Biobanking in LMIC settings for infectious diseases: Challenges and enablers

Biobanking facilities are well established in high-income settings,where substantial funding has been invested in infrastructure.In contrast,such facilities are much less developed in resource-restricted settings.However,low-and middle-income countries(LMICs)still face a disproportionately high infectious diseases burden.Thus,the further development of infrastructure facilities,including biobanks is warranted as an important component of this unfolding clinical research environment.This perspective manuscript summarises the challenges and enablers for biobanking in LMICs,with a particular focus on infectious diseases,incorporating some of the lessons learned from the recent coronavirus disease 2019(COVID-19)pandemic.

Burnout and mental distress among community health workers in low- and middle-income countries: a scoping review of studies during the COVID-19 pandemic

Community health workers(CHWs)represent the backbone of primary health systems,especially in many low-and middle-income countries(LMICs).The coronavirus disease 2019(COVID-19)pandemic stretched health sys-tems and increased the workload for CHWs.The objective of this scoping review was to identify the mental health symptoms experienced among CHWs in LMICs during the COVID-19 pandemic.We searched PubMed for published literature,from January 1,2020 to December 31,2022 that focused on documenting the experiences of burnout,distress,and mental health symptoms among CHWs in LMICs.The quality of included studies was assessed using the Joanna Briggs Institute Critical Appraisal Tool.Included studies were grouped into the follow-ing broad thematic categories:(1)symptoms experienced;(2)drivers of different mental health symptoms;and(3)strategies for coping with different symptoms.We identified 10 cross-sectional,qualitative,and observational studies from 11 LMICs in South and Southeast Asia,South America,and Eastern/Southern Africa that assessed the mental health burden CHWs faced during the pandemic.The studies identified disorders and symptoms such as depression,anxiety,fear,burnout,worsened stress,and fatigue.Contributing factors included increased work-load,financial constraints,and an understaffed and underequipped workplace.CHWs reported using different adaptive responses like humor,support from family and colleagues,denial,and substance use,and asked for recommended regular mental health checkups and counseling.More research and policies should be targeted to-wards promoting the mental wellbeing of CHWs to help ensure responsive and resilient health systems in LMICs in the face of future emerging public health threats.

Reasons for Elective Surgery Cancellations in a Senegalese Pediatric Surgery Department

Introduction: Cancellation of elective surgery is common in developing countries. This decision is difficult to make as it generates economic and organizational consequences for the healthcare facility and an additional source of stress for patients and their caregivers. This study aimed to analyze the various aspects of this medical problem. Patients and Methods: We conducted a prospective and descriptive study over six months (from January 1st, 2017, to June 30th, 2017) at the pediatric surgery department of Aristide Le Dantec University Teaching Hospital in Senegal. Results: Ninety-one cases were collected. The cancellation rate was 20.8%. Infants were affected in 36.3% of cases. Among anesthesiologists, 83.5% were residents, and 16.5% were specialists. Cancellation in nephroblastoma children with an indication for extended nephrectomy represented 15.4% of cases. Concerning reasons for cancellation, comorbidities, dominated by respiratory infections, accounted for 28.5% of cases, patient absences for 24.2%, and issues related to the anesthesiologist for 17.6%. Cancellations were avoidable in 33% of cases. Patients were responsible for cancellation in 37.4% of cases, the healthcare system in 33%, and medical reasons in 29.7%. Conclusion: Our findings suggest that one-third of cancellations could have been avoided with improvements in the healthcare system. Actions should be taken to reduce the cancellation rate in our context.

关于健康社会决定因素研究的博士及博士后人才培养案例

全球特别是中低收入国家的健康及健康不公平问题日益严峻,这些国家缺乏健康社会决定因素研究能力,无法有效地参与国家和国际卫生政策的改革,实现健康公平。面对这一问题和挑战,中低收入国家亟需进行医学教育的创新和改革,培养一批从事健康社会决定因素研究的人才。在此背景下,"加强亚洲地区健康社会决定因素研究能力(Asian Regional Capacity Development for Research on Social Determinants of Health,ARCADE-RSDH)"应运而生。该项目通过国际化强强合作,应用混合教学模式,培养一批在健康社会决定因素研究领域学有所长的博士和博士后人才,以提高中低收入国家在健康社会决定因素领域的研究能力,力图解决当前的健康不公平问题。对该项目的研究背景、定位和实施、教学创新等方面作了简要概述。

Environmental health perspectives for low- and middle-income countries

In recent decades, the ecological environment has been increasingly challenged by the development of global industrialization and urbanization all over the world, even as global attention for health has raised dramatically. Common global environmental issues, such as air pollution and noise pollution, are associated with lasting impacts on health and contribute significantly to the overall burden of disease. Moreover, a global disparity exists between the burden of such environmental health issues and the global resources available to address this issue. To alleviate the environmental health impacts and ensure a sustainable future for human beings, China has made an important contribution to improving access to ecological protection, environmental governance, patriotic health campaigns, smart city construction, and so on. Experiences gained in China may be useful for some other countries, particularly the low- and middle-income countries with limited sources.

Hospitals’responsibility in response to the threat of infectious disease outbreak in the context of the coronavirus disease 2019(COVID-19)pandemic:implications for low-and middle-income countries

The WHO declared the coronavirus disease 2019(COVID-19)outbreak as a public health emergency of international concern on January 30,2020,and then a pandemic on March 11,2020.COVID-19 affected over 200 countries and territories worldwide,with 25,541,380 confirmed cases and 852,000 deaths associated with COVID-19 globally,as of September 1,2020.1 While facing such a public health emergency,hospitals were on the front line to deliver health care and psychological services.The early detection,diagnosis,reporting,isolation,and clinical management of patients during a public health emergency required the extensive involvement of hospitals in all aspects.The response capacity of hospitals directly determined the outcomes of the prevention and control of an outbreak.The COVID-19 pandemic has affected almost all nations and territories regardless of their development level or geographic location,although suitable risk mitigation measures differ between developing and developed countries.In low-and middle-income countries(LMICs),the consequences of the pandemic could be more complicated because incidence and mortality might be associated more with a fragile health care system and shortage of related resources.2-3 As evidenced by the situation in Bangladesh,India,Kenya,South Africa,and other LMICs,socioeconomic status(SES)disparity was a major factor in the spread of disease,potentially leading to alarmingly insufficient preparedness and responses in dealing with the COVID-19 pandemic.4 Conversely,the pandemic might also bring more unpredictable socioeconomic and long-term impacts in LMICs,and those with lower SES fare worse in these situations.This review aimed to summarize the responsibilities of and measures taken by hospitals in combatting the COVID-19 outbreak.Our findings are hoped to provide experiences,as well as lessons and potential implications for LMICs.

Can health technology assessments assist the global campaign against poverty?

Although a key tenant of the Sustainable Development Goals is to achieve universal health coverage,the global drug gap persists-cver a third of the global population lack access to essential medicines.Without access to affordable drugs,people have worse health outcomes,higher medical expenses,and productivity loss,pushing them into poverty.Health technology assessments(HTAs)offer an opportunity to decrease the global drug gap and increase access to essential medicines by overcoming barriers to medicine access.These barriers include drug procurement,drug affordability for payers and patients,a patienfs ability to obtain essential medicines,and health system capacity.Using HTAs can therefore close the global drug gap by increasing access to affordable essential medicines.In turn,people have better health outcomes,spend less money on medical care,and can have better productivity.Ultimately,use of HTAs can lift the population out of poverty and force fewer people into poverty by creating better health outcomes at affordable prices.

Evaluation of a multidisciplinary global health online course in Mexico

Background:Global Health Education(GHE)focuses on training proactive global citizens to tackle health challenges in an increasingly interconnected and interdependent world.Studies show that health professionals in training have reported that GHE has improved their teamwork,responsiveness to contextual factors that impact health,and understanding of health systems;however,there is little research on the impact of GHE courses in undergraduate settings,especially in low and middle-income countries(LMICs).Methods:Our study analyzes a multidisciplinary online global health course at Tecnologico de Monterrey,México.We conducted a cross-sectional study with pre-and post-design.Students who took the multidisciplinary course of Global Health for Leaders in the Fall of 2019(n=153)and Spring of 2020(n=348)were selected for this study.Using a five-point Likert scale(strongly agree to strongly disagree),the survey assessed seven competencies as well as questions about course expectations,takeaways,and recommendations to improve the course.We performed descriptive statistical analyses comparing the combined pre-tests(from Fall and Spring cohorts)to the combined post-tests.Fisher’s exact test was used to compare the samples.Results:Of the 501 pre-course surveys administered,456 responses were completed in the pre-course and 435 in the post-course(91%overall response rate).Only 8.7%of the respondents in the pre-course survey strongly agreed that they could describe fundamental aspects of global health such as the Millennium Development Goals or Sustainable Development Goals,in contrast to a 56%of the students who strongly agreed in the post-course survey(p<0.001).Similar differences were captured in understanding the global burden of disease,social determinants of health,the effects of globalization in health,health systems’goals and functions,and human rights.38%felt that the course helped them develop a more empathetic perception of the suffering of others experiencing global health-related issues.Conclusion:In this study,we have presented our experience in teaching an online global health course for multidisciplinary undergraduates in a LMIC.The competencies reported by our students indicate that the course prepared them to confront complex global health issues.

Perceptions of Nurses on Patient Outcomes Related to Nursing Shortage and Retention Strategies at a Public Hospital in the Coastal Region of Tanzania

Background: There is little disagreement that the shortage of nurses affects patients’ outcomes globally. However, within the low and middle income country setting, there is minimal known about the perceptions of nurses on nursing shortages impact the health outcomes of their patients and what recruitment and retention strategies might be appropriate to address some of these challenges. This study explored the perceptions of nurses on the health outcomes of patient related to shortage of registered nurses and the strategies to retain nurses at a public hospital in Tanzania. Method: This qualitative descriptive study used semi-structured in-depth interviews with a select group of nurses in a large public hospital. Findings: Through an iterative coding process, a series of categories were derived which yielded three major themes—factors contributing to nursing shortage;compromised quality of care;and recruitment and retention strategies. Conclusion: A shortage of nurses affects the health outcomes of patients as it potentially hinders timely accomplishment of the optimal nursing. Efforts need to be proactive in recognizing the reasons for nursing shortages which are rooted in individual, institutional (agency), and organizational (systemic) issues. Within the LMIC context, such as where this study was conducted, it became apparent that the nurses wanted acknowledgement and opportunities to work collaboratively towards the resolution of workload issues for the benefit of the patients.

Minor Gynecologic Surgery: A Review of the Training Experience and Skill Building Opportunities for Providers in Low and Middle Income Countries

Purpose: Minor gynecologic surgery is the cornerstone of gynecologic evaluation and intervention in countries with a well-established medical infrastructure. Surgical training and exposure to minor procedures are not available in low and middle-income countries due to the complex challenges of patient delay and lack of access to healthcare, physician shortages, and the lack of ancillary services such as pathology and radiology. This paper reviews current training statistics, the international literature on minor gynecologic surgery and training strategies. Methods: PubMed searches using MESH terms cone biopsy, dilation and curettage, and loop electrosurgical excision procedure were performed. Statistics of minor surgical procedures among US Obstetrics and Gynecology Residency programs were tabulated. We then searched for data of training programs and surgical statistics in low resource countries. Results:Dilation and curettage is the most common minor gynecologic procedure in the United States but is performed with significantly lower frequency in low and middle-income countries. The most common procedure for the treatment of preinvasive disease was cryotherapy followed by loop electrosurgical excision procedure. There was no information about minor surgical procedures performed in hospitals in low and middle-income countries. Statistics from four-year American training programs showed an average of 209 minor cervical procedures performed annually. Conclusion: Expertise in minor gynecologic procedures is vital and requires the development of both adequate training programs and local medical infrastructure. Strategies for training in minor surgery for providers in low and middle-income countries include online curriculums, mentored relationships with senior physicians, and simulation models.

Can the Urine Dipstick Test Be an Alternative in the Screening of Urinary Tract Infections for Inpatients in the Context of a Low-Income Country?

Background: Urinary Tract Infection (UTI), a prevalent bacterial infection in adults, heavily relies on cytobacteriological examination of urine (CBEU) for diagnosis. However, in resource-limited countries, accessibility to CBEU remains hindered by cost and availability. This study aims to assess the utility of the Urinary Dipstick Test (UDT) in diagnosing UTIs among hospitalized patients in the context of limited resources. Methods: A cross-sectional study was conducted from February to May 2019, encompassing hospitalized patients who underwent CBEU at the bacteriology unit of Sour? Sanou University Hospital. UDT and CBEU were concurrently performed, and UDT’s analytical and diagnostic performance was evaluated against CBEU, considered the gold standard. Results: A total of 274 CBEU requests were registered, involving 274 patients (159 males) with a mean age of 45.8 ± 21.3 years (ranging from 1 to 90 years). UTI was confirmed in 90 patients, yielding a frequency of 32.85%. The UTI bacteriological profile was dominated by Enterobacteriaceae (75.23%), primarily Escherichia coli (60.55%). Nitrite and Leukocytes were positive in 54 (19.8%) and 157 (53.6%) of the samples tested. Among patients with confirmed UTI, Nitrite, and Leukocytes were positive in 30 (33%) and 71 (79%) patients respectively. UDT demonstrated variable performance based on nitrite and leukocyte combination: Sensitivity (57%-82%), Specificity (7%-98%), Positive Predictive Value (PPV) (43%-57%), Negative Predictive Value (NPV) (43%-67%). UDT performed slightly better in women (NPV = 88%) and inpatients without urinary catheters (NPV = 75% and PPV = 80%). Conclusion: This study underscores UDT’s potential utility in excluding UTIs among women, younger patients, and inpatients without urinary catheters, albeit with limited confidence. The UDT emerges as a complementary tool for UTI screening, particularly in resource-limited settings.

Lessons from the coronavirus disease 2019(COVID-19)pandemic response in China,Italy,and the U.S.:a guide for Africa and low-and middle-income countries

Africa can be"left behind"after other advanced continents recover from the coronavirus disease 2019(COVID-19)pandemic as reflected by the global pandemic of HIV/MDS.In this paper,we summarize potentially adaptable,effective and innovative strategies from China,Italy,and the U.S.The purpose is to help African countries with weaker healthcare systems better respond to the COVID-19 pandemic.China,being the first to report COVID-19 infection swiftly swung into anti-epidemic actions by the use of innovative risk communication and epidemic containment strategies.Italy and U.S.,the next rapidly hit countries after China,however,experienced sustained infections and deaths due to delayed and ineffective response.Many African countries responded poorly to the COVID-19 pandemic as evidenced by the limited capacity for public health surveillance,poor leadership,low education and socioeconomic status,among others.Experience from China,Italy and U.S.suggests that a better response to the COVID-19 pandemic in Mrica needs a strong public health leadership,proactive strategies,innovative risk communication about the pandemic,massive tests and isolation,and scaling-up community engagement.Lastly,African countries must collaborate with other countries to facilitate real-time information and experience exchange with other countries to avoid being left behind.

Assessment and validation of the Community Maternal Danger Score algorithm

Background:High rates of maternal mortality in low-and-middle-income countries(LMICs)are associated with the lack of skilled birth attendants(SBAs)at delivery.Risk analysis tools may be useful to identify pregnant women who are at risk of mortality in LMICs.We sought to develop and validate a low-cost maternal risk tool,the Community Maternal Danger Score(CMDS),which is designed to identify pregnant women who need an SBA at delivery.Methods:To design the CMDS algorithm,an initial scoping review was conducted to identify predictors of the need for an SBA.Medical records of women who delivered at the Federal Medical Centre in Makurdi,Nigeria(2019-2020)were examined for predictors identified from the literature review.Outcomes associated with the need for an SBA were recorded:caesarean section,postpartum hemorrhage,eclampsia,and sepsis.A maternal mortality ratio(MMR)was determined.Multivariate logistic regression analysis and area under the curve(AUC)were used to assess the predictive ability of the CMDS algorithm.Results:Seven factors from the literature predicted the need for an SBA:age(under 20 years of age or 35 and older),parity(nulliparity or grand-multiparity),BMI(underweight or overweight),fundal height(less than 35 cm or 40 cm and over),adverse obstetrical history,signs of pre-eclampsia,and co-existing medical conditions.These factors were recorded in 589 women of whom 67%required an SBA(n=396)and 1%died(n=7).The MMR was 1189 per 100,000(95%CI 478-2449).Signs of pre-eclampsia,obstetrical history,and co-existing conditions were associated with the need for an SBA.Age was found to interact with parity,suggesting that the CMDS requires adjustment to indicate higher risk among younger multigravida and older primigravida women.The CMDS algorithm had an AUC of 0.73(95%CI 0.69-0.77)for predicting whether women required an SBA,and an AUC of 0.85(95%CI 0.67-1.00)for in-hospital mortality.Conclusions:The CMDS is a low-cost evidence-based tool that uses 7 risk factors assessed on 589 women from Makurdi.Non-specialist health workers can use the CMDS to standardize assessment and encourage pregnant women to seek an SBA in preparation for delivery,thus improving care in countries with high rates of maternal mortality.

Impact of federalization for health financing and workforce in Nepal

The adoption of its 2015 constitution has converted Nepal to a federal government while simultaneously resulted in significant reforms of the health system in Nepal in terms of both structure and commitment.In this commentary,we review evidence ranging from health financing to health workforce development to show that the impact of federalization on Nepal’s health system and its efforts to achieve equitable and affordable universal health care have been mixed.On the one hand,careful efforts of the federal government to support subnational governments during the transition appears to have avoided serious disruption,subnational governments have successfully taken on the financial burden of the health system,and increase subnational control has allowed more flexible adaptation to changing needs than might have otherwise been possible.On the other hand,financing resource and ability disparities across subnational governments contributes to significant disparities in workforce development,and subnational authorities appear to have underestimated significant health issues(e.g.NCDs)in their budgets.We then provide three recommendations to improve the success of the Nepalese system:(1)to assess whether the services covered by health financing and insurance schemes like the National Health Insurance Program adequately address the needs of the rising burden of NCDs in Nepal,(2)to set clear minimum requirements on key metrics for subnational health systems,and(3)to extend grant programs to address resource disparities.

Hospitalized for poverty:orthopaedic discharge delays due to financial hardship in a tertiary hospital in Northern Tanzania

Background:Musculoskeletal injury contributes significantly to the burden of disease in Tanzania and other LMICs.For hospitals to cope financially with this burden,they often mandate that patients pay their entire hospital bill before leaving the hospital.This creates a phenomenon of patients who remain hospitalized solely due to financial hardship.This study aims to characterize the impact of this policy on patients and hospital systems in resource-limited settings.Methods:A mixed-methods study using retrospective medical record review and semi-structured interviews was conducted at a tertiary hospital in Moshi,Tanzania.Information regarding patient demographics,injury type,days spent in the ward after medical clearance for discharge,and hospital invoices were collected and analyzed for orthopaedic patients treated from November 2016 to June 2017.Results:346 of the 867 orthopaedic patients(39.9%)treated during this time period were found to have spent additional days in the hospital due to their inability to pay their hospital bill.Of these patients,72 patient charts were analyzed.These 72 patients spent an average of 9 additional days in the hospital due to financial hardship(range:1-64 days;interquartile range:2-10.5 days).They spent an average of 112,958 Tanzanian Shillings(TSH)to pay for services received following medical clearance for discharge,representing 12.3%of the average total bill(916,840 TSH).646 hospital bed-days were spent on these 72 patients when they no longer clinically required hospitalization.7(9.7%)patients eloped from the hospital without paying and 24(33.3%)received financial assistance from the hospital’s social welfare office.Conclusions:Many patients do not have the financial capacity to pay hospital fees prior to discharge.This reality has added significantly to these patients’overall financial hardship and has taken hundreds of bed-days from other critically ill patients.This single-institution,cross-sectional study provides a deeper understanding of this phenomenon and highlights the need for changes in the healthcare payment structure in Tanzania and other comparable settings.

Effective antimicrobial therapies of urinary tract infections among children in low-and middle-income countries:A systematic review

Importance:Urinary tract infection(UTI)is one of the most common infections encountered in infancy and childhood.Despite the emerging problem of antibiotic resistance in recent years,the use of antibiotics for better management of UTIs is inevitable.Objective:This study aims to explore the efficacy and adverse effects of the available antimicrobial agents that are used in pediatric UTIs in low-and middle-income countries(LMICs).Methods:Five electronic databases were searched to identify relevant articles.Two reviewers independently performed screening,data extraction,and quality assessment of the available literature.Randomized controlled trials providing antimicrobial interventions in both male and female participants within the age range of 3 months to 17 years in LMICs were included.Results:Six randomized controlled trials from 13 LMICs were included in this review(four trials explored the efficacy).Due to high heterogeneity across the studies,a meta-analysis was not performed.Other than attrition and reporting bias,the risk of bias was moderate to high due to poor study designs.The differences in the efficacy and adverse events of different antimicrobials were not found to be statistically significant.Interpretation:This review indicates the necessity for additional clinical trials on children from LMICs with more significant sample numbers,adequate intervention periods,and study design.

Lifestyle behaviours of immigrant and Australian children:Evidence from a nationally representative sample

This study aimed to examine the prevalence of physical activity(PA),screen time(ST),sleep,and fruit and vegetable intake of children with low-and-middle-income countries(LMIC)parents,high-income countries(HIC),and Australian children,and whether these behaviours are associated with their immigrant status.Data for this study were from wave 7 of the Birth cohort(B cohort)of the Longitudinal Study of Australian Children.We used generalized estimating equations(GEE)to examine associations between health behaviours and immigrant status.The models were adjusted for a number of covariates.Children with LMIC parents had lower odds of meeting PA and sleep recommendations and higher odds ratio(OR)of meeting fruit and vegetable intake,and ST recommendations than Australian or HIC children.Children with LMIC parents had one-third the odds of meeting the PA recommendations(OR 0.39[95%CI 0.22–0.70])than Australian children.No significant differences were observed in lifestyle behaviours among children with HIC parents and Australian children.Lifestyle behaviours of children with LMIC parents differed from those of HIC and Australian children.However,children with HIC parents and Australian children had comparable lifestyle behaviours.Identified disparities in lifestyle behaviours among immigrant children can inform strategies to bring equity in Australian children's lifestyles.Our study underscores the importance of culturally appropriate targeted interventions to promote PA and sleep of children with LMIC parents.