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A new Oxford University collaboration between the BDI and the Centre for Tropical Medicine and Global Health will support understanding and action around one of the world’s biggest health threats, drug-resistant infections.
Strengthening respectful communication with patients and colleagues in neonatal units — developing and evaluating a communication and emotional competence training for nurse managers in Kenya
Introduction: Effective communication is essential to delivering compassionate, high-quality nursing care. The intensive, stressful and technical environment of a new-born unit (NBU) in a low-resource setting presents communication-related challenges for nurses, with negative implications for nurse well-being, team relationships and patient care. We adapted a pre-existing communication and emotional competence course with NBU nurse managers working in Kenya, explored its’ value to participants and developed a theory of change to evaluate its’ potential impact. Methods 18 neonatal nurse managers from 14 county referral hospitals helped adapt and participated in a nine-month participatory training process. Training involved guided ‘on the job’ self-observation and reflection to build self-awareness, and two face-to-face skills-building workshops. The course and potential for future scale up was assessed using written responses from participant nurses (baseline questionnaires, reflective assignments, pre and post workshop questionnaires), workshop observation notes, two group discussions and nine individual in-depth interviews. Results Participants were extremely positive about the course, with many emphasizing its direct relevance and applicability to their daily work. Increased self-awareness and ability to recognize their own, colleagues’ and patients’ emotional triggers, together with new knowledge and practical skills, reportedly inspired nurses to change; in turn influencing their ability to provide respectful care, improving their confidence and relationships and giving them a stronger sense of professional identity. Conclusion Providing respectful care is a major challenge in low-resource, high-pressure clinical settings but there are few strategies to address this problem. The participatory training process examined addresses this challenge and has potential for positive impacts for families, individual workers and teams, including worker well-being. We present an initial theory of change to support future evaluations aimed at exploring if and how positive gains can be sustained and spread within the wider system.
Trends in inpatient antibiotic use in Indonesia and the Philippines during the COVID-19 pandemic.
ObjectiveIncreased antibiotic use (AU) has been reported globally during the COVID-19 pandemic despite low rates of bacterial co-infection. We assessed changes in AU during the COVID-19 pandemic in Indonesia and the Philippines.MethodsWe evaluated hospital-wide AU over 36 months in six hospitals, 3 in Indonesia and 3 in the Philippines. Intravenous antibiotics commonly used for respiratory conditions were selected and grouped for analysis. AU rates were calculated as monthly defined daily dose per 1000 patient-days or patient discharges. Median AU rates were compared from the pre-pandemic (March 2018-February 2020) and pandemic periods (March 2020-February 2021) using quantile regression to assess for statistical significance. Changes in AU during the COVID-19 pandemic were analyzed using interrupted time series analysis.ResultsSignificant increases were noted in the median AU rate from the pre-pandemic to pandemic period of all antibiotics combined in 3/6 hospitals (percentage change, Δ, 12.5%-63.6%) and anti-pseudomonal antibiotics in 3/6 hospitals (Δ 51.5%-161.5%). In the interrupted time series analysis, an immediate increase (range: 125.40-1762) in the use of all included antibiotics combined was observed in 3/6 hospitals at the onset of the COVID-19 pandemic. One of these 3 hospitals experienced a statistically significant sustained increase, while another experienced a decrease over time.ConclusionsWe observed significant increases in facility-wide inpatient AU during the COVID-19 pandemic in our participating hospitals in Indonesia and the Philippines. These findings reinforce the importance of antibiotic stewardship practices to optimize AU, especially during infectious disease pandemics.
Exploring early childhood development programming in Kenya’s arid and semi-arid lands
Background: Promoting high-quality early childhood development (ECD) is vital for individuals’ physical and social well-being and yields significant societal returns. However, children in marginalised regions like Kenya’s arid and semi-arid lands (ASALs) face significant barriers to accessing quality ECD services. Aim: This study aimed to document existing ECD services in Kenya’s ASAL areas, including their availability, types and key characteristics; identify gaps in their provision and propose solutions to enhance access and quality. Setting: This qualitative study was conducted in 10 ASAL counties in Kenya. Methods: Using purposive and snowball sampling techniques, 103 key informants, including pre-primary teachers, parents, healthcare workers, religious leaders and county ECD coordinators, were interviewed. The interviews were audio-recorded, transcribed verbatim and analysed thematically. Results: The study found that while diverse ECD programmes exist in ASAL regions, their quality and effectiveness are hindered by challenges such as inadequate funding, insecurity, extreme weather events, food insecurity, poor infrastructure, inadequate healthcare access and limited early learning opportunities. Recommendations include increasing ECD funding, improving healthcare, enhancing early learning opportunities, promoting livelihood diversification and addressing security and food insecurity. Conclusion: Despite investments in ECD programmes, significant challenges persist, underscoring the need to provide children with high-quality services that foster nurturing care and mitigate risks to their development. This study highlights the urgency of adopting a multi-sectoral approach to strengthen ECD programmes and services in Kenya’s ASAL. Contribution: This article contributes to the scarce literature on ECD programming in Kenya’s ASALs by documenting existing ECD services, identifying critical gaps in their provision and offering actionable recommendations to address barriers to programme quality and effectiveness.
Metagenomic exploration of antimicrobial resistance genes in marine bacteria ecosystem
Background: Antibiotic resistance (AMR) is a crucial threat to human health and challenges the effectiveness of clinical interventions. Antibiotic resistance is often perpetuated by the indiscriminate use of antibiotics leading to selection pressure and the transfer of the resistance genes between humans, domestic animals, and the environment. Being the ultimate recipient of runoffs and effluents, the marine environment is a potential reservoir of Antimicrobial Resistance Genes (ARGs). Terrestrial input from anthropogenic activities such as the indiscriminate use of antibiotics drives the accumulation of ARGs in the marine environment. The dissemination of these genes in the marine environment is aided by Horizontal Gene Transfer (HGT) using Mobile Genetic elements (MGEs). Despite the reported evidence on the presence of ARGs in world oceans, antimicrobial resistance monitoring in the African marine environment remains limited. Methods This exploratory study conducted a bioinformatics-based screening for Antimicrobial Resistance Genes (ARGs) using secondary data from the European Nucleotide Archive (ENA). Antimicrobial Resistance Gene screening was done using the Resistance Gene Identifier and AMRFinderPlus tools. Results We found 38 different Antimicrobial Resistance Genes (ARGs) classified into 10 drug classes from the analyzed marine metagenomes. The most abundant genes identified include vanT and vanY belonging to the glycopeptide class, adeF in fluoroquinolone and tetracycline, bla OXA and bla SGM in the b-lactam class, and qacG in the small multidrug resistance group. Conclusion These findings underscore the crucial role of the marine environment in harbouring resistance genes, particularly in the African region, highlighting the urgent need to integrate environmental screening in the surveillance and monitoring programs of AMR.
Safety and tolerability of metformin in overweight and obese patients with dengue: An open-label clinical trial (MeDO)
Background Despite dengue being a major public health problem, there are no antiviral or adjunctive treatments for the disease. Novel therapeutics are needed, particularly for patients at high risk of severe disease, including those living with obesity. Metformin reduces dengue viral replication in vitro through AMPK activation and may also have beneficial immunomodulatory effects. Methods We conducted an open label trial at the Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam, enrolling 120 patients with dengue and obesity (60 treatment arm, 60 control arm receiving standard of care only). Within the treatment arm, the first 10 patients were prescribed low dose metformin, and the remaining 50 patients received weight-based dosing of 1-1.5g/day. The primary outcome was the number of adverse events (AEs), and secondary outcomes were clinical and laboratory parameters, including fever clearance time, platelet nadir, percentage of haematocrit change from baseline, maximum creatinine and highest AST/ALT, and the kinetics of plasma viraemia and NS1 antigenaemia. Results The majority of patients in both groups had dengue with warning signs. Six patients in the metformin group and 5 controls developed dengue shock syndrome, and no patients died. There were more AEs recorded in the metformin treated group than in the control group (mean±SD: 15 ± 4 vs. 11 ± 6), particularly the high-dose metformin group (15 ± 5). Twenty-five patients (42%) had to stop the study drug due to AEs, including severe diarrhea (n = 12), dengue shock (n = 5), increased lactate of >3mmol/L (n = 4), hypoglycemia (n = 3), and persistent vomiting (n = 1). There were no clear differences in secondary outcomes between the two groups. Conclusions Metformin was poorly tolerated in patients with dengue, mainly due to gastrointestinal side effects. Metformin did not beneficially affect clinical evolution or virological parameters compared to supportive care alone. Our data does not support progression to larger phase 3 trials of metformin in patients with dengue. Trial registration ClinicalTrials.gov: NCT04377451 (May 6th, 2020).
Optimizing dog population control strategies in Thailand using mathematical and economic modeling.
A mathematical model was constructed to investigate dog population dynamics and explore the impact of population management and rabies prevention. We aimed to evaluate cost-effective sterilization and vaccination strategies for dog population control and rabies prevention in Thailand. The developed compartmental model was calibrated with dog population data from Lopburi province (between 2019 and 2022) and simulated five sterilization scenarios. These measures included a combined 80% coverage of the rabies vaccine and 20% coverage of a sterilization program among non-specific dog types. Our findings indicated that sterilization programs targeting female indoor, outdoor, and stray dogs may prove to be the most effective in reducing the total dog population above 50% over a five-year period, surpassing the efficacy of the current intervention. Furthermore, the cost-effectiveness analysis showed that the two female dog sterilization strategies were cost-saving compared to the current practice, as the total costs of sterilization and vaccination decreased over time due to the reduction in the dog population. In conclusion, targeting female dog sterilization could reduce the population and was cost-saving compared to current strategies. Further data to inform dog population demographic and available resources including manpower, rabies vaccine, sterilization toolkits, and related materials will be required to fully explore intervention accessibility and feasibility within the context of rabies prevention and control in Thailand.
Acceptability and feasibility of glucose-6-phosphate dehydrogenase (G6PD) testing using SD Biosensor by village malaria workers in Cambodia: a qualitative study
IntroductionPlasmodium vivaxis the predominant cause of malaria in the Greater Mekong Subregion. To ensure safe treatment with primaquine, point-of-care glucose-6-phosphate dehydrogenase (G6PD) testing was rolled out in Cambodia at the health facility level, although most malaria patients are diagnosed in the community. The current study aims to explore the acceptability and feasibility of implementing community-level G6PD testing in Cambodia.MethodsSemistructured interviews and focus group discussions (FGD) were conducted. Across eight study sites in three provinces, 142 respondents, including policymakers, programme officers, healthcare providers and patients, participated in 67 interviews and 19 FGDs in 2022 and 2023. Data were analysed thematically using an adapted framework derived from Bowenet al’s feasibility framework and Sekhonet al’s acceptability framework.ResultsAll stakeholders attributed value to the intervention. Acknowledging an intervention’s different values can help discern policy implications for an intervention’s successful implementation. Building and maintaining confidence in the device, end users, infrastructure and health systems were found to be key elements of acceptability. In general, health centre workers and village malaria workers (VMWs) had confidence that VMWs could conduct the test and administer treatment given appropriate initial training, monthly refresher training and the test’s repeated use. More is required to build policymakers’ confidence, while some implementation challenges, including the test’s regulatory approval, stability above 30°C and cost, need to be overcome.ConclusionImplementation of G6PD testing at the community level in Cambodia is an acceptable and potentially feasible option but requires addressing implementation challenges and building and maintaining confidence among stakeholders.
Epidemiology and excess mortality of antimicrobial resistance in bacteraemias among cancer patients: a cohort study using routinely collected health data from regional hospital trusts in Oxford and Oslo, 2008–2018
Objectives We investigated the epidemiology and impact on mortality of antimicrobial resistance (AMR) in cancer patients with bacteraemia at Oxford University Hospitals (OxUH), UK, and Oslo University Hospital (OsUH), Norway, during 2008–2018. Design Historical cohort study. Setting Regional hospital trusts with multiple sites in OxUH and OsUH. Methods Patients with cancer and blood cultures positive for one of six pathogen groups during a hospital stay within 3 years following their first cancer diagnosis were followed for 30 days after their first bacteraemia episode. We determined the number of cases and the proportion of infections with an AMR phenotype. Excess mortality and the population-attributable fraction (PAF) due to AMR were estimated by contrasting observed mortality at the end of follow-up with an estimated counterfactual scenario where AMR was absent from all bacteraemias, using inverse probability weighting. Main outcome measure 30-day all-cause mortality following the first bacteraemia episode. Main exposure measure A resistant phenotype of the causative pathogen. Results The study included 1929 patients at OxUH and 1640 patients at OsUH. The highest resistance proportions were found for vancomycin resistance in enterococci (85/314, 27.1%) and carbapenem-resistance in Pseudomonas aeruginosa (63/260, 24.2%) at OxUH, and third-generation cephalosporin resistance in Escherichia coli (62/743, 8.3%) and Klebsiella pneumoniae (14/223, 6.3%) at OsUH. Observed mortality for all infections was 26.4% at OxUH, with an estimated counterfactual mortality without AMR of 24.7%, yielding an excess mortality of 1.7% (95% CI: 0.8 to 2.5%). The PAF was 6.3% (95% CI: 2.9 to 9.6%), meaning an estimated 32 of 509 deaths could be attributed to AMR. Limited events at OsUH precluded a similar estimate. Conclusions Despite estimating modest excess mortality, the mortality attributable to resistance in these two high-income, low-prevalence settings highlights the potential for escalation if global resistance trends continue to worsen.
Urban gentrification and infectious diseases: an interdisciplinary narrative review.
Urban gentrification, the transformation of neighbourhoods by influx of new residential groups, leading to displacement of lowerincome communities, is a complex, multifaceted process with significant but generally unexplored public health implications. This study focused on the impact of this process on infectious disease dynamics investigating key factors such as sociodemographic disparities, economic conditions, housing and urban environmental changes. A systemic literature research was performed based on the search terms: gentrification and infectious disease in PubMed, Scopus, Web of Science, ScienceDirect, and Google Scholar, with additional references identified using the snowballing method. After screening the resulting 542 articles, 14 studies were selected based on relevance, with data were extracted through a consensusdriven process. This review identified the complex challenges posed by gentrification in the context of infectious disease dynamics and burdens providing valuable insights both to academic discourse and public health policy discussions. Gentrification may contribute to higher infection rates within specific urban neighbourhoods or among certain residents. For blood-borne and Sexually Transmitted Infections (STIs), gentrification leads to reduced access to essential healthcare services, including HIV and STI testing, particularly among marginalised populations, such as female sex workers and LGBTQ+ communities. For airborne diseases, gentrification can exacerbate health inequalities by increasing residential overcrowding and displacement from gentrified areas to more disadvantaged suburbs. Housing and urban planning associated with changes in the urban environment are primarily linked with vector-borne diseases, tick-borne diseases in particular, among displaced populations. We advocate the use of spatial epidemiology to examine the potential impact of gentrification on the risk for infectious diseases. Since many gentrification metrics are area-specific, mapping and visualising key indicator data can pre-emptively support practical decision-making. This approach also helps capture the complex dynamics of displacement and the within-place changes experienced by populations affected by gentrification, which might affect infectious disease dynamics. Finally, we outline key research priorities to bridge existing knowledge gaps in future multidisciplinary research on infectious diseases and gentrification.
Epidemiological profiles and outcomes of healthcare workers hospitalized for COVID-19 in five Sub-Saharan African countries: a cohort study.
BackgroundThe COVID-19 pandemic placed immense strain on global health systems and healthcare workers (HCWs). This study aimed to analyze the epidemiological profiles and outcomes of HCWs hospitalized for COVID-19 across five sub-Saharan African countries.MethodsThis was a cohort study using secondary data collected between January 30, 2020, and December 31, 2022, as part of the International Severe Acute Respiratory and emerging Infection Consortium study. The study population consisted of HCWs who were hospitalized due to clinically suspected or laboratory-confirmed SARS-CoV-2 infection. Demographic and clinical characteristics and case management were summarized using proportions or medians and interquartile ranges. Factors associated with risk of mortality among HCWs were assessed using a Cox proportional hazards model, adjusted for age and sex.ResultsFindings showed that South Africa recorded a lower percentage (2.4%) of patients who were HCWs compared to Gambia, Ghana, Guinea, and Malawi. Overall, many HCWs were aged ≥50 years and the majority were females (66.8%). In three of the five countries, however, the majority of the HCWs were <39 years old and were males. Antibiotics were the most commonly used medical treatments across three countries (Ghana, 67.8%; Guinea, 97.3%; Malawi, 80%), while antimalarials were commonly used in Guinea (87.8%) and Ghana (30.4%). Guinea and South Africa reported deaths with case-fatality rates varying from 22% in March 2020 to 1.4% in February 2022. Risk factors for mortality included age over 50 years, hypertension, diabetes mellitus, and chronic kidney disease.ConclusionsOur study underscores the critical need for continuous protection and enhanced readiness for HCWs, particularly during epidemics and pandemics. Strengthening infection prevention and control measures and focusing on vulnerable groups such as older and female HCWs are essential for mitigating the impact of future health crises. Further research is required to fully comprehend the implications of these findings.
Association of cancer and outcomes of patients hospitalized for COVID-19 between 2020 and 2023.
BackgroundThe coronavirus disease 2019 (COVID-19) has caused substantial morbidity and mortality on a global scale. A strong correlation has been found between COVID-19 treatment outcomes and noncommunicable diseases such as cancers. However, there is limited information on the outcomes of cancer patients who were hospitalised for COVID-19.MethodsWe conducted an analysis on data collected in a large prospective cohort study set-up by the International Severe Acute Respiratory and Emerging Infection Consortium (ISARIC). All patients with laboratory-confirmed or clinically-diagnosed SARS-CoV-2 infection were included. Cancer was defined as having a current solid organ or haematological malignancy. The following outcomes were assessed; 30-day in-hospital mortality, intensive care unit (ICU) admission, length of hospitalization and receipt of higher-level care.ResultsOf the 560,547 hospitalised individuals who were analysed, 27,243 (4.9%) had cancer. Overall, cancer patients were older and had more comorbidities than non-cancer patients. Patients with cancer had higher 30-day in-hospital mortality than non-cancer patients (29.1.3% vs 18.0%) and longer hospital stays (median of 12 days vs 8 days). However, patients with cancer were admitted less often to intensive care units than non-cancer patients (12.6% vs 17.1%) and received less invasive mechanical ventilation than non-cancer patients (4.5% vs 7.6%). The hazard ratio of dying from cancer, adjusted for age, sex and country income level was 1.18 (95%CI: 1.15-1.2).ConclusionsThis study's findings underscore the heightened vulnerability of hospitalized COVID-19 patients with cancer, revealing a higher mortality rate, longer hospital stays, and an unstructured pattern of care that reflects the complexity of managing severely ill patients during a public health crisis like the COVID-19 pandemic.
Small for Gestational Age sub-groups have differential morbidity, growth and neurodevelopment at age 2: the INTERBIO-21<sup>st</sup> Newborn Study.
BackgroundSmall for Gestational Age (SGA) is a complex perinatal syndrome associated with increased neonatal morbidity, mortality, and impaired childhood growth and neurodevelopment. Current classifications rely primarily on birth weight, which does not capture the heterogeneity of the condition nor predict long-term health outcomes. Here we aim to identify and characterise distinct SGA sub-groups and assess their neonatal and early childhood health trajectories.ObjectivesTo refine the classification of SGA by identifying sub-groups based on maternal, fetal, and environmental factors and evaluating their associations with neonatal morbidity, growth, and neurodevelopment at age 2.Study designProspective Cohort Study. In six countries worldwide, between 2012 and 2018, the INTERBIO-21st Study enrolled SGA and non-SGA newborns defined by the <10th centile of international standards with moderate (≥3rd to <10th centile) and severe (<3rd centile) SGA sub-groups; we assessed their growth, health, nutrition, motor development, and neurodevelopment up to age 2. We used 2-step cluster analysis to identify SGA sub-groups, and a probabilistic approach to choose the optimal sub-group model based on a statistical measure of fit. We performed logistic regression analysis (OR; 95% CI) to assess health and development outcomes among sub-groups using the non-SGA as reference group, adjusting for key confounders.ResultsWe enrolled 5153 non-SGA and 1549 SGA newborns: moderate (≥3rd to <10th centile) SGA=947 and severe (<3rd centile) SGA=602). We identified nine SGA sub-groups: 'no main condition detected' (29.0%); 'previous low birth weight (LBW)/preterm birth (PTB)' (14.6%); 'severe maternal disease' (12.0%); 'maternal short stature (11.6%); 'hypertensive disorders' (9.6%); 'extrauterine infection' (6.8%); 'previous miscarriage(s)' (6.5%); 'smoking' (5.2%), and 'maternal under-nutrition' (4.7%). Severe SGA newborns in the 'severe maternal disease' (OR: 3.2; 95% CI, 1.8-6.0), 'previous LBW/PTB' (OR: 2.8; 95% CI, 1.6-4.8), and 'smoking' (OR: 5.4; 95% CI, 1.3-21.8) sub-groups had increased risk of neonatal and long-term morbidity, and low anthropometric measures at age 2 as compared to the non-SGA group. Moderate SGA newborns in the "hypertensive disorders" sub-group had increased risk of neonatal morbidity (OR: 2.6; 95% CI, 1.5-4.6), and higher odds of scoring <10th centile of normative values in language (OR: 3.5; 95%CI, 1.0-12.0) and positive behavior (OR: 2.2; 95%CI, 1.1-4.5). The 'severe maternal disease' sub-group had also higher risk of deficit (<10th centile of normative values) in language (OR: 5.7; 95%CI, 1.3-24.8), positive behavior (OR: 3.4; 95%CI, 1.5-7.6).ConclusionsSGA comprises heterogeneous sub-groups with distinct patterns of neonatal morbidity, postnatal growth, and neurodevelopmental outcomes up to age 2.
What Is a Person?: Untapped Insights from Africa
What makes us 'persons' in the moral sense, beings with a certain dignity and worth? What Is a Person? Untapped Insights from Africa explores this question by bringing African and Western philosophies into conversation. Chapter 1 characterizes the contemporary scene in Africa and the West, noting striking differences. It proposes that these differences were not always present, are hardly inevitable, and can and should be bridged. Chapter 2 introduces Emergent Personhood, a new philosophy of personhood that combines insights from Africa and the West. It holds that beings with superlative worth emerge through social relational processes involving human beings, yet they are more than the sum of these relationships. Persons have an identity of their own and exhibit superlative moral worth, a remarkable feature not present at the base. Emergent Personhood justifies personhood for all human beings from birth to death, held equally by them, that cannot be lost or diminished. It also gives strong support to personhood for a wide range of animals, soils, rocks, and ecosystems. Focusing on human personhood, chapters 3 and 4 argue that high moral status emerges at birth, is stable across the lifespan, and reaches a terminus with death's declaration, which ends the human-human associations that enable personhood to arise. Chapters 5, 6, and 7 turn to non-human personhood, considering personhood for artificial intelligence, animals, non-living nature, and extraterrestrial life and lands.