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Public health financing in Brazil (2019–2022): an analysis of the national health fund and implications for health management
Get PDFIntroduction: The Unified Health System (SUS) in Brazil provides free, universal health services to all inhabitants of the country. This study aims to describe the allocation of public health resources in Brazil, both overall and across regions, based on National Health Fund (FNS) data from 2019 to 2022. The goal is to provide an understanding of the profile and distribution of resources sourced exclusively from the federal government during this period.
Methods: A quantitative, descriptive study using data extracted from the FNS portal covering the period 2019–2022, along with publications and open data linked to Brazil’s Ministry of Health, was undertaken. Data collection included the resources allocated to health within each of the financing blocks (operational and investment), according to FNS as well as the Transparency Portal of the Office of the Comptroller General for more information about the COVID-19 pandemic.
Results: A total of USD 75.310 billion (406.283 billion BRL) was allocated to health services between 2019 and 2022, with 64.6% allocated to Specialized, Medium, and High Complexity Care and 30.2% to Primary Health Care (USD 21.096 billion). A lower percentage was dedicated to investment actions within the SUS, and there was heterogeneous distribution of resources across the country’s regions, with the Southeast receiving the most resources (38.5%), while the Central-West region received only 7.7%. In addition, more than USD 111 billion (600 billion BRL) was allocated by the federal government to the COVID-19 pandemic response, not exclusively for health-related purposes.
Conclusion: The distribution profile of resources transferred from the FNS reflected population sizes but it is less clear whether resources were allocated based on need. Overall, there was a scarcity of resources allocated to areas such as investment. However, the COVID-19 pandemic represented a considerable impact on government funds. Health and social needs must be assessed and considered going forward to improve the allocation of resources within a unified health system
Surge of Branded Generics and Antimicrobial Resistance: Analyzing the Antibiotic Market Dynamics in Pakistan Through the WHO Essential Medicines and AWaRe Lens
Get PDFBackground: Access to safe and effective antibiotics is crucial in low- and middle-income countries (LMICs) coupled with reducing overuse to reduce antimicrobial resistance (AMR). We sought to systematically analyze the extent of branded generic antibiotics in Pakistan particularly Watch antibiotics given concerns with AMR in Pakistan. Methodology: Data on registered antibiotics was collected from the Drug Regulatory Authority of Pakistan (DRAP) and the Pharmaguides. 257 antibiotics were analyzed using the AWaRe classification. Results: Of these, 99 were registered in Pakistan including 91 single entities and 8 combinations, with 6,025 brands and 14,076 presentations. Distribution across AWaRe categories included Access - 37, Watch – 56, and Reserve - 6. Cephalosporins (2186 brands, 6447 presentations) and Quinolones (1333 brands, 2586 presentations) are the most prevalent, with Ciprofloxacin (393 brands, 1158 presentations) leading in brand and presentation counts. 6 antibiotics from the WHO Essential Medicines List lacked registered brands in Pakistan, while many available antibiotics were not included in the WHO framework. Conclusion: Extensive availability of branded generics particularly Watch antibiotics in Pakistan poses a serious risk, exacerbated by current misuse of antibiotics. Improving regulatory frameworks and strengthening stewardship are critical to reducing AMR in Pakistan along with addressing uncontrolled registration by DRAP
The burden, clinical outcomes and risk factors related to neglected tropical diseases and malaria in migrant populations in the Middle East and North Africa: a systematic review and meta-analyses
Get PDFIntroduction
This systematic review investigates the burden, clinical outcomes and risk factors of neglected tropical diseases (NTDs) and malaria in the Middle East and North African region, highlighting the urgency and scope of these health challenges.
Methods
We searched six databases for peer-reviewed literature and additional sources to capture grey literature in any language from 2000 to 28 August 2024. Studies were included if they provided primary data on outcomes in migrants. Primary outcomes were prevalence, incidence and mortality. Peer-reviewed articles were critically appraised using Joanna Briggs Institute tools, while the AACODS (Authority, Accuracy, Coverage, Objectivity, Date and Significance) checklist was used for grey literature. Estimates were pooled using random-effects meta-analysis where possible or synthesised narratively.
Results
We included 39 studies with 81 678 migrants across 11 countries for NTDs and 16 studies encompassing 12 823 migrants across five countries for malaria. The pooled prevalence of specific NTDs among migrants was 4.7% for hookworm (95% CI 0.9% to 11.3%, I²=99%), 1.8% for Trichuris trichiura (95% CI 0.3% to 4.3%, I²=98%), 1.75% for Ascaris lumbricoides (95% CI 0.6% to 3.5%, I²=96%) and 1.8% for taeniasis (95% CI 0.3% to 4.4%, I²=98%). Compared with non-migrants, migrants exhibited higher prevalence rates for hookworm (1.8% vs 0.03%), Ascaris lumbricoides (0.3% vs 0%), Trichuris trichiura (0.5% vs 0%), dengue (26% vs 3.5%) and chikungunya (4.2% vs 0.5%). Migrants had a higher proportion of confirmed cases of schistosomiasis (0.21–20.3% vs 0–0.013%), cystic echinococcosis (7.4% vs 3.5%) and dengue (57.2% vs 56.4%) among suspected cases compared with non-migrants. Case fatality rates were 3.1% for dengue and 0.2–1.5% for malaria. Malaria incidence was only reported in Sudan (internally displaced persons: 6.8/1000; refugees: 2.72/1000; refugees <5 years old: 7.3/1000). While hospitalisation and intensive care unit rates for malaria were 25.8% and 1.3%, respectively, severe malaria was higher in non-migrants compared with migrants in Qatar (50% vs 5.2%, respectively).
Conclusions
Despite a wide range of diseases reported in 55 studies, there were gaps in the evidence, primarily related to risk factors, clinical outcomes and the subregion of North Africa. We generally found that migrants were disproportionately affected by both NTDs and malaria, especially in the Middle East.
PROSPERO registration number CRD4202340774
Vessel‐Specific Myocardial Mass in Patients With Stable Coronary Artery Disease
Get PDFBackground
Assessing the myocardial mass at risk is essential in evaluating patients with coronary artery disease. This study aims to establish reference values for vessel‐specific myocardial mass derived from coronary computed tomography angiography, providing a quantitative assessment of the myocardial mass subtended by each epicardial vessel.
Methods
Left ventricular (LV) and vessel‐specific myocardial mass were calculated from coronary computed tomography angiography using the Voronoi method in patients with stable coronary artery disease. Myocardial mass was quantified for each epicardial coronary artery with a diameter >1.5 mm.
Results
We included 948 patients with 9228 epicardial coronary artery branches. Mean age was 66±9 years. The cohort was predominantly male (77%); 66% had hypertension, and 22% had diabetes. Vessel‐specific myocardial mass was calculated for 2767 main epicardial arteries (948 left anterior descending, 948 left circumflex, and 871 right coronary artery) and 6461 side branches (1888 diagonals, 1208 septals, 1422 obtuse marginals, 247 ramus intermedius, 850 right posterior descending, and 846 posterolateral branches). Median LV mass was 141 grams (interquartile range 118–166); women had smaller LV mass than men (106 [93–123] grams versus 150 [132–173] grams, P<0.001). On average, the left anterior descending subtended 42.5% [37.9–48.1] of LV mass, the left circumflex artery 28.8% [21.9–5.7], and the right coronary artery 26.4% [20.9–31.9]. Median LV mass subtended by the first septal, first diagonal, and first obtuse marginal were 8.9% [6.4–11.1], 7.9% [4.52–2.0], and 10.2% [4.52–12.0], respectively.
Conclusions
This study quantified the myocardial mass subtended by each major artery in the coronary circulation. Understanding the vessel‐specific mass at risk has significant clinical implications for personalizing revascularization strategies.
Registration
This is a retrospective analysis of 5 prospectively conducted trials (P3: NCT03782688; P4: NCT05253677; PPG Global: NCT04789317; Euro‐CRAFT: NCT05805462; INSIGHTFUL‐FFR: NCT05437900). No additional registration was required
Proliferation makes a substantive contribution to the maintenance of airway resident memory T-cell subsets in young pigs
Get PDFTissue-resident memory (TRM) T cells play an important role in protection against respiratory infection but whether this memory is maintained by long-lived or dividing cells remains controversial. To address the rate of division of lung TRM T cells, deuterium-enriched water was administered orally to young pigs to label dividing lymphocytes. T-cell subsets were separated from blood, lymph nodes, and airways [bronchoalveolar lavage (BAL)], the latter comprising almost exclusively TRM. We show that, as in other species, circulating memory T-cell subsets divide more rapidly than naïve T cells. Rates of labelling of memory subsets were similar in blood and lymph nodes, consistent with the rapid and free exchange. Strikingly, the fraction of label in BAL was similar to those in blood/lymph nodes after 5–21 days of labelling, suggesting replacement with recently divided cells, but this was preceded at Day 2 by a phase when labelling was lower in BAL than blood/lymph node in some memory subsets. Our data exclude long-lived TRM as the source of BAL memory cells leaving three possible hypotheses: blood/airway exchange, in situ proliferation, or proliferation in the lung interstitium followed by migration to BAL. When considered in the context of other information, we favour the latter interpretation. These results indicate the dynamic nature of memory in the lung and have implications for harnessing immune responses against respiratory pathogens
Sympathetic Shift and Insular Alteration: Unravelling the Link Between Anxiety and Heart Rate Variability in Parkinson's Disease
Get PDFBackground
Anxiety and autonomic dysfunction are frequent non‐motor symptoms of Parkinson's disease (PD). Their relationship, as well as the neural mechanisms underlying this relationship, remain unexplored.
Objectives
We aimed to investigate the relationship between cardiovascular functions and anxiety in PD and the structural neural changes underlying this putative interaction. We also investigated the effect of dopaminergic medications on such a relationship.
Methods
Fifty PD patients (27 with anxiety, PD_Anx; 23 without anxiety, PD_noAnx) and 16 age‐ and gender‐matched healthy controls (HC) were included. Blood pressure (BP), heart rate, and heart rate variability (HRV) were assessed at rest and in response to an orthostatic challenge, both ON and OFF dopaminergic medications. Voxel‐based morphometry was used to examine grey matter volume in brain areas linked to autonomic regulation and anxiety, including the amygdala, insula, cingulate cortex, hypothalamus, and putamen.
Results
PD_Anx patients showed significantly lower HRV compared with both PD_noAnx patients and HC (P < 0.05), indicating increased sympathetic activity. Both PD groups had higher BP OFF medication compared with HC (P < 0.001, P < 0.005, respectively); there was no difference between PD_Anx and PD_noAnx (P = 0.31). Structural brain analyses showed that anxiety altered the relationship between HRV and left insula volume, with a positive correlation in PD_noAnx patients and a reversed relationship in PD_Anx patients.
Conclusions
Anxiety in PD is associated with a shift toward sympathetic predominance, which correlates with structural changes in the insula. Insular alteration may predispose PD patients to heightened sympathetic outflow and anxiety. Changes in HRV may be interpreted as a functional indicator of anxious states in PD. © 2025 The Author(s). Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society
External validation of a prediction model for estimating fat mass in Arab children and adolescents.
Get PDFBACKGROUND/AIMS: Current childhood fat mass (FM) assessment techniques are not suitable for clinical and population-level adiposity assessment. A prediction model, which accurately estimates childhood FM using predictor variables of weight, height, age, sex and ethnicity, requires validation in Arab populations. We evaluate the model's performance in Kuwaiti, Lebanese and Moroccan children/adolescents. METHODS: Data from three cross-sectional studies on 471 individuals, aged 6-15 years, were obtained with complete information on predictors and the outcome of log transformed fat-free mass assessed by reference standard deuterium dilution (lnFFM). Country-specific predictive performance statistics of R2, calibration slope and calibration-in-the-large (measures the calibration/agreement between observed and predicted lnFFM with ideal values of 1 and 0, respectively) and root mean square error (RMSE) were quantified and pooled across countries via random-effects meta-analysis. FM estimates from bioimpedance were also available for Lebanese children and were compared to the reference standard. RESULTS: The model showed strong predictive ability in all populations. Pooled R2 calibration slope and calibration-in-the-large values on the original lnFFM scale were 87.73% (95% CI: 77.20, 98.26%), 0.95 (95% CI: 0.83, 1.08) and -0.03 (95% CI: -0.16, 0.11), respectively. Model intercepts were recalibrated in each country to improve accuracy; updated country-specific equations are provided. After recalibration, RMSEs on the FM scale were 1.3, 1.6 and 2.8 kg in Kuwait, Lebanon and Morocco, respectively. The RMSE from the model was lower than bioimpedance (2.4 kg) amongst Lebanese children. INTERPRETATION: The model explained a large proportion of the variance in FM, produced well-calibrated predictions and relatively low RMSEs in Arab settings. It predicted FM more accurately than bioimpedance, indicating its potential for implementation in clinical- and population-level settings, particularly in low- and middle-income countries
Effectiveness of a personalised self-management intervention for people living with long covid (Listen trial): pragmatic, multicentre, parallel group, randomised controlled trial
Get PDFObjective To evaluate the effectiveness of Listen, a self-management support intervention, for people living with long covid who were not in hospital.
Design Pragmatic, multicentre, parallel group, randomised controlled trial.
Setting Twenty four sites in England and Wales.
Participants Identified from long covid clinic waiting lists, word of mouth, and adverts/social media self-referred to the trial, 554 adults with long covid were randomised to receive either the Listen trial intervention or NHS usual care.
Interventions The Listen intervention involved up to six one-to-one personalised sessions with trained healthcare practitioners and an accompanying handbook co-designed by people with lived experience and health professionals. Usual NHS care was variable, ranging from no access, access to mobile applications and resources, and to specialist long covid clinics.
Main outcome measures The primary outcome was the Oxford participation and activities questionnaire (Ox-PAQ) routine activities scale score at three months assessed in the intention-to-treat population. Secondary outcomes included Ox-PAQ emotional wellbeing and social engagement scale scores, the Short Form-12 (SF-12) health survey, the fatigue impact scale, and the generalised self-efficacy scale at three months. The EuroQol five-dimension five-level (EQ-5D-5L) assessed health utility. Serious adverse events were recorded.
Results Between 27 May 2022 and 15 September 2023, 554 people with long covid (mean age 50 (standard deviation 12.3) years; 394 (72.4%) women) were randomly assigned. At three months, participants assigned to the intervention group reported small non-significant improvements in the primary outcome of capacity for daily activities as assessed by Ox-PAQ routine activities scale score (adjusted mean difference −2.68 (95% confidence interval (CI) −5.38 to 0.02), P=0.052) compared with usual NHS care. For the secondary outcomes, people receiving the intervention also reported significant improvements in mental health (Ox-PAQ emotional wellbeing −5.29 (95% CI −8.37 to −2.20), P=0.001; SF-12 2.36 (95% CI 0.77 to 3.96), P=0.004), reductions in fatigue (fatigue impact score −7.93 (95% CI −11.97 to −3.88), P<0.001), and increases in self-efficacy (generalised self-efficacy scale 2.63 (95% CI 1.50 to 3.75), P<0.001). No differences were found in social engagement (−2.07 (95% CI −5.36 to 1.22), P=0.218) or SF-12 physical health (0.32 (95% CI −0.93 to 1.57), P=0.612). No intervention related serious adverse events were reported.
Conclusions The personalised self-management support intervention of the Listen trial resulted in non-significant short term improvements in routine activities when compared with usual care. Improvements in emotional wellbeing, fatigue, quality of life, and self-efficacy for people living with long covid were also reported. Physical health and social engagement were not affected by the trial intervention. The limited understanding of how much change is clinically meaningful in this population along with the unblinded design, the use of self-referral as a recruitment method and variable usual care may have introduced unintended bias and thus limits robust conclusions about this intervention. Further research is required to fully establish the impact of the intervention
Etiology and Antimicrobial Resistance of Culture-Positive Infections in Ugandan Infants: A Cohort Study of 7000 Neonates and Infants
Get PDFBackground
Epidemiological evidence about the etiology and antimicrobial resistance of neonatal infections remains limited in low-resource settings. We aimed to describe the etiology of neonatal infections in a prospective observational cohort study conducted at two hospital sites in Kampala, Uganda.
Methods
Babies admitted to either unit with risk factors or signs of sepsis, pneumonia, or meningitis had a blood culture, nasopharyngeal swab, and lumbar puncture (if indicated) collected. Basic demographics were collected, and babies were followed up until discharge or death to determine admission outcome. Blood cultures were processed using the BACTEC system and identification confirmed by matrix-assisted laser desorption/ionization time-of-flight mass spectrometry. Cerebrospinal fluid was processed using standard microbiological testing and swabs were processed using the multiplex real-time polymerase chain reaction assay. Antimicrobial susceptibilities of bacterial isolates to World Health Organization–recommended first-line antibiotics (ampicillin or benzylpenicillin and gentamicin) were assessed using e-tests.
Results
A total of 7323 infants with signs or risk factors for sepsis had blood cultures, 2563 had nasopharyngeal swabs, and 23 had lumbar punctures collected. Eleven percent of blood cultures and 8.6% of swabs were positive. Inpatient mortality was 12.1%, with 27.7% case fatality observed among infants with Gram-negative bloodstream infections. Escherichia coli (14.8%), Acinetobacter spp. (10.3%), and Klebsiella spp. (7.6%), were notable contributors to Gram-negative sepsis, whereas Group B Streptococcus was the predominant Gram-positive pathogen identified (13.5%). Almost 60% of Gram-negative pathogens were ampicillin- and gentamicin-resistant.
Conclusions
Our study demonstrates high levels of antimicrobial resistance and inpatient mortality from neonatal sepsis in the first months of life in Uganda. This underscores the pressing need for revised, context-specific antimicrobial treatment guidelines that account for the evolving landscape of antimicrobial resistance in neonatal sepsis
Drivers of human papillomavirus vaccine uptake in migrant populations and interventions to improve coverage: a systematic review and meta-analysis
Get PDFBackground
WHO's Cervical Cancer Elimination Initiative has set a target for 90% of girls to be fully vaccinated against human papillomavirus (HPV) by the age of 15 years by 2030, to substantially reduce deaths from cervical and other HPV-related cancers. However, progress has been slow, with only 27% global vaccine coverage in 2023. Migrants are an under-immunised group globally for many vaccine-preventable diseases, with data showing that they experience a high burden of HPV infection and widespread HPV under-immunisation. We aimed to identify drivers of HPV vaccine uptake in migrants, as well as assess uptake and explore recommended approaches, strategies, and best practices to promote uptake in migrant communities.
Methods
In this systematic review and meta-analysis, we searched seven databases and several grey literature sources for information published in any language between Jan 1, 2006, and Dec 4, 2024, on the drivers of HPV vaccine uptake among migrants globally. Defining migrants as foreign-born nationals, we included qualitative and quantitative cross-sectional studies, cohort studies, and randomised controlled trials focused on first-generation and second-generation migrants and excluded studies of internal migrants. Outcomes were frequency and percentage of HPV vaccine uptake; factors positively or negatively influencing uptake; and recommended approaches, strategies, and best practices to promote uptake as reported by study authors or participants. We conducted a hybrid thematic analysis using the WHO Behavioural and Social Drivers of Vaccination model to map drivers of uptake, and a random-effects meta-analysis to calculate pooled estimates of uptake. Risk of bias was assessed using Joanna Briggs Institute checklists. This study is registered with PROSPERO, CRD42022347513.
Findings
Of 3562 records returned by the search, 117 studies were included in the analysis, involving 5 638 838 participants across 16 countries and one territory, of whom 933 189 were first-generation and second-generation migrants. The pooled estimates of HPV vaccine uptake were 23·0% (95% CI 10·0–44·0; I2=99·3%; n=7614) among female migrants, 21·0% (5·0–58·0; I2=99·3%; n=2764) among male migrants, and 17·0% (8·0–33·0; I2=98·0%; n=3583) among male and female migrants combined. 79 (68%) studies were considered at low risk of bias, 32 (27%) were considered at moderate risk, and six (5%) were considered at high risk. Factors negatively influencing vaccine uptake included concerns about vaccine safety, cultural beliefs, uncertainty and low levels of knowledge about HPV vaccines or infection, exposure to negative information, and lack of recommendations from health-care providers. Practical barriers to uptake included little information on services, language barriers, logistical challenges, and the high cost of the vaccine. Enablers mainly included positive perceptions and trust in the vaccine and health-care providers, realistic expectations from parents regarding adolescents' sexual activity, a sense of responsibility, recommendations from health-care providers, and support from social networks. Recommended strategies and interventions to improve uptake included culturally sensitive messaging and tailored communication for different target groups (eg, parents or caregivers and adolescents). Deploying trusted mediators (eg, peer school health promoters, religious champions, and community health workers) was key, alongside implementing practical solutions to address missed opportunities (eg, bundling HPV vaccination with other services), implementing eHealth initiatives, ensuring strong provider recommendations, reducing access barriers (eg, through walk-in, mobile, and outreach services), and strengthening vaccination monitoring systems.
Interpretation
We show that migrants globally face complex individual, family and social, and provider-level and system-level barriers to HPV vaccination, resulting in low uptake of HPV vaccines and missed opportunities for protection. In many low-income and middle-income countries, there is little to no availability of vaccines and/or the recipient must pay for them. Achieving global commitments to universal and equitable immunisation across the life course—and making progress towards cervical cancer elimination—requires these barriers to be addressed through multipronged strategies. Collaborative efforts with migrant communities are essential to co-develop effective, tailored delivery models that meet their unique needs.
Funding
The National Institute for Health and Care Research, the Academy of Medical Sciences, and the Medical Research Council
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