headquarters
Food and Nutrition Bulletin | Year: 2011

Background : By 2000, the global track record on universal salt iodization (USI) indicated 26% access to adequately iodized salt in the Central and Eastern Europe, Commonwealth of Independent States (CEE/ CIS) Region. Objective: Aimed at extracting lessons learned, this study examined experiences, achievements, and outcomes of USI strategies in CEE/CIS countries during the subsequent decade. Methods: Information from the design, timing, execution, outputs, multi-sector management and results of actions by national stakeholders yielded 20 country summaries. Analysis across countries used a LogFrame Analysis typical for public nutrition development. Results: By 2009, USI strategies had reached the target and population iodine nutrition shown adequate levels in 9 countries, while in 6 others, USI was close and/or population iodine status showed only minor imperfection. True USI, i.e., iodization of salt destined both for the food industry and the household, had been made mandatory in 13 of these 15 countries. In the Balkan area, USI and iodine nutrition advanced more than in CIS. Of the 20 sample countries, 17 (85%) had exceeded the mark of 50% adequate access, while the overall regional score reached 55% by 2010. Conclusions: Experience from this region suggests that strong partnership collaboration, a new concept in post- Soviet societies, was a major success factor. Voluntary iodization or focusing on household salt alone was less likely conducive for success. Achieving optimum iodine nutrition required the setting of proper iodine standards. Weak political leadership insistence in the Russian Federation and Ukraine to embrace USI is the main factor why the region remains behind in the global progress. © 2011, The United Nations University.


PubMed | World Health Organization, UNICEF, GroundWork, Helen Keller International and 2 more.
Type: Journal Article | Journal: Nutrients | Year: 2016

Salt iodization programs are a public health success in tackling iodine deficiency. Yet, a large proportion of the worlds population remains at risk for iodine deficiency. In a nationally representative cross-sectional survey in Sierra Leone, household salt samples and womens urine samples were quantitatively analyzed for iodine content. Salt was collected from 1123 households, and urine samples from 817 non-pregnant and 154 pregnant women. Household coverage with adequately iodized salt (15 mg/kg iodine) was 80.7%. The median urinary iodine concentration (UIC) of pregnant women was 175.8 g/L and of non-pregnant women 190.8 g/L. Women living in households with adequately iodized salt had higher median UIC (for pregnant women: 180.6 g/L vs. 100.8 g/L, respectively, p < 0.05; and for non-pregnant women: 211.3 g/L vs. 97.8 g/L, p < 0.001). Differences in UIC by residence, region, household wealth, and womens education were much smaller in women living in households with adequately iodized salt than in households without. Despite the high household coverage of iodized salt in Sierra Leone, it is important to reach the 20% of households not consuming adequately iodized salt. Salt iodization has the potential for increasing equity in iodine status even with the persistence of other risk factors for deficiency.

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