The Changing Aspects of Motherhood in Face of the COVID-19 Pandemic in Low- and Middle-Income Countries.

PURPOSE: To advocate perspectives to strengthen existing healthcare systems to prioritize maternal health services amidst and beyond the COVID-19 pandemic in low- and middle income countries. DESCRIPTION: COVID-19 directly affects pregnant women causing more severe disease and adverse pregnancy outcomes. The indirect effects due to the monumental COVID-19 response are much worse, increasing maternal and neonatal mortality. ASSESSMENT: Amidst COVID-19, governments must balance effective COVID-19 response measures while continuing delivery of essential health services. Using the World Health Organization's operational guidelines as a base, countries must conduct contextualized analyses to tailor their operations. Evidence based information on different services and comparative cost-benefits will help decisions on trade-offs. Situational analyses identifying extent and reasons for service disruptions and estimates of impacts using modelling techniques will guide prioritization of services. Ensuring adequate supplies, maintaining core interventions, expanding non-physician workforce and deploying telehealth are some adaptive measures to optimize care. Beyond the COVID-19 pandemic, governments must reinvest in maternal and child health by building more resilient maternal health services supported by political commitment and multisectoral engagement, and with assistance from international partners. CONCLUSIONS: Multi-sectoral investments providing high-quality care that ensures continuity and available to all segments of the population are needed. A robust primary healthcare system linked to specialist care and accessible to all segments of the population including marginalized subgroups is of paramount importance. Systematic approaches to digital health care solutions to bridge gaps in service is imperative. Future pandemic preparedness programs must include action plans for resilient maternal health services.

Beginning of a journey: unraveling the mystery of chronic kidney disease of unknown aetiology (CKDu) in Sri Lanka.

BACKGROUND: Globally, chronic kidney disease of unknown aetiology (CKDu) is observed in several areas and among specific ethnic or occupational groups. Given the widespread environmental pollution and the proportions of agriculture workers world-wide, CKDu may be the next global public health issue demanding attention. Recent escalation of CKDu in Sri Lanka has caused a serious public health crisis in the country, made worse by lack of national data. MAIN TEXT: The specific geographic distribution, preponderance among farming population, similar histology findings and absence of usual risk factors for kidney disease indicate undetected nephrotoxic agents playing a role in causation. Some of the challenges for the country are uncoordinated preventive efforts, diverse opinions among stakeholders on causality and fragmented research efforts with limited focus on potential causes of CKDu. As a result, accurate estimation of the CKDu burden, identification of causative agents and implementation of effective actions have been delayed. Stakeholder engagement, with involvement of international experts has been the starting point for finalizing a working case definition to establish community based surveillance as a future platform to conduct long-term research. CONCLUSION: The country is now poised to contribute to global knowledge by solving the mystery of 'u' in CKDu. This commentary highlights the importance and the mechanisms of making an effective breakthrough as early as possible; failing which CKDu can progress rapidly as demonstrated by the situation in Sri Lanka.

Addressing the social and environmental determinants of urban health equity: evidence for action and a research agenda.

Urban living is the new reality for the majority of the world's population. Urban change is taking place in a context of other global challenges--economic globalization, climate change, financial crises, energy and food insecurity, old and emerging armed conflicts, as well as the changing patterns of communicable and noncommunicable diseases. These health and social problems, in countries with different levels of infrastructure and health system preparedness, pose significant development challenges in the 21st century. In all countries, rich and poor, the move to urban living has been both good and bad for population health, and has contributed to the unequal distribution of health both within countries (the urban-rural divide) and within cities (the rich-poor divide). In this series of papers, we demonstrate that urban planning and design and urban social conditions can be good or bad for human health and health equity depending on how they are set up. We argue that climate change mitigation and adaptation need to go hand-in-hand with efforts to achieve health equity through action in the social determinants. And we highlight how different forms of governance can shape agendas, policies, and programs in ways that are inclusive and health-promoting or perpetuate social exclusion, inequitable distribution of resources, and the inequities in health associated with that. While today we can describe many of the features of a healthy and sustainable city, and the governance and planning processes needed to achieve these ends, there is still much to learn, especially with respect to tailoring these concepts and applying them in the cities of lower- and middle-income countries. By outlining an integrated research agenda, we aim to assist researchers, policy makers, service providers, and funding bodies/donors to better support, coordinate, and undertake research that is organized around a conceptual framework that positions health, equity, and sustainability as central policy goals for urban management.

Promoting health equity in cities through evidence-based action.

The impact of the urban setting on health and, in particular, health inequities has been widely documented. However, only a few countries have examined their inter- or intra-city health inequalities, and few do so regularly. Information that shows the gaps between cities or within the same city is a crucial requirement to trigger appropriate local actions to promote health equity. To generate relevant evidence and take appropriate actions to tackle health inequities, local authorities need a variety of tools. In order to facilitate a comprehensive understanding of health systems performance, these tools should: (1) adopt a multi-sectorial approach; (2) link evidence to actions; (3) be simple and user-friendly; and (4) be operationally feasible and sustainable. In this paper we have illustrated the use of one such tool, The World Health Organization's Urban HEART, which guides users through a process to identify health inequities, focusing on health determinants and then developing actions based on the evidence generated. In a time of increasing financial constraints, there is a pressing need to allocate scarce resources more efficiently. Tools are needed to guide policy makers in their planning process to identify best-practice interventions that promote health equity in their cities.

A Review of Chronic Kidney Disease of Unknown Etiology in Sri Lanka, 2001-2015.

An increase in the prevalence of chronic kidney disease of unknown etiology (CKDu) was observed in several countries of the world since the early 2000s. We reviewed the literature to summarize the existing knowledge regarding epidemiology, clinical features, and risk factors for CKDu in Sri Lanka. We reviewed published literature from PubMed and unpublished literature from literature repository of CKDu published by the World Health Organization. We identified 36 articles based on various inclusion/exclusion criteria and reviewed the full text of all selected articles. The prevalence of CKDu was approximately 5% in endemic areas based on the surveillance data. CKDu accounted for 70% of CKD cases in endemic areas. Clustering of cases was observed in select divisions and districts in the dry region of the country. Low body mass index, normal blood pressure, scanty proteinuria, and tubulointerstitial pathology were characteristics of early stages of a disease. Genetic susceptibility, farmer as occupation, heavy metals (cadmium and arsenic), and drinking well water were identified as risk factors. Data were limited on the association with agrochemical use and heat stress/dehydration. Community- and facility-based surveillance needs to be strengthened to document the burden of disease and trends over time.

Trachoma: transmission, infection, and control.

Mass antibiotic treatment and facial cleanliness are central to WHO's strategy for the elimination of blindness caused by trachoma. Recent studies have highlighted the heterogeneous response of communities to mass treatment and the complex relation between infection with Chlamydia trachomatis and clinical disease. It is important to be able to explain these findings to predict and maximise the effect of treatment on active trachoma disease and blindness in the community. Here we review the immunobiology of trachoma and provide a simple conceptual model of disease pathogenesis. We show how incorporating this model into a mathematical framework leads to an explanation of the observed community distribution of infection, bacterial load, and disease with age. The predictions of the model and empirical data show some differences that underscore the importance of individual heterogeneity in response to infection. The implications of disease transmission and pathogenesis for trachoma control programmes are discussed.

The possibility of eliminating blinding trachoma.

Global elimination of blinding trachoma, the world's leading preventable cause of blindness, now seems possible. The disease, which persists most severely in the poorest parts of Africa and Asia, is already eliminated in North America and Europe. On a scientific basis, the case for elimination was outlined at a WHO global scientific meeting in 1996. To facilitate action, WHO founded the Alliance for Global Elimination of Trachoma by 2020 (GET 2020) in 1997. In 1998 a World Health Assembly resolution called for member states to take steps to eliminate blinding trachoma by 2020 using the WHO recommended SAFE strategy (surgery of late stage disease, antibiotics for acute infection, and improved facial hygiene and environmental change-ie, improved access to water and sanitation). These developments contributed to the decision by Pfizer Inc to donate azithromycin in support of national programmes implementing SAFE and, with the Edna McConnell Clark Foundation, to found the International Trachoma Initiative as a charity dedicated to the elimination of blinding trachoma by 2020. Reports of the early programme scope and impact are encouraging. In ten national programmes currently underway (constituting about 50% of the global burden) more than 55,000 lid surgeries have halted further corneal damage and prevented blindness, and more than 6 million treatments with azithromycin have been given with reductions in acute infections of around 50% in children. Morocco, one of the first countries to implement SAFE with azithromycin, has achieved remarkable results and expects to eliminate blinding trachoma by 2005. If political will and public-health support can be mobilised, the goal of eliminating this cause of blindness can become a reality by 2020.

The global elimination of blinding trachoma: progress and promise.

Trachoma is the world's leading cause of preventable blindness. It affects approximately 150 million people living in the world's poorest, rural communities and causes an estimated loss of $2.9 billion in productivity annually. In 1985, the Edna McConnell Clark Foundation joined with the World Health Organization to support studies on trachoma epidemiology and control, resulting in the elaboration of the surgery, antibiotics, facial cleanliness and environmental improvement (SAFE) strategy as the basis for the elimination of this blinding disease. Founded in 1998 by the Clark Foundation and Pfizer, Inc., the International Trachoma Initiative (ITI) is the only organization dedicated to eliminating blinding trachoma through support to national control programs. The availability of donated Zithromax (azithromycin) by Pfizer, Inc. has been paramount to the support of the ITI for implementation of SAFE in 10 country programs. The program has made considerable progress in four years. More than seven million individuals have received treatment, resulting in a cumulative reduction of 50% in active disease rates in children. More than 60,000 have also benefited from lid surgery that has halted progression to blindness. Morocco is expecting to attain the elimination of blinding trachoma by 2005. However, the challenges facing the goal of global elimination by 2020 involve a vital program expansion, increased financial and technical support, environmental improvement, and continued advocacy efforts.