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Legal mobilization and anti‐fluoridation campaigning in post‐war Britain
Get PDFAbstract
The fluoridation of public water supplies to improve dental health is often cited as an example of an ‘intractable controversy’ in public health, reflecting deeply held principles about rights and the public sphere. This article examines legal mobilization to prevent fluoridation in Britain, from the first pilot studies in the mid‐1950s through to
McColl
v.
Strathclyde
in 1983 and the subsequent Water (Fluoridation) Act 1985. I argue that efforts to evade the objections of anti‐fluoridationists helped to create an ambiguous legal position from the outset, generating an opportunity for campaigners to use the law to stop fluoridation schemes. I show that, despite there being no decisive legal judgments in their favour, the legal campaigns of anti‐fluoridationists were remarkably successful in terms of their indirect effects. Finally, building on recent work that highlights legal mobilization by conservative causes, this historical case study offers insight into the rights claims of a politically diverse populist movement
Evaluation of a combined tuberculosis case-finding, treatment and prevention strategy in Thailand: protocol for a pragmatic phase IV stepped-wedge cluster-randomised trial, the CaPThai study.
No full textBackground: To end the tuberculosis (TB) epidemic, the WHO recommends implementing active case-finding to increase TB detection, as well as the provision of TB preventive treatment (TPT) in contacts of people with TB. However, the scale-up of both strategies remains limited in high TB-burden countries such as Thailand. Despite the country's highly decentralised healthcare system, significant inequalities remain in access to care, particularly in vulnerable populations. We designed an intervention study investigating the effectiveness and feasibility of a novel strategy combining active case-finding and the implementation of short-course TPT in households of newly diagnosed adults with TB in Thailand.
Methods: This is a pragmatic phase IV stepped-wedge cluster-randomised trial conducted in 20 provincial hospitals (clusters). The study population comprises household members who were exposed within the last 3 months to adults with newly detected bacteriologically confirmed TB. The intervention combines an educational video to the index TB case, provision of an invitation card to household contacts for free TB screening at the facility, with a transport voucher, and support from village or urban health volunteers. Household contacts without active TB are offered TPT regimens according to age: 1-month rifapentine-isoniazid (1HP), 3-month rifapentine-isoniazid (3HP) or 3-month rifampicin-isoniazid (3HR). In the control phase, TB staff implement the current standard of care, including verbal information to persons newly diagnosed with TB on the need to screen their household contacts and provision of standard TPT. Hospitals shift from the control to the intervention phase every 3 months in four randomised sequences until all clusters apply the intervention. Generalised linear mixed models will be used to compare the intervention outcomes versus the standard of care, controlling for clustering and confounding by time.
Discussion: Active case-finding and systematic TPT in at-risk populations is currently limited in Thailand. This protocol incorporates pragmatic design features with a participant-centred approach to assess the effectiveness, feasibility and acceptability of a combined strategy including systematic screening of household contacts, active case-finding and TPT provision. If successful, this strategy will likely contribute to TB elimination in Thailand and beyond.
Trial registration: The study is registered at ClinicalTrials.gov NCT05581212 on April 3rd, 2024, and is currently recruiting
Simulation-based assessment of a Bayesian M-spline survival model with flexible baseline hazard and time-dependent effects.
Get PDFBackground: There is increasing interest in flexible Bayesian models for the analysis of time-to-event data, especially with their use in medical applications such as Health Technology Assessment (HTA). While these Bayesian approaches offer advantages of incorporating prior knowledge and transparently expressing model uncertainty to aid decision-making, they remain underused in practice. A flexible Bayesian model has recently been proposed for use in HTA settings which uses M-splines to model the hazard function, and is implemented in the survextrap R package.
Methods: We conducted a simulation study to assess the statistical performance of the Bayesian survival model implemented in survextrap. We simulate survival outcomes based on control arm data from two oncology clinical trials, and generate treatment arm survival based on different realistic treatment effect scenarios. Statistical performance in modelling a single treatment arm or the difference between treatment arms is compared across a range of flexible models, varying the M-spline specification, smoothing procedure, priors, treatment effect modelling choices and other computational settings.
Results: We demonstrate good model fit and convergence of complex baseline hazard functions and time-dependent covariate effects across realistic clinical trial scenarios. We show that a sufficiently flexible M-spline, implemented using a weighted random walk prior on the spline coefficients, can provide a smooth fit to the hazard without risk of overfitting, and gives unbiased estimates of restricted mean survival over the trial follow-up with good coverage of the credible intervals. Bayesian model fitting with an efficient Laplace approximation provides unbiased estimation but overestimates posterior variance. In some treatment effect scenarios, the survextrap non-proportional hazards models displayed greater bias than standard frequentist survival modelling tools such as flexsurv and rstpm2.
Conclusions: This work helps inform key considerations to guide model selection and estimation performance when fitting flexible Bayesian models to trial data. These findings help identify appropriate default model settings in the software that should perform well in a broad range of settings, as well as more specific considerations to guide model selection for advanced users. This work further ensures users have greater confidence in the validity of these survival models and their implementation
The future of European outdoor summer sports through the lens of 50 years of the tour de France.
Get PDFUNLABELLED: In this study, we consider how excessive heat, due to changing climate conditions, could affect the safety of summer sport competitions in Europe. We use the example of the world’s largest bicycle race, the Tour de France, to assess the changes in heat stress over the past five decades and discuss extreme heat protocols, data gaps and safe ways forward. We show that although July heat stress values have been increasing throughout France, the actual Tour de France race dates have so far been fortunate to avoid the days featuring the highest heat. For example, although July hourly heat stress values for Paris and its surroundings have crossed the high-risk threshold (Wet Bulb Globe Temperature (WBGT) > 28 °C) on five occasions over the last 50 years, four of which have occurred since 2014, this has so far not happened on the date of the Tour de France stage through Paris. Between 1974 and 2023, the hottest Parisian stage finish was in July 2002, with the hourly WBGT maximum of 26.8 °C staying just below the high-risk mark. With record-breaking heatwaves becoming more frequent, it seems only a question of time as to when the race will encounter the extreme heat stress days that will test the existing heat safety protocols. Considering the historical heat stress values, we find that the episodes of dangerous heat levels exceeding 28 °C WBGT, have been most common around Toulouse, Pau and Bordeaux in France’s southwest, and around Nîmes and Perpignan in the southeast. However, locations like Paris and Lyon are starting to cross the 28 °C WBGT threshold more frequently, becoming new heat stress hotspots. Our hourly July analysis for France, shows that morning hours are the safest part of the day and that high heat stress can persist late into the afternoon hours. Mountain locations largely remain safe. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1038/s41598-025-30129-8
Antibiotic surveillance: an action-oriented integrated approach [version 1; peer review: awaiting peer review].
Get PDFBackground: Antibiotics have become lynchpins of our modern systems of healthcare, animal health and agriculture. Monitoring the types and volumes of antibiotics distributed, used and discharged across these systems is critical to provide evidence for action. With limited resources, implementation of multiple tools and recommendations for antibiotic monitoring is challenging. This paper sets out the principles and case study illustrations for establishing antibiotic surveillance in resource-constrained settings.
Methods: A technical working group drew together expertise and experience from around the world and across One Health domains to establish the value of antibiotic surveillance across sectors, review tools and guidelines, share experiences and generate principles for prioritisation of surveillance activity. This included a literature review, in person workshop, online meetings and collaborative writing between August 2024 and May 2025.
Results: The working group identified multiple purposes for establishing a coordinated antibiotic surveillance within countries, to inform efforts to mitigate antimicrobial resistance (AMR) mitigation efforts and beyond. Tools showed increasing complexity towards the end user level, corresponding with decreasing standardisation in approach. Proposed steps for establishing national antibiotic surveillance included starting where the greatest impact can be anticipated in a given context and alignment with other programmes.
Conclusions: Countries vary in their agricultural, population, epidemiological, cultural and economic contexts and require different starting points for establishing antibiotic surveillance. This project characterised an action-oriented prioritisation approach, targeting collection and collation of antibiotic data that have the highest likelihood of affecting change that can achieve impact. Such an approach is risk-based, prioritising surveillance of antibiotic use that poses greatest risks as locally defined and is feasible to change; sustainable, aligning local expertise, infrastructure and technology with other country priorities; and transparent, ensuring evidence availability within the system alongside reporting ‘up and out.’ Achieving effective antibiotic surveillance requires a collaborative and coordinated strategy focusing on data for action.
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Developing a Climate-Tailored Integrated Long-Term Care Framework: Strengthening Policy and Practice Response
Get PDFAs countries confront rapid population ageing alongside escalating climate hazards, long-term care (LTC) systems are increasingly exposed to climate-related risks yet remain under-recognised within climate adaptation policy. This study aims to bridge the gap between climate and health adaptation frameworks and LTC system planning by developing a climate-tailored integrated LTC framework. A horizon scanning and theory-informed synthesis approach was employed, drawing on peer-reviewed and grey literature published between 2010 and 2025 to identify climate hazards affecting LTC users and systems. Evidence was organised by hazard type and analysed in relation to system-level disruption mechanisms and adaptation functions. Findings demonstrate that major climate hazards, including heatwaves, flooding, storms, droughts, wildfires, and air pollution, disproportionately affect LTC users, leading to increased morbidity, cognitive decline, and functional deterioration. At the same time, LTC systems are vulnerable to cascading infrastructure failures, workforce strain, supply chain disruptions, and service discontinuities. Despite these risks, the WHO Operational Framework for Climate-Resilient and Low-Carbon Health Systems does not explicitly address LTC, while the WHO Integrated LTC Framework does not incorporate climate-related risks. In response, this paper proposes a climate-tailored LTC framework that systematically embeds climate risk, adaptation, and mitigation within the four core LTC domains of needs, governance, service delivery, and system enablers. Equity, user participation, and decarbonisation are integrated as cross-cutting principles. The framework provides a policy-oriented architecture to strengthen climate-resilient LTC systems and align long-term care reform with broader climate and sustainable development strategies
Genomic Insights into Chromosomal Colistin Resistance and Virulence-Resistance Convergence in MDR/XDR Klebsiella pneumoniae from Tertiary Hospitals in Peshawar, Pakistan.
Get PDFBackground: Klebsiella pneumoniae is a World Health Organization-listed critical priority pathogen and a major cause of healthcare-associated infections, driven by the global emergence of multidrug-resistant (MDR) and extensively drug-resistant (XDR) lineages and their alarming convergence with hypervirulence. Methods: In this study, 152 clinical specimens, including urine, blood, pus, wound swabs, and respiratory samples, were collected from tertiary care hospitals in Peshawar, Pakistan. Standard microbiological and biochemical methods identified 55 K. pneumoniae isolates. Antimicrobial susceptibility testing (AST) was performed using the Kirby-Bauer disk diffusion and broth microdilution methods, with results interpreted according to Clinical and Laboratory Standards Institute (CLSI) guidelines. MDR and XDR phenotypes were defined based on European Centre for Disease Prevention and Control (ECDC) criteria. Whole-genome sequencing (WGS) was conducted on 16 phenotypically confirmed MDR/XDR isolates, followed by comprehensive bioinformatic analyses to characterize sequence types (STs), acquired antimicrobial resistance genes, resistance-associated chromosomal mutations, virulence determinants, plasmid replicons, and phylogenetic relationships. Results: Among 55 confirmed K. pneumoniae isolates, 19 (34.5%) were classified as MDR and 10 (18.2%) as XDR. WGS revealed substantial genomic heterogeneity, identifying 11 distinct STs, with ST39 being the most prevalent. Resistance to multiple antibiotic classes was mediated by the combined presence of plasmid-borne carbapenemases and extended-spectrum β-lactamases, alongside chromosomal mutations affecting outer membrane porins (OmpK35/OmpK36), fluoroquinolone targets (gyrA/parC), efflux regulation (ramR, marR), and lipid A modification pathways associated with colistin resistance (mgrB, pmrA/pmrB, arnC, crrB). IncF-family plasmids predominated and frequently co-occurred with additional resistance-associated replicons. Notably, one isolate exhibited an expanded virulence gene repertoire, including multiple siderophore systems and a complete type II secretion system, consistent with a hypervirulence-associated genomic profile. Phylogenetic analyses demonstrated close relatedness to international lineages from Asia, the Middle East, and Europe, indicating regional and transnational dissemination. Conclusions: This study highlights the complex interplay between plasmid-mediated gene acquisition and chromosomal adaptive mutations driving MDR and XDR phenotypes in K. pneumoniae circulating in Peshawar, Pakistan. The identification of hypervirulence-associated genetic features within an MDR background underscores the growing threat posed by convergent lineages and emphasizes the need for sustained WGS-based surveillance to inform infection control and antimicrobial stewardship strategies
Relationships between alcohol use and dementia: protocol for an observational study in the UK Clinical Practice Research Datalink.
Get PDFINTRODUCTION: Alcohol consumption is an increasingly recognised modifiable risk factor for dementia, yet whether it has differential impacts on dementia subtypes and its role in disease progression remains unclear. This study aims to: (1) quantify the association between alcohol intake and incidence of dementia subtypes and (2) examine whether individuals who drink heavily and develop dementia referred to hereafter as 'alcohol-related'-have poorer post-diagnosis outcomes compared with other dementia cases. Clarifying these relationships will determine whether alcohol selectively increases risk for specific dementia phenotypes or broadly heightens neurodegenerative vulnerability, with implications for prevention, clinical counselling and therapeutic targeting.
METHODS AND ANALYSIS: This population-based cohort study of alcohol and dementia will use linked UK electronic health records from Clinical Practice Research Datalink, Hospital Episode Statistics and Office for National Statistics (ONS). Participants will be eligible if they have available linked data from January 1998, when ONS death registrations became available, until the end of follow-up. Alcohol exposure will be defined through self-reported recorded weekly alcohol units and diagnostic codes for harmful or dependent alcohol use. Primary outcomes including incident all-cause and subtype-specific dementia (eg, Alzheimer's, vascular, Lewy body, Parkinson's, frontotemporal) as well as secondary outcomes (ie, mortality, care-home entry and neuropsychiatric symptoms). Key covariates encompassing socio-demographic factors, smoking and relevant comorbidities will be adjusted for. Multivariable Cox proportional hazards and Fine-Gray competing risk models will estimate associations with dementia incidence. Post-diagnosis prognosis will be compared for dementia in individuals with a history of heavy alcohol use ('alcohol-related') and dementia in individuals with minimal alcohol exposure ('non-alcohol-related') cases using survival and logistic regression models. Multiple testing correction will be applied across dementia subtype comparisons. Alcohol exposure will be modelled continuously and non-linearly using restricted cubic splines and categorically using binary indicators of harmful/dependent use. Missing covariate data will be assessed and addressed using appropriate methods, including multiple imputation and complete-case analysis. Data extraction and analysis are scheduled from October 2025 to October 2026.
ETHICS AND DISSEMINATION: Use of de-identified routine data will proceed under existing Research Ethics Committee and data governance approvals. Findings will be disseminated via open-access peer-reviewed journals, academic conferences and summaries targeted at patient, public and policy audiences. The results of this study will be reported according to the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) and The REporting of studies Conducted using Observational Routinely-collected health Data (RECORD) guidelines
Cohort profile: Infant Gut Bacterial Study in Nigeria (INBUGS-NG).
Get PDFPURPOSE: The Infant Gut Bacterial Study in Nigeria (INBUGS-NG) investigates how delivery mode, antibiotic exposure, feeding practices and environmental factors shape gut microbiome development and acquisition of antibiotic resistance genes (ARGs) during the first year of life in northern Nigeria.
PARTICIPANTS: Between February and July 2024, 90 mother-infant dyads were enrolled at a tertiary hospital in Kano city, Nigeria. This was a prospective longitudinal cohort with follow-ups at 10 scheduled time points: days 0, 1, 3, 5, 7, 14, 28, 90, 180 and 365. We also intensified stool sampling after infant antibiotic administration, enabling dense early-life sampling. To date, the cohort has contributed 480 infant stool samples, 232 maternal rectal swabs, 254 breast milk samples and 806 environmental samples (total 1772). In parallel, socio-demographic, clinical and cultural data were collected using Research Electronic Data Capture (REDCap) and household visit diaries.
FINDINGS TO DATE: Baseline data show that 84/90 mothers (93.3%) received postpartum antibiotics, and 26/90 infants (28.9%) received antibiotics within the first 3 months of life. Only 8% of infants were exclusively breastfed, with early water supplementation common. Caesarean deliveries accounted for 25% of births, and the mean gestational age was 38.5 weeks. Across the cohort, high retention was achieved, and the study has generated a unique long-read metagenomic resource from an African infant population, with analyses ongoing.
FUTURE PLANS: Shotgun long-read metagenomic sequencing (Oxford Nanopore) will enable strain-level and plasmid-level profiling of microbial communities and ARGs. Planned analyses include associations between early-life exposures and resistome dynamics, as well as cross-cohort comparisons with a parallel study in Pakistan. Follow-up will continue through 12 months
Innovative approaches for engaging adolescents in Primary HIV prevention: lessons from the peer-Led health education program in Nimule, South Sudan.
Get PDFBACKGROUND: The involvement and engagement of adolescents in community-based HIV prevention programmes are crucial for enhancing the effectiveness and sustainability of these programmes yet few programmes have documented their engagement strategies. This study aimed to describe and innovative approaches used to actively engage adolescents in HIV prevention health education programmes designed to increase awareness of HIV prevention methods, reduce risky behaviours, and increase uptake of HIV testing.
METHODS: We employed participatory approaches involving pre-programme consultations with adolescents’ peer educators and conducting post-programme reflection sessions. The pre-programme consultations were aimed at identifying objective opinions from peer educators on the best approaches for actively engaging peers in health education sessions. The post-programme reflection sessions involving peers were aimed at collecting feedback across eight approaches adopted to identify which of those motivated and actively engaged them in their groups. Thematic context analysis was used to identify and validate the most preferred approaches.
RESULTS: Of the 50 participants, 27 (54%) were female and 23 (46%) were male adolescents. The participants were within the age range of 14–17 years. More than 90% of the adolescents identified that being in groups facilitated by a peer of the same gender, having a peer educator representing greater diversity, being in a group with flexible meeting dates, times, and venues, and staying connected were the major motivators for their active engagement in their groups. Conversely, having peer educators with good facilitation skills, finding mental health and psychosocial support, and having a sense of ownership of the group were the least rated motivators.
CONCLUSIONS AND RECOMMENDATIONS: Employing approaches that enhance active participation can substantially improve adolescents engagement in HIV primary prevention interventions. This implies that employing a multifaceted and innovative approaches is a game-changer in actively engaging adolescents in community-based HIV programmes and hence the need to advocate for adolescents' engagement in HIV prevention as well as future research into approaches crucial in strengthening and scaling effective programmes.
SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s12978-025-02234-4