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A positive yet complicated case of gender‐based violence coordination: a qualitative study of Lebanon's protracted humanitarian emergency, 2012–22
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Gender‐based violence (GBV), a global health and human rights concern, often intensifies during emergencies. This paper explores the evolution of GBV coordination in Lebanon's protracted Syrian refugee crisis from 2012–22. Utilising 38 in‐depth interviews and a document review, the findings were analysed using the framework for effective GBV coordination. Lebanon provides a positive yet complicated example of GBV coordination. Initially established to address the refugee crisis, it matured into a collaborative national coordination mechanism, fostering trust and advancing localisation amidst sectarian complexities. However, the volatile, restrictive policy context hindered government co‐leadership and engagement with refugee‐led organisations. While essential GBV response services were expanded nationwide, lack of an interagency strategy on GBV risk mitigation and prevention compromised lasting change. The paper emphasises the importance of dedicated GBV coordinators, multi‐year funding, and increased attention to GBV prevention. The findings underscore the transformative potential of humanitarian responses and advocate for enhanced engagement with national stakeholders to promote sustainability in protracted crises
Agent-based modeling of the COVID-19 pandemic in Florida
Get PDFThe onset of the COVID-19 pandemic drove a widespread, often uncoordinated effort by research groups to develop mathematical models of SARS-CoV-2 to study its spread and inform control efforts. The urgent demand for insight at the outset of the pandemic meant early models were typically either simple or repurposed from existing research agendas. Our group predominantly uses agent-based models (ABMs) to study fine-scale intervention scenarios. These high-resolution models are large, complex, require extensive empirical data, and are often more detailed than strictly necessary for answering qualitative questions like “Should we lockdown?” During the early stages of an extraordinary infectious disease crisis, particularly before clear empirical evidence is available, simpler models are more appropriate. As more detailed empirical evidence becomes available, however, and policy decisions become more nuanced and complex, fine-scale approaches like ours become more useful. In this manuscript, we discuss how our group navigated this transition as we modeled the pandemic. The role of modelers often included nearly real-time analysis, and the massive undertaking of adapting our tools quickly. We were often playing catch up with a firehose of evidence, while simultaneously struggling to do both academic research and real-time decision support, under conditions conducive to neither. By reflecting on our experiences of responding to the pandemic and what we learned from these challenges, we can better prepare for future demands
Delivery and Safety of a Two-Dose Preventive Ebola Virus Disease Vaccine in Pregnant and Non-Pregnant Participants during an Outbreak in the Democratic Republic of the Congo.
Get PDFDuring the 2018-2020 Ebola virus disease (EVD) outbreak, residents in Goma, Democratic Republic of the Congo, were offered a two-dose prophylactic EVD vaccine. This was the first study to evaluate the safety of this vaccine in pregnant women. Adults, including pregnant women, and children aged ≥1 year old were offered the Ad26.ZEBOV (day 0; dose 1), MVA-BN-Filo (day 56; dose 2) EVD vaccine through an open-label clinical trial. In total, 20,408 participants, including 6635 (32.5%) children, received dose 1. Fewer than 1% of non-pregnant participants experienced a serious adverse event (SAE) following dose 1; one SAE was possibly related to the Ad26.ZEBOV vaccine. Of the 1221 pregnant women, 371 (30.4%) experienced an SAE, with caesarean section being the most common event. No SAEs in pregnant women were considered related to vaccination. Of 1169 pregnancies with a known outcome, 55 (4.7%) ended in a miscarriage, and 30 (2.6%) in a stillbirth. Eleven (1.0%) live births ended in early neonatal death, and five (0.4%) had a congenital abnormality. Overall, 188/891 (21.1%) were preterm births and 79/1032 (7.6%) had low birth weight. The uptake of the two-dose regimen was high: 15,328/20,408 (75.1%). The vaccine regimen was well-tolerated among the study participants, including pregnant women, although further data, ideally from controlled trials, are needed in this crucial group
A nurse-led model of care to improve access to contraception and abortion in rural general practice: Co-design with consumers and providers.
Get PDFAIM: To describe key features of a co-designed nurse-led model of care intended to improve access to early medication abortion and long-acting reversible contraception in rural Australian general practice. DESIGN: Co-design methodology informed by the Experience-Based Co-Design Framework. METHODS: Consumers, nurses, physicians and key women's health stakeholders participated in a co-design workshop focused on the patient journey in seeking contraception or abortion care. Data generated at the workshop were analysed using Braun and Clarkes' six-step process for thematic analysis. RESULTS: Fifty-two participants took part in the co-design workshop. Key recommendations regarding setting up the model included: raising awareness of the early medication abortion and contraceptive implant services, providing flexible booking options, ensuring appointment availability, providing training for reception staff and fostering good relationships with relevant local services. Recommendations for implementing the model were also identified, including the provision of accessible information, patient-approved communication processes that ensure privacy and safety, establishing roles and responsibilities, supporting consumer autonomy and having clear pathways for referrals and complications. CONCLUSION: Our approach to experience-based co-design ensured that consumer experiences, values and priorities, together with practitioner insights, were central to the development of a nurse-led model of care. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: The co-designed nurse-led model of care for contraception and medication abortion is one strategy to increase access to these essential reproductive health services, particularly in rural areas, while providing an opportunity for nurses to work to their full scope of practice. IMPACT: Nurse-led care has gained global recognition as an effective strategy to promote equitable access to sexual and reproductive healthcare. Still, nurse-led contraception and abortion have yet to be implemented andevaluated in Australian general practice. This study will inform the model of care to be implemented and evaluated as part of the ORIENT trial to be completed in 2025. REPORTING METHOD: Reported in line with the Standards for Reporting Qualitative Research (SRQR) checklist. PATIENT OR PUBLIC CONTRIBUTION: Two consumer representatives contributed to the development of the co-design methodology as members of the ORIENT Intervention Advisory Group Governance Committee
"Arming half-baked people with weapons!" Information enclaving among professionals and the need for a care-centred model for antibiotic use information in Uganda, Tanzania and Malawi.
Get PDFBACKGROUND: The overuse of antimicrobial medicines is a global health concern, including as a major driver of antimicrobial resistance. In many low- and middle-income countries, a substantial proportion of antibiotics are purchased over-the-counter without a prescription. But while antibiotics are widely available, information on when and how to use them is not. OBJECTIVE: We aimed to understand the acceptability among experts and professionals of sharing information on antibiotic use with end users - patients, carers and farmers - in Uganda, Tanzania and Malawi. METHODS: Building on extended periods of fieldwork amongst end-users and antibiotic providers in the three countries, we conducted two workshops in each, with a total of 44 medical and veterinary professionals, policy makers and drug regulators, in December 2021. We carried out extensive documentary and literature reviews to characterise antibiotic information systems in each setting. RESULTS: Participants reported that the general public had been provided information on medicine use in all three countries by national drug authorities, health care providers and in package inserts. Participants expressed concern over the danger of sharing detailed information on antibiotic use, particularly that end-users are not equipped to determine appropriate use of medicines. Sharing of general instructions to encourage professionally-prescribed practices was preferred. CONCLUSIONS: Without good access to prescribers, the tension between enclaving and sharing of knowledge presents an equity issue. Transitioning to a client care-centred model that begins with the needs of the patient, carer or farmer will require sharing unbiased antibiotic information at the point of care
‘When I tried to explain, they shouted back at me!’: exploring how community pharmacists navigate tensions implementing antimicrobial stewardship in Vietnam
Get PDFAntimicrobial resistance is a major global and national health challenge, accelerated by ‘irrational’ antibiotic use. In response, Vietnam has been implementing a public health plan of antimicrobial stewardship since 2013 to reduce antibiotic sales in community pharmacies, although it has had limited effect. Given that private pharmacies are increasingly the entry point to access healthcare, reflective of the inhibited accessibility of primary healthcare, understanding how the positioning of community pharmacists shapes the delivery of antimicrobial stewardship plans warrant further investigation. This qualitative analysis draws on data from 24 in-depth interviews with licensed community pharmacists in Vietnam. Interviewees described being constrained in rationing the sale of antibiotics by tensions within their professional role, in which the delivery of antimicrobial stewardship within their public health commitments rubs up against commercial and social obligations to their livelihoods and communities respectively. The concept of ‘resistance’ provides insight into what obstructs the integration of national antimicrobial stewardship guidance and policy, hindering the transformation of local practices concerning antibiotic sales at the community level. Findings reveal opportunities to recast community pharmacists as ‘productive anchors’ who can facilitate the appropriate use of antibiotics and strengthen links to primary care within the local context. Structural changes are needed, however, so that people do not use antibiotics as a proxy for health care. Improving the accessibility of primary healthcare would also curtail the reliance on community pharmacists’ to dispense antibiotics as a local mechanism of financial protection and social care within community
Clinical Characteristics and Risk Factors for Severe Japanese Spotted Fever: A Retrospective Multicenter Study in the Nagasaki Prefecture, Western Japan.
Get PDFJapanese spotted fever (JSF) is a tick-borne rickettsial disease prevalent in western Japan with an increasing incidence and geographical distribution. This retrospective study aimed to describe the clinical features of JSF and identify factors associated with its severe form. We included adult patients with laboratory-confirmed JSF in the Nagasaki Prefecture between 2010 and 2021. Severe JSF was defined as an altered mental status, low blood pressure, or low oxygen saturation. In total, 65 JSF cases were diagnosed. Common symptoms included fever (87%), rash (48%), and fatigue (48%), with eschars detected in 50 (79.4%) patients. Thirty-eight (60.3%) patients were initially diagnosed with non-JSF conditions. Twenty-one (33.3%) patients were categorized as having severe JSF, including one death. Prehospital factors associated with severe JSF included age ≥75 (adjusted odds ratio [aOR] 37.53, 95% confidence interval [CI] 3.03-465.38), male sex (aOR 26.5, 95% CI 4.23-166.00), and a treatment delay ≥4 days from onset (aOR 5.96, 95% CI 1.13-31.60). This study highlights the diagnostic challenges of JSF owing to its non-organ-specific clinical presentation. Delayed initial treatment, advanced age, and male sex significantly increase the risk of disease severity. It is crucial to raise awareness of JSF among clinicians and residents in endemic areas
A comprehensive evaluation on the associations between hearing and vision impairments and risk of all-cause and cause-specific dementia: results from cohort study, meta-analysis and Mendelian randomization study.
Get PDFBACKGROUND: Epidemiological studies show inconsistent links between hearing/vision impairment and dementia risk. Using multisource data, we investigated how single or combined sensory impairments relate to risks of all-cause and specific types of dementia. METHODS: We employed a triangulation approach combining three methodologies. We analyzed 90,893 UK Biobank (UKB) adults to explore single and joint effects of hearing and vision impairments on all-cause and Alzheimer's disease (AD), vascular dementia (VD) and non-AD non-VD (NAVD). A meta-analysis of prospective studies involving 937,908 participants provided stronger evidence. Finally, we conducted Mendelian randomization (MR) analysis using genome-wide association studies from UKB (361,194 participants) and FinnGen (412,181 participants) to validate relationships between sensory impairments and dementia occurrence. RESULTS: In the UKB cohort study, compared to participants with normal hearing, those in the mild and severe hearing impairment groups had progressively and significantly higher risk of all-cause dementia (mild: HR1.52, 95%CI 1.31-1.77; severe: HR1.80, 95%CI 1.36-2.38), AD (mild: HR1.63, 95%CI 1.30-2.04; severe: HR2.18, 95%CI 1.45-3.27), VD (mild: HR1.68, 95%CI 1.19-2.37; severe: HR1.47, 95%CI 1.22-1.78), and NAVD (mild: HR1.47, 95%CI 1.22-1.78; severe: HR1.98, 95%CI 1.43-2.75). Besides, vision impairment was associated with an increased risk of all-cause dementia (HR1.55, 95%CI 1.18-2.04) and NAVD (HR1.51, 95%CI 1.07-2.13). Furthermore, dual sensory impairment was associated with stepwise increased risks of all-cause and cause-specific dementia than single hearing or vision impairment. In the meta-analysis of 31 prospective cohort studies, risks of all-cause dementia and AD were elevated in participants with single hearing impairment (all-cause dementia: HR1.30, 95%CI 1.21-1.40; AD: HR1.30, 95%CI 1.21-1.40) and dual sensory impairment (all-cause dementia: HR1.63, 95%CI1.14-2.12; AD: HR 2.55, 95%CI 1.19-3.91), while single vision impairment only associated with higher risk of all-cause dementia (HR1.43, 95%CI 1.16-1.71) but not AD. Finally, the MR analysis revealed a significant association between hearing impairment and all-cause dementia (OR1.74, 95%CI 1.01-2.99), AD (OR1.56, 95%CI 1.09-2.23), and NAVD (OR1.14, 1.02-1.26), as well as vision impairment and NAVD (OR1.62, 95%CI 1.13-2.33). CONCLUSIONS: Our findings showed significant associations between hearing and vision impairments and increased risks of all-cause and cause-specific dementia. Standardized hearing and vision assessment and intervention should be emphasized in dementia prevention strategies
Cohort studies on 71 outcomes among people with atopic eczema in UK primary care data.
Get PDFAtopic eczema may be related to multiple subsequent adverse health outcomes. Here, we provide evidence to judge and compare associations between eczema and a comprehensive set of outcomes. We conducted 71 cohort studies (age, sex, general practice-matched) using Clinical Practice Research Datalink Aurum primary care records (1997-2023), comparing up to 3.6 million people with eczema to 16.8 million without. Eczema was associated with subsequent diagnosis of outcomes with adjusted hazard ratios (99% confidence intervals) from Cox regression of up to 4.02(3.95-4.10) for food allergy (rate difference [RD] per 1,000 person-years of 1.5). Besides strong associations with atopic and allergic conditions (e.g., asthma 1.87[1.39-1.82], RD5.4) and skin infections (e.g., molluscum contagiosum 1.81[1.64-1.96], RD1.8), the strongest associations were with Hodgkin's lymphoma (1.85[1.66-2.06], RD0.02), Alopecia Areata (1.77[1.71-1.83], RD0.2), Crohn's disease (1.62[1.54-1.69], RD0.1), Urticaria (1.58[1.57-1.60], RD1.9), Coeliac disease (1.42[1.37-1.47], RD0.1), Ulcerative colitis (1.40[1.34-1.46], RD0.1), Autoimmune liver disease (1.32[1.21-1.43], RD0.01), and Irritable bowel syndrome (1.31[1.29-1.32], RD0.7). Sensitivity analyses revealed the impact of consultation bias or choice of cohort age cut-off on findings. Comparatively large HRs in severe eczema were seen for some liver, gastrointestinal and cardiovascular conditions, osteoporosis, and fractures. Most cancers and neurological conditions were not associated with eczema
Novel management of pseudomonas biofilm-like structure in a post-pneumonectomy empyema.
Get PDFWe present a patient with a post-pneumonectomy empyema refractory to surgical debridement and systemic antibiotics. The patient initially presented with a bronchopleural fistula and pneumothorax secondary to tuberculosis (TB) destroyed lung, which required a pneumonectomy with Eloesser flap. Ongoing pleural infection delayed the closure of the Eloesser flap, and thoracoscopic inspection of his chest cavity revealed a green, mucous biofilm-like structure lining the postpneumonectomy pleural cavity. Cultures identified pan-susceptible Pseudomonas aeruginosa. Despite debriding this biofilm-like structure and administering systemic antibiotics, the patient continued to show persistent signs of infection and regrowth of the film. We employed a novel approach to dissolve the biofilm-like structure using intrapleural dornase alfa followed by intrapleural antibiotic washes. After 3 weeks of daily washes, repeat inspection demonstrated the biofilm-like structure had completely resolved. Resolving the pseudomonas biofilm-like structure allowed permanent closure of his chest without further need for systemic antibiotics. At follow up 3 months later, he showed no sequalae. This treatment option can be an important adjunct to improve likelihood of chest closure in patients with post-pneumonectomy empyema that resists standard treatment options due to biofilm formation