Empiric treatment of healthcare-associated central nervous system infections in Denmark: do we need carbapenems?

BACKGROUND: Carbapenems are widely used for empiric treatment of healthcare-associated central nervous system (CNS) infections. We investigated the feasibility of a carbapenem-sparing strategy, utilising a third-generation cephalosporin (ceftriaxone or cefotaxime) (combined with vancomycin) for the empirical treatment of healthcare-associated CNS infections in Eastern Denmark. METHODS: The departments of neurosurgery and neuro-intensive care at Copenhagen University Hospital Rigshospitalet. First, we analysed local microbiological data (1st January 2020-31st August 2022) to identify microorganisms non-susceptible to third-generation cephalosporin. Subsequently, we assessed all carbapenem prescriptions over a three-month period for their indication and justification. RESULTS: In total, 25,247 bacterial cultures were identified, of which 2,563 CNS-related, were included in the analysis. The positivity rate was 10.5% (n = 257/2439) for cerebrospinal-fluid samples and 75.8% (n = 95/124) for brain parenchyma. CNS samples from five individual patients revealed bacteria non-susceptible to third generation cephalosporins (Enterobacter spp. (n = 3), Pseudomonas spp. (n = 2), Klebsiella spp. (n = 2), Citrobacter freundii (n = 1)). All five patients had been hospitalised for ≥10days at the time-point of antibiotic therapy. Out of 11,626 sets of blood cultures, a total of 10 individual patients had Gram-negative blood-stream infections with resistance to ceftriaxone and piperacillin/tazobactam. 140 days-of-therapy (32%) with carbapenem in 18 patients (36%) were definitively or possibly indicated according to guidelines, none were indicated for healthcare-associated CNS-infections. CONCLUSION: An empiric treatment strategy relying on a third-generation cephalosporin appears suitable for healthcare-associated CNS infections at our tertiary hospital, serving a population of 2.6 million. However, in patients with prolonged hospitalization (≥10 days), immunosuppression, prior broad-spectrum antibiotic use, or history of resistant Gram-negative bacteria, empirical prescription of carbapenem may be needed.

Differences in integrated assessment and management of non-communicable diseases (NCDs) for people with HIV across the WHO European region.

OBJECTIVES: We aimed to assess the extent of integration of non-communicable disease (NCD) assessment and management in HIV clinics across Europe. METHODS: A structured electronic questionnaire with 41 multiple-choice and rating-scale questions assessing NCD assessment and management was sent to 88 HIV clinics across the WHO European Region during March-May 2023. One response per clinic was collected. RESULTS: In all, 51 clinics from 34 countries with >100 000 people with HIV under regular follow-up responded. Thirty-seven clinics (72.6%) reported shared NCD care responsibility with the general practitioner. Systematic assessment for NCDs and integration of NCD management were common overall [median agreement 80%, interquartile range (IQR): 55-95%; and 70%, IQR: 50-88%, respectively] but were lowest in central eastern and eastern Europe. Chronic kidney disease (median agreement 96%, IQR: 85-100%) and metabolic disorders (90%, IQR: 75-100%) were regularly assessed, while mental health (72%, IQR: 63-85%) and pulmonary diseases (52%, IQR: 40-75%) were less systematically assessed. Some essential diagnostic tests such as glycated haemoglobin (HbA1c) for diabetes (n = 38/51, 74.5%), proteinuria for kidney disease (n = 30/51, 58.8%) and spirometry for lung disease (n = 11/51, 21.6%) were only employed by a proportion of clinics. The most frequent barriers for integrating NCD care were the lack of healthcare workers (n = 17/51, 33.3%) and lack of time during outpatient visits (n = 12/51, 23.5%). CONCLUSION: Most HIV clinics in Europe systematically assess and manage NCDs. People with HIV appear to be screened more frequently than the general population at the same age. There are, however, larger gaps among eastern European clinics in general and for clinics in all regions related to mental health, pulmonary diseases and the employment of some essential diagnostic tests.

Long-term outcomes after tuberculosis for people with HIV in eastern Europe.

BACKGROUND: Eastern Europe has a high burden of tuberculosis (TB)/HIV coinfection with high mortality shortly after TB diagnosis. This study assesses TB recurrence, mortality rates and causes of death among TB/HIV patients from Eastern Europe up to 11 years after TB diagnosis. METHODS: A longitudinal cohort study of TB/HIV patients enrolled between 2011 and 2013 (at TB diagnosis) and followed-up until end of 2021. A competing risk regression was employed to assess rates of TB recurrence, with death as competing event. Kaplan-Meier estimates and a multivariable Cox-regression were used to assess long-term mortality and corresponding risk factors. The Coding Causes of Death in HIV (CoDe) methodology was used for adjudication of causes of death. RESULTS: Three hundred and seventy-five TB/HIV patients were included. Fifty-three (14.1%) were later diagnosed with recurrent TB [incidence rate 3.1/100 person-years of follow-up (PYFU), 95% confidence interval (CI) 2.4-4.0] during a total follow-up time of 1713 PYFU. Twenty-three of 33 patients with data on drug-resistance (69.7%) had multidrug-resistant (MDR)-TB. More than half with recurrent TB ( n  = 30/53, 56.6%) died. Overall, 215 (57.3%) died during the follow-up period, corresponding to a mortality rate of 11.4/100 PYFU (95% CI 10.0-13.1). Almost half of those (48.8%) died of TB. The proportion of all TB-related deaths was highest in the first 6 ( n  = 49/71; 69%; P  < 0.0001) and 6-24 ( n  = 33/58; 56.9%; P  < 0.0001) months of follow-up, compared deaths beyond 24 months ( n  = 23/85; 26.7%). CONCLUSION: TB recurrence and TB-related mortality rates in PWH in Eastern Europe are still concerningly high and continue to be a clinical and public health challenge.

Climate change and health risks in Mukuru informal settlement in Nairobi, Kenya - knowledge, attitudes and practices among residents.

BACKGROUND: Residents of informal settlements in Sub-Sahara Africa (SSA) are vulnerable to the health impacts of climate change. Little is known about the knowledge, attitudes and practices (KAP) of inhabitants of informal settlements in SSA regarding climate change and its health impacts. The aim of this study was to investigate how inhabitants of an informal settlement in SSA experience climate change and its health impacts and assess related knowledge, attitudes and practices. The study was conducted in Mukuru informal settlement in Nairobi City County, Kenya. METHODS: A cross-sectional study was conducted in September 2021 using a structured, semi-closed KAP questionnaire. Inclusion criteria were ≥ 18 years of age and living in one of the three main sections in Mukuru: Kwa Njenga, Kwa Reuben or Viwandani. By spinning a pen at the geographic centre of each section, a random direction was selected. Then, in every second household one individual was interviewed, creating a representative mix of ages and genders of the local community. To assess participant characteristics associated with climate change knowledge multivariable logistic regression was used. Thematic content analysis was performed for qualitative responses. RESULTS: Out of 402 study participants, 76.4% (n = 307) had heard of climate change before the interview, 90.8% (n = 365) reported that climate change was affecting their community, and 92.6% (n = 372) were concerned with the health-related impact of climate change. Having lived in Mukuru for more than 10 years and living in a dwelling close to the riverside were factors significantly associated with having heard of climate change before (aOR 3.1, 95%CI 1.7 - 5.8 and aOR 2.6, 95%CI 1.1 - 6.1, respectively) and experiencing a climate change related impact on the community (aOR 10.7, 95%CI 4.0 - 28.4 and aOR 7.7; 95%CI 1.7 - 34.0, respectively). Chronic respiratory conditions, vector-borne diseases, including infectious diarrhoea, malnutrition and cardiovascular diseases were identified by respondents as climate related health risks. CONCLUSIONS: Most respondents were knowledgeable about climate change and were experiencing its (health-related) impact on their community. This study provides insights which may prove useful for policy makers, intervention planners and researchers to work on locally adapted mitigation and adaption strategies.

[New and rediscovered treatments for tuberculosis].

Tuberculosis (TB) is still a major challenge for global health, but in recent years there have been several important developments in treatment options. Shorter treatment regimens for latent TB, based on conventional drugs, offer better adherence and fewer side effects, while new and repurposed antibiotics have opened the door to more effective, shorter and less side effect-heavy treatments for drug susceptible TB and multidrug-resistant/extensively drug resistant TB as well as atypical mycobacterioses. This review investigates how these shorter and predominantly oral treatments, in the future, are expected to be used in combination with individualized precision medicine.

Healthcare Provider Advocacy for Primary Health Care Strengthening: A Call for Action.

Primary Health Care (PHC) is the backbone of health systems and a cornerstone of Universal Health Coverage. In 2018, political commitment to PHC, including a comprehensive approach based on essential care throughout the lifespan, integrated public health functions, and community empowerment was reaffirmed by international stakeholders in Astana. As recent events exposed weaknesses of health care systems worldwide, growing attention has been paid to strengthening PHC. While the role of care providers as health advocates has been recognized, they may lack skills, opportunities, and resources to actively engage in advocacy. Particularly for PHC providers, guidance and tools on how to advocate to strengthen PHC are scarce. In this article, we review priority policy areas for PHC strengthening with relevance for several settings and health care systems and propose approaches to empower PHC providers-physician, non-physician, or informal PHC providers-to advocate for strengthening PHC in their countries by individual or collective action. We provide initial ideas for a stepwise advocacy strategy and recommendations for practical advocacy activities. Our aim is to initiate further discussion on how to strengthen health care provider driven advocacy for PHC and to encourage advocates in the field to reflect on their opportunities for local, national, and global action.

Improving healthcare for patients with HIV, tuberculosis and hepatitis C in eastern Europe: a review of current challenges and important next steps.

OBJECTIVES: In some eastern European countries, serious challenges exist to meet the HIV-, tuberculosis (TB)- and hepatitis-related target of the United Nations Sustainable Development Goals. Some of the highest incidence rates for HIV and the highest proportion of multi-drug-resistant (MDR) tuberculosis worldwide are found in the region. The purpose of this article is to review the challenges and important next steps to improve healthcare for people living with TB, HIV and hepatitis C (HCV) in eastern Europe. METHODS: References for this narrative review were identified through systematic searches of PubMed using pre-idientified key word for articles published in English from January 2000 to August 2020. After screening of titles and abstracts 37 articles were identified as relevant for this review. Thirty-eight further articles and sources were identified through searches in the authors' personal files and in Google Scholar. RESULTS: Up to 50% of HIV/MDR-TB-coinfected individuals in the region die within 2 years of treatment initiation. Antiretroviral therapy (ART) coverage for people living with HIV (PLHIV) and the proportion virological suppressed are far below the UNAIDS 90% targets. In theory, access to various diagnostic tests and treatment of drug-resistant TB exists, but real-life data point towards inadequate testing and treatment. New treatments could provide elimination of viral HCV in high-risk populations but few countries have national programmes. CONCLUSION: Some eastern European countries face serious challenges to achieve the sustainable development goal-related target of 3.3 by 2030, among others, to end the epidemics of AIDS and tuberculosis. Better integration of healthcare systems, standardization of health care, unrestricted substitution therapy for all people who inject drugs, widespread access to drug susceptibility testing, affordable medicines and a sufficiently sized, well-trained health workforce could address some of those challenges.

TIPS and splenorenal shunt for complications of portal hypertension in chronic hepatosplenic schistosomiasis-A case series and review of the literature.

BACKGROUND: Transjugular intrahepatic portosystemic shunt (TIPS) and shunt surgery are established treatment options for portal hypertension, but have not been systematically evaluated in patients with portal hypertension due to hepatosplenic schistosomiasis (HSS), one of the neglected tropical diseases with major impact on morbidity and mortality in endemic areas. METHODS: In this retrospective case study, patients with chronic portal hypertension due to schistosomiasis treated with those therapeutic approaches in four tertiary referral hospitals in Germany and Italy between 2012 and 2020 were included. We have summarized pre-interventional clinical data, indication, technical aspects of the interventions and clinical outcome. FINDINGS: Overall, 13 patients with confirmed HSS were included. 11 patients received TIPS for primary or secondary prophylaxis of variceal bleeding due to advanced portal hypertension and failure of conservative management. In two patients with contraindications for TIPS or technically unsuccessful TIPS procedure, proximal splenorenal shunt surgery in combination with splenectomy was conducted. During follow-up (mean follow-up 23 months, cumulative follow-up time 31 patient years) no bleeding events were documented. In five patients, moderate and transient episodes of overt hepatic encephalopathy were observed. In one patient each, liver failure, portal vein thrombosis and catheter associated sepsis occurred after TIPS insertion. All complications were well manageable and had favorable outcomes. CONCLUSIONS: TIPS implantation and shunt surgery are safe and effective treatment options for patients with advanced HSS and sequelae of portal hypertension in experienced centers, but require careful patient selection.

Patient perspectives on integrated healthcare for HIV, hypertension and type 2 diabetes: a scoping review.

INTRODUCTION: Antiretroviral therapy has reduced mortality and led to longer life expectancy in people living with HIV. These patients are now at an increased risk of non-communicable diseases (NCDs). Integration of care for HIV and NCDs has become a focus of research and policy. In this article, we aim to review patient perspectives on integration of healthcare for HIV, type 2 diabetes and hypertension. METHODS: The framework for scoping reviews developed by Arksey and O'Malley and updated by Peter et al was applied for this review. The databases PubMed, Web of Science and Cochrane library were searched. Broad search terms for HIV, NCDs (specifically type 2 diabetes and hypertension) and healthcare integration were used. As the review aimed to identify definitions of patient perspectives, they were not included as an independent term in the search strategy. References of included publications were searched for relevant articles. Titles and abstracts for these papers were screened by two independent reviewers. The full texts for all the publications appearing to meet the inclusion criteria were then read to make the final literature selection. RESULTS: Of 5502 studies initially identified, 13 articles were included in this review, of which 11 had a geographical origin in sub-Saharan Africa. Nine articles were primarily focused on HIV/diabetes healthcare integration while four articles were focused on HIV/hypertension integration. Patient's experiences with integrated care were reduced HIV-related stigma, reduced travel and treatment costs and a more holistic person-centred care. Prominent concerns were long waiting times at clinics and a lack of continuity of care in some clinics due to a lack of healthcare workers. Non-integrated care was perceived as time-consuming and more expensive. CONCLUSION: Patient perspectives and experiences on integrated care for HIV, diabetes and hypertension were mostly positive. Integrated services can save resources and allow for a more personalised approach to healthcare. There is a paucity of evidence and further longitudinal and interventional evidence from a more diverse range of healthcare systems are needed.

Perspectives of Local Community Leaders, Health Care Workers, Volunteers, Policy Makers and Academia on Climate Change Related Health Risks in Mukuru Informal Settlement in Nairobi, Kenya-A Qualitative Study.

Sub-Saharan Africa has been identified as one of the most vulnerable regions to climate change. The objective of this study was to explore knowledge and perspectives on climate change and health-related issues, with a particular focus on non-communicable diseases, in the informal settlement (urban slum) of Mukuru in Nairobi, Kenya. Three focus group discussions and five in-depth interviews were conducted with total of 28 participants representing local community leaders, health care workers, volunteers, policy makers and academia. Data were collected using semi-structured interview guides and analyzed using grounded theory. Seven main themes emerged: climate change related diseases, nutrition and access to clean water, environmental risk factors, urban planning and public infrastructure, economic risk factors, vulnerable groups, and adaptation strategies. All participants were conscious of a link between climate change and health. This is the first qualitative study on climate change and health in an informal settlement in Africa. The study provides important information on perceived health risks, risk factors and adaptation strategies related to climate change. This can inform policy making, urban planning and health care, and guide future research. One important strategy to adapt to climate change-associated health risks is to provide training of local communities, thus ensuring adaptation strategies and climate change advocacy.

Delayed diagnosis of tuberculosis in persons living with HIV in Eastern Europe: associated factors and effect on mortality-a multicentre prospective cohort study.

BACKGROUND: Early diagnosis of tuberculosis (TB) is important to reduce transmission, morbidity and mortality in people living with HIV (PLWH). METHODS: PLWH with a diagnosis of TB were enrolled from HIV and TB clinics in Eastern Europe and followed until 24 months. Delayed diagnosis was defined as duration of TB symptoms (cough, weight-loss or fever) for ≥ 1 month before TB diagnosis. Risk factors for delayed TB diagnosis were assessed using multivariable logistic regression. The effect of delayed diagnosis on mortality was assessed using Kaplan-Meier estimates and Cox models. FINDINGS: 480/740 patients (64.9%; 95% CI 61.3-68.3%) experienced a delayed diagnosis. Age ≥ 50 years (vs. < 50 years, aOR = 2.51; 1.18-5.32; p = 0.016), injecting drug use (IDU) (vs. non-IDU aOR = 1.66; 1.21-2.29; p = 0.002), being ART naïve (aOR = 1.77; 1.24-2.54; p = 0.002), disseminated TB (vs. pulmonary TB, aOR = 1.56, 1.10-2.19, p = 0.012), and presenting with weight loss (vs. no weight loss, aOR = 1.63; 1.18-2.24; p = 0.003) were associated with delayed diagnosis. PLWH with a delayed diagnosis were at 36% increased risk of death (hazard ratio = 1.36; 1.04-1.77; p = 0.023, adjusted hazard ratio 1.27; 0.95-1.70; p = 0.103). CONCLUSION: Nearly two thirds of PLWH with TB in Eastern Europe had a delayed TB diagnosis, in particular those of older age, people who inject drugs, ART naïve, with disseminated disease, and presenting with weight loss. Patients with delayed TB diagnosis were subsequently at higher risk of death in unadjusted analysis. There is a need for optimisation of the current TB diagnostic cascade and HIV care in PLWH in Eastern Europe.

Climate change and health in urban informal settlements in low- and middle-income countries - a scoping review of health impacts and adaptation strategies.

Background: Climate change affects human health with those with the least resources being most vulnerable. However, little is known about the impact of climate change on human health and effective adaptation methods in informal settlements in low- and middle-income countries.Objective: The objective of this scoping review was to identify, characterize, and summarize research evidence on the impact of climate change on human health in informal settlements and the available adaptation methods and interventions.Method: A scoping review was conducted using the Arksey and O'Malley framework. The four bibliographic databases PubMed, Web of Science, Embase, and the Cochrane library were searched. Eligibility criteria were all types of peer-reviewed publications reporting on climate change or related extreme weather events (as defined by the United Nations Framework Convention on Climate Change), informal settlements (as defined by UN-Habitat), low- and middle-income countries (as defined by the World Bank) and immediate human health impacts. Review selection and characterization were performed by two independent reviewers using a predefined form.Results: Out of 1197 studies initially identified, 15 articles were retained. We found nine original research articles, and six reviews, commentaries, and editorials. The articles were reporting on the exposures flooding, temperature changes and perceptions of climate change with health outcomes broadly categorized as mental health, communicable diseases, and non-communicable diseases. Six studies had a geographical focus on Asia, four on Africa, and one on South America, the remaining four articles had no geographical focus. One article investigated an adaptation method for heat exposure. Serval other adaptation methods were proposed, though they were not investigated by the articles in this review.Conclusion: There is a paucity of original research and solid study designs. Further studies are needed to improve the understanding of the impact, the most effective adaptation methods and to inform policy making.

Comparison of clinical characteristics and disease outcome of COVID-19 and seasonal influenza.

While several studies have described the clinical course of patients with coronavirus disease 2019 (COVID-19), direct comparisons with patients with seasonal influenza are scarce. We compared 166 patients with COVID-19 diagnosed between February 27 and June 14, 2020, and 255 patients with seasonal influenza diagnosed during the 2017-18 season at the same hospital to describe common features and differences in clinical characteristics and course of disease. Patients with COVID-19 were younger (median age [IQR], 59 [45-71] vs 66 [52-77]; P < 0001) and had fewer comorbidities at baseline with a lower mean overall age-adjusted Charlson Comorbidity Index (mean [SD], 3.0 [2.6] vs 4.0 [2.7]; P < 0.001) than patients with seasonal influenza. COVID-19 patients had a longer duration of hospitalization (mean [SD], 25.9 days [26.6 days] vs 17.2 days [21.0 days]; P = 0.002), a more frequent need for oxygen therapy (101 [60.8%] vs 103 [40.4%]; P < 0.001) and invasive ventilation (52 [31.3%] vs 32 [12.5%]; P < 0.001) and were more frequently admitted to the intensive care unit (70 [42.2%] vs 51 [20.0%]; P < 0.001) than seasonal influenza patients. Among immunocompromised patients, those in the COVID-19 group had a higher hospital mortality compared to those in the seasonal influenza group (13 [33.3%] vs 8 [11.6%], P = 0.01). In conclusion, we show that COVID-19 patients were younger and had fewer baseline comorbidities than seasonal influenza patients but were at increased risk for severe illness. The high mortality observed in immunocompromised COVID-19 patients emphasizes the importance of protecting these patient groups from SARS-CoV-2 infection.

Primary health care and nutrition.

Globally, dietary factors are responsible for about one in five deaths. In many low- and middle-income countries different forms of malnutrition (including obesity and undernutrition) can co-exist within the same population. This double burden of malnutrition is placing a disproportional strain on health systems, slowing progress towards universal health coverage (UHC). Poor nutrition also impedes the growth of local economies, ultimately affecting the global economy. In this article, we argue that comprehensive primary health care should be used as a platform to address the double burden of malnutrition. We use a conceptual framework based on human rights and the Astana Declaration on primary health care to examine existing recommendations and propose guidance on how policy-makers and providers of community-oriented primary health care can strengthen the role of nutrition within the UHC agenda. Specifically, we propose four thematic areas for action: (i) bridging narratives and strengthening links between the primary health care and the nutrition agenda with nutrition as a human rights issue; (ii) encouraging primary health-care providers to support local multisectoral action on nutrition; (iii) empowering communities and patients to address unhealthy diets; and (iv) ensuring the delivery of high-quality promotive, preventive, curative and rehabilitative nutrition interventions. For each theme we summarize the available strategies, policies and interventions that can be used by primary health-care providers and policy-makers to strengthen nutrition in primary health care and thus the UHC agenda.

Environ un décès sur cinq dans le monde est dû à des facteurs alimentaires. Dans de nombreux pays à faible et moyen revenu, différentes formes de malnutrition (y compris l'obésité et la dénutrition) peuvent coexister au sein d'une même population. Ce double fardeau de malnutrition exerce une pression démesurée sur les systèmes de santé, ralentissant la progression vers une couverture maladie universelle (CMU). Une mauvaise alimentation entrave également la croissance des économies locales, ce qui en fin de compte affecte l'économie mondiale. Dans cet article, nous estimons qu'il est impératif d'utiliser une approche globale des soins de santé primaires comme plateforme pour s'attaquer au double fardeau de la malnutrition. Nous avons employé un cadre conceptuel fondé sur les droits humains et la Déclaration d'Astana sur les soins de santé primaires. D'une part pour examiner les recommandations existantes, et d'autre part pour fournir un éclairage sur la manière dont les législateurs et les prestataires de soins de santé primaires, implantés au niveau communautaire, peuvent renforcer le rôle de la nutrition dans le programme de CMU. Nous proposons plus exactement quatre champs d'action : (i) aligner les discours et consolider les liens entre les soins de santé primaires et le programme de nutrition, en intégrant ce dernier dans la thématique des droits humains; (ii) encourager les prestataires de soins de santé primaires à soutenir les initiatives locales multisectorielles portant sur la nutrition; (iii) donner aux patients et aux collectivités le pouvoir de lutter contre l'alimentation déséquilibrée; et enfin, (iv) assurer la mise en œuvre d'interventions de qualité pour la promotion, la prévention, le traitement et la réhabilitation en matière de nutrition. Pour chaque champ d'action, nous résumons les stratégies, politiques et interventions à la disposition des législateurs et prestataires de soins de santé primaires pour renforcer le rôle de la nutrition dans les soins de santé primaires et, par conséquent, le programme de CMU.

Los factores alimentarios son responsables de aproximadamente una de cada cinco muertes en todo el mundo. Diferentes tipos de malnutrición (incluidas la obesidad y la desnutrición) pueden coexistir en la misma población de muchos países de ingresos bajos y medios. Esta doble carga de la malnutrición está ejerciendo una presión desproporcionada sobre los sistemas sanitarios, lo que ralentiza los progresos hacia la cobertura sanitaria universal (CSU). Además, la mala nutrición dificulta el crecimiento de las economías locales, lo que en última instancia afecta a la economía global. En este artículo, se argumenta que la atención primaria de salud integral se debería utilizar como plataforma para abordar la doble carga de la malnutrición. Se utiliza un marco conceptual basado en los derechos humanos y en la Declaración de Astaná sobre la atención primaria de salud para analizar las recomendaciones existentes y proponer directrices sobre cómo los responsables de formular las políticas y los proveedores de atención primaria de salud orientada a la comunidad pueden fortalecer la función de la nutrición dentro del programa de la CSU. En concreto, se proponen cuatro áreas temáticas de acción: (i) narrativas de vinculación y fortalecimiento de los vínculos entre la atención primaria de salud y el programa de nutrición en donde la nutrición sea una cuestión de derechos humanos; (ii) alentar a los proveedores de atención primaria de salud a que apoyen la medida multisectorial local sobre la nutrición; (iii) potenciar a las comunidades y a los pacientes para tratar las dietas poco saludables; y (iv) garantizar la realización de intervenciones de nutrición de alta calidad de tipo promocional, preventivo, curativo y de rehabilitación. Para cada tema se resumen las estrategias, políticas e intervenciones disponibles que los proveedores de atención primaria de salud y los responsables de formular las políticas pueden utilizar para fortalecer la nutrición en la atención primaria de salud y, por consiguiente, el programa de la CSU.

Fighting non-communicable diseases in East Africa: assessing progress and identifying the next steps.

Sub-Saharan Africa has seen a rapid increase in non-communicable disease (NCD) burden over the last decades. The East African Community (EAC) comprises Burundi, Rwanda, Kenya, Tanzania, South Sudan and Uganda, with a population of 177 million. In those countries, 40% of deaths in 2015 were attributable to NCDs. We review the status of the NCD response in the countries of the EAC based on the available monitoring tools, the WHO NCD progress monitors in 2017 and 2020 and the East African NCD Alliance benchmark survey in 2017. In the EAC, modest progress in governance, prevention of risk factors, monitoring, surveillance and evaluation of health systems can be observed. Many policies exist on paper, implementation and healthcare are weak and there are large regional and subnational differences. Enhanced efforts by regional and national policy-makers, non-governmental organisations and other stakeholders are needed to ensure future NCD policies and implementation improvements.

Digital telemedicine interventions for patients with multimorbidity: a systematic review and meta-analysis.

OBJECTIVE: To determine the effectiveness of digital telemedicine interventions designed to improve outcomes in patients with multimorbidity. DESIGN: Systematic review and meta-analysis of available literature. DATA SOURCES: MEDLINE, EMBASE, The Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, and the Database of Abstracts of Reviews of Effectiveness and hand searching. The search included articles from inception to 19 April 2019 without language restrictions. The search was updated on 7 June 2020 without additional findings. ELIGIBILITY CRITERIA: Prospective interventional studies reporting multimorbid participants employing interventions with at least one digital telemedicine component were included. Primary outcomes were patient physical or mental health outcomes, health-related quality of life scores and the utilisation of health services. RESULTS: Out of 5865 studies initially identified, 7 articles, reporting on 6 studies were retained (total of 699 participants). Four of these studies reported interventions including integration with usual care, two studies had interventions with no links to usual patient care. Follow-up periods lasted between 2 and 6 months. Among the studies with links to usual care, the primary outcomes were systolic blood pressure (SBP) (three studies), haemoglobin A1c (HbA1c) (three studies), total cholesterol (two studies) and self-perceived health status (one study). The evidence ranged from very low to moderate certainty. Meta-analysis showed a moderate decrease in SBP (8 mm Hg (95% CI 4.6 to 11.4)), a small to moderate decrease in HbA1c (0.46 mg/dL (95% CI 0.25 to 0.67)) and moderate decrease in total cholesterol (cholesterol 16.5 mg/dL (95% CI 8.1 to 25.0)) in the intervention groups. There was an absence of evidence for self-perceived health status. Among the studies with no links to usual care, time to hospitalisation (median time to hospitalisation 113.4 days intervention and 104.7 days control group, absolute difference 12.7 days) and the Minnesota Living with Heart Failure Questionnaire (intervention group 35.2 score points, control group 23.9 points, absolute difference 11.3, 95% CI 5.5 to 17.1) showed small reductions. The Personal Health Questionnaire (PHQ-8) showed no evidence of improvement (intervention 7.6 points, control 8.6 points, difference 1.0 points, 95% CI -22.9% to 11.9%). CONCLUSION: Digital telemedicine interventions provided moderate evidence of improvements in measures of disease control but little evidence and no demonstrated benefits on health status. Further research is needed with clear descriptions of conditions, interventions and outcomes based on patients' and healthcare providers' preferences. PROSPERO REGISTRATION NUMBER: CRD42019134872.

The COVID-19 Pandemic and Non-communicable Diseases-A Wake-up Call for Primary Health Care System Strengthening in Sub-Saharan Africa.

Strengthening Primary Health Care Systems is the most effective policy response in low-and middle-income countries to protect against health emergencies, achieve universal health coverage, and promote health and wellbeing. Despite the Astana declaration on primary health care, respective investment is still insufficient in Sub-Sahara Africa. The SARS-CoV-2019 pandemic is a reminder that non-communicable diseases (NCDs), which are increasingly prevalent in Sub-Sahara Africa, are closely interlinked to the burden of communicable diseases, exacerbating morbidity and mortality. Governments and donors should use the momentum created by the pandemic in a sustainable and effective way by pivoting health spending towards primary health care.