BACKGROUND
Alleviating suffering and preserving dignity are essential components of healthcare. Patients in need of palliative care often require opioid medication to relieve breathlessness and pain. However, a lack of access to essential opioids, particularly morphine, remains a major challenge in low- and middle-income countries (LMICs). This is notably critical in the humanitarian context. We conducted two case studies to identify the barriers and facilitators of access to opioids, particularly morphine, for palliative care patients in humanitarian settings while exploring humanitarian healthcare workers’ perceptions and experiences with opioids.
METHODS
Two case studies were conducted based on two Médecins Sans Frontières (MSF) projects which integrated palliative care: advanced HIV care in Patna, Bihar, India, and paediatric and neonatal care in the refugee context in Cox’s Bazar, Bangladesh. Six semi-structured interviews were conducted with key MSF healthcare professionals. Interviews were conducted in English, video- and/or audio-recorded and transcribed verbatim. Transcripts were coded and analysed using the grounded theory approach.
RESULTS
Several barriers impeding access to and use of essential opioids in palliative care were reported by the participants. These included limited availability, accessibility obstacles, sociocultural challenges such as low awareness and misconceptions, lack of healthcare providers’ training on opioid use, and burdensome regulatory processes. Most participants reported that clinical guidelines, familiarity with the use of opioids and interdisciplinary teamwork were important facilitators of opioid prescribing. Participants expressed the urgency for further educational and advocacy initiatives to improve access to essential opioids for patients requiring palliative care.
CONCLUSION
Humanitarian healthcare workers face multiple challenges, leading to inadequate access to essential opioid medication, which undermines effective palliative care delivery. Further training on the use of opioids and strong advocacy efforts led by humanitarian organizations and the medical community are critical to improving access to these essential medicines for the relief of pain and suffering.
BACKGROUND
Circulating markers of immune and endothelial activation risk stratify infection syndromes agnostic to disease aetiology. However, their utility in children presenting from the community remains unclear.
METHODS
This study recruited children aged 1-59 months presenting with community-acquired acute febrile illnesses to seven hospitals in Bangladesh, Cambodia, Indonesia, Laos, and Viet Nam. Clinical parameters and biomarker concentrations were measured at presentation. The outcome measure was death or receipt of vital organ support within two days of enrolment. Prognostic performance of endothelial (Ang-1, Ang-2, sFlt-1) and immune (CHI3L1, CRP, IP-10, IL-1ra, IL-6, IL-8, IL-10, PCT, sTNFR-1, sTREM-1, suPAR) activation markers, WHO Danger Signs, and two validated severity scores (LqSOFA, SIRS) was compared.
RESULTS
3,423 participants were recruited. 133 met the outcome (weighted prevalence: 0.34%; 95% CI 0.28-0.41). sTREM-1 exhibited highest prognostic accuracy (AUC 0.86; 95% CI 0.82-0.90), outperforming WHO Danger Signs (AUC 0.75; 95% CI 0.70-0.80; p < 0.001), LqSOFA (AUC 0.74; 95% CI 0.70-0.78; p < 0.001), and SIRS (AUC 0.63; 95% CI 0.58-0.68; p < 0.001). Discrimination of immune and endothelial activation markers was particularly strong for children who deteriorated later in the course of their illness. Compared to WHO Danger Signs, an sTREM-1-based triage strategy improved recognition of children at risk of progression to life-threatening infection (sensitivity: 0.80 vs. 0.72), while maintaining comparable specificity (0.81 vs. 0.79).
CONCLUSIONS
Measuring circulating markers of immune and endothelial activation may help earlier recognition of febrile children at risk of poor outcomes in resource-constrained community settings.
BACKGROUND
Nipah virus (NiV), a highly lethal virus in humans, circulates in Pteropus bats throughout South and Southeast Asia. Difficulty in obtaining viral genomes from bats means we have a poor understanding of NiV diversity.
METHODS
We develop phylogenetic approaches applied to the most comprehensive collection of genomes to date (N = 257, 175 from bats, 73 from humans) from 6 countries over 22 years (1999–2020). We divide the 4 major NiV sublineages into 15 genetic clusters. Using Approximate Bayesian Computation fit to a spatial signature of viral diversity, we estimate the presence and the average size of genetic clusters per area.
RESULTS
We find that, within any bat roost, there are an average of 2.4 co-circulating genetic clusters, rising to 5.5 clusters at areas of 1500–2000 km2. We estimate that each genetic cluster occupies an average area of 1.3 million km2 (95% confidence interval [CI], .6–2.3 million km2), with 14 clusters in an area of 100 000 km2 (95% CI, 6–24 km2). In the few sites in Bangladesh and Cambodia where genomic surveillance has been concentrated, we estimate that most clusters have been identified, but only approximately 15% of overall NiV diversity has been uncovered.
CONCLUSIONS
Our findings are consistent with entrenched co-circulation of distinct lineages, even within roosts, coupled with slow migration over larger spatial scales.
INTRODUCTION
Both high- and low-income countries reported increased antibiotic consumption among COVID-19 patients during the first months of the pandemic. To date, however, no studies have examined changes in antibiotic consumption during the COVID-19 pandemic within humanitarian emergency contexts.
METHODS
Data was collected by Médecins Sans Frontières (MSF) for the years 2018-2021 across the following humanitarian settings: Afghanistan (Lashkar Gah), Bangladesh (Kutupalong), the Democratic Republic of Congo (Mweso and Baraka), and South Sudan (Bentiu). Inpatient and outpatient antibiotic consumption was calculated as Daily Defined Dose (DDD) per 1000 inhabitants per day, as per the World Health Organisation's (WHO) Collaborating Centre for Drug Statistics Methodology. Interrupted time series (ITS) analysis, using an autoregressive integrated moving average (ARIMA) model was used to analyse retrospective monthly antibiotic consumption. The impact of COVID-19 pandemic was evaluated as total antibiotic consumption and according to WHO Access, Watch, Reserve (AWaRe) group classifications within each humanitarian setting.
RESULTS
The COVID-19 pandemic had no statistically significant impact on total antibiotic consumption in South Sudan (Bentiu) and Bangladesh (Kutupalong). Similarly, the pandemic had no impact on total antibiotic consumption in DR Congo (Baraka), despite an initial 0.27% (estimate=.274, p-value=0.006) increase in March 2020 driven by Access group antibiotics. Meanwhile, total antibiotic consumption in DR Congo (Mweso) and Afghanistan (Lashkar Gah) declined by 0.74% (estimate = -.744, p = 0.003) and 0.26% (estimate = -.26, p < 0.001), respectively with the COVID-19 pandemic.
CONCLUSION
Further studies are required to investigate what may have contributed to these results.
South Asia emerges as one of the most susceptible regions to a plethora of direct and indirect repercussions stemming from climate change. These include, but are not limited to, the rising sea levels, heightened cyclonic activity, and shifts in ambient temperature or precipitation patterns. Despite an abundance of publications delving into the associated impacts, our objective is to synthesize pertinent literature with the aim of discerning commonalities in research findings, assessing the most affected areas in terms of health, and delving into potential avenues for mitigating the associated impacts.
Notwithstanding its relatively minor contribution to greenhouse gas emissions, South Asia finds itself exceptionally vulnerable to the perils of climate change due to a confluence of factors, including its geographical and topographical positioning, burgeoning population density, rapid urbanization, deficient health infrastructure, and an economy predominantly reliant on agriculture. This region stands at the forefront of vulnerability to various direct and indirect consequences of climate change, such as sea level rise, extreme weather events encompassing cyclones and droughts, as well as alterations in ambient temperature and precipitation patterns.
Our comprehensive review is centered on an in-depth, country-wise exploration of the available literature pertaining to four South Asian nations: India, Bangladesh, Nepal, and Sri Lanka. Through this analysis, we seek to evaluate the impacts of climate change from both direct and indirect perspectives. A discernible trend emerges, indicating that extreme weather events exert a palpable impact on health and healthcare systems in areas deemed 'climate-sensitive.' However, noteworthy gaps persist in the existing literature, warranting further investigation to substantiate the link between climate events and their health impacts. This void also presents an opportune moment to contextualize strategies for mitigation and adaptation, crafting more sustainable approaches that contribute to the well-being of both the populace and the planet
BACKGROUND
Antimicrobial resistance is of great global public health concern. In order to address the paucity of antibiotic consumption data and antimicrobial resistance surveillance systems in hospitals in humanitarian settings, we estimated antibiotic consumption in six hospitals with the aim of developing recommendations for improvements in antimicrobial stewardship programs.
METHODS
Six hospitals supported by Médecins sans Frontières were included in the study: Boost-Afghanistan, Kutupalong-Bangladesh, Baraka and Mweso-Democratic Republic of Congo, Kule-Ethiopia, and Bentiu-South Sudan. Data for 36,984 inpatients and antibiotic consumption data were collected from 2018 to 2020. Antibiotics were categorized per World Health Organization Access Watch Reserve classification. Total antibiotic consumption was measured by Defined Daily Doses (DDDs)/1000 bed-days.
RESULTS
Average antibiotic consumption in all hospitals was 2745 DDDs/1000 bed-days. Boost hospital had the highest antibiotic consumption (4157 DDDs/1000 bed-days) and Bentiu the lowest (1598 DDDs/1000 bed-days). In all hospitals, Access antibiotics were mostly used (69.7%), followed by Watch antibiotics (30.1%). The most consumed antibiotics were amoxicillin (23.5%), amoxicillin and clavulanic acid (14%), and metronidazole (13.2%). Across all projects, mean annual antibiotic consumption reduced by 22.3% during the study period, mainly driven by the reduction in Boost hospital in Afghanistan.
CONCLUSIONS
This was the first study to assess antibiotic consumption by DDD metric in hospitals in humanitarian settings. Antibiotic consumption in project hospitals was higher than those reported from non-humanitarian settings. Routine systematic antibiotic consumption monitoring systems should be implemented in hospitals, accompanied by prescribing audits and point-prevalence surveys, to inform about the volume and appropriateness of antibiotic use and to support antimicrobial stewardship efforts in humanitarian settings.