Mapping geographical inequalities in oral rehydration therapy coverage in low-income and middle-income countries, 2000-17

Kirsten E. Wiens, Paulina A. Lindstedt, Brigette F. Blacker, Kimberly B. Johnson, Mathew M. Baumann, Lauren E. Schaeffer, Hedayat Abbastabar, Foad Abd-Allah, Ahmed Abdelalim, Ibrahim Abdollahpour, Kedir Hussein Abegaz, Ayenew Negesse Abejie, Lucas Guimarães Abreu, Michael R.M. Abrigo, Ahmed Abualhasan, Manfred Mario Kokou Accrombessi, Dilaram Acharya, Maryam Adabi, Abdu A. Adamu, Oladimeji M. AdebayoRufus Adesoji Adedoyin, Victor Adekanmbi, Olatunji O. Adetokunboh, Beyene Meressa Adhena, Mohsen Afarideh, Sohail Ahmad, Keivan Ahmadi, Anwar E. Ahmed, Muktar Beshir Ahmed, Rushdia Ahmed, Temesgen Yihunie Akalu, Fares Alahdab, Ziyad Al-Aly, Noore Alam, Samiah Alam, Genet Melak Alamene, Turki M. Alanzi, Jacqueline Elizabeth Alcalde-Rabanal, Beriwan Abdulqadir Ali, Mehran Alijanzadeh, Vahid Alipour, Syed Mohamed Aljunid, Ali Almasi, Amir Almasi-Hashiani, Hesham M. Al-Mekhlafi, Khalid A. Altirkawi, Nelson Alvis-Guzman, Nelson J. Alvis-Zakzuk, Saeed Amini, Arianna Maever L. Amit, Catalina Liliana Andrei, Mina Anjomshoa, Amir Anoushiravani, Fereshteh Ansari, Carl Abelardo T. Antonio, Benny Antony, Ernoiz Antriyandarti, Jalal Arabloo, Hany Mohamed Amin Aref, Olatunde Aremu, Bahram Armoon, Amit Arora, Krishna K. Aryal, Afsaneh Arzani, Mehran Asadi-Aliabadi, Hagos Tasew Atalay, Seyyed Shamsadin Athari, Seyyede Masoume Athari, Sachin R. Atre, Marcel Ausloos, Nefsu Awoke, Beatriz Paulina Ayala Quintanilla, Getinet Ayano, Martin Amogre Ayanore, Yared Asmare Aynalem, Samad Azari, Peter S. Azzopardi, Ebrahim Babaee, Tesleem Kayode Babalola, Alaa Badawi, Mohan Bairwa, Shankar M. Bakkannavar, Senthilkumar Balakrishnan, Ayele Geleto Bali, Maciej Banach, Joseph Adel Mattar Banoub, Aleksandra Barac, Till Winfried Bärnighausen, Huda Basaleem, Sanjay Basu, Vo Dinh Bay, Mohsen Bayati, Estifanos Baye, Neeraj Bedi, Mahya Beheshti, Masoud Behzadifar, Meysam Behzadifar, Bayu Begashaw Bekele, Yaschilal Muche Belayneh, Michelle L. Bell, Derrick A. Bennett, Dessalegn Ajema Berbada, Robert S. Bernstein, Anusha Ganapati Bhat, Krittika Bhattacharyya, Suraj Bhattarai, Soumyadeep Bhaumik, Zulfiqar A. Bhutta, Ali Bijani, Boris Bikbov, Binyam Minuye Birihane, Raaj Kishore Biswas, Somayeh Bohlouli, Hunduma Amensisa Bojia, Soufiane Boufous, Oliver J. Brady, Nicola Luigi Bragazzi, Andrey Nikolaevich Briko, Nikolay Ivanovich Briko, Gabrielle B. Britton, Sharath Burugina Nagaraja, Reinhard Busse, Zahid A. Butt, Luis Alberto Cámera, Ismael R. Campos-Nonato, Jorge Cano, Josip Car, Rosario Cárdenas, Felix Carvalho, Carlos A. Castañeda-Orjuela, Franz Castro, Wagaye Fentahun Chanie, Pranab Chatterjee, Vijay Kumar Chattu, Tesfaye Yitna Chichiabellu, Ken Lee Chin, Devasahayam J. Christopher, Dinh Toi Chu, Natalie Maria Cormier, Vera Marisa Costa, Carlos Culquichicon, Matiwos Soboka Daba, Giovanni Damiani, Lalit Dandona, Rakhi Dandona, Anh Kim Dang, Aso Mohammad Darwesh, Amira Hamed Darwish, Ahmad Daryani, Jai K. Das, Rajat D. Das Gupta, Aditya Prasad Dash, Gail Davey, Claudio Alberto Dávila-Cervantes, Adrian C. Davis, Dragos Virgil Davitoiu, Fernando Pio De la Hoz, Asmamaw Bizuneh Demis, Dereje Bayissa Demissie, Getu Debalkie Demissie, Gebre Teklemariam Demoz, Edgar Denova-Gutiérrez, Kebede Deribe, Assefa Desalew, Aniruddha Deshpande, Samath Dhamminda Dharmaratne, Preeti Dhillon, Meghnath Dhimal, Govinda Prasad Dhungana, Daniel Diaz, Isaac Oluwafemi Dipeolu, Shirin Djalalinia, Kerrie E. Doyle, Eleonora Dubljanin, Bereket Duko, Andre Rodrigues Duraes, Mohammad Ebrahimi Kalan, Hisham Atan Edinur, Andem Effiong, Aziz Eftekhari, Nevine El Nahas, Iman El Sayed, Maysaa El Sayed Zaki, Maha El Tantawi, Teshome Bekele Elema, Hala Rashad Elhabashy, Shaimaa I. El-Jaafary, Hajer Elkout, Aisha Elsharkawy, Iqbal R.F. Elyazar, Aklilu Endalamaw, Daniel Adane Endalew, Sharareh Eskandarieh, Alireza Esteghamati, Sadaf Esteghamati, Arash Etemadi, Oluchi Ezekannagha, Mohammad Fareed, Roghiyeh Faridnia, Farshad Farzadfar, Mehdi Fazlzadeh, Valery L. Feigin, Seyed Mohammad Fereshtehnejad, Eduarda Fernandes, Irina Filip, Florian Fischer, Nataliya A. Foigt, Morenike Oluwatoyin Folayan, Masoud Foroutan, Richard Charles Franklin, Takeshi Fukumoto, Mohamed M. Gad, Reta Tsegaye Gayesa, Teshome Gebre, Ketema Bizuwork Gebremedhin, Gebreamlak Gebremedhn Gebremeskel, Hailay Abrha Gesesew, Kebede Embaye Gezae, Keyghobad Ghadiri, Ahmad Ghashghaee, Pramesh Raj Ghimire, Paramjit Singh Gill, Tiffany K. Gill, Themba G. Ginindza, Nelson G.M. Gomes, Sameer Vali Gopalani, Alessandra C. Goulart, Bárbara Niegia Garcia Goulart, Ayman Grada, Mohammed Ibrahim Mohialdeen Gubari, Harish Chander Gugnani, Davide Guido, Rafael Alves Guimarães, Yuming Guo, Rajeev Gupta, Nima Hafezi-Nejad, Dessalegn H. Haile, Gessessew Bugssa Hailu, Arvin Haj-Mirzaian, Arya Haj-Mirzaian, Randah R. Hamadeh, Samer Hamidi, Demelash Woldeyohannes Handiso, Hamidreza Haririan, Ninuk Hariyani, Ahmed I. Hasaballah, Md Mehedi Hasan, Edris Hasanpoor, Amir Hasanzadeh, Hadi Hassankhani, Hamid Yimam Hassen, Mohamed I. Hegazy, Behzad Heibati, Behnam Heidari, Delia Hendrie, Nathaniel J. Henry, Claudiu Herteliu, Fatemeh Heydarpour, Hagos Degefa De Hidru, Thomas R. Hird, Chi Linh Hoang, Enayatollah H. Homaie Rad, Praveen Hoogar, Mohammad Hoseini, Naznin Hossain, Mostafa Hosseini, Mehdi Hosseinzadeh, Mowafa Househ, Mohamed Hsairi, Guoqing Hu, Mohammedaman Mama Hussen, Segun Emmanuel Ibitoye, Ehimario U. Igumbor, Olayinka Stephen Ilesanmi, Milena D. Ilic, Mohammad Hasan Imani-Nasab, Usman Iqbal, Seyed Sina Naghibi Irvani, Sheikh Mohammed Shariful Islam, Chinwe Juliana Iwu, Neda Izadi, Anelisa Jaca, Nader Jahanmehr, Mihajlo Jakovljevic, Amir Jalali, Achala Upendra Jayatilleke, Ravi Prakash Jha, Vivekanand Jha, John S. 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Research output: Contribution to journalArticlepeer-review

4 Scopus citations

Abstract

Background: Oral rehydration solution (ORS) is a form of oral rehydration therapy (ORT) for diarrhoea that has the potential to drastically reduce child mortality; yet, according to UNICEF estimates, less than half of children younger than 5 years with diarrhoea in low-income and middle-income countries (LMICs) received ORS in 2016. A variety of recommended home fluids (RHF) exist as alternative forms of ORT; however, it is unclear whether RHF prevent child mortality. Previous studies have shown considerable variation between countries in ORS and RHF use, but subnational variation is unknown. This study aims to produce high-resolution geospatial estimates of relative and absolute coverage of ORS, RHF, and ORT (use of either ORS or RHF) in LMICs. Methods: We used a Bayesian geostatistical model including 15 spatial covariates and data from 385 household surveys across 94 LMICs to estimate annual proportions of children younger than 5 years of age with diarrhoea who received ORS or RHF (or both) on continuous continent-wide surfaces in 2000–17, and aggregated results to policy-relevant administrative units. Additionally, we analysed geographical inequality in coverage across administrative units and estimated the number of diarrhoeal deaths averted by increased coverage over the study period. Uncertainty in the mean coverage estimates was calculated by taking 250 draws from the posterior joint distribution of the model and creating uncertainty intervals (UIs) with the 2·5th and 97·5th percentiles of those 250 draws. Findings: While ORS use among children with diarrhoea increased in some countries from 2000 to 2017, coverage remained below 50% in the majority (62·6%; 12 417 of 19 823) of second administrative-level units and an estimated 6 519 000 children (95% UI 5 254 000–7 733 000) with diarrhoea were not treated with any form of ORT in 2017. Increases in ORS use corresponded with declines in RHF in many locations, resulting in relatively constant overall ORT coverage from 2000 to 2017. Although ORS was uniformly distributed subnationally in some countries, within-country geographical inequalities persisted in others; 11 countries had at least a 50% difference in one of their units compared with the country mean. Increases in ORS use over time were correlated with declines in RHF use and in diarrhoeal mortality in many locations, and an estimated 52 230 diarrhoeal deaths (36 910–68 860) were averted by scaling up of ORS coverage between 2000 and 2017. Finally, we identified key subnational areas in Colombia, Nigeria, and Sudan as examples of where diarrhoeal mortality remains higher than average, while ORS coverage remains lower than average. Interpretation: To our knowledge, this study is the first to produce and map subnational estimates of ORS, RHF, and ORT coverage and attributable child diarrhoeal deaths across LMICs from 2000 to 2017, allowing for tracking progress over time. Our novel results, combined with detailed subnational estimates of diarrhoeal morbidity and mortality, can support subnational needs assessments aimed at furthering policy makers' understanding of within-country disparities. Over 50 years after the discovery that led to this simple, cheap, and life-saving therapy, large gains in reducing mortality could still be made by reducing geographical inequalities in ORS coverage. Funding: Bill & Melinda Gates Foundation.

Original languageEnglish (US)
Pages (from-to)e1038-e1060
JournalThe Lancet Global Health
Volume8
Issue number8
DOIs
StatePublished - Aug 2020

Bibliographical note

Funding Information:
This work was primarily supported by a grant from the Bill & Melinda Gates Foundation (OPP1132415). L G Abreu has received support from Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (Finance Code 001), Conselho Nacional de Desenvolvimento Científico e Tecnológico and Fundação de Amparo à Pesquisa do Estado de Minas Gerais. O O Adetokunboh acknowledges the South African Department of Science and Innovation and the National Research Foundation. S M Aljunid acknowledges the Department of Health Policy and Management, Faculty of Public Health, Kuwait University and International Centre for Casemix and Clinical Coding, Faculty of Medicine, National University of Malaysia for the approval and support to participate in this research project. H T Atalay acknowledges Aksum University. M Ausloos and C Herteliu are partially supported by a grant of the Romanian National Authority for Scientific Research and Innovation, CNDS-UEFISCDI, project number PN-III-P4-ID-PCCF-2016-0084. P S Azzopardi was supported by an Australian National Health and Medical Research Council (NHMRC) early career fellowship. A Badawi is supported by the Public Health Agency of Canada. T W Bärnighausen was supported by the Alexander von Humboldt Foundation through the Alexander von Humboldt Professor award, funded by the German Federal Ministry of Education and Research; the EU; the Wellcome Trust; and from National Institute of Child Health and Human Development of National Institutes of Health (NIH; R01-HD084233), National Institute on Aging of NIH (P01-AG041710), National Institute of Allergy and Infectious Diseases of NIH (R01-AI124389 and R01-AI112339), as well as Fogarty International Center of NIH (D43-TW009775). G B Britton is supported by Sistema Nacional de Investigación (SNI) de la Secretaría Nacional de Ciencia, Tecnología e Innovación (SENACYT) of Panamá. A Barac is funded by the Project of Ministry of Education, Science and Technology of the Republic of Serbia (number III45005). D A Bennett was supported by the National Institute for Health Research (NIHR) Oxford Biomedical Research Centre. The views expressed are those of the authors and not necessarily those of the National Health Service, the NIHR, or the UK Department of Health and Social Care. V M Costa acknowledges her grant (SFRH/BHD/110001/2015), received by Portuguese national funds through Fundação para a Ciência e Tecnologia (FCT), IP, under the Norma Transitória DL57/2016/CP1334/CT0006. F Carvalho acknowledges UID/MULTI/04378/2019 and UID/QUI/50006/2019 support with funding from FCT/Ministério da Ciência, Tecnologia e Ensino Superior through national funds. K Deribe is supported by a Wellcome Trust grant (number 201900/Z/16/Z) as part of his International Intermediate Fellowship. C Herteliu is partially supported by a grant co-funded by European Fund for Regional Development through the Operational Program for Competitiveness (project ID P_40_382). P Hoogar thanks Centre for Bio Cultural Studies, Directorate of Research, Manipal Academy of Higher Education, Manipal and Centre for Holistic Development and Research, Kalaghatgi-Karnataka. S M S Islam is funded by a Fellowship from National Heart Foundation of Australia and Deakin University. M Jakovljevic and the Serbian part of this GBD contribution was co-funded through grant OI175014 of the Ministry of Education Science and Technological Development of the Republic of Serbia. A P Kengne is supported by the South African Medical Research Council. Y J Kim's work was supported by the Research Management Centre, Xiamen University Malaysia, grants number XMUMRF/2018-C2/ITCM/0001. K Krishan is supported by a DST PURSE grant and UGC Center of Advanced Study awarded to the Department of Anthropology, Panjab University, Chandigarh, India. M Kumar acknowledges K43 TW010716-03. B Lacey acknowledges support from the NIHR Oxford Biomedical Research Centre and the British Heart Foundation Centre of Research Excellence, Oxford. P T N Memiah acknowledges the Council for the Development of Social Science Research in Africa. M Molokhia is supported by the NIHR Biomedical Research Center at Guy's and St Thomas' National Health Service Foundation Trust and King's College London. I Moreno Velásquez is supported by the Sistema Nacional de Investigación (SENACYT, Panamá). G C Patton is funded by an NHMRC Fellowship. A M Samy received a fellowship from the Egyptian Fulbright Mission programme. M M Santric-Milicevic acknowledges the support of the Ministry of Education, Science and Technological Development of the Republic of Serbia (contract number 175087). A Sheikh acknowledges the support of Health Data Research UK. M R Sobhiyeh acknowledges the Clinical Research Development Center of Imam Reza Hospital, Kermanshah University of Medical Sciences for their wise advice. R Tabarés-Seisdedos was supported in part by grant PI17/00719 from Instituto de Salud Carlos III–FEDER. B Unnikrishnan acknowledges Manipal Academy of Higher Education, Manipal. M R Weaver was supported by the Bill & Melinda Gates Foundation grant OPP1127433. C S Wiysonge was supported by the South African Medical Research Council.

Funding Information:
M L Bell reports grants from US Environmental Protection Agency, National Institutes of Health (NIH), and the Wellcome Trust Foundation, during the conduct of the study; and honoraria or travel reimbursement from NIH (for review of grant proposals), American Journal of Public Health (participation as editor), Global Research Laboratory and Seoul National University, Royal Society (London, UK), Ohio University, Atmospheric Chemistry Gordon Research Conference, Johns Hopkins, Bloomberg School of Public Health, Arizona State University, Ministry of the Environment, Japan, Hong Kong Polytechnic University, University of Illinois—Champaign, and University of Tennessee—Knoxville, outside of the submitted work. A Deshpande reports grants from Bill & Melinda Gates Foundation, during the conduct of the study. S M S Islam reports grants from National Heart Foundation of Australia, Institute for Physical Activity and Nutrition, and Deakin University, during the conduct of the study. V Jha reports grants from Baxter Healthcare, GlaxoSmithKline, NephroPlus, and Zydus Cadilla, and personal fees from AstraZeneca, outside of the submitted work. J J Jozwiak reports personal fees from Amgen, ALAB Laboratoria, Teva, Synexus, and Boehringer Ingelheim, outside of the submitted work. W Mendoza is a Program Analyst in Population and Development at the UN Population Fund Country Office in Peru, an institution which does not necessarily endorse this study. M J Postma holds stocks in Ingress Health and Pharmacoeconomics Advice Groningen and is advisor to Asc Academics, all pharmacoeconomic consultancy companies. M J Postma reports grants and personal fees from Merck Sharpe & Dohme, GlaxoSmithKline, Pfizer, Boehringer Ingelheim, Novavax, Bristol-Myer Squibb, AstraZeneca, Sanofi, IQVIA, Seqirus, Quintiles, Nocartis, and Pharmerit; grants from Bayer, BioMerieux, WHO, EU, FIND, Antilope, DIKTI, LPDP, and Budi; and other support from Ingress Health, Pharmacoeconomics Advice Groningen, and Asc Academics, outside of the submitted work. J A Singh reports personal fees from Crealta/Horizon, Medisys, Fidia, UBM, Trio health, Medscape, WebMD, Clinical Care options, Clearview Healthcare Partners, Putnam Associates, Spherix, Practice Point Communications, NIH, American College of Rheumatology, and Simply Speaking; other support from Amarin Pharmaceuticals and Viking Pharmaceuticals; non-financial support from US Food and Drug Administration Arthritis Advisory Committee, Steering committee of OMERACT (an international organisation that develops measures for clinical trials and receives arms-length funding from 12 pharmaceutical companies), Veterans Affairs Rheumatology Field Advisory Committee, outside of the submitted work. J A Singh is editor and director of the University of Alabama at Birmingham Cochrane Musculoskeletal Group Satellite Center on Network Meta-analysis. All other authors declare no competing interests.

Funding Information:
This work was primarily supported by a grant from the Bill & Melinda Gates Foundation (OPP1132415). L G Abreu has received support from Coordena??o de Aperfei?oamento de Pessoal de N?vel Superior (Finance Code 001), Conselho Nacional de Desenvolvimento Cient?fico e Tecnol?gico and Funda??o de Amparo ? Pesquisa do Estado de Minas Gerais. O O Adetokunboh acknowledges the South African Department of Science and Innovation and the National Research Foundation. S M Aljunid acknowledges the Department of Health Policy and Management, Faculty of Public Health, Kuwait University and International Centre for Casemix and Clinical Coding, Faculty of Medicine, National University of Malaysia for the approval and support to participate in this research project. H T Atalay acknowledges Aksum University. M Ausloos and C Herteliu are partially supported by a grant of the Romanian National Authority for Scientific Research and Innovation, CNDS-UEFISCDI, project number PN-III-P4-ID-PCCF-2016-0084. P S Azzopardi was supported by an Australian National Health and Medical Research Council (NHMRC) early career fellowship. A Badawi is supported by the Public Health Agency of Canada. T W B?rnighausen was supported by the Alexander von Humboldt Foundation through the Alexander von Humboldt Professor award, funded by the German Federal Ministry of Education and Research; the EU; the Wellcome Trust; and from National Institute of Child Health and Human Development of National Institutes of Health (NIH; R01-HD084233), National Institute on Aging of NIH (P01-AG041710), National Institute of Allergy and Infectious Diseases of NIH (R01-AI124389 and R01-AI112339), as well as Fogarty International Center of NIH (D43-TW009775). G B Britton is supported by Sistema Nacional de Investigaci?n (SNI) de la Secretar?a Nacional de Ciencia, Tecnolog?a e Innovaci?n (SENACYT) of Panam?. A Barac is funded by the Project of Ministry of Education, Science and Technology of the Republic of Serbia (number III45005). D A Bennett was supported by the National Institute for Health Research (NIHR) Oxford Biomedical Research Centre. The views expressed are those of the authors and not necessarily those of the National Health Service, the NIHR, or the UK Department of Health and Social Care. V M Costa acknowledges her grant (SFRH/BHD/110001/2015), received by Portuguese national funds through Funda??o para a Ci?ncia e Tecnologia (FCT), IP, under the Norma Transit?ria DL57/2016/CP1334/CT0006. F Carvalho acknowledges UID/MULTI/04378/2019 and UID/QUI/50006/2019 support with funding from FCT/Minist?rio da Ci?ncia, Tecnologia e Ensino Superior through national funds. K Deribe is supported by a Wellcome Trust grant (number 201900/Z/16/Z) as part of his International Intermediate Fellowship. C Herteliu is partially supported by a grant co-funded by European Fund for Regional Development through the Operational Program for Competitiveness (project ID P_40_382). P Hoogar thanks Centre for Bio Cultural Studies, Directorate of Research, Manipal Academy of Higher Education, Manipal and Centre for Holistic Development and Research, Kalaghatgi-Karnataka. S M S Islam is funded by a Fellowship from National Heart Foundation of Australia and Deakin University. M Jakovljevic and the Serbian part of this GBD contribution was co-funded through grant OI175014 of the Ministry of Education Science and Technological Development of the Republic of Serbia. A P Kengne is supported by the South African Medical Research Council. Y J Kim's work was supported by the Research Management Centre, Xiamen University Malaysia, grants number XMUMRF/2018-C2/ITCM/0001. K Krishan is supported by a DST PURSE grant and UGC Center of Advanced Study awarded to the Department of Anthropology, Panjab University, Chandigarh, India. M Kumar acknowledges K43 TW010716-03. B Lacey acknowledges support from the NIHR Oxford Biomedical Research Centre and the British Heart Foundation Centre of Research Excellence, Oxford. P T N Memiah acknowledges the Council for the Development of Social Science Research in Africa. M Molokhia is supported by the NIHR Biomedical Research Center at Guy's and St Thomas' National Health Service Foundation Trust and King's College London. I Moreno Vel?squez is supported by the Sistema Nacional de Investigaci?n (SENACYT, Panam?). G C Patton is funded by an NHMRC Fellowship. A M Samy received a fellowship from the Egyptian Fulbright Mission programme. M M Santric-Milicevic acknowledges the support of the Ministry of Education, Science and Technological Development of the Republic of Serbia (contract number 175087). A Sheikh acknowledges the support of Health Data Research UK. M R Sobhiyeh acknowledges the Clinical Research Development Center of Imam Reza Hospital, Kermanshah University of Medical Sciences for their wise advice. R Tabar?s-Seisdedos was supported in part by grant PI17/00719 from Instituto de Salud Carlos III?FEDER. B Unnikrishnan acknowledges Manipal Academy of Higher Education, Manipal. M R Weaver was supported by the Bill & Melinda Gates Foundation grant OPP1127433. C S Wiysonge was supported by the South African Medical Research Council. Editorial note: the Lancet Group takes a neutral position with respect to territorial claims in published maps and institutional affiliations.

Publisher Copyright:
© 2020 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license

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