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Aeromonas in South Asia: genomic insights into an environmental pathogen and reservoir of antimicrobial resistance.
Get PDFAeromonads are an ecologically versatile group of bacteria that cause infections in aquatic animals and are recognised as emerging human pathogens. Despite this, our understanding of Aeromonas diversity, especially the relationship between clinical and environmental strains, remains limited. Here, we present a genomic analysis of the Aeromonas genus, comprising 1853 genomes, and a detailed comparison of clinical and environmental strains from South Asia, including 996 newly sequenced genomes from Bangladesh and India. Phylogenetic analyses revealed that Aeromonas is a highly diverse genus, with no distinct clade separating clinical and environmental isolates. We identified 28 Aeromonas species and 905 novel sequence types, comprising 72.5% of the genomes. Notably, we show a high incidence of antimicrobial resistance (AMR) genes across all isolates, including against front and last-line antibiotics. Finally, we highlight frequent misidentification of Aeromonas as Vibrio cholerae, which is relevant to cholera-endemic regions where both genera co-exist and are associated with diarrhoeal disease. Our study underscores Aeromonas as an important environmental AMR reservoir and emerging multi-species pathogen capable of spilling over into human populations
Pathway for life course research in low-income and middle-income countries: Andhra Pradesh Children and Parents Study (APCAPS) 1994-2023
Get PDFAbstract
Low-income and middle-income countries (LMICs) share a higher burden of cardiovascular diseases (CVDs). Rapid transitions in the built environment impacts life course trajectories of physical activity, diet, and body composition. Life course epidemiology is a valid approach to unravel CVD etiology. Effective use of life course approaches requires the adoption of conceptual models, overcoming data availability gaps in resource-poor settings, and using appropriate statistical methods. We provide a template for using life course epidemiology in LMICs to highlight the knowledge and resource gaps. For illustration we use a case study to assess multi-level determinants of the South Asian thin-fat phenotype in the Andhra Pradesh Children and Parents Study (APCAPS, 1994-2023) based in rural India. A socio-ecological causal model of CVD risk specific to South Asians was adopted and setting-specific indicators identified. Life course data acquisition challenges and solutions used were described. The complex nature of multi-level determinants and appropriate statistical approaches were discussed using Directed Acyclic Graphs. An increasing number of birth cohort studies in LMICs are at different stages of maturity and are spread across settings that have an untapped potential to contribute toward contextualization of life course epidemiology in these settings. The proposed template in this paper serves as a guide toward the same
Leveraging community insights and navigating logistical challenges: a case study of the 2024 polio vaccination campaign in Gaza, State of Palestine.
Get PDFThis case study describes how high vaccination coverage was achieved during the 2024 polio vaccination campaign in Gaza amid an ongoing humanitarian crisis marked by damaged critical infrastructure, an obstruction of the entry of health supplies, mass displacement and security concerns for health workers. Despite the immense challenges, 559 161 children were vaccinated in the first round (94% of the revised target of 591 714) and 556 774 in the second round, exceeding expectations. While this represents an impressive achievement, some areas remained inaccessible, which prevented an estimated 7000-10 000 children from being reached for vaccination.Strong coordination and collaboration stewarded by the Gaza Ministry of Health with support from national and international partners.Negotiated humanitarian pauses in the form of 'days of tranquillity' agreed to by parties to the conflict enabling safe access for vaccinators, outreach teams and families.Prevaccination campaign sociobehavioural research to identify barriers and map information flows.Community engagement led by locally recruited volunteers embedded within affected communities, many of whom had themselves experienced displacement, supporting trust and acceptance.Culturally responsive communication strategies using multiple channels and feedback mechanisms.Adaptive vaccine management strategies and the development of a mobile cold chain.The campaign's success was underpinned by a multifaceted approach that included:Strong coordination and collaboration stewarded by the Gaza Ministry of Health with support from national and international partners.Negotiated humanitarian pauses in the form of 'days of tranquillity' agreed to by parties to the conflict enabling safe access for vaccinators, outreach teams and families.Prevaccination campaign sociobehavioural research to identify barriers and map information flows.Community engagement led by locally recruited volunteers embedded within affected communities, many of whom had themselves experienced displacement, supporting trust and acceptance.Culturally responsive communication strategies using multiple channels and feedback mechanisms.Adaptive vaccine management strategies and the development of a mobile cold chain.This case demonstrates that even in complex humanitarian crises, effective, community-centred vaccination strategies are possible. It also highlights how access and availability, not parental reluctance (or vaccine hesitancy), were the primary constraints on coverage. Parents showed strong willingness to vaccinate when services were accessible. Sustained advocacy and diplomacy remain essential to secure access, deliver equitable immunisation and create an enabling environment for humanitarian public health responses in conflict settings. However, the gains achieved through this campaign cannot meaningfully be sustained without a lasting ceasefire, the restoration of essential services and ongoing humanitarian access, particularly for infants born after the vaccination campaign who remain at heightened risk
Location of births by health facility type: a time trend analysis from 1995 to 2023 in 130 low- and middle-income countries.
Get PDFBACKGROUND: With major increases in facility births in low- and middle-income countries (LMICs) since 1995, a key question is what types of facilities met the increased demand. Understanding the evolving delivery landscape is crucial to informing debates about optimal models for balancing access, quality, and equity. We studied the distribution of delivery location by health facility level and sector (private versus public) in 130 LMICs from 1995 to 2023. METHODS: We used 745 data sources with delivery location information in our analysis. We first categorised births as in-facility or not, then further classified facility births by level (hospital or lower-level) and sector (public or private). We used spatiotemporal Gaussian process regression to model the share of births by facility type from 1995 to 2023 and compared delivery patterns to development and health indicators. FINDINGS: In 2023, 47.5% (95% uncertainty interval [UI] 46.4-48.6) of deliveries in LMICs were in public hospitals, 19.2% (18.3-20.2) were in private hospitals, 13.0% (12.3-13.8) were in lower-level public facilities, 2.0% (1.9-2.2) were in private lower-level facilities, and the remaining 18.2% (17.3-19.2) were outside health facilities. In 106 countries, more than half of deliveries were in public hospitals, while in 12 countries, public lower-level facilities provided care for more than half of births. In only two countries were private hospitals used for more than half of births, while in the remaining ten countries no facility type provided the majority of care. Between 1995 and 2023, nearly two-thirds (62.1%) of the 41.0 percentage-point increase in facility births was borne by public hospitals. Delivery in lower-level facilities was more common in countries with lower levels of development and higher neonatal mortality rates. INTERPRETATION: The mix of delivery locations represents the diversity of health systems worldwide. Our analysis highlights the pivotal and growing role of public hospitals in delivery care, though public lower-level delivery care is common in high-mortality contexts. Policy makers should account for the facility mix and the complex roles of public and private sectors when designing strategies to improve maternal and perinatal outcomes. FUNDING: The Gates Foundation
A public resource of 15 genomically characterized representative strains of Shigella sonnei.
Get PDFShigella sonnei is rapidly emerging as the dominant agent of shigellosis, an enteric disease responsible for a significant burden of morbidity and mortality worldwide. Whole-genome sequencing of S. sonnei isolated over the last three decades has revealed phylogenomic diversity within the population and the emergence of multiple lineages associated with distinct epidemiological patterns such as resistance to critical antimicrobials and/or transmission within different groups. However, most experimental work on S. sonnei biology and pathogenicity has focused on a single laboratory strain (53G), which is phylogenetically distant from currently circulating strains. Here, we introduce a set of phylogenetically diverse and epidemiologically relevant S. sonnei isolates made available through publicly accessible culture collections as a resource for laboratory science. We present their complete whole-genome sequences, including the pINV invasion plasmid (missing from a large proportion of public genome data due to loss during laboratory culture). Finally, the characterization and comparison of these complete genome sequences highlight evidence for ongoing adaptive evolution in S. sonnei, featuring the accumulation of insertion sequences, gene pseudogenization and structural variation
Asymptomatic testing compared with standard care of the care home staff in shaping care home COVID-19 testing policy: the VIVALDI-CT pragmatic cluster RCT (VIVALDI-CT).
Get PDFBACKGROUND: Regular severe acute respiratory syndrome coronavirus 2 testing of care home staff was introduced to reduce transmission following significant morbidity, mortality and disruption for residents early in the pandemic. However, evidence was lacking on benefits relative to disadvantages.
OBJECTIVES: The VIVALDI-Clinical Trial aimed to investigate whether regular asymptomatic staff testing for severe acute respiratory syndrome coronavirus 2, alongside funding for sick pay and agency backfill, was feasible and effective in reducing severe coronavirus disease discovered in 2019-related outcomes in residents.
DESIGN AND METHODS: VIVALDI-Clinical Trial comprised five interlinking work packages. A cluster randomised controlled trial was conducted from January to August 2023. The 'Test to Care' intervention was coproduced with the care sector.
SETTINGS AND PARTICIPANTS: Eighty-one residential/nursing homes in England providing care to adults aged ≥ 65 years. Forty-one homes were randomised to intervention and 40 to control.
INTERVENTIONS: Care homes were randomised 1 : 1 to intervention (twice weekly staff testing, staff sick pay and agency backfill) or control arm (national testing guidance at time of trial).
MAIN OUTCOME MEASURE: Primary outcome was incidence of coronavirus disease discovered in 2019-related hospital admissions in residents.
DATA SOURCES: Health data from routine national data sets were used alongside aggregate data from participating homes. Health economic and modelling analyses evaluated costs and cost-effectiveness of staff testing. Interviews with care home managers explored post-pandemic policies on staff testing, sickness pay and absence. A process evaluation was conducted to understand intervention roll-out. A mixed-study design investigated the impact of coronavirus disease discovered in 2019 outbreaks on care home residents' quality of life. Stakeholder engagement was undertaken to enable the sector to coproduce recommendations for policy-makers.
RESULTS: The trial stopped early for futility due to site recruitment and primary outcome incidence being lower than expected. There was no significant difference in resident coronavirus disease discovered in 2019-linked hospital admission incidence between intervention and control arms (incidence rate ratio 1.19, 95% confidence interval 0.55 to 2.58; p = 0.66). The process evaluation found that changing epidemiology, policy and social norms around coronavirus disease discovered in 2019 shaped the uptake and maintenance of testing. Interviews with care home managers suggested most homes no longer test staff, even when symptomatic, and do not pay for sickness absence outside of statutory sick pay. Modelling concluded that regular staff testing, when combined with non-pharmaceutical interventions preventing transmission among residents, is an effective strategy to reduce cases and deaths among care home residents that could also lead to significant cost savings. There was lower-than-expected quality of life for 43 residents from 9 care homes without outbreak and 1 home with recent coronavirus disease discovered in 2019 outbreak, with older residents experiencing greater benefits from social care support.
LIMITATIONS: Intervention acceptability was initially high, but waned because of the changing epidemiological, policy and social context.
CONCLUSIONS: Contextual changes undermined our ability to evaluate the intervention's impact. However, trial set-up was achieved in < 3 months, and we present findings on the feasibility and economic implications of routine testing and impact of disease control measures on residents' quality of life. Costs associated with severe acute respiratory syndrome coronavirus 2 testing including support payments for care home staff and for care homes to fund agency staff backfill were funded by the United Kingdom Health Security Agency.
FUTURE WORK: Our approach provides a model for agile interventional studies in care homes. Research training and capacity building for care home staff are important to ensure that future trials can be delivered efficiently in this setting.
FUNDING: This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme as award number NIHR154310
Predictive models for stillbirths and neonatal deaths: Protocol for a global scoping review with focus on sub-Saharan Africa.
Get PDFBackground Sub-Saharan Africa (SSA) accounts for nearly half of the global burden of stillbirths and neonatal deaths. Many of these deaths are preventable through improved quality of maternal and newborn care, particularly timely risk recognition and clinical response. Advancements in artificial intelligence and its applications offer opportunities to improve care through real-time monitoring, assisting clinical decisions, and enhancing public health management, thereby contributing to better care and outcomes. This scoping review will map prediction models and modelling approaches for predicting stillbirths and neonatal deaths globally with focus on SSA. We will compare the performance of classical, machine learning (ML) and artificial intelligence (AI) methods, and examine model development, validation and transportation to SSA. Methods The scoping review will follow the framework proposed by Arksey and O’Malley. We will search five databases (EMBASE, Medline, Scopus, Web of Science, Global Health) and grey literature sources. Two reviewers will independently screen titles, abstracts, and full studies for inclusion based on inclusion criteria, focussing on three predictive approaches (classical, ML, and AI) for stillbirths and neonatal deaths globally, with emphasis to models developed in or transported to SSA. Data extraction will follow a conceptual framework encompassing six domains: predictors, data sources, model types, evaluation metrics, model performance, and model validation. Risk of bias will be assessed using PROBAST+AI. Findings will be summarised using tables, figures, and maps. Anticipated findings The review will identify and characterise predictive models for stillbirths and neonatal deaths, including classical statistical, ML, and AI approaches. We will map predictors, data sources used, evaluation metrics reported, and compare model performance across methodological approaches, and identify which models have been developed in or transported to SSA. Conclusions Findings will identify methodological gaps and inform future model development to support targeted interventions for reducing perinatal mortality in Sub-Saharan Africa.</ns3:p
Recognition of depression by nurses in primary healthcare in Zimbabwe: Cross-sectional study.
Get PDFDepression is underrecognized in primary care, which is a barrier to treatment. For the last decade, Zimbabwe has invested in increasing access to depression treatment within primary healthcare. This study describes depression recognition by nurses and referral to treatment in four primary care clinics in Zimbabwe. Research staff screened 200 patients after they attended a primary care visit at a study clinic. They assessed depression using the PHQ-9 and assessed depression and/or anxiety using the Shona Symptoms Questionnaire (SSQ-14). Medical records were examined for depression and/or anxiety diagnoses. Positive depression and anxiety screens were compared with nurse documentation. 69.5% of participants were women and 56.5% were living with HIV. 6.0% had a PHQ-9 score ≥11, indicative of depression, and 22.0% had an SSQ score ≥9, indicative of depression and/or anxiety. None of the patients who screened positive for probable depression and/or anxiety were recognized by nurses. Nurses who saw the patients in the sample were surveyed. Most had not received formal training on mental health in primary care (mhGAP) prior to patient data collection. Despite efforts to expand depression treatment in Zimbabwe, individuals with probable depression were unrecognized by nurses, though nurses offered some care for other mental health conditions
Implementation of a decision aid to promote shared decision-making on mode of birth in low-risk pregnant women: a cross-sectional study within the QUALI-DEC hybrid trial.
Get PDFINTRODUCTION: Implementing shared decision-making (SDM) in maternity care remains challenging in low-income and middle-income countries (LMICs). Decision aids can support SDM, but evidence on their effectiveness in such settings is limited. We assessed the impact of a decision analysis tool (DAT) for pregnant women on mode of birth (MOB) within the QUALIty DECision-making project, a multisite, multicountry pragmatic trial to reduce unnecessary caesarean sections. METHODS: We conducted a cross-sectional survey among postpartum women considered at low risk for caesarean section in early pregnancy and who delivered in 32 hospitals across Argentina, Burkina Faso, Thailand and Viet Nam. Associations between DAT exposure and selected outcomes were analysed using multilevel, multivariate regression models adjusting for confounders and cluster effects. RESULTS: Of 2368 women included, 249 (11%) had used it outside antenatal care visits, 212 (9%) had heard of but not used it, and 1907 (80%) had never heard of the DAT. Compared with women who had never heard of the DAT, users were more likely to identify at least three risks/benefits of each MOB (adjusted OR (aOR) 1.9; 95% CI 1.3 to 2.8; p=0.001) and to communicate their preferred MOB to providers (aOR 2.3; 95% CI 1.5 to 3.6; p<0.001). DAT users were less likely to prefer caesarean section in late pregnancy (aOR 0.4; 95% CI 0.2 to 0.8; p=0.006) and reported higher birth experience and satisfaction scores (adjusted β=1.9; 95% CI 0.5 to 3.3; p=0.006). CONCLUSIONS: The use of the DAT was associated with improved knowledge, communication of birth preferences, lower caesarean preference and greater satisfaction, without adverse outcomes. Findings suggest that decision aids can strengthen SDM and promote respectful, women-centred maternity care in LMICs. TRIAL REGISTRATION NUMBER: ISRCTN67214403
Overcoming barriers to adult immunization in Europe: A decalogue for policy action by the Adult Immunization Board
Get PDFAdult immunization is a critical yet underdeveloped area within European public health, as fragmented systems and implementation barriers persist. With a growing burden of vaccine-preventable diseases among adults due to demographic aging and emerging pathogens, this policy comment aims to address key barriers impeding a high vaccination uptake, including data availability, feasibility issues, political and financial constraints, vaccine confidence and literacy among the population and healthcare providers, and access issues and organization. Drawing on insights from Adult Immunization Board (AIB) meetings and discussions, a decalogue of actionable policy recommendations is proposed to overcome these barriers. This comprehensive strategy underscores the need for coordinated, multidisciplinary efforts and sustained political commitment to optimize adult immunization programs, leveraging lessons from the recent COVID-19 pandemic response