Housing, sanitation and living conditions affecting SARS-CoV-2 prevention interventions in 54 African countries.

The feasibility of non-pharmacological public health interventions (NPIs) such as physical distancing or isolation at home to prevent severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission in low-resource countries is unknown. Household survey data from 54 African countries were used to investigate the feasibility of SARS-CoV-2 NPIs in low-resource settings. Across the 54 countries, approximately 718 million people lived in households with ⩾6 individuals at home (median percentage of at-risk households 56% (95% confidence interval (CI), 51% to 60%)). Approximately 283 million people lived in households where ⩾3 people slept in a single room (median percentage of at-risk households 15% (95% CI, 13% to 19%)). An estimated 890 million Africans lack on-site water (71% (95% CI, 62% to 80%)), while 700 million people lacked in-home soap/washing facilities (56% (95% CI, 42% to 73%)). The median percentage of people without a refrigerator in the home was 79% (95% CI, 67% to 88%), while 45% (95% CI, 39% to 52%) shared toilet facilities with other households. Individuals in low-resource settings have substantial obstacles to implementing NPIs for mitigating SARS-CoV-2 transmission. These populations urgently need to be prioritised for coronavirus disease 2019 vaccination to prevent disease and to contain the global pandemic.

Transformative learning as pedagogy for the health professions: a scoping review.

CONTEXT: Transformative learning (TL) has been described as learning that challenges established perspectives, leading to new ways of being in the world. As a learning theory it has resonated with educators globally, including those in the health professions. Described as a complex metatheory, TL has evolved over time, eliciting divergent interpretations of the construct. This scoping review provides a comprehensive synthesis of how TL is currently represented in the health professions education literature, including how it influences curricular activities, to inform its future application in the field. METHODS: Arksey and O'Malley's six-step framework was adopted to review the period from 2006 to May 2018. A total of 10 bibliographic databases were searched, generating 1532 potential studies. After several rounds of review, first of abstracts and then of full texts, 99 studies were mapped by two independent reviewers onto the internally developed data extraction sheet. Descriptive information about included studies was aggregated. Discursive data were subjected to content analysis. RESULTS: A mix of conceptual and empirical research papers, which used a range of qualitative methodologies, were included. Studies from the USA, the UK and Australia were most prevalent. Insights relating to how opportunities for TL were created, how it manifests and influences behaviour, as well as how it is experienced, demonstrated much congruency. Conceptions of TL were seen to be clustered around the work of key theorists. CONCLUSIONS: The training of health professionals often takes place in unfamiliar settings where students are encouraged to be active participants in providing care. This increases the opportunity for exposure to learning experiences that are potentially transformative, allowing for a pedagogy of uncertainty that acknowledges the complexity of the world we live in and questions what we believe we know about it. TL provides educators in the health professions with a theoretical lens through which they can view such student learning.

Reframing undergraduate medical education in global health: Rationale and key principles from the Bellagio Global Health Education Initiative.

Global health education (GHE) continues to be a growing initiative in many medical schools across the world. This focus is no longer limited to participants from high-income countries and has expanded to institutions and students from low- and middle-income settings. With this shift has come a need to develop meaningful curricula through engagement between educators and learners who represent the sending institutions and the diverse settings in which GHE takes place. The Bellagio Global Health Education Initiative (BGHEI) was founded to create a space for such debate and discussion and to generate guidelines towards a universal curriculum for global health. In this article, we describe the development and process of our work and outline six overarching principles that ought to be considered when adopting an inclusive approach to GHE curriculum development.

What explains gender inequalities in HIV/AIDS prevalence in sub-Saharan Africa? Evidence from the demographic and health surveys.

BACKGROUND: Women are disproportionally affected by human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) in sub-Saharan Africa (SSA). The determinants of gender inequality in HIV/AIDS may vary across countries and require country-specific interventions to address them. This study aimed to identify the socio-demographic and behavioral characteristics underlying gender inequalities in HIV/AIDS in 21 SSA countries. METHODS: We applied an extension of the Blinder-Oaxaca decomposition approach to data from Demographic and Health Surveys and AIDS Indicator Surveys to quantify the differences in HIV/AIDS prevalence between women and men attributable to socio-demographic factors, sexual behaviours, and awareness of HIV/AIDS. We decomposed gender inequalities into two components: the percentage attributable to different levels of the risk factors between women and men (the "composition effect") and the percentage attributable to risk factors having differential effects on HIV/AIDS prevalence in women and men (the "response effect"). RESULTS: Descriptive analyses showed that the difference between women and men in HIV/AIDS prevalence varied from a low of 0.68 % (P = 0.008) in Liberia to a high of 11.5 % (P < 0.001) in Swaziland. The decomposition analysis showed that 84 % (P < 0.001) and 92 % (P < 0.001) of the higher prevalence of HIV/AIDS among women in Uganda and Ghana, respectively, was explained by the different distributions of HIV/AIDS risk factors, particularly age at first sex between women and men. In the majority of countries, however, observed gender inequalities in HIV/AIDS were chiefly explained by differences in the responses to risk factors; the differential effects of age, marital status and occupation on prevalence of HIV/AIDS for women and men were among the significant contributors to this component. In Cameroon, Guinea, Malawi and Swaziland, a combination of the composition and response effects explained gender inequalities in HIV/AIDS prevalence. CONCLUSIONS: The factors that explain gender inequality in HIV/AIDS in SSA vary by country, suggesting that country-specific interventions are needed. Unmeasured factors also contributed substantially to the difference in HIV/AIDS prevalence between women and men, highlighting the need for further study.

The Haiti Medical Education Project: development and analysis of a competency based continuing medical education course in Haiti through distance learning.

BACKGROUND: Recent calls for reform in healthcare training emphasize using competency-based curricula and information technology-empowered learning. Continuing Medical Education programs are essential in maintaining physician accreditation. Haitian physicians have expressed a lack access to these activities. The Haiti Medical Education Project works in alliance with Haitian medical leadership, faculty and students to support the Country's medical education system. We present the creation, delivery and evaluation of a competency-based continuing medical education curriculum for physicians in rural Haiti. METHODS: Real time lectures from local and international institutions were teleconferenced to physicians in remote Haitian sites using VidyoConferencing™ technology. With American Academy of Family Physicians (AAFP) and College of Family Physicians Canada (CFPC) guidelines as references, a competency-derived syllabus was created for a Haitian continuing medical education program. The resulting educational goals were reviewed by a committee of Haitian and North American physician/medical education practitioners to reflect local needs. All authors reviewed lectures and then conferred to establish agreement on competencies presented for each lecture. RESULTS: Sixty-seven lectures were delivered. Human immunodeficiency virus/Acquired Immunodeficiency Syndrome, ophthalmologic, infectious diseases, renal and endocrine competencies were well-represented, with more than 50 % of the joint AAFP and CFPC recommended competencies outlined. Areas under-represented included allergy and immunology, cardiology, surgery, pain management, gastroenterology, neurology, pulmonology, men's health and rheumatology; these topics accounted for less than 25 % of AAFP/CFPC recommended competencies. Areas not covered included geriatrics, nutrition, occupational health and women's health. Within practice-based lectures, only disaster medicine, health promotion and information management were included, but only partially covered. CONCLUSIONS: We identified teaching goals covered and competencies that were missing from a CME program for rural Haitian physicians. We aim to use this analysis to provide a competency-based CME lecture series that proportionally meets local needs while following recommendations of recognized national family medicine organizations.

Forecasting malaria in a highly endemic country using environmental and clinical predictors.

BACKGROUND: Malaria thrives in poor tropical and subtropical countries where local resources are limited. Accurate disease forecasts can provide public and clinical health services with the information needed to implement targeted approaches for malaria control that make effective use of limited resources. The objective of this study was to determine the relevance of environmental and clinical predictors of malaria across different settings in Uganda. METHODS: Forecasting models were based on health facility data collected by the Uganda Malaria Surveillance Project and satellite-derived rainfall, temperature, and vegetation estimates from 2006 to 2013. Facility-specific forecasting models of confirmed malaria were developed using multivariate autoregressive integrated moving average models and produced weekly forecast horizons over a 52-week forecasting period. RESULTS: The model with the most accurate forecasts varied by site and by forecast horizon. Clinical predictors were retained in the models with the highest predictive power for all facility sites. The average error over the 52 forecasting horizons ranged from 26 to 128% whereas the cumulative burden forecast error ranged from 2 to 22%. CONCLUSIONS: Clinical data, such as drug treatment, could be used to improve the accuracy of malaria predictions in endemic settings when coupled with environmental predictors. Further exploration of malaria forecasting is necessary to improve its accuracy and value in practice, including examining other environmental and intervention predictors, including insecticide-treated nets.

Implementation of a stepped-wedge cluster randomized design in routine public health practice: design and application for a tuberculosis (TB) household contact study in a high burden area of Lima, Peru.

BACKGROUND: We designed a pragmatic stepped-wedge cluster randomized controlled trial in order to evaluate provider-initiated evaluation of household contacts (HCs) of smear positive tuberculosis (TB) cases within a routine TB program in Lima, Peru. METHODS/DESIGN: National TB program (NTP) officers of San Juan de Lurigancho District (Lima, Peru) and university-based researchers jointly designed a pragmatic stepped-wedge cluster randomized trial design in order to evaluate a planned active case finding (ACF) program for all HCs of smear-positive TB cases in 34 district healthcare centres. Randomization of time to intervention initiation was stratified by health centre TB case rate. The ACF intervention included provider-initiated home visits of all new sputum smear positive TB patients in order to evaluate household contacts for active TB. Active TB was diagnosed using symptom screening, sputum screening, chest x-ray and clinical evaluation. Once initiated, ACF was provided by NTP staff and integrated into the routine DOTS TB program activities. DISCUSSION: This study protocol describes the pragmatic stepped-wedge cluster randomized trial of active household contact evaluations within an NTP. The stepped-wedge design met overlapping needs of local TB programmers and researchers to adequately evaluate the large-scale roll out of a new control program in a TB endemic setting. Multiple planning meetings were required to develop the necessary networks and in order to understand the operations, needs and goals of the NTP staff and researchers collaborating on this project. The advantages and challenges of using this study design in practice and within existing routine TB programs in a middle-income country context are discussed. TRIAL REGISTRATION: ClinicalTrials.gov NCT02174380. Registered 24 Jun 2014.

Impact of SARS-CoV-2 vaccines on Covid-19 incidence and mortality in the United States.

BACKGROUND: Given the waning of vaccine effectiveness and the shifting of the most dominant strains in the U.S., it is imperative to understand the association between vaccination coverage and Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2) disease and mortality at the community levels and whether that association might vary according to the dominant SARS-CoV-2 strains in the U.S. METHODS: Generalized estimating equations were used to estimate associations between U.S. county-level cumulative vaccination rates and booster distribution and the daily change in county-wide Coronavirus 2019 disease (COVID-19) risks and mortality during Alpha, Delta and Omicron predominance. Models were adjusted for potential confounders at both county and state level. A 2-week lag and a 4-week lag were introduced to assess vaccination rate impact on incidence and mortality, respectively. RESULTS: Among 3,073 counties in 48 states, the average county population complete vaccination rate of all age groups was 50.79% as of March 11th, 2022. Each percentage increase in vaccination rates was associated with reduction of 4% (relative risk (RR) 0.9607 (95% confidence interval (CI): 0.9553, 0.9661)) and 3% (RR 0.9694 (95% CI: 0.9653, 0.9736)) in county-wide COVID-19 cases and mortality, respectively, when Alpha was the dominant variant. The associations between county-level vaccine rates and COVID-19 incidence diminished during the Delta and Omicron predominance. However, each percent increase in people receiving a booster shot was associated with reduction of 6% (RR 0.9356 (95% CI: 0.9235, 0.9479)) and 4% (RR 0.9595 (95% CI: 0.9431, 0.9761)) in COVID-19 incidence and mortality in the community, respectively, during the Omicron predominance. CONCLUSIONS: Associations between complete vaccination rates and COVID-19 incidence and mortality appeared to vary with shifts in the dominant variant, perhaps due to variations in vaccine efficacy by variant or to waning vaccine immunity over time. Vaccine boosters were associated with notable protection against Omicron disease and mortality.

Forecasting high-priority infectious disease surveillance regions: a socioeconomic model.

BACKGROUND: Few researchers have assessed the relationships between socioeconomic inequality and infectious disease outbreaks at the population level globally. We use a socioeconomic model to forecast national annual rates of infectious disease outbreaks. METHODS: We constructed a multivariate mixed-effects Poisson model of the number of times a given country was the origin of an outbreak in a given year. The dataset included 389 outbreaks of international concern reported in the World Health Organization's Disease Outbreak News from 1996 to 2008. The initial full model included 9 socioeconomic variables related to education, poverty, population health, urbanization, health infrastructure, gender equality, communication, transportation, and democracy, and 1 composite index. Population, latitude, and elevation were included as potential confounders. The initial model was pared down to a final model by a backwards elimination procedure. The dependent and independent variables were lagged by 2 years to allow for forecasting future rates. RESULTS: Among the socioeconomic variables tested, the final model included child measles immunization rate and telephone line density. The Democratic Republic of Congo, China, and Brazil were predicted to be at the highest risk for outbreaks in 2010, and Colombia and Indonesia were predicted to have the highest percentage of increase in their risk compared to their average over 1996-2008. CONCLUSIONS: Understanding socioeconomic factors could help improve the understanding of outbreak risk. The inclusion of the measles immunization variable suggests that there is a fundamental basis in ensuring adequate public health capacity. Increased vigilance and expanding public health capacity should be prioritized in the projected high-risk regions.

Global capacity for emerging infectious disease detection.

The increasing number of emerging infectious disease events that have spread internationally, such as severe acute respiratory syndrome (SARS) and the 2009 pandemic A/H1N1, highlight the need for improvements in global outbreak surveillance. It is expected that the proliferation of Internet-based reports has resulted in greater communication and improved surveillance and reporting frameworks, especially with the revision of the World Health Organization's (WHO) International Health Regulations (IHR 2005), which went into force in 2007. However, there has been no global quantitative assessment of whether and how outbreak detection and communication processes have actually changed over time. In this study, we analyzed the entire WHO public record of Disease Outbreak News reports from 1996 to 2009 to characterize spatial-temporal trends in the timeliness of outbreak discovery and public communication about the outbreak relative to the estimated outbreak start date. Cox proportional hazards regression analyses show that overall, the timeliness of outbreak discovery improved by 7.3% [hazard ratio (HR) = 1.073, 95% CI (1.038; 1.110)] per year, and public communication improved by 6.2% [HR = 1.062, 95% CI (1.028; 1.096)] per year. However, the degree of improvement varied by geographic region; the only WHO region with statistically significant (α = 0.05) improvement in outbreak discovery was the Western Pacific region [HR = 1.102 per year, 95% CI (1.008; 1.205)], whereas the Eastern Mediterranean [HR = 1.201 per year, 95% CI (1.066; 1.353)] and Western Pacific regions [HR = 1.119 per year, 95% CI (1.025; 1.221)] showed improvement in public communication. These findings provide quantitative historical assessment of timeliness in infectious disease detection and public reporting of outbreaks.

Global health education in U.S. medical schools.

Interest in global health (GH) among medical students worldwide is measurably increasing. There is a concomitant emphasis on emphasizing globally-relevant health professions education. Through a structured literature review, expert consensus recommendations, and contact with relevant professional organizations, we review the existing state of GH education in US medical schools for which data were available. Several recommendations from professional societies have been developed, along with a renewed emphasis on competencies in global health. The implementation of these recommendations was not observed as being uniform across medical schools, with variation noted in the presence of global health curricula. Recommendations for including GH in medical education are suggested, as well as ways to formalize GH curricula, while providing flexibility for innovation and adaptation.

Timeliness of nongovernmental versus governmental global outbreak communications.

To compare the timeliness of nongovernmental and governmental communications of infectious disease outbreaks and evaluate trends for each over time, we investigated the time elapsed from the beginning of an outbreak to public reporting of the event. We found that governmental sources improved the timeliness of public reporting of infectious disease outbreaks during the study period.

Rifampicin Mono-Resistant Tuberculosis-A Review of an Uncommon But Growing Challenge for Global Tuberculosis Control.

Tuberculosis (TB) remains the leading cause of death by an infectious pathogen worldwide, and drug-resistant TB is a critical and rising obstacle to global control efforts. Most scientific studies and global TB efforts have focused on multidrug-resistant TB (MDR-TB), meaning isolates resistant to both isoniazid (INH) and rifampicin (RIF). Newer diagnostic tests are resulting in an increasing awareness of RIF-resistant TB in addition to MDR disease. To date, RIF resistance has been assumed to be synonymous with MDR-TB, but this approach may expose TB patients with RIF mono-resistance disease to unnecessarily long and toxic treatment regimens. We review what is currently known about RIF mono-resistant TB, its history and epidemiology, mechanisms of RIF resistance, available diagnostic techniques, treatment outcomes reported globally, and future directions for combatting this disease.

Global health competencies and approaches in medical education: a literature review.

BACKGROUND: Physicians today are increasingly faced with healthcare challenges that require an understanding of global health trends and practices, yet little is known about what constitutes appropriate global health training. METHODS: A literature review was undertaken to identify competencies and educational approaches for teaching global health in medical schools. RESULTS: Using a pre-defined search strategy, 32 articles were identified; 11 articles describing 15 global health competencies for undergraduate medical training were found. The most frequently mentioned competencies included an understanding of: the global burden of disease, travel medicine, healthcare disparities between countries, immigrant health, primary care within diverse cultural settings and skills to better interface with different populations, cultures and healthcare systems. However, no consensus on global health competencies for medical students was apparent. Didactics and experiential learning were the most common educational methods used, mentioned in 12 and 13 articles respectively. Of the 11 articles discussing competencies, 8 linked competencies directly to educational approaches. CONCLUSIONS: This review highlights the imperative to document global health educational competencies and approaches used in medical schools and the need to facilitate greater consensus amongst medical educators on appropriate global health training for future physicians.

A pragmatic stepped-wedge cluster randomized trial to evaluate the effectiveness and cost-effectiveness of active case finding for household contacts within a routine tuberculosis program, San Juan de Lurigancho, Lima, Peru.

BACKGROUND: Active case finding (ACF) in household contacts of tuberculosis (TB) patients is now recommended for National TB Programs (NTP) in low- and middle-income countries. However, evidence supporting these recommendations remains limited. This study evaluates the effectiveness and cost-effectiveness of ACF for household contacts of TB cases in a large TB endemic district of Lima, Peru. METHODS: A pragmatic stepped-wedge cluster randomized controlled trial was conducted in 34 health centers of San Juan de Lurigancho district. Centers were stratified by TB rate and randomly allocated to initiate ACF in groups of eight or nine centers at four-month intervals. In the intervention arm, NTP providers visited households of index patients to screen contacts for active TB. The control arm was routine passive case finding (PCF) of symptomatic TB cases. The primary outcomes were the crude and adjusted active TB case rates among household contacts. Program costs were directly measured, and the cost-effectiveness of the ACF intervention was determined. FINDINGS: 3222 index TB cases and 12,566 household contacts were included in the study. ACF identified more household contact TB cases than PCF, 199.29/10,000 contacts/year vs. 132.13 (incidence rate ratio of 1.51 (95% CI 1.21-1.88)). ACF was associated with an incremental cost-effectiveness ratio of US $16,400 per disability-adjusted life year averted and not cost-effective assuming a willingness-to-pay threshold for Peru of US $6360. CONCLUSION: ACF of TB case household contacts detected significantly more secondary TB cases than PCF alone, but was not cost-effective in this setting. In threshold analyses, ACF becomes cost-effective if associated with case detection rates 2.5 times higher than existing PCF programs.

Beyond borders: building global health programs at McGill University Faculty of Medicine.

Globalization has irrevocably altered the determinants of health as well as the delivery of health care. Although these changes have been increasingly recognized by governments and funding agencies, and despite the large and growing interest in global health topics among faculty and students, many medical educational programs lack courses or programs in this important area. At McGill University Faculty of Medicine, the Global Health Programs (GHP) were established to build research and training capacity in global health locally and internationally, to stimulate individuals to work in related fields and topics, and to facilitate partnerships with institutions around the world. These goals are addressed through programs that foster communication among interested faculty and students; provide resources such as project databases and easily accessed, centrally located reference materials; and provide both financial and consultative support for faculty and student initiatives. Important lessons learned in building GHP at McGill include (1) the need for a dedicated senior faculty member to lead the program while promoting activities and initiatives, (2) the need for resources to begin new projects, and (3) a willingness to work with others to achieve common goals. Most medical schools already have faculty engaged in and students interested in global health activities. By bringing interested individuals together with a modest infusion of additional resources and creativity, it is possible to develop programs that provide exciting global health educational opportunities for the medical school community and beyond.

Global health in Canadian medical education: current practices and opportunities.

PURPOSE: Globalization is altering health and health care. At the same time, prospective and current medical students are increasingly requesting global health training and creating opportunities when these are not provided by medical schools. To understand the type and amount of global health activities provided in Canadian medical schools, the authors undertook a survey of global health educational opportunities available at all 17 medical schools during the 2005-2006 academic year. METHOD: Using a structured questionnaire, information was collected from deans' offices, institutional representatives, faculty, students, and medical school Web sites. RESULTS: All 17 medical schools participated. Canadian medical schools vary widely in their approach to global health education, ranging from neither required nor elective courses in global health to well-developed, two-year electives that include didactic and overseas training. There is no consensus on the educational content covered, the year in which global health issues are taught, whether materials should be elective or required, or how much training is needed. Of the 16 Canadian medical schools that allow students to participate in international electives, 44% allow these electives to occur without clear faculty oversight or input. CONCLUSIONS: Despite both the strong, growing demand from medical students and the changing societal forces that call for better global health training, Canadian medical school curricula are not well positioned to address these needs. Improving global health opportunities in Canadian medical school curricula will likely require national leadership from governing academic bodies.

Moving from preventing HIV/AIDS in its infancy to preventing family illness and death (PFID).

In April 2007, UNAIDS released Securing the future--advocating for children, a call for the global community to recognize that "children still remain largely absent from national and international political responses to the AIDS pandemic". Most efforts to date to protect children from HIV have focused on prevention of mother-to-child transmission (PMTCT) programs. Though expanding PMTCT programs, particularly in sub-Saharan Africa, are crucial, even widespread PMTCT programs would still be grossly inadequate for achieving the goal of protecting children from HIV/AIDS. The global community needs to fundamentally reframe its approach to HIV prevention to fully address the health of families, otherwise the future for at-risk children is likely to remain bleak. After identifying challenges with current approaches, we review recent research that provides insights into ways prevention programs may be adapted to better protect families and children from the devastating consequences of HIV/AIDS. Only by protecting families from HIV/AIDS will we be able to achieve the goal of an AIDS-free generation.

Translating Predictions of Zoonotic Viruses for Policymakers.

Recent outbreaks of Ebola virus disease and Zika virus disease highlight the need for disseminating accurate predictions of emerging zoonotic viruses to national governments for disease surveillance and response. Although there are published maps for many emerging zoonotic viruses, it is unknown if there is agreement among different models or if they are concordant with national expert opinion. Therefore, we reviewed existing predictions for five high priority emerging zoonotic viruses with national experts in Cameroon to investigate these issues and determine how to make predictions more useful for national policymakers. Predictive maps relied primarily on environmental parameters and species distribution models. Rift Valley fever virus and Crimean-Congo hemorrhagic fever virus predictions differed from national expert opinion, potentially because of local livestock movements. Our findings reveal that involving national experts could elicit additional data to improve predictions of emerging pathogens as well as help repackage predictions for policymakers.