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School performance following invasive Group B Streptococcus disease in early infancy in Denmark.
Get PDFOBJECTIVES: Better quantification of long-term neurodevelopmental impairments following invasive Group B Streptococcus disease (iGBS) in early infancy can inform prognostication and societal impacts, including children's educational and social care needs. STUDY DESIGN: A population-based observational prevalence study. METHODS: Children born 1997-2010, who survived iGBS sepsis or meningitis within the first 89 days after birth and completed public school tests aged 8-15 years were matched 1:20 with a general population comparison group without iGBS by sex and year of birth in Denmark. IGBS was identified using the Danish National Patient Registry covering all Danish hospitals and International Classification of Diseases, Tenth Revision codes. Standardized school test scores from 2010 to 2019 were obtained from the Danish Ministry of Education. Adjusted differences (adj. diff.) in school performance and corresponding 95 % confidence intervals (CIs) were estimated by subject type, grade, sex (at birth), and preterm birth using multivariable linear regression models with robust variance estimators. RESULTS: Among 807 iGBS survivors (90.7 % sepsis, 9.3 % meningitis) and 16,140 comparators, iGBS-sepsis survivors' performance was comparable to children without iGBS across tests, subjects, or grades. However, iGBS-meningitis survivors performed poorer than their matched comparators (adj. diff. -2·74 [95 % CI -5·19; -0·29]). Preterm birth was associated with poorer performance, regardless of a history of iGBS. No difference in test scores was found between sexes. CONCLUSION: Among Danish school children, no overall difference was observed in school performance between children with a history of iGBS and comparators. However, iGBS-meningitis and preterm birth were linked to lower standardized test scores. This association was not observed in children who had iGBS-sepsis, unless they were also preterm
A synthesis of youth activation initiatives and their impact on tuberculosis knowledge, knowledge-seeking, and healthcare-seeking behavior in vulnerable populations
Get PDFBACKGROUND: Annually, up to 3 million people with tuberculosis (TB) fail to receive care due to delays in seeking TB care. Alongside active case finding, identifying cost-effective strategies that successfully mobilize vulnerable populations, such as young adults, to proactively present to care early is critical for ending the TB epidemic. Enabling populations to achieve optimized knowledge levels and proactively self-present to care may be more efficient than population-wide screening.
METHODS: Between August 2021 and December 2023, five youth activation initiatives (“Be the Change”, MumbraTB-ACTS, and MTV Nishedh in India; TB Warriors in Indonesia; UVTB5+ in China) were implemented. Initiatives were assessed on reach and program engagement, TB knowledge improvement, knowledge-seeking behaviors, healthcare-seeking behaviors, TB volunteering, and TB self-screening, as precursors to presentation to care. Program outcomes measurements included number of individuals reached and knowledge change before and after implementation using knowledge, attitudes, and practices (KAP) surveys. Core healthcare-seeking behavior indicators were also tracked where feasible.
RESULTS: Across programs, various strategies were implemented to reach youth including social media, hybrid case-finding, mass media, gamification and peer education, and/or volunteer-driven health promotion. Variability in measurement and reporting of program outcomes confounded the synthesis of information across initiatives, but collectively the initiatives resulted in broad reach within each local context, resulting in more than 200 million youths reached and 100 million engaged. More than 800,000 individuals reported knowledge-seeking activities with >50,000 completed KAP surveys. Initiatives demonstrated evidence of empowering communities to proactively undertake screening and/or volunteer for TB initiatives. Three also measured positive improvements in knowledge of disease transmission, symptoms, and curability.
CONCLUSION: These data highlight several locally successful strategies for increasing TB awareness and knowledge, and encouraging TB care seeking, as well as mobilizing youth to volunteer as community TB KAP advocates. Next steps to understanding the true impact of such activation TB initiatives should include the development of a global framework to provide guidance on best practices for impact assessment, particularly at the healthcare-seeking stage. This could support healthcare workers in their provision of equitable access to quality care and implementation of TB initiatives
A cost-consequence analysis of the children's administration oxygenation strategies trial (COAST) in severe pneumonia.
Get PDFOxygen supplementation is a recommended treatment for children with severe pneumonia or hypoxaemia. The open, fractional-factorial Children's Oxygen Administration Strategies Trial (COAST) recruited Kenyan and Ugandan children with severe pneumonia and hypoxaemia. Participants in the severe hypoxaemia stratum (SpO2 < 80%) were randomised to high-flow nasal therapy (HFNT) or low-flow oxygen (LFO), and in the hypoxaemia stratum (SpO2 80-91%) to HFNT, LFO or permissive hypoxaemia (ratio 1:1:2). The trial stopped early and there is ongoing uncertainty about the clinical benefits of the alternative strategies. There is a lack of evidence about the relative costs, of alternative oxygen delivery for critically-ill children in low- and middle- income countries. We used data from COAST to conduct a cost-consequence analysis of the treatment strategies. We measured resource use for 28 days post-randomisation (n = 1,842). Resources included oxygen delivery, medications, blood and fluid products, diagnostic tests, point of care tests, hospital admission and length of stay. We calculated the total costs and reported the incremental costs as the difference in the mean total costs between groups, adjusting for baseline differences. In the severe hypoxaemia stratum, the mean total cost was 218.73 for LFO. In the hypoxemia stratum, the mean total costs were 198.26 (LFO) and 184.43 (95% CI l: 240.95), and 99.53, 216.22 (95% CI: 271.68) and 11.49, $52.11), respectively. For children with severe hypoxaemia, HFNT is more costly than LFO. For children with hypoxaemia, either of HFNT or LFO were more costly than permissive hypoxaemia. The main driver of costs for HFNT is the high cost of equipment and consumables; other costs were similar across treatment groups in both strata, as were health outcomes
Associations Between Prior and Current Unhealthy Alcohol Use and Liver Morbidity Risk and Mortality Among Veterans With a History of Hepatitis C Who Have Achieved Sustained Virological Response.
No full textThe degree to which alcohol use is associated with the risk of all-cause mortality and hepatic decompensation after hepatitis C (HCV) diagnosis, treatment, and cure remains unknown. We sought to address this question among patients achieving sustained virologic response (SVR) after direct-acting antiviral treatment in the largest HCV health system in the United States. We extracted data on alcohol use, HCV treatment, SVR, HIV co-infection, demographics, risk behaviours, hepatic decompensation, and mortality from all patients in the 1945 to 1965 VA Birth Cohort. Alcohol use categories were generated using responses to the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) questionnaire and diagnostic codes for alcohol use disorder (AUD): abstinent without a history of AUD, abstinent with a history of AUD, current lower-risk consumption, current moderate-risk consumption, and current high-risk consumption with or without AUD. Cox proportional hazard models were used to examine associations between alcohol category and the risk of hepatic decompensation and all-cause mortality. Among 50,581 patients in the analytic cohort, compared to current drinkers exhibiting lower risk alcohol consumption (referent), current high-risk consumption with or without AUD was associated with increased risk of all-cause mortality (aHR: 1.40, 95% CI: 1.21-1.63) and hepatic decompensation (HR: 2.15, 95% CI: 1.60-2.89) as was abstinence with a history of AUD diagnosis (mortality aHR: 1.63, 95% CI: 1.41-1.89; hepatic decompensation aHR: 1.85, 95% CI: 1.36-2.51). AUD and high-risk alcohol consumption are associated with the risk of hepatic decompensation and all-cause mortality among Veterans who have achieved SVR, including those categorised as being currently abstinent. Interventions for alcohol consumption and use disorder among individuals treated for HCV infection may reduce morbidity and mortality in this population
Exploring changes to financial protection and equity in Lithuania following 2017-2020 policies to improve access to outpatient medicines.
Get PDFINTRODUCTION: Access to pharmaceuticals is a key area of health systems performance. Previous analyses showed medicines to be the largest contributor to catastrophic spending in Lithuania, particularly for people with lowest incomes. This paper examines changes to household spending on health following 2017-2020 pharmaceutical policies to improve access to outpatient medicines. METHODS: Household spending and catastrophic health spending were calculated using household budget survey data for 2016 and 2021. Pharmaceutical policies were obtained from the review of legislation and regulation, and publications by the relevant health authorities. RESULTS: Catastrophic spending in Lithuania reduced from 11.5% in 2016 to 9.4% in 2021, driven by reductions in out-of-pocket spending for medicines and with significant decrease in the poorest income quintile and among people aged 75 + . The measures introduced in 2017-2020 included eliminating percentage co-payments for nearly all covered medicines, as well as exempting people aged 75 + and some other groups on low income from co-payments for medicines. CONCLUSIONS: In 2017-2020 measures were implemented reduce the burden of household spending on medicines, resulting in reduction of catastrophic spending in the most vulnerable groups. Challenges remain, as still 9% of households experience catastrophic spending. Next steps could involve broadening exemptions, addressing gaps in the positive list, and understanding accessibility barriers in other health care services
Bayesian adaptive trial designs for evaluating low-risk programmatic changes for quality improvement in health services: a simulation study.
No full textBackground: Quality improvement in health service programmes often involves introducing small, low-risk programmatic changes, such as modifying workflows, to incrementally improve outcomes, which accumulate over time to have significant overall gains in quality and efficiency. Although these changes are common in health services, they are rarely evaluated using statistically rigorous designs, partly because conventional randomised trials are perceived as inefficient for detecting modest effects. This study was motivated by a vision screening and referral programme and focuses on evaluating the modest but important impacts of low-risk QI interventions.
Methods: To advance data-driven approaches for achieving quality improvement, we used a simulation study to explore the use of Bayesian adaptive trial designs to compare two variants of programmatic changes that yield small improvements in outcomes. The study examined key adaptive design features, including interim analysis frequency, prior specification, and early stopping rules for efficacy and equivalence. Changes in error rates, sample size, and bias were assessed across scenarios with small effect sizes ranging from 0% to 5%.
Results: The findings were used to configure an ideal trial design that prioritises rapid identification of the more effective programmatic change while minimizing the risk of adopting an inferior one. The recommended trial design incorporates a sceptical prior, a stringent stopping rule for efficacy, and a relaxed criteria to stop for equivalence. Under this design, a marginal improvement as small as 1% could be detected with high probability using considerably fewer participants than would be required under conventional, fixed-size randomised controlled trials.
Conclusions: Bayesian adaptive trial designs offer a feasible approach for evaluating low-risk, incremental QI interventions in high-throughput service settings. Their use may support more efficient, data-driven decision-making when modest improvements are expected and the consequences of incorrect adoption are limited
Impact of local and national policies to reduce agriculture-related air pollution through improving diet and farm management: the AMPHoRA mixed methods study.
Get PDFMETHODS: This study employed an interdisciplinary approach to assess the impact of agricultural production modifications and dietary changes on ammonia emissions, health outcomes and health inequalities. Statistical and econometric methods were applied to analyse agricultural emission trends and dietary patterns. Spatial data analysis and numerical modelling techniques were used to simulate the dispersion and transformation of atmospheric pollutants. Health impact modelling estimated mortality and morbidity outcomes under various policy scenarios, while cost-effectiveness and cost-benefit analyses supported decision-making. A participatory approach involving multistakeholder engagement was utilised to enhance policy relevance and implementation feasibility. A systematic scoping review of academic studies on agricultural-derived air pollution and clinically coded outcomes revealed very limited research on this topic, which presents an inconsistent picture as to whether agricultural-derived particulate matter affects health.
RESULTS: Key findings indicate that dietary modifications have greater potential health benefits than direct reductions in particulate matter exposure from ammonia emissions. Small reductions in meat and dairy consumption, supported by taxation and subsidies, could help achieve environmental and health targets. A 20% meat and dairy tax, coupled with a 20% subsidy on fruits and vegetables, could reduce meat consumption by 21.5% and increase fruit and vegetable intake by up to 13.5%. These dietary shifts also significantly lower greenhouse gas emissions and water use. While ammonia's environmental effects are well documented, its direct health impacts remain uncertain. Epidemiological studies suggest a possible association between ammonium-derived particulate matter and increased mortality and cardiorespiratory diseases, though findings are inconsistent. Toxicological assessments indicate limited intrinsic toxicity of ammonium nitrate and sulfate. A 'high-ambition mitigation' scenario integrating ammonia reduction measures with dietary shifts could prevent 67,000 premature deaths and 270,000 cases of respiratory diseases over 30 years. Notably, older adults and lower-income populations would experience the greatest health benefits. Most farm-based ammonia reduction strategies demonstrated net economic benefits, with only a few measures having limited abatement potential. Additionally, reduced greenhouse gas emissions further amplified the benefits of each scenario.
LIMITATIONS: Despite robust modelling techniques and multistakeholder engagement, several limitations exist. The direct health effects of ammonia-derived particulate matter remain an area of uncertainty, necessitating further epidemiological research. Additionally, while economic and environmental benefits were quantified, behavioural responses to policy interventions - such as consumer acceptance of dietary changes - require further exploration. The study primarily focused on UK-specific data, limiting generalisability to other regions with different agricultural practices and policy landscapes. Finally, unintended consequences of dietary shifts on food security and cultural preferences were not fully explored, indicating the need for future research to refine policy recommendations. The Assessing Mitigation Pathways to Realise Public Health Benefits of Air Pollutant Emission Reductions from Agriculture project provides a comprehensive, interdisciplinary framework for evaluating integrated policy measures. It underscores the importance of sustainable agricultural and dietary transitions in achieving cobenefits for public health and environmental sustainability, while emphasising the need for continued research to address remaining uncertainties. FUTURE WORK: More detailed spatial and temporal analyses are required to fully understand the potential importance of significant local sources on human health in specific areas/times of year. There is a need to better align evidence of studies, such as Assessing Mitigation Pathways to Realise Public Health Benefits of Air Pollutant Emission Reductions from Agriculture, with toxicological studies which suggest that (pure) ammonium nitrate and sulfate have only very modest toxicity.
STUDY REGISTRATION: This study is registered as PROSPERO CRD42020172116.
FUNDING: This award was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme (NIHR award ref: NIHR129440) and is published in full in Public Health Research; Vol. 14, No. 3. See the NIHR Funding and Awards website for further award information
Strengthening and sustaining gender-based violence (GBV) coordination in emergencies: a synthesis of practitioner-driven, globally applicable recommendations.
Get PDFINTRODUCTION: Gender-based violence (GBV) is a global public health and human rights crisis, requiring coordinated efforts to ensure effective prevention, risk mitigation, and response, particularly in emergencies. Despite policy commitments underlining the importance of addressing GBV in emergencies, funding remains insufficient, inconsistent, and poorly aligned with aid prioritisation in the changing humanitarian and global health financing landscape. This paper synthesizes evidence on GBV coordination in humanitarian and public health emergencies and presents global recommendations to inform policy and practice in the context of the ongoing Humanitarian Reset. METHODS: Using a three-phase qualitative methodology—comprising evidence synthesis, case study analysis, and a global expert practitioner consultation—we developed a framework and present strategic recommendations to strengthen and sustain GBV coordination in emergencies. RESULTS: Our findings identify seven strategic recommendations aimed at investing in, sustaining, and transforming GBV coordination efforts globally. Key investment priorities include expanding the GBV coordination workforce, including for risk mitigation, prioritizing and systematically addressing GBV within public health emergencies, and investing in information management systems and strategic research. To sustain GBV coordination, we recommend adapting funding models, diversifying financial sources, advancing national leadership and localization, and implementing context-specific coordination approaches, including at the sub-national level. Furthermore, we propose that emergencies can serve as catalysts for broader social and legal transformations that advance GBV prevention and gender equality. CONCLUSION: Rather than accepting the deprioritisation of GBV coordination as an inevitable consequence of funding reductions framed as efficiency gains, our findings underscore the critical value of maintaining a dedicated focus on GBV within humanitarian coordination. Our findings provide practical, evidence-based recommendations and a global framework for policymakers, donors, and practitioners to strengthen and sustain GBV coordination in diverse emergency contexts. Sustained progress will require collective commitment to address GBV, even as funding landscapes change, and the backlash against gender equality continues to intensify
Assessing the Transferability of Peer-Assisted Ultrasound Training for Medical Students: A Comparative Study Between Two Institutions in Germany and the UK.
Get PDFUltrasound (US) is a clinically important imaging modality that can also enhance medical students' understanding of anatomy, physiology, and pathology. However, its integration into preclinical curricula often remains limited due to challenges such as resource constraints and instructor availability. To address these shortcomings, we implemented and evaluated a peer-assisted learning (PAL)-based US course-Summer School of Anatomy-based Sonography Heidelberg (SASH)-with a daughter course at a second institution, the University of Cambridge (Cam-SASH). Both programs focused on teaching fundamental US techniques through a structured, tutor-led curriculum including an accompanying course manual. In 2022, we evaluated both programs prospectively, including 36 medical students. Over 1 week, student tutors trained participants in B-mode abdominal US through lectures, hands-on practice, and assessments, including Objective Structured Clinical Examinations (OSCEs) and pre- and post-course multiple-choice tests of anatomical knowledge. Post-course knowledge levels were comparable between Hei-SASH and Cam-SASH participants, with no significant differences observed in multiple-choice tests or OSCE performance (p ≥ 0.17). Feedback was overwhelmingly positive, with students reporting increased confidence and proficiency in performing US scans and interpreting images. This study highlights the transferability of PAL-led US courses, with comparable outcomes between institutions. Our findings support the inclusion of such programs in undergraduate medical curricula, as they provide a cost-effective and scalable solution to resource limitations. By enabling students to gain hands-on experience with real-time imaging, these courses bridge the gap between theoretical learning and clinical application, equipping future physicians with essential diagnostic skills