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.

Evaluation of a digital triage platform in Uganda: A quality improvement initiative to reduce the time to antibiotic administration

Background
Sepsis is the leading cause of death in children under five in low- and middle-income countries. The rapid identification of the sickest children and timely antibiotic administration may improve outcomes. We developed and implemented a digital triage platform to rapidly identify critically ill children to facilitate timely intravenous antibiotic administration.

Objective
This quality improvement initiative sought to reduce the time to antibiotic administration at a dedicated children’s hospital outpatient department in Mbarara, Uganda.

Intervention and study design
The digital platform consisted of a mobile application that collects clinical signs, symptoms, and vital signs to prioritize children through a combination of emergency triggers and predictive risk algorithms. A computer-based dashboard enabled the prioritization of children by displaying an overview of all children and their triage categories. We evaluated the impact of the digital triage platform over an 11-week pre-implementation phase and an 11-week post-implementation phase. The time from the end of triage to antibiotic administration was compared to evaluate the quality improvement initiative.

Results
There was a difference of -11 minutes (95% CI, -16.0 to -6.0; p < 0.001; Mann-Whitney U test) in time to antibiotics, from 51 minutes (IQR, 27.0–94.0) pre-implementation to 44 minutes (IQR, 19.0–74.0) post-implementation. Children prioritized as emergency received the greatest time benefit (-34 minutes; 95% CI, -9.0 to -58.0; p < 0.001; Mann-Whitney U test). The proportion of children who waited more than an hour until antibiotics decreased by 21.4% (p = 0.007). Conclusion A data-driven patient prioritization and continuous feedback for healthcare workers enabled by a digital triage platform led to expedited antibiotic therapy for critically ill children with sepsis. This platform may have a more significant impact in facilities without existing triage processes and prioritization of treatments, as is commonly encountered in low resource settings.

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.

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.

Barriers and facilitators of research in Cameroon (Part II) – an e-survey of medical students

Introduction: research fosters critical thinking and prepares students for a career in academic medicine. This study aimed to identify the facilitators and barriers to research among Cameroonian medical students.

Methods: an electronic survey was distributed between May 23, 2020, and June 07, 2020. The survey was made of closed-, opened-, and Likert scale questions. A Preference Score (PS) was used to quantify the medical students’ perception of barriers and facilitators to research. The Kruskal-Wallis H and Fisher’s Exact tests were used to evaluate bivariate relationships

Results: one hundred and eighty-eight (188) students with a mean age of 24.1 ± 2.3 years were enrolled. Most respondents were male (56.9%), francophone (69.1%), and in their final year of medical school (46.8%). Twenty-one students (11.1%) had a peer-reviewed article, and all the published students were in their sixth- or seventh-year of undergraduate medical studies. Barriers to research included lack of funding (PS=203), obsolete patient information management systems (PS=198), and limited understanding of biostatistics (PS=197). Facilitators to research included research focused on the student’s interests (PS=255), the study’s capacity to improve practice (PS=247), and scientific recognition (PS=198).
Conclusion: barriers to research among Cameroonian medical students are mainly institutional. However, facilitators are primarily linked to career goals. To improve research activities among these undergraduates, initiatives must target institutional barriers and incentives that foster career development.

Considerations for service delivery for emergency care in low resource settings

In a shift from the more traditional disease focused model of global health interventions, increasing attention is now being placed on the importance of strengthening healthcare systems as a key component for achieving improved health outcomes. As emergency care systems continue to develop and strengthen around the world, the concept of service delivery provides one way to assess how well these systems are functioning. By focusing on service delivery, a system can be evaluated based on its ability to provide patients with access to the high-quality emergency care that they deserve. While the concept of service delivery is commonly used to evaluate the effectiveness of care in high-resource settings, its use in low resource settings has previously been limited due to challenges in operationalizing the concept in a context appropriate way. This article will begin by discussing the concept of service delivery as it specifically applies to emergency care systems and then discuss some of the challenges in defining and assessing this concept in low resource settings. The article will then discuss several new tools that have been developed to specifically address ways to evaluate emergency care service delivery in low-resource settings that can be used to inform future systems strengthening activities.

Surgical referrals in Northern Tanzania: a prospective assessment of rates, preventability, reasons and patterns

Background
An effective referral system is essential for a high-quality health system that provides safe surgical care while optimizing patient outcomes and ensuring efficiency. The role of referral systems in countries with under-resourced health systems is poorly understood. The aim of this study was to examine the rates, preventability, reasons and patterns of outward referrals of surgical patients across three levels of the healthcare system in Northern Tanzania.

Methods
Referrals from surgical and obstetric wards were assessed at 20 health facilities in five rural regions prospectively over 3 months. Trained physician data collectors used data collection forms to capture referral details daily from hospital referral letters and through discussions with clinicians and nurses. Referrals were deemed preventable if the presenting condition was one that should be managed at the referring facility level per the national surgical, obstetric and anaesthesia plan but was referred.

Results
Seven hundred forty-three total outward referrals were recorded during the study period. The referral rate was highest at regional hospitals (2.9%), followed by district hospitals (1.9%) and health centers (1.5%). About 35% of all referrals were preventable, with the highest rate from regional hospitals (70%). The most common reasons for referrals were staff-related (76%), followed by equipment (55%) and drugs or supplies (21%). Patient preference accounted for 1% of referrals. Three quarters of referrals (77%) were to the zonal hospital, followed by the regional hospitals (17%) and district hospitals (12%). The most common reason for referral to zonal (84%) and regional level (66%) hospitals was need for specialist care while the most common reason for referral to district level hospitals was non-functional imaging diagnostic equipment (28%).

Conclusions
Improving the referral system in Tanzania, in order to improve quality and efficiency of patient care, will require significant investments in human resources and equipment to meet the recommended standards at each level of care. Specifically, improving access to specialists at regional referral and district hospitals is likely to reduce the number of preventable referrals to higher level hospitals, thereby reducing overcrowding at higher-level hospitals and improving the efficiency of the health system.

Antibiotic Use in Low and Middle-Income Countries and the Challenges of Antimicrobial Resistance in Surgery

Antimicrobial resistance (AMR) is a phenomenon resulting from the natural evolution of microbes. Nonetheless, human activities accelerate the pace at which microorganisms develop and spread resistance. AMR is a complex and multidimensional problem, threatening not only human and animal health, but also regional, national, and global security, and the economy. Inappropriate use of antibiotics, and poor infection prevention and control strategies are contributing to the emergence and dissemination of AMR. All healthcare providers play an important role in preventing the occurrence and spread of AMR. The organization of healthcare systems, availability of diagnostic testing and appropriate antibiotics, infection prevention and control practices, along with prescribing practices (such as over-the-counter availability of antibiotics) differs markedly between high-income countries and low and middle-income countries (LMICs). These differences may affect the implementation of antibiotic prescribing practices in these settings. The strategy to reduce the global burden of AMR includes, among other aspects, an in-depth modification of the use of existing and future antibiotics in all aspects of medical practice. The Global Alliance for Infections in Surgery has instituted an interdisciplinary working group including healthcare professionals from different countries with different backgrounds to assess the need for implementing education and increasing awareness about correct antibiotic prescribing practices across the surgical pathways. This article discusses aspects specific to LMICs, where pre-existing factors make surgeons’ compliance with best practices even more important.