Publications

2019
Nadella P, Smith ER, Muhihi A, Noor RA, Masanja H, Fawzi WW, Sudfeld CR. Determinants of delayed or incomplete Diphtheria-Tetanus-Pertussis vaccination in parallel urban and rural birth cohorts of 30,956 infants in Tanzania. BMC Infectious Disease. 2019;18. Publisher's VersionAbstract

Background

Delayed vaccination increases the time infants are at risk for acquiring vaccine-preventable diseases. Factors associated with incomplete vaccination are relatively well characterized in resource-limited settings; however, few studies have assessed immunization timeliness.

Methods

We conducted a prospective cohort study examining Diphtheria-Tetanus-Pertussis (DTP) vaccination timing among newborns enrolled in a Neonatal Vitamin A supplementation trial (NEOVITA) conducted in urban Dar es Salaam (n = 11,189) and rural Morogoro Region (n = 19,767), Tanzania. We used log-binomial models to assess the relationship of demographic, socioeconomic, healthcare access, and birth characteristics with late or incomplete DTP1 and DTP3 immunization.

Results

The proportion of infants with either delayed or incomplete vaccination was similar in Dar es Salaam (DTP1 11.5% and DTP3 16.0%) and Morogoro (DTP1 9.2% and DTP3 17.3%); however, the determinants of delayed or incomplete vaccination as well as their magnitude of association differed by setting. Both maternal and paternal education were more strongly associated with vaccination status in rural Morogoro region as compared to Dar es Salaam (p-values for heterogeneity < 0.05). Infants in Morogoro who had fathers and mothers with no education had 36% (95% CI: 22–52%) and 22% (95% CI: 10–34%) increased risk of delayed or incomplete DTP3 vaccination as compared to those with primary school education, respectively. In Dar es Salaam, mothers who attended their first antenatal care (ANC) visit in the 3rd trimester had 1.55 (95% CI: 1.36–1.78) times the risk of delayed or not received vaccination as compared to those with a 2nd trimester booking, while there was no relationship in Morogoro. In rural Morogoro, infants born at home had 17% (95% CI: 8–27%) increased risk for delayed or no receipt of DTP3 vaccination. In both settings, younger maternal age and poorer households were at increased risk for delayed or incomplete vaccination.

Conclusion

We found some risk factors for delayed and incomplete vaccination were shared between urban and rural Tanzania; however, we found several context-specific risk factors as well as determinants that differed in their magnitude of risk between contexts. Immunization programs should be tailored to address context-specific barriers and enablers to improve timely and complete vaccination.

Sudfeld CR, Smith ER. New Evidence Should Inform WHO Guidelines on Multiple Micronutrient Supplementation in Pregnancy. Journal of Nutrition. 2019;149 (3) :359–361. Publisher's VersionAbstract
Recent data from an individual patient data (IPD) meta-analysis of 17 randomized control trials including >100,000 women living in low- and middle-income countries found that multiple micronutrient supplementation (MMS) in pregnancy reduced the risk of low birth weight, preterm birth, and being born small for gestational age. Further, MMS reduced the risk of neonatal and infant mortality for females, and there was no evidence of increased risk among the 26 subgroups examined. The 2016 WHO antenatal care guidelines, which were released before the IPD meta-analysis, did not universally recommend MMS, noting: “There is some evidence of additional benefit … but there is also some evidence of risk.” The guidelines suggest that MMS may increase the risk of neonatal mortality based on an exploratory subgroup analysis of 6 randomized trials. However, we identified several issues with this subgroup analysis. In this report we correct and update the subgroup analysis and show that there is no evidence that MMS increases the risk of neonatal mortality. There is growing scientific consensus that MMS containing iron and folic acid (IFA) is superior to IFA alone. The WHO guidelines currently state that “policy-makers in populations with a high prevalence of nutritional deficiencies might consider the benefits of MMN [multiple micronutrient] supplements on maternal health to outweigh the disadvantages, and may choose to give MMN supplements that include iron and folic acid.” This equivocal guidance has created confusion about the best course of action for public health programs in low- and middle-income countries. Given the new evidence, WHO should review their statements regarding the potential neonatal mortality risks and re-evaluate the overall potential benefits of implementing MMS as a public health program.
Blakstad MM, Smith ER, Etheredge A, Locks LM, McDonald CM, Kupka R, Kisenge R, Aboud S, Bellinger D, Sudfeld CR, et al. Nutritional, Socioeconomic, and Delivery Characteristics Are Associated with Neurodevelopment in Tanzanian Children. Pediatrics. 2019;207 :71–79.e8. Publisher's Version
Kamenju P, Hertzmark E, Kabagambe E, Smith ER, Muhihi A, Noor R, Mshamu S, Briegleb C, Sudfeld C, Masanja H, et al. Factors associated with plasma n-3 and n-6 polyunsaturated fatty acid levels in Tanzanian infants. Public Health Nutrition. 2019;25. Publisher's Version
2018
Population-based rates, timing, and causes of maternal deaths, stillbirths, and neonatal deaths in south Asia and sub-Saharan Africa: a multi-country prospective cohort study. The Lancet Global Health. 2018. Publisher's Version
Smith ER. Global Nutrient Availability: a call for accountability and action. Lancet Planetary Health . 2018;2 (9) :e380-e381. Publisher's Version
Christian P, Smith ER. Adolescent undernutrition: global burden, physiology, and nutritional risks. Annals of Nutrition and Metabolism. 2018;72 (4). Publisher's VersionAbstract
Background: Adolescents, comprised of 10–19 year olds, form the largest generation of young people in our history. There are an estimated 1.8 billion adolescents in the world, with 90% residing in low- and middle-income countries. The burden of disease among adolescents has its origins in infectious and injury-related causes, but nutritional deficiencies, suboptimal linear growth, and undernutrition are major public health problems, even as overweight may be on the rise in many contexts. Summary and Key Messages: Girls are most vulnerable to the influences of cultural and gender norms, which often discriminate against them. Dietary patterns and physical activity, in addition to schooling and countervailing social norms for early marriage, influence health and nutritional well-being of adolescents. Nutrient requirements – ­including those for energy, protein, iron, calcium, and ­others – increase in adolescence to support adequate growth and development. In settings where dietary intakes are suboptimal, anemia and micronutrient deficiencies are high. Endocrine factors are essential for promoting normal adolescent growth and are sensitive to undernutrition. Growth velocity increases during puberty when peak height velocity occurs and catch-up is possible; in girls, about 15–25% of adult height is attained. A premature pregnancy can halt linear growth and increase the risk of adverse birth outcomes. Research is needed to fill the huge data gaps related to nutrition and growth during adolescence, in addition to testing interventions during this second window of opportunity to enhance growth and development, improve human capital, and to end the intergenerational cycle of growth failure.
Edmond KM, Yousufi K, Anwari Z, Sadat SM, Staniczai SM, Higgins-Steele A, Bellows A, Smith ER. Can community health worker home visiting improve care seeking and maternal and newborn care practices in fragile states such as Afghanistan? A population based intervention study. BMC Medicine. 2018;16 (1) :106. Publisher's Version
Pitchik H, Fawzi W, McCoy D, Darling AM, Abioye A, Tesha F, Smith ER, Mugusi F, Sudfeld CR. Prenatal nutrition, stimulation, and exposure to punishment are associated with early child motor, cognitive, language, and socioemotional development in Dar es Salaam, Tanzania. The Journal of Pediatrics. 2018;44 (6) :841-849. Publisher's Version
Neonatal_Vitamin_A_Supplementation_Evidence_Group. Early Neonatal Vitamin A Supplementation and infant mortality: a pooled-analysis of randomized controlled trials. Archives of Disease in Childhood. 2018;104 :217–226. Publisher's Version
Sania A, Smith ER, Manji KP, Duggan CP, Masanja H, Kisenge R, Msamanga G, Urassa W, Fawzi W. Neonatal and infant mortality risk associated with preterm and small-for-gestational-age births in Tanzania: individual level pooled analysis using the Intergrowth standard. Journal of Pediatrics. 2018;192 :66-72.
Aibana O, Franke MF, Huang C-C, Galea JT, Calderon R, Zhang Z, Becerra MC, Smith ER, Contreras C, Yataco R, et al. Vitamin E Status Is Inversely Associated with Risk of Incident Tuberculosis Disease among Household Contacts. The Journal of Nutrition. 2018;148 (1) :56-62.
2017
Bellows AL, Smith ER, Muhihi A, Briegleb C, Noor RA, Mshamu S, Sudfeld C, Masanja H, Fawzi W. Micronutrient Deficiencies among Breastfeeding Infants in Tanzania. Nutrients. 2017;9 (11) :1258.
Smith ER, Shankar AH, Wu L, Aboud S, Adu-Afarwuah S, Ali H, Agustina R, Arifeen S, Ashorn P, Bhutta Z, et al. Modifiers of the effect of maternal multiple micronutrient supplmenetation on stillbirth, birth outcomes, and infant mortality: an individual patient data meta-analysis of 17 randomized trials. Lancet Global Health. 2017;5 (11) :e1090-e1100.
Rodriguez CA, Smith ER, Zaveleta N, Respicio-Torres G, Contreras C, Perea S, Jimenez J, Tintaya K, Lecca L, Murray MB, et al. Development and Validation of a Food Frequency Questionnaire to Estimate Intake among Children and Adolescents in Urban Peru. Nutrients. 2017;9 (10) :112.
Smith ER, Locks LM, McDonald CM, Kupka R, Kisenge R, Aboud S, Fawzi WW, Duggan CP. Delayed Breastfeeding Initiation is Associated with Infant Morbidity. Journal of Pediatrics. 2017;191 :57-62.
Sudfeld C, Manji KP, Smith ER, Aboud S, Kisenge R, Fawzi WW, Duggan CP. Vitamin D deficiency is not associated with growth or the incidence of common morbidities among Tanzanian infants: a prospective cohort study. J Pediatric Gastro Nutr. 2017;65 (4) :467. Publisher's Version
Smith ER, Hurt L, Chowdhury R, Sinha B, Fawzi W, Edmond KM. Delayed breastfeeding initiation and infant survival: a systematic review and meta-analysis. Plos One. 2017;12 (7). Publisher's Version

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