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Computed Tomography of the Head Before Lumbar Puncture in Adults With Suspected Meningitis in High-HIV Prevalence Settings.
Get PDFBACKGROUND: The role of computed tomography (CT) before lumbar puncture (LP) is unclear, with limited evidence for a causal link between LP and cerebral herniation or for the ability of CT to identify individuals at risk of herniation. The risks of LP delay or deferral are potentially greater in high-HIV prevalence, resource-limited settings; we analyzed data from such a setting to determine the impact of CT on time to LP and treatment, as well as mortality. METHODS: Adults with suspected central nervous system (CNS) infection were enrolled prospectively into the Botswana National Meningitis Survey between 2016 and 2019. Inpatient mortality and clinical data including time of treatment initiation and CT were captured from medical records. Associations between preceding CT and outcomes were assessed using logistic regression. RESULTS: LPs were performed in 711 patients with suspected CNS infection; 27% had a CT before LP, and 73% were HIV positive. Time from admission to LP and time from admission to appropriate treatment were significantly longer in patients who had a CT before LP compared with those who did not (2.8 hours and 13.2 hours, respectively). There was some evidence for treatment delays being associated with increased mortality; however, there was no significant difference in mortality between those who had or did not have CT. CONCLUSIONS: Patients who had a CT had delays to diagnostic LP and initiation of appropriate treatment; although treatment delays were associated with increased mortality, our observational study could not demonstrate a causal association between delays in diagnosis and treatment introduced by CT and mortality
Reproductive factors and mammographic density within the International Consortium of Mammographic Density: A cross-sectional study.
Get PDFBACKGROUND: Elevated mammographic density (MD) for a woman's age and body mass index (BMI) is an established breast cancer risk factor. The relationship of parity, age at first birth, and breastfeeding with MD is less clear. We examined the associations of these factors with MD within the International Consortium of Mammographic Density (ICMD). METHODS: ICMD is a consortium of 27 studies with pooled individual-level epidemiological and MD data from 11,755 women without breast cancer aged 35-85 years from 22 countries, capturing 40 country-& ethnicity-specific population groups. MD was measured using the area-based tool Cumulus. Meta-analyses across population groups and pooled analyses were used to examine linear regression associations of square-root (√) transformed MD measures (percent MD (PMD), dense area (DA), and non-dense area (NDA)) with parity, age at first birth, ever/never breastfed and lifetime breastfeeding duration. Models were adjusted for age at mammogram, age at menarche, BMI, menopausal status, use of hormone replacement therapy, calibration method, mammogram view and reader, and parity and age at first birth when not the association of interest. RESULTS: Among 10,988 women included in these analyses, 90.1% (n = 9,895) were parous, of whom 13% (n = 1,286) had ≥ five births. The mean age at first birth was 24.3 years (Standard deviation = 5.1). Increasing parity (per birth) was inversely associated with √PMD (β: - 0.05, 95% confidence interval (CI): - 0.07, - 0.03) and √DA (β: - 0.08, 95% CI: - 0.12, - 0.05) with this trend evident until at least nine births. Women who were older at first birth (per five-year increase) had higher √PMD (β:0.06, 95% CI:0.03, 0.10) and √DA (β:0.06, 95% CI:0.02, 0.10), and lower √NDA (β: - 0.06, 95% CI: - 0.11, - 0.01). In stratified analyses, this association was only evident in women who were post-menopausal at MD assessment. Among parous women, no associations were found between ever/never breastfed or lifetime breastfeeding duration (per six-month increase) and √MD. CONCLUSIONS: Associations with higher parity and older age at first birth with √MD were consistent with the direction of their respective associations with breast cancer risk. Further research is needed to understand reproductive factor-related differences in the composition of breast tissue and their associations with breast cancer risk
Enhancing quantitative capacity for the health sector in post-Ebola Liberia, a tracer study of a locally developed and owned coding and biostatistics program.
Get PDFBACKGROUND: Despite the demonstrated value of quantitative research in understanding and responding to public health events, analytics capability is not always prioritized or available in settings that would greatly benefit from it. In Liberia, there are no university degree-granting programs in biostatistics or mathematical modeling, promoting dependence on external technical assistance. To address the gap, a local NGO, Quantitative-Data for Decision-Making (Q4D), was founded to enhance capacity and opportunities for analyzing quantitative data among Liberians. METHODS: To understand the relevance, utility, and impact of the skills being taught at Q4D, a tracer study was undertaken with current and former students. Participants completed an online survey that evaluated how often and in what ways they are applying course skills, as well as any personal or professional advancement they have attributed to their learning of coding and/or biostatistics through the program. RESULTS: Among 43 participants, 81% reported a high level of confidence in independently applying skills learned through Q4D classes in their jobs and/or academic programs. Most participants (81%) responded that they were actively demonstrating the skills they acquired; 74% were teaching the skills to others. Among the 83% of employed participants who reported using the skills currently in their jobs, 56% rated the skills they learned as very or extremely useful in their current positions. Several students attributed salary increments, consultancy opportunities, and scholarships to the skills gained through the program. CONCLUSIONS: Program skills are being applied by students employed in health-related sectors, suggesting that the training content is relevant and useful for addressing some of the workforce's analysis needs. Moreover, skills built through the program have positively impacted students by preparing them with the skills required for additional employment and training opportunities to advance in-country health research capacity and reduce inequities
The effect on HIV transmission and cost-effectiveness of programmes for female sex workers in East, Central, and Southern Africa: a modelling study.
Get PDFBACKGROUND: HIV prevalence and incidence has declined in East, Central, and Southern Africa (ECSA), but remains high among female sex workers (FSWs). Sex worker programmes have the potential to considerably increase access to HIV testing, prevention, and treatment. We aimed to quantify these improvements by modelling the potential effect of sex worker programmes at two different intensities on HIV incidence and key health outcomes, and assessed the programmes' potential cost-effectiveness in order to help inform HIV policy decisions. METHODS: Using a model previously used to review policy decisions in ECSA, we assumed a low-intensity sex worker programme had run from 2010 until 2023; this resulted in care disadvantages among FSWs being reduced, and also increased testing, condom use, and willingness to take pre-exposure prophylaxis (PrEP). After 2023, three policy options were considered: discontinuation, continuation, and a scale-up of the programme to high-intensity, which would have a broader reach, and higher influences on condom use, antiretroviral therapy (ART) adherence, testing, and PrEP use. Outputs of the key outcomes (the percentage of FSWs who were diagnosed with HIV, on ART, and virally suppressed; the percentage of FSWs with zero condomless partners, and HIV incidence) were compared in 2030. The maximum cost for a sex worker programme to be cost-effective was calculated over a 50-year time period and in the context of 10 million adults. The cost-effectiveness analysis was conducted from a health-care perspective; costs and disability-adjusted life-years were both discounted to present US500 per disability-adjusted life-year averted, $34 million per year can be spent for a high-intensity programme to be cost-effective. INTERPRETATION: A sex worker programme, even with low-level interventions, has a positive effect on key outputs for FSWs. A high-intensity programme has a considerably higher effect; HIV incidence among FSW and in the general population can be substantially reduced, and should be considered for implementation by policy makers. FUNDING: Wellcome Trust
Power and positionality in the practice of health system responsiveness at sub-national level: insights from the Kenyan coast.
Get PDFBACKGROUND: Health system responsiveness to public priorities and needs is a broad, multi-faceted and complex health system goal thought to be important in promoting inclusivity and reducing system inequity in participation. Power dynamics underlie the complexity of responsiveness but are rarely considered. This paper presents an analysis of various manifestations of power within the responsiveness practices of Health Facility Committees (HFCs) and Sub-county Health Management Teams (SCHMTs) operating at the subnational level in Kenya. Kenyan policy documents identify responsiveness as an important policy goal. METHODS: Our analysis draws on qualitative data (35 interviews with health managers and local politicians, four focus group discussions with HFC members, observations of SCHMT meetings, and document review) from a study conducted at the Kenyan Coast. We applied a combination of two power frameworks to interpret our findings: Gaventa's power cube and Long's actor interface analysis. RESULTS: We observed a weakly responsive health system in which system-wide and equity in responsiveness were frequently undermined by varied forms and practices of power. The public were commonly dominated in their interactions with other health system actors: invisible and hidden power interacted to limit their sharing of feedback; while the visible power of organisational hierarchy constrained HFCs' and SCHMTs' capacity both to support public feedback mechanisms and to respond to concerns raised. These power practices were underpinned by positional power relationships, personal characteristics, and world views. Nonetheless, HFCs, SCHMTs and the public creatively exercised some power to influence responsiveness, for example through collaborations with political actors. However, most resulting responses were unsustainable, and sometimes undermined equity as politicians sought unfair advantage for their constituents. CONCLUSION: Our findings illuminate the structures and mechanisms that contribute to weak health system responsiveness even in contexts where it is prioritised in policy documents. Supporting inclusion and participation of the public in feedback mechanisms can strengthen receipt of public feedback; however, measures to enhance public agency to participate are also needed. In addition, an organisational environment and culture that empowers health managers to respond to public inputs is required
Regulation of health professions education and the growth of schools in Somalia.
No full textBACKGROUND: Health professions education, encompassing training programs for medicine and surgery, nursing, midwifery, medical laboratory sciences,, and public health, along with their regulations, are pivotal to achieving universal health coverage and Sustainable Development Goals, contributing significantly to health outcomes and public trust in the healthcare workforce. However, low- and middle-income countries, especially in sub-Saharan Africa, face challenges, such as inadequate resources, outdated curricula, and weak governance. Somalia in particular grapples with a fragmented health system and a critical shortage of skilled health professionals, exacerbated by decades of civil war and political instability. METHODS: This study employed a mixed-method approach that incorporated both qualitative and quantitative data collection and analysis. A comprehensive literature review was conducted along with semi-structured interviews with 44 key informants, including representatives from professional health schools and officials from the Ministry of Health. Additionally, five focus group discussions were held with young professionals and an online survey was administered to students enrolled in professional health courses. The data analysis employed descriptive for quantitative data, and thematic analysis for qualitative data, guided by the human resources for health (HRH) maturity model framework. RESULTS: This study identified 112 health professions schools across Somalia, with a significant concentration in urban areas, particularly in Benadir. The health workforce analysis revealed a pronounced urban-rural disparity and a density of health professionals below the WHO's recommended threshold. The focus group discussions and surveys highlighted the employment challenges faced by young physicians and students' perceptions of their training and future employment opportunities. CONCLUSION: The proliferation of health professions schools without adequate quality control, the critical shortage and maldistribution of skilled health professionals, and the absence of a comprehensive regulatory framework are significant challenges facing Somalia's healthcare system. The establishment of the National Health Professionals' Council (NHPC) Act in 2020 marks a step towards addressing these issues. This study emphasizes the need for accreditation of health professions schools, capacity building of HRH teams, and collaboration among stakeholders to improve healthcare workforce development and regulation. Addressing urban-rural disparities and combating professional misconduct are also crucial for achieving universal health coverage and improving health outcomes in Somalia
Cost and cost-effectiveness of digital technologies for support of tuberculosis treatment adherence: a systematic review.
Get PDFBACKGROUND: Digital adherence technologies (DATs) may provide a patient-centred approach to supporting tuberculosis (TB) medication adherence and improving treatment outcomes. We synthesised evidence addressing costs and cost-effectiveness of DATs to support TB treatment. METHODS: A systematic review (PROSPERO-CRD42022313531) identified relevant literature from January 2000 to April 2023 in MEDLINE, Embase, CENTRAL, CINAHL, Web of Science along with preprints from medRxiv, Europe PMC and ClinicalTrials.gov. Studies with observational, experimental or quasi-experimental designs (minimum 20 participants) and modelling studies reporting quantitative data on the cost or cost-effectiveness of DATs for TB infection or disease treatment were included. Study characteristics, cost and cost-effectiveness outcomes were extracted. RESULTS: Of 3619 titles identified by our systematic search, 29 studies met inclusion criteria, of which 9 addressed cost-effectiveness. DATs included short message service (SMS) reminders, phone-based technologies, digital pillboxes, ingestible sensors and video-observed therapy (VOT). VOT was the most extensively studied (16 studies) and was generally cost saving when compared with healthcare provider directly observed therapy (DOT), particularly when costs to patients were included-though findings were largely from high-income countries. Cost-effectiveness findings were highly variable, ranging from no clinical effect in one study (SMS), to greater effectiveness with concurrent cost savings (VOT) in others. Only eight studies adequately reported at least 80% of the elements required by Consolidated Health Economic Evaluation Reporting Standards, a standard reporting checklist for health economic evaluations. CONCLUSION: DATs may be cost saving or cost-effective compared with healthcare provider DOT, particularly in high-income settings. However, more data of higher quality are needed, notably in lower-income and middle-income countries which have the greatest TB burden
A SARS-CoV-2 outbreak in a public order and safety training facility in England, June 2021.
Get PDFBACKGROUND: The public order and safety (POS) sector remains susceptible to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreaks, as workplace attendance is typically compulsory and close physical contact is often needed. Here, we report on a SARS-CoV-2 outbreak with an attack rate of 39% (9/23), which occurred between 19 and 29 June 2021 among a cohort of new POS recruits participating in a mandatory 18-week training programme in England. METHODS: The COVID-OUT (COVID-19 Outbreak investigation to Understand Transmission) study team undertook a multidisciplinary outbreak investigation, including viral surface sampling, workplace environmental assessment, participant viral and antibody testing, and questionnaires, at the two associated training facilities between 5 July and 24 August 2021. RESULTS: Environmental factors, such as ventilation, were deemed inadequate in some areas of the workplace, with carbon dioxide (CO2) levels exceeding 1,500 ppm on multiple occasions within naturally ventilated classrooms. Activities during safety training required close contact, with some necessitating physical contact, physical exertion, and shouting. Furthermore, most participants reported having physical contact with colleagues (67%) and more than one close work contact daily (97%). CONCLUSIONS: Our investigation suggests that site- and activity-specific factors likely contributed to the transmission risks within the POS trainee cohort. Potential interventions for mitigating SARS-CoV-2 transmission in this POS training context could include implementing regular rapid lateral flow testing, optimizing natural ventilation, using portable air cleaning devices in classrooms, and expanding use of well-fitted FFP2/FFP3 respirators during activities where prolonged close physical contact is required
Exploring the delivery of adult vaccination outside of primary care settings: A mixed methods scoping review.
Get PDFBACKGROUND: There are several identified barriers to immunisation delivery and uptake in adults, including governance issues, provider limitations, and patient access. While primary care settings have traditionally been responsible for vaccine delivery, there is a growing need to look to other settings to expand the equitable uptake of vaccinations in adults. OBJECTIVES: This scoping review aims to identify and explore the role of non-primary care settings in delivering adult vaccinations, operational barriers and facilitators to immunisation delivery in these settings, and interventions delivered to improve uptake. METHODS: This scoping review was conducted following the Joanna Briggs Institute (JBI) guidance for scoping reviews and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). Peer-reviewed studies published from 01/01/2010 to 31/12/2022 that focused on the delivery of influenza, COVID-19, pneumococcal and herpes zoster vaccines in adult populations outside of primary care settings were included. Studies were also included if they explored barriers and facilitators to delivery, and interventions to improve uptake. RESULTS: 75 studies were identified for inclusion. Most were quasi-experimental studies, and 58/75 were from the US. Studies were most frequently conducted in in-patient settings, outpatient clinics, nursing homes, and workplaces. Operational planning and logistics, and provider-level issues, such as poor documentation and workflow interruption were commonly identified barriers to delivery. Government funding, continuity of care, and patient convenience were frequently reported facilitators. Interventions shown to improve uptake were operational planning and clinical improvement systems (Plan-Do-Study-Act [PDSA] cycles), provider education and reminders, on-site vaccination, patient education, and financial incentives. CONCLUSIONS: Mapping of the evidence indicates that adult immunisation delivery may be achievable across tertiary and secondary care settings, as well as non-clinical settings, such as workplaces. There are several identified barriers to delivery, predominantly at the provider-level in tertiary-care settings. Intervention such as operational planning, clinical reminders, and on-site vaccination, may facilitate uptake
Study protocol for an observational cohort study of heat stress impacts in pregnancy in The Gambia, West Africa
Get PDFClimate change has resulted in an increase in heat exposure globally. There is strong evidence that this increased heat stress is associated with poor maternal and fetal outcomes, especially in vulnerable populations. However, there remains poor understanding of the biological pathways and mechanisms involved in the impact of heat in pregnancy. This observational cohort study of 764 pregnant participants based in sub-Saharan Africa, a geographical region at risk of extreme heat events, aims to evaluate the physiological and biochemical changes that occur in pregnancy due to heat stress. The key objectives of the study are to 1) map exposure to heat stress in the cohort and understand what environmental, social and community factors increase the risk of extreme heat exposure; 2) assess the impact of heat stress on maternal health, e.g. heat strain, subjective psychological well-being, sleep and activity level; 3) evaluate how heat stress impacts placenta structure and function; 4) determine how chronic heat exposure impacts birth outcomes; and 5) explore the epigenetic changes in the placenta and infant by heat stress exposure per trimester. Pregnant women will be recruited from two distinct regions in The Gambia to exploit the naturally occurring heat gradient across the country. Microclimate mapping of the area of recruitment will give detailed exposure measurements. Participants will be asked to wear a watch-style device at 28- and 35-weeks gestational age to evaluate maternal heart rate, activity and sleep. At the end of the week, an ultrasound scan will be performed to evaluate fetal size and placental blood flow. At delivery, birth outcomes will be recorded and maternal, placental and cord samples taken for epigenetic, biochemical and histological evaluation. Evaluation of neuro-behaviour and final infant samples will be taken at 1 month following birth.</ns3:p