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Beyond the States: Developing a Discrete Event Simulation Model Using R.
Get PDFThis illustration uses the Scottish Cardiovascular Disease (CVD) Policy Model as a case study to provide a comprehensive, step-by-step guide to building a discrete event simulation (DES) model in R. It is specifically designed for practitioners who are familiar with constructing Markov models in R and wish to transition their theoretical knowledge of DES into practical implementation. The Scottish CVD Policy Model was originally developed as an Excel-based Markov model with a sophisticated structure: a primary Markov model for first events and nested sub-Markov models for subsequent events. Later replicated in R by Xin, Yiqiao et al., the model's source code was made publicly available on GitHub, underscoring its potential as a teaching tool. The intricate structure of this model presents several challenges in health economic modeling, making it an ideal candidate for demonstrating how DES techniques can address such complexities effectively. In this illustration, we deliberately avoid using R packages developed specifically for DES to enhance transparency. Instead, we rely on base R functions, and the tidyverse package for tidy data wrangling. This approach ensures that every step of the DES implementation is clear and reproducible. In addition to covering fundamental topics such as how to simulate a time to event according to an assumed distribution, and continuous discounting, the illustration also provides solutions to more advanced modeling challenges, such as handling piecewise-modeled cost and utility. By discussing both general principles and complex scenarios, this paper equips readers with the practical tools needed to transition from Markov to DES frameworks, enhancing the accuracy and flexibility of health economic evaluations
Impact of a multicomponent training intervention (Clean FrontLine) on microbiological cleanliness in Cambodian referral hospitals: a multicentre, stepped-wedge, cluster-randomised trial.
Get PDFBACKGROUND: Cleanliness of near-patient hospital surfaces is essential for preventing health care-associated infections and the spread of antimicrobial-resistant pathogens. Randomised evaluations of cleaning interventions have not been done in low-resource settings. We assessed the effectiveness of a hospital-based training intervention (Clean Frontline) to improve the microbiological cleanliness of near-patient surfaces. METHODS: In this stepped-wedge, cluster-randomised trial in 13 Cambodian referral hospitals, we defined four steps (timings) that define the transition from control to intervention. All eligible public referral hospitals (district or provincial) in three selected provinces consented to participate. Pre-intervention, environmental cleaning practices remained unchanged. The multicomponent intervention selected, trained, and supervised facility cleaning champions, who in turn trained and supervised hospital cleaners. The primary outcome was microbiological cleanliness of near-patient surfaces, assessed using dipslides (a surface with <2·5 colony-forming units per cm2 was classified as clean). 30 samples per hospital were collected monthly over 10 months. Outcome data collection and analysis teams were masked to treatment allocation. The primary outcome was estimated at surface level (primary analysis, odds ratio) and hospital level (risk difference), using an intention-to-treat approach and adjusted for a-priori confounders: temperature, patient numbers, beds per cleaner, and surface type. This trial is registered with ClinicalTrials.gov, NCT05540886, and is complete. FINDINGS: Across the 13 participating hospitals, a total of 53 champions and 51 cleaners were trained. Outcomes were measured monthly between May 3, 2022, and March 23, 2023. We collected 3900 samples, 3822 of which were used in the analyses. We observed a positive, although non-significant, effect of the intervention on cleanliness in the surface analysis (odds ratio 1·39 [95% CI 0·95-2·03], p=0·081). The hospital-level analysis indicated a significant improvement of 5·04 percentage points (95% CI 0·76-9·33, p=0·026). INTERPRETATION: Improving microbiological cleanliness of near-patient surfaces in hospitals in low-resource settings through the delivery of context-appropriate training and support is feasible. Further research should test this intervention with a wider number of clusters. Lessons learnt from the implementation will inform WHO roll-out of the training package. FUNDING: Who Gives A Crap and the Reckitt Global Hygiene Institute
Co-benefits of climate mitigation action for health in the WHO European Region
Get PDFClimate change is a major threat to public health globally, and the WHO European Region is experiencing the fastest increase in temperatures, which rose at an average rate of about 0.5 °C per decade between 1991 and 2021. There is widespread recognition that protection and improvement of health are one of the strongest arguments for action on climate change and sustainable development. Many policies for addressing the climate crisis also have major near-term co-benefits for health. This brief calls for increased advocacy and support for mitigation policies and actions, not only to combat climate change but also to improve the health of populations in Europe
Prevalence, Associated Risk Factors, and Transmission Risk Scoring of Classical Swine Fever in Smallhold Farms in the Philippines
Get PDFBackground: Classical swine fever (CSF) is a notifiable disease, and the limited epidemiological data in the Philippines underscores the need for effective disease surveillance. Methods: This study aimed to determine the prevalence of antibodies against CSF virus (CSFv) using enzyme-linked immunosorbent assay and CSFv RNA using real-time reverse transcription polymerase chain reaction in pigs from smallhold farms in 21 Philippine provinces. The association between seropositivity and factors from interviews of abattoir officers was analyzed using the least absolute shrinkage selection operator regression. A semi-quantitative method was also adapted to estimate the transmission risk. Results: Our study found an overall seroprevalence of 36.0% (153/425, 95% Confidence Interval: 31.5%-40.8%), while all 423 samples tested negative for CSFv. A positive association was found in water treatment, swill feeding, CSF vaccination, and keeping vaccination records, while CSF history, proximity to residential areas, and raising native pigs negatively impacted seropositivity. Nueva Ecija was considered high-risk for CSF transmission, while others fell within the moderate, low, and very low risk categories. Conclusions: Our findings highlight the CSF seroprevalence and factors to consider for improved prevention and control. Classifying the provinces according to transmission risk also provided insights on future targeted surveillance and efficient resource allocation
Implementation of a task-shifting and task sharing intervention: A case of ward assistants in Kenyan neonatal units.
Get PDFBACKGROUND: Nurses working in intermediate care neonatal units in Kenya often experience workload that is six times greater than global recommendations, and this presents quality and safety concerns. Fiscal constraints often limit nurse recruitment. Therefore, addressing workforce shortages to improve quality of care requires careful consideration of skill-mix. We evaluated the feasibility of a task-shifting and task sharing intervention that involved (re)distribution of non-clinical roles from nurses to ward (care) assistants in Kenyan neonatal units. METHODS: We conducted a mixed methods convergent study. We enhanced staffing by adding three trained ward assistants to each of four Kenyan neonatal units. Pre- and post-intervention data were collected on a cumulative set of 593 babies using a structured Nursing Care Index tool that involved over 6520 person-hours of direct observation and was complemented by 1340 h of non-participant ethnographic observation and 47 in-depth interviews of nurses and ward assistants. Integration occurred at the analysis, results synthesis, and interpretation stages. RESULTS: After introducing ward assistants, the pattern of bedside care delivered remained largely unchanged; nurses continued to directly deliver an average of 32 % of the expected care bundle, ward assistants delivered only 1-2 % bedside care while about 19 % of overall expected care remained undone. Although they delivered little directly observed bedside care qualitative data confirmed that ward assistants took up 27 different tasks that we broadly categorized as routine newborn care, vital signs, catering, messenger, porter, customer care, cleaning and general housekeeping roles. Nurses and mothers appreciated ward assistants' work. While there was some element of extended roles, there was very minimal evidence of 'role creep'. CONCLUSION: Ward assistants undertook non-clinical roles as envisioned, and nurses viewed them as valuable additions to the workforce. In a care setting with constrained nurse staffing, introducing ward assistants to undertake non-technical tasks present an opportunity to support nurses and improve some aspects of care quality
An Agenda for Public Health Diplomacy in an Age of Populism.
Get PDFBACKGROUND: Public health is under pressure from rising populism, disinformation, and weakened global institutions, threatening cooperation, equity, and trust in science.
ANALYSIS: Populism politicises health, suppresses evidence, and marginalises vulnerable groups. Public health diplomacy must adapt, becoming more politically aware, ethically grounded, and resilient.
POLICY OPTIONS: We propose nine ways forward: create diplomacy labs for crisis simulation; empower non-state actors like cities and NGOs; strengthen ethical communication and listening; protect health workers; build alternative accountability systems; reframe health as a diplomatic priority; decentralise and diversify funding; develop a new diplomacy curriculum; reinvent and defend multilateralism.
CONCLUSION: Public health diplomacy must evolve into a bold, inclusive, and strategic force. By defending evidence, empowering diverse actors, and reforming institutions, it can safeguard health as a foundation for peace and global progress
Enhancing whole genome DNA amplification of Plasmodium falciparum for advanced molecular surveillance in malaria control.
Get PDFBACKGROUND: Genomics is critical for malaria control and elimination by providing population-level monitoring of malarial gene flow. Whole genome sequencing is valuable for identifying such genomic changes and antimalarial drug resistance. However, sequencing submicroscopic and asymptomatic cases presents challenges due to their low parasite densities and relative abundance of human DNA. Selective whole genome amplification (SWGA) is a method that employs oligonucleotide primers and phi29 DNA polymerase to specifically amplify Plasmodium DNA. SWGA has proven effective in generating increased genome coverage for various Plasmodium species. Despite its promise, current SWGA protocols have proven unsuitable in routine clinical settings. This study optimizes the SWGA protocol to improve amplification efficiency and simplify processing of clinical samples. METHODS: Thirteen P. falciparum clinical whole blood samples from returning travellers underwent SWGA with varying incubation durations of 2, 8, and 16 h. Using a newly developed SWGA protocol, three samples were additionally incubated at 3 h with EquiPhi29™ DNA Polymerase, a newer version of the phi29 enzyme. Effectiveness of the varying conditions were compared by their amplification and sequencing yield, parasite DNA recovery, genome coverage and coverage depth. After read number normalization through random selection with rasusa, pairwise SNP comparison was also performed to ensure variant calling by freebayes was unaffected by the changes in condition. Pairwise agreement was tested by Cohen's Kappa. Drug resistance profiles for each sample were generated with Malaria-Profiler to further verify these findings. RESULTS: The results demonstrate that there were comparable amplification and sequencing yields between the 8 and 16 h SWGA durations. These durations also showed significant results similarities in variant calling with up to > 90% SNP concordance. Moreover, using the newer developed SWGA protocol, sequencing yields and genome coverage were significantly enhanced, achieving over 63% P. falciparum genome coverage in just three hours processing prior to sequencing. While reducing reagent costs by almost 60%. Overall, drug resistance profiles remained consistent across all tested conditions. CONCLUSION: This advance holds promise for faster, more cost-effective malaria diagnostics and genomic surveillance, improving clinical decision-making and supporting malaria elimination efforts
Schistosoma haematobium infection is associated with oncogenic gene expression in Cervical Mucosa, with enhanced effects following treatment: A pilot study.
Get PDFBACKGROUND: Schistosoma haematobium is a parasitic worm that infects over 110 million people worldwide, laying eggs that migrate into host urinary and reproductive tracts. While S. haematobium is a known carcinogen in the urinary bladder, its role in cervical cancer remains unclear and molecular effects of parasite eggs in genital tissue are largely unknown. Our objective was to characterize cervical transcriptional profiles in women with or without active S. haematobium infection and after anti-schistosome treatment.
METHODS: We collected cervical cytobrush samples from women living in areas of Tanzania endemic for S. haematobium, before and 4-12 months after praziquantel treatment, and extracted RNA for transcriptome analysis. mRNA was isolated using poly(A) selection and sequencing was performed on an Illumina Hi-Seq4000 platform. Transcript alignment to the human hg19 reference genome and counting were accomplished using the HTSeq package. Genes were assessed for differential expression using DESeq2 and Limma. Ingenuity Pathway Analysis (IPA) was employed to identify gene networks altered in the presence of S. haematobium infection and following parasitological elimination of infection.
RESULTS: As part of this pilot study, we enrolled 20 participants with and 19 without S. haematobium infection. After adjusting for multiple comparisons, we identified 9 differentially expressed genes in women with versus without infection at baseline, 23 in women with parasitological clearance of infection post-treatment versus with infection at baseline, and 29 in those with parasitological elimination of infection versus without infection at baseline. Most differentially expressed genes were associated with heightened oncogenesis in both women with infection and in those with parasitological clearance of infection after treatment. Using IPA, we identified cancer-related networks and pathways in women with parasitological clearance compared to women with and without infection, as well as pathways involving inflammation and compromised epithelial integrity.
CONCLUSION: Women with S. haematobium infection and those with recent parasitological clearance were found to have cervical gene alterations that have been reported in various cancers. Our findings suggest a possible increase in cervical cancer risk and susceptibility to secondary infections shortly after treatment. Further research is necessary to ascertain whether altered gene expression after parasitological clearance of S. haematobium resolves over time
Women's experiences of communication and supportive care during labour: a qualitative study in rural KwaZulu-Natal, South Africa.
Get PDFBACKGROUND: Quality maternal care is crucial to improve outcomes for both mothers and newborns. Many initiatives to improve maternal care concentrate on improving clinical practice. However, women's experiences of care are also important determinants of health outcomes. Establishing strong interpersonal relationships between health workers and women is essential for delivering high-quality person-centered care, with health workers who empathize with women, respect their needs and concerns, and communicate effectively. Aligned with the World Health Organization standards of care framework, this study aimed to explore women's experiences of care during labour and childbirth, focusing on communication, respectful, and supportive care.
METHODS: A qualitative exploratory study was conducted with postpartum women in rural district hospitals in KwaZulu-Natal. Purposive sampling was used to recruit women from communities within the hospitals' catchment areas. Data were collected through focus group discussions (FGDs) conducted in the local language of participants. Five FGDs were conducted between January and April 2023. Inductive thematic analysis using NVivo v12 was employed to analyze the data.
FINDINGS: A few women described positive experiences of care, but most women reported suboptimal care characterized by poor communication, lack of privacy, and disrespectful treatment. Participants described experiences of verbal and physical abuse, being called demeaning names, facing invasive procedures without providing consent, and inadequate emotional support, such as their concerns being systematically ignored and birth companions being denied entry to labour wards. Some women responded to these challenges through various coping mechanisms including staying quiet to avoid confrontation, following instructions rigidly, seeking advice from other women in the labour ward, and in some cases standing up for themselves. Some women described persistent anger and distress as a result of their experiences.
CONCLUSION: The findings of the study highlight persistent gaps in effective communication and supportive care for women during labour and childbirth. Possible interventions could be aimed at improving communication skills of health workers as well as fostering a culture of empathy and respect for women in their care. In addition, empowering women through antenatal education and implementing birth companion policies could further improve women's experiences during labour and childbirth
The changing epidemiology of child and adolescent mental health requires an immediate policy response.
Get PDFThe epidemiology of child and adolescent mental health is rapidly evolving, necessitating urgent and coordinated responses across health, education, social services, and justice sectors. This commentary highlights key trends in adolescent mental health, emphasizing the shifting social, economic, and technological determinants shaping youth mental health. Recent evidence indicates a rise in mental health challenges, with increased gender disparities, heightened stress from academic pressures, social media exposure, and economic inequalities, among others, shaping adolescent mental health trajectories. Simultaneously, health systems are facing escalating demands for mental health care, compounded by workforce shortages and gaps in training to address emerging conditions such as digital addiction and societal withdrawal. The commentary underscores the importance of preventive, intersectoral, and life course approaches to mental health, advocating for increased investment in prevention, research, workforce development, and integrated care models. Addressing these issues requires evidence-based policies that consider cross-national differences and gendered trends while ensuring sustainable mental health systems for future generations. By prioritizing adolescent mental health within broader public health agendas, we can create a foundation for long-term well-being and social sustainability