Assessing the hidden burden and costs of COVID-19 pandemic in South Asia: Implications for health and well-being of women, children and adolescents.

The COVID-19 pandemic has disproportionately affected vulnerable populations. With its intensity expected to be cyclical over the foreseeable future, and much of the impact estimates still modeled, it is imperative that we accurately assess the impact to date, to help with the process of targeted rebuilding of services. We collected data from administrative health information systems in six South Asian countries (Afghanistan, Bangladesh, Nepal, India, Pakistan and Sri Lanka), to determine essential health services coverage disruptions between January-December 2020, and January-June 2021, compared to the same calendar months in 2019, and estimated the impact of this disruption on maternal and child mortality using the Lives Saved Tool. We also modelled impact of prolonged school closures on continued enrollment, as well as potential sequelae for the cohort of girls who have likely dropped out. Coverage of key maternal and child health interventions, including antenatal care and immunizations, decreased by up to 60%, with the largest disruptions observed between April and June 2020. This was followed by a period of recovery from July 2020 to March 2021, but a reversal of most of these gains in April/May 2021, likely due to the delta variant-fueled surge in South Asia at the same time. We estimated that disruption of essential health services between January 2020 and June 2021 potentially resulted in an additional 19,000 maternal and 317,000 child deaths, an increase of 19% and 13% respectively, compared to 2019. Extended school closures likely resulted in 9 million adolescents dropping out permanently, with 40% likely being from poorest households, resulting in decreased lifetime earnings. A projected increase in early marriages for girls who dropped out could result in an additional 500,000 adolescent pregnancies, 153,000 low birthweight births, and 27,000 additional children becoming stunted by age two years. To date, the increase in maternal and child mortality due to health services disruption has likely exceeded the overall number of COVID-19 deaths in South Asia. The indirect effects of the pandemic were disproportionately borne by the most vulnerable populations, and effects are likely to be long-lasting, permanent and in some cases inter-generational, unless policies aimed at alleviating these impacts are instituted at scale and targeted to reach the poorest of the poor. There are also implications for future pandemic preparedness.

Tuberculosis and HIV coinfection and related collaborative activities in Latin America and the Caribbean.

OBJECTIVE: To inform about the most recent epidemiological trends and integrated programmatic response to tuberculosis (TB) and HIV coinfection in Latin America and the Caribbean (LAC). METHODS: A descriptive review analyzed the most relevant indicators on TB/HIV coinfection in 33 countries in LAC with a cross-sectional and time-trend approach. Data were obtained from publicly available databases and analyzed through simple proportions, weighted means, and risk ratios. RESULTS: In LAC, during 2017, 80.8% of TB patients were actively screened for HIV, with a 25.6% increase between 2011 and 2017. In the same year, the proportion of TB patients with HIV-positive status was 11.2%, with a small but progressive reduction of 5% since 2011. The provision of antiretroviral therapy and anti-TB medication among TB/HIV coinfected patients for 2017 was at 60%. Only one-third of people living with HIV had access to isoniazid preventive therapy. Overall, the mortality in the TB/HIV cohort has not changed since 2012, hovering at around 20%. CONCLUSIONS: TB/HIV collaborative activities, as the backbone to address TB/HIV coinfection, are being scaled up in LAC and some indicators show a tendency toward improvement; nevertheless, our review shed light on the need to keep strengthening integration of service delivery, joint monitoring and evaluation, and data quality.

Tuberculosis and HIV coinfection and related collaborative activities in Latin America and the Caribbean

[ABSTRACT]. Objective. To inform about the most recent epidemiological trends and integrated programmatic response to tuberculosis (TB) and HIV coinfection in Latin America and the Caribbean (LAC). Methods. A descriptive review analyzed the most relevant indicators on TB/HIV coinfection in 33 countries in LAC with a cross-sectional and time-trend approach. Data were obtained from publicly available databases and analyzed through simple proportions, weighted means, and risk ratios. Results. In LAC, during 2017, 80.8% of TB patients were actively screened for HIV, with a 25.6% increase between 2011 and 2017. In the same year, the proportion of TB patients with HIV-positive status was 11.2%, with a small but progressive reduction of 5% since 2011. The provision of antiretroviral therapy and anti-TB medication among TB/HIV coinfected patients for 2017 was at 60%. Only one-third of people living with HIV had access to isoniazid preventive therapy. Overall, the mortality in the TB/HIV cohort has not changed since 2012, hovering at around 20%. Conclusions. TB/HIV collaborative activities, as the backbone to address TB/HIV coinfection, are being scaled up in LAC and some indicators show a tendency toward improvement; nevertheless, our review shed light on the need to keep strengthening integration of service delivery, joint monitoring and evaluation, and data quality.

[RESUMEN]. Objetivo. Informar sobre las tendencias epidemiológicas más recientes y la respuesta programática integrada frente a la coinfección por tuberculosis (TB) y VIH en América Latina y el Caribe. Métodos. En una revisión descriptiva se analizaron los indicadores más pertinentes sobre la coinfección por TB y VIH en 33 países de América Latina y el Caribe, por medio de un enfoque transversal y de tendencias en el tiempo. Los datos se obtuvieron de bases de datos disponibles públicamente y se analizaron mediante proporciones sencillas, medias ponderadas y cociente de riesgos. Resultados. En el 2017, en América Latina y el Caribe se sometió a 80,8% de los pacientes con TB a un tamizaje activo del VIH, lo que representó un aumento de 25,6% entre el 2011 y el 2017. En ese mismo año, la proporción de pacientes con TB e infección por el VIH fue de 11,2%, lo cual demuestra una pequeña reducción, aunque progresiva, de 5% desde el 2011. El suministro de tratamiento antirretroviral y de fármacos contra la TB a los pacientes con la coinfección en el 2017 fue del 60%. Solo un tercio de las personas con VIH tuvieron acceso al tratamiento preventivo con isoniacida. En términos generales, la tasa de mortalidad de las personas con coinfección por TB y VIH no ha cambiado desde el 2012, y ha permanecido en torno al 20%. Conclusiones. Se está aumentando la escala de las actividades de colaboración entre los servicios de TB y VIH en América Latina y el Caribe, como el tratamiento de base para abordar los casos de coinfección, y algunos indicadores muestran una tendencia positiva. No obstante, nuestra revisión muestra la necesidad de seguir fortaleciendo la integración de la prestación de servicios, las actividades conjuntas de seguimiento y evaluación, y la comprobación de la calidad de los datos.

[RESUMO]. Objetivo. Informar sobre as últimas tendências epidemiológicas e a resposta programática integrada à coinfecção por tuberculose (TB) e HIV na América Latina e Caribe (ALC). Métodos. Uma revisão descritiva analisou os indicadores mais relevantes sobre a coinfecção por TB/HIV em 33 países da ALC, usando uma abordagem transversal e de tendências temporais. Os dados foram obtidos em bases de dados disponíveis publicamente e analisados através de proporções simples, médias ponderadas e razões de risco. Resultados. Na ALC, em 2017, 80,8% dos pacientes com TB realizaram o rastreamento ativo para HIV, o que representou um aumento de 25,6% entre 2011 e 2017. No mesmo ano, a proporção de pacientes com TB com status HIV positivo foi de 11,2%, demonstrando uma pequena redução progressiva de 5% desde 2011. Em 2017, a oferta de terapia antirretroviral e medicação anti-TB aos pacientes coinfectados por TB/HIV foi de 60%. Somente um terço das pessoas que vivem com HIV teve acesso à terapia preventiva com isoniazida. A mortalidade geral na coorte coinfectada por TB/HIV não mudou desde 2012, oscilando em torno de 20%. Conclusões. As atividades colaborativas para TB/HIV, que são a espinha dorsal para combater esta coinfecção, estão sendo ampliadas na ALC, e alguns indicadores mostram uma tendência positiva; no entanto, a nossa revisão destaca a necessidade de continuar fortalecendo a integração da prestação de serviços, as atividades conjuntas de monitoramento e avaliação e a qualidade dos dados.

Tuberculosis and HIV coinfection and related collaborative activities in Latin America and the Caribbean / Coinfección por tuberculosis y VIH, y actividades de colaboración relacionadas en América Latina y el Caribe / Coinfecção por tuberculose e HIV e atividades colaborativas relacionadas na América Latina e Caribe

ABSTRACT Objective. To inform about the most recent epidemiological trends and integrated programmatic response to tuberculosis (TB) and HIV coinfection in Latin America and the Caribbean (LAC). Methods. A descriptive review analyzed the most relevant indicators on TB/HIV coinfection in 33 countries in LAC with a cross-sectional and time-trend approach. Data were obtained from publicly available databases and analyzed through simple proportions, weighted means, and risk ratios. Results. In LAC, during 2017, 80.8% of TB patients were actively screened for HIV, with a 25.6% increase between 2011 and 2017. In the same year, the proportion of TB patients with HIV-positive status was 11.2%, with a small but progressive reduction of 5% since 2011. The provision of antiretroviral therapy and anti-TB medication among TB/HIV coinfected patients for 2017 was at 60%. Only one-third of people living with HIV had access to isoniazid preventive therapy. Overall, the mortality in the TB/HIV cohort has not changed since 2012, hovering at around 20%. Conclusions. TB/HIV collaborative activities, as the backbone to address TB/HIV coinfection, are being scaled up in LAC and some indicators show a tendency toward improvement; nevertheless, our review shed light on the need to keep strengthening integration of service delivery, joint monitoring and evaluation, and data quality.(AU)

RESUMEN Objetivo. Informar sobre las tendencias epidemiológicas más recientes y la respuesta programática integrada frente a la coinfección por tuberculosis (TB) y VIH en América Latina y el Caribe. Métodos. En una revisión descriptiva se analizaron los indicadores más pertinentes sobre la coinfección por TB y VIH en 33 países de América Latina y el Caribe, por medio de un enfoque transversal y de tendencias en el tiempo. Los datos se obtuvieron de bases de datos disponibles públicamente y se analizaron mediante proporciones sencillas, medias ponderadas y cociente de riesgos. Resultados. En el 2017, en América Latina y el Caribe se sometió a 80,8% de los pacientes con TB a un tamizaje activo del VIH, lo que representó un aumento de 25,6% entre el 2011 y el 2017. En ese mismo año, la proporción de pacientes con TB e infección por el VIH fue de 11,2%, lo cual demuestra una pequeña reducción, aunque progresiva, de 5% desde el 2011. El suministro de tratamiento antirretroviral y de fármacos contra la TB a los pacientes con la coinfección en el 2017 fue del 60%. Solo un tercio de las personas con VIH tuvieron acceso al tratamiento preventivo con isoniacida. En términos generales, la tasa de mortalidad de las personas con coinfección por TB y VIH no ha cambiado desde el 2012, y ha permanecido en torno al 20%. Conclusiones. Se está aumentando la escala de las actividades de colaboración entre los servicios de TB y VIH en América Latina y el Caribe, como el tratamiento de base para abordar los casos de coinfección, y algunos indicadores muestran una tendencia positiva. No obstante, nuestra revisión muestra la necesidad de seguir fortaleciendo la integración de la prestación de servicios, las actividades conjuntas de seguimiento y evaluación, y la comprobación de la calidad de los datos.(AU)

RESUMO Objetivo. Informar sobre as últimas tendências epidemiológicas e a resposta programática integrada à coinfecção por tuberculose (TB) e HIV na América Latina e Caribe (ALC). Métodos. Uma revisão descritiva analisou os indicadores mais relevantes sobre a coinfecção por TB/HIV em 33 países da ALC, usando uma abordagem transversal e de tendências temporais. Os dados foram obtidos em bases de dados disponíveis publicamente e analisados através de proporções simples, médias ponderadas e razões de risco. Resultados. Na ALC, em 2017, 80,8% dos pacientes com TB realizaram o rastreamento ativo para HIV, o que representou um aumento de 25,6% entre 2011 e 2017. No mesmo ano, a proporção de pacientes com TB com status HIV positivo foi de 11,2%, demonstrando uma pequena redução progressiva de 5% desde 2011. Em 2017, a oferta de terapia antirretroviral e medicação anti-TB aos pacientes coinfectados por TB/HIV foi de 60%. Somente um terço das pessoas que vivem com HIV teve acesso à terapia preventiva com isoniazida. A mortalidade geral na coorte coinfectada por TB/HIV não mudou desde 2012, oscilando em torno de 20%. Conclusões. As atividades colaborativas para TB/HIV, que são a espinha dorsal para combater esta coinfecção, estão sendo ampliadas na ALC, e alguns indicadores mostram uma tendência positiva; no entanto, a nossa revisão destaca a necessidade de continuar fortalecendo a integração da prestação de serviços, as atividades conjuntas de monitoramento e avaliação e a qualidade dos dados.(AU)

Hospital-based tuberculosis control activities in five cities of Latin America / Actividades hospitalarias de control de la tuberculosis en cinco ciudades de América Latina / Atividades de controle da tuberculose em hospitais em cinco cidades da América Latina

Objective. To generate actionable insights for improving TB control in urban areas by describing the tuberculosis (TB) control activities of hospitals in five cities in Latin America. Methods. A descriptive study of hospital-based TB control activities was conducted in 2013–2015 using a cross-sectional survey designed by the Pan American Health Organization and administered in Guatemala City, Guatemala; Guarulhos, Brazil; Bogotá, Colombia; Lima, Peru; and Asunción, Paraguay. Data were analyzed using Chi-squared, Fisher exact tests, and the Mantel–Haenszel test for Risk Ratios, as necessary (P < 0.05). Results. While variation among cities existed, most hospitals (91.3%) conducted acid-fast bacilli smears for TB diagnosis and had a quality control process (94.0%), followed national TB guidelines (95%), and reported TB cases to the respective health authorities (96%). Additionally, TB treatment was offered free of charge almost universally (97.1%). However, only 74.2% of hospitals were supervised by the national or local TB programs; 52.8% followed up on the outcome of referrals; and 39.1% offered full ambulatory TB treatment, with 68.7% using Directly-Observed Therapy. Conclusion. The study underscored strengths and weaknesses in specific areas for TB control activities in hospitals and highlighted the importance and complexity of coordinating efforts among private and public hospitals and the various stakeholders. Local TB programs and health authorities should use these results to enhance the quality of TB-related actions in hospitals in similar settings.

Objetivo. Generar información utilizable para mejorar el control de la tuberculosis en las zonas urbanas describiendo las actividades hospitalarias de control de la tuberculosis de cinco ciudades de América Latina. Métodos. Se realizó un estudio descriptivo de las actividades hospitalarias de control de la tuberculosis mediante una encuesta transversal formulada por la Organización Panamericana de la Salud y administrada entre el 2013 y el 2015 en Ciudad de Guatemala (Guatemala), Guarulhos (Brasil), Bogotá (Colombia), Lima (Perú) y Asunción (Paraguay). Los datos fueron analizados con la prueba de la ji al cuadrado, la prueba exacta de Fisher y la prueba de asociación de Mantel-Haenszel de las razones de riesgos, según fuera necesario (P < 0,05). Resultados. Pese a la variación observada entre las ciudades, la mayor parte de los hospitales (91,3 %) realizan frotis de bacilos acidorresistentes para diagnosticar la tuberculosis y disponen de un proceso de control de la calidad (94,0 %), siguen las directrices nacionales respecto de la tuberculosis (95 %) y notifican los casos a las autoridades de salud respectivas (96 %). Además, casi todos ofrecen tratamiento antituberculoso gratuito (97,1 %). Sin embargo, solo el 74,2 % de los hospitales está supervisado por el programa nacional o local contra la tuberculosis; el 52,8 % hace el seguimiento de la evolución de los pacientes derivados; y el 39,1 % ofrece tratamiento antituberculoso plenamente ambulatorio a los pacientes, del cual el 68,7 % corresponde al tratamiento bajo observación directa. Conclusiones. En el estudio se ponen de relieve las fortalezas y las debilidades de aspectos específicos de las actividades hospitalarias de control de la tuberculosis, así como la importancia y la complejidad que reviste coordinar los esfuerzos entre los hospitales privados y públicos y los diversos interesados directos. Los programas locales contra la tuberculosis y las autoridades de salud deben aprovechar estos resultados para mejorar la calidad de las actividades hospitalarias relacionadas con la tuberculosis en entornos similares.

Objetivo. Originar insights proativos para melhorar o controle da tuberculose (TB) em áreas urbanas descrevendo as atividades de controle da TB em hospitais em cinco cidades na América Latina. Métodos. Estudo descritivo das atividades de controle da TB em hospitais realizado em 2013–2015 com base em pesquisa transversal concebida pela Organização Pan- Americana da Saúde e conduzida na Cidade da Guatemala (Guatemala), Guarulhos (Brasil), Bogotá (Colômbia), Lima (Peru) e Assunção (Paraguai). Os dados foram analisados com o uso do teste qui-quadrado, teste exato de Fisher e teste de Mantel– Haenszel para razões de risco, conforme necessário (P < 0,05). Resultados. Apesar de ter existido variação entre as cidades, a maioria dos hospitais (91,3%) realizou o teste de esfregaço de bacilos acidorresistentes para o diagnóstico de TB e dispunha de um processo de controle de qualidade (94,0%), seguiu os protocolos nacionais de TB (95%) e notificou casos de TB aos órgãos sanitários competentes (96%). Além disso, o tratamento de TB foi proporcionado gratuitamente quase como um todo (97,1%). Porém, somente 74,2% dos hospitais receberam supervisão dos programas locais ou nacionais de combate à TB; 52,8% acompanharam os desfechos dos encaminhamentos e 39,1% ofereceram tratamento de TB ambulatorial completo, sendo que 68,7% usaram o tratamento diretamente observado. Conclusões. O estudo destacou os pontos fortes e os pontos fracos em áreas específicas das atividades de controle da TB em hospitais e ressaltou a importância e a complexidade de coordenar esforços entre hospitais públicos e privados e as diversas partes envolvidas. Os programas locais de combate à TB e as autoridades sanitárias devem se basear nestes resultados para melhorar a qualidade das ações relacionadas à TB nos hospitais em condições semelhantes.

Hospital-based tuberculosis control activities in five cities of Latin America.

OBJECTIVE: To generate actionable insights for improving TB control in urban areas by describing the tuberculosis (TB) control activities of hospitals in five cities in Latin America. METHODS: A descriptive study of hospital-based TB control activities was conducted in 2013-2015 using a cross-sectional survey designed by the Pan American Health Organization and administered in Guatemala City, Guatemala; Guarulhos, Brazil; Bogotá, Colombia; Lima, Peru; and Asunción, Paraguay. Data were analyzed using Chi-squared, Fisher exact tests, and the Mantel-Haenszel test for Risk Ratios, as necessary (P < 0.05). RESULTS: While variation among cities existed, most hospitals (91.3%) conducted acid-fast bacilli smears for TB diagnosis and had a quality control process (94.0%), followed national TB guidelines (95%), and reported TB cases to the respective health authorities (96%). Additionally, TB treatment was offered free of charge almost universally (97.1%). However, only 74.2% of hospitals were supervised by the national or local TB programs; 52.8% followed up on the outcome of referrals; and 39.1% offered full ambulatory TB treatment, with 68.7% using Directly-Observed Therapy. CONCLUSION: The study underscored strengths and weaknesses in specific areas for TB control activities in hospitals and highlighted the importance and complexity of coordinating efforts among private and public hospitals and the various stakeholders. Local TB programs and health authorities should use these results to enhance the quality of TB-related actions in hospitals in similar settings.

Hospital-based tuberculosis control activities in five cities of Latin America / Actividades hospitalarias de control de la tuberculosis en cinco ciudades de América Latina / Atividades de controle da tuberculose em hospitais em cinco cidades da América Latina

ABSTRACT Objective To generate actionable insights for improving TB control in urban areas by describing the tuberculosis (TB) control activities of hospitals in five cities in Latin America. Methods A descriptive study of hospital-based TB control activities was conducted in 2013-2015 using a cross-sectional survey designed by the Pan American Health Organization and administered in Guatemala City, Guatemala; Guarulhos, Brazil; Bogotá, Colombia; Lima, Peru; and Asunción, Paraguay. Data were analyzed using Chi-squared, Fisher exact tests, and the Mantel-Haenszel test for Risk Ratios, as necessary (P < 0.05). Results While variation among cities existed, most hospitals (91.3%) conducted acid-fast bacilli smears for TB diagnosis and had a quality control process (94.0%), followed national TB guidelines (95%), and reported TB cases to the respective health authorities (96%). Additionally, TB treatment was offered free of charge almost universally (97.1%). However, only 74.2% of hospitals were supervised by the national or local TB programs; 52.8% followed up on the outcome of referrals; and 39.1% offered full ambulatory TB treatment, with 68.7% using Directly-Observed Therapy. Conclusion The study underscored strengths and weaknesses in specific areas for TB control activities in hospitals and highlighted the importance and complexity of coordinating efforts among private and public hospitals and the various stakeholders. Local TB programs and health authorities should use these results to enhance the quality of TB-related actions in hospitals in similar settings.

RESUMEN Objetivo Generar información utilizable para mejorar el control de la tuberculosis en las zonas urbanas describiendo las actividades hospitalarias de control de la tuberculosis de cinco ciudades de América Latina. Métodos Se realizó un estudio descriptivo de las actividades hospitalarias de control de la tuberculosis mediante una encuesta transversal formulada por la Organización Panamericana de la Salud y administrada entre el 2013 y el 2015 en Ciudad de Guatemala (Guatemala), Guarulhos (Brasil), Bogotá (Colombia), Lima (Perú) y Asunción (Paraguay). Los datos fueron analizados con la prueba de la ji al cuadrado, la prueba exacta de Fisher y la prueba de asociación de Mantel-Haenszel de las razones de riesgos, según fuera necesario (P < 0,05). Resultados Pese a la variación observada entre las ciudades, la mayor parte de los hospitales (91,3 %) realizan frotis de bacilos acidorresistentes para diagnosticar la tuberculosis y disponen de un proceso de control de la calidad (94,0 %), siguen las directrices nacionales respecto de la tuberculosis (95 %) y notifican los casos a las autoridades de salud respectivas (96 %). Además, casi todos ofrecen tratamiento antituberculoso gratuito (97,1 %). Sin embargo, solo el 74,2 % de los hospitales está supervisado por el programa nacional o local contra la tuberculosis; el 52,8 % hace el seguimiento de la evolución de los pacientes derivados; y el 39,1 % ofrece tratamiento antituberculoso plenamente ambulatorio a los pacientes, del cual el 68,7 % corresponde al tratamiento bajo observación directa. Conclusiones En el estudio se ponen de relieve las fortalezas y las debilidades de aspectos específicos de las actividades hospitalarias de control de la tuberculosis, así como la importancia y la complejidad que reviste coordinar los esfuerzos entre los hospitales privados y públicos y los diversos interesados directos. Los programas locales contra la tuberculosis y las autoridades de salud deben aprovechar estos resultados para mejorar la calidad de las actividades hospitalarias relacionadas con la tuberculosis en entornos similares.

RESUMO Objetivo Originar insights proativos para melhorar o controle da tuberculose (TB) em áreas urbanas descrevendo as atividades de controle da TB em hospitais em cinco cidades na América Latina. Métodos Estudo descritivo das atividades de controle da TB em hospitais realizado em 2013-2015 com base em pesquisa transversal concebida pela Organização Pan-Americana da Saúde e conduzida na Cidade da Guatemala (Guatemala), Guarulhos (Brasil), Bogotá (Colômbia), Lima (Peru) e Assunção (Paraguai). Os dados foram analisados com o uso do teste qui-quadrado, teste exato de Fisher e teste de Mantel-Haenszel para razões de risco, conforme necessário (P < 0,05). Resultados Apesar de ter existido variação entre as cidades, a maioria dos hospitais (91,3%) realizou o teste de esfregaço de bacilos acidorresistentes para o diagnóstico de TB e dispunha de um processo de controle de qualidade (94,0%), seguiu os protocolos nacionais de TB (95%) e notificou casos de TB aos órgãos sanitários competentes (96%). Além disso, o tratamento de TB foi proporcionado gratuitamente quase como um todo (97,1%). Porém, somente 74,2% dos hospitais receberam supervisão dos programas locais ou nacionais de combate à TB; 52,8% acompanharam os desfechos dos encaminhamentos e 39,1% ofereceram tratamento de TB ambulatorial completo, sendo que 68,7% usaram o tratamento diretamente observado. Conclusões O estudo destacou os pontos fortes e os pontos fracos em áreas específicas das atividades de controle da TB em hospitais e ressaltou a importância e a complexidade de coordenar esforços entre hospitais públicos e privados e as diversas partes envolvidas. Os programas locais de combate à TB e as autoridades sanitárias devem se basear nestes resultados para melhorar a qualidade das ações relacionadas à TB nos hospitais em condições semelhantes.

Public and Private Sector Dynamics in Scaling Up Rice Fortification: The Colombian Experience and its Lessons.

BACKGROUND: Fortification of cereal grains with at least iron or folic acid is legislated in 85 countries worldwide. Relative to wheat and maize flour, rice fortification is relatively new and provides an opportunity to deliver essential micronutrients to populations that consume rice as a dietary staple. OBJECTIVE: To describe miller and public sector experiences and perspectives on rice fortification with micronutrients in Colombia and offer recommendations for policy makers. METHODS: Interviews with Colombian rice millers, research and development personnel, and public sector leaders; desk review of key documents. RESULTS: In Colombia, rice fortified with micronutrients is market driven and a few very large rice millers, currently representing about 35% of the market, have voluntarily fortified rice since 2002. The technology used (spraying) is unique to Colombia and to date there is no independent verification of nutrient retention after washing and cooking rice fortified through this technology. Millers are unwilling to switch to more proven methods, such as extrusion or coating, which will incur higher capital investment and recurring costs. Despite interest from multiple stakeholders between 2002 and 2011, mandatory rice fortification is not part of the Colombian government policy as of July 2015. CONCLUSION: Rice fortified with micronutrients through spraying technology has achieved moderate coverage in Colombia, but the technology is unproven, its effectiveness unknown, and public health impact likely limited. For rice fortification to be an effective nutrition intervention to improve micronutrient status, policy makers should explore standards to guide industry and improvements to regulatory capacity.

Tocolysis for inhibiting preterm birth in extremely preterm birth, multiple gestations and in growth-restricted fetuses: a systematic review and meta-analysis.

This systematic review was to identify available evidence on the effectiveness of tocolysis in inhibiting preterm delivery for women with threatened extremely preterm birth, multiple gestations, and growth-restricted babies, and their infants' outcomes. A comprehensive search using MEDLINE, Embase, the Cochrane Library, CINAHL, POPLINE and the WHO Global Health Library databases was conducted on 14 February 2014. For selection criteria, randomized controlled trials and non-randomized studies that compared tocolysis treatment to placebo or no treatment were considered. Selection of eligible studies, critical appraisal of the included studies, data collection, meta-analyses, and assessment of evidence quality were performed in accordance with the Cochrane Collaboration's guidance and validated assessment criteria. The search identified seven studies for extremely preterm birth, in which three were randomized controlled trials (RCTs) and four were non-randomized studies (non-RCTs). There were no eligible studies identified for women with multiple pregnancy and growth-restricted fetuses. Meta-analyses indicated no significant difference was found for the relative effectiveness of tocolytics versus placebo for prolonging pregnancy in women with extremely preterm birth (RR 1.04, 95% CI 0.83 to 1.31) or reducing the rate of perinatal deaths (RR 2.22, 95% CI 0.26 to 19.24). In summary, there is no evidence to draw conclusions on the effectiveness of tocolytic therapy for women with threatened extremely preterm birth, multiple gestations, and growth-restricted babies.

Structural and community-level interventions for increasing condom use to prevent the transmission of HIV and other sexually transmitted infections.

BACKGROUND: Community interventions to promote condom use are considered to be a valuable tool to reduce the transmission of human immunodeficiency virus (HIV) and other sexually transmitted infections (STIs). In particular, special emphasis has been placed on implementing such interventions through structural changes, a concept that implies public health actions that aim to improve society's health through modifications in the context wherein health-related risk behavior takes place. This strategy attempts to increase condom use and in turn lower the transmission of HIV and other STIs. OBJECTIVES: To assess the effects of structural and community-level interventions for increasing condom use in both general and high-risk populations to reduce the incidence of HIV and STI transmission by comparing alternative strategies, or by assessing the effects of a strategy compared with a control. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, from 2007, Issue 1), as well as MEDLINE, EMBASE, AEGIS and ClinicalTrials.gov, from January 1980 to April 2014. We also handsearched proceedings of international acquired immunodeficiency syndrome (AIDS) conferences, as well as major behavioral studies conferences focusing on HIV/AIDS and STIs. SELECTION CRITERIA: Randomized control trials (RCTs) featuring all of the following.1. Community interventions ('community' defined as a geographical entity, such as cities, counties, villages).2. One or more structural interventions whose objective was to promote condom use. These type of interventions can be defined as those actions improving accessibility, availability and acceptability of any given health program/technology.3. Trials that confirmed biological outcomes using laboratory testing. DATA COLLECTION AND ANALYSIS: Two authors independently screened and selected relevant studies, and conducted further risk of bias assessment. We assessed the effect of treatment by pooling trials with comparable characteristics and quantified its effect size using risk ratio. The effect of clustering at the community level was addressed through intra-cluster correlation coefficients (ICCs), and sensitivity analysis was carried out with different design effect values. MAIN RESULTS: We included nine trials (plus one study that was a subanalysis) for quantitative assessment. The studies were conducted in Tanzania, Zimbabwe, South Africa, Uganda, Kenya, Peru, China, India and Russia, comprising 75,891 participants, mostly including the general population (not the high-risk population). The main intervention was condom promotion, or distribution, or both. In general, control groups did not receive any active intervention. The main risk of bias was incomplete outcome data.In the meta-analysis, there was no clear evidence that the intervention had an effect on either HIV seroprevalence or HIV seroincidence when compared to controls: HIV incidence (risk ratio (RR) 0.90, 95% confidence interval (CI) 0.69 to 1.19) and HIV prevalence (RR 1.02, 95% CI 0.79 to 1.32). The estimated effect of the intervention on other outcomes was similarly uncertain: Herpes simplex virus 2 (HSV-2) incidence (RR 0.76, 95% CI 0.55 to 1.04); HSV-2 prevalence (RR 1.01, 95% CI 0.85 to 1.20); syphilis prevalence (RR 0.91, 95% CI 0.71 to 1.17); gonorrhoea prevalence (RR 1.16, 95% CI 0.67 to 2.02); chlamydia prevalence (RR 0.94, 95% CI 0.75 to 1.18); and trichomonas prevalence (RR 1.00, 95% CI 0.77 to 1.30). Reported condom use increased in the experimental arm (RR 1.20, 95% CI 1.03 to 1.40). In the intervention groups, the number of people reporting two or more sexual partners in the past year did not show a clear decrease when compared with control groups (RR 0.90, 95% CI 0.78 to 1.04), but knowledge about HIV and other STIs improved (RR 1.15, 95% CI 1.04 to 1.28, and RR 1.23, 95% CI 1.07 to 1.41, respectively). The quality of the evidence was deemed to be moderate for nearly all key outcomes. AUTHORS' CONCLUSIONS: There is no clear evidence that structural interventions at the community level to increase condom use prevent the transmission of HIV and other STIs. However, this conclusion should be interpreted with caution since our results have wide confidence intervals and the results for prevalence may be affected by attrition bias. In addition, it was not possible to find RCTs in which extended changes to policies were conducted and the results only apply to general populations in developing nations, particularly to Sub-Saharan Africa, a region which in turn is widely diverse.