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Formulating antibiotic policy: Analysis of India's ban on colistin use in food producing animals.
Get PDFAntibiotics remain key tools for maintaining human health, and in many settings, food production. However, emergence of antibiotic resistance has become a global challenge, one that has resulted in multi-national calls for policy to improve antibiotic use. One such call has been to restrict the use of antibiotics deemed critically important for human health, such as colistin, during the production of food producing animals. Between 2016 and 2019 numerous countries, including India, implemented policies to heavily restricted the use of colistin in livestock. While this represents a key shift in the antibiotic policy landscape, other classes of critically important antibiotics continue to be used during food production. This paper provides a policy analysis of India's 2019 colistin ban to provide insight into how this came to be and to identify factors which could shape the development of future legislation. The analysis revealed that while antibiotic reform in food production had been in the background of India's policy agenda for some time, it took key-focusing events to shift the policy climate into a period of action. These focusing events included reporting of mobile colistin resistance genes in bacteria isolated from pigs in China and colistin resistant bacteria isolated from food samples in India. Consistent narratives had been built around colistin's role as a last resort antibiotic which, together with relatively low proportion of colistin resistance in bacteria isolated from human patients, framed legislation as a worthwhile endeavour for policy makers. In addition, India acted as a global player in antibiotic stewardship and followed the precedent set by several other countries in restricting colistin use during food production. As most colistin for animal use was imported into India from China, and viable alternative animal treatments existed, there was limited industry opposition that could block legislation. We suggest evaluation of these five critical factors (focusing events, consistent narratives, worthwhile endeavour, precedent for change, and industry opposition) should be part of the policy formulation process for legislation regarding the use of other critically important antibiotics in food production
Conflict exposure and mental health: a survey of adolescent girls and young women in Myanmar post the 2021 coup d'état.
Get PDFBACKGROUND: Following the 2021 military coup in Myanmar, adolescent girls and young women have faced a multitude of threats to their health and wellbeing. Beyond direct exposure to armed combat, injuries and loss of life, they are also experiencing displacement, family separation, and restricted access to education and healthcare. These challenges are further compounded by military-imposed restrictions on humanitarian aid and access to the country. This study sought to address a critical gap in understanding how exposure to conflict in Myanmar is impacting adolescent girls' mental health. METHODS: We conducted a survey, co-developed with peer-researchers, with 750 girls and young women aged 10 to 21 years from disproportionately disadvantaged communities across Myanmar. The survey included questions on participants' demographics, their exposure to conflict-related stressors and their self-reported depressive symptoms. RESULTS: Participants reported widespread exposure to traumatic conflict-related stressors and high levels of depressive symptoms. There was a significant positive association between the number of different conflict-related stressors experienced by the study participants and the number of depressive symptoms reported. Additionally, participants who were living away from their parents reported significantly higher levels of depressive symptoms, emphasising the psychological implications of family separation during conflict. CONCLUSIONS: Our results highlight the urgent need for tailored interventions for adolescents, particularly girls and young women, who are exposed to armed conflict. In contexts of protracted instability and uncertainty, such as in Myanmar, interventions should explore ways to foster a sense of social safety, especially among adolescent girls who are displaced or living away from their families. Strengthening social safety systems may help to reduce the adverse mental health impacts of conflict-related stressors
High-flow nasal cannula therapy versus continuous positive airway pressure for non-invasive respiratory support in paediatric critical care: the FIRST-ABC RCTs.
Get PDFBACKGROUND: Despite the increasing use of non-invasive respiratory support in paediatric intensive care units, there are no large randomised controlled trials comparing two commonly used non-invasive respiratory support modes, continuous positive airway pressure and high-flow nasal cannula therapy. OBJECTIVE: To evaluate the non-inferiority of high-flow nasal cannula, compared with continuous positive airway pressure, when used as the first-line mode of non-invasive respiratory support in acutely ill children and following extubation, on time to liberation from respiratory support, defined as the start of a 48-hour period during which the child was free of respiratory support (non-invasive and invasive). DESIGN: A master protocol comprising two pragmatic, multicentre, parallel-group, non-inferiority randomised controlled trials (step-up and step-down) with shared infrastructure, including internal pilot and integrated health economic evaluation. SETTING: Twenty-five National Health Service paediatric critical care units (paediatric intensive care units and/or high-dependency units) across England, Wales and Scotland. PARTICIPANTS: Critically ill children assessed by the treating clinician to require non-invasive respiratory support for (1) acute illness (step-up randomised controlled trial) or (2) within 72 hours of extubation (step-down randomised controlled trial). INTERVENTIONS: High-flow nasal cannula delivered at a flow rate based on patient weight (Intervention) compared to continuous positive airway pressure of 7-8 cm H2O pressure (Control). MAIN OUTCOME MEASURES: The primary clinical outcome was time to liberation from respiratory support. The primary cost-effectiveness outcome was 180-day incremental net monetary benefit. Secondary outcomes included mortality at paediatric intensive care unit/high-dependency unit discharge, day 60 and day 180; (re)intubation rate at 48 hours; duration of paediatric intensive care unit/high-dependency unit and hospital stay; patient comfort; sedation use; parental stress; and health-related quality of life at 180 days. RESULTS: In the step-up randomised controlled trial, out of 600 children randomised, 573 were included in the primary analysis (median age 9 months). Median time to liberation was 52.9 hours for high-flow nasal cannula (95% confidence interval 46.0 to 60.9 hours) and 47.9 hours (95% confidence interval 40.5 to 55.7 hours) for continuous positive airway pressure (adjusted hazard ratio 1.03, one-sided 97.5% confidence interval 0.86 to ∞). The high-flow nasal cannula group had lower use of sedation (27.7% vs. 37%) and mean duration of acute hospital stay (13.8 days vs. 19.5 days). In the step-down randomised controlled trial, of the 600 children randomised, 553 were included in the primary analysis (median age 3 months). Median time to liberation for high-flow nasal cannula was 50.5 hours (95% confidence interval, 43.0 to 67.9) versus 42.9 hours (95% confidence interval 30.5 to 48.2) for continuous positive airway pressure (adjusted hazard ratio 0.83, one-sided 97.5% confidence interval 0.70 to ∞). Mortality at day 180 was significantly higher for high-flow nasal cannula [5.6% vs. 2.4% for continuous positive airway pressure, adjusted odds ratio, 3.07 (95% confidence interval, 1.1 to 8.8)]. LIMITATIONS: The interventions were unblinded. A heterogeneous cohort of children with a range of diagnoses and severity of illness were included. CONCLUSIONS: Among acutely ill children requiring non-invasive respiratory support, high-flow nasal cannula met the criterion for non-inferiority compared with continuous positive airway pressure for time to liberation from respiratory support whereas in critically ill children requiring non-invasive respiratory support following extubation, the non-inferiority of high-flow nasal cannula could not be demonstrated. FUTURE WORK: (1) Identify risk factors for treatment failure. (2) Compare protocolised approaches to post-extubation non-invasive respiratory support, with standard care. (3) Explore alternative approaches for evaluating heterogeneity of treatment effect. (4) Explore reasons for increased mortality in high-flow nasal cannula group within step-down randomised controlled trial. STUDY REGISTRATION: Current Controlled Trials ISRCTN60048867. FUNDING: This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 17/94/28) and is published in full in Health Technology Assessment; Vol. 29, No. 9. See the NIHR Funding and Awards website for further award information
High Burden and Trend in Nonadherence to Blood Pressure-Lowering Medications: Meta-Analysis of Data From Over 34 000 Adults With Hypertension in Sub-Saharan Africa.
Get PDFBACKGROUND: Nonadherence to blood pressure (BP)-lowering medication is a strong predictor of poor BP control. Sub-Saharan Africa has extremely low BP control rates (~10%), but it is unclear what the burden of medication nonadherence among Africans with hypertension is. This systematic review estimated the prevalence and determinants of nonadherence to BP-lowering medications in Sub-Saharan Africa. METHODS AND RESULTS: Multiple databases were searched from inception to December 6, 2023. Two reviewers performed independent screening, extraction, and quality assessment of studies. We pooled the prevalence estimates using random effects meta-analyses and summarized the determinants using a narrative synthesis. From the 1307 records identified, we included 95 studies published between 1995 and 2023. The overall prevalence of nonadherence to BP-lowering medication among 34 102 people treated for hypertension in 27 countries was 43.9% (95% CI, 39.2-48.6). There was no change in the prevalence of nonadherence over time. Nonadherence varied by measurement method and by median age (39.4%, ≥57 years versus 47.9%, <57 years). Socioeconomic and patient-related factors were the most frequent factors influencing adherence. Active patient participation in management, accurate perceptions, and knowledge of hypertension and its treatment predicted good medication adherence, whereas high pill burden, medication cost, side effects, and comorbidities predicted poor adherence. CONCLUSIONS: Two out of every 5 people are nonadherent to their BP treatment. With the African population projected to increase from 1.4 to ~2.5 billion by 2050, targeted strategies are urgently needed to optimize medication adherence in people with hypertension in Sub-Saharan Africa
Effect of the 13-valent pneumococcal conjugate vaccine on pneumococcal carriage in rural Gambia 10 years after its introduction: A population-based cross-sectional study.
Get PDFBACKGROUND: Sub-Saharan Africa has a high burden of pneumococcal diseases. Pneumococcal carriage precedes invasive disease and transmission. The introduction of pneumococcal conjugate vaccines (PCVs) has significantly reduced global vaccine-type (VT) pneumococcal disease, but data on PCVs' long-term impact on VT serotypes in Africa are limited. We aimed to evaluate PCV13's long-term effect on pneumococcal carriage in rural Gambia. METHODS: From January to November 2022, we conducted a population-based, cross-sectional pneumococcal carriage survey in Central and Upper River Regions of The Gambia. We collected data on demographic characteristics, clinical history, risk factors, and PCV status. Nasopharyngeal swabs were taken from randomly selected household members of all ages. Streptococcus pneumoniae was isolated and serotyped using standard methods. We measured the prevalence of pneumococcal carriage by specific age groups, PCV13 vaccination status, and the proportions of different pneumococcal outcomes among carriers. We performed multivariable logistic regression to examine factors associated with VT carriage. RESULTS: Overall, 4087 participants were enrolled; the prevalence of pneumococcal carriage was 32.1% (95% CI: 29.34% - 35.03%). The estimated prevalence of PCV13 VT carriage was 6.4% (95% CI: 5.48% - 7.47%). Children aged 5-9 years had the highest VT carriage prevalence at 13.6% (95% CI: 10.34% - 17.56%). Among fully PCV-vaccinated children under 10, the odds of VT carriage in 5-9-year-olds were 1.60 times higher than in infants aged 0-11 months [AOR = 1.60, 95% CI:1.06-2.41]. The prevalence of VT carriage was similar among fully PCV-vaccinated and unvaccinated children under 10 years of age. Serotypes 19F, 3 and 6A were the most abundant VTs; 19F and 3 were the most prevalent among <5 and 5-14-year-old children, respectively. CONCLUSIONS: Ten years after the introduction of PCV13 in the Gambia, residual VT carriage persists, particularly in age groups in whom direct protection from immunization in infancy has waned. A booster dose or catch-up vaccinations could aid control of VT circulation
Author Correction: Eating habits and sociodemographic factors impact household dietary greenhouse gas emissions reduction in Great Britain
Get PDFCorrection to: Communications Earth & Environmenthttps://doi.org/10.1038/s43247-025-02252-x, published online 22 April 2025 In this article the author name Hassan Mahfouz was incorrectly written as Mahfouz Hassan. The original article has been corrected
Genome wide population genetics and molecular surveillance of insecticide resistance in Anopheles stephensi mosquitoes from Awash Sebat Kilo in Ethiopia.
Get PDFSince the detection of the Asian mosquito Anopheles stephensi in Dijbouti in 2012, it has spread throughout the Horn of Africa. This invasive vector continues to expand across the continent and is a significant threat to malaria control programs. Vector control methods, including insecticide-treated nets and indoor residual spraying, have substantially reduced the malaria burden. However, the increasing prevalence of mosquitoes resistant to insecticides, including An. stephensi populations, undermines ongoing malaria elimination efforts. Understanding population structure, gene flow between populations, and the distribution of insecticide resistance mutations is essential for guiding effective malaria control strategies. Here, we generated whole genome sequencing data for An. stephensi sourced from Awash Sebat Kilo, Ethiopia (n = 27) and compared with South Asian populations (n = 45; India and Pakistan) to assess genomic diversity, population structure, and uncovering insecticide resistance mutations. Population structure analysis using genome-wide single nucleotide polymorphisms (n = 15,533,476) revealed Ethiopian isolates clustering as a distinct ancestral group, separate from South Asian isolates. Three insecticide resistance-associated SNPs (gaba gene: A296S and V327I; vgsc L1014F) were detected. Evidence of ongoing selection was found in several loci, including genes previously associated with neonicotinoids, ivermectin, DDT, and pyrethroid resistance. This study represents the first whole genome population genetics study of invasive An. stephensi, revealing genomic differences from South Asian populations, which can be used for future assessments of vector population dispersal and detection of insecticide resistance mechanisms
Cardioprotective drugs and heart failure/cardiomyopathy incidence in chemotherapy-treated cancer survivors of breast cancer and non-Hodgkin lymphoma: a retrospective cohort study in England.
Get PDFAIMS: Evidence for the use of beta-blockers, angiotensin II receptor blockers (ARB), or angiotensin-converting enzyme inhibitors (ACEi) to mitigate chemotherapy-induced cardiotoxicity is inconclusive. The objectives are to investigate associations between prescription of ARBs, ACEis, and/or beta-blockers in the year following cancer diagnosis and subsequent risk of heart failure/cardiomyopathy (HF/CM) in chemotherapy-treated breast cancer and non-Hodgkin lymphoma (NHL) survivors. METHODS AND RESULTS: This cohort study used linked English electronic healthcare records from 9875 adult (≥18 years) breast cancer and NHL survivors who received chemotherapy. Cox regression was used to estimate the association between primary care-prescribed beta-blocker, ARB, and ACEi use in the year following cancer diagnosis, and subsequent HF/CM incidence, adjusting for potential confounders. Likelihood ratio tests were used to assess effect modification. The mean follow-up duration was 4.9 years (maximum 21.4). After adjusting for age, the risk of HF/CM was higher in the exposed group [hazard ratio (HR): 1.69, 95% confidence interval (CI): 1.34-2.14], but further adjustment for gender, comorbidities, and other medications reduced the association to close to null (HR: 1.07, 95% CI: 0.68-1.69). There was no evidence that the association differed by cancer site, age, radiotherapy, prior cardiovascular disease, or years since cancer diagnosis. CONCLUSION: We found no evidence that general practitioner prescribed beta-blocker, ARB, or ACEi use was associated with a reduced incidence of HF/CM in this population of chemotherapy-treated breast cancer and NHL survivors. This might be because the drug dosage and timing were not optimized to prevent chemotherapy-related cardiac damage; residual confounding by indication may also have obscured any treatment benefit
The influence of HIV on body composition and its relationship with physical function in mid-life women: a cross-sectional study from Zimbabwe.
Get PDFOBJECTIVE: Menopause-related changes in body composition and physical function are unclear in Southern Africa, particularly in the context of a generalized HIV epidemic with high antiretroviral therapy (ART) coverage. METHOD: A total of 263 Zimbabwean women (53% women living with HIV [WLH]) aged 40-60 years provided data on menopause, ART use, anthropometry, body composition (appendicular lean mass [ALM], muscle area, fat mass), handgrip strength (HGS) and gait speed. Linear regression determined relationships between body composition and physical function, unadjusted and age-menopause-adjusted, stratified by HIV status. Univariate logistic regression investigated associations between body composition and self-reported falls. RESULTS: WLH (96% ART established) were a median (interquartile range) 10.4 (6.4-14.5) years since diagnosis, with lower weight, body mass index, ALM, fat mass and HGS than women living without HIV (WLWOH). With menopause transition, WLH lost weight, ALM, gynoid mass and muscle area (all p-trend <0.05); however, WLWOH did not. Both WLH and WLWOH lost HGS (p-trend <0.05). ALM was positively associated with HGS in all women. In WLH, greater percentage body fat, particularly gynoid fat, was associated with increased odds of falls (1.69 [1.00-2.89], p = 0.049 and 1.72 [1.08-2.75], p = 0.023, respectively). CONCLUSION: Women living with HIV were more likely to experience adverse changes in body composition through menopause; fat mass gains were associated with risk of falls
From drought to displacement: Assessing the impacts of climate change on conflict and forced migration in West Africa's Sahel Region.
Get PDFAcross Africa's semiarid Sahel region, temperatures have risen faster than the global average, resulting in severe threats to water access, food security, and human health. Key climate factors such as desertification interact with ethnic and economic tensions, exacerbating violence between pastoral and farming groups competing over degraded productive land and water resources. Mounting climate pressures act as threat multipliers for both violent conflict and internal displacement across countries spanning Senegal to Sudan. This perspective examines intersections of climate change, violent clashes, and forced migration using incidents in Nigeria and Burkina Faso-where droughts, floods and agricultural losses continue to worsen. With 8 million internally displaced persons in the region now, urban areas face overburdened infrastructure while attempting to host influxes of traumatized, impoverished migrants facing further risks. This article argues that integrated policy action is urgently needed to mitigate climate change, enhance community resilience, and protect vulnerable groups to ease cascading humanitarian crises and achieve development goals amid spiraling environmental pressures across West Africa