Rishi Mediratta

All Publications

• Evaluating the implementation of the Pediatric Acute Care Education (PACE) program in northwestern Tanzania: a mixed-methods study guided by normalization process theory. BMC health services research Mwanga, J. R., Hokororo, A., Ndosi, H., Masenge, T., Kalabamu, F. S., Tawfik, D., Mediratta, R. P., Rozenfeld, B., Berg, M., Smith, Z. H., Chami, N., Mkopi, N. P., Mwanga, C., Diocles, E., Agweyu, A., Meaney, P. A. 2024; 24 (1): 1066

  Abstract

  In low- and middle-income countries (LMICs), such as Tanzania, the competency of healthcare providers critically influences the quality of pediatric care. To address this issue, we introduced Pediatric Acute Care Education (PACE), an adaptive learning program to enhance provider competency in Tanzania's guidelines for managing seriously ill children. Adaptive learning is a promising alternative to current in-service education, yet optimal implementation strategies in LMIC settings are unknown.(1) To evaluate the initial PACE implementation in Mwanza, Tanzania, using the construct of normalization process theory (NPT); (2) To provide insights into its feasibility, acceptability, and scalability potential.Mixed-methods study involving healthcare providers at three facilities. Quantitative data was collected using the Normalization MeAsure Development (NoMAD) questionnaire, while qualitative data was gathered through in-depth interviews (IDIs) and focus groups discussions (FGDs).Eighty-two healthcare providers completed the NoMAD survey. Additionally, 24 senior providers participated in IDIs, and 79 junior providers participated in FGDs. Coherence and cognitive participation were high, demonstrating that PACE is well understood and resonates with existing healthcare goals. Providers expressed a willingness to integrate PACE into their practices, distinguishing it from existing educational methods. However, challenges related to resources and infrastructure, particularly those affecting collective action, were noted. Early indicators point toward the potential for long-term sustainability of the PACE, but assessment of reflexive monitoring was limited due to the study's focus on PACE's initial implementation.This study offers vital insights into the feasibility and acceptability of implementing PACE in a Tanzanian context. While PACE aligns well with healthcare objectives, addressing resource and infrastructure challenges as well as conducting a longer-term study to assess reflexive monitoring is crucial for its successful implementation. Furthermore, the study underscores the value of the NPT as a framework for guiding implementation processes, with broader implications for implementation science and pediatric acute care in LMICs.

  View details for DOI 10.1186/s12913-024-11554-3

  View details for PubMedID 39272036

  View details for PubMedCentralID PMC11401409

• Diagnostic Accuracy of Clinical Sign Algorithms to Identify Sepsis in Young Infants Aged 0 to 59 Days: A Systematic Review and Meta-analysis. Pediatrics Fung, A., Shafiq, Y., Driker, S., Rees, C. A., Mediratta, R. P., Rosenberg, R., Hussaini, A. S., Adnan, J., Wade, C. G., Chou, R., Edmond, K. M., North, K., Lee, A. C. 2024; 154 (Suppl 1)

  Abstract

  Accurate identification of possible sepsis in young infants is needed to effectively manage and reduce sepsis-related morbidity and mortality.Synthesize evidence on the diagnostic accuracy of clinical sign algorithms to identify young infants (aged 0-59 days) with suspected sepsis.MEDLINE, Embase, CINAHL, Global Index Medicus, and Cochrane CENTRAL Registry of Trials.Studies reporting diagnostic accuracy measures of algorithms including infant clinical signs to identify young infants with suspected sepsis.We used Cochrane methods for study screening, data extraction, risk of bias assessment, and determining certainty of evidence using Grading of Recommendations Assessment Development and Evaluation.We included 19 studies (12 Integrated Management of Childhood Illness [IMCI] and 7 non-IMCI studies). The current World Health Organization (WHO) 7-sign IMCI algorithm had a sensitivity of 79% (95% CI 77%-82%) and specificity of 77% (95% CI 76%-78%) for identifying sick infants aged 0-59 days requiring hospitalization/antibiotics (1 study, N = 8889). Any IMCI algorithm had a pooled sensitivity of 84% (95% CI 75%-90%) and specificity of 80% (95% CI 64%-90%) for identifying suspected sepsis (11 studies, N = 15523). When restricting the reference standard to laboratory-supported sepsis, any IMCI algorithm had a pooled sensitivity of 86% (95% CI 82%-90%) and lower specificity of 61% (95% CI 49%-72%) (6 studies, N = 14278).Heterogeneity of algorithms and reference standards limited the evidence.IMCI algorithms had acceptable sensitivity for identifying young infants with suspected sepsis. Specificity was lower using a reference standard of laboratory-supported sepsis diagnosis.

  View details for DOI 10.1542/peds.2024-066588D

  View details for PubMedID 39087806

• Predictive Accuracy of Infant Clinical Sign Algorithms for Mortality in Young Infants Aged 0 to 59 Days: A Systematic Review. Pediatrics Shafiq, Y., Fung, A., Driker, S., Rees, C. A., Mediratta, R. P., Rosenberg, R., Hussaini, A. S., Adnan, J., Wade, C. G., Chou, R., Edmond, K. M., North, K., Lee, A. C. 2024; 154 (Suppl 1)

  Abstract

  Clinical sign algorithms are a key strategy to identify young infants at risk of mortality.Synthesize the evidence on the accuracy of clinical sign algorithms to predict all-cause mortality in young infants 0-59 days.MEDLINE, Embase, CINAHL, Global Index Medicus, and Cochrane CENTRAL Registry of Trials.Studies evaluating the accuracy of infant clinical sign algorithms to predict mortality.We used Cochrane methods for study screening, data extraction, and risk of bias assessment. We determined certainty of evidence using Grading of Recommendations Assessment Development and Evaluation.We included 11 studies examining 26 algorithms. Three studies from non-hospital/community settings examined sign-based checklists (n = 13). Eight hospital-based studies validated regression models (n = 13), which were administered as weighted scores (n = 8), regression formulas (n = 4), and a nomogram (n = 1). One checklist from India had a sensitivity of 98% (95% CI: 88%-100%) and specificity of 94% (93%-95%) for predicting sepsis-related deaths. However, external validation in Bangladesh showed very low sensitivity of 3% (0%-10%) with specificity of 99% (99%-99%) for all-cause mortality (ages 0-9 days). For hospital-based prediction models, area under the curve (AUC) ranged from 0.76-0.93 (n = 13). The Score for Essential Neonatal Symptoms and Signs had an AUC of 0.89 (0.84-0.93) in the derivation cohort for mortality, and external validation showed an AUC of 0.83 (0.83-0.84).Heterogeneity of algorithms and lack of external validation limited the evidence.Clinical sign algorithms may help identify at-risk young infants, particularly in hospital settings; however, overall certainty of evidence is low with limited external validation.

  View details for DOI 10.1542/peds.2024-066588E

  View details for PubMedID 39087802

• Trends and levels of the global, regional, and national burden of appendicitis between 1990 and 2021: findings from the Global Burden of Disease Study 2021. The lancet. Gastroenterology & hepatology 2024

  Abstract

  Appendicitis is a common surgical emergency that poses a large clinical and economic burden. Understanding the global burden of appendicitis is crucial for evaluating unmet needs and implementing and scaling up intervention services to reduce adverse health outcomes. This study aims to provide a comprehensive assessment of the global, regional, and national burden of appendicitis, by age and sex, from 1990 to 2021.Vital registration and verbal autopsy data, the Cause of Death Ensemble model (CODEm), and demographic estimates from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) were used to estimate cause-specific mortality rates (CSMRs) for appendicitis. Incidence data were extracted from insurance claims and inpatient discharge sources and analysed with disease modelling meta-regression, version 2.1 (DisMod-MR 2.1). Years of life lost (YLLs) were estimated by combining death counts with standard life expectancy at the age of death. Years lived with disability (YLDs) were estimated by multiplying incidence estimates by an average disease duration of 2 weeks and a disability weight for abdominal pain. YLLs and YLDs were summed to estimate disability-adjusted life-years (DALYs).In 2021, the global age-standardised mortality rate of appendicitis was 0·358 (95% uncertainty interval [UI] 0·311-0·414) per 100 000. Mortality rates ranged from 1·01 (0·895-1·13) per 100 000 in central Latin America to 0·054 (0·0464-0·0617) per 100 000 in high-income Asia Pacific. The global age-standardised incidence rate of appendicitis in 2021 was 214 (174-274) per 100 000, corresponding to 17 million (13·8-21·6) new cases. The incidence rate was the highest in high-income Asia Pacific, at 364 (286-475) per 100 000 and the lowest in western sub-Saharan Africa, at 81·4 (63·9-109) per 100 000. The global age-standardised rates of mortality, incidence, YLLs, YLDs, and DALYs due to appendicitis decreased steadily between 1990 and 2021, with the largest reduction in mortality and YLL rates. The global annualised rate of decline in the DALY rate was greatest in children younger than the age of 10 years. Although mortality rates due to appendicitis decreased in all regions, there were large regional variations in the temporal trend in incidence. Although the global age-standardised incidence rate of appendicitis has steadily decreased between 1990 and 2021, almost half of GBD regions saw an increase of greater than 10% in their age-standardised incidence rates.Slow but promising progress has been observed in reducing the overall burden of appendicitis in all regions. However, there are important geographical variations in appendicitis incidence and mortality, and the relationship between these measures suggests that many people still do not have access to quality health care. As the incidence of appendicitis is rising in many parts of the world, countries should prepare their health-care infrastructure for timely, high-quality diagnosis and treatment. Given the risk that improved diagnosis may counterintuitively drive apparent rising trends in incidence, these efforts should be coupled with improved data collection, which will also be crucial for understanding trends and developing targeted interventions.Bill and Melinda Gates Foundation.

  View details for DOI 10.1016/S2468-1253(24)00157-2

  View details for PubMedID 39032499

• Etiology of hospital mortality in children living in low- and middle-income countries: a systematic review and meta-analysis. Frontiers in pediatrics Kortz, T. B., Mediratta, R. P., Smith, A. M., Nielsen, K. R., Agulnik, A., Gordon Rivera, S., Reeves, H., O'Brien, N. F., Lee, J. H., Abbas, Q., Attebery, J. E., Bacha, T., Bhutta, E. G., Biewen, C. J., Camacho-Cruz, J., Coronado Muñoz, A., deAlmeida, M. L., Domeryo Owusu, L., Fonseca, Y., Hooli, S., Wynkoop, H., Leimanis-Laurens, M., Nicholaus Mally, D., McCarthy, A. M., Mutekanga, A., Pineda, C., Remy, K. E., Sanders, S. C., Tabor, E., Teixeira Rodrigues, A., Yuee Wang, J. Q., Kissoon, N., Takwoingi, Y., Wiens, M. O., Bhutta, A. 2024; 12: 1397232

  Abstract

  In 2019, 80% of the 7.4 million global child deaths occurred in low- and middle-income countries (LMICs). Global and regional estimates of cause of hospital death and admission in LMIC children are needed to guide global and local priority setting and resource allocation but are currently lacking. The study objective was to estimate global and regional prevalence for common causes of pediatric hospital mortality and admission in LMICs. We performed a systematic review and meta-analysis to identify LMIC observational studies published January 1, 2005-February 26, 2021. Eligible studies included: a general pediatric admission population, a cause of admission or death, and total admissions. We excluded studies with data before 2,000 or without a full text. Two authors independently screened and extracted data. We performed methodological assessment using domains adapted from the Quality in Prognosis Studies tool. Data were pooled using random-effects models where possible. We reported prevalence as a proportion of cause of death or admission per 1,000 admissions with 95% confidence intervals (95% CI). Our search identified 29,637 texts. After duplicate removal and screening, we analyzed 253 studies representing 21.8 million pediatric hospitalizations in 59 LMICs. All-cause pediatric hospital mortality was 4.1% [95% CI 3.4%-4.7%]. The most common causes of mortality (deaths/1,000 admissions) were infectious [12 (95% CI 9-14)]; respiratory [9 (95% CI 5-13)]; and gastrointestinal [9 (95% CI 6-11)]. Common causes of admission (cases/1,000 admissions) were respiratory [255 (95% CI 231-280)]; infectious [214 (95% CI 193-234)]; and gastrointestinal [166 (95% CI 143-190)]. We observed regional variation in estimates. Pediatric hospital mortality remains high in LMICs. Global child health efforts must include measures to reduce hospital mortality including basic emergency and critical care services tailored to the local disease burden. Resources are urgently needed to promote equity in child health research, support researchers, and collect high-quality data in LMICs to further guide priority setting and resource allocation.

  View details for DOI 10.3389/fped.2024.1397232

  View details for PubMedID 38910960

  View details for PubMedCentralID PMC11190367

• Global Health Education in Pediatric Hospital Medicine Fellowships in the United States. Hospital pediatrics Lenzen, C., Coria, A. L., Hofto, M. E., Pitt, M. B., Cheng, F. Y., Mediratta, R. P. 2024

  Abstract

  Pediatric fellows across all subspecialties are interested in global health (GH). Little is known about how GH is incorporated into Pediatric Hospital Medicine (PHM) fellowships. Our objective was to examine the current landscape of GH education in PHM fellowships.In 2022, we conducted a cross-sectional electronic survey of PHM fellowship directors (FDs), current fellows, and recently graduated fellows (alumni) via e-mail and listservs. Surveys asked about GH education (curriculum, electives, and research) in PHM fellowships, barriers to GH training, and fellow interest in GH.Response rates were 56% (34/61) among PHM FDs, 57% (102/178) among fellows, and 29% (59/206) among alumni. Most fellows (73%) and alumni (59%) were interested in GH electives. Although 53% of FDs reported offering GH electives, a minority of fellows (21%) and alumni (19%) reported being offered GH electives (P <.001). Few FDs reported offering a GH curriculum (9%), although most fellows (63%) and alumni (50%) expressed interest. Of the 16 FDs without GH electives, 81% planned to offer them. Cited barriers included a lack of GH curricula, insufficient funding, competing educational demands, and a lack of international partnerships. More FDs (82%) than fellows (64%) and alumni (45%) agreed that GH education improves overall fellow education (P = .01). Similarly, more FDs (75%) than fellows (56%) and alumni (38%) agreed that offering GH education improves recruitment (P = .002).There is an unmet demand for GH education in PHM fellowships, and fellows may not be aware of GH opportunities.

  View details for DOI 10.1542/hpeds.2023-007575

  View details for PubMedID 38779785

• Training the next generation of community-engaged physicians: a mixed-methods evaluation of a novel course for medical service learning in the COVID-19 era. BMC medical education Scala, J. J., Cha, H., Shamardani, K., Rashes, E. R., Acosta-Alvarez, L., Mediratta, R. P. 2024; 24 (1): 426

  Abstract

  Medical school curricula strive to train community-engaged and culturally competent physicians, and many use service learning to instill these values in students. The current standards for medical service learning frameworks have opportunities for improvement, such as encouraging students to have more sustainable and reciprocal impact and to ingrain service learning as a value to carry throughout their careers rather than a one-time experience. PEDS 220: A COVID-19 Elective is a Stanford University course on the frontlines of this shift; it provides timely education on the COVID-19 pandemic, integrating community-oriented public health work to help mitigate its impact.To analyze our medical service learning curriculum, we combined qualitative and quantitative methods to understand our students' experiences. Participants completed the Course Experience Questionnaire via Qualtrics, and were invited to complete an additional interview via Zoom. Interview transcripts were analyzed using an interactive, inductive, and team-based codebook development process, where recurring themes were identified across participant interviews.We demonstrate through self-determination theory that our novel curriculum gives students valuable leadership and project management experience, awards strong academic and community-based connections, and motivates them to pursue future community-engaged work.This educational framework, revolving around students, communities, and diversity, can be used beyond the COVID-19 pandemic at other educational institutions to teach students how to solve other emergent global health problems. Using proven strategies that empower future physicians to view interdisciplinary, community-engaged work as a core pillar of their responsibility to their patients and communities ensures long-term, sustainable positive impact.N/A.

  View details for DOI 10.1186/s12909-024-05372-8

  View details for PubMedID 38649984

  View details for PubMedCentralID PMC11034080

• Global burden of 288 causes of death and life expectancy decomposition in 204 countries and territories and 811 subnational locations, 1990-2021: a systematic analysis for the Global Burden of Disease Study 2021. Lancet (London, England) 2024

  Abstract

  Regular, detailed reporting on population health by underlying cause of death is fundamental for public health decision making. Cause-specific estimates of mortality and the subsequent effects on life expectancy worldwide are valuable metrics to gauge progress in reducing mortality rates. These estimates are particularly important following large-scale mortality spikes, such as the COVID-19 pandemic. When systematically analysed, mortality rates and life expectancy allow comparisons of the consequences of causes of death globally and over time, providing a nuanced understanding of the effect of these causes on global populations.The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 cause-of-death analysis estimated mortality and years of life lost (YLLs) from 288 causes of death by age-sex-location-year in 204 countries and territories and 811 subnational locations for each year from 1990 until 2021. The analysis used 56 604 data sources, including data from vital registration and verbal autopsy as well as surveys, censuses, surveillance systems, and cancer registries, among others. As with previous GBD rounds, cause-specific death rates for most causes were estimated using the Cause of Death Ensemble model-a modelling tool developed for GBD to assess the out-of-sample predictive validity of different statistical models and covariate permutations and combine those results to produce cause-specific mortality estimates-with alternative strategies adapted to model causes with insufficient data, substantial changes in reporting over the study period, or unusual epidemiology. YLLs were computed as the product of the number of deaths for each cause-age-sex-location-year and the standard life expectancy at each age. As part of the modelling process, uncertainty intervals (UIs) were generated using the 2·5th and 97·5th percentiles from a 1000-draw distribution for each metric. We decomposed life expectancy by cause of death, location, and year to show cause-specific effects on life expectancy from 1990 to 2021. We also used the coefficient of variation and the fraction of population affected by 90% of deaths to highlight concentrations of mortality. Findings are reported in counts and age-standardised rates. Methodological improvements for cause-of-death estimates in GBD 2021 include the expansion of under-5-years age group to include four new age groups, enhanced methods to account for stochastic variation of sparse data, and the inclusion of COVID-19 and other pandemic-related mortality-which includes excess mortality associated with the pandemic, excluding COVID-19, lower respiratory infections, measles, malaria, and pertussis. For this analysis, 199 new country-years of vital registration cause-of-death data, 5 country-years of surveillance data, 21 country-years of verbal autopsy data, and 94 country-years of other data types were added to those used in previous GBD rounds.The leading causes of age-standardised deaths globally were the same in 2019 as they were in 1990; in descending order, these were, ischaemic heart disease, stroke, chronic obstructive pulmonary disease, and lower respiratory infections. In 2021, however, COVID-19 replaced stroke as the second-leading age-standardised cause of death, with 94·0 deaths (95% UI 89·2-100·0) per 100 000 population. The COVID-19 pandemic shifted the rankings of the leading five causes, lowering stroke to the third-leading and chronic obstructive pulmonary disease to the fourth-leading position. In 2021, the highest age-standardised death rates from COVID-19 occurred in sub-Saharan Africa (271·0 deaths [250·1-290·7] per 100 000 population) and Latin America and the Caribbean (195·4 deaths [182·1-211·4] per 100 000 population). The lowest age-standardised death rates from COVID-19 were in the high-income super-region (48·1 deaths [47·4-48·8] per 100 000 population) and southeast Asia, east Asia, and Oceania (23·2 deaths [16·3-37·2] per 100 000 population). Globally, life expectancy steadily improved between 1990 and 2019 for 18 of the 22 investigated causes. Decomposition of global and regional life expectancy showed the positive effect that reductions in deaths from enteric infections, lower respiratory infections, stroke, and neonatal deaths, among others have contributed to improved survival over the study period. However, a net reduction of 1·6 years occurred in global life expectancy between 2019 and 2021, primarily due to increased death rates from COVID-19 and other pandemic-related mortality. Life expectancy was highly variable between super-regions over the study period, with southeast Asia, east Asia, and Oceania gaining 8·3 years (6·7-9·9) overall, while having the smallest reduction in life expectancy due to COVID-19 (0·4 years). The largest reduction in life expectancy due to COVID-19 occurred in Latin America and the Caribbean (3·6 years). Additionally, 53 of the 288 causes of death were highly concentrated in locations with less than 50% of the global population as of 2021, and these causes of death became progressively more concentrated since 1990, when only 44 causes showed this pattern. The concentration phenomenon is discussed heuristically with respect to enteric and lower respiratory infections, malaria, HIV/AIDS, neonatal disorders, tuberculosis, and measles.Long-standing gains in life expectancy and reductions in many of the leading causes of death have been disrupted by the COVID-19 pandemic, the adverse effects of which were spread unevenly among populations. Despite the pandemic, there has been continued progress in combatting several notable causes of death, leading to improved global life expectancy over the study period. Each of the seven GBD super-regions showed an overall improvement from 1990 and 2021, obscuring the negative effect in the years of the pandemic. Additionally, our findings regarding regional variation in causes of death driving increases in life expectancy hold clear policy utility. Analyses of shifting mortality trends reveal that several causes, once widespread globally, are now increasingly concentrated geographically. These changes in mortality concentration, alongside further investigation of changing risks, interventions, and relevant policy, present an important opportunity to deepen our understanding of mortality-reduction strategies. Examining patterns in mortality concentration might reveal areas where successful public health interventions have been implemented. Translating these successes to locations where certain causes of death remain entrenched can inform policies that work to improve life expectancy for people everywhere.Bill & Melinda Gates Foundation.

  View details for DOI 10.1016/S0140-6736(24)00367-2

  View details for PubMedID 38582094

• Global age-sex-specific mortality, life expectancy, and population estimates in 204 countries and territories and 811 subnational locations, 1950-2021, and the impact of the COVID-19 pandemic: a comprehensive demographic analysis for the Global Burden of Disease Study 2021. Lancet (London, England) 2024

  Abstract

  Estimates of demographic metrics are crucial to assess levels and trends of population health outcomes. The profound impact of the COVID-19 pandemic on populations worldwide has underscored the need for timely estimates to understand this unprecedented event within the context of long-term population health trends. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 provides new demographic estimates for 204 countries and territories and 811 additional subnational locations from 1950 to 2021, with a particular emphasis on changes in mortality and life expectancy that occurred during the 2020-21 COVID-19 pandemic period.22 223 data sources from vital registration, sample registration, surveys, censuses, and other sources were used to estimate mortality, with a subset of these sources used exclusively to estimate excess mortality due to the COVID-19 pandemic. 2026 data sources were used for population estimation. Additional sources were used to estimate migration; the effects of the HIV epidemic; and demographic discontinuities due to conflicts, famines, natural disasters, and pandemics, which are used as inputs for estimating mortality and population. Spatiotemporal Gaussian process regression (ST-GPR) was used to generate under-5 mortality rates, which synthesised 30 763 location-years of vital registration and sample registration data, 1365 surveys and censuses, and 80 other sources. ST-GPR was also used to estimate adult mortality (between ages 15 and 59 years) based on information from 31 642 location-years of vital registration and sample registration data, 355 surveys and censuses, and 24 other sources. Estimates of child and adult mortality rates were then used to generate life tables with a relational model life table system. For countries with large HIV epidemics, life tables were adjusted using independent estimates of HIV-specific mortality generated via an epidemiological analysis of HIV prevalence surveys, antenatal clinic serosurveillance, and other data sources. Excess mortality due to the COVID-19 pandemic in 2020 and 2021 was determined by subtracting observed all-cause mortality (adjusted for late registration and mortality anomalies) from the mortality expected in the absence of the pandemic. Expected mortality was calculated based on historical trends using an ensemble of models. In location-years where all-cause mortality data were unavailable, we estimated excess mortality rates using a regression model with covariates pertaining to the pandemic. Population size was computed using a Bayesian hierarchical cohort component model. Life expectancy was calculated using age-specific mortality rates and standard demographic methods. Uncertainty intervals (UIs) were calculated for every metric using the 25th and 975th ordered values from a 1000-draw posterior distribution.Global all-cause mortality followed two distinct patterns over the study period: age-standardised mortality rates declined between 1950 and 2019 (a 62·8% [95% UI 60·5-65·1] decline), and increased during the COVID-19 pandemic period (2020-21; 5·1% [0·9-9·6] increase). In contrast with the overall reverse in mortality trends during the pandemic period, child mortality continued to decline, with 4·66 million (3·98-5·50) global deaths in children younger than 5 years in 2021 compared with 5·21 million (4·50-6·01) in 2019. An estimated 131 million (126-137) people died globally from all causes in 2020 and 2021 combined, of which 15·9 million (14·7-17·2) were due to the COVID-19 pandemic (measured by excess mortality, which includes deaths directly due to SARS-CoV-2 infection and those indirectly due to other social, economic, or behavioural changes associated with the pandemic). Excess mortality rates exceeded 150 deaths per 100 000 population during at least one year of the pandemic in 80 countries and territories, whereas 20 nations had a negative excess mortality rate in 2020 or 2021, indicating that all-cause mortality in these countries was lower during the pandemic than expected based on historical trends. Between 1950 and 2021, global life expectancy at birth increased by 22·7 years (20·8-24·8), from 49·0 years (46·7-51·3) to 71·7 years (70·9-72·5). Global life expectancy at birth declined by 1·6 years (1·0-2·2) between 2019 and 2021, reversing historical trends. An increase in life expectancy was only observed in 32 (15·7%) of 204 countries and territories between 2019 and 2021. The global population reached 7·89 billion (7·67-8·13) people in 2021, by which time 56 of 204 countries and territories had peaked and subsequently populations have declined. The largest proportion of population growth between 2020 and 2021 was in sub-Saharan Africa (39·5% [28·4-52·7]) and south Asia (26·3% [9·0-44·7]). From 2000 to 2021, the ratio of the population aged 65 years and older to the population aged younger than 15 years increased in 188 (92·2%) of 204 nations.Global adult mortality rates markedly increased during the COVID-19 pandemic in 2020 and 2021, reversing past decreasing trends, while child mortality rates continued to decline, albeit more slowly than in earlier years. Although COVID-19 had a substantial impact on many demographic indicators during the first 2 years of the pandemic, overall global health progress over the 72 years evaluated has been profound, with considerable improvements in mortality and life expectancy. Additionally, we observed a deceleration of global population growth since 2017, despite steady or increasing growth in lower-income countries, combined with a continued global shift of population age structures towards older ages. These demographic changes will likely present future challenges to health systems, economies, and societies. The comprehensive demographic estimates reported here will enable researchers, policy makers, health practitioners, and other key stakeholders to better understand and address the profound changes that have occurred in the global health landscape following the first 2 years of the COVID-19 pandemic, and longer-term trends beyond the pandemic.Bill & Melinda Gates Foundation.

  View details for DOI 10.1016/S0140-6736(24)00476-8

  View details for PubMedID 38484753

• Implementing adaptive e-learning for newborn care in Tanzania: an observational study of provider engagement and knowledge gains. BMJ open Meaney, P. A., Hokororo, A., Ndosi, H., Dahlen, A., Jacob, T., Mwanga, J. R., Kalabamu, F. S., Joyce, C. L., Mediratta, R., Rozenfeld, B., Berg, M., Smith, Z. H., Chami, N., Mkopi, N., Mwanga, C., Diocles, E., Agweyu, A. 2024; 14 (2): e077834

  Abstract

  To improve healthcare provider knowledge of Tanzanian newborn care guidelines, we developed adaptive Essential and Sick Newborn Care (aESNC), an adaptive e-learning environment. The objectives of this study were to (1) assess implementation success with use of in-person support and nudging strategy and (2) describe baseline provider knowledge and metacognition.6-month observational study at one zonal hospital and three health centres in Mwanza, Tanzania. To assess implementation success, we used the Reach, Efficacy, Adoption, Implementation and Maintenance framework and to describe baseline provider knowledge and metacognition we used Howell's conscious-competence model. Additionally, we explored provider characteristics associated with initial learning completion or persistent activity.aESNC reached 85% (195/231) of providers: 75 medical, 53 nursing and 21 clinical officers; 110 (56%) were at the zonal hospital and 85 (44%) at health centres. Median clinical experience was 4 years (IQR 1-9) and 45 (23%) had previous in-service training for both newborn essential and sick newborn care. Efficacy was 42% (SD ±17%). Providers averaged 78% (SD ±31%) completion of initial learning and 7% (SD ±11%) of refresher assignments. 130 (67%) providers had ≥1 episode of inactivity >30 day, no episodes were due to lack of internet access. Baseline conscious-competence was 53% (IQR: 38%-63%), unconscious-incompetence 32% (IQR: 23%-42%), conscious-incompetence 7% (IQR: 2%-15%), and unconscious-competence 2% (IQR: 0%-3%). Higher baseline conscious-competence (OR 31.6 (95% CI 5.8 to 183.5)) and being a nursing officer (aOR: 5.6 (95% CI 1.8 to 18.1)), compared with medical officer, were associated with initial learning completion or persistent activity.aESNC reach was high in a population of frontline providers across diverse levels of care in Tanzania. Use of in-person support and nudging increased reach, initial learning and refresher assignment completion, but refresher assignment completion remains low. Providers were often unaware of knowledge gaps, and lower baseline knowledge may decrease initial learning completion or activity. Further study to identify barriers to adaptive e-learning normalisation is needed.

  View details for DOI 10.1136/bmjopen-2023-077834

  View details for PubMedID 38309746

• Research Methods: Diagnostic Test Characteristics. Hospital pediatrics Mediratta, R. P., Newman, T. B., Wang, M. E. 2023

  Abstract

  The goal of a diagnostic test is to provide information on the probability of disease. In this article, we review the principles of diagnostic test characteristics, including sensitivity, specificity, positive and negative predictive value, receiver operating characteristics curves, likelihood ratios, and interval likelihood ratios. We illustrate how interval likelihood ratios optimize the information that can be obtained from test results that can take on >2 values, how they are reflected in the slope of the receiver operating characteristics curve, and how they can be easily calculated from published data.

  View details for DOI 10.1542/hpeds.2023-007149

  View details for PubMedID 37144292

• Changes in preterm birth and stillbirth during COVID-19 lockdowns in 26 countries. Nature human behaviour Calvert, C., Brockway, M. M., Zoega, H., Miller, J. E., Been, J. V., Amegah, A. K., Racine-Poon, A., Oskoui, S. E., Abok, I. I., Aghaeepour, N., Akwaowo, C. D., Alshaikh, B. N., Ayede, A. I., Bacchini, F., Barekatain, B., Barnes, R., Bebak, K., Berard, A., Bhutta, Z. A., Brook, J. R., Bryan, L. R., Cajachagua-Torres, K. N., Campbell-Yeo, M., Chu, D. T., Connor, K. L., Cornette, L., Cortés, S., Daly, M., Debauche, C., Dedeke, I. O., Einarsdóttir, K., Engjom, H., Estrada-Gutierrez, G., Fantasia, I., Fiorentino, N. M., Franklin, M., Fraser, A., Gachuno, O. W., Gallo, L. A., Gissler, M., Håberg, S. E., Habibelahi, A., Häggström, J., Hookham, L., Hui, L., Huicho, L., Hunter, K. J., Huq, S., Kc, A., Kadambari, S., Kelishadi, R., Khalili, N., Kippen, J., Le Doare, K., Llorca, J., Magee, L. A., Magnus, M. C., Man, K. K., Mburugu, P. M., Mediratta, R. P., Morris, A. D., Muhajarine, N., Mulholland, R. H., Bonnard, L. N., Nakibuuka, V., Nassar, N., Nyadanu, S. D., Oakley, L., Oladokun, A., Olayemi, O. O., Olutekunbi, O. A., Oluwafemi, R. O., Ogunkunle, T. O., Orton, C., Örtqvist, A. K., Ouma, J., Oyapero, O., Palmer, K. R., Pedersen, L. H., Pereira, G., Pereyra, I., Philip, R. K., Pruski, D., Przybylski, M., Quezada-Pinedo, H. G., Regan, A. K., Rhoda, N. R., Rihs, T. A., Riley, T., Rocha, T. A., Rolnik, D. L., Saner, C., Schneuer, F. J., Souter, V. L., Stephansson, O., Sun, S., Swift, E. M., Szabó, M., Temmerman, M., Tooke, L., Urquia, M. L., von Dadelszen, P., Wellenius, G. A., Whitehead, C., Wong, I. C., Wood, R., Wróblewska-Seniuk, K., Yeboah-Antwi, K., Yilgwan, C. S., Zawiejska, A., Sheikh, A., Rodriguez, N., Burgner, D., Stock, S. J., Azad, M. B. 2023

  Abstract

  Preterm birth (PTB) is the leading cause of infant mortality worldwide. Changes in PTB rates, ranging from -90% to +30%, were reported in many countries following early COVID-19 pandemic response measures ('lockdowns'). It is unclear whether this variation reflects real differences in lockdown impacts, or perhaps differences in stillbirth rates and/or study designs. Here we present interrupted time series and meta-analyses using harmonized data from 52 million births in 26 countries, 18 of which had representative population-based data, with overall PTB rates ranging from 6% to 12% and stillbirth ranging from 2.5 to 10.5 per 1,000 births. We show small reductions in PTB in the first (odds ratio 0.96, 95% confidence interval 0.95-0.98, P value <0.0001), second (0.96, 0.92-0.99, 0.03) and third (0.97, 0.94-1.00, 0.09) months of lockdown, but not in the fourth month of lockdown (0.99, 0.96-1.01, 0.34), although there were some between-country differences after the first month. For high-income countries in this study, we did not observe an association between lockdown and stillbirths in the second (1.00, 0.88-1.14, 0.98), third (0.99, 0.88-1.12, 0.89) and fourth (1.01, 0.87-1.18, 0.86) months of lockdown, although we have imprecise estimates due to stillbirths being a relatively rare event. We did, however, find evidence of increased risk of stillbirth in the first month of lockdown in high-income countries (1.14, 1.02-1.29, 0.02) and, in Brazil, we found evidence for an association between lockdown and stillbirth in the second (1.09, 1.03-1.15, 0.002), third (1.10, 1.03-1.17, 0.003) and fourth (1.12, 1.05-1.19, <0.001) months of lockdown. With an estimated 14.8 million PTB annually worldwide, the modest reductions observed during early pandemic lockdowns translate into large numbers of PTB averted globally and warrant further research into causal pathways.

  View details for DOI 10.1038/s41562-023-01522-y

  View details for PubMedID 36849590

  View details for PubMedCentralID 8417352

• Applying Kern's Six Steps to the Development of a Community-Engaged, Just-in-Time, Interdisciplinary COVID-19 Curriculum. Journal of medical education and curricular development Scala, J. J., Braun, N. J., Shamardani, K., Rashes, E. R., Wang, W., Mediratta, R. P. 2022; 9: 23821205221096370

  Abstract

  Universities and medical schools often work towards operationalizing their shared mission of facilitating community-engaged work independently. Based on their experience teaching the COVID-19 Elective course at Stanford University School of Medicine, the authors proposed a novel solution for universities and medical schools to achieve an interdisciplinary collaboration within a diverse student population by creating targeted, project-based, and community-engaged courses for addressing emergent health needs. In this article, the authors discuss their curriculum, which was created using Kern's six-step approach for curriculum development, to address emergent health needs related to the novel coronavirus pandemic. The curriculum provides an opportunity for universities and medical schools to advance community health, educate students across the medical and non-medical education continuum, and foster interdisciplinary cooperation.

  View details for DOI 10.1177/23821205221096370

  View details for PubMedID 35509682

  View details for PubMedCentralID PMC9058336

• Overnight admissions to a neonatal intensive care unit in Ethiopia are not associated with increased mortality. PloS one Mediratta, R. P., Rajamani, M., Ayalew, M., Shehibo, A., Tazebew, A., Teklu, A. 2022; 17 (3): e0264926

  Abstract

  In 2019, 2.4 million neonates died globally, with most deaths occurring in low-resource settings. Despite the introduction of neonatal intensive care units (NICUs) in these settings, neonatal mortality remains high, and caring for sick neonates around the clock can be challenging due to limited staff and resources.To evaluate whether neonatal intensive care admissions during daytime and overnight hours affects in-hospital neonatal mortality.A retrospective case-control study was conducted using 2016 chart data at a University hospital in Ethiopia. Cases were defined as neonates who died in the NICU, and controls were defined as neonates who survived. Overnight hours were defined as 17:00 to 07:59, and day hours were defined as 08:00 to 16:59. Univariate and multivariate logistic regressions were used to investigate the relationship between time of admission and mortality, along with perinatal characteristics.A total of 812 neonates, 207 cases and 605 controls, met inclusion criteria. There were 342 admissions during the day and 470 overnight. Neonatal mortality (aOR 1.02, 95% CI [0.64-1.62], p = 0.93) was not associated with overnight admissions after controlling for maternal age, parity, C-section, birthweight, and gestational age, respiratory distress, and admission level of consciousness. Admission heart rate >160 (aOR 0.52, 95% CI [0.30-0.91], p = 0.02) was the only variable significantly associated with overnight admissions.Being admitted overnight to the NICU in Gondar, Ethiopia was not associated with increased mortality, consistent with a constant level of care, regardless of the time of admission. Further qualitative and implementation research are needed to understand contextual factors that have affected these data.

  View details for DOI 10.1371/journal.pone.0264926

  View details for PubMedID 35324936

  View details for PubMedCentralID PMC8947129

• The Burden of Critical Illness in Hospitalized Children in Low- and Middle-Income Countries: Protocol for a Systematic Review and Meta-Analysis. Frontiers in pediatrics Kortz, T. B., Nielsen, K. R., Mediratta, R. P., Reeves, H., O'Brien, N. F., Lee, J. H., Attebery, J. E., Bhutta, E. G., Biewen, C., Coronado Munoz, A., deAlmeida, M. L., Fonseca, Y., Hooli, S., Johnson, H., Kissoon, N., Leimanis-Laurens, M. L., McCarthy, A. M., Pineda, C., Remy, K. E., Sanders, S. C., Takwoingi, Y., Wiens, M. O., Bhutta, A. T. 2022; 10: 756643

  Abstract

  Background: The majority of childhood deaths occur in low- and middle-income countries (LMICs). Many of these deaths are avoidable with basic critical care interventions. Quantifying the burden of pediatric critical illness in LMICs is essential for targeting interventions to reduce childhood mortality.Objective: To determine the burden of hospitalization and mortality associated with acute pediatric critical illness in LMICs through a systematic review and meta-analysis of the literature.Data Sources and Search Strategy: We will identify eligible studies by searching MEDLINE, EMBASE, CINAHL, and LILACS using MeSH terms and keywords. Results will be limited to infants or children (ages >28 days to 12 years) hospitalized in LMICs and publications in English, Spanish, or French. Publications with non-original data (e.g., comments, editorials, letters, notes, conference materials) will be excluded.Study Selection: We will include observational studies published since January 1, 2005, that meet all eligibility criteria and for which a full text can be located.Data Extraction: Data extraction will include information related to study characteristics, hospital characteristics, underlying population characteristics, patient population characteristics, and outcomes.Data Synthesis: We will extract and report data on study, hospital, and patient characteristics; outcomes; and risk of bias. We will report the causes of admission and mortality by region, country income level, and age. We will report or calculate the case fatality rate (CFR) for each diagnosis when data allow.Conclusions: By understanding the burden of pediatric critical illness in LMICs, we can advocate for resources and inform resource allocation and investment decisions to improve the management and outcomes of children with acute pediatric critical illness in LMICs.

  View details for DOI 10.3389/fped.2022.756643

  View details for PubMedID 35372149

• Challenges and Opportunities in Deploying COVID-19 Cough AI Systems. Journal of voice : official journal of the Voice Foundation Khanzada, A., Hegde, S., Sreeram, S., Bower, G., Wang, W., Mediratta, R. P., Meister, K. D., Rameau, A. 2021

  View details for DOI 10.1016/j.jvoice.2021.08.009

  View details for PubMedID 34610883

• Derivation and validation of a prognostic score for neonatal mortality in Ethiopia: a case-control study. BMC pediatrics Mediratta, R. P., Amare, A. T., Behl, R., Efron, B., Narasimhan, B., Teklu, A., Shehibo, A., Ayalew, M., Kache, S. 2020; 20 (1): 238

  Abstract

  BACKGROUND: Early warning scores for neonatal mortality have not been designed for low income countries. We developed and validated a score to predict mortality upon admission to a NICU in Ethiopia.METHODS: We conducted a retrospective case-control study at the University of Gondar Hospital, Gondar, Ethiopia. Neonates hospitalized in the NICU between January 1, 2016 to June 31, 2017. Cases were neonates who died and controls were neonates who survived.RESULTS: Univariate logistic regression identified variables associated with mortality. The final model was developed with stepwise logistic regression. We created the Neonatal Mortality Score, which ranged from 0 to 52, from the model's coefficients. Bootstrap analysis internally validated the model. The discrimination and calibration were calculated. In the derivation dataset, there were 207 cases and 605 controls. Variables associated with mortality were admission level of consciousness, admission respiratory distress, gestational age, and birthweight. The AUC for neonatal mortality using these variables in aggregate was 0.88 (95% CI 0.85-0.91). The model achieved excellent discrimination (bias-corrected AUC) under internal validation. Using a cut-off of 12, the sensitivity and specificity of the Neonatal Mortality Score was 81 and 80%, respectively. The AUC for the Neonatal Mortality Score was 0.88 (95% CI 0.85-0.91), with similar bias-corrected AUC. In the validation dataset, there were 124 cases and 122 controls, the final model and the Neonatal Mortality Score had similar discrimination and calibration.CONCLUSIONS: We developed, internally validated, and externally validated a score that predicts neonatal mortality upon NICU admission with excellent discrimination and calibration.

  View details for DOI 10.1186/s12887-020-02107-8

  View details for PubMedID 32434513

• Liver Failure and Rash in a 6-week-old Girl PEDIATRICS IN REVIEW Mediratta, R., Schwenk, H., Rao, A., Chitkara, R. 2018; 39 (6): 315–U22

  View details for PubMedID 29858298

• Galvanizing medical students in the administration of influenza vaccines: the Stanford Flu Crew. Advances in medical education and practice Rizal, R. E., Mediratta, R. P., Xie, J., Kambhampati, S., Hills-Evans, K., Montacute, T., Zhang, M., Zaw, C., He, J., Sanchez, M., Pischel, L. 2015; 6: 471-477

  Abstract

  Many national organizations call for medical students to receive more public health education in medical school. Nonetheless, limited evidence exists about successful servicelearning programs that administer preventive health services in nonclinical settings. The Flu Crew program, started in 2001 at the Stanford University School of Medicine, provides preclinical medical students with opportunities to administer influenza immunizations in the local community. Medical students consider Flu Crew to be an important part of their medical education that cannot be learned in the classroom. Through delivering vaccines to where people live, eat, work, and pray, Flu Crew teaches medical students about patient care, preventive medicine, and population health needs. Additionally, Flu Crew allows students to work with several partners in the community in order to understand how various stakeholders improve the delivery of population health services. Flu Crew teaches students how to address common vaccination myths and provides insights into implementing public health interventions. This article describes the Stanford Flu Crew curriculum, outlines the planning needed to organize immunization events, shares findings from medical students' attitudes about population health, highlights the program's outcomes, and summarizes the lessons learned. This article suggests that Flu Crew is an example of one viable service-learning modality that supports influenza vaccinations in nonclinical settings while simultaneously benefiting future clinicians.

  View details for DOI 10.2147/AMEP.S70294

  View details for PubMedID 26170731

  View details for PubMedCentralID PMC4492543

• Risk Factors and Case Management of Acute Diarrhoea in North Gondar Zone, Ethiopia JOURNAL OF HEALTH POPULATION AND NUTRITION Mediratta, R. P., Feleke, A., Moulton, L. H., Yifru, S., Sack, R. B. 2010; 28 (3): 253-263

  Abstract

  In Ethiopia, evidence is lacking about maternal care-taking and environmental risk factors that contribute to acute diarrhoea and the case management of diarrhoea. The aim of this study was to identify the risk factors and to understand the management of acute diarrhoea. A pretested structured questionnaire was used for interviewing mothers of 440 children in a prospective, matched, case-control study at the University of Gondar Referral and Teaching Hospital in Gondar, Ethiopia. Results of multivariate analysis demonstrated that children who were breastfed and not completely weaned and mothers who were farmers were protective factors; risk factors for diarrhoea included sharing drinking-water and introducing supplemental foods. Children presented with acute diarrhoea for 3.9 days with 4.3 stools per day. Mothers usually did not increase breastmilk and other fluids during diarrhoea episodes and generally did not take children with diarrhoea to traditional healers. Incorporating messages about the prevention and treatment of acute diarrhoea into child-health interventions will help reduce morbidity and mortality associated with this disease.

  View details for Web of Science ID 000279758900007

  View details for PubMedID 20635636