Rapid response teams in the Eastern Mediterranean Region: Results from the baseline survey of country-level capacities, operations and outbreak response capabilities.

The aim of this study is to assess WHO/Eastern Mediterranean region (WHO/EMR) countries capacities, operations and outbreak response capabilities. Cross-sectional study was conducted targeting 22 WHO/EMR countries from May to June 2021. The survey covers 8 domains related to 15 milstones and key performance indicators (KPIs) for RRT. Responses were received from 14 countries. RRTs are adequately organised in 9 countries (64.3%). The mean retention rate of RRT members was 85.5% ± 22.6. Eight countries (57.1%) reported having standard operating procedures, but only three countries (21.4%) reported an established mechanism of operational fund allocation. In the last 6 months, 10,462 (81.9%) alerts were verified during the first 24 h. Outbreak response was completed by the submission of final RRT response reports in 75% of analysed outbreaks. Risk Communication and Community Engagement (RCCE) activities were part of the interventional response in 59.5% of recent outbreaks. Four countries (28.6%) reported an adequate system to assess RRTs operations. The baseline data highlights four areas to focus on: developing and maintaining the multidisciplinary nature of RRTs through training, adequate financing and timely release of funds, capacity and system building for implementing interventions, for instance, RCCE, and establishing national monitoring and evaluation systems for outbreak response.

Vector-Borne and Zoonotic Diseases in the Eastern Mediterranean Region: A Systematic Review.

BACKGROUND AND OBJECTIVE: World Health Organization Eastern Mediterranean Region (WHO EMR) has 40% people in the world in need of humanitarian assistance. This systematic review explores selected vector-borne and zoonotic diseases (VBZDs) of importance to EMR in terms of disease burden across countries and periods, disaggregated across sex, age groups, education levels, income status, and rural/urban areas, related vector or animal source reduction measures, and public health, social and economic impacts and related interventions. METHODS: We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and reviewed articles in PubMed, Embase, and WHO Global Index Medicus published between 1st of January 2011 and 27th of June 2022. Thirteen VBZDs with at least one reported outbreak in the last five years in the region or prioritized as per previous analysis at the WHO global and regional level and based on expert consultations, were included as part of the analysis. RESULTS: The review included 295 studies-55% on leishmaniasis and dengue combined, and 75% studies from Pakistan, Kingdom of Saudi Arabia, and Iran combined. Hospital-based and nationally representative studies constituted 60% and 10% respectively. Males were predominantly affected in most diseases; children reported high burden of Leishmaniasis, whereas elderly had a higher burden of Dengue Fever and Middle East Respiratory Syndrome. Although very few studies reported on socioeconomic differences in burden, the ones that reported showed higher burden of diseases among the disadvantaged socioeconomic groups such as the poor and the less educated. More than 80% studies reported an increase in burden over the years. CONCLUSION: The literature is scanty for most of the diseases reviewed and the number of studies from countries with humanitarian challenges is very low. The need for more nationally representative, population-based studies calls for prioritizing research investments.

Antibiotic consumption in India: geographical variations and temporal changes between 2011 and 2019.

Objectives: To describe and compare private sector systemic (J01) antibiotic consumption across Indian states from 2011 to 2019. Methods: We used the nationally representative PharmaTrac dataset to describe the consumption rates in DDD across national, state and state-group [high focus (HF) and non-high focus (nHF)] levels. We used median and IQRs to describe and compare across states and state groups, and relative change and compound annual growth rate (CAGR) to examine temporal changes. Results: The annual consumption rate decreased by 3.6% between 2011 and 2019. The share of Access antibiotics decreased (13.1%) and the Access/Watch ratio declined from 0.59 to 0.49. State consumption rates varied widely (HF states reported lower rates) and the inappropriate use increased over the years, especially among HF states. The HF and nHF states showed convergence in the share of the Access and the Access/Watch ratio, while they showed divergence in the use of Discouraged fixed-dose combinations. Conclusions and implications: India's private-sector antibiotic consumption rate was lower than global rates. The rates varied across states and appropriateness of use decreased in most states over the years. States with an increase in appropriate use over time could serve as best practice examples. Studies to understand the factors affecting inappropriate use are required alongside improved data systems to monitor the public-sector provision of antibiotics to understand the total consumption.

Quantifying antibiotic use in typhoid fever in India: a cross-sectional analysis of private sector medical audit data, 2013-2015.

OBJECTIVES: To estimate the antibiotic prescription rates for typhoid in India. DESIGN: Cross-sectional study. SETTING: Private sector primary care clinicians in India. PARTICIPANTS: The data came from prescriptions of a panel of 4600 private sector primary care clinicians selected through a multistage stratified random sampling accounting for the region, specialty type and patient turnover. The data had 671 million prescriptions for antibiotics extracted from the IQVIA database for the years 2013, 2014 and 2015. PRIMARY AND SECONDARY OUTCOME MEASURES: Mean annual antibiotic prescription rates; sex-specific and age-specific prescription rates; distribution of antibiotic class. RESULTS: There were 8.98 million antibiotic prescriptions per year for typhoid, accounting for 714 prescriptions per 100 000 population. Children 10-19 years of age represented 18.6% of the total burden in the country in absolute numbers, 20-29 year age group had the highest age-specific rate, and males had a higher average rate (844/100 000) compared with females (627/100 000). Ten different antibiotics accounted for 72.4% of all prescriptions. Cefixime-ofloxacin combination was the preferred drug of choice for typhoid across all regions except the south. Combination antibiotics are the preferred choice of prescribers for adult patients, while cephalosporins are the preferred choice for children and young age. Quinolones were prescribed as monotherapy in 23.0% of cases. CONCLUSIONS: Nationally representative private sector antibiotic prescription data during 2013-2015 indicate a higher disease burden of typhoid in India than previously estimated. The total prescription rate shows a declining trend. Young adult patients account for close to one-third of the cases and children less than 10 years account for more than a million cases annually.

What matters for health? Public views from eight countries.

INTRODUCTION: Despite growing scholarship on the social determinants of health (SDoH), wider action remains in its early stages. Broad public understanding of SDoH can help catalyse such action. This paper aimed to document public perception of what matters for health from countries with broad geographic, cultural, linguistic, population composition, language and income level variation. METHODS: We conducted an online survey in Brazil, China, Germany, Egypt, India, Indonesia, Nigeria and the USA to assess rankings of what respondents thought matters for health and what they perceived decision makers think matters for health. We analysed the percentages of each determinant rated as the most important for good health using two metrics: the top selection and a composite of the top three selections. We used two-tailed χ2 test for significance testing between groups. RESULTS: Of 8753 respondents, 56.2% (95% CI 55.1% to 57.2%) ranked healthcare as the most important determinant of good health using the composite metric. This ranking was consistent across countries except in China where it appeared second. While genetics was cited as the most important determinant by 22.3% (95% CI 21.5% to 23.2%) of the overall sample with comparable rates in most countries, the percentage increased to 33.3% (95% CI 30.5% to 36.3%) in Germany and 35.9% (95% CI 33.0% to 38.8%) in the USA. Politics was the determinant with the greatest absolute difference (18.5%, 95% CI 17.3% to 19.6%) between what respondents considered matters for health versus what they perceived decision makers think matters for health. CONCLUSION: The majority of people consider healthcare the most important determinant of health, well above other social determinants. This highlights the need for more investment in communication efforts around the importance of SDoH.

Tuberculosis and Diabetes in India: Stakeholder Perspectives on Health System Challenges and Opportunities for Integrated Care.

BACKGROUND: India has a dual burden of tuberculosis (TB) and diabetes mellitus (DM). Integrated care for TB/DM is still in the early phase in the country and can be considerably enhanced by understanding and addressing the challenges identified from stakeholders' perspectives. This study explored the challenges and opportunities at individual, health system and policy level for integrated care of TB/DM comorbidities in India. METHODS: We used an outlier case study approach and conducted stakeholder interviews and focus group discussions with relevant program personnel including field staff and program managers of TB and DM control programs as well as officials of partners in Indian states, Kerala and Bihar. RESULTS: The integrated management requires strengthening the laboratory diagnosis and drug management components of the two individual programs for TB and DM. Focused training and sensitization of healthcare workers in public and private sector across all levels is essential. A district level management unit that coordinates the two vertical programs with a horizontal integration at the primary care level is the way forward. Substantial improvement in data infrastructure is essential to improve decision-making process. CONCLUSION: Bi-directional screening and management of TB/DM comorbidities in India requires substantial investment in human resources, infrastructure, drug availability, and data infrastructure.

Public health implications of Sabarimala mass gathering in India: A multi-dimensional analysis.

INTRODUCTION: Mass gathering for religious and spiritual purposes are common in India. However, mass gathering health and travel medicine is still in its infancy in India. OBJECTIVES: The study explored bio-medical, environmental and psycho-social dimensions of mass gathering in Sabarimala pilgrimage, which is annually attended by 25 million pilgrims. METHODS: In a cross sectional design, the investigators travelled the pilgrim trail and stayed in the shrine area to conduct the interviews (sample = 1259), to observe the practices as well as to assess the environmental conditions including sanitation. We did in-depth interviews of a subset of samples of the pilgrims, laboratory tests for water quality and secondary analysis of health services data. RESULT: 43.4% pilgrims reported at least one health problem. Leg pain, joint/muscle pain, breathlessness, were the common symptoms. Pilgrims expressed concern about drinking water and food safety and majority of them felt the crowd management as unsatisfactory. Untreated sewage and solid waste were found to pollute the water downstream. Average patient presentation rate for 2014-2017 was 4999.6 per 100,000 pilgrims and referral to Hospital Rate was 19 per 100,000 pilgrims. Mortality rate ranged from 18.5 to 21 per 100,000 pilgrims among those who attended the health centers for ailments. Death due to Coronary Artery Heart Disease (CAHD) has slightly decreased over the period of 3 years from 97.6% to 85.1%. CONCLUSION: Data with respect to safety, health and environment at the pilgrim sites need to be continuously assessed to understand changes and trends and to develop an effective mass gathering and safe pilgrimage policy (MGSPP).