Research

Principal Investigator: Dr. Shaun Morris
Collaborators: Aga Khan Health Services, Pakistan, Aga Khan University, Karachi, and Aga Khan Foundation, Pakistan
Funders: Grand Challenges Canada and Aga Khan Foundation, Canada

Pakistan has the highest neonatal mortality (NMR) rate in the world, with close to 200,000 annual newborn deaths. Gilgit-Baltistan (GB), the northern most administrative territory in Pakistan, is burdened with some of the most alarming NMRs in the country, and limited access to reproductive health care services exacerbates the problem.

To address this challenge, Dr. Morris and his team have adapted an integrated Newborn Care Kit (iNCK) that was previously studied in Kwale County, Kenya, and Rahim Yar Khan, Pakistan, for implementation in GB.

The iNCK bundles seven low cost, easy-to-use, evidence-based interventions that are designed to reduce or provide early identification of the most frequent causes of neonatal death:

1. A clean birth kit to reduce infection at the time of delivery. 
2. An antiseptic, chlorhexidine, that is applied to the umbilical stump and has been shown to reduce the incidence of omphalitis and all-cause mortality. 
3. Sunflower oil emollient to promote skin integrity and reduce infection. 
4. ThermospotTM, a continuous temperature monitoring sticker, that enables the caregiver to detect fever, cold-stress, moderate, and severe hypothermia in the newborn. 
5. A blanket to keep the baby warm (until care can be sought) after moderate or severe hypothermia is detected. 
6. A reusable, instant heat pack to be used with the blanket when hypothermia is detected. 
7. Three tablets of misoprostol, to be used to prevent post-partum hemorrhage, one of the leading causes of maternal mortality in GB.
   

The iNCK will be distributed directly to over 13,000 expectant mothers in their third trimester by government-employed female health workers performing routine home visits. 

Principal Investigator: Dr. Daniel Roth 
Collaborators: International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), Child Health Research Foundation (CHRF), both based in Dhaka, Bangladesh, and Boston University
Funder: Bill & Melinda Gates Foundation

Globally, serious bacterial infections (SBIs) cause significant neonatal morbidity and mortality. In 2016, 21% of all neonatal deaths (approximately 546,000) were attributed to either sepsis, meningitis, or pneumonia. At present, few proven interventions are available to prevent SBIs during early infancy in low- and middle-income countries. The Synbiotics for the Early Prevention of Severe Infections in Infants (SEPSIS) project has established an adaptive clinical trial research platform aimed at describing the early infant microbiome and assessing the safety and efficacy of probiotic and/or synbiotic (probiotic plus prebiotic) interventions to prevent severe infections and promote growth and development during early infancy (0-60 days of age) in Dhaka, Bangladesh.

The research platform will include: an observational study that aims to characterize the early infant microbiome and estimate the baseline event rate of severe infection in the population; a phase II placebo-controlled randomized clinical trial (RCT) of a Lactobacillus plantarum plus fructo-oligosaccharide (FOS); and, if warranted based on results from observational studies, a phase II RCT of Bifidobacterium infantis probiotic or synbiotic regimens. The platform will also include a phase III placebo-controlled RCT of a 7-day regimen of Lactobacillus plantarum plus FOS, versus placebo, for the prevention of severe infections and death up to 60 days of age. Pending the results of observational and phase II studies of B. infantis, a parallel phase III B. infantis probiotic or synbiotic trial will be launched to evaluate the effect of B. infantis, versus placebo, on infant health outcomes (the primary outcome of which is yet to be determined). Once established, the platform can be leveraged to evaluate the impact of novel interventions in the prevention of severe infections, faltering in early infant growth and development, and effects on other health outcomes during the neonatal period and early infancy.

Principal Investigator: Dr. Stanley Zlotkin, post-doc student Nancy Dale 

Co-PI: Dr. Chris Parshuram 

Funding: Global Child Health Catalyst Grant and Mining4Life Chair (Zlotkin) 

Millions of children suffer from Severe Acute Malnutrition (SAM) each year, and the current treatment method, the community-based treatment of Acute Malnutrition model (CMAM), includes inpatient and outpatient care depending on the severity of illness.

The mortality rate is five per cent at best. Clinical tools, adapted to low-resource settings, are needed to improve identification and management of high-risk children beyond the current recommendations. The Bedside Paediatric Early Warning System (BedsidePEWS) is a clinical decision-support developed at SickKids, to quantify severity of illness. The BedsidePEWS score has yet to be validated in children with SAM in low- resource settings. 

The study site is the University of Maiduguri Teaching Hospital (UMTH), Nigeria. Children under five years of age with SAM in the inpatient therapeutic feeding centre (ITFC), supported by ALIMA, will have the seven BedsidePEWS items recorded and known risk factors for SAM measured. We have enrolled 750 of the planned 1000 patients. Preliminary data from the first 150 children demonstrates feasibility, suggests the seven-item score can identify sicker children, and children at points of escalation or de-escalation. Analyses of the complete dataset will evaluate performance of simplified scores and other SAM risk factors. Expert judgment will be used to select the simplest score.

Next, the RISQ score will be operationalized for clinical use. An expert focus group will develop care recommendations, revise the vital sign documentation record (with local clinicians) and education materials will be developed for clinical implementation. A prospective observational study will evaluate inpatient mortality and timeliness of clinical decision-making for patients who are at high risk of death.

Principal Investigator: Dr. Shaun Morris 
Co-PIs: Fatima Kakkar and Charlotte Moore
Collaborators: Multiple paediatricians and sub-specialists across the country 
Funders: Public Health Agency of Canada 

This national project launched in April 2020 uses the Canadian Paediatric Surveillance Program to identify all children in Canada who meet one of the following case definitions:  

1. hospitalized with acute COVID-19 infection, 
2. non-hospitalized with COVID-19 who are under one year of age or have a chronic co-morbidity, and 
3. hospitalized with paediatric inflammatory, multi-system disease temporally associated with COVID-19.  

Principal Investigator: Dr. Shaun Morris 
Collaborators: Multiple GeoSentinel co-investigators 
Funders: CDC and ISTM

This study leverages data collected by the GeoSentinel network to identify and collect clinical and microbiologic data on cases of extremely drug resistant typhoid exported from Pakistan to countries around the world. Analysis includes whole genome sequencing of selected isolates.

The objective of the study is to determine the cost and cost-effectiveness associated with delivering childhood cancer treatment in a diverse range of established Sub-Saharan African LMIC treatment units. 

Representatives from Kenya, Tanzania, Zimbabwe and Nigeria met at a preliminary meeting, funded by CIHR, on March 6, 2019 in Cairo, Egypt. The team discussed data collection tool and timelines for the study. Data collection commenced in May 2019 in four main sites in Kenya, Tanzania, Zimbabwe and Nigeria.

Collaborators: American Childhood Cancer Organization (USA)

ACCESS is working with key health system stakeholders across East Africa (Ethiopia, Kenya, Rwanda, Tanzania, and Uganda) to improve availability, accessibility and acceptability of essential medicines required to treat childhood cancer.

The ACCESS core team, in collaboration with site leads from Ethiopia, Kenya, Rwanda, Tanzania and Uganda, is mapping and analyzing the determinants of paediatric drug access in East Africa, with specific attention to political, macro-economic and health system contexts. 

The ultimate aim of this work is to inform policy and programming for enhanced harmonization of care, and to prompt opportunities for coordinated procurement of childhood cancer drugs across the region.

For more details on this project, visit the ACCESS website. 

This joint initiative between PERCC and the SickKids-Caribbean Initiative (SCI) aims to bridge the existing knowledge gap on drug access in the Caribbean by: 

1. Piloting data collection instruments to obtain key metrics of drug availability and price 
2. Describing policies and practices related to drug procurement and provision in select Caribbean countries 
3. Analyzing the key determinants of childhood cancer drug access in these jurisdictions 

Key stakeholders have been identified in Bahamas, Barbados, Jamaica, and Trinidad & Tobago. These include healthcare providers, policymakers & civil servants, civil society organizations and representatives from pharmaceutical companies. 37 key informant interviews have been conducted and transcribed. The results of these findings were shared with the study team at the SCI annual work planning meeting in Barbados in September 2019. Quantitative data collection and analysis is in progress.

This multi-site project, supported by the Optimus Foundation, aims to improve childhood cancer treatment outcomes in Sub-Saharan Africa through establishing Centres of Excellence for paediatric oncology in Ghana, building on a long-standing partnership between World Child Cancer UK, and the Ghanaian paediatric oncology community.

PERCC is contributing to the project in several ways: 

1. Improving the design and delivery of Early Warning Signs and Symptoms training 
2. Studying the determinants of drug access 
3. Improving the collection of data on patient outcomes to inform new initiatives to improve care 

The Lancet Oncology Commission on Sustainable Paediatric Cancer Care was a joint partnership between PERCC, St. Jude Children’s Research Hospital, and the Harvard T.H. Chan School of Public Health, which undertook a comprehensive analysis to develop an investment case for funding management and control of childhood cancer. 

For more details, you can read the full Commission Report. 

Principal Investigator: Dr. Zulfiqar Bhutta 

Collaborators: Aga Khan University, University of Adelaide, Mother and Child Care and Research Trust (MCCR), University of Ottawa, American University of Beirut (AUB) 

Funders: This work was carried out with the aid of a grant from the Innovating for Maternal and Child Health in Africa initiative - a partnership of Global Affairs Canada, the Canadian Institutes of Health Research (CIHR) and Canada’s International Development Research Centre (IDRC), and support from the World Health Organization Department of Maternal, Newborn, Child and Adolescent Health and Ageing (MCA).

Relevant Publications: Optimising the continuum of child and adolescent health and development

To address several issues related to new thinking in child and adolescent health, and the transition from the MDGs to the SDGs, a series of planned papers will address changing epidemiology, conceptualize the life course and intergenerational aspects, and provide an action and investment plan. As part of this effort, we'll build on a large body of work from the last two decades of evidence-based interventions and packages of care for survival, strategies for delivery, and platforms to reach those at greater risk of mortality.

Principal Investigator: Dr. Zulfiqar Bhutta

Funders: Gates Ventures and Bill & Melinda Gates Foundation 

Relevant Publications: COVID-19 pandemic and mitigation strategies: implications for maternal and child health and nutrition

The Exemplars in Stunting Reduction Project incorporates cross-country findings from comprehensive country case studies. The study aims to understand the major determinants of stunting (height-for-age z-score < 2 SD) prevalence decline in example nations, which have reduced child stunting beyond what might be expected based on economic growth or poverty reduction alone.  

In phase 1 of this project, we examined five exemplar nations: Peru, Kyrgyz Republic, Nepal, Senegal, and Ethiopia. In phase 2 (ongoing), we are undertaking a set of additional country case studies that include Pakistan, Uganda, Indonesia, Ghana, and Nigeria.  

Phase 2 will include sub-national analyses of ‘counterfactual’ regions, or those regions within countries that have not reduced stunting to the level expected based on economic growth and improvements in other areas (e.g. under-five mortality). Phase 2 will also include an examination of trends in wasting (weight-for-height z-score < 2 SD) and concurrent stunting and wasting. Examining both exemplary and counterfactual regions will provide a unique opportunity to learn about success stories, along with the gaps and challenges of addressing stunting at scale and can be used to design innovative and effective solutions for improving child stunting nationally.

Principal Investigator: Dr. Zulfiqar Bhutta

Funder: Bill & Melinda Gates Foundation through US Fund for UNICEF

The Countdown to 2030 (CD2030) initiative involves a multi-disciplinary and multi-institutional consortium of experts from global, regional, and country institutions and UN agencies that have been tracking progress in reproductive, maternal, newborn, child, and adolescent health and nutrition (RMNCAH&N) since 2003. 

A major priority of CD2030 is to provide support to Global Finance Facility (GFF) countries to generate evidence on the performance of RMNCAH&N investment cases that will assist with progress tracking, annual and midterm reviews, and subnational and multi-sectoral monitoring, learning, and evaluation.  

In partnership with in-country, academic collaborators, the aim of the country case studies (Nigeria and Tajikistan) are to guide the country’s health policies, strategies and plans by preparing an in-depth analysis all relevant progress and performance data related to the country’s RMNCAH&N targets. The studies will identify current gaps and challenges within the health system for better health systems planning, particularly for prioritization and resource allocation. Technical collaborations will also aim to generate evidence on the performance of RMNCAH&N investment cases and programs, analyze all data sources (e.g. surveys, facility data, administrative data) to improve cost-efficiencies such as targeting, enhance program impact in Global Financing Facility (GFF) countries, and strengthen the evidence and analytic capacity of country public health institutions and governments for progress tracking, annual and midterm reviews and sub-national and multi-sectoral Monitoring Learning and Evaluation. 

Principal Investigator: Dr. Zulfiqar Bhutta  

Funder: UNICEF 

Kyrgyzstan has made strong progress towards several Sustainable Development Goals (SDGs). However, insufficient progress has been made in promoting healthy lifestyles and well-being for youth and adolescents (SDG 3). Only a small portion of youth exercise and lead active lifestyles. Many of them face economic difficulties such as unemployment and migration (SDG 8). The level of youth engagement in socio-political activities remains very low (SDG 16). There is an urgent need and a large opportunity to close the health and well-being gaps for young people now. 

The purpose of this project is to present a comprehensive assessment and analysis of the situation of youth (aged 20-24) and adolescent (aged 10-19) in Kyrgyzstan, and to provide an evidence base to inform decision-making and future strategic planning.

To achieve this, we’ve developed an analytical framework of five basic domains and 12 subdomains of health, education, economic opportunities, social protection and participation. For each domain, we apply UNICEF’s human rights-based approach guidance to conduct a socio-demographic trend analysis, legislation and policy analysis, and stakeholder analysis.

Principal Investigator: Dr. Zulfiqar Bhutta 

Co-Investigators: Michelle F Gaffey, Paul B Spiegel, Ronald J Waldman, Paul H Wise, Karl Blanchet, Ties Boerma, Ana Langer, Robert E Black 

Collaborators: Collaborators from Canada, USA, Colombia, UK, Switzerland, Democratic Republic of Congo, Mali, Somalia, South Soudan, Lebanon, Yemen, Afghanistan, and Pakistan. 

Funders: Norad, IDRC, Bill & Melinda Gates Foundation, UNICEF, Family Larsson-Rosenquist Foundation, PMNCH

Relevant publications:

1. BRANCH Country case study collection
2. Delivering mental health and psychosocial support interventions to women and children in conflict settings: a systematic review
3. Delivering infectious disease interventions to women and children in conflict settings: a systematic review
4. Delivering non-communicable disease interventions to women and children in conflict settings: a systematic review
5. Delivering water, sanitation and hygiene interventions to women and children in conflict settings: a systematic review
6. Women and children living in areas of armed conflict in Africa: a geospatial analysis of mortality and orphanhood
7. Protecting women and children in conflict settings

Since November 2016, the Centre has led academic, research, operational and advocacy partners to collaboratively improve the evidence base to support effective action on women's, children's and adolescents' health and nutrition (WCH) in conflict settings.

This collection of partners, now known as the BRANCH Consortium, has been working to estimate the burden of armed conflict on maternal and child mortality, synthesize the literature on WCH intervention delivery in conflict settings, generate new data, find in-depth insight into key factors affecting intervention delivery to conflict affected WCH, and inform global guidance in this area.  

This study includes a set of three systematic reviews on the impact of mitigation strategies to control the spread of COVID-19 among women and children in low-and middle-income countries.

This project will be a critical piece of work regarding the indirect impacts of COVID-19 on women, adolescents and children in developing countries. At present, we have proposed three reviews with Campbell Collaboration:

1. Impact of COVID-19 on the Health and Nutrition of Women and Children in Low- and Middle- Income Countries 
2. Gender, Mental Health, and Family Violence: The Indirect Impacts of COVID-19 on Women and Children in Low- and Middle- Income Countries 
3. Indirect Impacts of COVID-19 on Education and Human Capital of Children and Adolescents in Low- and Middle- Income Countries
   

Two additional systematic reviews will examine the direct effects of SARS-CoV-2 on women and children globally to determine the differences in presentation between children and adults, factors associated with infection, and risk or predictive factors for mortality and severe morbidity. This work is in collaboration with the World Health Organization, UNICEF and International Paediatric Association, and will inform paediatricians across various regions of the world through a series of webinars.

A fourth systematic review and prospective body of work will describe the course of the COVID pandemic in the Islamic world, and in collaboration with the Aga Khan University Institute of Studies in Muslim Civilizations (ISMC), will evaluate the impact of varying policy responses and COVID mitigation strategies on cases and deaths in Muslim-majority countries. More specifically, the group will be working towards an implementation strategy to rapidly upscale MNCH and immunization interventions in two affected provinces of Pakistan. As the situation changes and evolves, we will continue to track the impact to try and improve health outcomes in women and children amid this COVID crisis.

Relevant publications

1. Covid-19 risks and response in South Asia
2. Evaluation of effects of public health interventions on COVID-19 transmission for Pakistan: A mathematical simulation study
3. Covid-19: how a virus is turning the world upside down
4. Pakistan’s Covid-19 response: 5 things we need to do
5. COVID-19 pandemic and mitigation strategies: implications for maternal and child health and nutrition

Principal Investigators: Dr. Zulfiqar Bhutta and Dr. Daniel Roth 

Funders: Joannah and Brian Lawson Centre for Child Nutrition, University of Toronto

During the preliminary stage of the project, we undertook a scoping review to understand the various characteristics of the food environment. We also wanted to develop a logic model to guide subsequent systematic reviews.

Our scoping review identified that the food environment is a complex adaptive system, with various industries that operate interdependently and adaptively, and their interaction is often shaped through spatial and temporal complexity. Additionally, the food environment possesses limitations and boundaries in relation to the greater food system.

The second stage of the project involved an intervention-focused review aimed to understand the effectiveness of food environment interventions, both preventive and curative in nature, on diet-related health outcomes in school-aged children and adolescents in LMIC. Using our conceptual framework as guidance, this exercise contributed to our overall project goal by identifying which food environment interventions (and associated ‘input indicators’) are most effective for preventing and treating diet-related health outcome indicators in school-age children and adolescents in LMIC. 

Lead agency: Amref Health Africa in Canada 
Partners: Christian Children’s Fund of Canada, SickKids Centre for Global Child Health and WaterAid Canada 
Funder: Government of Canada, through Global Affairs Canada 
Timeline: March 2016 to March 2020 
Location: Ethiopia, Kenya, Malawi and Tanzania 

Role: As a technical support partner, IPE led the development and deployment of the program’s monitoring and evaluation (M&E) strategy, developing baseline and end line data collection tools, sampling strategy, analysis and reporting. We also assisted in building the M&E capacity of all consortium partners. 

Lead agency: Aga Khan Foundation Canada (AKFC) 
Partners: Aga Khan Development Network, SickKids Centre for Global Child Health 
Funder: Government of Canada, through Global Affairs Canada 
Timeline: April 2016 to March 2020 
Location: Kenya, Mali, Mozambique and Pakistan 

Role: IPE, in collaboration with Aga Khan University (AKU), Nairobi, supported the AQCESS implementing agencies in the monitoring, evaluation, research and learning function of the project, including developing and implementing the monitoring and evaluation strategy, and leading implementation research projects across the countries. 

Lead agency: Canadian Red Cross 
Partners: Mali Red Cross, Mali’s Ministry of Health, SickKids Centre for Global Child Health 
Funder: Government of Canada through Global Affairs Canada 
Timeline: April 2016 to March 2020 
Location: Koulikoro and Sikasso regions, Mali 

Role: IPE provided a lead technical role in developing the evaluation strategy for the program, assisting in developing the monitoring methodology and tools, and improving the Health Management Information System (HMIS). We also designed and conducted an implementation research study. 

Lead agency: World Vision Canada 
Partners: SickKids Centre for Global Child Health 
Funder: Government of Canada, through Global Affairs Canada 
Timeline: January 2017 to June 2020 
Location: Tanzania 

Role: As a technical support partner, IPE led the development and deployment of the program’s evaluation strategy, developing baseline and end line data collection tools, sampling strategy, analysis and reporting. We also supported the assessment of current vital statistics record keeping, and worked with partners to develop a strategy for improving vital statistics recording in the SUSTAIN project area. 

Lead agency: Plan International Canada 
Partners: Promundo, SickKids Centre for Global Child Health 
Funder: The Government of Canada, through Global Affairs Canada 
Timeline: January 2016 to September 2020 
Location: Bangladesh, Ghana, Haiti, Nigeria and Senegal 

Role: IPE, in collaboration with Plan International Canada, designed and conducted research projects in the implementing countries and areas.

Partners: SickKids Centre for Global Child Health, Canadian Partnership for Women and Children’s Health (CanWaCH), Canadian Red Cross
Funder: Government of Canada, through Global Affairs Canada
Timeline: January 2019 to November 2020

Role: IPE conducted two scoping reviews to describe the measurement tools, methods and indicators used to measure sexual and reproductive health and rights (SRHR), gender equality and women’s empowerment (GEWE), respectively, in humanitarian settings. We then created interactive dashboards to illustrate our findings using Tableau Software, which allows for the creation of open platform, interactive dashboards in a story format. The dashboards are a synthesis of measurement tools, methods, and indicators extracted from publications found in both scoping reviews. As a whole, these dashboards provide an inventory of available toolkits and indicators relevant to SRHR and GEWE and their data sources, which can be sorted by topic, country, humanitarian setting, study design, or study method. They also highlight measurement gaps in indicators for SRHR and GEWE.

View the project's interactive data dashboards
Watch a video tutorial on how to use the data dashboards

Partners: CARE Canada, Plan International Canada, Save the Children Canada, World Vision Canada, SickKids Centre for Global Child Health, and the University of Toronto Munk School of Global Affairs
Funder: Government of Canada through the Department of Foreign Affairs, Trade and Development (DFATD)
Timeline: 2012-2015

Role: As an academic partner, our role was to analyze and assess the work of the Muskoka Initiative Consortium, a three-year collaboration among CARE Canada, Plan Canada, Save the Children Canada and World Vision Canada, in partnership with SickKids Centre for Global Child Health and the Munk School of Global Affairs, to improve maternal, newborn and child health in developing countries by strengthening Canadian-supported programs. Our group was tasked with analyzing and presenting the combined results of selected indicators of four organizations implementing 10 projects in seven countries: CARE Canada in Ethiopia and Zimbabwe; Plan Canada in Bangladesh, Ethiopia, Ghana, Mali, and Zimbabwe; Save the Children Canada in Mali and Pakistan; and World Vision Canada in Tanzania.

Read the final reports:

1. An Examination of Exclusive Breastfeeding Implementation in Ethiopia and Mali: Factors Influencing Change (PDF)
2. Perceptions and Experiences of Adolescent Mothers Accessing Antenatal Care Services in Volta and Eastern Regions, Ghana, and Singida and Iramba Regions, Tanzania (PDF)
3. Muskoka Initiative Consortium – Knowledge Management Initiative: Endline Report (PDF)

Watch a video synopsis of the work of MIC-KMI (YouTube)