Early diagnosis of kala-azar in Bangladesh: Findings from a population based mixed methods research informing the post-elimination era.

BACKGROUND: Global annual reports of visceral leishmaniasis or kala-azar ("black fever") reduced from 200,000 cases in 2012 to 23,804 in 2015. India, Bangladesh and Nepal reported 80% of the global cases in 2012, but 39% in 2015. We sought to identify major amenable barriers to early diagnosis of kala-azar in peripheral areas of Mymensingh district, an area of Bangladesh that was highly endemic for kala-azar. METHODS: We conducted sequential exploratory mixed methods research. Qualitative data were first derived from in-depth interviews and focus group discussions among 29 patients diagnosed with kala-azar, their families, and neighbours. Preliminary results from qualitative analysis were used to design a structured questionnaire, which was administered to collect data on the processes leading to the diagnosis of kala-azar from 102 patients. Qualitative and quantitative data were integrated consistent with the chronology for kala-azar patients seeking care. The study was conducted from September 2011 to May 2012 in Fulbaria and Gaffargaon sub-districts of Mymensingh. RESULTS: The median delay from fever onset to confirmatory diagnosis of kala-azar was 60 days, with 38% of the cases diagnosed within 30 days. Public health facilities and Gaffargaon sub-district achieved high proportions of early diagnosis. Individual barriers to early diagnosis were low awareness of symptoms and treatment facilities, poverty, and traditional beliefs. Other factors were the remoteness of health care centres, wet season transport difficulty, mis-diagnosis as typhoid, limited availability of rK-39 testing at the community level, and the inclusion of splenomegaly in the case definition. CONCLUSIONS: Targeted community awareness campaigns appropriate for underprivileged communities will increase care seeking and consequently diagnosis. Improved diagnostic guidelines and a strong referral chain for kala-azar will accelerate diagnosis. These steps will contribute significantly to the National Kala-azar Elimination Program of Bangladesh, especially during the post-elimination era.

A Transdisciplinary Approach to Address Climate Change Adaptation for Human Health and Well-Being in Africa.

The health sector response to dealing with the impacts of climate change on human health, whether mitigative or adaptive, is influenced by multiple factors and necessitates creative approaches drawing on resources across multiple sectors. This short communication presents the context in which adaptation to protect human health has been addressed to date and argues for a holistic, transdisciplinary, multisectoral and systems approach going forward. Such a novel health-climate approach requires broad thinking regarding geographies, ecologies and socio-economic policies, and demands that one prioritises services for vulnerable populations at higher risk. Actions to engage more sectors and systems in comprehensive health-climate governance are identified. Much like the World Health Organization's 'Health in All Policies' approach, one should think health governance and climate change together in a transnational framework as a matter not only of health promotion and disease prevention, but of population security. In an African context, there is a need for continued cross-border efforts, through partnerships, blending climate change adaptation and disaster risk reduction, and long-term international financing, to contribute towards meeting sustainable development imperatives.

Planetary Epidemiology: Towards First Principles.

PURPOSE OF REVIEW: To combine evolutionary principles of competition and co-operation with limits to growth models, generating six principles for a new sub-discipline, called "planetary epidemiology." Suggestions are made for how to quantify four principles. RECENT FINDINGS: Climate change is one of a suite of threats increasingly being re-discovered by health workers as a major threat to civilization. Although "planetary health" is now in vogue, neither it nor its allied sub-disciplines have, as yet, had significant impact on epidemiology. Few if any theorists have sought to develop principles for Earth system human epidemiology, in its ecological, social, and technological milieu. The principles of planetary epidemiology described here can be used to stimulate applied, quantitative work to explore past, contemporary, and future population health, at scales from local to planetary, in order to promote enduring health. It is also proposed that global well-being will decline this century, without radical reform.

Climate Change, Health and Existential Risks to Civilization: A Comprehensive Review (1989⁻2013).

Background: Anthropogenic global warming, interacting with social and other environmental determinants, constitutes a profound health risk. This paper reports a comprehensive literature review for 1989⁻2013 (inclusive), the first 25 years in which this topic appeared in scientific journals. It explores the extent to which articles have identified potentially catastrophic, civilization-endangering health risks associated with climate change. Methods: PubMed and Google Scholar were primarily used to identify articles which were then ranked on a three-point scale. Each score reflected the extent to which papers discussed global systemic risk. Citations were also analyzed. Results: Of 2143 analyzed papers 1546 (72%) were scored as one. Their citations (165,133) were 82% of the total. The proportion of annual papers scored as three was initially high, as were their citations but declined to almost zero by 1996, before rising slightly from 2006. Conclusions: The enormous expansion of the literature appropriately reflects increased understanding of the importance of climate change to global health. However, recognition of the most severe, existential, health risks from climate change was generally low. Most papers instead focused on infectious diseases, direct heat effects and other disciplinary-bounded phenomena and consequences, even though scientific advances have long called for more inter-disciplinary collaboration.

Climate change, food, water and population health in China.

Anthropogenic climate change appears to be increasing the frequency, duration and intensity of extreme weather events. Such events have already had substantial impacts on socioeconomic development and population health. Climate change's most profound impacts are likely to be on food, health systems and water. This paper explores how climate change will affect food, human health and water in China. Projections indicate that the overall effects of climate change, land conversion and reduced water availability could reduce Chinese food production substantially - although uncertainty is inevitable in such projections. Climate change will probably have substantial impacts on water resources - e.g. changes in rainfall patterns and increases in the frequencies of droughts and floods in some areas of China. Such impacts would undoubtedly threaten population health and well-being in many communities. In the short-term, population health in China is likely to be adversely affected by increases in air temperatures and pollution. In the medium to long term, however, the indirect impacts of climate change - e.g. changes in the availability of food, shelter and water, decreased mental health and well-being and changes in the distribution and seasonality of infectious diseases - are likely to grow in importance. The potentially catastrophic consequences of climate change can only be avoided if all countries work together towards a substantial reduction in the emission of so-called greenhouse gases and a substantial increase in the global population's resilience to the risks of climate variability and change.

Le changement climatique anthropique est à l'origine d'une augmentation de la fréquence, de la durée et de l'intensité de phénomènes météorologiques extrêmes. Ces phénomènes ont déjà eu des conséquences notables sur le développement socioéconomique et la santé des populations. Les effets les plus marqués du changement climatique se manifesteront certainement au niveau de l'alimentation, des systèmes sanitaires et de l'eau. Cet article examine la manière dont le changement climatique affectera l'alimentation, la santé humaine et l'eau en Chine. Selon les prévisions, les effets globaux du changement climatique, la conversion des terres et la diminution de l'eau disponible pourraient considérablement réduire la production alimentaire chinoise, bien que de telles prévisions comportent inévitablement un certain degré d'incertitude. Le changement climatique aura probablement des conséquences importantes sur les ressources en eau, avec par exemple des modifications des régimes de précipitations ou encore des sécheresses et des inondations plus fréquentes dans certaines régions de Chine. Ces effets mettront indubitablement en péril la santé et le bien-être de nombreuses communautés. À court terme, la santé des populations en Chine devrait se trouver affectée par l'augmentation des températures de l'air et de la pollution. Sur le moyen et le long terme, cependant, ce sont les effets indirects du changement climatique (par ex., changements au niveau de la disponibilité des denrées alimentaires, de l'eau et des lieux de résidence, dégradation de la santé mentale et du bien-être des personnes, changements dans la répartition et la saisonnalité des maladies infectieuses) qui devraient prendre de l'importance. Les conséquences potentiellement catastrophiques du changement climatique ne peuvent être évitées que si tous les pays œuvrent ensemble en vue de réduire sensiblement les émissions de gaz à effet de serre et d'augmenter la résilience de la population mondiale face aux risques de variabilité et de changement climatiques.

Parece que el cambio climático antropogénico está aumentando la frecuencia, duración e intensidad de fenómenos meteorológicos extremos. Tales fenómenos ya han afectado enormemente el desarrollo socioeconómico y la salud pública. Los efectos más profundos del cambio climático tienen posibilidades de afectar a la alimentación, los sistemas sanitarios y el agua. En este artículo se explora cómo influirá el cambio climático en la alimentación, la salud pública y el agua en China. Las previsiones indican que los efectos generales del cambio climático, la conversión del suelo y la menor disponibilidad de agua podrían reducir la producción de alimentación en China de forma sustancial, a pesar de que la incertidumbre es inevitable en dichas previsiones. Es probable que el cambio climático afecte de manera importante a los recursos de agua, por ejemplo, cambios en los patrones de las precipitaciones y aumentos de la frecuencia de las sequías y las inundaciones en algunas zonas de China. Sin duda, tales impactos amenazarán la salud pública y el bienestar de muchas comunidades. A corto plazo, la salud pública china se verá perjudicada por los aumentos de la temperatura del aire y la contaminación. Sin embargo, de medio a largo plazo, es probable que aumente la importancia de los efectos indirectos del cambio climático, como los cambios de la disponibilidad de alimentos, refugio y agua, una reducción del bienestar y la salud mental y cambios en la propagación y estacionalidad de enfermedades infecciosas. Las posibles consecuencias catastróficas del cambio climático pueden evitarse únicamente si todos los países trabajan juntos para reducir en gran medida la emisión de los conocidos gases de efecto invernadero y para aumentar la resistencia de la población mundial ante los riesgos de la variabilidad y el cambio climáticos.

Planetary Overload, Limits to Growth and Health.

Since the use of atomic weapons in 1945 visionaries have warned that without major changes the survival of global civilization is in question. These concerns deepened in following decades, during the Cold War, with The Limits to Growth, the best-selling environmental book of the 1970s. Yet, since then, most concern has faded, fuelled by technological developments and a shift in dominant global ideology. Public health, with a few exceptions (one of which is the book Planetary Overload), has been slow to recognize this debate, even as evidence emerges that civilization may indeed be at risk, driven by an increasingly ominous complex of events. This article outlines the key relevant literature and concepts, attempting to bring emerging and future health consequences to the attention of health workers, including the idea of a "social vaccine," conveying sufficient anxiety to provoke action for environmental protection, but insufficient to induce paralysis.

Sounding the Alarm: Health in the Anthropocene.

There is growing scientific and public recognition that human actions, directly and indirectly, have profoundly changed the Earth system, in a still accelerating process, increasingly called the "Anthropocene". Planetary transformation, including of the atmosphere, climate, ecosystems and biodiversity, has enormous implications for human health, many of which are deeply disturbing, especially in low-income settings. A few health consequences of the Anthropocene have been partially recognized, including within environmental epidemiology, but their long-term consequences remain poorly understood and greatly under-rated. For example Syria could be a "sentinel" population, giving a glimpse to a much wider dystopian future. Health-Earth is a research network, co-founded in 2014, which seeks, with other groups, to catalyse a powerful curative response by the wider health community. This paper builds on a symposium presented by Health-Earth members at the 2015 conference of the International Society for Environmental Epidemiology. It reviews and synthesizes parts of the large literature relevant to the interaction between the changing Earth system and human health. It concludes that this topic should be prominent within future environmental epidemiology and public health. Created by our species, these challenges may be soluble, but solutions require far more understanding and resources than are currently being made available.

Transformational change in healthcare: an examination of four case studies.

Objectives Healthcare leaders around the world are calling for radical, transformational change of our health and care systems. This will be a difficult and complex task. In this article, we examine case studies in which transformational change has been achieved, and seek to learn from these experiences. Methods We used the case study method to investigate examples of transformational change in healthcare. The case studies were identified from preliminary doctoral research into the transition towards future sustainable health and social care systems. Evidence was collected from multiple sources, key features of each case study were displayed in a matrix and thematic analysis was conducted. The results are presented in narrative form. Results Four case studies were selected: two from the US, one from Australia and one from the UK. The notable features are discussed for each case study. There were many common factors: a well communicated vision, innovative redesign, extensive consultation and engagement with staff and patients, performance management, automated information management and high-quality leadership. Conclusions Although there were some notable differences between the case studies, overall the characteristics of success were similar and collectively provide a blueprint for transformational change in healthcare. What is known about the topic? Healthcare leaders around the world are calling for radical redesign of our systems in order to meet the challenges of modern society. What does this paper add? There are some remarkable examples of transformational change in healthcare. The key factors in success are similar across the case studies. What are the implications for practitioners? Collectively, these key factors can guide future attempts at transformational change in healthcare.

Climate change, conflict and health.

Future climate change is predicted to diminish essential natural resource availability in many regions and perhaps globally. The resulting scarcity of water, food and livelihoods could lead to increasingly desperate populations that challenge governments, enhancing the risk of intra- and interstate conflict. Defence establishments and some political scientists view climate change as a potential threat to peace. While the medical literature increasingly recognises climate change as a fundamental health risk, the dimension of climate change-associated conflict has so far received little attention, despite its profound health implications. Many analysts link climate change with a heightened risk of conflict via causal pathways which involve diminishing or changing resource availability. Plausible consequences include: increased frequency of civil conflict in developing countries; terrorism, asymmetric warfare, state failure; and major regional conflicts. The medical understanding of these threats is inadequate, given the scale of health implications. The medical and public health communities have often been reluctant to interpret conflict as a health issue. However, at times, medical workers have proven powerful and effective peace advocates, most notably with regard to nuclear disarmament. The public is more motivated to mitigate climate change when it is framed as a health issue. Improved medical understanding of the association between climate change and conflict could strengthen mitigation efforts and increase cooperation to cope with the climate change that is now inevitable.

Performance of kala-azar surveillance in Gaffargaon subdistrict of Mymensingh, Bangladesh.

INTRODUCTION: Elimination of kala-azar is planned for South Asia requiring good surveillance along with other strategies. We assessed surveillance in Gaffargaon upazila (a subdistrict of 13 unions) of Mymensingh district, Bangladesh highly endemic for kala-azar. METHODS: In 4703 randomly sampled households, within nine randomly sampled villages, drawn from three randomly sampled unions, we actively searched for kala-azar cases that had occurred between January 2010 and December 2011. We then searched for medical records of these cases in the patient registers of Gaffargaon upazila health complex (UHC). We investigated factors associated with the medical recording by interviewing the cases and their families. We also did a general observation of UHC recording systems and interviewed health staff responsible for the monthly reports of kala-azar cases. RESULTS: Our active case finding detected 58 cases, but 29 were not recorded in the Gaffargaon UHC. Thus, only 50% (95% CI: 37%-63%) of kala-azar cases were reported via the government passive surveillance system. Interviews with health staff based in the study UHC revealed the heavy reporting burden for multiple diseases, variation in staff experience, high demands on the staff time and considerable complexity in the recording system. After adjusting for kala-azar treatment drug, recording was found more likely for those aged 18 years or more, males, receiving supply and administration of drug at the UHC, and more recent treatment. DISCUSSION: Fifty percent of kala-azar cases occurring in one highly endemic area of Bangladesh were recorded in registers that were the source for monthly reports to the national surveillance system. Recording was influenced by patient, treatment, staff and system factors. Our findings have policy implications for the national surveillance system. Future studies involving larger samples and including interviews with health authorities at more central level and surveillance experts at the national level will generate more precise and representative evidence on the performance of kala-azar surveillance in Bangladesh.

The future healthcare?

BACKGROUND: Healthcare systems in Australia and around the world are failing to address the challenges ofthe modern world. Healthcare leaders are calling for radical, transformational change and entirely new systems of care. However it is unclear what a future, sustainable healthcare system would look like. METHODS: A narrative review to examine emerging trends in health and social care was conducted. RESULTS AND CONCLUSIONS: Six key trends were identified. Collectively, they suggest that future systems are likely to be characterised by increasingly sophisticated technology, but at the same time greater personal and community responsibility for health and well being, innovative use of social capital, and a new approach to ageing and end-of-life care.