Background Across low-income and middle-income countries (LMICs), one in ten deaths in children younger than 5 years is attributable to diarrhoea. The substantial between-country variation in both diarrhoea incidence and mortality is attributable to interventions that protect children, prevent infection, and treat disease. Identifying subnational regions with the highest burden and mapping associated risk factors can aid in reducing preventable childhood diarrhoea.Methods We used Bayesian model-based geostatistics and a geolocated dataset comprising 15 072 746 children younger than 5 years from 466 surveys in 94 LMICs, in combination with findings of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017, to estimate posterior distributions of diarrhoea prevalence, incidence, and mortality from 2000 to 2017. From these data, we estimated the burden of diarrhoea at varying subnational levels (termed units) by spatially aggregating draws, and we investigated the drivers of subnational patterns by creating aggregated risk factor estimates.Findings The greatest declines in diarrhoeal mortality were seen in south and southeast Asia and South America, where 54•0% (95% uncertainty interval [UI] 38•1-65•8), 17•4% (7•7-28•4), and 59•5% (34•2-86•9) of units, respectively, recorded decreases in deaths from diarrhoea greater than 10%. Although children in much of Africa remain at high risk of death due to diarrhoea, regions with the most deaths were outside Africa, with the highest mortality units located in Pakistan. Indonesia showed the greatest within-country geographical inequality; some regions had mortality rates nearly four times the average country rate. Reductions in mortality were correlated to improvements in water, sanitation, and hygiene (WASH) or reductions in child growth failure (CGF). Similarly, most high-risk areas had poor WASH, high CGF, or low oral rehydration therapy coverage.Interpretation By co-analysing geospatial trends in diarrhoeal burden and its key risk factors, we could assess candidate drivers of subnational death reduction. Further, by doing a counterfactual analysis of the remaining disease burden using key risk factors, we identified potential intervention strategies for vulnerable populations. In view of the demands for limited resources in LMICs, accurately quantifying the burden of diarrhoea and its drivers is important for precision public health.Funding Bill & Melinda Gates Foundation.

BackgroundDespite the universalization of immunization against the six vaccine-preventable diseases (VPDs), the coverage of full immunization among the children under age five has remained a challenge globally. The 2015–16 National Family Health Survey (NFHS) indicated large disparity in the coverage of different vaccination doses (BCG, Polio, DPT and Measles) including full immunization across the districts of India. The spatial distribution of poor performing districts in terms of vaccination and the district level spatial, contextual determinants contributing to the low coverage have been poorly studied. Using the recent household survey (NFHS, 2015–16), this study examined the spatial heterogeneity and the factors associated with low vaccination coverage among the children aged 12–23 months across India.Data and methodsThis study used the data from fourth round of National Family Health Survey conducted in 2015–16. District-level prevalence of each of the vaccination doses including full immunization, were analysed. Moran’s I, Univariate and Bivariate LISA, Ordinary least square (OLS) and spatial models were employed to achieve the overall aim of the study.ResultsAt the national level, the prevalence of full immunization was 62 percent. Specific vaccination coverage for BCG, three doses of polio, three doses of DPT and measles were 92, 73, 78 and 81 percent, respectively. The value of the bivariate Moran’s I statistics confirmed the spatial dependence between specific vaccination and the set of independent variables. District-level prevalence of the specific vaccine and full immunization showed significant spatial clustering across India. The adjusted coefficients from the spatial error model confirmed that district-level proportion of utilization of post-natal care, institutional births, neonatal tetanus protection of the last birth, women’s education and coverage of health insurance showed statistically significant association with every doses of vaccination coverage.ConclusionThe full and specific immunization coverage was considerably low in the geographical hotspots as compared to the national coverage. Maternal and child health care services utilization, financial assistance to the mothers through JSY scheme and mother’s education were found to determine full immunization as well as the specific vaccination coverage. Appropriate intervention should be designed to reduce the geographical disparity in the coverage of specific and full immunization across India and thus safeguard child health protecting the children from the vaccine preventable diseases across the geography.

Background Although hepatitis B vaccinations have been integrated in the Universal Immunization Program (UIP) in India over a decade, only half of the children are immunized against hepatitis B. The national average in hepatitis B vaccination conceals large variations across states, districts and socio-economic groups. In this context, the aim of this paper is to examine the spatial heterogeneity and contextual determinants of hepatitis B vaccination across the districts of India. Methods Using data of 199,899 children aged 12–59 months from the National Family Health Survey-4 (NFHS-4), 2015–16 we have examined the district level spatial distribution and clustering of hepatitis B vaccination with the help of Moran’s I and Local Indicator of Spatial Autocorrelation (LISA) measures. We investigated the low coverage of HBV vaccination using spatial autoregressive models (SAR) at the meso scale. And we applied multivariate binary logistic regression analysis to understand the micro-level predictors of hepatitis B vaccination. Results In 2015–16, 45% of the children aged 12–59 months were not vaccinated against hepatitis B in India. The coverage of hepatitis B vaccine across the districts of India showed a highly significant spatial dependence (Moran’s I = 0.580). Bivariate Moran’s I confirmed the spatial clustering of hepatitis B vaccination with mother’s education, full antenatal care (ANC) utilization, post natal care (PNC) utilization, institutional births and registration of births at the district level. Districts with a very low coverage of HBV vaccine are clustered in the western, north-eastern regions and in some parts of central India. At the unit (child) level, children’s hepatitis B immunization status is mostly determined by the socio-economic and demographic characteristics like their mother’s educational status, caste, religion, household’s wealth condition, birth order, year of birth and the region they belong to. Conclusions District level variation in hepatitis B vaccination is spatially heterogeneous and clustered in India with a strong neighbourhood effect. Uptake of hepatitis B vaccine among Indian children is predominantly dependent upon their socio-economic and demographic characteristics.

, a transition in the level of child health outcomes can be observed. The proportion of anaemia amongst children was 74.3 percent (1998-99) 12 , 69.5 percent (2005-06) 13 and 58.4 percent (2015-16) 14. Also, the proportion of full immunization amongst children was 42.0 percent (1998-99) 12 , 43.5 percent (2005-06) 13 and 62.0 percent (2015-16) 14. The proportion of stunted children has reduced by 15 percent from year 1998-99 (46%) to 2015-16 (38%) 14 (Supplementary File S1). The country has achieved continued financial progress (over 5% growth in GDP) and decreased the poverty level by half (50% in 1993-94 to 22% in 2011-12). However, the improvement in the child health outcomes are still not at par with the international targets set by the MDGs 10,11. Existing literature suggests that nutritional status, blood anaemia level and VPDs, play a vital role in determining the overall development of child health 10,15. Stunting can be defined as a severe form of undernutrition and is identified as the height that is below two standard deviations from the median child growth standard laid by the World Health Organization (WHO) 16. Stunting proliferates the risk of poor health, which may affect scholastic and economic well-being of an individual in their later life 13,15. WHO defines anemia as a condition where either the number of red blood cells or their oxygen-carrying capacity becomes insufficient to satisfy the physiological needs of an individual's body 1. Children suffering from anaemia have weak immunity and are therefore at higher risk of having infections. Moreover, iron deficiency which is supposed to be the major cause of anemia highly affects the cognitive capacities like learning, memory and behavior of the children throughout their lifetime 16. Full immunization has emerged out as a worthwhile method to prevent a group of lethal diseases, generally referred to as VPDs 17. However, a large proportion of children in India, still do not receive all the doses of the full immunization schedule (around 40%) and it remains a key public health challenge 14. There is abundant literature which focuses on exploring the child health outcomes in terms of socioeconomic factors in different country settings. Though these studies explored the spatial heterogeneity and correlates of child malnutrition and different doses of full immunization coverage 15,17 , the relationship between child health (malnutrition) and health care utilization (immunization) with paternal characteristics has not been previously explored. Recent developments in public health research suggests that geospatial mapping and modeling of different demographic and epidemiological events by inter-linking different exposures help in the identification of the pockets and therefore, help in accurate resource allocation. This would, furthermore, help the government and policymakers to address the need of the community and, therefore, achieve the latest targets set by the Sustainable Development Goals (SDGs)-2015-30. Thus, the present study aims to explore th...