Spatial determinants affected maternal mortality of East Java province during the covid-19 pandemic era, in 2020-2021

Background. Every life aspect and group of the community have changed during the COVID-19 pandemic, including the group of pregnant, childbirth, and postpartum woman. COVID-19 Pandemic occurred in 2020-2021. Maternal mortality in East Java Province was the highest in Indonesia during the pandemic. Objective. This study analyzed the effect of spatial determinants that consist of antenatal, childbirth, and post-partum care on maternal mortality in East Java Province during the Pandemic. Methods. This study used a crossectional method with the unit of analysis in this study was all pregnant, childbirth and postpartum women in 38 districts of East Java Province from 2020 until 2021. Data were analyzed with spatial regression by using Geographically Weighted Regression Software. Results. Maternal mortality in East Java had a spreading pat-tern and negative value of the diff criterion, so we concluded that there was a spatial influence. The variables of antenatal care, accessibility of healthcare service, third postpartum visit, and complication service had significant effects on maternal mortality in all regions (P<0,05). There were four groups of districts that showed a similarity of significant factors. This result showed that each region's diversity of the accessibility of health services affects maternal mortality during the COVID-19 era. Antenatal services, access to health facilities and complication services affected maternal mortality in regions with high maternal mortality rate. Conclusion. Every region has its spatial determinants of maternal mortality. The top government should give authority to local government to have programs to reduce maternal mortality according to the condition in their region. r.Copyright © the Author(s), 2023.

Sharing the knowledge and expertise of BSH members throughout the global Haematology community

'BSH Global Speakers' was established in 2015 as a core project of the BSH Global Haematology Special Interest Group (SIG). As the project enters its eighth year, we present an update and reflection on the successes and challenges encountered. Initially known as the 'Plenary Speaker Scheme', the project was developed following a stakeholder meeting in 2015 at the inception of the SIG. Haematology colleagues from the UK and low-and middle-income countries (LMIC) came together to discuss how the BSH may be best placed to support haematologists practicing in LMICs. Sharing of expertise and building collaborative networks were identified as key priorities. The 'Plenary Speaker Project' was conceived;BSH haematologists would be supported in delivering plenaries at the meetings of colleagues in LMICs, with the aim that each visit could act as a catalyst for creating networks and developing collaborative projects in education, research, and capacity building. We established a yearly cycle of inviting applications from LMIC societies for a funded speaker at their scientific meetings, selecting the most impactful meetings, then recruiting appropriate UK-based speakers. We place emphasis on the likelihood of ongoing collaborative working or other impacts, for example engagement with local haematology trainees. To date, ten speakers have represented BSH at the meetings of LMIC societies, presenting on diverse topics, from molecularly guided interventions to prevent relapse in AML, to adapting lymphoma treatment strategies for low resource settings. Recently we have opened applications to nurse specialists and scientists, with our first scientific speaker presenting in Thailand May 2023. The COVID-19 pandemic created significant challenges for the project due to the disruption in international travel and the cancellation of many haematology meetings around the globe. We were, however, able to adapt the project to support virtual speakers at meetings in South Africa, Vietnam, and Ghana. Although virtual meetings do not naturally lend themselves to collaborative working, we were pleased that a longer term joint educational program in haemoglobinopathy care has been established with the Vietnamese Society of Haematology as a result of BSH support. The impact of BSH Global Speakers is significant. Even at smaller meetings, speakers will have the ear of the majority of practicing haematologists in a country. From the relationships built between societies and speakers we have seen the development of fellowship programmes, online education programmes, laboratory support, and numerous networks for informal advice in clinical care, research, and more.

Perceived Attitudes Toward Vaccines, Trust and Vaccination Behaviors

Objectives: The decision-making process for taking vaccination is influenced by a multitude of factors such as individual beliefs concerning vaccinations, trust in contextual forces, and sociodemographic. This study established a model to understand the relationship between people's beliefs in the safety, importance and effectiveness of vaccines, their trust in the medical advice from the government and doctors and their behaviors of having their children vaccinated from infectious diseases in low-and-middle-income countries (LMIC). Method(s): We structured a structural equation model with two latent variables, Motivation and Trust, and their relationships with the vaccination taking behavior. Motivation is constructed by people's beliefs in the safety, importance and effectiveness of vaccines and trust is constructed by people's trust in government, medical providers and scientists. This study used the 2018 Wellcome Global Monitor dataset and focused on people in 80 LMIC. The countries were divided into eight geographic regions: Eastern Africa, Central & Southern Africa, Norther Africa & Middle East, Western Africa, Central Asia, Southeast Asia, South Asia and Southern& Eastern Europe. Result(s): The latent variable Motivation is significantly positively associated with parental vaccination behaviors in all geographic areas except for South Asia and Western Africa. South Asia is the only area where the trust in government and medical system, providers had a significant association with vaccination behavior and such association is positive. Conclusion(s): In most LMIC, positive attitudes about vaccines are associated with an improved vaccine rate. Increasing people's belief in vaccines' importance, safety and effectiveness will be essential both for boosting vaccination rates and scaling up a vaccine for COVID-19. In South Asia, trust in the government and the public health system are important in deciding taking vaccines. In these countries, policymakers need to think of ways to improve people's trust in the public health system and further effectively communicate important health messages.Copyright © 2023

Development of a model of care based on the chronic care and collaborative care models to improve cardiometabolic health in low-to- middle income countries

Background: Non-communicable diseases (NCDs) are rising in low middle income countries (LMICs) mainly driven by cardiometabolic disease (cardiovascular disease, diabetes, and hypertension). Aim(s): To develop a model of care, based on the chronic care model and collaborative care model, to improve care, outcomes and risk factor control for adults with cardio metabolic disease in LMICs in the Covid-19 era. This will contribute to the sustainable development goals of promoting good health, well-being and reducing inequalities. Method(s): Using an iterative consultative approach with healthcare workers, clients, and community leaders in Kenya, Ghana and Mozambique, we developed a model of care, which includes core features from chronic care models: self-management support;decision support;clinical information systems;delivery system design;and community linkages. Result(s): We produced a culturally adapted self-management education programme, a training package for educators delivering the programme, as well as a training package for community and healthcare professional leaders to increase awareness and self-care for cardiometabolic disease. Given the lack of a robust health information system, we are offering a global registry to provide real world data on patient management and quality of care for people with type 2 diabetes, hypertension, heart failure and chronic kidney disease. Conclusion(s): This intervention will be tested in a mixed-methods single-arm feasibility study in five sites across three African countries: Kenya, Ghana, Mozambique.

A Multicenter Microcosting Study for COVID-19 in Brazil

Objectives: This study aims to evaluate COVID-19 in-hospital costs and identify predictors at a patient-level in Brazil. Method(s): This is multicenter, prospective cohort study that applied time-driven activity-based costing (TDABC) method in five Brazilian reference centers for COVID-19 treatment. Patients hospitalized between March and August 2020 (first wave of the disease) and had their COVID-19 status confirmed by reverse transcription-polymerase chain reaction (RT-PCR) at arrival were included in our sample. The cost information was calculated at the patient level and multivariable analyses were applied to identify clinical predictors of cost variability, considering ICU admissions and patient's comorbidities. Result(s): 830 patients were included into the analysis. The median cost per patient was I$4,428 (IQR 2,019;11,464), and patients hospitalized in ICU demonstrated significative higher costs (p<0.001). Patients hospitalized in ICU the median was I$11,596 (IQR 6,016;23,374), while for those who were hospitalized in ward was 1,895 (IQR 1,050;3,317). Median cost per day was I$ 455 (IQR 308;711) for the total sample, I$690 (IQR I,528;1,046) for ICU patients and I$350 (IQR 255;449) for non-ICU. Gender (p<0.001), Obesity (p = 0.005) and Chronic pulmonary diseases (p = 0.044) were identified as clinical predictors for hospital costs. Conclusion(s): By developing a multicenter microcosting study for COVID-19 this study allowed to measure the variability in resource consumption per patients' according their clinical characteristics. These findings can sustain the development of financially sustainable health policies in middle-income countries such as Brazil.Copyright © 2023

Seroprevalence of SARS-CoV- 2 in children of school-going age in district Swabi, Pakistan

Introduction: Earlier estimates of SARS-CoV- 2 do not accurately account for the extent of undiagnosed infections in children, who typically experience mild or asymptomatic disease. The purpose of this study was to estimate the seroprevalence of SARS-CoV- 2 antibodies in children from District Swabi, one of the populous districts of Pakistan, and to identify symptoms most frequently associated with seropositivity. Methodology: We used ELISA to test for the presence of antibodies, IgM and IgG, in blood samples collected from 246 children of school-going age (5-16 years old) selected randomly from the district of Swabi, Pakistan. This study was approved by Khyber Medical University, Peshawar, Ethical Board, and Advanced Studies Review Board. Data were collected on a purposefully built questionnaire. Result(s): Overall, 2.0% of our participants were seropositive for IgM, whereas 23.1% were seropositive for IgG. Older age, female gender, and contact history were significantly associated with higher seropositivity. Symptoms associated with seropositivity were: fever (98.0%), cough (90.0%), sore throat (79.0%), coryza (68.0%), myalgia (61.0%), loss of sense of smell and taste (49.0%), and vomiting or diarrhoea (8.0%). Although 77.6% of our IgG seropositive participants recalled experiencing flu-like symptoms, none of the participants in this study had visited the doctor or were tested for SARS-COV- 2. We found IgG titres to be significantly higher in symptomatic children. Conclusion(s): The number of undiagnosed infections in children may be substantially larger than the official accounts. Sparse data are available regarding coronavirus disease in children, particularly in low middle-income countries (LMIC). The most frequently symptoms were fever, cough, sore throat, coreza, myalgia, loss of sense of smell and taste and lastly vomiting and diarrhoea. Serological studies provide valuable insight into the immunological status of a population, and can prove vital when considering future strategies.

Use of Economic Evaluation of Vaccines: The Experience in Colombia, 2000 to 2021

Objectives: To describe the use of economic evaluation to update the antigens dispensed by the Colombian Expanded Program on Immunization (EPI) from 2000 and 2021. Method(s): a review of economic evaluation of vaccines (EEV) studies conducted by the Expanded Program of Immunization in Colombia between 2000 and 2021. A literature search was carried out in different databases complemented with information obtained from different stakeholders who participated in the updating process. Result(s): In 2000, sponsored by the Pan-American Health Office of the World Health Organization (PAHO/WHO), was conducted the cost-effectiveness analysis of vaccination against Hemophilus influenzae type b was the first economic evaluation of vaccines (EEV) conducted ever in Colombia. Between 2005 and 2007, 4 EEV (Rotavirus, Heptavalent Pneumococcus, Influenza and Hepatitis A) were carried out in order to inform the decision process at local level in Bogota DC, the Colombian capital. Between 2007 and 2010, the Ministry of Health sponsored 8 EEV (Rotavirus, 7- and 10-valent pneumococcus, Influenza, Hepatitis A, chickenpox, tetanus in men, and HPV) which were used to decide about the introduction of new vaccines at national level. Subsequently, with the support of PAHO's PROVAC initiative, Colombia went from having 6 EPI vaccines in the 1990s, to 21 EPI vaccines that currently protect against 29 diseases, not including the vaccines used against COVID-19 which Colombia have been using since March 2021. Conclusion(s): Colombia has been one of the middle-income countries with the highest number of vaccines included in its EPI in the last 20 years and the use of the EEV has been essential for decision-making.Copyright © 2023

Results from the first audit of an intensive care unit in Botswana.

Background: Botswana is an economically stable middle-income country with a developing health system and a large HIV and infectious disease burden. Princess Marina Hospital (PMH) is the largest referral and teaching hospital with a mixed eight-bed intensive care unit (ICU). Objectives: To conduct an audit of PMH ICU in order to investigate major admission categories and quantify morbidity and mortality figures using a validated scoring system for quality improvement, education and planning purposes. Methods: PMH medical records and laboratory data were accessed to record demographics, referral patterns, diagnoses, HIV status, Acute Physiologic Assessment and Chronic Health Evaluation (APACHE) II scores and mortality rates. Results: A total of 182 patients >14 years of age were enrolled over a 12-month period from April 2017 - March 2018. Patient's mean age was 42.9 years, males represented 56.6% of the study population and surgical conditions accounted for 46% of diagnostic categories. Sixty percent of the patients were HIV-negative and 12% had no HIV status recorded. The mean APACHE II score was 25 and the mean length of stay in ICU was 10.3 days. Higher APACHE II scores were associated with higher mortality regardless of HIV status. The overall mortality was 42.8% and there was no difference in mortality rates in ICU or at 30 days between HIV-positive and HIV-negative ICU patient groups. Conclusion: The PMH ICU population is young with a high mean APACHE II score, significant surgical and HIV burdens and a high mortality rate. PMH ICU has significant logistical challenges making comparison with international ICUs challenging, and further research is warranted. Contributions of the study: This study is the first published audit for an intensive care unit in Botswana. The findings are especially relevant for the development of critical care capacity in the country during the current COVID-19 pandemic. We advocate for the establishment of an ICU registry in the country to allow ongoing accurate research in the field of critical care medicine and to improve healthcare for all critically ill patients in Botswana.

Equitable Access

The COVID-19 epidemic has once again highlighted the challenges to achieve equitable access to critical antimicrobials and vaccines. The problem is particularly acute for antimicrobials. Despite recent investments improving the pipeline for new treatments, most new treatments are not available to populations most in need, especially in low- and middle-income countries. Once a drug is approved a range of factors may hinder access, from lack incentives to register and commercialize products due to unattractive market potential to unfunded national action plans that can help improve the uptake and appropriate use of new tools to combat antibiotic resistance. Previous studies have shown that the majority of the 18 new antibacterials approved and launched between 2010-2020 were accessible in only 3 out of 14 high-income countries (Sweden, UK, and US). In low- and middle-income countries, the problem is even worse, with only 10 of the 25 new antibiotics that entered the market between 1999 and 2014 registered in more than ten countries. While lack of equitable access to life-saving medicines, diagnostics, and vaccines is not a new problem for infectious diseases, emerging opportunities and innovative approaches can help improve access globally. This talk will review promising recent developments in governance and collaborations, policies, economic models and initiatives that may help correct deadly inequities. For example, the objectives of the Access to COVID-19 Tools Accelerator may serve as model that convenes diverse actors to mount a coordinated access response which may be applied to access to other antimicrobials and vaccines. In addition, novel licensing agreements for access and stewardship to cefiderocol, an antimicrobial that is on the WHO Essential Medicines List can help serve as a pathfinder to accelerate equitable access to novel antimicrobials. The talk will also surface critiques of ongoing initiatives and raise questions for further study and discussion.Copyright © 2023

Patient-Centered Surveillance of Drug-Resistant Infections

Drug resistance or multidrug resistance is multidimensional and complex. Over the past decade and especially during the covid-19 pandemic, the incidence of drug resistant infections increased despite the implementation of infection control precautions. This was most commonly seen in low- and middle-income countries, due to the higher burden of infectious diseases, lack of proper infrastructure, unregulated antimicrobial prescriptions over the counter, limited surveillance of antimicrobial use and resistance patterns. This was further compounded by the dearth of healthcare personnel trained in appropriate infectious disease management. Strategies in high income countries to prevent and manage drug resistant infections are unfortunately, not implementable in LMICs due to differences in antimicrobial resistance (AMR) burden, access to newer antibiotics, limited infrastructure and human resources with requisite expertise with lack of economic investment by regulatory authorities to tackle AMR. During the covid-19 pandemic, the lack of therapeutic options and the similar clinical picture initially led to rampant antimicrobial use which in turn contributed to rise in multi-drug resistant infections (MDR). Along with inappropriate antimicrobial use, redistribution of staff assigned to enforce infection control practices, shortage of personnel protective equipment, overcrowded healthcare settings, use of prolonged broad-spectrum antimicrobials in patients requiring during intensive care and mechanical ventilation contributed to the rise in hospital transmission of multidrug resistant infections during the pandemic. To mitigate the effects of drug resistance, healthcare systems must ensure effective implementation of surveillance of antimicrobials, AMR patterns especially in MDR HAIs and antimicrobial stewardship interventions to promote optimal antimicrobial use. National level investment to improve diagnostics must be given priority as it can limit drug resistance and promote the role of biomarkers in streamlining antimicrobial use. These need to be planned to facilitate future integration with any future pandemic surveillance.Copyright © 2023

Covid-19 Self-Testing among Healthcare Workers and General Population in Malawi

Background: COVID-19 testing is critical for identifying cases to prevent transmission. SARS-CoV-2 self-testing has the potential to increase diagnostic testing capacity and to expand access to hard-to-reach areas in low-andmiddle- income countries. We investigated the feasibility and acceptability of COVID-19 self-sampling and self-testing using SARS-CoV-2 Ag-Rapid Diagnostic Tests. Method(s): Between July 2021 to February 2022, we conducted a mixedmethods cross-sectional study examining self-sampling and self-testing using Standard Q and Panbio COVID-19 Ag Rapid Test Device in Urban and rural Blantyre, Malawi. Health care workers and adults (18y+) in the general population were systematically sampled. Result(s): Overall, 1,330 participants were enrolled of whom 674 (56.0%) were female with 664 for self-sampling and 666 for self-testing. Overall mean age was 30.7y (standard deviation [SD] 9.6). Self-sampling usability threshold for Standard Q was 273/333 (82.0%: 95% CI 77.4% to 86.0%) and 261/331 (78.8%: 95% CI 74.1% to 83.1%) for Panbio. Self-testing threshold was 276/335 (82.4%: 95% CI 77.9% to 86.3%) and 300/332 (90.4%: 95% CI 86.7% to 93.3%) for Standard Q and Panbio, respectively. Agreement between self-sample results and professional test results was 325/325 (100%) and 322/322 (100%) for Standard Q and Panbio, respectively. For self-testing, agreement was 332/333 (99.7%: 95% CI 98.3 to 100%) for Standard Q and 330/330 (100%: 95% CI 99.8 to 100%) for Panbio. Odds of achieving self-sampling threshold increased if the participant was recruited from an urban site (odds ratio [OR] 2.15 95% CI 1.44 to 3.23, P < .01. Compared to participants with primary school education those with secondary and those with tertiary achieved higher self-testing threshold OR 1.88 (95% CI 1.17 to 3.01), P = .01 and 4.05 (95% CI 1.20 to13.63), P = .02, respectively. Conclusion(s): One of the first studies to demonstrate high feasibility of self-testing using SARS-CoV-2 Ag-RDTs in low- and middle-income countries potentially supporting large scale-up.

SASA 2023 Congress

The proceedings contain 34 papers. The topics discussed include: comparison of intra-arterial blood pressures versus two noninvasive measuring systems: a cross-sectional analytic study employing Bland-Altman and error grid analyses;prevalence of vitamin D deficiency amongst anesthesia providers at the Universitas Academic Hospital;chemical and physical stability of an admixture of anesthetic drugs;postoperative pulmonary complications in adult surgical patients in low- and middle-income countries: a systematic review and meta-analysis;the prevalence of SARS-CoV-2 infection in an academic department of anesthesiology;evaluation of the use of a 3D printed video laryngoscope for tracheal intubation in a manikin;the prevalence of caregiver anxiety in theatre at universitas academic hospital;the spectrum of disease and short-term outcomes of obstetric patients with cardiac disease at a tertiary hospital in South Africa;and almost 30% reduction in carbon footprint using volatile anesthesia - a quality improvement project introducing low-flow anesthesia in a regional hospital.

Worldwide responses of health systems to the financial challenges of the COVID-19 pandemic

The SARS-CoV-2 coronavirus (COVID-19) pandemic is a major public health issue;it is the greatest challenge facing humanity in the 21st century, and a sharp increase in the prevalence of the disease has resulted in an increase in morbidity and mortality in many countries. The global health community, in an effort to reduce the spread of the virus, has been taking precautionary measures to address the crisis and alleviate the economic impact of the pandemic on healthcare services. Global information exchange is vital for health systems to meet these challenges. Health systems, even those in developed countries, appear to have been unprepared to meet this challenge, partly because of pre-existing problems. This study identifies some important features of health systems around the world, and the policies implemented by those responsible for addressing this global health crisis caused by SARSCoV-2. In addition, it highlights the government decisions and mechanisms that were implemented to strengthen and finance health systems, and to mitigate the cost of the pandemic. The response of health systems to the requirements created by the coronavirus pandemic shows adaptation to successive changes, allowing recovery and satisfaction of their needs for the protection of public health.Copyright © Athens Medical Society.

Enhancing Pharmaceutical Supply Chain Resilience: A Study of Pharmaceutical Companies in Multiple Geographies

Background: Pharmaceutical businesses had enormous difficulties in product distribution during COVID-19, and the solution to this perpetual issue is a resilient supply chain. Aim(s): The study aims to understand the vulnerabilities to which it subjected the pharmaceutical product distribution supply chains during the COVID-19 pandemic and further develop an adaptive model through which the pharmaceutical product supply chain can enhance its resilience capabilities. Material(s) and Method(s): The conceptual model is developed for the supply chain of pharmaceutical companies based on the literature survey, and then the conceptual model is explored through factor analysis. Researchers have developed a validated model after a statistical analysis using Cronbach's alpha. Subjective analysis has concluded that the pharmaceutical supply chain's resilience is driven by factors such as "trade cost," which comprises transport cost, business practices, and raw material sourcing cost;"shock propagation," which comprises country-specific shocks, production shocks, and policy changes;and "technological infrastructure bottleneck," which relates to the availability of cold chain storage warehouses and refrigerated transport vehicle facilities. Result(s): An empirical model pertaining to supply chain resilience may be further studied with different geographies, like Pune, Hyderabad, and Delhi NCR, for the purpose of generalizing the study. Conclusion(s): The identified major factors were trade cost, shock propagation, and technological infrastructure bottlenecks. The sensitivity of the issue under investigation required a personal touch to the survey, as the COVID-19 pandemic had left these respondents emotionally vulnerable. As COVID-19 is the recent catastrophe that has hit humanity, it has made the pharmaceutical product distribution channel vulnerable during the pandemic. This difficult time of pandemic has really tested the pharmaceutical products' supply chain capabilities as well.Copyright © 2023, Association of Pharmaceutical Teachers of India. All rights reserved.