Public health approaches to addressing trachoma

Introduction: Trachoma is a neglected tropical disease (NTD) caused by infection with Chlamydia trachomatis (C. trachomatis) and is the leading cause of preventable blindness globally. It is a disease rooted in poverty and remains endemic in several low- and middle-income countries, predominantly in the tropics, where determinants of health—including poor hygiene, sanitation, and living conditions—favour disease transmission. This paper aims to critically appraise the public health approaches addressing trachoma, namely implementation of the WHO ‘SAFE’ strategy, with reference to trachoma control in Tanzania.

Methods: Online databases were searched for literature containing relevant keywords. Literature sources included published data, peer-reviewed publications, and relevant grey literature.

Results: The SAFE strategy has been highly effective in reducing the global prevalence of trachoma. However, it has failed to reach its target of global elimination by 2020. Strengths of this approach include the dual focus on preventative and curative aspects of trachoma management and the GET2020 Alliance to aid state implementation. Challenges in trachoma management include the political landscape influencing global health governance and funding, as well as a pressing need for an intersectoral ‘Health in All Policies’ approach to address the social determinants of health perpetuating trachoma transmission.

Conclusions: An integrated, multisectoral approach to trachoma management with NTDs is required to attain increased and sustainable progress across the spectrum of NTDs, reduce the risk of resurgence, and achieve the United Nations Sustainable Development Goals (SDGs). This progress can be achieved only by continuing to address the underlying determinants of health and utilising integrated management programs.

Top 10 Resources in Global Surgery

The need is great. Surgical disease is among the top 15 causes of disability, and surgical conditions account for up to 30% of total disability-adjusted life years (DALYs) lost worldwide—with the greatest need in low- and middle-income countries (LMICs). Surgery has been shown to be highly cost-effective when compared with standard global health interventions.
The transition from the Millennium Development Goals to the Sustainable Development Goals has ushered in a new era for the global surgery community. Sustainable Development Goal 3, to “ensure healthy lives and promote well-being at all ages,” emphasizes health system strengthening and universal health coverage.6 The provision of available, accessible, safe, timely, and affordable surgical and anesthesia care is identified as an integral component of a functional health system in countries at all levels of economic development and as essential to achieving universal health coverage. In addition, the importance of increasing education, safety, and capacity for the provision of surgical, anesthetic, and obstetric care is highlighted by several global health and development agencies and policy makers, including the World Bank and the World Health Organization (WHO).

As a result, the emerging field of global surgery has increased in priority among health practitioners, including nonphysician surgeons and anesthetists, researchers, and students. Evidence of this prioritization includes a shift toward incorporating surgical care as an integral part of global health systems strengthening in LMICs that has occurred and will likely continue to grow in importance within global health agendas. Lastly, interest in the field from an academic research standpoint is evidenced by the increase in peer-reviewed publications. Between 2005 and 2015, research publications in the field of global surgery increased from approximately 570 articles in 2005 to more than 4,000 articles published in 2015, according to PubMed.

Because of the growing interest in global surgery, momentum in this emerging field, and the importance of global surgery in the training of health professionals, we aimed to summarize the top resources in global surgery to orient readers to the field. We undertook a 2-stage process to identify and select the top 10 resources in global surgery.

Essential Vascular Surgical Care in Low and Middle Income Countries: Towards the Tipping Point

We read with great interest Prendes et al.’ s commentary on lower limb revascularisation in low and middle income countries (LMICs). It has become increasingly apparent that the burden of vascular diseases disproportionally affects vulnerable and LMIC populations as a result of the epidemiological transition away from infectious diseases and towards non-communicable diseases, as a result of the rise in smoking, air pollution, obesity, diabetes, and trauma. Access to emergency and essential vascular surgical care, however, is grossly lacking in LMICs.

Pragmatic multicentre factorial randomized controlled trial testing measures to reduce surgical site infection in low‐ and middle‐income countries: study protocol of the FALCON trial

Aim
Surgical site infection (SSI) is the commonest postoperative complication worldwide, representing a major burden for patients and health systems. Rates of SSI are significantly higher in low‐ and middle‐income countries (LMICs) but there is little high‐quality evidence on interventions to prevent SSI in LMICs.

Method
FALCON is a pragmatic, multicentre, 2 x 2 factorial, stratified randomized controlled trial, with an internal feasibility study, which will address the need for evidence on measures to reduce rates of SSI in patients in LMICs undergoing abdominal surgery. To assess whether either (1) 2% alcoholic chlorhexidine versus 10% povidone‐iodine for skin preparation, or (2) triclosan‐coated suture versus non‐coated suture for fascial closure, can reduce surgical site infection at 30‐days post‐surgery for each of (1) clean‐contaminated and (2) contaminated/dirty surgery. Patients with predicted clean‐contaminated or contaminated/dirty wounds with abdominal skin incision ≥ 5 cm will be randomized 1:1:1:1 between (1) 2% alcoholic chlorhexidine and noncoated suture, (2) 2% alcoholic chlorhexidine and triclosan‐coated suture, (3) 10% aqueous povidone–iodine and noncoated suture and (4) 10% aqueous povidone–iodine and triclosan‐coated suture. The two strata (clean‐contaminated versus contaminated/dirty wounds) are separately powered. Overall, FALCON aims to recruit 5480 patients. The primary outcome is SSI at 30 days, based on the Centers for Disease Control definition of SSI.

Conclusion
FALCON will deliver high‐quality evidence that is generalizable across a range of LMIC settings. It will influence revisions to international clinical guidelines, ensuring the global dissemination of its findings.

Perspectives on perioperative management of children’s surgical conditions during the COVID-19 pandemic in low-income and middle-income countries: a global survey

Background
Many organizations have issued recommendations to limit elective surgery during the coronavirus disease 2019 (COVID-19) pandemic. We surveyed providers of children’s surgical care working in low-income and middle-income countries (LMICs) to understand their perspectives on surgical management in the wake of the COVID-19 pandemic and how they were subsequently modifying their surgical care practices.

Methods
A survey of children’s surgery providers in LMICs was performed. Respondents reported how their perioperative practice had changed in response to COVID-19. They were also presented with 26 specific procedures and asked which of these procedures they were allowed to perform and which they felt they should be allowed to perform. Changes in surgical practice reported by respondents were analyzed thematically.

Results
A total of 132 responses were obtained from 120 unique institutions across 30 LMICs. 117/120 institutions (97.5%) had issued formal guidance on delaying or limiting elective children’s surgical procedures. Facilities in LICs were less likely to have issued guidance on elective surgery compared with middle-income facilities (82% in LICs vs 99% in lower middle-income countries and 100% in upper middle-income countries, p=0.036). Although 122 (97%) providers believed cases should be limited during a global pandemic, there was no procedure where more than 61% of providers agreed cases should be delayed or canceled.

Conclusions
There is little consensus on which procedures should be limited or delayed among LMIC providers. Expansion of testing capacity and local, context-specific guidelines may be a better strategy than international consensus, given the disparities in availability of preoperative testing and the lack of consensus towards which procedures should be delayed.

Colorectal Surgery in the time of Covid 19

At the time of writing (early August 2020) the world is still in the middle of the Covid 19 pandemic with over 18 million recorded cases and nearly 700 000 deaths. Those countries (e.g. parts of the UK and Spain) that had seen peaks in March, April & May had started to see the onset of second waves. The Australian State of Victoria had declared a state of disaster with lockdown imposed in Melbourne and the virus was widespread across the USA. Low & Middle Income Countries (LMICs) had seen rising numbers of cases and the head of the World Health Organisation, Tedros Adhanom Ghebreyesus, had declared that there is ‘no silver bullet at the moment – and there might never be’. Advances in Covid 19 research over the preceding months had focused on various drug combinations and vaccine development with each development hailed as a major victory. Despite the positive news stories with no paucity of hyperbole in the lay press, the reality remains a grossly disrupted health sector that has been crippled by the greatest public health crisis in a generation. The political fallout of the (mis)management of the pandemic continues to ripple across the world and the resultant economic recession in many nations has seen the prospect of rising health expenditure slip away as unemployment levels surge and government borrowing rockets to prop up stuttering economies.

Effect of Coronavirus Disease 2019 and Pandemics on Global Surgical Outreach

The ongoing coronavirus disease 2019 (COVID-19) pandemic has led to a health care crisis, changing billions of lives worldwide. The ramifications of the contagion will likely be felt for the foreseeable future and will undoubtedly have a momentous effect on health care. While recent publications have focused on optimizing health care delivery, patient care, and physician safety in the setting of COVID-19, not much has been discussed regarding the effect on surgical global health programs (SGHPs).

Prior to the novel coronavirus outbreak from Wuhan, China, SGHPs played an important role in delivering care to low- and middle-income countries (LMICs). Such mission trips have long been a staple for facial plastic surgeons, plastic surgeons, and otolaryngologists–head and neck surgeons.1 Humanitarian organizations perform more than 250 000 procedures globally per year. Despite the volume of care provided, LMICs continue to demonstrate significant unmet surgical needs. While one-third of the global population inhabits LMICs, only 3% to 6% of operations occur there. From a global health perspective, access to surgical services have been cited as integral to minimizing patient morbidity and mortality.Economically, it is estimated that lack of access to surgical services in LMICs may contribute to cumulative losses of $20.7 trillion to the global economy from 2015 to 2030. During this uncertain time, SGHPs ought to consider how they may aid in the ongoing crisis and to consider the short- and long-term effects on global surgical outreach.

Beyond technology: review of systemic innovation stories in global surgery

Since the launch of the Lancet Commission on Global Surgery (LCOGS) in 2015, significant attention and interest have been invested in breaking down the barriers that prevent universal access to essential surgical, obstetric and anesthesia (SOA) services. Improving access to surgical care in low-resource areas, whether in low- and middle-income countries (LMICs) or within vulnerable populations in high-income countries (HICs), requires stakeholders to think outside of the box. Innovation, or the process of creatively resolving a problem, is a crucial strategy for addressing complex challenges in global health and global surgery. While technology has traditionally taken the spotlight, novel ideas that support surgical systems strengthening and advance the agenda of achieving access for all should also be highlighted. This narrative review will focus on the principal ideas and trends in global surgery innovation, stretching beyond habitual technological advancements. By centering the narrative around non-technological achievements, we will explore emerging ideas that are transforming infrastructures in health systems strengthening, financial capacity, advocacy, and research and partnerships. From the development of National Surgical, Obstetric, and Anesthesia Plans (NSOAPs) to the creation of collaborative authorship, systemic innovations have and will continue to improve the delivery and quality of essential surgical services in areas of need around the world.

The role of non-governmental organizations in advancing the global surgery and anesthesia goals

Non-governmental organizations (NGOs) are indispensable to social and economic development, particularly in states with limited resources or poor governance. With about five billion people globally lacking access to safe, timely and affordable surgical and anesthesia care, mostly in low-income and middle-income countries (LMICs), NGOs can play a critical role in meeting this significant surgical need and advancing the global surgery and anesthesia goals set by the Lancet Commission on Global Surgery in alignment with the Sustainable Development Goals (SDGs). Surgical-NGOs (s-NGOs) have historically and continue to play a vital role in reducing the surgical burden globally, providing at least 3 million surgical procedures annually in LMICs. They have done this primarily through service delivery by employing temporary platforms such as short-term surgical trips and self-contained surgical platforms or through the setting up of specialized hospitals. With the advent of the SDGs, s-NGOs are increasingly investing in strengthening local health systems by supporting various dimensions of the health systems building blocks. Health systems strengthening interventions by s-NGOs have primarily focused on the training of skilled local surgical workforce (pre-service and in-service) and investing in health infrastructure through equipment and supplies donations to capacitate local health facilities to provide high-quality sustainable surgical and anesthesia care. Despite these laudable efforts, s-NGOs have not been without challenges and criticism especially around the cost-effectiveness, sustainability, equity and quality of care provided. In this article, we review the current landscape of s-NGOs and the challenges they face. We also examine the roles of s-NGOs in advancing the global surgery and anesthesia goals and SDGs in light of the ongoing COVID-19 pandemic.

How to Implement a Small Blood Bank in Low and Middle-Income Countries Work in Progress?

Compared to High-Income countries (HIC), a shortfall in the provision of blood remains a multifaceted problem in Low and Middle-Income Countries (LMIC) with a direct negative effect on clinical care. The reasons are multifactorial: not only lack of knowledge, skills, and resources, but also huge differences in environment climate, endemic transfusion transmittable infections, clinical set-up, availability of clean water, electricity. It is therefore obvious that simple translation of guidelines, standards, experiences, and the total organization from HIC to LMIC is not the best way to proceed. Adapted, but not less adequate methods for blood transfusion training, organization, and accreditation are required. The Global Advisory Panel (GAP) already formulated an adapted specific answer in terms of training and accreditation. But this is not enough. Academic centres, the GAP, countries, non-governmental organizations, and others need to test current and innovative diagnostic, production, and storage methods in a joint venture with the industry. Also, medical decisions focused on transfusion must be tested before implementation in facilities allowing pre-qualification of tests and devices. The entire transfusion chain needs to be simulated in a competence and training centre, focusing on the region where it will be applied. One of the renowned tropical institutes, currently fulfilling all these requirements could be the ideal place for such a competence centre. This review highlights this and suggests possible ways and solutions.