COVID-19 and resilience of healthcare systems in ten countries

Declines in health service use during the Coronavirus Disease 2019 (COVID-19) pandemic could have important effects on population health. In this study, we used an interrupted time series design to assess the immediate effect of the pandemic on 31 health services in two low-income (Ethiopia and Haiti), six middle-income (Ghana, Lao People’s Democratic Republic, Mexico, Nepal, South Africa and Thailand) and high-income (Chile and South Korea) countries. Despite efforts to maintain health services, disruptions of varying magnitude and duration were found in every country, with no clear patterns by country income group or pandemic intensity. Disruptions in health services often preceded COVID-19 waves. Cancer screenings, TB screening and detection and HIV testing were most affected (26–96% declines). Total outpatient visits declined by 9–40% at national levels and remained lower than predicted by the end of 2020. Maternal health services were disrupted in approximately half of the countries, with declines ranging from 5% to 33%. Child vaccinations were disrupted for shorter periods, but we estimate that catch-up campaigns might not have reached all children missed. By contrast, provision of antiretrovirals for HIV was not affected. By the end of 2020, substantial disruptions remained in half of the countries. Preliminary data for 2021 indicate that disruptions likely persisted. Although a portion of the declines observed might result from decreased needs during lockdowns (from fewer infectious illnesses or injuries), a larger share likely reflects a shortfall of health system resilience. Countries must plan to compensate for missed healthcare during the current pandemic and invest in strategies for better health system resilience for future emergencies.

Fetal movement trials: where is the evidence in settings with high-burden of stillbirths?

Fetal movement (FM) is a sign of fetal life and wellbeing that is felt by the pregnant woman, and reduced FM is known to precede stillbirths (1,2). Therefore, women may be instructed to monitor and report if movements are fewer than usual (2). In high-income countries, there has been a renewed interest in FM with a recent wave of large-scale randomised controlled clinical trials investigating FM as a potential stillbirth reduction strategy. As published in BJOG, My Baby’s Fetal Movement trial was carried out in Australia/New Zealand, and the Mindfetalness trial in Sweden (3,4). Also, the AFFIRM trial published in the Lancet was conducted in UK and the CEPRA study is ongoing in the Netherlands, UK and Australia (5). None of the completed trials, however, found significant reductions in stillbirths, and they showed conflicting results on some potential harmful consequences such as increased rates of obstetric interventions. In this commentary, we reflect on these trials through a global lens, and we urgently call for more trials; but this time in settings suffering from the vast majority (98%) of the world’s 2 million annual stillbirths

Real-time diabetic retinopathy screening by deep learning in a multisite national screening programme: a prospective interventional cohort study

Background
Diabetic retinopathy is a leading cause of preventable blindness, especially in low-income and middle-income countries (LMICs). Deep-learning systems have the potential to enhance diabetic retinopathy screenings in these settings, yet prospective studies assessing their usability and performance are scarce.

Methods
We did a prospective interventional cohort study to evaluate the real-world performance and feasibility of deploying a deep-learning system into the health-care system of Thailand. Patients with diabetes and listed on the national diabetes registry, aged 18 years or older, able to have their fundus photograph taken for at least one eye, and due for screening as per the Thai Ministry of Public Health guidelines were eligible for inclusion. Eligible patients were screened with the deep-learning system at nine primary care sites under Thailand’s national diabetic retinopathy screening programme. Patients with a previous diagnosis of diabetic macular oedema, severe non-proliferative diabetic retinopathy, or proliferative diabetic retinopathy; previous laser treatment of the retina or retinal surgery; other non-diabetic retinopathy eye disease requiring referral to an ophthalmologist; or inability to have fundus photograph taken of both eyes for any reason were excluded. Deep-learning system-based interpretations of patient fundus images and referral recommendations were provided in real time. As a safety mechanism, regional retina specialists over-read each image. Performance of the deep-learning system (accuracy, sensitivity, specificity, positive predictive value [PPV], and negative predictive value [NPV]) were measured against an adjudicated reference standard, provided by fellowship-trained retina specialists. This study is registered with the Thai national clinical trials registry, TCRT20190902002.

Findings
Between Dec 12, 2018, and March 29, 2020, 7940 patients were screened for inclusion. 7651 (96·3%) patients were eligible for study analysis, and 2412 (31·5%) patients were referred for diabetic retinopathy, diabetic macular oedema, ungradable images, or low visual acuity. For vision-threatening diabetic retinopathy, the deep-learning system had an accuracy of 94·7% (95% CI 93·0–96·2), sensitivity of 91·4% (87·1–95·0), and specificity of 95·4% (94·1–96·7). The retina specialist over-readers had an accuracy of 93·5 (91·7–95·0; p=0·17), a sensitivity of 84·8% (79·4–90·0; p=0·024), and specificity of 95·5% (94·1–96·7; p=0·98). The PPV for the deep-learning system was 79·2 (95% CI 73·8–84·3) compared with 75·6 (69·8–81·1) for the over-readers. The NPV for the deep-learning system was 95·5 (92·8–97·9) compared with 92·4 (89·3–95·5) for the over-readers.

Interpretation
A deep-learning system can deliver real-time diabetic retinopathy detection capability similar to retina specialists in community-based screening settings. Socioenvironmental factors and workflows must be taken into consideration when implementing a deep-learning system within a large-scale screening programme in LMICs.

High value and cheap musculoskeletal health care interventions: lessons for low- and middle-income countries

To the Editor,

The Global Burden of Disease Study 2019 reported low back pain and other musculoskeletal disorders constitute the top ten cause of disability-adjusted life-year and are common from teenage years into old age [1]. The number of people experiencing musculoskeletal conditions in the coming decades will increase in low- and middle-income countries (LMICs) [2]. In addition to the likelihood of risk factors such as increased life expectancy and obesity associated with musculoskeletal conditions in high-income countries becoming more common in LMICs, the burden of musculoskeletal conditions will increase as a result of physically demanding agrarian work, and arduous portering due to poor access to modern transportation system [2].

In the past decades, the largest increase in disability due to low back pain occurred in LMICs, including Asia, Africa, and the Middle East region [2], where resource-constrained health and social systems are stressed by other burdens including infectious diseases, child and maternal health, and non-communicable diseases. The Lancet series on low back pain reported healthcare professionals in LMICs are providing wrong care for low back pain [3], resulting not only in burdens to individuals, communities, and health care systems but also contravening the 2010 Declaration of Montreal, which recognises pain relief as fundamental human right. Therefore, LMICs should develop innovative health policies to address this concern with fiscally cheaper but high value care. In this paper, the musculoskeletal conditions refer to the chronic, non-traumatic musculoskeletal pain disorders.

The impact of COVID-19 on healthcare-associated infections in intensive care units in low and middle income countries: International Nosocomial Infection Control Consortium (INICC) findings

Background
: This study examines the impact of the COVID-19 pandemic on healthcare-associated infection (HAI) incidence in low-to-middle-income countries (LMICs).

Methods
: Patients from 7 LMICs were followed during hospital intensive care unit (ICU) stays throughout January 2019 to May 2020. HAI rates were calculated using the INICC Surveillance Online System applying CDC-NHSN criteria. Pre-COVID-19 rates for 2019 were compared to COVID-19 era rates for 2020 for central line associated bloodstream infections (CLABs), catheter associated urinary tract infections (CAUTIs), ventilator associated events (VAEs), mortality and lengths of stay (LOS).

Results
: 7,775 patients were followed for 49,506 bed-days. 2019 to 2020 rate comparisons: 2.54 and 4.73 CLABSIs per 1,000 central line days (RR=1.85, p = 0.0006), 9.71 and 12.58 VAEs per 1,000 mechanical ventilator days (RR=1.29, p = 0.10), 1.64 and 1.43 CAUTIs per 1,000 urinary catheter days (RR=1.14; p = 0.69). Mortality rates were 15.2% and 23.2% for 2019 and 2020 (RR=1.42; p < 0.0001). Mean LOS were 6.02 and 7.54 days (RR=1.21, p < 0.0001). Discussion : This report documents a rise in HAI rates in 7 LMICs during the first 5 months of the COVID-19 pandemic and highlights the need to reprioritize and return to conventional infection prevention practices.

Development of a remote learning educational model for international Emergency Medicine trainees in the era of COVID-19

Background
The COVID-19 pandemic has pressured post-graduate medical education programs to shift from traditional in-person teaching to remote teaching and learning. Remote learning in medical education has been described in the literature mostly in the context of local in-country teaching. International remote medical education poses unique challenges for educators, especially in low-middle income countries (LMICs) who need continued Emergency Medicine (EM) specialty development. Our objective is to describe the development and implementation of our remote educational curriculum for EM trainees in West Bengal, India, and to assess trainee satisfaction with our remote learning curriculum.

Methods
Our curriculum was developed by adapting remote learning techniques used in Western post-graduate medical education, conducting literature searches on remote learning modalities, and through collaboration with local faculty in India. We assessed resident satisfaction in our curriculum with feedback surveys and group discussions.

Results
The remote educational curriculum had overall high trainee satisfaction ratings for weekly livestream video lectures and throughout our monthly educational modules (median ratings 9-10 out of a 10-point Likert scale). Qualitative feedback regarding specific lecture topics and educational modules were also received.

Conclusions
International remote education in LMICs poses a unique set of challenges to medical educators. Residents in our study reported high satisfaction with the curriculum, but there is a lack of clarity regarding how a remote curriculum may impact academic and clinical performance. Future studies are needed to further evaluate the efficacy and academic and clinical implications of remote medical education in LMICs.

Cost Evaluation of Minimally Invasive Tissue Sampling (MITS) Implementation in Low- and Middle-Income Countries

Background
Low- and middle-income countries (LMICs) face disproportionately high mortality rates, yet the causes of death in LMICs are not robustly understood, limiting the effectiveness of interventions to reduce mortality. Minimally invasive tissue sampling (MITS) is a standardized postmortem examination method that holds promise for use in LMICs, where other approaches for determining cause of death are too costly or unacceptable. This study documents the costs associated with implementing the MITS procedure in LMICs from the healthcare provider perspective and aims to inform resource allocation decisions by public health decisionmakers.

Methods
We surveyed 4 sites in LMICs across Sub-Saharan Africa and South Asia with experience conducting MITS. Using a bottom-up costing approach, we collected direct costs of resources (labor and materials) to conduct MITS and the pre-implementation costs required to initiate MITS.

Results
Initial investments range widely yet represent a substantial cost to implement MITS and are determined by the existing infrastructure and needs of a site. The costs to conduct a single case range between $609 and $1028 per case and are driven by labor, sample testing, and MITS supplies costs.

Conclusions
Variation in each site’s use of staff roles and testing protocols suggests sites conducting MITS may adapt use of resources based on available expertise, equipment, and surveillance objectives. This study is a first step toward necessary examinations of cost-effectiveness, which may provide insight into cost optimization and economic justification for the expansion of MITS.

Towards integration of transcranial Doppler in the management of severe TBI in LICs and LMICs: A cohort retrospective study

Background
Medical first-line management to fight against raised intracranial pressure due to severe TBI in LICs and LMICs is still precarious, especially with the lack of means for adequate monitoring of intracranial pressure.

Objective
In the cohort retrospective study, we aimed to show if the TCD could have an impact on decision-making to operate and on the GOS.

Methods
Patients treated at bi-institutional between March 2017 and July 2019, were included if they had Moderate to Severe TBI treated surgically. Variables associated with the outcome were tested using uni and multivariable analyses.

Results
One hundred and thirty-six TBI patients were admitted for management during the study period, 21 and 44 were excluded respectively because they were managed medically only, and were benign trauma. Seventy-one(71) patients were included in the final analysis. They had a mean age of 44.27 years old (+/− 15.99) at diagnosis and there was a male predominance (n = 59, 83,1%). 52(73.2%) of them benefited from TCD. The mean time between admission and the surgery in a cohort of patients from TCD monitoring was 6 h ± 4 vs 8 h ± 3 (P = 0.003). The mean GOS in the cohort group with non-TCD was 4,7 ± 1,1 versus 4,3 ± 1,1(P = 0.047)in the non-TCD cohort group. The paired test revealed statically significantly positive in the use of TCD for Severe TBI, Z = -3.859, P = 0.044 with a median effect (r = 0.23).

Conclusion
TCD has an impact on the early decision to go for DC and has a median effect on GOS.

Universal Eye Health and its relation to Digital Health: A Systematic Analysis

Background Despite the vigorous efforts of different Global public health sectors regarding eye health. It became now available, but not yet to everyone. From here appeared the urge of the development of Universal Eye Health (UEH) to ensure reducing social inequality in eye health services delivery and improving eye services’ coverage. Digital Health has also become an important frontier in health care services delivery nowadays. This research aims to study the availability and accessibility of UEH and the role of Digital Health as an additive factor in improving it. Methods This is an observational retrospective study. 2 methods where used for in-depth study of current situation of digital eye health in LMICs; Country profiles of the studied countries from different WHO regions and systematic analysis. Literatures have been searched at three search engines: PubMed, Google Scholar, and Cochrane Library. An overview of review articles was conducted using patient, intervention, comparison, and outcome (PICO) framework. Search keywords were; “Digital health”, “Smart health”, “eye health”, “Cataract”, and etc. Our 37 publications were identified as suitable regarding the three expected categories of outcomes. Results Digital health was found to be an important factor in the attainment of UEH in the studied countries. Three categories of outcomes representing the effect of digital health were found in the systematic analysis which helped in improving the eye health system: quality of life of patients with ocular diseases, quality of eye health services and access to the eye health services. Implication of these results on digital eye health in Egypt was identified as well. Conclusion Digital health was found to be an important additive factor in the attainment and expansion of UEH in many of the studied countries. Portable screening devices, Fundus photography, and retinal diagnostics AI innovations and Teleophthalmology have become the black horse of the eye field nowadays but still used in a limited range in many countries in need of such technologies. Using EHRs in research and gathering data for cataract surgical indicators still also used in a very narrow scope which needed to broaden. As it is strongly needed to monitor UEH indicators to be able to have a real assessment of the countries’ progress in their national eye plans and improve access and quality of eye services and of patient life, especially in LMICs.

The availability of psychological support following road travel injuries in Namibia: A qualitative study

Road traffic injuries (RTIs) are a major problem worldwide with a high burden of mental health problems and the importance of psychological support following road injury is well documented. However, globally there has been very little research on the accessibility of psychological services following road injury. Namibia is one of the countries most affected by RTIs but no previous studies have been done on this. In this qualitative study we investigated the availability of psychological services to RTI injured in Namibia. Our study findings are in line with those of other global studies in showing inadequate access to psychological support for injury survivors and we discuss the reasons. It is hoped these findings will help policymakers develop ways of enhancing access to psychological support for the many people injured in RTIs in Namibia. The models they develop may also be of use to other LMICs countries with high RTI rates.