Low Middle-income Settings Research Articles

Innovation Solution Sets: Components, Combinations, and Drivers in Low-Middle Income Settings

Innovation is crucial for improving health outcomes in low and middle-income settings (LMIS) in the U.S. and abroad. There has been extensive research on how organizations implement individual innovations separately. There has been less research on how organizations implement sets of innovations, how they are combined, and the drivers for these innovation sets. Furthermore, a lack of supporting infrastructure and challenges that arise from organizational structure and environmental uncertainty in LMIS require a better understanding of a combined approach to innovation. This study introduces the concept of innovation solution sets. We explore the relationship between innovation solution sets, combination approaches as influenced by organizational structure, and innovation drivers through a multi-case study using qualitative and archival information from five healthcare organizations in Repiblik Ayiti (Haiti). We find that organizations tend to combine product/service, business model, and social innovations simultaneously in private organizations and sequentially in public-private partnerships. Drivers of simultaneous combination include limited external support, determined autonomy through external opposition, and financial need identification and the requisite knowledge and will to meet the need. Drivers of sequential combination include social need identification, community connections, and flexibility.

CONGENITAL CYSTIC ADENOMATOID MALFORMATION OF THE LUNG: REPORT OF THREE CASES

TYPE: Late Breaking Abstract TOPIC: Pediatrics PURPOSE: Congenital cystic adenomatoid malformation (CCAM) is a rare abnormality of lung development. It is a benin lesion, typically discovered during a routine prenatal ultrasound. In low-middle income settings, the prenatal diagnosis is not always available, and these malformations are often revealed by respiratory distress during the neonatal period. METHODS: We report a series of three neonates admitted to our pediatric ICU for respiratory distress secondary to CCAM. RESULTS: Three neonates A, B and C were admitted to the pediatric ICU for respiratory distress. They were aged 18 , 21 and 90 days respectfully. Prenatal diagnosis of CCAM was available in one case. Thoracic CT-scan showed CCAM of the inferior left lobe in case A, of the superior and median right lobes in case B, and of the hole right lung in case C. Case A presented with pneumothorax, he underwent a needle aspiration before surgery. Left inferior lobectomy was performed. Case B presented with severe hemodynamic instability and surgery was not performed. He died 3days later. Case C underwent atypical resection of the cystic malformations. In both surgical cases, neonates were admitted to PICU, were extubated 4 hours post-operatively and put on continous positive airway pressure (CPAP) for 24 hours. Oxygen therapy weaning was successful after 48h.They were tranfered to the pediatric surgery ward. CONCLUSIONS: CCAM is a rare malformation causing respiratory distress in neonates. Surgical procedures such as lobectomy or atypical resections are usualy performed. Complications such as pneumothorax may occur before surgery. CLINICAL IMPLICATIONS: Prenatal diagnosis is essentiel to improve the outcome of CCAM. DISCLOSURE: Nothing to declare. KEYWORD: Congenital cystic adenomatoid malformation

Alternatives of Risk Prediction Models for Preeclampsia in a Low Middle-Income Setting

Abstract
 Objectives: To develop prediction models for the first-trimester prediction of PE (PE) using the established biomarkers including maternal characteristics and history, mean arterial pressure (MAP), uterine artery Doppler pulsatility index (UtA-PI ), and Placental Growth Factor (PlGF)) in combination with Ophthalmic artery Doppler peak ratio (PR).
 Methods: This was a prospective observational study in women attending a first-trimester screening at 11-14 weeks’ gestation. Maternal characteristics and history, measurement of MAP, ultrasound examination for UtA-PI measurement, maternal ophthalmic PR Doppler measurement, and serum PlGF collection were performed during the visit. Logistic regression analysis was used to determine if the maternal factor had a significant contribution in predicting PE. The Receiving Operator Curve (ROC) analysis was used to determine the area under the curve (AUC), positive predictive value (PPV), negative prefictive value (NPV) and positive screening cut-off in predicting the occurrence of PE at any gestational age.
 
 Results: Of the 946 eligible participants, 71 (7,49%) subjects were affected by PE. Based on the ROC curves, optimal high-risk cutoff value for prediction of preeclampsia at any gestational age for model 2 (primary care model) in this Indonesia study population were 63% with the sensitivity and specificity of 71.8% and 71.2%, respectively. Both sensitivity and specificity for model 3 (complete model) were 70.4% and 74.9%, respectively for the cutoff value 58%. The area under the curve of model 2, model 3 was 0.7651 (95% CI: 0.7023-0.8279)) and 0.7911 (95% CI: 0.7312-0.8511), respectively, for predicting PE. In addition, PPV and NPV for model 2 were 16.8% and 96.9%, respectively. PPV and NPV for model 3 were 18.55 and 96.9%, respectively.
 
 Conclusion: The prediction models of preeclampsia vary depending upon healthcare resource. Complete model is clinically superior to primary care model but it is not statistically significant. Prognostic models should be easy to use, informative and low cost with great potential to improve maternal and neonatal health in Low Middle Income Country settings.

Outcome of retinoblastoma treatment protocol in Cameroon as per SIOP-PODC recommendation for a low-income setting.

The International Society of Paediatric Oncology-Paediatric Oncology in Developing Countries (SIOP-PODC) group recommended graduated-intensity retinoblastoma treatment for children in low- and middle-income countries with limited local resources. The aim was to improve outcome of children with retinoblastoma by means of a treatment protocol for low-income settings as recommended by the SIOP-PODC recommendation in Cameroon. Children diagnosed with retinoblastoma between 2012 and 2016 were treated in two Baptist Mission hospitals in Cameroon, staging according to the International Retinoblastoma Staging System. Treatment included local therapy and combination chemotherapy (vincristine, cyclophosphamide, and doxorubicin) with or without surgery as per SIOP-PODC guidelines for low-income countries. Endpoint was survival at 24months. Kaplan-Meier curves with log-rank (Mantel-Cox) chi-square (χ2 ) with respective p-values were prepared. Eighty-two children were included, of whom 79.3% had unilateral disease. The majority were males (61.0%) with median age 24months (range 1-112months; standard deviation [SD] 19). Limited disease was diagnosed in 58.5%, metastatic disease in 35.4%, and unknown stage in 6.1%. Overall survival (OS) was 50.0% at 24months post diagnosis, but 68.8% for limited disease. Estimated cumulative survival at 24months was 0.528 (standard error [SE] 0.056). Causes of death included disease progression/relapses (60.5%), neutropenic sepsis (15.9%), unknown causes (18.4%), unrelated infection (2.6%), and death post surgery (2.6%). Stage was significantly associated with OS (p<.001). Stage was the most significant factor for good OS and demonstrated the efficacy and feasibility of the SIOP-PODC-proposed management guidelines for retinoblastoma in a lower middle-income setting.

The Atrial Fibrillation and Oral anticoagulation/Antiplatelet agents Practices in Low Middle-Income settings

Background: Atrial fibrillation (AF) is an arrhythmia which is diagnosed by the finding of irregularly irregular ventricular rhythm without discrete P waves in an electrocardiogram. Atrial fibrillation increases risk for intra-cardiac thrombosis and cerebral vascular event .it is a risk factor for ischemic stroke and affects abouts 33 million people globally and is more common in adults above 65 years. It a common complication among the patients with cardiovascular diseases. Aim of the study: The aim of this study was to audit the use oral anticoagulation/antiplatelet agents in patients with Atrial Fibrillation at Jakaya Kikwete Cardiac Institute Material and methods: A retrospective descriptive cross-sectional audit study which was conducted at Jakaya Kikwete cardiac institute among adult patients with a diagnosis atrial fibrillation. Patients were identified in a medpro systems and their age and sex were documented. Cross checking for the record of risk scores and OAC/antiplatelet prescription was done and recoded in a structured questionnaire which was designed to collect the data. Data analysis: The data entry and analysis were done using statistical package for social sciences (SPSS) version 20.0. Results Of 800 patients. 37(4.6%) were found to have a diagnosis of AF. Among patients with AF, females were 19 (51.4%), those aged 18-39 years were 13 (35.1%) same as those aged 40-64 years, 65+ years were 11 (29.7). Based on the structural/none structural diagnosis among patients with AF, 20 (54.0%) were having valvular heart diseases. and the rate of use of oral anticoagulation/antiplatelet agents was 73%. Among those using oral anticoagulation/antiplatelet agents, 24 (88.9%) were using warfarin, 2 (7.4%) NOAC and 1 (3.7%) was using antiplatelet (table 2). In terms of INR checking 24 (64.9%) were checked. Conclusion and Recommendations The rate of prescription of OAC were high while that for antiplatelet were low. The rate of INR checking in those who were using warfarin were high but not hundred percent. The documentation of risk scores before the prescription of OAC therapy was not done at all. We recommend for the good practice and follow the recommendations from ESC guideline 2020, our local protocol and evidence-based practice for the management of atrial fibrillation

Factors predicting in-hospital all-cause mortality in COVID 19 patients at the Laquintinie Hospital Douala, Cameroon

BackgroundDespite being a global pandemic, little is known about the factors influencing in-hospital mortality of COVID-19 patients in sub-Saharan Africa. This study aimed to provide data on in-hospital mortality among COVID-19 patients hospitalized in a single large center in Cameroon. MethodsA hospital-based prospective follow-up was conducted from March 18 to June 30, 2020, including patients >18 years with positive PCR for SARS-COV-2 on nasopharyngeal swab admitted to the Laquintinie Douala hospital COVID unit. Predictors of in-hospital mortality were assessed using Kaplan Meir survival curves and Weibull regression for the accelerated time failure model. Statistical significance was considered as p < 0.05. ResultsOverall 712 patients (65,7% men) were included, mean age 52,80 ± 14,09 years. There were 580 (67,8% men) in-hospital patients. The median duration of hospital stay was eight days. The in-hospital mortality was 22.2%. Deceased patients compared to survivors were significantly older, had a higher temperature, respiratory rate, and heart rate, and lowest peripheral oxygen saturation at admission. After adjusting for age, sex, and other clinical patient characteristics, increased heart rate, increased temperature, decreased peripheral oxygen saturation. The critical clinical status was significantly associated with increased in-hospital mortality. In contrast, hospitalization duration greater than eight days and the use of hydroxychloroquine (HCQ) + azithromycin (AZM) therapy was associated with decreased risk of in-hospital mortality. ConclusionOne in five hospitalized COVID-19 patients die in a low-middle income setting. Critical clinical status, dyspnea, and increased heart rate were predictors of in-hospital mortality. This study will serve as a prerequisite for more robust subsequent follow-up studies. Also, these results will aid in revising national guidelines for the management of COVID-19 in Cameroon.

232 “SuturesApp”: A Digital Application to Improve Cancer Patients” Understanding of Surgical Procedures

Abstract Aim Patient participation in decision making is of utmost importance, particularly in oncological surgery where body image altering procedures may be required. “SuturesApp” is a digital application developed by oncological surgeons in a low-middle income setting and where users can replicate any resection and/or reconstruction technique on the screen. The study is an interpretation of surgical residents’ opinion of the use of a digital application in comparison to traditional modalities (pen and paper) used to explain surgical procedures to patients. Method This is a qualitative study using semi-structured interviews conducted with surgical trainees following the use of “SuturesApp” for a 1-week period from July 13th to July 20th, 2020, in order to depict possible outcomes of “SuturesApp” use in comparison to pen and paper in explaining surgical procedures and body image changes in oncological surgery. Participants number was determined according to data saturation when no more new themes emerged from the individual interviews. Results Fifteen surgical residents were interviewed after using “SuturesApp'' for a 1-week period in preoperative consultations. Successful patient-surgeon communication faces the challenges of workload and illiteracy, which surgical residents try to overcome with verbal communication and drawing. The use of SuturesApp can provide a frame for the progressive explanation and visualization of procedures, despite the need for improvements. Conclusions The use of SuturesApp alongside verbal communication and drawing can benefit patient understanding and adherence to treatment, as well as future surgeons’ communication skills. A next step would be to further develop “SuturesApp” and engage patients in the process.

Safety in fragile, conflict-affected, and vulnerable settings: An evidence scanning approach for identifying patient safety interventions.

BackgroundThe number of people living in fragile, conflict-affected, and vulnerable (FCV) settings is growing rapidly and attention to achieving universal health coverage must be accompanied by sufficient focus on the safety of care for universal access to be meaningful. Healthcare workers in these settings are working under extreme conditions, often with insufficient contextualized evidence to support decision-making. Recognising the relative paucity of, and methodological issues in gathering evidence from these settings, the evidence scanning described in this paper considered which patient safety interventions might offer the ‘better bet’, eg, the most effective and appropriate intervention in FCV settings.MethodsAn evidence scanning approach was used to examine the literature. The search was limited to FCV settings and low-income settings as defined by the World Bank, but if a systematic review included a mix of evidence from FCV/low income settings, as well as low-middle income settings, it was included. The search was conducted in English and limited to studies published from 2003 onwards, utilising Google Scholar as a publicly accessible database and further review of the grey literature, with specific attention to the outputs of non-governmental organisations. The search and subsequent analysis were completed between April and June 2020.ResultsThe majority of studies identified related to strengthening infection prevention and control which was also found to be the ‘better bet’ intervention that could generalise to other settings, be most feasible to implement, and most effective for improving patient care and associated outcomes. Other prioritized interventions include risk management, with contributing elements such as reporting, audits, and death review processes.ConclusionsInfection prevention and control interventions dominate in the literature for multiple reasons including strength of evidence, acceptability, feasibility, and impact on patient and health worker well-being. However, there is an urgent need to further develop the evidence base, specialist knowledge, and field guidance on a range of other patient safety interventions such as education and training, patient identification, subject specific safety actions, and risk management.

Life-threatening infections during treatment for acute lymphoblastic leukemia on the Malaysia-Singapore 2003 and 2010 clinical trials: A risk prediction model.

Life-threatening infections significantly impact the care of children undergoing therapy for acute lymphoblastic leukemia (ALL) who are at risk of severe sepsis due to both host and treatment factors. Our aim was to develop a life-threatening infection risk prediction model that would allow remote rapid triage of patients to reduce time to first dose of antibiotics and sepsis-related mortality. A retrospective analysis of 2068 fever episodes during ALL therapy was used for model building and subsequent internal validation. Three hundred and seventy-seven patients were treated for ALL in two institutions with comparable critical and supportive care resources. A total of 55 patients accounted for 71 admissions to the critical care unit for sepsis that led to eight septic deaths during a 16-year study period. A retrospective analysis of risk factors for sepsis enabled us to build a model focused on 13 variables that discriminated admissions requiring critical care well: area under the receiver operating characteristic curve of .82; 95% CI .76-.87, p<.001, and Brier score of .033. Significant univariate predictors included neutropenia, presence of symptoms of abdominal pain, diarrhea, fever during induction or steroid-based phases, and the lack of any localizing source of infection at time of presentation. We have developed a risk prediction model that can reliably identify ALL patients undergoing treatment who are at a higher risk of life-threatening sepsis. Clinical applicability can potentially be extended to low-middle income settings, and its utility should be further studied in real-world settings.

Influence of Prognostic Group Classification of Advanced Male Germ Cell Tumor on Treatment Outcomes

Background: Male germ cell tumor is a rare disease, associated with high rates of cure, including in the advanced setting. This disease mostly affects young males aged 15-34 years. The rising incidence trends of germ cell tumors in the last two decades have defined a new priority area of oncology. Objective: To investigate the influence of prognostic group classification and histology on treatment outcomes in men treated in a single institution in Pakistan. Methods: We developed an observational study on fifty male patients diagnosed with advanced germ cell cancer completing first-line treatment, between 2011-2014. Patients with a follow-up time of at least 5 years post-treatment were included. Patients were classified into good, intermediate, and poor prognostic groups, according to the International Germ Cell Cancer Collaborative Group classification (IGCCCG). The outcomes of all three prognostic groups were measured including response to first-line treatment according to Memorial Sloan-Kettering Cancer Center criteria and five years OS. Survival rates were calculated using Kaplan and Meier method. The level of significance was set at P &lt; 0.05. Results: Overall 50 patients were included in the study. The mean age of patients was 30.6 years + 9.49 years. The most common primary site of involvement was the right testicle i.e.56.0%. Complete responses (CR) were observed in 23 (46.0%) patients. The patients classified into the good prognostic group (n=29) had significantly superior (p=0.002) five years OS (86.2%, n= 25) than intermediate and poor groups. Additionally, CR was higher for seminoma-type cancer i.e. 12 (63.15%) while it was limited to 11(35.48%) in non-seminoma; however, the inferior response rate in NSGCT did not translate into statistical significance in 5 years OS. Conclusion: The IGCCCG prognostic grouping system is an effective tool for predicting treatment outcomes in terms of 5-year overall survival in our local population based in a low-middle income setting.

Critical care nursing role in low and lower middle-income settings: a scoping review

ObjectivesA scoping review was conducted to answer the question: How is critical care nursing (CCN) performed in low-income countries and lower middle-income countries (LICs/LMICs)?DesignScoping review guided by the JBI Manual...

Improving antimicrobial use through antimicrobial stewardship in a lower-middle income setting: a mixed-methods study in a network of acute-care hospitals in Viet Nam

ObjectivesThis study aimed to analyse the current state of antimicrobial stewardship (AMS) in hospitals in Viet Nam, a lower-middle income country (LMIC), to identify factors determining success in AMS implementation and associated challenges to inform planning and design of future programmes. MethodsWe conducted a mixed-methods study in seven acute-care hospitals in the antimicrobial resistance (AMR) surveillance network in Viet Nam. Data collection included 7 focus group discussions, 40 in-depth interviews and a self-administered quantitative survey of staff on AMR and AMS programmes. We summarised qualitative data by reporting the most common themes according to the core AMS elements, and analysed quantitative data using proportions and a linear mixed-effects model. ResultsThe findings reveal a complex picture of factors and actors involved in AMS implementation from the national level to the departmental and individual level within each hospital. The level of implementation varied, starting from the formation of an AMS committee, with or without active delivery of specific interventions. Development of treatment guidelines, pre-authorisation of antimicrobial drug classes, and post-prescription audit and feedback to doctors in selected clinical departments were the main interventions reported. A higher level of leadership support and commitment to AMS led to a higher level of engagement with AMS activities from the AMS team and effective collaboration between departments involved. ConclusionEstablishing country-specific guidelines on AMS staffing and adapting standards for AMS education and training from international resources are needed to support capacity building to implement AMS programmes effectively in LMICs such as Viet Nam.

Demographic and clinical factors associated with early hospital Coronovirus disease 2019 deaths in a low middle income setting: A record-based analysis of 20,641 deaths from India.

Understanding the demographic and clinical characteristics cases and deaths is essential for better clinical and public health management of coronavirus disease-2019 (COVID-19) in resource-limited settings. We analyzed the COVID-19 deaths reported from India, to describe the demographic and clinical characteristics and identify the factors associated with early hospital deaths (within one day of hospitalization) and survival duration. We conducted a record review of the publicly available data on COVID-19 deaths reported between January 30th and November 30th, 2020. After imputation for missing data, we calculated unadjusted and adjusted prevalence ratio, and regression coefficient for factors associated with early hospital death and survival duration. Of the 20,641 COVID-19 deaths analyzed: a) 14,684 (71.1%) were males; b) 10,134 (50.9%) were aged <65 years; c) 9,722 (47.1%) treated at public hospitals and d) 5405 (27.1%) were early hospital deaths. Breathlessness was the most common presenting complaint. Diabetes (11,075,53.7%), hypertension (95,77,46.5%) and coronary artery disease (2,821,13.7%) were the common comorbidities. After adjustment, early hospital death was significantly higher among patients aged <65 years, without severe acute respiratory illness (SARI) at admission, non-diabetics, and cared at public hospitals compared to their counterparts. Similarly, the survival duration was at least one day higher among patients presented with SARI, chronic liver disease and cared at a private hospital. The analysis covered >10% of India's COVID-19 deaths, providing essential information regarding the COVID-19 epidemiology. The characteristics associated with early hospital death and survival duration among the COVID-19 fatalities may be deliberated as markers for prognosis and compared with survivors.

Demographic Profile, Knowledge, Attitude, and Practices of Blood Donors in a Low-Middle Income Country

Demographic profile, knowledge, attitude and practices (KAP) of blood donors in a low-middle income setting was investigated in this study. The study determined the demographic profile of blood donors in terms of sex, age, ethnicity and level of education and measured the level of knowledge, attitude and practices in terms of blood donation. The relationship of the donor profiles in terms of level of knowledge, attitude and practices was also determined. It utilized a cross-sectional study design which was conducted from February-October 2020. A self-administered questionnaire was distributed to the volunteers of blood donors of a non-institution-based blood bank establishment in Baguio City. Descriptive statistics and Chi-square were used to analyze the data. Ethical clearance was obtained and was approved. The results revealed that the majority of the respondents were female (59.2%) with age ranged from 18–30 years old (75.3%) and in collegiate level (83.2%). Majority of the respondents’ ethnicities were Tagalog (25.9%). Study revealed that respondents have a high level of knowledge in relation to blood donation, the attitude of the respondents revealed that blood donor had strong agreement to positive statements and disagreement to negative statements. Most of the respondents donated in the past, 62.3% are lapsed donors, 18% were first time donors and the majority had an intention to donate in the future. In terms of relationship of Demographic Profile to KAP, only Practices revealed a significant relationship to sex, age, ethnicity and level of education with P value ranging from 0.05–&lt;0.0001.

Cystic fibrosis in South Africa: spectrum of disease and determinants of outcome.

IntroductionLittle is known about cystic fibrosis (CF) in low- to middle-income settings. This study aimed to describe the spectrum and outcomes of CF in South Africa (SA) from the recently established SA CF registry (SACFR).MethodsDemographic, diagnosis and clinical data were extracted from the SACFR. Cross-sectional univariable and multivariable regression analysis of best forced expiratory volume in 1 s (FEV1; age≥6 years) and nutrition (all ages) in 2018 was conducted to investigate factors associated with severe lung disease (SLD; FEV1 ≤3.0 z-score) and undernutrition.ResultsBy December 2018, ancestry of 447 individuals included in the SACFR was Caucasian (315; 70%), mixed (87; 19%) and black African (41; 9%). Median diagnosis age was 7.6 months (IQR 2.7–37.1). Genotype was p.Phe508del homozygous (220; 49%); p.Phe508del heterozygous (144; 32%) and neither p.Phe508del or unknown Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) variant in 83 (19%); the second most frequent CFTR variant was 3120+1G>A, common in black Africans. Median age of patients in 2018 was 14.7 years (IQR 7.4–24.4). SLD was independently associated with chronic methicillin-resistant Staphylococcus aureus (MRSA) (adjusted odds ratio( aOR) 16.75; 95% CI 1.74–161.50), undernutrition (aOR 5.20; 95% CI 2.23–12.13) and age (aOR 2.23 per 10 years; 95% CI 1.50–3.31). Undernutrition was associated in univariable analysis with low weight at diagnosis, non-Caucasian ancestry, chronic P. aeruginosa infection and lower socioeconomic status.ConclusionInterventions targeting MRSA infection and nutrition are needed to improve CF outcomes in SA. Most people with CF in SA are eligible for highly effective CFTR modulator therapy.

Prospective Surveillance of Primary Healthcare Presentations for Scabies and Bacterial Skin Infections in Fiji, 2018-2019.

Scabies, impetigo, and other skin and soft tissue infections (SSTIs) are highly prevalent in many tropical, low-middle income settings, but information regarding their burden of disease is scarce. We conducted surveillance of presentations of scabies and SSTIs, including impetigo, abscesses, cellulitis, and severe SSTI, to primary health facilities in Fiji. We established a monthly reporting system over the course of 50 weeks (July 2018-June 2019) for scabies and SSTIs at all 42 public primary health facilities in the Northern Division of Fiji (population, ≈131,914). For each case, information was collected regarding demographics, diagnosis, and treatment. There were 13,736 individual primary healthcare presentations with scabies, SSTI, or both (108.3 presentations per 1000 person-years; 95% confidence interval [CI], 106.6-110 presentations). The incidence was higher for males than for females (incidence rate ratio [IRR], 1.15; 95% CI, 1.11-1.19). Children younger than 5 years had the highest incidence among all age groups (339.1 per 1000 person-years). The incidence was higher among the iTaukei (indigenous) population (159.9 per 1000 person-years) compared with Fijians of Indian descent (30.1 per 1000 person-years; IRR, 5.32; 95% CI, 5.03-5.61). Abscess was the condition with the highest incidence (63.5 per 1,000 person-years), followed by scabies (28.7 per 1,000 person-years) and impetigo (21.6 per 1,000 person-years). Scabies and SSTIs impose a substantial burden in Fiji and represent a high incidence of primary health presentations in this population. The incidence in low-middle income settings is up to 10-times higher than that in high-income settings. New public health strategies and further research are needed to address these conditions.

Cost-effectiveness evidence of mental health prevention and promotion interventions: A systematic review of economic evaluations.

BackgroundThe prevention of mental disorders and promotion of mental health and well-being are growing fields. Whether mental health promotion and prevention interventions provide value for money in children, adolescents, adults, and older adults is unclear. The aim of the current study is to update 2 existing reviews of cost-effectiveness studies in this field in order to determine whether such interventions are cost-effective.Methods and findingsElectronic databases (including MEDLINE, PsycINFO, CINAHL, and EconLit through EBSCO and Embase) were searched for published cost-effectiveness studies of prevention of mental disorders and promotion of mental health and well-being from 2008 to 2020. The quality of studies was assessed using the Quality of Health Economic Studies Instrument (QHES). The protocol was registered with PROSPERO (# CRD42019127778). The primary outcomes were incremental cost-effectiveness ratio (ICER) or return on investment (ROI) ratio across all studies.A total of 65 studies met the inclusion criteria of a full economic evaluation, of which, 23 targeted children and adolescents, 35 targeted adults, while the remaining targeted older adults. A large number of studies focused on prevention of depression and/or anxiety disorders, followed by promotion of mental health and well-being and other mental disorders. Although there was high heterogeneity in terms of the design among included economic evaluations, most studies consistently found that interventions for mental health prevention and promotion were cost-effective or cost saving. The review found that targeted prevention was likely to be cost-effective compared to universal prevention. Screening plus psychological interventions (e.g., cognitive behavioural therapy [CBT]) at school were the most cost-effective interventions for prevention of mental disorders in children and adolescents, while parenting interventions and workplace interventions had good evidence in mental health promotion. There is inconclusive evidence for preventive interventions for mental disorders or mental health promotion in older adults. While studies were of general high quality, there was limited evidence available from low- and middle-income countries.The review was limited to studies where mental health was the primary outcome and may have missed general health promoting strategies that could also prevent mental disorder or promote mental health. Some ROI studies might not be included given that these studies are commonly published in grey literature rather than in the academic literature.ConclusionsOur review found a significant growth of economic evaluations in prevention of mental disorders or promotion of mental health and well-being over the last 10 years. Although several interventions for mental health prevention and promotion provide good value for money, the varied quality as well as methodologies used in economic evaluations limit the generalisability of conclusions about cost-effectiveness. However, the finding that the majority of studies especially in children, adolescents, and adults demonstrated good value for money is promising. Research on cost-effectiveness in low-middle income settings is required.Trial registrationPROSPERO registration number: CRD42019127778.

HIV exposure and neurodevelopmental outcome in very low birth weight infants in a low-middle income setting: a prospective cohort study

ABSTRACT Neurodevelopmental impairment is common in premature infants. We aimed to describe neurodevelopmental outcomes in very low birth weight (VLBW) infants at 12 months postmenstrual age (PMA) and correlated with maternal HIV status. A single-centre, prospective cohort study was conducted from 1 June 2017 to 31 January 2019 with follow-up to 12 months. In-born infants with birth weight <1500 g were enrolled. Follow-up care was provided to 12 months PMA. Participants provided informed consent and ethics approval was obtained. A total of 279 patients were enrolled of which 84 (30.1%) died before 12 months and 91 (32.6%) were lost to follow-up. Neurodevelopmental assessment was performed on 104 participants. Mean general development quotient was 106.8, 2 (2.0%) patients had moderate-to-severe impairment and 1 (1.0%) mild impairment. HIV exposure was associated with lower developmental scores (104.3 vs. 109.0; p=0.005), whilst antenatal treatment with magnesium sulphate (109.6 vs. 105.2; p=0.01) and breastfeeding (108.0 vs. 104.0; p = 0.03) were associated with higher developmental scores. Neurodevelopmental outcome at 12 months PMA correlated with maternal HIV status. HIV exposure in VLBW infants is associated with lower neurodevelopmental scores at 12 months PMA. Antenatal treatment with magnesium sulphate and breastfeeding are associated with improved outcomes.

Next-Generation Sequencing Analysis of Pathogenic Leptospira: A Way Forward for Understanding Infectious Disease Dynamics in Low/Middle-Income, Disease-Endemic Settings.

In the current genomic era, knowledge of diversity of Leptospira, the spirochetal agents of leptospirosis, is changing rapidly. Next-generation sequencing has decreased in price and increased in scale, with the potential to democratize large-scale analysis of pathogens in resource-limited, low/middle-income (LMIC) regions. Consequently, the molecular classification of Leptospira, a pathogen disproportionately affecting LMIC countries, has changed dramatically over the last decade. Leptospira classification and molecular understandings of pathogen diversity have rapidly evolved, now most precisely based on core genome analysis supplemented by new insights provided by culture-independent methods directly using body fluids such as blood and urine. In places where leptospirosis disease burden is highest, genomic technologies have not been available, and serology-based methods remain the mainstay of leptospiral classification. Understanding the epidemiology, pathogenesis, and ultimately new approaches to treating and preventing leptospirosis requires detailed knowledge of regionally circulating Leptospira in highly endemic settings. Next-generation sequencing-based, culture-independent typing overcomes the limitation of culture isolation of Leptospira from clinical samples, with promise of providing public health-actionable information applicable to leptospirosis-endemic LMIC settings.

Investigating potential transmission of antimicrobial resistance in an open-plan hospital ward: a cross-sectional metagenomic study of resistome dispersion in a lower middle-income setting

BackgroundAntimicrobial resistance (AMR) represents a profound global health threat. Reducing AMR spread requires the identification of transmission pathways. The extent to which hospital wards represent a venue for substantial AMR transmission in low- and middle-income countries settings is poorly understood.MethodsRectal swabs were obtained from adult male inpatients in a “Nightingale” model general medicine ward in Yangon, Myanmar. Resistome characteristics were characterised by metagenomic sequencing. AMR gene carriage was related to inter-patient distance (representing inter-patient interaction) using distance-based linear models. Clinical predictors of AMR patterns were identified through univariate and multivariate regression.ResultsResistome similarity showed a weak but significant positive correlation with inter-patient distance (r = 0.12, p = 0.04). Nineteen AMR determinants contributed significantly to this relationship, including those encoding β-lactamase activity (OXA-1, NDM-7; adjusted p < 0.003), trimethoprim resistance (dfrA14, adjusted p = 0.0495), and chloramphenicol resistance (catB3, adjusted p = 0.002). Clinical traits of co-located patients carrying specific AMR genes were not random. Specifically, AMR genes that contributed to distance-resistome relationships (OXA-1, catB3, dfrA14) mapped to tuberculosis patients, who were placed together according to ward policy. In contrast, patients with sepsis were not placed together, and carried AMR genes that were not spatially significant or consistent with shared antibiotic exposure.ConclusionsAMR dispersion patterns primarily reflect the placement of particular patients by their condition, rather than AMR transmission. The proportion of AMR determinants that varied with inter-patient distance was limited, suggesting that nosocomial transmission is a relatively minor contributor to population-level carriage.