The continuum of care as a unifying framework for intergenerational and interspecies health equity.

Introduction: Unlocking the full potential of different people and organizations to address existential health threats requires shared goals and frameworks that allow people to see themselves contributing to a common and shared continuum of care. A new narrative to help people implement collective action for collective problems is needed. Methods: This paper is draw from the co-authors experience working from the local to international level on planetary health problems. Results: The proposed conceptual framework expands the socioecological model of health to help formulate multilevel approaches that foster healthier circumstances for all by revealing the mutual benefits that emerge from pooling expertise, funding, and political will to solve multiple problems with coordinated investment of resources and effort. It is intended to support program planning and communication. This framework is a response to the absence of systematic attempts to concurrently counteract the social and environmental conditions leading to disease, dysfunction and deficits which is increasingly seen as being problematic, especially as the root causes of health problems and solutions converge across species, sectors, and generations. The framework is embedded in the idea of interspecies and intergenerational health equity. Discussion: Ensuring interspecies and intergenerational health equity requires each actor to fulfill their roles along the continuum while supporting the needs of others. A socio-ecological continuum of care provides bundled options that combine knowledge from different sectors, disciplines and perspectives to guide interventions over time across a comprehensive array of services and support spanning all levels of needs, species and generations.

Fragility of statistically significant findings from randomized clinical trials of surgical treatment of humeral shaft fractures: A systematic review.

BACKGROUND: Despite recent meta-analyses of randomized controlled trials (RCTs), there remains no consensus regarding the preferred surgical treatment for humeral shaft fractures. The fragility index (FI) is an emerging tool used to evaluate the robustness of RCTs by quantifying the number of participants in a study group that would need to switch outcomes in order to reverse the study conclusions. AIM: To investigate the fragility index of randomized control trials assessing outcomes of operative fixation in proximal humerus fractures. METHODS: We completed a systematic review of RCTs evaluating the surgical treatment of humeral shaft fractures. Inclusion criteria included: articles published in English; patients randomized and allotted in 1:1 ratio to 2 parallel arms; and dichotomous outcome variables. The FI was calculated for total complications, each complication individually, and secondary surgeries using the Fisher exact test, as previously published. RESULTS: Fifteen RCTs were included in the analysis comparing open reduction plate osteosynthesis with dynamic compression plate or locking compression plate, intramedullary nail, and minimally invasive plate osteosynthesis. The median FI was 0 for all parameters analyzed. Regarding individual outcomes, the FI was 0 for 81/91 (89%) of outcomes. The FI exceeded the number lost to follow up in only 2/91 (2%) outcomes. CONCLUSION: The FI shows that data from RCTs regarding operative treatment of humeral shaft fractures are fragile and does not demonstrate superiority of any particular surgical technique.

Enhanced recovery after cleft palate repair: A quality improvement project.

BACKGROUND: Children undergoing cleft palate repair present challenges to postoperative management due to several factors that can complicate recovery. Utilization of multimodal analgesic protocols can improve outcomes in this population. We report experience designing and implementing an enhanced recovery after surgery (ERAS) pathway for cleft palate repair to optimize postoperative recovery. AIMS: The primary aim was to implement an ERAS pathway with >70% bundle adherence to achieve a 30% reduction in postoperative opioid consumption within 12 months. Our secondary aims assessed intraoperative opioid consumption, length of stay, timeliness of oral intake, and respiratory recovery. METHODS: A multidisciplinary team of perioperative providers developed an ERAS pathway for cleft palate patients. Key drivers included patient and provider education, formal pathway creation and implementation, multimodal pain therapy, and target-based care. Interventions included maxillary nerve blockade and enhanced intra- and postoperative medication regimens. Outcomes were displayed as statistical process control charts. RESULTS: Pathway compliance was 77.0%. Patients during the intervention period (n = 39) experienced a 49% reduction in postoperative opioid consumption (p < .0001) relative to our historical cohort (n = 63), with a mean difference of -0.33 ± 0.11 mg/kg (95% CI -0.55 to -0.12 mg/kg). Intraoperative opioid consumption was reduced by 36% (p = .002), with a mean difference of -0.27 ± 0.09 mg/kg (95% CI -0.45 to -0.09 mg/kg). Additionally, patients in the intervention group had a 45% reduction in time to first oral intake (p = .02) relative to our historical cohort, with a mean difference of -3.81 ± 1.56 h (95% CI -6.9 to -0.70). There was no difference in PACU or hospital length of stay, but there was a significant reduction in variance of all secondary outcomes. CONCLUSION: Opioid reduction and improved timeliness of oral intake is possible with an ERAS protocol for cleft palate repair, but our protocol did not alter PACU or hospital length of stay.

THE IMPLEMENTATION GAP IN EMERGING DISEASE RISK MANAGEMENT IN THE WILDLIFE TRADE.

The wildlife trade has been characterized as one of the biggest risk factors in the emergence of new infectious diseases. In the shadow of COVID-19, there is growing political and scientific urgency to manage this risk. Existing studies and experiences make it clear that something must be done but are less clear on how to get it done. It is a quite different task to accumulate evidence on the presence of pathogens, their locations in the supply chain, and their spillover to new hosts than to identify effective ways to prevent and mitigate emerging disease under real-world conditions. This study sought peer-reviewed evidence on the effectiveness, acceptability, feasibility, and sustainability of risk reduction interventions for zoonotic and nonzoonotic disease emergence in the wildlife trade. An environmental scan triangulated information from a scoping review following a Preferred Reporting Items for Systematic Reviews and Meta-analysis extension for scoping review protocol, two narrative literature reviews, and key informant interviews of 26 international wildlife health experts. Existing literature has been inattentive to program implementation or evaluation studies. There was insufficient evidence to identify effective and sustainable risk management actions. Studies on the effects of social, epidemiologic, and ecologic context on intervention success was lacking, as was research using a complex systems perspective. The lack of systematic program evaluations or implementation studies leaves decision makers with insufficient evidence to select interventions likely to be acceptable, effective, and sustainable within and across the disparate context of the wildlife trade. This necessitates adaptive risk management and innovations in program implementation and evaluation to ensure evidence-based risk management.

Health promotion and harm reduction attributes in One Health literature: A scoping review.

One Health faces enormous pressure and challenges as it attempts to mitigate dynamic, surprising and complex global events that threaten the health and sustainability of human and animal populations and the biosphere. One Health practitioners and researchers need every advantage to developing working solutions to the world's imminent complex issues. Heath promotion and harm reduction, interrelated approaches that have seen much success over decades of use in global public health, may be important models to consider. Both use an upstream socioecological determinant of health approach to reach beyond the health sector in all health efforts, and encourage active community participation and empowerment to attain and sustain human and ecological health. This scoping review of 411 documents, believed to be the first to relate health promotion and harm reduction to One Health, searched self-declared One Health research literature for evidence of health promotion and harm reduction policies, principles and methodologies. It sought to answer the questions: "What is the scope of practice of One Health in self-declared One Health publications?" and "Are attributes of health promotion and harm reduction found in self-declared One Health-reviewed research literature?" Over half of the papers revealed no health promotion or harm reduction attributes while 7% were well-endowed with these attributes. These 7% of papers focused on deep-seated, complex health issues with systemic knowledge gaps and decision-making issues revolving around specific population vulnerabilities, social inequities and competing stakeholders. Implementing 'on the ground change' was a common theme in the strongest health promotion/harm reduction papers we identified. Alternatively, papers lacking health promotion or harm reduction attributes focused on managing proximate risks, primarily for infectious diseases. The addition of health promotion and harm reduction to One Health practices may help the field rise to the growing expectations for its involvement in complex global issues like pandemics and climate change.

Implications of Zoonoses From Hunting and Use of Wildlife in North American Arctic and Boreal Biomes: Pandemic Potential, Monitoring, and Mitigation.

The COVID-19 pandemic has re-focused attention on mechanisms that lead to zoonotic disease spillover and spread. Commercial wildlife trade, and associated markets, are recognized mechanisms for zoonotic disease emergence, resulting in a growing global conversation around reducing human disease risks from spillover associated with hunting, trade, and consumption of wild animals. These discussions are especially relevant to people who rely on harvesting wildlife to meet nutritional, and cultural needs, including those in Arctic and boreal regions. Global policies around wildlife use and trade can impact food sovereignty and security, especially of Indigenous Peoples. We reviewed known zoonotic pathogens and current risks of transmission from wildlife (including fish) to humans in North American Arctic and boreal biomes, and evaluated the epidemic and pandemic potential of these zoonoses. We discuss future concerns, and consider monitoring and mitigation measures in these changing socio-ecological systems. While multiple zoonotic pathogens circulate in these systems, risks to humans are mostly limited to individual illness or local community outbreaks. These regions are relatively remote, subject to very cold temperatures, have relatively low wildlife, domestic animal, and pathogen diversity, and in many cases low density, including of humans. Hence, favorable conditions for emergence of novel diseases or major amplification of a spillover event are currently not present. The greatest risk to northern communities from pathogens of pandemic potential is via introduction with humans visiting from other areas. However, Arctic and boreal ecosystems are undergoing rapid changes through climate warming, habitat encroachment, and development; all of which can change host and pathogen relationships, thereby affecting the probability of the emergence of new (and re-emergence of old) zoonoses. Indigenous leadership and engagement in disease monitoring, prevention and response, is vital from the outset, and would increase the success of such efforts, as well as ensure the protection of Indigenous rights as outlined in the United Nations Declaration on the Rights of Indigenous Peoples. Partnering with northern communities and including Indigenous Knowledge Systems would improve the timeliness, and likelihood, of detecting emerging zoonotic risks, and contextualize risk assessments to the unique human-wildlife relationships present in northern biomes.

Geochemically Defined Space-for-Time Transects Successfully Capture Microbial Dynamics Along Lacustrine Chronosequences in a Polar Desert.

The space-for-time substitution approach provides a valuable empirical assessment to infer temporal effects of disturbance from spatial gradients. Applied to predict the response of different ecosystems under current climate change scenarios, it remains poorly tested in microbial ecology studies, partly due to the trophic complexity of the ecosystems typically studied. The McMurdo Dry Valleys (MDV) of Antarctica represent a trophically simple polar desert projected to experience drastic changes in water availability under current climate change scenarios. We used this ideal model system to develop and validate a microbial space-for-time sampling approach, using the variation of geochemical profiles that follow alterations in water availability and reflect past changes in the system. Our framework measured soil electrical conductivity, pH, and water activity in situ to geochemically define 17 space-for-time transects from the shores of four dynamic and two static Dry Valley lakes. We identified microbial taxa that are consistently responsive to changes in wetness in the soils and reliably associated with long-term dry or wet edaphic conditions. Comparisons between transects defined at static (open-basin) and dynamic (closed-basin) lakes highlighted the capacity for geochemically defined space-for-time gradients to identify lasting deterministic impacts of historical changes in water presence on the structure and diversity of extant microbial communities. We highlight the potential for geochemically defined space-for-time transects to resolve legacy impacts of environmental change when used in conjunction with static and dynamic scenarios, and to inform future environmental scenarios through changes in the microbial community structure, composition, and diversity.

Microbial Mats of the McMurdo Dry Valleys, Antarctica: Oases of Biological Activity in a Very Cold Desert.

Cyanobacterial mats in the Antarctic Dry Valleys are photosynthetic microbial ecosystems living at the extreme of conditions on Earth with respect to temperature, light, water and nutrient availability. They are metabolically active for about 8 weeks during the austral summer when temperatures briefly rise above freezing and glacial and lake melt waters are available. There is much to learn about the biogeochemical impact of mats in these environments and the microbial communities associated with them. Our data demonstrate that these mats attain surprisingly high rates of carbon (CO2) and dinitrogen (N2) fixation when liquid water is available, in some cases comparable to rates in warmer temperate or tropical environments. C and N2 fixation in Dry Valley mats in turn substantially elevate dissolved organic C and inorganic N pools and thereby promote enhanced microbial secondary production. Moreover, the microbial community fingerprint of these mats is unique compared with the more ubiquitous dry soils that do not contain mats. Components of the heterotrophic microbiota may also contribute substantially to N inputs through N2 fixation.

Missing in action: Sustainable climate change adaptation evidence for animal health.

Health impacts of climate change are now inevitable. The objective of this study was to see if animal health climate change adaptation was a subject of scholarly inquiry, advice, or discussion and if there was an evidence base from which to make adaptation recommendations. A scoping review of English-language literature over the past 10 years was undertaken and the top findings related to animal health adaptation and climate change were inventoried on Google. Documents found in the search focussed predominantly on hypothesizing what hazards might occur with climate change, describing their spread or proposing possible impacts. Scant evidence was found of scholarship related to sustainable animal health climate change adaptation planning or action. Investment and attention to adaptation planning and research are needed to increase confidence in climate change recommendations in the face of continuing uncertainty about the breadth of effects on animal health and the best actions to take in preparing and responding to them.

Les impacts sur la santé des changements climatiques sont maintenant inévitables. L'objectif de la présente étude était de voir si l'adaptation de la santé animale aux changements climatiques était un sujet d'enquête savante, un avis ou une discussion et s'il y avait une base factuelle à partir de laquelle faire des recommandations d'adaptation. Une recension de la littérature de langue anglaise des 10 dernières années fut entreprise et les principales trouvailles reliées à l'adaptation de la santé animale et des changements climatiques furent inventoriées sur Google. Les documents retrouvés dans la recension focussaient principalement en émettant des hypothèses sur quels risques peuvent survenir avec les changements climatiques, décrivant leur propagation ou proposant des impacts possibles. Peu d'évidences furent trouvées liées à la planification ou l'action relativement à l'adaptation durable aux changements climatiques en matière de santé animale. Des investissements et une attention à la planification de l'adaptation et de la recherche sont requis pour augmenter la confiance dans les recommandations liées aux changements climatiques compte tenu de l'incertitude persistante à propos de l'étendue des effets sur la santé animale et les meilleures actions à prendre pour s'y préparer et y répondre.(Traduit par Dr Serge Messier).

CHALLENGES AND OPPORTUNITIES FOR WILDLIFE DISEASE SURVEILLANCE IN SRI LANKA.

The Sri Lanka Wildlife Health Centre was created in 2011 as an intersectoral surveillance system intended to address gaps in emerging and zoonotic disease preparedness in the country. This study, which was conducted during August 2015 to November 2015, examined perceived obstacles and opportunities to undertake wildlife disease surveillance in Sri Lanka. Responses to a pretested postal questionnaire by 315 field officers from the Department of Wildlife Conservation (DWC) and Department of Animal Production and Health (livestock development instructors [LDIs] and field veterinary surgeons [FVSs]) were used in the analysis. Responses came from all 25 administrative districts in the country. The reported obstacles (and proportion of respondents) included lack of transport facilities (80%), skilled staff (75%), infrastructure (65%), human resources (62%), training (67%), and a mandate for getting involved in wildlife disease surveillance (28%). These obstacles have resulted in rare or sporadic collection and submission of samples and their testing for surveillance purposes. A focus on rabies surveillance found that 84 (78%) DWC officers whose mandate was to deal with wild animals and 41 (40%) LDIs whose mandate was to deal with agricultural animals had inadequate knowledge to inform rabies surveillance activities and actions. Despite being outside of their mandate, 68% of FVSs and 72% of LDI s were willing to contribute to wild animal disease surveillance. Overcoming legal impediments to handling wildlife was cited as an essential step to establishing a multisectoral surveillance system involving government branches, universities, and citizens.

Rethinking pandemic preparedness in the Anthropocene.

The social and ecological changes accompanying the Anthropocene require changes in how pandemics are anticipated, conceived, and managed. Pandemics need to be reframed from infections we can predict to inevitable infectious and non-communicable surprises with which we need to cope. A hazard-by-hazard approach to planning and response is insufficient when the next pandemic cannot be predicted. Decision-making will benefit from scoping the problem broadly to generate deeper insights into potential threats. The origins of pandemics come from our relationships with the world around us. Health leaders, therefore, need to be aware of primordial determinants of risk arising from these changing relationships. Cross-sectoral co-learning to anticipate surprise will require bridging agents embedded within a health agency to facilitate transdisciplinary intelligence gathering. A unified set of guidelines is needed to promote pandemic resilience by collaboratively tending to the determinants of health for each other, our communities, and the natural environment.

Is there a due diligence standard for wildlife disease surveillance? A Canadian case study.

Due diligence is a concept used to justify investment in wildlife health surveillance to satisfy trading partners and other animal health stakeholders. Canadian literature and legislation were reviewed and key informant interviews were used to determine if a wildlife surveillance due diligence standard existed. Wildlife surveillance is constrained by challenges that necessitate convenience and opportunistic sampling, making it difficult to apply surveillance performance standards from public or domestic animal health. Key informants cited due diligence to justify wildlife health surveillance activities but could not identify a due diligence threshold nor could regulations, international obligations, or the literature. The lack of a due diligence standard puts wildlife health surveillance managers at a disadvantage when trying to show public return on investment or when assessing the adequacy of surveillance efforts. Steps being taken by the Canadian Wildlife Health Cooperative to meet the performance needs of the Pan-Canadian Approach to Wildlife Health are introduced.

Est-ce qu'il y un standard de devoir de précaution pour la surveillance des maladies de la faune? Une étude de cas canadienne. Le devoir de précaution est un concept utilisé pour justifier les investissements dans la surveillance de la santé de la faune afin de satisfaire les partenaires commerciaux et les autres parties intéressées en santé animale. La littérature canadienne et la législation ont été passées en revue et des entrevues d'intervenants clés ont été utilisées afin de déterminer si un standard de devoir de précaution en matière de surveillance de la faune existe. La surveillance de la faune est limitée par des défis qui nécessitent un échantillonnage de convenance et opportuniste, rendant difficile la mise en place de standards de performance de surveillance provenant de la santé publique ou de celle des animaux domestiques. Les intervenants clés ont cité le devoir de précaution pour justifier les activités de surveillance de la santé de la faune mais n'ont pu identifier un seuil de devoir de précaution, pas plus que la règlementation, les obligations internationales, ou la littérature. L'absence d'un standard de devoir de précaution met les gestionnaires de la surveillance de la santé de la faune à un désavantage lorsqu'ils tentent de démontrer un retour public de l'investissement ou lors de l'évaluation de la pertinence des efforts de surveillance. Les démarches entreprises par la Coopérative canadienne de la santé de la faune pour atteindre les attentes de performance de la Stratégie pancanadienne pour la santé de la faune sont présentées.(Traduit par Dr Serge Messier).

Surveillance Opportunities and the Need for Intersectoral Collaboration on Rabies in Sri Lanka.

Sri Lanka is progressing towards its goal of eliminating human rabies. This goal rests on programs designed to limit canine rabies, which in turn requires a combination of targeted dog rabies control and a better understanding of the movement of the virus between domestic animals, people, and wildlife. Coordinated and integrated surveillance of the disease between human and animal health sectors underpins successful rabies elimination. Our objective was to review surveillance data from 2005 to 2014 to assemble the first multispecies synthesis of rabies information in Sri Lanka and, in doing so, assess needs and opportunities for a One Health approach to rabies surveillance in the country. Our descriptive epidemiological findings were consistent with other studies showing a decline in human cases, endemic and unchanging numbers of dog cases, a relationship between human density and the occurrence of human and animal cases, and significant gaps in understanding trends in rabies incidences in livestock and wildlife. Assessing the trends in the data from the three government organizations responsible for rabies surveillance was difficult due to lack of information on animal population sizes, unquantified sampling biases due to inequities in access to diagnostic capacities, regulatory and administrative barriers, and a continued reliance on clinical means to establish a diagnosis. The information required for a comprehensive rabies control programme was not standardized or consistent, was not in one place, showed significant gaps in completeness, and was not amenable to routine and rapid analysis. Achieving rabies elimination in Sri Lanka would benefit from harmonization of diagnostic and information management standards across animal and human health sectors as well as equitable access to diagnostic capacity for all regions and species.

Rapid Microbial Dynamics in Response to an Induced Wetting Event in Antarctic Dry Valley Soils.

The cold deserts of the McMurdo Dry Valleys (MDV), Antarctica, host a high level of microbial diversity. Microbial composition and biomass in arid vs. ephemerally wetted regions are distinctly different, with wetted communities representing hot spots of microbial activity that are important zones for biogeochemical cycling. While climatic change is likely to cause wetting in areas not historically subject to wetting events, the responses of microorganisms inhabiting arid soils to water addition is unknown. The purpose of this study was to observe how an associated, yet non-wetted microbial community responds to an extended addition of water. Water from a stream was diverted to an adjacent area of arid soil with changes in microbial composition and activities monitored via molecular and biochemical methods over 7 weeks. The frequency of genetic signatures related to both prokaryotic and eukaryotic organisms adapted to MDV aquatic conditions increased during the limited 7 week period, indicating that the soil community was transitioning into a typical "high-productivity" MDV community. This work is consistent with current predictions that MDV microbial communities in arid regions are highly sensitive to climate change, and further supports the notion that changes in community structure and associated biogeochemical cycling may occur much more rapidly than predicted.