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Does persistent active trachoma mandate antibiotic mass drug administration? A comparison of prevalence of trachomatous inflammation-follicular with that of conjunctival infection and anti-chlamydial antibodies, Western Province, Zambia.
Get PDFBACKGROUND: The evaluation unit comprising Kaoma, Luampa, and Nkeyema districts, Western Province, Zambia, has persistent active trachoma. In 2023, we sought to compare the evaluation unit-level prevalence of the active trachoma sign, trachomatous inflammation-follicular (TF), to that of conjunctival Chlamydia trachomatis (Ct) infection and anti-Chlamydia trachomatis (Ct) seropositivity.
METHODS: We conducted a cluster-sampled cross-sectional survey. In selected households, we examined all consenting residents ≥1 y of age for trachoma. We collected dried blood spots (DBSs) by finger-prick from children ages 1-9-y and conjunctival swabs from the left eyes of children ages 1-5-y. DBSs were tested for antibodies to the C. trachomatis antigen Pgp3 by lateral flow assay. We tested conjunctival swabs for C. trachomatis DNA by GeneXpert polymerase chain reaction (PCR).
RESULTS: The TF prevalence in children ages 1-9-y was 9.2%. In children ages 1-5-y, anti-Pgp3 seroprevalence was 1.7% and the seroconversion rate was 0.6 per 100 person-years. The prevalence of conjunctival C. trachomatis DNA in children ages 1-5-y was 0%.
CONCLUSIONS: Based on TF prevalence, this population qualified for additional antibiotic mass drug administration rounds, but PCR and serology-more specific indicators of current or recent C. trachomatis infection than TF-confirmed an absence of significant current community C. trachomatis transmission, allowing a transition to surveillance. Adding these indicators is helpful in persistent active trachoma
Effects of lipid-based nutrient supplements on gut markers in stunted children: Secondary analysis of a randomised trial.
Get PDFOBJECTIVES: To examine the effects of lipid-based nutrient supplements (LNS) containing milk protein (MP) and/or whey permeate (WP) on markers of intestinal inflammation and enterocyte mass among stunted children. Furthermore, to explore whether gut status modifies effects of LNS on growth and micronutrient status. METHODS: In a 2 × 2 factorial trial 12-59 months-old Ugandan children with stunting were randomized to four LNS formulations (100 g/day for 12 weeks) containing MP or soy protein and WP or maltodextrin, or to no supplementation. Linear mixed-effects models were used to explore faecal myeloperoxidase (f-MPO) and plasma citrulline (p-cit) as outcomes and modifiers of the intervention effects (ISRCTN13093195). RESULTS: Of 750 children, mean ± SD age was 32.0 ± 11.7 months and height-for-age Z-score was -3.02 ± 0.74. Neither MP nor WP had effects on p-cit or f-MPO. f-MPO decreased over time among controls (ratio of change 0.54, 95% confidence interval [CI]: 0.35, 0.84), but not among those given LNS (0.99, 95% CI: 0.79, 1.23) (p = 0.016). In contrast, LNS had no effect on p-cit (p = 0.27). The effect of LNS on cobalamin (B12) status was reduced in children with p-cit <20 µmol/L; whereby there was 20% (95% CI: 2, 35) lower increase in plasma cobalamin and 59% (95% CI: 13, 125) smaller decrease in plasma methylmalonic acid. p-cit or f-MPO did not modify the effects of LNS on growth or other micronutrient markers. CONCLUSION: LNS had no effect on enterocyte mass and possibly increased intestinal inflammation. The effect of LNS on cobalamin status was reduced in those with low enterocyte mass
The safety of intrauterine devices during breastfeeding: an updated systematic review.
Get PDFOBJECTIVES: To update a 2016 review and answer three questions: (1) Among women using an intrauterine device (IUD), does breastfeeding increase the risk of adverse events? (2) Among breastfeeding women, does IUD use increase the risk of adverse events? (3) Among breastfeeding women, does copper (Cu)-IUD use increase risk of adverse breastfeeding or infant outcomes? METHODS: We searched multiple databases from inception to August 2023. We extracted prespecified data and assessed risk of bias (RoB) for each article and certainty of evidence for each outcome. RESULTS: Thirty-eight articles met the inclusion criteria; 16 were newly identified since the previous review, most with high RoB. Evidence suggested no effect of breastfeeding on IUD-related adverse events (ie, expulsion, bleeding, pain and infection) compared with not breastfeeding; however, an increased relative risk of perforation was observed with breastfeeding at the time of IUD insertion compared with not breastfeeding. For perforation, relative measures of association ranged from 1.4 to 10.1, and absolute rates varied (eg, 0.6-7% or 6.8 per 1000). Evidence suggested no effect of IUD use on risk of adverse events (ie, bleeding, pain and infection) among breastfeeding women compared with no IUD use. Evidence suggested no effect of Cu-IUD use on breastfeeding or infant outcomes among breastfeeding women compared with no Cu-IUD use. CONCLUSIONS: We continued to find an increased relative risk of IUD perforation among breastfeeding women compared with no breastfeeding; however, the absolute risk is low. No other adverse effects with IUD use and breastfeeding were observed. The certainty of evidence for all outcomes was very low
Experiences of Individuals with Cutaneous Leishmaniasis Receiving Intralesional Sodium Stibogluconate or Liquid Nitrogen Cryotherapy in Addis Ababa, Ethiopia-A Cross-Sectional Study.
Get PDFLocalised cutaneous leishmaniasis (LCL) is a common neglected tropical disease in Ethiopia, which is mainly treated with intralesional (IL) pentavalent antimonial such as sodium stibogluconate (SSG) and/or cryotherapy. Both treatments are painful, and studies are lacking on the pain associated with these or affected individuals' experiences of them. A cross-sectional, observational study was conducted at ALERT Comprehensive Specialized Hospital, Addis Ababa/Ethiopia. The socio-demographic and clinical data of individuals affected by LCL receiving IL SSG and/or cryotherapy was gathered, and their treatment was observed. Participants quantified their treatment-associated pain using the Wong-Baker Pain Scale. Health-related quality of life was measured using the (Children's) Dermatology Life Quality Index. Adverse effects, participant experiences with local therapies, and dermatologists' experiences and opinions of local LCL treatment were assessed using structured questionnaires. Of the thirty-six individuals with LCL included (64% male, 14% children), 52% reported a treatment-associated pain score ≥ 8. Cryotherapy administered with a cotton bud was associated with lower pain scores ≤ 6 (odds ratio: 0.15, 95% confidence interval: 0.03-0.89) compared to a cryotherapy spray device. There was wide variation in treatment administration. Local LCL treatment is painful, and most individuals experience significant pain. This study highlights the need for less painful but effective treatments, structured training, and clear standard operating procedures
Understanding the financial hardships faced by TB and HIV patients during the COVID-19 pandemic: a mixed-method study in Bandung and Yogyakarta, Indonesia.
Get PDFThe COVID-19 pandemic had significant widespread financial impacts, resulting in decreased household income, increased unemployment, and disrupted health services. Despite the higher prevalence of infections of tuberculosis (TB) and human immunodeficiency virus (HIV) in poorer populations, research on the financial challenges faced by these populations during the pandemic is still limited. Indonesia recorded the highest COVID-19 cases in Southeast Asia (6 815 156) while contending with the dual burden of HIV and TB. This study investigates the factors influencing out-of-pocket (OOP) payments and catastrophic health spending during the pandemic, alongside patients' challenges and coping mechanisms in Bandung and Yogyakarta, Indonesia. We employed a parallel convergent mixed-methods approach, combining quantitative analysis of OOP costs with qualitative interviews. The determinants of OOP payments were analysed using a two-part cluster-robust regression model. Catastrophic health spending was defined as OOP payments exceeding 10% of a household's annual income. Data on OOP spending were recorded via diaries, while qualitative data were gathered from in-depth interviews with TB and HIV patients and healthcare workers from January to October 2022. The findings indicated that 5.13% [95% confidence interval (CI): 2.99-7.28] of households incurred catastrophically. The median household spent USD 8.48 OOP, with nonmedical expenses comprising the largest share (median USD 5.93). Key predictors of higher costs included facility location in Yogyakarta (OOP costs difference USD 23.84, 95% CI: 9.90-37.77, P < .001), seeking care from public hospitals (USD 17.37, 95% CI: 8.83-25.90, P < .001), and the absence of health insurance (USD 10.49, 95% CI: 2.40-18.58, P = .011). Patients reported that job losses during lockdowns exacerbated financial strain, while coping strategies documented included borrowing, family contributions, and selling assets. This is the first study to focus on OOP spending and the financial hardships experienced by TB and HIV patients in Indonesia during the pandemic, providing insights for targeted policy and preparedness efforts to alleviate the financial burden during large-scale public health crises
Benchmarking progress in non-communicable diseases: a global analysis of cause-specific mortality from 2001 to 2019.
Get PDFBACKGROUND: Non-communicable diseases (NCDs) have received substantial policy attention globally and in most countries. Our aim was to quantify how much NCD mortality changed from 2010 to 2019 in different countries, especially compared with the preceding decade and with the best-performing country in each region, and the specific NCD causes of death that contributed to change.
METHODS: We used data on NCD mortality by sex, age group, and underlying cause of death for 185 countries and territories from the 2021 WHO Global Health Estimates. Our primary outcome was the probability of dying from an NCD between birth and age 80 years in the absence of competing causes of death, and was calculated using age-specific death rates from NCDs and lifetable methods. We calculated change in the probability of death as the difference between values in the final and first year of each period (2001-10 and 2010-19). For 51 countries with high-quality mortality data and 12 countries with large populations within their region, we used the Horiuchi method of decomposition to calculate how much specific causes of death and 5-year age groups contributed towards: (1) increases or decreases in NCD mortality from 2010 to 2019; (2) improvements or deteriorations compared with the preceding decade (2001-10); and (3) differences from the country that had the largest reduction in each region.
FINDINGS: From 2010 to 2019, the probability of dying from an NCD between birth and age 80 years decreased in 152 (82%) of 185 countries for females and in 147 (79%) countries for males; it increased in the remaining 33 (18%) countries for females and 38 (21%) countries for males. The countries where NCD mortality declined for females accounted for 72% of the world female population in 2019, and those where NCD mortality declined for males accounted for 73% of the world male population. NCD mortality declined in all high-income western countries, with Denmark experiencing the largest decline for both sexes and the USA experiencing the smallest decline. Among the largest countries in other regions, NCD mortality declined for both sexes in China, Egypt, Nigeria, Russia, and Brazil, and increased for both sexes in India and Papua New Guinea. On average, females in countries in the central Asia, Middle East and north Africa region had the greatest reduction in NCD mortality followed by those in central and eastern Europe. For males, the largest reduction was among countries in central and eastern Europe, followed by those in central Asia, Middle East and north Africa. The smallest declines were those in the Pacific Island nations. Circulatory diseases were the greatest contributors to declines in NCD mortality from 2010 to 2019 in most countries, with some cancers (eg, stomach and colorectal cancers for both sexes, cervical and breast cancers for females, and lung and prostate cancers for males) also contributing towards lower NCD mortality in 2019 than in 2010 in many countries. Neuropsychiatric conditions and pancreatic and liver cancers contributed towards higher NCD mortality from 2010 to 2019 in most countries. In some countries, NCD mortality in working and older (≥65 years) ages changed in the same direction leading to large overall declines or increases; in others, it changed in opposite directions, diminishing the magnitude of the overall change. In 75 (41%) of 185 countries for females and in 73 (39%) countries for males, the change in NCD mortality from 2010 to 2019 was an improvement (ie, larger decline, smaller increase, or reversal of an increase) compared with the change from 2001 to 2010. These countries accounted for 29% and 63% of the world female and male population, respectively, and included both sexes in Russia and Egypt, and males in China, India, and Brazil. Decadal changes saw a deterioration (ie, smaller decline, larger increase, or reversal of a decline) in the remaining 110 (59%) countries for females and 112 (61%) countries for males, including in both sexes in the USA, Nigeria, and Papua New Guinea, and females in China, India, and Brazil. Change from 2010 to 2019 saw deterioration in direction or size compared with the preceding decade for both sexes in most high-income western countries, most countries in Latin America and the Caribbean, and in east and southeast Asia, and for females in south Asia. There was a decadal improvement in the direction or size of change for many countries in central and eastern Europe (eg, Russia) and central Asia, and in parts of the Middle East and north Africa. Improvements or deteriorations in the direction or size of change in NCD mortality between the two decades resulted from multiple NCD causes of death. Among causes of death, the decline in mortality from circulatory diseases was smaller from 2010 to 2019 than from 2001 to 2010 in most countries, except in countries in central and eastern Europe and some countries in central Asia, where these declines were larger from 2010 to 2019 than from 2001 to 2010. Change in lung cancer saw a decadal improvement in many countries, especially for males, and many other cancers saw a mix of improvement and deterioration.
INTERPRETATION: From 2010 to 2019, NCD mortality declined in four of every five countries in the world. These improvements were not as large as the preceding decade for most countries, driven by smaller declines in mortality from multiple NCDs. FUNDING: UK Medical Research Council, UK National Institute for Health and Care Research, and NCD Alliance
Routine immunisation coverage in the context of seasonal influenza vaccine introduction for children in Nakuru and Mombasa counties in Kenya, 2019-21: an observational study.
Get PDFBACKGROUND: Data on how the introduction of seasonal influenza vaccination for children might affect the coverage for other routine childhood immunisations are scarce. We assessed how introducing a new influenza vaccine for children aged 6-23 months in two counties in Kenya (Mombasa and Nakuru) affected the coverage rate for the diphtheria-tetanus-pertussis-hepatitis B-Haemophilus influenzae type b (pentavalent [Penta]) vaccine, measles-rubella (MR) vaccine, and vitamin A supplementation.
METHODS: In this observational study, we compared data from two sub-counties in Kenya that implemented a year-round (ie, annual routine immunisation) influenza vaccine delivery strategy and two that implemented a campaign-mode delivery strategy with data from two control sub-counties where no influenza vaccine was provided. We used facility-level immunisation tally sheets to obtain counts of monthly vaccine and supplement doses given and monthly summary data to estimate the coverage rates. We collected data for 1 year before (from Nov 1, 2018 to Oct 31, 2019) and during the seasonal influenza vaccine demonstration period (from Nov 1, 2019 to Oct 31, 2021). We used negative binomial Bayesian models, adjusted for time period (before vs during the demonstration project), facility ownership, and level of health facility, to compare coverage rates for routine immunisations between health facilities that participated in the influenza vaccine demonstration project and those that did not.
FINDINGS: Our study included 64 health facilities: 28 (44%) year-round, 12 (19%) campaign-mode, and 24 (38%) control sites. 42 (66%) of the facilities were level 2 (secondary) and 36 (56%) facilities were government owned. Before and during the influenza vaccine demonstration period, coverage rates for Penta doses one, two, and three and MR dose one were more than 65% in all the intervention sites; for comparison, in the control sites coverage was 62·9% (95% CI 62·1-63·8) for Penta dose one and 64·0% (63·1-64·9) for MR dose one. The coverage rate for MR dose one was significantly higher in the year-round sites versus the control sites across the timespan of the study (adjusted rate ratio 1·38, 95% CI 1·27-1·49), and the coverage rates for Penta dose two (aRR 0·24 [0·05-0·65]) and MR dose one (aRR 0·98 [0·82-0·97]) were significantly lower in the campaign-mode sites versus the control sites. There were no other significant differences in coverage rates for other routine vaccine or supplementation doses in the intervention (year-round and campaign-mode) versus the control sites. When comparing coverage before and during implementation of the influenza vaccination project, MR dose one coverage at the campaign-mode sites was significantly lower during the demonstration than before (rate ratio [RR] 0·75 [95% CI 0·70-0·80]), and MR dose two (RR 1·15, 1·06-1·24) and vitamin A dose two (RR 2·14 [2·00-2·29]) at the campaign-mode sites were significantly higher; none of the other changes before and during implementation at the other sites or for other doses were statistically significant.
INTERPRETATION: The introduction of seasonal influenza vaccine for eligible children had a minimal effect on the uptake for routine vaccines in Kenya's Expanded Programme on Immunization.
FUNDING: The Task Force for Global Health and The Centers for Disease Control and Prevention
Real-World Evaluation of AI-Driven Diabetic Retinopathy Screening in Public Health Settings: Validation and Implementation Study.
Get PDFBACKGROUND: Artificial intelligence (AI) algorithms offer an effective solution to alleviate the burden of diabetic retinopathy (DR) screening in public health settings. However, there are challenges in translating diagnostic performance and its application when deployed in real-world conditions.
OBJECTIVE: This study aimed to assess the technical feasibility of integration and diagnostic performance of validated DR screening (DRS) AI algorithms in real-world outpatient public health settings.
METHODS: Prior to integrating an AI algorithm for DR screening, the study involved several steps: (1) Five AI companies, including four from India and one international company, were invited to evaluate their diagnostic performance using low-cost nonmydriatic fundus cameras in public health settings; (2) The AI algorithms were prospectively validated on fundus images from 250 people with diabetes mellitus, captured by a trained optometrist in public health settings in Chandigarh Tricity in North India. The performance evaluation used diagnostic metrics, including sensitivity, specificity, and accuracy, compared to human grader assessments; (3) The AI algorithm with better diagnostic performance was integrated into a low-cost screening camera deployed at a community health center (CHC) in the Moga district of Punjab, India. For AI algorithm analysis, a trained health system optometrist captured nonmydriatic images of 343 patients.
RESULTS: Three web-based AI screening companies agreed to participate, while one declined and one chose to withdraw due to low specificity identified during the interim analysis. The three AI algorithms demonstrated variable diagnostic performance, with sensitivity (60%-80%) and specificity (14%-96%). Upon integration, the better-performing algorithm AI-3 (sensitivity: 68%, specificity: 96, and accuracy: 88·43%) demonstrated high sensitivity of image gradability (99.5%), DR detection (99.6%), and referral DR (79%) at the CHC.
CONCLUSIONS: This study highlights the importance of systematic AI validation for responsible clinical integration, demonstrating the potential of DRS to improve health care access in resource-limited public health settings
Establishing shared definitions of virological failure and discontinuation for long-acting injectable cabotegravir and rilpivirine therapy (the CONSENSUS-LAI Study): an international survey and Delphi process.
Get PDFBACKGROUND: Definitions of virological failure and treatment discontinuation for long-acting injectable (LAI) cabotegravir and rilpivirine antiretroviral therapy are inconsistent in clinical practice and observational studies, which complicates interpretation and implementation of findings. The CONSENSUS-LAI study aimed to establish consistent definitions of virological failure and treatment discontinuation to enhance evidence transferability and support optimal clinical outcomes.
METHODS: The study had two phases. Phase 1 was an international online survey exploring existing definitions of virological and treatment discontinuation, conducted between April 25 and July 1, 2024. Eligible participants were health-care professionals working in infectious disease or sexual health services who had provided care to at least ten people living with HIV in the past 6 months, had prescribed LAI cabotegravir and rilpivirine in clinical trials or clinical practice, and were able to give informed consent. Participants were recruited via social media and mailing lists of medical specialist societies. Phase 2 was a Delphi process, in which a panel of experts, selected to ensure representation from all six WHO regions, scored leading definitions from phase 1 on a 9-point Likert scale. The proposed definitions were scored according to four validity criteria: clarity, usability in the expert's setting, appropriateness across clinical purposes, and applicability across relevant population groups. Revisions were suggested in iterative rounds until consensus was reached. Consensus was predefined as at least 75% of experts agreeing or strongly agreeing (scores 7-9) with the validity criteria.
FINDINGS: 386 LAI cabotegravir and rilpivirine prescribers across 28 countries completed the survey, revealing 15 definitions for virological failure on LAI cabotegravir and rilpivirine and nine for treatment discontinuation. 52 experts participated in the Delphi process. Consensus agreement on both definitions was reached after two rounds for all validity criteria. For virological failure, the consensus definition was as follows: (a) viral load 200 copies or more per mL or more on two occasions 2-4 weeks apart, or (b) a single viral load of more than 1000 copies per mL, and/or (c) emergent resistance, in the context of timely injections and prior suppression of less than 200 copies per mL, OR (d) unable to suppress viral load to less than 200 copies per mL on continuous therapy. For treatment discontinuation the consensus definition was as follows: people on LAI cabotegravir and rilpivirine who have missed two consecutive injections and have not taken oral bridging in the interim, irrespective of reason for discontinuation.
INTERPRETATION: The consensus definitions provide a foundation for aligning practice and evaluating patient outcomes. Further validation of the viral load threshold for virological failure and the optimal viral load retesting window is required.
FUNDING: ViiV Healthcare
At Which Level Does Unemployment Affect Political Trust? A Multilevel Analysis Across Europe
Get PDFAbstract How does unemployment at the national, regional, and individual levels affect political trust in Europe? Previous research has assessed the negative impact of unemployment at the national and individual levels on political trust. However, the literature has not yet addressed the interactions between unemployment dynamics across levels, which are increasingly relevant in socio-political research. In this article, we posit that national, regional, and individual unemployment depress political trust and formulate hypotheses on their interactions, integrating perspectives from sociology, social psychology, and political science. We test these hypotheses relying on Rounds 4–9 (2008–2018) of the European Social Survey, for 28 countries, 218 regions, and 877 region-years. Results from three-level multilevel models with cross-level interactions indicate that individual and national unemployment are associated with lower political trust, although their interaction is unclear. In contrast, there are significant interactions between regional and individual unemployment levels. A Fairbrother decomposition further clarifies this pattern: lower average regional unemployment rates powerfully exacerbate the individual relationship, while the latter is mitigated at higher average unemployment rates. Robustness checks with linear regressions and country-year fixed effects reinforce the main results. Theoretically, these empirical patterns support the habituation mechanism emerging from related research on socio-political behaviour, and they thus illuminate the joint centrality of contextual and individual socio-economic hardships to understand political trust, which is crucial for the health of democracies