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Estimated cost and operational structure of pgSIT malaria vector control programs in selected West African countries.
Get PDFMalaria control has primarily been achieved through vector control, but current methods are insufficient to achieve elimination. Precision guided sterile insect technique (pgSIT) is a mosquito suppression technique that generates sterile male mosquitoes for mass release. Our previous studies showed that this intervention is expected to be highly cost-effective in a malaria endemic region of West Africa, but these estimates used only 15-31% capacity for sex sorting, which is the limiting production step and a primary cost. We, therefore, determined the most cost efficient facility size by calculating the cost per million Anopheles gambiae suppressed as the facility was scaled up to suppress more mosquitoes. We developed an optimized facility size per 9.2 million mosquitoes suppressed, which can be a framework for scaling and increases the cost effectiveness of this intervention. The development of this intervention can potentially interrupt malaria transmission, strengthen local public health institutions, create manufacturing capacity, provide local jobs, and enhance regional health security capabilities that are more resilient to disruptions in supply chains and malaria investment
Digital transformation and the Immunization agenda 2030.
Get PDFDigital transformation is the intentional, systematic implementation of integrated digital applications that change how governments plan, execute, measure and monitor programmes. This transformation can accelerate progress towards the Immunization agenda 2030, which aims to ensure that everyone, everywhere, at every age, fully benefits from vaccines. (1) Here we describe how digital transformation can help achieve equitable immunization outcomes, and outline recommendations for governments and global partners to ensure that children in low- and middle-income countries benefit fairly
Reliance on migrant healthcare workers in the United Kingdom: A critical discourse analysis.
Get PDFThe UK National Health Service (NHS) has relied on Migrant Healthcare workers (M-HCWs) since its inception. These M-HCWs have typically come from Low and Middle-Income countries (LMICs) and particularly, countries that were previously under British colonial rule. Despite this, medical workforce shortages persist in the NHS and there has been a lack of policy consensus about how best to ameliorate it. In June 2021, Baroness Dido Harding made an ultimately unsuccessful pitch to lead the NHS. During this period she made a statement where she expressed an ambition to reduce reliance on M-HCWs that was met with controversy in the general and medical press. This Critical Discourse Analysis (CDA) examines the responses published in newspaper, media and journal articles in the month following Baroness Harding's statement. The dataset includes a variety of opinions about medical migration and M-HCWs and explores how language is connected to power and knowledge constructed and the effects of these discourses. It draws on theoretical approaches derived from the philosopher Michel Foucault and the postcolonial analyst Edward Said. A total of 48 articles were included in the final dataset which highlighted two main strands of discourse. The first strand is dominant and dissents against Baroness Dido Harding herself, her position, and her statement, predominantly on the grounds that it undermines historic and ongoing contributions of M-HCWs to the NHS. The second strand, which is notable in its relative absence, supports the implications of reducing reliance on M-HCWs. We identified a dominant discourse of support for M-HCWs based on their valuable contributions to the NHS. However, the relative absence of the second strand suggests a marginalisation of debate about the reliance on migration pathways which were often founded on colonial roots, the exacerbation of brain-drain from the Global South, and the inequities that this perpetuates
Risk factors for mental disorders in pregnant women in two cities from São Paulo, Brazil: A cohort study.
Get PDFINTRODUCTION: Mental disorders during pregnancy are a significant public health problem due to the substantial physiological and psychological changes that occur during this period. This study aims to investigate the risk factors for mental disorders in pregnant women by comparing data from two distinct cohorts in Jundiaí and Araraquara, Brazil.
METHODS: This is a prospective cohort study that included pregnant women from two Brazilian cohorts in São Paulo state. The Jundiaí cohort (1997-2000) included 865 pregnant women, while the Araraquara cohort (2017-2024) included 755 pregnant women. Socioeconomic, demographic, obstetric history, and mental health data were collected and analyzed. Mental health was assessed using standardized questionnaires, including the General Health Questionnaire (GHQ), the State-Trait Anxiety Inventory (STAI), Trait Anxiety Inventory (TAI) and the Perceived Stress Scale (PSS). Statistical analysis included bivariate tests and univariate and multivariate random-effects models for panel data.
RESULTS: Araraquara participants showed significantly higher GHQ scores at baseline (mean = 4.00) than Jundiaí (mean = 2.78; p < 0.001), with similar trends for SAI, TAI, and PSS. Scores decreased across visits in both cohorts (GHQ Visit 3: Coef. = -1.053, p < 0.001). Being single (GHQ: Coef. = 0.404, p = 0.019), separated/widowed (SAI: Coef. = 3.961, p = 0.005), lower education (TAI: Coef. = -1.910, p = 0.006), and higher household density (PSS: Coef. = 0.946, p = 0.012) were significant risk factors. Maternal morbidities such as urinary infections (TAI: Coef. = 0.862, p = 0.031), cervicitis/vaginitis (GHQ: Coef. = 0.290, p = 0.009), and tuberculosis (TAI: Coef. = 6.989, p = 0.033) were also strongly associated with worse mental health outcomes. Cohort differences remained significant even after adjustment (GHQ: Jundiaí vs Araraquara, Coef. = -1.357, p < 0.001).
CONCLUSIONS: This study showed that pregnant women in the more recent Araraquara cohort exhibited significantly higher levels of psychological distress symptoms, anxiety, and perceived stress than those in the earlier Jundiaí cohort. These mental health outcomes were strongly associated with lower per capita income, lower education levels, higher household density, and adverse pregnancy conditions such as urinary infection and gestational hypertension. These findings highlight the worsening social vulnerability of pregnant women over time and reinforce the urgency of incorporating systematic mental health screening into prenatal care policies in Brazil
Health system-related barriers and facilitators to tuberculosis preventive treatment: a qualitative case study comparing implementation in the Republic of Moldova and Georgia.
Get PDFINTRODUCTION: Despite WHO's recommendations and the 2023-2030 Tuberculosis (TB) action plan, uptake of TB preventive treatment (TPT) remains suboptimal. In this paper, we use two countries of the WHO Europe Region, the Republic of Moldova and Georgia, that are at different stages of implementation of TB prevention policies, as a case study to examine health system barriers and facilitators to TPT scale-up. METHODS: In this case study, we used methods of qualitative research-interviews with three stakeholder groups: health service providers and National TB Programme staff; civil society organisations and international partners or donors. The data were collected via videoconference, transcribed, then coded and analysed using NVivo V.14. Thematic analysis was conducted. RESULTS: Facilitators for TPT delivery in both settings include an established TB clinical network, well-functioning communication systems and an uninterrupted supply of TPT medicines.In both settings, healthcare providers generally exhibit positive attitudes towards treating TB infection; however, some remain sceptical and cautious, particularly regarding prescribing TPT without confirmation of TB infection, a challenge compounded by limited access to testing for TB infection. Evidence of TB infection is also important for patients' decisions on initiation and adherence to treatment. Other barriers to effective service delivery of TPT include shortages and high workload of primary healthcare personnel, ambiguity in the role of family doctors in the management of TPT and low prioritisation of TPT during regular monitoring visits. CONCLUSIONS: The case study identified similar challenges in the rollout of TPT across both settings, highlighting common barriers hindering effective implementation. For optimal TPT rollout, enhancing provider confidence, improving access to testing for TB infection and strengthening integration with primary healthcare with refined roles of family doctors are essential. Both settings would also benefit from improved monitoring and evaluation systems and prioritisation of TB prevention in monitoring
Sexual and reproductive health service delivery innovations and adaptations during COVID-19: A systematic review and crowdsourcing open call.
Get PDFThis paper sought to identify and describe the innovations and adaptations implemented to ensure delivery of Sexual and Reproductive Health services during the COVID-19 pandemic and the potential for enhancing SRH services in other settings or in future emergencies. We searched five databases including PubMed, EMBASE, Scopus, Cochrane Library, and CINAHL. The review was registered on Prospero (CRD42022329411). The open call was launched and promoted widely; each submission was screened by five independent reviewers. The GRADE-CERQual methodology was used to assess confidence in each study finding. A thematic synthesis approach was employed for textual data and for studies with similar outcomes, a fixed effects model was employed. We identified 10,891 citations and 78 studies were included. We received 80 submissions to the open call, and 18 submissions contributed to the study findings. Submissions came from 42 countries, most of which were LMICs (37/42). Telemedicine was one main mode of continuing SRH services during the pandemic (moderate certainty). Teleabortion, or the provision of medication abortion remotely via telemedicine, was found to be a safe and effective way to maintain abortion service (97·9% of cases with 95% CI = 95·6 to 99·4%). However, increased reliance on telemedicine exacerbates inequities for low-income and rural populations. Self-care and self-testing enabled individuals to receive care for STIs (moderate certainty). This work identified strategies used to deliver SRH services during COVID-19 and the data suggest that many strategies relied on telemedicine to sustain SRH services. Self-care interventions were also used to sustain delivery of SRH services. There is need for further research to understand the long-term impact of these interventions and how they can be sustained over time
Age-specific distribution of cervical precancer and cancer among women living with HIV across seven countries: a systematic review and an individual patient data meta-analysis.
Get PDFBACKGROUND: Women living with HIV have an elevated risk for cervical cancer, present earlier, and have more recurrent human papillomavirus (HPV) infections compared with women without HIV. To update WHO recommendations on screening and treatment to prevent cervical cancer, we aimed to identify whether women living with HIV should be screened for cervical cancer at a specific age, the optimal screening interval following a negative cervical screen, and the screening interval following treatment. METHODS: We conducted a systematic literature review on cervical cancer and HIV by searching MEDLINE, Embase, CENTRAL, the Cochrane Library, and clinical trial registries covering Jan 1, 2012, through to Oct 13, 2019, updating a previous systematic review covering database inception to July, 2012. Included articles reported original data and assessed one or more outcomes related to cervical precancer and cancer in women living with HIV; no restrictions on study design or setting were made. Articles were excluded if they did not include any women living with HIV, or if they reported only HPV genotype prevalence without any other relevant data. Two authors extracted data from any study reporting cervical cancer screening tests and histopathologically confirmed disease outcomes, by age. We analysed summary data on optimal age and screening intervals, providing pooled estimates when possible; we then conducted an individual patient data meta-analysis (IPDMA) to analyse age-specific data on cervical cancer and precancer. Authors of studies with 40 or more women living with HIV and cervical intraepithelial neoplasia (CIN) grade 2+ were invited to submit individual patient data for meta-analysis. Random-effects models were used to calculate predicted probabilities for cervical cancer screening results by age, HIV status, and antiretroviral therapy (ART) status. FINDINGS: Of the 304 full-text articles screened, 34 studies from 12 countries, with 128 732 women, including 63 790 women living with HIV, were included in the systematic review. Of 55 studies potentially eligible for the IPDMA, eight studies provided data for 72 350 women, 12 527 of whom were living with HIV, from seven countries (Burkina Faso, Cameroon, India, Kenya, South Africa, Thailand, and the USA). In the IPDMA, the pooled predicted probability of CIN2 or CIN3 among women living with HIV increased from 6·0% (95% CI 0·74-64·1) for ages 15-19 years to 32·4% (8·3-72·7) for ages 20-24 years, 42·1% (16·4-80·2) for ages 25-29 years, 50·3% (16·3-80·0) for ages 30-34 years, 47·0% (16·3-80·0) for ages 35-39 years, 49·0% (16·3-80·2) for ages 40-44 years, 58·1% (17·0-81·5) for ages 45-49 years, and 55·3% (21·0-86·6) for age 50 years and older; invasive cervical cancer was uncommon before 30 years of age. In the systematic review, women living with HIV who had a negative baseline cytology result and negative HPV test had a cumulative incidence of developing CIN2+ that ranged from 0·8% to 5% within 4·2-6·4 years and a cumulative incidence of developing of CIN of any grade up to 10% within 12 years. Also in the systematic review, women living with HIV had high recurrence of CIN2+ following treatment (11-27% by 1 year follow-up, 3-64% by 3 years, and 57% by 10 years). No significant evidence of publication bias was found in the data included in the IPDMA (Egger's test p=0·83). INTERPRETATION: Our data show a clear, age-related increase in CIN2 and CIN3 among women living with HIV, with the highest risk occurring in the 45-49-year age group. Our findings informed WHO recommendations to initiate cervical cancer screening for women living with HIV at age 25 years, with regular screening every 3-5 years. Expanding screening and treatment is necessary to reduce cervical cancer incidence towards its elimination. FUNDING: US Agency for International Development and US President's Emergency Plan for AIDS Relief
Instrumental variable approaches for estimating time-varying treatment effects in comparative effectiveness research.
Get PDFBACKGROUND: The increased availability of large-scale longitudinal data offers important opportunities to assess the causal effects of health interventions. In this setting, Instrumental Variable (IV) approaches have the potential to reduce the risk of bias from confounding due to unmeasured variables. However, there has been a lack of attention given to the development of IV approaches in settings when both the instrument and the potential confounders vary over time. In this paper we critically evaluate two instrumental variable approaches in time-varying settings.
METHODS: The paper extends an existing g-estimation method that incorporates time-fixed IVs and compares it to an inverse probability weighting approach that incorporates time-varying IVs. A simulation study investigates the relative performance of these two approaches under varying scenarios. These methods are applied to a retrospective cohort from the US National Databank for Rheumatic Diseases, evaluating the sustained use of Adalimumab (Humira) versus other biologics on the health-related quality of life of patients with Rheumatoid Arthritis. Our case study considers physicians preference for Adalimumab as an instrument.
RESULTS: The g-estimation approach provided unbiased, precise estimates of treatment effects, across a wide range of scenarios, including weak IVs and complex time-varying confounding mechanisms. The performance of the weighting approach was reasonable in scenarios with a moderate or strong time-varying IV, but deteriorated with weak IV strength. Both methods suggest that sustained treatment with Adalimumab does not improve the health-related quality of life of rheumatoid patients, compared to other biologics, but the g-estimation approach led to narrower confidence intervals.
CONCLUSION: The proposed IV-based g-estimation approach can be reliably used in the estimation of time-varying treatments if a valid time-varying IV is available. The weighting approach offers an accessible alternative but was found to work well only when the IVs are strongly associated with treatment assignment, which is relatively unlikely in real-world applications
Pay-It-Forward 23-Valent Pneumococcal Polysaccharide Vaccination Among Older Adults: Protocol for a Randomized Controlled Trial.
Get PDFBACKGROUND: The 23-valent pneumococcal polysaccharide vaccine reduces the risk of pneumonia among adults by 38% to 46%. However, only a few older adults in resource-limited areas of China have received the pneumococcal vaccination. Pay-it-forward is a social innovation that offers participants free or subsidized health services and a community-engaged message, with an opportunity to donate to support subsequent recipients.
OBJECTIVE: This study aims to assess the effectiveness and cost-effectiveness of the pay-it-forward intervention in encouraging the uptake of the 23-valent pneumococcal polysaccharide vaccine in adults aged ≥60 years.
METHODS: A 2-arm, parallel randomized controlled trial will be conducted in 4 community health centers in Nanning city, Guangxi province, China. We will use a block randomization design. A total of 204 older adults will be randomly allocated in a 1:1 ratio to either the pay-it-forward group or the standard-of-care group. Each participant will complete a web-based questionnaire. The standard-of-care group will be required to pay for the vaccine themselves. In contrast, the pay-it-forward group will receive a 150 RMB (US $20.7) vaccination subsidy, postcards, and the opportunity to donate. The participants in both groups will be followed up in the second and fourth weeks after enrollment. The primary outcome will be uptake of the 23-valent pneumococcal polysaccharide vaccine, as determined by administrative data. Secondary outcomes include costs, pneumococcal vaccination knowledge, attitudes toward the vaccine, perceptions of gratitude, incidence of adverse reactions and adverse events, and the likelihood of recommending pneumococcal vaccination to others.
RESULTS: Participant recruitment and follow-up were conducted from January 2024 to September 2024. A total of 220 participants were enrolled. Finalized results are expected in June 2026.
CONCLUSIONS: This study will provide evidence on the effectiveness and economic costs of the pay-it-forward strategy for pneumonia vaccination among older adults. The findings could have implications for vaccination policy and offer a new approach for increasing vaccination in resource-limited areas.
TRIAL REGISTRATION: Chinese Clinical Trial Registry ChiCTR2400079410; https://www.chictr.org.cn/showprojEN.html?proj=213999. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/70246
Factors associated with death from COVID-19 in traditional peoples and communities in Brazil.
Get PDFINTRODUCTION: COVID-19 has disproportionately impacted vulnerable populations, including traditional communities in Brazil, who face socioeconomic and health disparities, increasing the risk of severe outcomes. This study aims to identify factors associated with mortality among hospitalized COVID-19 patients from traditional communities in Brazil.
METHODS: This cross-sectional study analyzed data from the System of Epidemiological Surveillance of Influenza (SIVEP-Gripe) on hospitalizations for COVID-19 between 2021 and 2023. Individuals from traditional communities were included. The variables analyzed included demographic characteristics, clinical symptoms, comorbidities, and the need for hospital support. Logistic regressions were performed to assess associations with mortality, considering p < 0.05 significant.
RESULTS: Of the 7,101 cases analyzed, males showed a higher risk of death (OR = 1.39; 95% CI: 1.18-1.63). Among ethnic groups, blacks presented with an OR = 2.92 (95% CI: 1.68-5.08) and indigenous, OR = 2.25 (95% CI: 1.73-2.94). Older age increased the risk, with OR = 6.57 (95% CI: 2.16-28.5) for ages 60-79 and OR = 12.8 (95% CI: 4.18-55.8) for ≥80 years. Dyspnea (OR = 2.16; 95% CI: 1.77-2.65) and low saturation (OR = 2.13; 95% CI: 1.78-2.55) were associated with death, while loss of taste was protective (OR = 0.62; 95% CI: 0.51-0.75). Immunosuppression (OR = 2.14; 95% CI: 1.23-3.79) and chronic renal disease (OR = 1.64; 95% CI: 1.10-2.46) increased the risk. Patients on invasive ventilation had the highest risk of death (OR = 19.4; 95% CI: 15.2-25.0), followed by non-invasive ventilation (OR = 2.65; 95% CI: 2.18-3.23) and ICU (OR = 2.15; 95% CI: 1.85-2.49).
CONCLUSION: Risk factors for mortality among hospitalized patients from traditional communities include male sex, older age, race/color, severe respiratory symptoms, comorbidities, and the need for invasive ventilation. These findings reinforce the importance of targeted health strategies to reduce the risk of mortality in these vulnerable populations.
UPDATE: This output has been corrected, please see the publisher’s website