Dynamic measurements of geographical accessibility considering traffic congestion using open data: a cross-sectional assessment for haemodialysis services in Cali, Colombia.

Background: Many cities with traffic congestion lack accessibility assessments accounting for traffic congestion and equity considerations but have disaggregated georeferenced municipal-level open data on health services, populations, and travel times big data. We convened a multistakeholder intersectoral collaborative group that developed a digital, web-based platform integrating open and big data to derive dynamic spatial-temporal accessibility measurements (DSTAM) for haemodialysis services. We worked with stakeholders and data scientists and considered people's places of residence, service locations, and travel time to the service with the shortest travel time. Additionally, we predicted the impacts of strategically introducing haemodialysis services where they optimise accessibility. Methods: Cross-sectional analyses of DSTAM, accounting for traffic congestion, were conducted using a web-based platform. This platform integrated traffic analysis zones, public census and health services datasets, and Google Distance Matrix API travel-time data. Predictive and prescriptive analytics identified optimal locations for new haemodialysis services and estimated improvements. Primary outcomes included the percentage of residents within a 20-min car drive of a haemodialysis service during peak and free-flow traffic congestion. Secondary outcomes focused on optimal locations to maximise accessibility with new services and potential improvements. Findings were disaggregated by sociodemographic characteristics, providing an equity perspective. The study in Cali, Colombia, used geographic and disaggregated sociodemographic data from the adjusted 2018 Colombian census. Predicted travel times were obtained for two weeks in 2020. Findings: There were substantial traffic variations. Congestion reduced accessibility, especially among marginalised groups. For 6-12 July, free-flow and peak-traffic accessibility rates were 95.2% and 45.0%, respectively. For 23-29 November, free-flow and peak traffic accessibility rates were 89.1% and 69.7%. The locations where new services would optimise accessibility had slight variation and would notably enhance accessibility and health equity. Interpretation: Establishing haemodialysis services in targeted areas has significant potential benefits. By increasing accessibility, it would enhance urban health and equity. Funding: No external or institutional funding was received.

Dynamic accessibility by car to tertiary care emergency services in Cali, Colombia, in 2020: cross-sectional equity analyses using travel time big data from a Google API.

OBJECTIVES: To test a new approach to characterise accessibility to tertiary care emergency health services in urban Cali and assess the links between accessibility and sociodemographic factors relevant to health equity. DESIGN: The impact of traffic congestion on accessibility to tertiary care emergency departments was studied with an equity perspective, using a web-based digital platform that integrated publicly available digital data, including sociodemographic characteristics of the population and places of residence with travel times. SETTING AND PARTICIPANTS: Cali, Colombia (population 2.258 million in 2020) using geographic and sociodemographic data. The study used predicted travel times downloaded for a week in July 2020 and a week in November 2020. PRIMARY AND SECONDARY OUTCOMES: The share of the population within a 15 min journey by car from the place of residence to the tertiary care emergency department with the shortest journey (ie, 15 min accessibility rate (15mAR)) at peak-traffic congestion hours. Sociodemographic characteristics were disaggregated for equity analyses. A time-series bivariate analysis explored accessibility rates versus housing stratification. RESULTS: Traffic congestion sharply reduces accessibility to tertiary emergency care (eg, 15mAR was 36.8% during peak-traffic hours vs 84.4% during free-flow hours for the week of 6-12 July 2020). Traffic congestion sharply reduces accessibility to tertiary emergency care. The greatest impact fell on specific ethnic groups, people with less educational attainment and those living in low-income households or on the periphery of Cali (15mAR: 8.1% peak traffic vs 51% free-flow traffic). These populations face longer average travel times to health services than the average population. CONCLUSIONS: These findings suggest that health services and land use planning should prioritise travel times over travel distance and integrate them into urban planning. Existing technology and data can reveal inequities by integrating sociodemographic data with accurate travel times to health services estimates, providing the basis for valuable indicators.

Dynamic geographical accessibility assessments to improve health equity: protocol for a test case in Cali, Colombia.

This protocol proposes an approach to assessing the place of residence as a spatial determinant of health in cities where traffic congestion might impact health services accessibility. The study provides dynamic travel times presenting data in ways that help shape decisions and spur action by diverse stakeholders and sectors.  Equity assessments in geographical accessibility to health services typically rely on static metrics, such as distance or average travel times. This new approach uses dynamic spatial accessibility measures providing travel times from the place of residence to the health service with the shortest journey time. It will show the interplay between traffic congestion, accessibility, and health equity and should be used to inform urban and health services monitoring and planning. Available digitised data enable efficient and accurate accessibility measurements for urban areas using publicly available sources and provide disaggregated sociodemographic information and an equity perspective. Test cases are done for urgent and frequent care (i.e., repeated ambulatory care). Situational analyses will be done with cross-sectional urban assessments; estimated potential improvements will be made for one or two new services, and findings will inform recommendations and future studies. This study will use visualisations and descriptive statistics to allow non-specialized stakeholders to understand the effects of accessibility on populations and health equity. This includes "time-to-destination" metrics or the proportion of the people that can reach a service by car within a given travel time threshold from the place of residence. The study is part of the AMORE Collaborative Project, in which a diverse group of stakeholders seeks to address equity for accessibility to essential health services, including health service users and providers, authorities, and community members, including academia.

Coverage and fidelity of the Xpert MTB/RIF™ implementation in a high-burden area for pulmonary tuberculosis in Colombia / [Cobertura y fidelidad de la prueba Xpert MTB/RIF™ en un área de alta carga de tuberculosis pulmonar en Colombia].

Introduction: The Xpert MTB/RIF™ is a rapid molecular test that diagnoses tuberculosis and rifampin resistance. Since 2010, it is recommended by the World Health Organization (WHO) and although it was introduced in Colombia since 2012, the results of its implementation are unknown. Objective: To describe the coverage and fidelity in the implementation of the Xpert MTB/RIF™ in patients with pulmonary tuberculosis in a city with a high burden for the disease in Colombia. Materials and methods: We conducted a retrospective, descriptive study of cases from a tuberculosis program in Cali between 2013 and 2019. We estimated the coverage as the total number of tests used compared to the cases registered in the program and the fidelity based on international Xpert MTB/RIF™ implementation protocols. We performed a multivariate analysis of multiple correspondences between the test and the sociodemographic variables. Results: We included 6,328 patients with pulmonary tuberculosis of whom 181 were drugresistant. The Xpert MTB/RIF™ coverage was 10,3% (n=655) with an annual variation between 0.2% and 23%. Loyalty among the highest risk groups of MDR-TB was 46.8%. The use of the test was related to being an Afro-Colombian man between 41 and 60 years of age. Conclusions: The coverage of the Xpert MTB/RIF in Cali is low and its use does not follow the recommended prioritization for its implementation. Implementation strategies are required for its proper use to contribute to the goal of ending tuberculosis.

Introducción. La prueba Xpert MTB/RIF™ es una prueba molecular rápida para el diagnóstico de la tuberculosis y la resistencia a la rifampicina. Desde el 2010 es la recomendada por la Organización Mundial de la Salud (OMS) y, aunque fue introducida en Colombia en el 2012, se desconocen los resultados de su uso. Objetivo. Describir la cobertura y la fidelidad en el uso de la prueba Xpert MTB/RIF™ en pacientes con tuberculosis pulmonar en una ciudad con alta carga de la enfermedad en Colombia. Materiales y métodos. Se hizo un estudio retrospectivo descriptivo de casos del programa de tuberculosis en Cali entre el 2013 y el 2019. La cobertura se estimó como el total de pruebas empleadas en los casos registrados en el programa. La fidelidad se midió con base en los protocolos internacionales de uso de la Xpert MTB/RIF™. Además, se hizo un análisis de correspondencias múltiples entre la prueba y las variables sociodemográficas. Resultados. Se incluyeron 6.328 pacientes con tuberculosis pulmonar, de los cuales 181 eran resistentes a los fármacos. La cobertura total de la Xpert MTB/RIF™ durante el periodo de estudio fue de 10,3 % (n=655), con una variación anual entre 0,2 y 23 %. La fidelidad fue de 46,8 % para los grupos de mayor riesgo de tuberculosis multirresistente (TB-MDR). El uso de la prueba se relacionó con la condición de ser hombre, afrocolombiano, y tener entre 41 y 60 años de edad. Conclusiones. La cobertura de la prueba Xpert MTB/RIF™ en Cali es baja y su uso no responde a la priorización recomendada para su implementación. Se requieren estrategias para promover su uso adecuado, de manera que contribuya a la meta de poner fin a la tuberculosis.

COVID-19 en América Latina y Caribe: determinación de prioridadesen investigación y llamado a la acción / COVID-19 in Latin America and Caribbean: a determination of research priorities and call to action

Antecedentes: La Red de Salud Global estableció, en enero 2020, una comunidad de práctica para abordar la investigación en COVID-19 en países de ingresos bajos/medios. Objetivo: Identificar prioridades en investigación sobre COVID-19 que requieren atención urgente en América Latina y el Caribe (LAC) y establecer una comunidad de práctica abierta local para apoyar su implementación. Métodos: Estudio exploratorio mixto. Se analizaron los resultados específicos para LAC de una encuesta en línea (enfoque cuantitativo) que evaluó si la agenda prioritaria de investigación para COVID-19 de la OMS sigue siendo pertinente solicitando a los participantes que clasificaran sus tres principales prioridades a corto y largo plazo. Asimismo, se organizó un taller virtual abierto (enfoque cualitativo) el cual fue grabado. Se realizó un análisis temático pragmático a partir de las presentaciones de los panelistas y de las preguntas y comentarios de la audiencia. Se generó un marco de codificación mediante enfoques inductivo y luego deductivo siguiendo la agenda OMS. Resultados: Se contó con 223 participantes de 22 países. Se identificó un consenso sobre los temas de investigación e innovación prioritarios para LAC, dentro y fuera del marco de la agenda OMS, siendo una gran prioridad la necesidad de estudios de ciencias sociales para ayudar a los científicos biomédicos. Discusión: Dado que los casos siguen aumentando en LAC, consideramos que nuestros hallazgos son útiles para orientar tanto a las redes de investigación en la planificación de estudios como a los financiadores en sus decisiones para la asignación de recursos para investigación e innovación...(AU)

An investigation into the knowledge, perceptions and role of personal protective technologies in Zika prevention in Colombia.

BACKGROUND: Arboviruses transmitted by day-biting Aedes mosquitoes are a major public health concern. With the challenges inherent in arbovirus vaccine and therapeutics development, vector control and bite prevention strategies are among the limited options available for immediate intervention. Bite prevention through personal protective technologies (PPT), such as topical mosquito repellents or repellent-impregnated clothing, may help to decrease biting rates and, therefore, the risk of disease in groups most susceptible to adverse outcomes from Zika virus. However, achieving high uptake and compliance with PPT can be challenging. METHODOLOGY/PRINCIPAL FINDINGS: To gain an insight into the knowledge and concerns of pregnant women surrounding Zika and their opinions regarding PPT, particularly repellent clothing, a focus group study was carried out with pregnant women, women of reproductive age, and semi-structured interviews with their male partners in two cities in Colombia. The discussions revealed shortfalls in basic knowledge of Zika virus, with several pregnant participants reporting being unaware of the potential for Zika-related congenital malformations. Although participants generally considered Zika to be a significant personal threat, most rated it as less of a concern than dengue or diarrheal diseases. Overall, repellent clothing and other forms of PPT were viewed as effective, although some participants expressed concerns over the high costs of repellents, and safety fears of regular contact with repellent chemicals, which they perceived as potentially harmful. Plant-derived repellents were considered to be safer than synthetic chemical repellents. Discussions also highlighted that health centers were the preferred source of information on bite-reduction. CONCLUSIONS/SIGNIFICANCE: Achieving high uptake and compliance with PPT in populations most at risk of adverse outcomes from Zika infection requires engaging key users in open dialogue to identify and address any practical issues regarding PPT use, and concerns over safety. The findings presented here suggest that educational campaigns should strongly emphasize the risks associated with Zika during pregnancy, and discuss safety profiles of approved synthetic repellents and the availability of EPA-approved plant-based repellents. In addition, the economic and political context should be a major consideration when evaluating personal mosquito-repellent strategies.

ZikaPLAN: addressing the knowledge gaps and working towards a research preparedness network in the Americas.

Zika Preparedness Latin American Network (ZikaPLAN) is a research consortium funded by the European Commission to address the research gaps in combating Zika and to establish a sustainable network with research capacity building in the Americas. Here we present a report on ZikaPLAN`s mid-term achievements since its initiation in October 2016 to June 2019, illustrating the research objectives of the 15 work packages ranging from virology, diagnostics, entomology and vector control, modelling to clinical cohort studies in pregnant women and neonates, as well as studies on the neurological complications of Zika infections in adolescents and adults. For example, the Neuroviruses Emerging in the Americas Study (NEAS) has set up more than 10 clinical sites in Colombia. Through the Butantan Phase 3 dengue vaccine trial, we have access to samples of 17,000 subjects in 14 different geographic locations in Brazil. To address the lack of access to clinical samples for diagnostic evaluation, ZikaPLAN set up a network of quality sites with access to well-characterized clinical specimens and capacity for independent evaluations. The International Committee for Congenital Anomaly Surveillance Tools was formed with global representation from regional networks conducting birth defects surveillance. We have collated a comprehensive inventory of resources and tools for birth defects surveillance, and developed an App for low resource regions facilitating the coding and description of all major externally visible congenital anomalies including congenital Zika syndrome. Research Capacity Network (REDe) is a shared and open resource centre where researchers and health workers can access tools, resources and support, enabling better and more research in the region. Addressing the gap in research capacity in LMICs is pivotal in ensuring broad-based systems to be prepared for the next outbreak. Our shared and open research space through REDe will be used to maximize the transfer of research into practice by summarizing the research output and by hosting the tools, resources, guidance and recommendations generated by these studies. Leveraging on the research from this consortium, we are working towards a research preparedness network.

A scoping review on the field validation and implementation of rapid diagnostic tests for vector-borne and other infectious diseases of poverty in urban areas.

BACKGROUND: Health personnel face challenges in diagnosing vector-borne and other diseases of poverty in urban settings. There is a need to know what rapid diagnostic technologies are available, have been properly assessed, and are being implemented to improve control of these diseases in the urban context. This paper characterizes evidence on the field validation and implementation in urban areas of rapid diagnostics for vector-borne diseases and other diseases of poverty. MAIN BODY: A scoping review was conducted. Peer-reviewed and grey literature were searched using terms describing the targeted infectious diseases, diagnostics evaluations, rapid tests, and urban setting. The review was limited to studies published between 2000 and 2016 in English, Spanish, French, and Portuguese. Inclusion and exclusion criteria were refined post hoc to identify relevant literature regardless of study design and geography. A total of 179 documents of the 7806 initially screened were included in the analysis. Malaria (n = 100) and tuberculosis (n = 47) accounted for the majority of studies that reported diagnostics performance, impact, and implementation outcomes. Fewer studies, assessing mainly performance, were identified for visceral leishmaniasis (n = 9), filariasis and leptospirosis (each n = 5), enteric fever and schistosomiasis (each n = 3), dengue and leprosy (each n = 2), and Chagas disease, human African trypanosomiasis, and cholera (each n = 1). Reported sensitivity of rapid tests was variable depending on several factors. Overall, specificities were high (> 80%), except for schistosomiasis and cholera. Impact and implementation outcomes, mainly acceptability and cost, followed by adoption, feasibility, and sustainability of rapid tests are being evaluated in the field. Challenges to implementing rapid tests range from cultural to technical and administrative issues. CONCLUSIONS: Rapid diagnostic tests for vector-borne and other diseases of poverty are being used in the urban context with demonstrated impact on case detection. However, most evidence comes from malaria rapid diagnostics, with variable results. While rapid tests for tuberculosis and visceral leishmaniasis require further implementation studies, more evidence on performance of current tests or development of new alternatives is needed for dengue, Chagas disease, filariasis, leptospirosis, enteric fever, human African trypanosomiasis, schistosomiasis and cholera.

Lo que todos debemos saber de las buenas prácticas clínicas / What everybody should know about good clinical practices

Cada vez son más los países que adoptan las guías de buenas prácticas clínicas como parte de la reglamentación de los estudios clínicos para el registro de productos farmacéuticos y de otros relacionados con la salud. Por ello, todos los involucrados en la investigación y el desarrollo de dichos productos tienen la obligación de conocerlas, implementarlas y velar por su cumplimiento. Sin embargo, las buenas prácticas clínicas son solo una de las iniciativas que buscan alcanzar los más altos estándares éticos y científicos en la investigación en salud y en otras áreas en las que los seres humanos son sujetos de investigación. En esta revisión se definen las buenas prácticas clínicas y su objetivo, se presenta en forma práctica su marco legal en Colombia, se aclara su aplicación en estudios con intervenciones sin medicamentos, o en aquellos que no son ensayos clínicos, y se discuten los retos para lograr que contribuyan a la protección de los participantes en investigaciones, a la formación de profesionales íntegros y a una cultura de respeto por el ser humano.

An increasing number of countries are adopting good clinical practices guidelines as part of the regulation of clinical studies to register pharmaceutical products and other health-related products. Consequently, all parties involved in the research and development of these products should know them, implement them and ensure their compliance. However, good clinical practices guidelines are just one of the initiatives seeking to achieve the highest ethical and scientific standards in health research and in other areas where humans are research subjects. This review defines such practices and their objectives presenting in a practical manner their legal framework in Colombia, and clarifying their application in studies where interventions use no medications or those that are not clinical trials. Finally, the work discusses the challenges to ensure that good clinical practices contribute to the protection of research participants, the education of trustworthy health professionals, and a culture of respect for human beings.

[Assessment of the efficacy of antimalarial drugs in Tarapacá, in the Colombian Amazon basin]. / Evaluación de la eficacia de los medicamentos antimaláricos en Tarapacá, Amazonas colombiano.

INTRODUCTION: The current antimalarial drug policy in Colombia has been based on studies conducted in Antioquia and the Pacific Coast. However, the efficacy of antimalarial drugs in other endemic regions is unknown. OBJECTIVE: The therapeutic efficacy of three monotherapies was assessed: amodiaquine and sulfadoxine/pyrimethamine for uncomplicated Plasmodium falciparum malaria, and chloroquine for Plasmodium vivax malaria in the municipality of Tarapacá, located in the Colombian province of Amazonas. MATERIALS AND METHODS: Treatment was supervised and clinical/parasitological follow-up was undertaken through a 28-day period following to World Health Organization standard protocols for subjects with a single P. falciparum or P. vivax infection. RESULTS: Due to a decrease in malaria transmission at the time of the study, the sample size was very small. The treatment failed for two subjects who received amodiaquine, and treatment with sulfadoxine/pyrimethamine was discontinued due to a high frequency of therapeutic failures (7/8). Most subjects (18/20) with P. vivax infections showed an adequate therapeutic response. CONCLUSIONS: The use of sulfadoxine/pyrimethamine in Tarapacá, and possibly in the Amazon region of Colombia, needs to be reviewed. Therapeutic efficacy studies in other endemic areas in the Amazon and Orinoco regions in Colombia are desirable but not feasible. Alternative methods such as in vitro assays or detection of molecular markers for resistance in the parasite can provide a basis for decisions concerning antimalarial drug policy for the Amazon and Orinoco regions in Colombia.

Evaluación de la eficacia de los medicamentos antimaláricos en Tarapacá, Amazonas colombiano / Assessment of the efficacy of antimalarial drugs in Tarapacá, in the Colombian Amazon basin

Introducción. La selección de los esquemas de tratamiento para malaria en Colombia se ha basado principalmente en estudios realizados en Antioquia y en la costa Pacífica, pero se desconoce la eficacia de los antimaláricos en la Orinoquia y Amazonia colombianas. Objetivo. Evaluar la eficacia terapéutica de tres monoterapias: amodiaquina y sulfadoxina/pirimetamina para el tratamiento de malaria no complicada por Plasmodium falciparum y de cloroquina para el tratamiento de malaria por Plasmodium vivax en Tarapacá, departamento del Amazonas. Materiales y métodos. Suministro de tratamiento supervisado y seguimiento clínico y parasitológico durante 28 días según protocolos estandarizados de sujetos con infección única por P. falciparum o P. vivax. Resultados. No fue posible completar el tamaño de muestra por disminución marcada en la transmisión. En el grupo de P. falciparum, el tratamiento con amodiaquina fracasó en dos sujetos; se suspendió el grupo de sulfadoxina/pirimetamina por alto número de fracasos terapéuticos (7/8). En el grupo de P. vivax, la mayoría (18/20) presentó respuesta adecuada al tratamiento. Conclusiones. Es necesario reconsiderar el uso de sulfadoxina/pirimetamina en Tarapacá y posiblemente en el Amazonas colombiano. Se requieren estudios de eficacia terapéutica en otras áreas endémicas, o la utilización de métodos in vitro o moleculares, para definir el esquema de tratamiento para malaria por P. falciparum en la Orinoquia y Amazonia colombianas.

Introduction. The current antimalarial drug policy in Colombia has been based on studies conducted in Antioquia and the Pacific Coast. However, the efficacy of antimalarial drugs in other endemic regions is unknown. Objective. The therapeutic efficacy of three monotherapies was assessed: amodiaquine and sulfadoxine/pyrimethamine for uncomplicated Plasmodium falciparum malaria, and chloroquine for Plasmodium vivax malaria in the municipality of Tarapacá, located in the Colombian province of Amazonas. Materials and methods. Treatment was supervised and clinical/parasitological follow-up was undertaken through a 28-day period following to World Health Organization standard protocols for subjects with a single P. falciparum or P. vivax infection. Results. Due to a decrease in malaria transmission at the time of the study, the sample size was very small. The treatment failed for two subjects who received amodiaquine, and treatment with sulfadoxine/pyrimethamine was discontinued due to a high frequency of therapeutic failures (7/8). Most subjects (18/20) with P. vivax infections showed an adequate therapeutic response. Conclusions. The use of sulfadoxine/pyrimethamine in Tarapacá, and possibly in the Amazon region of Colombia, needs to be reviewed. Therapeutic efficacy studies in other endemic areas in the Amazon and Orinoco regions in Colombia are desirable but not feasible. Alternative methods such as in vitro assays or detection of molecular markers for resistance in the parasite can provide a basis for decisions concerning antimalarial drug policy for the Amazon and Orinoco regions in Colombia.

Assessment of therapeutic response of Plasmodium vivax and Plasmodium falciparum to chloroquine in a Malaria transmission free area in Colombia.

In order to determine the frequency of therapeutic failures to chloroquine (CQ) in patients with malaria due to either Plasmodium falciparum or P. vivax, and to explore the usefulness of a malaria-free city as a sentinel site to monitor the emergence of drug resistance, 53 patients (44 infected with P. vivax and 9 with P. falciparum) were evaluated at the Laboratory of Parasitology, Universidad del Valle in Cali, Colombia. Patients received 25 mg/kg of CQ divided in three doses over 48 h; they were followed during 28 days according to WHO/PAHO protocols. While therapeutic failures to CQ in the P. vivax group were not detected, the proportion of therapeutic failures in the P. falciparum group was high (78%) and consistent with the reports from endemic areas in Colombia. The diverse origin of cases presenting therapeutic failure confirmed that P. falciparum resistant to CQ is widespread in Colombia, and further supports the change in the national antimalarial drug scheme. Monitoring of drug resistance in malaria free areas would be useful to identify sites requiring efficacy evaluation, and in some situations could be the most appropriate alternative to collect information from endemic areas where therapeutic efficacy studies are not feasible.

Assessment of Therapeutic Response of Plasmodium vivax and Plasmodium falciparum to Chloroquine in a Malaria Transmission Free Area in Colombia

In order to determine the frequency of therapeutic failures to chloroquine (CQ) in patients with malaria due to either Plasmodium falciparum or P. vivax, and to explore the usefulness of a malaria-free city as a sentinel site to monitor the emergence of drug resistance, 53 patients (44 infected with P. vivax and 9 with P. falciparum) were evaluated at the Laboratory of Parasitology, Universidad del Valle in Cali, Colombia. Patients received 25 mg/kg of CQ divided in three doses over 48 h; they were followed during 28 days according to WHO/PAHO protocols. While therapeutic failures to CQ in the P. vivax group were not detected, the proportion of therapeutic failures in the P. falciparum group was high (78 percent) and consistent with the reports from endemic areas in Colombia. The diverse origin of cases presenting therapeutic failure confirmed that P. falciparum resistant to CQ is widespread in Colombia, and further supports the change in the national antimalarial drug scheme. Monitoring of drug resistance in malaria free areas would be useful to identify sites requiring efficacy evaluation, and in some situations could be the most appropriate alternative to collect information from endemic areas where therapeutic efficacy studies are not feasible