World Health Organization Emergency Research Articles

Developing trauma care education in low, middle-income countries: Sequential Trauma Education Programs, challenges, and lessons learned

Background: As one of the leading causes of death and disability in the world, human trauma and injury disproportionately affects individuals in developing countries. During initial program development, senior MOHP physicians stated there was a critical need for a portable and flexible educational course on the clinical care of injured patients. To meet the need for improved trauma care in Egypt, the Sequential Trauma Emergency/Education ProgramS (STEPS) course was created through the collaborative effort of Egyptian and US expert physicians. The objective of course development was to create a high-quality, modular, adaptable, and sustainable trauma care course that could be readily adopted by a lower- or middle-income country. Methods: We describes the course development from 2006 to 2015, highlighting the challenges and solutions of creating a successful, flexible and sustainable in-country trauma care training program that suits low and middle-income countries. Results: STEPS was developed at the University of Maryland, based in part on World Health Organization's Emergency and Trauma Care materials, and introduced to the Egyptian Ministry of Health and Population and Ain Shams University in May 2006. The program is designed to adapt low cost and limited resources with maintaining high fidelity and unified standard. In 2008, the course transitioned completely to the leadership of Egyptian academic physicians. To date, more than 700 physicians from 8 countries have taken the course through the Ministry of Health and Population or public/governmental universities. For the first time the course will be held in Sudan on January 2016. Conclusion: STEPS has rapidly become a desired trauma care training program proved by sustainability based on 7 years of course conduct. Success of this collaborative educational program is demonstrated by the numbers of physicians trained, and program continuance after transitioning to in-country leadership and trainers.

Analytical Validation of the ReEBOV Antigen Rapid Test for Point-of-Care Diagnosis of Ebola Virus Infection.

Ebola virus disease (EVD) is a severe viral illness caused by Ebola virus (EBOV). The 2013-2016 EVD outbreak in West Africa is the largest recorded, with >11 000 deaths. Development of the ReEBOV Antigen Rapid Test (ReEBOV RDT) was expedited to provide a point-of-care test for suspected EVD cases. Recombinant EBOV viral protein 40 antigen was used to derive polyclonal antibodies for RDT and enzyme-linked immunosorbent assay development. ReEBOV RDT limits of detection (LOD), specificity, and interference were analytically validated on the basis of Food and Drug Administration (FDA) guidance. The ReEBOV RDT specificity estimate was 95% for donor serum panels and 97% for donor whole-blood specimens. The RDT demonstrated sensitivity to 3 species of Ebolavirus (Zaire ebolavirus, Sudan ebolavirus, and Bundibugyo ebolavirus) associated with human disease, with no cross-reactivity by pathogens associated with non-EBOV febrile illness, including malaria parasites. Interference testing exhibited no reactivity by medications in common use. The LOD for antigen was 4.7 ng/test in serum and 9.4 ng/test in whole blood. Quantitative reverse transcription-polymerase chain reaction testing of nonhuman primate samples determined the range to be equivalent to 3.0 × 105-9.0 × 108 genomes/mL. The analytical validation presented here contributed to the ReEBOV RDT being the first antigen-based assay to receive FDA and World Health Organization emergency use authorization for this EVD outbreak, in February 2015.

Bellwether Procedures for Monitoring and Planning Essential Surgical Care in Low- and Middle-Income Countries: Caesarean Delivery, Laparotomy, and Treatment of Open Fractures.

Surgical conditions represent a significant proportion of the global burden of disease, and therefore, surgery is an essential component of health systems. Achieving universal health coverage requires effective monitoring of access to surgery. However, there is no widely accepted standard for the required capabilities of a first-level hospital. We aimed to determine whether a group of operations could be used to describe the delivery of essential surgical care. We convened an expert panel to identify procedures that might indicate the presence of resources needed to treat an appropriate range of surgical conditions at first-level hospitals. Using data from the World Health Organization Emergency and Essential Surgical Care Global database, collected using the WHO Situational Analysis Tool (SAT), we analysed whether the ability to perform each of these procedures-which we term "bellwether procedures"-was associated with performing a full range of essential surgical procedures. The ability to perform caesarean delivery, laparotomy, and treatment of open fracture was closely associated with performing all obstetric, general, basic, emergency, and orthopaedic procedures (p<0.001) in the population that responded to the WHO SAT Survey. Procedures including cleft lip, cataract, and neonatal surgery did not correlate with performing the bellwether procedures. Caesarean delivery, laparotomy, and treatment of open fractures should be standard procedures performed at first-level hospitals. With further validation in other populations, local managers and health ministries may find this useful as a benchmark for what first-level hospitals can and should be able to perform on a 24/7 basis in order to ensure delivery of emergency and essential surgical care to their population. Those procedures which did not correlate with the bellwether procedures can be referred to a specialized centre or collected for treatment by a visiting specialist team.

Access to basic surgical oncologic services in 54 countries: Where to go from here?

e17525 Background: In low- and middle-income countries (LMIC), there are significant deficits in access to core cancer services including surgical care. Surgical biopsy is an essential modality in the diagnosis and staging of cancer and, thus, functions as an index indicator for access to basic cancer services in LMIC. The objective of this study is to describe the existing capacity of and access to cancer services in LMIC. Methods: Responses to the World Health Organization Emergency and Essential Surgical Care survey are analyzed, assessing service availability in 1269 health facilities in 54 countries. Responses describe the capacity to perform surgical biopsies along with facility and personnel characteristics. Results: Surgical biopsy is available in 608 (48%) surveyed health facilities. The most commonly stated reason for an inability to perform biopsies is a lack of necessary skills (79%). There are an estimated 1.65 physicians able to perform basic surgical procedures and 0.58 trained surgeons per...

Developing Sustainable Trauma Care Education in Egypt: Sequential Trauma Education Program, Steps to Success

As one of the leading causes of death and disability in the world, human trauma and injury disproportionately affects individuals in developing countries. To meet the need for improved trauma care in Egypt, the Sequential Trauma Emergency/Education ProgramS (STEPS) course was created through the collaborative effort of U.S. and Egyptian physicians. The objective of course development was to create a high-quality, modular, adaptable, and sustainable trauma care course that could be readily adopted by a lower- or middle-income country. We describe the development, transition, and host nation sustainability of a trauma care training course between a high-income Western nation and a lower-middle-income Middle Eastern/Northern African country, including the number of physicians trained and the challenges to program development and sustainability. STEPS was developed at the University of Maryland, based in part on World Health Organization's Emergency and Trauma Care materials, and introduced to the Egyptian Ministry of Health and Population and Ain Shams University in May 2006. To date, 639 physicians from multiple specialties have taken the 4-day course through the Ministry of Health and Population or public/governmental universities. In 2008, the course transitioned completely to the leadership of Egyptian academic physicians. Multiple Egyptian medical schools and the Egyptian Emergency Medicine Board now require STEPS or its equivalent for physicians in training. Success of this collaborative educational program is demonstrated by the numbers of physicians trained, the adoption of STEPS by the Egyptian Emergency Medicine Board, and program continuance after transitioning to in-country leadership and trainers.

Trauma capacity in the central plateau department of Haiti

BackgroundSurgical burden is a large and neglected global health problem in low- and middle-income countries. With the increasing trauma burden, the goal of this study was to evaluate the trauma capacity of hospitals in the central plateau of Haiti. Materials and methodsThe World Health Organization Emergency and Essential Surgical Care survey was adapted with a focus on trauma capacity. Interviewers along with translators administered the survey to key hospital staff. ResultsSeven hospitals in the region were surveyed. Of the hospitals surveyed, 3/7 had functioning surgical facilities. None of the hospitals had trauma registries. 71% of the hospitals had no formal trauma guidelines. 2/7 hospitals had a general surgeon available 100% of the time. All surgical facilities had oxygen cylinders available 100% of the time, but three of the primary level hospitals only had it available 51%–90% of the time. Intubation equipment was available at 57% of the facilities. Ventilators were only available in the operating room. Only the largest hospital had a computed tomography scanner. Other hospitals (66%) had a functioning x-ray machine 76%–90% of the time. Hospitals (57%) had an ultrasound machine. The most common reasons for referral were lack of appropriate facilities and supplies at the primary level care centers or lack of trained personnel at higher-level facilities. ConclusionsTrauma capacity in the central plateau of Haiti is limited. There is a great need for more personnel, trauma training at all staff levels, emergency care guidelines, trauma registries, and imaging equipment and training, specifically in ultrasonography. To accomplish this, coordination is needed between the Haitian government and local and international nongovernmental organizations.

Availability and access in modern obstetric care: a retrospective population‐based study

To assess the availability of obstetric institutions, the risk of unplanned delivery outside an institution and maternal morbidity in a national setting in which the number of institutions declined from 95 to 51 during 30 years. Retrospective population-based, three cohorts and two cross-sectional analyses. Census data, Statistics Norway. The Medical Birth Registry of Norway from 1979 to 2009. Women (15-49 years), 2000 (n = 1,050,269) and 2010 (n = 1,127,665). Women who delivered during the period 1979-2009 (n = 1,807,714). Geographic Information Systems software for travel zone calculations. Cross-table and multiple logistic regression analysis of change over time and regional differences. World Health Organization Emergency Obstetric and Newborn Care (EmOC) indicators. Proportion of women living outside the 1-hour travel zone to obstetric institutions. Risk of unplanned delivery outside obstetric institutions. Maternal morbidity. The proportion of women living outside the 1-hour zone for all obstetric institutions increased from 7.9% to 8.8% from 2000 to 2010 (relative risk, 1.1; 95% confidence interval, 1.11-1.12), and for emergency obstetric care from 11.0% to 12.1% (relative risk, 1.1; 95% confidence interval, 1.09-1.11). The risk of unplanned delivery outside institutions increased from 0.4% in 1979-83 to 0.7% in 2004-09 (adjusted odds ratio, 2.0; 95% confidence interval, 1.9-2.2). Maternal morbidity increased from 1.7% in 2000 to 2.2% in 2009 (adjusted odds ratio, 1.4; 95% confidence interval, 1.2-1.5) and the regional differences increased. The availability of and access to obstetric institutions was reduced and we did not observe the expected decrease in maternal morbidity following the centralisation.

Availability and access in modern obstetric care: a retrospective population-based study

ObjectiveTo assess the availability of obstetric institutions, the risk of unplanned delivery outside an institution and maternal morbidity in a national setting in which the number of institutions declined from 95 to 51 during 30 years.DesignRetrospective population-based, three cohorts and two cross-sectional analyses.SettingCensus data, Statistics Norway. The Medical Birth Registry of Norway from 1979 to 2009.PopulationWomen (15–49 years), 2000 (n = 1 050 269) and 2010 (n = 1 127 665). Women who delivered during the period 1979–2009 (n = 1 807 714).MethodsGeographic Information Systems software for travel zone calculations. Cross-table and multiple logistic regression analysis of change over time and regional differences. World Health Organization Emergency Obstetric and Newborn Care (EmOC) indicators.Main outcome measuresProportion of women living outside the 1-hour travel zone to obstetric institutions. Risk of unplanned delivery outside obstetric institutions. Maternal morbidity.ResultsThe proportion of women living outside the 1-hour zone for all obstetric institutions increased from 7.9% to 8.8% from 2000 to 2010 (relative risk, 1.1; 95% confidence interval, 1.11–1.12), and for emergency obstetric care from 11.0% to 12.1% (relative risk, 1.1; 95% confidence interval, 1.09–1.11). The risk of unplanned delivery outside institutions increased from 0.4% in 1979–83 to 0.7% in 2004–09 (adjusted odds ratio, 2.0; 95% confidence interval, 1.9–2.2). Maternal morbidity increased from 1.7% in 2000 to 2.2% in 2009 (adjusted odds ratio, 1.4; 95% confidence interval, 1.2–1.5) and the regional differences increased.ConclusionsThe availability of and access to obstetric institutions was reduced and we did not observe the expected decrease in maternal morbidity following the centralisation.

IDSR as a Platform for Implementing IHR in African Countries

Of the 46 countries in the World Health Organization (WHO) African region (AFRO), 43 are implementing Integrated Disease Surveillance and Response (IDSR) guidelines to improve their abilities to detect, confirm, and respond to high-priority communicable and noncommunicable diseases. IDSR provides a framework for strengthening the surveillance, response, and laboratory core capacities required by the revised International Health Regulations [IHR (2005)]. In turn, IHR obligations can serve as a driving force to sustain national commitments to IDSR strategies. The ability to report potential public health events of international concern according to IHR (2005) relies on early warning systems founded in national surveillance capacities. Public health events reported through IDSR to the WHO Emergency Management System in Africa illustrate the growing capacities in African countries to detect, assess, and report infectious and noninfectious threats to public health. The IHR (2005) provide an opportunity to continue strengthening national IDSR systems so they can characterize outbreaks and respond to public health events in the region.

Paediatric triage in South Africa

Reducing child mortality is a high priority in sub-Saharan Africa, and swift, appropriate triage can make an important contribution to this goal. There has been a lot of interest and work in the field of triage of sick children in South Africa over the past few years. Despite this, in many parts of South Africa no formal system for triage of children in acute and emergency settings is used. This article aims to explain some of the key paediatric triage tools being considered and developed in South Africa. The triage tools discussed are the World Health Organization Emergency Triage Assessment and Treatment (ETAT), the South African adaptation of this tool known as ETAT-SA, the South African Triage Scale (SATS), and the Revised Paediatric SATS (P-SATS). The article describes how they were developed and their relevance to the country.

World Health Organization Global Initiative for Emergency and Essential Surgical Care: 2011 and Beyond

The world's burden of surgical diseases is large and increasing. Unfortunately, <5 % of all surgical procedures are performed in countries ranked within the lowest one-third in terms of per-capita health expenditures [1]. The unmet need for surgical care results in unacceptable morbidity/mortality rates associated with a host of conditions (trauma, pregnancy-related complications, other emergencies). This is especially true for rural and marginalized populations in low- and middle-income countries (LMICs). Recognizing that variations in the spectrum of surgical diseases are observed among and within countries, “essential” surgery and anesthesia may be viewed as a core group of services that can be delivered within the context of universal access. These high-priority interventions are those for which: (1) there is a large public health burden; (2) the treatment is highly successful; (3) the treatment is cost-effective [2]. To date, essential surgery and anesthesia have received minimal financial and political support as public health strategies because of the perception that the services are costly, are resource-intensive, require highly specialized training, and benefit only a fraction of the population relative to competing health interests. Evidence is amassing to refute these claims. The World Health Organization (WHO) Global Initiative for Emergency and Essential Surgical Care (GIEESC) was launched in 2005. It is a global forum whose goal is to promote collaboration among a diverse group of stake-holders (individuals, institutions, societies, universities, ministries of health, other nongovernmental organizations) to strengthen the delivery of surgical services at the primary referral level in LMICs (http://www.who.int.surgery) [3–6]. The inaugural meeting was at WHO headquarters in Geneva, Switzerland in November 2005 [7], and subsequent biennial meetings were hosted by ministries of health in Dar es Salaam, Tanzania in September 2007) [8] and Ulaanbaatar, Mongolia in June 2009) [9]. There are currently more than 624 GIEESC members from 93 countries representing all six WHO regions. In all, 45 % of members are from LMICs. The LMICs with ≥10 GIEESC members are India, Nigeria, Ethiopia, Ghana, and Uganda. The WHO GIEESC members have contributed to a number of activities aimed at strengthening the delivery of essential surgical services in LMICs. One component involved the implementation, local adaptation, and translation of training tools that were developed by the WHO's Emergency and Essential Surgical Care (EESC) project, which was initiated in the Clinical Procedures Unit of the Department of Essential Health Technologies in 2004 [3–6]. These training tools include the WHO Integrated Management of Emergency and Essential Surgical Care (IMSCStoolkit [10] and the Manual of Surgical Care at the District Hospital [11]. These materials have been introduced in 39 countries through collaborations with the respective Ministry of Health (MoH) and WHO country offices. The materials have been translated into Mongolian, Spanish, Chinese, Vietnamese, Korean, Dari, and Farsi. A WHO situational analysis tool to assess the availability of EESC at the level of individual health facilities was developed in 2007. It was based on infrastructure, human resources, procedures, equipment, and supplies [12]. This questionnaire has now been utilized in more than 35 countries, and the data collected and entered in the WHO EESC Global Database has been published to highlight gross deficiencies in the availability of EESC [13–22]. The WHO EESC Global Database was created to facilitate data entry from different countries. The situational analysis tool has been integrated into the WHO's Service Availability Mapping (SAM) technology [23] with the goal of facilitating monitoring the availability of surgical services at the facilities level. This technology was introduced in Mongolia in 2009. Plans have been made to continue with a surgical module in the WHO's recent adaptation of facilities-based monitoring, Service Availability and Readiness Assessment (SARA). A planning tool was developed to assist policymakers integrate EESC into their national health plans.An online Global MedNet serves as a platform for online discussions and for posting announcements and materials related to GIEESC (http://www.who.int/ surgery/globalinitiative/en/).

Strengthening Surgical Services at the Soum (First‐referral) Hospital: The WHO Emergency and Essential Surgical Care (EESC) Program in Mongolia

Provision of surgical care continues to receive little attention and funding despite the growing burden of surgical disease worldwide. In 2004, The World Health Organization (WHO) established the Emergency and Essential Surgical Care (EESC) program, which was designed to strengthen surgical services at the first-referral hospital. There are limited data documenting the implementation and scale-up of such services. We describe the nationwide implementation of the EESC program in Mongolia over a 6 year period. Surgical services were increased in rural areas of Mongolia using the WHO Integrated Management of Emergency and Essential Surgical Care (IMEESC) toolkit from 2004 to 2010. Fund of knowledge tests and program evaluation was done to measure uptake, response, and perceived importance of the program. Two years after the pilot sites were launched, programmatic impact on short-term process measures was evaluated using the WHO Monitoring and Evaluation form. The program was implemented in 14 aimags/provinces (66.67 %) and 178 soum hospitals (52.66 %). Fund of knowledge scores increased from 47.72 % (95 % confidence interval (CI) 40.7-54.7) to 77.9 % (95 % CI 70.1-85.7, p = 0.0001) after the training program. 1 year post-training, there was a 57.1 % increase in the availability of emergency rooms, 59.1 % increase in the supply of emergency kits, a 73.64 % increase in the recording of emergency care cases, and a 46.66 % increase in the provision of facility and instrument usage instructions at the pilot sites. The EESC program was successfully implemented and scaled up at a national level with improvements in short-term process measures.