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Vaccination strategies against wild poliomyelitis in polio-free settings: outbreak risk modelling study and cost-effectiveness analysis.
Get PDFThe 2021 importation of wild poliovirus serotype 1 (WPV1) into Malawi with subsequent international spread represented the first WPV1 cases in Africa since 2016. Preventing importations and spread of WPV1 is critical and dependent on population immunity provided through routine immunisation (RI) and supplementary immunisation activities (SIAs). We aim to estimate outbreak risk and costs, given the importation of WPV1 for non-endemic countries in the WHO Africa region. We developed a stochastic mathematical model of polio transmission dynamics to evaluate the probability of an outbreak, expected number of poliomyelitis cases, costs and incremental cost-effectiveness ratios under different vaccination strategies. Across variable RI coverage, we explore three key strategies: RI+outbreak SIAs (oSIAs), RI+oSIAs+annual preventative SIAs (pSIAs) and RI+oSIAs+biennial pSIAs. Results are presented in 2023 USD over a 5year- time horizon from the Global Polio Eradication Initiative (GPEI) and health system perspectives. The annual pSIA strategy has the greatest probability of no outbreaks in comparison to other strategies: under our model assumptions, annual pSIAs result in an 80% probability of no outbreaks when RI coverage is ≥50%. The biennial pSIA strategy requires RI coverage ≥65% to achieve an equivalent risk of no outbreaks. The strategy with no pSIAs requires ≥75% RI coverage to achieve an equivalent risk of no outbreaks. For the health system, when RI coverage is between 35% and 60%, both pSIA strategies are cost-saving. For the GPEI, below 65% RI pSIA strategies are cost-effective, but the biennial pSIA strategy incurs higher costs in comparison to annual pSIAs due to more oSIAs required to stop outbreaks. Prioritisation of pSIAs must balance outbreak risk against implementation costs, ideally favouring the smallest manageable outbreak risk compatible with elimination. We infer that there are few short-term risks due to population immunity from RI, but without pSIAs, long-term risks accumulate and can result in outbreaks with the potential for international spread
Health Systems in Action (HSiA) Insights – North Macedonia
Get PDFKey points:
● North Macedonia’s health system provides a
relatively comprehensive basic benefits package,
with more than 90% of the population covered
under the social health insurance scheme.
● Public spending on health increased in response to
the COVID-19 pandemic, but remains comparatively
low. There is a continued strong reliance on
out-of-pocket (OOP) payments which accounted
for 41.7% of health spending in 2021, one of the
highest shares in south-eastern Europe.
● Most primary care services are free at the point of
delivery but certain health services, in particular
outpatient specialist visits, prescribed outpatient
medicines and inpatient care, require user charges.
● Catastrophic health spending remains a problem,
particularly for poorer households, and is largely
driven by OOP payments for outpatient medicines.
● Unmet needs for medical care due to financial
reasons have declined over the last decade
but remain relatively high among people on
low incomes.
● The information system Moj Termin (My
Appointment) has greatly improved scheduling
and waiting times for clinical appointments and
diagnostic tests. Its effectiveness could be
further expanded in primary care by using it for
scheduling appointments and allowing primary
care nurses access.
● The COVID-19 pandemic has severely impacted
life expectancy in North Macedonia, which in
2021 fell back almost to its 2000 level.
● Childhood immunization rates were falling even
prior to the COVID-19 pandemic and declined
further in 2020 and 2021.
● Maternal and infant health improved markedly
in recent years, but the quality of prenatal and
perinatal health service delivery remains a concern.
● The country faces a high burden of
noncommunicable diseases (NCDs), but
mortality from stroke and ischaemic heart
disease has decreased in recent years.
● The population is at risk from high blood pressure,
unhealthy diets (including high salt intake),
smoking, high blood sugar and, to a lesser extent,
alcohol consumption. North Macedonia has one of
the highest smoking rates worldwide. Increasing
overweight and obesity among adults and
adolescents, as well as respiratory ill-health and
death due to air pollution, are other major public
health concerns.
● The health workforce has increased in the last
decade, but faces pressures of outmigration
and ageing
A mixed methods protocol for an impact and implementation evaluation of the Pharmacy First Services for management of common conditions in England.
Get PDFOBJECTIVES: In response to high levels of demand for primary medical services in England, characterized by longer appointment waiting times and delayed referrals, the Government developed its National Health Service (NHS) Primary Care Recovery Plan. A key component of the plan is Pharmacy First (PF), which involves participating community pharmacies supplying prescription-only medicine after consultation with a pharmacist for seven common conditions: earache, uncomplicated urinary tract infections in women, sore throat, sinusitis, impetigo, shingles, and infected insect bites. The study aims to evaluate the implementation of the PF service and its impact on the volume of prescribing, case mix of General Practitioner consultations, accident and emergency department and other hospital use, equity of access, and cost for different groups of patients in different contexts, as well as its acceptability and fidelity. METHODS: A 36-month, mixed methods evaluation with five elements, namely evidence synthesis, semi-structured interviews, focus groups, quantitative analysis of impacts before and after implementation (e.g. using interrupted time series analysis) using routine data, and an economic evaluation. Findings will be synthesized and interpreted using the Consolidated Framework for Implementation Research supplemented by Proctor's Implementation Outcomes Framework. CONCLUSIONS: The evaluation should have service level, policy, professional, and research impact both in England and beyond. This includes generating evidence to show: whether PF contributes to improving primary healthcare access, assessing the quality of antimicrobial use, identifying the scope for refinements to PF, and, overall, informing better implementation of PF. The findings will also provide robust evidence to enable policymakers to determine how to enhance the role of community pharmacy in England in the future. Furthermore, the evaluation will develop a data dashboard, and the methods and codes used to interrogate it (though not the patient data), will be made publicly available that could support other similar evaluations in England and internationally
Standardised Methods for Developing Conceptual Frameworks for Placental Disorders of Pregnancy: Pre-Eclampsia and Stillbirth.
Get PDFBACKGROUND: Risk factors for the placental disorders of pregnancy (pre-eclampsia, fetal growth restriction, preterm birth, and stillbirth) are complex, frequently involving the interplay between clinical factors and wider social and environmental determinants of health. Biomarkers modulate the maternal and fetal responses to biological processes that underlie the development of placental disorders. OBJECTIVES: To develop a standardised methodology to assess the importance of, and inter-relationships between, candidate risk factors for the various placental disorders. SEARCH STRATEGY: Systematic searches were conducted using Medline, Embase, Health Technology Assessments, Database of Abstracts of Reviews of Effects, Cochrane Library databases, Google Scholar, and reference lists of retrieved papers. SELECTION CRITERIA: We deployed a hierarchy of reviews, systematic reviews, and cohort studies with at least 1000 participants (100 for biomarker studies), published in the prior decade. DATA COLLECTION AND ANALYSIS: We assessed the strengths of association and quality of evidence linking risk factors with individual placental outcomes. CONCLUSIONS: We have developed a standardised approach to assess the importance and inter-relatedness of putative risk factors for the placental disorders of pregnancy
Exploring Complex Dynamics of Early Marriage in Rural Bangladesh: Reasons, Psycho-Social, Health and Economic Implications
Get PDFEarly marriage remains a significant concern in rural regions of Bangladesh, making it imperative to examine the causes, psycho-social consequences, and economic impacts of early marriage. The cross-sectional study explored these complex dynamics and interviewed 400 girls/women who married before 18 in four selected districts. Descriptive and inferential statistics revealed early marriage being greatly influenced by family attitudes (62.85%) & economic pressures (42.2%). Furthermore, forcible family opinions (75.71%) with the groom’s pressure (12.85%) and love relationships (14.28%) played a major role in early marriage. Early married girls experienced depression & sadness (44%), malnutrition (42%), disrupted education (60%) and other economic challenges. Dowries impacted families massively, where 60% provided dowry by taking loans (60.37%) due to having no other option. Early-married girls faced significant hardships, enduring psycho-social and economic oppression that severely impacted their quality of life. There is a need to integrate education, awareness, and policy reforms to mitigate the far-reaching consequences of early marriage
Political commitment and implementation: the health system response to violence against women in Mexico.
Get PDFViolence against women (VAW) is a widespread concern globally and in Mexico, where in 2021, 44% of women aged ≥15 years have experienced some form of intimate partner violence during their relationship and a quarter have experienced sexual violence in the past 12 months. To respond, Mexico passed comprehensive legislation addressing VAW, which outlines the role of the health system in identifying, treating, and referring women experiencing violence; however, implementation of such regulations has been slow and far from successful. Using a conceptual framework of political commitment, we conducted a health policy analysis to evaluate how health policies addressing VAW in Mexico have been implemented. The political commitment framework includes the dimensions of expressed, institutional, and budgetary commitment. We adopted a multi-methods qualitative case study approach combining document analysis with 25 stakeholder interviews with policymakers and health facility directors in Mexico City. The results show that Mexico exhibits limited expressed political commitment from the president, but some commitment exists among Ministry of Health officials. We document that the mixed findings on expressed commitment are mediated, in part, by internalized social and gender norms that normalize and tolerate violence, which are present in society writ large. We find that institutional commitment exists through policies and institutions. However, monitoring systems for policy implementation were not working as designed, and there was limited effort and capacity to implement these policies, reflecting structural barriers and norms within the health system that shape the treatment of violence survivors. Finally, we found a budgetary allocation for VAW; however, it was unclear if the budget was utilized correctly. While progress has been made in addressing VAW in the health system in Mexico, implementation is lagging due to a lack of sustained political commitment, and thus, policies are likely not reaching their intended beneficiaries: survivors of violence
Making long-acting treatment work: Tracing connections with extended-release buprenorphine depot through time.
Get PDFINTRODUCTION: How people connect with opioid agonist treatment is an ongoing concern. Extended-release buprenorphine depot (BUP-XR) has been designed with 'retention' in mind. It is important to consider what makes a difference to clients in helping them to stay connected to treatment over time. METHODS: We report findings from the third wave of in-depth interviews with participants (n = 26) in the Community Long-Acting Buprenorphine (CoLAB) study, tracing accounts of connection, disconnection and reconnection with BUP-XR since initiation into treatment. RESULTS: Changing situations in treatment delivery and in people's lives created conditions of possibility for connection and disconnection to treatment. Clients used BUP-XR in different ways. Personalisation of dosing regimens and stretching out of time between doses was common, creating a sense of stability for some. For others, this flexibility potentiated fragility in treatment connection. Disconnection from BUP-XR was common, but frequently this was not the ultimate outcome. Treatment connections were shaped by fluctuating life circumstances, with re-connections imagined, attempted and sometimes realised. DISCUSSION AND CONCLUSIONS: Clients' accounts reveal the complexities of how 'long-acting' treatments are made to work over time. Connecting with treatment in the long-term is a process, contingent on social relations, fluctuating life conditions and systems of care. Rather than treating connection and disconnection as opposites, we suggest seeing these as entangled and fluid elements of an ongoing process. What is needed is an adaptive and emergent conceptualisation of what 'retention' in treatment can mean, reflective of how people connect with their treatment and make it work, in practice
Self-rated health differences between exclusive e-cigarette users and exclusive cigarette smokers: evidence from the 2017-2019 Scottish Health Survey.
Get PDFThe comparative health implications of e-cigarette use versus traditional cigarette smoking remain a critical focus in public health research. This cross-sectional study examined differences in self-rated general health between exclusive e-cigarette users and exclusive cigarette smokers, using data from the 2017-2019 Scottish Health Survey. A total of 2484 adults (aged 16 and above) were included and categorized as exclusive e-cigarette users (n = 565) or exclusive cigarette smokers (n = 1919). Self-rated health was assessed using a single-item measure with five response categories: "very bad," "bad," "fair," "good," and "very good". Generalized ordinal logistic regression models were used to estimate the association between nicotine product use and self-rated health, adjusting for age, sex, Scottish Index of Multiple Deprivation, marital status, ethnicity, alcohol consumption frequency, physical activity, presence of longstanding physical or mental health conditions, and age of smoking initiation. In the fully adjusted model, exclusive e-cigarette users had higher odds of reporting better self-rated health compared to exclusive cigarette smokers overall (OR = 1.26, 95% CI 1.05-1.51, p = 0.012). A graded relationship was also observed in the fully adjusted model, with progressively lower odds of reporting better self-rated health as smoking intensity increased, using exclusive e-cigarette users as the reference group. Heavy smokers (≥ 20 cigarettes/day) had the lowest odds of reporting better self-rated health (OR = 0.63, 95% CI 0.49-0.80, p < 0.001), followed by moderate smokers (10 to < 20 cigarettes/day) (OR = 0.81, 95% CI 0.66-0.99, p = 0.047). In contrast, light smokers (< 10 cigarettes/day) showed no significant difference in self-rated health compared to exclusive e-cigarette users (OR = 0.94, 95% CI 0.75-1.18, p = 0.614). These findings indicate that exclusive e-cigarette use is associated with better self-rated health compared to exclusive cigarette smoking, particularly among moderate and heavy smokers. Additional analyses revealed no significant differences in self-rated health among exclusive e-cigarette users based on prior smoking history (OR = 0.94, 95% CI 0.43-2.08, p = 0.882) or among exclusive cigarette smokers based on prior e-cigarette use (OR = 0.87, 95% CI 0.69-1.09, p = 0.219). These findings suggest that prior use is unlikely to explain the observed association between exclusive e-cigarette use and better self-rated health compared to exclusive cigarette smoking. Given the subjective nature of self-rated health, these findings should be interpreted with caution. Future longitudinal studies incorporating objective health measures are essential to assess the long-term impacts of e-cigarette use and inform evidence-based harm reduction policies
Health and associated economic benefits of reduced air pollution and increased physical activity from climate change policies in the UK.
Get PDFClimate change policies do not always include analysis of air quality and physical activity co-benefits. We compared business as usual (BAU) UK policy with Net Zero scenarios from the UK Climate Change Committee for road transport and building sectors. We quantified and monetised the health benefits of the Balanced Net Zero (BNZP) and Widespread Innovation (WI) Pathways. Air pollution concentrations were predicted using Chemical Transport Models and population-weighted. Shifts from car to walking and cycling for transport were converted to METhrs/week. Literature concentration-response functions were combined with baseline rates from routine statistics/other sources. Mortality and multi-morbidity impacts were calculated using lifetable analysis, and an incidence/prevalence model from 2019 to 2154 (a lifetime after 2050). Monetary values were applied to the results. The BNZP policy compared with BAU gave 4.9 (95 % confidence interval 1.0-9.0) million life-years gained (LYG) (UK population, to 2154), including 1.1 (0.7-1.6) million LYG from active travel improvements. Avoided COPD and childhood asthma cases were 201,000 (150,000 - 250,000) and 192,000 (64,600-311,000). The monetised air quality morbidity benefits (£52.1 (36.4 - 67.8) billion) substantially added to the air quality mortality benefits (£77.9 (42.9 to 90.8) billion). Total yearly monetised benefits for BNZP vs BAU summed to 2154 (air pollution/active travel) were £153 (122 to 184) billion (core); 278 (228 to 334) billion (+outcomes with weaker evidence). Adding the effects of air pollution reductions on disease incidence, with effects of air pollution and physical activity on mortality, increases the monetised benefits that may justify Net Zero policies in cost-benefit analysis
Challenges and opportunities to address the emerging burden of targeted therapies in ovarian cancer.
Get PDFOvarian cancer (OC) poses a significant socio-economic burden globally with the greatest impact observed in low-and-middle income countries (LMIC). Despite the survival benefit from targeted therapies such as bevacizumab and poly (ADP- ribose) polymerase (PARP) inhibitors, they are associated with high costs to patients and payers which widens the disparities between high and low-income countries. OC treatments may also cause significant morbidity from cytoreductive surgery through to the use of targeted therapies reducing quality of life (QoL). Innovative approaches are necessary to address the increasing burden from the cost and morbidity of OC treatment especially in LMIC. De-escalation of treatment without compromising oncological outcomes could be a strategy to reduce financial cost and morbidity. Moreover, de-escalation techniques integrating the knowledge of pharmacokinetics and pharmacodynamics for dose reduction should be incorporated into clinical trials to identify the minimum effective dose rather than the maximum tolerated with the goal of reducing clinical and financial toxicity. This review summarises the health and economic burden of ovarian cancer with particular reference to LMIC and proposes de-escalation of targeted therapy as a clinical and economic strategy in increasing accessibility and affordability with consideration of patient preferences