Nonspecific Effects of the Bacillus Calmette-Guérin Vaccine in Portuguese Children Under 5 Years of Age: Protocol for a Population-Based Historical Birth Cohort Study.

BACKGROUND: The Bacillus Calmette-Guérin vaccine (BCG) against tuberculosis (TB) shows beneficial nonspecific effects, which are likely related to innate immune training. Until 2016, a single BCG dose was administered to all newborns in Portugal. In July 2016, a clinical guideline established that only children under 6 years belonging to high-risk groups should receive BCG. This might have prevented nonvaccinated children from developing trained immunological responses as effectively as BCG-vaccinated children. OBJECTIVE: This study aims to investigate if there is variation in TB-related and all-cause mortality, and severe, moderate, or mild morbidity in children under 5 years of age, and whether such variation might be explained by the BCG vaccination policy change in 2016. METHODS: This population-based historical birth cohort study includes children under 5 years of age born in Portugal between July 1, 2010, and June 30, 2021. Newborns with low birth weight, premature status, or known or suspected HIV infection are excluded. The follow-up period is until the completion of 5 years of age or the end of follow-up (June 30, 2021). The study will use secondary data from the National Health Service user registry, death certificate database, vaccination registry, communicable diseases surveillance system, TB surveillance system, diagnosis-related group information system for hospital admissions and emergency department visits, and primary health care information system. The data will be linked. Primary outcomes include person-time incidence rates of death (all causes and TB), TB diagnosis, and all causes and some specific causes of severe, moderate, or mild morbidity, and the incidence rate ratio of nonvaccinated to BCG-vaccinated children. We will compare the probability of surviving the first and fifth years of life or of not having severe, moderate, or mild morbidity during the follow-up period according to exposure (BCG vaccinated or nonvaccinated, number of doses, and time from birth until the first dose), using the log-rank test for assessing differences in survival rates between exposed and nonexposed children and hazard ratios for quantifying the differences. Moreover, we will perform a proportional hazards regression analysis. RESULTS: Ethics approval has been obtained. In March 2022, database owners were contacted to present the project and discuss the request for data. A unique identifier will be used. In July 2023, a process of redefinition of the variables per database was initiated. Data were received in October and November 2023. In November 2023, further work was conducted. By April 2024, we expect to start analyzing the full data set. CONCLUSIONS: The results will contribute to the accumulating body of knowledge and might have relevance to guide global BCG vaccination policy. Data linkage can contribute to a swifter mechanism to use available health data to conduct population-based studies and inform policy decision-making. TRIAL REGISTRATION: ClinicalTrials.gov NCT05471167; https://clinicaltrials.gov/study/NCT05471167. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/55332.

Impacts for health and care workers of Covid-19 and other public health emergencies of international concern: living systematic review, meta-analysis and policy recommendations.

BACKGROUND: Health and care workers (HCW) faced the double burden of the SARS-CoV-2 pandemic: as members of a society affected by a public health emergency and as HWC who experienced fear of becoming infected and of infecting others, stigma, violence, increased workloads, changes in scope of practice, among others. To understand the short and long-term impacts in terms of the COVID-19 pandemic and other public health emergencies of international concern (PHEICs) on HCW and relevant interventions to address them, we designed and conducted a living systematic review (LSR). METHODS: We reviewed literature retrieved from MEDLINE-PubMed, Embase, SCOPUS, LILACS, the World Health Organization COVID-19 database, the ClinicalTrials.org and the ILO database, published from January 2000 until December 2021. We included quantitative observational studies, experimental studies, quasi-experimental, mixed methods or qualitative studies; addressing mental, physical health and well-being and quality of life. The review targeted HCW; and interventions and exposures, implemented during the COVID-19 pandemic or other PHEICs. To assess the risk of bias of included studies, we used the Johanna Briggs Institute (JBI) Critical Appraisal Tools. Data were qualitatively synthetized using meta-aggregation and meta-analysis was performed to estimate pooled prevalence of some of the outcomes. RESULTS: The 1013 studies included in the review were mainly quantitative research, cross-sectional, with medium risk of bias/quality, addressing at least one of the following: mental health issue, violence, physical health and well-being, and quality of life. Additionally, interventions to address short- and long-term impact of PHEICs on HCW included in the review, although scarce, were mainly behavioral and individual oriented, aimed at improving mental health through the development of individual interventions. A lack of interventions addressing organizational or systemic bottlenecks was noted. DISCUSSION: PHEICs impacted the mental and physical health of HCW with the greatest toll on mental health. The impact PHEICs are intricate and complex. The review revealed the consequences for health and care service delivery, with increased unplanned absenteeism, service disruption and occupation turnover that subvert the capacity to answer to the PHEICs, specifically challenging the resilience of health systems.

European Health Union: An emergent reality.

In this article we argue that the Member States of the European Union (EU) have consistently, since its inception, developed a shared framework to measure, monitor and intervene to improve the health status of its population, while invoking the subsidiarity principle for the health sector. As a result, a European Health Union (EHU) has been emerging insidiously and consistently, following the concept of a system for health. Using the World Health Organisation Building Blocks Framework, we analyse the normative and institutional developments related to EU citizens' health that have created a de facto EHU. Developments towards an EHU remain unequally distributed among the different building blocks analysed. The existing EHU is the result of a fragmented and incremental process, mostly grounded in governance, health intelligence and services' development. Health crisis, the Commission's agenda-setting activities and market pressures have been the most important push factors for these step-by-step processes.

Building-blocks to develop one health systems.

Notwithstanding the understandable rationale of the logical, expected and natural evolution of human behaviour towards an anthropocentric view of its relationship with other animals and the environment, a shift from this predatory "Ego-centric" behaviour towards an "Eco" conduct, with regard to their view of the world and of the global health, has become mandatory, contributing to the development of the "One Health" and of "One Health Systems" concepts. We contend for the usefulness of a building-blocks approach to facilitate an understanding of the development of One Health Systems. We assert that a building-blocks approach to One Health Systems with strong similarity to WHO's building-blocks for human health systems would help to strengthen the case for robust,resilient and anti-fragile One Health systems.

Policies and Management Interventions to Enhance Health and Care Workforce Capacity for Addressing the COVID-19 Pandemic: Protocol for a Living Systematic Review.

BACKGROUND: Countries and health systems have had to make challenging resource allocation and capacity-building decisions to promote proper patient care and ensure health and care workers' safety and well-being, so that they can effectively address the present COVID-19 pandemic as well as upcoming public health problems and natural catastrophes. As innovations are already in place and updated evidence is published daily, more information is required to inform the development and implementation of policies and interventions to improve health and care workforce capacity to address the COVID-19 pandemic response. OBJECTIVE: The objective of this protocol review is to identify countries' range of experiences with policies and management interventions that can improve health and care workers' capacity to address the COVID-19 pandemic response and synthesize evidence on the effectiveness of the interventions. METHODS: We will conduct a living systematic review of quantitative, qualitative, and mixed methods studies and gray literature (technical and political documents) published in English, French, Hindi, Portuguese, Italian, and Spanish between January 1, 2000, and March 1, 2022. The databases to be searched are MEDLINE (PubMed), Embase, SCOPUS, and Latin American and Caribbean Health Sciences Literature. In addition, the World Health Organization's COVID-19 Research Database and the websites of international organizations (International Labour Organization, Economic Co-operation and Development, and The Health System Response Monitor) will be searched for unpublished studies and gray literature. Data will be extracted from the selected documents using an electronic form adapted from the Joanna Briggs Institute quantitative and qualitative tools for data extraction. A convergent integrated approach to synthesis and integration will be used. The risk of bias will be assessed with Joanna Briggs Institute critical appraisal tools, and the certainty of the evidence in the presented outcomes will be assessed with the Grading of Recommendations, Assessment, Development and Evaluation. RESULTS: The database and gray literature search retrieved 3378 documents. Data are being analyzed by 2 independent reviewers. The study is expected to be published by the end of 2023 in a peer-reviewed journal. CONCLUSIONS: This review will allow us to identify and describe the policies and strategies implemented by countries and their effectiveness, as well as identify gaps in the evidence. TRIAL REGISTRATION: PROSPERO CRD42022327041; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=327041. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR1-10.2196/50306.

Implementation of policy and management interventions to improve health and care workforce capacity to address the COVID-19 pandemic response: a systematic review.

BACKGROUND: The COVID-19 pandemic highlighted pre-existing weaknesses in health and care systems and services and shortages of health and care workers (HCWs). As a result, policymakers needed to adopt measures to improve the health and care workforce (HCWF) capacity. This review aims to identify countries' range of policies and management interventions implemented to improve HCWs' capacity to address the COVID-19 pandemic response, synthesize their evidence on effectiveness, and identify gaps in the evidence. METHODS: The literature was searched in PubMed, Embase, Scopus, LILACS-BVS, WHO's COVID-19 Research Database and the ILO, OECD and HSRM websites for literature and documents published between January 2020 and March 2022. Eligibility criteria were HCWs as participants and policy and management interventions aiming to improve HCWF capacity to address the COVID-19 pandemic response. Risk of bias was assessed with Joanna Briggs Institute (JBI) Critical Appraisal Tools (CAT) and certainty of the evidence in presented outcomes with GRADE. RESULTS: The searches retrieved 3378 documents. A total of 69 were included, but only 8 presented outcomes of interventions implemented. Most of the selected documents described at least one intervention implemented by countries at the organizational environment level to increase the flexibility and capacity of the HCWF to respond to the pandemic, followed by interventions to attract and retain HCWs in safe and decent working environments. There was a lack of studies addressing social protection, human resources for health information systems, and regarding the role of community health workers and other community-based providers. Regarding the risk of bias, most of documents were rated as medium or high quality (JBI's CAT), while the evidence presented for the outcomes of interventions was classified as mostly low-certainty evidence (GRADE). CONCLUSIONS: Countries have implemented various interventions, some innovative, in response to the pandemic, and others had their processes started earlier and accelerated by the pandemic. The evidence regarding the impact and efficacy of the strategies used by countries during the pandemic still requires further research.

COVID-19-related adolescent mortality and morbidity in nineteen European countries.

Prior to the COVID-19 pandemic, adolescents in most countries experienced a syndemic of malnutrition, obesity, deprivation, mental health problems, inequalities, and the effects of climate change. Today, other factors have added to this burden during the pandemic, and it is important to have an updated reflection. We aimed to assess the risk and protective factors for COVID-19-related adolescent mortality and morbidity in the European region. Three double models were fitted to analyze the relationship between different factors with the number of diagnosed cases and deaths. The 1a and 1b use a multiple Poisson regression. The 2a and 2b are optimized models that use the same variables as prior models but with backward selection with a p value < 0.05 as the limit. Finally, the 3a and 3b models (backward stepwise multivariable Poisson regression) include the variable "fully vaccinated." All models used the at-risk population (15-19 years or total population) as a regression covariate (offset). Increased access to quality healthcare (IRR 0.68; CI 0.55-0.84), increased private sector involvement (IRR 0.86; CI 0.82-0.90), Gini coefficient (IRR 0.93; CI 0.88-0.99), and full vaccination (IRR 0.94; CI 0.90-0.99) represent protective factors of COVID-19 mortality in this population. Additionally, a positive association between pollution and mortality was found.  Conclusion: Being fully vaccinated and having access to quality medical care are protective factors against COVID-19 mortality in this age group. Interestingly, the more the pollution, the greater the risk of dying from COVID-19. We stress the great importance of coordination between the public and private sectors to address crises such as the current one. What is Known: • Compared to other age groups, adolescents have been little studied, and most studies focused on mental health during the COVID-19 pandemic. What is New: • In this study, we show how in 19 European countries, different factors interact, such as socio-demographic, environmental, health system, and control measures with morbidity and mortality by COVID-19, in a very little studied age group as teenagers.

The abiding, hidden, and pervasive centrality of the health research workforce.

Research for health and development (R4HD) acknowledges that many of the determinants of health lie outside the boundaries of the health system. The size and quality of the health and care workforce (HCWF) are key drivers towards the future trajectory of many of these factors. We consider researchers for health and development an abiding, pervasive but neglected constituent part of this HCWF. This workforce straddles many professional groups and sectors. The diversity of occupations, lack of standardization in occupational cadres, the complexity and gendered aspects of the labour market, and the variable demographic, epidemiological, socio-economic and health systems' contexts in the global south and the global north, led to a kaleidoscopic perception of the health research workforce that have kept it hidden from public opinion. This led to neglect by science as well as health policymakers and created an orphan sub-set of the HCWF. Understanding the health researchers' labour market will help to identify means to develop, retain and utilize the health research workforce, addressing size, composition, role, skills transferability, careers and social impact through building, enabling or sustaining its research functions, capacity, employment opportunities and career tracks, among other issues. This thematic series of the Human Resources for Health Journal, calls for papers that go beyond narrow conceptual approaches and professional understandings of health care workers and the health research workforce, and requests that contributors examine important workforce issues through the broad lens of R4HD within a sustainable development goals framework.

The burden of Noncommunicable Diseases in Portuguese Language Countries. / Carga das Doenças Crônicas Não Transmissíveis nos Países de Língua Portuguesa.

The present study analyzed trends in premature mortality from Noncommunicable diseases (NCDs) between 1990 and 2019, the projections up to 2030, and the risk factors (RFs) attributable to these diseases in the Community of Portuguese Language Countries (CPLP). Estimates from the Global Burden of Disease (GBD) study and the analysis of the burden of premature mortality due to NCDs were used for nine CPLP countries, applying age-standardized rates, using RStudio. Portugal, Brazil, Equatorial Guinea, Angola, and Guinea Bissau showed declining premature mortality rates caused by NCDs, while East Timor, Cape Verde, São Tomé and Príncipe, and Mozambique showed an increase in rates. Projections indicate that none of the countries is expected to achieve the goals of reducing premature mortality due to NCDs by one third by 2030. The attributable burden of disease showed that the most important RFs in 2019 were: high systolic blood pressure (SBP), tobacco, dietary risks, high body mass index (BMI), and air pollution. It can therefore be concluded that there are profound differences in the burden of NCDs among the countries, with better results in Portugal and Brazil, and that no CPLP country is likely to reach the NCD reduction target by 2030.

Foram analisadas tendências da mortalidade prematura por doenças crônicas não transmissíveis (DCNT) entre 1990 e 2019, as projeções até 2030 e os fatores de risco atribuíveis a estas doenças na Comunidade dos Países de Língua Portuguesa (CPLP). Utilizou-se estimativas do estudo Carga Global de Doenças e análise da carga de mortalidade prematura por DCNT para nove países da CPLP, utilizando taxas padronizadas por idade, usando-se RStudio. Portugal, Brasil, Guiné Equatorial, Angola e Guiné Bissau apresentam taxas de mortalidade prematura por DCNT em declínio e; Timor Leste, Cabo Verde, São Tomé e Príncipe e Moçambique apresentaram aumento das taxas. As projeções indicam que nenhum dos países deverá atingir as metas de redução em um terço da mortalidade prematura por DCNT até 2030. A carga de doença atribuível mostrou que os fatores de riscos mais importantes em 2019 foram: pressão arterial sistólica elevada, tabaco, riscos dietéticos, índice de massa corporal elevado e poluição do ar. Conclui-se pelas profundas diferenças na carga de DCNT entre os países, com melhores resultados em Portugal e Brasil e que nenhum país do CPLP deverá atingir a meta de redução das DCNT até 2030.

Carga das Doenças Crônicas Não Transmissíveis nos Países de Língua Portuguesa / The burden of Noncommunicable Diseases in Portuguese Language Countries

Resumo Foram analisadas tendências da mortalidade prematura por doenças crônicas não transmissíveis (DCNT) entre 1990 e 2019, as projeções até 2030 e os fatores de risco atribuíveis a estas doenças na Comunidade dos Países de Língua Portuguesa (CPLP). Utilizou-se estimativas do estudo Carga Global de Doenças e análise da carga de mortalidade prematura por DCNT para nove países da CPLP, utilizando taxas padronizadas por idade, usando-se RStudio. Portugal, Brasil, Guiné Equatorial, Angola e Guiné Bissau apresentam taxas de mortalidade prematura por DCNT em declínio e; Timor Leste, Cabo Verde, São Tomé e Príncipe e Moçambique apresentaram aumento das taxas. As projeções indicam que nenhum dos países deverá atingir as metas de redução em um terço da mortalidade prematura por DCNT até 2030. A carga de doença atribuível mostrou que os fatores de riscos mais importantes em 2019 foram: pressão arterial sistólica elevada, tabaco, riscos dietéticos, índice de massa corporal elevado e poluição do ar. Conclui-se pelas profundas diferenças na carga de DCNT entre os países, com melhores resultados em Portugal e Brasil e que nenhum país do CPLP deverá atingir a meta de redução das DCNT até 2030.

Abstract The present study analyzed trends in premature mortality from Noncommunicable diseases (NCDs) between 1990 and 2019, the projections up to 2030, and the risk factors (RFs) attributable to these diseases in the Community of Portuguese Language Countries (CPLP). Estimates from the Global Burden of Disease (GBD) study and the analysis of the burden of premature mortality due to NCDs were used for nine CPLP countries, applying age-standardized rates, using RStudio. Portugal, Brazil, Equatorial Guinea, Angola, and Guinea Bissau showed declining premature mortality rates caused by NCDs, while East Timor, Cape Verde, São Tomé and Príncipe, and Mozambique showed an increase in rates. Projections indicate that none of the countries is expected to achieve the goals of reducing premature mortality due to NCDs by one third by 2030. The attributable burden of disease showed that the most important RFs in 2019 were: high systolic blood pressure (SBP), tobacco, dietary risks, high body mass index (BMI), and air pollution. It can therefore be concluded that there are profound differences in the burden of NCDs among the countries, with better results in Portugal and Brazil, and that no CPLP country is likely to reach the NCD reduction target by 2030.

Antimicrobial resistance, society and environment: A glocal syndemic.

•Multidimensionality of AMR determination argues in favour of considering it a glocal syndemic.•Lack of attention to syndemic nature of AMR limits the effectiveness of measures taken so far.•The syndemic approach provides policy makers with conceptual tools to design effective responses.

Developing One Health Systems: A Central Role for the One Health Workforce.

The health of people, wild and domesticated animals, and natural living systems is syndemically connected, and this interplay is a pillar of the concept of One Health [...].

Is workplace violence against health care workers in Mozambique gender related?

This report revisits data used to describe the typology and the perceived impact of violence against health care workers (VHCW) at the health services of the City of Lichinga in Mozambique, based on an observational, descriptive, cross-sectional study, carried out from March to May 2019. In this report we attempt to understand if our reanalysis of VHCW in Niassa can explain it as an example of gender-based violence. Our findings-particularly that women more than men reported not knowing if the health services had any policies or procedures to deal with VHCW, felt that they were not encouraged to report acts of VHCW and were more frequently threatened/violented by different sex aggressors-although not conclusive, support the need to consider gender as a dimension when conducting research on VHCW. If we do not do so, gender will continue to be an invisible and ignored dimension of intervention strategies to prevent and address VHCW.

Violence against health care workers in the workplace in Mozambique - An unrecognised managerial priority.

INTRODUCTION: Recognition of the relevance of violence against health workers in their work place has been growing around the world. In Mozambique, workplace violence in the health sector needs better documentation. Therefore, this article is part of a study that describes the typology and the perceived impact of violence against health care workers in their workplace at the Lichinga Provincial Hospital and at the Health Centre of the City of Lichinga in 2019. METHOD: This was an observational, descriptive, cross-sectional study. The study was carried out in a simple random sample of health workers victims of violence at the Provincial Hospital and the Health Centre of the City of Lichinga, in the Province of Niassa in northern Mozambique. The questionnaire applied was adapted from the original developed by the International Labour Organization, the International Council of Nurse, the World Health Organization and Public Services International and applied in Maputo, Mozambique during 2002. Statistical analysis was carried out with Statistical Package for the Social Sciences 20.0 and WinPepi 11.65. RESULTS: Two hundred and 60 healthcare workers (HCW) were selected to participate, 180 agreed, 145 had inclusion criteria and five gave up participating in the study during the consent procedure. Thus, a total of 140 HCW answered the questionnaire. Predominant types of violence were: verbal threat/aggression 34% (n = 62/180); moral pressure/bullying/mobbing 30% (n = 54/180); ethnic discrimination 9% (n = 16/180); against personal property 6% (n = 10/180); physical 4% (n = 8/180); sexual harassment 4% (n = 8/180). One hundred and 37 victims reported 154 episodes of violence, where 7% (n = 13/180) reported more than one type of violence. Most victims reported no reaction (55%, n = 76/137) and few said that they confronted the offender (16%, n = 22/137, particularly victims of sexual harassment, 38%, n = 3/8). Most HCW reported non-existence (39%, n = 54/137) or unawareness (32%, n = 44/137) of procedures to report violence within the Institution. Most (80%, n = 33/41) of those knowing about the procedures, knew how to use them. More than half (55%; n = 76/137) of HCW said that they were discouraged to report acts of violence. CONCLUSIONS: Like for previous studies in Mozambique and elsewhere in Africa, the study confirms: a relatively high prevalence, a reluctance to talk about the issue and unawareness about procedures on how to report incidents. The findings reconfirm the necessity for the development and implementation of procedures to address violence incidents towards HCW, to develop support services for victims of health workplace violence. Like elsewhere in Africa, successive health workforce plans in Mozambique have failed to address this issue.

Relevant HRH leadership during public health emergencies.

BACKGROUND: Inadequate leadership capacity compounds the world's workforce lack of preparedness for outbreaks of all sizes, as illustrated by the COVID-19 pandemic. Traditional human resources for health (HRH) leadership has focused on determining the health workforce requirements, often failing to fully consider the unpredictability associated with issues such as public health emergencies (PHE). MAIN ARGUMENTS: The current COVID-19 pandemic demonstrates that policy-making and relevant leadership have to be effective under conditions of ethical uncertainty and with inconclusive evidence. The forces at work in health labor markets (HLM) entail leadership that bridges across sectors and all levels of the health systems. Developing and applying leadership competencies must then be understood from a systemic as well as an individual perspective. To address the challenges described and to achieve universal health coverage (UHC) by 2030, countries need to develop effective HRH leaderships relevant to the complexity of HLM in the most diverse contexts, including acute surge events during PHE. In complex and rapidly changing contexts, such as PHE, leadership needs to be attentive, nimble, adaptive, action oriented, transformative, accountable and provided throughout the system, i.e., authentic, distributed and participatory. This type of leadership is particularly important, as it can contribute to complex organizational changes as required in surge events associated with PHE, even in in the absence of formal management plans, roles, and structures. To deal with the uncertainty it needs agile tools that may allow prompt human resources impact assessments. CONCLUSIONS: The complexity of PHE requires transformative, authentic, distributed and participatory leadership of HRH. The unpredictable aspects of the dynamics of the HLM during PHE require the need to rethink, adapt and operationalize appropriate tools, such as HRH impact assessment tools, to redirect workforce operations rapidly and with precision.

The Covid-19 pandemic reinforces the need for sustainable health planning.

The 2030 Agenda for Sustainable Development highlighted the growing attention to the adequacy of health planning models to sustainable development. A re-reading of the results of a round table debate on "sustainable planning", which took place at the 5th National Congress of Tropical Medicine (Portugal, 2019) under a participant observation strategy, framed by the findings of a "synthesis of better evidence" literature review and cross-referenced with the reflections of different authors and experts about the momentum created by the COVID-19 pandemic, underlined the challenges to sustainable health planning that have emerged and are projected beyond the current pandemic context. Variable perceptions of the term "sustainable health development", leading to the potential loss of their relevance in guiding the elaboration of policies and strategic plans, and the potential higher effectiveness of the participatory approaches of health planning in achieving sustainable health were highlighted in the debate and literature, in general and in public health emergency contexts. Those results gained new relevance during the current COVID-19 pandemic, bringing back to the forefront a reflection of the inadequate planning framework that has usually been used to understand and respond to global health challenges, despite the already existing experience, evidence and support instruments.