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Objectives: This study assesses the opinions of health professionals in Malaysia on the disruption of non-communicable disease (NCD) services during the COVID-19 pandemic from March 2020 to January 2022.Methods: We conducted a cross-sectional online survey with 191 non-clinical public health workers and clinical health service workers in Malaysia from November 2021 to January 2022. Participants were recruited by the Malaysian Ministry of Health using major networks including key experts and practitioners. Secondary respondents were subsequently enrolled through snowballing.Results: The most notable issues raised by the survey participants relate to NCD service disruption, the redirection of NCD care resources, and NCD care being overburdened post-pandemic. Respondents also reported accounts of resilience and prompt reaction from the healthcare system, as well as calls for innovation.Conclusion: Most respondents perceived that the challenges arising from COVID-19 were mostly managed well by the healthcare system, which was able to provide the necessary services to NCD patients during this health emergency. However, the study identifies gaps in the health system response and preparedness capacity, and highlights solutions for strengthening NCD services. more...

Stingray punctures are relatively common in several coastal regions and may result in chronic wounds and disability due to injury and envenomation. Vascular complications are rare but can be severe. We describe a case of high-flow arteriovenous fistula resulting from a stingray injury that required a venous bypass. more...

Care for non-communicable diseases, including hypertension and diabetes (HTN/DM), is recognized as a growing challenge in humanitarian crises, particularly in low- and middle-income countries (LMICs) where most crises occur. There is little evidence to support humanitarian actors and governments in designing efficient, effective, and context-adapted models of care for HTN/DM in such settings. This article aimed to systematically review the evidence on models of care targeting people with HTN/DM affected by humanitarian crises in LMICs. A search of the MEDLINE, Embase, Global Health, Global Indexus Medicus, Web of Science, and EconLit bibliographic databases and grey literature sources was performed. Studies were selected that described models of care for HTN/DM in humanitarian crises in LMICs. We descriptively analysed and compared models of care using a conceptual framework and evaluated study quality using the Mixed Methods Appraisal Tool. We report our findings according to PRISMA guidelines. The search yielded 10 645 citations, of which 45 were eligible for this review. Quantitative methods were most commonly used (n = 34), with four qualitative, three mixed methods, and four descriptive reviews of specific care models were also included. Most studies detailed primary care facility-based services for HTN/DM, focusing on health system inputs. More limited references were made to community-based services. Health care workforce and treatment protocols were commonly described framework components, whereas few studies described patient centredness, quality of care, financing and governance, broader health policy, and sociocultural contexts. There were few programme evaluations or effectiveness studies, and only one study reported costs. Most studies were of low quality. We concluded that an increasing body of literature describing models of care for patients with HTN/DM in humanitarian crises demonstrated the development of context-adapted services but showed little evidence of impact. Our conceptual framework could be used for further research and development of NCD models of care. more...

Introduction Multi-parameter diagnostic devices can simplify cardiometabolic disease diagnosis. However, existing devices may not be suitable for use in low-resource settings, where the burden of non-communicable diseases is high. Here we describe the development of a target product profile (TPP) for a point-of-care multi-parameter device for detection of biomarkers for cardiovascular disease and metabolic disorders, including diabetes, in primary care settings in low- and middle-income countries (LMICs). Methods A draft TPP developed by an expert group was reviewed through an online survey and semi-structured expert interviews to identify device characteristics requiring refinement. The draft TPP included 41 characteristics with minimal and optimal requirements; characteristics with an agreement level for either requirement of ≤ 85% in either the survey or among interviewees were further discussed by the expert group and amended as appropriate. Results Twenty people responded to the online survey and 18 experts participated in the interviews. Twenty-two characteristics had an agreement level of ≤ 85% in either the online survey or interviews. The final TPP defines the device as intended to be used for basic diagnosis and management of cardiometabolic disorders (lipids, glucose, HbA1c, and creatinine) as minimal requirement, and offering an expanded test menu for wider cardiometabolic disease management as optimal requirement. To be suitable, the device should be intended for level 1 healthcare settings or lower, used by minimally trained healthcare workers and allow testing using self-contained cartridges or strips without the need for additional reagents. Throughput should be one sample at a time in a single or multi-analyte cartridge, or optimally enable testing of several samples and analytes in parallel with random access. Conclusion This TPP will inform developers of cardiometabolic multi-parameter devices for LMIC settings, and will support decision makers in the evaluation of existing and future devices. more...

Background and rationale Geneva University Hospitals were granted a temporary authorization to administer the recombinant live vesicular stomatitis virus rVSV-ZEBOV (Ervebo®) vaccine to expatriate humanitarian frontline workers (FLWs) prior to mission deployment. Objectives Our aims were to assess the feasibility of FLW vaccination before deployment and to report adverse events (AEs). Methods FLWs received a single injection of rVSV-ZEBOV (>7.2E7 plaque forming unit) during their pre-deployment medical check-up at the Travel Medicine Clinic of the Geneva University Hospitals (Day 0). A safety questionnaire regarding potential AEs was emailed to FLWs on Days 3 and 21. Early and delayed AEs were those starting within 3 or 21 days of vaccination, respectively. Results Between 1 August 2019 and 30 June 2020, 124 FLWs received the rVSV-ZEBOV vaccine. Eighty-six volunteers (86/124; 69%) received a concomitant vaccine. The response rate to the follow-up questionnaire was 88 and 55% at Days 3 and 21, respectively. Most respondents (105/109; 96.3%), experienced at least one AE, with a mean of three (±SD 1.75) AEs per person. The most common AE was injection site pain, followed by fever (53/109; 48.6%), fatigue (51/109; 46.7%) and myalgia (49/109; 44.9%). Most early AEs (360/377; 95.4%) resolved within 3 days, reflecting vaccine reactogenicity. Delayed AEs were reported by 6/69 (7.2%) subjects, the median time to symptom onset was 11 days (range: 5–14); half of them were joint-related AEs (3/6). Four serious adverse events (SAE) were observed: two cases of high grade fever, one rash and one case of arthritis. Two suspected unexpected serious adverse reactions were observed: one case of continuing recurrent transient dizziness and fatigue considered related to the vaccine; and one case of presbyopia that was deemed unrelated. Conclusion AEs to rVSV-ZEBOV were common but in general transient and were well tolerated, pre-deployment rVSV-ZEBOV vaccination in FLW is feasible and can be included with pre-mission check-up. more...

Background: We are currently facing unprecedented humanitarian crises. With diabetes at record-high levels and projected increases in humanitarian crises globally, data on the burden and management of DM in humanitarian crises is needed to stop unnecessary disability and death. Methods: We surveyed data on diabetes care provision in humanitarian medical services in 2018 across 4 humanitarian agencies (Doctors Without Borders, International Committee of the Red Cross, International Rescue Committee, United Nations High Commissioner for Refugees) with 83 randomly selected sites across 27 countries in 5 global regions. Of 83 sites, 65 (78%) reported collecting DM care data and were used for cross-sectional analysis of rates and proportions. Results: Of 65 sites, most were in the Eastern Mediterranean (n=29, 45%) and Africa (35%), with 20% elsewhere; 34% were refugee camps, 34% rural non-camp sites, 21% urban non-camp sites, 11% internally displaced persons (IDP) camps. Populations were mostly a mix of refugees, IDPs and the general population (n=46/65, 71%), with refugees only at 23% and IDPs only at 6% of sites. Of 65 sites, 58 were affected by conflict (89%), 5% epidemics, 1% natural disasters and 5% multiple crisis types. Most sites (n=49) were in protracted crises (75%), with 23% in recovery stages and 2% in acute crisis. Of 65 sites, 46 (71%) reported providing clinical DM management. However, only 66% had insulin available, 71% had capillary glucose testing, 55% urine dipstick glucose, 19% hemoglobin A1c testing, 22% home glucose monitoring, 35% community outreach, 58% patient education, 32% training of staff and 52% continuity of care systems. Conclusions: DM services were mostly provided in protracted humanitarian settings. Services were widespread but often rudimentary and delivered to the general population as well as refugees and IDPs. Improving DM care for crisis-affected populations is urgently needed. Disclosure S. Kehlenbrink: None. S. Kayden: None. K. Donelan: None. B. Porneala: None. J. B. Meigs: Consultant; Self; Quest Diagnostics. O. Mahboob: None. S. A. Al-zubi: None. P. Boulle: None. S. Aebischer perone: None. L. Kiapi: None. A. H. Alani: None. H. Hering: None. M. Woodman: None. more...

Before a trip, a screening for SARS-CoV-2 infection by RT-PCR is often required and raises the problem of detection of residual viral RNA at distance from the acute infection (post-Covid). At the University Hospital of Geneva, we developed an expertise to distinguish acute from post-Covid infections. Between October and December 2020, 30% of the people tested positive were able to travel because the result corresponded to post-Covid and 65% were put in isolation because of an acute infection with a risk of transmission. To overcome the detection of residual viral RNA by RT-PCR, a rapid antigenic test would be an interesting and less expensive alternative. It could also be performed a few hours before departure.Avant un voyage, un dépistage de l’infection à SARS-CoV-2 par RT-PCR est souvent exigé et soulève le problème de la détection d’ARN viral résiduel chez une personne à distance de l’infection aiguë (post-Covid). Aux HUG, nous avons développé une expertise permettant de distinguer les infections aiguës des post-Covid. Entre octobre et décembre 2020, 30 % des personnes dépistées positives ont pu voyager car le résultat correspondait à des post-Covid et 65 % ont été mises en isolement en raison d’une infection aiguë avec risque de transmission. Pour pallier la détection de l’ARN viral résiduel par la RT-PCR, un test rapide antigénique serait une alternative intéressante et moins chère. Il pourrait également être effectué juste avant le départ. more...

Avant un voyage, un dépistage de l'infection à SARS-CoV-2 par RT-PCR est souvent exigé et soulève le problème de la détection d'ARN viral résiduel chez une personne à distance de l'infection aiguë (post-Covid). Aux HUG, nous avons développé une expertise permettant de distinguer les infections aiguës des post-Covid. Entre octobre et décembre 2020, 30 % des personnes dépistées positives ont pu voyager car le résultat correspondait à des post-Covid et 65 % ont été mises en isolement en raison d'une infection aiguë avec risque de transmission. Pour pallier la détection de l'ARN viral résiduel par la RT-PCR, un test rapide antigénique serait une alternative intéressante et moins chère. Il pourrait également être effectué juste avant le départ. more...

The current COVID-19 pandemic is a major concern for the diabetes community. A meta-analysis in China found that the proportions of people with COVID-19 and diabetes was 9.7% and that having diabetes resulted in a two-fold increased risk of having a severe case. Global guidance on confinement measures for the prevention of COVID-19 have a particular emphasis on vulnerable populations which include people with diabetes. These recommendations are coherent to avoid the spread of SARSCoV-2 infection, but are in contradiction with comprehensive diabetes care, which requires regular patient–provider interactions for patient education, prescriptions and possible management of complications or mental health. Moreover, confinement drives risk for unhealthy diets, decreased physical activity, mental health related concerns, in parallel to delayed care-seeking due to fear of contracting COVID-19. Another weakness in the current COVID-19 response is the focus on hospital care which overlooks the importance of Primary Care in guaranteeing continuity of care. Ensuring the availability of insulin, other medicines, self-monitoring and diagnostic tools is another challenge. These are all global concerns for the diabetes community, as well as for those suffering from other chronic conditions. Undoubtedly, the global priority is to contain the spread and impact of COVID-19. However, health systems still need to meet the needs of the entire population, including individuals with diabetes. Clear guidance for preparedness, crisis and post-crisis management of diabetes and chronic diseases during mass disruptions to health systems are lacking. Therefore, in parallel to the epidemic response efforts to ensure existing healthcare services keep running should be supported to avoid health consequences that might be worse than the epidemic itself. This includes targeted messaging for people with diabetes and vulnerable populations with regards to possible risk of infection as well as their disease-related management; continued support via telephone, video conferencing or even home visits; ensuring access to insulin and other medicines and supplies both nationally and individually; and most importantly, preparing for the future. more...

Humanitarian work is stressful and can have an impact on the mental health of humanitarian expatriates. In order to reduce stress and its consequences, humanitarian organizations are implementing various measures to keep their staff healthy. Humanitarian workers, on the other hand, must take care of themselves and apply self-protection mechanisms. Most humanitarian workers are doing well. The treating doctor plays a key role in detecting people and behavior at risk. He/she encourages the expatriate to use his/her resources and provide the adequate support and medical follow-up if necessary. Collaboration with the staff health units of humanitarian organizations allows for optimal care of humanitarian workers' medical conditions.Le travail humanitaire est générateur de stress qui peut avoir un impact sur la santé mentale des expatriés humanitaires. Afin de diminuer au maximum le stress et ses conséquences, les organisations humanitaires mettent en place différents dispositifs afin de garder leur personnel en bonne santé. L’humanitaire, quant à lui, doit mettre en place des mécanismes d’autoprotection. La majorité des humanitaires vont bien. Le médecin traitant joue un rôle clé dans la détection des personnes et conduites à risque. À l’écoute de l’expatrié, il l’encourage à utiliser ses ressources et met en place un soutien adéquat ainsi qu’un suivi médical si nécessaire. Une collaboration entre le médecin traitant et l’unité santé des collaborateurs des organisations humanitaires permet une prise en charge optimale des problèmes médicaux. more...

Highlights • Rothia dentocariosa is part of the normal oropharynx microflora in 1.3%–29% of healthy individuals. • R. dentocariosa rarely causes a severe systemic condition. • The spread of R. dentocariosa beyond the oropharynx must be identified and rapidly treated with antimicrobials. • There is limited data available on R. dentocariosa antimicrobial susceptibilities. The ceftriaxone-rifampin combination is a good option., Rothia dentocariosa is part of the normal human oropharyngeal microflora and is frequently associated with dental caries and periodontal disease. Invasive disease has been described essentially in immunocompromised hosts and/or patients with underlying conditions as predisposing factors. We present a case of an otherwise healthy 46-years old male with spondylodiscitis caused by this pathogen. Treatment with ceftriaxone and rifampin was successful. To our knowledge, this is the first R. dentocariosa spondylodiscitis reported in an immunocompetent patient, and the second one in the literature overall. more...

To identify gaps in national stroke guidelines that could be bridged to enhance the quality of stroke care services in low- and middle-income countries.We systematically searched medical databases and websites of medical societies and contacted international organizations. Country-specific guidelines on care and control of stroke in any language published from 2010 to 2020 were eligible for inclusion. We reviewed each included guideline for coverage of four key components of stroke services (surveillance, prevention, acute care and rehabilitation). We also assessed compliance with the eight Institute of Medicine standards for clinical practice guidelines, the ease of implementation of guidelines and plans for dissemination to target audiences.We reviewed 108 eligible guidelines from 47 countries, including four low-income, 24 middle-income and 19 high-income countries. Globally, fewer of the guidelines covered primary stroke prevention compared with other components of care, with none recommending surveillance. Guidelines on stroke in low- and middle-income countries fell short of the required standards for guideline development; breadth of target audience; coverage of the four components of stroke services; and adaptation to socioeconomic context. Fewer low- and middle-income country guidelines demonstrated transparency than those from high-income countries. Less than a quarter of guidelines encompassed detailed implementation plans and socioeconomic considerations.Guidelines on stroke in low- and middle-income countries need to be developed in conjunction with a wider category of health-care providers and stakeholders, with a full spectrum of translatable, context-appropriate interventions.Identifier les lacunes présentes dans les directives nationales de prise en charge des accidents vasculaires cérébraux (AVC), ainsi que la manière de les combler afin d'améliorer la qualité des soins dans les pays à faible et moyen revenu.Nous avons analysé systématiquement une série de bases de données médicales et sites Internet de sociétés médicales. Nous avons également contacté des organismes internationaux. Toutes les directives nationales de prévention et de prise en charge des AVC, publiées dans n'importe quelle langue entre 2010 et 2020, étaient admises dans cette analyse. Nous avons examiné chaque directive incluse à la recherche de quatre composants clés de la prise en charge des AVC (surveillance, prévention, soins intensifs et rééducation). Enfin, nous avons évalué le degré de conformité avec les huit standards de l'Institut de médecine pour les directives de pratique clinique, mais aussi la facilité avec laquelle ces directives étaient appliquées et la manière dont elles étaient censées être diffusées auprès du public cible.Nous avons étudié 108 directives retenues provenant de 47 pays dont quatre à faible revenu, 24 à moyen revenu et 19 à haut revenu. Globalement, le nombre de directives concernant la prévention primaire des AVC était moins élevé que d'autres volets de soins, et aucune ne recommandait une surveillance. Les directives relatives aux AVC dans les pays à faible et moyen revenu ne répondaient pas aux exigences en matière de développement des directives; d'étendue du public cible; d'intégration des quatre composants de prise en charge des AVC; ni d'adaptation au contexte socioéconomique. La transparence des directives nationales était moins souvent assurée dans les pays à faible et moyen revenu que dans les pays à haut revenu. Moins d'un quart des directives comportaient des plans de mise en œuvre détaillés et des considérations économiques.Les directives relatives à la prise en charge des AVC dans les pays à faible et moyen revenu doivent être renforcées avec le concours d'une plus large catégorie de prestataires et d'acteurs du secteur de la santé. Elles doivent en outre prévoir une gamme complète d'interventions transposables sur le terrain et adaptées au contexte.Identificar las lagunas en las directrices nacionales sobre accidentes cerebrovasculares que podrían subsanarse para mejorar la calidad de los servicios de atención a los accidentes cerebrovasculares en los países con ingresos bajos y medios.Se realizaron búsquedas sistemáticas en bases de datos médicas y sitios web de sociedades médicas y se contactó con organizaciones internacionales. Se incluyeron las directrices específicas de cada país sobre la atención y el control de los accidentes cerebrovasculares en cualquier idioma, publicadas entre 2010 y 2020. Se revisó cada directriz incluida para la cobertura de cuatro componentes clave de los servicios por ataques cerebrovasculares (vigilancia, prevención, atención aguda y rehabilitación). También se evaluó el cumplimiento de los ocho estándares del Instituto de Medicina para las guías de práctica clínica, la facilidad de implementación de las directrices y los planes de difusión al público objetivo.Se revisaron 108 directrices elegibles de 47 países, incluyendo cuatro de bajos ingresos, 24 de medianos ingresos y 19 de altos ingresos. Globalmente, la prevención primaria de los ataques cerebrovasculares estaba cubierta en menos directrices que otros componentes de la atención médica, y ninguna recomendaba la vigilancia. Las directrices sobre ataques cerebrovasculares en los países de ingresos bajos y medios no cumplían con los estándares requeridos para el desarrollo de directrices; la amplitud del público objetivo; la cobertura de los cuatro componentes de los servicios de ataques cerebrovasculares; ni la adaptación al contexto socioeconómico. El número de directrices de los países de ingresos bajos y medios que demostraron ser transparentes fue menor que el de los países de ingresos altos. Menos de una cuarta parte de las directrices incluían planes de aplicación detallados y consideraciones socioeconómicas.Las directrices sobre los ataques cerebrovasculares en los países de ingresos bajos y medios deben elaborarse en colaboración con una categoría más amplia de proveedores de servicios sanitarios y partes interesadas, con un espectro completo de intervenciones traducibles y adecuadas al contexto.تحديد الفجوات في المبادئ التوجيهية الوطنية للسكتة الدماغية التي يمكن سدها لتحسين جودة خدمات رعاية السكتة الدماغية في البلدان منخفضة الدخل والبلدان متوسطة الدخل.قمنا بإجراء البحث بشكل منهجي في قواعد البيانات الطبية والمواقع الإلكترونية للجمعيات الطبية، واتصلنا بالمنظمات الدولية. إن المبادئ التوجيهية الخاصة بكل بلد حول رعاية السكتة الدماغية والسيطرة عليها، بأية لغة منشورة في الفترة من 2010 إلى 2020، كانت مؤهلة ليتم تضمينها. قمنا بمراجعة كل مبدأ توجيهي متضمن لتغطية أربعة مكونات رئيسية لخدمات السكتة الدماغية (المراقبة، والوقاية، والرعاية الدقيقة، وإعادة التأهيل). كما قمنا بتقييم الامتثال لمعايير معهد الطب الثمانية للمبادئ التوجيهية للممارسة الإكلينيكية، وسهولة تنفيذ المبادئ التوجيهية، وخطط النشر بين الجماهير المستهدفة.قمنا بمراجعة 108 من المبادئ التوجيهية المؤهلة من 47 بلدًا، بما في ذلك أربعة بلدان منخفضة الدخل، و24 بلدًا متوسط الدخل، و19 بلدًا مرتفع الدخل. على الصعيد العالمي، غطى القليل من المبادئ التوجيهية الوقاية الأولية من السكتة الدماغية، مقارنةً بمكونات الرعاية الأخرى، مع عدم توصية أي منها بالمراقبة. كانت المبادئ التوجيهية حول السكتة الدماغية في البلدان منخفضة الدخل والبلدان متوسطة الدخل أقل من المعايير المطلوبة لتطوير المبادئ التوجيهية؛ وقاعدة الجمهور المستهدف؛ وتغطية المكونات الأربعة لخدمات السكتة الدماغية؛ والتكيف مع السياق الاجتماعي والاقتصادي. عدد المبادئ التوجيهية للبلدان منخفضة الدخل ومتوسطة الدخل التي أظهرت الشفافية أقل من المبادئ التوجيهية من البلدان ذات الدخل المرتفع. اشتمل أقل من ربع المبادئ التوجيهية على خطط تفصيلية للتنفيذ والاعتبارات الاجتماعية الاقتصادية.إن المبادئ التوجيهية حول السكتة الدماغية في البلدان ذات الدخل المنخفض، والبلدان ذات الدخل المتوسط، تحتاج إلى تطويرها بالاشتراك مع فئة أكبر من مقدمي الرعاية الصحية وأصحاب المصلحة، مع نطاق كامل من التدخلات القابلة للتفسير والملائمة للسياق.旨在确定国家中风指南存在的差距，并对这些差距加以弥补以增强中低收入国家中风护理服务的质量。.我们系统性地检索了医学数据库和医学会网站，并联系了国际组织。自 2010 年至 2020 年以任何语言发表的针对特定国家的中风护理和控制指南均满足纳入资格。我们回顾了各个指南所涵盖的中风服务四大关键要素（监测、预防、紧急护理和康复）。我们还评估了医学研究所八项临床实践指南标准的遵守情况，指南实施的难易程度以及出于目标群体宣传目的而制定的计划。.我们回顾了来自 47 个国家（其中包括 4 个低收入国家、24 个中等收入国家和 19 个高收入国家）的 108 份符合条件的指南。整体而言，与其他护理要素相比，涵盖初级中风预防的指南较少，且没有指南针对监测给出建议。低收入和中等收入国家的中风指南在以下方面低于指南制定所需达到的标准：目标受众的广度、涵盖中风服务的四大要素以及对社会经济环境的适应程度。与高收入国家的指南相比，低收入和中等收入国家的指南透明度较低。不到四分之一的指南涵盖详细的实施计划和社会经济学方面的考虑因素。.低收入和中等收入国家的中风指南需要与更广泛的医疗护理提供者以及利益相关者共同制定，并因地制宜地采取一系列可转化的干预调控措施。.Выявить пробелы в национальных рекомендациях по инсульту, которые возможно устранить с целью повышения качества услуг по лечению инсульта в странах с низким и средним уровнем доходов.Авторы систематически проводили поиск в медицинских базах данных и на веб-сайтах медицинских обществ, а также связывались с международными организациями. Национальные рекомендации по лечению и контролю инсульта, опубликованные с 2010 по 2020 г. на любом языке, соответствовали критериям для включения. Авторы изучили каждую включенную рекомендацию в отношении охвата четырьмя ключевыми компонентами услуг по инсульту (эпиднадзор, профилактика, неотложная помощь и реабилитация). Было также оценено соответствие восьми стандартам Института медицины для рекомендаций по клинической практике, простота внедрения рекомендаций и планы по их распространению среди целевых аудиторий.Авторы изучили 108 подходящих рекомендаций из 47 стран, включая четыре страны с низким уровнем доходов, 24 страны со средним уровнем доходов и 19 стран с высоким уровнем доходов. Во всем мире первичная профилактика инсульта охватывала меньшее количество рекомендаций по сравнению с другими компонентами медицинской помощи, и ни один из них не рекомендовал эпиднадзор. Рекомендации по инсульту в странах с низким и средним уровнем доходов не соответствовали требуемым стандартам для разработки рекомендаций, широте целевой аудитории, охвату четырьмя компонентами услуг по инсульту и адаптации к социально-экономическим условиям. Рекомендации, принятые в странах с низким и средним уровнем доходов, в меньшей степени демонстрировали прозрачность, в отличие от рекомендаций для стран с высоким уровнем дохода. Менее четверти рекомендаций включали подробные планы по реализации и социально-экономические соображения.Рекомендации по инсульту в странах с низким и средним уровнем доходов необходимо разрабатывать совместно с более широкой категорией поставщиков медицинских услуг и заинтересованных сторон, с полным спектром реализуемых и соответствующих обстановке вмешательств. more...

The International Committee of the Red Cross (ICRC) works in fragile States and in armed conflict zones. Some of them are affected by the HIV pandemic. Within the framework of its social responsibility programme concerning HIV affecting its staff members, the organization has implemented an HIV workplace programme since 2004. We carried out a retrospective analysis over 10 years. Data collected were initially essentially qualitative and process-oriented, but were complemented over the years by data on annual voluntary counselling and testing (VCT) uptake and on direct annual costs covering awareness, testing and antiretroviral therapy. The number of people covered by the programme grew from none in 2003 to 4,438 in 2015, with an increase in annual VCT uptake over the years increasing from 376 persons (14 %) in 2007 to 2,663 in 2015 (60 %). Over the years, the services were expanded from awareness raising to bringing VCT to the workplace, as well as offering testing and health coverage of other conditions and innovative approaches to facing challenges linked to situations of violence. Within its social responsibility framework, the ICRC has shown the importance and feasibility of a workplace HIV programme in conflict zones. A sustainable workplace programme in these conflict settings requires constant adaptation, with regular follow-up given the relatively high turnover of staff, and ensuring sustainable stocks of condoms and antiretroviral drugs. more...

Background In 2007 the “Crisp Report” on international partnerships increased interest in Northern countries on the way their links with Southern partners operated. Since its establishment in 2007 the Division of Tropical and Humanitarian Medicine at the Geneva University Hospitals has developed a variety of partnerships. Frameworks to assess these partnerships are needed and recent attention in the field of public management on collaborative governance may provide a useful approach for analyzing international collaborations. Methods Projects of the Division of Tropical and Humanitarian Medicine were analyzed by collaborators within the Division using the model proposed by Emerson and colleagues for collaborative governance, which comprises different components that assess the collaborative process. Results International projects within the Division of Tropical and Humanitarian Medicine can be divided into four categories: Human resource development; Humanitarian response; Neglected Tropical Diseases and Noncommunicable diseases. For each of these projects there was a clear leader from the Division of Tropical and Humanitarian Medicine as well as a local counterpart. These individuals were seen as leaders both due to their role in establishing the collaboration as well as their technical expertise. Across these projects the actual partners vary greatly. This diversity means a wide range of contributions to the collaboration, but also complexity in managing different interests. A common definition of the collaborative aims in each of the projects is both a formal and informal process. Legal, financial and administrative aspects of the collaboration are the formal elements. These can be a challenge based on different administrative requirements. Friendship is part of the informal aspects and helps contribute to a relationship that is not exclusively professional. Conclusion Using collaborative governance allows the complexity of managing partnerships to be presented. The framework used highlights the process of establishing collaborations, which is an element often negated by other more traditional models used in international partnerships. Applying the framework to the projects of the Division of Tropical and Humanitarian Medicine highlights the importance of shared values and interests, credibility of partners, formal and informal methods of management as well as friendship. more...

We welcome Tonelli et al 's1 contribution to raising the profile of non-communicable diseases (NCD), especially on NCD medicines in humanitarian emergencies, a topic that to date has received very little attention.2 However, we would question the message and conclusion of this paper on three grounds. First, from a clinical perspective, the inclusion only of mixed insulin for diabetes exacerbations would seem to be a mistake, with rapid acting and NPH being more important. Although we agree with the authors that the benefits of treatment of NCDs ‘will take time to accrue’ as well as the exclusion of cancer and chronic kidney disease, it would seem to make little sense then to include statins … more...

To the Editor: In today's globalized world, a growing number of people are migrating in search of a better life. Simultaneously, industrialized countries are strengthening border controls and administrative barriers to contain this influx of newcomers, resulting in a significant increase in illegal migration and human trafficking. The U.S. Department of State estimates the annual flow of irregular migrants worldwide to be 700,000–2 million (1). Many of the migrants are from countries where tuberculosis is endemic, and they contribute to the increasing proportion of foreign-born persons with tuberculosis in North America and Europe. These persons may be highly contagious in the local population, as they have limited access to healthcare and often go untreated (2,3). Of 450,000 residents in Geneva, Switzerland, 10,000–20,000 are undocumented and come from developing countries or Eastern Europe. All patients treated for tuberculosis in Geneva are systematically registered by the Antituberculosis Center, a facility at Geneva University Hospital. An outpatient clinic provides free consultations for patients with tuberculosis who have no health insurance, and patients are not required to disclose their immigration status to physicians. Patients with sufficient funds pay for their medication. All cases of tuberculosis in undocumented migrants (foreign residents with no resident permits) reported from 1994 to 1998 were reviewed by the same investigator. Their sociodemographic and clinical characteristics were compared with those of 7 South American legal residents with tuberculosis (representing the whole sample of South American tuberculosis patients) during the same period and with a group of 50 tuberculosis patients from the general population. Characteristics of HIV-positive and HIV-negative patients with tuberculosis were compared also. From 1994 to 1998, a total of 397 persons in Geneva were notified that they were infected with tuberculosis. Twenty-two (6%) case-patients were found among undocumented migrants. The mean age was 31 years (19–48 years), and 20 (91%) were women; 15 (68%) came from South America, 5 (22%) came from Africa, and 2 (9%) came from Europe. Nineteen (95%) of 20 persons had symptoms for >1 month preceding their first medical encounter. Approximately 27.2% had pulmonary manifestations only, 36.4% had extrapulmonary manifestations only, and the remaining 36.4% had both pulmonary and extrapulmonary manifestations. Mycobacterium tuberculosis was found in 11 of 14 with pulmonary involvement, and chest radiograph was normal in 5 (22%). When compared with patients from the general population, women were more numerous (91% vs. 30%), and extrapulmonary tuberculosis was more frequent among undocumented residents (72% vs. 34%). The time from first symptoms to first consultation was also longer when compared to the general population and the registered South American residents (5% vs. 30% and 40%, respectively, consulting in the first month; p = 0.008). In 4 (19%) patients, resistance to >1 antituberculosis drug was identified, with no multidrug resistance (defined as rifampicin) identified, a rate of resistance similar to that seen in their countries of origin but higher than the Swiss rate (6.3%) (4). All patients were treated with a 4-drug regimen (HRZE: H = isoniazid, R = rifampicin, Z = pyrazinamid, E = ethambutol) for 2 months, followed by a 2-drug therapy (HR) for 4 months. Eighteen (82%) patients adhered to the regimen, as determined by monthly medical interviews and urine isoniazid checks. Only the 4 remaining patients who missed more than one third of the appointments with 50% of negative urine checks, or who defaulted, were placed under directly observed therapy. Fifteen (68%) patients regularly attended their appointments until completion of treatment. Seven (32%) patients left Switzerland before the end of treatment, 2 of whom were deported. Fourteen (64%) patients were hospitalized to initiate treatment. Four had health insurance; the other patients contracted a debt for hospitalization. The lack of insurance did not influence adherence to treatment negatively. However, as a consequence of tuberculosis, 8 (66%) lost their jobs. Of 102 identified close contacts, 88 (87%) were evaluated by tuberculin skin testing. Chest x-ray was performed on 21 (24%) patients with a positive test (>10 mm induration), and isoniazid was prescribed prophylactically. No secondary case of active tuberculosis was identified. Most undocumented immigrants with tuberculosis in Geneva are young South American or African women engaged in domestic activities. This finding reflects the irregular work opportunities in Geneva, an area with little agriculture and industry. As suspected, a delay of several weeks occurred before seeking care (5). The economic and social impact of tuberculosis was high for this population. Two thirds of these patients lost their jobs as a consequence of tuberculosis. Joblessness could be an additional factor to further deter patients from seeking care. Adherence to treatment was good, which suggested confidence that care providers would not report to immigration authorities and that supportive follow-up care was available. Of more concern, approximately one third of the patients left Switzerland before completing the full course of treatment. This transfer rate (43%) of undocumented migrants corresponds to that observed among foreign-born patients with unknown legal status in Switzerland (6). Failure to complete a full course of treatment may lead to relapse and emergence of resistant strains. A growing proportion of cases of tuberculosis observed in Europe is in migrants, some undocumented, from the developing world (3). Strong political measures should be enforced to ensure access to healthcare services with respect to confidentiality (as recently stated in the Netherlands) (7). Much emphasis has been put on screening at time of arrival. Screening can be conducted for immigrants and asylum seekers, but undocumented migrants are not screened (8). Facilitated access to medical services and free affordable therapy is a necessity; active tuberculosis develops in most foreign-born residents several years after their arrival (2). In an era of high mobility, specific innovative programs should be established to control and prevent tuberculosis for this high-risk, foreign-born population. Early detection with nonidentifying tuberculosis tracking systems (9), screening at unspecialized clinics (10), and free treatment with adequate administrative measures are needed. Industrialized countries must take responsibility to reduce the spread of resistant tuberculosis. more...