Overcoming geographical and socioeconomic limitations in colorectal cancer screening

Despite colorectal cancer's (CRC) high global incidence, residents of low- and middle- income countries, as well as low-income minorities in advanced economies have low screening rates. Observational studies demonstrate that in these groups higher incidence of CRC is observed, yet screening rates remain low for consistent reasons. Low income, low educational background, and lack of awareness in combination with inadequate social security of certain population groups impede access and compliance rates to CRC screening. On the other hand, despite the global availability of multiple screening approaches (colonoscopy, sigmoidoscopy, faecal occult blood test, faecal immunochemical test, computed tomography-colonography, etc.) with proven diagnostic validity, many low-income countries still lack established screening programs. The absence of screening guidelines in these countries along with the heterogeneity of guidelines in the rest of the world, demonstrate the need for global measures to tackle this issue comprehensively. An essential step forward is to develop a global approach that will link specific elements of screening with the incidence and available resources in each country, to ensure the achievement of at least a minimum screening program in low-income countries. Utilizing cheaper, cost-effective techniques, which can be carried out by less specialized healthcare providers, might not be equivalent to endoscopy for CRC screening but seems more realistic for areas with fewer resources. Awareness has been highlighted as the most pivotal element for the effective implementation of any screening program concerning CRC. Moreover, multiple studies have demonstrated that outreach strategies and community-based educational programs are associated with encouraging outcomes, yet a centrally coordinated expansion of these programs could provide more consistent results. Additionally, patient navigator programs, wherever implemented, have increased CRC screening and improved follow-up. Therefore, global coordination and patient education seem to be the main areas on which policy making needs to focus.

Environment, animals, and food as reservoirs of antibiotic-resistant bacteria for humans: One health or more?

Antimicrobial resistance (AMR) is a major public health challenge. For several years, AMR has been addressed through a One Health approach that links human health, animal health, and environmental quality. In this review, we discuss AMR in different reservoirs with a focus on the environment. Anthropogenic activities produce effluents (sewage, manure, and industrial wastes) that contaminate soils and aquatic environments with antibiotic-resistant bacteria (ARB), antibiotic-resistant genes (ARGs), and selective agents such as antibiotics, biocides, and heavy metals. Livestock treated with antibiotics can also contaminate food with ARB. In high-income countries (HICs), effective sanitation infrastructure and limited pharmaceutical industries result in more controlled discharges associated with human activities. Hence, studies using genome-based typing methods have revealed that, although rare inter-reservoir transmission events have been reported, human acquisition in HICs occurs primarily through person-to-person transmission. The situation is different in low- and middle-income countries (LMICs) where high population density, poorer sanitation and animal farming practices are more conducive to inter-reservoir transmissions. In addition, environmental bacteria can be a source of ARGs that, when transferred to pathogenic species under antibiotic selection pressure in environmental hotspots, produce new antibiotic-resistant strains that can potentially spread in the human community through human-to-human transmission. The keys to reducing AMR in the environment are (i) better treatment of human waste by improving wastewater treatment plants (WWTPs) in HICs and improving sanitation infrastructure in LMICs, (ii) reducing the use of antibiotics by humans and animals, (iii) prioritizing the use of less environmentally harmful antibiotics, and (iv) better control of pharmaceutical industry waste.

Cognitive performance in depression in low- and middle-income countries: A systematic review with meta-analytic components

BACKGROUND

Depression is highly prevalent in low- and middle- income countries (LMIC) and associated with significant cognitive dysfunction across multiple domains. However, little is known about neurocognitive tests used in people with depression in LMIC. We aimed to investigate cognitive performance and cognitive tests in depression research in LMIC.

METHODS

APA PsycInfo, Embase, Ovid MEDLINE, and Global Health were systematically searched for studies that implemented a cognitive performance test in a depressed, LMIC population. Tool quality was assessed using an adapted scale for quality of measures in cross-cultural settings. Data extracted included demographics, depression and cognitive performance measures, and cognitive performance comparisons between depression and control groups.

RESULTS

29 studies met eligibility criteria, involving a total of 19,100 participants from 11 LMIC. 93.1 % of studies were conducted in upper middle-income countries. 67 cognitive performance tools were implemented. Reliability was reported for 5.6 % of cognitive performance tests and validity was reported for 8.3 %. 36.1 % of tests used were culturally adapted. 75.9 % of included studies implemented at least one memory test. Cognitive deficits were observed in all depressed groups, especially in memory (Cohen's d = -1.60, 95 % CI -2.02 to -1.18).

LIMITATIONS

Heterogeneity between studies; averaged results across memory subtypes; no assessment of depression severity and cognitive deficits associations; restrictive search terms.

CONCLUSIONS

Cognitive impairments in depression, especially in memory, are prevalent in LMIC. This research has drawn attention to the burden of cognitive dysfunction in depression in LMIC, and to the disparate research gap in LMIC. PROSPERO registration CRD42022315397.

Bovine lead exposure from informal battery recycling in India

We provide an estimate of annual bovine lead exposure and attributable mortality at informal lead acid battery recycling sites in India. We use Pure Earth's Toxic Sites Identification Program database, the FAO's Gridded Livestock dataset, and a Poisson plume model of lead particle air dispersion to estimate site-level mortality. We calculate that India suffers 2370 excess bovine fatalities each year, resulting in more than USD $2.1 million of economic damage. The distribution of damages by location is highly skewed. While we find most sites (86.3%) induce no mortalities, 6.2% of sites induce minor damage (1 to 5 fatalities), 4.1% induce moderate damage (6 to 20 fatalities), and 3.4% induce severe damage (21 + fatalities). These findings highlight the importance of geospatial data to prioritize mitigation efforts and identify a previously unquantified burden on the rural poor.

How does women's empowerment relate to antenatal care attendance? A cross-sectional analysis among rural women in Bangladesh

BACKGROUND

In South Asia, roughly half of women attend at least four antenatal care visits with skilled health personnel, the minimum number recommended by the World Health Organization for optimal birth outcomes. A much greater proportion of women attend at least one antenatal care visit, suggesting that a key challenge is ensuring that women initiate antenatal care early in pregnancy and continue to attend after their first visit. One critical barrier to antenatal care attendance may be that women do not have sufficient power in their relationships, households, or communities to attend antenatal care when they want to. The main goals of this paper were to 1) understand the potential effects of intervening on direct measures of women's empowerment-including household decision making, freedom of movement, and control over assets-on antenatal care attendance in a rural population of women in Bangladesh, and 2) examine whether differential associations exist across strata of socioeconomic status.

METHODS

We analyzed data on 1609 mothers with children under 24 months old in rural Bangladesh and employed targeted maximum likelihood estimation with ensemble machine learning to estimate population average treatment effects.

RESULTS

Greater women's empowerment was associated with an increased number of antenatal care visits. Specifically, among women who attended at least one antenatal care visit, having high empowerment was associated with a greater probability of ≥ 4 antenatal care visits, both in comparison to low empowerment (15.2 pp, 95% CI: 6.0, 24.4) and medium empowerment (9.1 pp, 95% CI: 2.5, 15.7). The subscales of women's empowerment driving the associations were women's decision-making power and control over assets. We found that greater women's empowerment is associated with more antenatal care visits regardless of socioeconomic status.

CONCLUSIONS

Empowerment-based interventions, particularly those targeting women's involvement in household decisions and/or facilitating greater control over assets, may be a valuable strategy for increasing antenatal care attendance.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04111016, Date First Registered: 01/10/2019.

The effect of short-term preoperative nutritional intervention for cleft surgery eligibility

BACKGROUND

Children with orofacial clefts are highly susceptible to malnutrition, with severe malnutrition restricting their eligibility to receive safe surgery. Ready-to-use therapeutic foods (RUTF) are an effective treatment for malnutrition; however, the effectiveness has not been demonstrated in this patient population prior to surgery. We studied the effectiveness of short-term RUTF use in transitioning children with malnutrition, who were initially ineligible for surgery, into surgical candidates.

METHODS

A cohort of patients from Ghana, Honduras, Malawi, Madagascar, Nicaragua, and Venezuela enrolled in a nutrition program were followed by Operation Smile from June 2017 to January 2020. Age, weight, and length/height were tracked at each visit. Patients were included until they were sufficiently nourished (Z >  = -1) with a secondary outcome of receiving surgery. The study was part of a collaborative program between Operation Smile (NGO), Birdsong Peanuts (peanut shellers and distributors), and MANA Nutrition (RUTF producer).

RESULTS

A total of 556 patients were recruited between June 2017 and January 2020. At baseline 28.2% (n = 157) of patients were diagnosed with severe, 21.0% (n = 117) moderate, and 50.7% (n = 282) mild malnutrition. 324 (58.3%) presented for at least one return visit. Of those, 207 (63.7%) reached optimal nutrition status. By visit two, the mean z-score increased from -2.5 (moderate) to -1.7 (mild) (p < 0·001). The mean time to attain optimal nutrition was 6 weeks. There was a significant difference in the proportion of patients who improved by country(p < 0.001).

CONCLUSION

Malnutrition prevents many children with orofacial clefts in low- and middle-income countries from receiving surgical care even when provided for free. This creates an even larger disparity in access to surgery. In an average of 6 weeks with an approximate cost of $25 USD per patient, RUTF transitioned over 60% of patients into nutritionally eligible surgical candidates, making it an effective, short-term preoperative nutritional intervention. Through unique partnerships, the expansion of cost-effective, large-scale nutrition programs can play a pivotal role in ensuring those at the highest risk of living with unrepaired orofacial clefts receive timely and safe surgical care.

Brief interventions for alcohol use disorders in low- and middle-income countries: barriers and potential solutions

Global alcohol consumption and harmful use of alcohol is projected to increase in the coming decades, and most of the increase will occur in low- and middle-income countries (LMICs); which calls for cost-effective measures to reduce alcohol exposure in these countries. One such evidence based measure is screening and brief intervention (BI) for alcohol problems. Some of the characteristics of BI make them a particularly appealing choice of interventions in low-resource settings. However, despite evidence of effectiveness, implementation of BI in LMICs is rare. In this paper we discuss barriers to implementation of BI in LMICs, with examples from Latin America and India. Key barriers to implementation of BI in LMICs are the lack of financial and structural resources. Specialized services for alcohol use disorders are limited or non-existent. Hence primary care is often the only possible alternative to implement BI. However, health professionals in such settings generally lack training to deal with these disorders. In our review of BI research in these countries, we find some promising results, primarily in countries from Latin America, but so far there is limited research on effectiveness. Appropriate evaluation of efficacy and effectiveness of BI is undermined by lack of generalisability and methodological limitations. No systematic and scientific efforts to explore the implementation and evaluation of BI in primary and community platforms of care have been published in India. Innovative strategies need to be deployed to overcome supply side barriers related to specialist manpower shortages in LMICs. There is a growing evidence on the effectiveness of non-specialist health workers, including lay counsellors, in delivering frontline psychological interventions for a range of disorders including alcohol use disorders in LMICs. This paper is intended to stimulate discussion among researchers, practitioners and policy-makers in LMICs because increasing access to evidence based care for alcohol use disorders in LMICs would need a concerted effort from all these stakeholders.

Prevalence and trends in tobacco use, secondhand smoke exposure at home and household solid fuel use among women in 57 low- and middle-income countries, 2000-2018

BACKGROUND

Tobacco use, secondhand smoke (SHS) exposure and household solid fuel use in women of reproductive age can cause morbidity and mortality for both women and offspring.

OBJECTIVES

We aimed to determine the prevalence of tobacco use, SHS exposure at home and household solid fuel use among women in low- and middle-income countries (LMICs) and their secular trends between 2000 and 2018.

METHODS

We used the most recent data from the Demographic and Health Surveys in 57 LMICs (n = 1,598,111) that were completed between 2010 and 2018 to assess the prevalence of tobacco use, SHS exposure at home and household solid fuel use among women of reproductive age (15-49 years). We also used data from 41 selected LMICs that had data from two or more surveys completed between 2000 and 2018 to assess secular trends in the prevalence of tobacco use and household solid fuel use among women.

RESULTS

In 2010-2018, the overall prevalence of tobacco use, daily SHS exposure at home and household solid fuel use among women in 57 LMICs was 3.2% (95 %CI = 3.1-3.3), 23.0% (22.8-23.2), and 65.6% (65.3-65.9), respectively. The prevalence of tobacco use was lower among pregnant women than non-pregnant women (2.1% vs. 3.3%), but the prevalence of daily SHS exposure at home (24.4% vs. 22.8%) and household solid fuel use (69.1% vs. 65.3%) was higher among pregnant women than non-pregnant women. About 16% of the women presented two or three simultaneous risk factors. Between 2000 and 2018, the prevalence of tobacco use decreased in 24 (64.9%) of 37 countries, and the prevalence of household solid fuel use decreased in 20 (50.0%) of 40 countries.

CONCLUSIONS

Tobacco use among women was much low in LMICs, but SHS exposure at home was more common. Although the prevalence of household solid fuel use decreased over time in most LMICs, these recent estimates remained unacceptably high.

Trauma training in low- and middle-income countries: A scoping review of ATLS alternatives

INTRODUCTION

Trauma training for front-line providers is a critical component of injury mitigation and trauma systems strengthening. Although the Advanced Trauma Life Support (ATLS) course is standard in much of the world, cost and administrative barriers are prohibitive to deploying the course in many low and middle income countries (LMICs). The purpose of this study was to identify alternative trauma training courses used in LMICs by scoping review and compare their effectiveness.

METHODS

Several peer-reviewed and grey literature databases were searched for relevant articles describing trauma training courses for front-line medical providers in LMICs. Studies were included if: performed in a LMIC; utilized a general trauma training course other than ATLS; trainees were hospital-based medical providers; study included some type of outcome measure.

RESULTS

A total of 34 manuscripts met inclusion criteria. The majority of courses were novel, hospital-initiated courses and ranged in length from 1 day to 1 week. Physicians were the most common target audience, followed by medical students and nurses. Courses were taught in 24 different countries throughout the Middle East, Asia, Latin America and Africa. Comparison of pre- and post-test knowledge was the most common metric used and nearly all courses demonstrated a statistically significant knowledge gain. One study demonstrated a reduction in mortality for injured patients after course implementation. The majority of courses were a collaboration between universities in a high income country and local faculty/practitioners in the LMIC where the course was taught. Reported cost per participant ranged from $10 to $232 USD.

CONCLUSIONS

Several trauma courses are currently being utilized in LMICs effectively with increases in knowledge gained and at a lower reported cost than ATLS. More research is needed to link trauma training courses to patient outcomes.

Community engagement and involvement in Ghana: conversations with community stakeholders to inform surgical research

BACKGROUND

Involving patients and communities with health research in low- and middle-income countries (LMICs) contributes to increasing the likelihood that research is relevant in local context and caters to the needs of the population, including vulnerable and marginalised groups. When done right, it can also support empowerment of wider communities in taking ownership of their own health, lead to increased access and uptake of health services and generally improve the wellbeing of individuals. However, the evidence base of how to undertake successful community engagement and involvement (CEI) activities in LMICs is sparse. This paper aims to add to the available literature and describes how the Global Health Research Unit on Global Surgery's (GSU) team in Ghana worked collaboratively with the Unit's team in the UK and a UK-based Public Advisory Group to involve community stakeholders in rural Ghana with surgical research. The aim was to explore ways of reaching out to patients and community leaders in rural Ghana to have conversations that inform the relevance, acceptability, and feasibility of a clinical trial, called TIGER.

METHODS

As this kind of larger scale involvement of community stakeholders with research was a novel way of working for the team in Ghana, a reflective approach was taken to outline step-by-step how the GSU team planned and undertook these involvement activities with 31 hernia patients, two Chiefs (community leaders), a community finance officer and a local politician in various locations in Ghana. The barriers that were experienced and the benefits of involving community stakeholders are highlighted with the aim to add to the evidence base of CEI in LMICs.

RESULTS

GSU members from the UK and Ghana planned and organised successful involvement activities that focused on establishing the best way to talk to patients and other community stakeholders about their experiences of living with hernias and undergoing hernia repairs, and their perceptions of the impact of hernias on the wider community. The Ghanaian team suggested 1:1 conversations in easily accessible locations for rural patient contributors, creating a welcoming environment and addressing contributors in their local dialects. A UK-based Public Advisory Group helped in the initial stages of planning these conversations by highlighting potential barriers when approaching rural communities and advising on how to phrase questions around personal experiences. Conversations mainly focused on understanding the needs of hernia patients in rural Ghana to then incorporate these in the design of the TIGER trial to ensure its relevance, acceptability and feasibility. When talking to patient contributors, the GSU teams found that they were more likely to open up when they knew members of the team and the opportunity to speak to local leaders only arose because of the Ghanaian team members being well-respected amongst communities. The experiences of the patient and community contributors led to changes in the study protocol, such as including women in the patient cohort for the trial, and allowed the GSU teams to confirm the relevance and acceptability of this trial. These conversations also taught the team a lot about perceptions of health in rural communities, allowed the Ghanaian team to establish relationships with community leaders that can be utilised when future studies need input from the public, and has changed the minds of the Ghanaian research team about the importance of involving patients with research.

CONCLUSION

This paper contributes to the evidence base on successful CEI activities in LMICs by providing an example of how CEI can be planned and organised, and the benefits this provides. The conversations the teams had with patient contributors in Ghana are an example of successful patient consultations. Even though there are certain limitations to the extent of these involvement activities, a solid foundation has been built for researchers and community stakeholders to establish relationships for ongoing involvement.

"He lets me go although he does not go with me.": Rwandan women's perceptions of men's roles in maternal health

Background

Increasing men’s involvement in their pregnant partners’ wellness has been reported as one of the ways to improve access to and utilization of maternal health services, including birth preparedness and complication readiness. Men can play meaningful roles in the support systems that pregnant women need to achieve better maternal health outcomes. In Rwanda, the roles that men take vary, resulting in diverse expectations and responsibilities to support the health of women during this critical time. In this study, we aimed to examine the views, perspectives, and experiences of women on men’s involvement in maternal health and how this impacts access and utilization of maternal health services.

Methods

We conducted 21 interviews with pregnant and recently-pregnant women to gain an understanding of their views on men’s involvement in facilitating their partners’ health during pregnancy. Interviews were conducted across five Rwandan districts in both rural and urban settings of the country. Data analysis was guided by a thematic analysis approach. This started with independent transcript review by the investigators, after which a meeting was held to discuss emergent themes and to identify potential codes. A coding scheme was created and transcripts were coded in NVIVO™ software according to conceptual and practical topics that formed an understanding of men’s involvement in maternal care.

Results

Three key themes emerged during the analytic process that categorize the specific roles that men play in maternal health: 1) facilitating access to maternal health services, which involves assisting women with getting and or attending appointments jointly with men; 2) supporting women’s decisions, wherein men can support the decisions women make with regard to their maternal healthcare in a number of ways; and 3) evaluating information, including gathering information from multiple sources, especially from community health workers, to assist women with making informed decisions.

Conclusion

Rwandan men take on three types of roles in supporting women’s maternal health, and their responsibilities are experienced differently by women. Interventions involving men are encouraged to increase their understanding of the implications of their involvement in maternal health without compromising women’s autonomy in decision-making and to promote positive maternal health outcomes.

Prevalence of hypertension and its risk factors among cotton textile workers in low- and middle-income countries: a protocol for a systematic review

BACKGROUND

Cotton workers are exposed to various hazards in the textile industry that might result in different ailments including hypertension (HTN). However, few attempts have been made to systematically review the prevalence of hypertension and its risk factor among cotton textile workers in low-and middle-income countries (LMICs). The objective of this study will be to evaluate the prevalence of hypertension and its risk factors among adult cotton textile workers in low- and middle-income countries.

METHODS

We designed and registered a study protocol for a systematic review of descriptive epidemiology data. We will include observational studies (e.g., cross-sectional, cohort, surveys) on the epidemiology of hypertension among adult cotton textile workers in low- and middle-income countries. The primary outcome will be the prevalence of hypertension. Secondary outcomes will be the prevalence of risk factors of hypertension. Literature searches will be conducted in multiple electronic databases (from January 2000 onwards), including PubMed/MEDLINE, CINAHL, Science Direct, and Cochrane Library. Gray literature will be identified through searching conference abstracts, thesis dissertations, and public repositories. Two investigators will independently screen all citations, full-text articles, and abstract data. The study methodological quality (or bias) will be appraised using an appropriate tool. If feasible, we will conduct random effects meta-analysis. Additional analyses will be conducted to explore the potential sources of heterogeneity (e.g., age, gender, years of service, textile department).

DISCUSSION

This systematic review will identify, evaluate, and integrate evidence on the prevalence and risk factors of hypertension among adult cotton textile workers in low- and middle-income countries. Our findings will be made publicly available in a repository and published in a peer-reviewed journal.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020167175.

Pre-service and in-service education and training for maternal and newborn care providers in low- and middle-income countries: An evidence review and gap analysis

BACKGROUND

Good quality midwifery care has the potential to reduce both maternal and newborn mortality and morbidity in high, low, and lower-middle income countries (LMIC) and needs to be underpinned by effective education. There is considerable variation in the quality of midwifery education provided globally.

OBJECTIVE

To determine what are the most efficient and effective ways for LMICs to conduct pre-service and in-service education and training in order to adequately equip care providers to provide quality maternal and newborn care.

DESIGN

Rapid Systematic Evidence Review METHODS: A systematic search of the following databases was conducted: Medline, CINAHL, LILACs, PsycInfo, ERIC, and MIDIRs. Studies that evaluated the effects of pre-service and in-service education that were specifically designed to train, educate or upskill care providers in order to provide quality maternal and newborn care were included. Data was extracted and presented narratively.

FINDINGS

Nineteen studies were included in the review. Of these seven were evaluations of pre-service education programmes and 12 were evaluations of in-service education programmes. Whilst studies demonstrated positive effects on knowledge and skills, there was a lack of information on whether this translated into behaviour change and positive effects for women and babies. Moreover, the level of the evidence was low and studies often lacked an educational framework and theoretical basis. Mapping the skills taught in each of the programmes to the Quality Maternal and Newborn Care framework (Renfrew et al., 2014) identified that interventions focused on very specific or individual clinical skills and not on the broader scope of midwifery.

KEY CONCLUSIONS

There is a very limited quantity and quality of peer reviewed published studies of the effectiveness of pre service and in service midwifery education in LMICs; this is at odds with the importance of the topic to survival, health and well-being. There is a preponderance of studies which focus on training for specific emergencies during labour and birth. None of the in-service programmes considered the education of midwives to international standards with the full scope of competencies needed. There is an urgent need for the development of theoretically informed pre-service and in-service midwifery education programmes, and well-conducted evaluations of such programmes. Upscaling quality midwifery care for all women and newborn infants is of critical importance to accelerate progress towards Sustainable Development Goal 3. Quality midwifery education is an essential pre-requisite for quality care. To deliver SDG 3, the startling underinvestment in midwifery education identified in this review must be reversed.

Knowledge translation for public health in low- and middle- income countries: a critical interpretive synthesis

Background

Effective knowledge translation allows the optimisation of access to and utilisation of research knowledge in order to inform and enhance public health policy and practice. In low- and middle- income countries, there are substantial complexities that affect the way in which research can be utilised for public health action. This review attempts to draw out concepts in the literature that contribute to defining some of the complexities and contextual factors that influence knowledge translation for public health in low- and middle- income countries.

Methods

A Critical Interpretive Synthesis was undertaken, a method of analysis which allows a critical review of a wide range of heterogeneous evidence, through incorporating systematic review methods with qualitative enquiry techniques. A search for peer-reviewed articles published between 2000 and 2016 on the topic of knowledge translation for public health in low- and middle – income countries was carried out, and 85 articles were reviewed and analysed using this method.

Results

Four main concepts were identified: 1) tension between ‘global’ and ‘local’ health research, 2) complexities in creating and accessing evidence, 3) contextualising knowledge translation strategies for low- and middle- income countries, and 4) the unique role of non-government organisations in the knowledge translation process.

Conclusion

This method of review has enabled the identification of key concepts that may inform practice or further research in the field of knowledge translation in low- and middle- income countries.

Electronic supplementary material

The online version of this article (10.1186/s41256-018-0084-9) contains supplementary material, which is available to authorized users.

Options for design of real-world impact studies of single-dose vaccine schedules

Based on existing evidence for efficacy, savings, and advantages in delivery, some countries may elect to pilot or roll out single-dose human papillomavirus (HPV) vaccination (instead of, or in combination with, two-dose) in advance of a WHO policy decision. Accelerated evidence of population-based effectiveness (hereafter referred to as overall effectiveness, OE) of one-dose vaccine programs could be gained through regular surveys of HPV prevalence in young women before and after vaccination introduction. In order to offer the earliest information on OE, one-dose HPV vaccination should target one or more birth cohorts as close as possible to the age when sexual activity most often starts in a given population. A catch-up one-dose vaccination program of girls up to 18 years of age who would have been too old to profit from the introduction of a routine HPV vaccination program in preadolescents would minimize the interval between vaccination and the possibility to monitor vaccination impact in young women. In addition, catch-up is especially desirable in low- and middle-income countries with little access to screening as "missed" cohorts may face high risk of cervical cancer death. HPV prevalence should be firstly monitored in age groups of women who may already be sexually active but still reluctant to admit it and to accept vaginal examination for the collection of cervical cells. Hence, HPV testing from urine samples, for which good concordance with cervical cells has been proven, offers a feasible approach to assess periodically vaccine OE in representative samples of 17-20 year-old women. This type of observational study would greatly benefit from the presence of a population census and the creation of a vaccination registry. A real-world demonstration of OE of the new schedule would complement the findings of ongoing clinical trials and immunogenicity studies on the efficacy of single-dose HPV vaccination.

Challenges to conducting epidemiology research in chronic conflict areas: examples from PURE- Palestine

Little has been written on the challenges of conducting research in regions or countries with chronic conflict and strife. In this paper we share our experiences in conducting a population based study of chronic diseases in the occupied Palestinian territory and describe the challenges faced, some of which were unique to a conflict zone area, while others were common to low- and middle- income countries. After a short description of the situation in the occupied Palestinian territory at the time of data collection, and a brief overview of the design of the study, the challenges encountered in working within a fragmented health care system are discussed. These challenges include difficulties in planning for data collection in a fragmented healthcare system, standardizing data collection when resources are limited, working in communities with access restricted by the military, and considerations related to the study setting. Ways of overcoming these challenges are discussed. Conducting epidemiological research can be very difficult in some parts of our turbulent world, but data collected from such regions may contrast with those solely from politically and economically more stable regions. Therefore, special efforts to collect epidemiologic data from regions engulfed by strife, while challenging are essential.