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The Lancet commission on malaria

​The Lancet commission on malaria

The global malaria community unsuccessfully tried to eradicate this disease in the mid-20th century. However, since 2000, considerable progress has taken place, which has motivated the reconsideration of malaria eradication. For example, both domestic and international yearly spending on malaria almost tripled, the number of countries with endemic malaria dropped from 106 to 86 and the worldwide incidence rate of the diseases decreased 36% whereas its annual death rate decreased 60%. Along with this remarkable progress, there has been also problems such as 55 countries experiencing an increase in cases between 2015 and 2017. With this in mind, the Lancet convened a commission to assess whether malaria eradication is feasible, affordable, and worthwhile.

A series of articles from the commission analyses topics such as the complexity of malaria biology, the cost of malaria eradication and its high dependency on managerial efficiency, the efficacy and cost of new tools, and the development assistance plateau since 2011. The Commission concludes its analysis with optimism stating that ‘malaria eradication by 2050 is a bold but attainable goal’. However, the commission estimates that to achieve this goal an additional investment of $2 billion per year is necessary, along with closer collaboration and a clearer definition of roles between the two apex organisations, WHO and the RBM Partnership to End Malaria. The conclusion also advocates for greater alignment of policies and investment strategies between The Global Fund to Fight AIDS, Tuberculosis and Malaria and the US President's Malaria Initiative, who are the two major malaria funders. The Commission also recommends the creation of an independent monitoring board for malaria eradication, which is crucial to increase accountability from all the actors involved.

Using different methods for analysis, the commission identifies opportunities and suggest specific actions to overcome the main challenges to achieve eradication by 2050. However, it also states that these actions are not enough without a higher ambition and vision to propel and sustain the community in the road to a malaria-free world. The commission on malaria is available here.

Contact:

Salvador Camacho, Swiss TPH

salvador.camacho@swisstph.ch

19/09/2019 13:32
The double burden of malnutrition at household level

​The double burden of malnutrition at household level

Two years ago the joint UNICEF-WHO-WB report on global child malnutrition[1] documented that most low- and middle-income countries are undergoing nutrition transition and experiencing the coexistence of overweight mothers and undernourished children in the same households. This is termed “the double burden of malnutrition at household level” (DBMHL) and its prevalence ranges from as low as 1.8% in Ethiopia to as high as 15.9% in Egypt. DBMHL is of particular concern, as it is an important promoter of the double burden of infectious and non-communicable diseases (NCDS).

The recent study by Anik et al “Double burden of malnutrition at household level: A comparative study among Bangladesh, Nepal, Pakistan, and Myanmar” explored the prevalence of DBMHL and its associated factors in the South Asian countries where there is a declining, but still high trend of child malnutrition at the same time as a significant increase in overweight and obesity among women. Using data extracted from the latest Demographic and Health Surveys (DHS), the study identified some 18,500 mother and child household pairs across the region with DBMHL.

Results revealed the highest prevalence of DBMHL to be in Myanmar (5.5%) and the lowest was in Nepal (1.5%) with 4.1% in Bangladesh and 3.9% in Pakistan. In all four countries, prevalence of DBMHL was found to be higher in urban areas than in rural areas. Households with no breastfeeding practice had a higher prevalence of DBMHL than the households that breastfed in Bangladesh (5.4% vs 3.0%), Nepal (3.2% vs 1.4%), Pakistan (5.7% vs 2.2%), and Myanmar (8.5% vs 3.3%). The association between breastfeeding and a reduced prevalence of DBMHL reflects the positive effect of the metabolic cost of breastfeeding on the weight loss of lactating mothers as well as the positive nutritional impact of breastfeeding on their children.

The study showed a positive association between higher wealth-index households and DBMHL, especially in Bangladesh and Pakistan. This is likely due to excessive intake of processed energy-dense foods and sodas in combination with a lack of physical exercise that are more common in middle and high income households compared with lower-income households in the two settings.

Older mothers were also found to be more closely associated with the increased risk of DBMHL than the younger mothers (in all study countries except Nepal) which reflects previous studies that showed women aged 30 years or older were overweight and obese in Bangladesh, Myanmar, and Pakistan. This is associated with increasingly sedentary lifestyles with increasing age in the three countries.

Regular media exposure was found to have a protective impact on DBMHL, indicating the potential benefits of multi-media approaches to behaviour change to support a balance between energy intake and expenditure in mothers, and optimal nutrition for foetal and child development. Although variation in findings between the four countries indicate the need for further research on the determinants of DBMHL, efforts towards the promotion and support of breastfeeding in combination with NCD reduction interventions, including positive nutrition and physical activity, appear to be key starting points.

The full article, published by PLOS One on August 16, 2019 can be accessed here: https://doi.org/10.1371/journal.pone.0221274


[1] Hayashi, C, et al. Joint Malnutrition Estimates 2017 Edition—Worldwide. UNICEF-WHO-WB; 2017: http://public.tableau.com/views/JointMalnutritionEstimates2017Edition-Wide/WB


Contact:
Kate Molesworth, Swiss TPH  kate.molesworth@swisstph.ch


02/09/2019 15:35
Evidence of falling use of modern contraception and rising abortion in sub-Saharan Africa with enactment of the US Mexico City Policy

Evidence of falling use of modern contraception and rising abortion in sub-Saharan Africa with enactment of the US Mexico City Policy ​

As the world's largest absolute donor of development assistance, the USA’s decisions regarding allocation of its global health resources have substantial impacts upon health services worldwide. Of particular concern the influence of US domestic abortion politics on the disbursement of foreign health funding. The Mexico City Policy introduced by the Reagan administration at the International Conference on Population in 1984 has influenced US family planning assistance ever since. This policy, which has been repeatedly rescinded and reinstated by presidents along partisan lines, prohibits NGOs that perform abortions or counsel women about abortion from receiving US federal funding.  

On the one hand, the policy's restrictions imply an intention g to reduce abortions, but on the other hand, if the policy also curtails the operations of organisations that provide family planning services, it could also limit the supply and use of modern contraception. This in turn may have the unintended consequence of increasing abortions because lower modern contraceptive use is associated with unintended pregnancies and demand for abortion. Many family planning and reproductive health organisations face a difficult choice between complying with the policy and maintaining US funding, or maintaining services that conflict with the policy and forfeiting US funding. Two of the largest international family planning organisations, International Planned Parenthood Federation and Marie Stopes International, have historically refused to sign the policy, sacrificing access to a substantial source of support.

A large-scale study published in the Lancet this month compared modern contraceptive uptake and abortion during periods of time when the policy was rescinded by William Clinton, reinstated by George W Bush, and rescinded again by Barack Obama. “USA aid policy and induced abortion in sub-Saharan Africa: an analysis of the Mexico City Policy” by Brooks et al shows how a US policy intended to restrict federal funding for abortion services can lead to a rise in abortions in poor countries.

The study found that when the Mexico City Policy was in effect in 2001–08 (under George W. Bush’s reinstatement of the policy) abortion rates rose by approximately 40% compared with periods when the policy was repealed during 1995–2000 (under the Clinton administration) and 2009–14 (under Obama). The study showed that underlying the increase in abortion under restrictions imposed by the policy was a 14% reduction in modern contraceptive use, accompanied by a 12% increase in pregnancies. The study also revealed that the policy's effects reversed after each repeal, providing further evidence of the policy's role in the fall in modern contraceptive use, rise in pregnancy and abortion.

Access to safe and regulated abortion services is crucial for women's reproductive health, but it is also a highly emotive and political topic. This study is the first to show that enactment of the Mexico City Policy is followed by an increase in abortions, many of which are likely to be unsafe. However, this trend can be reversed with an improvement in the policy environment and adequate support for family planning organisations. The evidence generated by Brooks et al’s research is timely given that Donald Trump reinstated and expanded the policy in a Presidential Memorandum in 2017.

The full article can be accessed here.

Contact:
Kate Molesworth, Swiss TPH  kate.molesworth@swisstph.ch

19/08/2019 09:54
​Researchers develop intervention to eliminate schistosomiasis and draw lessons from persistent transmission and reinfection

​Researchers develop intervention to eliminate schistosomiasis and draw lessons from persistent transmission and reinfection

Schistosomiasis is a neglected tropical disease with considerable impact on global health. More than 200 million people are infected, mainly in sub-Saharan Africa. Researchers from Swiss TPH, the Natural History Museum London and partner institutions in Zanzibar developed an intervention aiming to eliminate schistosomiasis in Zanzibar, Tanzania. The researchers found that while schistosomiasis was eliminated as a public health problem in over 90% of the study regions, the transmission was not interrupted and reinfection occurred.

Schistosomiasis is a neglected tropical disease affecting more than 200 million people and putting in risk to around 800 million people. The global burden of the disease by 2016 was estimated at 1.86 million disability-adjusted life years, which caused a shift from the World Health Organisation to move from morbidity control towards elimination, i.e. elimination of schistosomiasis as a public health problem and interruption of transmission in selected areas by 2025.

Schistosomiasis is caused by blood flukes (parasitic flatworms) released by freshwater snails when they get in contact with human skin and penetrate it. That means that infection occurs when individuals, particularly children, are exposed to contaminated natural freshwater while swimming, bathing or washing. The risk of infection is higher in areas that lack clean water and sanitation. This parasitic disease, if left untreated, can lead to anaemia, severe damage of organs, infertility, cancer, and even death. The essential control of schistosomiasis is through mass drug administration (MDA) of praziquantel but this measure does not interrupt transmission because it does not impede the contamination of freshwater bodies. Therefore, it is necessary to investigate interventions to assist people in changing their behaviour to prevent water bodies' contamination and infection.

A group of scientists from Swiss TPH together with the Natural History Museum of London and partner institutions in Zanzibar, Tanzania conducted a 5-year cluster-randomised trial to assess the effect of different interventions for elimination of urogenital schistosomiasis in children aged 9-12 years from Zanzibar. The intervention was done on top of biannual MDA and it had one control and three arms, namely, a group with a preventive chemotherapy, a group with the preventive chemotherapy plus behaviour change interventions and the last group with the preventive chemotherapy plus snail control interventions.

The scientists eliminated urogenital schistosomiasis as a public health problem in more than 90% of the populations included in the study, however, the intervention did not manage to interrupt transmission/contamination and reinfection reoccurred. Nevertheless, valuable lessons can be learned from the trial as it can be noted in the published study here.

The complete study design can be consulted here.


Contact:
Salvador Camacho, Swiss TPH | salvador.camacho@swisstph.ch


24/07/2019 10:55
Community engagement in the Ebola response

​Community engagement in the Ebola response

A recent commentary by Melissa Parker and others, "Ebola, community engagement, and saving loved ones" reflects upon the much-discussed importance of community engagement in the control of Ebola outbreaks. Depending upon how individuals in a community are affected by an epidemic, they may not share the same opinions as their authorities or desire the approaches essential to collective action. The nature of community engagement may therefore create tension and those empowered by external agencies to implement control policy are at risk of being resented by their communities and even violence.

During the Ebola epidemic in Sierra Leone Parker et al observed how people were not prepared to give up their loved ones to official health care services and were convinced that protecting and assisting them was the right thing to do. In this way, relatives avoided public health authorities and evaded the instructions of their chief to report cases. Relatives of people exhibiting symptoms of Ebola infection took the sick into secluded forest locations, where they provided care themselves. Carers attempted to keep sick relatives hydrated and made protective clothing for themselves: Some of the sick survived and the dead were buried with the help of members of secret societies that are prevalent across the region, enabling their families could mourn them. These findings highlight that more people were probably infected with Ebola virus than official data indicate and that extensive unreported care was provided for those infected. For example, the authors found that while 58 Ebola cases were officially reported in Ribbi chiefdom, their research found a further 57 suspected cases, in just one village in the same chiefdom, only eight of which were referred to the chief or district authorities.

The article concludes that the most useful insight for Ebola policy is that in some contexts relatives will provide secret care for those they love and feel responsible for, regardless of regulations imposed by their immediate and national authorities: These realities present diverse challenges, particularly in identifying and working with those involved, but isolating relatives who believe themselves to be acting morally is likely to be counter-productive.

The commentary can be accessed at: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)31364-9/fulltext#back-bib3.

Further references on community approaches to Ebola can be found at: https://blogs.lse.ac.uk/africaatlse/2018/02/15/publicauthority-what-will-happen-when-there-is-another-epidemic-ebola-in-mathiane-sierra-leone/ (LSE PublicAuthority blog #PublicAuthority: What will happen when there is another epidemic? Ebola in Mathiane, Sierra Leone)

https://www.economist.com/middle-east-and-africa/2015/08/29/hail-to-the-chiefs (The Economist: Ebola in Sierra Leone. Hail to the chiefs. How local leaders helped to curb an epidemic.)

https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(19)30044-1/fulltext (Trapido J. Ebola: public trust, intermediaries, and rumour in the DR Congo.Lancet Infect Dis. 11)


Contact:
Kate Molesworth, Swiss TPH | kate.molesworth@swisstph.ch


10/07/2019 10:52
Lancet Series on Gender Equality, Norms, and Health

Lancet Series on Gender Equality, Norms, and Health​

Evidence is accumulating that the traditional disregard for gender inequalities in health planning and intervention design, implementation, monitoring and evaluation weaken health outcomes in populations. The first of the five main articles in the Series, “Gender inequality and restrictive gender norms: framing the challenges to health“ by Heise et al, explores the relationships between gender inequalities, restrictive gender norms and health and wellbeing. Building upon the evidence base, it sets out a conceptual framework that shows how sexism and patriarchy intersect with other forms of discrimination, such as racism, classism and homophobia, to structure pathways to poor health. The article sets out evidence of the extensive consequences of these pathways, including how gender inequality and restrictive gender norms impact health through differential exposure, health-related behaviours and access to care, as well as how gender-biased health research and health-care systems reinforce and reproduce gender inequalities, with serious implications for health.


Using existing global, national, and subnational data, Weber et al in their article “Gender norms and health: insights from global survey data” present evidence that gender norms affect the health of females and males at all stages of the life course, in health sectors, and in all regions of the world. The authors present six case studies showing that: (1) gender norms are complex and can intersect with other social factors to impact health over the life course; (2) early gender-normative influences by parents and peers can have multiple and differing health consequences for girls and boys; (3) non-conformity with, and transgression of, gender norms can be harmful to health, particularly when they trigger negative sanctions; and (4) the impact of gender norms on health can be context-specific, demanding care when designing effective gender-transformative health policies and programmes.

Heymann et al in their article“Improving health with programmatic, legal, and policy approaches to reduce gender inequality and change restrictive gender norms” present the results of a comprehensive review of the literature on rigorously evaluated programmes that aimed to reduce gender inequality and restrictive gender norms and improve health. Their review identified four mutually-reinforcing factors underpinning positive change: (1) multi-sectoral collaborative action, (2) multilevel, multi-stakeholder involvement, (3) diversified programming, and (4) social participation and empowerment. The team also examined whether laws and policies significantly affect gender-related health outcomes. This revealed that free primary education, paid maternity and parental leave significantly improve the health of mothers  and their children's. The article concludes by discussing examples of how improved governance can support gender-equitable laws, policies, and programmes, immediate next steps, and future research needs.

The need for concerted action and accountability on gender equality is clear: introduction of the 2030 Agenda for Sustainable Development and the Universal Health Coverage goals demand greater attention to the social determinants of health, including gender, for the purpose of enabling all people to reach their full potential. The last two articles in the series: by Hay et al “Improving health with programmatic, legal, and policy approaches to reduce gender inequality and change restrictive gender norms” and by Gupta et al “Gender equality and gender norms: framing the opportunities for health” propose an agenda for action to systematically identify and address restrictive gender norms and gender inequalities in health systems as well as in broader settings including the corporate sector.

The five articles in the Lancet Series and further commentaries can be accessed here.


Contact:
Kate Molesworth, Swiss TPH  kate.molesworth@swisstph.ch

24/06/2019 16:28
How to disinvest in public health

How to disinvest in public health​

Aging populations, increase in chronic diseases and higher expectations of consumers are some of the main drivers increasing the cost of healthcare not only in Western countries but also in low and middle-income ones. More procedures, medications, and services are added to publicly funded health systems, which raises concerns about their sustainability. These concerns are aggravated by the fact that even if some new services are proved cost-effective, the existing ones are rarely verified to prove their cost-effectiveness. Health economists have suggested starting disinvestment strategies to address these concerns. Disinvestment is defined as the complete or partial withdrawal of resources from healthcare services that are considered as either unsafe, ineffective and/or inefficient, shifting those resources to more cost-effective health services.

Despite the logic of this suggestion, disinvestment can be an unpopular measure with little or no take-up. Deb Mitchel and colleagues investigate the response of health practitioners when confronted with a plan to disinvest from a health service that they previously provided to their patients at two Australian hospitals. This was a qualitative study with two data collection points: prior to and during a disinvestment phase of a multisite stepped wedge cluster randomized controlled trial that removed the weekend allied health service from twelve acute medical and surgical wards. The researchers focused on staff behaviour to understand its responses to disinvestment projects. Their results depict the way the responses from the personnel change over time, ranging from immediate negative reactions, looking for strategies to avoid the disinvestment project, to see it as an opportunity. The study from Mitchel and colleagues provides valuable insights on how to manage disinvestments to increase the cost-effectiveness while avoiding disincentives for clinicians and affected healthcare professionals.

The study with the response phases found by the researchers and relevant recommendations can be found here.

17/06/2019 13:07
Trained dogs identify people with malaria parasites by their odour

Trained dogs identify people with malaria parasites by their odour 

Millions of lives saved and global rates dropping by 60 percent are some of the arguments to consider the fight against malaria as one of the biggest successes of the 21st century. Nevertheless, The Global Fund remarks that the fight is not over because malaria is on the rise in endemic places and new tools are needed to get the malaria response back on track. There are huge efforts to do so. For instance, the malaria vaccine is currently being tested in humans through pilot programmes in three African countries (Malawi, Ghana and Kenya). The aim of these pilots is to generate evidence and experience to inform policy recommendations on the broader use of the vaccine.

However, the vaccine is part of the holistic malaria control and it should be complemented by the already recommended measures for prevention, such as the use of insecticide-treated bed nets, indoor spraying with insecticides, and the timely use of malaria testing and treatment. Timely testing for malaria has been particularly challenging and a non-invasive method probably would turn malaria elimination simpler. That is why Claire Guest and colleagues trained dogs to identify people with malaria parasites by their odour.

Based on the evidence showing that people infected with malaria parasites produce a body odour that is detected by mosquitoes, which use this information to feed on asymptomatic malaria-infected individuals, the researchers hypothesised that dogs with their advanced sense of smell could be trained to detect people with the disease. With the support of Bill & Melinda Gates Foundation, Guest and colleagues trained dogs and assessed their diagnostics accuracy using a blinded study. The specificity and the sensitivity of the trained dogs met the thresholds recommended by the World Health Organization for malaria diagnostics. The results from the researchers open the possibility to use dogs to overcome specific barriers in malaria detection such as detecting individuals infected with malaria at ports of entry in countries or regions that are either free of malaria or approaching elimination. The study was published online by The Lancet ahead of the printed version and can be found here.


Contact:
Salvador Camacho, Swiss TPH | salvador.camacho@swisstph.ch

27/05/2019 16:48
Creating and sustaining health research capacity in conflict-affected areas.

​Creating and sustaining health research capacity in conflict-affected areas

Building and sustaining research capacity has been continuously promoted as the best strategy to overcome health disparities worldwide. Yet, health research capacity is disproportionately located in the global north where most academic papers are produced and published, and where most implementation is done. This is due to several reasons such as low and middle-income countries (LMICs) lacking human and financial resources, or low training capability/capacity for domestic researchers. This situation undermines the capacity of the health systems from LMICs to continuously learn preventing them to become communities producing scientific knowledge to address both global and local concerns.

For countries in conflict, it is even less common if not impossible to build research capacity or to put it in place although these countries are the ones that could benefit the most. Research in areas with conflicts is conducted mostly by non-governmental organisations under financial and human resources constraints, within an environment full of barriers such as political pressures, instability, undervaluing research, and ethical challenges. This affects not only the quality and quantity of the research but also its impact on policies. Besides, health research in LMICs affected by armed conflict is often fragmented, under-developed, or driven by researchers and research agendas from the global North due to large-funders' interests, perception about the local capacity to absorb resources, and risk appetite.

With this in mind, Gemma Bowsher and colleagues carried a narrative review examining the current literature on health research capacity strengthening (sometimes referred to as research capacity building) in LMICs to support the undertaking of future capacity strengthening programmes in conflict settings. Their review covered peer-reviewed articles published from 1990 to 2018 and grey literature from the World Health Organization (WHO) Global Health Observatory (GHO), Reliefweb and the Social Science Relief Network, among other sources. The authors clearly identified the main factors influencing research capacity strengthening and they broke it into several categories and by the type of influence, i.e. either positive or negative.

By highlighting the challenges to research capacity strengthening in conflict-countries, as well as examples of good practice, the authors make the case for the need for support and attention to this vital practice. Bowsher and colleagues also manage to inform effectively about the enablers and deterrents of research capacity strengthening with the aim of building and sustaining research capacity in these settings that need it the most. Their article can be found here.

17/05/2019 15:25
WHO Guideline: recommendations on digital interventions for health system strengthening

​WHO Guideline: recommendations on digital interventions for health system strengthening


Digital health interventions have demonstrated positive impacts in global health such as increasing the quality of care offered at the community level, improving service utilization, quality of care and information, reducing supply stock-outs, among others advantages. It is thought that digital health interventions can overcome the challenges that currently limit the achievements of health systems. The World Health Assembly Resolution on Digital Health approved unanimously in 2018 by all the Member States of the World Health Organisation (WHO), is a proof of the collective recognition of the value of digital health to contribute to achieving universal health coverage (UHC) and ultimately sustainable developments goals (SDGs). Digital health is a broad “umbrella term” defined as the use of digital technologies for health. Within digital health, there is a subset of specific concepts, such as “eHealth” -the use of information and communications technology in support of health and health-related fields, and mobile health or mHealth, defined as the use of mobile wireless technologies for health. Digital health also covers emerging areas such as the use of big-data, genomics and artificial intelligence.

Due to its perceived advantages, digital health is a strong and common practice to address health needs from all kind of stakeholders, ranging from medical practitioners and community health workers to international aid agencies. However, the enthusiasm for digital health implementations have brought along a wide assortment of short-term implementations and an extensive diversification of digital tools, including software and programming languages, as well as a lack of evaluations to assess their benefits and harms. To help to overcome these concerns, the WHO has created the first Digital Health guideline with recommendations based on critical evaluations of evidence on digital health interventions and their impact on health system improvements. The evaluations cover benefits, harms, acceptability, feasibility, resource use and equity considerations. The guide also includes a comparison of the digital interventions against their non-digital alternatives with the aim of providing health policy-makers and stakeholders with recommendations and implementation to support their decisions and actions.

It is important to note that although this is a digital health guideline, the document makes the case that “health interventions are not a substitute for functioning health systems, and that there are significant limitations to what digital health is able to address. Digital health interventions should complement and enhance health systems functions…but will not replace the fundamental components needed by health systems…” This approach makes the guideline a valuable document for both enthusiastic supporters and critics of digital health interventions. The guideline covers context delimitation, evidence and recommendations, and research and implementation considerations. The electronic version also contains two web supplements. The guideline can be consulted and downloaded at this link.

Contact:
Salvador Camacho, Swiss TPH | salvador.camacho@swisstph.ch

24/04/2019 08:28
Assessing the measurement tools of quality to improve maternal and newborn care

Assessing the measurement tools of quality to improve maternal and newborn care ​

While there has been a marked increase globally in skilled birth attendance and institutional deliveries, only a few countries met their Millennium Development Goals (MDGs) of reducing the maternal mortality ratio and infant mortality rate. The quality of maternity services including antenatal and postnatal care that determine the extent of preventable maternal and neonatal morbidity and mortality remain poor in many country settings, where preventable birth injury and death occur in spite of skilled attendance and facility-based deliveries.  By the end of the MDGs era, it was evident that an increase in institutional births and skilled birth attendance alone were not effective in reducing maternal mortality ratios and infant mortality rates. Quality health care during pregnancy and childbirth have since received substantial attention as essential to improving health outcomes for women and their newborns. This is reflected in the Sustainable Development Goals (SDGs) and the 2016–30 Global Strategy for Women's, Children's, and Adolescents' Health.

WHO responded in 2016 with a substantial framework and global standards for quality maternal and new-born care. As the figure below illustrates, this comprises eight domains for improving the provision and experience of care. Each domain of the framework has specific standards describing what is expected to be provided to achieve high-quality care around the time of childbirth.  These are elaborated by 31 statements of priorities for measurably improving quality of care, organised into 352 quality measures for assessing, measuring and monitoring the quality of care as specified in the quality statement. The WHO standards are used to guide national and facility level quality improvements, such as creating national standards of care, measuring the quality of care, providing benchmarks for ensuring high-quality services at the facility level, and informing health facility audits.

Understanding the extent to which existing tools can be used to measure quality is therefore imperative. A recent study assessed the effectiveness of large-scale facility assessment tools currently used to measure quality of maternal and newborn care.
 
At a time when quality of maternal and newborn care are receiving considerable global attention, understanding, the extent to which existing tools effectively measure quality is essential. A recent study by Brizuela et al “Measuring quality of care for all women and newborns: how do we know if we are doing it right? A review of facility assessment tools” assessed the effectiveness of large-scale facility assessment tools currently used to measure quality of maternal and newborn care.This review is the first assessment and comparison of the ability of widely used facility assessment tools to measure quality of maternal and new-born care according to WHO's standards.
 
The study revealed there to be no unified global tool available that can capture the comprehensive list of indicators for maternal and newborn health set out by WHO. The full report that can be accessed here details specific quality assessment tools that were assessed and rates their performance. It concluded that current tools have substantial limitations such that they fail to explore adequately input and process quality measures, health information systems and patient experience of care.

The study concludes that improved guidance and simplified recommendations are needed to operationalise and prioritise WHO’s standards on quality of maternal and neonatal care. The authors call for better coordination of the different agencies leading multicounty surveys to reduce inconsistencies and enable a more precise and standardised approach to measurement of quality of maternal and newborn health care, including a more accessible way in which countries can understand and use the data generated to practically improve services.

Contact
Dr Kate Molesworth
kate.molesworth@swisstph.ch


15/04/2019 12:14
TB case detection by prison peer educators

​TB case detection by prison peer educators

Prisoners worldwide are one of the most at- risks groups for acquiring TB, and are up to 30 times more likely to be infected than the general population. Despite the well-documented high risk of this population, people in detention are commonly missed or not reached by awareness campaigns, testing and treatment services, which perpetuate their vulnerability to illness and premature mortality.

Two critical and challenging elements in the global response to TB are early detection and adherence to treatment, which are more challenging for people in detention due to the nature of the prison environment. For instance, prisons commonly face resource scarcity and a shortage of health personnel, as well as poor living conditions, poor nutrition, overcrowded spaces, and stressful surroundings. This translates into inadequate health infrastructure, lack of awareness about tuberculosis, and health inequalities in accessing diagnosis and treatment, making traditional detection approaches such as microscope-based diagnosis (sputum smear) or chest X-rays, inaccessible.  


A study in Ethiopia by Adane and colleagues in resource-limited prisons in the regions of Amhara and Tigray aimed to contribute to developing alternative tools and approaches to improve inmates’ access to diagnostic services. A cluster-randomised controlled trial tested the effects of peer education to as a cost-effective method to increase case detection. In the intervention prisons peer educators received a 3-day training in the detection of TB cases, and provided education to all other prison inmates about TB prevention and control every two weeks for one year. They also actively searched for symptomatic prison inmates and conducted routine symptom-based tuberculosis screening. A set of control prisons continued with their existing passive case finding system for comparison. The study found that involving trained inmates as peer educators significantly improved the case detection rate of TB. These results are relevant not only for low-income countries but also from prisons or similar settings that face scarcity of resources. The full research report can be found here.

Contact:
Salvador Camacho, Swiss TPH | salvador.camacho@swisstph.ch

01/04/2019 09:38
Diabetes and TB: convergence of two epidemics

Diabetes and TB: convergence of two epidemics

This year, the theme of World TB Day: “It’s Time” emphasised the urgency for action on commitments made by global leaders to fight the disease, as the dedicated World Health Organisation site sets out. Global efforts to address TB are estimated to have saved approximately 54 million lives per year since 2000. However, there is still a lot left to do beyond World TB Day (March 24th) to reduce the negative health, social and economic consequences of the disease, particularly in terms of its interaction with non-communicable diseases (NCDs) that are rising rapidly in low- and middle-income countries.


Diabetes is estimated by WHO to triple a person's risk of developing TB and it is estimated that about 15% of TB cases globally may be linked to diabetes. A recently published systematic review and meta-analysis by Noubiap and colleagues of data from 2·3 million patients with TB from 50 countries explored the relationship between diabetes and TB. The research team found that it is not clear yet whether diabetes increases vulnerability to TB infection, or if TB triggers the onset of diabetes. However, it is evident that the two conditions occur together and that the incremental prevalence of diabetes hinders TB control. This study highlights the need more in-depth research on this topic to inform policymakers to ensure adequate planning and service delivery of integrated disease programmes. The meta-analysis of Jean Jacques Noubiap and colleagues can be found here and a WHO factsheet “Tuberculosis and Diabetes” on the dual epidemic can be accessed here.

Contact:
Salvador Camacho, Swiss TPH | salvador.camacho@swisstph.ch

01/04/2019 09:30
Incorporating NCDs into facility-based surveillance systems

​Incorporating NCDs into facility-based surveillance systems

Mozambique is a low-income country that faces endemic diseases such as malaria, tuberculosis, and HIV and neglected infectious diseases that account for 57% of all deaths. But like many countries it is experiencing a rise in NCDs that has not been quantified as health facility surveillance systems have been focused on CDs. In an article published this month, a group of researchers report on an intervention designed to adapt data collection tools to include NCDs in the Mozambique health information system (HIS). Mocumbi et al (2019) collected data on the prevalence of selected NCDs in a general hospital serving nearly 800,000 people, based on the WHO Global Action Plan and Brazzaville Declaration for NCD prevention and control: arterial hypertension, diabetes, stroke, chronic respiratory diseases, mental illness and cancers.

Registration books used for consultations were adapted by replacing age group with the exact patient’s age, adding an extra column for gender, and using the observations column to register the immediate outcome (discharge, transfer or death). To respond to the better awareness of NCD prevalence, staff were trained on the diagnosis and treatment of the selected NCDs.




The study detected the selected NCDs among 7.2% (6,423) of the 89,381 patients in the sample. Of the NCD diagnoses sample, the distribution of diseases was found to be dominated by diabetes in 6,289 patients (78%) and stroke 2,994 (66 %); followed by arterial hypertension in 2,397 patients (37%), mental illness 1,497 (23%) and asthma 1,495 (23%); with a lower prevalence of chronic obstructive pulmonary disease 61 (0.95%) and cancers among 46 patients (0.72%). The data show that many patients were diagnosed with more than one NCD.

This research provides a simple model to incorporate NCD surveillance into existing health facility mechanisms in low-resource settings and can be effectively used to design better strategies and actions to tackle the double burden by maximizing resources.

The full article by Mocumbi et al (2019) “Incorporating selected non-communicable diseases into facility-based surveillance systems from a resource-limited setting in Africa” can be accessed here.

Contact:
Salvador Camacho, Swiss TPH | salvador.camacho@swisstph.ch

20/02/2019 13:44
Global Syndemic of Obesity, Undernutrition, and Climate Change

​Global Syndemic of Obesity, Undernutrition, and Climate Change

Obesity continues to increase in prevalence in almost all countries and is an important risk factor for poor health and mortality. The condition is widely regarded to be an individual’s responsibility, and a result of poor choices and behaviours. However, the Lancet Commission argues that this position is no longer acceptable as there are “deep systemic problems” underlying the syndemic of obesity, undernutrition and climate change. For instance, the current food system requires agriculture to generate products that need large amounts of energy and at the same time generate methane and pollution that impact on climate change. Current food systems also favour cheap food, which is linked to malnutrition.

Therefore, a total rethink of the way we eat, produce, consume, move, and in general, how we interact with our environment is crucial. Our food systems, transportation, buildings, and of course, health facilities need to be designed or re-designed in a holistic way to blend into the planet in the less aggressive way. This would not only reduce their negative impact on the wellbeing of people and the planet but also would help to achieve a sustainable and healthier economic grow.

The global syndemic commission successfully incorporates the concept of obesity into a holistic approach beyond individual diseases. It facilitates understanding of the underlying human-made drivers and existing feedback loops that lead to malnutrition in all its forms—obesity, undernutrition, and nutrient deficiency—and climate change. The commission discusses the interactions between climate change and its effects on health, considering also food insecurity and the way climate change affects it.

The analysis and recommendations presented by the Global Syndemic Commission are highly relevant considering the predicted population growth, and the accompanying rising need for food production, transport, and housing among others.

The series of articles from the Lancet Commission Report: Global Syndemic of Obesity can be found here.

Contact:

Salvador Camacho, Swiss TPU | salvador.camacho@swisstph.ch

12/02/2019 16:22
World Cancer Day on February 4th, 2019

World Cancer Day on February 4th, 2019

The Union for International Cancer Control (UICC) represents the world’s major cancer societies, ministries of health and patient groups and includes influential policy makers, researchers and experts in cancer prevention and control. Working closely with key international UN agencies including the World Health Organization (WHO), UICC takes the lead in convening, capacity building and advocacy initiatives to reduce the global cancer burden through delivering the targets of the World Cancer Declaration to ensure cancer control continues to be a priority in the world health and development agenda.


The 2013 World Cancer Declaration that can be accessed here: https://www.uicc.org/sites/main/files/private/UICC_WCD_Declaration_Refresh_Screen_FA.pdf has the overarching goal of major reductions in premature deaths from cancer, and improvements in quality of life and cancer survival rates. It has 9 targets to be reached by 2025.



To support focussed and effective action, a set of tools has been developed for free use online at https://www.worldcancerday.org/materials?#4,9. These provide guides and templates for individuals and groups to customise their own communication materials to contribute to the ‘I Am and I Will’ campaign. As the pictures below show, templates are offered in a number of languages.

Kate Molesworth, Swiss Swiss TPH | kate.molesworth@swisstph.ch

29/01/2019 14:29
UCL–Lancet Commission on Migration and Health: the health of a world on the move

​UCL–Lancet Commission on Migration and Health: the health of a world on the move

The UCL–Lancet Commission on Migration and Health, in light of current emotive political debate, sets out evidence for cooperation and action on what has become one of the most pressing issues of our time. It takes the position that migration and health are intricately linked and key to sustainable development. It challenges some of the myths around migration to provide evidence of the multiple factors that might be beneficial or detrimental to individuals and systems along the migration journey from point of origin, through transit, destination, and return. It documents the devastating impacts of forced migration, especially on girls and women, but also the overall benefits to the health of individuals and populations that planned, economic migration can generate. Articles include:

  • Systematic reviews and meta-analyses of 1) global patterns of mortality in international migrants. 2) health impacts of parental migration on left-behind children and adolescents.

  • The unmet needs of refugees and internally displaced people.

  • Migration, health and human rights.

  • Advancing health in migration governance, and migration in health governance

  • The role of the Global Compact for Migration for children and adolescents on the move.


The Commission report, which can be accessed here: https://www.thelancet.com/commissions/migration-health sets out a research agenda to better ensure and address the health of migrants. Using a health perspective the Commission shows that migration policies can be both ethical and feasible calls for governments, international agencies, and professionals to promote health in global mobility.

24/01/2019 17:57
Effectiveness of HIV self-testing and same day ART

​Effectiveness of HIV self-testing and same day ART

Yesterday Dr Niklaus Labhardt presented at the Swiss TPH its joint study with Solidarmed in Lesotho on the effect of offering same-day ART to individuals who test HIV positive at home, versus health facility referral on linkage to care and viral suppression (reduction of the function and replication of HIV using antiretroviral therapy (ART). Participants were 278 individuals aged 18 years or older who tested HIV positive at home and had not previously taken ART. Half (n = 138) were randomly assigned to be offered same-day home-based ART initiation and subsequent follow-up intervals of 1.5, 3, 6, 9, and 12 months after treatment initiation at the health facility or to receive usual care (n = 140) with referral to the nearest health facility for preparatory counselling followed by ART initiation and monthly follow-up visits.

Results showed that in the same-day treatment group, 134 (97.8%) indicated readiness to start ART that day and 2 (1.5%) within the next few days. These were given a 1-month supply of ART. At 3 months, 69% (94 people) in same-day group versus 43% (59) in the usual health facility care group had linked to care – a difference of 26 %.  At 12 months, 50% (69) in the same-day group versus 34% (47) in usual care group achieved viral suppression.

The study that can be accessed in full here concludes that among adults in the high HIV prevalence setting of rural Lesotho, offering same-day home-based ART initiation to individuals who tested positive during home-based HIV testing, compared with usual care and standard clinic referral, significantly increased linkage to care at 3 months and HIV viral suppression at 12 months. These findings support the practice of offering same-day ART initiation during home-based HIV testing.

A short interview by the first author can be viewed here.

28/11/2018 09:47
GBD 2017: A fragile world

​GBD 2017: A fragile world

The results of GBD 2017, published this month, explode the comforting trend of gradual improvement and instead show plateauing mortality rates on a background of faltering and uneven progress, era-defining epidemics, and dramatic health worker shortages. Instead of the progress updates we have become accustomed to, GBD 2017 comes as an urgent warning signal from a fragile and fragmented world.

The 2017 study reports that the previous trend of decreasing global adult mortality rates has plateaued, and in some cases, mortality rates have increased. Conflict and violence have become two of the fastest growing causes of death globally (increasing by 118% between 2007 and 2017). Epidemics such as opioid dependence, non-communicable diseases, depression and dengue fever have become more severe. Opioid dependence has grown to an unprecedented scale, with 4 million new cases in 2017 and 110,000 deaths. Non-communicable diseases accounted for 73% of all global deaths in 2017, with over half (28·8 million) attributable to just four risk factors: high blood pressure, smoking, high blood glucose, and high body-mass index. Obesity prevalence has risen in almost every country in the world, leading to more than a million deaths from type 2 diabetes, half a million deaths from diabetes-related chronic kidney disease, and 180,000 deaths related to non-alcoholic steatohepatitis - a type of fatty liver disease, characterized by inflammation with fat accumulation in the liver, associated with obesity and diabetes. In 2017, depressive disorders became the third leading cause of years lived with disability, after low back pain and headache disorders, and deaths from dengue fever, a disease often associated with struggling development and urbanisation, increased substantially in most tropical and subtropical countries, rising from 24,500 deaths globally in 2007 to 40,500 in 2017.

The improvement in sex-specific disaggregation of data in GBD 2017 reveals areas where the gendered aspects of health, often overlooked, need to  be addressed. Estimates show that substantial differences in health for men and women that underlie the overall headline figures are still pervasive. Whereas deaths among adult men remain stagnant in many parts of the world, in some areas, mortality has increased: women are living longer, but with more years spent in poor health. The greatest sex differences in health outcomes: substance use disorders, transport injuries, and self-harm and interpersonal violence, are socially driven, suggesting that more attention and action are needed are needed in response to underlying factors.

For the first time in the history of the GBD study, estimates of health worker density have been included. These show that the global shortage and unequal distribution of health workers requires urgent attention in order not to undermine reaching the Sustainable Development Goals (SDGs). The report estimates that in 2017 only half of all countries had the health-care workers required to deliver quality health care (The standard estimated to be 30 physicians, 100 nurses or midwives, and five pharmacists per 10,000 people). Although many European countries have highly-resourced health workforces, countries across sub-Saharan Africa, southeast Asia, south Asia, and some countries in Oceania were estimated to have the greatest shortfalls.

Alarmingly, the GBD 2017 report estimates that no country is on track to meet all of WHO's health-related SDGs by 2030. Under-five mortality, neonatal mortality, maternal mortality, and malaria indicators had the most countries with at least 95% probability of success. However, for many other targets, including child malnutrition and violence reduction goals, no country in the world has attained the pace of change that is required for these goals to be met.

GBD 2017 is disturbing. Not only do the amalgamated global figures show a worrying slowdown in progress, but the data reveal exactly how patchy progress has been. The report provides a reminder that without vigilance and constant effort, progress can easily be reversed. But the GBD is also an encouragement to think differently in this time of crisis. By cataloguing inequalities in health-care delivery and patterns of disease geography, the new version of the GBD presents an opportunity to move away from the generic application of UHC, towards a more tailored approach to UHC. The shock of GBD 2017 should be used to galvanise national governments and international agencies to amplify their efforts to avoid the loss of hard-won gains and also to adopt fresh and effective approaches to growing threats.

View the full article here.

27/11/2018 14:05
World Diabetes Day 2018-19: Focus on family

​World Diabetes Day 2018-19: Focus on family


The theme of WDD on Wednesday 14 November 2018 is “Diabetes Concerns Every Family” and aims to build towards a month of awareness-raising of the impact that diabetes has on the family and to promote the role of the family in the identification, management, care, prevention and education of the condition.

A number of resources are available to enable schools, health facilities and places of work to participate in this year’s awareness-raising campaign and for individuals to take messages home to their families.

The International Diabetes Federation WDD 2018 campaign Toolkit, is available in English, French and Spanish. It provides guidance and resources to support the detection, prevention and management of diabetes, with a special emphasis on spotting diabetes warning signs within the family. Current figures are provided as well as future projections of the diabetes pandemic.

As well as providing support for organisers of events, the Toolkit guides readers to engaging and participate through various channels of social media.

The Toolkit can be accessed here.

A number of posters are available in different languages, free for download that can easily be printed and posted in our places of work. They can be accessed here.

12/11/2018 19:55
Round table with Sir Michael Marmot on health inequities

​Round table with Sir Michael Marmot on health inequities

On 8 November 2018, the SDC had the fantastic opportunity to welcome Sir Michael Marmot – a renowned leading and inspiring figure in addressing social and economic determinants of health and health inequities – to discuss on how to unpack and address drivers of inequities.

Together with the other panelists, Pierre-Yves Maillard (State Councilor Canton of Vaud, and Head of the Department of Health and Social Action), Serge Houmard (Co-Head Section Health Equity, Federal Office of Public Health) and Patrick Bodenmann (Associate Professor, MSc, Holder of the Chair of Medicine for Vulnerable Populations, University of Lausanne, and Head of Centre for Vulnerable Populations PMU (University Medical Policlinic)) we also discussed how to build on Swiss experiences in offering inclusive service provision for vulnerable populations.

We’d like to use this opportunity to draw your attention to two new infographics the SDC has put together on the topic of health inequity: Facts on Health Inequity and the Factsheet Inequity through life-course.

In case you were not able to participate in the event, you are welcome to listen in to it:

You’ll find more information on the background of the event here.

12/11/2018 19:40
Call: Looking for a new SUN Donor Network Facilitator in Switzerland

​Call: Looking for a new SUN Donor Network Facilitator in Switzerland

SDC is conducting a tender to procure a new SUN Donor Network Facilitator from 01.02.2019-31.12.2020 (optional for 3 additional years until 2023) in Switzerland.
 
SDC is looking for a legal or natural person with experience in food security, nutrition, health, WASH (water, sanitation, hygiene) or a related field and proven skills to act as a coordinator of the Scaling-up Nutrition (SUN) Movements Donor Network. The mandate requires a continuous physical presence in Switzerland and consists of facilitating and coordinating the regular exchange and joint strategic development of the SUN Donor Network. This requires proven competencies in network coordination, multicultural communication, results-based negotiation, efficient documentation and strategic visioning regarding nutritional challenges.
 
Further information can be found on the SIMAP platform: www.simap.ch (Project-ID 177849)
Deadline for the submission of the bids: 5.12.2018.
07/11/2018 18:17
High quality health systems – high time for a revolution

High quality health systems – high time for a revolution

The Lancet Global Health Commission on High-Quality Health Systems in the SDG Era has a clear message: improving quality is imperative and it will require health system-wide interventions that many of the authors refer to as a “health system quality revolution”. The framework offers links five foundational pillars of health systems (population, governance, platforms, workforce, and tools) to processes of care which, as they impact positively on quality, feedback in a virtuous cycle. Primary care is a fundamental service delivery platform in many health systems that is highly sensitive to quality. Poor-quality primary care leads to poor health outcomes because it engenders inadequate diagnosis and treatment of health conditions. It derails the health system by introducing inefficiencies and encouraging waste of resources through underuse of effective care or overuse of unnecessary care. It discourages patients to seek care and increases inequalities.

In the first article of the report commissioned by the Lancet, Dr Tedros Adhanom Ghebreyesus Director General of the World Health Organization (WHO) asks How could health care be anything other than high quality?. He argues that without quality, universal health coverage (UHC) remains little more than an empty promise. Even with increased access to services, health improvements are not made unless services are of sufficient quality to be effective. For example, in some countries, increasing the proportion of births that happen in health facilities has not always translated into reductions in maternal mortality. Likewise, some populations experience inadequate control of hypertension despite increased access to treatment. Health facilities without adequate water, sanitation and hygiene can be a source of health-care-associated infections and health plans for disease outbreaks fail with poor infection control practices, expired medicines, or unmaintained vehicles.

Rubinstein et al in their article Quality first for effective universal health coverage in low-income and middle-income countries states that the Commission proposes that health systems be judged mainly on their population impact, equitable distribution of health gains, improvement of processes of care through the translation of scientific evidence into better patient care, reduction of waste and increased financial protection, and confidence and positive experiences of people and users to ensure that UHC shifts from being  aspirational to actual.

In Al-Janabi et al’s article Bellagio Declaration on high-quality health systems: from a quality moment to a quality movement reflects on this year’s Bellagio Forum for High-Quality Health Systems that brought together policymakers, global stakeholders including SDC, and academics to discuss how to turn the Lancet Commission’s results into action. This included endorsing a new definition of high-quality health systems as those that consistently deliver services that improve or maintain health, are trusted by people, and can adapt to changing needs and health shocks. This emphasises that health systems must become more people-centred, equitable, efficient, and resilient.

Articles are presented in the Global Health Commission on country case studies from Mexico, South Africa, Tanzania and Nepal. These can be accessed here.

19/10/2018 17:38
World Mental Health Day 2018

​World Mental Health Day 2018

Adolescence and the early years of adulthood are a time of life when many changes occur, for example changing schools, leaving home, and starting university or a new job. For many, these are exciting times. However, they can also be times of stress and apprehension. In some cases, if not recognized and managed, these feelings can lead to mental illness.

The expanding use of online technologies, while undoubtedly bringing many benefits, can also bring additional pressures, as connectivity to virtual networks at any time of the day and night grows.

Read more about the importance of better understanding the illness and building mental resilience – after all, prevention begins with better understanding!

10/10/2018 16:54
Cervical cancer and HIV—two diseases, one response

​Cervical cancer and HIV—two diseases, one response

More than 500, 000 women each year develop cervical cancer as a result of infection by the human papillomavirus (HPV) through sexual transmission, half of whom die. HPV infection can be prevented by a combination of vaccination, health promotion and education, screening and treatment. 

If infection is detected early it can be successfully treated to halt progression of the disease. UNAIDS argues that existing HIV programmes have the potential to play a strategic role in expanding cervical cancer prevention services. In its article published on October 1, UNAIDS predicts that if cervical cancer prevention, screening and treatment efforts are not urgently scaled up, it is projected that this number could double by 2035. 

Although most cases of invasive cervical cancer caused by HPV are preventable, the majority of cases occur in low- and middle-income countries (LMICs), where cervical cancer screening and early treatment are uncommon. Pap smear screening that is widely used in high-income countries is expensive and challenging for implementation in LMICs, where lower-cost, effective alternatives such as visual inspection with acetic acid (VIA) and rapid HPV based screening tests offer promise for scaling up prevention services in resource-poor settings.

The UNAIDS campaign is supported by multiple studies that have confirmed that HIV-positive women are  four to five times more likely to develop cervical cancer when co-infected with HPV. 

The UNAIDS news release can be accessed here: http://www.unaids.org/en/resources/presscentre/featurestories/2018/october/cervical-cancer-and-hiv

More information on the approach can be accessed here: http://www.unaids.org/sites/default/files/media_asset/JC2851_HPV-HIV-cervicalcancer_en.pdf

09/10/2018 08:54
Multiple drivers of antimicrobial resistance identified with global policy implications

​Multiple drivers of antimicrobial resistance identified with global policy implications

There is increasing concern globally over the rise in antimicrobial resistance (AMR). This is the ability of micro-organisms such as bacteria, viruses, and some parasites to prevent medicines such as antibiotics, antivirals and antimalarials, from working effectively against them. Multidrug-resistant bacteria that develop in any country or region have been shown to spread rapidly and antimicrobial resistance is recognised as a One Health problem (i.e. requiring multiple sectors to work together in designing and implementing programmes, policies, legislation and research to effect improved public health outcomes).


A study published this month by Collignon, et al, entitled “Anthropological and socioeconomic factors contributing to global antimicrobial resistance: a univariate and multivariable analysis” analysed a number of potential socio-economic drivers of AMR, in addition to antibiotic consumption and antimicrobial resistance levels. It is the first study to examine how several factors affect antimicrobial resistance at the global level.

The multivariate analysis showed that better infrastructure and governance, GDP per capita, education, and public health-care spending were significantly associated with lower antimicrobial resistance, but that antibiotic consumption was not significantly associated with higher antimicrobial resistance.  In other words, antibiotic consumption explains only partly antimicrobial resistance levels. These findings have major policy implications as intervention measures currently focus on decreasing antibiotic consumption. The study has shown that reducing antibiotic consumption alone will not be sufficient to control antimicrobial resistance, because contagion—the spread of resistant strains—seems to be the dominant factor. Therefore,  improving sanitation, increasing access to clean water, ensuring good governance, as ell as increasing public health-care expenditure all need to be addressed to reduce global antimicrobial resistance.

The full article can be accessed here, as well as in the  Lancet Volume 2, ISSUE 9, Pe398-e405, September 01, 2018.

17/09/2018 10:00
Cost–effectiveness of risk-based breast cancer screening

Cost–effectiveness of risk-based breast cancer screening

Breast cancer, in common with a number of NCDs, is a potentially curable disease if diagnosed and treated at an early stage. Although early detection and treatment have been widely adopted in high-income countries for more than 30 years using population-based mammography, studies have shown the approach to be economically unattractive to LMICs such as China, Ghana and Iran.

Li Sun, et al this month published a study: “Cost–effectiveness of risk-based breast cancer screening programme, China” in the WHO Bulletin (Volume 96, Number 8, August 2018, 568-577) that can beaccessed here. The article provides evidence that high-risk population-based breast cancer screening programme can contribute to a much higher detection rate and at the same time be cost-effective. The study is based on data generated since the Government of China’s launch in 2012 of a cancer screening programme in 14 cities.

Women aged 40–69 years where invited to health facilities and individual cancer scores were calculated by attributing risk scores to factors such as family history, height, age of first menstruation, age of first birth, number of births, age at menopause, use of oral contraceptives, oestrogen replacement, heritage linked to a higher prevalence of BRAC1/2 gene mutations and exposure to ionizing radiation. A total of 198,097 women subsequently underwent mammography and ultrasound, and those with indications of cancer underwent biopsy and positive cases were treated.

The findings in this large-scale study in China show high-risk population-based breast screening to be cost–effective, which provides economic information to support policy for more equitable access to cancer screening in LMICs. Evidence such as this has the potential to encourage stronger investment in early diagnosis and treatment of cancer patients to improve health outcomes and reduce mortality.

03/09/2018 12:34
Adapting tools for tackling NCDs in different country settings

​Adapting tools for tackling NCDs in different country settings


More than 90% of premature and preventable deaths from NCDs, including cardiovascular disease, cancers, chronic lung diseases and diabetes, occur in low- and middle-income countries. They are linked to four established risk factors: tobacco use, unhealthy diet, physical inactivity and harmful use of alcohol. The World Health Organisation (WHO) website provides access to a number of useful tools providing information from the Global Health Observatory and visual materials, such as maps of risk, some of which are interactive. These are useful for gaining rapid overall and country-specific data as well as materials for presentations and reports. There are eight specific topic pages that include, for example:


The burden of prolonged morbidity and disability that accompany the rise in NCDs places a substantial burden on health systems as well as households that are impacted by reduced income and productivity by affected members and the need for home-based care.


The WHO Package of Essential Noncommunicable Disease Interventions (WHO PEN) for primary care is an action-oriented set of cost-effective interventions that can be delivered in resource-poor settings. It was designed to enable early detection and management of cardiovascular diseases, diabetes, chronic respiratory diseases and cancer to prevent life-threatening and disabling conditions such as heart attacks, stroke, kidney failure, amputations, and blindness. Details of PEN can be accessed here. WHO has published generic for adaptation and implementation here.

An example of adaptation to a particular country setting is set out in a recent publication in the Bulletin of the World Health Organisation by a consortium of organisations from Switzerland, the Netherlands, Samoa and Denmark. The artilce discusses how the WHO PEN package was adapted to the Samoan national setting of high NCD risk among the general population, combined with a shortage of health staff and unequally distributed health resources. The article: “Adapting the WHO package of essential noncommunicable disease interventions, Samoa” by Bollars et al describes a community participatory approach, whereby village chiefs nominated representatives including some of their local Women’s Committees as voluntary facilitators whose role was to regularly inform their communities of planned events such as NCD screening performed in village halls by health staff. The full article published this month (Bull World Health Organ. 2018 Aug 1;96(8):578-583. doi: 10.2471/BLT.17.203695. Epub 2018 Jun 28.) can be accessed here. This shows the central importance of community participation to the success of screening programmes and awareness of the symptomless nature of early stage NCDs to enable early detection of NCDs and timely intervention.

22/08/2018 17:27
End to recent Ebola outbreak in DRC

​End to recent Ebola outbreak in DRC

In Kinshasa on 24th July 2018, the World Health Organization (WHO) announced the end of the ninth outbreak of Ebola virus disease in the Democratic Republic of the Congo (DRC).  Also known as Ebola haemorrhagic fever, it is transmitted to people from wild animals and spreads through human-to-human transmission and has an average case fatality rate of around 50%, but has varied from 25% to 90% in past outbreaks.


This May 2018 outbreak presented particular challenges, as unlike previous occurrences (for example the 2014–2016 outbreak in West Africa), it involved four separate locations, including an urban centre with river connections to the capital and remote rainforest villages, as well as with neighbouring countries, raising initial concerns of a rapid spread.

WHO appeared to have learnt from blistering criticism of its slow and inadequate response to the 2014-16 outbreak (reported on the Health Network Shareweb August 2015), by rapidly releasing USD 2 million from its Contingency Fund for Emergencies on the same day as the outbreak was declared in May, and later scaling this to USD 4 million. It also deployed a team to support capacity in the field, and activated an emergency incident management system. The Office for the Coordination of Humanitarian Affairs (OCHA) Financial Tracking Service revealed that recent appeal with partners for USD57 million to halt the latest Ebola outbreak was exceeded with a total funding of  USD 63 million received by all partners.

Ring vaccination, whereby only those who are most likely to be infected are vaccinated, was used a strategy to inhibit the spread of Ebola this year. This has been led by the National Institute of Biomedical Research and the Ministry of Health of DRC, working with a wide range of partners, including WHO, Médecins sans Frontières and UNICEF. Gavi, the Vaccine Alliance, contributed funds and through an agreement with the vaccine developer Merck, helped ensure that 300,000 doses of the vaccine are available on standby in case of an outbreak. The vaccination has been provided to the contacts of confirmed cases, and the contacts of contacts, as well as healthcare workers, front line responders and other people with potential exposure to Ebola.

The Africa regional response was particularly strong, with more than three-quarters of the 360 response personnel being deployed from the region, including dozens of experts in ring vaccination from Guinea. In the process Guinea transferred its expertise to the DRC, equipping its own personnel to respond effectively during the May outbreak as well as in the case of future need.

A short commentary by Joseph Lewnard of the Harvard School of Public Health published recently in the Lancet “Ebola virus disease:11,323 deaths later, how far have we come?” provides an concise reflection on the handling and lessons learned from the recent outbreak. This can be accessed here and The Lancet Vol 392, July 21, 2018 pp 189-190.

25/07/2018 11:00
Underway: the 22nd International AIDS Conference

Underway: the 22nd International AIDS Conference

The AIDS conference this week (23-27 July 2018) in Amsterdam is showcasing the latest research on vaccines and other prevention tools; new lessons learned from the scale-up of pre-exposure prophylaxis (PrEP) and other proven interventions; as well as innovative strategies for key populations, such as adolescents and young adults.

Some of the programme highlights of the latest scientific findings include:

  • The first long-term results from APPROACH, an HIV vaccine study evaluating the safety and immune response provoked by multiple regimens.

  • New research on the potential for broadly-neutralizing antibodies (bNAbs) that work by defending cells from infectious agents by neutralizing its effects to prevent transmission.

  • Insights into how the menstrual cycle affects the risk of HIV acquisition.

  • Innovations in epidemiology, including the use of molecular surveillance to help guide HIV prevention strategies.

  • An assessment of the likelihood of controlling the HIV epidemic among adolescents in sub-Saharan Africa by 2030.

  • New data on long-term HIV incidence trends in eastern and southern Africa.

Conference bulletins and newsfeeds in a variety of languages are being published daily online by aidsmap and can be accessed here.

Given the low funding priority of HIV and AIDS in recent years, the conference not only plays an important role in highlighting exciting advances in HIV prevention science to stakeholders and professionals, but also among the general public through the publicity associated with a celebrity presence including entertainer Elton John and the British Prince Henry.

25/07/2018 10:52
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