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Background: Cutaneous squamous cell carcinoma (cSCC) is the most common keratinocyte carcinoma in dark-skinned ethnic groups. Available studies are primarily focused on white populations, with fewer data available for black Africans, including Ethiopians. Therefore, less priority may be given to treatment and prevention in this population. Objective: To determine the prevalence and risk factors of cSCC among patients presenting to All Africa Leprosy, Tuberculosis, and Rehabilitation Training Center , Addis Ababa, Ethiopia. Methods: A literature review was performed to determine existing knowledge. A retrospective descriptive cross-sectional study was then conducted based on stored data of confirmed cases of cSCC from 2011 to 2021 at ALERT. Demographics, other parameters related to cSCC (size, anatomic location, degree of differentiation, metastasis, and recurrence), and potential risk factors including scars, burns, HIV status, xeroderma pigmentosum, and leprosy were collected and entered on a prepared data extraction sheet and analyzed using SPSS version 25 manufactured by IBM. Results: Among 15,075 total pathologic samples reviewed, 3.8% (n = 570) were reported histopathologically as invasive cSCC (n = 437), keratoacanthoma, or (squamous cell carcinoma in-situ (Bowen disease). 50.3% (n = 287) occurred in female, and the mean age of affected patients was 50.1 years (SD 17.2). Nearly 70% were reported after >1 year of symptoms, including morphologic change, ulceration, and nonhealing wound. HIV status was not universally screened but was positive in 9.8% (46/437). Cases were commonly found to occur on the lower extremities (X2 = 2.7196, Pr = 0.099) and >4 cm in size (46.3%). Among 274 cases with adequate histologic description, 82.5% (n = 226) were well-differentiated. Loco-regional metastases comprised 6.0% (n = 34) and 46.7% (n = 266) had ulceration. Conclusion: The biologic significance of ulceration in this population is unclear. Ulceration may indicate chronic wounds or Marjolin’s ulcers. High rates of metastasis call for a better understanding of risk factors, preventive measures, and early diagnosis. This model of research may serve as a foundation for future nationwide investigations through the Federal Ministry of Health of Ethiopia’s Disease Prevention and Control Directorate.

ABSTRACT: Introduction: Oral diseases affect a significant proportion of the world's population, yet international comparisons involving oral health outcomes have often been limited due to differences in the way country-level primary data are collected. In response to this, the World Dental Federation (FDI) Oral Health Observatory project was launched with the goal of collecting and producing standardised international data on oral health across countries. The aim of this descriptive cross-sectional study was to examine associations between self-reported general health and a range of factors (sociodemographics, oral health–related behaviours, oral impacts, clinical variables) using these standardised international datasets. Methods: Dentists within FDI member National Dental Associations who chose to take part in the project were selected using a multistage sampling method. The number of dentists in each cluster was set according to the proportion of the national population living in the area, and 50 patients per dentist were systematically approached to take part. Patients and dentists completed 2 separate questionnaires on a mobile app. Ordinal logistic regression (conducted in December 2022) was used to analyse the linked patient and dentist data from 6 countries: China (n = 2242); Colombia (n = 1029); India (n = 999); Italy (n = 711); Japan (n = 1271); and Lebanon (n = 798). Self-reported general health was the dependent variable, with age, sex, education, self-reported oral health–related behaviours, self-reported oral impacts, and clinical variables acting as the independent variables. Results: The results demonstrated a different pattern of associations in the different countries. Better self-reported general health was associated with degree-level education in all 6 countries and with reporting no oral impact and no sensitive teeth in 4 countries. Several country-specific patterns were also found, including the importance of tooth brushing in Colombia, periodontal health in Italy, and differing associations with sugary drinks consumption in India and Japan. Conclusions: These descriptive findings provide a basis for further research and, importantly, for advocacy in identifying patient oral health care needs according to both person-reported and clinical aspects. This can facilitate optimisation of service provision and potentially influence policy and investments.

The emergence of the clade 1b variant of mpox has transformed the virus into a global health threat, prompting the World Health Organization to declare it a public health emergency. Clade 1b is characterized by enhanced transmissibility, particularly through human-to-human contact, including sexual transmission. This variant has spread rapidly from its epicenter in the Democratic Republic of Congo to neighboring African countries and beyond, with confirmed cases in Europe and Asia. The global response has focused on enhancing surveillance, improving diagnostics, and increasing access to the Jynneos vaccine and antiviral treatments, such as tecovirimat. However, several challenges remain, particularly in resource-limited settings. This review emphasizes the need for robust public health infrastructure, international collaboration, and ongoing research to mitigate the impact of mpox and prepare for future outbreaks.

Summary: Ensuring health systems responsiveness is crucial for health equity and outcomes of all individuals, particularly disadvantaged groups such as people with disabilities. However, attention to and discussions on health system responsiveness for people with disabilities remains lacking. This viewpoint highlights the pervasive issues within health systems rooted in ableism and proposes an agenda to tackle ableism, aiming to make health systems responsive to the needs of people with disabilities. Their needs are complex and diverse, varying with the disability, its severity, progression, and intersection with other factors. Ableism creates significant obstacles to identifying and addressing their needs and expectations, damages provider–patient interactions, poses multiple challenges in healthcare, and impacts the overall responsiveness of the health system to the populations it is meant to serve. The proposed agenda outlines areas for action and research across six building blocks of health systems as a way forward to enhance the health system's responsiveness to the needs of people with disabilities.

Background: Family planning programs are foundationally important to public health, but like any medical intervention, contraception has drawbacks in addition to its benefits. Knowledge of these drawbacks in addition to benefits is essential for informed choice. Despite a general consensus among family planning researchers and providers that contraceptive counseling should be unbiased, little quantitative research has assessed the extent of bias in contraceptive counseling, and in people's contraceptive knowledge more broadly. Objective: To understand the extent to which women report being told more about the advantages of contraception than the disadvantages—a concept we call “asymmetry” in contraceptive counseling, at two research sites in Burkina Faso. Methods: We use data from a cross-sectional population-based survey of 3,929 women residing in the catchment areas of the Ouagadougou (urban) and the Nouna (rural) Health and Demographic Surveillance Systems in Burkina Faso. We use descriptive statistics to explore asymmetry in knowledge of the benefits/advantages and risks/disadvantages of contraceptive use overall, as well as method-specific asymmetry among current method users regarding their counseling experience. Findings: Results show substantial asymmetry in knowledge of advantages/benefits of contraception compared to disadvantages/risks. 86% of respondents said they could name any advantage of family planning, while half of that proportion (43%) could name any disadvantage. We find a similarly stark asymmetry in method-specific results among contraceptive users, especially for hormonal/biomedical methods. We also find substantial variation between research sites, with urban respondents much less likely to self-report complete family planning knowledge than their rural counterparts. Conclusion: Our results suggest that family planning messaging in Burkina Faso may place an emphasis on the advantages without a commensurate focus on disadvantages. Family planning programs worldwide must ensure that people can make informed choices based on balanced, accurate information about both the benefits and the disadvantages of contraception.

Summary: Background: Surgical care holds significant importance in healthcare, especially in low and middle-income countries, as at least 50% of the 4.2 million deaths within the initial 30 days following surgery take place in these countries. The Lancet Commission on Global Surgery proposed six indicators to enhance surgical care. In Colombia, studies have been made using secondary data. However, strategies to reduce perioperative mortality have not been implemented. This study aims to describe the fourth indicator, perioperative mortality rate (POMR), with primary data in Colombia. Methods: A multicentre prospective cohort study was conducted across 54 centres (hospitals) in Colombia. Each centre selected a 7-day recruitment period between 05/2022 and 01/2023. Inclusion criteria involved patients over 18 years of age undergoing surgical procedures in operating rooms. Data quality was ensured through a verification guideline and statistical analysis using mixed-effects multilevel modelling with a case mix analysis of mortality by procedure-related, patient-related, and hospital-related conditions. Findings: 3807 patients were included with a median age of 48 (IQR 32–64), 80.3% were classified as ASA I or II, and 27% of the procedures had a low-surgical complexity. Leading procedures were Orthopedics (19.2%) and Gynaecology/Obstetrics (17.7%). According to the Clavien–Dindo scale, postoperative complications were distributed in major complications (11.7%, 10.68–12.76) and any complication (31.6%, 30.09–33.07). POMR stood at 1.9% (1.48–2.37), with elective and emergency surgery mortalities at 0.7% (0.40–1.23) and 3% (2.3–3.89) respectively. Interpretation: The POMR was higher than the ratio reported in previous national studies, even when patients had a low–risk profile and low-complexity procedures. The present research represents significant public health progress with valuable insights for national decision-makers to improve the quality of surgical care. Funding: This work was supported by Universidad del Rosario and Fundación Cardioinfantil-Instituto de Cardiología grant number CTO-057-2021, project-ID IV-FGV017.

Measures of physical growth, such as weight and height have long been the predominant outcomes for monitoring child health and evaluating interventional outcomes in public health studies, including those that may impact neurodevelopment. While physical growth generally reflects overall health and nutritional status, it lacks sensitivity and specificity to brain growth and developing cognitive skills and abilities. Psychometric tools, e.g., the Bayley Scales of Infant and Toddler Development, may afford more direct assessment of cognitive development but they require language translation, cultural adaptation, and population norming. Further, they are not always reliable predictors of future outcomes when assessed within the first 12–18 months of a child’s life. Neuroimaging may provide more objective, sensitive, and predictive measures of neurodevelopment but tools such as magnetic resonance (MR) imaging are not readily available in many low and middle-income countries (LMICs). MRI systems that operate at lower magnetic fields (< 100mT) may offer increased accessibility, but their use for global health studies remains nascent. The UNITY project is envisaged as a global partnership to advance neuroimaging in global health studies. Here we describe the UNITY project, its goals, methods, operating procedures, and expected outcomes in characterizing neurodevelopment in sub-Saharan Africa and South Asia.

Summary: Background: Deployment and access to state-of-the-art precision medicine technologies remains a fundamental challenge in providing equitable global cancer care in low-resource settings. The expansion of digital pathology in recent years and its potential interface with diagnostic artificial intelligence algorithms provides an opportunity to democratize access to personalized medicine. Current digital pathology workstations, however, cost thousands to hundreds of thousands of dollars. As cancer incidence rises in many low- and middle-income countries, the validation and implementation of low-cost automated diagnostic tools will be crucial to helping healthcare providers manage the growing burden of cancer. Methods: Here we describe a low-cost ($230) workstation for digital slide capture and computational analysis composed of open-source components. We analyze the predictive performance of deep learning models when they are used to evaluate pathology images captured using this open-source workstation versus images captured using common, significantly more expensive hardware. Validation studies assessed model performance on three distinct datasets and predictive models: head and neck squamous cell carcinoma (HPV positive versus HPV negative), lung cancer (adenocarcinoma versus squamous cell carcinoma), and breast cancer (invasive ductal carcinoma versus invasive lobular carcinoma). Findings: When compared to traditional pathology image capture methods, low-cost digital slide capture and analysis with the open-source workstation, including the low-cost microscope device, was associated with model performance of comparable accuracy for breast, lung, and HNSCC classification. At the patient level of analysis, AUROC was 0.84 for HNSCC HPV status prediction, 1.0 for lung cancer subtype prediction, and 0.80 for breast cancer classification. Interpretation: Our ability to maintain model performance despite decreased image quality and low-power computational hardware demonstrates that it is feasible to massively reduce costs associated with deploying deep learning models for digital pathology applications. Improving access to cutting-edge diagnostic tools may provide an avenue for reducing disparities in cancer care between high- and low-income regions. Funding: Funding for this project including personnel support was provided via grants from NIH/NCI R25-CA240134, NIH/NCI U01-CA243075, NIH/NIDCR R56-DE030958, NIH/NCI R01-CA276652, NIH/NCI K08-CA283261, NIH/NCI-SOAR 25CA240134, SU2C (Stand Up to Cancer) Fanconi Anemia Research Fund – Farrah Fawcett Foundation Head and Neck Cancer Research Team Grant, and the European Union Horizon Program (I3LUNG).

Background: The increasing prevalence of falsified and counterfeit medicines globally poses risks to international travellers. This narrative literature review examines the global challenge of falsified and counterfeit medicines, with a specific focus on risks for travellers. The aim is to provide a comprehensive understanding of this multidimensional issue, exploring potential solutions for effective intervention. Methods: A comprehensive search of databases, including PubMed, MEDLINE, and Scopus, as well as relevant reports from international organisations, was undertaken. There was a focus on extracting information pertaining to the prevalence, types, and geographical patterns of falsified and counterfeit medicines encountered by international travellers. Synthesising this information helped to identify overarching trends and patterns. This narrative review utilised a thematic analysis approach to synthesise the findings. Results: The findings revealed a diverse range of counterfeit drug categories, spanning from antibiotics to lifestyle medications, posing unique risks to travellers navigating the global pharmaceutical landscape. The review emphasises the geographical distribution of these drugs, with varying consequences for both high- and low-income nations. The inadequate formulations and inconsistent drug release arising from these practices pose severe threats to public health, especially for individuals travelling abroad. The review also highlights the significance of international collaboration in addressing this global challenge, as pharmaceutical supply chains seamlessly cross borders, necessitating a collaborative approach for effective regulation and enforcement. Conclusions: This review underscores the need for targeted research, collaborative interventions, and technological innovations to address the complexities associated with falsified and counterfeit medicines, ensuring the safety and well-being of international travellers.

Background: The new injury severity score (NISS) is widely used within trauma outcomes research. NISS is a composite anatomic severity score derived from the Abbreviated Injury Scale (AIS) protocol. It has been postulated that NISS underestimates trauma severity in resource-constrained settings, which may contribute to erroneous research conclusions. We formally compare NISS to an expert panel's assessment of injury severity in South Africa. Methods: This was a retrospective chart review of adult trauma patients seen in a tertiary trauma center. Randomly selected medical records were reviewed by an AIS-certified rater who assigned an AIS severity score for each anatomic injury. A panel of five South African trauma experts independently reviewed the same charts and assigned consensus severity scores using a similar scale for comparability. NISS was calculated as the sum of the squares of the three highest assigned severity scores per patient. The difference in average NISS between rater and expert panel was assessed using a multivariable linear mixed effects regression adjusted for patient demographics, injury mechanism and type. Results: Of 49 patients with 190 anatomic injuries, the majority were male (n = 38), the average age was 36 (range 18–80), with either a penetrating (n = 23) or blunt (n = 26) injury, resulting in 4 deaths. Mean NISS was 16 (SD 15) for the AIS rater compared to 28 (SD 20) for the expert panel. Adjusted for potential confounders, AIS rater NISS was on average 11 points (95 % CI: 7, 15) lower than the expert panel NISS (p

Objectives: Meningitis is a medical emergency, and it is crucial to diagnose it accurately and promptly in order to manage patients effectively. It would, therefore, be essential to introduce and have fast, accurate, and user-friendly methods to determine the cause of these infections. This study aimed to demonstrate a potentially cost-effective new approach for detecting meningitis using a paper-based vertical flow microarray, which could be useful in settings with limited resources. Methods: We describe a multiplex paper microarray for detecting Neisseria meningitidis, Haemophilus influenzae, Streptococcus pneumoniae, and Salmonella spp. by the passive vertical flow of PCR-amplified clinical samples. A multibiotinylated amplicon was obtained as a product of PCR in the presence of both a biotinylated primer and biotin-11-dUTP. An enhancement step based on an enzyme-free gold enhancement protocol was also used to facilitate visual detection. Results: This study showed that the vertical flow microarray (previously evaluated for one pathogen) can discriminately detect the amplification results down to the 102 copies of DNA limit for four meningitis pathogens in a multiplexed set-up. The study further demonstrated the ability of this device and setup to detect three of the four pathogens from clinical biosamples. Discussion: This study demonstrated the capacity of a vertical flow microarray device to detect amplification products for four prevalent meningitis pathogens in a multiplex format. The vertical flow microarray demonstrated consistent visualization of the expected gene amplification results; however, indicating limitations in the pre- and amplification steps. This study highlights the potential of this multiplexing method for diagnosing meningitis and other syndromic diseases caused by various pathogens, especially in resource-limited areas.

Background: Multisystem inflammatory syndrome in children (MIS-C) is a severe complication associated with SARS-CoV-2 infection. The clinical epidemiology of MIS-C is not completely understood in low- and middle-income countries (LMICs) due to limited reporting, including in Asia where there was a substantial burden of COVID-19. We aimed to discuss the challenges of diagnosing MIS-C and factors which may cause children from Asian LMICs to have an increased risk of MIS-C. Methods: Not applicable. Results: The burden of MIS-C in Asian LMICs may be disproportionately high due to underlying risk factors, resource-limited health systems, and the increased infectivity and transmissibility of recent SARS-CoV-2 variants. Complex clinical features of MIS-C contributed to missed or delayed diagnosis and treatment, while underlying risk factors including ethnicity, chronic health conditions, and socioeconomic factors may have predisposed children in Asian LMICs to MIS-C. Conclusions: There was a lack of data on the clinical epidemiology of MIS-C in Asian LMICs during the COVID-19 pandemic, despite reports of higher paediatric mortality rates compared to high-income countries. This highlights the need for LMICs to have strong surveillance systems to collect high-quality and timely data on newly emerging complications associated with a pandemic, such as MIS-C. This will lead to rapid understanding of these emerging complications, and inform clinical management, disease prevention and health system planning.

The rise of African trypanocide resistance (ATr) is influenced by various factors such as evolutionary changes in the pathogen, the presence of resistance genes in the population, poor policy decisions, limited private-public partnerships to engage local communities, and insufficient funding for the development of new drugs over the past sixty years. These challenges have been exacerbated by the inadequate implementation of drug liberalization policies in the mid 20th century, leading to poor pharmacovigilance practices for veterinary drugs in low and middle income countries (LMICs). One health (OH), a disease management framework, provides practical solutions for addressing ATr, drawing on its success in managing previous epidemics like avian influenza in 2004 and the recent COVID-19 pandemic, where institutional collaborations were rapidly established. To combat ATr, OH initiatives involving both international and local partners at the policy and grassroots levels are crucial to generate community interest. The importance of political commitment, media involvement, and nongovernmental organizations cannot be overstated, as they are essential for resource mobilization and long-term sustainability in LMICs.

Low- and middle-income countries are underresourced in subspecialist care. This study describes a unique maternal-fetal medicine clinical fellowship training program at Moi University School of Medicine and Moi Teaching and Referral Hospital in Eldoret, Western Kenya. The first of its kind in Eastern Africa, it has met with success in the retention of highly qualified practitioners providing complex pregnancy care to a population that has been heretofore underserved.

Summary: Background: Since the initial identification of the Severe Fever with Thrombocytopenia Syndrome (SFTS) in ticks in rural areas of China in 2009, the virus has been increasingly isolated from a diverse array of hosts globally, exhibiting a rising trend in incidence. This study aims to conduct a systematic analysis of the temporal and spatial distribution of SFTS cases, alongside an examination of the infection rates across various hosts, with the objective of addressing public concerns regarding the spread and impact of the disease. Methods: In this systematic review and meta-analysis, an exhaustive search was conducted across multiple databases, including PubMed, Web of Science, Embase, and Medline, CNKI, WanFang, and CQVIP. The literature search was confined to publications released between January 1, 2009, and May 29, 2023. The study focused on collating data pertaining to animal infections under natural conditions and human infection cases reported. Additionally, species names were unified using the National Center for Biotechnology Information (NCBI) database. The notification rate, notification death rate, case fatality rate, and infection rates (or MIR) were assessed for each study with available data. The proportions were pooled using a generalized linear mixed-effects model (GLMM). Meta-regressions were conducted for subgroup analysis. This research has been duly registered with PROSPERO, bearing the registration number CRD42023431010. Findings: We identified 5492 studies from database searches and assessed 238 full-text studies for eligibility, of which 234 studies were included in the meta-analysis. For human infection data, the overall pooled notification rate was 18.93 (95% CI 17.02–21.05) per ten million people, the overall pooled notification deaths rate was 3.49 (95% CI 2.97–4.10) per ten million people, and the overall pooled case fatality rate was 7.80% (95% CI 7.01%–8.69%). There was an increasing trend in notification rate and deaths rate, while the case fatality rate showed a significant decrease globally. Regarding animal infection data, among 94 species tested, 48 species were found to carry positive nucleic acid or antibodies. Out of these, 14 species were classified under Arthropoda, while 34 species fell under Chordata, comprising 27 Mammalia and 7 Aves. Interpretation: This systematic review and meta-analysis present the latest global report on SFTS. In terms of human infections, notification rates and notification deaths rates are on the rise, while the case fatality rate has significantly decreased. More SFTSV animal hosts have been discovered than before, particularly among birds, indicating a potentially broader transmission range for SFTSV. These findings provide crucial insights for the prevention and control of SFTS on a global scale. Funding: None.

Summary: Antimicrobial resistance (AMR) poses a multifaceted threat to the human, animal, and environment sectors. In response, China has formulated a series of policies since the 2000s. Thus far, there has been no comprehensive assessment of these policy documents. This study aims to review the content of AMR policy documents at the national level using a governance framework covering three areas: Policy Design; Implementation Tools; and Monitoring and Evaluation. We identified 44 AMR documents from 2003 to 2022 sourced from government agency websites. Our findings have revealed noticeable discrepancies across the three governance areas. The Policy Design and Monitoring and Evaluation areas should be strengthened, particularly in the domains of ‘Coordination’, ‘Accountability’, ‘Sustainability’, and ‘Effectiveness’. From a ‘One Health’ perspective, the environment sector has received less attention compared to the human and animal sectors. Effectively addressing these challenges requires a stronger commitment and widespread support from diverse stakeholders.

Climate change interacts with social and biological factors to exacerbate the vulnerabilities and health inequities of people in displacement, with particularly severe implications for women and girls. In 2022, over 100 million people –1 in every 78 people in the world – were forced to flee their homes to a location within or beyond their country's borders, due to climatic or other man-made catastrophes. Most displaced people are housed in communities already experiencing climatic stress, exacerbating the risk of water insecurity, food insecurity, disease, struggles over resources, marginalization, and conflict between host and displaced populations. Amid the social upheaval caused by displacement, we call for a gendered approach to fostering resilience, with a particular emphasis on women. In this perspective piece, we advocate for policy and program changes that respond to the unique challenges and circumstances of displaced women and locally derived solutions that promote resilience. We start by providing an overview of health inequities during displacement, exacerbated by climate change, and then examine how gender interacts with displacement to shape women's health and wellbeing. We close with an illustrative example of Rohingya women displaced in Bangladesh who have adapted technology to combat climate change and mitigate social and health inequities to build resilience, even under severe restrictions. Gender-informed research on health, climate change, and resilience in contexts of humanitarian disasters and mass population displacement can elucidate the effectiveness of culturally- and contextually- specific interventions over the short- and long-term.

Recent global salmonella outbreak was linked to chocolate products but potential role of cocoa beans has been neglected. Chocolate related salmonella outbreaks have occurred mostly during low cocoa price levels. Food business operators should ensure hygiene at all production stages. These outbreaks highlight corporate social responsibility while demonstrating the need of multi-professional approaches.

Summary: Background: Maternal mortality remains a challenge in global health, with well-known disparities across countries. However, less is known about disparities in maternal health by subgroups within countries. The aim of this study is to estimate maternal health indicators for subgroups of women within each country. Methods: In this simulation-based analysis, we used the empirically calibrated Global Maternal Health (GMatH) microsimulation model to estimate a range of maternal health indicators by subgroup (urban/rural location and level of education) for 200 countries/territories from 1990 to 2050. Education levels were defined as low (less than primary), middle (less than secondary), and high (completed secondary or higher). The model simulates the reproductive lifecycle of each woman, accounting for individual-level factors such as family planning preferences, biological factors (e.g., anemia), and history of maternal complications, and how these factors vary by subgroup. We also estimated the impact of scaling up women's education on projected maternal health outcomes compared to clinical and health system-focused interventions. Findings: We find large subgroup differences in maternal health outcomes, with an estimated global maternal mortality ratio (MMR) in 2022 of 292 (95% UI 250–341) for rural women and 100 (95% UI 84–116) for urban women, and 536 (95% UI 450–594), 143 (95% UI 117–174), and 85 (95% UI 67–108) for low, middle, and high education levels, respectively. Ensuring all women complete secondary school is associated with a large impact on the projected global MMR in 2030 (97 [95% UI 76–120]) compared to current trends (167 [95% UI 142–188]), with especially large improvements in countries such as Afghanistan, Chad, Madagascar, Niger, and Yemen. Interpretation: Substantial subgroup disparities present a challenge for global maternal health and health equity. Outcomes are especially poor for rural women with low education, highlighting the need to ensure that policy interventions adequately address barriers to care in rural areas, and the importance of investing in social determinants of health, such as women's education, in addition to health system interventions to improve maternal health for all women. Funding: John D. and Catherine T. MacArthur Foundation, 10-97002-000-INP.

Background: The COVID-19 pandemic disproportionately impacted Latin America (LATAM), significantly disrupting cardiovascular testing. This study evaluated cardiac procedure recovery in LATAM one year after the outbreak. Methods: The International Atomic Energy Agency (IAEA) surveyed 669 centers in 107 countries worldwide, including 135 facilities in 19 LATAM countries, to assess cardiovascular procedure volumes in March 2019, April 2020, and April 2021, and changes in center practices and staffing conditions one year into the COVID-19 pandemic. Findings: LATAM centers reported a 21 % decrease in procedure volumes in April 2021 from pre-pandemic-baseline, vs. a 0 % change in the rest of the world (RoW), and greater volume reductions for almost all procedure types. Centers in Central America and Mexico reported the largest procedure reductions (47 % reduction) compared to the Caribbean (15 %), and South America (14 %, p = 0.01), and this LATAM region was a significant predictor of lower procedure recovery in multivariable regression. More LATAM centers reported reduced salaries and increased layoffs of clinical staff compared to RoW, and LATAM respondents estimated that half of physician and non-physician staff experienced excess psychological stress related to the pandemic, compared to 25 % and 30 % in RoW (p

Zoonoses have rapidly spread globally, necessitating the implementation of vaccination strategies as a control measure. Emerging and re-emerging vector-borne diseases are among the major global public health concerns. Dengue, a zoonotic viral infection transmitted to humans by a vector, the Aedes mosquito, is a severe global health problem. Dengue is a serious tropical infectious disease, second only to malaria, causing around 25,000 deaths each year. The resurgence of Dengue is mainly due to climate change, demographic transitions and evolving social dynamics. The development of an effective vaccine against Dengue has proven to be a complex undertaking due to four different viral serotypes with distinct antigenic profiles. This review highlights the urgent need to address the dengue threat by exploring the application of biotechnological and -OMICS sciences.

Background: One Health focuses on sustainable health for humans, animals, and ecosystems. The approach has been well demonstrated, yet most efforts have not been scaled up. Understanding the organisations involved in scaling up processes is critical to translating research into practice. The Lao People's Democratic Republic has successfully implemented One Health projects for multiple decades; however, the organisational network has not been described and scaling up efforts have been limited. Methods: Data from organisations involved in One Health projects over the past five years were collected by key-informant interview or workshop. The network was investigated using a mixture of quantitative network analysis and qualitative thematic analysis. Results: The organisational network was quantitatively described as sparse and centralised. Organisations were required to harness pre-existing relationships to maximise scarce resources and make co-ordination and alignment of priorities more efficient. A lack of international organisations in the top 10% of resource sharing metrics suggests a potential disconnect between donors. This was reflected in the challenges faced by national organisations and a feeling of being stretched thin over numerous externally funded projects with donor-driven priorities. Conclusions: It appears that high-level political support for country ownership of development and aid priorities remains unrealised. Developing network capacity and capability may assist scaling up efforts and build resilience in the network and its core organisations. This may allow for the inclusion of more development, education, environment, and water, sanitation, and hygiene organisations that were perceived to be lacking. Future One Health programmes should focus on practical activities that do not overload staff capacity. There is much for One Health to learn about the art of scaling up and organisations are encouraged to include implementation science in their research to inform future scaling up efforts.

Introduction: Snakebites are a neglected tropical disease. In many areas, envenoming incidence and antivenom administration rates are unknown. This study compared antivenom (AV) availability to rates of envenoming and recommendations to treat (RTT) in South Africa. Methods: This retrospective study identified, extracted, and reviewed all cases of envenoming (snake bites and spits) reported to the Poisons Information Helpline of the Western Cape of South Africa (PIHWC) from June 1, 2015 to May 31, 2020 by public hospitals in the Western Cape. A standardized interview was administered to the pharmacies of the 40 hospitals in winter and summer to determine how many vials of monovalent and polyvalent AV they had on hand at the time of the call and their expiration dates. Descriptive analysis was used to compare rates of envenoming and recommendations to treat to antivenom stock in winter and summer and by hospital type and location. Results: Public hospitals reported 300 envenomings, 122 from snakes. The PIHWC recommended antivenom administration in 26% of cases (N = 32). All hospital pharmacies queried answered our questions. Our study demonstrates urban district hospitals have higher ratios of AV vials compared to mean annual rates of envenoming and RTT than rural district hospitals at both the winter and summer timepoints. Conclusion: This study evaluates antivenom supply and demand in a province of South Africa. The findings suggest South African urban hospitals have a relative excess of antivenom, and thus more capacity to meet demand, than their rural counterparts. It supports consideration of a redistribution of antivenom supply chains to match seasonal and local rates of envenoming. It indicates a need for higher quality, prospective data characterizing envenoming incidence and treatment.

Summary: Background: Identification of unvaccinated children is important for preventing deaths due to infections. Number of siblings and birth order have been postulated as risk factors for zero-dose prevalence. Methods: We analysed nationally representative cross-sectional surveys from 85 low and middle-income countries (2010–2020) with information on immunisation status of children aged 12–35 months. Zero-dose prevalence was defined as the failure to receive any doses of DPT (diphtheria-pertussis-tetanus) vaccine. We examined associations with birth order and the number of siblings, adjusting for child's sex, maternal age and education, household wealth quintiles and place of residence. Poisson regression was used to calculate zero-dose prevalence ratios. Findings: We studied 375,548 children, of whom 13.7% (n = 51,450) were classified as zero-dose. Prevalence increased monotonically with birth order and with the number of siblings, with prevalence increasing from 11.0% for firstborn children to 17.1% for birth order 5 or higher, and from 10.5% for children with no siblings to 17.2% for those with four or more siblings. Adjustment for confounders attenuated but did not eliminate these associations. The number of siblings remained as a strong risk factor when adjusted for confounders and birth order, but the reverse was not observed. Among children with the same number of siblings, there was no clear pattern in zero-dose prevalence by birth order; for instance, among children with two siblings, the prevalence was 13.0%, 14.7%, and 13.3% for firstborn, second, and third-born, respectively. Similar results were observed for girls and boys. 9513 families had two children aged 12–35 months. When the younger sibling was unvaccinated, 61.9% of the older siblings were also unvaccinated. On the other hand, when the younger sibling was vaccinated, only 5.9% of the older siblings were unvaccinated. Interpretation: The number of siblings is a better predictor than birth order in identifying children to be targeted by immunization campaigns. Zero-dose children tend to be clustered within families. Funding: Gavi, the Vaccine Alliance.

This scoping review addresses the transformation and development of new healthcare systems in nine countries —Armenia, Azerbaijan, Belarus, Kazakhstan, Kyrgyzstan, Russia, Tajikistan, Turkmenistan, and Uzbekistan over the period following the collapse of the Soviet Union from 1991 to the present. This assessment focuses on maternal and child health, mental health, communicable diseases, and non-communicable diseases in an effort to highlight the changes in the healthcare status of these nine countries under scrutiny. Considering that all the post-Soviet nations are officially recognized members of the World Health Organization (WHO) and have demonstrated their commitment to attaining the WHO's objectives, the evaluation of healthcare system progress and improvement was carried out utilizing indicators provided by the WHO. This review reveals that the evolution of healthcare systems could be considered sustainable, given that average life expectancy has returned to the level it was in 1991— the year of the USSR's breakup, and people's health has improved since the turn of the twenty-first century. To enhance the potential success of future healthcare reforms, however, governments must monitor implementation of the reform process, evaluate the achievement of objectives, and make necessary adjustments. The success of future healthcare changes will depend on the active involvement of the government, medical community, and patient community, as well as obtaining the support of local health authorities. This study may help identify successful and failed strategies, guiding future healthcare changes and investments.

Summary: Background: The COVID-19 pandemic impacted mental health disorders, affecting both individuals with pre-existing conditions and those with no prior history. However, there is limited evidence regarding the pandemic's impact on mental health visits to primary care physicians. The International Consortium of Primary Care Big Data Researchers (INTRePID) explored primary care visit trends related to mental health conditions in Argentina, Australia, Canada, China, Norway, Peru, Singapore, Sweden, and the USA. Methods: We conducted an interrupted time series analysis in nine countries to examine changes in rates of monthly mental health visits to primary care settings from January 1st, 2018, to December 31st, 2021. Sub-group analysis considered service type (in-person/virtual) and six categories of mental health conditions (anxiety/depression, bipolar/schizophrenia/other psychotic disorders, sleep disorders, dementia, ADHD/eating disorders, and substance use disorder). Findings: Mental health visit rates increased after the onset of the pandemic in most countries. In Argentina, Canada, China, Norway, Peru, and Singapore, this increase was immediate ranged from an incidence rate ratio of 1·118 [95% CI 1.053–1.187] to 2.240 [95% CI 2.057–2.439] when comparing the first month of pandemic with the pre-pandemic trend. Increases in the following months varied across countries. Anxiety/depression was the leading reason for mental health visits in most countries. Virtual visits were reported in Australia, Canada, Norway, Peru, Sweden, and the USA, accounting for up to 40% of the total mental health visits. Interpretation: Findings suggest an overall increase in mental health visits, driven largely by anxiety/depression. During the COVID-19 pandemic, many of the studied countries adopted virtual care in particular for mental health visits. Primary care plays a crucial role in addressing mental ill-health in times of crisis. Funding: Canadian Institutes of Health Research grant #173094 and the Rathlyn Foundation Primary Care EMR Research and Discovery Fund.

Addressing the global challenge of vaccine hesitancy, amplified during the COVID-19 pandemic due to misinformation propagated via social media, necessitates innovative health communication strategies. This investigation scrutinizes the efficacy of Short, Animated, Story-based (SAS) videos in fostering knowledge, behavioral intent, and engagement around COVID-19 vaccination.We conducted an online three-arm parallel randomized controlled trial (RCT) involving 792 adult participants (≥18 years, English-speaking) from the United States. The intervention group viewed a SAS video on COVID-19 vaccination, the attention placebo control group watched a SAS video on hope, and the control group received no intervention. Our primary objectives were to assess the influence of SAS videos on knowledge, behavioral intent, and engagement regarding COVID-19 vaccination.Participants in the intervention group displayed significantly higher mean knowledge scores (20.6, 95 % CI: 20.3–20.9) compared to both the attention placebo control (18.8, 95 % CI: 18.5–19.1, P

Background: In the aftermath of the COVID-19 pandemic, medical students and residents in the U.S. and globally have gained more exposure to teledermatology, both for the purposes of clinical practice and education. Objective: We conducted a systematic review to assess outcomes from teledermatology interventions for dermatology trainees in the U.S. and globally in accordance with Preferred Reporting Items for Systematic Reviews (PRISMA). Methods: We searched MEDLINE, EMBASE, Web of Science, and Cochrane CENTRAL for articles written in English and published database inception to November 20, 2022. Results: In total, 15 studies met the inclusion criteria. Outcomes reported ranged broadly from resident-provider concordance rates, diagnostic accuracy in comparison to control groups, number of patients seen, and self-reported satisfaction and improvement. Generally, studies indicated high satisfaction rates and improvement in educational outcomes among medical students, residents, and other trainees in the global health setting. Limitations: Because of the heterogeneity of study design and outcomes reported, meta-analysis could not be performed. Conclusion: Teledermatology can be successfully deployed for clinical care and education domestically and in the global health setting.

Summary: Background: Chronic cough is a common respiratory symptom with an impact on daily activities and quality of life. Global prevalence data are scarce and derive mainly from European and Asian countries and studies with outcomes other than chronic cough. In this study, we aimed to estimate the prevalence of chronic cough across a large number of study sites as well as to identify its main risk factors using a standardised protocol and definition. Methods: We analysed cross-sectional data from 33,983 adults (≥40 years), recruited between Jan 2, 2003 and Dec 26, 2016, in 41 sites (34 countries) from the Burden of Obstructive Lung Disease (BOLD) study. We estimated the prevalence of chronic cough for each site accounting for sampling design. To identify risk factors, we conducted multivariable logistic regression analysis within each site and then pooled estimates using random-effects meta-analysis. We also calculated the population attributable risk (PAR) associated with each of the identifed risk factors. Findings: The prevalence of chronic cough varied from 3% in India (rural Pune) to 24% in the United States of America (Lexington,KY). Chronic cough was more common among females, both current and passive smokers, those working in a dusty job, those with a history of tuberculosis, those who were obese, those with a low level of education and those with hypertension or airflow limitation. The most influential risk factors were current smoking and working in a dusty job. Interpretation: Our findings suggested that the prevalence of chronic cough varies widely across sites in different world regions. Cigarette smoking and exposure to dust in the workplace are its major risk factors. Funding: Wellcome Trust.

Summary: As a developing region, Latin America faces unique cancer control and prevention challenges, which are intensified when considering rare cancers, including sarcomas. Sarcomas are a group of malignancies that arise in the connective tissues of the body—such as muscle, fat, nerves, blood vessels, and bones—accounting for a diverse range of tumours that, although rare, require specialized attention. Sarcoma care and research in Latin America require a comprehensive approach that includes deeper epidemiologic knowledge, diagnostic capacity building, access to innovative treatments, increased patient advocacy, and strengthening of clinical research capacity. This article will review current challenges and opportunities for treating patients with sarcoma in Latin America and outline a pathway toward improvement for regional collaborative groups.

Problem considered: Cervical cancer is the second most prevalent cancer in India and the fourth most common cancer globally. The lack of awareness surrounding cervical cancer creates challenges in achieving early detection and timely screening. The study aimed to assess the awareness about cervical cancer, to identify the risk for cervical cancer, and to assess the readiness for Pap testing. Methods: A descriptive survey design was adopted among female housekeeping staff in a tertiary care hospital in Udupi district, Karnataka. A total of 340 female housekeeping staff were selected based on the purposive sampling technique. Data was collected using structured questionnaires developed by the researcher that were self-administered to the participants and analysis was done using both descriptive and inferential statistics. Results: Out of 340, the majority 210(61.8%) had poor awareness on cervical cancer and 310(91.2%) were ready for Pap test. The top five self-reported risk factors among the participants were: partners not using condoms during sexual intercourse 326(95.9%), partners not circumcised 325(95.6%), given birth 312(91.2%), had not undergone regular Pap test for screening cervical cancer 291(85.6%), and being sexually active 137(40.3%). There was a significant association between awareness and variables like attainment of menopause (χ2 = 8.28, p = 0.016), and heard about cervical cancer (χ2 = 21.8, p=

Summary: Background: Under-five mortality remains concentrated in resource-poor countries. Post-discharge mortality is becoming increasingly recognized as a significant contributor to overall child mortality. With a substantial recent expansion of research and novel data synthesis methods, this study aims to update the current evidence base by providing a more nuanced understanding of the burden and associated risk factors of pediatric post-discharge mortality after acute illness. Methods: Eligible studies published between January 1, 2017 and January 31, 2023, were retrieved using MEDLINE, Embase, and CINAHL databases. Studies published before 2017 were identified in a previous review and added to the total pool of studies. Only studies from countries with low or low-middle Socio-Demographic Index with a post-discharge observation period greater than seven days were included. Risk of bias was assessed using a modified version of the Joanna Briggs Institute critical appraisal tool for prevalence studies. Studies were grouped by patient population, and 6-month post-discharge mortality rates were quantified by random-effects meta-analysis. Secondary outcomes included post-discharge mortality relative to in-hospital mortality, pooled risk factor estimates, and pooled post-discharge Kaplan–Meier survival curves. PROSPERO study registration: #CRD42022350975. Findings: Of 1963 articles screened, 42 eligible articles were identified and combined with 22 articles identified in the previous review, resulting in 64 total articles. These articles represented 46 unique patient cohorts and included a total of 105,560 children. For children admitted with a general acute illness, the pooled risk of mortality six months post-discharge was 4.4% (95% CI: 3.5%–5.4%, I2 = 94.2%, n = 11 studies, 34,457 children), and the pooled in-hospital mortality rate was 5.9% (95% CI: 4.2%–7.7%, I2 = 98.7%, n = 12 studies, 63,307 children). Among disease subgroups, severe malnutrition (12.2%, 95% CI: 6.2%–19.7%, I2 = 98.2%, n = 10 studies, 7760 children) and severe anemia (6.4%, 95% CI: 4.2%–9.1%, I2 = 93.3%, n = 9 studies, 7806 children) demonstrated the highest 6-month post-discharge mortality estimates. Diarrhea demonstrated the shortest median time to death (3.3 weeks) and anemia the longest (8.9 weeks). Most significant risk factors for post-discharge mortality included unplanned discharges, severe malnutrition, and HIV seropositivity. Interpretation: Pediatric post-discharge mortality rates remain high in resource-poor settings, especially among children admitted with malnutrition or anemia. Global health strategies must prioritize this health issue by dedicating resources to research and policy innovation. Funding: No specific funding was received.

It is unclear whether the health equity of autism spectrum disorders (ASDs) has changed in different years, regions, and gender. The aims of this study were to provide a comprehensive description of the ASDs burden and provide evidence for improvement in health policies regarding ASDs inequality. This study is a population-based cross-sectional study based on the Global Burden of Disease datasets 1990–2019. We collected detailed information on ASDs between 1990 and 2019 in 204 countries worldwide, derived from the Global Burden of Disease study in 2019. Burden was calculated in terms of the incidence, prevalence and years lived with disability (YLDs). Concentration curves and concentration indices were used to summarize the degree of income-related inequality in the burden of ASDs. The overall age-standardized incidence rate (ASIR), age-standardized prevalence rate (ASPR) and age-standardized YLDs rate (ASYR) of ASDs was 9.3 (95 %UI 7.7–11.1), 369.4 (95 %UI 305.9–441.2), 56.3 (95 %UI 36.8–81.5) per 100,000 people, respectively. The ASIR, ASPR and ASYR of ASDs affected three times as many males as females. The changing trends of age-standardized rates of ASDs showed that the ASIR of ASDs a slow growing trend globally. However, the ASPR and ASYR of ASDs showed a slow decreasing trend globally. All the concentration curves were below the line of equality and statistically significant. There was no significant difference in the age-standardized rate for different years in socio-demographic index-related inequality happened over 29 years (p > 0.05). The global burden of ASDs has remained higher in males and pro-rich, the income-related inequality tended not to change between 1990 and 2019.

Recent advances in technology can be leveraged to enhance public health research and practice. This study aimed to assess the effects of mobility and policy changes on COVID-19 case growth and the effects of policy changes on mobility using data from Google Mobility Reports, information on public health policy, and COVID-19 testing results. Multiple bivariate regression analyses were conducted to address the study objectives. Policies designed to limit mobility led to decreases in mobility in public areas. These policies also decreased COVID-19 case growth. Conversely, policies that did not restrict mobility led to increases in mobility in public areas and led to increases in COVID-19 case growth. Mobility increases in public areas corresponded to increases in COVID-19 case growth, while concentration of mobility in residential areas corresponded to decreases in COVID-19 case growth. Overall, restrictive policies were effective in decreasing COVID-19 incidence in the Dominican Republic, while permissive policies led to increases in COVID-19 incidence.

Summary: In low- and middle-income countries (LMICs), the fields of medicine and public health grapple with numerous challenges that continue to hinder patients' access to healthcare services. ChatGPT, a publicly accessible chatbot, has emerged as a potential tool in aiding public health efforts in LMICs. This viewpoint details the potential benefits of employing ChatGPT in LMICs to improve medicine and public health encompassing a broad spectrum of domains ranging from health literacy, screening, triaging, remote healthcare support, mental health support, multilingual capabilities, healthcare communication and documentation, medical training and education, and support for healthcare professionals. Additionally, we also share potential concerns and limitations associated with the use of ChatGPT and provide a balanced discussion on the opportunities and challenges of using ChatGPT in LMICs.

Pain is a significant yet underappreciated dimension of population health. Its associations with individual- and country-level wealth are not well characterized using global data. We estimate both individual- and country-level wealth inequalities in pain in 51 countries by combining data from the World Health Organization's World Health Survey with country-level contextual data. Our research concentrates on three questions: 1) Are inequalities in pain by individual-level wealth observed in countries worldwide? 2) Does country-level wealth also relate to pain prevalence? 3) Can variations in pain reporting also be explained by country-level contextual factors, such as income inequality? Analytical steps include logistic regressions conducted for separate countries, and multilevel models with random wealth slopes and resultant predicted probabilities using a dataset that pools information across countries. Findings show individual-level wealth negatively predicts pain almost universally, but the association strength differs across countries. Country-level contextual factors do not explain away these associations. Pain is generally less prevalent in wealthier countries, but the exact nature of the association between country-level wealth and pain depends on the moderating influence of country-level income inequality, measured by the Gini index. The lower the income inequality, the more likely it is that poor countries experience the highest and rich countries the lowest prevalence of pain. In contrast, the higher the income inequality, the more nonlinear the association between country-level wealth and pain reporting such that the highest prevalence is seen in highly nonegalitarian middle-income countries. Our findings help to characterize the global distribution of pain and pain inequalities, and to identify national-level factors that shape pain inequalities.

Purpose: Climate change has several known impacts on health, from increasing the spread of communicable disease, exacerbating the impacts of health disparities, disrupting food supplies, and detrimentally impacting mental health. Both the Lancet and the Global Consortium on Climate and Health Education (GCCHE) argue for the inclusion of climate and health competencies in health professional training programs. While these impacts on health are increasingly well documented, little is known about whether, and to what extent, physician associate/physician associate-comparable (PA/PA-comparable) professions around the world are trained on the health impacts of climate change. With this study, we aimed to assess whether a global sample of international PA/PA-comparable programs incorporated information about climate change and its impacts on health into their curricula. Methods: A survey developed by PA faculty members and an environmental epidemiologist was distributed to over 350 educational programs over a six-month period. Of these programs, 67 completed the survey, and these responses were analyzed using descriptive statistics. Results: 53.7% of programs do not currently incorporate climate change and health topics into their overall education plan. Main barriers include time constraints and coverage of a large amount of material. While most respondents felt only slightly knowledgeable in teaching related content, most felt a pre-made climate change curriculum would help facilitate inclusion of this content in their programs. Conclusion: While climate change has well-documented and widespread health impacts, these were not addressed in the majority of curricula of a global convenience sample of PA/PA comparable programs.

BACKGROUND: A female genital fistula, primarily caused by prolonged obstructed labor or after cesarean delivery in resource-limited countries, affects 500,000 to 2,000,000 women worldwide. Fistula is preventable with timely access to high-quality obstetrical care. Access to surgical repair of a female genital fistula has greatly increased over time. However, research surrounding postrepair reintegration, the process of returning to an individual's normal life, remains limited, and further efforts are needed to understand the factors shaping women's ability to rebuild their relationships and lives following repair. OBJECTIVE: This study aimed to characterize the 12-month reintegration trajectory after female genital fistula repair by participant sociodemographic and clinical characteristics. STUDY DESIGN: This study analyzed quantitative survey and medical record data of women (N=60) participating in a longitudinal cohort study assessing recovery after genital fistula repair in Uganda, with baseline and 4 quarterly follow-up assessments in 12 months. The primary outcome of reintegration was assessed using a 19-item postfistula repair reintegration instrument (range, 0–100) where a higher score represents better reintegration. Predictors of interest included parity and living children, quality of life, depressive symptoms at baseline, self-esteem, stigma, trauma, physical symptoms, and social support. We described participant baseline characteristics using means and proportions and estimated a series of mixed-effects linear regression models, including interactions of characteristics with time to understand how these characteristics influence reintegration trajectory in the 12 months after repair. RESULTS: The participants’ physical and psychosocial morbidities at baseline were high; more than 80% of participants reported fistula-related physical symptoms, 82% of participants described their general health as poor, and measures of self-esteem, overall social support, and overall quality of life were low. The mean reintegration score at baseline was 33 (standard deviation, 20), which increased to 78 (standard deviation, 19) at 12 months after fistula repair. The participant sociodemographic characteristics statistically associated with reintegration included any living children (β, 1.08; 95% confidence interval, −0.08 to 2.23). Moreover, psychosocial factors significantly affected reintegration with steeper trajectories for women with depressive symptoms (β, 0.89; 95% confidence interval, 0.02–1.75) or women experiencing internalized stigma (β, 0.05; 95% confidence interval, −0.00 to 0.11) and less steep for those with higher self-esteem (β, −0.11; 95% confidence interval, −0.24 to 0.01), overall social support (β, −0.06; 95% confidence interval, −0.12 to −0.01), and partner support (β, −0.21; 95% confidence interval, −0.35 to −0.07). CONCLUSION: Understanding the prominent factors associated with differences in reintegration trajectories across the year after genital fistula surgery has the potential to inform interventions that mitigate challenges and improve women's postrepair recovery experiences.

Summary: Background: Accessibility to surgical services can impact earthquake preparedness and response. We aimed to estimate the population with timely access to surgical care in Guerrero, a Mexican state with high tectonic activity, and identify populations at risk in the event of an earthquake. Methods: We conducted an ecological study using open government data. We extracted data from Guerrero municipalities regarding their earthquake risk, social vulnerability, social inequality, marginalisation, and resilience indices. The latest combines municipalities’ resistance to unexpected events and capacity to maintain optimal functionality without immediate federal or international support. Geographical coordinates of active public and private surgical facilities in Guerrero were combined with ancillary spatial data on roads and municipalities' population density to estimate population coverage within 30-min and 1-h driving time to surgical facilities in Redivis. We built an ordered beta regression model for each driving time estimate. Findings: We identified 25 public and 16 private facilities capable of providing surgical care in Guerrero. The population with access to facilities with surgical capacity within 30 min and 1-h driving times were 48.4% and 69.1%, respectively. We found that municipalities with very high levels of earthquake risk, social vulnerability, social inequality, and marginalisation, and very low levels of resilience had decreased coverage. In the multivariable analysis, the resilience index was statistically significant only for the 30-min model, with an effect size of 0.524 (95% CI 0.082, 1.089). Interpretation: Access to surgical care remains unequally distributed in Guerrero municipalities at the highest risk for earthquakes. Municipalities' resilience was the most significant predictor of higher surgical care coverage in 30-min driving time. Our study provides insights on how surgical system strengthening can enhance earthquake emergency disaster planning. Funding: No funding.

Introduction: The influence of non-technical skills training on resuscitation performance in low-resource settings is unknown. This study investigates combining the Vital Anaesthesia Simulation Training Course with Advanced Cardiac Life Support training on resuscitation performance in Rwanda. Methods: Participants in this mixed method study are members of resuscitation teams in three district hospitals in Rwanda. The intervention was participation in a 2-day Advanced Cardiac Life Support course followed by the 3-day Vital Anaesthesia Simulation Training Course. Quantitative primary endpoints were time to initiation of cardiopulmonary resuscitation, time to epinephrine administration, and time to defibrillation. Qualitative data on workplace implementation were gathered during focus groups held 3-months post-intervention. Results: Forty-seven participants were recruited. Quantitative data showed a statistically significant decrease in time to cardiopulmonary resuscitation, epinephrine administration, and defibrillation from pre- to post-Advanced Cardiac Life Support, with times of [43.3 (49.7) seconds] versus [16.5 (20) sec], p =

الملخص: أهداف البحث: فقر الدم هو مشكلة صحية عالمية وله معدل انتشار مرتفع للغاية في البلدان النامية والمتقدمة على حد سواء، وخاصة بين الأطفال والنساء. تقيم الدراسة الحالية مؤشرات أمراض الدم ونقص التغذية والالتهابات الطفيلية وارتباطها بانتشار فقر الدم. يساعد هذا التحليل في تحديد حالة فقر الدم لدى أطفال ما قبل المدرسة في المناطق القبلية. طرق البحث: أجريت دراسة مقطعية لدى 300 طفل في عمر 6 أشهر إلى 5 سنوات في قرية سانترامبور، غوجارات. تم جمع الدم وإجراء تعداد الدم الكامل و تحليل إليزا (المقايسة المناعية المرتبطة بالإنزيم) لتقدير الفيريتين، الترانسفيرين، مستقبل الترانسفيرين القابل للذوبان، فيتامين ب12، وفيتامين ب9 (الفولات). تم جمع عينات البراز وتقييمها من أجل بكتيريا ''المتحولة الحالة للنسج'' و''الجياردية اللمبلية''، و''خفية الأبواغ'' بواسطة طريقة إليزا. كما تم فحص الملاريا عن طريق الفحص المجهري. النتائج: من بين 300 طفل، كان 87.7٪ من الأطفال مصابين بفقر الدم. كان 239 طفلا يعانون من فقر الدم الخفيف، بينما كان 20 منهم يعانون من فقر الدم المتوسط و 4 أطفال يعانون من فقر الدم الشديد. كان متوسط الهيموغلوبين 9.49 ± 1.47 جم / ديسيلتر حيث كان للذكور والإناث 9.39 ± 1.59 جم / ديسيلتر و 9.58 ± 1.34 جم / ديسيلتر، على التوالي. ومن بين هؤلاء، كان 26 طفلا مصابين بفقر الدم المنجلي و 5 أطفال مصابين بالثلاسيميا. أكثر من 50٪ من الأطفال يعانون من نقص فيتامين ب12 وب9 إلى جانب 16٪ لديهم خلل في بروتين سي التفاعلي. العدوى الطفيلية لـ''خفية الأبواغ'' ارتبطت بشكل أكثر إيجابية بفقر الدم يليه انتشار ''الجياردية اللمبلية'' و''المتحولة الحالة للنسج''. الاستنتاجات: يوصى بنشر الوعي حول تحسين المرافق الصحية وتقديم المشورة الغذائية للآباء والأمهات بشأن استهلاك الأطعمة الغنية بالحديد للوقاية من فقر الدم بين الأطفال في سن ما قبل المدرسة. لتقليل الإصابة بالطفيليات، يطلب إجراء تدبير دوري فعال للتخلص من الديدان. Abstract: Objectives: Anemia is a global health problem and has very high prevalence in developing as well as developed countries, particularly in children and women. The present study evaluates hematological predictors, nutrition deficiency, parasitic infections and their association with the prevalence of anemia. This analysis will help to identify the anemic status of tribal preschool children. Methods: This was a cross-sectional study conducted in 300 children (age: 6 months to 5 years) in Santrampur village, Gujarat. Blood was collected and used to determine complete blood count (CBC); we also performed ELISA (enzyme-linked immunoassay) for the estimation of ferritin, transferrin, sTfR (soluble transferrin receptor), vitamin B12 and vitamin B9 (folate). Stool samples were also collected and assessed by ELISA for Entamoeba histolytica, Giardia lamblia and Cryptosporidium parvum. Microscopy was used to screen samples for malaria. Results: Of the 300 children analyzed, 87.7% were anemic, 239 children were mildly anemic, 20 were moderately anemic and 4 were severely anemic. Mean Hb level was 9.49 ± 1.47 g/dL; males and females had an Hb level of 9.39 ± 1.59 g/dL and 9.58 ± 1.34 g/dL, respectively. Twenty-six children had sickle cell anemia and five had thalassemia. Over 50% of the children had vitamin B12 and B9 deficiency and 16% had abnormalities in CRP (C-reactive protein) levels. Parasitic infection by C. parvum was positively associated the anemia followed by the prevalence of G. lamblia and E. histolytica. Conclusion: An increased awareness of parents in the improvement of sanitary facilities and nutritional counselling with regards to iron-rich food consumption is recommended to if we are to prevent anemia among pre-school children. To reduce parasitic infestation, effective periodic deworming measures are also recommended