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Estimating the epidemiological and economic impact of providing nutritional care for tuberculosis-affected households across India: a modelling study.
Get PDFBACKGROUND: Approximately 20% of global tuberculosis incidence is attributable to undernutrition, increasing to more than a third in India. Targeting nutritional interventions to tuberculosis-affected households is a policy priority, but understanding of epidemiological and economic impacts is limited. We aimed to estimate the population-level epidemiological and economic effect of such an intervention. METHODS: We used a previously published, age-stratified, compartmental transmission model of tuberculosis in India, and incorporated explicit BMI strata linked to disease progression and treatment outcomes. We used results from a recent trial of an intervention in which nutritional support in the form of food baskets was provided to people initiating tuberculosis treatment and to their household contacts (1200 kcal for patients and 750 kcal for contacts) to inform estimates of the impact and costs of nutritional support. We estimated the numbers of cases of tuberculosis disease and deaths due to tuberculosis disease that could be averted from 2023 to 2035 under the intervention scenario. FINDINGS: Compared with a baseline with no nutritional intervention, at 50% coverage of adults on tuberculosis treatment and their households (around 23% of households affected by incident tuberculosis in India), providing the nutritional support intervention could prevent 361 200 (95% uncertainty interval 318 000-437 700) tuberculosis deaths and 880 700 (802 700-974 900) disease episodes from 2023 to 2035. This would be equivalent to averting approximately 4·6% (4·2-5·5) tuberculosis deaths and 2·2% (2·1-2·4) tuberculosis episodes. The additional health system cost would be US167 (147-187) per disability-adjusted life-year averted. The median number of households needed to treat to prevent one tuberculosis death was 24·4 and to prevent one tuberculosis case was 10·0. INTERPRETATION: A nutritional intervention for tuberculosis-affected households could avert a substantial amount of tuberculosis disease and death in India, and would be highly likely to be cost-effective on the basis of the tuberculosis-specific benefits alone. FUNDING: None. TRANSLATIONS: For the Bangla and Hindi translations of the abstract see Supplementary Materials section
Unveiling the ghost: machine learning's impact on the landscape of virology.
Get PDFThe complexity and speed of evolution in viruses with RNA genomes makes predictive identification of variants with epidemic or pandemic potential challenging. In recent years, machine learning has become an increasingly capable technology for addressing this challenge, as advances in methods and computational power have dramatically improved the performance of models and led to their widespread adoption across industries and disciplines. Nascent applications of machine learning technology to virus research have now expanded, providing new tools for handling large-scale datasets and leading to a reshaping of existing workflows for phenotype prediction, phylogenetic analysis, drug discovery and more. This review explores how machine learning has been applied to and has impacted the study of viruses, before addressing the strengths and limitations of its techniques and finally highlighting the next steps that are needed for the technology to reach its full potential in this challenging and ever-relevant research area
Syrian refugee and diaspora healthcare professionals: Case studies from the eastern mediterranean and European regions.
Get PDFUNLABELLED: Thousands of Syrian healthcare professionals have been forced to leave Syria since the onset of the uprisings in March 2011 and subsequent descent into conflict. Initially, many stayed in the eastern mediterranean region; however, as the conflict became increasingly protracted and employment policies for Healthcare Professionals (HCPs) became increasingly restrictive, some moved elsewhere, particularly to Germany and the United Kingdom, both of which have aimed to capitalise on both refugee and diaspora HCPs to support human resources gaps in their health systems. Our aim is to explore the different policy practices towards Syrian refugee and diaspora HCPs in the eastern mediterranean and European regions. METHODS: We completed a narrative literature review and held a closed, virtual workshop in November 2022 in which 45 participants, most of whom had lived experience in the different refugee hosting contexts, participated. This allowed us to probe the primary themes arising from the literature review and the authors' observations and present our findings as case studies. RESULTS: We explore through case studies from countries near Syria (Turkey, Lebanon, Jordan, Egypt) and in Europe (Germany, UK) different policies which support or restrict entry into the health workforce. For host countries, those which implement policies that support retraining, accreditation and entry into the workforce have the potential for sustained and cost-effective benefit to their health systems; the impact of this on the HCPs and health system needs further exploration. Without such policies, Syrian HCPs are forced to work in the informal health sector such as in Lebanon or Egypt, leading to potential exploitation and security risks. DISCUSSION: Now is an important opportunity to support Syrian and other refugee HCPs who have been forced to leave their homes to capitalise on their skills to explore the impacts of potentially effective policies and interventions. Such policies that aim to invest in refugee HCPs' skills, further develop their aptitudes, and potentially establish a connection between them and their homeland in a mutually beneficial manner for both health systems in exile and in their homeland. Nonetheless, this topic still has large research gaps and remains in need of urgent research and data, particularly in view of the fall of the Syrian regime in December 2024 and its potential impacts
Tranexamic acid for preventing postpartum haemorrhage after vaginal birth.
Get PDFRATIONALE: Postpartum haemorrhage (PPH) is common and potentially life-threatening. The antifibrinolytic drug tranexamic acid (TXA) is thought to be effective for treating PPH. There is growing interest in whether TXA is effective for preventing PPH after vaginal birth. In randomised controlled trials (RCTs), TXA has been associated with increased risk of seizures and unexplained increased mortality when given more than three hours after traumatic bleeding. Reliable evidence on the effects, cost-effectiveness and safety of prophylactic TXA is required before considering widespread use. This review updates one published in 2015. OBJECTIVES: To assess the effects of TXA for preventing PPH compared to placebo or no treatment (with or without uterotonic co-treatment) in women following vaginal birth. SEARCH METHODS: We searched MEDLINE, Embase, CENTRAL, and WHO ICTRP (to 6 September 2024). We also searched reference lists of retrieved studies. ELIGIBILITY CRITERIA: We included RCTs evaluating TXA alone or in addition to standard care (uterotonics) for preventing PPH following vaginal birth. For this update, we required trials to be prospectively registered (before participant recruitment), and we applied a trustworthiness checklist. OUTCOMES: Critical outcomes were blood loss ≥ 500 mL and blood loss ≥ 1000 mL. Important outcomes included maternal death, severe morbidity, blood transfusion, receipt of additional surgical interventions to control PPH, thromboembolic events, receipt of additional uterotonics, hysterectomy, and maternal satisfaction. RISK OF BIAS: We used the Cochrane risk of bias tool (RoB 1) to assess the risk of bias in the studies. SYNTHESIS METHODS: Two review authors independently selected trials, extracted data, assessed risk of bias, and assessed trial trustworthiness. We used random-effects meta-analysis to combine data. We assessed the certainty of the evidence using GRADE. INCLUDED STUDIES: We included three RCTs with 18,974 participants in total. The trials were conducted in both high- and low-resource settings and involved participants at both low and high risk of PPH. The trials compared intravenous TXA (1 g) and standard care versus placebo (saline) and standard care. After applying our trustworthiness checklist, we did not include any of the 12 trials in the previous version of this review. SYNTHESIS OF RESULTS: Prophylactic tranexamic acid in addition to standard care compared to placebo in addition to standard care TXA results in little to no difference in blood loss ≥ 500 mL (risk ratio (RR) 0.93, 95% confidence interval (CI) 0.81 to 1.06; 2 studies, 18,897 participants; 5 fewer per 1000, 95% CI 15 fewer to 5 more; high-certainty evidence). TXA likely results in little to no difference in blood loss ≥ 1000 mL (RR 0.86, 95% CI 0.69 to 1.07; 2 studies, 18,897 participants; 3 fewer per 1000, 95% CI 6 fewer to 1 more; moderate-certainty evidence). TXA likely results in little to no difference in severe morbidity (RR 0.88, 95% CI 0.69 to 1.12; 1 study, 15,066 participants; 2 fewer per 1000, 95% CI 6 fewer to 2 more; moderate-certainty evidence). TXA results in little to no difference in receipt of blood transfusion (RR 1.00, 95% CI 0.95 to 1.06; 3 studies, 18,972 participants; 0 fewer per 1000, 95% CI 10 fewer to 12 more; high-certainty evidence). TXA may result in little to no difference in receipt of additional surgical interventions to control PPH (RR 0.63, 95% CI 0.32 to 1.23; 2 studies, 18,972 participants; 1 fewer per 1000, 95% CI 2 fewer to 1 more; low-certainty evidence). In women with anaemia, TXA results in little to no difference in receipt of additional uterotonics (RR 1.02, 95% CI 0.94 to 1.10; 1 study, 15,066 participants; 3 more women per 1000, 95% CI 8 fewer to 24 more; high-certainty evidence). In women with no anaemia, TXA results in a slight reduction in receipt of additional uterotonics (RR 0.75, 95% CI 0.61 to 0.92; 1 study, 3891 participants; 24 fewer women per 1000, 95% CI 38 fewer to 8 fewer; high-certainty evidence). TXA likely results in little to no difference in maternal satisfaction. The evidence is very uncertain about the effect of TXA on maternal death, thromboembolic events, and hysterectomy (very low-certainty evidence): maternal death (RR 0.99, 95% CI 0.39 to 2.49; 2 studies, 15,081 participants; 0 fewer per 1000, 95% CI 1 fewer to 2 more); thromboembolic events (RR 0.25, 95% CI 0.03 to 2.24; 3 studies, 18,774 participants; 3 fewer women per 10,000, 95% CI 4 fewer to 5 more); hysterectomy (RR 0.89, 95% CI 0.36 to 2.19; 1 study, 15,066 participants; 1 fewer women per 10,000, 95% CI 9 fewer to 16 more). AUTHORS' CONCLUSIONS: Adding prophylactic TXA to standard care of women during vaginal birth makes little to no difference to blood loss ≥ 500 mL and likely makes little to no difference to blood loss ≥ 1000 mL or the risk of severe morbidity, compared to placebo and standard care. TXA may result in little to no difference in additional surgical interventions to control PPH and results in little to no difference in blood transfusions. One trial found that TXA reduced the use of additional uterotonics in women without anaemia, whereas the largest trial found little to no difference in the use of additional uterotonics in women with anaemia. Although there were very few serious adverse events reported, the evidence is insufficient to draw conclusions about the effect of TXA on maternal death, thromboembolic events, hysterectomy, or seizures. TXA likely results in little to no difference in maternal satisfaction. These findings are based mainly on two large trials. In the smaller of these, less than 30% of study participants were at high risk of PPH. In the largest trial, all participants had moderate to severe anaemia. Those making decisions about routine administration of prophylactic TXA for all women having vaginal births should consider that current evidence does not show a benefit of TXA for blood loss outcomes and related morbidity, and the evidence is very uncertain about serious adverse events. FUNDING: This review was partially funded by the World Health Organization (WHO). REGISTRATION: Protocol (2009) DOI: 10.1002/14651858.CD007872 Original review (2010) DOI: 10.1002/14651858.CD007872.pub2 Review update (2015) DOI: 10.1002/14651858.CD007872.pub3
Postpartum maternal bonding scale: Development and validation in a low- and middle- income country setting.
Get PDFINTRODUCTION: The World Health Organization's Nurturing Care Framework recommends promoting secure postpartum maternal-infant bonding practices through responsive caregiving for healthy child development. Various instruments exist to assess maternal-infant bonding, but they differ in theoretical foundations and constructs, limiting their broad application and comparability. Notably, there is a lack of bonding instruments developed for low- and middle-income countries (LMICs), where children under five are most at risk of not reaching their developmental potential. This paper describes the development and psychometric validation of a conceptually grounded postpartum maternal bonding scale in an LMIC context and highlights its potential applications in similar settings. METHODS: Based on a literature review of bonding concepts and measurement processes, we developed a postpartum maternal bonding scale using a cultural adaptation model for psychometric instruments for children and adolescents. This involved identifying and reviewing existing bonding-related tools, generating items, iterative rounds of expert reviews, and pretesting with postpartum women. We then conducted a final survey with a large sample of women at 42 days postpartum to establish the scale's psychometric properties. The study was conducted in the Thatta and Sujawal districts of Sindh, Pakistan. RESULTS: An initial pool of 44 items was developed following a literature review and interviews with postpartum women. After multiple rounds of expert review and cognitive pretesting, a 30-item tool was selected for field testing. Using data from 310 postpartum women, we examined the tool's structure through exploratory (EFA) and confirmatory factor analysis (CFA), leading to a refined 12-item tool. The EFA revealed three factors related to Emotional, Cognitive, and Behavioural bonding. Taking the four highest loading items from each domain, we performed CFA using three models: a first-order model with the three domains, a second-order model, and a bifactor model, which included an overall bonding construct. The bifactor model showed the best fit (comparative fit index = 0.951; root mean square error of approximation = 0.066; standardized root mean square residual = 0.045). This indicates that both an overall bonding construct and specific domains can be measured separately. Pairwise domain correlations were all below 0.67, and internal reliability statistics ranged from 0.63-0.72 (Cronbach's Alpha) and 0.64-0.77 (global omega). Regression analysis showed associations between bonding scores and factors such as cesarean delivery (reduced behavioural bonding score for mothers having caesarean: -0.94, 95% Confidence Interval -1.86 to -0.01, p-value 0.047), maternal disability (reduced overall bonding score for mothers with severe disability -1.54, 95% CI -3.12 to 0.03, p-value 0.054), and probable postpartum depression (reduced overall bonding score in mothers with probable PPD -1.57, 95% CI -2.70 to -0.45, p-value 0.006). CONCLUSION: The 12-item postpartum maternal bonding scale (PMBS) is a conceptually grounded instrument. It is a brief, easy-to-administer tool with potential cross-cultural use in low- and middle-income settings after cultural adaptation
Factors associated with sexually transmitted reinfections, number of sexual partners and condom use among previously infected young people.
Get PDFBackgroundSexually transmitted infections (STIs) are prevalent in young people. Digital interventions promoting safer sexual behaviours are low-cost and scalable. We use data from a randomised controlled trial of one such potential intervention (safetxt) to investigate factors associated with STI reinfection and risky sexual behaviours.MethodsWe use data from 6248 young people with STIs recruited from 92 UK sexual health clinics. Multivariable logistic regression models were developed with the outcomes: reinfection, condom use at last sex and number of sexual partners (≤1 or >1) at 1 year. A pre-specified variable selection process assessed effects of sociodemographic and sexual behaviour factors measured at trial baseline.ResultsFactors associated with reinfection included sexuality, ethnicity, baseline diagnosis of gonorrhoea and chlamydia, index of multiple deprivation, whether the participant and/or the last new partner tested before sex. Risk factors for condom use at last sex and number of sexual partners included sexuality and education level. The multivariable models had good calibration but poor discrimination.ConclusionsIn this large sample with good representation across social and ethnic groups, we identified patient characteristics associated with higher risk of reinfection. Improved understanding of factors associated with reinfections and higher-risk sexual behaviours can aid development of interventions.Trial RegistrationISRCTN64390461
Building HPV vaccine confidence through codesigned interventions with and for healthcare workers in Nigeria: protocol for a pilot cluster randomised controlled trial.
Get PDFINTRODUCTION: The human papillomavirus (HPV) vaccine can effectively prevent cervical cancer, yet HPV vaccine uptake is particularly low in some low-income settings, due to supply and vaccine confidence barriers. HPV vaccine confidence has also been found to be lacking among healthcare workers in some countries, including Nigeria. Nigeria has a long history of low vaccine confidence in some parts of the country. HPV vaccine rumours and concerns have been observed throughout the country, including among healthcare workers. Interventions that specifically address healthcare workers' vaccine confidence are limited, since vaccine confidence is often assumed among this group. The aim of our pilot cluster randomised control trial (cRCT) is to evaluate the feasibility of conducting a trial that evaluates codesigned interventions to improve HPV vaccine confidence in healthcare workers and the acceptability and feasibility of delivering this intervention. METHODS AND ANALYSIS: This is a 3-arm pilot cRCT, using a mixed-methods approach to assess the feasibility of the trial design, alongside the feasibility and acceptability of intervention delivery in two states in Nigeria (Jigawa and Oyo). We will implement two interventions: one with a focus on digital delivery, and one with an HPV champion present at a health facility. Both will be compared with a control arm, providing standard information on HPV vaccine only. Overall, 12 trial clusters (six in Jigawa and six in Oyo), defined as government primary healthcare facilities, will be randomised using a 1:1:1 ratio, stratified by state. All healthcare workers within these facilities will be eligible to take part in the intervention and evaluation. The primary outcome of interest will be intervention uptake, as a measure of subsequent trial feasibility given concerns around contamination in control clusters. This will be assessed through an endline healthcare worker survey. Intervention feasibility and acceptability will be assessed through quantitative intervention monitoring and qualitative interviews with healthcare workers. ETHICS AND DISSEMINATION: We received approval from Jigawa State Ethics Committee (ref: JGHREC/2023/151), Jigawa Ministry of Health (ref: MOH/PH/PHRAT/MN/23/003), Oyo State Research Ethics Review Committee (ref: AD/13/479/362A), The University of Ibandan and University College Hospital Research Ethics Committee (UI/UCH Ethics Committee) (ref: UI/EC/23/308) and from the Swedish National Ethics Review Board (2023-04772-01-471058). Data will be presented in manuscript form and submitted to relevant conferences for dissemination. REGISTRATION DETAILS: The pilot trial has been registered with ISRCTN-the UK's Clinical Study Registry, registration number ISRCTN37847119
Do sports utility vehicles (SUVs) and light truck vehicles (LTVs) cause more severe injuries to pedestrians and cyclists than passenger cars in the case of a crash? A systematic review and meta-analysis.
Get PDFQUESTIONS: In the case of a road traffic crash, do sports utility vehicles (SUVs) and light truck vehicles (LTVs) cause more severe injuries to pedestrians and cyclists than passenger cars? Does any effect differ between adults and children? DESIGN: Systematic review and meta-analysis. DATA SOURCES: MEDLINE, TRID and Global Index Medicus were searched up to September 2024, with no restrictions by setting or language. INCLUSION CRITERIA: Eligible studies had to compare injury severity between pedestrians and/or cyclists hit by an SUV or LTV versus a passenger car. Only sources using real-world crash data were included. MAIN OUTCOME MEASURE: Injury severity, defined either as 'fatal versus non-fatal injury' or as 'killed or seriously injured (KSI) versus slight injury'. RESULTS: 24 studies were included in the meta-analysis. The results were similar between pedestrians and cyclists. When combining pedestrians and cyclists, the pooled odds of KSI versus slight injury if hit by an SUV/LTV versus a passenger car were higher among adults/all-age samples by 1.24 (95% CI 1.15, 1.34) and higher among children by 1.28 (95% CI 1.19, 1.37). The odds of fatal versus non-fatal injury if hit by an SUV/LTV versus a passenger car increased among adults/all-age samples by 1.44 (95% CI 1.33, 1.56) and among children by 1.82 (95% CI 1.57, 2.11; p=0.006 for heterogeneity by age). CONCLUSION: In the case of a crash, SUVs and LTVs cause more severe injuries to pedestrians and cyclists than passenger cars. This effect is larger for fatalities than for KSIs, and the fatality effect is particularly large for children. PROSPERO registration number CRD42024597283
Long-term psychological and neurological outcomes among people with a history of non-malignant meningioma in the UK Biobank cohort.
Get PDFBACKGROUND: Meningiomas are among the most common brain tumours in the United Kingdom and incidence is increasing. Up to 90% of meningiomas are Grade 1 (non-malignant) and have high survival. Brain tumour survivors are at risk of psychological and neurological late effects but risks in persons with non-malignant meningioma are not well characterized. METHODS: We used UK Biobank, a cohort of approximately 500 000 adults recruited ages 40-69 during 2006-2010. Non-malignant meningioma patients were identified through linked cancer registry data. Follow-up for 10 outcomes was based on linkage to Hospital Episode Statistics. Standardized incidence ratios (SIRs) compared risks in meningioma patients to rates from UK Biobank overall, adjusted for age, sex, and calendar time. RESULTS: Four hundred and sixty-seven individuals were diagnosed with non-malignant meningioma after joining UK Biobank (77% female). Median age at diagnosis was 65 and median follow-up was 5 years. Persons with meningioma had significantly increased risks of 9 of 10 sequelae studied. The lowest SIR was for stroke (1.3, 95% confidence interval [CI] 0.6-2.9) and the highest SIRs were for epilepsy (18.9, 95%CI: 13.3-26.9) and visual disturbances (6.6, 95%CI: 3.3-13.1). SIRs for depression, anxiety, headache, fatigue, hearing loss, limb weakness, and cognitive issues (in ascending order) ranged from 2.3 (95%CI: 1.6-3.4) to 4.4 (95%CI: 2.8-6.9). CONCLUSIONS: By providing preliminary evidence of excess risk of a range of long-term sequelae, this research can provide insight into future risks and validate survivor experience for people diagnosed with non-malignant meningioma and build momentum for future research using larger population-based databases and primary care records
Development and external validation of a risk prediction score (DASHI) for cardiovascular events following acute respiratory infections: derivation and validation retrospective cohort study.
Get PDFBACKGROUND: Acute respiratory infections increase the short-term risk of myocardial infarction (MI) and stroke in primary care patients. Clinical guidelines for acute respiratory infections in primary care do not consider the risk of cardiovascular events, and CVD risk prediction tools target long-term risk. We aimed to develop and validate a prediction tool for the risk of cardiovascular disease events within 28-days of acute respiratory infection. METHODS: The design was a retrospective cohort study using two different databases of routinely collected data from electronic health records from January 1999 to December 2019. We used Clinical Practice Research Datalink (CPRD) Aurum data to derive models, and CPRD GOLD data from a different population for external validation. This data is from UK primary care, with data linkage to Hospital Episode Statistics, Office of National Statistics mortality data, and Index of Multiple Deprivation data. Participants were patients aged 40 years or older with no history of cardiovascular events, and a first diagnosis with acute respiratory infection. The outcome was a composite of new diagnoses of myocardial ischaemia (myocardial infarction, angina, acute coronary syndromes, or ischaemic cardiomyopathy), stroke or transient ischaemic attack, or deaths with these diagnoses, within 28 days of presentation with an acute respiratory infection. We derived a list of 57 potential predictors based on prior studies and asked clinical experts to rank them. We derived two logistic regression models, one with the top ranked variables, and another including additional lower ranked variables. We derived a clinical prediction score from the most parsimonious logistic regression model. We validated each model and the score in the external dataset using C statistics, calibration plots, and expected to observed ratios. We examined clinical utility using decision curve analysis. FINDINGS: The derivation cohort comprised 3.8 million patients with an acute respiratory infection (mean age 56.5 years, (SD 13.7); 57.7% female), of whom 11,996 had a subsequent cardiovascular outcome (0.3%). The validation cohort included 2.6 million patients (mean age 56.7 years, SD 13.6, 58.0% female), of whom 6868 (0.3%) had a subsequent cardiovascular outcome. The DASHI score comprised five clinical variables: Diabetes (1 point, yes/no), Age (40-59, 0 points; 60-79, 2 points; 80+, 4 points), current Smoking (1 point, yes/no), Heart failure (1 point, yes/no), and Infection diagnosis (Upper Respiratory Tract Infection-0 points. Lower Respiratory Tract Infection (LRTI)-1 point, or LRTI with a pneumonia diagnosis-4 points). Upon external validation, each model and the score showed similar performance. The score showed good discrimination (AUC 0.85, IQR 0.848-0.849) and calibration with an expected to observed ratio of 0.85 (IQR 0.85-0.85). INTERPRETATION: The DASHI score allows primary care clinicians to estimate the risk of cardiovascular complications within 28 days in patients with acute respiratory infections. FUNDING: This research was funded in part by the Wellcome Trust [211182/Z/18/Z] and NIHR [NIHR300738]. For the purpose of open access, the author has applied a CC BY public copyright licence to any Author Accepted Manuscript version arising from this submission. The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care