Developing an integrated clinical decision support system for the early identification and management of kidney disease-building cross-sectoral partnerships.

BACKGROUND: The burden of chronic conditions is growing in Australia with people in remote areas experiencing high rates of disease, especially kidney disease. Health care in remote areas of the Northern Territory (NT) is complicated by a mobile population, high staff turnover, poor communication between health services and complex comorbid health conditions requiring multidisciplinary care. AIM: This paper aims to describe the collaborative process between research, government and non-government health services to develop an integrated clinical decision support system to improve patient care. METHODS: Building on established partnerships in the government and Aboriginal Community-Controlled Health Service (ACCHS) sectors, we developed a novel digital clinical decision support system for people at risk of developing kidney disease (due to hypertension, diabetes, cardiovascular disease) or with kidney disease. A cross-organisational and multidisciplinary Steering Committee has overseen the design, development and implementation stages. Further, the system's design and functionality were strongly informed by experts (Clinical Reference Group and Technical Working Group), health service providers, and end-user feedback through a formative evaluation. RESULTS: We established data sharing agreements with 11 ACCHS to link patient level data with 56 government primary health services and six hospitals. Electronic Health Record (EHR) data, based on agreed criteria, is automatically and securely transferred from 15 existing EHR platforms. Through clinician-determined algorithms, the system assists clinicians to diagnose, monitor and provide guideline-based care for individuals, as well as service-level risk stratification and alerts for clinically significant events. CONCLUSION: Disconnected health services and separate EHRs result in information gaps and a health and safety risk, particularly for patients who access multiple health services. However, barriers to clinical data sharing between health services still exist. In this first phase, we report how robust partnerships and effective governance processes can overcome these barriers to support clinical decision making and contribute to holistic care.

Nutritional status of a young adult population in saline-prone coastal Bangladesh.

Introduction: Like many low- and middle-income countries, understanding the nutritional status of the young population in Bangladesh has had less attention. With projected climate change and associated sea level rise, the existing problem of salinity in coastal Bangladesh will significantly increase and further worsen agrobiodiversity. This research aimed to examine the nutritional status of a young population in climate-vulnerable coastal Bangladesh to inform appropriate intervention strategies to reduce the burden on health and economic outcomes. Methods: A cross-sectional survey was conducted in 2014, and anthropometric measures were conducted for 309 young people aged 19-25 years in a rural saline-prone subdistrict in southwestern coastal Bangladesh. Body mass index (BMI) was calculated from body height and weight, and data about socio-demographic factors were collected. To identify the socio-demographic risk factors affecting undernutrition (BMI <18.5 kg/m2) and overweight/obesity (BMI ≥ 25.0 kg/m2), multinomial logistic regression analysis was used. Results: Overall, one-fourth of the study population was classified as underweight, and nearly one-fifth were overweight or obese. The proportion of underweight was significantly higher in women (32.5%) compared to that of men (15.2%). Overall, employment, especially in women, was associated with reduced odds of being underweight (adjusted odds ratio-aOR: 0.32; 95% confidence interval - CI: 0.11, 0.89). Subjects with secondary education incomplete (grades 6-9) compared to those with primary or below education (grades 0-5; aOR: 2.51; 95% CI: 1.12, 5.59) and employed compared to those unemployed groups (aOR: 5.84; 95% CI: 2.67, 12.74) were more likely to be overweight or obese in this study population. These associations were more pronounced in women. Discussion: Multisectoral program strategies are required to tackle the growing burden of malnutrition (both under and overweight) in this young age group tailored to local contexts including in climate-vulnerable coastal Bangladesh.

High Human T-Cell Leukemia Virus Type 1c Proviral Loads Are Associated With Diabetes and Chronic Kidney Disease: Results of a Cross-Sectional Community Survey in Central Australia.

BACKGROUND: A link between chronic inflammation and several noncommunicable diseases (NCDs) has been established. Although chronic infection with the human T-cell leukemia virus type 1 (HTLV-1) is the recognized cause of several inflammatory diseases and these are associated with a high number of HTLV-1-infected cells in peripheral blood (proviral load [PVL]), possible interactions between PVL and NCDs have not been studied at a community level. METHODS: Adult Aboriginal residents of 7 remote communities were invited to complete a health survey between 25 August 2014 and 30 June 2018. Blood was drawn for HTLV-1 serology and PVL, and relevant medical conditions were obtained from health records. Associations between HTLV-1 PVL and diabetes, chronic kidney disease (CKD), and coronary artery disease (CAD) were determined using logistic regression, adjusting for available confounders. RESULTS: Among 510 participants (56% of the estimated adult resident population, 922), 197 (38.6%) were HTLV-1-infected. A high HTLV-1 PVL was associated with a 2-fold increase in the odds of diabetes and CKD (diabetes, adjusted odds ratio [aOR], 1.95; 95% confidence interval [CI], 1.06-3.61; P = .033 and CKD: aOR, 2.00; 95% CI, 1.03-3.8; P = .041). A nonsignificant association between high PVL and CAD (aOR, 7.08; 95% CI, 1.00-50.18; P = .05) was found for participants aged <50 years at the time of angiography. CONCLUSIONS: In a community-based study in central Australia, people with HTLV-1 who had high HTLV-1 PVL were more likely to have diabetes and CKD. These findings have potential clinical implications.

Prevalence and Risk Factors of Gestational Diabetes Mellitus in Bangladesh: Findings from Demographic Health Survey 2017-2018.

Gestational diabetes mellitus (GDM) has serious consequences for both maternal and neonatal health. The growing number of noncommunicable diseases and related risk factors as well as the introduction of new World Health Organization (WHO) diagnostic criteria for GDM are likely to impact the GDM prevalence in Bangladesh. Our study aimed to assess the national prevalence and identify the risk factors using the most recent WHO criteria. We used the secondary data of 272 pregnant women (weighted for sampling strategy) from the Bangladesh Demographic and Health Survey 2017-2018. Multivariate logistic regression was performed to determine the risk factors of GDM. The overall prevalence of GDM in Bangladesh was 35% (95/272). Increased odds of GDM were observed among women living in the urban areas (adjusted odds ratio (aOR) 2.74, 95% confidence interval (CI) 1.43-5.27) compared to rural areas and those aged ≥25 years (aOR 2.03, 95% CI 1.13-3.65). GDM rates were less prevalent in the later weeks of pregnancy compared to early weeks. Our study demonstrates that the national prevalence of GDM in Bangladesh is very high, which warrants immediate attention of policy makers, health practitioners, public health researchers, and the community. Context-specific and properly tailored interventions are needed for the prevention and early diagnosis of GDM.

The Association between Diabetes and Human T-Cell Leukaemia Virus Type-1 (HTLV-1) with Strongyloides stercoralis: Results of a Community-Based, Cross-Sectional Survey in Central Australia.

In central Australia, an area that is endemic for the human T-cell leukaemia virus type-1 (HTLV-1), the prevalence of Strongyloides stercoralis and its association with other health conditions are unknown. A cross-sectional community-based survey was conducted in seven remote Aboriginal communities in central Australia, from 2014 to 2018. All residents aged ≥10 years were invited to complete a health survey and to provide blood for Strongyloides serology, HTLV-1 serology and HTLV-1 proviral load (PVL). Risk factors for Strongyloides seropositivity and associations with specific health conditions including diabetes and HTLV-1 were determined using logistic regression. Overall Strongyloides seroprevalence was 27% (156/576) (children, 22% (9/40); adults (≥15 years), 27% (147/536), varied widely between communities (5-42%) and was not associated with an increased risk of gastrointestinal, respiratory or dermatological symptoms. Increasing age, lower HTLV-1 PVL (<1000 copies per 105 peripheral blood leucocytes) compared to the HTLV-1 uninfected group and community of residence were significant risk factors for Strongyloides seropositivity in an adjusted model. A modest reduction in the odds of diabetes among Strongyloides seropositive participants was found (aOR 0.58, 95% CI 0.35, 1.00; p = 0.049); however, this was lost when body mass index was included in the adjusted model (aOR 0.48, 95% CI 0.48, 1.47; p = 0.542). Strongyloides seropositivity had no relationship with anaemia. Exploring social and environmental practices in communities with low Strongyloides seroprevalence may provide useful lessons for similar settings.

The effect of high temperatures on risk of hospitalization in northern Vietnam.

Vietnam is one Southeast Asian country most vulnerable to climate change. By the end of the twenty-first century, temperature could rise above 5°C across Vietnam according to the IPCC highest emission pathway scenario. However, research on the temperature-health effects from the geographically diverse sub-tropical northern region of Vietnam is limited making location specific health system preparedness difficult. This study examines the elevated temperature-hospitalization relationship for the seven provinces in northern Vietnam by using generalized linear and distributed lag models. A random-effect meta-analysis was used to estimate the pooled temperature hospitalizations risks for all causes, and for infectious, cardiovascular, and respiratory diseases. The pooled estimates show a significant effect of high temperature on hospitalizations for the same day (lag 0), when a 1°C increase in temperature above 24°C was significantly associated with 1.1% (95% CI, 0.9-1.4%) increased risk for all-cause hospital admissions, 2.4% (95% CI, 1.9-2.9%) increased risk for infectious disease admissions, 0.5% (95% CI, 0.1-0.9%) increased risk for cardiovascular disease admissions, and 1.3% (95% CI, 0.9-1.6%) increased risk for respiratory disease admissions. This research adds to the scant evidence examining heat and health morbidity effects in sub-tropical climates and has important implications for better understanding and preparing for the future impacts of climate change related temperature on Vietnam residents.

Very high prevalence of infection with the human T cell leukaemia virus type 1c in remote Australian Aboriginal communities: Results of a large cross-sectional community survey.

Infection with the human T cell leukaemia virus type 1 (HTLV-1) subtype C is endemic among Aboriginal people in central Australia. To provide insights into the risk factors for transmission, we conducted the first large-scale, community-based prevalence study in seven remote Aboriginal communities. Residents >2 years old were invited to participate in the study between August 2014 and June 2018. HTLV-1 infection was defined as a positive western blot (WB) test or a positive HTLV-1 PCR. 720 community residents participated in the study (children <15 years, 142; adults, 578). Prevalences for children and adults were 3.5% (5/142) and 36.8% (213/578), respectively, reaching 49.3% (106/215) for those older than 45 years. A wide range of proviral loads were measured for both asymptomatic and symptomatic participants with no difference within groups according to age or gender; however, median PVL was 1.34 log10 higher for symptomatic participants. The adult prevalence of HTLV-1 infection in central Australia is the highest reported worldwide. Sexual contact is likely to be the predominant mode of transmission.

Pulmonary Disease Is Associated With Human T-Cell Leukemia Virus Type 1c Infection: A Cross-sectional Survey in Remote Aboriginal Communities.

BACKGROUND: The human T-cell leukemia virus type 1 (HTLV-1) subtype c is endemic to central Australia. We report the first large-scale, community-based, health survey of HTLV-1 and its disease associations in this setting. METHODS: Aboriginal community residents aged >2 years in 7 remote communities were invited to do a health survey that included a questionnaire, spirometry, and clinical examination by a physician blinded to HTLV-1 status, clinical records, and spirometry results. Blood was drawn for HTLV-1 serology and proviral load (PVL). Pulmonary disease was assessed clinically and spirometrically and, where records were available, radiologically after the clinical assessment. Associations between specific diseases and HTLV-1 status were determined using logistic regression, adjusting for available confounders. RESULTS: Overall, 579 residents (164 children aged 3-17 years; 415 adults) were examined (37.7% of the estimated resident population). HTLV-1 prevalences for children and adults were 6.1% and 39.3%, respectively. No associations were found between HTLV-1 and any assessed clinical condition among children. Chronic pulmonary disease and gait abnormalities were more common among adults with HTLV-1 infection. Adjusted odds ratios among participants with PVL ≥1000 per 105 peripheral blood leukocytes were 7.08 (95% confidence interval [CI], 2.67-18.74; P < .001), 9.81 (95% CI, 3.52-27.35; P < .001), and 14.4 (95% CI, 4.99-41.69; P < .001) for clinically defined chronic pulmonary disease, moderate-severe expiratory airflow limitation, and radiologically determined bronchiectasis/bronchiolitis, respectively, and 5.21 (95% CI, 1.50-18.07; P = .009) for gait abnormalities. CONCLUSIONS: In the first study of HTLV-1 disease associations based on community recruitment and blinded assessment, HTLV-1 infection was strongly associated with pulmonary disease and gait abnormalities.

Higher human T-cell leukaemia virus type 1 (HTLV-1) proviral load is associated with end-stage kidney disease in Indigenous Australians: Results of a case-control study in central Australia.

Case series suggest that human T-cell leukaemia virus type 1 (HTLV-1) is associated with kidney disease; however, little is known about the impact of proviral load (PVL). The present study was commenced to determine whether higher HTLV-1 PVL is associated with end stage kidney disease (ESKD) in Indigenous Australians. A case-control study was conducted in Alice Springs Hospital (ASH), 1 July 2007 to 30 November 2015. Cases included all 80 Indigenous adults (>17 years) with HTLV-1c and ESKD, matched 1:1 by sex to controls with HTLV-1 who had no renal disease or other recognised disease associations of HTLV-1, and were recruited during the same period. The association between PVL and ESKD was assessed using logistic regression. Median (IQR) HTLV-1c PVL for subjects with ESKD (6.86, IQR (3.35, 8.23) log copies per 105 peripheral blood leukocytes (PBL) (ie, 0.95; IQR, 0.03; 3.70% PBL) was significantly higher than that of the asymptomatic group (3.47; IQR (-0.04, 6.61) log copies per 10 5 PBL (ie, 0.01; IQR, 0.00; 0.52% PBL) (asymptomatic vs ESKD, P (ranksum) < .001). Major factors associated with ESKD were diabetes (adjusted odds ratio [aOR], 21.80; 95% CI, 4.84, 98.22; P < .001), hypertension (aOR, 4.16; 1.11, 15.64; P = .03), remote residence (aOR, 5.34; 95% CI, 1.17, 27.29; P = .03) and HTLV-1c PVL greater than or equal to 100 copies per 10 5 PBL (aOR, 3.67; 95% CI, 1.36, 9.92; P = .01). Higher HTLV-1c PVL are strongly associated with inflammatory diseases. The high HTLV-1c PVL reported here may have clinical implications for people with HTLV-1 who require haemodialysis. Longitudinal studies are required to determine whether this association is causal.

Correlates of Climate Variability and Dengue Fever in Two Metropolitan Cities in Bangladesh.

Dengue fever is a major public health concern in Bangladesh with increased incidence during monsoon. We aimed to assess the correlation of temperature, humidity, and rainfall on dengue fever in two dengue endemic cities in Bangladesh. It was a time series analysis of climate factors and dengue occurrence data in Dhaka and Chittagong cities from 1 January 2000 to 31 December 2009. Daily mean temperature, rainfall, and humidity data were obtained from the Bangladesh meteorological department and daily dengue cases data were obtained from the directorate general of health services (DGHS) of Bangladesh. The mean dengue incidence was 31.62 (SD 28.7) per 100,000 in Dhaka whereas it was 5.76 (SD 11.7) per 100,000 population in Chittagong. The incidence of dengue cases was found significantly associated with the monthly mean temperature, total rainfall, and mean humidity in Dhaka, though in Chittagong, the significantly associated factors​ ​​​​​​were monthly total rainfall and mean humidity. The autoregressive integrated moving average (ARIMA) model identified monthly mean humidity and total rainfall as the most significant contributing factors for dengue cases in Dhaka and Chittagong, respectively. Our study reinforces the relationship of climate parameters with dengue fever, which will support policy-makers in developing a climate-based early warning system for dengue in Bangladesh.

Association between salinity and hospital admission for hypertension: an ecological case-control study in the Mekong Delta Region in Vietnam.

Background: Drinking water in the Mekong Delta Region (MDR) is highly vulnerable to salinity intrusion and this problem is expected to increase with the projected climate change and sea level rise. Despite this, research on health effects of saline contaminated water is scarce in this region. This study examines the risk of hospital admission for hypertension in salinity-affected areas of the MDR. Methods: Cases and controls were obtained from national/provincial hospital admission records for 2013. The cases were adult patients whom hypertension (ICD10-code: I10-I15) was primary diagnosis for admission. Of the 13 provinces in the MDR, we identified seven as 'salinity exposed' and the remaining as 'non-exposed' areas. A multi-level logistic regression model was used to examine the association between salinity exposure and hypertension outcome. Results: Of the total 573 650 hospital admissions, 22 382 (~3.9%) were hypertensive cases. The multi-level logistic model combining both individual and ecological factors showed a 9% increase in risk (95% CI: 3-14%) of hypertension admission among individuals in exposed areas compared to those in non-exposed areas. Conclusion: In order to develop and promote appropriate adaptation strategies, further research is recommended to identify the salt exposure pathways and consumption behaviours in the salinity exposed areas.

Drinking water salinity and risk of hypertension: A systematic review and meta-analysis.

We summarized epidemiological studies assessing sodium in drinking water and changes in blood pressure or hypertension published in English from 1960 to 2015 from PubMed, Scopus, and Web of Science. We extracted data on blood pressure level or prevalence of hypertension and calculated pooled estimates using an inverse variance weighted random-effects model. The pooled standardized mean difference (SMD) in 7 studies (12 data sets) comparing the low and high water sodium exposure groups for systolic blood pressure (SBP) was 0.08 (95% CI, -0.17 to 0.34) and for diastolic blood pressure (DBP) was 0.23 (95% CI, 0.09-0.36). Of the 3 studies that assessed the association between high water sodium and odds of hypertension, 2 recent studies showed consistent findings of higher risk of hypertension. Our systematic review suggests an association between water sodium and human blood pressure (more consistently for DBP) but remain inconclusive because of the small number of studies (largely in young populations) and the cross-sectional design and methodological drawbacks. In the context of climate-change-related sea level rise and increasing saltwater intrusion into drinking water sources, further research is urgently warranted to investigate and guide intervention in this increasingly widespread problem.

A climate-based prediction model in the high-risk clusters of the Mekong Delta region, Vietnam: towards improving dengue prevention and control.

OBJECTIVE: To develop a prediction score scheme useful for prevention practitioners and authorities to implement dengue preparedness and controls in the Mekong Delta region (MDR). METHODS: We applied a spatial scan statistic to identify high-risk dengue clusters in the MDR and used generalised linear-distributed lag models to examine climate-dengue associations using dengue case records and meteorological data from 2003 to 2013. The significant predictors were collapsed into categorical scales, and the ß-coefficients of predictors were converted to prediction scores. The score scheme was validated for predicting dengue outbreaks using ROC analysis. RESULTS: The north-eastern MDR was identified as the high-risk cluster. A 1 °C increase in temperature at lag 1-4 and 5-8 weeks increased the dengue risk 11% (95% CI, 9-13) and 7% (95% CI, 6-8), respectively. A 1% rise in humidity increased dengue risk 0.9% (95% CI, 0.2-1.4) at lag 1-4 and 0.8% (95% CI, 0.2-1.4) at lag 5-8 weeks. Similarly, a 1-mm increase in rainfall increased dengue risk 0.1% (95% CI, 0.05-0.16) at lag 1-4 and 0.11% (95% CI, 0.07-0.16) at lag 5-8 weeks. The predicted scores performed with high accuracy in diagnosing the dengue outbreaks (96.3%). CONCLUSION: This study demonstrates the potential usefulness of a dengue prediction score scheme derived from complex statistical models for high-risk dengue clusters. We recommend a further study to examine the possibility of incorporating such a score scheme into the dengue early warning system in similar climate settings.

The effect of drinking water salinity on blood pressure in young adults of coastal Bangladesh.

More than 35 million people in coastal Bangladesh are vulnerable to increasing freshwater salinization. This will continue to affect more people and to a greater extent as climate change projections are realised in this area in the future. However the evidence for health effects of consuming high salinity water is limited. This research examined the association between drinking water salinity and blood pressure in young adults in coastal Bangladesh. We conducted a cross-sectional study during May-June 2014 in a rural coastal sub-district of Bangladesh. Data on blood pressure (BP) and salinity of potable water sources was collected from 253 participants aged 19-25 years. A linear regression method was used to examine the association between water salinity exposure categories and systolic BP (SBP) and diastolic BP (DBP) level. Sixty five percent of the study population were exposed to highly saline drinking water above the Bangladesh standard (600 mg/L and above). Multivariable linear regression analyses identified that compared to the low water salinity exposure category (<600 mg/L), those in the high water salinity category (>600 mg/L), had statistically significantly higher SBP (B 3.46, 95% CI 0.75, 6.17; p = 0.01) and DBP (B 2.77, 95% CI 0.31, 5.24; p = 0.03). Our research shows that elevated salinity in drinking water is associated with higher BP in young coastal populations. Blood pressure is an important risk factor of hypertension and cardiovascular diseases. Given the extent of salinization of freshwater in many low-lying countries including in Bangladesh, and the likely exacerbation related to climate change-induced sea level rise, implementation of preventative strategies through dietary interventions along with promotion of low saline drinking water must be a priority in these settings.

Drinking water contributes to high salt consumption in young adults in coastal Bangladesh.

Increasing salinity of freshwater from environmental and anthropogenic influences is threatening the health of 35 million inhabitants in coastal Bangladesh. Yet little is known about the characteristics of their exposure to salt (sodium), a major risk factor for hypertension and related chronic diseases. This research examined sodium consumption levels and associated factors in young adults. We assessed spot urine samples for 282 participants (19-25 years) during May-June 2014 in a rural sub-district in southwestern coastal Bangladesh and measured sodium levels of their potable water sources. The significant factors associated with high sodium consumption were determined from logistic regression analyses. Mean sodium content in tube-well water (885 mg/L) was significantly higher than pond water (738 mg/L) (P = 0.01). Fifty three percent of subjects were consuming sodium at levels above the WHO recommended level (≥2 g/day). The users of tube-well water were more likely to consume sodium above this recommended level than pond water users. Salinity problems are projected to increase with climate change, and with large populations potentially at risk, appropriate public health and behavior-change interventions are an urgent priority for this vulnerable coastal region along with targeted research to better understand sodium exposure pathways and health benefits of alternative water supplies.