Search

BackgroundSevere acute respiratory infections (SARIs) are the leading cause of pediatric death globally, particularly in low- and middle-income countries (LMICs). Given the potential rapid clinical decompensation and high mortality rate from SARIs, interventions that facilitate the early care of patients are critical to improving patient outcomes. The aim of this systematic review was to evaluate the impact of emergency care interventions on improving clinical outcomes of pediatric patients with SARIs in LMICs.MethodsPubMed, Global Health, and Global Index Medicus electronic databases were searched to identify peer-reviewed clinical trials or studies with comparator groups published before November 2020. All studies which evaluated acute and emergency care interventions on clinical outcomes for children (29 days to 19 years) with SARIs conducted in LMICs were included. Given the heterogeneity of interventions and outcomes, a narrative synthesis was performed. Bias was assessed using the Risk of Bias 2 and Risk of Bias in Non-Randomized Studies of Interventions.Results20,583 studies were screened, with 99 meeting criteria for final inclusion. The most common conditions studied were pneumonia or acute lower respiratory infection (61.6%) and bronchiolitis (29.3%). The majority of studies evaluated medications (80.8%), followed by respiratory support (14.1%) and supportive care (5%). The strongest evidence of benefit was found for respiratory support interventions such as improved medical oxygen systems to decrease risk of death. Results were notably inconclusive on the utility of continuus positive airway pressure (CPAP). Mixed results were found for interventions for bronchiolitis, although possible benefit was found for hypertonic nebulized saline to decrease hospital length of stay. Early use of adjuvant treatments such as Vitamin A, D, and zinc for pneumonia and bronchiolitis did not appear to have convincing evidence of benefit on clinical outcomes.ConclusionsWhile the burden of SARI in pediatric populations is high, few emergency care (EC) interventions have high quality evidence for benefit on clinical outcomes in LMICs. Respiratory support interventions have the strongest evidence for decreasing hospital length of stay and mortality and improvement of clinical status. Further research on the use of CPAP in diverse settings and populations is needed. A stronger evidence base for EC interventions for children with SARI, including metrics on the timing of interventions, is greatly needed.

Since its inception, the World Health Organization’s Emergency Medical Teams (EMT) Initiative has strived to save lives, preserve health, and alleviate suffering through inclusiveness, transparency, global cohesion, and regional adaptation of quality standards and methodology.1 The mission of the Global EMT Initiative is to enhance the surge capacity of countries through the promotion of rapid mobilization and efficient coordination of both national and international medical teams and health care workforce to reduce loss of life and prevent long-term disability because of disasters, outbreaks, and other emergencies.1Over the past decade, four EMT Global Meetings have been held and serve as a platform to foster collaboration and support among the global EMT community, which consists of clinicians and non-clinical providers, Member States, and partners. The gatherings in Geneva, Panama, Hong Kong, and Bangkok created momentum for the development of a global network and proved vital in guiding the direction of the initiative.Under the leadership of the EMT Strategic Advisory Group, the 2022 EMT Global Meeting in Yerevan convened over 500 participants from 110 countries and organizations. The event provided the network an opportunity to define a longer EMT strategy – EMT 2030 – which serves to strengthen national EMT and rapid response capacities as part of the global health emergency preparedness, response, and resilience (HEPR) architecture outlined by the 75th World Health Assembly in May 2022.2One of the four core objectives of the EMT 2030 strategy is to Strengthen information systems, evidence, and research. To further this objective, for the first time in 2022, the EMT secretariat introduced a research program into the EMT Global Meeting.The overall aim of research among EMTs is to support improvement of care provided to populations affected by emergencies, and therefore further the mission and vision of the EMT initiative. Even though the adoption of an experience-based strategy has had a positive impact in the past years, there is a need for an evidence-based generalizable guidance, aiming to increase predictability of response, strengthen advanced planning, and facilitate early actions. To this end, since late 2021, the EMT Secretariat has begun compiling a Global EMT Research Agenda, including documenting innovative solutions and products, deployments of national and international teams, and lessons learned from responses. The Secretariat also launched new platforms for advocacy and information exchange among the EMT Network.The 2022 EMT Global Meeting abstracts highlight the vast number of accomplishments that the EMT Network can and has already accomplished. From documenting the process of developing teams to modeling impact of effective responses, to demonstrating regional and sub-regional enhancements in knowledge sharing and after-action reviews of responses, there has been a wealth of experience presented in Yerevan. It is our pleasure to present them here.We look forward to strengthening the evidence base for EMT preparedness and response, with many of these abstracts developed further into manuscripts and more research to come.

Severe acute respiratory infections (SARIs) remain a leading cause of death globally, particularly in low- and middle-income countries (LMICs). Early intervention is critical, considering the potential for rapid decompensation in patients with SARIs. We aimed to evaluate the impact of acute and emergency care interventions on improving clinical outcomes in patients10 years old with SARIs in LMICs.A systematic literature search was performed in PubMed, Global Health, and Global Index Medicus databases to identify peer-reviewed studies containing SARI, LMICs, and emergency care interventions. Studies published prior to November 2020 focusing on patients10 years old were included. A narrative synthesis was performed due to the heterogeneity of identified articles. Risk of bias was assessed using the Risk of Bias 2 and Risk of Bias In Non-Randomized Studies of Interventions tools.20 223 studies were screened and 58 met the inclusion criteria. Thirty-four studies focused on coronavirus-2019 (COVID-19), 15 on pneumonia, seven on influenza, one study on severe acute respiratory syndrome, and one on undifferentiated SARI. Few COVID-19 studies found a benefit of the tested intervention on clinical status, mortality, or hospital length-of-stay. Little to no benefit was found for azithromycin, convalescent plasma, or zinc, and potential harm was found for hydroxychloroquine/chloroquine. There was mixed evidence for immunomodulators, traditional Chinese medicine, and corticosteroids among COVID-19 studies, with notable confounding due to a lack of consistency of control group treatments. Neuraminidase inhibitor antivirals for influenza had the highest quality of evidence for shortening symptom duration and decreasing disease severity.We found few interventions for SARIs in LMICs with have high-quality evidence for improving clinical outcomes. None of the included studies evaluated non-pharmacologic interventions or were conducted in low-income countries. Further studies evaluating the impact of antivirals, immunomodulators, corticosteroids, and non-pharmacologic interventions for SARIs in LMICs are urgently needed.PROSPERO registration number: CRD42020216117.

Background In 2021, the Nepal national emergency care system’s assessment (ECSA) identified 39 activities and 11 facility-specific goals to improve care. To support implementation of the ECSA facility-based goals, this pilot study used the World Health Organization’s (WHO) Hospital Emergency Unit Assessment Tool (HEAT) to evaluate key functions of emergency care at tertiary hospitals in Kathmandu, Nepal. Methods This cross-sectional study used the standardized HEAT assessment tool. Data on facility characteristics, human resources, clinical services, and signal functions were gathered via key informant interviews conducted by trained study personnel. Seven tertiary referral centers in the Kathmandu valley were selected for pilot evaluation including governmental, academic, and private hospitals. Descriptive statistics were generated, and comparative analyses were conducted. Results All facilities had continuous emergency care services but differed in the extent of availability of each item surveyed. Academic institutions had the highest rating with greater availability of consulting services and capacity to perform specific signal functions including breathing interventions and sepsis care. Private institutions had the highest infrastructure availability and diagnostic testing capacity. Across all facilities, common barriers included lack of training of key emergency procedures, written protocols, point-of-care testing, and ancillary patient services. Conclusion This pilot assessment demonstrates that the current emergency care capacity at representative tertiary referral hospitals in Kathmandu, Nepal is variable with some consistent barriers which preclude meeting the ECSA goals. The results can be used to inform emergency care development within Nepal and demonstrate that the WHO HEAT assessment is feasible and may be instructive in systematically advancing emergency care delivery at the national level if implemented more broadly.

Health consequences that persist beyond the acute infection phase of COVID-19, termed post-COVID-19 condition (also commonly known as long COVID), vary widely and represent a growing global health challenge. Research on post-COVID-19 condition is expanding but, at present, no agreement exists on the health outcomes that should be measured in people living with the condition. To address this gap, we conducted an international consensus study, which included a comprehensive literature review and classification of outcomes for post-COVID-19 condition that informed a two-round online modified Delphi process followed by an online consensus meeting to finalise the core outcome set (COS). 1535 participants from 71 countries were involved, with 1148 individuals participating in both Delphi rounds. Eleven outcomes achieved consensus for inclusion in the final COS: fatigue; pain; post-exertion symptoms; work or occupational and study changes; survival; and functioning, symptoms, and conditions for each of cardiovascular, respiratory, nervous system, cognitive, mental health, and physical outcomes. Recovery was included a priori because it was a relevant outcome that was part of a previously published COS on COVID-19. The next step in this COS development exercise will be to establish the instruments that are most appropriate to measure these core outcomes. This international consensus-based COS should provide a framework for standardised assessment of adults with post-COVID-19 condition, aimed at facilitating clinical care and research worldwide.

People with COVID-19 might have sustained postinfection sequelae. Known by a variety of names, including long COVID or long-haul COVID, and listed in the ICD-10 classification as post-COVID-19 condition since September, 2020, this occurrence is variable in its expression and its impact. The absence of a globally standardised and agreed-upon definition hampers progress in characterisation of its epidemiology and the development of candidate treatments. In a WHO-led Delphi process, we engaged with an international panel of 265 patients, clinicians, researchers, and WHO staff to develop a consensus definition for this condition. 14 domains and 45 items were evaluated in two rounds of the Delphi process to create a final consensus definition for adults: post-COVID-19 condition occurs in individuals with a history of probable or confirmed SARS-CoV-2 infection, usually 3 months from the onset, with symptoms that last for at least 2 months and cannot be explained by an alternative diagnosis. Common symptoms include, but are not limited to, fatigue, shortness of breath, and cognitive dysfunction, and generally have an impact on everyday functioning. Symptoms might be new onset following initial recovery from an acute COVID-19 episode or persist from the initial illness. Symptoms might also fluctuate or relapse over time. A separate definition might be applicable for children. Although the consensus definition is likely to change as knowledge increases, this common framework provides a foundation for ongoing and future studies of epidemiology, risk factors, clinical characteristics, and therapy.

Background/Introduction:Health emergencies such as the COVID-19 pandemic strain health systems and emergency response mechanisms. Identifying critical points during the response cycle where emergency workforce and operational capacity can be improved can help break the protracted nature of responses. Global health emergency workforce, or health emergency and alert response teams such as multidisciplinary Public Health Rapid Response Teams (RRTs) and Emergency Medical Teams (EMTs), play critical roles in the response to public health emergencies.Objectives:The project aims to explore and understand how countries manage and operationalize their RRT and EMT programs. With anecdotal evidence of countries integrating the two historically disparate groups, we propose to examine how countries are jointly or separately addressing legal frameworks and policies; management practices; reporting processes and protocols; training; as well as program operations and standards.Method/Description:Through existing global partnerships and networks, a convenience sample of national focal points responsible for the management of their RRT and EMT program are sent an online survey followed by participating in a one-on-one interview. Quantitative and qualitative analyses will be conducted.Results/Outcomes:Twelve countries representing all six World Health Organization regions with both RRT and EMT programs have been selected for engagement.Conclusion:Factors contributing to or against countries integration of RRT and EMT programs will be identified. Areas of divergence or synergy of plans and standard operating procedures will be mapped. Recommendations for strengthening global health emergency alert and response teams will be generated.

Background/Introduction:In November 2021, a tanker exploded in Freetown, injuring and killing people. The WHO facilitated a seven-week first deployment of the Senegalese military to support the Ministry of Health (MOH) in providing care to the wounded in three referral hospitals.Objectives:Review the deployed team’s processes and outputs of medical care provided to burns patients.Method/Description:This is a cross-sectional After-Action Review (AAR) debrief of the deployment, including the WHO and MOH staff (n =14) in a virtual workshop. Six thematic areas: mobilization, deployment, coordination, case management activities, national capacity, and community acceptance were analyzed.Results/Outcomes:The WHO facilitated the team’s deployment and mobilized medical supplies and equipment whilst the MOH provided accommodation and logistics through collaboration. The team dispensed their functions with professionalism, adapted to the environment and available resources, and augmented the care provided by the available health workers. They offered additional care: reconstructive surgery, pain management, palliative and wound care, rehabilitation, physiotherapy, and psychosocial counselling, which were initially inadequate. 87 out of 155 patients were discharged home at the end, the national clinicians acquired additional skills, and the community appreciated the team. Despite being perceived as a weakness, the language barrier did not hinder the patient-doctor/nurse relationship or the provision of clinical care.Conclusion:This sub-regional response had significant benefits, including speed, political acceptability, and health context experience to support rapid and safe deployment. Mechanisms to facilitate rapid and quality-assured deployment of EMTs at regional and sub-regional levels in collaboration with WHO should be strengthened in region to support future responses.

This is the twelfth version (eleventh update) of the living guideline, replacing earlier versions (available as data supplements). New recommendations will be published as updates to this guideline.What is the role of drugs in the treatment of patients with covid-19?The evidence base for therapeutics for covid-19 is evolving with numerous randomised controlled trials (RCTs) recently completed and under way. The emerging SARS-CoV-2 variants (such as omicron) and subvariants are also changing the role of therapeutics. This update provides updated recommendations for remdesivir, addresses the use of combination therapy with corticosteroids, interleukin-6 (IL-6) receptor blockers, and janus kinase (JAK) inhibitors in patients with severe or critical covid-19, and modifies previous recommendations for the neutralising monoclonal antibodies sotrovimab and casirivimab-imdevimab in patients with non-severe covid-19.• Remdesivir: a conditional recommendation for its use in patients with severe covid-19; and a conditional recommendation against its use in patients with critical covid-19. • Concomitant use of IL-6 receptor blockers (tocilizumab or sarilumab) and the JAK inhibitor baricitinib: these drugs may now be combined, in addition to corticosteroids, in patients with severe or critical covid-19. • Sotrovimab and casirivimab-imdevimab: strong recommendations against their use in patients with covid-19, replacing the previous conditional recommendations for their use.When moving from new evidence to updated recommendations, the Guideline Development Group (GDG) considered a combination of evidence assessing relative benefits and harms, values and preferences, and feasibility issues. For remdesivir, new trial data were added to a previous subgroup analysis and provided sufficiently trustworthy evidence to demonstrate benefits in patients with severe covid-19, but not critical covid-19. The GDG considered benefits of remdesivir to be modest and of moderate certainty for key outcomes such as mortality and mechanical ventilation, resulting in a conditional recommendation. For baricitinib, the GDG considered clinical trial evidence (RECOVERY) demonstrating reduced risk of death in patients already receiving corticosteroids and IL-6 receptor blockers. The GDG acknowledged that the clinical trials were not representative of the world population and that the risk-benefit balance may be less advantageous, particularly in patients who are immunosuppressed at higher risk of opportunistic infections (such as serious fungal, viral, or bacteria), those already deteriorating where less aggressive or stepwise addition of immunosuppressive medications may be preferred, and in areas where certain pathogens such as HIV or tuberculosis, are of concern. The panel anticipated that there would be situations where clinicians may opt for less aggressive immunosuppressive therapy or to combine medications in a stepwise fashion in patients who are deteriorating. The decision to combine the medications will depend on their availability, and the treating clinician's perception of the risk-benefit balance associated with combination immunosuppressive therapy, particularly in patient populations at risk of opportunistic infections who may have been under-represented in clinical trials. When making a strong recommendation against the use of monoclonal antibodies for patients with covid-19, the GDG considered in vitro neutralisation data demonstrating that sotrovimab and casirivimab-imdevimab evaluated in clinical trials have meaningfully reduced neutralisation activity of the currently circulating variants of SARS-CoV-2 and their subvariants. There was consensus among the panel that the absence of in vitro neutralisation activity strongly suggests absence of clinical effectiveness of these monoclonal antibodies. However, there was also consensus regarding the need for clinical trial evidence in order to confirm clinical efficacy of new monoclonal antibodies that reliably neutralise the circulating strains in vitro. Whether emerging new variants and subvariants might be susceptible to sotrovimab, casirivimab-imdevimab, or other anti-SARS-CoV-2 monoclonal antibodies cannot be predicted.• Recommended for patients with severe or critical covid-19—strong recommendations for systemic corticosteroids; IL-6 receptor blockers (tocilizumab or sarilumab) in combination with corticosteroids; and baricitinib as an alternative to IL-6 receptor blockers, in combination with corticosteroids. • Recommended for patients with non-severe covid-19 at highest risk of hospitalisation—a strong recommendation for nirmatrelvir/ritonavir; conditional recommendations for molnupiravir and remdesivir. • Not recommended for patients with non-severe covid-19—a conditional recommendation against systemic corticosteroids; a strong recommendation against convalescent plasma; a recommendation against fluvoxamine, except in the context of a clinical trial; and a strong recommendation against colchicine. • Not recommended for patients with non-severe covid-19 at low risk of hospitalisation—a conditional recommendation against nirmatrelvir/ritonavir. • Not recommended for patients with severe or critical covid-19—a recommendation against convalescent plasma except in the context of a clinical trial; and a conditional recommendation against the JAK inhibitors ruxolitinib and tofacitinib. • Not recommended, regardless of covid-19 disease severity—a strong recommendations against hydroxychloroquine and against lopinavir/ritonavir; and a recommendation against ivermectin except in the context of a clinical trial.This living guideline from the World Health Organization (WHO) incorporates new evidence to dynamically update recommendations for covid-19 therapeutics. The GDG typically evaluates a therapy when the WHO judges sufficient evidence is available to make a recommendation. While the GDG takes an individual patient perspective in making recommendations, it also considers resource implications, acceptability, feasibility, equity, and human rights. This guideline was developed according to standards and methods for trustworthy guidelines, making use of an innovative process to achieve efficiency in dynamic updating of recommendations. The methods are aligned with the WHO Handbook for Guideline Development and according to a pre-approved protocol (planning proposal) by the Guideline Review Committee (GRC). A box at the end of the article outlines key methodological aspects of the guideline process. MAGIC Evidence Ecosystem Foundation provides methodological support, including the coordination of living systematic reviews with network meta-analyses to inform the recommendations. The full version of the guideline is available online in MAGICapp and in PDF, with a summary version here in The BMJ. These formats should facilitate adaptation, which is strongly encouraged by WHO to contextualise recommendations in a healthcare system to maximise impact.Recommendations on anticoagulation are planned for the next update to this guideline.

The COVID-19 pandemic began as a cluster of reported cases of acute respiratory illness in China on 31 December 2019 and went on to spread with exponential growth across the globe. By the time it was characterized as a global pandemic on 11 March 2020, 17 of 22 countries in the Eastern Mediterranean Region (EMR) had reports of infected persons. EMR countries are particularly susceptible to such outbreaks due to the presence of globally interconnected markets; complex emergencies in more than half of the countries; religious mass gatherings that draw tens of millions of pilgrims annually; and variation in emergency care systems capacity and health systems performance within and between countries.

Burn therapies should focus on achieving outcomes that are most important to patients. The authors wanted to discover which outcomes newly burned patients would anticipate as most important to them and explored the association between demographic/burn characteristics and patient preferences. The authors surveyed 753 of 776 patients seen by our burn service from 2008 to 2013 during the initial encounter. Patients were asked to rate the anticipated importance of several burn outcomes including cosmetic appearance, resumption of normal function, and the lack of pain/itching on a four-item Likert scale (not important, somewhat important, important, and extremely important). The association between demographic and burn characteristics with patient's views on the importance of various outcomes was explored with χ and nonparametric tests. Patient mean (SD) age was 30 (22) years, 58% were males, 69% were white. Overall, function was extremely important to 96% of patients, lack of pain/itching was extremely important to 85% of patients, and cosmesis was extremely important to 59% of patients. Cosmesis was extremely important to more females than males (69 vs 52%; P < .001) and the mean age of patients in whom cosmesis was extremely important was lower than those in whom it was not (25 vs 40; P < .001). Cosmesis was more commonly extremely important in patients with head/neck than extremity burns (67 vs 57%; P < .001). Levels of importance for function and lack of pain/itching did not differ by gender, age, TBSA, or burn location. Thus, return to normal function and lack of pain and itching appear to be more commonly very important to burn patient than the cosmetic appearance of their burns. Cosmesis was of greater importance to younger patients, female patients, and those with head/neck burns.

The global health development community is increasingly examining the phenomenon of short-term experiences in global health (STEGH), with an aim to mitigate the negative impacts of such activities on host communities. Appropriate supervision is one strategy, but various barriers (e.g., institutional requirements) limit the availability of qualified supervisors. Remote supervision represents one potential model to provide supervision that may mitigate the negative impacts of STEGH. This paper reports observed outcomes from a description of a pilot remote supervision program employed in a global health program for Canadian undergraduate students. Benefits for learners included greater confidence and independence, greater perceived effectiveness in conducting their project abroad, and reassurance of remote support from their supervisor, supplemented with day-to-day guidance from the local partner. Host communities reported greater trust in the bidirectional nature of partnership with the visiting institution, empowerment through directing students’ work, and improved alignment of projects with community needs. Finally, faculty noted that remote supervision provided greater flexibility and freedom when compared to traditional in-person supervision, allowing them to maintain professional duties at home. Collectively, this pilot suggests that remote supervision demonstrates a potential solution to mitigating the harms of STEGHs undertaken by learners by providing adequate and appropriate remote supervision.

Clinical distinction between superficial and deep burns is problematic. The authors determined whether an infrared thermal imaging (IRTI) camera could predict burn depth. Burn depth was assessed by an experienced surgeon, and the burns were imaged with a portable, lightweight IRTI camera that measures heat emission from the skin using long infrared wavelengths (7.5-13 μm). Burns were considered "deep" if they were surgically excised and confirmed to be of full thickness on microscopic evaluation or if they did not heal spontaneously within 21 days of injury. All other burns were considered "nondeep." There were 39 burns that had both days 1 and 2 IRTI measurements and available outcome. Of these, 16 were "deep" burns and 23 were "nondeep." The mean temperatures of "nondeep" burns between days 1 and 2 increased from 30.6 ± 2.7 to 32.1 ± 3.0°C (difference of 1.5 ± 2.3°C). The mean temperatures of "deep" burns decreased from 32.3 ± 2.0 to 30.8 ± 1.3°C (difference of -1.5 ± 2.0°C) between days 1 and 2. Any decrease in temperatures between days 1 and 2 was predictive of a deep wound, and any increase between days 1 and 2 was predictive of a nondeep burn. Using the ultimate burn depth as the criterion standard, the overall accuracy of IRTI was considerably higher than that of clinical assessment; 87.2% (95% CI: 71.8-95.2) vs 54.1% (95% CI: 37.1-70.2). Any decrease in temperatures between days 1 and 2 was predictive of a deep wound. Our results suggest that thermography using IRTI is more accurate than clinical examination in predicting burn depth and could potentially reduce unnecessary surgery as well as reduce delays to surgery when necessary.

Hepatobiliary radionuclide imaging is typically performed to detect cholecystitis. Infrequently, imaging reveals an obstructive pattern. Although delayed hepatobiliary imaging is commonly used to differentiate between intrahepatic (IH) and extrahepatic (EH) obstruction in the newborn; there is room to clarify the use of delayed imaging in the adult population. A retrospective review was performed of adult patients demonstrating a complete obstructive pattern on initial Tc-99m mebrofenin hepatobiliary imaging. Delayed imaging was divided into early delayed (ED) (