Comprehensive analysis of antimicrobial resistance in the Southwest Indian Ocean: focus on WHO critical and high priority pathogens.

The spread of antimicrobial resistance (AMR) is a major global concern, and the islands of the Southwest Indian Ocean (SWIO) are not exempt from this phenomenon. As strategic crossroads between Southern Africa and the Indian subcontinent, these islands are constantly threatened by the importation of multidrug-resistant bacteria from these regions. In this systematic review, our aim was to assess the epidemiological situation of AMR in humans in the SWIO islands, focusing on bacterial species listed as priority by the World Health Organization. Specifically, we examined Enterobacterales, Acinetobacter spp., Pseudomonas spp. resistant to carbapenems, and Enterococcus spp. resistant to vancomycin. Our main objectives were to map the distribution of these resistant bacteria in the SWIO islands and identify the genes involved in their resistance mechanisms. We conducted literature review focusing on Comoros, Madagascar, Maldives, Mauritius, Mayotte, Reunion Island, Seychelles, Sri Lanka, and Zanzibar. Our findings revealed a growing interest in the investigation of these pathogens and provided evidence of their active circulation in many of the territories investigated. However, we also identified disparities in terms of data availability between the targeted bacteria and among the different territories, emphasizing the need to strengthen collaborative efforts to establish an efficient regional surveillance network.

Use of indices to measure socio-economic status (SES) in South-Asian urban health studies: a scoping review.

BACKGROUND: Universal health coverage (UHC) is a key area in post-2015 global agenda which has been incorporated as target for achieving health-related Sustainable Development Goals (SDGs). A global framework has been developed to monitor SDG indicators disaggregated by socioeconomic and demographic markers. This review identifies the indices used to measure socio-economic status (SES) in South Asian urban health studies. METHODS: Two reviewers searched six databases including Cochran Library, Medline, LILACS, Web of Science, Science Direct, and Lancet journals independently. All South Asian health studies covering urban population, with any research-designs, written in English language, and published between January 2000 and June 2016 were included. Two reviewers independently screened and assessed for selection of eligible articles for inclusion. Any conflict between the reviewers was resolved by a third reviewer. RESULTS: We retrieved 3529 studies through initial search. Through screening and applying inclusion and exclusion criteria, this review finally included 256 articles for full-text review. A total of 25 different SES indices were identified. SES indices were further categorized into 5 major groups, e.g., (1) asset-based wealth index, (2) wealth index combining education, (3) indices based on income and expenditure, (4) indices based on education and occupation, and (5) "indices without description." The largest proportion of studies, irrespective of country of origin, thematic area, and study design, used asset-based wealth index (n = 142, 54%) as inequality markers followed by the index based on income and expenditure (n = 80, 30%). Sri Lankan studies used income- and expenditure-based indices more than asset-based wealth index. Majority of the reviewed studies were on "maternal, neonatal, and child health" (n = 98, 38%) or on "non-communicable diseases" (n = 84, 33%). Reviewed studies were mostly from India (n = 145, 57%), Bangladesh (n = 42, 16%), and Pakistan (n = 27, 11%). Among the reviewed articles, 55% (n = 140) used primary data while the rest 45% studies used secondary data. CONCLUSION: This scoping review identifies asset-based wealth index as the most frequently used indices for measuring socioeconomic status in South Asian urban health studies. This review also provides a clear idea about the use of other indices for the measurement SES in the region.

Economic analysis of dengue prevention and case management in the Maldives.

As tourism is the mainstay of the Maldives' economy, this country recognizes the importance of controlling mosquito-borne diseases in an environmentally responsible manner. This study sought to estimate the economic costs of dengue in this Small Island Developing State of 417,492 residents. The authors reviewed relevant available documents on dengue epidemiology and conducted site visits and interviews with public health offices, health centers, referral hospitals, health insurers, and drug distribution organizations. An average of 1,543 symptomatic dengue cases was reported annually from 2011 through 2016. Intensive waste and water management on a resort island cost $1.60 per occupied room night. Local vector control programs on inhabited islands cost $35.93 for waste collection and $7.89 for household visits by community health workers per person per year. Ambulatory care for a dengue episode cost $49.87 at a health center, while inpatient episodes averaged $127.74 at a health center, $1,164.78 at a regional hospital, and $1,655.50 at a tertiary referral hospital. Overall, the cost of dengue illness in the Maldives in 2015 was $2,495,747 (0.06% of gross national income, GNI, or $6.10 per resident) plus $1,338,141 (0.03% of GNI or $3.27 per resident) for dengue surveillance. With tourism generating annual income of $898 and tax revenues of $119 per resident, results of an international analysis suggest that the risk of dengue lowers the country's gross annual income by $110 per resident (95% confidence interval $50 to $160) and its annual tax receipts by $14 per resident (95% confidence interval $7 to $22). Many innovative vector control efforts are affordable and could decrease future costs of dengue illness in the Maldives.

First Rapid Assessment of Avoidable Blindness Survey in the Maldives: Prevalence and Causes of Blindness and Cataract Surgery.

PURPOSE: A nationwide rapid assessment of avoidable blindness survey was undertaken in the Maldives among people aged 50 years or more to assess the prevalence and causes of blindness and visual impairment, cataract surgical coverage, cataract surgery outcome, and barriers to uptake of cataract surgical services. DESIGN: Prospective population-based study. METHODS: In the cluster sampling probability proportionate to size method, 3100 participants in 62 clusters across all 20 atolls were enrolled through house-to-house visits. They were examined in clusters by an ophthalmologist-led team. Data was recorded in mRAAB version 1.25 software on a smartphone. RESULTS: The age-sex standardized prevalence of blindness was 2.0% [95% confidence interval (CI), 1.5-2.6]. Cataract was the leading cause of blindness (51.4%) and uncorrected refractive error was the leading cause of visual impairment (50.9%). Blindness was more prevalent in higher age groups and women (16.3%). Cataract surgical coverage was 86% in cataract blind eyes and 93.5% in cataract blind persons. Good visual outcome in cataract operated eyes was 67.9% (presenting) and 76.6% (best corrected visual acuity). In this study, 48.1% of people had received cataract surgery in neighboring countries. Important barriers for not using the services were "did not feel the need" (29.7%) and "treatment deferred" (33.3%). CONCLUSIONS: Cataract surgical coverage is good, though nearly half the people received surgery outside the Maldives. Cataract surgery outcomes are below World Health Organization standards. Some barriers could be overcome with additional human resources and training to improve cataract surgical outcomes, which could encourage greater uptake of services within the country.

Long-Term Effectiveness of a Lifestyle Intervention for the Primary Prevention of Type 2 Diabetes in a Low Socio-Economic Community--An Intervention Follow-Up Study on Reunion Island.

In type 2 diabetes (T2D) prevention research, evidence for maintenance of risk factor reduction after three years of follow-up is needed. The objective of this study was to evaluate the long-term effectiveness of a combined lifestyle intervention aiming at controlling body weight (BW) and waist circumference (WC) in non-diabetic, overweight/obese adults living in a low socio-economic community. On Reunion Island, 445 adults living in deprived areas, aged 18-40 and at high-risk for T2D, were included in an intervention versus control trial for primary prevention (2001-2002). The intervention promoted a healthy diet and moderate regular physical activity, through actions strengthening individuals or community and improving living conditions. The control group received a one-shot medical information and nutritional advices. After the end of the trial (2003), 259 of the subjects participated in a follow-up study (2010-2011). The outcomes were the nine-year changes from baseline in BW, body mass index (BMI) and WC measurements, separately. Statistical analyses were performed on an intention-to-treat basis, using available and imputed datasets. At inclusion, T2D risk factors were prevalent: family history of diabetes in first-degree relatives (42%), women with a personal history of gestational diabetes (11%), total obesity (43%, median BMI 29.1 kg/m²) and central obesity (71%). At follow-up, the adjusted effect on imputed dataset was significant for WC -2.4 cm (95% confidence interval: -4.7 to -0.0 cm, p = 0.046), non-significant for BW -2.2 kg (-4.6 to +0.2 kg, p = 0.073) and BMI -0.81 kg/m² (-1.69 to +0.08 kg/m², p = 0.074). A specific long-term effect was the increased likelihood of reduction in adiposity: BW loss, BMI reduction, and WC reduction were more frequent in the intervention group. In the context of low socio-economic communities, our data support the assumption of long-term effect of lifestyle interventions targeting total obesity and central obesity two major drivers of T2D.

Prevalence and Sociodemographic Determinants of Any Tobacco Use and Dual Use in Six Countries of the WHO South-East Asia Region: Findings From the Demographic and Health Surveys.

BACKGROUND: Tobacco control is an important strategy to reduce the disease burden caused by several noncommunicable diseases. An in-depth understanding of the sociodemographic variations in tobacco use is an important step in achieving effective tobacco control. AIMS: We aimed to estimate the age-standardized prevalence of any tobacco use and dual tobacco use and determine their association with sociodemographic variables in six countries (Bangladesh, Indonesia, India, Maldives, Nepal, and Timor Leste) of the WHO South-East Asia Region. METHODS: The main outcome variables "any tobacco use" and "current dual use" were created from the latest available Demographic and Health Surveys data for each country. The prevalence estimates were weighted using sample weights and age standardized using the WHO standard population. Associations between the sociodemographic variables and tobacco use were calculated by performing multivariable logistic regression analysis. Analyses were performed in Stata 12 using "svyset" and "svy" commands. RESULTS: The highest prevalence of any tobacco use among men was in Indonesia (76.4%) and among women in Nepal (15.7%). Also, Nepal had the highest prevalence of dual tobacco use in both men (17.9%) and women (1.5%). With regard to sociodemographic determinants, despite the inter-country variations, any and dual tobacco use were significantly associated with age, higher education, greater wealth, rural residence, and ever-married marital status. The poor and uneducated had a higher odds ratio for these practices. CONCLUSION: Prevalence of dual tobacco use and its underlying socioeconomic disparities should be taken into account for the planning of tobacco control activities in the region. IMPLICATIONS: The dual tobacco use phenomenon is being increasingly recognized as a distinct entity in the fight against tobacco addiction. When compared with single product users, dual users have a greater risk of developing tobacco related diseases and are less likely to quit their habits. However, this phenomenon has not been studied adequately in the South-East Asia region. In this context, this study has provided a detailed and comprehensive view of dual tobacco use and its sociodemographic determinants in six countries of the region. This study recommends that tobacco control interventions should be targeted specifically at the disadvantaged sections of the society, such as the poor and the uneducated, who are more likely to engage in "dual" as well as "any" tobacco use. This study could prove as an important reference and tool for policy making in the South-East Asia region.

The economic burden of overseas medical treatment: a cross sectional study of Maldivian medical travelers.

BACKGROUND: Access to tertiary care is a problem common to many small states, especially island ones. Although medical treatment overseas (MTO) may result in cost savings to high income countries, it can be a relatively high cost for low and middle income source countries. The purpose of this study was to estimate the costs of overseas medical treatment incurred by the households of medical travelers from Maldives and assess the burden of medical treatment overseas on the government and on households. METHODS: A survey was conducted of inbound Maldivian medical travelers who traveled during the period June - December 2013. Participants were stratified by the source of funds used for treatment abroad. Three hundred and forty four government-subsidized and 471 privately funded Maldivians were interviewed. Self-reported data on the utilization and expenses incurred during the last visit abroad, including both expenses covered by the government and borne by the household, were collected using a researcher administered structured questionnaire. RESULTS: The median per capita total cost of a medical travel episode amounted to $1,470. Forty eight percent of the cost was spent on travel. Twenty six percent was spent on direct medical costs, which were markedly higher among patients subsidized by the government than self-funded patients (p = <0.001). The two highest areas of spending for public funds were neoplasms and diseases of the circulatory system in contrast to diseases of the musculoskeletal system and nervous system for privately funded patients. Medical treatment overseas imposed a considerable burden on households as 43% of the households of medical travelers suffered from catastrophic health spending. Annually, an estimated $68.9 million was spent to obtain treatment for Maldivians in overseas health facilities ($204 per capita), representing 4.8% of the country's GDP. CONCLUSIONS: Overseas medical treatment represents a substantial economic burden to the Maldives in terms of lost consumer spending in the local economy and catastrophic health spending by households. Geographical inequality in access to public funds for MTO and the disproportionate travel cost borne by travelers from rural areas need to be addressed in the existing Universal Health Care programme to minimize the burden of MTO. Increased investment to create more capacity in the domestic health infrastructure either through government, private or by foreign direct investment can help divert the outflow on MTO.

Cost of illness due to typhoid Fever in pemba, zanzibar, East Africa.

The aim of this study was to estimate the economic burden of typhoid fever in Pemba, Zanzibar, East Africa. This study was an incidence-based cost-of-illness analysis from a societal perspective. It covered new episodes of blood culture-confirmed typhoid fever in patients presenting at the outpatient or inpatient departments of three district hospitals between May 2010 and December 2010. Cost of illness was the sum of direct costs and costs for productivity loss. Direct costs covered treatment, travel, and meals. Productivity costs were loss of income by patients and caregivers. The analysis included 17 episodes. The mean age of the patients, was 23 years (range=5-65, median=22). Thirty-five percent were inpatients, with a mean of 4.75 days of hospital stay (range=3-7, median=4.50). The mean cost for treatment alone during hospital care was US$ 21.97 at 2010 prices (US$ 1=1,430.50 Tanzanian Shilling─TSH). The average societal cost was US$ 154.47 per typhoid episode. The major expenditure was productivity cost due to lost wages of US$ 128.02 (83%). Our results contribute to the further economic evaluation of typhoid fever vaccination in Zanzibar and other sub-Saharan African countries.

Longitudinal health outcome and wellbeing of mother-infant pairs after adolescent pregnancy in Reunion Island, Indian Ocean.

OBJECTIVE: To evaluate longitudinal care needs and health service access among mother-infant pairs after adolescent pregnancy. METHODS: In a case-control study, data were analyzed from primiparous adolescent and adult mother-infant pairs who delivered at Reunion Island University Hospital, France, between January 2004 and December 2006, and were followed-up from maternity discharge until December 2011. Infant outcomes were hospitalization during the first 2 years of life, hospital access for "non-medical" reasons, and neuropsychiatric care. Maternal outcomes were number of pregnancies and childbirths, rapid repeat pregnancy (RRP) rate, pregnancy morbidities, and use of health services. RESULTS: Data from 476 cases and 476 controls were analyzed. Adolescent and control offspring did not differ in the measured outcomes. Adolescent and control mothers had, respectively, 2.4 ± 1.3 and 1.9 ± 1.1 pregnancies; 1.9 ± 0.8 and 1.6 ± 0.7 childbirths; and RRP rates of 7.6% and 2.7% (all P<0.001). Adolescents had less pregnancy-related pathologies at the index pregnancy and more frequently had natural deliveries (P<0.05). Younger mothers exhibited higher rates (19.7% versus 6.9%, P=0.001) of care for psychosocial reasons (suicide attempt, acute alcohol or drug intoxication, road accident, psychiatric problems, physical abuse). CONCLUSION: Concerns arise from the long-term psychosocial risk among adolescent mothers.

Rapid assessment of trachoma in underserved population of Car-Nicobar Island, India.

PURPOSE: To determine the burden of trachoma and its related risk factors amongst the native population of Car-Nicobar Island in India. METHODS: Rapid assessment for trachoma was conducted in ten villages of Car-Nicobar Island according to standard WHO guidelines. An average of 50 children aged 1-9 years were assessed clinically for signs of active trachoma and facial cleanliness in each village. Additionally, all adults above 15 years of age in these households were examined for evidence of trachomatous trichiasis and corneal opacity. Environmental risk factors contributing to trachoma like limited access to potable water & functional latrine, presence of animal pen and garbage within the Nicobari hut were also noted in all villages. RESULTS: Out of a total of fifteen villages in Car-Nicobar Island, ten villages were selected for trachoma survey depending on evidence of socio-developmental indicators like poverty and decreased access to water, sanitation and healthcare facilities. The total population of the selected clusters was 7277 in the ten villages. Overall, 251 of 516 children (48.6%;CI: 46.5-55.1) had evidence of follicular stage of trachoma and 11 children (2.1%;CI:1.0-3.4) had evidence of inflammatory stage of trachoma. Nearly 15%(CI:12.1-18.3) children were noted to have unclean faces in the ten villages. Trachomatous trichiasis was noted in 73 adults (1.0%;CI:0.8-1.2). The environmental sanitation was not found to be satisfactory in the surveyed villages mainly due to the co-habitance of Nicobari people with domestic animals like pigs, hens, goats, dogs, cats etc in most (96.4%) of the households. CONCLUSION: Active trachoma and trachomatous trichiasis was observed in all the ten villages surveyed, wherein trachoma control measures are needed.

Clinical and epidemiological features of typhoid fever in Pemba, Zanzibar: assessment of the performance of the WHO case definitions.

BACKGROUND: The gold standard for diagnosis of typhoid fever is blood culture (BC). Because blood culture is often not available in impoverished settings it would be helpful to have alternative diagnostic approaches. We therefore investigated the usefulness of clinical signs, WHO case definition and Widal test for the diagnosis of typhoid fever. METHODOLOGY/PRINCIPAL FINDINGS: Participants with a body temperature ≥37.5°C or a history of fever were enrolled over 17 to 22 months in three hospitals on Pemba Island, Tanzania. Clinical signs and symptoms of participants upon presentation as well as blood and serum for BC and Widal testing were collected. Clinical signs and symptoms of typhoid fever cases were compared to other cases of invasive bacterial diseases and BC negative participants. The relationship of typhoid fever cases with rainfall, temperature, and religious festivals was explored. The performance of the WHO case definitions for suspected and probable typhoid fever and a local cut off titre for the Widal test was assessed. 79 of 2209 participants had invasive bacterial disease. 46 isolates were identified as typhoid fever. Apart from a longer duration of fever prior to admission clinical signs and symptoms were not significantly different among patients with typhoid fever than from other febrile patients. We did not detect any significant seasonal patterns nor correlation with rainfall or festivals. The sensitivity and specificity of the WHO case definition for suspected and probable typhoid fever were 82.6% and 41.3% and 36.3 and 99.7% respectively. Sensitivity and specificity of the Widal test was 47.8% and 99.4 both forfor O-agglutinin and H- agglutinin at a cut-off titre of 1:80. CONCLUSIONS/SIGNIFICANCE: Typhoid fever prevalence rates on Pemba are high and its clinical signs and symptoms are non-specific. The sensitivity of the Widal test is low and the WHO case definition performed better than the Widal test.

Uncovering the "skeleton in the closet": the issue of bone and joint disorders in the Maldives and the opportunities for primary prevention and health promotion.

Disorders of bones and joints are the most common cause of severe long-term pain and disability around the world yet receive inadequate attention in many countries. Bone/joint health is absent from current health policy and the primary prevention/health promotion agenda in Maldives and diagnostic and curative infrastructure is very limited. In 2004, tentative evidence emerged indicating that degenerative bone and joint conditions may impose a large burden on community health. A study was undertaken amongst a representative community sample of women aged 15-50 to further investigate the issue. One third reported bone/joint problems; very high proportions manifested a range of osteoporosis risk factors, and sizeable numbers appear to be at elevated risk of osteoarthritis. Bone/joint health knowledge was very limited. The findings suggest strong potential for primary prevention on modifiable risk factors, need for research with other population groups, and development of screening and curative care. EDITORS' STRATEGIC IMPLICATIONS: The author provides important data on the burden of disorders of bones/joints on a "developing" community and presents recommendations for behavioral and educational prevention strategies that may prove useful across societies.

Rapid assessment of trachoma in 9 governorates and Socotra Island in Yemen.

This study described the pattern of trichiasis, active trachoma and trachoma risk factors in 9 governorates of Yemen plus Socotra Island, using a rapid assessment during October and February 2004. A total of 3169 children aged 1-9 years were examined in a central meeting point or at home. Active trachoma was found in a high percentage of children in Al-Jawf, Mareb and Shabwah governorates and the SAFE strategy (Surgery, Antibiotic treatment, Facial cleanliness, Environmental improvement) should be directed toward these governorates. Trichiasis cases were also found in Hadramout and Taiz, suggesting that eyelid surgery should be provided in these governorates.

Comparison of four human studies of perinatal exposure to methylmercury for use in risk assessment.

Newer data from human epidemiologic studies of methylmercury (MeHg) poisoning in which perinatal exposure occurred are available from four distinct populations. The results of an Iraqi grain-consuming population are compared to results from studies performed in fish-consuming groups in the Faroe Islands, the Seychelles Islands and in Peruvian fishing villages. A comparison of the results indicate that the Iraqi population does not represent a sensitive subpopulation within a perinatal group, but rather the relative lower threshold identified from this study was the results of confounders. Use of this benchmark dose for regulatory purposes may place a severe limitation upon fish consumption in the United States that is not fully supported by the scientific data.