Resource-constrained Countries Research Articles

Data driven contagion risk management in low-income countries using machine learning applications with COVID-19 in South Asia

In the absence of real-time surveillance data, it is difficult to derive an early warning system and potential outbreak locations with the existing epidemiological models, especially in resource-constrained countries. We proposed a contagion risk index (CR-Index)—based on publicly available national statistics—founded on communicable disease spreadability vectors. Utilizing the daily COVID-19 data (positive cases and deaths) from 2020 to 2022, we developed country-specific and sub-national CR-Index for South Asia (India, Pakistan, and Bangladesh) and identified potential infection hotspots—aiding policymakers with efficient mitigation planning. Across the study period, the week-by-week and fixed-effects regression estimates demonstrate a strong correlation between the proposed CR-Index and sub-national (district-level) COVID-19 statistics. We validated the CR-Index using machine learning methods by evaluating the out-of-sample predictive performance. Machine learning driven validation showed that the CR-Index can correctly predict districts with high incidents of COVID-19 cases and deaths more than 85% of the time. This proposed CR-Index is a simple, replicable, and easily interpretable tool that can help low-income countries prioritize resource mobilization to contain the disease spread and associated crisis management with global relevance and applicability. This index can also help to contain future pandemics (and epidemics) and manage their far-reaching adverse consequences.

Battling chronic myeloid leukemia in a resource-constrained country: A case of public-private partnerships

Pakistan, where chronic myeloid leukemia constitutes around 80% of all myeloproliferative disorders, has been exploring multiple avenues in order to ensure the accessibility and affordability of imatinib and nilotinib. While most provinces of the country have joined hands with a pharmaceutical company to dispense free anti-CML medicines as part of a public-private partnership, the patients are still facing numerous challenges in the form of geographical disparity in the availability of these medicines, other out-of-pocket expenditures and most importantly, the uncertainty associated with the long-term continuation of this public-private endeavor due to procedural delays. In light of these predicaments, channeling resources towards research and development, fostering partnerships between government and NGOs and tapping into the domain of compulsory licensing appear to be the most sustainable solutions.

Barriers to implementing National Action Plans on antimicrobial resistance using a One Health Approach: policymakers’ perspectives from South Africa and Eswatini

ObjectivesAntimicrobial resistance poses a global public health concern that threatens human, animal, and environmental health. If it is not addressed, it is estimated to cost the global economy between USD 90 trillion and USD 210 trillion, and the death burden could balloon to 10 million lives per year by 2050. This study aimed to explore policymakers experiences on barriers to implementing National Action Plans on antimicrobial resistance using a One Health approach in South Africa and Eswatini. MethodsThirty-six policy makers were recruited using purposive and snowballing sampling in South Africa and Eswatini. Data were collected between November 2018 and January 2019 in South Africa, and February to March 2019 in Eswatini. Data was then analysed based on Creswell methods. ResultsThree themes and five subthemes emerged from our findings. The themes were resource barriers, political barriers, and regulation barriers to the implementation of National Action Plans on antimicrobial resistance in South Africa and Eswatini. ConclusionSouth African and Eswatini governments should commit funds to their One Health sector budgets to enable the implementation of National Action Plans on antimicrobial resistance. Specialized human resources issues need to be prioritized to unlock barriers of implementation. A renewed political commitment is needed to combat antimicrobial resistance in a One Health approach, as it plays a significant role in resource mobilization from regional and international organizations to support the resource-constrained countries to successfully implement policies.

Synergetic recycling of recycled concrete aggregate and waste mussel shell in concrete: Mechanical properties, durability and microstructure

The sustainable management of solid wastes and the development of alternative construction materials are essential issues that have plagued urban green development, especially for some resource-constrained island countries or cities. The efficient resource utilization of solid wastes as the alternative of construction materials during the concrete production might provide a potentially promising solution to meet these challenges. In this study, the effects of the combined utilization of mussel shell aggregate (MSA) and recycled concrete aggregate (RCA) on mechanical, durability and microstructural properties of mussel shell-recycled aggregate concrete (MS-RAC) were investigated. The results show that the increased MSA replacement rate exhibited a more negative influence on the compressive strength and splitting tensile strength of MS-RAC than the increased RCA replacement rate. The combined utilization of MSA and RCA resulted in a lower steel corrosion resistance (i.e. more negative open circuit potential, higher corrosion current density, and higher corrosion rate) during the chloride attacks. These could be attributed to the higher debonding rate of MSA-mortar interface and more complicated ITZs due to the incorporation of MSA and RCA. Furthermore, compared with the RCA, the incorporation of MSA resulted in more macropores and an increased porosity in MS-RAC, thereby significantly weakening the mechanical and durability properties of concrete.

Effects of Ganoderma lucidum on chemical-induced and bacterial-infected corneal ulceration of rabbits’ eyes

Background: Corneal ulcerations pose risks to blindness, and their treatment presents huge challenges, in part due to increased resistance to anti-bacterial drugs, accessibility and cost issues, particularly in developing countries. This study investigated the pharmacological effect of Ganoderma Lucidum, on chemical-induced and bacterial-infected corneal ulceration of rabbits’ eyes. Methods: This was a randomized-controlled experiment of 16 healthy New Zealand rabbits, randomly assigned into four groups (A–D). The right eye cornea was injured using a drop of 1 Molar sodium hydroxide and followed by infection with Pseudomonas aeruginosa after 12 hours, in all groups except group A. Treatment with freshly prepared crude aqueous extract of G. lucidum (40 μg/mL) for groups A and B, the standard treatment protocol for group C, and atropine alone for group D commenced after 24 hours and continued every four hours for seven days. All data collected, pre-and post-tests, were analysed at α=0.05 using Wilcoxon signed-rank test for correlated variables and the Mann–Whitney U test for independent variables. Results: G. lucidum has significant clinical effects (74%) on corneal injury and ulcers (92%). The healing effects observed at the 168th hour were significantly better than those observed at the 24th hour (p<0.05). Although the difference between the healing effect of the standard treatment and the crude extract was not significant (p>0.05), the mean effect size was clinically significant (31%). Conclusion: This study demonstrates the potential antimicrobial potential of G. lucidum. G. lucidum may provide an alternative treatment option for chemical-induced and bacterial-infected corneal ulcers, particularly in resource-constrained countries.

209 - Incidence of Early Toxicities and Mortality after Four Types of Conditioning Regimens for Autologous Hematopoietic Cell Transplantation in Patients with Lymphoma: Impact of National Drug Shortages in a Resource-Constrained Country

209 - Incidence of Early Toxicities and Mortality after Four Types of Conditioning Regimens for Autologous Hematopoietic Cell Transplantation in Patients with Lymphoma: Impact of National Drug Shortages in a Resource-Constrained Country

Risk communication during health emergencies in Nigeria: What are its challenges?

Although globalization has been advantageous in facilitating the free movement of people, goods, and services, the ease of movement of cross-border pathogens has increased the risk of international public health emergencies in recent years. Risk communication is an integral part of every country's response during public health emergencies such as the coronavirus disease (COVID-19) pandemic. To effectively increase adherence to guidelines during health emergencies, it is essential to understand the impact of social, cultural, political, and environmental factors on people's behaviours and lifestyles in any given context, as well as how these factors influence people's perception of risks. During the recent response to the COVID-19 pandemic in Nigeria, the need to comprehend these influences was pronounced, and these influences ultimately shaped risk communication in Nigeria. We have identified risk communication challenges in Nigeria based on sociocultural diversity, the complexity of the health system, the impact of social media on communications, and other contextual factors surrounding multisectoral partnerships. To achieve global health security, these challenges must be addressed in resourceconstrained countries like Nigeria. In this paper, we emphasize the need to contextualize risk communication strategies in order to improve their effectiveness during health emergencies. In addition, we urge increased country commitment to a multi-hazard and multisectoral effort, deliberate investment in subnational risk communication systems, and investments in capacity building for risk communication activities.

Novel co-axial, disposable, low-cost 3D printed videolaryngoscopes for patients with COVID-19: a manikin study

BACKGROUND COVID-19 continues to present challenges to both patient management and the protection of the airway management team involved, in particular in resource-constrained low-income countries. Among the most concerning complications in affected patients is rapid hypoxemic respiratory failure requiring tracheal intubation and mechanical ventilation. Videolaryngoscopy without peri-intubation oxygenation is the recommended approach in COVID-19 patients. However, the absence of peri-intubation oxygenation during intubation attempts can lead to hypoxia, and result in life-threatening complications in already critically ill patients. OBJECTIVE To develop low-cost disposable 3D printed videolaryngoscope designs with integrated channels for oxygen, suction, WIFI-enabled camera and tracheal tube channels, as well as a flexible transparent barrier anchor to offer optional additional protection to the user and airway management team. DESIGN A manikin study. SETTING AND PARTICIPANTS Three experienced consultant anaesthetists in the Mater Misericordiae University Hospital, Dublin, Ireland. MAIN OUTCOME MEASURES To generate novel co-axial videolaryngoscopes that meet International Standards, ISO7376 : 2020 standards for anaesthetic and respiratory equipment (laryngoscopes for tracheal intubation), and to demonstrate successful tracheal intubation of a manikin trainer in a range of configurations (‘easy’ to ‘difficult’) in accordance with the Cormack-Lehane grading of laryngeal view. RESULTS Final design prototypes met the minimum criteria for strength and rigidity according to ISO7376 : 2020, including blade tip displacement under load (65 N and 150 N). Preliminary validation has demonstrated successful tracheal intubation of a manikin trainer in all configurations including ‘difficult’ (Cormack-Lehane Grade 3 view). CONCLUSIONS This low-cost, rapid in-house manufacture could offer a mitigation of supply chain disruptions that can arise during global pandemics. Furthermore, it could offer a low-cost solution in low-income countries where there is an infection risk caused by re-using most current videolaryngoscopes requiring sterilisation before re-use, as well as limitations in the availability of personal protective equipment.

Priorities and Future of the ISBER Standards Community of Practice and Pediatric Special Interest Group

Priorities and Future of the ISBER Standards Community of Practice and Pediatric Special Interest Group

Monitoring invasive pines using remote sensing: a case study from Sri Lanka

Production plantation forestry has many economic benefits but can also have negative environmental impacts such as the spreading of invasive pines to native forest habitats. Monitoring forest for the presence of invasive pines helps with the management of this issue. However, detection of vegetation change over a large time period is difficult due to changes in image quality and sensor types, and by the spectral similarity of evergreen species and frequent cloud cover in the study area. The costs of high-resolution images are also prohibitive for routine monitoring in resource-constrained countries. This research investigated the use of remote sensing to identify the spread of Pinus caribaea over a 21-year period (2000 to 2021) in Belihuloya, Sri Lanka, using Landsat images. It applied a range of techniques to produce cloud free images, extract vegetation features, and improve vegetation classification accuracy, followed by the use of Geographical Information System to spatially analyze the spread of invasive pines. The results showed most invading pines were found within 100 m of the pine plantations’ borders where broadleaved forests and grasslands are vulnerable to invasion. However, the extent of invasive pine had an overall decline of 4 ha over the 21 years. The study confirmed that remote sensing combined with spatial analysis are effective tools for monitoring invasive pines in countries with limited resources. This study also provides information to conservationists and forest managers to conduct strategic planning for sustainable forest management and conservation in Sri Lanka.

Impact of an Online Program of Bubble Continuous Positive Airway Pressure Education in a Resource-Constrained Setting.

Respiratory distress is a leading cause of preterm infant mortality in sub-Saharan Africa. Bubble continuous positive airway pressure (CPAP) is emerging as a potentially safe, cost-effective way of delivering noninvasive respiratory support in low-income and middle-income countries. However, without healthcare providers who are knowledgeable and skilled in the use of this technology, suboptimal neonatal care and related health disparities are likely to persist. We hypothesized that an Internet-based, blended curriculum on bubble CPAP for bedside providers in low-resource mother-baby units (MBUs) could be developed and implemented and lead to improvements in clinical knowledge, reasoning, and learner confidence in bubble CPAP. Clinical educators from Israel, Ghana, and the United States used the analysis, design, development, implementation, and evaluation (ADDIE) design framework to create an online curriculum for two MBUs in Kumasi, in the Ashanti Region of Ghana. Participants completed pre and post curriculum knowledge tests and completed surveys on their perspectives. Fifty-four interdisciplinary health professionals from the MBUs participated in the curriculum. Median knowledge test scores improved from 64% (interquartile range [IQR] = 50-72%) to 81% (IQR = 71-89%) after participation in the curriculum (P < 0.001). Learners reported high levels of confidence with bubble CPAP after participating in the curriculum and evaluated the curricular components highly. An online curriculum was successfully implemented and led to changes in healthcare worker knowledge in bubble CPAP. This may be an effective way to deliver education to healthcare professionals in resource-constrained countries and warrants further study.

Sputum smears quality inspection using an ensemble feature extraction approach.

The diagnosis of tuberculosis (TB) is extremely important. Sputum smear microscopy is thought to be the best method available in terms of accessibility and ease of use in resource-constrained countries. In this paper, research was conducted to evaluate the effectiveness of tuberculosis diagnosis by examining, among other things, the underlying causes of sputum smear quality for Ethiopian states such as Tigray, Amahira, and Oromia. However, because it is done manually, it has its limitations. This study proposes a model for sputum smear quality inspection using an ensemble feature extraction approach. The dataset used was recorded and labeled by experts in a regional lab in Bahir Dar, near Felege Hiwot Hospital after being collected from Gabi Hospital, Felege Hiwot Hospital, Adit Clinic and Gondar Hospital, as well as Kidanemihret Clinic in Gondar. We used a controlled environment to reduce environmental influences and eliminate variation. All the data was collected using a smartphone (the standard 15) with a jpg file extension and a pixel resolution of 1,728 × 3,840. Prior to feature extraction, bicubic resizing, and ROI extraction using thresholding was performed. In addition, sequential Gaussian and Gabor filters were used for noise reduction, augmentation, and CLAHE was used for enhancement. For feature extraction, GLCM from the gray label and CNN from the color image were both chosen. Ultimately, when CNN, SVM, and KNN classifiers were used to test both CNN and GLCM features, KNN outperformed them all with scores of 87, 93, and 94% for GLCM, CNN, and a hybrid of CNN and GLCM, respectively. CNN with GLCM outperformed other methods by 0.7 and 0.1% for GLCM and CNN feature extractors using the same classifier, respectively. In addition, the KNN classifier with the combination of CNN and GLCM as feature extractors performed better than existing methods by 1.48%.

The effects of a peripartum strategy to prevent and treat primary postpartum haemorrhage at health facilities in Niger: a longitudinal, 72-month study

Primary postpartum haemorrhage is the principal cause of birth-related maternal mortality in most settings and has remained persistently high in severely resource-constrained countries. We evaluate the impact of an intervention that aims to halve maternal mortality caused by primary postpartum haemorrhage within 2 years, nationwide in Niger. In this 72-month longitudinal study, we analysed the effects of a primary postpartum haemorrhage intervention in hospitals and health centres in Niger, using data on maternal birth outcomes assessed and recorded by the facilities' health professionals and reported once per month at the national level. Reported data were monitored, compiled, and analysed by a non-governmental organisation collaborating with the Ministry of Health. All births in all health facilities in which births occurred, nationwide, were included, with no exclusion criteria. After a preintervention survey, brief training, and supplies distribution, Niger implemented a nationwide primary postpartum haemorrhage prevention and three-step treatment strategy using misoprostol, followed if needed by an intrauterine condom tamponade, and a non-inflatable anti-shock garment, with a specific set of organisational public health tools, aiming to reduce primary postpartum haemorrhage mortality. Among 5 382 488 expected births, 2 254 885 (41·9%) occurred in health facilities, of which information was available on 1 380 779 births from Jan 1, 2015, to Dec 31, 2020, with reporting increasing considerably over time. Primary postpartum mortality decreased from 82 (32·16%; 95% CI 25·58-39·92) of 255 health facility maternal deaths in the 2013 preintervention survey to 146 (9·53%; 8·05-11·21) of 1532 deaths among 343 668 births in 2020. Primary postpartum haemorrhage incidence varied between 1900 (2·10%; 2·01-2·20) of 90 453 births and 4758 (1·47%; 1·43-1·52) of 322 859 births during 2015-20, an annual trend of 0·98 (95% CI 0·97-0·99; p<0·0001). Primary postpartum haemorrhage morbidity and mortality declined rapidly nationwide. Because each treatment technology that was used has shown some efficacy when used alone, a strategic combination of these treatments can reasonably attain outcomes of this magnitude. Niger's strategy warrants testing in other low-income and perhaps some middle-income settings. The Government of Norway, the Government of Niger, the Kavli Trust (Kavlifondet), the InFiL Foundation, and individuals in Norway, the UK, and the USA. For the French translation of the abstract see Supplementary Materials section.

Chronic graft-versus-host-disease treatment in Brazil: analyses of failure-free survival

Failure-free survival (FFS), defined as the absence of new systemic treatment, recurrence of original malignancy and mortality not associated with recurrence after allogeneic hematopoietic stem cell transplantation (HCT), is a robust clinical measure to interpret results of initial systemic treatment of chronic graft-versus-host disease (cGVHD). We evaluate FFS after initial treatment of cGVHD in a mixed-race cohort from a resource-constrained country. This retrospective study included 354 consecutive patients after their first HCT between January 2014 and August 2020, who received initial systemic treatment for moderate or severe cGVHD at 13 Brazilian centers. Cox regression models were used to identify risk factors for treatment failure. The overall median follow-up among survivors was 28 months (range 1-71) after initial treatment. FFS was 89% at 6 months, 71% at 1 year and 52% at 2 years. New systemic treatment was the major cause of failure. In multivariable models, prior grades II-IV acute GVHD, a National Institutes of Health severity score of 3 in liver, gastrointestinal tract or lung involvement, and onset of initial treatment of cGVHD within 12 months after transplantation were all associated with an increased risk of treatment failure. Our results could serve as a benchmark for the design of future clinical trials evaluating initial treatment of cGVHD in resource-constrained locations.

Assessing levels of knowledge, compliance with preventive measures and behavioral adjustments to the ‘new normal’ of COVID-19: Empirical evidence from Ghana

Countries have managed COVID-19 infection and mortality differently. Ghana, a resource-constrained country, with a poorer healthcare system, had fewer infections and more recoveries than high-income countries. Although an acculturation framework is commonly discussed in relation to individuals adapting to a new society, we used it to understand how people adapt to rapid changes orchestrated by the COVID-19 pandemic. From pre-pandemic to post-pandemic era, we see a change from the ‘old normal’ to the ‘new normal’. Thus, we sought to understand how people were living their lives under the ‘new normal’. Data was gathered from 416 adults on their attitudes towards obedience to authority, compliance with COVID-19-related activities, and changes in the extent of carrying out these activities three and nine months into the pandemic. COVID-19 acculturation strategies were also assessed. Descriptive and inferential analyses showed that most Ghanaians obeyed authorities and followed the preventive measures. However, after five months of the peak period, compliance dropped, and behavioral fatigue increased significantly. Regarding the acculturation strategies integration, which involves keeping old health care practices and adopting new ones, improved behavioral adjustment the most followed by separation (i.e., rejecting the new health care practices and holding on strongly to the old ones) and assimilation (i.e., rejecting old health care practices and adopting new ones). Marginalization which encompasses rejecting both old and new health care practices was the least. These results suggest that integration strategy had a significant positive impact on behavioral adjustment compared to assimilation and separation strategies.

A novel workflow for streamflow prediction in the presence of missing gauge observations

AbstractStreamflow predictions are vital for detecting flood and drought events. Such predictions are even more critical to Sub-Saharan African regions that are vulnerable to the increasing frequency and intensity of such events. These regions are sparsely gaged, with few available gaging stations that are often plagued with missing data due to various causes, such as harsh environmental conditions and constrained operational resources. This work presents a novel workflow for predicting streamflow in the presence of missing gage observations. We leverage bias correction of the Group on Earth Observations Global Water and Sustainability Initiative ECMWF streamflow service (GESS) forecasts for missing data imputation and predict future streamflow using the state-of-the-art temporal fusion transformers (TFTs) at 10 river gaging stations in the Benin Republic. We show by simulating missingness in a testing period that GESS forecasts have a significant bias that results in poor imputation performance over the 10 Beninese stations. Our findings suggest that overall bias correction by Elastic Net and Gaussian Process regression achieves superior performance relative to traditional imputation by established methods. We also show that the TFT yields high predictive skill and further provides explanations for predictions through the weights of its attention mechanism. The findings of this work provide a basis for integrating Global streamflow prediction model data and the state-of-the-art machine learning models into operational early-warning decision-making systems in resource-constrained countries vulnerable to drought and flooding due to extreme weather events.

SACCSG HL-2018. Barriers and enablers of a harmonized treatment protocol for childhood and adolescent Hodgkin lymphoma in South Africa

Introduction: Collaborative studies have contributed to improved survival of pediatric Hodgkin lymphoma in well-resourced settings, but few are documented in resource-constrained countries. The South Africa Children’s Cancer Study Group initiated harmonization of management protocols in 2015. This article analyzes barriers and enablers of the process. Methods: Clinician-researchers at 11 state-funded pediatric oncology units completed preparatory questionnaires in June 2018. Parameters included infrastructure, access to therapeutic modalities and clinician numbers. A reassessment of 13 sites (two new pediatric oncology unit) in February 2021 ascertained changes in resources and identified challenges to full participation. Questions investigated the presence and quality of diagnostic radiology, availability of surgeons, cytology/pathology options and hematology laboratory facilities. Results: The response rate was 11/11 to survey 1 and 13/13 to survey 2. The anticipated pre-study barriers to participation of pediatric oncology units included time constraints and understaffing. PET-CT was unavailable to two centers. The majority of pediatric oncology units met the minimum criteria to participate. The interim survey confirmed chemotherapy and radiotherapy availability nearly 100% of the time. One site reported improved access to radiotherapy while another reported improved access to PET-CT. Barriers to participation included excessive times to obtain regulatory approvals, time constraints and lack of dedicated research staff. Enablers include the simple management algorithm and communication tools. Conclusion: This study demonstrates that multicenter collaboration and harmonization of management protocols are achievable in a middle-income setting. Minimal funding is required but full participation to run high-quality studies requires more financial investment. Focused funding and increased prioritization of research may address systemic barriers to full participation.

Analysis of systemic and behavioral barriers to COVID-19 vaccination in rollout phase

ABSTRACT Vaccines play a critical role in preventing deaths, and hospitalization caused by infectious diseases. This study utilized a Systematic Literature Review (SLR) to identify the systemic and behavioral barriers to vaccination for COVID-19. Then the study applied Multi-Criteria Decision Making (MCDM) Technique, Fuzzy-Analytic Hierarchy Process (AHP) to calculate the importance scores for these barriers. The study used a focus group of six experts working in healthcare for group decision-making. Three identified systemic barriers (importance score) were (1) Cost (0.048) (2) Convenience (0.043), and (3) Supply Chain Issue (0.037); while three behavioral barriers were (1) Complacency (0.128) (2) Lack of Trust (0.280), and (3) Lack of Awareness (0.488). The study concluded that the most important barrier to overcome was the Lack of Awareness followed by the Lack of Trust. The significant contribution of this study was that it established that the importance of behavioral barriers was significantly higher than the systemic barriers, which got more attention in planning. The result of the study concurred with the findings of the SLR. Thus, this study provided a descriptive and prescriptive framework for overcoming barriers to vaccination in resource-constrained countries. The findings of the study are useful for policymakers and healthcare administrators.

Implications of the antiviral drug favipiravir on rabies immunoglobulin for post-exposure prophylaxis of rabies in mice model with category III-like exposures

Rabies is a fatal zoonotic disease caused by the rabies virus (RABV), with almost 100% mortality if proper post-exposure prophylaxis (PEP), consisting of rabies immunoglobulin (RIG) and rabies vaccine, is not applied in a timely manner. However, this is challenged by the limited availability of RIG, especially in resource-constrained countries. In this study, we assessed the scope of the antiviral drug favipiravir to treat rabies-infected mice as an alternative to RIG. Category III-like wounds were induced in RABV-challenged mice treated with favipiravir instead of RIG in the PEP regimen. The use of favipiravir followed by rabies vaccine provided complete protection against rabies-related death in 100% of mice, even after RABV propagated to the central nervous system during infection. Additionally, the virus-neutralizing antibody titer in the favipiravir and vaccine group was significantly higher than that of the RIG and vaccine recipients. The use of favipiravir with rabies vaccine seemingly prevents fatal outcomes and even rescues the cases that already express clinical symptoms. A clinical trial of this approach is warranted, especially in countries with low RIG availability.

Singapore’s Sustainable Energy Story: Low-carbon energy deployment strategies and challenges

Being a small, resource-constrained country, Singapore has been dependent on the import of energy products, such as coal, petroleum, natural gas, etc., since its independence. Specifically, it has relied on natural gas, which is the cleanest form of fossil fuel, for several years. In the past, the natural gas supply came from the neighboring countries of Indonesia and Malaysia through pipelines. However, the construction of the Singapore Liquefied Natural Gas Terminal in 2013 allowed Singapore to import and store liquefied natural gas from many different countries and sources, thus broadening its natural gas supply options. A four-switch approach (see <xref ref-type="fig" rid="fig1" xmlns:mml="http://www.w3.org/1998/Math/MathML" xmlns:xlink="http://www.w3.org/1999/xlink">Figure 1</xref> ) was presented with the aim of having a future where energy is sustainable, reliable, affordable, and produced and consumed efficiently. The four switches mentioned are as follows: