Variation in global COVID-19 symptoms by geography and by chronic disease: A global survey using the COVID-19 Symptom Mapper.

Background: COVID-19 is typically characterised by a triad of symptoms: cough, fever and loss of taste and smell, however, this varies globally. This study examines variations in COVID-19 symptom profiles based on underlying chronic disease and geographical location. Methods: Using a global online symptom survey of 78,299 responders in 190 countries between 09/04/2020 and 22/09/2020, we conducted an exploratory study to examine symptom profiles associated with a positive COVID-19 test result by country and underlying chronic disease (single, co- or multi-morbidities) using statistical and machine learning methods. Findings: From the results of 7980 COVID-19 tested positive responders, we find that symptom patterns differ by country. For example, India reported a lower proportion of headache (22.8% vs 47.8%, p<1e-13) and itchy eyes (7.3% vs. 16.5%, p=2e-8) than other countries. As with geographic location, we find people differed in their reported symptoms if they suffered from specific chronic diseases. For example, COVID-19 positive responders with asthma (25.3% vs. 13.7%, p=7e-6) were more likely to report shortness of breath compared to those with no underlying chronic disease. Interpretation: We have identified variation in COVID-19 symptom profiles depending on geographic location and underlying chronic disease. Failure to reflect this symptom variation in public health messaging may contribute to asymptomatic COVID-19 spread and put patients with chronic diseases at a greater risk of infection. Future work should focus on symptom profile variation in the emerging variants of the SARS-CoV-2 virus. This is crucial to speed up clinical diagnosis, predict prognostic outcomes and target treatment. Funding: We acknowledge funding to AAF by a UKRI Turing AI Fellowship and to CEC by a personal NIHR Career Development Fellowship (grant number NIHR-2016-090-015). JKQ has received grants from The Health Foundation, MRC, GSK, Bayer, BI, Asthma UK-British Lung Foundation, IQVIA, Chiesi AZ, and Insmed. This work is supported by BREATHE - The Health Data Research Hub for Respiratory Health [MC_PC_19004]. BREATHE is funded through the UK Research and Innovation Industrial Strategy Challenge Fund and delivered through Health Data Research UK. Imperial College London is grateful for the support from the Northwest London NIHR Applied Research Collaboration. The views expressed in this publication are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.

Twenty years with the public health intervention wheel: Evidence for practice.

The Public Health Intervention Wheel (PHI Wheel) is a population-based practice model for public health nursing practice that encompasses three levels of practice (community, systems, individual/family) and 17 public health interventions. This article shares the story of how the PHI Wheel was created, disseminated, implemented by public health nurses (PHNs) and educators across the globe, and updated with new evidence published in the second edition of Public Health Interventions: Applications for Public Health Nursing in 2019. Evidence on the relevance of PHI Wheel interventions for public health practice in cultural and international settings supports the model's value in explaining PHN practice. This article highlights the experiences of various countries with the PHI Wheel including Canada, Ireland, New Zealand, Norway, Sweden, the United Kingdom, and the United States. The evidence update confirms the relevance of the model to PHN education and practice and reinforces the conviction that development of new evidence is essential for promoting population health.

Challenges and Approaches of the Global Governance of Public Health Under COVID-19.

Public health events, as the common concern faced by the international community, call for the joint response from all mankind. The outbreak of the COVID-19 has highlighted the problems confronting the global governance of international public health, such as limited functions of international organizations and difficulties in achieving objectives, poor collaboration between governance subjects and their limited performance, overlapping legal basis of governance and blurred core function, and lack of solutions to special problems. The corresponding approaches can be taken to improve the efficiency of the governance of global public health, including supporting the role of international organizations to achieve the objectives, enhancing coordination among international governance subjects to form synergy, promoting the compliance with IHR2005 to avoid conflict of law application and upholding the vision of a community with a shared future for mankind to jointly respond to the special problems.

Debordering public health: the changing patterns of health border in modern Europe / Tirando as fronteiras da saúde pública: mudanças nos padrões de fronteira sanitária na Europa moderna

Abstract According to David Fidler, the governance of infectious diseases evolved from the mid-nineteenth to the twenty-first century as a series of institutional arrangements: the International Sanitary Regulations (non-interference and disease control at borders), the World Health Organization vertical programs (malaria and smallpox eradication campaigns), and a post-Westphalian regime standing beyond state-centrism and national interest. But can international public health be reduced to such a Westphalian image? We scrutinize three strategies that brought health borders into prominence: pre-empting weak states (eastern Mediterranean in the nineteenth century); preventing the spread of disease through nation-building (Macedonian public health system in the 1920s); and debordering the fight against epidemics (1920-1921 Russian-Polish war and the Warsaw 1922 Sanitary Conference).

Resumo Segundo David Fidler, a gestão de doenças infecciosas entre meados do século XIX e e o XXI guiou-se por uma série de acordos institucionais: Regulamento Sanitário Internacional (não interferência e controle de doenças em fronteiras), programas verticais da OMS (campanhas de erradicação da malária e varíola), e posicionamento pós-vestefaliano além do estado-centrismo e interesse nacional. Mas pode a saúde pública internacional ser reduzida à tal imagem vestefaliana? Examinamos três estratégias que destacaram as fronteiras sanitárias: prevenção em estados vulneráveis (Mediterrâneo oriental, século XIX); prevenção à disseminação de doenças via construção nacional (sistema público de saúde macedônico, anos 1920); remoção de fronteiras no combate às epidemias (guerra polaco-soviética, 1920-1921 e Conferência Sanitária de Varsóvia, 1922).

Achievements of the HERACLES Project on Cystic Echinococcosis.

The FP7 project 'Human Cystic Echinococcosis ReseArch in CentraL and Eastern Societies' (HERACLES), developed between 2013 and 2018 by nine partners in five countries, is one of the largest projects on cystic echinococcosis. Here we present the core HERACLES achievements, which should help to foster the translation of scientific investigations on health policies.

El Impacto de las infecciones de las vías urinarias en la Salud Pública del Paraguay / The Impact of urinary tract infections in Public Health of Paraguay

Las infecciones de las vías urinarias son a veces consideradas de poco interés médico, fácil de diagnosticar y tratar. Sin embargo, las mismas representan ingentes gastos para la Salud Pública, debido a su alta frecuencia, por los estudios de laboratorio necesarios para el adecuado manejo y de imágenes que son solicitados. Por otra parte los antibióticos utilizados en general, y en particular para los gérmenes que presentan resistencia a los mismos. En el presente artículo de revisión se exponen informaciones respecto a datos estadísticos de la frecuencia de las principales infecciones de vías urinarias en ambos sexos, el costo que representan los mismos, tasas de mortalidad, tasas de recurrencia y algunas perspectivas desde el punto de vista de la Salud Pública general y el de nuestro país en particular.

Urinary tract infections are sometimes considered of little medical interest, easy to diagnose and treat. However, they represent huge expenses for public health, due to their frequency, laboratory studies and images that are also requested by the antibiotics used in general and in particular for the germs that are resistant to them. In this review article we present information regarding statistical data on the frequency of the main urinary tract infections in both sexes, their cost, mortality rates, recurrence rates and some perspectives from the point of view of general Public Health and that of our country in particular.

Circumcision of male infants and children as a public health measure in developed countries: A critical assessment of recent evidence.

In December of 2014, an anonymous working group under the United States' Centers for Disease Control and Prevention (CDC) issued a draft of the first-ever federal recommendations regarding male circumcision. In accordance with the American Academy of Pediatrics' circumcision policy from 2012 - but in contrast to the more recent 2015 policy from the Canadian Paediatric Society as well as prior policies (still in force) from medical associations in Europe and Australasia - the CDC suggested that the benefits of the surgery outweigh the risks. In this article, we provide a brief scientific and conceptual analysis of the CDC's assessment of benefit versus risk, and argue that it deserves a closer look. Although we set aside the burgeoning bioethical debate surrounding the moral permissibility of performing non-therapeutic circumcisions on healthy minors, we argue that, from a scientific and medical perspective, current evidence suggests that such circumcision is not an appropriate public health measure for developed countries such as the United States.

Public health agencies' obligations and the case of Zika.

This article focuses on the initial reactions to the Zika epidemic by national and international public health agencies. It presents and analyzes some responses public officials made about sexual and reproductive health at the inception of the epidemic. It also describes the different challenges and obligations faced by local and international public health agencies, as these have not been clearly outlined. The article argues that these agencies have different obligations and should fulfill them despite existing obstacles. While international agencies should honor their leadership role and make recommendations at a meta-level, local agencies should provide, in the case of Zika, a framework for empowerment and grant women the freedom to achieve sexual and reproductive health so that they can avoid the consequences of this epidemic.

Enhancing an International Perspective in Public Health Teaching through Formalized University Partnerships.

Teaching in the field of public health needs to employ a global perspective to account for the fact that public health problems and solutions have global determinants and implications as well. International university partnerships can promote such a perspective through the strengthening of cooperation, exchange, and communication between academic institutions across national boundaries. As an example for such an academic network in the field of public health, we introduce the International Public Health Partnership-a collaboration between a university in Germany and universities in India, Turkey, and Nigeria. Formed in 2005, it facilitated the exchange of information, fostered discussion about the transferability of public health concepts, contributed to the structural development of the universities involved, and promoted an intercultural dialog through a combination of local and distance learning activities. Although well accepted by students and staff, different obstacles were encountered; these included limited external funding, scarce own financial, time and personnel resources, and diverging regulations and structures of degree programs at the partnership sites. In the present article, we share several lessons that we learned during our joint collaboration and provide recommendations for other universities that are involved in partnerships with institutions of higher education or are interested to initiate such collaborations.

Needs and availability of snake antivenoms: relevance and application of international guidelines.

BACKGROUND: Snakebite has recently been declared a global public health emergency. Empirical data showing the true burden of snakebite is lacking. Treatment with specific antivenoms is considered the only cure. However, several factors have led to an ongoing antivenom crisis. This study offers recommendations concerning the improvement of antivenom access and control, by providing an overview of the factors limiting the successful implementation of international guidelines within the international industry and state institutions. It further investigates the reasons for the epidemiological knowledge gap regarding snakebites. METHODS: Data for this study was collected using surveys with closed- and open-ended questions, which allowed for descriptive and thematic analysis, respectively. Participants for this study were selected as follows: 46 manufacturers were contacted from the open-access World Health Organization (WHO) Database for antivenom producers; 23 National Health Authorities (NHAs) of high-burden countries were contacted; and 11 poison centers or experts were randomly contacted. RESULTS: In total, responses from 6/46 (13%) manufacturers, 10/23 (43%) NHAs, and 3/11 (27%) poison centers were received. The low response rates had a limiting effect on the coverage of this study, allowing only exploratory conclusions to be drawn. Based on the gathered information, a probable reason for the epidemiological knowledge gap is the low priority given to snakebites on public health agendas, driving interest and funding away from research in this field. As a consequence, the ensuing lack in funding is preventing state institutions and manufacturers from implementing international guidelines to the highest standards. Furthermore, manufacturers indicated that international guidelines were often not applicable in the field, lacking technical information and protocols. CONCLUSION: Snakebite ranks low on international public health agendas, and partially due to this low priority, NHAs have shown limited efforts in conducting epidemiological studies, training health workers on snakebite management and creating national snakebite management strategies. The lack of NHA involvement is reflected in poor access to appropriate antivenoms as well as a lack of antivenom regulation. Manufacturers are taking positive steps toward full implementation of international guidelines and are improving quality control procedures. However, in order for international guidelines to become truly useful in the field, more technical guidance is required. This study reflects that there is a general lack of knowledge transfer amongst various actors: most producers, health authorities, and experts expect increased and improved communication and guidance from leading international bodies. Due to the low response rates observed in this study, conclusions drawn herein are not representative of the global situation; yet provide an exploratory insight on the difficulties facing antivenom management.

Hybrid forum or network? The social and political construction of an international 'technical consultation': male circumcision and HIV prevention.

The technical consultation in Montreux, organised by World Health Organization and UNAIDS in 2007, recommended male circumcision as a method for preventing HIV transmission. This consultation came out of a long process of releasing reports and holding international and regional conferences, a process steered by an informal network. This network's relations with other parties is analysed along with its way of working and the exchanges during the technical consultation that led up to the formal adoption of a recommendation. Conducted in relation to the concepts of a 'hybrid forum' and 'network', this article shows that the decision was based on the formation and consolidation of a network of persons. They were active in all phases of this process, ranging from studies of the recommendation's efficacy, feasibility and acceptability to its adoption and implementation. In this sense, this consultation cannot be described as the constitution of a 'hybrid forum', which is characterised by its openness to a debate as well as a plurality of issues formulated by the actors and of resources used by them. On the contrary, little room was allowed for contradictory discussions, as if the decision had already been made before the Montreux consultation.

Reflexiones sobre salud pública internacional / Reflections on the international public health

El objetivo del presente trabajo es examinar los conceptos y fundamentos sobre Salud Pública Internacional de mayor aceptación universal, lo que puede aportar una dimensión utilitaria, pues su aplicación en un país determinado puede contribuir a que su sistema de salud se ajuste mejor a los problemas concretos de salud que afectan a su sociedad y a las influencias de la coyuntura internacional sobre estos problemas. Se encontró que es impreciso el inicio del uso del término y que no existe un concepto universalmente aceptado sobre salud pública internacional, de hecho, algunos autores usan el término Salud Global. Para su análisis la Salud Pública Internacional debe dividirse en dos polos: la dimensión internacional de la salud y la salud como asunto internacional, los que conforman una intrincada relación dialéctica, pero es la superposición de estos dos ámbitos lo que determina el resultado total. La salud pública internacional se fundamenta en determinada ideología y al aceptar que es un recorte de las relaciones internacionales, corresponderá a cada Estado determinar el alcance y la aplicación de este concepto en su territorio. Se apreció que los aspectos de la Salud Pública Internacionalno están incluidos de forma sistemática dentro de los campos de estudio de las escuelas de salud pública en la región, por lo que se sugiere desarrollar eventos de carácter regional que permitan lograr consenso en una definición coherente sobre el término salud pública internacionaly su marco conceptual.(AU)

The objective of this paper is to analyze the most universally accepted concepts and fundamentals on International Public Health. This can provide one utilitarian dimension since their application in a particular country could contribute to better adjust the public health system to the particularities of the health problems affecting its society and to the influence of the international situation over these problems. It was found that data about the use of this term for the first time was inaccurate and that there was not one universally accepted concept on International Public Health; as a matter of fact, some authors prefer the term Global Health. For the analysis, international health should be divided into two poles: international dimension of health on one hand and health as international issue on the other; both make up an intrincate dialectical relation but the overlapping of these two aspects determines the final result. international public health is based on certain ideology and once accepted as a part cut out from the international relations, it is up to every state to determine the scope and range of application of this concept in its territory. It was observed that the International Public Health aspects are not systematically included in the curricula of the schools of public health in the region; therefore, it is suggested that regional events be held in order to reach consensus with respect to a coherent definition on the term international public health and its conceptual framework.(AU)

Reflexiones sobre salud pública internacional / Reflections on the international public health

El objetivo del presente trabajo es examinar los conceptos y fundamentos sobre Salud Pública Internacional de mayor aceptación universal, lo que puede aportar una dimensión utilitaria, pues su aplicación en un país determinado puede contribuir a que su sistema de salud se ajuste mejor a los problemas concretos de salud que afectan a su sociedad y a las influencias de la coyuntura internacional sobre estos problemas. Se encontró que es impreciso el inicio del uso del término y que no existe un concepto universalmente aceptado sobre salud pública internacional, de hecho, algunos autores usan el término Salud Global. Para su análisis la Salud Pública Internacional debe dividirse en dos polos: la dimensión internacional de la salud y la salud como asunto internacional, los que conforman una intrincada relación dialéctica, pero es la superposición de estos dos ámbitos lo que determina el resultado total. La salud pública internacional se fundamenta en determinada ideología y al aceptar que es un recorte de las relaciones internacionales, corresponderá a cada Estado determinar el alcance y la aplicación de este concepto en su territorio. Se apreció que los aspectos de la Salud Pública Internacionalno están incluidos de forma sistemática dentro de los campos de estudio de las escuelas de salud pública en la región, por lo que se sugiere desarrollar eventos de carácter regional que permitan lograr consenso en una definición coherente sobre el término salud pública internacionaly su marco conceptual.

The objective of this paper is to analyze the most universally accepted concepts and fundamentals on International Public Health. This can provide one utilitarian dimension since their application in a particular country could contribute to better adjust the public health system to the particularities of the health problems affecting its society and to the influence of the international situation over these problems. It was found that data about the use of this term for the first time was inaccurate and that there was not one universally accepted concept on International Public Health; as a matter of fact, some authors prefer the term Global Health. For the analysis, international health should be divided into two poles: international dimension of health on one hand and health as international issue on the other; both make up an intrincate dialectical relation but the overlapping of these two aspects determines the final result. international public health is based on certain ideology and once accepted as a part cut out from the international relations, it is up to every state to determine the scope and range of application of this concept in its territory. It was observed that the International Public Health aspects are not systematically included in the curricula of the schools of public health in the region; therefore, it is suggested that regional events be held in order to reach consensus with respect to a coherent definition on the term international public health and its conceptual framework.

Another vaccine, another story: BCG vaccination against tuberculosis in India, 1948 to 1960 / Outra vacina, outra história: a vacinação de BCG contra tuberculose na Índia, 1948 a 1960

Através da observação da vacinação em massa de BCG contra a tuberculose na Índia durante os anos de 1948 a 1960, este artigo chama a atenção para a diversidade da história da vacinação. As características das campanhas de vacinação geralmente diferem daquelas celebradas nas campanhas para erradicação da varíola. Devido às diferenças entre a varíola e a turberculose, assim como entre as vacinas desenvolvidas para combater essas doenças, uma análise da vacinação em massa de BCG contra a turberculose parece especialmente bem situada para essa proposta. Três pontos de diferença foram identificados. O primeiro é que em contextos não ocidentais os procedimentos da vacinação de BCG foram modificados em uma extensão maior do que a vacinação contra a varíola. Em segundo lugar, a tuberculose não tinha o drama e a urgência da varíola, e as campanhas de vacinação de BCG sofreram mais com problemas de recrutamento do que a mais "heroica" campanha de erradicação da varíola. E por último, a vacina de BCG foi contestada em círculos médicos e foi muito mais bem adaptada do que a vacina contra varíola como um veículo para articulação de preocupações sobre a modernização pós-colonial.

Through an examination of mass BCG vaccination against tuberculosis in India between 1948 and 1960 this article draws attention to the diversity of the history of vaccination. The features of vaccination campaigns often differed from those of the celebrated campaign to eradicate smallpox. Due to differences between smallpox and tuberculosis as well as between the vaccines developed against them, an analysis of BCG mass vaccination against tuberculosis seems particularly well suited for this purpose. Three points of difference are identified. First, in non-Western contexts BCG vaccination procedures were modified to a greater extent than vaccination against smallpox. Second, tuberculosis lacked the drama and urgency of smallpox and BCG vaccination campaigns suffered more from recruitment problems than did the more "heroic" smallpox eradication campaign. Third, the BCG vaccine was contested in medical circles and was much better suited than the vaccine against smallpox as a vehicle for the articulation of concerns about post-colonial modernization.

Globalización, salud y equidad: contradicciones e incertidumbres / Globalization, health and equity: contradictions and uncertainties

Al exponer algunas ideas sobre los retos del salubrista, el autor se declara partidario del optimismo en el trabajo que se fundamenta en las siguientes consideraciones: el papel del salubrista seguirá en ascenso en la sociedad y en los estamentos gubernamentales o no gubernamentales, porque tienen las respuestas para las crisis, han vivido sus propias revoluciones epidemiológicas y su aporte a la salud de los pueblos es significativo. Se han incorporado al quehacer científico y de trabajo del salubrista, con carácter interdisciplinario y transprofesional, los aportes de la economía, de las ciencias sociales, de la psicología, de la pedagogía, de la cibernética, de la ecología y la demografía, lo que permite ampliar el horizonte de trabajo. No están los salubristas fuera de las reformas políticas, de los proyectos de descentralización y, sobre todo, de los lineamientos de justicia social, de equidad y de la batalla por el desarrollo humano como base para el desarrollo económico. Los salubristas son democráticos desde los albores de la salud pública y, por lo tanto, el bien individual no lo ven aislado de su propio asidero: el bien social, nacional y mundial. La salud pública se ha desarrollado a través del tiempo por la búsqueda de la calidad y con sólidas bases estadísticas que le permite llegar con claridad a la cibérnética, no como un fin, sino como un medio. La internacionalización del conocimiento es una tesis definida por los salubristas, se tiene experiencias y formas para enfrentar los nuevos cantos de sirena.

On stating some ideas on the challenges faced by the public health professionals, the author declares his optimism about their work and this optimism is supported on the following considerations: the public health professionals will continue playing a growing role at govermental and non-governmental levels because they have answers for the crises, they have lived their own epidemiological revolutions and because their contribution to the people´s health is significant. There have been incorporated to the scientific work of the public health professionals, with interdisciplinary and trans-professional character, the contributions made by economics, social sciences, psychology, pedagogy, cybernetics, ecology and demographics, all of which allows extending working horizons. Public health professionals are not unaware of political reforms, decentralization projects and above all, of the social justice, the equity guidelines and of the battle for the human development as a basis for the economic development. Public health professionals are democratic since the very beginning of public health, and thus, individual good is not isolated from their own support that is national and international social good. Public health has developed in the course of time on the basis of search for quality on sound statistical grounds that allow clearly reaching cybernetics to use it not as an objective but as a means. Internationalization of knowledge is a thesis defined by public health professionals who have experience and means to face the new siren songs.