Technologies for global health

Children's Oxygen Administration Strategies Trial (COAST): A randomised controlled trial of high flow versus oxygen versus control in African children with severe pneumonia

Background: In Africa, the clinical syndrome of pneumonia remains the leading cause of morbidity and mortality in children in the post-neonatal period. This represents a significant burden on in-patient services. The targeted use of oxygen and simple, non-invasive methods of respiratory support may be a highly cost-effective means of improving outcome, but the optimal oxygen saturation threshold that results in benefit and the best strategy for delivery are yet to be tested in adequately powered randomised controlled trials. There is, however, an accumulating literature about the harms of oxygen therapy across a range of acute and emergency situations that have stimulated a number of trials investigating permissive hypoxia. Methods: In 4200 African children, aged 2 months to 12 years, presenting to 5 hospitals in East Africa with respiratory distress and hypoxia (oxygen saturation < 92%), the COAST trial will simultaneously evaluate two related interventions (targeted use of oxygen with respect to the optimal oxygen saturation threshold for treatment and mode of delivery) to reduce shorter-term mortality at 48-hours (primary endpoint), and longer-term morbidity and mortality to 28 days in a fractional factorial design, that compares: Liberal oxygenation (recommended care) compared with a strategy that permits hypoxia to SpO 2 > or = 80% (permissive hypoxia); andHigh flow using AIrVO 2 TM compared with low flow delivery (routine care). Discussion: The overarching objective is to address the key research gaps in the therapeutic use of oxygen in resource-limited setting in order to provide a better evidence base for future management guidelines. The trial has been designed to address the poor outcomes of children in sub-Saharan Africa, which are associated with high rates of in-hospital mortality, 9-10% (for those with oxygen saturations of 80-92%) and 26-30% case fatality for those with oxygen saturations <80%. Clinical trial registration: ISRCTN15622505 Trial status: Recruiting.

Optimized Lateral Flow Immunoassay Reader for the Detection of Infectious Diseases in Developing Countries

Detection and control of infectious diseases is a major problem, especially in developing countries. Lateral flow immunoassays can be used with great success for the detection of infectious diseases. However, for the quantification of their results an electronic reader is required. This paper presents an optimized handheld electronic reader for developing countries. It features a potentially low-cost, low-power, battery-operated device with no added optical accessories. The operation of this proof of concept device is based on measuring the reflected light from the lateral flow immunoassay and translating it into the concentration of the specific analyte of interest. Characterization of the surface of the lateral flow immunoassay has been performed in order to accurately model its response to the incident light. Ray trace simulations have been performed to optimize the system and achieve maximum sensitivity by placing all the components in optimum positions. A microcontroller enables all the signal processing to be performed on the device and a Bluetooth module allows transmission of the results wirelessly to a mobile phone app. Its performance has been validated using lateral flow immunoassays with influenza A nucleoprotein in the concentration range of 0.5 ng/mL to 200 ng/mL.

Examining the need & potential for biomedical engineering to strengthen health care delivery for displaced populations & victims of conflict

Conflict and the subsequent displacement of populations creates unique challenges in the delivery of quality health care to the affected population. Equitable access to quality care demands a multi-pronged strategy with a growing need, and role, for technological innovation to address these challenges. While there have been significant contributions towards alleviating the burden of conflict via data informatics and analytics, communication technology, and geographic information systems, little has been done within biomedical engineering. This article elaborates on the causes for gaps in biomedical innovation for refugee populations affected by conflict, tackles preconceived notions, takes stock of recent developments in promising technologies to address these challenges, and identifies tangible action items to create a stronger and sustainable pipeline for biomedical technological innovation to improve the health and well-being of an increasing group of vulnerable people around the world.

Maxillofacial prostheses challenges in resource constrained regions

BACKGROUND

This study reviewed the current state of maxillofacial rehabilitation in resource-limited nations.

METHOD

A rigorous literature review was undertaken using several technical and clinical databases using a variety of key words pertinent to maxillofacial prosthetic rehabilitation and resource-limited areas. In addition, interviews were conducted with researchers, clinicians and prosthetists that had direct experience of volunteering or working in resource-limited countries.

RESULTS

Results from the review and interviews suggest rehabilitating patients in resource-limited countries remains challenging and efforts to improve the situation requires a multifactorial approach.

CONCLUSIONS

In conclusion, public health awareness programmes to reduce the causation of injuries and bespoke maxillofacial prosthetics training programmes to suit these countries, as opposed to attempting to replicate Western training programmes. It is also possible that usage of locally sourced and cheaper materials and the use of low-cost technologies could greatly improve maxillofacial rehabilitation efforts in these localities. Implications for Rehabilitation More information and support needs to be provided to maxillofacial defect/injuries patients and to their families or guardians in a culturally sensitive manner by governments. The health needs, economic and psychological needs of the patients need to be taken into account during the rehabilitation process by clinicians and healthcare organizations. The possibility of developing training programs to suit these resource limited countries and not necessarily follow conventional fabrication methods must be looked into further by educational entities.

Children's Oxygen Administration Strategies Trial (COAST): A randomised controlled trial of high flow versus oxygen versus control in African children with severe pneumonia

Background: In Africa, the clinical syndrome of pneumonia remains the leading cause of morbidity and mortality in children in the post-neonatal period. This represents a significant burden on in-patient services. The targeted use of oxygen and simple, non-invasive methods of respiratory support may be a highly cost-effective means of improving outcome, but the optimal oxygen saturation threshold that results in benefit and the best strategy for delivery are yet to be tested in adequately powered randomised controlled trials. There is, however, an accumulating literature about the harms of oxygen therapy across a range of acute and emergency situations that have stimulated a number of trials investigating permissive hypoxia. Methods: In 4200 African children, aged 2 months to 12 years, presenting to 5 hospitals in East Africa with respiratory distress and hypoxia (oxygen saturation < 92%), the COAST trial will simultaneously evaluate two related interventions (targeted use of oxygen with respect to the optimal oxygen saturation threshold for treatment and mode of delivery) to reduce shorter-term mortality at 48-hours (primary endpoint), and longer-term morbidity and mortality to 28 days in a fractional factorial design, that compares: Liberal oxygenation (recommended care) compared with a strategy that permits hypoxia to SpO 2 > or = 80% (permissive hypoxia); andHigh flow using AIrVO 2TM compared with low flow delivery (routine care). Discussion: The overarching objective is to address the key research gaps in the therapeutic use of oxygen in resource-limited setting in order to provide a better evidence base for future management guidelines. The trial has been designed to address the poor outcomes of children in sub-Saharan Africa, which are associated with high rates of in-hospital mortality, 9-10% (for those with oxygen saturations of 80-92%) and 26-30% case fatality for those with oxygen saturations <80%. Clinical trial registration: ISRCTN15622505 Trial status: Recruiting.

Impact of Point-of-Care Xpert MTB/RIF on Tuberculosis Treatment Initiation. A Cluster-randomized Trial

RATIONALE

Point-of-care (POC) diagnostics have the potential to reduce pretreatment loss to follow-up and delays to initiation of appropriate tuberculosis (TB) treatment.

OBJECTIVES

To evaluate the effect of a POC diagnostic strategy on initiation of appropriate TB treatment.

METHODS

We conducted a cluster-randomized trial of adults with cough who were HIV positive and/or at high risk of drug-resistant TB. Two-week time blocks were randomized to two strategies: (1) Xpert MTB/RIF test (Cepheid, Sunnyvale, CA) performed at a district hospital laboratory or (2) POC Xpert MTB/RIF test performed at a primary health care clinic. All participants provided two sputum specimens: one for the Xpert test and the other for culture as a reference standard. The primary outcome was the proportion of participants with culture-positive pulmonary tuberculosis (PTB) initiated on appropriate TB treatment within 30 days.

MEASUREMENTS AND MAIN RESULTS

Between August 22, 2011, and March 1, 2013, 36 two-week blocks were randomized, and 1,297 individuals were enrolled (646 in the laboratory arm, 651 in the POC arm), 159 (12.4%) of whom had culture-positive PTB. The proportions of participants with culture-positive PTB initiated on appropriate TB treatment within 30 days were 76.5% in the laboratory arm and 79.5% in the POC arm (odds ratio, 1.13; 95% confidence interval, 0.51-2.53; P = 0.76; risk difference, 3.1%; 95% confidence interval, -16.2 to 10.1). The median time to initiation of appropriate treatment was 7 days (laboratory) versus 1 day (POC).

CONCLUSIONS

POC positioning of the Xpert test led to more rapid initiation of appropriate TB treatment. Achieving one-stop diagnosis and treatment for all people with TB will require simpler, more sensitive diagnostics and broader strengthening of health systems. Clinical trial registered with www.isrctn.com (ISRCTN 18642314) and www.sanctr.gov.za (DOH-27-0711-3568).

Antimalarial efficacy of Pongamia pinnata (L) Pierre against Plasmodium falciparum (3D7 strain) and Plasmodium berghei (ANKA)

Background

The objective of the current study was to assess the in vitro antiplasmodial activities of leaf, bark, flower, and the root of Pongamia pinnata against chloroquine-sensitive Plasmodium falciparum (3D7 strain), cytotoxicity against Brine shrimp larvae and THP-1 cell line. For in vivo study, the plant extract which has shown potent in vitro antimalarial activity was tested against Plasmodium berghei (ANKA strain).

Methods

The plant Pongamia pinnata was collected from the herbal garden of Acharya Nagarjuna University of Guntur district, Andhra Pradesh, India. Sequentially crude extracts of methanol (polar), chloroform (non-polar), hexane (non-polar), ethyl acetate (non-polar) and aqueous (polar) of dried leaves, bark, flowers and roots of Pongamia pinnata were prepared using Soxhlet apparatus. The extracts were screened for in vitro antimalarial activity against P. falciparum 3D7 strain. The cytotoxicity studies of crude extracts were conducted against Brine shrimp larvae and THP-1 cell line. Phytochemical analysis of the plant extracts was carried out by following the standard methods. The chemical injury to erythrocytes due to the plant extracts was checked. The in vivo study was conducted on P. berghei (ANKA) infected BALB/c albino mice by following 4-Day Suppressive, Repository, and Curative tests.

Results

Out of all the tested extracts, the methanol extract of the bark of Pongamia pinnata had shown an IC₅₀ value of 11.67 μg/mL with potent in vitro antimalarial activity and cytotoxicity evaluation revealed that this extract was not toxic against Brine shrimp and THP-1 cells. The injury to erythrocytes analysis had not shown any morphological alterations and damage to the erythrocytes after 48 h of incubation. Because methanolic bark extract of Pongamia pinnata has shown good antimalarial activity in vitro, it was also tested in vivo. So the extract had exhibited an excellent activity against P. berghei malaria parasite while decrement of parasite counts was moderately low and dose-dependent (P < 0.05) when compared to the control groups, which shown a daily increase of parasitemia, unlike the CQ-treated groups. The highest concentration of the extract (1000 mg/kg b.wt./day) had shown 83.90, 87.47 and 94.67% of chemo-suppression during Suppressive, Repository, and Curative tests respectively which is almost nearer to the standard drug Chloroquine (5 mg/kg b.wt./day). Thus, the study has revealed that the methanolic bark extract had shown promisingly high ((P < 0.05) and dose-dependent chemo-suppression. The phytochemical screening of the crude extracts had shown the presence of alkaloids, flavonoids, triterpenes, tannins, carbohydrates, phenols, coumarins, saponins, phlobatannins and steroids.

Conclusions

The present study is useful to develop new antimalarial drugs in the scenario of the growing resistance to the existing antimalarials. Thus, additional research is needed to characterize the bioactive molecules of the extracts of Pongamia pinnata that are responsible for inhibition of malaria parasite.

Mapping mHealth (mobile health) and mobile penetrations in sub-Saharan Africa for strategic regional collaboration in mHealth scale-up: an application of exploratory spatial data analysis

Background

Mobile health (mHealth), a term used for healthcare delivery via mobile devices, has gained attention as an innovative technology for better access to healthcare and support for performance of health workers in the global health context. Despite large expansion of mHealth across sub-Saharan Africa, regional collaboration for scale-up has not made progress since last decade.

Methods

As a groundwork for strategic planning for regional collaboration, the study attempted to identify spatial patterns of mHealth implementation in sub-Saharan Africa using an exploratory spatial data analysis. In order to obtain comprehensive data on the total number of mHelath programs implemented between 2006 and 2016 in each of the 48 sub-Saharan Africa countries, we performed a systematic data collection from various sources, including: the WHO eHealth Database, the World Bank Projects & Operations Database, and the USAID mHealth Database. Additional spatial analysis was performed for mobile cellular subscriptions per 100 people to suggest strategic regional collaboration for improving mobile penetration rates along with the mHealth initiative. Global Moran’s I and Local Indicator of Spatial Association (LISA) were calculated for mHealth programs and mobile subscriptions per 100 population to investigate spatial autocorrelation, which indicates the presence of local clustering and spatial disparities.

Results

From our systematic data collection, the total number of mHealth programs implemented in sub-Saharan Africa between 2006 and 2016 was 487 (same programs implemented in multiple countries were counted separately). Of these, the eastern region with 17 countries and the western region with 16 countries had 287 and 145 mHealth programs, respectively. Despite low levels of global autocorrelation, LISA enabled us to detect meaningful local clusters. Overall, the eastern part of sub-Saharan Africa shows high-high association for mHealth programs. As for mobile subscription rates per 100 population, the northern area shows extensive low-low association.

Conclusions

This study aimed to shed some light on the potential for strategic regional collaboration for scale-up of mHealth and mobile penetration. Firstly, countries in the eastern area with much experience can take the lead role in pursuing regional collaboration for mHealth programs in sub-Saharan Africa. Secondly, collective effort in improving mobile penetration rates for the northern area is recommended.

Electronic supplementary material

The online version of this article (doi:10.1186/s12992-017-0286-9) contains supplementary material, which is available to authorized users.

Methods for medical device and equipment procurement and prioritization within low- and middle-income countries: findings of a systematic literature review

Background

Forty to 70 % of medical devices and equipment in low- and middle-income countries are broken, unused or unfit for purpose; this impairs service delivery to patients and results in lost resources. Undiscerning procurement processes are at the heart of this issue.

We conducted a systematic review of the literature to August 2013 with no time or language restrictions to identify what product selection or prioritization methods are recommended or used for medical device and equipment procurement planning within low- and middle-income countries. We explore the factors/evidence-base proposed for consideration within such methods and identify prioritization criteria.

Results

We included 217 documents (corresponding to 250 texts) in the narrative synthesis. Of these 111 featured in the meta-summary. We identify experience and needs-based methods used to reach procurement decisions. Equipment costs (including maintenance) and health needs are the dominant issues considered. Extracted data suggest that procurement officials should prioritize devices with low- and middle-income country appropriate technical specifications – i.e. devices and equipment that can be used given available human resources, infrastructure and maintenance capacity.

Conclusion

Suboptimal device use is directly linked to incomplete costing and inadequate consideration of maintenance services and user training during procurement planning. Accurate estimation of life-cycle costing and careful consideration of device servicing are of crucial importance.

Electronic supplementary material

The online version of this article (doi:10.1186/s12992-017-0280-2) contains supplementary material, which is available to authorized users.

Development and implementation of Models of Care for musculoskeletal conditions in middle-income and low-income Asian countries

This chapter discusses the challenges faced in the development and implementation of musculoskeletal (MSK) Models of Care (MoCs) in middle-income and low-income countries in Asia and outlines the components of an effective MoC for MSK conditions. Case studies of four such countries (The Philippines, Malaysia, Bangladesh and Myanmar) are presented, and their unique implementation issues are discussed. The success experienced in one high-income country (Singapore) is also described as a comparison. The Community Oriented Program for Control of Rheumatic Diseases (COPCORD) project and the role of Asia Pacific League of Associations for Rheumatology (APLAR), a professional body supporting MoC initiatives in this region, are also discussed. The experience and lessons learned from these case studies can provide useful information to guide the implementation of future MSK MoC initiatives in other middle-income and low-income countries.

Cervical cancer screening in rural Bhutan with the careHPV test on self-collected samples: an ongoing cross-sectional, population-based study (REACH-Bhutan)

OBJECTIVES

The Bhutanese Screening Programme recommends a Pap smear every 3 years for women aged 25-65 years, and coverage ranges from 20% to 60%, being especially challenging in rural settings. The 'REACH-Bhutan' study was conducted to assess the feasibility and outcomes of a novel approach to cervical cancer screening in rural Bhutan.

DESIGN

Cross-sectional, population-based study of cervical cancer screening based on the careHPV test on self-collected samples.

SETTING

Women were recruited in rural primary healthcare centres, that is, Basic Health Units (BHU), across Bhutan.

PARTICIPANTS

Overall, 3648 women aged 30-60 were invited from 15 BHUs differing in accessibility, size and ethnic composition of the population.

INTERVENTIONS

Participants provided a self-collected cervicovaginal sample and were interviewed. Samples were tested using careHPV in Thimphu (the Bhutanese capital) referral laboratory.

MAIN OUTCOME MEASURES

Screening participation by geographic area, centre, age and travelling time. Previous screening history and careHPV positivity by selected characteristics of the participants.

RESULTS

In April/May 2016, 2590 women (median age: 41) were enrolled. Study participation was 71% and significantly heterogeneous by BHU (range: 31%-96%). Participation decreased with increase in age (81% in women aged 30-39 years; 59% in ≥50 years) and travelling time (90% in women living <30 min from the BHU vs 62% among those >6 hours away). 50% of participants reported no previous screening, with the proportion of never-screened women varying significantly by BHU (range: 2%-72%). 265 women (10%; 95% CI 9% to 11%) were careHPV positive, with a significant variation by BHU (range: 5%-19%) and number of sexual partners (prevalence ratio for ≥3 vs 0-1, 1.55; 95% CI 1.05 to 2.27).

CONCLUSIONS

Community-based cervical cancer screening by testing self-collected samples for human papillomavirus (HPV) can achieve high coverage in rural Bhutan. However, solutions to bring self-collection, HPV testing and precancer treatment closer to the remotest villages are needed.

Cost effectiveness of medical devices to diagnose pre-eclampsia in low-resource settings

BACKGROUND

Maternal mortality remains a major health challenge facing developing countries, with pre-eclampsia accounting for up to 17 percent of maternal deaths. Diagnosis requires skilled health providers and devices that are appropriate for low-resource settings. This study presents the first cost-effectiveness analysis of multiple medical devices used to diagnose pre-eclampsia in low- and middle-income countries (LMICs).

METHODS

Blood pressure and proteinuria measurement devices, identified from compendia for LMICs, were included. We developed a decision tree framework to assess the cost-effectiveness of each device using parameter values that reflect the general standard of care based on a survey of relevant literature and expert opinion. We examined the sensitivity of our results using one-way and second-order probabilistic multivariate analyses.

RESULTS

Because the disability-adjusted life years (DALYs) averted for each device were very similar, the results were influenced by the per-use cost ranking. The most cost-effective device combination was a semi-automatic blood pressure measurement device and visually read urine strip test with the lowest combined per-use cost of $0.2004 and an incremental cost effectiveness ratio of $93.6 per DALY gained relative to a baseline with no access to diagnostic devices. When access to treatment is limited, it is more cost-effective to improve access to treatment than to increase testing rates or diagnostic device sensitivity.

CONCLUSIONS

Our findings were not sensitive to changes in device sensitivity, however they were sensitive to changes in the testing rate and treatment rate. Furthermore, our results suggest that simple devices are more cost-effective than complex devices. The results underscore the desirability of two design features for LMICs: ease of use and accuracy without calibration. Our findings have important implications for policy makers, health economists, health care providers and engineers.

Affordable stroke therapy in high-, low- and middle-income countries: From Theradrive to Rehab CARES, a compact robot gym

Affordable technology-assisted stroke rehabilitation approaches can improve access to rehabilitation for low-resource environments characterized by the limited availability of rehabilitation experts and poor rehabilitation infrastructure. This paper describes the evolution of an approach to the implementation of affordable, technology-assisted stroke rehabilitation which relies on low-cost mechatronic/robot devices integrated with off-the-shelf or custom games. Important lessons learned from the evolution and use of Theradrive in the USA and in Mexico are briefly described. We present how a stronger and more compact version of the Theradrive is leveraged in the development of a new low-cost, all-in-one robot gym with four exercise stations for upper and lower limb therapy called Rehab Community-based Affordable Robot Exercise System (Rehab C.A.R.E.S). Three of the exercise stations are designed to accommodate versions of the 1 DOF haptic Theradrive with different custom handles or off-the-shelf commercial motion machine. The fourth station leverages a unique configuration of Wii-boards. Overall, results from testing versions of Theradrive in USA and Mexico in a robot gym suggest that the resulting presentation of the Rehab C.A.R.E.S robot gym can be deployed as an affordable computer/robot-assisted solution for stroke rehabilitation in developed and developing countries.

Perceived reciprocal value of health professionals' participation in global child health-related work

Background

Leading children’s hospitals in high-income settings have become heavily engaged in international child health research and educational activities. These programs aim to provide benefit to the institutions, children and families in the overseas locations where they are implemented. Few studies have measured the actual reciprocal value of this work for the home institutions and for individual staff who participate in these overseas activities. Our objective was to estimate the perceived reciprocal value of health professionals’ participation in global child health-related work. Benefits were measured in the form of skills, knowledge and attitude strengthening as estimated by an adapted Global Health Competency Model.

Methods

A survey questionnaire was developed following a comprehensive review of literature and key competency models. It was distributed to all health professionals at the Hospital for Sick Children with prior international work experience (n = 478).

Results

One hundred fifty six health professionals completed the survey (34%). A score of 0 represented negligible value gained and a score of 100 indicated significant capacity improvement. The mean respondent improvement score was 57 (95% CI 53–62) suggesting improved overall competency resulting from their international experiences. Mean scores were >50% in 8 of 10 domains. Overall scores suggest that international work brought value to the hospital and over half responded that their international experience would influence their decision to stay on at the hospital.

Conclusions

The findings offer tangible examples of how global child health work conducted outside of one’s home institution impacts staff and health systems locally.

Electronic supplementary material

The online version of this article (doi:10.1186/s12992-017-0250-8) contains supplementary material, which is available to authorized users.

The effectiveness of a Supported Self-management task-shifting intervention for adult depression in Vietnam communities: study protocol for a randomized controlled trial

Background

Depressive disorders are one of the leading causes of disease and disability worldwide. In Vietnam, although epidemiological evidence suggests that depression rates are on par with global averages, services for depression are very limited. In a feasibility study that was implemented from 2013 to 2015, we found that a Supported Self-management (SSM) intervention showed promising results for adults with depression in the community in Vietnam.

This paper describes the Mental Health in Adults and Children: Frugal Innovations (MAC-FI) trial protocol that will assess the effectiveness of the SSM intervention, delivered by primary care and social workers, to community-based populations of adults with depression in eight Vietnamese provinces.

Methods/design

The MAC-FI program will be assessed using a stepped-wedge, randomized controlled trial. Study participants are adults aged 18 years and over in eight provinces of Vietnam. Study participants will be screened at primary care centres and in the community by health and social workers using the Self-reporting Questionnaire-20 (SRQ-20). Patients scoring >7, indicating depression caseness, will be invited to participate in the study in either the SSM intervention group or the enhanced treatment as usual control group. Recruited participants will be further assessed using the World Health Organization’s Disability Assessment Scale (WHODAS 2.0) and the Cut-down, Annoyed, Guilty, Eye-opener (CAGE) Questionnaire for alcohol misuse. Intervention-group participants will receive the SSM intervention, delivered with the support of a social worker or social collaborator, for a period of 2 months. Control- group participants will receive treatment as usual and a leaflet with information about depression. SRQ-20, WHODAS 2.0 and CAGE scores will be taken by blinded outcome assessors at baseline, after 1 month and after 2 months. The primary analysis method will be intention-to-treat.

Discussion

This study has the potential to add to the knowledge base about the effectiveness of a SSM intervention for adult depression that has been validated for the Vietnamese context. This trial will also contribute to the growing body of evidence about the effectiveness of low-cost, task-shifting interventions for use in low-resource settings, where specialist mental health services are often limited.

Trial registration

Retrospectively registered at ClinicalTrials.gov, identifier: NCT03001063. Registered on 20 December 2016.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-1924-5) contains supplementary material, which is available to authorized users.

Current challenges in the management of sepsis in ICUs in resource-poor settings and suggestions for the future

BACKGROUND

Sepsis is a major reason for intensive care unit (ICU) admission, also in resource-poor settings. ICUs in low- and middle-income countries (LMICs) face many challenges that could affect patient outcome.

AIM

To describe differences between resource-poor and resource-rich settings regarding the epidemiology, pathophysiology, economics and research aspects of sepsis. We restricted this manuscript to the ICU setting even knowing that many sepsis patients in LMICs are treated outside an ICU.

FINDINGS

Although many bacterial pathogens causing sepsis in LMICs are similar to those in high-income countries, resistance patterns to antimicrobial drugs can be very different; in addition, causes of sepsis in LMICs often include tropical diseases in which direct damaging effects of pathogens and their products can sometimes be more important than the response of the host. There are substantial and persisting differences in ICU capacities around the world; not surprisingly the lowest capacities are found in LMICs, but with important heterogeneity within individual LMICs. Although many aspects of sepsis management developed in rich countries are applicable in LMICs, implementation requires strong consideration of cost implications and the important differences in resources.

CONCLUSIONS

Addressing both disease-specific and setting-specific factors is important to improve performance of ICUs in LMICs. Although critical care for severe sepsis is likely cost-effective in LMIC setting, more detailed evaluation at both at a macro- and micro-economy level is necessary. Sepsis management in resource-limited settings is a largely unexplored frontier with important opportunities for research, training, and other initiatives for improvement.

Implementing monitoring technologies in care homes for people with dementia: A qualitative exploration using Normalization Process Theory

Background

Ageing societies and a rising prevalence of dementia are associated with increasing demand for care home places. Monitoring technologies (e.g. bed-monitoring systems; wearable location-tracking devices) are appealing to care homes as they may enhance safety, increase resident freedom, and reduce staff burden. However, there are ethical concerns about the use of such technologies, and it is unclear how they might be implemented to deliver their full range of potential benefits.

Objective

This study explored facilitators and barriers to the implementation of monitoring technologies in care homes.

Design

Embedded multiple-case study with qualitative methods.

Setting

Three dementia-specialist care homes in North-West England.

Participants

Purposive sample of 24 staff (including registered nurses, clinical specialists, senior managers and care workers), 9 relatives and 9 residents.

Methods

36 semi-structured interviews with staff, relatives and residents; 175 h of observation; resident care record review. Data collection informed by Normalization Process Theory, which seeks to account for how novel interventions become routine practice. Data analysed using Framework Analysis.

Results

Findings are presented under three main themes: 1. Reasons for using technologies: The primary reason for using monitoring technologies was to enhance safety. This often seemed to override consideration of other potential benefits (e.g. increased resident freedom) or ethical concerns (e.g. resident privacy); 2. Ways in which technologies were implemented: Some staff, relatives and residents were not involved in discussions and decision-making, which seemed to limit understandings of the potential benefits and challenges from the technologies. Involvement of residents appeared particularly challenging. Staff highlighted the importance of training, but staff training appeared mainly informal which did not seem sufficient to ensure that staff fully understood the technologies; 3. Use of technologies in practice: Technologies generated frequent alarms that placed a burden upon staff, but staff were able to use their contextual knowledge to help to counter some of this burden. Some technologies offered a range of data-gathering capabilities, but were not always perceived as useful complements to practice.

Conclusion

Implementation of monitoring technologies may be facilitated by the extent to which the technologies are perceived to enhance safety. Implementation may be further facilitated through greater involvement of all stakeholders in discussions and decision-making in order to deepen understandings about the range of potential benefits and challenges from the use of monitoring technologies. Staff training might need to move beyond functional instruction to include deeper exploration of anticipated benefits and the underlying rationale for using monitoring technologies.

Ebola research funding: a systematic analysis, 1997-2015

BACKGROUND

The latest outbreak of Ebola in West Africa overwhelmed the affected countries, with the impact on health extending far beyond Ebola-related deaths that have exceeded 11 000. The need to promptly mobilise resources to control emerging infections is widely recognized. Yet, data on research funding for emerging infections remains inadequately documented.

METHODS

We defined research investment as all funding flows for Ebola and/or Marburg virus from 1997 to April 2015 whose primary purpose was to advance knowledge and new technologies to prevent or cure disease. We sourced data directly from funding organizations and estimated the investment in 2015 US dollars (US$).

RESULTS

Funding for Ebola and Marburg virus research in 1997 to 2015 amounted to US$ 1.035 billion, including US$ 435.4 million (42.0%) awarded in 2014 and 2015. Public sources of funding invested US$ 758.8 million (73.1%), philanthropic sources US$ 65.1 million (6.3%), and joint public/private/philanthropic ventures accounted for US$ 213.8 million (20.6%). Prior to the Ebola outbreak in 2014, pre-clinical research dominated research with US$ 443.6 million (73.9%) investment. After the outbreak, however, investment for new product development increased 942.7-fold and that for clinical trials rose 23.5-fold. Investment in new tools to control Ebola and Marburg virus amounted to US$ 399.1 million, with 61.3% awarded for vaccine research, 29.2% for novel therapeutics research such as antivirals and convalescent blood products, and 9.5% for diagnostics research. Research funding and bibliometric output were moderately associated (Spearman's ρ = 0.5232, P = 0.0259), however number of Ebola cases in previous outbreaks and research funding (ρ = 0.1706, P = 0.4985) and Ebola cases in previous outbreaks and research output (ρ = 0.3020, P = 0.0616) were poorly correlated.

CONCLUSION

Significant public and philanthropic funds have been invested in Ebola and Marburg virus research in 2014 and 2015, following the outbreak in West Africa. Long term, strategic vision and leadership are needed to invest in infections with pandemic potential early, including innovative financing measures and open access investment data to promote the development of new therapies and technologies.

The social value of candidate HIV cures: actualism versus possibilism

A sterilising or functional cure for HIV is a serious scientific challenge but presents a viable pathway to the eradication of HIV. Such an event would be extremely valuable in terms of relieving the burden of a terrible disease; however, a coordinated commitment to implement healthcare interventions, particularly in regions that bear the brunt of the HIV epidemic, is lacking. In this paper, we examine two strategies for evaluating candidate HIV cures, based on our beliefs about the likelihood of global implementation. We reject possibilist interpretations of social value that do not account for the likelihood that a plan to cure HIV will be followed through. We argue, instead, for an actualist ranking of options for action, which accounts for the likelihood that a cure will be low cost, scalable and easy to administer worldwide.

Considerations for an Access-Centered Design of the Fever Thermometer in Low-Resource Settings: A Literature Review

Background

The lack of adequate information about fever in low-resource settings, its unreliable self-assessment, and poor diagnostic practices may result in delayed care and under-or-overdiagnosis of diseases such as malaria. The mismatches of existing fever thermometers in the context of use imply that the diagnostic tools and connected services need to be studied further to address the challenges of fever-related illnesses and their diagnostics.

Objective

This study aims to inform a product-service system approach to design a reliable and accessible fever thermometer and connected services, as well as contribute to the identification of innovative opportunities to improve health care in low-resource settings.

Methods

To determine what factors impede febrile people seeking health care to access adequate fever diagnostics, a literature search was conducted in Google Scholar and PubMed with relevant keywords. Next, these factors were combined with a patient journey model to design a new product-service system for fever diagnostics in low-resource settings.

Results

In total, 37 articles were reviewed. The five As framework was used to categorize the identified barriers. The results indicate that there is a poor distribution of reliable fever diagnostic practices among remote communities. This paper speaks to the global public health and design communities. Three complementary considerations are discussed that support the idea of a more holistic approach to the design of fever diagnostics: (1) understanding of the fever diagnostics patient journey, (2) identifying user groups of the thermometers in a specific health care system, and (3) assessing different needs and interests of the different users.

Conclusions

Access to basic, primary health care may be enhanced with better information and technology design made through the involvement of system users.

Health hackathons: theatre or substance? A survey assessment of outcomes from healthcare-focused hackathons in three countries

Background

Healthcare-focused hackathons are 48-hour platforms intended to accelerate novel medical technology. However, debate exists about how much they contribute to medical technology innovation. The Consortium for Affordable Medical Technologies (CAMTech) has developed a three-pronged model to maximise their effectiveness. To gauge the success of this model, we examined follow-up outcomes.

Methods

Outcomes of 12 hackathons from 2012 to 2015 in India, Uganda and the USA were measured using emailed surveys. To minimise response bias, non-responding teams were coded as having made no progress.

Results

331 individuals provided information on 196 of 356 projects (55.1% response rate), with no difference in responses from teams participating in different countries (Cramer's V=0.09, p=0.17). 30.3% of projects had made progress after a mean of 12.2 months. 88 (24.7%) teams had initiated pilot testing, with 42 (11.8%) piloting with care providers and 24 (6.7%) with patients. Overall, 97 teams (8.1 per hackathon) drafted business plans, 22 (1.8 per hackathon) had filed patents on their innovations and 15 (1.3 per hackathon) had formed new companies. Teams raised US$64.08 million in funding (average US$5.34 million per hackathon; median award size of $1800). In addition, 108 teams (30.3%) reported at least one member working on additional technologies with people they met at a hackathon. Individual confidence to address medical technology challenges was significantly increased after attending (t(1282)=192.77, p 0.001).

Conclusion

CAMTech healthcare hackathons lead to consistent output with respect to medical technology innovation, including clinical trials, business plan development, securing investment capital/funding and new company formation.

Effectiveness of the WHO SCC on improving adherence to essential practices during childbirth, in resource constrained settings

Background

India accounts for 27 % of world’s neonatal deaths. Although more Indian women deliver in facilities currently than a decade ago, early neonatal mortality has not declined, likely because of insufficient quality of care. The WHO Safe Childbirth Checklist (SCC) was developed to support health workers to perform essential practices known to reduce preventable maternal and new-born deaths around the time of childbirth. Despite promising early research many outstanding questions remain about effectiveness of the SCC in low-resource settings.

Methods

In collaboration with the Ministry of Health SCC was modified for Indian context and introduced in 101 intervention facilities in Rajasthan, India and 99 facilities served as comparison to study if it reduces mortality. This Quasi experimental Observational intervention-comparison was embedded in this larger program to test whether a program for introduction of SCC with simple implementation package was associated with increased adherence to 28 evidence-based practices. This study was conducted in 8 intervention and 8 comparison sites. Program interventions to promote appropriate use of the SCC included orienting providers to the checklist, modest modifications of the SCC to promote provider uptake and accountability, ensuring availability of essential supplies, and providing supportive supervision for helping providers in using the SCC.

Results

The SCC was used by providers in 86 % of 240 deliveries observed in the eight intervention facilities. Providers in the intervention group significantly adhered to practices included in the SCC than providers in the comparison group controlling for baseline scores and confounders. Women delivering in the intervention facilities received on an average 11.5 more of the 28 practices included compared with women in the comparison facilities. For selected practices provider performance in the intervention group increased as much as 93 % than comparison sites.

Conclusion

Use of the SCC and provider performance of best practices increased in intervention facilities reflecting improvement in quality of facility childbirth care for women and new-born in low resource settings.

Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980-2015: a systematic analysis for the Global Burden of Disease Study 2015

BACKGROUND

Improving survival and extending the longevity of life for all populations requires timely, robust evidence on local mortality levels and trends. The Global Burden of Disease 2015 Study (GBD 2015) provides a comprehensive assessment of all-cause and cause-specific mortality for 249 causes in 195 countries and territories from 1980 to 2015. These results informed an in-depth investigation of observed and expected mortality patterns based on sociodemographic measures.

METHODS

We estimated all-cause mortality by age, sex, geography, and year using an improved analytical approach originally developed for GBD 2013 and GBD 2010. Improvements included refinements to the estimation of child and adult mortality and corresponding uncertainty, parameter selection for under-5 mortality synthesis by spatiotemporal Gaussian process regression, and sibling history data processing. We also expanded the database of vital registration, survey, and census data to 14 294 geography-year datapoints. For GBD 2015, eight causes, including Ebola virus disease, were added to the previous GBD cause list for mortality. We used six modelling approaches to assess cause-specific mortality, with the Cause of Death Ensemble Model (CODEm) generating estimates for most causes. We used a series of novel analyses to systematically quantify the drivers of trends in mortality across geographies. First, we assessed observed and expected levels and trends of cause-specific mortality as they relate to the Socio-demographic Index (SDI), a summary indicator derived from measures of income per capita, educational attainment, and fertility. Second, we examined factors affecting total mortality patterns through a series of counterfactual scenarios, testing the magnitude by which population growth, population age structures, and epidemiological changes contributed to shifts in mortality. Finally, we attributed changes in life expectancy to changes in cause of death. We documented each step of the GBD 2015 estimation processes, as well as data sources, in accordance with Guidelines for Accurate and Transparent Health Estimates Reporting (GATHER).

FINDINGS

Globally, life expectancy from birth increased from 61·7 years (95% uncertainty interval 61·4-61·9) in 1980 to 71·8 years (71·5-72·2) in 2015. Several countries in sub-Saharan Africa had very large gains in life expectancy from 2005 to 2015, rebounding from an era of exceedingly high loss of life due to HIV/AIDS. At the same time, many geographies saw life expectancy stagnate or decline, particularly for men and in countries with rising mortality from war or interpersonal violence. From 2005 to 2015, male life expectancy in Syria dropped by 11·3 years (3·7-17·4), to 62·6 years (56·5-70·2). Total deaths increased by 4·1% (2·6-5·6) from 2005 to 2015, rising to 55·8 million (54·9 million to 56·6 million) in 2015, but age-standardised death rates fell by 17·0% (15·8-18·1) during this time, underscoring changes in population growth and shifts in global age structures. The result was similar for non-communicable diseases (NCDs), with total deaths from these causes increasing by 14·1% (12·6-16·0) to 39·8 million (39·2 million to 40·5 million) in 2015, whereas age-standardised rates decreased by 13·1% (11·9-14·3). Globally, this mortality pattern emerged for several NCDs, including several types of cancer, ischaemic heart disease, cirrhosis, and Alzheimer's disease and other dementias. By contrast, both total deaths and age-standardised death rates due to communicable, maternal, neonatal, and nutritional conditions significantly declined from 2005 to 2015, gains largely attributable to decreases in mortality rates due to HIV/AIDS (42·1%, 39·1-44·6), malaria (43·1%, 34·7-51·8), neonatal preterm birth complications (29·8%, 24·8-34·9), and maternal disorders (29·1%, 19·3-37·1). Progress was slower for several causes, such as lower respiratory infections and nutritional deficiencies, whereas deaths increased for others, including dengue and drug use disorders. Age-standardised death rates due to injuries significantly declined from 2005 to 2015, yet interpersonal violence and war claimed increasingly more lives in some regions, particularly in the Middle East. In 2015, rotaviral enteritis (rotavirus) was the leading cause of under-5 deaths due to diarrhoea (146 000 deaths, 118 000-183 000) and pneumococcal pneumonia was the leading cause of under-5 deaths due to lower respiratory infections (393 000 deaths, 228 000-532 000), although pathogen-specific mortality varied by region. Globally, the effects of population growth, ageing, and changes in age-standardised death rates substantially differed by cause. Our analyses on the expected associations between cause-specific mortality and SDI show the regular shifts in cause of death composition and population age structure with rising SDI. Country patterns of premature mortality (measured as years of life lost [YLLs]) and how they differ from the level expected on the basis of SDI alone revealed distinct but highly heterogeneous patterns by region and country or territory. Ischaemic heart disease, stroke, and diabetes were among the leading causes of YLLs in most regions, but in many cases, intraregional results sharply diverged for ratios of observed and expected YLLs based on SDI. Communicable, maternal, neonatal, and nutritional diseases caused the most YLLs throughout sub-Saharan Africa, with observed YLLs far exceeding expected YLLs for countries in which malaria or HIV/AIDS remained the leading causes of early death.

INTERPRETATION

At the global scale, age-specific mortality has steadily improved over the past 35 years; this pattern of general progress continued in the past decade. Progress has been faster in most countries than expected on the basis of development measured by the SDI. Against this background of progress, some countries have seen falls in life expectancy, and age-standardised death rates for some causes are increasing. Despite progress in reducing age-standardised death rates, population growth and ageing mean that the number of deaths from most non-communicable causes are increasing in most countries, putting increased demands on health systems.

FUNDING

Bill & Melinda Gates Foundation.

Assessing suicide attempts and depression among Chinese speakers over the Internet

BACKGROUND

In populations where mental health resources are scarce or unavailable, or where stigma prevents help-seeking, the Internet may be a way to identify and reach at-risk persons using self-report validated screening tools as well as to characterize individuals seeking health information online.

AIMS

We examined the feasibility of delivering an Internet-based Chinese-language depression and suicide screener and described its users.

METHOD

An Internet-based depression and suicide screener was created and advertised primarily through Google AdWords. Participants completed a suicide and depression screening measure and received individualized feedback, which, if necessary, included the suggestion to seek additional mental health resources.

RESULTS

In 7 months, 11,631 individuals visited the site; 4,709 provided valid information. Nearly half reported a current major depressive episode (MDE) and 18.3% a recent suicide attempt; however, over 75% reported never having sought help, including 77.7% of those with MDEs and 75.9% of those reporting a suicide attempt. As participants found the site by searching for depression information online, results may not generalize to the entire Chinese-speaking population.

CONCLUSION

Online screening can feasibly identify and reach many at-risk Chinese-speaking persons. It may provide resources to those with limited access to services or to those reluctant to seek such services.

Computer-assisted initial diagnosis of rare diseases

Introduction. Most documented rare diseases have genetic origin. Because of their low individual frequency, an initial diagnosis based on phenotypic symptoms is not always easy, as practitioners might never have been exposed to patients suffering from the relevant disease. It is thus important to develop tools that facilitate symptom-based initial diagnosis of rare diseases by clinicians. In this work we aimed at developing a computational approach to aid in that initial diagnosis. We also aimed at implementing this approach in a user friendly web prototype. We call this tool Rare Disease Discovery. Finally, we also aimed at testing the performance of the prototype. Methods. Rare Disease Discovery uses the publicly available ORPHANET data set of association between rare diseases and their symptoms to automatically predict the most likely rare diseases based on a patient's symptoms. We apply the method to retrospectively diagnose a cohort of 187 rare disease patients with confirmed diagnosis. Subsequently we test the precision, sensitivity, and global performance of the system under different scenarios by running large scale Monte Carlo simulations. All settings account for situations where absent and/or unrelated symptoms are considered in the diagnosis. Results. We find that this expert system has high diagnostic precision (≥80%) and sensitivity (≥99%), and is robust to both absent and unrelated symptoms. Discussion. The Rare Disease Discovery prediction engine appears to provide a fast and robust method for initial assisted differential diagnosis of rare diseases. We coupled this engine with a user-friendly web interface and it can be freely accessed at http://disease-discovery.udl.cat/. The code and most current database for the whole project can be downloaded from https://github.com/Wrrzag/DiseaseDiscovery/tree/no_classifiers.

A systematic review of randomized controlled trials of mHealth interventions against non-communicable diseases in developing countries

Background

The reasons of deaths in developing countries are shifting from communicable diseases towards non-communicable diseases (NCDs). At the same time the number of health care interventions using mobile phones (mHealth interventions) is growing rapidly. We review studies assessing the health-related impacts of mHealth on NCDs in low- and middle-income countries (LAMICs).

Methods

A systematic literature search of three major databases was performed in order to identify randomized controlled trials (RCTs) of mHealth interventions. Identified studies were reviewed concerning key characteristics of the trial and the intervention; and the relationship between intervention characteristics and outcomes was qualitatively assessed.

Results

The search algorithms retrieved 994 titles. 8 RCTs were included in the review, including a total of 4375 participants. Trials took place mostly in urban areas, tested different interventions (ranging from health promotion over appointment reminders and medication adjustments to clinical decision support systems), and included patients with different diseases (diabetes, asthma, hypertension). Except for one study all showed rather positive effects of mHealth interventions on reported outcome measures.

Furthermore, our results suggest that particular types of mHealth interventions that were found to have positive effects on patients with communicable diseases and for improving maternal care are likely to be effective also for NCDs.

Conclusions

Despite rather positive results of included RCTs, a firm conclusion about the effectiveness of mHealth interventions against NCDs is not yet possible because of the limited number of studies, the heterogeneity of evaluated mHealth interventions and the wide variety of reported outcome measures. More research is needed to better understand the specific effects of different types of mHealth interventions on different types of patients with NCDs in LaMICs.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-016-3226-3) contains supplementary material, which is available to authorized users.

M-Health for Improving Screening Accuracy of Acute Malnutrition in a Community-Based Management of Acute Malnutrition Program in Mumbai Informal Settlements

BACKGROUND

Acute malnutrition is linked to child mortality and morbidity. Community-Based Management of Acute Malnutrition (CMAM) programs can be instrumental in large-scale detection and treatment of undernutrition. The World Health Organization (WHO) 2006 weight-for-height/length tables are diagnostic tools available to screen for acute malnutrition. Frontline workers (FWs) in a CMAM program in Dharavi, Mumbai, were using CommCare, a mobile application, for monitoring and case management of children in combination with the paper-based WHO simplified tables. A strategy was undertaken to digitize the WHO tables into the CommCare application.

OBJECTIVE

To measure differences in diagnostic accuracy in community-based screening for acute malnutrition, by FWs, using a mobile-based solution.

METHODS

Twenty-seven FWs initially used the paper-based tables and then switched to an updated mobile application that included a nutritional grade calculator. Human error rates specifically associated with grade classification were calculated by comparison of the grade assigned by the FW to the grade each child should have received based on the same WHO tables. Cohen kappa coefficient, sensitivity and specificity rates were also calculated and compared for paper-based grade assignments and calculator grade assignments.

RESULTS

Comparing FWs (N = 14) who completed at least 40 screenings without and 40 with the calculator, the error rates were 5.5% and 0.7%, respectively (p < .0001). Interrater reliability (κ) increased to an almost perfect level (>.90), from .79 to .97, after switching to the mobile calculator. Sensitivity and specificity also improved significantly.

CONCLUSION

The mobile calculator significantly reduces an important component of human error in using the WHO tables to assess acute malnutrition at the community level.

Endoscopic capacity in West Africa

BACKGROUND

Levels of endoscopic demand and capacity in West Africa are unclear.

OBJECTIVES

This paper aims to: 1. describe the current labor and endoscopic capacity, 2. quantify the impact of a mixed-methods endoscopy course on healthcare professionals in West Africa, and 3. quantify the types of diagnoses encountered.

METHODS

In a three-day course, healthcare professionals were surveyed on endoscopic resources and capacity and were taught through active observation of live cases, case discussion, simulator experience and didactics. Before and after didactics, multiple-choice exams as well as questionnaires were administered to assess for course efficacy. Also, a case series of 23 patients needing upper GI endoscopy was done.

RESULTS

In surveying physicians, less than half had resources to perform an EGD and none could perform an ERCP, while waiting time for emergency endoscopy in urban populations was at least one day. In assessing improvement in medical knowledge among participants after didactics, objective data paired with subjective responses was more useful than either alone. Of 23 patients who received endoscopy, 7 required endoscopic intervention with 6 having gastric or esophageal varices. Currently the endoscopic capacity in West Africa is not sufficient. A formal GI course with simulation and didactics improves gastrointestinal knowledge amongst participants.

Innovative techniques to discover novel antimalarials

Malaria a global pandemic has engulfed nearly 0.63 million people globally. It is high time that a cure for malaria is required to stop its ever increasing menace. Our commentary discusses the advent and contribution of genetic algorithm (GA) in the drug discovery efforts towards developing cure for malaria. GAs are computational models of Darwinian evolution, ideally capture and mimic the principles of genetic variation and natural selection to evolve good solutions through multiple iterations on the space of all possible candidate solutions, called the search space, to a given optimization problem. Herein we will discuss the applications, advantages, disadvantages and future directions of GA with respect to malaria.

Assessing health program performance in low- and middle-income countries: building a feasible, credible, and comprehensive framework

Background

Many health service delivery models are adapting health services to meet rising demand and evolving health burdens in low- and middle-income countries. While innovative private sector models provide potential benefits to health care delivery, the evidence base on the characteristics and impact of such approaches is limited. We have developed a performance measurement framework that provides credible (relevant aspects of performance), feasible (available data), and comparable (across different organizations) metrics that can be obtained for private health services organizations that operate in resource-constrained settings.

Methods

We synthesized existing frameworks to define credible measures. We then examined a purposive sample of 80 health organizations from the Center for Health Market Innovations (CHMI) database (healthmarketinnovations.org) to identify what the organizations reported about their programs (to determine feasibility of measurement) and what elements could be compared across the sample.

Results

The resulting measurement framework includes fourteen subgroups within three categories of health status, health access, and operations/delivery.

Conclusions

The emphasis on credible, feasible, and comparable measures in the framework can assist funders, program managers, and researchers to support, manage, and evaluate the most promising strategies to improve access to effective health services. Although some of the criteria that the literature views as important – particularly population coverage, pro-poor targeting, and health outcomes – are less frequently reported, the overall comparison provides useful insights.

Innovative approaches for improving maternal and newborn health--A landscape analysis

Background

Essential interventions can improve maternal and newborn health (MNH) outcomes in low- and middle-income countries, but their implementation has been challenging. Innovative MNH approaches have the potential to accelerate progress and to lead to better health outcomes for women and newborns, but their added value to health systems remains incompletely understood. This study’s aim was to analyze the landscape of innovative MNH approaches and related published evidence.

Methods

Systematic literature review and descriptive analysis based on the MNH continuum of care framework and the World Health Organization health system building blocks, analyzing the range and nature of currently published MNH approaches that are considered innovative. We used 11 databases (MedLine, Web of Science, CINAHL, Cochrane, Popline, BLDS, ELDIS, 3ie, CAB direct, WHO Global Health Library and WHOLIS) as data source and extracted data according to our study protocol.

Results

Most innovative approaches in MNH are iterations of existing interventions, modified for contexts in which they had not been applied previously. Many aim at the direct organization and delivery of maternal and newborn health services or are primarily health workforce interventions. Innovative approaches also include health technologies, interventions based on community ownership and participation, and novel models of financing and policy making. Rigorous randomized trials to assess innovative MNH approaches are rare; most evaluations are smaller pilot studies. Few studies assessed intervention effects on health outcomes or focused on equity in health care delivery.

Conclusions

Future implementation and evaluation efforts need to assess innovations’ effects on health outcomes and provide evidence on potential for scale-up, considering cost, feasibility, appropriateness, and acceptability. Measuring equity is an important aspect to identify and target population groups at risk of service inequity. Innovative MNH interventions will need innovative implementation, evaluation and scale-up strategies for their sustainable integration into health systems.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-015-0784-9) contains supplementary material, which is available to authorized users.

Innovative financing for late-stage global health research and development: the Global Health Investment Fund

Innovative financing strategies for global health are urgently needed to reinvigorate investment and new tools for impact. Bottleneck areas along the research and development (R&D) pipeline require particular attention, such as the transitions from preclinical discovery to clinical study, and product development to implementation and delivery. Successful organizations mobilizing and disbursing resources through innovating financing mechanisms include UNITAID, the Global Fund, and Gavi, the Vaccine Alliance. Although precise numbers are poorly documented, estimated investment in low-income settings falls seriously short of local need. This commentary discusses the newly established Global Health Investment Fund as a case study to support late-stage global health R&D.

Diagnosis of Opisthorchis viverrini Infection with Handheld Microscopy in Lao People's Democratic Republic

Opisthorchiasis is a neglected tropical disease, yet it is of considerable public health importance in Southeast Asia given the predilection for chronically infected persons to develop cholangiocarcinoma. We evaluated a handheld microscope for the diagnosis of Opisthorchis viverrini in a community-based setting in Lao People's Democratic Republic in comparison with conventional light microscopy. In stool samples collected from 104 individuals, handheld microscopy revealed a sensitivity of 70.6% and a specificity of 89.5% for O. viverrini infection. Pearson's correlation for quantitative fecal egg counts between the two devices was 0.98 (95% confidence interval: 0.98-0.99). With small adjustments to further increase diagnostic sensitivity, a handheld microscope may become a helpful tool to screen for O. viverrini and other helminth infections in public health settings.

Promoting public health legal preparedness for emergencies: review of current trends and their relevance in light of the Ebola crisis

BACKGROUND

Public health legal preparedness (PHLP) for emergencies is a core component of the health system response. However, the implementation of health legal preparedness differs between low- and middle-income countries (LMIC) and developed countries.

OBJECTIVE

This paper examines recent trends regarding public health legal preparedness for emergencies and discusses its role in the recent Ebola outbreak.

DESIGN

A rigorous literature review was conducted using eight electronic databases as well as Google Scholar. The results encompassed peer-reviewed English articles, reports, theses, and position papers dating from 2011 to 2014. Earlier articles concerning regulatory actions were also examined.

RESULTS

The importance of PHLP has grown during the past decade and focuses mainly on infection-disease scenarios. Amid LMICs, it mostly refers to application of international regulations, whereas in developed states, it focuses on independent legislation and creation of conditions optimal to promoting an effective emergency management. Among developed countries, the United States' utilisation of health legal preparedness is the most advanced, including the creation of a model comprising four elements: law, competencies, information, and coordination. Only limited research has been conducted in this field to date. Nevertheless, in both developed and developing states, studies that focused on regulations and laws activated in health systems during emergencies, identified inconsistency and incoherence. The Ebola outbreak plaguing West Africa since 2014 has global implications, challenges and paralleling results, that were identified in this review.

CONCLUSIONS

The review has shown the need to broaden international regulations, to deepen reciprocity between countries, and to consider LMICs health capacities, in order to strengthen the national health security. Adopting elements of the health legal preparedness model is recommended.

New technologies for essential newborn care in under-resourced areas: what is needed and how to deliver it

Globally, the largest contributors to neonatal mortality are preterm birth, intrapartum complications and infection. Many of these deaths could be prevented by providing temperature stability, respiratory support, hydration and nutrition; preventing and treating infections; and diagnosing and treating neonatal jaundice and hypoglycaemia. Most neonatal health-care technologies which help to accomplish these tasks are designed for high-income countries and are either unavailable or unsuitable in low-resource settings, preventing many neonates from receiving the gold standard of care. There is an urgent need for neonatal health-care technologies which are low-cost, robust, simple to use and maintain, affordable and able to operate from various power supplies. Several technologies have been designed to meet these requirements or are currently under development; however, unmet technology needs remain. The distribution of an integrated set of technologies, rather than separate components, is essential for effective implementation and a substantial impact on neonatal health. Close collaboration between stakeholders at all stages of the development process and an increased focus on implementation research are necessary for effective and sustainable implementation.

Impact of Noncommunicable Disease Multimorbidity on Healthcare Utilisation and Out-Of-Pocket Expenditures in Middle-Income Countries: Cross Sectional Analysis

Background

The burden of non-communicable disease (NCDs) has grown rapidly in low- and middle-income countries (LMICs), where populations are ageing, with rising prevalence of multimorbidity (more than two co-existing chronic conditions) that will significantly increase pressure on already stretched health systems. We assess the impact of NCD multimorbidity on healthcare utilisation and out-of-pocket expenditures in six middle-income countries: China, Ghana, India, Mexico, Russia and South Africa.

Methods

Secondary analyses of cross-sectional data from adult participants (>18 years) in the WHO Study on Global Ageing and Adult Health (SAGE) 2007–2010. We used multiple logistic regression to determine socio-demographic correlates of multimorbidity. Association between the number of NCDs and healthcare utilisation as well as out-of-pocket spending was assessed using logistic, negative binominal and log-linear models.

Results

The prevalence of multimorbidity in the adult population varied from 3∙9% in Ghana to 33∙6% in Russia. Number of visits to doctors in primary and secondary care rose substantially for persons with increasing numbers of co-existing NCDs. Multimorbidity was associated with more outpatient visits in China (coefficient for number of NCD = 0∙56, 95% CI = 0∙46, 0∙66), a higher likelihood of being hospitalised in India (AOR = 1∙59, 95% CI = 1∙45, 1∙75), higher out-of-pocket expenditures for outpatient visits in India and China, and higher expenditures for hospital visits in Russia. Medicines constituted the largest proportion of out-of-pocket expenditures in persons with multimorbidity (88∙3% for outpatient, 55∙9% for inpatient visit in China) in most countries.

Conclusion

Multimorbidity is associated with higher levels of healthcare utilisation and greater financial burden for individuals in middle-income countries. Our study supports the WHO call for universal health insurance and health service coverage in LMICs, particularly for vulnerable groups such as the elderly with multimorbidity.

A Review of Realizing the Universal Health Coverage (UHC) Goals by 2030: Part 2- What is the Role of eHealth and Technology?

This paper is the second part of a review of how to realize the Universal Health Coverage (UHC) goals by 2030. The objective of this review is to investigate the role of eHealth and technology in achieving UHC, focusing on four aspects: 1) identifying the importance of UHC and highlighting how UHC is influenced by health systems and eHealth, 2) investigating the current status of UHC worldwide and indicating the current challenges facing the realization of UHC, 3) reviewing the current research activities in the UHC domain and emphasizing the role of eHealth and technology in achieving UHC, and 4) discussing the results of the review to identify the current gaps in UHC implantation and the corresponding research lines for future investigation. This part covers the last two aspects through providing a comprehensive understanding of the role of eHealth in the current research activities in the UHC domain. Specifically, eHealth can be extensively deployed in connecting the healthcare information systems, strengthening the health systems, building the health workforce capacity, in addition to forming frameworks of integrated mHealth strategies for achieving UHC.

"You cannot know if it's a baby or not a baby": uptake, provision and perceptions of antenatal care and routine antenatal ultrasound scanning in rural Kenya

Background

Antenatal care early in pregnancy enables service providers to identify and manage risks to mother and fetus. In the global north, ultrasound scans are routinely offered in pregnancy to provide an accurate estimate of gestational age and identify potential problems. In sub-Saharan Africa, such services are rarely available and women often delay initiating antenatal care. This study describes the uptake and provision of antenatal care in a rural Kenyan hospital and explores how pregnant women and healthcare providers perceived the provision of ultrasound scanning, following its introduction in an international foetal growth study.

Methods

A descriptive study, using qualitative and quantitative methods, was conducted in Kilifi District Hospital, Kenya, between June 2011 and April 2012. In-depth interviews were conducted with 10 nurses working in the antenatal clinic (ANC) and 59 pregnant women attending ANC. Structured observations of 357 ANC consultations and 30 ultrasound scans were made.

Results

Women sought antenatal care for information about the health of their baby and the protection provided by the ANC services. Uncertainty about pregnancy status contributed to delay in ANC attendance; more than 78 % of women were over 20 weeks’ gestation at their first visit. Healthcare workers found it difficult to detect pregnancies below 16 weeks gestation and, accurate assessment of gestational age below 20 weeks’ gestation could be problematic. Provision of services depended on the pregnancy being detected and gestational age assessed. The “seeing”, made possible through ultrasound scanning was perceived by pregnant women and healthcare workers to be beneficial: confirming the pregnancy, and providing reassurance about the fetus’ condition. Few participants raised concerns about ultrasound scanning.

Conclusions

Uncertainty about pregnancy status and gestational age for women and healthcare providers is a key factor influencing timing of ANC attendance, contributing to delays and restricting early provision of ANC services. Ultrasound scanning was perceived to enhance antenatal care through confirmation of pregnancy status and enabling more accurate estimation of gestational age and the health status of the fetus. There is a need to make available more affordable means of pregnancy testing as a strategy towards encouraging early attendance, and delivery of antenatal care.

IMPLICATIONS OF GLOBAL PRICING POLICIES ON ACCESS TO INNOVATIVE DRUGS: THE CASE OF TRASTUZUMAB IN SEVEN LATIN AMERICAN COUNTRIES

OBJECTIVES

Differential pricing, based on countries' purchasing power, is recommended by the World Health Organization to secure affordable medicines. However, in developing countries innovative drugs often have similar or even higher prices than in high-income countries. We evaluated the potential implications of trastuzumab global pricing policies in terms of cost-effectiveness (CE), coverage, and accessibility for patients with breast cancer in Latin America (LA).

METHODS

A Markov model was designed to estimate life-years (LYs), quality-adjusted life-years (QALYs), and costs from a healthcare perspective. To better fit local cancer prognosis, a base case scenario using transition probabilities from clinical trials was complemented with two alternative scenarios with transition probabilities adjusted to reflect breast cancer epidemiology in each country.

RESULTS

Incremental discounted benefits ranged from 0.87 to 1.00 LY and 0.51 to 0.60 QALY and incremental CE ratios from USD 42,104 to USD 110,283 per QALY (2012 U.S. dollars), equivalent to 3.6 gross domestic product per capita (GDPPC) per QALY in Uruguay and to 35.5 GDPPC in Bolivia. Probabilistic sensitivity analysis showed 0 percent probability that trastuzumab is CE if the willingness-to-pay threshold is one GDPPC per QALY, and remained so at three GDPPC threshold except for Chile and Uruguay (4.3 percent and 26.6 percent, respectively). Trastuzumab price would need to decrease between 69.6 percent to 94.9 percent to became CE in LA.

CONCLUSIONS

Although CE in other settings, trastuzumab was not CE in LA. The use of health technology assessment to prioritize resource allocation and support price negotiations is critical to making innovative drugs available and affordable in developing countries.