Asbestos exposure and asbestosis mortality in Italian cement-asbestos cohorts: Dose-response relationship and the role of competing death causes.

OBJECTIVES: In Italy, asbestos was used intensively until its ban in 1992, which was extended for asbestos cement factories until 1994. The aim of this study was to evaluate the dose-response between asbestos exposure and asbestosis mortality across a pool of Italian occupational cohorts, taking into account the presence of competing risks. METHODS: Cohorts were followed for vital status and the cause of death was ascertained by a linkage with mortality registers. Cause-specific (CS) Cox-regression models were used to evaluate the dose-exposure relationship between asbestosis mortality and the time-dependent cumulative exposure index (CEI) to asbestos. Fine and Gray regression models were computed to assess the effect of competing risks of death. RESULTS: The cohort included 12,963 asbestos cement workers. During the follow-up period (1960-2012), of a total of 6961 deaths, we observed 416 deaths attributed to asbestosis, 879 to lung cancer, 400 to primary pleural cancer, 135 to peritoneal cancer, and 1825 to diseases of the circulatory system. The CS model showed a strong association between CEI and asbestosis mortality. Dose-response models estimated an increasing trend in mortality even below a CEI of 25 ff/mL-years. Lung cancer and circulatory diseases were the main competing causes of death. CONCLUSIONS: Asbestos exposure among Italian asbestos-cement workers has led to a very high number of deaths from asbestosis and asbestos-related diseases. The increasing risk trend associated with excess deaths, even at low exposure levels, suggests that the proposed limit values would not have been adequate to prevent disability and mortality from asbestosis.

Features that hindered the capacity development of a national prostate cancer service.

Introduction: In Scotland, prostate cancer services have struggled to meet demand, and urological cancer services have missed Scottish Government waiting time targets to a greater extent than other cancer services. This study provides understanding of the capacity development needs of a national prostate cancer service including why the service had been unable to adapt to meet demand and how capacity could be developed. Methods: Delphi technique was applied to a purposive sample of prostate cancer clinicians working across Scotland between 2015 and 2017. Interviews were conducted with healthcare professionals involved in delivery of care to people with prostate cancer including General Practitioners, followed by questionnaires which were distributed to Specialist Nurses, Oncologists and Urologists involved in delivering specialist prostate cancer services within NHS Scotland. Findings are reported from interviews analysed using a directed approach to content analysis, followed by three rounds of iterative online questionnaires analysed using descriptive statistics. Results: Reform is needed to meet demand within prostate cancer services in Scotland. Barriers to capacity development included: lack of shared understanding of quality of care between policy makers and healthcare professionals; lack of leadership of service developments nationally and regionally; and difficulties in drawing on other capacities to support the service. Cohesive working and a need for efficient training for nurse specialists were needed to develop capacity. Consensus was reached for development of national working groups to set standards for quality care (100% agreement) and further development of existing regional working groups (100% agreement) to implement this care (91% agreement), which should include input from primary and community care practitioners (100% agreement) to meet demand. Discussion: This work provides important understanding of barriers and facilitators to service development across a national service, including highlighting the importance of a shared vision for quality care between policy makers and healthcare professionals. Mechanisms to support service change are identified.

Partnering to build surgical capacity in low-resource settings: a qualitative study of Canadian global surgeons.

OBJECTIVES: This qualitative study aimed to explore the perspectives of Canadian global surgeons with experience developing surgical education partnerships with low- and middle-income countries (LMICs) for the purpose of identifying factors for success. DESIGN: A purposive sample of leaders from global surgery programmes at Canadian Faculties of Medicine participated in virtual semi-structured interviews. A six-phase thematic analysis was performed using a constructivist lens on verbatim transcripts by three independent researchers. Key factors for success were thematically collated with constant comparison and inter-investigator triangulation in NVivo software until theoretical saturation was reached. PARTICIPANTS: Fifteen surgeons, representing 11 subspecialties at 6 Canadian academic institutions and a combined experience across 6 continents, were interviewed between January and June 2022. RESULTS: Four facilitators for success of global surgery training programmes were identified, with a strong undertone of relationship-building permeating all subthemes: (1) facilitative skill sets and infrastructure, (2) longitudinal engagement, (3) local ownership and (4) interpersonal humility. Participants defined facilitative skill sets to include demonstrated surgical competence and facilitative infrastructure to include pre-existing local networks, language congruency, sustainable funding and support from external organisations. They perceived longitudinal engagement as spanning multiple trips, enabled by strong personal motivation and arrangements at their home institutions. Ownership of projects by local champions, including in research output, was noted as key to preventing brain drain and catalysing a ripple effect of surgical trainees. Finally, interviewees emphasised interpersonal humility as being crucial to decolonising the institution of global surgery with cultural competence, reflexivity and sustainability. CONCLUSIONS: The interviewed surgeons perceived strong cross-cultural relationships as fundamental to all other dimensions of success when working in low-resource capacity-building. While this study presents a comprehensive Canadian perspective informed by high-profile leadership in global surgery, a parallel study highlighting LMIC-partners' perspectives will be critical to a more complete understanding of programme success.

Exploring the similarities and differences of variables collected by burn registers globally: protocol for a data dictionary review study.

INTRODUCTION: Burn registers can provide high-quality clinical data that can be used for surveillance, research, planning service provision and clinical quality assessment. Many countrywide and intercountry burn registers now exist. The variables collected by burn registers are not standardised internationally. Few international burn register data comparisons are completed beyond basic morbidity and mortality statistics. Data comparisons across registers require analysis of homogenous variables. Little work has been done to understand whether burn registers have sufficiently similar variables to enable useful comparisons. The aim of this project is to compare the variables collected in countrywide and intercountry burn registers internationally to understand their similarities and differences. METHODS AND ANALYSIS: Burn register custodians will be invited to participate in the study and to share their register data dictionaries. Study objectives are to compare patient inclusion and exclusion criteria of each participating burn register; determine which variables are collected by each register, and if variables are required or optional, identify common variable themes; and compare a sample of variables to understand how they are defined and measured. All variable names will be extracted from each register and common themes will be identified. Detailed information will be extracted for a sample of variables to give a deeper insight into similarities and differences between registers. ETHICS AND DISSEMINATION: No patient data will be used in this project. Permission to use each register's data dictionary will be sought from respective register custodians. Results will be presented at international meetings and published in open access journals. These results will be of interest to register custodians and researchers wishing to explore international data comparisons, and countries wishing to establish their own burn register.

A Pandemic Treaty: Learning From the Framework Convention on Tobacco Control.

The World Health Organization recently began developing a "pandemic treaty" in response to the perceived failures of the global COVID-19 response. The Framework Convention on Tobacco Control, which obligates members to certain global standards in tobacco control, is an example of a global public health agreement that may be used as a model for the pandemic treaty. Several challenges related to the convention, many from the tobacco industry itself, must be addressed if it is to be used as a prototype for a pandemic agreement. These include harm reduction policies, private-sector involvement, and its impact in low- and middle-income countries. A pandemic treaty may encounter similar challenges faced by the Framework Convention on Tobacco Control, particularly from industry groups with financial interests related to infectious disease control and prevention. Addressing challenges at the outset may facilitate the development and implementation of a more robust international instrument.

Systematic review of intervention functions, theoretical constructs and cultural adaptations of school-based smoking prevention interventions in low-income and middle-income countries.

OBJECTIVE: To identify the approaches and strategies used for ensuring cultural appropriateness, intervention functions and theoretical constructs of the effective and ineffective school-based smoking prevention interventions that were implemented in low-income and middle-income countries (LMICs). DATA SOURCES: Included MEDLINE, EMBASE, Global Health, PsycINFO, Web of Science and grey literature which were searched through August 2022 with no date limitations. ELIGIBILITY CRITERIA: We included randomised controlled trials (RCTs) with ≥6 months follow-up assessing the effect of school-based interventions on keeping pupils never-smokers in LMICs; published in English or Arabic. DATA EXTRACTION AND SYNTHESIS: Intervention data were coded according to the Theoretical Domains Framework, intervention functions of Behaviour Change Wheel and cultural appropriateness features. Using narrative synthesis we identified which cultural-adaptation features, theoretical constructs and intervention functions were associated with effectiveness. Findings were mapped against the capability-motivation and opportunity model to formulate the conclusion. Risk of bias was assessed using the Cochrane risk of bias tool. RESULTS: We identified 11 RCTs (n=7712 never-smokers aged 11-15); of which five arms were effective and eight (four of the effective) arms had a low risk of bias in all criteria. Methodological heterogeneity in defining, measuring, assessing and presenting outcomes prohibited quantitative data synthesis. We identified nine components that characterised interventions that were effective in preventing pupils from smoking uptake. These include deep cultural adaptation; raising awareness of various smoking consequences; improving refusal skills of smoking offers and using never-smokers as role models and peer educators. CONCLUSION: Interventions that had used deep cultural adaptation which incorporated cultural, environmental, psychological and social factors, were more likely to be effective. Effective interventions considered improving pupils' psychological capability to remain never-smokers and reducing their social and physical opportunities and reflective and automatic motivations to smoke. Future trials should use standardised measurements of smoking to allow meta-analysis in future reviews.

Establishing nursing-sensitive quality indicators for pediatric oncology: An international mixed methods Delphi study.

INTRODUCTION: Nursing-sensitive indicators (NSIs) measure factors influencing nursing care quality and patient outcomes. Established NSIs reflect general and select specialty nursing practices. However, a core set of NSIs for international pediatric oncology nursing practice does not currently exist. Without valid and reliable quality indicators, the impact of nursing care on children and adolescents with cancer cannot be effectively measured and improved. The purpose of this study was to develop a preliminary core set of NSIs for international pediatric oncology nursing that would be important, actionable, and feasible to measure across varied resource settings and countries. DESIGN/METHODS: A multiphase sequential mixed methods research design, intersected with a classical Delphi method, was utilized. Through purposive snowball sampling, 122 expert pediatric oncology nurses from 43 countries participated. Round One: Panelists identified five potential NSIs and constructs. Open-ended responses were coded and categorized through descriptive content analysis and integrated into the next round. Round Two: Panelists selected their top 10 NSIs and constructs and ranked them by importance to patient care quality. Mean importance scores were calculated through reverse scoring; the top 10 NSIs and constructs were integrated into the next round. Round Three: Panelists ranked the top 10 NSIs and constructs by order of importance for this particular population, then rated each NSI/Construct for actionability and feasibility of measurement by Likert-scale. Rounds Two and Three were analyzed using descriptive statistics. Mixed methods meta-inferences were derived from the integration of Rounds One and Three findings. RESULTS: Eighty-five (70%) panelists from 38 countries completed all Delphi survey rounds. The preliminary core set of NSIs and constructs identified by the expert panel, and ranked in order of importance, were as follows: safe chemotherapy administration and handling, infection prevention/control, pediatric oncology nursing orientation program, early warning score system/recognition of patient deterioration, chemotherapy/biotherapy education/course, pain assessment/management, symptom assessment/management, patient and family education, palliative/end of life care, and continuing nursing education/competency. All NSIs and constructs were rated as actionable; all but palliative/end of life care were rated as feasible to measure. Each of the 10 NSIs and constructs were nominated in Round One by at least one expert panelist from low- and middle-income and high-income countries, and at least one panelist from the Americas. CONCLUSION: Preliminary core NSIs and constructs provide insight into common attributes of international pediatric oncology nursing practice that are important, actionable, and feasible for quality measurement. CLINICAL RELEVANCE: NSIs have the potential to drive quality improvement, guide comparison with other institutions, promote knowledge-sharing, and advance pediatric oncology nursing outcomes around the world. These NSIs and constructs may also be relevant to other pediatric and adult oncology settings.

Medical services provided on the 'Harmonious Mission-2017' Peace Ark from China.

INTRODUCTION: The Chinese Naval ship Peace Ark provided humanitarian medical services to people in eight low-income countries in Africa and Asia during the 2017 "Harmonious Mission'. The expedition lasted 155 days. Our study aimed to analyse the details of the medical services provided including outpatient care, medical patrol, operations, examinations and medications. METHOD: The patient demographic data and medical information were extracted from electronic medical records. The diagnoses and procedures aboard were coded by the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). The sociodemographic data of the medical staff aboard were collected via questionnaire. Descriptive statistics and statistical software (SAS, V.9.4) were used to analyse the data. RESULTS: In total, 115 Chinese military medical personnel participated in the mission, completing a total of 50 758 outpatient visits, 10 232 medical patrols and 252 operations. The five most frequently used outpatient departments were ophthalmology, general surgery, general internal medicine, orthopaedics and traditional Chinese medicine. The five most common operations were lipoma excision, cataract extraction, skin tissue removal (such as warts and cysts), pterygium transposition and herniorrhaphy. CONCLUSIONS: Our study revealed the medical services in demand during the 'Harmonious Mission-2017'. It is essential to report their experiences so that future ventures can provide medical services more effectively.

Atividades práticas no processo de formação em Fisioterapia no Brasil e em Portugal: olhar de docentes e gestores / Practical activities on physiotherapy degree courses in Brazil and Portugal through the lens of teachers and course coordinators / Actividades prácticas en el proceso de formación en Fisioterapia en Brasil y en Portugal: la mirada de docentes y gestores

O estudo se propôs a desvelar atividades práticas realizadas no processo de formação profissional em Fisioterapia em cursos de Graduação no Brasil e em Portugal. Estudo de casos múltiplos (Brasil e Portugal) e integrados (cursos de Fisioterapia), com oito gestores (coordenadores/diretores), quatro de cada país, e 12 professores, seis de cada país. Utilizou-se entrevista semiestruturada de gestores e grupo focal de professores, com análise de conteúdo temática. Os resultados apontam para cenários diversificados, evidenciando a existência de práticas nos três níveis de Atenção à Saúde. Outrossim, essas atividades desenvolvidas durante a formação, em ambos os países, assumem uma complexidade crescente, entretanto ocorrem, em maior número, nos níveis secundário e terciário, com predomínio do perfil reabilitador. Portanto, a elucidação dessas práticas pode fomentar aproximações para ações de internacionalização na graduação em dois países de língua portuguesa.(AU)

Abstract The aim of this study was to investigate practical activities on physiotherapy degree courses in Brazil and Portugal. We carried out an integrated (physiotherapy courses) multiple case (Brazil and Portugal) study with eight course coordinators/directors (four in each country) and 12 professors (six in each country). We conducted semi-structured interviews with the coordinators/directors and focus group meetings with the professors, the results of which were analyzed using thematic content analysis. The results point to different training scenarios with practices encompassing all three levels of health care. In both countries the findings reveal the increasing complexity of practices, focusing mainly on secondary and tertiary care and rehabilitation. The elucidation of these practices can therefore help promote the internationalization of degree courses in these two Portuguese-speaking countries.(AU)

Resumen El estudio se propone desvelar actividades prácticas realizadas en el proceso de formación profesional en Fisioterapia en cursos de graduación en Brasil y en Portugal. Estudio de casos múltiples (Brasil y Portugal) e integrados (cursos de Fisioterapia), con ocho gestores (coordinadores/directores), cuatro de cada país, y 12 profesores, seis de cada país. Se utilizó la entrevista semiestructurada para los gestores y el grupo focal para los profesores y el análisis se realizó por contenido temático. Los resultados señalan escenarios diversificados, poniendo en evidencia la existencia de prácticas en los tres niveles de atención de la salud. Por otro lado, esas actividades desarrolladas durante la formación en ambos países asumen una complejidad creciente; sin embargo, ocurren en mayor número en los niveles secundario y terciario con predominio del perfil rehabilitador. Por lo tanto, la aclaración de esas prácticas puede fomentar aproximaciones en dos países de lengua portuguesa para acciones de internacionalización en la graduación.(AU)

Covid-19 na América Latina: desigualdades e capacidades de resposta dos sistemas de saúde a emergências sanitárias / COVID-19 in Latin America: inequalities and response capacity of health systems to health emergencies / COVID-19 en América Latina: desigualdades y capacidad de respuesta de los sistemas de salud ante emergencias de salud

RESUMO Objetivo. Identificar correlações entre a covid-19, características demográficas e socioeconômicas e capacidade dos sistemas de saúde latino-americanos para resposta a emergências sanitárias. Método. Realizou-se um estudo ecológico, utilizando dados secundários de 20 países latino-americanos relativos a incidência, mortalidade, testagem e cobertura vacinal para covid-19 no período de 2020 a 2021, assim como informações demográficas e socioeconômicas. A preparação dos países para responder a emergências sanitárias foi explorada a partir do Relatório Anual de Autoavaliação dos Estados Partes da Organização Mundial da Saúde de 2019 sobre a implementação do Regulamento Sanitário Internacional (RSI). Realizaramse análises estatísticas por meio do teste de correlação de Spearman (rho). Resultados. Observou-se correlação positiva alta do produto interno bruto per capita e do índice de desenvolvimento humano com incidência de covid-19, testagem e cobertura vacinal; e entre proporção da população idosa e cobertura vacinal. Não foram identificadas correlações entre os indicadores da covid-19 e as capacidades prévias de implementação do RSI. Conclusões. A ausência de correlação entre indicadores relativos à covid-19 e a capacidade de implementação do RSI pode estar relacionada a limites dos indicadores utilizados ou da ferramenta de acompanhamento do RSI como instrumento indutor da preparação dos países para enfrentamento de emergências sanitárias. Os resultados sugerem a importância de condicionantes estruturais e a necessidade de estudos longitudinais, comparativos e qualitativos para compreender os fatores que influenciaram a resposta dos países à covid-19.

ABSTRACT Objective. To identify correlations between COVID-19, demographic and socioeconomic characteristics, and the capacity of Latin American health systems to respond to health emergencies. Method. An ecological study was performed using secondary data from 20 Latin American countries regarding incidence, mortality, testing and vaccination coverage for covid-19 from 2020 to 2021 as well as demographic and socioeconomic indicators. The preparedness of countries to respond to health emergencies was explored based on the 2019 State Party Self-Assessment Annual Report on the implementation of the International Health Regulations (IHR). Statistical analyses were performed using the Spearman correlation test (rho). Results. A high positive correlation was noted between gross domestic product per capita and the human development index with the incidence of COVID-19, testing, and vaccination coverage; and between the proportion of elderly population and vaccination coverage. No correlations were identified between the covid-19 indicators and previous IHR implementation capacities. Conclusions. The lack of correlation between indicators related to COVID-19 and the ability to implement the IHR may reflect limitations of the indicators used or of the IHR monitoring tool as an instrument that induces the preparedness of countries to face health emergencies. The results suggest the importance of structural conditioning factors and the need for longitudinal, comparative, and qualitative studies to understand the factors that influenced the response of countries to COVID-19.

RESUMEN Objetivo. Determinar las posibles correlaciones entre la COVID-19, las características demográficas y socioeconómicas, y la capacidad de los sistemas de salud latinoamericanos para responder a emergencias de salud. Método. Se realizó un estudio ecológico con datos secundarios de 20 países latinoamericanos sobre la incidencia, la mortalidad, las pruebas y la cobertura de vacunación relativas a la COVID-19 en el período 2020-2021, y con información demográfica y socioeconómica. Se exploró la preparación de los países para responder a emergencias de salud a partir del Informe Anual de Autoevaluación de los Estados Miembros de la Organización Mundial de la Salud del 2019 sobre la implementación del Reglamento Sanitario Internacional (RSI). Los análisis estadísticos se realizaron con la prueba de correlación (ro) de Spearman. Resultados. Se observó una alta correlación positiva del producto interno bruto per cápita y del índice de desarrollo humano con la incidencia, las pruebas y la cobertura de vacunación respecto a la COVID-19, así como de la proporción de personas mayores en la población con la cobertura de vacunación. No se observó ninguna correlación entre los indicadores de COVID-19 y la capacidad previa de implementación del RSI. Conclusiones. La falta de correlación entre los indicadores relativos a la COVID-19 y la capacidad de implementación del RSI puede deberse a limitaciones de los indicadores utilizados o del mecanismo de seguimiento del RSI como instrumento inductor de la preparación de los países para enfrentar emergencias de salud. Los resultados sugieren la importancia de los factores condicionantes estructurales y la necesidad de realizar estudios longitudinales, comparativos y cualitativos para determinar los factores que influyeron en la respuesta de los países a la COVID-19.

COVID-19 in the Americas: the role of collaborating centers in understanding lessons and best practices in pandemic preparedness and response / COVID-19 en la Región de las Américas: papel de los centros colaboradores en la comprensión de las enseñanzas y mejores prácticas en la preparación y respuesta frente a pandemias / COVID-19 nas Américas: o papel dos centros colaboradores para entender as lições e melhores práticas de preparação e resposta a pandemias

ABSTRACT COVID-19 exposed major gaps in global, regional, state, and local responses to public health emergencies. In preparation for the WHA Special Session to consider the benefits of developing an international instrument on pandemic preparedness, the O'Neill Institute in partnership with Foundation for the National Institutes of Health convened 30 of the world's leading authorities on global health law, financing, biomedical science, implementation, and emergency response along with leaders from prominent international organizations. This meeting was followed by regional consultations convened in Latin America-Caribbean, Africa, and Southeast Asia. These high-level expert consultations generated in-depth discussions on weaknesses and persisting gaps in global pandemic preparedness and what a new international agreement might include to address them. Regional intergovernmental organizations like PAHO can work closely with related multilateral development banks to develop financial instruments that can smooth systemic economic disruption; and regional centers of research and manufacturing excellence can offer a strong front line for producing medicines and vaccines rapidly during a pandemic. With our research focused on the regional response to COVID-19 we are able to look at country responses individually and collectively to see how Latin America - Caribbean countries can capitalize and leverage their regional connections to strengthen their pandemic preparedness and response. By identifying existing gaps and examining the responses and approaches taken by PAHO, we can better understand the role of international and regional organizations and their collaborating centers in preparing and responding to pandemics.

RESUMEN La COVID-19 expuso grandes brechas en las respuestas locales, nacionales, regionales y mundiales a las emergencias de salud pública. En preparación para la reunión extraordinaria de la Asamblea Mundial de la Salud para considerar los beneficios de elaborar un instrumento internacional sobre la preparación frente a las pandemias, el Instituto O'Neill, en colaboración con la Fundación para los Institutos Nacionales de Salud, convocó a 30 de las principales autoridades mundiales en materia de derecho, financiamiento, ciencia biomédica, implementación y respuesta a emergencias de salud, así como a líderes de organizaciones internacionales prominentes. A esta reunión le siguieron consultas regionales convocadas en América Latina y el Caribe, África y el sudeste asiático. Estas consultas con expertos de alto nivel generaron debates en profundidad acerca de las debilidades y brechas persistentes en la preparación frente a las pandemias y qué podría incluirse en un nuevo acuerdo internacional sobre cómo abordarlas. Las organizaciones intergubernamentales regionales como la Organización Panamericana de la Salud pueden trabajar en estrecha colaboración con los bancos multilaterales de desarrollo relacionados para elaborar instrumentos financieros que puedan aliviar las perturbaciones económicas sistémicas; y los centros regionales de excelencia en investigación y producción pueden formar una sólida primera línea de acción para producir medicamentos y vacunas rápidamente durante una pandemia. Con esta investigación centrada en la respuesta regional a la COVID-19, podemos analizar las respuestas de los países de forma individual y colectiva para observar la manera en que América Latina y el Caribe pueden capitalizar y aprovechar sus conexiones regionales para fortalecer su preparación y respuesta frente a una pandemia. Al determinar cuáles son las brechas existentes y examinar las respuestas y los enfoques adoptados por la OPS, podemos comprender mejor el papel de las organizaciones regionales e internacionales y sus centros colaboradores en la preparación y respuesta frente a las pandemias.

RESUMO A COVID-19 expôs grandes lacunas nas respostas globais, regionais, estaduais e locais a emergências de saúde pública. Nos preparativos para a Sessão Especial da Assembleia Mundial da Saúde para avaliar os benefícios de desenvolver um instrumento internacional de preparação para pandemias, o Instituto O'Neill, em parceria com a Fundação para os Institutos Nacionais de Saúde, reuniu 30 das principais autoridades mundiais em direito sanitário global, financiamento, ciências biomédicas, implementação e resposta a emergências, além de líderes de organizações internacionais proeminentes. Essa reunião foi seguida por consultas regionais convocadas na América Latina/Caribe, na África e no sudeste da Ásia. Essas consultas com especialistas de alto nível geraram discussões minuciosas sobre os pontos fracos e as lacunas persistentes na preparação global para pandemias e o que poderia ser incluído em um novo acordo internacional para resolvê-los. Organizações intergovernamentais regionais, como a OPAS, podem trabalhar em estreita colaboração com os bancos multilaterais de desenvolvimento para desenvolver instrumentos financeiros capazes de atenuar a ruptura econômica sistêmica; por outro lado, centros regionais de excelência em pesquisa e fabricação podem oferecer uma linha de frente expressiva para a rápida produção de medicamentos e vacinas durante uma pandemia. Usando os dados da nossa pesquisa sobre a resposta regional à COVID-19, podemos analisar as respostas dos países de forma individual e coletiva para avaliar como os países da América Latina e do Caribe podem capitalizar e alavancar suas conexões regionais para fortalecer sua preparação e resposta à pandemia. Ao identificar lacunas existentes e analisar as respostas e abordagens adotadas pela OPAS, podemos compreender melhor o papel das organizações internacionais e regionais e de seus centros colaboradores na preparação e resposta a pandemias.

Gerenciamento tensionado: o sistema de vigilância em saúde e a resposta à pandemia da covid-19 no Brasil / Management in tension: the Brazilian public health surveillance system and its response to the covid-19 pandemic

Resumo O artigo aborda a resposta do governo brasileiro à pandemia da covid-19, enfatizando o sistema de vigilância em saúde e de inteligência epidemiológica. Retoma a evolução da vigilância em resposta às normas do Regulamento Sanitário Internacional, no contexto da saúde global. Analisa os atos do Executivo publicados no Diário Oficial da União e se detém nos atores e grupos formados para o enfrentamento da pandemia da covid-19 de janeiro de 2020 até março de 2022. Parte da premissa de que a inteligência epidemiológica deve estar a serviço da saúde pública. Constata-se que certo tensionamento burocrático e a transferência de protagonismo entre grupos marcam o desmonte dos mecanismos de inteligência.

Abstract This article addresses the Brazilian government's response to the covid-19 pandemic, particularly the public health surveillance and epidemic intelligence system. It traces the evolution of disease surveillance as a response to the International Health Regulations in the context of global health. Executive orders published in the official gazette, Diário Oficial da União, are analyzed, as well as the actors and groups formed to tackle the pandemic between January 2020 and March 2022. The founding assumption is that epidemic intelligence must be placed at the service of public health. Bureaucratic tension and changes in protagonism among different groups can be observed as these intelligence mechanisms were dismantled.

Impact of COVID-19 on access to cancer care in Rwanda: a retrospective time-series study using electronic medical records data.

INTRODUCTION: The COVID-19 pandemic has caused disruptions in access to routine healthcare services worldwide, with a particularly high impact on chronic care patients and low and middle-income countries. In this study, we used routinely collected electronic medical records data to assess the impact of the COVID-19 pandemic on access to cancer care at the Butaro Cancer Center of Excellence (BCCOE) in rural Rwanda. METHODS: We conducted a retrospective time-series study among all Rwandan patients who received cancer care at the BCCOE between 1 January 2016 and 31 July 2021. The primary outcomes of interest included a comparison of the number of patients who were predicted based on time-series models of pre-COVID-19 trends versus the actual number of patients who presented during the COVID-19 period (between March 2020 and July 2021) across four key indicators: the number of new patients, number of scheduled appointments, number of clinical visits attended and the proportion of scheduled appointments completed on time. RESULTS: In total, 8970 patients (7140 patients enrolled before COVID-19 and 1830 patients enrolled during COVID-19) were included in this study. During the COVID-19 period, enrolment of new patients dropped by 21.7% (95% prediction interval (PI): -31.3%, -11.7%) compared with the pre-COVID-19 period. Similarly, the number of clinical visits was 25.0% (95% PI: -31.1%, -19.1%) lower than expected and the proportion of scheduled visits completed on time was 27.9% (95% PI: -39.8%, -14.1%) lower than expected. However, the number of scheduled visits did not deviate significantly from expected. CONCLUSION: Although scheduling procedures for visits continued as expected, our findings reveal that the COVID-19 pandemic interrupted patients' ability to access cancer care and attend scheduled appointments at the BCCOE. This interruption in care suggests delayed diagnosis and loss to follow-up, potentially resulting in a higher rate of negative health outcomes among cancer patients in Rwanda.

Diagnostic pathways for breast cancer in 10 International Cancer Benchmarking Partnership (ICBP) jurisdictions: an international comparative cohort study based on questionnaire and registry data.

OBJECTIVES: A growing body of evidence suggests longer time between symptom onset and start of treatment affects breast cancer prognosis. To explore this association, the International Cancer Benchmarking Partnership Module 4 examined differences in breast cancer diagnostic pathways in 10 jurisdictions across Australia, Canada, Denmark, Norway, Sweden and the UK. SETTING: Primary care in 10 jurisdictions. PARTICIPANT: Data were collated from 3471 women aged >40 diagnosed for the first time with breast cancer and surveyed between 2013 and 2015. Data were supplemented by feedback from their primary care physicians (PCPs), cancer treatment specialists and available registry data. PRIMARY AND SECONDARY OUTCOME MEASURES: Patient, primary care, diagnostic and treatment intervals. RESULTS: Overall, 56% of women reported symptoms to primary care, with 66% first noticing lumps or breast changes. PCPs reported 77% presented with symptoms, of whom 81% were urgently referred with suspicion of cancer (ranging from 62% to 92%; Norway and Victoria). Ranges for median patient, primary care and diagnostic intervals (days) for symptomatic patients were 3-29 (Denmark and Sweden), 0-20 (seven jurisdictions and Ontario) and 8-29 (Denmark and Wales). Ranges for median treatment and total intervals (days) for all patients were 15-39 (Norway, Victoria and Manitoba) and 4-78 days (Sweden, Victoria and Ontario). The 10% longest waits ranged between 101 and 209 days (Sweden and Ontario). CONCLUSIONS: Large international differences in breast cancer diagnostic pathways exist, suggesting some jurisdictions develop more effective strategies to optimise pathways and reduce time intervals. Targeted awareness interventions could also facilitate more timely diagnosis of breast cancer.

Evaluating the feasibility, effectiveness and costs of implementing person-centred follow-up care for childhood cancer survivors in four European countries: the PanCareFollowUp Care prospective cohort study protocol.

INTRODUCTION: Long-term survival after childhood cancer often comes at the expense of late, adverse health conditions. However, survivorship care is frequently not available for adult survivors in Europe. The PanCareFollowUp Consortium therefore developed the PanCareFollowUp Care Intervention, an innovative person-centred survivorship care model based on experiences in the Netherlands. This paper describes the protocol of the prospective cohort study (Care Study) to evaluate the feasibility and the health economic, clinical and patient-reported outcomes of implementing PanCareFollowUp Care as usual care in four European countries. METHODS AND ANALYSIS: In this prospective, longitudinal cohort study with at least 6 months of follow-up, 800 childhood cancer survivors will receive the PanCareFollowUp Care Intervention across four study sites in Belgium, Czech Republic, Italy and Sweden, representing different healthcare systems. The PanCareFollowUp Care Intervention will be evaluated according to the Reach, Effectiveness, Adoption, Implementation and Maintenance framework. Clinical and research data are collected through questionnaires, a clinic visit for multiple medical assessments and a follow-up call. The primary outcome is empowerment, assessed with the Health Education Impact Questionnaire. A central data centre will perform quality checks, data cleaning and data validation, and provide support in data analysis. Multilevel models will be used for repeated outcome measures, with subgroup analysis, for example, by study site, attained age, sex or diagnosis. ETHICS AND DISSEMINATION: This study will be conducted in accordance with the guidelines of Good Clinical Practice and the Declaration of Helsinki. The study protocol has been reviewed and approved by all relevant ethics committees. The evidence and insights gained by this study will be summarised in a Replication Manual, also including the tools required to implement the PanCareFollowUp Care Intervention in other countries. This Replication Manual will become freely available through PanCare and will be disseminated through policy and press releases. TRIAL REGISTRATION NUMBER: Netherlands Trial Register (NL8918; https://www.trialregister.nl/trial/8918).

Reasons for referral and referral compliance among Congolese and Burundian refugees living in Tanzania: a community-based, cross-sectional survey.

OBJECTIVES: In order to prevent overburdening of higher levels of care, national healthcare systems rely on processes of referral, including for refugee populations which number 26 million globally. The goal of this study is to use data from a population-based household survey to describe patterns of referral services among a population of Congolese and Burundian refugees living in Tanzania. DESIGN: Cross-sectional survey using cluster randomised sampling. SETTING: Nyarugusu refugee camp, Kigoma, Tanzania. PARTICIPANTS: 153 refugees. PRIMARY OUTCOME: Referral compliance. SECONDARY OUTCOMES: Proportion of referrals that were surgical; proportion of referrals requiring diagnostic imaging. RESULTS: Out of 153 individuals who had been told they needed a referral, 96 (62.7%) had gone to the referral hospital. Of the 57 who had not gone, 36 (63%) reported they were still waiting to go and had waited over a month. Of the participants who had been referred (n=96), almost half of the participants reported they were referred for a surgical problem (n=43, 45%) and the majority received radiological testing at an outside hospital (n=72, 75%). Congolese refugees more frequently had physically completed their referral compared with Burundians (Congolese: n=68, 76.4% vs Burundian: n=28, 43.8%, p<0.001). In terms of intracamp referral networks, most refugees reported being referred to the hospital or clinic by a community health worker (n=133, 86.9%). CONCLUSION: To our knowledge, this is the first community-based study on patterns of referral healthcare among refugees in Tanzania and sub-Saharan Africa. Our findings suggest patients were referred for surgical problems and for imaging, however not all referrals were completed in a timely fashion. Future research should attempt to build prospective referral registries that allow for better tracking of patients and examination of waiting times.

Joint external evaluation of the international health regulations (2005) capacity in South Sudan: assessing the country´s capacity for health security.

Introduction: joint external evaluation is a voluntary and collaborative process to assess a country´s capacity under International Health Regulations (2005) to prevent, detect, and respond to public health threats. The main objective is to measure a country´s status in building the necessary capacities to prevent, detect, and respond to infectious disease threats and establish a baseline measurement of capacities and capabilities. The Republic of South Sudan conducted the Joint External Evaluation from 16-20 October 2017, where its capacities were assessed to public health threats per the International Health Regulation (2005). Methods: cross-sectional descriptive study of the Joint External Evaluation process and the findings are described along with major findings and recommendations for the country. Results: South Sudan's overall mean score across 48 indicators was 1.5 (min= 1, max= 4) and 42/48 indicators (87.5%) scored < 2 on a 1 to 5 scale. Technical areas in the prevent category with the lowest score were antimicrobial resistance, biosafety and biosecurity, and National legislation, policy, and financing. In the detect category, the mean score was 2. Technical areas with the lowest mean scores were workforce development and the National Laboratory System. Preparedness, medical countermeasures, personnel deployment, linking public health, and security authorities had the lowest scores in the respond category. Chemical events, radiation emergencies, and points of entry had a score of 1 in the other IHR-related hazards and points of entry category. Conclusion: South Sudan's mean score of 1.5 can be attributed to several civil conflicts experienced, which have impacted negatively on the health system. Recommendations from the Joint External Evaluation need to be implemented and these must be aligned with the costed National Action Plan for Health Security.

Safe handling of cytostatic drugs: recommendations from independent science.

OBJECTIVES: Due to their mechanism of action, most classical cytostatic drugs have carcinogenic, mutagenic and/or reprotoxic properties. Therefore, occupational exposure of healthcare staff to these drugs should be prevented. Our objective was to lay out European legislation on this topic and reflect on the process of revising the European CM-directive. We summarise independent European and Dutch studies, and give a concise set of basic recommendations for safe working with cytotoxic drugs in healthcare facilities. METHODS: We were directly involved in the process of revising the CM-directive: first, through an EU commissioned workshop in the Netherlands, and after that by contributing to the pan-European stakeholder symposium. For this aim, we had to gather the relevant study data from the Netherlands and from Europe. We analysed all relevant industry-independent studies and collated a set of basic recommendations. RESULTS: Independent studies show that the development of measures in recent years can lead to a safe work environment. Standardising the cleaning process leads to a significant improvement in environmental contamination in the majority of hospitals. In the Netherlands, exposure of workers was shown to be well beneath the limit value of 0.74 µg cyclophosphamide per week, therefore showing that the measures taken in recent years are adequate. CONCLUSIONS: The safety of healthcare workers is of the utmost importance. Current practice in the Netherlands show that measures taken in recent years are adequate. European legislation should be based on independent scientific research and practice. The first goal should be to bring countries with less safe working levels to a higher level instead of introducing measures that only increase healthcare budgets but not healthcare safety.

Acceptability of text messages and knowledge change for cervical cancer screening: a Tanzanian mixed methods study.

OBJECTIVES: To investigate the acceptability of a text message intervention and evaluate if text messages could increase knowledge of cervical cancer and screening. DESIGN: This study was a substudy of a randomised controlled trial that used a mixed methods research design combining a quantitative questionnaire dataset and qualitative interview data. A before and after assessment was made of questionnaire responses. Acceptability was measured on a 6-point Likert scale and knowledge was measured through 16 binary true/false knowledge questions concerning cervical cancer and screening. Qualitative data were coded using a combined inductive-deductive approach. SETTING: Ocean Road Cancer Institute in Dar es Salaam as well as Kilimanjaro Christian Medical Center and Mawenzi Regional hospital in the Kilimanjaro Region in Tanzania. PARTICIPANTS: Human papillomavirus (HPV) positive women who had been randomised to the intervention group and received educative and reminder messages. Qualitative interviews were conducted with a subgroup of women in the intervention group. INTERVENTIONS: 15 one-way educative and reminder text messages. RESULTS: A total of 115 women in the intervention group responded to both the baseline and follow-up questionnaire. Overall, women found it highly acceptable to receive text messages, and there was a trend towards acceptability rising between baseline and follow-up (mean: 0.22; 95% CI 0.00 to 0.44; p=0.05; t-statics=1.96). A significant increase in acceptability was found among the lowest educated and those who had not previously been screened. The qualitative interviews showed that the underlying reasons for the high acceptability rate were that the women felt someone cared for them and that the text messages were for their own benefits. The text messages did not improve the women's knowledge on cervical cancer and screening. CONCLUSIONS: Educative and reminder text messages are highly acceptable among HPV-positive Tanzanian women; however, they do not increase the women's knowledge of cervical cancer and screening. TRIAL REGISTRATION NUMBER: clingov (NCT02509702).

Career aspirations of specialty among medical students in sub-Saharan Africa: a systematic review and meta-analysis of data from two decades, 2000-2021.

OBJECTIVES: To determine the distribution of career aspirations for the discipline of specialty among undergraduate medical students in sub-Saharan Africa (SSA). DESIGN: We searched PubMed/MEDLINE, EMBASE Google Scholar and Google for studies published between 1 January 2000 and 31 June 2021. Two reviewers extracted data from eligible studies, with disagreements resolved through consensus with a third reviewer. The random effects model was used to pool proportions, presented with the corresponding 95% CI. Heterogeneity was assessed using Cochrane's (Q) test but quantified with I2 values. Sources of heterogeneity were checked using meta-regression analysis while publication bias was assessed using funnel plot and Egger's test. SETTING: SSA. PARTICIPANTS: Undergraduate medical students. OUTCOMES: Primary outcome was pooled proportion of career aspirations for the discipline of medical specialty and the secondary outcome was reasons for the specialty selection. RESULTS: We identified 789 citations but meta-analysed 32 studies, with an overall sample size of 8231 participants. The most popular career aspiration for the discipline of specialty was surgery (29.5%; 95% CI 25.0% to 34.2%), followed by internal medicine (17.3%, 95% CI 11.7% to 23.7%), and then obstetrics and gynaecology (15.0%, 95% CI 12.3% to 17.9%), and paediatrics (11.3%; 95% CI 9.6% to 13.2%). The less popular medical disciplines of specialty included public health, orthopaedics, ophthalmology, family medicine, pathology, anaesthesiology, dermatology, otolaryngology, psychiatry and emergency medicine. The reasons for the selection of a medical discipline for specialty related to mentor and peer influences, prospect for economic gains, personal factors, long-term career interests and goals and discipline-specific factors. CONCLUSION: Surgery is the most preferred career aspiration for medical students in SSA, followed by internal medicine. The choices do not necessarily match the disease burden on the continent and medical schools should consider strengthening career counselling and mentoring in their curriculum. PROSPERO REGISTRATION NUMBER: CRD42021260501.