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Navigating a polycrisis: barriers to maternal healthcare access in Burkina Faso
Get PDFBurkina Faso exemplifies a polycrisis, where overlapping sociopolitical, health, security and environmental disruptions collectively undermine public health progress. Despite decades of advancement in maternal and reproductive healthcare–through policies like fee abolition and expanded health facilities–recent crises have severely eroded these gains. Since 2014, Burkina Faso has faced escalating insecurity, becoming the world’s most terrorism-affected country, compounded by political instability following the ousting of long-time president Blaise Compaoré, repeated coups and increasingly militarized regimes. Simultaneously, the nation is grappling with deep economic inequality, environmental degradation and the lingering effects of the COVID-19 pandemic. These intertwined crises disproportionately impact the most vulnerable, deepening healthcare inequities. Emerging research highlights how this converging crisis landscape threatens access to quality maternal care, jeopardizing two decades of progress. Recognizing the polycrisis as a public health threat is critical to safeguarding maternal and reproductive health achievements in Burkina Faso and developing more resilient health systems amid compounded adversities
The impact and legacy of COVID-19 on community-based multidisciplinary teams organising integrated health and social care for older people with long-term conditions: Findings from the evaluation of the integrated care and support Pioneers.
Get PDFObjectivesThe COVID-19 pandemic severely disrupted health and social care (HSC) services in many countries, including England. At the same time, it forced systems to respond innovatively to radically changed circumstances and challenges. This study identifies the impacts and emerging legacy of the pandemic for community-based multidisciplinary teams (MDTs) supporting older people with multiple long-term conditions living in their own homes.MethodsThirty-eight strategic, operational, and frontline staff involved with MDTs in seven areas in England were interviewed between July 2020 and August 2021, as part of a wider evaluation of the Integrated Care and Support Pioneers programme. Interview transcripts were analysed thematically.ResultsInterviewees described an initial period of pandemic disruption characterised by uncertainty, shifting of priorities and resources within the HSC system towards emergency care, and redeployment of staff away from MDTs. These circumstances required the development of new ways of working with MDT patients/clients and with one another. Remote, mostly virtual, MDT working between professionals was seen by most as a positive adaptation, though some felt that in-person meetings were better for the development of working relationships. Others raised concerns about access to, and quality of, care provided to vulnerable patients remotely, or in person but with a delay. At the local system level, the crisis response lowered barriers to collaboration between organisations, blurred professional roles, increased flexibility in the use of resources, and engendered a stronger sense of local cohesion among a wide range of staff in HSC. Most respondents wished to retain these attributes of the local system permanently.ConclusionsThe pandemic's legacy seemed to accelerate innovations in health and care provision and increased cohesion and closer working relationships. Remote ways of working were perceived to have improved the efficiency of MDT meetings and facilitated involvement of professionals external to MDTs. The implications for patient/client care were more complex. We suggest that the potential impact on inequalities of remote access to, and provision of, care for people served by MDTs will need to be considered if these changes are to be maintained. The resilience of MDTs and the HSC system may be improved by upskilling staff and creating a more flexible workforce capable of working across organisations during future crises
Surveys to substantiate elimination of trachoma as a public health problem in the Republic of the Union of Myanmar.
Get PDFBACKGROUND: To determine whether trachoma elimination thresholds have been met in Myanmar, surveys were undertaken in 2019 to estimate the prevalence of trachomatous inflammation-follicular (TF) in children ages 1-9 y and the prevalence of trachomatous trichiasis (TT) unknown to the health system in adults ≥15 y of age. METHODS: Surveys were conducted in 14 townships (evaluation units [EUs]) that were considered formerly endemic for trachoma. A two-stage cluster survey design was applied, whereby 30 villages and 30 households per village were sampled. Consenting eligible participants ≥1 y of age were examined for trachoma using the World Health Organization (WHO) simplified trachoma grading system. RESULTS: A total of 12 594 households were surveyed, with a total of 5901 children ages 1-9 y and 31 097 people ≥15 y of age examined. In all 14 EUs, the prevalences of TF and TT unknown to the health system were below the elimination thresholds of <5% and <0.2%, respectively. CONCLUSIONS: Surveys showed that trachoma was no longer a public health problem in Myanmar and trachoma elimination thresholds had been attained. Partly on the basis of these data, in September 2020, Myanmar was validated by WHO as having eliminated trachoma as a public health problem
No Time to Waste: A Synthesis of Evidence on Time Reallocation Following Water, Sanitation and Hygiene Interventions
Get PDFLarge amounts of time are wasted globally accessing water for domestic uses and sanitation, disproportionately impacting women and girls. We conducted a systematic review and meta‐analysis based on evidence mapping initiatives. Our synthesis of the evidence found a mean reduction of 15 min per trip for water supply interventions, and 3 min per trip for sanitation interventions, adding up to around 8 h per week and 3.5 h per week respectively at the household level. Time‐savings from improvements in the quantity of water supplied were very large, whether improved water supplies were provided at the household or community level. In contrast, studies on water treatment reported small increases in time, and there were no studies that reported reallocation following hygiene interventions. We found limited evidence on time reallocation to other activities, but disaggregated data showed girls were significantly more likely to attend school following interventions that improved water supply, sanitation and hygiene (WASH) at the household level. Of note, nearly half of the eligible studies collecting information about time use were identified in the grey literature. This policy‐relevant evidence contributes to the case for increasing investments in appropriate water supply and sanitation interventions
Multiple soil and landscape properties are associated with the spatial variation of selenium concentration in maize grain in Malawi
Get PDFDietary selenium (Se) deficiency is widespread in Malawi, due to the limited supply of Se in the predominantly maize based-food system characterised by low Se concentration. In this study, the aim was to examine the spatial variation of Se in maize grains in Malawi, in relation to soil properties and landscape features. Co-located soil and maize grain samples were collected in a spatially representative survey. Selenium concentration in maize, soil properties, and environmental covariates were determined. Soil and environmental variables were tested as potential predictors of Se concentration in maize. A false discovery rate (FDR) control was used within a linear mixed model (LMM) framework. Selenium concentrations in maize ranged from below detection limits (7.69 µg kg−1) to 1852 µg kg−1 with mean and median values of 39.1 and 16.8 µg kg−1 respectively. The ranges of concentrations of Se fractions in soil were (i) soluble Se 0.181–18.8 µg kg−1with mean and median values of 3.94 and 3.29 mg µg kg−1 respectively; (ii) adsorbed Se 0.019–119 µg kg−1 with mean and median values of 3.72 and 3.02 µg kg−1 respectively; (iii) organically bound Se 9.43–1334 µg kg−1 with mean and median values of 123 and 92.3 µg kg−1 respectively. A LMM for maize Se concentration was used for which the independent log transformed variables of soil soluble Se, adsorbed Se, oxalate extracted oxides, soluble and exchangeable sulphur had predictive value (p
0.01 in all cases, with FDR controlled at
0.05). Downscaled mean annual temperature also explained some of the spatial variation in grain Se concentration. Spatial variation of Se in maize showed relationships with soil and environmental variables, which can be used to identify areas most at risk of Se deficiency and thus inform policy responses. However, only a small proportion of the variation was explained indicating more analysis of Se geochemistry in soil may provide more explanatory insights
Hospitalization outcomes in people living with HIV on Dolutegravir-based regimen in Mwanza, Tanzania: a comparative cohort.
Get PDFINTRODUCTION: Hospitalized people living with HIV (PLWH) experienced extremely high mortality rates in the first year after an index hospitalization in the pre-Dolutegravir (DTG) era. We conducted a multi-center study in Mwanza, Tanzania to (1) describe causes of hospitalization for PLWH on DTG; (2) determine in-hospital and 3-month post-hospital mortality; (3) examine factors associated with overall mortality; and (4) determine changes in trends and predictors of mortality pre- and post-DTG era. METHODS: Between August 2020 and February 2021, hospitalized PLWH on dolutegravir-based antiretroviral therapy were enrolled and followed for three months after hospitalization. The primary outcome was mortality within 3-months of hospitalization. Cox regression analysis was used to calculate hazard ratios to identify predictors of mortality. RESULTS: Of the 154 enrolled patients, the median [interquartile range] age was 42 [33-50] years and 57% were female. Suspected immune reconstitution inflammatory syndrome (IRIS) and antiretroviral therapy (ART) non-adherence leading to an HIV-associated admission were common. The overall all-cause mortality was 42%. Male sex, using DTG-based regimen for < 3 months, diagnosis of suspected IRIS, diagnosis of ART side effect, advanced WHO clinical stage, CD4 count < 200 cells/mm3, hemoglobin level 7-11.9 gm/dl and hemoglobin level < 7 gm/dl were all independent risk factors for death. CONCLUSION: In conclusion, the mortality rate of hospitalized PLWH in Africa remains high in the DTG era. Clinical trials are urgently needed to test novel interventions for improving survival in this high-risk group. In the meantime, hospital clinicians should be aware of the very high mortality among PLWH with IRIS and those with ART side effect to ensure that all possible diagnostic and therapeutic options are explored
Changing life expectancy in European countries 1990-2021: a subanalysis of causes and risk factors from the Global Burden of Disease Study 2021.
Get PDFBACKGROUND: Decades of steady improvements in life expectancy in Europe slowed down from around 2011, well before the COVID-19 pandemic, for reasons which remain disputed. We aimed to assess how changes in risk factors and cause-specific death rates in different European countries related to changes in life expectancy in those countries before and during the COVID-19 pandemic. METHODS: We used data and methods from the Global Burden of Diseases, Injuries, and Risk Factors Study 2021 to compare changes in life expectancy at birth, causes of death, and population exposure to risk factors in 16 European Economic Area countries (Austria, Belgium, Denmark, Finland, France, Germany, Greece, Iceland, Ireland, Italy, Luxembourg, the Netherlands, Norway, Portugal, Spain, and Sweden) and the four UK nations (England, Northern Ireland, Scotland, and Wales) for three time periods: 1990-2011, 2011-19, and 2019-21. Changes in life expectancy and causes of death were estimated with an established life expectancy cause-specific decomposition method, and compared with summary exposure values of risk factors for the major causes of death influencing life expectancy. FINDINGS: All countries showed mean annual improvements in life expectancy in both 1990-2011 (overall mean 0·23 years [95% uncertainty interval [UI] 0·23 to 0·24]) and 2011-19 (overall mean 0·15 years [0·13 to 0·16]). The rate of improvement was lower in 2011-19 than in 1990-2011 in all countries except for Norway, where the mean annual increase in life expectancy rose from 0·21 years (95% UI 0·20 to 0·22) in 1990-2011 to 0·23 years (0·21 to 0·26) in 2011-19 (difference of 0·03 years). In other countries, the difference in mean annual improvement between these periods ranged from -0·01 years in Iceland (0·19 years [95% UI 0·16 to 0·21] vs 0·18 years [0·09 to 0·26]), to -0·18 years in England (0·25 years [0·24 to 0·25] vs 0·07 years [0·06 to 0·08]). In 2019-21, there was an overall decrease in mean annual life expectancy across all countries (overall mean -0·18 years [95% UI -0·22 to -0·13]), with all countries having an absolute fall in life expectancy except for Ireland, Iceland, Sweden, Norway, and Denmark, which showed marginal improvement in life expectancy, and Belgium, which showed no change in life expectancy. Across countries, the causes of death responsible for the largest improvements in life expectancy from 1990 to 2011 were cardiovascular diseases and neoplasms. Deaths from cardiovascular diseases were the primary driver of reductions in life expectancy improvements during 2011-19, and deaths from respiratory infections and other COVID-19 pandemic-related outcomes were responsible for the decreases in life expectancy during 2019-21. Deaths from cardiovascular diseases and neoplasms in 2019 were attributable to high systolic blood pressure, dietary risks, tobacco smoke, high LDL cholesterol, high BMI, occupational risks, high alcohol use, and other risks including low physical activity. Exposure to these major risk factors differed by country, with trends of increasing exposure to high BMI and decreasing exposure to tobacco smoke observed in all countries during 1990-2021. INTERPRETATION: The countries that best maintained improvements in life expectancy after 2011 (Norway, Iceland, Belgium, Denmark, and Sweden) did so through better maintenance of reductions in mortality from cardiovascular diseases and neoplasms, underpinned by decreased exposures to major risks, possibly mitigated by government policies. The continued improvements in life expectancy in five countries during 2019-21 indicate that these countries were better prepared to withstand the COVID-19 pandemic. By contrast, countries with the greatest slowdown in life expectancy improvements after 2011 went on to have some of the largest decreases in life expectancy in 2019-21. These findings suggest that government policies that improve population health also build resilience to future shocks. Such policies include reducing population exposure to major upstream risks for cardiovascular diseases and neoplasms, such as harmful diets and low physical activity, tackling the commercial determinants of poor health, and ensuring access to affordable health services. FUNDING: Gates Foundation
Age and Sex Differences in Efficacy of Treatments for Type 2 Diabetes: A Network Meta-Analysis.
Get PDFIMPORTANCE: Sodium-glucose cotransporter 2 (SGLT2) inhibitors, glucagon-like peptide-1 (GLP-1) receptor agonists, and dipeptidyl peptidase 4 (DPP4) inhibitors improve hyperglycemia, and SGLT2 inhibitors and GLP-1 receptor agonists reduce the risk of major adverse cardiovascular events (MACEs) among individuals with type 2 diabetes. It is not clear whether efficacy varies by age or sex. OBJECTIVE: To assess whether age or sex are associated with differences in the efficacy of SGLT2 inhibitors, GLP-1 receptor agonists, and DPP4 inhibitors. DATA SOURCES AND STUDY SELECTION: The MEDLINE and Embase databases and US and Chinese clinical trial registries were searched for articles published from inception to November 2022; in August 2024, the search was updated to capture the trial results. Two reviewers screened for randomized clinical trials of SGLT2 inhibitors, GLP-1 receptor agonists, or DPP4 inhibitors vs a placebo or active comparator in adults with type 2 diabetes. DATA EXTRACTION AND SYNTHESIS: Individual participant data and aggregate data were used to estimate age × treatment interactions and sex × treatment interactions in multilevel network meta-regression models. MAIN OUTCOME AND MEASURES: Hemoglobin A1c (HbA1c) and MACEs. RESULTS: Of the 601 eligible trials identified (592 trials with 309 503 participants reported HbA1c; mean age, 58.9 [SD, 10.8] years; 42.3% were female and 23 trials with 168 489 participants reported MACEs; mean age, 64.0 [SD, 8.6] years; 35.3% were female), individual participant data were obtained for 103 trials (103 reported HbA1c and 6 reported MACEs). The use of SGLT2 inhibitors (vs placebo) was associated with less HbA1c lowering with increasing age for monotherapy (absolute reduction [AR], 0.24% [95% credible interval {CrI}, 0.10% to 0.38%] per 30-year increment in age), for dual therapy (AR, 0.17% [95% CrI, 0.10% to 0.24%]), and for triple therapy (AR, 0.25% [95% CrI, 0.20% to 0.30%]). The use of GLP-1 receptor agonists was associated with greater HbA1c lowering with increasing age for monotherapy (AR, -0.18% [95% CrI, -0.31% to -0.05%] per 30-year increment in age) and for dual therapy (AR, -0.24% [95% CrI, -0.40% to -0.07%]), but not for triple therapy (AR, 0.04% [95% CrI, -0.02% to 0.11%]). The use of DPP4 inhibitors was associated with slightly better HbA1c lowering in older people for dual therapy (AR, -0.09% [95% CrI, -0.15% to -0.03%] per 30-year increment in age), but not for monotherapy (AR, -0.08% [95% CrI, -0.18% to 0.01%]) or triple therapy (AR, -0.01% [95% CrI, -0.06% to 0.05%]). The relative reduction in MACEs with use of SGLT2 inhibitors was greater in older vs younger participants per 30-year increment in age (hazard ratio, 0.76 [95% CrI, 0.62 to 0.93]), and the relative reduction in MACEs with use of GLP-1 receptor agonists was less in older vs younger participants (hazard ratio, 1.47 [95% CrI, 1.07 to 2.02]). There was no consistent evidence for sex × treatment interactions with use of SGLT2 inhibitors and GLP-1 receptor agonists. CONCLUSIONS AND RELEVANCE: The SGLT2 inhibitors and GLP-1 receptor agonists were associated with lower risk of MACEs. Analysis of age × treatment interactions suggested that SGLT2 inhibitors were more cardioprotective in older than in younger people despite smaller reductions in HbA1c; GLP-1 receptor agonists were more cardioprotective in younger people
Umbrella review of the safety of Chikungunya vaccine platforms used in other vaccines.
Get PDFChikungunya virus (CHIKV), transmitted through Aedes mosquitoes, is a significant global health concern. Various vaccine platforms have been explored to combat CHIKV, including formalin inactivation, live-attenuated strains, virus-like particles (VLPs), viral vectors, and mRNA technologies. This umbrella review synthesizes evidence on the safety profiles of vaccine platforms used in Chikungunya vaccines that have been applied in other vaccines, focusing on adverse events of special interest (AESI) in pregnant persons, children, and adolescents. A comprehensive overview of systematic reviews (SRs) was conducted. Results: Seven systematic reviews were included and complemented with primary studies. Vaccines like influenza, human papillomavirus (HPV), and COVID-19, which share platforms with Chikungunya vaccines, showed no significant increase in AESI. Moderate-to high-quality SRs supported favorable safety profiles. Vaccines sharing platforms with Chikungunya vaccines generally exhibit acceptable safety profiles in pregnant persons, children, and adolescents
Patterns of linear growth among children and adolescents living with HIV on antiretroviral therapy in Zimbabwe and Zambia.
Get PDFBACKGROUND: Adolescents with HIV (AWH) frequently exhibit impaired growth, which manifests as stunting and wasting. We studied trajectories in leg-length (appendicular), sitting (axial), and standing height among AWH on antiretroviral therapy (ART), determining peak height velocity (PHV) and age at PHV (aPHV). METHODS: Analyses used VITALITY trial data from Zimbabwe and Zambia (PACTR20200989766029), which recruited AWH (11-19 years) established on ART to determine whether vitamin D3/calcium supplementation improves bone health. The study enrolled participants between January and December 2021. Weight-for-age and height-for-age z-scores (WAZ/HAZ) were calculated from 12-weekly anthropometry over 96 weeks. Height trajectory analyses used SuperImposition by Translation And Rotation (SITAR) methods adjusting for height, tempo (aPHV) and velocity. Linear associations between vitamin D/calcium supplementation, HIV-specific factors, WAZ, HAZ, and SITAR parameters were determined. RESULTS: Overall, 842 participants (53·2% female; median age 15·5 [IQR:13·2-17·9] years), were taking ART for median 9·8(IQR:6·3-12·3) years. Mean(SD) HAZ was 1·21(1·05) in females, -1·68(1·05) in males. Overall, 251(29·8%) AWH were stunted (HAZ 4-years) were associated with later aPHV and shorter axial height in females. In all, unsuppressed VL had a more negative effect on aPHV for axial (Females: β = 0·39 years [95%CI:0·12,0·65]; Males: β = 0·45 [95%CI:0·10,0·80]) than appendicular growth (Females: β = 0.31 [95%CI 0·08,0·53]; Males: β = 0·2 [95%CI:-0·17,0·56]). Conversely, delayed ART initiation was more negatively related to aPHV for appendicular (Females: β = 0·25 [95% CI:0·08,0·43]; Males: β = 0·63 [95%CI:0·32, 0·93] than axial growth (Females: β = 0·13 [95%CI:-0·08,0·34]; Males: β = 0·56 [95%CI:0·28,0·86]. Lower HAZ and WAZ were associated with lower height, later aPHV and lower PHV. At 48-week vitamin-D3/calcium supplementation had no effect on the growth pattern. CONCLUSION: Unsuppressed viral load and delayed ART-initiation predicted later aPHV. Stunting and wasting were associated with attenuated growth velocity and later aPHV. Adolescents with HIV experience persistent linear growth impairments, potentially persisting into adulthood. TRIAL REGISTRATION: (PACTR20200989766029|| http://www.pactr.org/ ); First registered on 03/09/2020