Interventions to address antimicrobial resistance: an ethical analysis of key tensions and how they apply in low- income and middle-income countries.

Antimicrobial resistance (AMR) is a global health and one health problem. Efforts to mitigate the problem of AMR are challenging to implement due to unresolved ethical tensions. We present an in-depth ethical analysis of tensions that might hinder efforts to address AMR. First, there is a tension between access and excess in the current population: addressing lack of access requires facilitating use of antimicrobials for some populations, while addressing excessive use for other populations. Second, there is a tension between personal interests and a wider, shared interest in curbing AMR. These personal interests can be viewed from the perspective of individuals seeking care and healthcare providers whose livelihoods depend on using or selling antimicrobials and who profit from the sales and use of antimicrobials. Third, there is a tension between the interests of current populations and the interests of future generations. Last, there is a tension between addressing immediate health threats such as pandemics, and AMR as a 'silent', chronic threat. For each of these tensions, we apply 'descriptive ethics' methods that draw from existing evidence and our experiences living and working in low-income and middle-income countries to highlight how these ethical tensions apply in such settings.

Towards a multi-lateral framework for cross-border surveillance and information sharing between Nigeria and neighbouring countries.

Nigeria sits at the crossroads of West and Central Africa; two increasingly critical regions for global health security. To strengthen cross-border collaboration for health security between its neighbors from West and Central Africa, the Federal Ministry of Health, Nigeria through the public health authority at the Points of Entry-Port Health Services, led the design of a multi-lateral framework for cross-border collaboration between Nigeria, the Republic of Benin, the Republic of Chad, the Republic of Cameroon and the Republic of Niger. This framework provides a platform for agreeing on bilateral national and district-level infectious disease surveillance information sharing as well as laying the groundwork for expanded collaboration in incident reporting, joint investigation and response across borders.

Long-term healthcare utilisation, costs and quality of life after invasive group B Streptococcus disease: a cohort study in five low-income and middle-income countries.

INTRODUCTION: There are no published data on the long-term impact of invasive group B Streptococcus disease (iGBS) on economic costs or health-related quality of life (HRQoL) in low-income and middle-income countries. We assessed the impact of iGBS on healthcare utilisation, costs and HRQoL in Argentina, India, Kenya, Mozambique and South Africa. METHODS: Inpatient and outpatient visits, out-of-pocket (OOP) healthcare payments in the 12 months before study enrolment, and health-state utility of children and caregivers (using the EuroQol 5-Dimensions-3-Level) were collected from iGBS survivors and an unexposed cohort matched on site, age at recruitment and sex. We used logistic or Poisson regression for analysing healthcare utilisation and zero-inflated gamma regression models for family and health system costs. For HRQoL, we used a zero-inflated beta model of disutility pooled data. RESULTS: 161 iGBS-exposed and 439 unexposed children and young adults (age 1-20) were included in the analysis. Compared with unexposed participants, iGBS was associated with increased odds of any healthcare utilisation in India (adjusted OR 11.2, 95% CI 2.9 to 43.1) and Mozambique (6.8, 95% CI 2.2 to 21.1) and more frequent healthcare visits (adjusted incidence rate ratio (IRR) for India 1.7 (95% CI 1.4 to 2.2) and for Mozambique 6.0 (95% CI 3.2 to 11.2)). iGBS was also associated with more frequent days in inpatient care in India (adjusted IRR 4.0 (95% CI 2.3 to 6.8) and Kenya 6.4 (95% CI 2.9 to 14.3)). OOP payments were higher in the iGBS cohort in India (adjusted mean: Int$682.22 (95% CI Int$364.28 to Int$1000.16) vs Int$133.95 (95% CI Int$72.83 to Int$195.06)) and Argentina (Int$244.86 (95% CI Int$47.38 to Int$442.33) vs Int$52.38 (95% CI Int$-1.39 to Int$106.1)). For all remaining sites, differences were in the same direction but not statistically significant for almost all outcomes. Health-state disutility was higher in iGBS survivors (0.08, 0.04-0.13 vs 0.06, 0.02-0.10). CONCLUSION: The iGBS health and economic burden may persist for years after acute disease. Larger studies are needed for more robust estimates to inform the cost-effectiveness of iGBS prevention.

Urgent support mechanism: saving millions of COVID-19 vaccines from expiry in Africa.

Delivering COVID-19 vaccines with 4-6 weeks shelf life remains one of Africa's most pressing challenges. The Africa Centres for Disease Control and Prevention (Africa CDC) leadership recognised that COVID-19 vaccines donated to many African countries were at risk of expiry considering the short shelf life on delivery in the Member States and slow vaccine uptake rates. Thus, a streamlined rapid response system, the urgent support mechanism, was developed to assist countries accelerate COVID-19 vaccine uptake. We describe the achievements and lessons learnt during implementation of the urgent support mechanism in eight African countries. An Africa CDC team was rapidly deployed to meet with the Ministry of Health of each country alerted for COVID-19 vaccine expiry and identified national implementing partners to quickly develop operational work plans and strategies to scale up the urgent use of the vaccines. The time between the initiation of alerts to the start of the implementation was typically within 2 weeks. A total of approximately 2.5 million doses of vaccines, costing $900 000, were prevented from expiration. The urgent support has also contributed to the increased COVID-19 vaccination coverage in the Member States from 16.1% at the initiation to 25.3% at the end of the urgent support. Some of the effective strategies used by the urgent support mechanism included coordination between Africa CDC and country vaccine task forces, establishment of vaccination centres, building the capacity of routine and surge health workforce, procurement and distribution of vaccine ancillaries, staff training, advocacy and sensitisation events, and use of trusted religious scriptures and community influencers to support public health messages. The urgent support mechanism demonstrated a highly optimised process and serves as a successful example for acceleration and integration of vaccination into different healthcare delivery points.

Maternal and perinatal health research during emerging and ongoing epidemic threats: a landscape analysis and expert consultation.

INTRODUCTION: Pregnant women and their offspring are often at increased direct and indirect risks of adverse outcomes during epidemics and pandemics. A coordinated research response is paramount to ensure that this group is offered at least the same level of disease prevention, diagnosis, and care as the general population. We conducted a landscape analysis and held expert consultations to identify research efforts relevant to pregnant women affected by disease outbreaks, highlight gaps and challenges, and propose solutions to addressing them in a coordinated manner. METHODS: Literature searches were conducted from 1 January 2015 to 22 March 2022 using Web of Science, Google Scholar and PubMed augmented by key informant interviews. Findings were reviewed and Quid analysis was performed to identify clusters and connectors across research networks followed by two expert consultations. These formed the basis for the development of an operational framework for maternal and perinatal research during epidemics. RESULTS: Ninety-four relevant research efforts were identified. Although well suited to generating epidemiological data, the entire infrastructure to support a robust research response remains insufficient, particularly for use of medical products in pregnancy. Limitations in global governance, coordination, funding and data-gathering systems have slowed down research responses. CONCLUSION: Leveraging current research efforts while engaging multinational and regional networks may be the most effective way to scale up maternal and perinatal research preparedness and response. The findings of this landscape analysis and proposed operational framework will pave the way for developing a roadmap to guide coordination efforts, facilitate collaboration and ultimately promote rapid access to countermeasures and clinical care for pregnant women and their offspring in future epidemics.

Disseminating information on acute public health events globally: experiences from the WHO's Disease Outbreak News.

WHO works, on a daily basis, with countries globally to detect, prepare for and respond to acute public health events. A vital component of a health response is the dissemination of accurate, reliable and authoritative information. The Disease Outbreak News (DON) reports are a key mechanism through which WHO communicates on acute public health events to the public. The decision to produce a DON report is taken on a case-by-case basis after evaluating key criteria, and the subsequent process of producing a DON report is highly standardised to ensure the robustness of information. DON reports have been published since 1996, and up to 2022 over 3000 reports have been published. Between 2018 and 2022, the most frequently published DON reports relate to Ebola virus disease, Middle East respiratory syndrome, yellow fever, polio and cholera. The DON web page is highly visited with a readership of over 2.6 million visits per year, on average. The DON report structure has evolved over time, from a single paragraph in 1996 to a detailed report with seven sections currently. WHO regularly reviews the DON report process and structure for improvements. In the last 25 years, DON reports have played a unique role in rapidly disseminating information on acute public health events to health actors and the public globally. They have become a key information source for the global public health response to the benefit of individuals and communities.

A review of authorship in herpes simplex virus type-2 (HSV-2) research conducted in low-income and middle-income countries between 2000 and 2020.

INTRODUCTION: Equitable inclusion of low-income and middle-income country (LMIC) researchers and women in research authorship is a priority. A review of progress in addressing WHO-identified priorities provided an opportunity to examine the geographical and gender distribution of authorship in herpes simplex virus type-2 (HSV-2) research. METHODS: Publications addressing five areas prioritised in a WHO workshop and published between 2000 and 2020 were identified. Data on author country, gender, authorship position and research funding source were collected by manuscript review and internet searches and analysed using IBM SPSS V.26. RESULTS: Of, 297 eligible papers identified, (n=294) had multiple authors. Of these, 241 (82%) included at least one LMIC author and 143 (49%) and 122 (41%) had LMIC first and last authors, respectively. LMICs funded studies were more than twice as likely to include an LMIC first or last author as high-income country-funded studies (relative risk 2.36, 95% CI 1.93 to 2.89). Respectively, 129 (46%) and 106 (36%) studies had female first and last authors. LMIC first and last authorship varied widely by HSV-2 research area and increased over time to 65% and 59% by 2015-2020. CONCLUSION: Despite location of the research itself in LMIC settings, over the 20-year period, LMIC researchers held only a minority of first and last authorship positions. While LMIC representation in these positions improved over time, important inequities remain in key research areas and for women. Addressing current and historical power disparities in global health research, research infrastructure and how it is funded may be key addressing to addressing these issues.

At-home specimen self-collection as an additional testing strategy for chlamydia and gonorrhoea: a systematic literature review and meta-analysis.

INTRODUCTION: Chlamydia trachomatis (Ct) and Neisseria gonorrhoeae (Ng) infections are often asymptomatic; screening increases early detection and prevents disease, sequelae and further spread. To increase Ct and Ng testing, several countries have implemented specimen self-collection outside a clinical setting. While specimen self-collection at home is highly acceptable to patients and as accurate as specimens collected by healthcare providers, this strategy is new or not being used in some countries. To understand how offering at home specimen self-collection will affect testing uptake, test results, diagnosis and linkage to care, when compared with collection in clinical settings, we conducted a systematic literature review and meta-analysis of peer-reviewed studies. METHODS: We searched Medline, Embase, Global Health, Cochrane Library, CINAHL (EBSCOHost), Scopus and Clinical Trials. Studies were included if they directly compared specimens self-collected at home or in other non-clinical settings to specimen collection at a healthcare facility (self or clinician) for Ct and/or Ng testing and evaluated the following outcomes: uptake in testing, linkage to care, and concordance (agreement) between the two settings for the same individuals. Risk of bias (RoB) was assessed using Cochrane Risk of Bias (RoB2) tool for randomised control trials (RCTs). RESULTS: 19 studies, from 1998 to 2024, comprising 15 RCTs with a total of 62 369 participants and four concordance studies with 906 participants were included. Uptake of Ct or Ng testing was 2.61 times higher at home compared with clinical settings. There was a high concordance between specimens collected at home and in clinical settings, and linkage to care was not significantly different between the two settings (prevalence ratio 0.96 (95% CI 0.91-1.01)). CONCLUSION: Our meta-analysis and systematic literature review show that offering self-collection of specimens at home or in other non-clinical settings could be used as an additional strategy to increase sexually transmitted infection testing in countries that have not yet widely adopted this collection method.

Costs-effectiveness and cost components of pharmaceutical and non-pharmaceutical interventions affecting antibiotic resistance outcomes in hospital patients: a systematic literature review.

INTRODUCTION: Limited information on costs and the cost-effectiveness of hospital interventions to reduce antibiotic resistance (ABR) hinder efficient resource allocation. METHODS: We conducted a systematic literature review for studies evaluating the costs and cost-effectiveness of pharmaceutical and non-pharmaceutical interventions aimed at reducing, monitoring and controlling ABR in patients. Articles published until 12 December 2023 were explored using EconLit, EMBASE and PubMed. We focused on critical or high-priority bacteria, as defined by the WHO, and intervention costs and incremental cost-effectiveness ratio (ICER). Following Preferred Reporting Items for Systematic review and Meta-Analysis guidelines, we extracted unit costs, ICERs and essential study information including country, intervention, bacteria-drug combination, discount rates, type of model and outcomes. Costs were reported in 2022 US dollars ($), adopting the healthcare system perspective. Country willingness-to-pay (WTP) thresholds from Woods et al 2016 guided cost-effectiveness assessments. We assessed the studies reporting checklist using Drummond's method. RESULTS: Among 20 958 articles, 59 (32 pharmaceutical and 27 non-pharmaceutical interventions) met the inclusion criteria. Non-pharmaceutical interventions, such as hygiene measures, had unit costs as low as $1 per patient, contrasting with generally higher pharmaceutical intervention costs. Several studies found that linezolid-based treatments for methicillin-resistant Staphylococcus aureus were cost-effective compared with vancomycin (ICER up to $21 488 per treatment success, all 16 studies' ICERs

Development of a cross-sectoral antimicrobial resistance capability assessment framework.

Antimicrobial resistance (AMR) is an urgent and growing global health concern, and a clear understanding of existing capacities to address AMR, particularly in low-income and middle-income countries (LMICs), is needed to inform national priorities, investment targets and development activities. Across LMICs, there are limited data regarding existing mechanisms to address AMR, including national AMR policies, current infection prevention and antimicrobial prescribing practices, antimicrobial use in animals, and microbiological testing capacity for AMR. Despite the development of numerous individual tools designed to inform policy formulation and implementation or surveillance interventions to address AMR, there is an unmet need for easy-to-use instruments that together provide a detailed overview of AMR policy, practice and capacity. This paper describes the development of a framework comprising five assessment tools which provide a detailed assessment of country capacity to address AMR within both the human and animal health sectors. The framework is flexible to meet the needs of implementers, as tools can be used separately to assess the capacity of individual institutions or as a whole to align priority-setting and capacity-building with AMR National Action Plans (NAPs) or national policies. Development of the tools was conducted by a multidisciplinary team across three phases: (1) review of existing tools; (2) adaptation of existing tools; and (3) piloting, refinement and finalisation. The framework may be best used by projects which aim to build capacity and foster cross-sectoral collaborations towards the surveillance of AMR, and by LMICs wishing to conduct their own assessments to better understand capacity and capabilities to inform future investments or the implementation of NAPs for AMR.

A step towards reinvigorating the COVID-19 response: an intra-action review of the WHO Regional Office for Africa Incident Management Support Team.

The WHO Regional Office for Africa (AFRO) COVID-19 Incident Management Support Team (IMST) was first established on 21 January 2020 to coordinate the response to the pandemic in line with the Emergency Response Framework and has undergone three modifications based on intra-action reviews (IAR). An IAR of the WHO AFRO COVID-19 IMST was conducted to document best practices, challenges, lessons learnt and areas for improvement from the start of 2021 to the end of the third wave in November 2021. In addition, it was designed to contribute to improving the response to COVID-19 in the Region. An IAR design as proposed by WHO, encompassing qualitative approaches to collecting critical data and information, was used. It employed mixed methods of data collection: document reviews, online surveys, focus group discussions and key informant interviews. A thematic analysis of the data focused on four thematic areas, namely operations of IMST, data and information management, human resource management and institutional framework/governance. Areas of good practice identified, included the provision of guidelines, protocols and technical expertise, resource mobilisation, logistics management, provision of regular updates, timely situation reporting, timely deployment and good coordination. Some challenges identified included a communication gap; inadequate emergency personnel; lack of scientific updates; and inadequate coordination with partners. The identified strong points/components are the pivot for informed decisions and actions for reinvigorating the future response coordination mechanism.

Expediting approval for medical countermeasures to address high burden disease: an ethical justification to move beyond emergency use authorisation.

Addressing global health crises requires a receptive and expedient policy environment to minimise delays in making available potentially life-saving technologies. Over time, the policy environment has adapted to ensure that communities have expedited access to promising technologies, such as vaccines, that can mitigate morbidity and mortality. Emergency authorisations are one such policy mechanism. While these have been employed successfully for several diseases, such as influenza, Ebola and COVID-19, the policy mechanism is tied to contexts where key bodies have designated the disease an 'emergency', whereas no equivalent mechanism exists for those failing to acquire the designation (eg, malaria and tuberculosis). In this paper, we examine ethical issues associated with emergency authorisations. We argue that there is no moral difference between those diseases considered emergencies and many that fail to be designated as such with respect to impact on affected communities. Thus, tying access to an expedient policy mechanism for approval to an emergency designation is ethically unjustified-it should be based on considerations of risks and benefits, the disease burden and the values of the communities that carry those risks and not contingent on if the disease is designated an emergency. We suggest the need to further enhance the policy environment to ensure access to similar expedited approval programmes irrespective of if a disease is an emergency. Levelling the field for access to expedited approval programmes across diseases can help in moving towards achieving global health equity but is not a panacea.

Investing in a global pooled-funding mechanism for late-stage clinical trials of poverty-related and neglected diseases: an economic evaluation.

INTRODUCTION: Poverty-related and neglected diseases (PRNDs) cause over three million deaths annually. Despite this burden, there is a large gap between actual funding for PRND research and development (R&D) and the funding needed to launch PRND products from the R&D pipeline. This study provides an economic evaluation of a theoretical global pooled-funding mechanism to finance late-stage clinical trials of PRND products. METHODS: We modelled three pooled-funding design options, each based on a different level of coverage of candidate products for WHO's list of PRNDs: (1) vaccines covering 4 PRNDs, (2) vaccines and therapeutics covering 9 PRNDs and (3) vaccines, therapeutics and diagnostics covering 30 PRNDs. For each option, we constructed a discrete event simulation of the 2019 PRND R&D pipeline to estimate required funding for phase III trials and expected product launches through 2035. For each launch, we estimated global PRND treatment costs averted, deaths averted and disability-adjusted life-years (DALYs) averted. For each design option, we calculated the cost per death averted, cost per DALY averted, the benefit-cost ratio (BCR) and the incremental cost-effectiveness ratio (ICER). RESULTS: Option 1 averts 18.4 million deaths and 516 million DALYs, has a cost per DALY averted of US$84 and yields a BCR of 5.53. Option 2 averts 22.9 million deaths and 674 million DALYs, has a cost per DALY averted of US$75, an ICER over option 1 of US$49 and yields a BCR of 3.88. Option 3 averts 26.9 million deaths and 1 billion DALYs, has a cost per DALY averted of US$114, an ICER over option 2 of US$186 and yields a BCR of 2.52. CONCLUSIONS: All 3 options for a pooled-funding mechanism-vaccines for 4 PRNDs, vaccines and therapeutics for 9 PRNDs, and vaccines, therapeutics and diagnostics for 30 PRNDs-would generate a large return on investment, avert a substantial proportion of the global burden of morbidity and mortality for diseases of poverty and be cost-effective.

Expert guidance on target product profile development for AMR diagnostic tests.

Diagnostics are widely considered crucial in the fight against antimicrobial resistance (AMR), which is expected to kill 10 million people annually by 2030. Nevertheless, there remains a substantial gap between the need for AMR diagnostics versus their development and implementation. To help address this problem, target product profiles (TPP) have been developed to focus developers' attention on the key aspects of AMR diagnostic tests. However, during discussion between a multisectoral working group of 51 international experts from industry, academia and healthcare, it was noted that specific AMR-related TPPs could be extended by incorporating the interdependencies between the key characteristics associated with the development of such TPPs. Subsequently, the working group identified 46 characteristics associated with six main categories (ie, Intended Use, Diagnostic Question, Test Description, Assay Protocol, Performance and Commercial). The interdependencies of these characteristics were then identified and mapped against each other to generate new insights for use by stakeholders. Specifically, it may not be possible for diagnostics developers to achieve all of the recommendations in every category of a TPP and this publication indicates how prioritising specific TPP characteristics during diagnostics development may influence (or not) a range of other TPP characteristics associated with the diagnostic. The use of such guidance, in conjunction with specific TPPs, could lead to more efficient AMR diagnostics development.

Trends in public health emergencies in the WHO African Region: an analysis of the past two decades public health events from 2001 to 2022.

The African Region reports the heaviest burden of public health emergencies globally. This paper presents an exploratory analysis of public health events data collected the past 22 years in the WHO Africa region, to explore patterns and trends that can inform public health strategies, policy changes and develop appropriate tools to improve disease surveillance, preparedness and response to public health emergencies. A suite of exploratory data analysis methods combining time series analysis, summary statistics, temporal visualisations, geographic information system (GIS) mapping, trend analysis and statistical tests were used to derive patterns and trends from the data. An in-depth analysis of zoonotic disease outbreaks by geography and time was explored. The analysis also focused on whether these outbreaks were viral haemorrhagic related or had other characteristics. Results reveal that between 2001 and 2022, a total of 2234 public health events have been recorded in the WHO African Region of which 1886 events (84.4%) were substantiated. The paper confirms an average of 102 public health events reported yearly during the last 22 years time frame. The large majority (92%) of the substantiated events were infectious diseases (n=1730), 30% (n=566) are zoonoses and 5% (n=95) are humanitarian crises such as disaster events and conflicts. The number of zoonotic disease outbreaks has significantly increased (by 87%) between the past two decades, from 2003 to 2012 period (M=18.6, SD=4.8) and 2013-2022 period (M=34.7, SD=14); t(18) = 3.4, p=0.0032. This analysis shows growing challenges faced in the Africa region every year. One-health approach and its coordination across multiple sectors, disciplines and communities is critical to achieve the objectives.

Impact of breastfeeding on the incidence and severity of respiratory syncytial virus (RSV)-associated acute lower respiratory infections in infants: a systematic review highlighting the global relevance of primary prevention.

BACKGROUND: Respiratory syncytial virus (RSV) is the principal cause of acute lower respiratory infections (ALRI) among infants worldwide, and an important cause of morbidity, hospitalisation and mortality. While infants are universally exposed to RSV, most mortality occurs among normal term infants from low-income and middle-income countries. Breastfeeding has been suggested to have a protective effect against RSV infection. This study aims to determine the association of breastfeeding on the frequency and severity of RSV-associated ALRI among infants. METHODS: A systematic review was conducted using keywords and Medical Subject Headings on MEDLINE, PubMed, Google Scholar, EMBASE, MedRxiv and Cochrane Central Register of Controlled Trials. Full-text articles published in English from 2000 to 2021 that studied exclusively or partially breastfed infants who developed RSV-associated ALRI <12 months of age were included. Covidence software-based evidence extraction and Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol guidelines were followed. Quality of evidence was analysed using UK National Service Framework grading and the risk-of-bias assessment using Robvis. RESULTS: Among 1368 studies screened, 217 qualified full-text review and 198 were excluded based on pre-agreed criteria. Nineteen articles published from 12 countries that included 16 787 infants from 31 countries (of which 8 middle-income) were retained for analysis. Results indicate that non-breastfeeding practices pose a significant risk for severe RSV-associated ALRI and hospitalisation. Exclusive breastfeeding for >4-6 months significantly lowered hospitalisation, length of stay, supplemental oxygen demand and admission to intensive care units. CONCLUSION: In the context of no effective or standardised treatment for established RSV-associated ALRI, available evidence suggest that breastfeeding is associated with lower frequency and severity of RSV-associated ALRI, based on observational studies of variable grades of evidence and risk-of-bias. With both exclusive and partial breastfeeding benefiting infants who develop RSV-associated ALRI, breastfeeding should be promoted globally as an adjunct primary prevention; in addition to emerging immunoprophylaxis and maternal immunisation strategies.

Effectiveness of a multicomponent intervention to face the COVID-19 pandemic in Rio de Janeiro's favelas: difference-in-differences analysis.

INTRODUCTION: Few community-based interventions addressing the transmission control and clinical management of COVID-19 cases have been reported, especially in poor urban communities from low-income and middle-income countries. Here, we analyse the impact of a multicomponent intervention that combines community engagement, mobile surveillance, massive testing and telehealth on COVID-19 cases detection and mortality rates in a large vulnerable community (Complexo da Maré) in Rio de Janeiro, Brazil. METHODS: We performed a difference-in-differences (DID) analysis to estimate the impact of the multicomponent intervention in Maré, before (March-August 2020) and after the intervention (September 2020 to April 2021), compared with equivalent local vulnerable communities. We applied a negative binomial regression model to estimate the intervention effect in weekly cases and mortality rates in Maré. RESULTS: Before the intervention, Maré presented lower rates of reported COVID-19 cases compared with the control group (1373 vs 1579 cases/100 000 population), comparable mortality rates (309 vs 287 deaths/100 000 population) and higher case fatality rates (13.7% vs 12.2%). After the intervention, Maré displayed a 154% (95% CI 138.6% to 170.4%) relative increase in reported case rates. Relative changes in reported death rates were -60% (95% CI -69.0% to -47.9%) in Maré and -28% (95% CI -42.0% to -9.8%) in the control group. The case fatality rate was reduced by 77% (95% CI -93.1% to -21.1%) in Maré and 52% (95% CI -81.8% to -29.4%) in the control group. The DID showed a reduction of 46% (95% CI 17% to 65%) of weekly reported deaths and an increased 23% (95% CI 5% to 44%) of reported cases in Maré after intervention onset. CONCLUSION: An integrated intervention combining communication, surveillance and telehealth, with a strong community engagement component, could reduce COVID-19 mortality and increase case detection in a large vulnerable community in Rio de Janeiro. These findings show that investment in community-based interventions may reduce mortality and improve pandemic control in poor communities from low-income and middle-income countries.

Social determinants of health among people working on informal gold mines in French Guiana: a multicentre cross-sectional survey.

INTRODUCTION: Social determinants of health, such as living and working conditions, economical and environmental context and access to care, combine to impact the health of individuals and communities. In French Guiana (FG), the persons working in informal artisanal and small-scale gold mining in the rainforest are a particularly vulnerable population which lives in precarious conditions and far from the health system. Previous studies have demonstrated their high morbidity due to infectious diseases. This study aims to describe the social determinants of health in this specific population. METHODS: This international multicentre cross-sectional survey included people working on the informal FG gold mines at the crossing points located at both borders with Suriname and Brazil. After collecting written informed consent, a structured questionnaire was administered. RESULTS: From September to December 2022, 539 gold miners were included. These poorly educated migrants, mainly from Brazil (99.1%) did not have access to drinkable water (95.4%), lived in close contact with wild fauna by hunting, eating bushmeat or being bitten and were exposed to mercury by inhalation (58.8%) or ingestion (80.5%). They report frequent accidents (13.5%) and chronic treatment interruptions (26.6% of the 11.9% reporting chronic treatment). Half of them considered themselves in good health (56.4%). CONCLUSION: This study shows a singular combination of adverse exposures of gold miners working in FG such as zoonoses, heavy metal poisoning, aggression of wild fauna. For ethical as well as public health reasons, actions towards health equity must be considered at different levels: individual, community, environmental, systemic and global level. As end users of minerals, we must assume our responsibilities for the well-being of the extractors by including health in political decisions to engage together in global health. TRIAL REGISTRATION NUMBER: NCT05540470.

Research opportunities for the primordial prevention of rheumatic fever and rheumatic heart disease-streptococcal vaccine development: a national heart, lung and blood institute workshop report.

Streptococcus pyogenes, also known as group A streptococcus (StrepA), is a bacterium that causes a range of human diseases, including pharyngitis, impetigo, invasive infections, and post-infection immune sequelae such as rheumatic fever and rheumatic heart disease. StrepA infections cause some of the highest burden of disease and death in mostly young populations in low-resource settings. Despite decades of effort, there is still no licensed StrepA vaccine, which if developed, could be a cost-effective way to reduce the incidence of disease. Several challenges, including technical and regulatory hurdles, safety concerns and a lack of investment have hindered StrepA vaccine development. Barriers to developing a StrepA vaccine must be overcome in the future by prioritising key areas of research including greater understanding of StrepA immunobiology and autoimmunity risk, better animal models that mimic human disease, expanding the StrepA vaccine pipeline and supporting vaccine clinical trials. The development of a StrepA vaccine is a complex and challenging process that requires significant resources and investment. Given the global burden of StrepA infections and the potential for a vaccine to save lives and livelihoods, StrepA vaccine development is an area of research that deserves considerable support. This report summarises the findings of the Primordial Prevention Working Group-VAX, which was convened in November 2021 by the National Heart, Lung, and Blood Institute. The focus of this report is to identify research gaps within the current StrepA vaccine landscape and find opportunities and develop priorities to promote the rapid and successful advancement of StrepA vaccines.

Negotiating public-health intellectual property licensing agreements to increase access to health technologies: an insider's story.

Public health voluntary licensing of intellectual property has successfully been applied to increase access to medicines in certain disease areas, producing health benefits and economic savings, particularly in low-income and middle-income countries. There is however limited understanding of the intricacies of the approach, the modalities by which it works in practice, its levers and the trade-offs made. Such knowledge may be critical in deciding what role licensing should have in pandemic preparedness and equitable access to health technologies more broadly. This paper examines the case for licensing, the considerations for balancing public health needs, the challenges of negotiations, and the processes for validating proposed agreements. No access mechanism is perfect, but evidence suggests that public-health licensing has an important role to play, although it remains underused. Understanding some of the realities, strengths, limitations and complexities of applying the model may help calibrate expectations and develop incentives to expand its applications.