Expanding beyond zoonoses: the benefits of a national One Health coordination mechanism to address antimicrobial resistance and other shared health threats at the human-animal-environment interface in Kenya.

In order to manage global and transnational health threats at the human- animal-environment interface, a multisectoral One Health approach is required. Threats of this nature that require a One Health approach include, but are not limited to, emerging, endemic and re-emerging zoonotic diseases, food safety, antimicrobial resistance (AMR), vector-borne and neglected infectious diseases, toxicosis and pesticides. Relevant Kenyan authorities formally institutionalised One Health in 2011 through the establishment of the Zoonotic Disease Unit (ZDU) and its advisory group, the Zoonoses Technical Group. At that time, the One Health agenda focused on zoonotic diseases. As the issue of AMR began to gain traction globally, a One Health approach to its management was advocated in Kenya in 2015. This paper summarises a series of interviews (with respondents and key informants) that describe how AMR institutionalisation evolved in Kenya. It also examines how responses to other health threats at the human-animal- environment interface were coordinated and used to identify gaps and make recommendations to improve One Health coordination at the national level in Kenya. Results showed that the road to the institutionalisation of AMR through the National Action Plan on Prevention and Containment of Antimicrobial Resistance, 2017-2022 and a formally launched One Health coordination mechanism, the National Antimicrobial Stewardship Interagency Committee (NASIC), took ten years. Moreover, supplementary actions are still needed to further strengthen AMR coordination. In addition to the ZDU and NASIC, Kenya has established two other formal multisectoral and multidisciplinary coordination structures, one for aflatoxicosis and the other for health threats associated with pesticide use. The country has four distinct and separate One Health coordination mechanisms: for zoonoses, for AMR, for aflatoxicosis and for the health threats associated with pesticide use. The main gap lies in the lack of overall coordination between these topic-specific structures. An overall coordination mechanism for all One Health issues is therefore needed to improve synergy and complementarity. None of the topic-specific mechanisms plays a critical role in the policy development process, institutionalisation or implementation of activities related to the other topic areas. The authors recommend renaming the ZDU as the One Health Office, and expanding it to include AMR and food safety teams, and their associated technical working groups. Through this restructuring, the One Health Office would become an umbrella organisation dealing with all four issues mentioned above. Based on Kenya's experience, the authors recommend that other countries also consider expanding the scope of multisectoral One Health coordination mechanisms to include other shared health threats.

La gestion des menaces sanitaires mondiales et transnationales à l'interface homme­animal­environnement nécessite de faire appel à une approche Une seule santé multisectorielle. Les menaces de cette nature appelant une approche Une seule santé sont notamment (mais ne s'y limitent pas) les maladies zoonotiques émergentes, endémiques et réémergentes, la sécurité sanitaire des aliments, la résistance aux agents antimicrobiens, les maladies à transmission vectorielle, les maladies infectieuses négligées, les toxicoses et les pesticides. Les autorités kényanes ont institutionnalisé formellement l'approche Une seule santé en 2011 en mettant en place l'Unité Maladies zoonotiques (ZDU : Zoonotic Disease Unit) et son groupe consultatif, le Groupe technique Zoonoses. Le programme d'activités Une seule santé était alors centré sur les maladies zoonotiques. La problématique de l'antibiorésistance ayant gagné du terrain à l'échelle mondiale, en 2015 il a été préconisé de recourir à l'approche Une seule santé pour y faire face au Kenya. Les auteurs résument une série d'entretiens conduits auprès d'interlocuteurs et d'acteurs clés concernant l'évolution de l'institutionnalisation de la lutte contre la résistance aux agents antimicrobiens au Kenya. Ils mettent également en lumière le déroulement de la coordination des réponses mises en place pour contrer d'autres menaces sanitaires à l'interface homme­animal­environnement et l'éclairage que ces réponses ont permis d'apporter afin d'identifier les lacunes et de formuler des recommandations pour améliorer la coordination Une seule santé à l'échelle nationale. Il ressort de cette analyse qu'il a fallu dix ans pour que le Kenya institutionnalise le domaine de l'antibiorésistance à travers le Plan d'action national pour la prévention et la maîtrise de l'antibiorésistance (2017­2022) et pour qu'il mette en place un mécanisme officiel de coordination Une seule santé, le Comité national inter-agences de gestion concertée des agents antimicrobiens (NASIC : National Antimicrobial Stewardship Interagency Committee). Il est également apparu que des mesures complémentaires devaient être prises pour renforcer la coordination en matière d'antibiorésistance. Outre le ZDU et le NASIC, deux autres structures officielles de coordination multidisciplinaires et multisectorielles ont été créées au Kenya, chargées respectivement de l'aflatoxicose et des menaces sanitaires en lien avec l'utilisation de pesticides. Le pays dispose donc de quatre mécanismes de coordination distincts portant respectivement sur les zoonoses, l'antibiorésistance, l'aflatoxicose et les menaces sanitaires liées à l'utilisation de pesticides. La faille centrale est l'absence de coordination d'ensemble entre ces structures thématiques. Il faut donc instituer un mécanisme de coordination général pour toutes les questions relevant de l'approche Une seule santé, afin d'améliorer les synergies et la complémentarité. Aucun des mécanismes thématiques ne joue de rôle déterminant dans le processus d'élaboration des politiques, l'institutionnalisation ou la mise en œuvre de mesures relevant des autres thématiques. Les auteurs recommandent de modifier le nom du ZDU en Bureau Une seule santé et d'en élargir les compétences pour intégrer les équipes chargées de l'antibiorésistance et de la sécurité sanitaire des aliments ainsi que leurs groupes de travail techniques respectifs. Suite à cette restructuration, le Bureau Une seule santé pourrait devenir l'organisation transversale traitant des quatre thèmes précités. En se basant sur l'expérience du Kenya, les auteurs recommandent que d'autres pays s'engagent à leur tour sur la voie d'un élargissement de la portée des mécanismes de coordination multisectoriels Une seule santé afin d'inclure d'autres menaces sanitaires communes.

Para lidiar con las amenazas sanitarias mundiales o transnacionales en la interfaz de personas, animales y medio ambiente es preciso trabajar desde la óptica multisectorial de Una sola salud. Este tipo de amenazas que apelan al concepto de Una sola salud son, entre otras, las enfermedades zoonóticas emergentes, endémicas o reemergentes, los factores que afectan a la inocuidad de los alimentos, las resistencias a los antimicrobianos, las enfermedades infecciosas de transmisión vectorial o desatendidas, las toxicosis y los efectos del uso de plaguicidas. En 2011, con la creación de la ZDU (Zoonotic Disease Unit: unidad de enfermedades zoonóticas) y de un grupo técnico sobre zoonosis encargado de asesorarla, las autoridades competentes kenianas pusieron en práctica oficialmente la noción de Una sola salud. En aquel momento los programas de Una sola salud se centraban sobre todo en las enfermedades zoonóticas. A partir de 2015, cuando las resistencias a los antimicrobianos empezaron a ganar terreno en todo el mundo, en Kenia se apostó por combatirlas desde la óptica de Una sola salud. Los autores, sintetizando la información obtenida con una serie de encuestas y entrevistas con informadores clave, describen la progresiva institucionalización en Kenia de la lucha contra esas resistencias. También explican cómo se coordinaron las actividades de respuesta a otras amenazas sanitarias surgidas en la interfaz de personas, animales y medio ambiente y cómo ello sirvió para detectar deficiencias y formular recomendaciones encaminadas a mejorar la coordinación en clave de Una sola salud en todo el territorio nacional. Los resultados demuestran que hicieron falta diez años para institucionalizar la lucha contra la resistencia a los antimicrobianos, materializada en un plan nacional de acción sobre prevención y contención de antibiorresistencias para 2017­2022 y en la creación oficial de un mecanismo de coordinación de Una sola salud, el NASIC (National Antimicrobial Stewardship Interagency Committee: comité nacional interinstitucional de gestión de antimicrobianos). No obstante, aún hacen falta más medidas para mejorar la coordinación en todo lo relativo a las antibiorresistencias. Además de la ZDU y el NASIC, Kenia ha creado otras dos estructuras oficiales de coordinación multisectorial y multidisciplinar, una para la aflatoxicosis y otra para las amenazas sanitarias derivadas del uso de plaguicidas. El país cuenta así con cuatro mecanismos distintos e independientes de coordinación en clave de Una sola salud, centrados en las zoonosis, las antibiorresistencias, la aflatoxicosis y los riesgos sanitarios ligados a los plaguicidas. La principal deficiencia estriba en la falta de coordinación global entre estas estructuras de carácter temático. Para lograr mayores cotas de sinergia y complementariedad, por lo tanto, se requiere un mecanismo de coordinación general de todos los ámbitos de trabajo que tocan a la noción de Una sola salud. Ninguno de los mecanismos temáticos cumple una función decisiva en el proceso de formulación de políticas o de institucionalización y ejecución de actividades relacionadas con los demás ámbitos temáticos. Los autores recomiendan que la ZDU pase a denominarse Oficina de Una sola salud y que sea ampliada para integrar en ella a los equipos encargados de las antibiorresistencias y la inocuidad de los alimentos y a los correspondientes grupos de trabajo técnicos. Con semejante reestructuración, la Oficina de Una sola salud pasaría a ser una supraentidad que abarcaría los cuatro temas ya mencionados. Teniendo en cuenta la experiencia de Kenia, los autores recomiendan que otros países se planteen también la posibilidad de ampliar la cobertura de los mecanismos de coordinación multisectorial de Una sola salud para que incluyan otras amenazas sanitarias que tengan elementos en común.

Quantification of risk of emergency caesarean during labour after one previous caesarean section.

In its 2007 guideline, the Royal College of Obstetricians and Gynaecologists (RCOG) recommends vaginal birth after caesarean (VBAC) as safer than repeat elective caesarean sections. However, this document does not give details of risk of emergency caesarean section for women accepting VBAC. An emergency caesarean is associated with increased maternal and neonatal morbidity, and women do consider the eventuality of emergency delivery when deciding mode of delivery. We sought to quantify this risk by designing a retrospective cohort study in a consultant-led unit. While higher than average rates of successful planned VBAC were achieved, the odds of emergency caesarean delivery were increased in women undergoing VBAC (OR 3.0, 95% CI 1.2-7.6, p = 0.03). Odds of requiring a Category 1 emergency caesarean were markedly raised. Our data adds to the VBAC literature by quantifying the risk of Category 1 or 2 emergency caesarean section for women entering labour who have delivered by caesarean section once previously, giving the odds of emergency caesarean section on entering labour compared with women without a scar. This gives further information to those counselling women about birth after caesarean section.

Treatment of overactive bladder (OBA) with anti-cholinergic drugs and the risk of glaucoma.

Overactive bladder (OAB) and glaucoma are prevalent and frequently co-exist, particularly in the elderly. Anti-cholinergic drugs are the cornerstone of medical management of OAB. There is a great deal of confusion about the safety of use of the anti-cholinergic medication regarding the risk of glaucoma. This review examines the pharmacological relationship of anti-cholinergic medications used to treat OAB and the various types of glaucoma.

Intravesical migration of a GyneFix intrauterine device.

A case of intravesical migration of a GyneFix intrauterine device (IUD) is described, in which the patient presented with supra-pubic pain and urinary symptoms. The diagnosis was made 34 months after the insertion of the IUD, by ultrasound scan. The GyneFix was removed endoscopically. A description of the GyneFix device, the possible adverse effects and incidences of its complications, the importance of post-insertion follow-up, and the need for awareness of the possibility of intravesical migration are discussed.

Detection of glove puncture and skin contamination during caesarean section.

Measures that can be taken to reduce exposure to potentially infected body fluids are of particular relevance in obstetric and gynaecological surgery due to high rates of glove puncture and relatively higher prevalence of human immunodeficiency virus seropositivity in the obstetric age group. We describe the use of a simple electronic device that alarms following puncture of surgical gloves or the creation of a fluid bridge between surgeon and patient. Further exposure to potentially infected body fluids is thus prevented. This present study was performed in the context of caesarean section, but the application of the technique to gynaecological procedures is appropriate.

Changes in metabolism of collagen in genitourinary prolapse.

BACKGROUND: Genitourinary prolapse is a common problem, the pathophysiology of which is unknown. METHODS: We analysed vaginal-epithelial tissue from premenopausal women with genitourinary prolapse and compared them with controls. FINDINGS: We found that genitourinary prolapse is associated with a reduction in total collagen content and a decrease in collagen solubility. Both intermediate intermolecular cross-links and advanced glycation cross-links were increased in prolapse tissue. Collagen turnover, as indicated by matrix metalloproteinase activity, was up to four times higher in prolapse tissue. Collagen-type ratios, mature cross-link pyridinoline and total elastin content were similar in both prolapse and control tissues. Increased collagenolytic activity causes loss of collagen from prolapse tissue. INTERPRETATION: Based on these findings, we have identified a probable mechanism for genitourinary prolapse. Development of agents to inhibit collagenolytic activity may help in the treatment of this condition.

The Bristol Female Lower Urinary Tract Symptoms questionnaire: development and psychometric testing.

OBJECTIVE: To develop a questionnaire that is sensitive to changes in the symptomatology of the female lower urinary tract, particularly urinary incontinence, providing an instrument that can characterize symptom severity, impact on quality of life and evaluate treatment outcome. PATIENTS, SUBJECTS AND METHODS: Items covering as wide a range of urinary symptoms as possible were devised after consultation with clinicians and a health scientist, a literature review and discussion with patients. Additional items assessed the degree of 'bother' that symptoms were causing. Eighty-five women with clinical symptoms attending for urodynamic assessment and 20 women with none were asked to self-complete the questionnaire. The instrument's validity was assessed by interviewing patients and measuring levels of missing data, comparing symptom scores between clinical and non-clinical populations and comparison with frequency/volume charts and data from pad tests. The instrument's reliability was assessed by measuring both internal consistency and stability, using a 2-week test-retest analysis. RESULTS: The questionnaire was completed by the patients with a mean of only 2% of items missing; most questions were easily understood. Construct validity was good, with the instrument easily differentiating clinical and non-clinical populations. Criterion validity, as tested against frequency/volume charts and pad-test data, was acceptable, with Kappa coefficients of 0.29-0.79 for frequency/volume data and Spearman rank correlations of 0.50-0.97 and 0.31-0.67 for frequency/volume and pad-test data, respectively. The reliability of the instrument was good; a Cronbach's alpha of 0.78 indicated that the symptom questions had high internal consistency, while stability was excellent, with 78% of symptoms and problems answered identically on two occasions, and Spearman rank correlations of 0.86 and 0.90, respectively. CONCLUSION: The instrument has good psychometric validity and reliability. The stability demonstrated at baseline and the ability to differentiate clearly between community and clinical populations suggest that it should be ideal for measuring changes following therapeutic intervention. The addition of life-impact items and a 'bother' factor may provide the opportunity to identify those women who wish treatment for their symptoms; this dimension requires further exploration.

The continence control pad--a new external urethral occlusion device in the management of stress incontinence.

OBJECTIVE: To assess the use of an external urethral occlusion pad (the continence control pad, CCP) in the management of stress incontinence. PATIENTS AND METHODS: Nineteen women (median age 47 years, range 36-72) complaining of stress incontinence were taught to use the CCP. The patients were assessed during the week before, and again after using the CCPs for 2 weeks, by urinary diaries, pad-tests and a review of their symptoms. RESULTS: Use of the CCP was associated with a cure or improvement in 17 women, as assessed by the number of incontinent episodes per week. There was a significant decrease in both the number of incontinent episodes (P < 0.001) and pad-test leakage (P = 0.002) when using the CCP. Minor difficulties in placement and removal were described in a minority of women. CONCLUSION: The CCP offers a simple, non-invasive treatment for women complaining of stress incontinence. The short-term success rate was better than that with other conservative methods of treatment, is independent of the general practitioner and safe. It is a promising home-based method of managing stress incontinence.