What are the mental health impacts of epidemics on relatives of people affected, and relatives of healthcare workers: What interventions are available to support them? A systematic review and narrative synthesis.

BACKGROUND: Previous research has mainly focused on the impacts of epidemics on those people who are directly affected by the epidemic infection, or of healthcare workers caring for them. Less is known about the impact on mental health of their relatives, and potential interventions to support them. METHODS: Systematic review and narrative synthesis. OUTCOMES: 28 studies were identified, sixteen quantitative and twelve qualitative. One involved health workers' relatives, and the rest covered relatives of directly affected individuals. We found considerable burden of mental ill-health in both groups. Among relatives of healthcare workers, 29.4% reported symptoms consistent with probable anxiety disorder and 33.7% with probable depression. Prevalence rates for probable anxiety disorder ranged from 24-42% and probable depression 17-51% for the relatives of affected people. One study found a 2% prevalence of PTSD and another found odds of PTSS were significantly higher among relatives of affected individuals compared with the general population. Only two intervention studies were identified and both were descriptive in nature. INTERPRETATION: Available evidence suggests relatives of people affected by infective outbreaks report mental ill-health. Having a relative who died particularly increased risk. Good outcomes for relatives of affected individuals were promoted by practical and social support, public health guidance that recognises the caring role of relatives, and being supported to see the positives as well as negatives in their situation. Good outcomes for relatives of health workers were promoted by perceived effectiveness of protective equipment. High quality evidence on potential interventions to support relatives is lacking. FUNDING: No external funding sought.

Managing intensive care admissions when there are not enough beds during the COVID-19 pandemic: a systematic review.

The surge in cases of severe COVID-19 has resulted in clinicians triaging intensive care unit (ICU) admissions in places where demand has exceeded capacity. In order to assist difficult triage decisions, clinicians require clear guidelines on how to prioritise patients. Existing guidelines show significant variability in their development, interpretation, implementation and an urgent need for a robust synthesis of published guidance. To understand how to manage which patients are admitted to ICU, and receive mechanical ventilatory support, during periods of high demand during the COVID-19 pandemic, a systematic review was performed. Databases of indexed literature (Medline, Embase, Web of Science, and Global Health) and grey literature (Google.com and MedRxiv), published from 1 January until 2 April 2020, were searched. Search terms included synonyms of COVID-19, ICU, ventilation, and triage. Only formal written guidelines were included. There were no exclusion criteria based on geographical location or publication language. Quality appraisal of the guidelines was performed using the Appraisal of Guidelines for Research and Evaluation Instrument II (AGREE II) and the Appraisal of Guidelines for Research and Evaluation Instrument Recommendation EXcellence (AGREE REX) appraisal tools, and key themes related to triage were extracted using narrative synthesis. Of 1902 unique records identified, nine relevant guidelines were included. Six guidelines were national or transnational level guidance (UK, Switzerland, Belgium, Australia and New Zealand, Italy, and Sri Lanka), with one state level (Kansas, USA), one international (Extracorporeal Life Support Organization) and one specific to military hospitals (Department of Defense, USA). The guidelines covered several broad themes: use of ethical frameworks, criteria for ICU admission and discharge, adaptation of criteria as demand changes, equality across health conditions and healthcare systems, decision-making processes, communication of decisions, and guideline development processes. We have synthesised the current guidelines and identified the different approaches taken globally to manage the triage of intensive care resources during the COVID-19 pandemic. There is limited consensus on how to allocate the finite resource of ICU beds and ventilators, and a lack of high-quality evidence and guidelines on resource allocation during the pandemic. We have developed a set of factors to consider when developing guidelines for managing intensive care admissions, and outlined implications for clinical leads and local implementation.

Randomised controlled trial comparing uptake of NHS Health Check in response to standard letters, risk-personalised letters and telephone invitations.

BACKGROUND: NHS Health Check is a primary prevention programme offering cardiovascular disease (CVD) risk assessment to adults in England aged 40-74. Uptake remains a challenge and invitation method is a strong predictor of uptake. There is evidence of low uptake when using invitation letters. Telephone invitations might increase uptake, but are not widely used. We explored the potential to improve uptake through personalising letters to patient's CVD risk, and to compare this with generic letters and telephone invitations. METHODS: HEalth Check TRial (HECTR) was a three-arm randomised controlled trial in nine general practices in Staffordshire (UK). Eligible patients were randomised to be invited to a NHS Health Check using one of three methods: standard letter (control); telephone invitation; letter personalised to the patient's CVD risk. The primary outcome was attendance/non-attendance. Data were collected on a range of patient- and practice-level factors (e.g., patient socio-demographics, CVD risk, practice size, Health Checks outside usual working hours). Multi-level logistic regression estimated the marginal effects to explore whether invitation method predicted attendance. Invitation costs were collated from practices to estimate cost benefit. RESULTS: In total, 4614 patients were included in analysis (mean age 50.2 ± 8.0 yr.; 52.4% female). Compared with patients invited by standard letter (30.9%), uptake was significantly higher in those invited by telephone (47.6%, P < .001), but not personalised letter (31.3%, p = .812). In multi-level analysis, compared with the standard letter arm, likelihood of attendance was 18 percentage points higher in the telephone arm and 4 percentage points higher in the personalised letter arm. The effect of telephone calls appeared strongest in patients who were younger and had lower CVD risk. We estimated per 1000 patients invited, risk-personalised letters could result in 40 additional attended Health Checks (at no extra cost) and telephone invitations could result in 180 additional Health Checks at an additional cost of £240. CONCLUSIONS: Telephone invitations should be advocated to address the substantial deficit between current and required levels of NHS uptake, and could be targeted at younger and lower CVD risk adults. Risk-personalised letters should be explored further in a larger sample of high risk individuals. TRIAL REGISTRATION: Registration number: ISRCTN15840751 date of registration: 24/10/2017.

Transmission of toxigenic Corynebacterium diphtheriae by a fully immunised resident returning from a visit to West Africa, United Kingdom, 2017.

In early 2017, a United Kingdom (UK)-born person in their 20s presented with a skin ulcer on the foot 3 weeks after returning from Ghana. The patient had last received a diphtheria-containing vaccine in 2013, completing the recommended course. MALDI-TOF of a cutaneous swab identified Corynebacterium diphtheriae. Real-time PCR ascertained the species and presence of the diphtheria toxin gene. An Elek test confirmed toxigenicity. The isolate was macrolide sensitive and penicillin resistant. The local Public Health England (PHE) Health Protection Team obtained the patient's clinical history and traced contacts to inform appropriate public health action. One close contact (in their early 80s with uncertain immunisation status who had not recently travelled) had a positive throat swab for toxigenic C. diphtheriae and reported a history of mild coryzal symptoms. Multilocus sequence typing revealed that strains from the index case and contact had Sequence Type 463. Diphtheria is extremely rare in the UK due to high vaccine coverage and this is the first documented transmission in 30 years. Clinicians and laboratory staff should remain highly suspicious of lesions in overseas travellers, even when patients are fully vaccinated. Older individuals who might not have completed a full immunisation course may have higher diphtheria susceptibility.

Optimizing primary healthcare experience: assessing client satisfaction in Kaduna State, Northwest Nigeria.

BACKGROUND: Client satisfaction is a multidimensional construct focusing on clients' perceptions and evaluations of the treatment and care received. It is one of the factors affecting the outcomes of healthcare and the use of health services. Therefore, we aimed to assess clients' satisfaction with PHC services in Kaduna State, Northwest Nigeria. METHODOLOGY: A cross-sectional descriptive study was conducted in Kaduna State, Northwest, Nigeria which evaluate the satisfaction of clients and caregivers accessing healthcare in PHC centres. A sample size of 217 was determined using Fisher's formula, with a multi-stage sampling technique used to randomly select eligible respondents, who have accessed at least a PHC service in any of the PHCs in the State were included in the study, A semi-structured, interviewer-administered questionnaire was administered, and the data collected was analyzed using SPSS version 23.0. Appropriate statistical tests were used to examine the association between dependent and independent variables, while predictor variables that showed significant association with the outcome variables were further subjected to logistic regression analysis, to determine factors that affect clients' satisfaction with PHC services. Statistical significance was determined at an alpha level set at 0.05 at a 95% confidence interval. RESULTS: Thirty-one percent of the respondents were satisfied with PHC services in Kaduna State with a mean composite satisfaction score of 3.78 ± 0.67. Age, ethnicity, level of education, and occupational status were factors affecting clients' satisfaction with PHC services among the respondents. On multivariate analysis, age, ethnicity, educational status, and occupational status were significant factors affecting clients' satisfaction with PHC services. Clients of Hausa/Fulani extraction are one and a half times less likely to be satisfied with PHC services when compared to clients from other tribes [aOR = 1.5, 95% CI (1.21-4.67); p = 0.003]. In terms of educational status, clients with formal education are one and a one-third times more likely to be satisfied [aOR = 1.3, 95% CI (0.17-0.94)] with PHC service when compared with their counterparts with informal education (p = 0.034). CONCLUSION: Clients' satisfaction with PHC services in Kaduna State, Northwest Nigeria was sub-optimal. Healthcare providers were recommended to improve their attitude bearing in mind clients' peculiarities.

Cancer control funding in Nigeria: A case for universal health coverage.

Nigeria's health spending per capita remains relatively low, with an out-of-pocket expenditure on health estimated at three-quarters of the nation's health expenditure in 2018. A large percentage of the population cannot afford-and have limited access to-cancer treatment services. Our study was aimed at analyzing all cancer funding-related policies from 2010 to 2020. We used qualitative methods to contextualize the challenges of funding cancer control, and recommend steps in policy implementation needed to achieve universal health coverage (UHC) for cancer care in Nigeria. We found that cancer control is grossly underfunded, with a glaring lack of political will identified by most participants as the root cause of underfunding. Recommendations by the participants included mandatory enrollment in health insurance schemes, encouraging public-private partnerships and advocacy for increased taxation to democratize access to treatment. Additionally, channeling a portion of tax revenues from tobacco sales to cancer will reduce catastrophic health spending and move Nigeria closer toward achieving UHC for cancer.

Humanities, criticality and transparency: global health histories and the foundations of inter-sectoral partnerships for the democratisation of knowledge.

Historians of medicine have been influential actors in a broader movement to highlight the social, institutional and administrative benefits of historical research, and its relevance for national and international policy intended to extend and improve contemporary healthcare. Historical perspectives are fundamentally useful to health policy actors because questions about what it is to be healthy, to suffer disease or disability, and the presentation and acceptance of solutions are interwoven in culturally and historically complex webs of meaning. Historians, as they have examined the social and cultural social determinants of health, have also used their work as public engagement, educational and policy resource tools, demonstrating that history is an effective way of making key issues in science, medicine and well-being more administratively responsive and accessible to lay audiences. This article explores such issues through the case study of the long-running World Health Organization (WHO) Global Health Histories project. Established in late 2004, the project's enduring rationale has been that understanding the history of health helps the global public health community to respond to the challenges of today and help shape a healthier future. It has sought to do this by bringing together researchers and policy-makers into honest and democratic conversations and exchanges of ideas. The aim has been to stimulate a fusion between historical evidence and current policy approaches to many of the most urgent health issues. This article discusses the challenges and opportunities in bringing health history and policy together, and explores the importance of explaining historical method and the need to convince policy partners how history is evidence-based, that it can access and provide useful strategic information from archives of major institutions, and, therefore, a useful contributor to making policy initiatives adaptable and acceptable within complex polities and societies.

The growing impact of HIV infection on the epidemiology of tuberculosis in England and Wales: 1999 2003.

BACKGROUND: Previous studies have estimated the prevalence of tuberculosis and HIV infection in population subgroups in the UK. This study was undertaken to describe recent trends in the proportion of individuals with HIV infection among reported cases of tuberculosis in England and Wales, and to review the implications for clinical and public health care. METHODS: A population-based matching study using national surveillance databases was used to investigate all persons aged 15 years and over reported with a diagnosis of tuberculosis to the Health Protection Agency in England and Wales in 1999-2003. Record linkage was used to match the national tuberculosis and HIV/AIDS surveillance databases to identify all cases of tuberculosis and determine the proportion of patients with tuberculosis co-infected with HIV. The distribution and characteristics of the cases were determined and the trend examined by year. RESULTS: Of 30,670 cases of tuberculosis reported in England and Wales between 1999 and 2003, an estimated 1743 (5.7%) were co-infected with HIV. There was a year on year increase in the proportion from 3.1% (169/5388) in 1999 to 8.3% (548/6584) in 2003 (p for trend <0.0001). Co-infected patients contributed to almost a third of the increase in the number of cases of tuberculosis during the 5 year period. Patients co-infected with HIV were predominantly those born abroad. 18.5% (n = 323) of co-infected patients had not been reported as active cases of tuberculosis on the national tuberculosis database. CONCLUSION: The proportion of patients with tuberculosis co-infected with HIV in England and Wales is increasing, with the greatest impact on those born abroad regardless of their ethnic origin. With HIV infection contributing substantially to the increase in the number of cases of tuberculosis, close cooperation in the clinical management and accurate notification of patients is vital if appropriate care and public health action is to be achieved.