Journal Article > ReviewFull Text
Confl Health. 2021 February 25; Volume 15 (Issue 1); DOI:10.1186/s13031-021-00345-w
Bausch FJ, Beran D, Hering H, Boulle P, Chappuis F, et al.
Confl Health. 2021 February 25; Volume 15 (Issue 1); DOI:10.1186/s13031-021-00345-w
Non-communicable diseases (NCD) represent an increasing global challenge with the majority of mortality occurring in low- and middle-income countries (LMICs). Concurrently, many humanitarian crises occur in these countries and the number of displaced persons, either refugees or internally displaced, has reached the highest level in history. Until recently NCDs in humanitarian contexts were a neglected issue, but this is changing. Humanitarian actors are now increasingly integrating NCD care in their activities and recognizing the need to harmonize and enhance NCD management in humanitarian crises. However, there is a lack of a standardized response during operations as well as a lack of evidence-based NCD management guidelines in humanitarian settings. An informal working group on NCDs in humanitarian settings, formed by members of the World Health Organization, Médecins Sans Frontières, the International Committee of the Red Cross, the International Federation of the Red Cross and others, and led by the United Nations High Commissioner for Refugees, teamed up with the University of Geneva and Geneva University Hospitals to develop operational considerations for NCDs in humanitarian settings. This paper presents these considerations, aiming at ensuring appropriate planning, management and care for NCD-affected persons during the different stages of humanitarian emergencies. Key components include access to treatment, continuity of care including referral pathways, therapeutic patient education/patient self-management, community engagement and health promotion. In order to implement these components, a standardized approach will support a consistent response, and should be based on an ethical foundation to ensure that the "do no harm" principle is upheld. Advocacy supported by evidence is important to generate visibility and resource allocation for NCDs. Only a collaborative approach of all actors involved in NCD management will allow the spectrum of needs and continuum of care for persons affected by NCDs to be properly addressed in humanitarian programmes.
Journal Article > ResearchFull Text
PLOS One. 2021 February 3; Volume 16 (Issue 2); e0245372.; DOI:10.1371/journal.pone.0245372
Kaufmann B, Boulle P, Berthou F, Fournier M, Beran D, et al.
PLOS One. 2021 February 3; Volume 16 (Issue 2); e0245372.; DOI:10.1371/journal.pone.0245372
Strict storage recommendations for insulin are difficult to follow in hot tropical regions and even more challenging in conflict and humanitarian emergency settings, adding an extra burden to the management of people with diabetes. According to pharmacopeia unopened insulin vials must be stored in a refrigerator (2-8°C), while storage at ambient temperature (25-30°C) is usually permitted for the 4-week usage period during treatment. In the present work we address a critical question towards improving diabetes care in resource poor settings, namely whether insulin is stable and retains biological activity in tropical temperatures during a 4-week treatment period. To answer this question, temperature fluctuations were measured in Dagahaley refugee camp (Northern Kenya) using log tag recorders. Oscillating temperatures between 25 and 37°C were observed. Insulin heat stability was assessed under these specific temperatures which were precisely reproduced in the laboratory. Different commercialized formulations of insulin were quantified weekly by high performance liquid chromatography and the results showed perfect conformity to pharmacopeia guidelines, thus confirming stability over the assessment period (four weeks). Monitoring the 3D-structure of the tested insulin by circular dichroism confirmed that insulin monomer conformation did not undergo significant modifications. The measure of insulin efficiency on insulin receptor (IR) and Akt phosphorylation in hepatic cells indicated that insulin bioactivity of the samples stored at oscillating temperature during the usage period is identical to that of the samples maintained at 2-8°C. Taken together, these results indicate that insulin can be stored at such oscillating ambient temperatures for the usual four-week period of use. This enables the barrier of cold storage during use to be removed, thereby opening up the perspective for easier management of diabetes in humanitarian contexts and resource poor settings.
Journal Article > ResearchFull Text
PLOS One. 2024 August 26; Volume 19 (Issue 8); e0309062.; DOI:10.1371/journal.pone.0309062
Safary E, Lepeska M, Beran D, Ewen M, Zhaparova A, et al.
PLOS One. 2024 August 26; Volume 19 (Issue 8); e0309062.; DOI:10.1371/journal.pone.0309062
AIMS
Most glucose self-monitoring devices have been developed with high-income countries in mind. We developed a target product profile (TPP) for new glucose self-monitoring technologies for users in low- and middle-income countries (LMICs).
METHODS
A draft TPP including 39 characteristics was developed by an expert group including diabetes specialists, device specialists, and people with diabetes, incorporating findings from qualitative research in LMICs. Each characteristic had minimal and optimal requirements for two use cases, frequent and sporadic use. Characteristics requiring refinement were identified via online survey. Characteristics with agreement level <90% for any requirement were reviewed by the expert group and amended as appropriate.
RESULTS
One characteristic (shelf life) had agreement <75% (both requirements for both use cases). Characteristics with agreement ≥75% and <90% for the frequent use case included infrastructure level, measurement cycle, duration of use before replacement, interchangeability, and calibration (both requirements), and activity log and price per month to end payer (minimal requirement). Intended use (both requirements), accuracy, and price per month to end payer (optimal requirement) had agreement ≥75% and <90% for the sporadic use case.
CONCLUSIONS
This TPP will inform developers on requirements for glucose self-monitoring technologies for LMICs, and support decision-makers in evaluating existing devices.
Journal Article > ReviewFull Text
Toxicon: X. 2021 October 26; Volume 12; 100086.; DOI:10.1016/j.toxcx.2021.100086
Potet J, Beran D, Ray N, Alcoba G, Habib AG, et al.
Toxicon: X. 2021 October 26; Volume 12; 100086.; DOI:10.1016/j.toxcx.2021.100086
Access to safe, effective, quality-assured antivenom products that are tailored to endemic venomous snake species is a crucial component of recent coordinated efforts to reduce the global burden of snakebite envenoming. Multiple access barriers may affect the journey of antivenoms from manufacturers to the bedsides of patients. Our review describes the antivenom ecosystem at different levels and identifies solutions to overcome these challenges. At the global level, there is insufficient manufacturing output to meet clinical needs, notably for antivenoms intended for use in regions with a scarcity of producers. At national level, variable funding and deficient regulation of certain antivenom markets can lead to the procurement of substandard antivenom. This is particularly true when producers fail to seek registration of their products in the countries where they should be used, or where weak assessment frameworks allow registration without local clinical evaluation. Out-of-pocket expenses by snakebite victims are often the main source of financing antivenoms, which results in the underuse or under-dosing of antivenoms, and a preference for low-cost products regardless of efficacy. In resource-constrained rural areas, where the majority of victims are bitten, supply of antivenom in peripheral health facilities is often unreliable. Misconceptions about treatment of snakebite envenoming are common, further reducing demand for antivenom and exacerbating delays in reaching facilities equipped for antivenom use. Multifaceted interventions are needed to improve antivenom access in resource-limited settings. Particular attention should be paid to the comprehensive list of actions proposed within the WHO Strategy for Prevention and Control of Snakebite Envenoming.
Journal Article > ReviewFull Text
Lancet Diabetes Endocrinol. 2019 August 1; Volume 7 (Issue 8); 648-656.; DOI:10.1016/S2213-8587(19)30083-X
Boulle P, Kehlenbrink S, Smith JS, Beran D, Jobanputra K
Lancet Diabetes Endocrinol. 2019 August 1; Volume 7 (Issue 8); 648-656.; DOI:10.1016/S2213-8587(19)30083-X
The humanitarian health landscape is gradually changing, partly as a result of the shift in global epidemiological trends and the rise of non-communicable diseases, including diabetes. Humanitarian actors are progressively incorporating care for diabetes into emergency medical response, but challenges abound. This Series paper discusses contemporary practical challenges associated with diabetes care in humanitarian contexts in low-income and middle-income countries, using the six building blocks of health systems described by WHO (information and research, service delivery, health workforce, medical products and technologies, governance, and financing) as a framework. Challenges include the scarcity of evidence on the management of diabetes and clinical guidelines adapted to humanitarian contexts; unavailability of core indicators for surveillance and monitoring systems; and restricted access to the medicines and diagnostics necessary for adequate clinical care. Policy and system frameworks do not routinely include diabetes and little funding is allocated for diabetes care in humanitarian crises. Humanitarian organisations are increasingly gaining experience delivering diabetes care, and interagency collaboration to coordinate, improve data collection, and analyse available programmes is in progress. However, the needs around all six WHO health system building blocks are immense, and much work needs to be done to improve diabetes care for crisis-affected populations.
Journal Article > CommentaryFull Text
BMJ Glob Health. 2020 June 21; Volume 5 (Issue 6); e002820.; DOI:10.1136/bmjgh-2020-002820
Aebischer Perone S, Jacquerioz Bausch F, Boulle P, Chappuis F, Miranda JJ, et al.
BMJ Glob Health. 2020 June 21; Volume 5 (Issue 6); e002820.; DOI:10.1136/bmjgh-2020-002820
• The current WHO independent high-level commission on non-communicable diseases’ report lacks clear focus on addressing the issues of inequalities in non-communicable diseases.
• Much stronger recommendations are needed to ensure appropriate investment in strengthening and improving the quality of health systems, especially at primary healthcare.
• Governments, the private sector and other actors all need to be involved in finding sustainable solutions to ensure access to medicines and technologies for non-communicable diseases.
• Non-communicable diseases in humanitarian emergencies need to be included in any global guidance on the issue.
• In all contexts allocation of resources needs to optimise access for long-term care and treatment, paired with population-wide prevention efforts in order to guarantee universal health coverage.
• Much stronger recommendations are needed to ensure appropriate investment in strengthening and improving the quality of health systems, especially at primary healthcare.
• Governments, the private sector and other actors all need to be involved in finding sustainable solutions to ensure access to medicines and technologies for non-communicable diseases.
• Non-communicable diseases in humanitarian emergencies need to be included in any global guidance on the issue.
• In all contexts allocation of resources needs to optimise access for long-term care and treatment, paired with population-wide prevention efforts in order to guarantee universal health coverage.
Journal Article > ResearchFull Text
BMC Cardiovascular Disorders. 2021 October 9; Volume 21; 486.; DOI:10.1186/s12872-021-02298-7
Vetter B, Beran D, Boulle P, Chua AC, de la Tour R, et al.
BMC Cardiovascular Disorders. 2021 October 9; Volume 21; 486.; DOI:10.1186/s12872-021-02298-7
INTRODUCTION
Multi-parameter diagnostic devices can simplify cardiometabolic disease diagnosis. However, existing devices may not be suitable for use in low-resource settings, where the burden of non-communicable diseases is high. Here we describe the development of a target product profile (TPP) for a point-of-care multi-parameter device for detection of biomarkers for cardiovascular disease and metabolic disorders, including diabetes, in primary care settings in low- and middle-income countries (LMICs).
METHODS
A draft TPP developed by an expert group was reviewed through an online survey and semi-structured expert interviews to identify device characteristics requiring refinement. The draft TPP included 41 characteristics with minimal and optimal requirements; characteristics with an agreement level for either requirement of ≤ 85% in either the survey or among interviewees were further discussed by the expert group and amended as appropriate.
RESULT
Twenty people responded to the online survey and 18 experts participated in the interviews. Twenty-two characteristics had an agreement level of ≤ 85% in either the online survey or interviews. The final TPP defines the device as intended to be used for basic diagnosis and management of cardiometabolic disorders (lipids, glucose, HbA1c, and creatinine) as minimal requirement, and offering an expanded test menu for wider cardiometabolic disease management as optimal requirement. To be suitable, the device should be intended for level 1 healthcare settings or lower, used by minimally trained healthcare workers and allow testing using self-contained cartridges or strips without the need for additional reagents. Throughput should be one sample at a time in a single or multi-analyte cartridge, or optimally enable testing of several samples and analytes in parallel with random access.
CONCLUSIONS
This TPP will inform developers of cardiometabolic multi-parameter devices for LMIC settings, and will support decision makers in the evaluation of existing and future devices.
Multi-parameter diagnostic devices can simplify cardiometabolic disease diagnosis. However, existing devices may not be suitable for use in low-resource settings, where the burden of non-communicable diseases is high. Here we describe the development of a target product profile (TPP) for a point-of-care multi-parameter device for detection of biomarkers for cardiovascular disease and metabolic disorders, including diabetes, in primary care settings in low- and middle-income countries (LMICs).
METHODS
A draft TPP developed by an expert group was reviewed through an online survey and semi-structured expert interviews to identify device characteristics requiring refinement. The draft TPP included 41 characteristics with minimal and optimal requirements; characteristics with an agreement level for either requirement of ≤ 85% in either the survey or among interviewees were further discussed by the expert group and amended as appropriate.
RESULT
Twenty people responded to the online survey and 18 experts participated in the interviews. Twenty-two characteristics had an agreement level of ≤ 85% in either the online survey or interviews. The final TPP defines the device as intended to be used for basic diagnosis and management of cardiometabolic disorders (lipids, glucose, HbA1c, and creatinine) as minimal requirement, and offering an expanded test menu for wider cardiometabolic disease management as optimal requirement. To be suitable, the device should be intended for level 1 healthcare settings or lower, used by minimally trained healthcare workers and allow testing using self-contained cartridges or strips without the need for additional reagents. Throughput should be one sample at a time in a single or multi-analyte cartridge, or optimally enable testing of several samples and analytes in parallel with random access.
CONCLUSIONS
This TPP will inform developers of cardiometabolic multi-parameter devices for LMIC settings, and will support decision makers in the evaluation of existing and future devices.
Journal Article > CommentaryFull Text
Int J Tuberc Lung Dis. 2016 June 1; Volume 20 (Issue 6); 717-728.; DOI:10.5588/ijtld.15.0734
Bissell K, Perrin C, Beran D
Int J Tuberc Lung Dis. 2016 June 1; Volume 20 (Issue 6); 717-728.; DOI:10.5588/ijtld.15.0734
Chronic respiratory diseases (CRDs) affect hundreds of millions of people. The United Nations 2011 meeting on non-communicable diseases (NCDs) marked a turning point in addressing this burden. The targets established following this meeting incorporated specific measures to address the availability and affordability of essential medicines. These are aligned with the sustainable development goals (SDGs) and the push for universal health coverage. However, essential medicines for CRDs remain unaffordable and unavailable to many. For asthma, the availability of medicines was respectively 30.1% and 43.1% in the public and private sectors. The maximum annual costs of treatment were US$102.10 for beclometasone, US$82.99 for salbutamol and US$1501.79 for budesonide, representing respectively 40%, 15% and 209% of per capita income in Malawi, Burkina Faso and Guinea. Multiple factors contribute to poor availability and affordability. Experience from human immunodeficiency virus/acquired immune-deficiency syndrome shows that medicines and care can be delivered in low-income countries and among the NCDs. A unique example of an effective mechanism for providing access to affordable essential CRD medicines is the Asthma Drug Facility. Working on the six health system building blocks proposed by the World Health Organization can help countries address not only problems regarding access to medicines, but also those hampering adequate care. Improving medicine supply systems, training, national guidelines, financing, research, data utilisation and models of care at the primary health care level will help. A CRD target (e.g., 50% reduction in asthma hospitalisations) as well as the use of asthma as a measure for health system effectiveness and CRDs as a tracer for SDGs would help focus global, national and local leadership.
Journal Article > ReviewFull Text
Res Rep Trop Med
Journal of research and reports in tropical medicine. 2023 November 13; Volume 14; 111-120.; DOI:10.2147/RRTM.S397127
Le Bec E, Kam M, Aebischer Perone S, Boulle P, Cikomola J, et al.
Res Rep Trop Med
Journal of research and reports in tropical medicine. 2023 November 13; Volume 14; 111-120.; DOI:10.2147/RRTM.S397127
Lack of awareness, access to insulin and diabetes care can result in high levels of morbidity and mortality for children with type 1 diabetes (T1DM) in sub-Saharan Africa (SSA). Improvements in access to insulin and diabetes management have improved outcomes in some settings. However, many people still present in diabetic ketoacidosis (DKA) in parallel to misdiagnosis of children with T1DM in contexts with high rates of communicable diseases. The aim of this study was to highlight the complexity of diagnosing pediatric T1DM in a healthcare environment dominated by infectious diseases and lack of adequate health system resources. This was done by developing clinical vignettes and recreating the hypothetico-deductive process of a clinician confronted with DKA in the absence of identification of pathognomonic elements of diabetes and with limited diagnostic tools. A non-systematic literature search for T1DM and DKA in SSA was conducted and used to construct clinical vignettes for children presenting in DKA. A broad differential diagnosis of the main conditions present in SSA was made, then used to construct a clinician's medical reasoning, and anticipate the results of different actions on the diagnostic process. An examination of the use of the digital based Integrated Management of Childhood Illness diagnostic algorithm was done, and an analysis of the software's efficiency in adequately diagnosing DKA was assessed. The main obstacles to diagnosis were low specificity of non-pathognomonic DKA symptoms and lack of tools to measure blood or urine glucose. Avenues for improvement include awareness of T1DM symptomatology in communities and health systems, and greater availability of diagnostic tests. Through this work clinical vignettes are shown to be a useful tool in analyzing the obstacles to underdiagnosis of diabetes, a technique that could be used for other pathologies in limited settings, for clinical teaching, research, and advocacy.
Journal Article > LetterFull Text
Lancet Diabetes Endocrinol. 2022 March 25; Volume S2213-8587 (Issue 22); 00105-X.; DOI:10.1016/S2213-8587(22)00105-X
Maystruk G, Aebischer-Perone S, Anufriyeva V, Boulle P, Chappuis F, et al.
Lancet Diabetes Endocrinol. 2022 March 25; Volume S2213-8587 (Issue 22); 00105-X.; DOI:10.1016/S2213-8587(22)00105-X